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Delegation and Supervision, by Registered Nurses of Medication Administration
within Aged Care Facilities


This advice provides guidance to registered nurses in aged care regarding the delegation and supervision of medication administration. Following wide consultation in 1999, the Board issued a document regarding the delegation of medication administration in residential aged care facilities and this view was reiterated in a further article published in the Board's newsletter in 2005. Subsequently the Board was requested to review the guidance provided to registered nurses about this matter in recognition of the changing composition of the workforce and changing models of care.

Consideration of these issues has been assisted by consultation with representatives of the aged care industry and other interested parties, as well as by legal advice regarding the requirements of current legislation.

The Nurses and Midwives Board recognises that aged care is an important area of practice for nurses. The following advice is intended to assist registered nurses, who work in aged care, in fulfilling their professional obligations while contributing to the delivery of quality care. This document reflects consideration of current legal context and recognises that there are situations:
(a) where medication administration is managed entirely by nurses;
(b) where the resident is clearly in control of own medication management; and
(c) where nurses may provide assistance and support to other care workers who may administer medication, following suitable risk assessment.

It is recognised that the organisations which provide aged care services ("Approved Providers" under the Aged Care Act 1997 (Commonwealth)) are responsible for the quality of care provided to residents in their facilities. This includes responsibility for the actions of their employees. It is the responsibility of the Approved Provider to ensure that medications are handled, managed and distributed in a manner that complies with their care obligations and statutory obligations. The Approved Provider may delegate medication administration to persons other than nurses. However, if registered nurses or enrolled nurses are involved in the administration of medications, the nurses have a professional responsibility to practise in accord with professional standards.

If medications have been properly prescribed for a patient by an appropriate health professional and dispensed by a pharmacist, it is a matter for the Approved Provider to determine how these medications are to be distributed and managed within the facility. If the Approved Provider gives a registered nurse the responsibility for managing those medications in the facility, the nurse is subject to the employer's directions as well as being required to practise in accord with the standards of the profession.
The Context of Nursing Care

In their practice, registered nurses and enrolled nurses demonstrate high standards of knowledge, skill, judgement and care, at a level which care workers, in the aged care setting, are not necessarily expected to demonstrate.

In some instances, members of the public would reasonably expect that the care provided is nursing care and that the care is directed and supervised by a registered nurse in accord with professional nursing standards. For example:
· in facilities identified as "nursing homes"; or
· in facilities which, even if differently titled, fall within the definition of "nursing homes" in the
   Public Health Act 1991; or
· where the director of clinical services is identified by a title or by qualifications which may
   reasonably lead residents and/or their families to perceive that a nurse is responsible for
   directing the provision of care in accord with nursing standards; or
· in other circumstances which may reasonably lead members of the public to believe that
   nursing care is being provided by nurses or by other care workers who have been delegated
   and are supervised by a registered nurse.

In these instances, the public would reasonably expect that the registered nurse directs nursing care (including delegation to other care workers and supervision of their work). The other care workers may have titles such as Personal Care Assistants, Care Service Employees or Assistants in Nursing.

In other instances, nurses may be engaged to provide clinical services for residents and may act as consultants and resource persons to other care workers. In cases where nurses are employed as consultants or resource persons and are not in supervisory roles, nurses are responsible for their own practice and must provide care consistent with the standards established by the nursing profession, but are not expected to be responsible for the overall care of residents nor for the care workers who provide that care. However a registered nurse may be held responsible where an unsafe system is in place if the nurse ignores or complies with such a system leading to harm or potential harm to residents.

The following guidelines are intended to assist registered nurses working in circumstances where members of the public would reasonably expect that the care provided is nursing care and that the care is directed and supervised by a registered nurse in accord with professional nursing standards.

Registered nurses who are unclear about their duties and responsibilities, should clarify with their employers whether they, the registered nurses, are responsible for supervision of the work of other care workers. If so, the registered nurses are responsible for the delegations they make and supervision they provide.

In a situation where the Approved Provider has given responsibility for distributing properly prescribed and dispensed medications to care workers, registered nurses employed in the facility should exercise their professional judgement in determining whether that arrangement is safe and appropriate. In a situation where a nurse is not satisfied as to the safety of such an arrangement, there may be a professional responsibility to bring those concerns to the attention of the Approved Provider and/or the relevant Commonwealth Government agency. In some circumstances it may be appropriate for the nurse to withdraw her/his services from a situation he/she believes compromises resident safety and their professional responsibilities.
Delegation

The principles of delegation and supervision are generally applicable wherever nurses practise. Professional standards in regard to delegation and supervision are expressed in documents including:
· Australian Nursing and Midwifery Council, Guideline: Delegation and Supervision for Nurses
   and Midwives, reissued May 2006.
· Australian Nursing and Midwifery Council, National Competency Standards for the Registered
   Nurse, 4th ed, January 2006.
· Australian Nursing and Midwifery Council, Code of Professional Conduct for Nurses in
   Australia, 2003.

The above documents may be accessed on the Australian Nursing and Midwifery Council website (www.anmc.org.au). A further document outlining a scope-of-practice decision-making framework is under development by the Australian Nursing and Midwifery Council and is expected to be available in 2007.

Based on the principles above and professional discretion, registered nurses may make the decision to delegate aspects of care to other nurses and to other care workers. In deciding whether to delegate particular activities, the registered nurse must take into consideration the needs of clients and the skills of the other care workers to ensure that delegation does not jeopardise the provision of safe care.

The decision about whether or not the administration of medication can be delegated is not dependent solely on the fact that the medication is supplied as a dispensed medicine that is fully labelled with explicit instructions for use. Other factors must also be taken into account, including:
· the stability and health status of the patient;
· the route of administration;
· any special considerations associated with administration of the particular medication(s);
· the knowledge and skills of the person to whom the delegation is given.

The registered nurse may delegate medication administration only to care workers who have been appropriately educated and who accept the delegation.

The delegations discussed above in relation to care workers apply equally to enrolled nurses without medication endorsement. The registered nurse may delegate the administration of medications to an enrolled nurse who does not have medication endorsement but only if the medications have been dispensed and labelled by a pharmacist and only if the registered nurse is satisfied that the enrolled nurse has undertaken appropriate education to be able to carry out the delegated task safely. As noted above, the administration of medications from ward stock may be delegated only to another registered nurse or to an enrolled nurse with medication endorsement.

Dispensed Medications Distinguished from Stock

Delegation to other care workers is permitted only where medications have been dispensed by a registered pharmacist and labelled with specific directions for an individual resident.

Medications administered from stock medicines (not dispensed and labelled for an individual resident) may be administered only by a registered nurse or an enrolled nurse with medication endorsement. Further, the definition of "nurse" in the Poisons and Therapeutic Goods Regulation 2002 effectively limits the administration of Schedule Eight medications from stock supplies to registered nurses only.

Emergency stock systems provide ward stocks of certain medications that are allowed, by the Director General of Health, to be held in "nursing homes" for emergency use. These medications are held in manufacturer's labelled containers but not identified for particular residents. In "nursing homes" (within the meaning of the Public Health Act 1991) medications may be administered from ward stocks only by registered nurses and enrolled nurses with medication endorsement. (NSW Government Gazette No 25, 11 February 2005, page 401). The Chief Pharmacist, NSW Department of Health, advises that this provision applies to drugs that are administered from an emergency stock supply on the basis of the authority of the resident's medical practitioner, and does not apply where medications have been dispensed for an individual resident with appropriate labelling etc. by a pharmacist in accordance with a medical prescription.

Packaging of Medications

The packaging in which medications are supplied does not alter the responsibilities of the registered nurse or in administering medications or supervising the administration of medications by other care workers.

However the use of dose administration aids, such as medications for an individual resident packaged in individual clearly labelled blisters in a medication card, may assist other care workers in ensuring that the correct medications are administered to a resident at the correct time.

Medication Administration in Residential Aged Care Settings

In residential aged care settings, supporting factors should be in place to assist a registered nurse to determine the safety of delegation of medication administration. These would include:

· policies and procedures within the facility that clearly articulate the role and functions of each
  nurse and other care workers involved in the administration of medications, including regular
  medications, those administered when needed (often referred to as "p.r.n." medications),
  nurse initiated medications and schedule 8 drugs.
· an expectation that the registered nurse is responsible for medication management and the
  care worker administers medication where delegated. Care workers should report to the
  registered nurse any concerns about medication administration.
· provision for a handover of care between registered nurses at the commencement of each
  shift so that the registered nurse is made aware of any changes in health status of residents
  prior to delegating the administration of medication to care workers. 
· provision for the registered nurse, having delegated medication administration, to exercise
  supervision in order to be assured that the delegation remains safe.  The level of supervision
  is determined by the registered nurse after consideration of both the health status of the
  resident and the education and skills of the care worker to whom medication administration
  has been delegated.
· provision, where a resident’s health status has become unstable, for the registered nurse to
  withdraw delegation and administer medications personally until the resident’s health status
  becomes more stable or has been medically assessed.
· the registered nurse being allowed adequate time to appraise a resident’s status in regard to
  ongoing safety of delegated medication administration.
· awareness of the total medication system to promote safety and accuracy across all aspects
   including charting, dispensing and administration. 
· registered nurses being provided with information about the operation of the facility's
  Medication Advisory Committee and having the opportunity to contribute to the committee's
  deliberations through a registered nurse who is a member of the committee.
· a registered nurse who is a member of the facility's Medication Advisory Committee being
  able to participate in risk management by promoting best practice in medication
  administration, the accurate and consistent reporting and recording of medication
  misadventures such as Adverse Drug Events, and maintaining professional development.
· provision, by the facility management, of a list of care workers who have completed education
  at a competence level that enables the registered nurse to determine to whom medication
  administration may safely be delegated.

Recommendations for Best Practice when a Registered Nurse is Delegating Medication Administration in Aged Care Facilities

To assist registered nurses to make decisions relating to the delegation of medication administration, the Nurses and Midwives Board makes the following recommendations. Registered nurses may be further assured of the safety of their delegation where the following circumstances exist:
1. Following each admission, the medical practitioner and a registered nurse discuss appropriate delegation of medication administration for the resident.
2. Regular meetings are held for medication review in accord with the Australian Pharmaceutical Advisory Council (APAC)  Guidelines and criteria for resident selection for medication review.
3. The facility provides a mechanism for contact with a pharmacist and/or medical practitioner at all hours for consultation with the registered nurses in relation to medication management.
4. The registered nurse is assured that a representative of the facility's medication advisory committee undertakes regular audits of the labelling and contents of medication packages.
5. The pharmacist is responsible for the correct packaging and labelling of medications while the role of the registered nurse is more appropriately focused on whether the resident has been assessed to determine if it remains safe to continue to take the medication as ordered and administered either by the registered nurse or as delegated to a care worker.
6. The facility  employs care workers who have completed appropriate education in medication administration and provides further education for care workers whose prior education did not include the applicable knowledge and skill.
7. Care workers should be accredited initially by the employing facility and then at regular intervals, to determine their competence and ability to safely administer medications to residents. They must be assessed at each subsequent employing facility to ensure they meet those individual standards.
8. Best practice is followed in the use of medication administration aids.


References:
   1.
Guidelines for medication management in residential aged care facilities, Australian
       Pharmaceutical Advisory Council, November 2002, page 9.
   2. Integrated best practice model for medication management in residential aged care
       facilities, Australian Pharmaceutical Advisory Council, February 2000, page 13.

     
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