International Journal for Quality in Health Care 16:237-243 (2004)
International Journal for Quality in Health Care vol. 16 no. 3 © International Society for Quality in Health Care and Oxford University Press 2004; all rights reserved
Home care aides in the administration of medication
Department of Community Medicine, Division of Geriatric Medicine, Malmö University Hospital, Malmö, Sweden
Objective. To assess to what extent home care aides (HCAs) within the social services are engaged in medication administration, including their knowledge of how to perform this work correctly, and also to assess their knowledge of pharmacology, adverse drug effects, diseases, and symptoms. Furthermore, we wanted to study if there were any changes to be seen in these areas since a previous study.
Design. A repeated survey, carried out in 1998, 5 years after a cross-sectional study. In a stratified sample of personnel within the social services in nine of Malmö’s (Sweden) 10 administrative districts, a questionnaire with multiple-choice and open-ended questions was answered individually and under supervision. Statistical analyses were carried out using the chi-square test, except for logistic regression where odds-ratios were presented.
Study participants. Employees (341) within the social services in the municipality of Malmö, of whom 313 were HCAs and 28 were supervisors, most of whom also were HCAs, at a total of 36 workplaces. The study 5 years earlier included 393 employees, of whom 39 were supervisors and 354 were HCAs.
Main outcome measures. Where possible, the answers in the knowledge test were classified as ‘correct’, ‘partially correct’ or ‘erroneous’, or were assigned to the group ‘do not know/have not answered’.
Results. Most (95%) of the HCAs were engaged in medication administration. On average, 53% managed to give a correct or partially correct answer on questions concerning medication administration. The result concerning indications for common drugs was 55%, contra-indications and adverse drug effects 25%, and symptoms 59%. Some general improvements in knowledge were seen from 1993 to 1998, mostly in the area of medication administration, but the results also indicated a change for the worse in the area of indications for common drugs.
Conclusions. Although most HCAs are engaged in medication administration, to a great extent they lack knowledge in the area. There is a need for additional personnel with the appropriate professional background, i.e. registered nurses, and a need for further training of HCAs in order to ensure patient safety. With respect to this, issues of learning and quality improvement are discussed.
Keywords: clinical competence, health manpower, home care services, home health aides, medication errors, medication systems, quality of health care, safety
Address reprint requests to: Johan Axelsson, Department of Community Medicine, Division of Geriatric Medicine, Malmö University Hospital, Entrance 59, S-20502 Malmö, Sweden. E-mail: johan.axelsson{at}smi.mas.lu.se
Accepted for publication January 14, 2004.
In the last few years’ there has been an increase in drug use, alongside greater efficiency in the treatment of several diseases, which entails an increased risk of adverse drug reactions (ADRs), especially in the elderly [1,2]. Personnel helping a patient with medication administration have a great responsibility, because errors can have severe consequences.
Home care aides (HCAs) do not have the proper professional preparation needed for medication administration, but the task can be delegated to them if a registered nurse decides that it can be done safely [3–5]. This was originally meant to be only on a temporary basis, but most of the HCAs within social services today are handling medications in their daily work. Since delegating the task of medication administration to non-nurse personnel entails an increased risk for the patient, in 2000 the Swedish National Board of Health and Welfare decided on more restrictive regulations for these delegations. Due to a lack of resources within health care and social services and problems finding enough registered nurses, in 2002 these regulations again became less restrictive.
In 1993, a cross-sectional study [6,7] was performed in Malmö, Sweden, which showed that 95% of the HCAs within the social services were engaged in medication administration, but that they had insufficient knowledge of medications and their administration, and also of common diseases and symptoms. Since the study, increased efforts have been made to increase education and we have also seen some organizational changes.
The aims of this study, in 1998, were to assess: to what extent the HCAs within the social services were engaged in medication administration; HCAs’ knowledge of how to perform this work correctly; and HCAs’ knowledge of pharmacology, adverse drug effects, diseases, and symptoms. Furthermore, we wanted to examine any changes in these areas since the study 5 years earlier (1993).
Parts of this study have been reported previously (in Swedish) in the journal Läkartidningen [8].
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Methods |
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Study design
A repeated survey was carried out in 1998, 5 years after a cross-sectional study in 1993.
In a stratified sample of personnel within the social services in nine of Malmö’s 10 administrative districts, a questionnaire was answered individually and under supervision. We used a separate randomization list for each of the nine districts in order to ensure representativeness. The 10th district was excluded because of the small number of elderly people and HCAs. We aimed to reach >300 subjects within the shortest possible time to minimize the risk of rumours reaching the subjects before the questionnaire. The subjects were summoned for a meeting and were not told of the survey beforehand. They were informed of the right to abstain from participation and of the confidentiality of their information. As far as possible the questionnaire was designed to allow a comparison with the former study in 1993, with the same multiple-choice and open-ended questions.
The subjects were asked questions about indications, contra-indications and adverse effects of common drugs (drugs were exemplified with common brand names), medication administration, and what steps to take in some presented cases. We also sought information on age, sex, education, previous occupation(s), current post, delegation, and participation in medication administration.
Participants
We reached 29% of the total number of HCAs within the social services in the municipality of Malmö; these comprised a total of 341 employees, 313 of whom were employed as HCAs and 28 were employed as supervisors, most of whom also were HCAs, at a total of 36 workplaces.
One participant refused to continue after a few questions. Six other participants did not complete the questionnaire due to emergencies. Thus, 98% of the study sample completed the questionnaire.
The study 5 years earlier included 393 employees within the social services in Malmö, of whom 39 were employed as supervisors and 354 as HCAs.
Measurements
Where possible, the answers in the knowledge test were classified as ‘correct’, ‘partially correct’ or ‘erroneous’, or were placed in a group entitled ‘do not know/have not answered’. Several questions had more than one correct alternative. In cases where the subject identified more than half the correct alternatives and those outnumbered any erroneous answers in that question, the answer was classified as ‘partially correct’.
Data analysis
Statistical analyses were carried out using the chi-square test, except for logistic regression where odds-ratios were presented.
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Results |
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Ninety-five per cent of the HCAs participated in medication administration. It is notable that 10% of the staff was engaged in medication administration without the delegation needed. According to informal discussions with personnel during the study, compliance with the delegation regulations differed between workplaces. Some HCAs had medication administration delegated to them without their education or knowledge being tested. This was said to be due to work pressures, in particular a shortage of personnel.
On average, 55% of the HCAs managed to give correct or partially correct answers to questions about indications for common drugs (Table 1); this average was only 25%, however, when HCAs answered questions about contra-indications and adverse drug effects (Table 2). Even though most of the questions were difficult to answer for the subjects, most of them seem to know that acetyl salicylate (aspirin) can cause gastric ulcers and haemorrhages.
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Subjects were asked if it is advisable to give a patient his/her sleeping pill after 2 a.m. The majority correctly answered ‘no’. Few, however, knew that the duration of the hypnotic’s effects is often considerably longer in the elderly than in the younger patients.
A number of questions involved symptoms and treatment of diabetes (Table 3). In an open-ended question, a case was described where a patient shows typical symptoms of hypoglycaemia. When asked how to act, 81% of the HCAs say they would contact a nurse or a doctor, or at least give the patient some form of carbohydrates. However, 6% say they would give the patient insulin, which could easily be fatal. Some others reasoned that the patient needs more insulin, but chose to ask a nurse before giving the insulin. In the group that wanted to give insulin, fewer recognized the patient’s hypoglycaemia. There seemed to be a rather common misconception among HCAs that insulin raises the blood glucose level. On average, 59% of HCAs managed to correctly or partially correctly identify the symptoms presented in the various cases, including both diabetic and non-diabetic patients (Tables 3 and 4).
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On average, 53% of HCAs managed to give correct or partially correct answers to the questions concerning medication administration in the 1998 study (Table 5).
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Medication lists are marked with warnings of any drug constituting a lethal risk for the patient, e.g. those that may elicit an anaphylactic reaction. In order to avoid any misunderstanding, the warnings are formulated in a fixed manner all over the country, as follows. ‘VARNING (WARNING)’: followed by the name of the drug, according to directions from the National Board of Health and Welfare [9]. A minority (28%) of the HCAs were able to interpret this warning in a medication list. Seventy-two per cent could correctly recognize the red triangle that in Sweden is used to mark psychotropic drugs that impair driving performance.
We asked about the correct interpretation of some common abbreviations used in medication lists within the medical services. On average, 16% of HCAs understood the abbreviations of four different dosage forms, and 53% could correctly interpret the six different presented abbreviations used to describe when to give the patient his or her medication and in what quantity. The risk of misunderstandings arising in the communication between the medical services and the HCAs in the social services is also illustrated by other results from the study. Only 66% of HCAs understood the term used within the medication services when a drug treatment is terminated. Half (50%) correctly identified the common term within the medical services in Sweden for suppository, which differs from colloquial language.
Fifty-eight per cent of HCAs knew that all tablets with the same formulation but different strength are designed or marked differently. Ninety-seven per cent answered correctly that medication cannot simply be doubled if it was forgotten the previous time. One per cent said that they would give the patient a double dose of the medication.
Thirteen per cent of the HCAs thought that only one mouthful of water was enough to swallow a pill. Especially for an old patient, one mouthful of water is not enough to be sure that the pill reaches the stomach. Sixty-three per cent answered correctly that age and weight have some implication for the dosage of the medication.
Subjects were asked if they had received any education in medication administration. The groups that answered ‘yes’ (67%) and ‘no’ (30%) were compared for each question in the knowledge test. The tendency in the responses for all questions was that personnel with education answered more of them correctly or partially correctly than those without education. The differences were significant in 18 out of 23 questions on medication administration, and these 18 questions included all those concerning common abbreviations for dosage instructions in medication lists. Four out of nine questions concerning indications for common drugs showed strongly significant (P < 0.001) differences between the two groups.
When compared with the 1993 study, the repeated 1998 study indicated an improvement in the HCAs’ knowledge of medication administration (Table 5). The 1998 study also indicated an improvement concerning the interpretation of symptoms in the cases presented, which in four out of five cases were strongly significant (P < 0.001). In the area of indications for common drugs, the results were poorer in the later study. While 48% of the HCAs in the earlier study in 1993 had some form of schooling within the health care area, 63% had such a background in 1998.
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Discussion and conclusion |
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Like many other countries, Sweden has an increasingly growing population of elderly residents, who have greater medical needs than younger people [10]. At the age of 85 years, around 90% report having at least one chronic disease [11]. With existing resources failing to cope with growing demand, the health and social services have been able to provide help for a decreasing proportion of the elderly [12]. In recent years, the social services have become increasingly focused on medical tasks [12]. HCAs have an increasingly important role in the contact and communication between patients and health care professionals. Studies have shown that the admission of elderly patients to emergency departments due to lack of community support is most often caused by a reduced ability to eat, drink, and walk [13,14]. In one of these studies, 87% of the women and 67% of the men were living alone and contact with health care professionals was initiated by personnel within the social services.
With an increased prevalence of disease comes an increased use of medications. Members of the population aged 
75 years are estimated to account for more than one-third of the country’s total drug consumption [15]. Also, among this group, 90% of the community-dwelling elderly receive some form of medication [16]. The increase in drug use in recent years, alongside the striving for greater efficiency in the treatment of several diseases, entails an increased risk of adverse drug reactions (ADRs), especially in the elderly [1,2]. Ten to 20% of hospital admissions of elderly patients are believed to be drug related [2,16]. Age-related changes in pharmacokinetics and pharmacodynamics are complicating factors in drug treatment [2,17–19]. Ageing itself may be an explanatory factor in the increased risk of ADRs, especially concerning centrally acting agents. However, it is probably less important than the influence of the multiple pathologies of old age, individual characteristics, and polypharmacy [1,2]. The frail elderly with multiple pathologies are at a higher risk of ADRs than the more robust elderly [20]. The use of multiple medications is a well-known risk for ADRs and loss of compliance [21]. A large number of ADRs among the elderly may be avoidable, as they are due to inappropriate prescribing [22]. However, despite having several prescribed drugs, many patients rather infrequently see their doctor, who often does not have time for more than a very short consultation. In line with what is mentioned above, HCAs have an increased responsibility for identifying and reporting possible ADRs to health care professionals.
A further complication is that with increasing age we see a higher prevalence of cognitive impairment along with impaired hearing and vision, making it harder for the patient to manage his or her own prescribed medication, and harder to identify any errors that may occur in drug administration. The personnel helping a patient with medication administration have a large amount of responsibility because errors can have severe consequences. It is also necessary that the personnel know when it is safe, and in particular when it is not safe, to give the patient his or her medicine.
Since HCAs often lack the appropriate education, the questions posed concerning medication administration, indications and contra-indications for common drugs, adverse drug effects, and symptoms were difficult to answer. Despite the fact that to a great extent they lack basic knowledge in the area, most of them perform tasks best suited to a qualified nurse. Ninety-five per cent of the HCAs in the study were engaged in medication administration. This reflects the fact that a large proportion of reported errors by personnel within the health and social services involve medication administration [23,24], and often errors have been made in delegating the task [23,24]. Even though there are protocols on how these delegations are to be handled and followed up, informal interviews outside the questionnaire study revealed several failures. HCAs were frequently delegated tasks without any education, experience or testing, and felt that they had to agree with this in order to keep the job, which is totally against the regulations. The usual explanation for the former statement was lack of time.
For both the 1993 and 1998 studies we stratified samples, which were collected within limited time spans. We used the same methods and, as far as possible, the same battery of questions. Both studies are believed to provide a representative picture and comparisons between the two should thus be valid.
The general improvements seen from 1993 to 1998 in the areas of medication administration and interpretation of symptoms are probably related to the higher education rate among HCAs in 1998. The proportion of HCAs with formal schooling within the health care area had risen from 48% to 63% between the two studies. Furthermore, after the first study there were increased efforts by the municipality of Malmö in educating HCAs within the social services. Between the two studies, the regulations became more restrictive concerning HCA participation in medication administration, demanding a formal delegation from a registered nurse.
The poorer results concerning indications for common drugs shown in the later survey could be explained by changes in prescribing patterns over the 5 years. However, it is also possible that there is a difference concerning education in this area. In 1998, the higher scores for correct answers achieved in this area by HCAs with education in medication administration were highly significant (P < 0.001) in four out of nine questions.
Even if some general improvements in knowledge were seen from 1993 to 1998, the initial knowledge level was low and there is a great need for further training of HCAs. As can be seen in this study, education makes a difference. There was a tendency in the answers to all questions for the personnel with education to answer correctly or partially correctly to a greater extent than those without education, with significant differences in the majority of questions on medication administration. When looking at some of the questions dealing with situations where errors could be fatal, basic HCA schooling seems to provide some benefit. However, more specific education—in this study we asked about education in medication administration—would be more to the point, and those who have such education perform markedly better (Table 6). Disappointingly, working as an HCA for a longer period of time does not seem to be related to a higher degree of knowledge in the area. This gives the impression of unmet needs for continuing education within the organization.
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Individual and organizational learning are crucial factors for the continuous improvements sought in quality assurance. But how is this achieved? Not least at the individual level, learning styles can differ greatly. Based on four studies, Gerber [25] stated 11 ways by which workers learn, all of which should be considered in developing meaningful training programmes. In no special order, these were: by making mistakes and learning not to repeat the mistake; self-education on and off the job; practising one’s personal values; applying theory and practising skills; solving problems; interacting with others; planning for learning with an open mind; being an advocate for colleagues; offering leadership to others; formal training; and practising quality assurance. Attitudes to education and training also differ. A Swiss study [26] among young adults on willingness to participate in continual vocational training found that it depended on achievement motivation, contingency beliefs, self-efficacy cooperation, independence, and level of education. However, many adverse incidents may be rooted in the organization and errors cannot always be attributed to incompetent individuals.
West [27] describes four characteristics of health care organizations relevant to the level of risk. Firstly, there is the division of labour and structural secrecy in complex organizations, where information is always partial and incomplete, where the potential for things going wrong increases when information crosses boundaries, and where segregated knowledge hinders detection of deviations from normative standards and expectations. This is relevant to this study, especially where information between the physician and the caregivers may be incomplete. Secondly, there are social structural barriers to communication, having to do with social networks and status distinctions. Ethnicity and language difficulties can be expected to contribute to these barriers. Thirdly, there is the problem of a diffusion of responsibility in large organizations. Without a feeling of individual responsibility, the team member easily becomes an unresponsive bystander. For example, the lack of proper formal delegation and routines increases this risk. Further, it is harder to localize the origin of latent failures, created by decisions made higher up in the organization by managers or politicians, without immediate adverse consequences, than to identify the active failures, i.e. unsafe acts by individuals at the ‘sharp end’ of the system. Fourthly, West highlights the threat from goal displacement, where economic pressures on health care organizations create a primary focus on economic goals, thereby reducing the quality of care.
Organizational change is an important means in the aim for improved safety and quality. In changing the culture of the organization to be receptive to change, Garside [28] highlights the need for effective communication to involve staff in the process of change, and to train and develop individuals. Davies et al. [29] put a post-modern perspective on changing organizational culture, not focusing on cultures as means of control, but encouraging dialogue among the stakeholders and placing the emphasis ‘on challenging existing authorised accounts and balances of power, rather than on the refinement of mechanisms of control’. As McPherson et al. [30] discuss, quality care depends on collaborative working between professions, and inter-professional education is an important tool in achieving that. In the learning organization, the leader should be both a learner and a teacher. However, there has for a time been a trend towards emphasizing economic steering of health care organizations. As in other parts of Sweden, the social services in this study have had to deal with increasingly more health-care-related work, although many of the decisions about the care of individual patients are made by people with no health care education. Leaders in the organization often lack experience in health care. A considerable proportion of supervisors instead have a background in economics. There is a great need for additional personnel with the appropriate professional background, i.e. registered nurses, in order to ensure patient safety, especially in situations where the supervisor lacks health care education.
As Walshe and Freeman [31] point out, the effectiveness of quality improvement depends on perseverance. Rather than trying a succession of different ways, the approach should be selected with care and implemented with consistency. Changes take time. When it comes to medication administration by HCAs, changes will definitely have to take time. There is no real alternative to HCAs at the current time and somebody has to be there to help the patients. What we can do is to increase the competence of the existing work force and organization parallel to recruiting competent personnel.
Although not for everyone, the informal caregiver is an alternative for many patients, and one might question whether it is reasonable to demand a higher standard for HCAs than for patients and informal caregivers who handle medications themselves. HCAs help several patients every day, that alone increasing their responsibility. Furthermore, they do not know the patient as well as the family caregiver. Besides, the alternatives do not have to be set against each other. Even though existing regulations require a certain level of competence for HCAs, it cannot be required from informal caregivers, and every increase in competence, whether of HCAs or informal caregivers, promotes quality and safety. The burden on the family caregiver is often considerable, and education and support from health care professionals improve the situation for both the patient and the family caregiver [32–34].
The authors wish to thank the personnel in the social services and the chief community nurses who participated in and helped us to perform this study. We particularly wish to thank Marie Klint and Berit Häll, both chief community nurses in the municipality of Malmö, for their suggestions and support.
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Footnotes |
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Parts of this study have been reported previously [Axelsson J, Elmståhl S. Unqualified home care aides put the patient at risk. Better knowledge concerning drug administration must be required (in Swedish with English summary). Läkartidningen 2002; 99: 1178–1183].
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