The Assessment Of Administration Of Medicines By Nurses .
The Assessment of Administration of Medicines by Nurses,Midwives and Nursing AssociatesPolicy and ProceduresApproved By:Policy and Guideline CommitteeDate of OriginalApproval:20th April 2009Trust Reference:B13/2009Version:3Supersedes:2 – March 2016Trust Lead:Richard May (Education and Practice DevelopmentCharge Nurse) - Chair of Medicines ManagementAssessment GroupClaire Agnew Van Asch (Senior Nurse – PracticeDevelopment)Board DirectorLead:Carolyn Fox, Chief NurseDate of LatestApproval21 December 2018 – Policy and Guideline CommitteeNext Review Date:December 2021
CONTENTSSectionPage1Introduction and Overview32Policy Scope – Who the Policy applies to and any specific exemptions33Definitions and Abbreviations44Roles- Who Does What45Policy Implementation and Associated Documents-What needs to bedone.76Education and Training107Process for Monitoring Compliance108Equality Impact Assessment109Supporting References, Evidence Base and Related Policies1110Process for Version Control, Document Archiving and Review11AppendicesPage1LCAT assessors recording form122Assessment process for experienced registered staff new to UHL143Assessment process for newly registered staff154Triennial Competency assessment165What to do in cases of failed assessment176Education staff process for numeracy and theoretical assessment19REVIEW DATES AND DETAILS OF CHANGES MADE DURING THE REVIEWUpdated to include Nursing AssociatesKEY WORDSMedication Administration, Triennial Assessment, Medication Assessment, Medication,medicines Management, drug administration, maths, numeracy, calculationsAssessment of Administration of Medicines by Nurses, Midwives and Nursing AssociatesV3 Approved by Policy and Guideline Committee on 21 December 2018 Trust Ref: B13/2009Page 2 of 19Next Review: December 2021NB: Paper copies of this document may not be most recent version. The definitive version is held on INsite Documents
1INTRODUCTION AND OVERVIEW1.1NMC registered staff relates to those Nurses, Midwives and Nursing Associateswho are registered with the Nursing and Midwifery Council.1.2NMC registered staff working for the University Hospitals of Leicester NHS Trust(UHL) must be able to clearly demonstrate that they are up to date andcompetent in the safe administration of medicines to patients, supported by theNMC Code (2018) NMC , Leicestershire medicines Code, Royal PharmaceuticalSociety and the Health and Social Care Act (2012)1.3This document sets out the processes for the initial assessment and competencyreassessment (hereafter known as the Triennial competency assessment) ofnursing and midwifery staff in the administration of medicines. The initialassessment must take place upon appointment to the Trust and every threeyears thereafter.1.4It is an essential requirement of the job role that all Newly Registered staffundertake an initial administration of medicines competency assessment. Allcomponents must be completed before the NMC registered staff can administermedication without supervision.1.5It is expected that all experienced registered staff who are new to the Trustundertake a triennial competency assessment as part of their local induction andwithin 6 weeks of commencing employment. All components must be completedbefore the staff member can administer medication without supervision. (seeappendix 2 for flowchart of process)1.6It is an essential requirement of the job role that all NMC registered staffundertake an administration of medicines triennial competency assessmentevery 3 years. This is a reassessment and therefore no formal training is requiredas the staff member should be competent in the skill.1.7The triennial competency assessment process must be discussed as part of thereturn to work process for staff who return after an extended period of time off,e.g. maternity leave or sickness of three months or more. Reassessment can beconsidered as part of confidence building for these members of staff.1.8The triennial competency assessment could be used as evidence of proof ofcapability during individual performance review.1.9The aim of this policy is to ensure that NMC registered staff safely administermedicines by standardising the assessment process and ensuring regularassessment of competence2POLICY SCOPE –WHO THE POLICY APPLIES TO AND ANY SPECIFIC EXCLUSIONS2.1This policy applies to NMC registered staff employed by UHL (including those onthe UHL bank and The Alliance).2.2It is recognised that medicines are administered by other groups of staff such asRadiographers, Operating Department Practitioners, Assistant Practitioners,Medicines Management Technicians and Healthcare Scientists. It isrecommended that the principles laid out in this Policy are also applied to thesegroups of staff.Assessment of Administration of Medicines by Nurses, Midwives and Nursing AssociatesV3 Approved by Policy and Guideline Committee on 21 December 2018 Trust Ref: B13/2009Page 3 of 19Next Review: December 2021NB: Paper copies of this document may not be most recent version. The definitive version is held on INsite Documents
2.3This policy details both the initial and ongoing competency assessment processfor the administration of medicines2.4The assessment of medicines applies to all medicines and all routes.2.5While it is acknowledged that not all NMC registered staff will regularly practicethis skill as part of their current role (e.g. staff in outpatients, staff in non clinicalnursing roles and certain specialist roles, those with an honorary contract), it is aprofessional requirement that these staff maintain a basic level of skill in relationto the administration of medicines which is grounded in patient safety (Seesection 5.6 for more details)3DEFINITIONS AND ABBREVIATIONS3.1Competence: Relates to the need for the NMC registered staff to demonstratetheir ‘capability’ in certain skill areas to a required standard at a point in time.3.2Competencies: Component skills which contribute to being competent andachieving standards of proficiency.3.3Dyscalculia: Is an inability to understand simple number concepts and to gainbasic number skills.3.4Dyslexia: Manifests itself as a difficulty with reading, writing and spelling.3.5LCAT: Leicestershire Clinical Assessment Tool, a local evidence basedassessment, used to establish competence in practice.3.6Pass: Achieving 100% in the numeracy assessment, 80% or more in thetheoretical assessment and successful completion of the practical assessment.3.7Retrieving a fail: If the staff member fails the Numeracy part of the assessmentby 1 or 2 questions, an opportunity will be given to re attempt these questions.4ROLES – WHO DOES WHAT4.1The Executive Lead for this Policy is the Chief Nurse4.2Heads of Nursing / Assistant Chief Nurse – Education and PracticeDevelopment4.3a)To ensure that processes are in place within their Clinical ManagementGroup (CMG) / Corporate Directorates to implement this policy andprocedures.b)To monitor compliance and support Matrons and Ward Sisters/Managerswith any issues or concerns that may be raised.c)To give final approval to modifications to the assessment process inspecial circumstances.Senior Nurse - Medicines Management and Senior Nurse – Clinical PracticeDevelopmenta)To support the implementation of this policy and procedures and tomonitor compliance.b)To support the Assistant Chief Nurse – Education and PracticeDevelopment in implementing this policy for nurses and midwives workingin Corporate Directorates.Assessment of Administration of Medicines by Nurses, Midwives and Nursing AssociatesV3 Approved by Policy and Guideline Committee on 21 December 2018 Trust Ref: B13/2009Page 4 of 19Next Review: December 2021NB: Paper copies of this document may not be most recent version. The definitive version is held on INsite Documents
4.44.5c)Provide advice to the UHL Medication Administration Assessment ReviewGroup, Nursing and Midwifery Education Teams and Heads of Nursing onadapting the assessment in specific circumstances (see section 6.4 formore details)d)To give final approval to modifications to the assessment process inspecial circumstances.Nursing and Midwifery Education Leadsa)To support the Education and Practice Development Team to facilitate thetheoretical and numeracy elements of the assessment.b)To give final approval to modifications to the assessment process inspecial circumstances.Matrona)4.64.7Support the Ward Sister / Charge Nurse / line manager with theassessment process and any subsequent performance managementconcerns.Ward Sister/Charge Nurse/Line Managera)Ensure that the staff member is given every opportunity to undertake theirassessmentb)Ensure that the assessment process is followed and in the event of failureprovide support for the staff member and involve the Matron andEducation and Practice Development Teamc)Ensure that relevant documentation is stored in the member of staff’spersonal file and a copy sent to the Nursing and Midwifery EducationTeam to be recorded on the staff member HELM accountd)Ensure that their staff complete the process within relevant time scales. Ifthe individual is unable to complete, a meeting must take place to discussthe reasons and set an action plan to complete within the next four weeks.e)If the individual is unable to complete after the additional four weeks, theline manager must discuss the reasons with them. The circumstances canthen be reviewed and a decision made as to whether the individual shouldrestart the process. Advice can be sought from the Education and PracticeDevelopment Team.f)Identify and support appropriate assessors for their clinical area.Education and Practice Development Teama)Act as a resource to signpost staff to further education and trainingopportunities as a result of any learning needs or actions identified.b)Share/raise awareness of new and updated policies relating to MedicinesManagementc)Provide opportunities for staff to complete the theory and calculationassessmentd)Record the outcome of the assessment process on the staff member’selectronic skills passport.e)A Summary of the Education process is in appendix threeAssessment of Administration of Medicines by Nurses, Midwives and Nursing AssociatesV3 Approved by Policy and Guideline Committee on 21 December 2018 Trust Ref: B13/2009Page 5 of 19Next Review: December 2021NB: Paper copies of this document may not be most recent version. The definitive version is held on INsite Documents
4.8AssessorThis refers to the practical component only.4.94.10a)Must be competent in medication administration, have undertaken theirown Triennial assessment competency, be identified as an Assessor bytheir Line Manager and be LCAT trained.b)Liaise with the staff member to book a suitable time for the practicalcomponent of assessment.c)Feedback to the staff member and Ward Sister/Charge Nurse/LineManager the results of assessment using the LCAT (Appendix One),copies of which are to be given to the staff member and their LineManager.d)Provide constructive feedback and set realistic action plans to addressknowledge and/or competency deficits after the assessment has beencompleted. Support can be sought from the Education and PracticeDevelopment Team.Nurse/Midwife/Nursing Associatea)Ensure, in conjunction with their manager, that they complete the initialassessment and subsequent Triennial competency assessments withinthe specified time frame.b)Arrange a time to undertake the theory and calculation assessment withthe Education and Practice Development Team.c)Liaise with their assessor to book a suitable time for the practicalcomponent of the assessment.d)Take responsibility for their own learning and practice, updatingknowledge on policies relating to Medicines Management, see supportingevidence - Section 11.e)Undertake any further reading required to update their knowledge prior tothe assessment. This should include knowledge of commonly usedmedications and patient information.f)Complete any actions relating to knowledge and/or competence deficitsidentified at the assessment.g)Ensure that all parts of the assessment are completed within the required6 week time frame. If unable to do this they must discuss the reasons withtheir line manager and complete within the next 4 weeks.h)Those who do not practice this skill as part of their current role mustdiscuss and agree the assessment requirements as part of their appraisal(please refer to Section 5.6)UHL Medication Administration Assessment Review Groupa)Responsible for the coordination and standardisation of the assessmentprocesses including the exam / test papers and Medicines ManagementClinical Competency Booklet (MMCCB)b)Actively seek out resources to signpost staff to further education andtraining opportunities as a result of any learning needs or actionsidentified.c)Be a point of contact for staff for advice on the administration ofassessment processAssessment of Administration of Medicines by Nurses, Midwives and Nursing AssociatesV3 Approved by Policy and Guideline Committee on 21 December 2018 Trust Ref: B13/2009Page 6 of 19Next Review: December 2021NB: Paper copies of this document may not be most recent version. The definitive version is held on INsite Documents
5.POLICY IMPLEMENTATION AND ASSOCIATED DOCUMENTS5.1Initial Medication Assessment for Newly Registered Nurses, Midwives andNursing Associates (see flowchart of process in Appendix 3)The assessment process includes the completion of:a)A numeracy exam consisting of 20 fundamental maths and medicationcalculations. Staff undertaking the assessment will not be allowed to use acalculator. The staff member must achieve 100% to be deemedcompetent.b)A theoretical exam consisting of 20 multiple choice questions based onthe Leicestershire Medicines Code and the relevant Trust policies. Thestaff member must achieve 80% to be deemed competent.c)A practical assessment following a period of practice under directsupervision. This must include a formative and summative LCATassessment in order to be deemed competent. In general ward areas thesummative assessment must consist of administering medications to ateam of patients, for areas that provide 1:1 nursing care this must consistof at least three separate administrations. This assessment must alsocover the range of administration types appropriate to their clinicalarea/speciality/clinical role, e.g. Oral, Nasogastric, subcutaneous.d)UHL Medicines Management Clinical Competency Booklet (MMCCB)consisting of: Record of discussion with a named assessor demonstrating theirknowledge of:o commonly used medication.o routes of administration.o associated polices.5.2 Documentation for the practical assessment Final completion statement.Triennial Competency Assessment (see flowchart of process in Appendix4)This must be completed every Three Years. The assessment process includesthe completion of:a)A numeracy test consisting of 10 medication calculations. Staffundertaking the assessment will not be allowed to use a calculator. Thestaff member must achieve 100% to be deemed competent.b)A theoretical test consisting of 20 multiple choice questions based on theLeicestershire Medicines Code and relevant Trust policies. The staffmember must achieve 80% to be deemed competent.c)A practical LCAT assessment must be carried out in order to be deemedcompetent. In general ward areas the assessment must consist of aminimum of four patients. In areas that provide 1:1 nursing care this mustAssessment of Administration of Medicines by Nurses, Midwives and Nursing AssociatesV3 Approved by Policy and Guideline Committee on 21 December 2018 Trust Ref: B13/2009Page 7 of 19Next Review: December 2021NB: Paper copies of this document may not be most recent version. The definitive version is held on INsite Documents
consist of at least three separate administrations. The assessment mustalso cover the range of administration types appropriate to their clinicalarea/speciality (e.g. Oral, Intravenous, and Nasogastric). Those NMCregistered staff who have been deemed competent to administer IVmedication must have this skill reassessed as part of the practicalassessment.5.35.45.5Adapting the Assessment in Specific Circumstancesa)In specific circumstances and under the guidance of the Education andPractice Development Team, elements of the assessment process can beadapted in relation to staff member’s current role. Some staff may alsorequire more frequent assessments; these will have been identified by theline manager in discussion with the Education and Practice DevelopmentTeam and the staff member. Final approval of any Specific Circumstanceswill be agreed on a case by case basis by Senior Nurse – Clinical PracticeDevelopment, Senior Nurse – Medicines Management, Education Leadsand Heads of Nursing.b)The Senior Nurse – Medicines Management and Senior Nurse – ClinicalPractice Development will keep a log of the special circumstances thathave been approved for consistency checking and on-going learning.Reasonable Adjustments.a)Reasonable adjustments will be made for staff with an identified learningdifference where possible.b)Staff who believe that they have a learning difference will be supportedusing the Equality, Diversity and Inclusion Policy (Trust ReferenceB61/2011)What to do in cases of a failed assessment (see flowchart of processes inAppendix 5)5.5.1 Retrieving a one or two question fail in the numeracy exam/testa)If the staff member fails the numeracy exam/test by one or two questionsthey will be given these questions again to re-sit, ideally on the same daybut if this is not possible within 3 working days. If they get them correctthey will have retrieved their fail and be granted a pass5.5.2 A fail of three or more questions in the numeracy exam/test and / or theoreticaltesta)If the staff member fails the numeracy assessment by three or morequestions they must retake the full assessment within 2 weeks.b)If the staff member fails the theoretical test then they must retake the fullassessment within 2 weeks.5.5.3 A fail in the Initial Practical LCAT Assessmenta)The assessor must immediately discuss this with the nurse/midwife andtheir line manager.b)The staff member can continue to administer medication under directsupervision until a reassessment is undertaken.Assessment of Administration of Medicines by Nurses, Midwives and Nursing AssociatesV3 Approved by Policy and Guideline Committee on 21 December 2018 Trust Ref: B13/2009Page 8 of 19Next Review: December 2021NB: Paper copies of this document may not be most recent version. The definitive version is held on INsite Documents
5.5.4 A fail in the Triennial Practical LCAT assessmenta)The assessor must immediately discuss this with the staff member andtheir line manager.b)The fail may impact on whether the staff member can continue toadminister medication. Following a review by the line manager they maybe suspended from administering and/or checking medication. Thisdecision must be discussed with the Matron or Head of Nursing and anaction plan developed and documented by the clinical area to address anyconcerns. The practical assessment must be repeated within two weeks.5.5.5 A second or Third fail5.6a)If the staff member fails any part of the assessment a second time thenthe Ward Sister/Charge Nurse/line manager must, in discussion with theMatron/Head of Nursing put an action plan in place, with a period ofeducation and support before reassessment within 2 weeks.b)If after this period the staff member fails any part of the assessment a thirdtime, they should be managed in accordance with the ImprovingPerformance (Capability) Policy and Procedure – Non-Medical Staff (Trustreference B12/2014).c)If the staff member fails any part of the assessment a second time and arealso a Non-Medical Prescriber they must discuss their prescribing rolewith the Senior Nurse – Medicines Management.Registered Nurses, Midwives and Nursing Associates who do not regularlyAdminister Medicines as part of their rolea
medicines Management, drug administration, maths, numeracy, calculations Assessment of Administration of Medicines by Nurses, Midwives and Nursing Associates Page 2 of 19 V3 Approved by Policy and Guideline Committee on 21 December 2018 Trust Ref: B13/2009 Next Review: December 2021
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