This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).
Healthcare workforces are currently facing multiple challenges, including aging populations; increasing prevalence of long-term conditions; and shortfall of registered nurses. Employing non-registered support workers is common across many countries to expand service capacity of nursing teams. One task delegated to non-registered support workers is medication administration, which is considered a complex task, with associated risks. This is an important topic given the predicted global increase in patients requiring assistance with medication in community settings. This review explores the evidence on delegation of medication administration from registered nurse to non-registered support workers within community settings, to better understand factors that influence the process of delegation and its impact on service delivery and patient care.
The review followed key principles of Critical Interpretative Synthesis and was structured around Preferred Reporting Items for Systematic Reviews and Meta‐analysis guidelines. Literature searches were conducted in MEDLINE, CINAHL, Embase, and ProQuest-British Nursing Index databases. Twenty studies were included.
Findings are reported under four themes: 1, Regulatory and contextual factors; 2, Individual and team level factors; 3, Outcomes of delegation; and 4, Process of implementation and evaluation. Delegation was found to be a complex phenomenon, influenced by a myriad of interconnecting factors at the macro, meso, micro level. At the macro level, the consistency and clarity of government and state level regulations was found to facilitate or impede delegation of medication administration. Lack of clarity at the macro level, impacted at meso and micro levels, resulting in confusion around what medication administration could be delegated and who held responsibility. At the micro level, central to the interpretation of success was the relationship between the delegator and delegatee. This relationship was influenced by personal views, educational and systems factors. Many benefits were reported as an outcome of delegation, including service efficiency and improved patient care. The implementation of delegating medication administration was influenced by regulatory factors, communication, stakeholder engagement, and service champions.
Delegation of medication administration is a complex process influenced by many interrelating factors. Due to the increased risk associated with medication administration, clear and consistent regulatory and governance frameworks and procedures are crucial. Delegation of medication administration is more acceptable within a framework that adequately supports the process, backed by appropriate policy, skills, training, and supervisory arrangements. There is a need for further research around implementation, clinical outcomes and medication errors associated with delegation of medication administration.
Keywords: Barriers to delegation, Community nursing, Facilitators to delegation, Healthcare assistant, Medicine administration, Nurse-delegation, Nursing assistant, Registered nurse
What is already known
The administration of medicines can be a complex and time-consuming procedure that requires in-depth knowledge of the medicine and its intended effect.
Within acute care setting, clarity of roles, responsibilities, education, and effective inter-professional and team relationships have all been identified as important factors in registered nurse to non-registered support worker delegation.
What this paper adds
Registered nurses in several countries delegate medicines administration to non-registered support workers in a range of community settings, in order to improve service efficiency.
The success and safety of delegation is influenced by multiple factors and requires robust training and governance to build and support trusting relationships between delegator and delegatee.
This review presents a framework that visually demonstrates the complex interactions that may influence successful delegation. This consolidated evidence base may act as a reference point for any community nursing team looking to implement delegation of medication administration.
The global healthcare workforce is facing numerous challenges with increasing populations, longer life expectancies and increased burden of long-term conditions (Bates et al., 2016). A healthcare workforce that is of adequate size and skills, is critical to the attainment of any population health goal (WHO, 2016). However, many countries face difficulties in the training and retention of their healthcare workforce (WHO, 2016; Buchan et al., 2019). There is an estimated global healthcare workforce shortage of 7.2 million; predicted to grow to 12.9 million by 2030, including a shortfall of 5.9 million nurses (WHO, 2016, 2020a). In the United Kingdom (UK), as in other countries such as Australia and Italy (Shepperd et al., 2009), there is a desire to support healthcare provision in the community and prevent hospital admissions (RCN, 2014). With predicted shortfalls of 108,000 nurses in the UK by 2030, substantial investment in the community nursing workforce will be needed over the next 10 years (Buchan et al., 2019; Kings Fund, Closing the Gap, 2019; NHS Long Term Plan, 2019). This community nursing shortage has been exacerbated during the COVID-19 pandemic (WHO, 2020b).
The employment of non-registered healthcare workers (such as healthcare assistants, nursing assistants, assistant practitioners, medication technicians) is common across many countries to expand service capacity in nursing teams (Blay and Roche, 2020). In this review, the term ‘non-registered support worker’ is used to encompass these many different titles. In the UK, there has been an 11% increase in non-registered support workers between 2014 and 2018 (Buchan et al., 2019); comprising approximately 24% of the NHS healthcare workforce (n = 106,500) (The Cavendish Review, 2013), with approximately 16,968 employed in community health services (Spilsbury et al., 2013). However, this does not account for those working outside of the NHS, employed by local authorities or private organisations who might provide care for NHS patients. Similar increases in the non-registered support workers workforce have been reported in Australia and the United States of America (USA) (Blay and Roche, 2020). Non-registered support workers are part of the broader nursing team in acute, primary and community care settings. In community settings, this can include homecare, residential homes, assisted living facilities and nursing homes (Kessler et al., 2010; Bosley and Dale, 2008).
Non-registered support workers do not hold a qualification accredited by a professional association and are not formally regulated by a statutory body (Kessler et al., 2010). As such, it is common practice for registered nurses to delegate nursing tasks to non-registered support workers (Gillan and Graffin, 2010). In this review we adopt the Nursing and Midwifery Council (NMC) 2018 definition of delegation as ‘the transfer to a competent individual, of the authority to perform a specific task in a specified situation’. Importantly, the registered nurse retains legal responsibility for the delegated nursing care, as is stipulated in multiple international standards (ANA and NCSBN, 2019; Intercollegiate information paper developed by the CSP, RCSLT, BDA and the RCN, 2006). Clarity of roles and responsibilities (Munn et al., 2013; Blay and Roche, 2020), effective inter-professional and team relationships (12Campbell et al., 2020, Hopkins et al., 2012) and the quality of supervision ((Bifarin and Stonehouse, 2017)oe have all been identified as important factors in nurse to non-registered support worker delegation. There is mixed evidence that non-registered support workers provide care of equivalent standard to registered nurses (12Griffiths et al., 2019, Hopkins et al., 2012), reports of missed opportunities to provide care (Bittner and Gravlin, 2009; Kalisch, 2006) and potential errors/risks to patient care in different settings (Potter et al., 2010; Kalisch, 2011; RCN, 2017). While nurse to non-registered support worker delegation has been reviewed in acute care settings, a lack of evidence is reported for community settings (Blay and Roche, 2020; Munn et al., 2013; Hewko et al., 2015). It is therefore important to review delegation in the community context where non-registered support workers may undertake different types of activities with less opportunity for direct contact with registered nurses (Blay and Roche, 2020; Bosley and Dale, 2008) and where job stability may be lower than other settings (Hewko et al., 2015).
Non-registered support worker activity have been categorised as mainly direct care involving routine tasks associated with personal hygiene and mobilisation (Blay and Roche, 2020), however, some are delegated medication administration (Kesler, Spilsbury, Heron 2014; Dickens et al., 2008) and other tasks previously restricted to registered nurses, such as electrocardiograms, cannulation, and sutures (Blay and Roche, 2020; Spilsbury et al., 2013). The preparation and administration of medication are considered a complex higher-grade task (Blay and Roche, 2020), with associated risks to healthcare and costs (Assiri et al., 2018). As such, medication administration (the manner in which a medicine is administered) can be argued to require knowledge and competence to assess and administer safely (Blay and Roche, 2020). Prevalence of medication errors in community settings can be wide ranging and include errors of prescribing (5–94%), administering (44%) and monitoring (73%) (Assiri et al., 2018). The safe delegation of medication administration to non-registered support workers is an important topic given the predicted global increase in patients with long-term conditions who will require assistance with medication in community settings (Mangin et al., 2018; CQC, 2019). For these reasons, it is timely to review the research evidence on the delegation of medication administration from registered nurses to non-registered support workers within community settings.
The aim was to review evidence regarding the delegation of medication administration from registered nurse to non-registered support workers within community care settings to better understand factors that influence the process of delegation and its impact on service delivery and patient care.
Critical Interpretative Synthesis (CIS) is an approach that adopts a systematic method for combining qualitative and quantitative research and an inductive approach to generating theory to further develop an understanding of a topic (Dixon-wood et al., 2006; Depraetere et al., 2020). This review followed key principles of Critical Interpretative Synthesis, with an emphasis on theory development, critical orientation, and flexibility (Dixon-Woods et al., 2006). However, flexibility can be a disadvantage if authors are not explicit about their review process, raising concerns about trustworthiness (Depraetere et al., 2020). To provide rigour and structure to the review processes, a pre-defined protocol was used in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement (Moher et al., 2009) and registered with the International prospective register of systematic reviews (CRD42020201453).
Critical Interpretative Synthesis allows for the formulation of an open research question, which is then refined (Dixon-wood et al., 2006; Depraetere et al., 2020). The initial research questions were:
What are stakeholders’ views (registered nurses, non-registered support workers & patients) on the acceptance of and/or barriers and facilitators to the delegation of medication administration from registered nurse to non-registered support workers within community care settings?
What evidence is there of impact (service development, care delivery, medication errors, cost, and patient outcomes) associated with delegation of medication administration from registered nurses to non-registered support workers within community care settings?
During the process of data extraction and analysis (described below) the research question was extended to capture emergent factors and strategies associated with the implementation of medication administration delegation. Furthermore, it became apparent that data needed to be viewed and understood at the macro, meso, micro levels (described below) and a visual framework was created to present the complex nature of delegation (described below).
A comprehensive, replicable search strategy was developed (CS, KS, and FM) to identify primary research on the delegation of medication administration from registered nurse to non-registered support workers in community settings. The search strategy was supported by the use of SPIDER (Sample, Phenomenon of Interest, Design, Evaluation, Research type) (Cooke et al., 2012). Staged purposive sampling, advocated for Critical Interpretative Synthesis (Dixon-wood et al., 2006; Depraetere et al., 2020) was performed, however, additional theoretical sampling was not necessary as the primary research evidence base was sufficient to answer the research questions.
Four international electronic databases were searched, starting with MEDLINE, and customised using index terms across three other databases (CINAHL, Embase, ProQuest-British Nursing Index), using a combination of free-text words within the title/abstract. Search terms related closely to the review questions, and included: ‘medication’, ‘delegation’, ‘community nursing’, ‘registered practitioner’ and ‘unlicensed practitioner’ (Appendix 1). Searches began from inception of electronic databases, 1949, up to July 2020, to ensure a wide scope of material. Alerts were set up for each database to ensure most current inclusion. Hand searches of Nursing Times, British Journal of Healthcare Assistants, International Journal of Nursing Studies, NHS Evidence website and grey literature sources (Social Science Research Network and Open Grey), were conducted until September 2020. Hand searches also included the review of reference lists of relevant papers and contact with known researchers working in this area. One thousand, five hundred and fifty-six search results were found across all databases.
The title of registered nurse is inclusive of titles that might be held in different countries (e.g., home health nurse, community nurse) registered according to their country's regulations. Multiple nomenclatures were used to describe non-registered support workers, including: Healthcare support worker; Healthcare assistants; Associate practitioners; Homecare aides; Medication aides; Non-registered practitioners; Unlicensed assistive personnel; Community care aides; and Medication technicians.
Once duplicates were excluded (n = 157), one member of the research team (CS) independently screened 1399 papers from their title. Three hundred and four papers were screened by title and abstracts against the inclusion and exclusion criteria by one author (CS), of which a subset of excluded papers was cross-referenced by another author (KS). Two authors (CS, KS), confirmed articles to be excluded at full text, discussing discrepancies until a consensus was reached. All studies satisfying the eligibility criteria ( Table 1 ) were included (n = 20). Fig. 1 depicts the search process and the justification of excluding articles at multiple stages of the selection process.
Inclusion and exclusion criteria used in collating evidence on delegation of medication administration from registered nurse to non-registered support workers in community care settings.
| Language | English language unless translated versions were available. Any country of origin |
|---|---|
| Study | Any empirical study design, including service evaluation, that describes delegation of medication administration from an registered nurse to a non-registered support worker. Manuscripts that were commentary, opinion/editorial pieces, policy, or delegation guidance were excluded |
| Setting | Delegation must be within a community healthcare setting where a nurse delegates medication administration to an non-registered support workers |
| Population | Adults ages 18 years who are employed as registered nurse or non-registered support worker or where alternative job titles are used for example, Unlicensed Practitioner or Healthcare Assistant |
| Outcomes | Barriers to and/or facilitators of the delegation of medication administration; consumers’, carers’ and/or healthcare professionals’ perceptions and experiences of medication administration delegation Impact of delegation of medication administration; economic comparisons/patient, staff and/or educational satisfaction/expectation/service development/care delivery/medication errors and patient outcomes |