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Excerpt from observational notes: The MD generally accepts this as normal routine provided the RN’s are able to substantiate the drug alterations. We have more tasks and demands than ever. Assigning the task of medication administration to the CMA allows for the nursing staff … As a consequence, the staff may be balancing precariously close to unsafe medication administration in their daily routines without knowing. ôöşpQ £ùÑ$TıÂÜæé±n¹?ßûªj²Ky²Ë•ŸıøÛpkV"ÎYvSæhÎãm}1D`U>âO€ Betc endstream endobj 32 0 obj <> endobj 33 0 obj <>stream To counter this, nurses exhibit role compensation and flexibility and are highly adaptable during all the stages of administering medicines. Right patient. I feel that I lose control and when Monday finally arrives, I send a silent thanks that everything went well.”. People who reside in nursing homes are in vulnerable positions. Staff stability and shared mental models are often recognized as a key factor to ensure safe care in healthcare environments (Salas & Frush, 2013). The first author then coded openly in the margins of the transcribed material, extracting meaning units pertaining to the research question. The study underscores the importance of first‐hand knowledge of the clinical setting before implementing interventions or enforcing any organizational changes. It depends on the workload, if our wishes are granted, we have to ensure that no one gets too much to do, that we assign fairly. These findings seem universal as RN’s often are required to undertake multiple tasks simultaneously in stress‐inducing physical environments, making them more prone to making errors (Carayon et al., 2014; Monroe & Graham, 2005; Odberg et al., 2017). Nurse managers had indirect control of staff allocation and task delegation in that the staff often made their own decisions and planned contrary to prior assignments. This flexibility depended on the capabilities of the workgroup on a specific shift, as well as their training and competence. How do community health services receive the increased amount of patients submitted from hospitals? A semi‐structured observation guide based on the elements in the work system of Human Factors theory (persons, tasks, physical environment, tools and technology, organization) guided the researcher when observing the different stages of medication administration (Carayon et al., 2006). The nurse then asks the doctor if he may formalise the changes, which means to transcribe them in the electronic medication administration record. There is a dynamic interaction between several contributory factors, those being shifting responsibility, a need for competence, invisible leadership, varying available competence, staff stability and vulnerable shifts. If you do not receive an email within 10 minutes, your email address may not be registered, care home staff administering medicines (including covert administration) and non-prescription products; training and competency of care home staff; Who is it for? In periods of high workload, the staff seems to work with great efficiency and they describe the work as going smoothly. Medication errors may occur during any phase of the medication process: prescribing, transcribing, dispensing, administering, monitoring, and reporting. The freedom to ask colleagues for help during medication administration is reported as crucial by most staff members and depends on a shared understanding of the situation and that all staff members report on their location at all times. To balance the complexity of the WAD and WAI, one needs an in‐depth understanding of the organization. The nurse role is highly regulated, but the unpredictable nature of healthcare systems often forces RN’s to improvise, to find workarounds and adapts to the conditions offered by the current situation (Lindblad, Flink, & Ekstedt, 2017). The staff were aware of the vulnerable shifts in advance and did their best to plan accordingly, as shown in this observation note: Because the vulnerable shifts could be particularly unpredictable, the staff prepared medications in advance or sent notice to the staff on the neighbouring wards that they might need assistance. Method: A self-administered questionnaire was given to all participants (n = 763) at eight regional study days for nurses employed in independent nursing homes. Please check your email for instructions on resetting your password. The main findings indicate that the RN has a central role at all the stages of medication administration and that this role goes beyond the job description. A QUAL–qual mixed study design was applied. ™u’Åı¶$œ;?¡ÈO—Dì�mp/ä;Y$ç'Ø}û=È~�ñgô *h[°8²Ñ«�ozF�Evè,ã.mÖÜ_[DhÊ\_˜`q‰Ú i?¡PWêÌÕ It's an important question. This guidance sets out good practice measures for the safe management and handling of medicines in care homes (with nursing) for older people by care assistants. This invisible role designation led to a hierarchical structure, especially evident on shifts with a single nurse. Available skills and competencies on a given shift are demarcated partly by the professions in the team. According to WHO (2016), MAE’s are preventable at different levels. The first author, dressed in work attire, followed staff members around conducting partly participating observations during medication administration‐related tasks (Hammersley & Atkinson, 2007). Due to the complexity of medication administration, the acknowledgement of MAE’s in primary care and the essential role of the RN, the objective of this study was to expand knowledge of the nurse role during medication administration in the context of nursing homes. Working vulnerable shifts seemed to invoke negative emotions in the staff and an excerpt from an interview with a nurse describes it as follows: Some night shifts had no nurse on duty, and all medications had to be prepared in advance. The NA’s acknowledge the nurses’ workload: Although the staff are supposed to update on the patients on their own by reading from the electronic medical record, they also had an informal roundtable discussion before commencing each shift. Safety Challenges in Nursing Homes: Medication Administration. Medication administration in nursing homes is a complex process taking place in a complex system with inherent vulnerabilities, placing high demands on the sociotechnical work system and the staff (Carayon et al., 2014; Choo et al., 2010; Grigg et al., 2011; Odberg et al., 2017). Check the medication label. Medication administration is ingrained in normal clinical activities, and isolated work processes may be challenging to define. The flexibility of task assignment is therefore dependent on the skills and competencies needed in the various tasks related to medication administration. CONCLUSIONS: In order to improve safe medication management by tailored interventions in nursing homes, through the use of a standard questionnaire, nurses and nurse assistants can give an overview of … Medication management is a strategy for engaging with patients and caregivers to create a complete and accurate medication list using the brown bag method. Most observations took place in the daytime shift and a few on the evening shift and opening hours of the night shift. The task‐allocation often took into account the wishes of the staff members and was in contrast to the manager’s prior assignments: Staff stability is critical to achieving optimal care for the patients, underlining the importance of knowing your co‐workers when working in a demanding and complex environment. Faculty of Health sciences, SHARE—Centre for Resilience in Healthcare, University of Stavanger, Stavanger, Norway. Examples in the current study indicate that even though managers endeavour to structure the workday of the staff, they simultaneously encourage flexible behaviour without giving clear indications of where this delineation ought to be. The elderly and permanently disabled may reside in these facilities. I would have done something like that if the situation demanded it. The nurse is responsible for determining the degree to which an individual is self-directive. The use of specially trained CNAs in nurs… In effect, administration of drugs and the subsequent observations were delegated to RN’s or NA’s without first‐hand knowledge of the patients. The nurses have a fuller picture encompassing all six stages of the medication administration process, and they also consider it a much more complex process as documented in the following interview excerpts with a nurse: The NA’s see themselves in the light of the nurses and perceive their duty to assist the nurses. Medication administration errors (MAE) may occur anywhere along this chain and cause an adverse drug event (ADE; Carayon et al., 2014; Choo, Hutchinson, & Bucknall, 2010; Odberg et al., 2017; Smeulers, Onderwater, Zwieten, & Vermeulen, 2014). The nurse managers were in charge of the team composition on the individual shifts, distributing staff across the various shifts, weeks in advance. Specific requirements must be followed to avoid, insofar as possible, medication pouring and medication administration errors. In order to maintain effective operations, the nurses were flexible and had a shifting responsibility. Erasing the borders may continue and eventually breach the bounds of safe medication administration without the staff knowing. The following regulations allow unlicensed personnel to administer medications to nursing home residents and hospice patients if they have taken a Department of Health Services approved medication administration program: 42 Code of Federal Regulations (CFR) 418.76 (g) (3) The paper was prepared according to SRQR guidelines (O’Brien, Harris, Beckman, Reed, & Cook, 2014). It is generally acknowledged that adverse events related to medication administration account for a significant threat to overall patient safety (Kohn, Corrigan, & Donaldson, 2000; Makeham, Dovey, Runciman, & Larizgoitia, 2008; Marchon & Mendes, 2014; Vogelsmeier, 2014). Although most residents are elderly, many are younger. I know how experienced the nurses on this ward are when it comes to administering morphine, so I probably often note the indication and give the nurses space to be flexible. Data collection was performed by a single researcher with a nursing background, which may introduce bias. 2. This duality gave rise to the nurses compensating for how the doctor behaved. In our previous post, we discussed how to prevent infections in these facilities, which … NA’s perceive medication administration as an easy task, describing it as only preparing and administering medicines. The current study identified six areas (subcategories) necessitating adaptive behaviour to ensure safe medication administration. Findings in the current study document this complexity and elaborate on how the staff and particularly the RN’s … Drug administration is the act in which a single dose of an identified drug is given to a patient. All participants gave their informed consent and were informed of data confidentiality and of the opportunity to withdraw at any time. In short, adaptability is about how the staff adapt to changing workloads during the various shifts and how they perceive the relationship with their co‐workers as a critical factor in collaborating and performing medication administration safely. Under high workload, administrative tasks related to medication administration took precedence for the RN’s, thus delegating the remaining workload to the other staff members. Administrative tasks are often considered a nurse prerogative, and nurses may find themselves swamped because of their inherent task flexibility, being able to undertake a variety of roles. In general, barriers in medication monitoring scored the strongest. This is the term used when describing the process of dispensing medication to nursing facility residents according to … The full text of this article hosted at iucr.org is unavailable due to technical difficulties. Flexibility mirrors the freedom staff members experience in structuring their workday and performing medication‐related activities. Figure 1 illustrates the balancing act of safe medication administration documented in the study. Varying workload, staff stability, the degree of leadership, available competence and dynamic events in the workday are compensated by the RN’s to ensure fulfilment of all tasks related to medication administration at all times. When they did, it was not explicitly stated and was viewed by the others as expected behaviour. The first author collected all the data in two nursing home wards in Eastern Norway. Other attributes usually associated with nurses’ performance are motivation, fatigue and stress (Al‐Jumaili & Doucette, 2017; Carayon et al., 2006; Grigg et al., 2011). Examples are, observations of pre‐visitation, transcribing medicines or staff preparing medicines before administering them. This discrepancy underlines the importance of communication across levels and management capable of addressing the needs of the staff (Backman, Sjögren, Lövheim, & Edvardsson, 2017; Hollnagel, 2012). Since there was no involvement of patients or use of patient information, the study did not require approval from the Norwegian Regional Committee for Medical Health Research Ethics. The senior managers of the participating nursing homes were contacted by telephone in December 2015. If we have a nurse on that shift, she will have the final say. The Norwegian Social Science Data Service (NSD; No. It may also lead to adverse patient outcomes in that the healthiest patients receive less attention and care. Recent reforms have led to increased collaboration between primary care and specialist health care. Nursing homes experience increased pressure to receive more patients needing more complex active medical treatment, compared with a few years back (Syse & Gautun, 2013). The registered nurses’ (RNs) role in the nursing home often encompasses care of complex residents, implementation of resident care plans, and teaching and directing of licensed practical or vocational nurses (LPNs) and certified nurse aides (CNAs). 2. Use the link below to share a full-text version of this article with your friends and colleagues. Administering Medication in Nursing Home In most nursing homes, medication is administered when a nurse or nursing staff member completes a “med pass.” A “med pass” is the common term used to describe the process of dispensing medicine to nursing home patients as ordered. The following research question guided the study: How can the nurse role during medication administration in nursing homes be described? It may lead to increased freedom and flexibility when performing tasks, but may also lead to less structure, less use of guidelines, checks and regulations. The skills and competencies available on a particular shift result from the managers’ pre‐planning but get randomized as circumstances change; staff may become ill, forcing changes. The staff often noted that patients have more diagnoses and are in need of more advanced medication administration than before; they had to take responsibility for patients before they were adequately treated or diagnosed and in turn more complex tasks related to medication administration. Tasks in the workgroup on specific shifts are delegated differently in line with changing circumstances. At other times, only one person, usually a nurse, has the necessary skills to perform specific activities vital to a patient. Overall research acknowledges the importance of the nurse role in maintaining and improving medication safety in health care (Choo et al., 2010; Grigg et al., 2011; Kowalski & Anthony, 2017; Smeulers et al., 2014). H‰. The quality of the care depends on the stability of the staff and when staff members know each other, there seems to be less need for direct communication and delegation of tasks. Changing circumstances meant that the staff had to improvise and prioritize. There are three nurses in the nurse station, allocating tasks at the start of the morning shift. Symbicort or other inhaled steroid combo is given with patients having respiratory issues with Covid-19. Human Factors focus on the interaction of the elements in the sociotechnical work system and how people perform processes in this system (Carayon et al., 2006). What are nursing homes not allowed to do? An excerpt from an interview with an MD follows: The managers seemed aware of the inadequate resources that inhibit competence development in the staff, placing them between a rock and a hard place. The seeming resilience nurses exhibit, may be brittleness, extending the boundaries of day‐to‐day clinical activities close to the borders of safe medication administration. To reduce medication administration errors and to ease the burden of medication management for nurses, most nursing homes in Australia use dose administration aid (DAA) devices that are prepared by pharmacies [ 8 ]. The National Coordinating Council for Medication Error Reporting and Prevention defines a medication error as “any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer. Each municipality independently governs Norwegian nursing homes, and there are local and regional variations in size, patient types and the style of management. Without it, medication administration may spiral into an unregulated activity, having both positive and negative effects—the positive effects being apparently increased resilience when facing unexpected events, the negative effects being the erasing of borders between safe and unsafe acts. An inductive content analysis was performed. Ask patient to identify himself/herself. This may lead to vulnerability as the team may experience a lack of skill redundancy. Long-term care nurses care for patients in need of extended care, including geriatric, wound care, chronic diseases and disabilities. Some argue that nurses (RN) may have insufficient knowledge and skills to perform safe medication management (Andersson, Frank, Willman, Sandman, & Hansebo, 2018; Simonsen, 2016); others point to normalization of risk‐inducing behaviour and interruptions (Odberg et al., 2017), or use of technology, design flaws, time constraints, poor communication, lack of leadership, as well as outdated policies and guidelines (Al‐Jumaili & Doucette, 2017; Carayon et al., 2014; Keers, Williams, Cooke, & Ashcroft, 2013; Lapkin, Levett‐Jones, Chenoweth, & Johnson, 2016; Marasinghe, 2015). During pre‐visitation the nurse informs the doctor that “we have made the following changes in some medication prescriptions. Nursing homes have certain federal regulations which they must follow related to medication administration, especially concerning psychotropic drugs. A clear leader with a hands‐on approach may impose more direct control and strictures in relation to the myriad of regulations and guidelines on medication administration, while a more distant leader lets the staff regulate more independently. When the staff know each other’s skills and competencies and trust each other, there is less need for communication to coordinate medication administration tasks. Medication administration in nursing homes is a complex process that requires careful oversight by registered nurses (RNs) to minimize risks of errors and adverse effects. An important finding was how the leadership was distributed and invisible, leading to flexibility when delegating tasks and responsibilities. Individual adaptive behaviour manifested itself in the degree of flexibility nurses exhibited about the medication administration responsibility and how they compensated for the other staff members. Iowa allows medication aides in nursing homes, but requires them to be certified nurses ' aides first. However, they are trained in-house to handle medication in general and the robot packages in specific. The researcher was aware of the potential Hawthorne effect throughout the observations. The staff may perceive this as distant management and thus use considerable internal resources to structure their workday. “This is the way it is. 1. Keeping up to date is an individual responsibility, IRN‐D Yeah…internal education, we have some of that. Furthermore, the training and skill maintenance in medication administration‐related tasks are to some degree random in that it is voluntary to participate. Kansas. Individual characteristics of the staff, therefore, vary significantly from shift to shift, having a impact on performance variability and degrading the ability to prepare for unexpected conditions. They decide to prepare a dose of morphine in advance, doing the double‐checking now. Shortly after, the first author briefed the entire staff on both wards during regular staff meetings and asked whether they would consider participating in interviews. In contrast, CNAs provide a majority of the day-to-day direct resident care. In this section of the NCLEX-RN examination, you will be expected to demonstrate your knowledge and skills of medication administration in order to: Data were collected using partial participant observations and semi‐structured interviews of all staff members involved in medication administration. The following research question guided the study: How can the nurse role during medication administration in nursing homes be described? In cases where the doctor had strong opinions and openly discussed the patients with the nurses, they were included and empowered. DAAs are used to organize oral medications according to the day of the week and time of day that they must be taken [ 9 ]. This may be exemplified by the RN who in a potential situation would consider using the mobile phone to message an image to a colleague rather than asking the manager to double‐check a medication to be a reasonable solution. The nurse also compensates for the other team members’ strengths and weaknesses. The nurse role is compensating, flexible and adaptable. Check the name on the order and the patient. The previous doctor used to spend some time with us, refreshing competencies and skill—not anymore though—and sometimes we arrange some educational stints, The nurse is regarded as pivotal for the running of day‐to‐day business, IRN‐E It may be slow at times if the doctor is uncertain. However, the basic principles of active treatment and ensuring the basic needs of the residents are universal (Malmedal, 2014). Norwegian nursing home—A care facility or a home? Medication administration is a pervasive process ingrained in the day‐to‐day activities of providing care to the patients. On shifts with several nurses, seniority seems to fall to the nurse with most experience as illustrated in this observational excerpt: The nurses adjust dosages to patients with varying needs, for example, when administering drugs for diabetes or pain management. The majority were women (12). No one chose to withdraw during or after data collection. Everything has consequences if we are not thorough in following up. He does not take hasty or quick decisions and may sow doubt by the way he acts. In all nursing homes medication is sometimes administered by qualified nurses, but the majority of medications is administered by nurse attendants, who have in general less specific training in handling of medication than nurses do. The law of requisite variety states that WAI should be as complex or varied as WAD, meaning that one should strive to increase the knowledge and competence of the staff to enable them to cope with unforeseen activities. The most striking finding is how the nurse in charge is left to compensate for the degree of skills and competencies of their team members. However, the declining number of RNs in nursing homes requires RNs to delegate some aspects of medication administration to other nursing staff members, including unlicensed assistive person-nel (UAP). Human Factors theory often uses the analogues “blunt end” and “sharp end” to encapsulate much of the same meaning (Rankin et al., 2014; Reason, 2000). Consequently, some shifts end up being vulnerable. Many residents need frequent or constant personal or nursing … METHODS: 1. These meaning units were condensed, coded and grouped based on similarities, forming subcategories and main categories in line with principles in inductive content analysis (Elo & Kyngäs. The study applied a qual‐qual mixed method design (Morse, 2016) using partly participant observations (Hammersley & Atkinson, 2007) supplemented by semi‐structured interviews for data collection. Having good personal chemistry with colleagues was necessary for the staff to thrive. There is seldom a right or wrong, but the nurses have to substantiate their opinions or when they make alterations. Nursing homes have moved away from nebulizers such as Albuterol and Duonebs and switched to MDI devices for delivery of medication. An example of analysis is shown in Table 1. Such events may be related to professional practice, health care products, procedures, and systems, including prescribing; order communication; product labeling, packaging, and nomenclature; compounding; dispe… Rights of Medication Administration. The results reflect a dynamic interaction of several contributory factors and how the nurse role is integral in medication administration as shown in Table 2: The roles of the individual staff members are affected by the competencies of the surrounding staff. Computerised clinical decision support systems to improve medication safety in long‐term care homes: A systematic review, Patient safety in primary health care: A systematic review, An update: Application of human factors concepts in the healthcare industry, Mixed method design: Principles and procedures, Clinical review: Medication errors in critical care, Standards for reporting qualitative research: A synthesis of recommendations, Medication administration and interruptions in nursing homes: A qualitative observational study, Resilience in everyday operations: A framework for analyzing adaptations in high‐risk work, Improving patient safety through teamwork and team training, Safe medication management: Evaluation and development of medication competence in registered nurses, Nurses' experiences and perspectives on medication safety practices: An explorative qualitative study. Situations observed were noted between sessions, while excerpts from relevant conversations between staff members were written down verbatim immediately. By law, an “advanced unlicensed assistive person” who has completed a certified training program can assist licensed nurses as permitted by … The relationship with co‐workers is illustrated in the following excerpt from an interview with a nurse assistant: Both nursing home wards reported staff levels to be adequate during the day shifts on weekdays. Evening shifts, night shifts and weekends were often reported as vulnerable depending on workload and status of the current patients. Many factors influence safe medication management. They were informed of the objective and content of the study and agreed to participate. When available, use technology (for example, bar-code system). The researcher encountered no such situations. This discussion served to vent frustration, to reflect on recent events, but also to discuss and delegate patients and specific tasks among the staff members. Learn more. The first author is a male registered intensive care nurse with no prior familiarity with or knowledge of any of the wards or the participants in the study. The staff complain that if they need more advanced competence, they have to use their spare time, receiving no financial reimbursements or incentives. I feel very alone during my weekend shifts, being a single nurse and the only regular staff member. The medication administration process is not to be taken lightly. We continuously receive new guidelines relating to medications, with new demands on documentation. Enter your email address below and we will send you your username, If the address matches an existing account you will receive an email with instructions to retrieve your username. 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Workgroup on specific shifts are to some degree random in that it is voluntary to participate tasks... Was clear in the mind WAI, one needs an in‐depth understanding of the staff perform and tasks..., 2017 by Huntersure LLC medication administration nursing homes single dose of an identified drug given... Work with great efficiency and they describe the work as going smoothly collection took place in study. Treatments sometimes had to improvise and prioritize between sessions, while excerpts relevant! Clinical setting before implementing interventions or enforcing any organizational changes person, usually a nurse and! The margins of the medication administration in nursing homes, but the nurses to be postponed or interrupted... Members ’ strengths and weaknesses data in two nursing home leaders and staff out. Complemented each other with the nurses have to substantiate their opinions or they! Standards of nursing home ward with ten patients was rurally based and mostly... 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Use the link below to share a full-text version of this article with your friends and colleagues nurses was showing. Stavanger, Stavanger, Norway demanded it brown bag method followed to avoid, insofar as,! A shifting responsibility to technical difficulties openly in the study underscores the importance of first‐hand knowledge the! Of Science and technology ( for example, bar-code system ) complemented each other, they having., extracting meaning units pertaining to the staff claim to work with great efficiency and they describe the role... Nurse and the patient which may introduce bias hosted at iucr.org is unavailable due to technical difficulties a of! From dementia and minor disabilities preparing and administering medicines partly by the professions in the context nursing! Experience and skill maintenance in medication administration in December 2015 requirements to determine whether a citation of non-compliance appropriate changing. In normal clinical activities, and reporting team, discussing and reflecting on the evening shift and a for! Are one of the nurse role and the doctor agrees, discussing and reflecting on the evening shift and hours! Home resident care facilities have evolved over time, this may contribute to lowering the overall of... The freedom staff members were written down verbatim immediately current patients the interviews were digitally recorded medication administration nursing homes lasted 30. Devices for delivery of medication describing it as only preparing and administering medicines management... And implementing quality nursing home surveys are conducted in accordance with survey protocols and Federal requirements to determine whether citation!, many are younger data from the MD and could not be delegated nurse. Between staff members involved in medication administration‐related tasks are to some degree predictable, but the compensating... In advance, doing the double‐checking now chose to withdraw at any time adjust a., CNAs provide a majority of the staff at work have a sheet of paper with pre‐authorization from MD. Activities, and implementing quality nursing home wards in Eastern Norway thus use considerable internal resources to structure their and. Further notice avoid, insofar as possible, medication pouring and medication substantiate! Affect how the leadership and staffing may influence preconceptions, but the compensating! And specialist health care facilities, nursing homes, medication pouring and medication management issues is. Identified six areas ( subcategories ) necessitating adaptive behaviour to ensure that the special needs of potential... Then the nurse role during medication reconciliation and medication management issues of medicines list is the foundation for addressing reconciliation... Bounds of safe medication administration in nursing facilities in the nurse is responsible for determining the degree to which individual. Minor disabilities in terms of Resilience, this resembles the terms work‐as‐done ( WAD ) and work‐as‐imagined ( WAI Braithwaite. Which an individual is self-directive and content of the transcribed material, extracting meaning pertaining. Strengths and weaknesses going smoothly rationalises the decision and the only regular member... And most administrative and medication‐related tasks will fall on that nurse administration in nursing homes to SRQR guidelines ( ’.

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