SUMMARY - Safe Medications Management project: Key issues and ...

The findings summarised in this document were produced by a project funded by the Health WorkforceAustralia (HWA) Workforce Innovation: Caring for Older People Program. This document is in draft and hasnot been approved by HWA and does not reflect any official position of HWA. The report is provided asbackground information to the Request for Proposal Building Workforce Capacity in Safe MedicationManagement HWA-RFP/2011/002 to enable organisations to prepare their application and is provided onthe condition that is not distributed, beyond the current recipients.SUMMARY - Safe Medications Management project: Key issues and evidenceProject focus: aged and community care staff involved in medication management. Access andlinkages with medical practitioners and pharmacists has also been explored.Information is summarised from two separate reports produced by Aged and Community ServicesAustralia: Gap Analysis Report and the Roundtable Report (2011).Gap Analysis:The strategy developed would attempt to be aligned with:workforce harmonisation,the harmonisation of workforce governance (health professional registration),national standards for program delivery,national VET competencies,national health reform (including safety and quality),National Health Practitioners Regulation, the development in 2009 and 2010 of the national modern awards 1eventual national harmonisation of drugs, poisons and controlled substances legislation,andCommonwealth attention to electronic prescribing.Two approaches Industry Survey: 52 respondents Literature searchTable 1: Industry survey figuresSurveys Providers Other OrganisationsNon Profit For Profit Public Advoc’y GovDeptPeak Profess UnionNo. Distributed 51 11 13 3 2 5 1 6No. Responses 31 3 10 2 0 2 0 4Response Rate % 61% 27% 77% 67% 0% 40% 0% 50%1 Aged Care Award 2010 and Social, Community, Home Care and Disability Services Industry Award 2010

1. Results of Industry SurveyThe Consultants identified emerging themes under the key domains.1.1. Issues Identified By DomainsIn presenting the results, the Professional/Industry Codes and Guidelines Themes have beencombined with the Legislative/Regulatory Themes as respondents frequently did not discriminatebetween these two Domains in their responses.1.1.1. Workforce ThemesRecruitment difficulties RNs & ENs - Residential & CommunityUnpopular field of nursing – high workloads, little recognition, not as prestigious.High proportion of older RNs approaching retirement.Pay disparities with acute hospital nursing.Shortage of RNs and ENs in rural and remote areas.High turnover.Few full time nurses – placing high demands on those who are full time or work substantialhours.Low staffing levels - ResidentialFunding formulae does not match resident/client needs or unexpected absences andunfilled shifts (see Recruitment above).Many ENs do not want the responsibility of medication administration.Workloads – Residential Onerous and time-consuming regulatory, transaction and compliance demands -Residential Aged Care Standards, documentation, authorisations, checking prepackedmedicines from Pharmacy, “chasing” scripts from doctors & supplies from pharmacies.Insufficient time to supervise, teach and mentor care staff. Increasing numbers ofresidents in both low and high care settings require specialised nursing and/or complexcare, resulting in a need for more supervision of personal care staff.High requirement for RNs to undertake all or most of the medication administration. Thiscan be time consuming due to complex care, polypharmacy & medication managementarrangements required to address resident swallowing problems, combined with broadermanagement roles.1.1.2. Clinical Practice ThemesKnowledge, skills, competency, and literacy of care staff:Inconsistencies in training personal care staff on medication management.2

Inconsistencies in achieving and maintaining competency levels especially in medicationmanagement.Issues of English literacy and comprehension of staff from non English speakingbackgrounds.No systems or requirements for continuing education and training of personal care staff.Little time or funding for RN and ENs to attend to continuing professional development(CPD) requirements in work time.Scope of Practice, Professional Guidelines, and organisational policies and procedures:Inconsistencies in Scope of Practice between States/Territories for RNs and ENs and nomeans for staff to be trained to meet new Australian Health Practitioner Regulation Agency(AHPRA) Scope of Practices (SoPs) where relevant.Poor knowledge and compliance with Scope of Practice, policies and standards/guidelinespossibly because of,o workload and time constraints,o management knowledge and skills,o absence of relevant training for staff in these matters, and/oro inability to recruit suitable staff.Pharmacy difficulties:Frequent packing errors in Dose Administration Aids (DAA) and other dispensed medicines.Delays in receiving medication supplies.Changes to DAA packing and/or presentations without notice.Changes to medication brands supplied without notice or discussion. This is oftendisturbing for residents/clients and their families, particularly if different in appearance.Delays in getting emergency medicines – usually for pain.GP or Local Medical Officer (LMO) difficulties:Inconsistencies in notating cessation date of drugs on Medication Charts.Delays in writing up new scripts for new/changed medications, phone orders or for newMedication Charts in timely fashion.Delays in addressing urgent pain needs of residents and especially community clients.1.1.3. Legislative/Regulatory, and Professional/Industry Codes and Guidelines ThemesInterstate Regulatory/Guidelines inconsistenciesDifferent provisions regarding dispensing, possession and administration of medications ineach State/Territory.3

Inconsistent regulations relating to storage and checking of medications – some due toDrugs and Poisons Regulations, and some due to State/Territory Health Authoritymandatory policy. Different regulations and policies on medication dispensing, possession, administration andchecking for hospitals, community and aged care facilities.Professional, Health Authority and Industry Standards, Guidelines and PositionsMultiplicity of Registration Board, Professional, Health Authority and Industry Codes andGuidelines on Medication Management – some of which have no “authority” sinceState/Territory Registration Boards ceased to exist with the commencement of AHPRA.Poor understanding by all staff (nursing and carers) as to what is regulated, what is “goodpractice” and/or local policy/practice regarding medication administration andmanagement.Different Accreditation Standards on Medication Management – ACQSHC, ACHS, ACSAA.Personal Care Workers,o Inconsistent scope of practice across states.(Lack of consistent training, education and meaningful inclusion in national and stateworkforce planning for aged residential and community care, despite making up thebulk of the workforce.)Table 2: Distribution of Themes from 323 Major Issues Identified and Coded.Workforce Clinical Practice Regulations & GuidelinesStaffinglevelsSkills,training etcRecruitmentWorkloadsNoncompliance & errorsPharmacyGPsInconsistenciesMultipli-cityUnreg’dworkers39 24 66 44 30 26 36 23 19 1312% 7% 20% 14% 9% 8% 11% 7% 6% 4%1.2. Barriers in medication processes to effective and efficient medication managementRespondents were asked to rank 7 elements of the medication process listed below, from 1 to 7,with 1 being the most problematic. 2 Reported in Table 5 are the “No 1” problems identified by 39of the 52 respondents.2 The question was not included in the survey sent to non-provider organisations and not alleligible respondents completed the question.4

Table 3: List of BarriersBarrier ItemN reported as No 1 barrierMedication orders/chart 15Administration 12Prescribing 8Dispensing and labelling 3Supply and receipt 1Storage 0Disposal 01.3. Packaging and Charting IssuesA majority of respondents commented specifically on packaging and charting revealing thefollowing results:Packaging:8 (23.5%) used mainly pre-packaged medicines, using bottles/boxes only for respite clientsor in unusual circumstances, and 26 (76.5%) used only pre-packaged medicines.Charting:4 (9%) used both paper and electronic charts,24 (73%) used paper charts only, and5 (15%) used electronic charts only.1.4. Suggested ImprovementsRespondents were asked to nominate 3 key improvements which would enable their organisationto provide more efficient and effective medication management for its clients. Analysis of theresponses highlighted some common themes. There were also a large number of practicalsuggestions on medication practices which could be implemented by an organisation as part of itsown quality improvement system. Since these are not dependent on national strategies, systemsor regulation for implementation at a local level they have not been included here.5

Table 4: Key Themes for ImprovementsThemeNumber of citationsElectronic medication & communication systems 25Increased/consistent education on medication managementguidelines and/or legal matters for RNs, ENs, GPs andunlicensed health workers (UHNs)Workforce improvements including staff increases and betterpay and conditionsNationally consistent sets of guidance and/or regulation onmedication management and those who deliver its variouselementsImproved communication and support between Aged CareFacilities/GPs/Pharmacies and Acute HospitalsReduced “overmedication” and “polypharmacy” 7Standardised Medication Chart/Charts as Scripts 6Standardised and limited range of Drug Administration Aids 5212018151.4.1. Electronic medication & communication systemsRespondents’ suggestions on electronic systems for use in residential and community aged care,ranged from electronic charts, to electronic prescribing, ordering, charting and recording systems,with or without integration with GP practices and pharmacies. It is likely that these suggestedimprovements reflect a wide range of experience and understanding of electronic systemsamongst those completing the surveys.1.4.2. Increased/consistent education on medication management guidelines and/orlegal matters for GPs, RNs, ENs, and personal care workersThese suggestions included:Increased education and training, including agreed minimum qualifications in medicationmanagement for personal care workers,Overall increases in education, training and competency testing for RNs and ENs inmedication management generally,Managing certain medication types (e.g. insulin, anticoagulants), and in non-chemicalbehavioural and pain management for all categories of care personnel (nurses, doctors,pharmacists and other allied health professionals, and personal care workers),Education and updating for all categories of care personnel in the legal and policy/guidelineframeworks governing medication management practice.6

It was apparent that some respondents themselves had little understanding of the differencesbetween Statute and Common Law, particularly in relation to consent.1.4.3. Workforce improvements including staff increases and better pay and conditionsThe most frequently suggested workforce improvement cited not only by RNs, ENs & personalcare workers, but also GPs, Pharmacists, and administrative/clerical staff, was to increase staffinglevels. There were also suggestions of improving the staff mix between nurses and personal careworkers, which were not quantified.Other suggestions included increased pay (sometimes noting the need for parity with public sectoror acute hospital rates), improved conditions and inducements/ incentives to attract students andqualified staff into Aged Care.1.4.4. Nationally consistent sets of guidance and/or regulation on medicationmanagement and those who deliver its various elementsSuggested improvements included the standardisation of laws and guidelines. It was evident thatmany respondents were unclear about which, if any, laws or regulations governed aspects ofpractice. In addition there was a presumption by many that some departmental policies, and stateor national standards, codes and guidelines had the force of law. Some respondents clearly sawsimple, clear and nationally consistent guidance or law as a major plank in any platform toimprove the safety, effectiveness and efficiency of medication management in the settings inwhich they worked.1.4.5. Improved communication and support between Aged CareFacilities/GPs/Pharmacies and Acute HospitalsA range of suggestions were made by respondents for improvements to communication systemsbetween these stakeholders, but many were non-specific as to what strategies should be adoptedto enable the improvements sought. Several suggested use of a single rather than multiplepharmacies as well as increasing the levels of:pharmacy back-up/support, consultation about medication changes with both pharmacies and GPs, and/or ,consultation with staff by prescribing GPs and use of Residential Medication ManagementReviews.There were also some suggestions of employing an “in house” pharmacist and/or GP. Some notedthat prescribing needed to be more aligned with:the practicalities of either residents’ overall health status and limitations; and/or,community organisations’ resource limitations in administering or providing assistancewith medications more than once or twice a day.Most of the system-based specific suggestions have been covered under the education/training orelectronic systems themes above.A few respondents drew attention to the need to have mechanisms in place in acute hospitals toensure that when medications which were current on someones admission are changed, that this7

is communicated clearly and in a timely fashion with the relevant residential care/community careagencies, GPs and pharmacies. This open communication would ensure all parties had thenecessary information to manage the transition from acute to residential setting or own home.1.4.6. Reduced “overmedication” and “polypharmacy”Most respondents who suggested these improvements were non-specific as to the method ofachieving them other than improved education and training, particularly in palliative care andbehaviour management. Polypharmacy was identified specifically as a key clinical practice problemby a number of respondents.1.4.7. Standard Medication Chart/Charts as ScriptsSome jurisdictions or organisations use the medication chart as the prescription, or supply thechart to the pharmacy which then “chases” the GP for the actual prescription. This is identified asan improvement to practice issues. Electronic systems were also seen as an improvement whichwould facilitate smoother and timely renewal and cessation of orders in line with best medicationpractice.1.4.8. Standardised and limited range of Drug Administration AidsRespondents referred to having to deal, not only with a range of Dose Administration Aids (DAA),but with them being changed either by the manufacturer or other parties involved in themedication management processes for any given resident, community or client.1.5. Other improvements/considerations from the Survey FindingsThere were a handful of respondents who raised some interesting and possibly highly importantissues. They have not been identified elsewhere as they were mostly “one-offs” rather thanmatters shared with several other respondents.However three very important matters emerged:Exploration of medication management in people’s homes where a number of people(client, carer, service providers, GPs and Pharmacists) are all participants in prescribing,supplying, storing, administering, monitoring and disposing of medicines.Complementary medicines and interventions in residential care. In many cases, the facilityor the treating GP may be reluctant to consider such treatment, or prohibit it altogether. Itis a complex area, but to maintain optimum independence and choice for residents, it mustbe considered in terms of ethics, safety, legality, right and risks.English language proficiency of staff (particularly care workers) and visiting professionals inresidential care facilities. This included strategies which would mitigate the risks ofmisunderstandings and errors. A resource in this area is the International MedicationSafety Network which offers a range of practical tools to address these issues. Otheravenues, such as English proficiency requirements (similar to Police Checks processes) andeducation options could also be considered.8

2. Literature review of key documents2.1. Legislative FrameworkThe National Competition Policy Review of Drugs, Poisons and Controlled Substances LegislationReport (The Report) was presented to the Australian Health Ministers Conference (AHMC) inJanuary 2001 with 27 recommendations. The Chair of the Review, Rhonda Galbally, wrote in thecovering letter to the Report that,“Despite differences in demographics across the States and Territories, Australia is increasinglybecoming a single market and national uniformity is a recurring issue. In this report, Irecommend the development and adoption by reference of model medicines and poisonslegislation in order to achieve uniformity. I accept that this may not be supported by alljurisdictions; however, I think that one of the purposes of the Review is to set some benchmarkstowards a nationally uniform system of regulation. I hope that you will give seriousconsideration to the adoption of model legislation, and alternatively, I challenge you to worktowards national uniformity following another path.” 3The Report recognised the importance of the close relationship between drugs and poisonslegislation and legislation regulating professional practice. It confirmed that comprehensivelegislation to regulate drugs and poisons was still required. Recommendation No. 24 specificallyrecommended that uniform national model legislation be developed and adopted.Whilst all States and Territories supported the concept of uniformity, the Report noted thatcurrent drugs and poisons legislation is complimented by other legislation and may not bepossible. Some states and territories (QLD, NT, WA) proposed alternative strategies to achieve thesame outcome.The Report also urged professional registration boards to consider options for improvingeffectiveness of their legislation to achieve compliance. Recommendation No. 27 specified that insome cases it might be appropriate for professional practice legislation to deem certain breachesof drugs and poisons legislation as professional misconduct. This matter is now under thejurisdiction of the Australian Health Practitioner Regulation Agency, (AHPRA). The Working Part ofAHMC accepted the recommendations and undertook further consultation, but was unsuccessfulin gaining uniformity of legislation Other means to achieve uniformity are being investigated - thestatus of this work is not known.Appendix A provides a list of all relevant legislation on Medicare, drugs, poisons and health.2.1.1. Australian Government LegislationThe three major pieces of national legislation which provide a framework for medicationmanagement and older people are: The National Health Act 1953, The Aged Care Act 1997; and The Therapeutic Goods Act 1989.3 National Competition Policy Review of Drugs, Poisons and Controlled Substances LegislationReport 20009

In addition, the Pharmaceutical Benefits Scheme has an important role both in the community andin residential care through the provision of medicines via PBS scripts.A comparison of the legislation follows:2.1.1.1. The National Health Act 1953This Act relates to the provision of pharmaceutical, sickness and hospital benefits, and of medicaland dental services and is administered by the Australian Government Department of Health andAgeing.Relevant definitions in this legislation relate to – (authorised) and (eligible) nurse practitioner and(approved) pharmacist defined and referred to in Part I and Part VII of the Act. A medicalpractitioner and an authorised nurse practitioner are also defined as PBS prescribers. It does referto a medical practitioner being authorised to write a prescription for the supply of apharmaceutical. The only specific reference to aged care is where a prescribed institution means aresidential care service within the meaning of the Aged Care Act 1997.There are no other references to aged care, medicines or health professionals’ roles andresponsibilities.2.1.1.2. The Aged Care Act 1977The Aged Care Act 1997, and associated Aged Care Principles (there are approximately 23 sets ofPrinciples under the Act which determine and describe a range of key responsibilities andrequirements), provide the legislative framework for the provision of the majority of aged careservices relating to community care, residential care and flexible care in Australia and isadministered by the Australian Government Department of Health and Ageing.This Act replaced the provisions in the National Health Act 1953 (the National Health Act) and theAged or Disabled Persons Care Act 1954, wherein nursing homes and hostels had been previouslyadministered.The current Act identifies the arrangements to determine:Who can provide care, and their roles and responsibilities,Who can receive care, and their rights and responsibilities, What types of aged care services are available, and How aged care is funded. 4In addition, under Part 2.1 Division 8-1 and 8-3A Approved Provider and Key Personnel are themain roles defined and described in the Act (and in the associated Aged Care Principles)particularly relating to Quality of Care, Accreditation, User Rights, Accountability and theStandards relating to residential care, community care and flexible care. These roles arefundamental in the legislative accountability for the provision of aged care.2.1.1.3. The Therapeutic Goods Act 1989 and Therapeutic Goods Regulations 19904 Report on the Operation of the Aged Care Act for 2009/201010

The Therapeutic Goods Administration under the Department of Health and Ageing administersthe Therapeutic Goods Act 1989, which is the national legislation for the establishment andmaintenance of systems relating to quality, safety, efficacy and availability of therapeutic goods.The Act also provides the framework for the states and territories to take a uniform approach inestablishing relevant legislation for the safe handling of drugs and poisons. It is supported by theTherapeutic Goods Regulations 1990.The Poisons Standard 2010 is a legislative instrument under the Therapeutic Goods Act 1989. It isalso known as the Standard for the Uniform Scheduling of Medicines and Poisons (SUSMP), whichclassify medicines and chemicals into Schedules for inclusion in relevant legislation of the statesand territories. The Poisons Standard also includes model provisions about containers and labels, alist of products recommended to be exempt from these provisions, and recommendations aboutother controls on drugs and poisons. This is a national standard which is not routinely referred toin the States/Territories legislation.The Pharmaceutical Benefits Scheme (PBS) provides timely, reliable and affordable access tonecessary medicines for Australians and is part of the Australian Government’s broader NationalMedicines Policy. Under the PBS, the government subsidises the cost of medicine for mostmedical conditions. Most of the listed medicines are dispensed by pharmacists, and used by thecommunity at home. 5 The PBS is also the primary source of medications being supplied to theelderly in residential aged care.The National Medicines Policy has four key aims 6 :timely access to and affordability of medicines for the Australian community,appropriate standards of quality, safety and efficacy for medicines,quality use of medicines, andmaintenance of a responsible and viable medicines industry.2.1.1.4. The Health Practitioner Regulation National LawThe following announcement was made on 26 th March 2008.“COAG also took a major step towards improving Australia’s health system by signing anIntergovernmental Agreement on the health workforce. This agreement will for the first timecreate a single national registration and accreditation system for nine health professions:medical practitioners; nurses and midwives; pharmacists; physiotherapists; psychologists;osteopaths; chiropractors; optometrists; and dentists (including dental hygienists, dentalprosthetists and dental therapists). The new arrangement will help health professionals movearound the country more easily, reduce red tape, provide greater safeguards for the public andpromote a more flexible, responsive and sustainable health workforce. For example, the newscheme will maintain a public national register for each health profession that will ensure thata professional who has been banned from practicing in one place is unable to practiceelsewhere in Australia.”5 Dept. of Health & Ageing PBS6 Dept. of Health & Ageing National Medicines Policy11

The Health Practitioner Regulation National Law referred to as The National Law has established anational scheme for the regulation of health practitioners and students undertaking programs ofstudy leading to registration as a health practitioner. It applied initially to 10 health professionalgroups from 1st July 2010.It is known as “an applied law” model as the legislative powers are with the states/territories.Queensland has initially enacted the National Law. All of the other states/territories are enactinglegislation to adopt and apply the National Law as a law of their own jurisdiction.The Commonwealth does not apply the National Law, but needs to make consequentialamendments to Commonwealth laws to ensure effective interface between the various agenciesand the national scheme.This Act will be reviewed by jurisdiction under the next section on the States and TerritoriesLegislation.2.1.2. States and Territories LegislationEvery jurisdiction, except Queensland, has a specific Act relating to medicines, poisons, drugs orcontrolled substances with corresponding Regulations. Queensland utilizes the Queensland HealthAct 1937 as its overarching Act and has specific drugs and poisons Regulations to spell out thedetail.The relevant Acts and Regulations have been reviewed for each State and Territory for theelements that are relevant to this project. Specific definitions relating to the health professionsare identified in the legislation and the steps in medication management, which relate to”prescribing, supplying, dispensing and administering”, are noted.A Summary Jurisdictional Table of the Acts and Regulations pertaining to medicines, drugs andpoisons and the Acts relating to Health Professionals are available in Appendix A. A jurisdictionalcomparative table relating to the elements of Medication Management is available in Appendix B.Detailed tables for each jurisdictional legislation can be found in Appendix C to J.2.1.2.1. Australian Capital TerritoryThe ACT Medicines, Poisons and Therapeutic Goods Act and Regulations 2008, (effective21/12/2010), and the most recent legislation amongst the jurisdictions.The Act and the Regulations refer to Health Professionals as defined in the Health PractitionerRegulations National Law (ACT) and the Health Professionals Act 2004 and defines a residentialaged care facility in accordance with the Aged Care Act 1997.The majority of detail is left to the Regulation to specify who can do what. The terminology of“doctor” is used rather than medical practitioner, with nurse practitioner, nurse, enrolled nurseand pharmacist identified with each role qualified viz.:“to the extent necessary to practice(medicine, nursing, pharmacy) and, if employed, within the scope of employment”.Of note is that:An Enrolled Nurse, under Schedule 1 Part 1.6, can obtain, possess and administermedicines.12

Directors of Nursing and Medical Superintendents for a RACF (Residential Aged CareFacility) under Schedule 1 Part 1.11 have particular activities relating to emergencyadministration of medicines.Assistants under Part 5.2 can administer medicines to an “assisted person” under specificconditions.The Health Practitioner Regulation National Law (ACT) effective 01/07/2010 refers to a healthpractitioner’s authorisation under the Act.2.1.2.2. New South WalesThe NSW Poisons and Therapeutic Goods Act 1966 (effective 1/07/2010), under Part 1.4specifically defines a nurse practitioner as per the Health Practitioner Regulation National Law andunder Part 3 s17A (1) details as a person authorised to possess, use, supply, prescribe a poison,restricted substance or drug of addiction. The Act also refers to a Nurse Practitioner beingauthorised in writing by the Director General to possess, use, supply or prescribe. Carers areidentified in the Act with regard to the possession and supply of drugs of addiction by carers whoare caring or assisting in the care of another.The Poisons and Therapeutic Good Regulation 2008 effective (27/08/2010) under Part 1 s3defines an authorised practitioner as a medical practitioner or a nurse. In Part 2 Div 3 it details thata Medical Practitioner can issue a prescription for a restricted substance and a nurse practitionercan only supply a restricted substance in the course of practising as a nurse practitioner.Of note is the reference to a Code of conduct for unregistered health practitioners referred to inthe Public Health Act 1991 and cross-referenced to the Health Care Complaints Act 1993.Under the Health Practitioner Regulation Act 2009 – Health Practitioner Regulation National Law(NSW) effective 27/08/2010 there is specific reference to a nurse practitioner as being qualified topractice as a nurse practitioner.2.1.2.3. Northern TerritoryThe Northern Territory Poisons and Dangerous Drugs Act (effective 07/07/2010) provides themajority of authority as to legislative roles and activities. Part 1 S6 defines medical practitioner asone who practices in the NT and a nurse and pharmacist as registered under the HealthPractitioners Regulation National Law.Under the Act Parts V and VA special reference is made to remote area nurses and aboriginalhealth workers to supply medicines and it notes that “there is no applicable legislation regardingthe practice of Enrolled Nurses in this regard”.The Act defines supply as including prescribe, administer and having in possession for the purposeof supply, prescription and administration. It makes specific reference under the Act to Aboriginalhealth worker with the right of practice under the Health Practitioners Act of the NT to possessand supply a Schedule 1, 2, 3, and 4 substance.There is nothing specific in the Poisons and Dangerous Drugs Regulations effective (01/07/2010)relevant to this project.The Health Practitioner Regulation National Law (NT) Act 2010 effective 02/07/2010 adopts theQueensland Health Practitioner Regulation National Law Act 2009.13

2.1.2.4. QueenslandThe Health Act 1937 is the overarching Act, however, the Health (Drugs and Poisons) Regulation1996 effective (28/01/2011) provides the majority of the legislative direction and the most detailregarding the roles of health practitioners.Part 2 Div 2 of the Regulation uses the term “doctors” and “physician’s assistant” (under thesupervision of a supervising medical officer) as being able to possess, administer, supply andprescribe a controlled drug. Similarly a nurse practitioner can obtain, administer, supply andprescribe; a registered nurse can posses and administer drugs and under s 58A, an enrolled nursecan “possess, administer controlled and restricted drugs under the supervision or writteninstruction of a doctor, nurse practitioner or physician’s assistant”. Pharmacists can dispense, selland possess drugs.Similar to the Northern Territory, under Ch 2 Part 2 s59A and s164A Indigenous health workers inan isolated area can obtain, possess, administer a controlled and restricted drug on oral or writtenorder of doctor, nurse practitioner, physician’s assistant. In addition an “endorsed nurse” in arural hospital or isolated practice area can obtain, supply and administer a controlled drug.Ch 2 Part 7 s110 makes particular reference to a nursing home and identifies the responsibleperson of a nursing home being the Director of Nursing, a medical superintendent or theregistered nurse in charge and under Part 2 s63 they can obtain possess and issue controlled andrestricted drugs.There are no specific definitions in the Regulations for health practitioners as these are detailedunder the Health Practitioner Regulation National Law (Queensland) Act 2009 which defines ahealth practitioner as one who practises a health profession and a registered health practitioner asbeing registered under the Law.2.1.2.5. South AustraliaThe South Australia Controlled Substances Act 1984 effective (28/11/10) defines a medicalpractitioner, a nurse, and pharmacist as registered under the Health Practitioner RegulationNational Law.The Act refers to a medical practitioner and nurse acting in the ordinary course of his or herprofession being able to sell, supply, administer a prescription drug (not of dependence) and apharmacist can dispense the prescription of a medical practitioner.The Controlled Substance (Poisons) Regulations 1996 effective (01/07/10) makes detailedreference to the Uniform Poisons Standard under the TG Act 1989 and the Schedules. It describesa “prescriber” as a person who lawfully gives a prescription for a drug. Reference is made to amedical practitioner or nurse relating to supplying and administering a drug of dependence anddetails relating to recording.Detailed information listed in the Regulations regarding prescriptions and dispensing under Part 4s 25 refers to the responsibilities of the “prescriber”. Part 4 s 27 describes dispensing of apharmacist or medical practitioner.Amendments to Part 5A s 31G and 31I in 2009 deleted the word “registered” leaving the word“nurse” and provided the ability for an enrolled nurse to administer a drug of dependence.14

Regulation 31I (2) refers to a “designated nurse for a ward of a health service for a particular shift,not the registered nurse in charge of the ward”Under the Health Practitioner Regulation National Law (South Australia) Act 2010 a healthpractitioner practises a health profession/registered health practitioner registered under this Law.2.1.2.6. TasmaniaThe Tasmania Poisons Act 1971 effective (01/01/11) provides for the Minister to authorise aregistered nurse to possess and supply restricted or narcotic substances and for the Secretary toauthorise a nurse practitioner to sell, be in possession of or supply restricted and narcoticsubstances. The Governor can also make regulations for the control, supply, prescription,possession of narcotic substances regulating the issue by medical practitioners and authorisednurse practitionersThere is also reference to an “authorised nurse practitioner” and a “nurse practitioner” in Part 1 s3of the Act with reference to the Health Practitioner Regulation National Law (Tasmania). A Medicalpractitioner is also referred to as one who must be present in Tasmania.The Act defines supply to include administering and dispensing and medical practitioners,pharmaceutical chemist and authorised nurse practitioner are permitted to sell or supply “in thelawful practice of his or her profession or business”.The Poisons Regulations 2008 effective (01/01/09) Part 1 s3 refers to a health professional as amedical practitioner, a registered nurse, an authorised nurse practitioner, a pharmaceuticalchemist. It also refers to an authorised nurse as one who holds a nursing authority. A medicalinstitution also includes the provision of accommodation for persons who are aged.Under Part 6 s95 EA there is reference to the administration of certain substances by aged careworkers in residential care services under the general supervision or direction of a registerednurse but they also have to have “met the requirements of relevant nationally accredited trainingmodules relating to the administration and storage of medication and maintain any competencyrequirements of those modules and acting in accordance with guidelines approved by theSecretary”. To support this regulation there is a set of “Guidelines for the administration ofcertain substances by aged care workers in residential aged care services” approved by theSecretary of the Department of Health and Human Services and effective from September 2010. Itdetails the roles for the approved provider, aged care worker, and registered and enrolled nurses.There is also a similar regulation with respect to aged care workers in community care.Carers are referred to in Part 6 s95G as able to administer or make available for selfadministration,medicinal poison, restricted substance, and narcotic substance under a range ofconditions.Part 3 of the Regulations identifies what a medical practitioner, authorised nurse practitioner andauthorised nurse may not do regarding supply or prescribing. In Part 4 s61 a registered nurse maypossess and administer without instructions from a medical practitioner if attending an emergencyin a remote area but has to have undergone an educational program approved by the Nursing andMidwifery Board of Australia and been endorsed by the same Board. Reference is also made to theMinister granting authority to registered nurses in certain circumstances and in Part 4 s60 anenrolled nurse may administer certain substances listed in Schedule 2,3,4,8 if acting with thewritten authority of a medical practitioner or authorised nurse practitioner.15

The Health Practitioner Regulation National Law (Tasmania) Act 2010 refers to terms used in thisAct and also in the Health Practitioner Regulation National Law set out in the Schedule to theHealth Practitioner Regulation National Law Act 2009 of Queensland have the same meanings inthis Act as they have in that Law.2.1.2.7. VictoriaIn Victoria in the Drugs, Poisons and Controlled Substances Act 1981 effective (06/01/11), underPart II 10A reference is made to the administration of medication in aged care services and therole of the approved provider to ensure that the registered nurse manages the administration ofany drug of dependence to a resident receiving high level care. Part II S34F and S36E make specificreference regarding aged care and the permit and administration for Schedule 8 drugs. TheApproved provider under the Aged Care Act must ensure that the registered nurse manages theadministration of any drug of dependence Schedule 9.8.4 poisons to a high care resident – and inthis regard, must manage the administration in accordance with a Code or guidelines (if any)issued by the Nursing and Midwifery Board of Australia under the Health Practitioner RegulationNational Law. (At this stage they have not produced a guideline or code of guidance).There is also a clause in Part II s36F relating to registered nurses having a regard to the relevantcode or guideline (if any) issued by the Nursing and Midwifery Board of Australia under the HealthPractitioner Regulations National Law.Under the Act a registered medical practitioner and nurse practitioner can administer, supply,prescribe a Schedule 8 poison as well as poisons and controlled substances. In addition, apharmacist and a registered nurse can possess, use, sell or supply specific drugs.The Act also defines a nurse practitioner, registered medical practitioner, pharmacist, registerednurse as registered under the Health Practitioner Regulation National Law and further refers tothe aged care services and the Aged Care Act as well as the Commonwealth Standard for uniformscheduling of drugs and poisons.Where a registered nurse whose registration is endorsed under the Health Practitioner RegulationNational Law, that person can obtain, use, sell, and supply a Schedule 2, 3, 4,and 8 approved bythe Minister.The Minister can also approve scope of prescribing rights or supply of poisons for a registerednurse in clinical circumstances.The Drugs, Poisons and Controlled Substances Regulations 2006 (effective 26/10/10) defines anaged care service in accordance with the Aged Care Act and refers to an authorised registerednurse, and an enrolled nurse in accordance with the Heath Practitioner Regulation National Law.Part 2 in the Regulations refers to what a nurse, an authorised registered nurse and a pharmacistcan do in the administration of schedule, 4, 8 and 9 and it also describes what a registered medicalpractitioner and a nurse practitioner must not do with regard to the areas relating to administer,prescribe, sell or supply schedules 4 and 8.Particular reference is made to an approved provider of an aged care service where there is aresident receiving high care and their responsibilities regarding schedule 4, 8 and 9 poisons.16

The Health Practitioner Regulation National Law (Victoria) Act 2009 adopts the National Law in theSchedule of the Queensland Health Practitioner Regulation and defines a health practitioner, amedical practitioner and a registered health practitioner.2.1.2.8. Western AustraliaThe WA Poisons Act 1964 (effective 18/12/10) Part 1 defines an endorsed health practitioner,registered under the HPRNL to practise a health profession and registration endorsed toadminister, obtain, possess, prescribe, sell, supply or use medicines. It further defines a medicalpractitioner, nurse practitioner and pharmacist as registered under the Health PractitionerRegulation National Law (Western Australia).Part III states that a medical practitioner can write, issue or authorise a prescription for the use,sale or supply of a drug of addiction and a nurse practitioner is able to possess, use, supply orprescribe any poison.The Governor can also make regulations to regulate the issue, dispensing and supply ofprescriptions by medical practitioners and nurse practitioners.Under the Poisons Regulations 1965 (effective 20/11/10) Part 6, an authorised person is definedand a physician is described as recognised by the Medical Board. A registered nurse has themeaning in the Nurses and Midwives Act 2006 (however this has been repealed). NIMC is referredto as the National Inpatient Medication Chart.Supply includes distribution and selling. Administration does not include supplying, anddispensing means supply of a medicine in accordance with a prescription.A medical practitioner, nurse practitioner and pharmacist can supply schedule 4 poisons and amedical practitioner and pharmacist can procure and dispense schedule 8 and drugs of addiction.In part 6 it refers to a registered nurse employed in a hospital having authority to procure andadminister poisons under the instructions of a medical practitionerThe Health Practitioner Regulation National Law (WA) Act 2010 in its Schedule defines a healthpractitioner, a medical practitioner, and a registered health practitioner.2.1.2.9. Where are the Gaps?In analysing the jurisdictional legislation and extracting the relevant aspects, the following issueshave been identified: A variety of terminology and definitions are used with no consistent approach. Forexample ‘doctor’ is used in some legislation, ‘medical officer’ and ‘medical practitioner’used in others and ‘health practitioner’ in others with some being interchangeable. Somedefine a nurse practitioner, others define a nurse or registered nurse as well as authorisedperson, and there are only a few references to enrolled nurses. Even within thejurisdictional legislation, it is difficult to decipher the roles and definitions.Further roles are referred to relating to carers, assistants, physician assistants and otherhealth workers in some jurisdictions and others are silent. Specific references to aged careworkers and approved providers are noted in some jurisdictions but not in others.17

There is no uniform identification and definition of the health practitioners’ roles relatingto their legislative responsibilities in who can prescribe, supply, dispense and administermedicines, poisons and drugs. There is also inconsistency in the definitions of themedication management stages.The use of the terminology relating to medicines, poisons and drugs appears variable in thetitles of the legislation and within the legislation.Efforts have been made to reference the Health Practitioner Regulation National Laws, butagain there is no consistency in this approach.2.2. Guidance documents2.2.1. Sources and types of documents reviewedDocuments were identified initially through internet searches, the use of Pub Med and a variety offollow-up contacts. The eventual range of document sources was:• Government – departments, statutory authorities, committees, commissioned reports -State/Territory, Australia, US & UK.• Professional organisations – nursing, medical, pharmacy, unions.• Industry organisations – aged care, pharmacy, General Practice, health – State/Territory,and Australia-wide.• Others – Provider organisations and Non Government Organisations (NGOs) such as elderadvocacy, consumer, particular interest and specific disease focus (e.g. Alzheimer)organisations.Interviews about aged care medication practice and workforce issues were also held with ProfTrisha Dunning, Chair in Nursing (Barwon Health) Deakin University, and Ms Belinda Moyes, CEOCountry Health South Australia and former Chair of the National Nursing and Nursing EducationTaskforce.While the resulting list of documents could easily be supplemented, the range and contentrepresents the most important documents, and a meaningful cross-section of the academicliterature in English.About sixty percent of the documents identified related specifically to medication managementprinciples and practice, the remainder relating to workforce, and broad professional practice andhealth worker education matters.2.2.2. Medication Management documents2.2.2.1. Government DocumentsDocuments from Australian and State/Territory governments comprised the largest group, apartfrom journal articles, found in the document search.Comprehensive guidance on Medication Management in aged care was found in the APAC(Australian Pharmaceutical Advisory Council) publications which address medication managementin residential aged care facilities and in the community, and continuity of medication18

management. These Guidelines have the endorsement and support of Australian andState/Territory health and ageing authorities: the nursing, medical and pharmacy professionalorganisations, and of aged care and general practice industry peak organisations.The Guidelines for Medication Management in Residential Aged Care Facilities is under review;however the appendices to their documents are not to be included in the review and areconsidered by the industry to be outdated and not reflective of industry workforce or practice.Other guidance documents which were, until July 2010, widely used by nurses in the field, werethose developed and distributed by the former nurse registration boards in each of the states andterritories. There was, however, no uniformity across these documents. This was also the casewith the various health departments’ guidance documents developed for staff of department runfacilities to address medication management (generally or in aged care) and the various roles.The range of these documents covered inter alia,general Standards, Codes and Scopes of Practice for Registered Nurse (RN) Enrolled Nurse(EN) or Midwife practice,Standards specifically for RN and/or EN medication management,policies on delegation by RNs to ENs and/or other unlicensed health workers (variouslytitled), guidance for medication management for high care residents in aged care,position statements and policies on dose administration aids (DAA), and on use ofcomplementary and alternative medicines.Some of these documents included references to:the applicable jurisdiction’s drugs and poisons regulation,national health practitioner legislation, andcodes and guidelines such as the APAC Guidelines.Queensland Health has produced a very comprehensive handbook on “The Health (Drugs andPoisons) Regulation 1996 - What Nurses Need to Know”. The Victorian Department of HumanServices, in partnership with GP Divisions and service providers, has published a comprehensiveguide to implementing the APAC Guidelines for Residential Care.The Victoria Department of Health has produced the Drugs and Poisons Controls in Victoria,managing drugs in residential Aged Care and Key requirements for nurses in residential Aged CareServices.Neither the new Nursing and Midwifery Board of Australia, (nor the newly tasked and renamedAustralian Nursing and Midwifery Accreditation Council) has developed standards or guidelineswhich specifically address medication management or aged care. Nurses must now understandand apply the relevant national nursing competency and registration standards, and decisionmaking frameworks, and their organisation’s own policies, to inform their practice, accountabilityand delegation of medication management in aged care.2.2.2.2. Professional Organisation documentsThe main documents identified were the:19

Australian Nursing Federation (ANF)/Royal College of Nursing Australia (RCNA) NursingGuidelines - Aged Care settings,several relevant Professional Practice Standards;three guidance documents on Residential Medication Management Reviews (RMMR) in agedcare facilities from the Pharmaceutical Society of Australia;Position Statement from the Australian Society for Geriatric Medicine; andRoyal Australian College of General Practitioners (RACGP) Guidelines for the medical care ofolder persons in residential aged care facilities (The Silver Book) - Chapter 3.Victoria Department of Health has produced the Drugs and Poisons Controls in Victoria,managing drugs in residential Aged Care and Key requirements for nurses in residential AgedCare Services“The Silver Book’ makes clear references to the three sets of APAC guidelines, and theANF/RCNA Nursing Guidelines are incorporated in the APAC Guidelines for Residential Care.2.2.2.3. Industry Organisation documentsRelevant guidance documents were found from several industry organisations. The AustralianGeneral Practice Network (AGPN) has released a set of information and tools for RMMRs. Severalindividual GP Divisions have developed Resource Kits for Medication Management in aged care,usually based on the APAC guidelines, and initiated or led several Quality Use of Medicinesprojects run in partnership with service providers. One example is the MedGap project whichdeveloped systems and tools to ensure safe and prompt continuity of medication for patientsmoving between acute hospitals and either home or residential care.The Pharmacy Guild has also produced a range of sound information documents on aspects ofmedication management in aged care.The two Aged Care industry peak bodies and the Aged Care Industry IT Council have initiated aproject to implement an electronic medication management system in aged care facilities, which isoutlined in the 2009 publication “Case for Electronic Medication Management in Aged Care –Executive Summary”.All these guidance documents discussed briefly above, vary in depth and specificity but clearlyreflect good if not best, practice. Many include well-designed forms and tools to support and assistsafe practice in aged care and community settings.2.2.2.4. Academic and Overseas LiteratureA wide ranging search identified a range of documents and tools that were reviewed in greaterdetail. Of particular note were the following points:a Pharmaceutical Care Package for assessing and providing shared pharmaceutical care in thecommunity;Standards for Medicines Management from the Nursing and Midwifery Council UK,(comparable to those of the former Western Australian and South Australian nurse registrationboards);20

The Centre for Policy on Ageing (UK) reports and tools. London-based projects to improvemedication management through a “Single Assessment Process”; andThe nurse registration board for Ireland Comprehensive Guidance to Nurses and Midwives onMedication Management.The following themes were identified from these overseas documents. However Australian AgedCare services do not collect national data and so little is known on actual medication error rates.Medication errors (which can occur at many points from prescription through dispensing,packaging, storage and administration) and adverse events occur in residential aged carefacilities and among the elderly in the community with rates of 20% to 30% (of medicinesadministered) with up to 75% of residents in aged care affected. Errors were highest forpsychotropic, diabetes, and anticoagulant medications. Contributing factors included:o complex medication regimes with high numbers of individual drugs prescribed;o prescribing, charting, dispensing, and supply errors and inconsistencies;o medication information transfer problems where patients moved between settings(home, hospital, residential care);o workload levels and interruptions to those administering medications;o inadequate medication monitoring systems;o certain formulations (creams, liquids, aerosols) and changes to formulations (crushingtablets, emptying capsules).Strategies identified to reduce errors included:o Dose Administration Aids (although some studies suggest these cause errors),o integrated computerised prescription, order and entry (CPOE) systems linking theprescriber, dispenser and administrator,o electronic health records (with some qualified support),o pharmacist involvement in medication management systems for both residential andcommunity care,o multidisciplinary medication reviews and medication management systems,o pharmacist training of direct care staff in aged care medications and systems,o medication monitoring systems, ando reducing medication management staff workload and interruptions.The conclusions that can be drawn from this literature review include:There is no uniformity of guidance on medication management for nurses in aged careamongst the states/territories.APAC guidelines have differing authoritative credibility amongst professionals and healthauthorities.Little is known of actual medication error rates in Australian aged care.Multidisciplinary medication review and management systems; staff education bypharmacists, CPOE and other electronic systems and other tools may reduce medicationerrors.21

Clarity of legalities, and simplicity of guidance on medication management, as well as clarityaround nurses’ delegations to, and roles of, personal care workers in medicationmanagement are all necessary to improve the safety and efficiency of medicationmanagement systems.There is a growing interest in researching and furthering intersectoral collaboration toachieve greater consistency and shared “good practice” in managing medication for, andwith, older people.The literature suggests the following gaps in medication management need to be addressed:Consistent, authoritative and widely applied guidance for all players in medicationmanagement, on systems and practices which promote safe, effective and efficientmedication management.Effective multidisciplinary medication review and monitoring systems to assist medicationmanagement players to identify and address risk and problem areas, and to benchmarkpractice across the aged care sectors.Consistent clinical governance systems in both residential and community careorganisations, which would bring the guidance, the medication systems, and theirevaluation and improvement together.2.2.3. Workforce Issues Documents2.2.3.1. Government DocumentsThe Productivity Commission Annual Reports on Government Services – Aged Care chapters -presented useful industry profiles and some workforce statistics for consecutive years, along withsome commentary on changing factors in the aged care environment.Release of the Draft Report in January 2011 on its Inquiry - Caring for Older Australians -providesfurther confirmation of previous findings (and the anecdotal evidence provided to the consultantson key workforce issues through the survey), particularly:problems of staff supply,recruitment and retention, and training, contributed to by low status/image and inequitable(compared with acute hospitals) pay and conditions in the aged and community sectors.The draft report also points to an exacerbation of these problems as the community ages, and theavailable pool of younger workers declines, and notes the dominant influence of regulatory andcompliance approaches on the aged care service culture.These findings are consistent with those identified in the workforce issues section of the Report ofthe Senate Standing Committee on Finance and Public Administration on Residential andCommunity Aged Care in Australia, and with the 2001 Final Report of the Victorian Department ofHuman Services’ Nurse Recruitment and Retention Committee.22

Department of Health and Ageing documents provided information on Aged Care legislation andstandards. There were also some State/Territory health authority documents, particularly fromVictoria, which outlined the role of the department in aged care, jurisdiction over residentialfacilities which do not fall under the national Aged Care Act, and staffing guidance, frameworksand indicators for quality in their public sector residential aged care facilities (which also fall underthe national Aged Care Act).The Department of Education, Science and Training, (predecessor to the current Department ofEducation, Employment and Workplace Relations), commissioned the National Review of NursingEducation, which examined a wide range of workforce and education matters. It commissioned areview Australian Aged Care Nursing: A Critical Review which examined:the aged care workforce profile;future demand and supply;education and training;recruitment and retention in the overall aged care workforce.There was a substantial body of documents from national education, training, and employeerelations departments and authorities. The most current of these were detailed curriculadeveloped and regularly reviewed by the Community Services and Health Industry Skills Councilfor Certificates III and IV in Aged Care, Health Services Assistance and Enrolled Nursing.Medication management has not been a core unit in these courses, and this has contributed tovariable skills and training needs of those working in the field.The Nursing and Midwifery Board of Australia intends that all Enrolled Nurses will haveundertaken approved study in medication administration, and they note that “this will require arange of strategies to ensure a consistent scope of practice across the Enrolled Nurse workforce”(NMBA, Enrolled Nurses and Medicine Administration: Explanatory Note).Studies and reports by, and for, the National Nursing and Nursing Education Taskforce (N 3 ET)identify and address factors for current shortages in health workforce, recruitment and retentionstrategies through e.g. Myth Busters, and implementation of recommendations from the NationalReview of Nursing Education including:instituting qualifications and suitability checks for personal care workers,working towards consistent regulation of nursing;collaboration for improvement in aged care;developing a national decision making framework for nurses; andintroducing consideration of scopes of practice for nurses.The National Health Workforce Taskforce identifies work programs which would have addressedall the following workforce planning issues which are as relevant to aged care as to the rest of thehealth and community services sectors. For example:23

ensuring and sustaining supply,workforce distribution that optimises access to health care and meets health needs for allAustralians,health environments being places in which people want to work,ensuring the health workforce is always skilled and competent,optimal uses of skills and workforce adaptability.A constant theme in many documents, and in this study and ACSA’s earlier survey amongst itsstate peak body members, is the importance to an effective and efficient workforce of getting theskill mix “right”. In 1990 a Deakin University team was commissioned by the Minister for Aged,Family and Health Services to research and reported on an “Optimal Skills Mix for Desired ResidentOutcomes in Non-Government Nursing Homes”. This work identified a mix of RN, EN and personalcare workers, with nursing leadership, as being effective, but proposed that further work wasrequired to increase the proportion of diversional therapists (however titled) and further clarifythe role and training of enrolled nurses. In 2004, the National Aged Care Alliance (comprisingindustry, professional, consumer and aged-care specific interest organisations) published“Principles for Staffing Levels and Skills Mix in Aged Care Settings” to guide the field in itsworkforce strategies, and the Government as funder and regulator in developing a funding modelwhich would enable the Principles to be implemented.The 2005 National Aged Care Workforce Strategy proposed actions to address leadership andmanagement; education, training and development; a responsive workforce; status and image;and effective linkages. Determining what progress was made, and any points at which it mayusefully be reinvigorated may be worth pursuing.2.2.3.2. Professional Organisation documentsMost of the professional organisations’ documents are from the Australian Nursing Federation(ANF) and its State/Territory branches. These documents address skill mix issues and credentialingof personal care workers by registered nurses, and provide guidance to nurses on roles andrelationships with other staff, including other nurses and personal care workers.The ANF has also published a booklet – Balancing risk and safety for our community – whichdiscusses the issues relating to personal care workers in the health and aged care systems, andproposes seven options to address these. This issue was frequently raised in both this survey, andthe 2008 Aged and Community Services Australia (ACSA) survey. The ANF options range from selfregulationand licensing to co-regulation.2.2.3.3. Industry Organisation documentsACSA has a medication management policy which seeks:a national framework,a sound training system,an Overseas Workers’ employment policy,24

a Workforce Framework which outlines strategies to address aged care image, attractingand retaining staff, funding to support quality care, development of models of care, usinglabour-saving technology, securing a national industry-wide workforce plan, and supportingaged care providers to become preferred employers.These reflect the workforce issues already cited and support ACSA’s goal of using labour-savingtechnology as outlined in the document “The Case for Electronic Medication Management in AgedCare” referred to in 4.2.2.3 above.2.2.3.4. Academic LiteratureMost of the academic literature reviewed focussed on nursing, with much of it examining nursingfrom a quality of care and staff/mix perspective against ownership type (chain, private, not forprofit & public). In some instances, there is limited comparison able to be made with theAustralian system.Articles on alternate and innovative models of care highlight the need for non-traditional skill andoccupation mixes within multidisciplinary approaches, and emphasise empowerment and enablingof staff and residents through very effective nursing leadership.Other articles addressed recruitment, retention and rates of turnover of nursing and other carestaff, and revealed rates that are fairly consistent with reported rates and experience in Australia.Recruitment issues associated with the relatively low pay, status and image of aged care appear tobe problems also in the UK, Europe and North America.2.2.3.5. Main observations and inferences from these documents and articles• Aged care work is unpopular with RNs and ENs. Factors contributing to this are the low statusand pay compared with the acute sector, the heavy workloads and regulatory and compliancedemands, and issues with staffing levels and skill mix particularly in residential care.• Many national initiatives have been aimed at improving aged care worker education/training,promoting workforce planning & development, and clarifying roles, functions and appropriatestaffing levels and mix in aged care.• Some national initiatives are underway or proposed at present, but seem, as yet, to have“borne no fruit”.• There is little agreement between professions, the aged care industry and government as toeffective staffing patterns and skills mix, though there are examples of effective models whichcould be replicated or trialled by service providers.• There is a good range of resources, suggestions and projects to use or guide providers, butfinding out about them is difficult as there are so many players (Governments, professionalbodies, researchers) dealing with different aspects of workforce development and planning,and supporting different policy and education strategies.25

2.2.3.6. Where are the gaps?These documents and articles on workforce issues in aged care suggest that there has been muchwork initiated to address workforce issues, but little appears to have been completed. Untilstrategies are implemented and completed, some “gaps” will be present in:Workforce design and planning, which takes into account the changing population profile,workforce profile and increasing demands for residential and community care.Effective, safe and efficient staffing patterns and skills mix which have actually beendeveloped and trialled.Consistent education and training to match agreed staffing and care needs.An easily accessed and inexpensive evidence–based repository of models of care for bothresidential and community care, and other successful initiatives which are improvingmedication management quality and workforce efficiency and effectiveness.Some prerequisites to address these gaps may be:Role and scope of practice delineation for all nurses and direct care workers, includingactivity and recreation staff (however titled).Consistency of scopes of practice vis-à-vis medication administration nationally.Alignment of Enrolled Nurse educational preparation and registration for medicationadministration with consistent enabling provisions in all jurisdictions medicines/poisonslegislation.3. ConclusionThis literature search is the first step in this project. As a result of this review, the followingmatters and strategies have been identified for further work and consideration:Education and training modules explaining the applications and practices expected underthe Nursing and Midwifery Board of Australia’s national Scope of Practice documents forRNs and ENs. This may work best as a joint union/industry initiative perhaps incollaboration with ANF and RCNA to gain maximum communication with nurses nationally.Ideally this could be on-line but should have assessment/test/feedback capacity. Thiscould be of value for all fields of nursing practice and not just aged and community care.Some State/Territory health authorities already have extensive on-line education programsfor health practitioners, which could “host” such education – either in face-to-face oronline modes.Exploration of the range of electronic systems which can or do incorporate medicationmanagement and which can be utilised by GPs, pharmacy and care organisations(residential or community). Examination of the feasibility of developing a “preferredprovider” list for General Practice, pharmacy and care organisations. This might be anexercise for Medicare Locals to lead in their “catchments”, and could build on work alreadyunderway around electronic records and health management (e.g. Monash Institute ofHealth Services Research, e-Health Unit).26

Longer-term work on establishing common authorities and practice directives for ‘who cando what’ in medication management across all the State/Territory Drugs and Poisonslegislation.Full implementation of the APAC Guidelines, with organisational or regional MedicationAdvisory Committees to oversee medication management systems for residential andcommunity aged care. The collection of data and the monitoring of medication activitiesagainst standards are fundamental to good clinical governance.Development of a small, easily referable set of agreed Guidelines on effective and safemedication management for use by clinical staff in residential and community aged caresettings – also to be promulgated nationally for use by medical, aged care and pharmacystaff.Options for a standard core curriculum in medication management in the Vocational andEducation Training (VET) level Certificates III and IV in Aged Care Work and Home andCommunity Care, and Certificate III in Health Services Assistance. A related issue is anagreed standard for course delivery and measuring the achievement of course objectives.Development of education modules in basic national/state/territory health law, regulation,principles and practice applicable to RNs, aged care facility and service managers, andothers involved in the day-to-day delivery of medications. For example – the module ‘Therole of the RN in contemporary aged care’, as delivered in Queensland, Victoria and NewSouth Wales. In addition to understanding the legal framework relating to medicationmanagement, there are some indications that service managers and nurses are concernedabout consent, confidentiality and privacy. Their anxiety about handling such matters isheightened by difficulties in understanding the differences between statute and commonlaw, particularly as it applies to consent, and how the various national and state/territorylaws on privacy and confidentiality, information privacy, and Freedom of Information apply.A system to address discharge from acute hospital to residential care has been developed inVictoria by the North East Valley Division of GPs in collaboration with the VictorianDepartment of Health. It might be prudent to consider the feasibility of extending thisnationally.Methods for strengthening the management knowledge and skills of senior and supervisingaged care staff (residential and community) to enable them to plan and implementsolutions to problems in their work environments. It was evident from many responses tothe survey, that senior staff could see practical problems and often had ideas about how toaddress them (e.g. auditing medication errors), but appeared to lack either the confidenceor the authority to implement them.Identification of relevant national committees and working groups on medicationmanagement and co-ordination of efforts. This may include establishment of a nationalclearing house. In an article in the Medical Journal of Australia, Volume 189 Number 10 inNovember 2008, by Russell, Boxall and Leeder, it was noted that t.here are over 100advisory bodies nationally (not including sub-committees and working parties) but no oneofficial site to source them. The Department of Health and Ageing were contacted andasked for the list of all extra-departmental national and advisory committees. They27

provided a list of approximately 223 committees/groups although some committees listedwere time-limited and had ceased operations.28

Roundtable Discussion:Key issues identified in the Gap Analysis and Industry Survey were tabled at a roundtablediscussion, which is detailed under the following headings:1. LegislationToo much is expected of legislation as it largely relates to the supply of medicines ingeneral (most drugs used in aged care are funded under the national PharmaceuticalBenefits Scheme).There is a need to consider other national legislation particularly the National Health Act.Legislation can be difficult to interpret and understand.Nurses feel both accountable to, and bound by, legislation and guidelines.Aged Care Approved Providers manage Residential Aged Care Facilities and CommunityAged Care services across states/territories and need a consistent system.Different states’ regulations are apt to cause confusion for services and workers whooperate or work across state borders.There would appear to be an overall deficit of knowledge in relation to medicines’legislation.2. AccreditationAccreditation has a greater potential than regulation to improve and resolve problems.However, accreditation itself requires clearer processes to achieve this.Aged Care Accreditation assessors do not refer to the Australian Pharmaceutical AdvisoryCouncil (APAC) guidelines nor expect the Residential Aged Care Facilities (RACF) to utilisethe APAC guidelines per se.3. MedicationsMedication management is a series of problems in a chain of processes (prescribing,dispensing, supplying, administering).Under-medication is another dimension to consumer medication compliance alongsidepolypharmacy.There is lack of data collection and reporting mechanisms to enable medication error ratesto be determined in aged care. This is in contrast to the availability of evidence in the acutehealth sector.The biggest problem is that of under-reporting of medication errors which requiresestablishment of a “no blame” culture if it is to be remedied.Maintaining continuity of the care-workers who administer medications is important.Registered Nurses from other countries can have difficulty with the different drug namesused in Australia versus their countries of origin or other jurisdictions where they havebeen educated or worked.For many workers, including Personal Care Workers, English is a second language.

There is a need for greater involvement of older people in their own medicationmanagement.4. Clinical GovernanceThere is no single coherent system of clinical governance across residential and communityaged care.There is a lack of clear understanding of “clinical governance” through the industry.General Practitioners, Community Pharmacists and Consumers most often are responsiblefor managing consumers’ medication safety and compliance in the wider community.There are few medication advisory committees and only small numbers of RegisteredNurses involved.5. WorkforceA demographic wave of older people needing care is coming.The current proportion of people in the workforce is predicted to decline as a result of thechanging demographics.There will be insufficient workers to meet the Australian population’s need for aged careand support if we maintain the status quo.Workforce planning and regulation needs revisiting if it is to support the most effectiveapproach.The workforce has to choose, interpret and implement multiple codes and guidelines toachieve good practice.The aged care workforce has a high level of commitment to its clientele, but tends to beconstrained as a result of the current regulatory regime.There is a need to map medication management and care functions in order to informcompetencies and the roles of various participants in these functions.Clarity is needed about the training and roles of personal care workers.Greater consistency is required in Enrolled Nurses’ roles and the way in which theyarticulate with the roles of personal care workers in residential and community care.There are national Vocation Education and Training qualifications for the Certificate III andIV level courses used in the aged care sector. However, delivery of these qualifications isnot consistent across Registered Training Organisations (RTOs).6. Australian Pharmaceutical Advisory Council (APAC) GuidelinesThe APAC guidelines inform policy and practice.APAC guidelines for residential aged care are currently scheduled for review and this maypresent an opportunity to move toward a nationally consistent approach.Conflict between the guidelines of professional bodies and the APAC guidelines needs tobe reviewed and addressed.There seems to be a gap between APAC guidelines and practice.30

There is a need to establish whether Medication Advisory Committees are consistently inplace in Residential Aged Care Facilities and evaluate their performance.The guidelines need to address whole of workforce issues – GPs/pharmacist/multipleservices/allied health /nurses/personal care workers.Use of the APAC guidelines is limited and ways to enhance this may be required.7. ConsumersConsumers need to get better, not sicker, as an outcome of taking medications.Family members need to be listened to regarding medications and medicationmanagement.Consumer directed care is needed as an overarching approach to care and services.More work needs to be undertaken on promoting Quality Use of Medications in the olderpopulation.As a result of this discussion and subsequent group work the roundtable identified the followingactions which need to occur:A picture, or map, of what a good medication management system comprises – the mostfeasible system that will consistently deliver good health outcomes.Medication management to start with a profile/good assessment of elderly people’s needs,then accurate prescribing, dispensing, administration and monitoring would follow.Highly effective communication systems are required between general practitioners,pharmacists and hospitals upon a person’s return to a residential aged care facility or theirhome in the community.Good governance structures at a systems and service provider level which enableperformance to be monitored, and improve and enable strategically directed change tooccur. This includes an overarching risk management framework which would identify risksand impact on the workforce in assessment, prescribing and administration.New systems for medication management and measuring outcomes to demonstrate whatis achievable.Sector education and application of clinical governance tools and thinking. Case studies,root cause analysis, fishbone analysis all offer ways to approach the issues and identifysolutions in medication management.Use of workforce in a smarter way. Identify innovative examples of managing/monitoringmedications e.g. personal care workers – Dutchcare.Identify quality indicators for a good service e.g. ideal carer time per resident.There is a need to focus on robust and flexible systems rather than a restrictive set of rules.31

A change culture which adopts a “no blame” approach, striving for best practice and notjust compliance, is required to drive improvement and innovation.The industry needs empowered teams where personal care workers and others can effectgreater input.The right skills are needed for certain levels of work including nationally consistenteducation for the aged care workforce. (This should include clearing up the confusionamongst many aged care providers on care worker skills and qualifications.)Identify the risks associated with transition points in the medication system.Develop national e-health records for older people.Practical questions and reminders such as “Have you….? Do you …..?” are importantprompts at a service level to ensure compliance with standard operating procedures andpolicies.Medical students or post graduate gerontological students should be rotated throughResidential Aged Care Facilities.Communication between all those involved in a person’s care is critical.Accessible forms of information are needed about medications for older people who live athome.Consistency is required in the competencies/roles/scope of practice/education for ENs andpersonal care workers.Older people from culturally and linguistically diverse (CALD) backgrounds need improvedaccess to qualified interpreters rather than relying on family or friends.More evidence and research is needed about the current skill mix as a basis for futureplanning across the system and staffing models at a service level.Use of evidence and research to inform the development of alternate models of careincluding the services needed and who can deliver them.A greater emphasis needs to be placed on a wellness, rather than a medical, model.Personal care workers need more time to attend to people’s psycho-social needs. Inpractical terms this is about building trust and good connections with residents and clients.A national review of the APAC guidelines for Medication Management in the Community,and for Continuity of Medication Management is required.32

8. SummaryA better medication system needs to:place the person (resident/client and family or carer) at the centre of care,where appropriate, share relevant information with all parties,support self-administration of medication (administration by others is the exception, notthe rule),include good clinical governance,have the right workforce with the right skills/competencies, andpromote greater use of technology.33