A recurring theme that has been brought to light in the recent Royal Commission Community Forums around the country, was that a large portion of aged care staff feel as though current conditions do not allow them to do their job properly.
Day-after-day, those in attendance heard aged care professionals stand up in front of Commissioner Lynelle Briggs and detail the issues that stand in between current conditions and a scenario that would allow them to do their job in a manner that they could be proud of.
One ex-nurse fought back tears as she spoke about being unable to sleep on a regular basis because of the stress that she was not delivering high-level care until she eventually could not cope anymore and made the choice to quit.
Administering medication is a very big part of the daily activity within the walls of every aged care facility, and the increase in more complex residents entering facilities means that aged care staff are currently having to manage more medication than ever before.
The number of high-care residents has risen sharply from 4.1% in 2009, through to an astronomical 31% in 2018, and two-thirds of Australians over the age of 75 now meet the definition of polypharmacy – meaning, they take five or more medications concurrently.
Though registered nurses manage medication- due to staff shortages – personal care workers, enrolled nurses, and assistants in nursing are being called upon to actually administer the medicines to residents – despite not having the same level of clinical expertise.
The regulatory guidelines on administering medication may vary slightly in each state, but as an example, Victorian regulation states that registered nurses can ‘delegate’ other members of staff to administer medication based on their judgement – but the registered nurse will also be accountable for their professional decisions and actions.
And while there will always be a risk involved when you put your credibility in the hands of others, the situation becomes even worse when you are forced to do so because of a lack of staff.
HelloCare was recently contacted by a registered nurse named Betty* (not her real name) who had spent years working in the aged care industry, and felt the need to let readers and know just how difficult administering medication has become.
“I’ve worked as an agency nurse and turned up at facility’s that have close to 100 residents where I’m the only registered nurse. I don’t know much about the other staff at that point and I’m supposed to somehow assess whether I think the personal care worker was competent in handing out medication? How could I?” said Betty.
Unlike most of the aged care industry which regulate standards on a federal level, regulation of administering medication is governed by state laws, which can make knowledge around best practise rather confusing.
“I’ve only ever worked in Victoria, but I reckon pretty much every nurse in Australian nursing homes would have the same problems. When I come on shift, I only have enough time to worry about what I have to do – not, is the PCA on level 3 up to standard,” said Betty.
“Personal carers who are administering medications have obviously been approved and completed a short course on medication administration, which really, is not much. But you assume that whoever has signed them off for the completion of their course is credible because that’s the only indication you have. But if they make a mistake it’s my fault.”
“The thing is, if they make a mistake it shouldn’t be only their fault either. Rules have bent so that carers and EN’s are allowed to give medication out of necessity, it’s not their fault that they are being asked to do these things even though they don’t have the clinical expertise. It’s a burden on them, just like it’s a burden on us RN’s.”
One of the biggest concerns for a number of registered nurses is that carers and other staff members can lack the clinical knowledge that would allow them to pick up on mistakes that most RN’s should be able to detect.
Seventy-five percent of all complaints to the Aged Care Complaints Commissioner in 2017/18 were about residential aged care, and the most common issue for complaint was the mismanagement of medication.
In fact, a 2017 review of Coroner’s recommendations showed that complications in clinical care that included medication administration errors, featured in close to 13 percent of deaths.
“I worked at an aged care facility a while back, and there was a woman who was being treated for constipation with Lactulose. Eventually, she started to get really bad diarrhoea and was in excruciating pain, and after nearly a week of her being in pain, not one of the carers who were administering her medications thought that having diarrhoea might be an indication to stop giving this poor woman laxatives,” said Betty.
“I went in there, had a look at the chart, and knew what the problem was immediately, and this was an extremely blatant example. There are a lot of scenarios just like this where it is a whole lot harder to detect an error.”
“But at the end of the day, you don’t know what you don’t know – and that includes not knowing when you have made a mistake.”
“It’s hard enough to speak up as it is, and I can’t go to management and say that I’m not comfortable with a certain staff member administering meds if I have no real knowledge of their capabilities. There is simply not enough time to assess them at all, and if there was, you would probably use that time to give the medication yourself.”
“If I’m told a PCA or EN needs help with something, I do my absolute best to guide or assist them. But most of the time I’m just trying to get by and do my own job to the best of my abilities.”
Given the fragility and sheer volume of aged care residents who require medication, the risk of error is ever-present.
Most residents in aged care facilities are using ‘high risk’ medicines to manage chronic conditions, such as anticoagulants, insulin, chemotherapy agents, narcotics and sedatives, that all require careful monitoring.
Although medication error rates may not necessarily be higher for PCA/EN’s versus RN’s, when an error occurs the consequences can potentially have an impact on the RN’s registration.
“You will be pulled into the coroners who would have their report and look at all the steps and processes that occurred leading up to the death – and the registered nurse would have to take some responsibility for that,” said Betty.
“It may not lead to something like being deregistered as a nurse but it’s still going to put them through a lot of stress – because according to guidelines – they should have identified or highlighted that the PCA or EN was not competent to be giving meds.”
“At the end of the day, my view is that we either need more nurses or we need the other medication endorsed workers to be provided more detailed training”.
“They are working just as hard as I am, but neither of us should have to wear a responsibility that we aren’t comfortable with – especially when people’s lives are at stake.”