Journal of Gerontological Nursing

Feature Article 

Medication Management Roles in Assisted Living

Suzanne K. Sikma, PhD, RN; Heather M. Young, PhD, RN, FAAN; Susan C. Reinhard, PhD, RN, FAAN; Donna J. Munroe, PhD, RN; Juliana Cartwright, PhD, RN; Glenise McKenzie, PhD, RN

Abstract

Residents in assisted living (AL) frequently need assistance with medication management. Rooted in a social model, AL serves people facing increasing health management challenges as they “age in place.” This study explored roles in AL medication management and satisfaction with unlicensed assistive personnel (UAP) as medication aides, a cost-effective staffing approach that is used frequently. The sample included 112 participants representing all parties involved in medication administration (residents, medication aides, administrators, RNs and licensed practical nurses, pharmacists, and primary care providers) in 15 AL settings in four states. Results include description of medication management roles; empirical validation of existing AL nursing professional standards; and satisfaction with the role of UAP as medication aide from all perspectives. Clinical implications include creating a supportive environment for medication aides (i.e., UAPs); the importance of the RN role as facilitator of AL medication management; and the need for collaboration and interprofessional team development across disparate settings. [Journal of Gerontological Nursing, 40(6), 42–53.]

Dr. Sikma is Professor, Nursing & Health Studies, University of Washington Bothell, Bothell, Washington; Dr. Young is Associate Vice Chancellor for Nursing, University of California (UC) Davis, and Dean and Professor, Betty Irene Moore School of Nursing at UC Davis, Sacramento, California; Dr. Reinhard is Senior Vice President, AARP Public Policy Institute and Chief Strategist, Center to Champion Nursing in America, Washington, DC; Dr. Munroe is Professor, Nursing & Health Studies, Northern Illinois University (NIU) College of Health & Human Sciences, DeKalb, Illinois; and Dr. Cartwright is Associate Professor and Dr. McKenzie is Assistant Professor, School of Nursing Ashland Campus, Oregon Health & Science University, Ashland, Oregon.

This study was funded by a National Institute of Nursing Research grant (R21 NR009201-01); Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services; the Robert Wood Johnson Foundation; the Sarah S. Fuller Memorial Scholarship, NIU School of Nursing; and the Illinois Department of Healthcare and Family Services, Medicaid Advisory Committee, Long-Term Care Subcommittee. The authors thank Barbara Hines, Janis Miller, Tiffany Allen, Gail Mauer, and Jennifer Farnham for assistance with data management and analysis.

Address correspondence to Suzanne K. Sikma, PhD, RN, Professor, Nursing & Health Studies, University of Washington Bothell, 18115 Campus Way NE, Box 358532, Bothell, WA 98011; e-mail: ssikma@uwb.edu.

Received: March 15, 2013
Accepted: December 18, 2013
Posted Online: February 19, 2014

Abstract

Residents in assisted living (AL) frequently need assistance with medication management. Rooted in a social model, AL serves people facing increasing health management challenges as they “age in place.” This study explored roles in AL medication management and satisfaction with unlicensed assistive personnel (UAP) as medication aides, a cost-effective staffing approach that is used frequently. The sample included 112 participants representing all parties involved in medication administration (residents, medication aides, administrators, RNs and licensed practical nurses, pharmacists, and primary care providers) in 15 AL settings in four states. Results include description of medication management roles; empirical validation of existing AL nursing professional standards; and satisfaction with the role of UAP as medication aide from all perspectives. Clinical implications include creating a supportive environment for medication aides (i.e., UAPs); the importance of the RN role as facilitator of AL medication management; and the need for collaboration and interprofessional team development across disparate settings. [Journal of Gerontological Nursing, 40(6), 42–53.]

Dr. Sikma is Professor, Nursing & Health Studies, University of Washington Bothell, Bothell, Washington; Dr. Young is Associate Vice Chancellor for Nursing, University of California (UC) Davis, and Dean and Professor, Betty Irene Moore School of Nursing at UC Davis, Sacramento, California; Dr. Reinhard is Senior Vice President, AARP Public Policy Institute and Chief Strategist, Center to Champion Nursing in America, Washington, DC; Dr. Munroe is Professor, Nursing & Health Studies, Northern Illinois University (NIU) College of Health & Human Sciences, DeKalb, Illinois; and Dr. Cartwright is Associate Professor and Dr. McKenzie is Assistant Professor, School of Nursing Ashland Campus, Oregon Health & Science University, Ashland, Oregon.

This study was funded by a National Institute of Nursing Research grant (R21 NR009201-01); Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services; the Robert Wood Johnson Foundation; the Sarah S. Fuller Memorial Scholarship, NIU School of Nursing; and the Illinois Department of Healthcare and Family Services, Medicaid Advisory Committee, Long-Term Care Subcommittee. The authors thank Barbara Hines, Janis Miller, Tiffany Allen, Gail Mauer, and Jennifer Farnham for assistance with data management and analysis.

Address correspondence to Suzanne K. Sikma, PhD, RN, Professor, Nursing & Health Studies, University of Washington Bothell, 18115 Campus Way NE, Box 358532, Bothell, WA 98011; e-mail: ssikma@uwb.edu.

Received: March 15, 2013
Accepted: December 18, 2013
Posted Online: February 19, 2014

Assistance with medication management is a common need for residents in assisted living (AL) who frequently have multiple health conditions and take multiple routine medications (Assisted Living Federation of America, 2006; Center for Excellence in Assisted Living, 2008). Although AL as a residential setting is growing dramatically, there are no federal standards or definitions, and state licensing definitions and standards regulating medication administration/management vary greatly (Mollica, Houser, & Ujvari, 2012). Depending on state regulations, day-to-day assistance with medications may be provided by unlicensed assistive personnel (UAP), often known as medication aides, under the general supervision and/or delegation of an RN. Stone (2010) called for research to obtain a better understanding of direct care workers’ (i.e., UAP) involvement in AL medication management. Medication management, one of the top quality issues in AL (U.S. General Accounting Office, 1999), involves communication among residents/families, primary care providers (PCPs), pharmacists, and AL staff (e.g., administrative, nursing, UAP).

This article reports a component of a four-state study of medication management in AL. Previously published findings focused on medication errors by UAP (Young et al., 2008) and strategies to promote safe medication administration (Young, Sikma, Reinhard, McCormick, & Cartwright, 2013). The purpose of this article is to: (a) describe the perceptions of residents, UAP, RNs, PCPs, and pharmacists regarding their roles in the medication management process in AL facilities; and (b) describe the satisfaction of these individuals with their medication management roles.

Method

The study was conducted in 15 AL settings in four states (Oregon, Washington, New Jersey, and Illinois). These states were selected to reflect variation in state AL policy, resident mix, delivery model, and licensed staff involvement in medication administration. Focused interviews and a 6-item Satisfaction with Medication Management Survey (SMMS) were used to gather and measure the perceptions of participants in the medication management process, including: AL residents, UAP, RNs/licensed practical nurses (LPNs), PCPs of AL residents, pharmacists, and facility administrators. All participants were asked to complete demographic information including role, age, gender, and ethnicity. Research procedures for the protection of human subjects were approved by institutional review boards in each respective state/university.

The SMMS was adapted for this study based on items developed with an expert panel and tested in previous studies (Sikma & Young, 2003; Young & Sikma, 2003). The SMMS assessed satisfaction with using UAP in medication management, and perceptions of the preparation and capabilities of medication aides to manage medications using a 5-point scale, with 1 = very positive to 5 = very negative. The SMMS included two open-ended questions regarding concerns and benefits of UAP assistance with medication administration. Data from the open-ended SMMS questions were combined with the interview data in the qualitative analysis. The SMMS was administered to a subset of the focused interview sample in Washington and Oregon. Data were analyzed using SPSS (version 21) to examine descriptive statistics and relationships among variables. Internal consistency reliability for the SMMS was determined using Cronbach’s alpha. Prior to examining differences among groups using one-way analysis of variance, the SMMS scores were examined to determine whether they met the assumptions of a normal distribution and homogeneity of variance. Post-hoc testing of differences among groups was conducted using the Tukey test.

Focused interviews lasting 30 to 60 minutes were conducted in a private location, audiorecorded, and transcribed. Open-ended questions (Table 1) elicited descriptions of medication management in the facility including the interviewee’s own role as well as others’ roles in medication management. Data analysis followed established procedures for constant comparative analysis (Corbin & Strauss, 2008). Codes were identified in domains such as roles, medication management logistics, medication systems, quality, training, and suggestions. Text could be assigned multiple codes. Each transcript was reviewed and coded by three members of the research team. The analysis for this article focused on discerning the role of each type of participant. After coding, four categories were developed (medication administration, supervision and training of UAPs, error management, and quality monitoring) from which the themes for each role were derived. Saturation was determined when a theme was reflected in transcripts from at least three states and from at least three participant perspectives (i.e., RN, UAP, resident, PCP, pharmacist, administrator). The data were then reviewed to discern any variation in role themes that reflect state regulatory differences and these variations were noted. This article focuses on themes from the domain of medication management roles.

Focused Interview Guide

Table 1:

Focused Interview Guide

Results

Findings include a description of the settings, quantitative results of the SMMS, and qualitative description of the various roles in the medication management process.

Description of the Settings

Fifteen facilities in Oregon, Washington, New Jersey, and Illinois participated. Facility capacity ranged from 42 to 142 units with an average size of 96 units. The sample included rural facilities from Oregon, Washington, and Illinois and suburban facilities from New Jersey and Illinois. Table 2 reflects the variety of regulation of UAP involvement in medication management in the four states at the time of the study. Table 3 summarizes our observations of how state-based variations in regulation also influenced the RN role and RN staffing. Across settings, there were two predominant models for pharmacy service. The first was a corporate wholesale pharmacy model in which a contracted pharmacy assumed responsibility of dispensing medications for the entire resident population. The second was a retail pharmacy model involving contracted relationships with small local retail pharmacies according to the personal choice and coverage of the resident (Young et al., 2008).

State Regulations and the UAP Role in Medication Management

Table 2:

State Regulations and the UAP Role in Medication Management

Influence of State Regulation on RN Role and RN Staffing in Sample

Table 3:

Influence of State Regulation on RN Role and RN Staffing in Sample

Satisfaction with Medication Management Survey

SMMS Sample. The SMMS assessed satisfaction with medication management and perceptions of the preparation and capabilities of UAP to manage medications. The sample of 82 respondents came from eight facilities in Washington and Oregon. Demographic characteristics are summarized in Table 4 and reflect younger age and greater diversity among UAP, and a high proportion of women among residents, UAP, and nurses.

Demographics of the Sample

Table 4:

Demographics of the Sample

Table 5 summarizes satisfaction with medication management and includes item scores and the total score by role. The scale has strong internal consistency, with Cronbach’s alpha = 0.87. The total satisfaction score for the entire sample was 1.81, indicating overall high satisfaction with using UAP to manage medications in AL. UAP were the most satisfied overall, followed by residents. Although PCPs and pharmacists were the least satisfied, mean total scores of health care professionals (RN/LPN, NP-PCP, MD-PCP, and pharmacists) were all in the 2 to 3 range, indicating moderate satisfaction.

Satisfaction with Medication Management by Role and Survey Item

Table 5:

Satisfaction with Medication Management by Role and Survey Item

In examining the item scores, UAP perceive themselves as more prepared and more capable than any other group’s perception of their readiness. The pharmacists believed UAP were fairly capable, though not as prepared and they were somewhat willing to promote this practice, but they and the PCPs were dissatisfied at the lack of choice in deciding whether UAP could assist with medications. RNs/LPNs and nurse practitioners (NPs) had similar ranges of mean scores. Both were moderately satisfied with the capability of UAP, slightly less satisfied with their preparedness, but were willing to promote UAP in this practice. For NPs, the highest mean score (least positive) was related to the question about choice in the decision of whether UAP would assist with medications. For RN/LPNs, the two items tied as least positive were about the capability of UAP to assist with medications and whether they had choice in deciding whether this practice occurred.

Group differences in satisfaction were also examined, comparing four groups: residents, UAP, facility professionals (nurses and administrators), and external professionals (PCPs and pharmacists). Overall trends were positive for UAP medication management, with facility professionals and residents similarly positive; however, external professionals were the least positive about UAP managing medications. Total satisfaction was statistically significantly different among these groups as determined by one-way ANOVA, F(3, 77) = 10.21, p < 0.000. Because the scores met the assumption of homogeneity of variance, Tukey’s honestly significant difference post-hoc test was used to examine the group differences, substantiating that the external professionals had a more negative perspective on UAP managing medications than any of the other three groups (p < 0.05).

Roles in Medication Management

Qualitative Sample. The qualitative data provide a description of the roles and perceptions of participants in the medication administration process. The sample included 112 participants in 15 facilities in Washington, Oregon, Illinois, and New Jersey.

All participants commented on their own roles and expectations related to other members of the team. The themes (Table 6) elaborated below for each role reflect a synthesis of these perspectives. Except where specifically noted, there was solid agreement among perspectives on the themes that emerged. As might be expected, those most closely involved in medication administration (UAP and nurses) provided richer descriptions of the roles. There was also solid agreement across states on role themes except for the state regulatory variations described in roles of UAP, RNs, and pharmacists.

Roles in Medication Management in Assisted Living (AL)

Table 6:

Roles in Medication Management in Assisted Living (AL)

AL Resident Role. The first resident role theme was deciding to get medication service. The residents predominantly viewed the assistance in medication management provided by the AL facility as a benefit, making managing their medications easier and safer because they struggled with remembering to take their medications on their own. Some reported being reluctant about starting medication service, either because of the added cost, or because of fear of loss of autonomy, but had become comfortable with the ease and safety it ultimately provided.

The second resident role theme was communication link between external providers and AL staff after health care visits outside the AL facility. After a visit to the PCP, emergency department, or hospital, residents reported that they or a family member were responsible for giving new or updated information about medications to the nurse or UAP on duty. Most residents were appreciative of medication service and reported positive communication with UAP and nurses about their medications.

The third resident role theme was asking questions and reporting concerns. Most residents identified the AL nurse or the PCP as the individual they would go to with questions about their medications. Residents report problems or concerns about the administration of their medications to either UAP or the AL nurse. Although a few residents expressed concerns about the qualifications of UAP helping them with medications (e.g., “They just hire them off the street”), most seemed unaware of the training or preparation of UAP and viewed them as competent because of positive personal relationships and helpful interactions with them.

UAP Role. The first and most discussed theme in the UAP role was passing, verifying, and documenting the delivery of medications to residents. In Illinois, regulation limited “passing medications” to handing pre-packaged medications to residents. Verification that residents took their medications and documentation of this was common to all four states. The “medication pass” was a central focus of the UAP role in medication management in New Jersey, Oregon, and Washington. Medication administration passes were described by UAP as physically and mentally demanding times with a large volume of medications needing to be administered correctly in relatively limited periods of time, while maintaining concentration and accuracy. For example, we observed one UAP who administered 375 medications to 49 residents in a 2-hour time frame. In addition to the intense time demands of such a medication pass, UAP report being challenged by the physical demands of assisting frail or confused residents: “It’s hard sometimes because they’re confused and declining.” Some UAP reported that concurrent job tasks (e.g., assisting a resident with a personal care need or responding to an emergency) create additional demands on them while administering medications. In addition, UAP were often responsible for additional tasks needed to facilitate medication administration: calling in new orders to the right pharmacy; ordering medications; stocking medication carts or room-based medication storage boxes; pulling old medications when told to do so by the RN; and packaging medications for residents going on family/community visits outside of the facility.

The second theme in the role of UAP was relational demands. The work of UAP in medication management was described as relationally demanding and required strong support from the RN. UAP report communicating with residents about new medications or reminding residents about the purpose of the medications they are taking. If a resident initially refuses a medication, UAP described attempting to explain why the medication is important and encouraging the resident to take it. UAP described the challenge of convincing a confused resident to take a medication: “We make three attempts to convince if initially refused.” UAP report the need to communicate frequently with professionals on the team (i.e., RN, PCP, and pharmacist). They report medication errors or unusual incidents to the RN. They may also need to communicate via phone or fax with PCPs regarding unusual incidents, request order clarifications, or report resident changes. They may communicate with multiple pharmacies about orders or medication supply issues.

The third theme in the UAP role is relationship with supervising nurse. In the area of supervision and training, regardless of the parameters set by different regulatory structures across the states, an important relationship is the one between UAP and facility nurse. UAP described routine reporting about resident changes such as side effects for routine medications, side effects for higher risk medications such as warfarin (Coumadin®) (bruising or bleeding), exceptions such as resident refusal of medications or “leftover” medications, and general changes in resident behavior or conditions (“Just noticing if something is different.”). UAP felt supported by having the nurse available for consultation via phone on evenings, nights, and weekends. UAP described facility-specific systems for routine written documentation and communication of issues to the nurse. Although formal preparation for the UAP role was limited and varied by state, UAP described the nurse as the person who provided facility- and resident-specific training beyond the state mandates and individual instruction for performing tasks under applicable nurse delegation protocols. UAP consulted with the nurse in problem-solving team or resident issues.

A fourth UAP role theme was selected tasks to promote quality. UAP described a sense of accountability and responsibility that went along with their work. During medication administration, UAP reported being cognizant of the need for accuracy and the “rights” of medication administration—right person, right drug, right dose, right form, right route, right time, the right to privacy, and the right of the resident to refuse medication. They reported worrying about residents after they left work and calling the facility to follow up regarding medication-related details they forgot to report at the end of their shift. Facility nurses reported that they rely on UAP to report changes in the resident but also worry about their ability to understand the complete picture of what is occurring with residents and the risks or urgency associated with certain medications. Some UAP reported a role in quality monitoring. Monitoring tasks reported included monthly checking of new medication administration records (MARs) to ensure that items on newly printed MARs matched the orders; checking incoming medications to ensure they matched the MARs; sending out quarterly MARs to PCPs for their review; and processing changes on MARs when orders come back from PCPs.

The fifth theme in the UAP role was team leadership. UAP performing the medication administration/assistance functions were often the most experienced or strongest caregivers in the facility. They described a role of team leader, especially during hours when the nurse or other managers are not present in the facility. They might cover for another medication aide so that he or she can concentrate on monthly MARs review; come in early or stay late to finish important tasks; or assume other roles as needed (e.g., caregiver, wait staff, dishwasher, receptionist, supervisor) to facilitate the work of the team. In summary, the UAP role is the frontline of AL medication management. As the staff members who spend the most time with residents, they are perceived by all participants as key to safe and effective medication services.

RN Role. Overall, the RN role was described from all perspectives as essential to safe medication management in AL. LPNs and licensed vocational nurses (LVNs) were found to perform selected functions comparable to the RN role at two facilities, and their narratives are included with the RNs’ narratives.

The first RN role theme was clinical assessment and oversight of resident health and care. Tasks related to this function include resident assessment for self-medication or need for medication assistance; assessment of residents relative to medication effectiveness and potential side effects; monitoring residents with variable dose and higher-risk medications (e.g., psychotropic drugs, anticoagulant agents, insulin, analgesic agents); regular clinical assessment of resident health to discern changes necessitating further evaluation by the PCP and possible medication changes; collaborating with other health professionals regarding resident care needs and health changes; review/update of changes ordered following a PCP visit or transfer from another setting; and overall coordination of admission, discharge, and ongoing service plans. RNs may also provide selected direct medication administration tasks, depending on the state regulations and facility policies. The community retail pharmacy (Young et al., 2008) added a complexity not present in other institutional settings. Depending on residents’ pharmacy coverage, the facility may be receiving medications from several different pharmacy providers or systems so that coordination by the RN to accommodate multiple, disparate pharmacy providers may be needed.

A second RN role theme was supervision and training. RNs described the need to understand both state scope of practice regulations for RN, LPN, and UAP roles as well as state regulations regarding delegation of medications and clinical procedures to UAP in AL. The RN has to negotiate delegation and medication administration functions when LPNs are part of the AL staffing model and when home health care or hospice agencies are involved in a resident’s care. Supervision involved ensuring that UAP and LPNs are not going beyond the state-defined scope of their practice and being available (in-person or via telephone) for questions, changes, or resident problems. UAP reported highly valuing having an RN available for questions and consultation. RNs reported being involved in training UAP in a variety of ways: teaching facility-specific medication administration policies and procedures; teaching medication administration fundamental skills; facilitating UAP access to standardized, state-based training; testing UAP medication knowledge; direct observation of UAP medication passes; providing resident-specific instruction regarding new or higher-risk medications; and ongoing training for UAP about medication administration and side effects.

A third RN role theme was error processing and management. RNs reported being responsible for taking reports regarding medication errors or suspected errors, investigating the incident, and assessing the resident involved. Based on the resident assessment and situation investigation, the RN needed to follow up with residents, families, PCPs, and pharmacists as necessary. RNs discussed providing follow-up counseling and retraining as necessary with the staff involved. Finally, the RN assured that required documentation of the event was reported to appropriate parties/regulators.

A fourth RN role theme was quality monitoring. Nurses reported monitoring occurring at the individual, group, and facility level. At the individual level, they described providing oversight and monitoring of individual resident medication profiles and looking for problems such as duplicates, contraindications, timing issues, and undocumented medication changes. They also assessed the competence of each individual UAP through skill testing, direct observation of medication administration, feedback from residents and other staff, and daily supervision and communication. At the group level, the RN promoted quality through regular monitoring of UAP assignments and staffing, medication order transcription and processing, MARs, audits of the medication room/carts for missing or extra medications and proper storage of medications, the controlled medications log, and all aspects of the environment for cleanliness and proper use of infection control procedures related to medication administration. At the facility level, RNs described tasks reflecting system-level quality promotion and monitoring such as developing and assuring that needed systems are in place and evaluating existing systems and troubleshooting with relevant parties such as pharmacists, administrators, PCPs, staff, and residents/families. RNs were generally tasked with dealing with complaints about clinical care and following up on medication issues that were identified in regulatory facility surveys.

PCP Role. The first PCP role theme in medication management was overall assessment of resident health status. PCPs included nurse practitioners (NPs) and physicians. Some saw residents off-site in private practices in the community. Others made regular visits and followed residents on-site as the facility NP or medical director. NPs often saw frail older adults at several different types of community-based residences, including AL facilities. The second PCP role theme was medication profile determination and review. Although some community PCPs described superb periodic medication reviews, our observation was that comprehensive medication review was done more consistently for residents in facilities with a PCP (MD or NP) who was regularly on-site and in New Jersey, where regular pharmacy review was a regulatory requirement. A frustration noted by PCPs in rural areas was the challenge of managing medication profiles for mental/behavioral health issues when there was a lack of geropsychiatric experts in the community with whom to consult.

The third PCP role theme was communication with AL facility staff. PCPs in the off-site practices reflected less understanding of facility processes and staff preparation than those who regularly visited residents in the AL community. PCPs did not report being involved in training or supervision of UAP and, except for those employed as a facility medical director, did not report involvement in quality monitoring in the facility. “Care management by fax” was reported as an irritant in the role of community PCPs who faced frequent fax communications from the facility regarding medication issues. Some expressed frustration at the communication from UAP and a lack of understanding of the limited scope of practice of UAP in relation to RNs and the context of the AL environment in general. PCPs reported receiving incomplete clinical information related to poorly articulated clinical problems. This frustration with the limited expertise and scope of UAP practice was exacerbated because of frequent faxes from facility UAP, which were time consuming and for which the PCP would not be paid unless the resident was seen for an office visit.

The Pharmacy Role. The first theme in the pharmacy role was communication with PCPs. This role includes clarifying orders with PCPs when necessary and making recommendations to PCPs regarding medications when appropriate. The second pharmacy role theme was dispensing, packaging, and delivering medications to the AL facility. There was frequent communication between facility staff and pharmacies regarding medication changes and questions from the staff (e.g., dosage, interactions).

A third pharmacy role theme was contracted tasks as facility pharmacy. Many facilities had a contractual agreement with a community pharmacy. Under these agreements, the pharmacy assists the AL with tasks such as generating MARs for all residents in the facility, collaborating in developing pharmacy procedures, and assuring that pharmacy regulations are followed (e.g., tracking controlled drugs). Except for New Jersey, where regulations require pharmacist involvement in systematic medication review, there are no regulatory requirements for having quality enhancement programs to review higher-risk medications and medication reduction. New Jersey AL staff were positive about this additional pharmacy involvement, citing additional beneficial services provided as a part of the required quarterly consultation, such as review of facility medication administration processes, medication error review, and training for the medication aides.

Facility Administrator Role. The first administrator role theme was regulatory compliance and oversight of facility policies and procedures for medication management. Administrators described ensuring regulatory compliance of facility policies and procedures and overseeing the response to medication management events/incidents that might put the facility at risk. Administrators often reported delegating clinical oversight of UAP and resident care to RNs, who would ensure that UAP are properly trained and collaborate with the administrator in ensuring that adequate staffing is provided for medication management. Although some administrators with a nursing license may be more directly involved in selection, supervision, and training of UAP involved in medication management, most appropriately delegate this clinical oversight to the facility nurse. Responsibility for managing costs and ensuring financial resources for safe medication systems were consistent role expectations.

A second administrator role theme was managing contractual relationships and costs as well as ensuring financial resources for safe medication systems. This theme involved collaboration with the facility nurse in planning a safe and effective staffing mix and prioritizing resources to ensure medication administration was safe. It also involved managing contractual arrangements with consultant pharmacies and, if applicable, the medical director, who work with the facility on medication management.

The third identified role of administrator was operational leadership to manage risk and negotiate diverse needs. Operational leadership was described as providing structure and leadership for managing risk by balancing needs of residents, facility staff, outside providers, contractors, and regulatory bodies. Descriptions included an active role in problem solving with pharmacy systems and ensuring that residents receive medication services needed and required by regulations.

Discussion and Clinical Implications

These findings help elucidate the diverse roles and relationships involved in medication management in AL. The UAP–resident dyad is central in the daily management and administration of routine medications. The RN is closely related and critical to quality, providing clinical assessment and oversight, supervision and training of UAP, error management, and quality monitoring functions. The administrator role focuses on regulatory compliance through policies and procedures, resource/contract management, and operational leadership. The PCP and pharmacist roles focus on the quality of individual resident medication prescribing and dispensing and are generally (with the exception of the minority of facilities with a medical director or contract pharmacist) more peripheral by design in system quality monitoring functions. In general, satisfaction data (SMMS) indicate moderately positive perceptions of UAP involvement in medication management in AL by all parties involved. Despite differences among state regulatory standards, the qualitative findings also suggest that the practice of using UAP in medication administration seems to be working.

Although the philosophy behind AL is a home-like social model, the reality is that the environment is complex. Our findings confirm that medication management requires mobilizing disparate participants and negotiating competing needs in a setting that has both home-like and institutional characteristics (Ryder, Joseph, Zuckerman, & Zuckerman, 2009). Residents want congruence between their perceived need for assistance with medications and the facility practices that provide it. This is consistent with the findings of Carder, Zimmerman, and Schumacher (2009). Our findings further support that the health needs of residents and “aging in place” requires competent institutional systems to ensure safe medication administration (Young et al., 2013).

The comments from multiple perspectives highlight the importance of consistent, positive relationships to manage this complexity. The need to coordinate medication dispensing with multiple pharmacies presents challenges to residents/families, facility staff, and PCPs. Similar challenges are faced by facilities in working with multiple PCP private practices. Facilities with an NP or medical director with regular presence seemed to have an advantage at managing this complexity. Our observations and results reported elsewhere (Young et al., 2008, 2013) suggest that facilities with a regular onsite pharmacist or consultant contracted for medication review seemed to encourage medication reduction programs. In facilities without a regular PCP and/or pharmacist, communication challenges may make it difficult for the RN to facilitate medication reduction interventions.

The complexity of AL environments ultimately influences the front line of medication management by UAP. They face the daily challenge of high volume, time pressured, physically, and emotionally demanding work with limited preparation. Typically selected for the medication aide role because they are the “best” of the facility’s caregivers, they feel a sense of responsibility and accountability for this important task in medication management. Potential negative consequences of the role may include increased work stress or turnover, “taking shortcuts” to meet the time demands of a heavy medication pass, or becoming task-oriented on medication administration rather than providing person-centered care. Positive consequences of the role may include opportunity for promotion, pride/satisfaction in the role, and increased employment tenure. Ball, Hollingsworth, and Lepore (2010) described how AL medication aides remain “universalists” and reported a significant relationship between feeling pressed and job dissatisfaction. Their findings are also consistent with our recommendation that quality is enhanced by developing clear role expectations, policies, appropriate staff support (teamwork, positive relationships), and training for the role of medication aide.

The Patient Protection and Affordable Care Act (2010) is driving health care reform across practice settings, creating a renewed focus on the issues of access, quality, and cost required by its provisions. In this context, coordination of care for residents in AL takes on new importance, as these residents are among the most chronically ill and most likely to use health care resources, including acute hospitalizations. It is troubling that potentially ill or impaired residents and families must assume the primary responsibility as communication link among providers and settings. The gap is most obvious between the PCP practice and the AL setting, with minimal information exchanged between professionals. Communication during transitions is of particular importance, and medication reconciliation and accuracy are key issues for effective collaboration across settings and among professionals on the health care team.

Increasingly, interprofessional teams are accountable for outcomes, and there is a growing recognition of the importance of highly functioning teams as a mechanism to promote and enhance health care delivery practices and clinical outcomes (Institute of Medicine, 2008, 2010). As our study participants noted, medication management requires the involvement of multiple professions and unlicensed staff who must communicate with one another to accomplish the process of medication management, yet, the structures of AL preclude the team from gathering as an interprofessional group to plan and evaluate care. Rather, individual players engage in individual encounters with one another without an overarching shared process for enacting their roles. Core interprofessional competencies, such as communication and clarity of roles (Interprofessional Education Collaborative, 2011), are not readily developed in this setting due to geographic isolation and lack of team structures to support such interaction. Despite this, members of the teams in our study were able to coordinate an impressive quantity of medication delivery, raising the question of whether improvements in safety and in appropriateness of medications could be accomplished through greater team collaboration.

Finally, these findings support our conclusion that the RN is the ideal role to facilitate a holistic model of medication management in AL that bridges the dichotomy between the ideal social model from which AL originated and the actual medical needs of AL residents that are the result of aging in place. These findings also serve as validation of the responsibilities and competencies related to the role function of medication management developed by the Americana Assisted Living Nurses Association (2006a, 2006b). AL staffing models control costs through the use of UAP for medication assistance. RNs can mobilize disparate participants to facilitate holistic monitoring and risk management of clinical issues; provide strong training, supervision, and support to UAPs; and develop and implement risk management and quality monitoring systems. The limited RN staffing resource must be used wisely. RNs may find a community health nursing model (Sikma, 2009) useful to promote UAP competence, staff/resident/family relationships, and resident well-being. Nurses should advocate for the value of a strong nursing presence in AL facilities by emphasizing the savings, rather than the costs, of nursing. Investing in RN staffing helps a facility avoid bad outcomes (e.g., unhappy residents and families, liability for negative events, citations), retain residents (e.g., keeping units full), retain staff (e.g., avoiding turnover costs), and promote positive outcomes such as resident satisfaction, positive facility reputation, and high occupancy.

References

  • American Assisted Living Nurses Association. (2006a). Assisted living nurse competencies. Retrieved from http://www.alnursing.org/resources/AALNANurseCompetencies.pdf
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Focused Interview Guide

1. Please describe to me how medications are managed in this facility.
2. What role do you play in medication management?
3. What has been your experience with medication management here—how do you view it?
4. In your role, what do you do when there is a change in medications?
5. What is your perspective on the quality of care provided with medications here?
6. How is the quality of medication management monitored here in this facility?
7. What would you do if you identified a problem with medications here?
8. Are there any particular issues that you have with medication management here?
9. How satisfied are you with medication management here?
10. Do you have any suggestions for improving the service or for training or support?
11. Is there anything else you would like to tell me about medications here at this facility?

State Regulations and the UAP Role in Medication Management

Regulation for UAP Involvement Oregon Washington New Jersey Illinois
May receive and process new medication orders X X X
May set up and prepare medications sent in a variety of pre-packaged forms from pharmacy X X X
May hand medications to resident and assist him or her as needed to take them X X X
May only deliver pre-packaged medications to resident X
Confirm that resident took medication X X X X
Document that dose was taken/refused X X X X
May administer insulin under nurse delegation regulations X X
May administer PRN medications X X X
May administer controlled drugs X X X
Required training for UAP involvement in medication management OTJ at RN discretion 28-hour fundamentals; 8-hour BON delegation 24-hour BON medication aide certification; OTJ by RN delegation OTJ by RN for medication reminders

Influence of State Regulation on RN Role and RN Staffing in Sample

State Influence of State Regulation on RN Role RN Staffing (Average FTE per Facility)
New Jersey State regulations requiring RN monitoring of residents, supervising/delegating UAPs, and reducing polypharmacy led to generally higher RN staffing and involvement. 2.19
Illinois UAP role most limited, thus licensed nurses manage medications from order to administration of medications to residents who are not able to receive and self-administer pre-packaged medications. 1.08
Oregon State requires RN documentation of nurse delegation. RN less involved in overall resident monitoring and direct supervision of UAPs and more focused on compliance with required nurse delegation documentation. A senior UAP was often designated as resident care coordinator and supervised UAPs. 1.0
Washington State regulation allows a range of RN practice with some facilities having an evolved RN role consistent with New Jersey and some using an alternate model of delegation of selected medication management functions to LPNs as well as UAPs. 1.0

Demographics of the Sample

Focused Interview Sample (n = 112)/Satisfaction Survey Sample (n = 82)
Residents UAP RN/LPN Pharmacist Administrator PCP
Sample (N) 27/25 32/21 16 RN, 2 LPN/8 RN, 2 LPN 8/6 17/11 5 MD, 4 NP/5 MD, 4 NP
Age (mean, SD) (years) 81 (5.5)/83.6 (5.9) 38.7 (12.5)/36.6 (13) 49 (9.6)/48.3 (11.8) 48 (11.5)/46.3 (11.6) 46.3 (8.9)/46.3 (7.9) 50.2 (5.3)/50.2 (5.3)
Sex (% female) 77.8/80 96.9/95.2 100/100 37.5/33.3 76.5/72.7 55.6/55.6
Ethnicity (%)
  Native American 3.7/4 0/0 0/0 0/0 5.9/9.1 0/0
  Hispanic 0/0 9.4/4.8 0/0 12.5/16.7 5.9/9.1 0/0
  African American 0/0 18.8/0 5.6/0 0/0 0/0 0/0
  Asian American 0/0 6.3/9.5 0/0 0/0 0/0 0/0
  Caucasian 96.3/96 53.1/81 88.9/100 75/83.3 82.4/81.8 100/100
  Other 0/0 6.3/0 0/0 0/0 0/0 0/0
  Missing 0/0 6.3/4.8 5.6/0 12.5/0 5.9/0 0/0

Satisfaction with Medication Management by Role and Survey Item

Mean (SD), Range
Survey Item Residents/Family (n = 25) UAPs (n = 21) RN/LPN (n = 10) NP-PCP (n = 4) MD-PCP (n = 5) Pharmacy (n = 6) Administration (n = 11)
1. In GENERAL, what do you think of UAPs assisting with medications? 1.48 (0.95) 1.38 (0.50) 2.30 (1.49) 2.5 (1.29) 3.20 (1.10) 2.50 (1.05) 1.36 (0.50)
1 to 5 1 to 2 1 to 5 1 to 4 2 to 4 1 to 4 1 to 2
2. What do you THINK of UAPs assisting with medications in this setting? 1.74 (1.25) 1.19 (0.40) 2.30 (1.70) 1.75 (0.50) 2.60 (0.89) 2.17 (0.75) 1.36 (0.50)
1 to 5 1 to 2 1 to 5 1 to 2 2 to 4 1 to 3 1 to 2
3. How willing are you to PROMOTE UAPs assisting with medications? 1.88 (1.30) 1.095 (0.30) 1.60 (1.26) 2.50 (1.00) 2.40 (1.14) 2.33 (1.03) 1.36 (0.50)
1 to 5 1 to 2 1 to 5 2 to 4 1 to 4 1 to 4 1 to 2
4. Would you agree that you have CHOICE in deciding whether UAPs assist with medications? 1.96 (1.37) 1.43 (0.75) 2.40 (1.84) 3.25 (0.50) 4.25 (0.96) 3.8 (1.79) 1.82 (1.17)
1 to 5 1 to 4 1 to 5 3 to 4 3 to 5 1 to 5 1 to 4
5. How PREPARED do you feel UAPs are to assist with medications safely? 1.92 (1.04) 1.24 (0.44) 2.40 (0.97) 2.75 (0.96) 2.80 (1.30) 2.17 (0.75) 1.82 (0.88)
1 to 5 1 to 2 2 to 5 2 to 4 2 to 5 1 to 3 1 to 4
6. How CAPABLE do you believe UAPs are to assist with medications? 1.84 (1.07) 1.14 (0.36) 1.70 (0.67) 1.75 (0.50) 2.60 (0.89) 1.83 (0.75) 1.36 (0.50)
1 to 5 1 to 2 1 to 3 1 to 2 2 to 4 1 to 3 1 to 2
Total Score 1.817 (0.83) 1.25 (0.31) 2.12 (1.06) 2.4 (0.62) 3.0 (0.85) 2.43 (0.85) 1.515 (0.43)
1 to 4.5 1 to 2 1.17 to 4.67 1.67 to 3.17 2 to 4.33 1 to 3.17 1 to 2.17

Roles in Medication Management in Assisted Living (AL)

Role Title Core Role Elements
Resident

Deciding to get medication service

Communication link

Asking questions and reporting concerns

Unlicensed assistive personnel (UAP)

Passing, verifying, and documenting delivery of medications to residents

Relational demands

Relationship with supervising nurse

Selected tasks to promote quality

Team leadership

RN (LPN/LVNs perform selective functions based on state scope of practice regulations)

Clinical assessment and oversight of resident health and care

Supervision and training of UAPs

Error processing and management

Quality monitoring

Primary care provider (PCP)

Overall assessment of resident health status

Medication profile determination and review

Communication with AL facility staff

Pharmacy

Communication with PCP

Dispensing, packaging, and delivering medications to facility

Contracted tasks as facility pharmacy

Facility administrator

Regulatory compliance and oversight of facility policies and procedures for medication management

Managing contractual arrangements, costs, and ensuring financial resources for safe medication systems

Operational leadership to manage risk and negotiate diverse needs

Keypoints

Sikma, S.K., Young, H.M., Reinhard, S.C., Munroe, D.J., Cartwright, J. & McKenzie, G. (2014). Medication Management Roles in Assisted Living. Journal of Gerontological Nursing, 40(6), 42–53.

  1. Satisfaction data indicated moderately positive perceptions of unlicensed assistive personnel (UAP) involvement in medication management in assisted living by all parties involved.

  2. Quality is enhanced by clear role expectations, policies, staff support, and training for the role of medication aide.

  3. The RN role is critical to quality and avoidance of bad outcomes by providing clinical assessment and oversight, supervision and training of UAP, error management, and quality monitoring.

10.3928/00989134-20140211-02

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