Examining Health Care Aide Utilization in Continuing Care ... · PDF fileWe also thank our...

Examining Health Care Aide Utilization in Continuing Care Facilities

with a Particular Focus on Medication Assistance

FINAL REPORT

AUGUST 22, 2016

COMPLETED BY: WORKFORCE RESEARCH & EVALUATION, AHS

Siegrid Deutschlander, Senior Research & Evaluation Consultant

Mubashir Aslam Arain, Senior Research & Evaluation Consultant

Mahnoush Rostami, Research & Evaluation Consultant

Esther Suter, Director

Funded by: Alberta Health

HCA Utilization in Continuing Care, August 2016

Project Team Members

CO-PIS

Esther Suter Director, Workforce Research & Evaluation, AHS

Siegrid Deutschlander Sr Research & Evaluation Consultant, Workforce Research & Evaluation, AHS

CO-INVESTIGATORS

Thorsten Duebel former Administrator, Kipnes Centre for Veterans, CapitalCare Mubashir Aslam Arain Sr Research & Evaluation Consultant, Workforce Research & Evaluation, AHS Mahnoush Rostami Research & Evaluation Consultant, Workforce Research & Evaluation, AHS Amanda Wilhelm former Research & Evaluation Consultant, Workforce Research & Evaluation,

AHS

ADVISORY COMMITTEE MEMBERS

Henry Dakurah former Workforce Analyst, Workforce Design, Alberta Health Nora Yaghi Manager, Quality Improvement, Continuing Care Branch, Alberta Health Kathryn Brandt Director, Practice Development, Seniors Health, AHS Lenora Carriere Senior Consultant, HCA Competency Development Program, Health Professions

Strategy and Practice, AHS Barbara Fredrich Director Chronic Care, Royal Park, Carewest Carol Henckel Director of Care, AgeCare Glenmore, AgeCare Reena Kelndorfer Acute Care & LTC Manager, Covenant Killam, Covenant Health Geraldine Clark Site Administrator, Covenant Killam, Covenant Health Aruna Mitra Senior Director, Clinical Operations, Bethany Care Society Karin van Goudoever Site Manager, Bethany Harvest Hills, Bethany Care Society

ACKNOWLEDGEMENTS

We thank management and staff for sharing their valuable time to speak with us about medication delivery at their site between June 2014 and March 2015. We are truly grateful for the insights and perspectives they shared with us. Staff and families face many challenges in continuing care. Caring for seniors is complex, and all sites have demonstrated that quality resident‐centered care can be achieved through collaboration and commitment. We also thank our advisory committee members for their insightful and invaluable contributions to this study.

i HCA Utilization in Continuing Care, August 2016

Table of Contents

Executive Summary ............................................................................................................................................................ 1

Key Messages .................................................................................................................................................................. 1

Project Description (March 2014 – June 2016) ............................................................................................................. 3

Objectives ........................................................................................................................................................................ 3

Workforce Research in Continuing Care ........................................................................................................................ 4

HCAs in the Alberta Context ....................................................................................................................................... 4

Optimizing Workforce Utilization in Long-term Care ............................................................................................. 4

The HCA Role in Medication Assistance ................................................................................................................... 5

Research Activities .............................................................................................................................................................. 6

Survey of Continuing Care Sites ....................................................................................................................................... 7

HCA Staffing ................................................................................................................................................................... 8

Other Healthcare Professionals .................................................................................................................................... 8

In-depth Analysis of Five Long-term Care Sites ........................................................................................................... 9

Staff Interviews ............................................................................................................................................................... 9

Medication Error Reports ............................................................................................................................................. 9

Resident Assessment Instrument (RAI) Data .......................................................................................................... 10

Research Questions .......................................................................................................................................................... 10

Question 1: What is the utilization of HCAs at continuing care facilities with particular focus on the role of HCAs in medication assistance? ...................................................................................................... 10

HCA Medication Assistance - Differences Between SL and LTC ..................................................................... 122

The Medication Delivery Process at the Five LTC Study Sites ............................................................................ 13

Staff Views: Strength and Concerns about the Medication Process .................................................................... 14

Staff Views: Medication Assistance as Part of the HCA Role ............................................................................... 15

Research Question 2: What is the impact of HCA medication assistance on staff utilization and resident safety in continuing care facilities? .................................................................................................... 166

Results from the Medication Error Reports ............................................................................................................. 16

Staff Views: Circumstances Leading to Medication Errors ................................................................................... 18

Staff Views: Resident Safety and Workforce Utilization ........................................................................................ 19

Resident Safety .......................................................................................................................................................... 19

Workforce Utilization .............................................................................................................................................. 19

ii HCA Utilization in Continuing Care, August 2016

Discussion of Findings ..................................................................................................................................................... 20

References .......................................................................................................................................................................... 22

Appendices A-B ................................................................................................................................................................ 24

Appendix A Tables 4, 6, 7, 8, 9, 10,12 ..................................................................................................................... 24

Appendix B Staff Questionnaire and Interview Guide .......................................................................................... 29

1 HCA Utilization in Continuing Care, August 2016

Executive Summary

This study provides a comprehensive understanding of Health Care Aide (HCA) utilization in continuing care. Using survey data from 130 continuing care sites, we highlight the current roles of HCAs at supportive living (SL=52) and long‐term care (LTC=64) sites with a particular focus on oral medication assistance. Our in‐depth analysis of five LTC sites gives a detailed description of medication administration and examines the impact of HCA medication assistance on resident safety at two of these sites where HCAs give oral medications. We show that HCA oral medication assistance in LTC is extremely rare and occurs at only three LTC sites in our sample. Our data indicate that HCAs do not pose a greater threat to resident safety than other providers handing out oral medications, even for complex residents. All sites have internal processes in place to address medication errors. While we suggest the following key messages, these results need further validation given our small sample of LTC sites.

KEY MESSAGES

HCA Education The majority of HCAs in Alberta continuing care are trained at educational institutions with the

government‐approved curriculum graduating with a HCA certification (81% HCAs). The certification comprises a range of competencies including oral and non‐oral medication assistance. This high number of certified HCAs is encouraging and shows a highly trained workforce.

HCA Utilization The utilization of HCAs appears to be greater at SL than at LTC sites based on the range of HCA

responsibilities in general and oral medication assistance in particular. Given that there is different HCA utilization between type of setting, not all HCA skills are

translated into practice. From a workforce utilization perspective, this implies unused resources for the healthcare system, loss of provider skills and knowledge, and less benefits to the residents.

Medication Errors

Based on error reports from two LTC sites, medication errors do occur but the overall incidence rate is fairly low (2.4‐3.1 errors per 10,000 medications for different providers). HCAs show a lower error rate than regulated nursing staff, and most of these are dose omissions.

HCAs can be involved in oral medication assistance in LTC if appropriate training, technology, and supports are in place.

Distractions in the medication process are seen as a major cause for medication errors. Opportunities to enhance the medication process overall through technology can reduce errors, for example by adding monitors for scanning multi‐medication packages or electronic charting.

Resident Safety While HCAs do not only have a relatively low error rate, they are also less likely to cause

moderate harm to the residents (the sites did not report any severe harm). These error‐related findings have emerged in the context of high resident complexity and total

care needs of most residents.

HCA Utilization in Continuing Care, August 2016 3

Workforce utilization refers to the organization and deployment of regulated and unregulated healthcare providers to optimize their collective ability to work to full scope of practice (Alberta Health Services 2012). Health care aide is the generic term utilized in this document to describe unregulated nursing providers assisting clients with personal support and basic health services in the health system in Alberta (based on Brandt 2014).

Oral medication assistance is a service provided to clients to ensure medication is taken as intended by the prescriber when the client is assessed as being unable to independently take his or her own medication safely (Brandt 2013).

Project Description (March2014 – June 2016)

In this mixed‐methods study, we examined workforce utilization with a particular focus on healthcare aide (HCA) roles in continuing care in Alberta. Workforce utilization has emerged as a critical issue given staff shortages and fiscal constraints. While we examined the role of HCAs overall, we had a particular interest in understanding whether and how HCAs are involved in medication delivery. In Alberta, the involvement of HCAs in medication delivery is referred to as medication assistance to indicate that HCAs do not make decisions about medication management (Brandt 2013). HCAs follow a clearly circumscribed process when handing out medications and are always supervised by regulated nursing providers. While medication assistance may refer to handing out any type of medications to residents, we are specifically interested in HCAs assisting with oral medications. Medication assistance by HCAs is a controversial topic involving patient safety concerns with medication errors and their potential harm to patients. Beside the human cost, medication errors amount to billions of dollars for the healthcare system annually.

The WRE project team conducted this study between March 2014 and June 2016. Prior to starting data collection, we obtained ethics approval from the Conjoint Health Research Ethics Board (CHREB), University of Calgary.

OBJECTIVES

1. To gather data on HCA education and utilization across continuing care sites.

2. To understand the medication management process at five long‐term care sites with a focus on the roles of HCAs in medication assistance.

3. To identify the strengths and challenges of the medication

management process in addressing medication errors and mitigating future errors.

4. To compare HCA utilization between SL and LTC sites.

5. To examine how HCAs assisting with medications affect resident safety and workforce utilization.


Competency refers to the “specific knowledge, behavior, attitudes and skills required by workers to effectively and successfully fulfill the requirements of a specific job description.” Certified HCA: certificate obtained from a Government of Alberta licensed post-secondary institution using the provincial HCA curriculum. Substantially Equivalent: an educational background deemed equivalent to the approved provincial HCA curriculum. Deemed competent: assessed as competent using the provincial Competency Assessment Profile (CAP) tool. (All definitions based on Fact Sheet, HCA Competency Development Committee, AHS, no date).

Workforce Research in Continuing Care

HCAS IN THE ALBERTA CONTEXT

HCAs are unregulated direct care providers working across the continuum of care (Hewko et al. 2015) also known as personal care attendants, resident care workers, nursing aides and others. HCAs are a valued and major component of the workforce in all three subsectors of continuing care (e.g., home living, supportive living and facility‐based living) in Alberta. As a member of the team, they provide physical and emotional support for clients with medical conditions or major functional limitations under the supervision of regulated nursing staff or other health professionals. The range of care depends on the patient population, care setting, knowledge and skills of individual HCAs, legislation and policy (in Brandt 2014). HCAs may be recent newcomers to Canada with varying levels of skills and qualifications from their countries of origin. Some have been trained internationally as healthcare workers, in particular RNs, but did not complete the training requirements for these roles in Canada. In Alberta, HCAs are classified in one of three competency statuses including certified, substantially equivalent and deemed competent (see sidebar). Their status depends on whether they completed the government‐approved curriculum comprising the competencies as outlined in the HCA Competency profile (Alberta Health & Wellness 2001; under revision). Alberta appears to be the only province in Canada where HCAs have a competency profile guiding their practice in patient care. An environmental scan on Canadian educational standards for HCAs reported that the vast majority of private institutions and all public colleges in Alberta follow the Government of Alberta Health Care Aide Provincial Prototype Curriculum (HCA‐PPC) from 2005 with all 37 modules (2012). The certification includes various core competencies with medication assistance as one of them.

OPTIMIZING WORKFORCE UTILIZATION IN LONG-TERM CARE

Four recent studies have highlighted workforce utilization issues including HCAs in continuing care in Alberta (Alberta Continuing Care Association 2012, Strain et al. 2011, Cummings et al. 2013, Suter et al. 2013). ACCA has predicted significant shortages of LPNs, RNs and HCAs for 2015 in this subsector while it is a high priority area of special need. HCAs have low job satisfaction as their skills and training are not fully utilized. It recommended aligning educational practicums with continuing care workforce priorities and needs (ACCA 2012). In a comprehensive study on 59 supportive living (SL) and 54 long‐term care (LTC) sites, Strain et al. outlined the need for changes to staff roles as “frequently related to challenges of multi‐skilling and working to full scope of practice” (2011:145). The changing role of the RN toward increased care management and leadership responsibilities and the complex care needs of the residents require a fresh look at the roles of other providers. In 2013, the WRE research team completed a study on workforce utilization in continuing care in Alberta (Suter et al. 2013). The authors pointed to differences in staff utilization, in particular of HCAs, as one of the top two issues:


There were notable differences in the HCA roles and responsibilities in the three facilities studied, with HCAs having restricted roles in the LTC facilities as compared to the supportive living facility. Although a standard provincial HCA curriculum has existed since 2005, there is wide disparity of education levels (provincial curriculum vs. equivalent training vs. practice experience) and competency levels among HCAs currently employed in continuing care. Organizations have different internal hiring standards, which may lead to confusion [about] the expectations of HCAs and their roles (Suter et al. 2013).

Shining a Light is a study that specifically focused on the complexity and diversity of the HCA workforce in Alberta (Cummings et al. 2013). The authors reported on the increased demand for highly qualified HCAs given that “HCAs are viewed as least prepared (lowest skill set, least education) workers caring for the most complex patients” (2013: 70). Cummings and colleagues commented on the various levels of HCA curricula and lack of a standardized education approach to HCA training (2013). Appropriate workforce utilization can have many benefits for patients, providers and the system. Researchers have argued that HCA involvement in oral medication assistance in LTC could improve the utilization of HCAs and optimize the use of other health human resources (Hussein & Manthorpe 2005; Pan‐Canadian Planning Committee 2009; Stone et al. 2004; Stone & Harahan 2010). Involving non‐regulated health care providers in the care process can also be a cost‐effective choice (MetLife 2010).

THE HCA ROLE IN MEDICATION ASSISTANCE

Medication delivery is seen as a high‐risk area in all healthcare sectors due to the potentially serious consequences of medication errors for the clients. It tends to be the responsibility of regulated nursing staff (RNs and LPNs) as part of their scope of practice, in particular prescribed oral medications. Medication delivery implies that nurses make decisions and assessments about the clients when giving medications. By comparison, medication assistance by HCAs occurs under close supervision of regulated nurses without any decision‐making by HCAs. As outlined by several provincially developed documents (Alberta Provincial Continuing Care Medication Assistance Manual 2014; HCA Role in Medication Assistance 2013; HCA Provincial Curriculum, Lab and Practicum Skills Checklist 2012), medication assistance comprises a range of oral and non‐oral medications:

Table 1 HCA Medication Assistance HCAs are allowed to assist with HCA are not allowed to assist with

Oral medications Topical medications (lotions, creams, ointments) Ophthalmic medications (eye drops and

ointments) Nasal medications (sprays, drops), Otic medications (ear drops) Inhaled medications Rectal suppositories é fleet enemas Transdermal patches

High‐risk medications Medications where assessment is needed prior

to administering Un‐packaged medications Medications for unstable residents Injectable medications

A Medication error is 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 (National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP), 2012).


It might be a safety risk to have HCAs assist with meds given the population, esp. with dementia. They aren’t necessarily able to say who they are or that they understand the medication. (Manager)

While HCAs obtain medication assistance competencies, the employer ultimately decides whether to involve HCAs in any medication delivery. This decision tends to be based on HCA qualification and resident complexity. If HCAs are involved, they assist with routine, regularly scheduled oral medications in multi‐dose packages to stable residents. Cummings and colleagues mentioned “medication delivery” as one of many tasks of HCAs but did not specify the setting or the type of medications (2013). Strain and colleagues mentioned all three nursing groups (RNs, LPNs, HCAs) being involved in medication administration (2011). Out of 113 DAL and LTC sites, HCAs were part of medication delivery at 87% of these. While not specifying which setting, some of these sites must have been LTC sites since their sample only included 52% DAL sites. Strain and colleagues did not clarify the type of medications HCAs gave at these but stated that “39% of the [DAL] facility representatives reported that only [HCAs] administered medications” (2011: 143). They recommended further research on the role and medication training of unregulated staff at DAL and LTC sites. The various authors also use medication delivery more broadly than we do by including non‐oral medications (e.g., creams, oitments, suppositories) as part of medication delivery. When focusing on oral medications only, the number of sites where HCAs give these becomes much smaller. Some researchers suggested that involving unregulated providers in medication assistance may result in more medication errors, potentially jeopardizing the health of residents (Woods et al. 2010). Other evidence suggested that assistive personnel like HCAs do not make more mistakes related to medications than professional nursing staff (Scott‐Cawiezell et al. 2007; Young et al. 2008; Zimmerman et al. 2011). Young et al. showed that in 12 assisted living facilities, medication errors by assistive personnel were most commonly related to their timing (i.e., medications given more than one hour before or after the scheduled time; 2008). Medication errors related to time (i.e., given at the wrong time) were more about policies, staffing levels and processes at the facility than about the skills or knowledge of the individuals administering the medications, thus time errors could occur with any staff giving medications (Young et al. 2008; Scott‐Cazwiezell et al. 2007). A lack of consistency in delegating medication assistance to HCAs and unclear processes around medication management were also seen a risk factor for increased medication errors (Budden 2012; Mitty 2009). This study further examines HCA utilization with a particular focus on the role of HCAs in medication assistance.

Research Activities

We surveyed 319 continuing care facilities associated with AHS. The survey collected information on site context, staffing, HCA utilization and service delivery. Five long‐term care sites were part of the in‐depth study. In these five sites, we collected additional information through staff interviews and we reviewed RAI data and medication error reports where possible. This information helped us better understand the medication process at these sites, HCA involvement in medication assistance and potential safety concerns, and complexity of the residents. Table 2 below summarizes all project activities.


Table 2 Research Activities

Survey of 319 continuing care sites affiliated with AHS; 130 completed questionnaires (40% return)

In‐depth study of 5 LTC sites

Data collected Site A Site B Site C Site D Site E

Medication error reports

Yes Yes No No No

RAI data Yes Yes Yes Yes Yes

Staff interviews 14 16 8 19 19

Project Management Activities

Literature search We searched for HCAs and medication assistance using synonyms for HCAs, continuing care, and medication administration.

Research team meetings

The members of the research team met regularly to discuss their analysis and findings toplan next steps over the last 2 years.

Advisory Committee meetings

The AC met monthly during the first year of the project. When the research team conducted the data collection, the regular meetings with the AC were discontinued. The project co‐lead provided written updates via email to keep the AC informed of the progress.

Knowledge Translation Activities

A. Presentations at Conferences Canadian Association of Gerontologists 2014 (Oct 16‐18): Exploring HCA Medication Assistance in Alberta;

HCA Utilization in Alberta. Canadian Association of Gerontologists 2015 (Oct 23‐25): HCA Utilization and their Perceptions of

Medication Assistance in LTC in Alberta; Safe Medication Delivery: The Role of HCAs in LTC facilities. B. Presentations Other Online Presentations to stakeholders in Continuing Care: Safe Medication Delivery in Long‐term Care: The Role of Healthcare Aides in Medication Assistance

January 28, 2016 to the Provincial Medication Management Committee February 18, 2016 at Practice‐Wise (internal AHS informative 1‐hr lunch session) March 15, 2016 to the LTC Collaborative Working Group

We were also invited by other stakeholders (Covenant Health, Supportive Living Working Group) to present in the Fall 2016. C. Publications: Arain MA, Deutschlander S, Rostami M, Suter E. 2015. Should healthcare aides be involved in

medication assistance in long‐term care? Gerontology & Geriatric Medicine, Vol 2: 1‐6. 2 manuscripts are in progress (1 on the perceptions of staff on HCA medication assistance; 1 on the

survey results with a focus on workforce utilization).

Survey of Continuing Care Sites With the endorsement of the five zonal Seniors Health Executive Directors, the WRE study team distributed a questionnaire (Appendix B, p. 29) to management of continuing care sites affiliated with AHS. The questionnaire asked for: Site context and staffing (type of services, bed count, public/private ownership, staff numbers

and full‐time equivalents (FTEs))


HCA training and responsibilities (HCA competency status, type of responsibilities, medication involvement, concerns about medication delivery)

Service delivery and resident care (collaborative activities, workforce utilization) Table 3 below shows the survey responses from LTC and SL sites across the five zones with a response rate of 40% (130 out of 319). Nearly half of the respondents were at LTC sites (49%), 41% at SL sites and 10% at sites offering both types of services. We analyzed survey responses in SPSS version 19.

Table 3 Survey Response by Zone Types of Sites North Edmonton Central Calgary South Unknown* Total

LTC (%) 7 (10.9) 18 (28.1) 10 (15.6) 18 (28.1) 9 (14.1) 2 (3.1) 64

SL (%) 6 (11.3) 17 (32.1) 11 (20.8) 6 (11.3) 10 (18.9) 3 (5.7) 53

LTC and SL (%) 1 (7.7) 2 (15.4) 3 (23.1) 4 (30.8) 3 (23.1) 0 13

All sites (%) 14 (10.8) 37 (28.5) 24 (18.5) 28 (21.5) 22 (16.9) 5 (3.8) 130

*Fax transmission provided incomplete sender information

HCA STAFFING

Our survey results showed that HCAs were a significant part of the workforce in continuing care (Appendix A, Table 4, p. 24). On average, 60 HCAs worked at continuing care sites including full‐time, part‐time and casual positions. The HCAs workforce comprised mainly certified HCAs (81%) as compared to substantially equivalent or deemed competent HCAs (9.5% each) (Figure 1 below). We did not find a statistically significant difference in certified HCAs between SL and LTC sites (about 79% at each type of setting; we excluded combined SL and LTC sites from this comparison). Figure 1 Competency Status of HCAs

OTHER HEALTHCARE PROFESSIONALS

The other nursing staff comprised on average 6 LPNs and 5 RNs per site but sites tended to have a large range in staff (Appendix A, Table 4, p. 24). This likely corresponds to the large range in bed count across sites and the required onsite presence for RNs at LTC sites 24/7. There was a greater site presence of management staff including care managers and administrators rather than nurse practitioners, clinical educators or care coordinators. Among the allied health staff, we found higher average FTEs for recreational therapy aide/assistants (1.5 FTE) and recreational therapists (0.7 FTE), for occupational therapy/assistants (0.9 FTE) and occupational therapist (0.5 FTE) than other allied health staff. It is also

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noteworthy that volunteers can give significant resident support to continuing care sites with their numbers adding up to 242 (average 6 volunteers). The managers at the sites told us that staffing arrangements respond to the care and safety needs of their residents while also considering current funding constraints. LTC sites required at least one RN on duty at all times. The RNs were in charge of patient assessments, determining resident status, care planning, interventions and care evaluation. Sites tended to increase staffing at specific times when the workload is particularly heavy. For example, more staff was needed in the mornings for getting the residents ready for breakfast, bathing and taking their medications. Therefore, management maximized staff under the current funding model to optimize patient care.

In-depth Analysis of Five Long-term Care Sites

We conducted an in‐depth analysis of five LTC sites. This included three sites where HCAs assisted with oral medications. Table 5 below shows the five sites with sites A, B and C engaging their HCAs in oral medication assistance.

Table 5 Study Site Information Site Ownership/Location Location Bed Count

Site A Publicly owned and operated, Edmonton Zone Urban 120 beds (60 secure beds)

Site B Publicly owned and operated, Central Zone Rural 44 secure beds (1 palliative care bed)

Site C Private for‐profit, Calgary Zone Urban 215 beds

Site D Publicly owned and operated, Calgary Zone Urban 50 beds

Site E Private not‐for‐profit, Calgary Zone Urban 60 secure beds

STAFF INTERVIEWS

At these five sites, we collected qualitative information on HCA utilization in staff interviews (face‐to‐face/telephone, up to 1 hour long) (Appendix B, Interview Guide, p. 40). We interviewed 28 HCAs and 48 other staff about various aspects of the medication process and medication assistance as part of the HCA role. The interviews were held with all three types of nursing providers (RNs, LPNs, HCAs), pharmacists, practice leads, safety coordinators and managers (site administrators and care managers). We analyzed the open‐ended responses in NVivo10.

MEDICATION ERROR REPORTS

We approached the five LTC study sites for their medication error reports to examine the nature of errors, especially as related to the staff professions. We received reports from three sites for errors reported over 16 months (October 2012 to January 2014). One site did not report on the staff professions and thus we omitted this report from our analysis. Site managers compiled the reports based on self‐reported medication incidents by nursing staff. They provided information about the errors including date, time, profession making the error, type of error, and the severity of harm. Severity of harm was classified as “no apparent harm”, “minimal harm”, “moderate harm”, “severe harm” and “death” (for definitions Appendix A, Table 12, p. 27). We statistically analyzed the reports to calculate the incidence rate of errors and severity of harm related to HCAs and other health professions.


RESIDENT ASSESSMENT INSTRUMENT (RAI) DATA

We also examined resident composition and health conditions of the residents at the five sites using their RAI data. From the RAI data, we pulled demographic data (age, gender) and various outcomes scales and Quality Indicators from October 2014 to July 2015. RAI indicators are validated measures originally designed for care planning that can also be used for research purposes. We used the RAI data to create a profile of the residents based on their most recent RAI assessment. The profile included number of medications, number of days residents receive injections, pain scores, ADL scores, CPS scores, PURS stages, ISE scores, short‐term/long‐term memory loss, indicators on depression, peptic ulcers, incontinence, falls, antipsychotic medication, and chemical restraints. We analyzed the RAI data to show whether there were differences between the health status of the residents at the LTC sites with HCA oral medication assistance and the two other LTC sites. On most RAI indicators, the residents were similar in characteristics (Appendix A, Table 6, p. 25). On the following indicators, the residents were more complex at sites where HCAs assisted with oral medications (significance p<0.01): Older seniors (average 87 years) Lower social engagement (ISE) Higher end‐stage disease scale (CHESS) Higher percentage of seniors with depression

Staff at the sites told us that, with a few exceptions, their residents were dependent on individualized total care. Caring for dependent residents, many of them immobile, is physically demanding and time‐consuming since transfers often require two staff members. Three‐quarters or more of the residents had short‐term or long‐term memory loss (Appendix A, Table 6, p. 25). Besides a greater need for assistance with ADLs, residents with cognitive decline and functional impairments are unable to communicate and their behaviours must be managed. According to staff, the majority of the residents at our study sites also needed extra care and attention (e.g., urethral catheterization, wound care, feeding tubes, and addressing seizures). Our tentative conclusion based on this small number of sites is that the residents at LTC sites with HCA medication assistance were equally, if not more complex on some of the characteristics than residents at other LTC sites. Thus, the complexity of residents may not be a barrier to involving HCAs in medications.

Research Questions

QUESTION 1: WHAT IS THE UTILIZATION OF HCAS AT CONTINUING CARE FACILITIES

WITH PARTICULAR FOCUS ON THE ROLE OF HCAS IN MEDICATION ASSISTANCE? Based on the survey, we found statistically significant differences in the way HCAs are utilized in LTC versus SL sites, as well as in public versus private sites. Based on the data from 52 SL sites and 64 LTC sites, we found that HCA do significantly more of the following tasks at SL compared to LTC sites (p<0.01) (Appendix A, Table 7, p. 26):


Meal preparation (39% versus 6%) Housekeeping (60% versus 13%) Laundry services (73% versus 20%) Charting in resident charts (90% versus 63%) Assisting with therapy activities (67% versus 41%)

Equally common at both types of sites are support with ADLs, tick charting, assisting with recreational activities and taking vital signs. Significantly more respondents viewed HCAs as fully utilized in SL than LTC (91% versus 55%, respectively). We also found some statistically significant differences across the LTC sites when dividing these into private (combining for‐profit and not‐for‐profit) and publicly owned and operated sites (Appendix A, Table 8, p. 26). Specifically, HCAs do more of the following tasks at public than at private LTC sites (p<0.01): Housekeeping (23% versus 0%) Laundry services (31% versus 7%) Charting in resident charts (91% versus 28%) Doing vital signs (77% versus 38%) Assisting with recreation activities (80% versus 35%)

Equally common at both types of sites are support with ADLs, tick charting, assisting with therapy activities, and preparing meals, and medication assistance. More than 50% of respondents viewed HCAs as fully utilized at private and public LTC sites. The HCAs at our five study sites were typically assigned 7‐10 residents on their shift and support residents in all ADLs. Staff tended to work in teams with at least two HCAs in each team to facilitate lifting and transferring patients and answering call bells in the morning. HCAs work in pairs to bath residents and some sites have permanent bath teams. Assisting with respiratory equipment (e.g., filling oxygen tanks) and simple wound care are also part of their duties. HCAs were expected to assist nurses with changing dressings or catheters. Furthermore, they answered resident calls for assistance, communicate with them and ensure their safety and comfort. HCAs also take regular measurements including weight, blood pressure, temperature, oxygen levels, respiration rate and pulse and they collect samples for testing. At two sites, they also do housekeeping. Since HCAs are closely involved with resident care, they offer valuable observations about resident health conditions and behaviors. Two study sites have adopted Point of Care (POC) charting for more immediate and standardized reporting at computer stations throughout the units. This electronic system allows HCAs to choose between multiple responses for each activity. This information also feeds into the RAI assessments carried out by the nurses. While tick charting with checklists is more common across sites, more extensive charting would allow HCAs to document their observations and insights. At LTC sites, mandatory training in narrative charting was offered at 64% private LTC sites to HCAs as compared to 36% HCAs at public sites (statistically significant p<0.01). This result is surprising given that significantly more public LTC sites involve their HCAs in charting in resident charts (=narrative charting).


HCA MEDICATION ASSISTANCE - DIFFERENCES BETWEEN SL AND LTC

One major focus of the questionnaire was on medication assistance by HCAs. We asked specific questions about types of medications given, training in medication assistance, concerns about patient safety, and other. We examined medication assistance by type of site including LTC versus SL, and public versus private LTC. The results for public versus private LTC sites only differed significantly in assistance with eye/ear/nasal drops occurring in more public LTC sites (Appendix A, Table 9, p. 26). Otherwise, medication assistance did not differ between public and private LTC sites. By contrast, the survey results showed statistically distinct differences in medication assistance at SL versus LTC sites (Appendix A, Table 10, p. 27). Specifically, HCAs give more of the following medications at SL sites than at LTC sites (p<0.01): Inhaled (79% versus 6%) Oral (83% versus 6%) Eye/ear/nose (81% versus 19%) Vaginal (36% versus 2%) Patches (77% versus 8%)

HCAs applying topical creams were equally common at both types of sites while rectal suppositories were more often given by HCAs at LTC sites than at SL sites (90% versus 72%). The two sets of bar graphs below (Figures 2 and 3) illustrate the differences in all medication assistance versus oral medications only between SL and LTC sites. Figure 2 on the left shows the results to the general question: Do HCAs give medications at your site? These results tell us that HCAs at SL sites more commonly assist with medications than HCAs at LTC sites. The medications at SL sites include all types of medications as listed above. Figure 2 HCA Medication Assistance Figure 3 HCA Oral Medication Assistance

The left set of graphs also shows that HCA medication assistance in SL is a common practice, with only a few SL sites noting that HCAs were not involved. In LTC, almost half of the sites reported that HCAs were involved in some form of medication assistance. This result was somewhat surprising and may be


reflective of the broad definition of “medication” that respondents used likely including non‐oral medications. Figure 3 on the right focuses on HCAs assisting with oral medications and a pronounced difference between SL and LTC is visible. The data show that at only 3 LTC sites HCAs give oral medications whereas this practice is much more widespread in SL sites. These three sites are included in our in‐depth study. The results are not surprising and they confirm what we assumed ‐‐ that HCAs assisting with oral medication in LTC is rare. Hence, mandatory medication training is much more common at SL sites (Appendix A, Table 10, p. 27). At all five sites, HCAs give suppositories and fleet enemas and they provide routine skin care with topical creams and ointments to residents under supervision of regulated providers. HCAs often delegate the suppositories fleet/enema (glycerin suppository) to the night shift for residents who do not respond to the oral laxatives. They apply the topical skin creams / lotions to the affected areas before dressing residents in the morning shift; they apply oral hygiene rinses (chlorhexidine mouthwash) generally under the guidance and supervision of nurses. HCAs at two sites also assist with ophthalmic, nasal, otic and inhaled medications and they remove transdermal patches like pain or smoking cessation patches under nurse supervision. At one site, HCAs assist with eye drops.

THE MEDICATION DELIVERY PROCESS AT THE FIVE LTC STUDY SITES

Nursing staff across the five LTC sites described a similar medication process with some minor variations and the HCA role being essentially the same. The RNs, best practice leads, and physicians and clinical pharmacists collaborated closely to develop and improve the medication management for each resident to reduce medication interactions and side effects. Physicians prescribed medication orders (on‐site and off‐site) that the RNs subsequently processed and kept as paper records in the resident chart. They then entered all medications into each resident Medication Administration Record (MAR) guiding the nursing providers in their medication administration. After receiving the electronic medication request from the RN, the off‐site pharmacist entered the orders into their information system to verify them and flag any medication interactions or clinical alerts. These pharmacies tended to deliver to continuing care sites only without medication services to the public. At all five sites, the routine oral medications were dispensed in multi‐dose pouches by delivery time for the weekly supply of medications to the sites (unless urgent changes to medications were required). Each sealed PacMed pouch was clearly labeled with resident name and delivery time as well as number, shape, and color of the content. For each resident, the pharmacy delivered a weekly roll of sealed pouches. As a further control, a pharmacist did manual checks of the pouches before they left the pharmacy. All nursing staff had to follow the “7 Rights” as a check to ensure safe medication delivery: right medication, right dose, right client, right route, right time and frequency, right documentation, and right reason. The RNs checked and placed the pouches of oral medications in locked drawers or locked boxes the night before in preparation for the nursing staff to dispense the next day. Each box had a photo of the resident to prevent mix‐ups. After cutting open the pouch (the top is disposed securely in a separate disposal bin for shredding), nursing staff might prepare medications (e.g., crushing them and mixing them with fluids or sauces) in medication cups on top of the cart. After giving all medications and watching the resident swallow them (some residents try to dispose of them in imaginative ways), staff signed the MAR to indicate that the medication pass for that resident was complete. Nursing staff then moved to the next resident. Some residents may refuse taking the medications. In these cases, the

This study shows that HCAs assist with oral medications at 3 long-term care sites in Alberta.


nursing staff must approach residents three times before documenting “refused medication” in the MAR. At three sites, the HCAs closely followed the same process as the other nursing staff with the pre‐packaged oral medications. One site involved HCAs in medication delivery starting in 2008, followed by another site in 2010 and the third one in 2011. HCAs did not know what the individual pills were for but they did know that medication errors were serious. HCAs checked the packages for the right number, colour, shape, name and time as well as the resident information. Pre‐packaged medication given by HCAs comprised nutritional supplements (vitamins, calcium) as well as other key medications (antihypertensive, antipsychotics, antidepressants, and medicine for diabetes and pain). If given to the wrong resident, any of these medications can have serious consequences. HCAs did not give any unpackaged medications. Also, they did not assist with medications to unstable and acutely sick residents or those requiring assessments prior to getting their medications. Staff noted some variations across the five sites: While staff at four sites gave medications 3 to 5 times daily, staff from one site changed

medication times from 4 to 2 times daily to reduce the workload for staff. This required switching to long‐acting (sustained release) medications in consultation with pharmacists and physicians.

Two sites did not have proper medication carts, they used utility carts instead and installed a locked box for the medications on top of the cart.

Two sites reduced the number of medications to spend less time on medication delivery (especially important for residents with dementia).

At four sites, staff handed out medications during meal times in the dining area. One site wanted to provide a more satisfying and exclusive dining experience without interruptions. Thus, medications were given in resident rooms outside of the meals.

Two sites planned to support their staff with eMAR technology (e.g., monitors to scan the barcode on the packages). This monitoring system increases safety by reducing medication errors and omissions.

One site used to involve LPNs and HCAs in medication delivery without any RN involvement. Due to reductions in HCA staffing and perceived high medication error rates, only regulated nursing providers were subsequently involved with medication delivery.

STAFF VIEWS: STRENGTH AND CONCERNS ABOUT THE MEDICATION PROCESS

Staff shared their perceptions on the safety of the current medication process at their site. Most staff saw a number of strengths in the medication process, especially where HCAs assisted with medications. The HCAs expressed that they were well‐trained to assist with oral medications (e.g., exams and observations on medication passes, regular meeting with the best practice leads, recertification training) and that they could always approach the nurses for questions and support. While all HCAs were trained for oral medication assistance at the three sites, not all HCAs give medications on a regular basis. At one site, only two HCAs handed out oral medications and both were internationally trained RNs. While that did not apply to all three sites, there appeared to be a preference to assign medication assistance to specific HCAs based on their qualifications and experience. All five sites had adopted measures to increase medication safety including training, automated medication dispensing (multi‐packs), regular meetings with best practice leads and safety checks. The 1‐2 hours flexibility to give the medications appeared to be sufficient. HCAs at one site emphasized that consistency and routine were important for medication assistance. Furthermore, that they needed to know the residents, their medications, and


I feel it adds to my job in a good way, I am actually trained to do something else than dress someone. (HCA)

Some residents are a challenge and they choose the person they like [for medications]. (HCA)

their MARs as otherwise the medication pass will take longer and may lead to medication mistakes. Other staff and managers had a few concerns about HCA medication assistance. Some staff were not convinced that the medication training prepared HCAs sufficiently to think critically about any issues with the residents when giving the medications. HCAs generally did not know what a specific medication was for, and some HCAs saw an advantage to understanding them better (also to better answer questions from the residents). Some staff suspected that HCAs were not always willing to bring forward issues or questions arising for them. They suspect that medication errors were under‐reported due to fear of reporting or poor communication. Even if they did, the nurses were not always available to answer questions and supervise the HCAs given their own workload. According to staff, some nurses also lacked the supervision and leadership skills to support the HCAs.

STAFF VIEWS: MEDICATION ASSISTANCE AS PART OF THE HCA ROLE

We also wanted to find out whether medication assistance would add value to the work of the HCAs at the five sites. Most of them were certified and also received additional medication training at their site if part of their role. Almost all of them said that after overcoming their initial discomfort and anxiety, medication assistance had become part of their daily routine and they were comfortable doing it. Most of the HCAs found medication assistance rewarding in that it allowed them to more fully use their knowledge and skills. Almost all HCAs who assisted with medications at Sites A, B, and C expressed that they worked to their full potential utilizing all their learned skills.

Other HCAs at these three sites did not see it as adding to their role in providing care to the residents but rather taking away from “being on the floor focusing on resident care”. Even after many years, these HCAs did not like the responsibility of giving medications and still think of medication delivery as belonging to the nurses’ job. The HCAs not assisting with medications at the two other sites told us that they would have a hard time handing out medications. It appeared to them as an overwhelming responsibility since they have not received post‐secondary or on‐site medication training. Some of them were previously asked by nurses to help with oral medications for residents who were un‐cooperative. In these cases, a nurse would

unsuccessfully approach residents with medications and had to ask the HCA to hand over the medications while they stood by. While some HCAs were satisfied with this level of involvement in medication assistance, others would like to take it on more fully. While the HCAs welcomed assisting with medications, they had concerns about the heavy workload, especially in times of short‐staffing or when working with more inexperienced staff who also need their attention. HCAs on the day shift start with a heavy workload in the morning. Medication assistance is time‐consuming, in particular when giving them to residents in their rooms or when the residents are un‐cooperative. They worried about potential errors and causing harm to the residents. Some HCAs suggested hiring more HCAs to be on the floor at all times and sharing ADL care with the LPNs if they were to take on more tasks.

My job is all about heart and soul, it is not about meds; it is about the care and compassion I give. I think LPNs can do the medication, that’s their job. Why not let me have that extra time to give to the resident without having the stress in my brain about whether I’m giving the right meds. (HCA)


RESEARCH QUESTION 2: WHAT IS THE IMPACT OF HCA MEDICATION ASSISTANCE ON

STAFF UTILIZATION AND RESIDENT SAFETY IN CONTINUING CARE FACILITIES?

We answered this research question by analysing site‐specific medication error reports and staff perceptions on patient safety and workforce utilization from our survey and interviews. Our survey results showed that about 27% of respondents at LTC and 15% of respondents at SL reported concerns about patient safety in the medication process (not statistically significant) (Appendix A, Table 10, p. 27). Staff and managers at the sites expressed concern about medication errors and told us that these can occur at any stage in the medication delivery process with potentially serious consequences for the residents. Other staff were concerned about under‐reporting medication errors (e.g., fear of reprisals, not done before). All sites have procedures in place to address medication errors that involve any of the strategies below: Completing the Quality Assurance Unusual Occurrence Report Close monitoring of residents for any adverse effects Notifying the site physician, family members and residents Filing Severe Incident Reports for serious effects of medication errors with Alberta Health and

Continuing Care We analyzed the error reports from two sites where HCAs assist with oral medications and where medication training is mandatory for HCAs. Site staff compiled their own medication error reports internally and each site had its own reporting template. These reports were voluntarily filed when individual staff bring forward any problems with medication delivery. The reports tracked medication errors by date and time, type of profession, type of error and/or the severity of harm to the resident (7 levels: death, severe harm, moderate harm, minimal harm, no apparent harm, close call and hazard). We examined the types of errors and severity of harm made by HCAs and other healthcare professionals related to oral medication delivery (including pharmacists).

RESULTS FROM THE MEDICATION ERROR REPORTS

Over 16 months (October 2012 to January 2014), the two sites had a combined total of 220 errors for oral medication delivery. While the number of errors was different at each site, the sites also had different bed counts (44 LTC beds versus 120 LTC beds). We took the different number of resident beds into account when we calculated error rates. HCAs assisted with about 50% of medications at one site and about 70% of medications at the second site. Table 11 below shows the various types of errors by healthcare providers.

Table 11 Type of Error by Healthcare Provider at 2 Sites (n=220*) Type of Error Type of Healthcare Provider

HCAs (%) Other Providers (%)

Documentation Error 0 (0.0) 3 (100.0)Dose Omission 96 (71.6) 38 (28.4)Extra Dose to Resident 1 (16.7) 5 (83.3)Extra Dose in Package 0 (0.0) 1 (100.0)Incorrect Drug 3 (25.0) 9 (75)Incorrect Time 11 (91.7) 1 (8.3)Frequency Scheme Error 2 (66.7) 1 (33.3)Incorrect Narcotic Count 0 (0.0) 1 (100.0)Not Performed Where Indicated 2 (22.2) 7 (77.8)


Wrong Dose Strength 4 (57.1) 3 (42.9)Wrong Duration 0 (0.0) 4 (100.0)Wrong Resident 16 (80.0) 4 (20)Wrong Storage 0 (0.0) 1 (100.0)Wrong Technique 1 (100.0) 0 (0.0)Other 1 (25.0) 3 (75.0)

Total number of Errors 137 (63%) 81 (37%)

*Two errors were not linked to professional background and omitted from the analysis

When examining type of error, the three most frequent errors included dose omissions (61.5%; n=134) followed by medicines given to the wrong resident (9.2%; n=20), and given at the incorrect time and the incorrect drug (each 5.5%, n=12). Only 4% or less of the incidents include: not performed where indicated (4.1%; n=9), wrong dosage (3.2%; n=7), extra dose to resident 2.8% (n=6), frequency scheme error 1.4% (n=3), wrong duration 1.8% (n=4), documentation errors (1.4%; n=3), extra dose in package 0.5% (n=1), incorrect narcotic count 0.5% (n=1), wrong storage 0.5% (n=1), wrong technique 0.5% (n=1) and others 1.8% (n=4).

When analyzing these errors by profession, HCAs were involved in 137 errors (63%) and the other providers in 81 (37%). Out of the latter, pharmacists were involved in only four errors (2%) (e.g., extra dose in package, frequency scheme error, wrong dose strength, and not performed where indicated). Table 11 shows that HCAs accounted for two‐thirds of the dose omissions. HCAs also approached the wrong resident (12%) and gave the medication at the wrong time (8%) more often than other providers even though these errors were rare. By comparison, other nursing providers gave the incorrect drug relatively more often (11%). We then calculated the incidence rate of medication errors for each type of provider based on all medications administered at each site as provided by the pharmacist. The average monthly incidence rate of medication errors is 2.6 per 10,000 medicines administered by all staff. HCAs were slightly below this average with 2.4 per 10,000 while regulated nursing providers were above this average with a rate of 3.1 per 10,000 medications. We examined the severity of harm to the residents resulting from these errors (Appendix A, Table 12, p. 27 for definitions). Neither of the reports documented “death” or “severe harm” (high severity), thus “moderate harm” was the highest level reported for any error. Most errors were of “minimal severity” at 53% (n=117), followed by “no apparent harm” with 43% (n=95) and “moderate severity” with 4% (n=8) of the time. When comparing “moderate harm” with all other less severe harm levels combined (minimal/no apparent harm/close call and hazard), HCAs were significantly less likely to be involved in errors of “moderate severity” than all other health care providers (2% vs 7%; Chi‐Square=5.1; p‐ value=0.04). Thus, the data from two sites show that HCAs not only made less medication errors per number of medications administered, they were also less likely to cause moderate levels of harm to the residents. We also analyzed the time of the medication errors (Figure 4). Staff have a window of two hours for giving the scheduled medications before these are considered omissions. For some conditions (e.g., Parkinson’s disease), the delivery time is more tightly prescribed than for others. The two spikes reflect the morning and evening medication rounds at which most of the medications were handed out. Only a few errors occurred in‐between these major medication delivery times. At all five study sites, the morning medication delivery was still the most time‐consuming and intense, typically taking at least two


People were coming up and talking to the person as she was delivering the meds. She got really flustered and picked up the wrong med and went to the wrong person. (Manager)

hours. Most staff talked about mornings as the most likely time for errors while this graph shows evenings as the time for more errors.

Figure 4 Medication Errors by Delivery Time

STAFF VIEWS: CIRCUMSTANCES LEADING TO MEDICATION ERRORS

While all five sites had safety measures in place, staff pointed to a number of factors affecting safe medication delivery. In combination with staff shortages and high workloads, staff listed distractions, multitasking, rushing and unfamiliarity with residents as contributors to medication errors. These errors comprise omissions and other mistakes. Almost every staff member viewed distractions as the most frequent cause for errors. Interruptions by peers, family members and residents or call bells happened constantly during medication passes. In case of emergency situations (e.g., a resident falling and needing the help of several staff, acute care referrals), nursing staff interrupt the medication delivery, lock the cart and help out. Staff told us that RNs or LPNs may not be as distracted as HCAs since the nurses do not necessarily have resident assignments. Staff routinely multitask during morning care when medications are given. At meal times, they have to focus on feeding residents and responding to residents’ meal requests while handing out medications. Other omissions easily happen when staff do not wake residents either early in the morning or at night, or when the resident is out of their room at medication time. In other cases, residents with dementia often refuse medication increasing the likelihood of omissions. Staff also frequently rush to get patient care done in the morning and easily forget to give the non‐packaged medications (e.g., eye and ear drops, patches, and insulin). When staff give medications to the wrong resident, confusing residents with the same name may be one reason. Some staff may be unfamiliar with the residents and their medication requirements. For example, while some casual staff give medications who have worked on a site for a long time, they may still not be as familiar with the residents as the permanent staff. Some staff also mentioned the small writing on the medication packaging that makes it difficult to read the information. In other cases, discontinued medications are not removed from the medication rolls, while others are not added to the roll on time. In a few cases, a language barrier may exist for staff decreasing their understanding of the


I would like to assist with medication delivery; … it’s going to help my coworkers and my residents. (HCA)

RNs have unique skills to oversee the big picture of the residents and setting; however, they spend lots of time delivering medications. (Manager)

medications. Some nurses also have had issues with verbal prescriptions or poorly written orders that can easily be misunderstood.

STAFF VIEWS: RESIDENT SAFETY AND WORKFORCE UTILIZATION

RESIDENT SAFETY The HCAs and other staff saw a number of benefits to residents where HCAs give medications. While the residents knew the HCAs helping them with their ADLs and other needs, they did not always recognize other nursing staff. The frequent contact with HCAs had led to close relationships with the residents and a better knowledge of their needs. HCAs also said that giving medications further enhanced their opportunity to learn more about the residents, their health conditions and preferences. Some of the staff at the five sites raised arguments against HCA medication assistance. We also heard some arguments from other staff that HCA medication assistance may diminish the quality of patient care. HCAs are another group of providers giving medications to the residents and increasing their confusion about the staff. Regulated nursing staff were concerned about higher medication errors when HCAs give medications and more severe outcomes for residents. RNs were also concerned that they had to rely too much on the HCAs and that some of the resident conditions may get missed. Not giving all medications, nurses would lack the knowledge about the residents and some direct observations at medication delivery: for example, residents’ ability to open their mouth, take their pills, and swallow as well as their general appearance, pain and necessary adjustments for them. For the nurses, medication delivery in the morning and bedtime was also an opportunity for directly assessing the residents. They viewed HCAs as not having the clinical training to assess the residents and therefore miss any distress or pain (e.g., residents who may be dizzy, look pale, do not eat or sleep well). Unlike the nurses, HCAs were not trained to make decisions on whether to administer the medication or call for more consultation with the physician. Finally, some nurses were concerned that families might complain about changing medication practice. WORKFORCE UTILIZATION Staff also commented on the influence of medication assistance on the work of other providers. If HCAs do not assist with medications, this task falls to LPNs and RNs. Some HCAs felt good about helping the nurses by assisting with the medications since they were also overwhelmed with their responsibilities. Some of the managers at the three sites mentioned that HCA medication assistance made better use of the skills of the RNs who could concentrate on other parts of their role (e.g., pain assessment, post fall management, care planning, clinical assessments, reports, and addressing resident and family concerns). Some nurses at all sites said that HCAs taking on medications relieved their heavy workload, especially at busy times and during emergencies. For example, noon was a busy time for nurses who must respond to physician calls, process orders, do the RAI paperwork as well as catch up on care planning. According to staff, noon medications were routine and low risk whereas the morning and bedtime medications were more complex. One argument against medication assistance was that supervising HCAs added more responsibility for the nurses.


Discussion of Findings

This study has provided a comprehensive understanding of HCA utilization in continuing care. Using survey data from 130 continuing care sites, we highlight the current roles of HCAs at SL and LTC sites, with particular focus on oral medication assistance. The in‐depth analysis of five LTC sites describes the medication administration processes in some detail and examines the impact of HCA medication assistance on resident safety. Our survey data confirm that HCAs comprise the majority of the workforce in continuing care with an average of 60 HCAs at a site as compared to small numbers of RNs and LPNs providing patient care. Our survey results show eight areas of responsibility for HCAs with some of them being more common in SL than in LTC sites. HCAs primarily support residents with their ADLs. They also assist with recreational activities, measure vital signs and do tick charting. This checklist “charting” highlights completed tasks rather than documenting observations on the residents. HCAs have a number of other responsibilities in SL sites that they do not carry out as frequently in LTC sites. The type of tasks HCAs carry out in public versus private LTC sites also differed significantly; the reason for this is not clear. Survey respondents view HCAs as being more fully utilized in SL than in LTC, which is consistent with their greater range of responsibilities at SL sites. With over 80% certified HCAs in continuing care, our results show a qualified HCA workforce graduating from licensed institutions with government‐approved curricula. When trained in government‐approved HCA curricula, HCAs become competent in medication assistance of low‐risk medications. The employers also support HCAs with additional training to assist with medications. We broadly define medications to include creams/ointments, medicinal drops, suppositories, patches and oral medications. The majority of SL sites report that HCAs are involved in medication assistance, including oral medications. In contrast, HCAs assist in less than half of the LTC sites with any medications and only 3 out of 64 LTC sites involve HCAs with oral medication assistance. At these three sites, HCAs assist with routine, regularly scheduled oral medications in multi‐dose packages to stable residents. The most common reasons for not involving HCAs in oral medication assistance are safety concerns and complexity of residents. The RAI data suggest that the residents at all five sites are highly complex and most have total care needs with immobility and dementia as prevalent conditions. It is noteworthy that our RAI data comparison between the three LTC sites with HCA medication assistance and the two without shows that residents at the former sites are significantly more advanced in age, low social engagement, high end‐stage disease, and depression. Our error report analysis from two LTC sites where HCAs assist with oral medications yields some important results. With 220 errors made over 16 months, HCAs account for nearly two‐thirds of these errors with dose omissions as the most frequent error, and to a much smaller extent by giving medications to the wrong resident and the wrong time. However, when calculating the error rates by profession, HCAs are slightly below the average rate with 2.4 per 10,000 medications given (average is 2.6 errors/10,000 medications), while regulated nursing providers were above this average with 3.1 per 10,000 medications. The error reports also show different levels of harm arising from medication errors by professional group with HCAs being significantly less likely of causing moderate harm to the residents (no severe harm was reported at all). However, more severe harm can potentially occur when giving the wrong drug to a resident ‐‐ an incident that should be closely monitored at any time. While the data from two sites show that HCAs not only made relatively fewer errors, they were also less likely to cause moderate levels of harm to the residents. Given the high complexity of residents at these two sites,


these findings are encouraging and suggest that it appears safe to engage HCAs in oral medication assistance even for residents with complex care needs. Interview participants speak to the importance of proper training for HCAs on medication assistance and standardized medication delivery processes. All five LTC sites describe similar protocols including seven safety checks and HCAs adhering to the same protocols as regulated nursing providers. However, many staff pointed out that distractions are the greatest threat when handing out medications and a likely cause for medication errors. Various suggestions on how to ensure safe medication assistance include: Ongoing training or annual refreshers for HCAs to ensure they know their responsibilities, follow

the right process of medication delivery, concentrate on safety checks and report medication errors.

Learning from mistakes is seen by all staff as a way to improve the system. The medication errors should be discussed at collaborative meetings and the staff encouraged to report the errors. This process ensures assessing the causes of errors and suggesting some controls or solutions.

Reducing the number of medication rounds as a strategy to lessen the workload of HCAs in medication delivery.

Increasing staff focus on medication assistance by holding them outside of meals to avoid meal‐related distractions for the residents.

Using multi‐package technology and electronic charting to enhance medication safety by reducing some of the errors.

Together with the existing internal process to address medication errors at the sites, our data suggest that HCAs do not pose a greater threat to resident safety than other providers giving oral medications. In summary, we approached this research from a workforce perspective to understand the roles of HCA in medication assistance in LTC and SL sites and the potential impact on resident safety. The prevalent argument appears to be that resident complexity in LTC is high and not matched by HCA training to provide safe medication care by this group of providers. Our data suggest that HCA involvement in medication assistance in general, and in assistance with oral medications in particular, is still rare in LTC. However, based on error reports from two LTC sites, it appears that HCAs can be involved in this process without jeopardizing the safety of even complex residents. These findings are encouraging but need further validation. Ultimately, expanding the roles of HCAs at the workplace to include medication assistance can support a patient‐centred approach and contribute to optimal utilization of all care providers.

This study has a few limitations. First, only 41% of continuing care sites responded to the survey implying that the respondents may not have been representative of typical HCA utilization in continuing care in Alberta. Second, we only reviewed error reports from two sites introducing a potential bias to the analysis. Given that the error reports show self‐reported incidents, medication errors may be under‐reported at these continuing care sites.


References

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Appendices A-B

APPENDIX A TABLES 4, 6, 7, 8, 9, 10,12

Table 4 Facility Type and Staffing Information (N=130) Variables Average [range]

Number of beds Long‐term Care Supportive Living

Supportive Living Level 3 Supportive Living Level 4

Supportive Living Level 4D Private Assisted/Supportive Living

Seniors Lodges and Other Supportive Living

103.1 [8 – 414] 61.5 [8 – 325] 20.8 [2 – 65] 43.2 [5 – 170] 27.9 [10 – 105] 48.6 [10 – 122] 50.8 [19 – 190

Average number of HCAs Full‐timePart‐time

Casual

60 [3 – 384] 16.1 [0 – 104] 28.1 [0 – 242] 14.9 [0 – 137]

HCA competency status HCAs certified

HCAs substantially equivalent HCAs deemed competent

42.8 [0 – 335] 4.9 [0 – 69] 4.9 [0 – 45]

Nursing Staff Registered Nurses

Registered Psychiatric Nurses Licensed Practical Nurses

Health Care Aides/Nursing Assistants

5.0 [0 – 103] 0.1 [0 – 2] 6.4 [0 – 56] 35.3 [0 – 165]

Managerial Staff Care Manager

Administrator/Director of CareClinical Educator

Nurse Practitioner Care Coordinator

1.3 [0 – 26] 0.7 [0 – 3] 0.4 [0 – 3] 0.1 [0 – 2] 0.1 [0 – 5]

Allied Health Staff Dietitian/Nutritionist

Occupational Therapist Pharmacist

Pharmacy Technician Physiotherapist

Psychologist Recreational Therapist

Speech and Language Pathologist Social Worker

Recreational Therapy Aide/AssistantOccupational Therapy Aide/Assistant

0.2 [0 – 2] 0.5 [0 – 4] 0.1 [0 – 2] 0.1 [0 – 2] 0.2 [0 – 3] None

0.7 [0 – 3] 0.1 [0 – 1] 0.3 [0 – 4] 1.5 [0 – 6] 0.9 [0 – 5]


Other Staff/Volunteers Housekeeping

Food ServicesMaintenance/Physical Plant Services

Hospitality (Laundry)Volunteers

3.0 [0 – 18] 5.8 [0 – 34] 1.2 [0 – 12] 0.8 [0 – 6]

9.6 [0 – 242]

Table 6 Resident Profiles at the 5 LTC Sites Variables HCAs assist with oral

medications (3 sites) Mean (SD) [n=367]

HCAs do not assist with oral medications (2 sites) Mean (SD) [n=482]

T‐test statistic

P‐value

Age 86.75 (9.0) 81.39 (11.9) ‐7.4 <0.01*

Sex Male %

45.4% 36.1%

7.61 <0.01*

Number of medications

9.84 (3.9) 9.76 (4.4) ‐0.3 0.76

Number of days residents receive injections**

6.40 (1.8) [n=30] 5.44 (2.6) [n=36] ‐1.7 0.08

Pain scores 0.56 (0.79) 0.46 (0.76) ‐1.8 0.07

ADL scores 12.96 (4.4) 12.47 (5.2) ‐1.5 0.14

CPS scores 3.31 (1.4) 3.30 (1.5) ‐0.1 0.90

PURS stages 2.31 (1.5) 2.15 (1.5) ‐1.4 0.15

ISE scores 2.17 (1.7) 3.4 (1.8) 10.2 <0.01*

CHESS scores 1.46 (1.2) 1.09 (0.9) ‐4.9 <0.01*

Short‐term memory loss %

85.0% 83.8% 0.2 0.35

Long‐term memory loss %

70.3% 71.9% 0.31 0.33

Residents with depression %

44.4% 26.3% 30.21 <0.01*

Residents with Peptic ulcer %

13.6% 13.1% 0.11 0.45

Residents with urinary tract infection (UTI) %

9.3% 5.6% 4.21 0.03

Residents with incontinence %

66.2% 61.8% 1.71 0.10

Residents with falls % 21.3% 16.4% 3.31 0.04

Residents on antipsychotic medication %

20.2% 25.1% 2.91 0.05

Residents receiving chemical restraints %

2.5% 5.0% 3.61 0.04

1Chi‐square statistic **Comparison between residents getting injections; residents not getting injections are excluded


Table 7 HCA Utilization at LTC and SL Sites (N=115) Activities Long‐term Care

n (%) Supportive Living

n (%) Chi‐square statistic

P‐value

Support residents with ADLs 63 (98.4) 52 (100.0) 0.82 0.55

Prepare meals 4 (6.3) 20 (38.5) 18.1 <0.01*

Housekeeping 8 (12.5) 31 (59.6) 28.5 <0.01*

Do laundry 13 (20.3) 38 (73.1) 32.4 <0.01*

Do charting Tick charting Resident charts

58 (90.6) 40 (62.5)

42 (80.8) 47 (90.4)

2.3 11.9

0.10 <0.01*

Assist with recreational activities

38 (59.4) 36 (69.2) 1.2 0.18

Assist with therapy activities 26 (40.6) 35 (67.3) 8.2 <0.01*

Do vital signs 38 (59.4) 29 (55.8) 0.2 0.42

*Statistically significant difference

Table 8 HCA Utilization at Private and Public LTC sites (N=60)

Activities Privaten (%)

Publicn (%)

Chi‐square statistic

P‐value

HCAs do ADLs 28 (96.6) 35 (100) 1.2 0.45

HCAs do housekeeping 0 (0.0) 8 (22.9) 7.6 0.01*

HCAs do laundry 2 (6.9) 11 (31.4) 5.9 0.02*

HCAs do writing in resident charts 8 (27.6) 32 (91.4) 27.6 <0.01*

HCAs do tick charting 28 (96.6) 30 (85.7) 2.2 0.15

HCAs do vital signs 11 (37.9) 27 (77.1) 10.1 <0.01*

HCAs assist with therapy activities 9 (31.0) 17 (48.6) 2.0 0.12

HCAs assist with recreation activities 10 (34.5) 28 (80.0) 13.6 <0.01*

HCAs assist with preparing meals 1 (3.4) 3 (8.6) 0.7 0.38

* Statistically significant difference

Table 9 HCA Medication Assistance at Public and Private LTC sites

HCA Activities Privaten (%)

Publicn (%)

Chi‐square statistic

P‐value

HCA Medication Assistance All Medications 12 (41.4) 17 (48.6) 0.62

HCAs assist with oral medication 1 (3.4) 2 (5.7) 0.7 0.38

HCAs assist with rectal suppositories 25 (86.2) 32 (91.4) 0.44 0.39

HCAs assist with topical medications 27 (93.1) 33 (94.3) 0.04 0.62

HCAs assist with inhaled medications 0 (0) 4 (11.4) 3.5 0.08

HCAs assist with vaginally inserted medications 0 (0) 1 (2.9) 0.8 0.55

HCAs assist with application and removal of patches 1 (3.4) 4 (11.4) 1.4 0.24

HCAs assist with eye/ear/nasal drops 1 (3.4) 11 (31.4) 8.1 <0.01*

Concerned about patient safety in medication process

7 (24.1) 10 (28.6) 0.2 0.46

HCAs are seen as fully utilized 15 (51.7) 20 (57.1) 0.19 0.43

Mandatory Training** 1. Medication Assistance 2. Narrative charting 3. End of life care

7 (33.3) 14 (63.6) 15 (53.6)

17 (63.0) 11 (35.5) 24 (77.4)

4.2 4.1 3.7

0.04* 0.04* 0.05


4. Dementia care 5. Safe use of equipment 6. Nutrition assistance 7. Non‐violent crises 8. Supportive pathways

22 (75.9)28 (96.6) 24 (82.8) 12 (48.0) 19 (65.5)

20 (60.6)32 (94.1) 22 (71.0) 10 (31.3) 20 (60.6)

1.6 0.2 1.2 1.7 0.16

0.160.56 0.22 0.16 0.45

*Statistically significant difference **Other mandatory training included safe transfer & lift, safe bathing assistance and reducing back injuries Note: Private included for‐profit and not‐for‐profit sites

Table 10 HCA Medication Assistance in LTC and SL Activities Long‐term Care

n (%) Supportive Living

n (%) Chi‐square statistic

P‐value

Medication Assistance Rectal suppositories Topic creams Inhaled medication Oral medication Rx eye/ear/nasal spray/drops Vaginally inserted medications Application/removal of patches

29 (45.3)57 (89.1) 60 (93.8) 4 (6.3) 4 (6.3) 12 (18.8) 1 (1.6) 5 (7.8)

44 (86.3)27 (71.8) 49 (92.5) 42 (79.2) 44 (83.0) 43 (81.1) 19 (35.8) 41 (77.4)

20.5420.8 0.1 64.7 70.6 45.3 24.0 58.7

<0.01*<0.01* 0.53 <0.01* <0.01* <0.01* <0.01* <0.01*

Mandatory training Medication assistance

24 (50.0) 44 (86.3) 15.1 <0.01*

HCAs paid to take training 61 (95.3) 50 (98.0) 0.6 0.39

Perceived that HCAs are fully utilized

35 (54.7) 48 (90.6) 18.1 <0.01*

Concerns about patient safety in medication process

17 (26.5) 8 (15.3) 2.1 0.11

* Statistically significant difference

Table 12 Severity Level of Harm Hazard

A hazard or hazardous situation with the potential to escalate to a close call or a harmful event. This hazard exists as a latent condition. Examples: a piece of equipment may be difficult to use, the staff may feel that it is potentially error prone. Another example is two similar looking drugs located side by side in a container.

Close Call

An event or circumstance with the potential to cause a harmful event but did not actually occur due to corrective action and/or timely intervention. The event did NOT reach the patient. Examples: pouring the wrong medication and having taken it to the bedside, the mistake is caught on the last check before giving it to the patient. An inappropriate dosage of a medication is detected before an order is processed. A nurse discovers a patient is allergic to penicillin when checking the name band before hanging the IV penicillin dose. A physician is reading the wrong CT results for the patient that is being examined but notices that the report is not making sense and requests the correct report.

No Apparent Harm

An event or circumstance that does not make the patient suffer at the time of the event or reporting it, but who could do so in the future. No physical and/or psychological symptoms are evident and no intervention is required. Examples: a patient falls and hits their head but no evidence is found of bruising, swelling or any change in neurological status or cognitive function. A patient received a wrong medication but exhibited no change in symptoms or condition as a result.


Minimal Harm

An event or circumstance with minimal harm to the patient. Minimal adverse effects may include abrasions, skin breakdown, pain, minor burns, bruises, scratches, confusion, emotional distress and anxiety. These effects may or may not require intervention. Intervention for minimal harm may include x‐ rays, sutures, physician examination, blood collection or re‐collection and closer observation, even if short‐term in nature. Examples: a patient received a dose of insulin that was higher than expected, a new order was received and extra food was given to reduce blood glucose levels with a follow‐up glucometer check. A patient falls, sustains a bruised and swollen knee and requires some Tylenol and an ice bag for a few hours but this does not extend the stay in hospital. Extra observation and monitoring may be needed such as an increase in vital signs frequency for the next four hours but no overall changes in the treatment plan would be required.

Moderate Harm

An event or circumstance where there is moderate harm to the patient. Moderate adverse effects may include moderate lacerations, fractures of the extremities, burns and unintentional heavy sedation. Intervention and extended observation are required. Intervention for moderate harm may include diagnostic testing such as MRI, CT scans with contrast, blood gas analysis or cross‐match for blood products. An event or circumstance causing moderate harm has the potential to prolong length of stay. Examples: a patient falls, sustains a fractured arm which is casted and function recovers through a short period of physiotherapy. A patient is found to have retained a sponge in abdominal surgery, develops an internal infection and requires a repeat procedure to retrieve the sponge and a 10‐day course of antibiotics. A change occurs in the treatment plan to deal with the new symptoms or condition arising from the adverse event.

Severe Harm

An event or circumstance where there is severe harm to the patient. Severe adverse effects may include anaphylaxis, permanent injury or disfigurement, fractures (other than extremities) or a sudden life‐threatening change in vital signs. Immediate, life‐saving intervention is required and may include life support and/or an emergency surgical occurrence. For example, during a surgical procedure, the wrong part is inadvertently removed. A patient receives a contrast dye to which they had a known allergy and suffers a cardiac arrest. A wrong dose of a medication leads to a loss of hearing.

Death

An event or circumstance causing death in which the most likely cause is due to an error that occurred in the course of receiving care. Note that multiple deaths should be entered in separate reporting and learning submissions.


APPENDIX B STAFF QUESTIONNAIRE AND INTERVIEW GUIDE

Please Return Questionnaire by July 31, 2014

PURPOSE This questionnaire was developed by the research team from Workforce Research & Evaluation, Alberta Health Services (AHS) with input from operators and policy makers. It is part of a project to understand workforce issues and their effects on resident care in continuing care facilities. An important consideration about the workforce is how site managers organize and assign roles to regulated and unregulated health care providers. This project examines the role of health care aides (HCAs) in long‐term care and supportive living facilities in medication assistance. We know that education and competency levels vary widely among HCAs. Also, different facilities envision different roles for their HCAs. Both, education and role expectations influence how HCAs are being utilized. The role of one provider influences that of others and therefore understanding overall staffing at your site is also important for us to know. METHODOLOGY

Questionnaire to be completed by: Director of Care or appropriate designate.

Time to Complete: Approximately 45 minutes.

We would also ask you to have staffing information available to answer some of the questions. ETHICS

The Conjoint Health Research Ethics Board (CHREB) approved this study (REB 14‐0377).

Raw data (e.g., questionnaire, spreadsheets) will not be shared beyond the core research team.

You have provided your consent to participate by completing and submitting the questionnaire.

You have the right to decline our invitation to participate in this survey. CONFIDENTIALITY

Collection, access, use, disclosure of data is in compliance with the Health Information Act and Freedom of Information and Privacy Act.

Anonymous results will be reported in final report and other written documents.

Data Storage is in compliance with AHS data protection policy.

Thank you for your participation!

I have read and understand the purpose of this survey: Yes No

Please return this questionnaire to: Siegrid Deutschlander at [email protected]. or

Fax: 403‐943‐2875

Part I Background Information on Setting and Staff

Please answer all questions keeping in mind typical events and circumstances influencing the daily practice of your

site during the last 3 months. In this survey, “health care aide” (HCA) applies to non‐regulated, direct client service

providers offering basic health services and assistance/support with activities of daily living. HCAs may also use

other titles, such as nursing attendants, personal care aide, home support aides, home support workers or

residential support workers.

Please provide your site name and location. While your name will not be linked to any data provided by you, it will

help us to determine response gaps for a better analysis of the data.

Information on Your Participation


What type(s) of setting(s) and number of beds does your site have?

Facility‐based Care (Long‐term Care)

Residential Care Services (Supportive Living)

Designated Supportive Living Level 3

Designated Supportive Living Level 4

Designated Supportive Living Level 4‐D

Private Assisted/Supportive Living (non‐designated Level 3 & 4 SL)

Seniors Lodges and Other Supportive Living (Level 1 and 2 SL)

Safe Living (secure) Spaces: Our site includes (number of beds) in safe living units.

Which of the following program‐funded beds do you have (non‐Patient Care Based Funding)?

Type of Care Number of Beds

Brain Injury Care

Palliative care

Post‐acute/Sub‐acute Care

Other:

Other:

Other:

This site is:

Private not‐for profit

Private for‐profit

Publicly owned and operated

Please enter the assigned FTE for each of the following provider types at your site. For each provider type, please

enter the FTE for staff who are employed directly by your site followed by the FTE for those contracted to your site

through another agency. If your facility does not have access to a specific type of provider, please enter “0”

accordingly. For provider types that are accessed on a consult‐only basis, please estimate how many hours per

week they are used:

Number of Beds


Provider Type Total FTE Assigned FTE for LTC

Assigned FTE for SL

Consult Only

(estimated hours/week)

Nursing Staff

Registered Nurses (RNs)

Agency/Contract RNs

Registered Psychiatric Nurses (RPNs)

Agency/Contract RPNs

Licensed Practical Nurses (LPNs)

Agency/Contract LPNs

Health Care Aides/Nursing Assistants (HCAs/NAs)

Agency/Contract HCAs/NAs

Other

Other Agency/Contract Staff

Managerial or Specialty Staff

Care Manager

Administrator/Director of Care

Clinical Educator

Nurse Practitioner

Agency/Contract Nurse Practitioner

Care Coordinator /Transition Services

Agency/Contract Care Coordinator/Transition Services

Other

Allied Health Staff

Dietitian/Nutritionist

Agency/Contract Dietitian/Nutritionist

Occupational Therapist

Agency/Contract Occupational Therapist

Pharmacist

Agency/Contract Pharmacist

Pharmacy Technician/Aide

Agency/Contract Pharmacy Technician/Aide

Physiotherapist

Agency/Contract Physiotherapist

Psychologist

Agency/Contract Psychologist

Recreational Therapist

Agency/Contract Recreational Therapist

Speech & Language Pathologist

Agency/Contract Speech Pathologist

Social Worker

Agency/Contract Social Worker

Recreational Therapy aide/assistant

Agency/Contract Recreational Therapy Aide/Assistant

Occupational Therapy or Physiotherapy Therapy Aide/Assistant


Provider Type Total FTE Assigned FTE for LTC

Assigned FTE for SL

Consult Only

(estimated hours/week)

Agency/Contract OT/Physio Aide/Assistant

Other

Other Staff/Volunteers

Housekeeping

Agency/Contract Housekeeping

Food services

Agency/Contract Food Services

Maintenance/Physical Plant Services

Hospitality (Laundry)

Agency/Contract Hospitality (Laundry)

Volunteers

Other

Does your site use any other providers? If so, please provide details here (FTE, provider type):

If your site uses casual nursing staff, please indicate for which nursing groups and estimate the number of shifts

per week filled by casual staff:

Provider Type Shifts/Week

HCAs

LPNs

RNs

Please provide the number of HCAs (i.e., head count) you currently employ in each of the following categories:

Total # HCAs

# Full‐time HCAs

# Part‐time HCAs

# Casual HCAs

Part II HCA Responsibilities

Please provide the number of HCAs by competency status at your site:

# Certified (i.e., certificate obtained from a licensed Alberta educational institution offering the Health Care

Aide Government of Alberta Provincial Curriculum)

# Substantially Equivalent (i.e., employer determined the employee has education that meets and/ or

exceeds the Health Care Aide Government of Alberta Provincial Curriculum which includes 500 hours of theory and

supervised practice)

# Deemed competent (i.e., employer assessed the employee as competent using a Competency Assessment

Profile (CAP) tool)

# Don’t Know

What are the responsibilities currently carried out by HCAs? Check all that apply.


Support residents with ADLs (e.g., bathing, dressing, grooming, toileting, eating)

Prepare meals

Do housekeeping

Do laundry

Do charting

Tick‐charting (i.e., checking off items on a checklist)

Writing in resident charts

Assist with medications

Assist with recreation activities

Assist with therapy activities

Do vital signs

Other:

What technology is in place to support medication delivery (i.e., any supports starting with medication dispensing

to facilitate the different steps of the process)? Please explain.

What types of medications do HCAs assist with? Check all that apply.

Rectal suppositories/fleets

Topical Rx creams

Inhaled medications (e.g., nebulizers, inhalers)

Oral medications

Eye/ear/nasal Rx drops/sprays/treatments

Vaginally inserted meds

Application/removal of patches

If you have selected any of these options, please proceed to the next question


Other:

No assistance with medication (please skip the next 2 questions)

If HCAs assist with medications, who is primarily responsible for supervising HCA medication assistance?

RN

LPN

Manager

Other:

What mechanisms have you put in place to ensure safe medication assistance by your HCAs? (such as training,

supervision, medication carts with safety features such as scanning, etc). Please explain.

If HCAs do not currently assist with oral/inserted medications, have they done so in the past? (Please skip this

question if HCAs assist with medication)

Yes

If yes, why has this practice been discontinued? Please explain.

No

If no, what are the reasons for not having HCAs assist in medication assistance? Please explain.

Which other nursing provider delivers the various medications most of the time?

Types of Medications RN LPN

Rectal suppositories/fleets

Topical Rx creams

Inhaled medications (e.g., nebulizers, inhalers)

Oral medications

Eye/ear/nasal Rx drops/sprays/treatments

Vaginally inserted meds


Application/removal of patches

Other:

Do you have any concerns about patient safety and adverse events in the current medication management process?

No

Yes

If yes, please explain your concerns:

What collaborative/joint team activities do HCAs at your site attend? Check all that apply.

HCA Meetings

Interprofessional Meetings

Care Planning

Rounds (e.g., wounds, falls, restraints)

Family Conferences

Moving‐in Meetings with new residents/families

Other:

Do you consider your HCAs to be fully utilized? (We define “being fully utilized” as fully applying one’s training and education to practice).

Yes

If yes, what are the enablers to HCAs being fully utilized at your site? Check all that apply.

Our HCAs have strong English skills

Our HCAs are well trained in medication assistance

Our HCAs are all certified or have demonstrated a strong level of competency

We offer ongoing training for skill development

We have enthusiastic HCA staff able to take on new challenges

RNs and/or LPNs provide strong supervision and mentorship of HCAs


Other:

No

If not, what are the barriers to HCAs being fully utilized at your site? Check all that apply.

The English skills of our HCAs are not sufficient

The medication assistance skills of our HCAs are not sufficient

Most HCAs work part‐time at several facilities and are not available to upgrade their skills

Casual HCAs are not expected to upgrade their skills

RNs and LPNs require more training for supervision and mentorship of HCAs

Other:

What training do HCAs take that is either mandatory (required) or non‐mandatory (i.e., it is suggested to support

their professional development but not required)? Check all that apply.

Type of Training Mandatory Non-mandatory Medication assistance

Training in dementia care

Safe transfers & lifts

Safe bathing assistance

Safe use of equipment, etc.

Nutrition assistance

Narrative charting

Care at the end of life

Reducing back injuries

Non-Violent Crisis Intervention

Supportive Pathways

Other:

Are HCAs paid to take training? Yes

No

Are there any other challenges for HCAs taking training? Check all that apply.

Back‐filling shifts


Rural location

Work part‐time at several facilities

Other:

What other responsibilities would you like HCAs to take on? Check all that apply.

Prepare meals

Do housekeeping

Do laundry

Do charting

Tick‐charting (i.e., checking off items on a checklist)

Writing in resident charts

Attend care planning meetings

Attend rounds

Assist with medications

Assist with recreation activities

Assist with therapy activities

Do vital signs

Other:

Please add any comments or concerns about HCA utilization at your site that you think are important:

Part III Service Delivery and Resident Care In each column, please select the option that most closely describes how RNs’ and LPNs’ work is organized on each shift: RN

Day Shift

RN Evening

Shift

RN Night Shift

LPN Day Shift

LPN Evening

Shift

LPN Night Shift


They have overall shift responsibility for a group of residents to manage and coordinate their nursing care They provide almost all of the care for their assigned residents throughout each shift but may not have the same residents for an extended period of time

They work collaboratively in smaller groupings of nursing staff (e.g., 1 or more regulated nursing providers with HCAs) to provide care to a group of residents over the shift

They look at the tasks that need to be completed on the shift for residents and each nurse is assigned various tasks

Please rate your agreement with each of the following statements: Overall, staff from all disciplines (e.g., nursing,

therapy) at my site....

Strongly Disagree

Disagree Neither Agree nor Disagree

Agree Strongly Agree

Work well together

O

O

Work collaboratively to make decisions about resident care

Communicate effectively with each other about resident needs

What collaborative activities and structures are in place to enable collaboration amongst diverse types of

providers? Check all that apply.

Interprofessional Meetings

Care Planning

Rounds (e.g., wounds, falls, restraints)

Family conferences

Moving‐in meetings

Policies reflect collaboration in their language and expectations

Performance reviews reflect expectations for collaboration

Other:

Please rate your agreement with each of the following statements:


Strongly Disagree

Disagree Neither Agree nor Disagree

Agree Strongly Agree

At my site, RNs/RPNs are able to work to full scope (i.e., the full range of knowledge and skills that are associated with their profession)

At my site, LPNs are able to work to full scope (i.e., the full range of knowledge and skills that are associated with their profession)

At my site, HCAs are able to work to the full range of knowledge and skills that are associated with their occupation

At my site, allied health providers (e.g., therapists) are able to work to full scope (i.e., the full range of knowledge and skills that are associated with their profession)

O

O

Part IV Feedback and Further Participation We are seeking feedback to the questions asked in this questionnaire. Please provide us with your comments as to the appropriateness of the questions.

For this project, we will also work with sites to collect in-depth data about HCA medication assistance. Do you have an interest in being contacted to participate in that data collection?

Yes No

Would you be interested in being contacted for future studies?

Yes No

We really appreciate your responses. Thank you for your participation!

Date of completing questionnaire:

Please return the questionnaire by email or fax to: [email protected] (Fax:

403.943.2875). Thank you!


STAFF INTERVIEW GUIDE

Medication Process [ALL] Questionnaire:

‐ No scanning/bar coding technology at the unit level? ‐ med assistance with rectal suppositories and topical Rx creams.

What is your role in medication assistance? Which meds do you assist with? Common meds? PRNs (not scheduled)? Higher risk meds? How does the process work? Steps involved? (med cart, electronically entered, bubble packs, crush meds, mix them with fluids)

‐ How often given (times/day); how long does it take ‐ Once med given, where do you check off that it is given? Written in resident chart? ‐ How do they have to identify the resident? (ID photo program utilizing 2 identifiers?) ‐ What would you say are the strengths of your medication management process?

Weaknesses? Have there been any changes made to this process throughout the years, and why?

Tell me about your workload and the various care you provide to the residents. What are the effects of HCAs’ involvement in medication assistance on the roles, utilization and workload of HCAs? Other providers?

‐ What is the impact of HCA medication assistance on staff satisfaction? ‐ HCA: do you enjoy assisting with medications? ‐ What opportunities would you see in HCAs being involved with medication assistance? ‐ Would you consider HCAs to be fully utilized at this site? Why or why not?

Only HCAs: How do regulated providers (LPNs, RNs) support you (HCAs) with medication assistance? Are they present when medications given? Which meds do they need to supervise? How is it decided when LPN or RN gives meds? Which collaborative team activities do you participate in? (HCA meetings, IP meetings (care planning, rounds, family conferences), move in meetings? other?) Only LPNs or RNs: How do you support/supervise HCAs with medication assistance? Provide examples. Is RN/LPN in room when medication given? Which meds need to be supervised? How is it decided when LPN or RN gives meds? How are meds divided up b/w LPN and RN? Education Questionnaire:

‐ Med assistance not a mandatory course ‐ What on‐the‐job training is provided at this site for HCAs and medication assistance? ‐ How long/intensive was this training? How often given? Mandatory? Challenges?

Do providers have to take repeated training to stay updated on medication delivery? Therapy aide working as HCA? Education background? Only HCAs: When you think of your educational background, do you remember having been trained in medication assistance?

‐ How long intensive/extensive was the training? (Certified? Deemed competent?) ‐ Do you feel your education/training has prepared you enough to assist with medications? Feel

competent/confident in doing so? RNs/LPNs: Do you feel the education/training of HCA’s has prepared them enough to assist with medications?


And feel competent/confident in doing so? ‐ repeated training /updates to stay on top of medication delivery? (for themselves, and HCAs)

Do you feel competent in supervising HCAs? Resident Safety What are your thoughts on the current medication process in terms of resident safety?

‐ Are you aware of the medication errors? If they occur, how are they dealt with? Reported? ‐ Do you discuss these with supervisors/leadership? ‐ Would you feel comfortable coming forward and reporting medication errors? ‐ Is there an effective process in place that helps reduce medication errors and ensure safe

medication management by all providers? How do you think that resident needs and characteristics impact the medication management process? E.g. more complex residents. Unstable residents. Pharmacist:

‐ How safe is the current medication delivery? (see above questions) ‐ What if any errors occur at the dispensing stage?

Administrator/Best Practice Lead/Clinical Educator: ‐ What are the policies guiding the medication management process? ‐ What influenced the decision to involve or not involve HCAs in medication assistance?

Site information ‐ Questionnaire was more general to all X Sites, no specific data for each site (other than # of

HCAs). o How many secured living spaces? o How many other staff employed? (can we get this info on staffing in a separate doc?)

‐ What is the incidence of medication errors, including staff involved and resident outcomes? (see above)

‐ Therapy Aides at Site X are typically HCA trained? Med assistance? Leadership: (Clinical Educator, administrator,)

‐ Has there been a time where HCAs assisted with meds and this was discontinued? Probe for the various reasons: has resident population changed, staff shortage.

‐ What influenced the decision to involve or not involve HCAs in medication assistance?

Copyright © (2016) Alberta Health Services

This report is owned and copyrighted by AHS. It may be reproduced in whole or part for internal AHS

use. WRE must be acknowledged in all publications where materials produced under this agreement are

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The citation for this report should appear as follows:

Deutschlander S, Arain MA, Rostami M, Suter E. 2016. Examining HCA utilization in continuing care facilities in Alberta with a particular focus on medication assistance.

Final Report. Workforce Research & Evaluation, Alberta Health Services.

Workforce Research & Evaluation (WRE)

. . . is a research department in Research Priorities & Implementation of Alberta Health Services. Workforce Research & Evaluation occupies a unique niche as an applied research unit with focus on workforce and health systems issues. The unit has forged strong partnerships with AHS teams and

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