To balance the complexity of the WAD and WAI, one needs an in‐depth understanding of the organization. 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. Most observations took place in the daytime shift and a few on the evening shift and opening hours of the night shift. 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. Performance variability in a system should aim to be proportional to the system complexity, meaning that the staff of the nursing homes should have appropriate skills, resources and flexibility at hand to meet any unforeseen events (Braithwaite, Wears, & Hollnagel, 2016; Grigg et al., 2011). The other nursing home ward, with six patients, was in a neighbouring urban municipality, with patients having multiple complex medical diagnoses and in need of palliative care. An example of analysis is shown in Table 1. The following research question guided the study: How can the nurse role during medication administration in nursing homes be described? We have more tasks and demands than ever. The researcher encountered no such situations. Shortly after finalizing the data collection, the authors read all the material multiple times to reach a common understanding of the data as a whole. 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. Safety Challenges in Nursing Homes: Medication Administration. It is highly structured and regulated by standards of nursing practice. The staff may perceive this as distant management and thus use considerable internal resources to structure their workday. At the same time, we need to keep tabs on everything; it always comes down to the economy, who pays for what. Medication administration in nursing homes is often considered a simple task of “passing medications.” However, in reality medication administration is a complex process requiring many interactions of specific decisions and actions (Kaushal et al., 2001). Although most residents are elderly, many are younger. A pilot study was conducted in a nursing home ward providing a similar contextual setting as the current study to test the data collection methods. We continuously receive new guidelines relating to medications, with new demands on documentation. Some shifts have only one nurse, and most administrative and medication‐related tasks will fall on that nurse. They describe it as working in silent agreement. Nursing homes have moved away from nebulizers such as Albuterol and Duonebs and switched to MDI devices for delivery of medication. When they did, it was not explicitly stated and was viewed by the others as expected behaviour. In cases where the doctor had strong opinions and openly discussed the patients with the nurses, they were included and empowered. At other times, the nurses make changes or adjustments themselves, based on observations and patient needs and inform the doctor on a later occasion. 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. The opposite happens if there are many substitute nurses; the continuity of care may be disrupted and a proportionally higher fraction of the total workload is taken on by the regular staff members. This proactive engagement seems to be due partly to the unpredictable nature of working in a complex healthcare system; the staff expected the unexpected. Some nurses thrive on this, making them feel competent and taking the role as leaders. Findings in the current study document this complexity and elaborate on how the staff and particularly the RN’s adjust to shifting circumstances in their work environment. Drug administration is the act in which a single dose of an identified drug is given to a patient. The coordination reform. Use the link below to share a full-text version of this article with your friends and colleagues. Medication aides can give regularly scheduled, non-injectable medications in Oklahoma's nursing homes, reports Barbara Acello, R.N. The researcher was aware of the potential Hawthorne effect throughout the observations. This article focuses on nurses' roles in medication administration. One nursing home ward with ten patients was rurally based and catered mostly to patients suffering from dementia and minor disabilities. 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. Nursing homes have certain federal regulations which they must follow related to medication administration, especially concerning psychotropic drugs. It may also lead to adverse patient outcomes in that the healthiest patients receive less attention and care. This was countered by a research team, discussing and reflecting on the data throughout the research process. Observations documented that when the doctor was uncertain, the nurses experienced more responsibility together with a feeling of uneasiness. In periods of high workload, the staff seems to work with great efficiency and they describe the work as going smoothly. The use of specially trained CNAs in nurs… Most often, they have a sheet of paper with pre‐authorization from the doctor on various drugs. The following research question guided the study: How can the nurse role during medication administration in nursing homes be described? According to WHO (2016), MAE’s are preventable at different levels. The senior managers of the participating nursing homes were contacted by telephone in December 2015. Everyday adaptations to cope with dynamic events can be described as performance variability, encompassing individual adaptations and how the surroundings react to them (Hollnagel, 2009, 2014 ). 2. One nurse (IRN‐C) said during observations that “when it is busy we prioritise medication to the patients most needing it.” At the same time, several stated that they like working when it is busy since it gives them a feeling of higher self‐worth. 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 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. That is not okay. Assigning the task of medication administration to the CMA allows for the nursing staff … Breaks in the medication administration chain may increase the risk of committing MAE’s and potential ADE’s (Carayon et al., 2014). The elderly and permanently disabled may reside in these facilities. In the current study, the nurse managers of both nursing homes “imagined” how the wards should be run (WAI), something that not always translated to how it was actually done (WAD). In our last article in our series of posts regarding overcoming safety challenges in nursing homes and assisted living facilities, we will explore the issue of improper medication administration. 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 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. If there are NA’s present, they are most often engaged in clinical work, close to the patient, reporting verbally to the nurse on the team. A substantial number of the tasks related to medication administration were delegated from the MD and could not be delegated to nurse assistants. Observations document that the nurses often regard themselves as being “the spoke of the wheel” and often define specific medication administration tasks as more important than other tasks. 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). Keeping up to date is an individual responsibility, IRN‐D Yeah…internal education, we have some of that. Consequently, they consider the nurses to be their superior in all settings, referring to them if questions or problems arise. Participants working more than a 50% position for more than a year were interviewed. 1. At the same time, all staff members acknowledge that complex healthcare environments and nursing sciences are in constant flux due to advances both medically and procedurally. In general, barriers in medication monitoring scored the strongest. In our previous post, we discussed how to prevent infections in these facilities, which … Available skills and competencies on a given shift are demarcated partly by the professions in the team. Consequently, some shifts end up being vulnerable. 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. In contrast, CNAs provide a majority of the day-to-day direct resident care. … The leadership and style of management seem to affect how the staff perform and delegate tasks. 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). In nursing homes, medication errors are one of the most common types of mistakes made by staff members. The nurse is responsible for determining the degree to which an individual is self-directive. The nurse in charge realises that there are no nurse set up on the next shift and that they have a patient suffering from pains hard to relieve. By identifying normal operations, one may learn, adapt and develop appropriate safety measures in the future. Over time, this may contribute to lowering the overall competence of the staff. 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). Nursing home administrators have worked hard to improve the quality of care provided to residents and to improve neglectful reputations earned by nursing homes in previous decades. 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. 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). The nurse role is compensating, flexible and adaptable. The interview guide was constructed in line with observational findings and from elements in the work system in Human Factors theory (Carayon et al., 2006). 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. The Administration of Medication in the Nursing Home In most nursing facilities, the medication is given when the nursing staff member completes what is known as a “med pass”. 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. Nursing facility residents have special care needs that in many cases require more intensive medication management and alternative forms of medication administration. Examples of additional tasks could be how the nurse offered to take on documentation tasks belonging to the doctor (transcribing), merely to ensure that this was done. Like one nurse said: IRN‐B “When it’s busy we are like well‐oiled machinery.” Another nurse stated that it is a balancing act. These categories reflect an intrinsic ability to confront and adjust to a dynamic and challenging workday. Flexibility mirrors the freedom staff members experience in structuring their workday and performing medication‐related activities. It gave me a lot of the basic skills necessary, but of course, there is a lot more responsibility as a nurse. Figure 1 illustrates the balancing act of safe medication administration documented in the study. This vulnerability was directly linked to the professions and competencies of the staff at work. 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. Method: A self-administered questionnaire was given to all participants (n = 763) at eight regional study days for nurses employed in independent nursing homes. Having good personal chemistry with colleagues was necessary for the staff to thrive. By law, an “advanced unlicensed assistive person” who has completed a certified training program can assist licensed nurses as permitted by … An important finding was how the leadership was distributed and invisible, leading to flexibility when delegating tasks and responsibilities. As a consequence, the staff may be balancing precariously close to unsafe medication administration in their daily routines without knowing. The first author, dressed in work attire, followed staff members around conducting partly participating observations during medication administration‐related tasks (Hammersley & Atkinson, 2007). An inductive content analysis was performed. 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. He does not take hasty or quick decisions and may sow doubt by the way he acts. 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. However, the basic principles of active treatment and ensuring the basic needs of the residents are universal (Malmedal, 2014). 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. Skip to content 800.437.6633 All participants gave their informed consent and were informed of data confidentiality and of the opportunity to withdraw at any time. 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. Such high workloads may have positive professional outcomes, as the staff claim to work more smoothly. People who reside in nursing homes are in vulnerable positions. They must undergo 50 hours of training and then engage in administering medication under the supervision of a nurse (Iowa Code § 135C.34). Before observations, the researcher informed all participants that professional ethics overrode researcher neutrality, meaning that the staff would be alerted if the researcher identified situations where patient harm could be averted (Guillemin & Gillam, 2004). 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. An earlier study exploring the nurse role during medication administration in nursing homes (Odberg et al., 2019), found that the staff members were seldom aware of the risk of ADE's. Long-term care nurses care for patients in need of extended care, including geriatric, wound care, chronic diseases and disabilities. These areas are on an individual level (Need for Competence and Shifting Responsibility), team level (Leadership and Available Competence) and organizational level (Staff Stability and The Vulnerable Shifts). 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). COVID-19 - Medication Administration Classes All in-person Regional Office Medication Administration classes have been canceled until further notice. 45389) approved the study. Many factors influence safe medication management. 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. There were eight staff nurses, three nurse assistants, two nurse managers and two doctors. The main category “adaptable” contains two related categories: Staff stability and Vulnerable shifts. This entails the staff forming ad hoc teams with a random team‐structure and performing many of the tasks of the regular nurse manager. H‰. Medication management is a strategy for engaging with patients and caregivers to create a complete and accurate medication list using the brown bag method. If you have the evening shift alongside a nurse, they have a higher workload, because a majority of the activity on this ward demands a nurse, because of competence and such. 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. Norwegian nursing home—A care facility or a home? 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. The nurse managers were in charge of the team composition on the individual shifts, distributing staff across the various shifts, weeks in advance. Primary health care in the Western World reaches out to a broad segment of the population and is the facet of the healthcare system with which most people interface. 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. One nurse manager described it in an interview as: Some shifts may experience staff lacking the competencies to administer certain medications. Everything has consequences if we are not thorough in following up. Recent reforms have led to increased collaboration between primary care and specialist health care. The data collection took place in 2016, consisting of 140 hr of observations supplemented by 16 semi‐structured interviews of staff members. Ask patient to identify himself/herself. Tasks in the workgroup on specific shifts are delegated differently in line with changing circumstances. 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). Many tasks during a shift are indirectly care‐related or related to medication administration; these are perceived as administrative tasks. 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). METHODS: 1. In coping with the provision of medicines around the clock, the staff knowingly bent guidelines and procedures to fit the reality of their work environment. Working well together depends on personality, and there are individual differences influencing cooperation. Sometimes these adaptations may lead to unsafe situations, but most often they will have a successful outcome (Hollnagel, 2009). 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. Work system factors such as competence, leadership and staffing may influence the ability to perform safe medication administration. 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. A lack of task redundancy often resulted in task vulnerability, and medications or treatments sometimes had to be postponed or were interrupted. 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