Development of a Standardized Medication Assistant Curriculum · 2014-10-14 · Certified nursing...

Copyright @ Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

Acrossthecountry,many

nonnurses are admin-

istering medications to

individuals in nonacute health-

care settings and in other set-

tings where healthcare is not the

primary focus (hereinafter, these

will be referred to as nonacute

settings). Because many states

are using medication assistants

in nonacute settings, the Boards

of Nursing, in their mission to

protect the public, became con-

cerned about a lack of unifor-

mity in the qualifications and

training of these unlicensed as-

sistive personnel. Therefore, the

Member Boards of the National

Council State Boards of Nursing

(NCSBN)* passed a resolution

asking NCSBN to conduct a job

analysis of medication assistants,

develop a model curriculum, and

explore the feasibility for admin-

istering a competency examina-

tion. At NCSBN’s 2007 annual

meeting, the information on the

job analysis and feasibility study

was presented, and the Member

Boards adopted, through a ma-

jority vote, the model medication

assistant curriculum. This article

will discuss the development of

that NCSBN model curriculum,

thus enabling employers and reg-

ulators to understand how and

why it was established and to

learn about its recommendations.

The National Council State

Boards of Nursing took the posi-

tion in their 2004 Model Nursing

Practice Act and Model Adminis-

trative Rules,1 Article XVIII, Chap-

ter 18, that if jurisdictions use

medication assistants, they should

be regulated by Boards of Nurs-

ing. The NCSBN model practice

act and rules termed the medi-

cation assistant who received

and passed an approved training

program and successfully complet-

ed a comprehensive examination,

a medication assistant certified. Cur-

rently, 14 Boards of Nursing

regulate medication assistants.

This model curriculum will pro-

vide those Boards that do regulate

medication assistants, as well as

those that may in the future, with

a resource for regulating and

training medication assistants.

.................................................

Background

There are many sociocultural

and health-related factors that

Author Affiliations: National Council of StateBoards of Nursing (NCSBN), Chicago, Illinois.Corresponding author: Nancy Spector, PhD,

RN, NCSBN, 111 E. Wacker, Suite 2900,Chicago, IL 60601 ([email protected]).

................................................

JONA’S Healthcare Law, Ethics, and Regulation / Volume 9, Number 4 / Copyright B 2007 Wolters Kluwer Health | Lippincott Williams & Wilkins

JONA’S Healthcare Law, Ethics, and Regulation / Volume 9, Number 4 / October–December 2007 119

*NCSBN is composed of 59 Member Boardsof Nursing, including the 50 states, 4 territories,the District of Columbia, and 4 PracticalNursing Boards.

....................

Development of aStandardized Medication

Assistant CurriculumNancy Spector, PhD, RN, NCSBN � Mary Doherty, JD, RN


have led to the need to change the healthcare work-force, thus prompting the emergence of the medicationassistant in nonacute settings. Some of these factorsinclude the shortage of nurses and other healthcarepersonnel; an aging population, as well as an aginghealthcare workforce; and a steep increase in chronicconditions worldwide. Furthermore, more and morepeople are taking medications; Aspden et al2 reportthat in the United States, 4 out of 5 adults take at least1 medication or dietary supplement every day. Partiallyreflecting these trends, but also the need for moreconcerted efforts for preventing medical errors, the 2003Institute of Medicine called for a ‘‘need for a majoroverhaul’’ of the education of health professionals.3(p1)

However, caution must be exercised whenever there isany overhaul that involves patient safety. Moreover, thechanges should be based on the best available evidenceand the outcomes should be continuously evaluated. Tothat end, NCSBN’s Practice, Regulation, and EducationCommittee members worked very deliberately for morethan 2 years in the development of the curriculum,designing it based on the available evidence. Further-more, NCSBN will continue to monitor the literatureand research related to the safety of utilizing medica-tion assistants.

The goal of this curriculum is to provide a documentthat is reflective of the current healthcare environmentin states where medication assistants provide nursing-related functions to individuals in nonacute settings. Toachieve that, a job analysis that provided a descriptionof current activities undertaken by these unlicensedhealthcare workers, their preparation, and their demo-graphics was conducted.4 There were 1,288 respondentsto this job analysis, and they were employed in avariety of nonacute settings, including the followingtypes of facilities: long-term care, assisted living,rehabilitation, developmental, residential, home health,psychiatric, hospice, group home, hospital, community-based, correctional, schools, and daycare (adult andchild). The job analysis identified low and highfrequency activities, as well as activities that were oflow importance or high importance to their jobs.4 Thesewere all taken into account, along with the otheravailable evidence, when developing the curriculum.

Under most state and territory nurse practice acts,medication administration is the responsibility oflicensed registered nurses and licensed practical/vocational nurses. In those states that allow both dele-gation and medication assistants, licensed nurses candelegate certain tasks of medication administration tomedication assistants. However, the licensed nurseremains accountable for the supervision of these unli-censed personnel. It is important to note that medica-tion assistants are only responsible for a limited role inthe comprehensive process of medication administra-tion; that is, they deliver the medication to the indi-vidual, whereas the licensed nurse is responsible fordelegation, supervision, conversion/calculations, judg-ment, and assessment (see Figure). That means that the

medication assistant cannot replace the licensed nurse’srole in the administration of medications. The licensednurse still must exercise judgment when delegatingmedication, such as: deciding when to give as neededmedication; assessing the need for, or response to, medi-cation; and educating the patients. There are other spe-cific limitations to this medication assistant role, such asthey are not allowed to administer parenteral medica-tions or medications through nasogastric, gastrointes-tinal, or jejunostomy tubes. These limitations were allsupported by the results from NCSBN’s job analysis.4

One very important aspect of incorporating themedication assistant role into nonacute settings ispatient safety. Although there are not many observationstudies available, Scott-Cawiezell et al5 conducted adescriptive and exploratory study, using a naı̈veobservation methodology, observing 39 healthcareproviders, including registered nurses, licensed practi-cal nurses, and medication assistants, as they deliveredmedication in nursing homes. Naı̈ve observations allowthe nurse observers to unobtrusively observe themedication delivery process without preconceivedideas about what should be administered. They definederror as a dose that was discrepant with the order. Theyalso observed for (1) distractions, which were definedas events that did not stop the medication administra-tion, but that could have diverted the medicationadministrator’s attention, (2) and interruptions, definedas stopping the medication administration process.There were no significant differences between thegroups for errors, although registered nurses had thehighest percentage of interruptions and licensed prac-tical nurses had the highest percentage of distractions.These authors have further data that confirm these

Figure � Visual representation of the role of medicationassistants certified (MA-Cs). An illustration showing thatthe MA-C is only responsible for medication delivery,whereas the licensed nurse retains the responsibilities ofsupervision, delegation, conversion/calculation, judgment,and assessment.

120 JONA’S Healthcare Law, Ethics, and Regulation / Volume 9, Number 4 / October–December 2007


findings (J. Scott-Cawiezell, personal communication,August 20, 2007), and there are similar studies beingconducted elsewhere (H. Young, personal communica-tion, July 7, 2006; P. Randolph, personal communication,August 8, 2007). The studies of error rates with medi-cation assistants bear watching, although preliminaryevidence shows that with proper training and supervi-sion, medication assistants can safely deliver medication.

............................................................................

Development of the Curriculum

After reviewing relevant materials from the variousstates and territories, including many different admin-istrative agencies, it was clear to NCSBN’s Practice,Regulation, and Education Committee members thatthere needs to be more uniformity in the regulation ofthe medication assistant. Currently, there are a numberof different agencies that regulate medication assistants;they have various titles (at least 16 different titles werefound); there is an array of training requirements (from4 hours to well over 100); the extent of limitations indelivering various medications is diverse; and thehealthcare settings where they are allowed are varied.To assure that the task of medication delivery is safelyand competently performed, nurses must remaininvolved in the process, and Boards of Nursing shouldbe the sole regulatory entity.1 There should beconsistency across jurisdictions as to the training andutilization of the medication assistant.

In preparation for developing the medicationassistant curriculum, the Practice, Regulation, andEducation Committee members studied the results ofNCSBN’s medication assistant job analysis.4 They alsoreviewed the literature and analyzed the following:

� Rules and regulations across all the states and territoriesregarding medication assistants

� Medication assistant curricula from various agencies� Pharmacology texts� National standards from organizations, such as theNational Coordinating Council for Medication ErrorReporting and Prevention, MEDMARX, NationalQuality Forum Endorsed Set of Safe Practices, and theJoint Commission

� Consultation with nursing experts in pharmacology

The NCSBN model medication assistant curriculum6

includes a preamble that explains the purpose andgoals of the standardized curriculum and describesexpectations on how the medication assistant roleshould be utilized. There is a section with relevantdefinitions, including a definition for the medication

assistant certified,y and this is followed by suggestedminimal admission requirements for the trainingprogram. The admission requirements were based onthe committee members’ review of the NCSBN jobanalysis4 and of the relevant materials from jurisdic-tions. When establishing the admission requirements,the committee members discussed at length the missionof Boards in protecting the public, thus the importanceof educating a safe and competent healthcare worker,especially considering the number of injuries anddeaths that result from medication errors. There wasalso discussion about the importance of establishingrequirements that will provide medication assistantswith the opportunity of being successful in theirtraining programs and their roles of delivering medi-cation. The minimal requirements recommended in thecurriculum include the following:

� Able to read, speak, and write English� Competent in basic math skills� Earned high school diploma or successfully passedthe general education development test

� Certified nursing assistant before beginning the program� 18 years or older� Cardiopulmonary resuscitation certification

This curriculum recommends 60 hours of didactictraining, which includes work in a skills laboratoryand/or simulation facility, in addition to 40 hours ofsupervised clinical practicum. The committee membersbased this decision on a review of the medicationassistant curricula that were provided and expertopinions from those who have taught these, or similar,courses. This is also in line with the NCSBN jobanalysis,4 which found that, on average, the medicationassistant received 50 hours of classroom training and31 hours of clinical training.

The elements of this standardized curriculum in-clude the essential content, practical/actual experience,demonstration of skills, and a competency examinationafter successful completion of the modules. There are5 modules, and their assigned times are recommended,based on review of other medication assistant curriculaand the experiences of those teaching these classes.Content areas in the curriculum include the following:

� Medication Fundamentals (20 hours of didactic,including 4 hours of skills laboratory)

� Safety (7 hours of didactic, including 1 hour of skillslaboratory)

� Communication and Documentation (8 hours ofdidactic, including 2 hours of skills laboratory)

� Medication Administration (20 hours of didactic,including 2 hours of skills laboratory)

� Ethical and Legal Issues (5 hours of didactic, including1 hour of skills laboratory)

� Practicum (40 hours of supervised clinical practice)

To effectively utilize medication assistants, thereshould be adequate education on delegation and

............................................................................yMedication Assistant Certified—an individual who receives training for arole in administering medications (with the exception of parenteral routesand enteral routes through nasogastric, gastrostomy, or jejunostomytubes) and who works under the supervision of a licensed nurse (modifiedfrom NCSBN7).



supervision, both for the medication assistant andfor the delegating nurse. Whereas the licensed nursemust learn about the effective execution of delega-tion and supervision, the medication assistant mustunderstand what is involved in accepting the dele-gated task. Interestingly, NCSBN studies8,9 havefound that new nurses report that they are notadequately prepared in their nursing programs todelegate tasks to others. Li and Kenward9 furtherfound that when new nurses reported that they werenot adequately prepared to delegate tasks to others,they had significantly more difficulty with theircurrent client care assignments, thus indicating theimportance of teaching appropriate delegation innursing programs and in precepted experiences. Themodel curriculum includes references to the Ameri-can Nurses Association and NCSBN Joint Statementon Delegation10 and NCSBN’s Working with Othersposition paper7 for licensed nurses and medicationassistants to use as sources for understanding delega-tion and supervision.

Pivotal to the successful implementation of medi-cation assistants delivering medications competentlyand safely is the development of a cooperative work-ing relationship with all the healthcare providersinvolved in medication administration. Likewise, com-munication with and about the individual receivingthe medication is a key component to safe medica-tion administration. As is indicated in the VisualRepresentation of the Role of the Medication Assistant(Figure), the patient and patient safety are always thefocus of medication administration.

See Appendix 1 for the ‘‘Medication Assistant-Certified Model Curriculum Quick Reference,’’ whichis available for instructors to assess whether studentshave mastered the major content areas of thecurriculum. Successful completion of a final compre-hensive examination, including content and perfor-mance of medication administration skills, is requiredfor certification. Once certified, the medication assis-tant certified is minimally competent at an entry-levelposition to deliver medications to individuals, asdescribed in the model curriculum, in settings asdetermined by state and federal laws and under thesupervision of a licensed nurse.

............................................................................

Conclusion

Across the United States, unlicensed personnel areadministering medications in nonacute settings. Cur-rently, there are no national standards on the trainingor expectations of these medication assistants, and thereis wide variation as to their roles, their training, andeven their titles. The National Council of State Boardsof Nursing has developed, based on the available evi-dence, a curriculum and other standards that willprovide for consistency with the training and function-ing of medication assistants, to assist the Boards ofNursing in their mission of public protection.

Appendix 1, ‘‘Quick Reference to Medication Assis-tant Certified Curriculum,’’ is available to the instruc-tors for assessing whether students have mastered themajor content of the curriculum. Since it can be printeddouble-sided, it is a handy 1-page tool for instructors tocomplete on each student.

R E F E R E N C E S

1. NCSBN. Model nursing act and rules. 2004. https://www.ncsbn.org/312.htm. Accessed August 29, 2007.

2. Aspden P, Wolcott JA, Bootman JL, Cronenwett LR, eds.Preventing Medication Errors: Quality Chasm Series.Washington, DC: The National Academies Press; 2007.

3. Greiner AC, Knebel E. Health Professions Education: A Bridge toQuality. Washington, DC: The National Academies Press; 2003.

4. Wendt A. NCSBN Research Brief: 2006 Job Analysis ofMedication Assistants. Chicago: NCSBN; 2007.

5. Scott-Cawiezell J, Pepper GA, Madsen RW, Petroski G,Vogelsmeier A, Zellmer D. Nursing home error and levelof staff credentials. Clin Nurs Res. 2007;16(1):72–78.

6. NCSBN. Medication Assistant-Certified Curriculum. 2007.https://www.ncsbn.org/388.htm. Accessed August 30, 2007.

7. NCSBN. Working with others: a position paper. 2006.https://www.ncsbn.org/Working_with_Others.pdf. AccessedJuly 31, 2007.

8. Kenward K, Zhong E. Transition to Practice: Newly LicensedRegistered Nurse (RN) and Licensed Practical/Vocational Nurse(LPN/VN) Activities. Chicago: NCSBN; 2006.

9. Li S, Kenward K. A National Survey on Elements of NursingEducation. Chicago: NCSBN; 2006.

10. ANA & NCSBN (2006). Joint Statement on Delegation. https://www.ncsbn.org/Joint_statement.pdf. Accessed August 31,2007.


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