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Last modified: Dec. 22, 2005

Long-term care teleconference: Standards in Practice

Further dialogue from the November 15, 2005, session

In 2005, the College of Nurses of Ontario initiated a series of teleconferences to further explore the realities of long-term care practice settings and to provide opportunities for nurse leaders to engage in collective problem-solving.

The November 15 session was the last teleconference in the four-part series. The College’s next step is to review the themes that emerged in the series and distribute a survey to participants to confirm the themes.

These themes will be useful when engaging in dialogue with members of the Ministry of Health and Long-Term Care and other key stakeholders regarding the long-term care environment. In addition, the College plans to participate in related conferences and workshops. The College is currently partnering with the Collaborative Research Program: Rehabilitation & Long-Term Care at the University of Toronto to examine issues of nursing leadership in the long-term care sector.

The final teleconference focused on standards in practice, and the discussion centred on the questions that participants submitted prior to the session. Most questions related to applying College and Ministry of Health and Long-Term Care medication standards. The topics illustrate the necessity for long-term care caregivers to be nurses, who have the knowledge, skill and judgment to appropriately address the complex health needs of clients. Here are some of the topics that the participants discussed.

  • A nurse’s responsibility when a client refuses a treatment or medication. First, it is a client’s legal and ethical right to refuse a medication or treatment, as long as he/she is capable of making the decision to refuse. Second, a nurse is responsible for documenting interventions and outcomes in the client’s health record.

    When a capable client refuses , a nurse is responsible for ensuring that the client received the necessary information to make an informed decision, and to explore with the client and health care team the reasons for refusal. In collaboration with the client and team, a nurse will develop a plan of care that may include ongoing discussion and health teaching, but may not include insisting or coercing a client to take a medication or treatment that the client disagrees with.

    If a client is not capable of making treatment decisions, the substitute decision-maker (SDM) must be consulted and given the necessary information to make an informed decision on the client’s behalf. If a SDM refuses treatment, the nurse is responsible for exploring the reasons for refusal and, in collaboration with the SDM and health care team, developing a plan to address it. A nurse is responsible for acting in accordance with the SDM’s wishes, unless the nurse does not believe that he/she is acting in accordance with the client’s prior capable wishes and/or best interests. In such instances, the nurse may advocate with the health care team to apply to the Consent and Capacity Board for a review of the SDM’s decision to refuse.

    Incapable clients have a right to refuse care that has not been specifically mandated by a consenting SDM. Nurses are responsible for respecting such wishes and for working collaboratively with the client, SDM and health care team to develop approaches for dealing with refusals. Approaches are generally aimed at negotiating mutually agreeable outcomes, and may include tailoring communication to a client’s level of understanding and interests, offering simple choices, and leaving and returning to re-offer care. It is important to note that even when there is consent from a SDM for treatment that a client refuses, nurses are responsible for implementing the same type of mutual approaches to ensure that a client receives the treatment with as little discomfort and disruption as possible. (See further discussion on forcible treatment below.)

    Medication may be administered in an emergency situation against the client/SDM’s wishes when a client is agitated to an extent that he/she is posing an imminent risk of physical harm to himself/herself or others and requires assistance to maintain safety. If such emergency situations persist and medication that has been refused is required on an ongoing basis, a plan must be established to assure the safety of everyone (including staff) and to safeguard the client’s right to refuse treatment. Such a plan may involve transfer to a hospital for stabilization, and may include informal admission under the Health Care Consent Act and Substitute Decisions Act for treatment (authorized SDM consents to admission against incapable client’s wishes) or involuntary admission under the Mental Health Act for a psychiatric assessment (Form 1 completed by a physician).
  • Mixing medication in a client’s food. This may be an appropriate practice if a client or SDM is informed and agrees to mixing medication in food as part of a therapeutic plan of care to address client needs (e.g., client preference, facilitating swallowing), and the food and medication are compatible. Nurses are responsible for ensuring that the medication and food are compatible for mixing, and may consult with members of the health care team (e.g., a pharmacist) or other resources to ensure that mixing won’t alter the medication.
  • A nurse’s responsibility for notifying the client or SDM of a medication change. If a change in medication is part of a plan of care that the client or SDM has already agreed to, it is not necessary to re-notify. If, however, the change has not been previously discussed, notification is necessaryto enable the client or SDM to provide informed consent for the change.

    For example , if a client is on a course of antibiotics that has been consented to, but the results of culture and sensitivity tests indicate that a medication change is warranted, and this has been discussed, it may not be necessary to notify the SDM of the medication change. In a similar fashion, if an SDM has agreed that a behavioural plan of care may include intermittent use of a range of psychotropic medication. and the medication is changed within the range of what has been agreed to, it may not be necessary to notify the SDM, unless he/she has requested notification. However, if a different type of psychotropic medication is being used or the medication is required on a more frequent basis or in greater doses than what was anticipated and agreed to, notification is warranted.

    In providing notification, a nurse is responsible for informing the client or SDM about the change in treatment to enable him/her to provide informed consent. The nurse must also document the interaction and outcome. It is helpful if nurses, in collaboration with the health care team, discuss the plan of care with the family or SDM prior to the client being admitted to the facility and clarify when they would like to be informed of a treatment or medication change.
  • What to do when you can’t reach a family member/SDM regarding a medication issue. When a nurse is unable to reach a family member/SDM in an emergency situation, the nurse may administer any ordered medication or treatment and then follow up with the family/SDM as soon as possible. If the SDM is persistently unavailable to participate in necessary treatment decisions, a nurse may advocate with the health care team to apply to the Consent and Capacity Board for a review of the SDM’s ability to fulfil their responsibilities.
  • Receiving an IM order from a physician and forcibly administering a medication on a client (e.g., a confused client who is agitated or disruptive and unsafe). Forcible administration of medication may only occur when the medication has been specifically ordered and the client or SDM has consented, or on a short-term, emergency basis when a client is posing imminent risk of harm to themselves or others.

    If there is no consent, and an agitated, disruptive, unsafe client requires ongoing forcible administration, a plan must be made that provides for the safety of all parties (including health care team members) and safeguards the client/SDM’s right to refuse medication. The plan may involve transfer to a hospital for stabilization or an involuntary admission for a psychiatric assessment (see further discussion on transferring in the “Medication may be administered in an emergency situation” paragraph above) . If transfer is not indicated, the nurse should participate with the team and SDM to establish a plan of care that addresses the safety issues. This may include applying to the Consent and Capacity Board for a review of the treatment refusal and/or transfer to a more appropriate place for ongoing care. As a last resort, and for the protection of the client and caregivers, involvement of the legal system may be warranted. This team plan must be carefully considered and implemented only when all other clinical measures have failed to address pressing safety issues, and the risk of harm outweighs breaching client confidentiality and the possible compromises to ongoing clinical care.

    When forcible administration of medication is warranted, a nurse is responsible for ensuring that consent has been obtained from the client or SDM. If the client or SDM refuses to give consent, a nurse is responsible for discussing the reasons for refusal with the client/SDM and the health care team and for establishing an appropriate plan that addresses safety issues and the client/SDM’s right to refuse. A nurse is responsible for ensuring forcible administration is done therapeutically, using health teaching and interpersonal skills to maintain client well-being and the nurse-client relationship, and that behaviours, interventions and outcomes are accurately and completely documented.

    Pre-admission assessments with nursing participation can be an optimal means to ensure a good match between client needs and wishes and the ability of a specific long-term care setting to address those needs and wishes. If forcible treatment may be necessary and it is not something that the facility can safely and therapeutically provide, admission may not be an appropriate option.
  • Recognizing patterns of client behaviour and escalation when administering a medication or treatment. Nurses are responsible for recognizing and identifying patterns of behaviour indicating escalation so they can implement the appropriate response to maintain client well-being and safety. It is important for nurses to be alert to the possibility that escalation may indicate a change in physiological status (e.g., infection, cardiovascular event, constipation) and to assess and address it accordingly. Appropriate responses to an escalation in behaviour include health teaching and interpersonal interventions when clients are in an initial stage of escalation (e.g., are restless and distractible but able to respond to contact and information) through to physical and chemical restraint as a last resort when a less restrictive intervention hasn’t been effective, and behaviours indicate imminent risk of harm (e.g., clients have become loud, irritable and are using threatening gestures and/or throwing objects).

    Each client’s behaviours and patterns of escalation may vary; therefore, it may be a challenge to identify and respond to effectively, especially initially. Nurses are encouraged to consult all possible sources – the client, family members, the health care team, clinical experts and literature to assist in establishing a behavioural history and appropriate plan of care for the client. It is important for nurses to accurately and objectively identify and document behaviours, interventions and outcomes to facilitate effective care planning and provision.

    Need for support from management when administering medication to a large number of clients. In collaboration with management, nurses are responsible for identifying conditions that compromise client well-being and advocating for solutions; this includes presenting factual information to managers. Undertaking a systematic review to identify the actual time that it takes to administer medications to a specific group of clients over a number of days may be useful. Factors to include in such a review include: medication preparation time, client verification time, assessment and health teaching time, administration and recording time, time necessary for informing clients/SDMs of changes, and obtaining consent and/or follow-up. Include any impact on client safety (e.g., any administration errors that have occurred, or less-than-adequate assessments or health teaching time due to competing priorities with other clients). Work in collaboration with management to collect the data, and organize a team meeting to discuss and address the issues and concerns and identify strategies and solutions. Establish dates by which solutions are to be implemented. If acceptable headway is not achieved, see the College’s Professional Standards (link to online document) practice standard, specifically the section on accountability for next steps.
  • Is there research that indicates the number of clients that a nurse can safely administer medications to in a one-hour period? No, there is no set number. The number varies significantly according to situation-specific variables such as client conditions and environmental attributes (e.g., staff mix and experience, the physical lay-out of the care setting, and the availability of resources such as policies, procedures and equipment to provide care). It is important for nurses to document the complexity of client care, the staff mix and available environmental supports to determine what an appropriate ratio is for their setting, since all of these factors influence the time required to administer medications safely in accordance with College and Ministry standards.
  • Medication-administration strategies suggested by teleconference participants:
    • Work with the physician to stagger the timing of medications.
    • Use regular medication reviews to ensure that the type and number of medications are current, optimised and minimized. Involve the pharmacist in reducing non-essential medications or changing to long-acting medications, when possible.
    • Look at alternatives to address issues related to administering medications in the dining room. (Pros: many medications are to be taken with food, and efficient and effective administration. Cons: may be disruptive for clients, confidentiality issues and against guidelines.) Try administering medications to clients as they enter or exit the dining room. Or engage clients in a vote through the Client and Family Council to determine their wishes regarding the administration of medications in the dining room.
    • Record discussions with the client and family regarding the client’s preferences for medication administration.
    • Look into the feasibility and viability of medication self-administration systems for capable and able clients. (Note: significant nursing time may still be indicated, especially for monitoring client health status, health teaching and for initiating and maintaining the system for each client. An advantage may be that it frees up time during routine administration activities since clients on self-administration programs may have their medication-related needs addressed at other times.)
    • Look into optimising the medication administration system and equipment for maximum efficiency and effectiveness.

 

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