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1 JONA S Healthcare Law, Ethics, and Regulation / Volume 9, Number 4 / Copyright B 2007 Wolters Kluwer Health Lippincott Williams & Wilkins Development of a Standardized Medication Assistant Curriculum Nancy Spector, PhD, RN, NCSBN Mary Doherty, JD, RN Acrossthecountry, many nonnurses are administering medications to individuals in nonacute healthcare settings and in other settings where healthcare is not the primary focus (hereinafter, these will be referred to as nonacute settings). Because many states are using medication assistants in nonacute settings, the Boards of Nursing, in their mission to protect the public, became concerned about a lack of uniformity in the qualifications and training of these unlicensed assistive personnel. Therefore, the Member Boards of the National Council State Boards of Nursing (NCSBN)* passed a resolution asking NCSBN to conduct a job. *NCSBN is composed of 59 Member Boards of Nursing, including the 50 states, 4 territories, the District of Columbia, and 4 Practical Nursing Boards. analysis of medication assistants, develop a model curriculum, and explore the feasibility for administering a competency examination. At NCSBN s 2007 annual meeting, the information on the job analysis and feasibility study was presented, and the Member Boards adopted, through a majority vote, the model medication assistant curriculum. This article will discuss the development of that NCSBN model curriculum, thus enabling employers and regulators to understand how and why it was established and to learn about its recommendations. The National Council State Boards of Nursing took the position in their 2004 Model Nursing Practice Act and Model Administrative Rules, 1 Article XVIII, Chapter 18, that if jurisdictions use medication assistants, they should be regulated by Boards of Nursing. The NCSBN model practice act and rules termed the medication assistant who received and passed an approved training program and successfully completed a comprehensive examination, a medication assistant certified. Currently, 14 Boards of Nursing regulate medication assistants. This model curriculum will provide those Boards that do regulate medication assistants, as well as those that may in the future, with a resource for regulating and training medication assistants.... Background There are many sociocultural and health-related factors that... Author Affiliations: National Council of State Boards of Nursing (NCSBN), Chicago, Illinois. Corresponding author: Nancy Spector, PhD, RN, NCSBN, 111 E. Wacker, Suite 2900, Chicago, IL (nspector@ncsbn.org). JONA S Healthcare Law, Ethics, and Regulation / Volume 9, Number 4 / October December

2 have led to the need to change the healthcare workforce, thus prompting the emergence of the medication assistant in nonacute settings. Some of these factors include the shortage of nurses and other healthcare personnel; an aging population, as well as an aging healthcare workforce; and a steep increase in chronic conditions worldwide. Furthermore, more and more people are taking medications; Aspden et al 2 report that in the United States, 4 out of 5 adults take at least 1 medication or dietary supplement every day. Partially reflecting these trends, but also the need for more concerted efforts for preventing medical errors, the 2003 Institute of Medicine called for a need for a major overhaul of the education of health professionals. 3(p1) However, caution must be exercised whenever there is any overhaul that involves patient safety. Moreover, the changes should be based on the best available evidence and the outcomes should be continuously evaluated. To that end, NCSBN s Practice, Regulation, and Education Committee members worked very deliberately for more than 2 years in the development of the curriculum, designing it based on the available evidence. Furthermore, NCSBN will continue to monitor the literature and research related to the safety of utilizing medication assistants. The goal of this curriculum is to provide a document that is reflective of the current healthcare environment in states where medication assistants provide nursingrelated functions to individuals in nonacute settings. To achieve that, a job analysis that provided a description of current activities undertaken by these unlicensed healthcare workers, their preparation, and their demographics was conducted. 4 There were 1,288 respondents to this job analysis, and they were employed in a variety of nonacute settings, including the following types of facilities: long-term care, assisted living, rehabilitation, developmental, residential, home health, psychiatric, hospice, group home, hospital, communitybased, correctional, schools, and daycare (adult and child). The job analysis identified low and high frequency activities, as well as activities that were of low importance or high importance to their jobs. 4 These were all taken into account, along with the other available evidence, when developing the curriculum. Under most state and territory nurse practice acts, medication administration is the responsibility of licensed registered nurses and licensed practical/ vocational nurses. In those states that allow both delegation and medication assistants, licensed nurses can delegate certain tasks of medication administration to medication assistants. However, the licensed nurse remains accountable for the supervision of these unlicensed personnel. It is important to note that medication assistants are only responsible for a limited role in the comprehensive process of medication administration; that is, they deliver the medication to the individual, whereas the licensed nurse is responsible for delegation, supervision, conversion/calculations, judgment, and assessment (see Figure). That means that the Figure Visual representation of the role of medication assistants certified (MA-Cs). An illustration showing that the MA-C is only responsible for medication delivery, whereas the licensed nurse retains the responsibilities of supervision, delegation, conversion/calculation, judgment, and assessment. medication assistant cannot replace the licensed nurse s role in the administration of medications. The licensed nurse still must exercise judgment when delegating medication, such as: deciding when to give as needed medication; assessing the need for, or response to, medication; and educating the patients. There are other specific limitations to this medication assistant role, such as they are not allowed to administer parenteral medications or medications through nasogastric, gastrointestinal, or jejunostomy tubes. These limitations were all supported by the results from NCSBN s job analysis. 4 One very important aspect of incorporating the medication assistant role into nonacute settings is patient safety. Although there are not many observation studies available, Scott-Cawiezell et al 5 conducted a descriptive and exploratory study, using a naïve observation methodology, observing 39 healthcare providers, including registered nurses, licensed practical nurses, and medication assistants, as they delivered medication in nursing homes. Naïve observations allow the nurse observers to unobtrusively observe the medication delivery process without preconceived ideas about what should be administered. They defined error as a dose that was discrepant with the order. They also observed for (1) distractions, which were defined as events that did not stop the medication administration, but that could have diverted the medication administrator s attention, (2) and interruptions, defined as stopping the medication administration process. There were no significant differences between the groups for errors, although registered nurses had the highest percentage of interruptions and licensed practical nurses had the highest percentage of distractions. These authors have further data that confirm these 120 JONA S Healthcare Law, Ethics, and Regulation / Volume 9, Number 4 / October December 2007

3 findings (J. Scott-Cawiezell, personal communication, August 20, 2007), and there are similar studies being conducted elsewhere (H. Young, personal communication, July 7, 2006; P. Randolph, personal communication, August 8, 2007). The studies of error rates with medication assistants bear watching, although preliminary evidence shows that with proper training and supervision, medication assistants can safely deliver medication.... Development of the Curriculum After reviewing relevant materials from the various states and territories, including many different administrative agencies, it was clear to NCSBN s Practice, Regulation, and Education Committee members that there needs to be more uniformity in the regulation of the medication assistant. Currently, there are a number of different agencies that regulate medication assistants; they have various titles (at least 16 different titles were found); there is an array of training requirements (from 4 hours to well over 100); the extent of limitations in delivering various medications is diverse; and the healthcare settings where they are allowed are varied. To assure that the task of medication delivery is safely and competently performed, nurses must remain involved in the process, and Boards of Nursing should be the sole regulatory entity. 1 There should be consistency across jurisdictions as to the training and utilization of the medication assistant. In preparation for developing the medication assistant curriculum, the Practice, Regulation, and Education Committee members studied the results of NCSBN s medication assistant job analysis. 4 They also reviewed the literature and analyzed the following: Rules and regulations across all the states and territories regarding medication assistants Medication assistant curricula from various agencies Pharmacology texts National standards from organizations, such as the National Coordinating Council for Medication Error Reporting and Prevention, MEDMARX, National Quality Forum Endorsed Set of Safe Practices, and the Joint Commission Consultation with nursing experts in pharmacology The NCSBN model medication assistant curriculum 6 includes a preamble that explains the purpose and goals of the standardized curriculum and describes expectations on how the medication assistant role should be utilized. There is a section with relevant definitions, including a definition for the medication... y Medication Assistant Certified an individual who receives training for a role in administering medications (with the exception of parenteral routes and enteral routes through nasogastric, gastrostomy, or jejunostomy tubes) and who works under the supervision of a licensed nurse (modified from NCSBN 7 ). assistant certified, y and this is followed by suggested minimal admission requirements for the training program. The admission requirements were based on the committee members review of the NCSBN job analysis 4 and of the relevant materials from jurisdictions. When establishing the admission requirements, the committee members discussed at length the mission of Boards in protecting the public, thus the importance of educating a safe and competent healthcare worker, especially considering the number of injuries and deaths that result from medication errors. There was also discussion about the importance of establishing requirements that will provide medication assistants with the opportunity of being successful in their training programs and their roles of delivering medication. The minimal requirements recommended in the curriculum include the following: Able to read, speak, and write English Competent in basic math skills Earned high school diploma or successfully passed the general education development test Certified nursing assistant before beginning the program 18 years or older Cardiopulmonary resuscitation certification This curriculum recommends 60 hours of didactic training, which includes work in a skills laboratory and/or simulation facility, in addition to 40 hours of supervised clinical practicum. The committee members based this decision on a review of the medication assistant curricula that were provided and expert opinions from those who have taught these, or similar, courses. This is also in line with the NCSBN job analysis, 4 which found that, on average, the medication assistant received 50 hours of classroom training and 31 hours of clinical training. The elements of this standardized curriculum include the essential content, practical/actual experience, demonstration of skills, and a competency examination after successful completion of the modules. There are 5 modules, and their assigned times are recommended, based on review of other medication assistant curricula and the experiences of those teaching these classes. Content areas in the curriculum include the following: Medication Fundamentals (20 hours of didactic, including 4 hours of skills laboratory) Safety (7 hours of didactic, including 1 hour of skills laboratory) Communication and Documentation (8 hours of didactic, including 2 hours of skills laboratory) Medication Administration (20 hours of didactic, including 2 hours of skills laboratory) Ethical and Legal Issues (5 hours of didactic, including 1 hour of skills laboratory) Practicum (40 hours of supervised clinical practice) To effectively utilize medication assistants, there should be adequate education on delegation and JONA S Healthcare Law, Ethics, and Regulation / Volume 9, Number 4 / October December

4 supervision, both for the medication assistant and for the delegating nurse. Whereas the licensed nurse must learn about the effective execution of delegation and supervision, the medication assistant must understand what is involved in accepting the delegated task. Interestingly, NCSBN studies 8,9 have found that new nurses report that they are not adequately prepared in their nursing programs to delegate tasks to others. Li and Kenward 9 further found that when new nurses reported that they were not adequately prepared to delegate tasks to others, they had significantly more difficulty with their current client care assignments, thus indicating the importance of teaching appropriate delegation in nursing programs and in precepted experiences. The model curriculum includes references to the American Nurses Association and NCSBN Joint Statement on Delegation 10 and NCSBN s Working with Others position paper 7 for licensed nurses and medication assistants to use as sources for understanding delegation and supervision. Pivotal to the successful implementation of medication assistants delivering medications competently and safely is the development of a cooperative working relationship with all the healthcare providers involved in medication administration. Likewise, communication with and about the individual receiving the medication is a key component to safe medication administration. As is indicated in the Visual Representation of the Role of the Medication Assistant (Figure), the patient and patient safety are always the focus of medication administration. See Appendix 1 for the Medication Assistant- Certified Model Curriculum Quick Reference, which is available for instructors to assess whether students have mastered the major content areas of the curriculum. Successful completion of a final comprehensive examination, including content and performance of medication administration skills, is required for certification. Once certified, the medication assistant certified is minimally competent at an entry-level position to deliver medications to individuals, as described in the model curriculum, in settings as determined by state and federal laws and under the supervision of a licensed nurse.... Conclusion Across the United States, unlicensed personnel are administering medications in nonacute settings. Currently, there are no national standards on the training or expectations of these medication assistants, and there is wide variation as to their roles, their training, and even their titles. The National Council of State Boards of Nursing has developed, based on the available evidence, a curriculum and other standards that will provide for consistency with the training and functioning of medication assistants, to assist the Boards of Nursing in their mission of public protection. Appendix 1, Quick Reference to Medication Assistant Certified Curriculum, is available to the instructors for assessing whether students have mastered the major content of the curriculum. Since it can be printed double-sided, it is a handy 1-page tool for instructors to complete on each student. REFERENCES 1. NCSBN. Model nursing act and rules Accessed August 29, Aspden P, Wolcott JA, Bootman JL, Cronenwett LR, eds. Preventing Medication Errors: Quality Chasm Series. Washington, DC: The National Academies Press; Greiner AC, Knebel E. Health Professions Education: A Bridge to Quality. Washington, DC: The National Academies Press; Wendt A. NCSBN Research Brief: 2006 Job Analysis of Medication Assistants. Chicago: NCSBN; Scott-Cawiezell J, Pepper GA, Madsen RW, Petroski G, Vogelsmeier A, Zellmer D. Nursing home error and level of staff credentials. Clin Nurs Res. 2007;16(1): NCSBN. Medication Assistant-Certified Curriculum Accessed August 30, NCSBN. Working with others: a position paper Accessed July 31, Kenward K, Zhong E. Transition to Practice: Newly Licensed Registered Nurse (RN) and Licensed Practical/Vocational Nurse (LPN/VN) Activities. Chicago: NCSBN; Li S, Kenward K. A National Survey on Elements of Nursing Education. Chicago: NCSBN; ANA & NCSBN (2006). Joint Statement on Delegation. Accessed August 31, JONA S Healthcare Law, Ethics, and Regulation / Volume 9, Number 4 / October December 2007

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