Is it ever appropriate for security staff to administer oral medications if that's what the client has asked for?
We asked a nurse, a nurse educator, security staff, clients, a pharmacist and bioethicists. Here's what they say.
There are many issues to consider.
Our traditional practice has been that security staff do not give medication – nurses do. Nurses prepare and administer medication to clients in a safe, effective and ethical manner, as outlined in the College of Nurses of Ontario (CNO) practice standard of medication. Nurses follow the "eight rights of medication administration," which include measuring out the dose and making sure medication is given to the right client at the right time.
Another CNO practice standard focuses on working with unregulated care providers. The question is whether security staff are considered unregulated care providers. I would say they are not, which means they should never administer medication.
The practice standard on working with unregulated care providers also talks about teaching new skills or knowledge: nurses are expected to have the competence themselves and be able to train others in these competencies in order to ensure client safety. Currently, there is no process for security staff to receive training about medications or how to administer them.
If the client is asking to have security staff present, does that need to be part of the care plan? Does this happen on other units? Does the team need to re-evaluate its relationship with the client and start to build a rapport with that person?
Some clients have behavioural plans, so this issue might be a component of the plan that needs to be assessed with another discipline to improve the situation so it meets CNO standards. A behavioural plan is more in-depth about the assessment of a client's behaviour. It asks what might be causing the behaviour and then determines the best way to approach the behaviour and what strategies to use to reduce the likelihood that the behaviour will escalate.
Another issue to consider is that consistency within the team is crucial, so documentation should reflect the team's approach. The care plan is your documentation. It is a form of promoting consistency that is outlined in the CNO practice standard on documentation.
Another issue related to medication is the emergency restraint policy. If security staff is present or giving the medication, the medication is being given coercively. That's how we define chemical restraint. It's having that presence. You have created a very visible power differential that affects the client's experience.
In some cases authority can be effective, but we need to be careful that we're minding the therapeutic relationship and not making it even more imbalanced. The CNO practice standard on therapeutic relationships talks about boundaries. We talk about setting limits and shifting control to the client. We ask: What are the pros and cons? Is this actually helping the client? Is it developing a dependence? What is the risk? Are we meeting the client's goals?
Behaviour is quite complex. We don't want to develop a pattern where security personnel are continuously being called to dispense medication. It goes right back to relationships.
Generally, allowing security staff to dispense medication is not appropriate. Security staff don't have the knowledge, skill and clinical judgment to administer medication safely, especially in a hospital setting, so doing so would really be an intervention of last resort.
We are responsible for acting in the least intrusive way. If a client refuses to take an oral medication, it might be appropriate to ask security staff to administer it supervised by nursing staff. That said, there are some issues to consider if you take this approach:
Does the client routinely refuse to take medication? Sometimes clients will try to split staff as a way of coping – they see some people as bad and some people as good.
There is also the element of coercion. When security staff appear that usually indicates a situation where we have to restrain the client. The client may be willing to take the medication from security because there is a sense of coercion. The medication then becomes a chemical restraint. But we have to pay attention to power issues. Our population is especially challenging because many clients lack communication skills and have substitute decision-makers. We need to ask, are we serving the client's best interests in terms of setting up patterns of behaviour that wouldn't work in the real world or would cause issues?
Sometimes as care providers we have not found a way to set limits and structure that clients need. If we don't create that safe containment, that's pushing the limits in a way that does not help clients. Sometimes clients will test limits because of interpersonal dynamics they have lived with all their life, so they will try to push the limits. But what they are really trying to do is find someone they can trust who has a consistent response.
These are important ethical considerations around dispensing medication that should not be taken lightly.
The College of Nurses of Ontario standard of practice around working with unregulated care providers is a valuable resource to guide our thinking about this situation.
Whether security staff should be able to administer oral medication to clients is a hot topic. There's no definitive answer. It depends on the situation.
If a client asks security staff to give medication, the first thing that comes to my mind is that the client is now dictating the care plan – how the client should receive medication and care, not just from security staff but also with the clinical team, preferring one individual over another. This situation can cause an issue with the care plan if it is not outlined in the care plan.
The other issue is accountability. Nursing is a regulated profession that involves administering medication. Security staff are also regulated – in Ontario by the Ministry of Community Safety and Correctional Services and the Private Security and Investigative Services Act. So who should administer medication – security staff or someone who has been trained and licensed to administer medication? I think it should be the trained and licensed clinical professional – the nurse.
However, there are some situations in which it may be appropriate for security staff to administer medication. One example is an escalating situation that may result in harm to staff or clients. It becomes a matter of handing the client the medication in the presence of the clinical professionals. I don't see a major issue with that if it will de-escalate the situation. The decision depends on the situation. It's not a matter of regular procedure.
For security staff, our opinions about dispensing medication are really a matter of each person's comfort level. I know from my own experience that opinions vary. Some security staff say, "It's not my role to give medication. That's your role as a clinician. I'm here for your safety. You need to figure out how to administer the medications." Others say "Yes, I will assist as long as you're present."
One concern is that if security staff give medication in one situation, it will become their responsibility to do it again. Another concern is that if one security staff member dispenses medication, the expectation develops that all security staff be willing to do it.
I think the Centre for Addiction and Mental Health is a unique place for security. Our security staff are very engaged with clients and also nursing staff. We have a direct impact on client care, whether it's for medication, bathing, restraint or response.
A person who says they would rather get their medication from security staff might have experienced a problem with therapeutic staff. I have met people who say they prefer police to hospital professionals. One reason is that they feel police talk to them more as adults, whereas health professionals are more condescending. They think non–health professionals aren't as coercive in some ways, not trying to manipulate them. The person also might not want to sour their relationship with therapy staff. A person who doesn't want medication won't have good feelings about the person forcing the medication.
Mental health professionals have extraordinary powers, more even than the legal system, in terms of controlling people. That's a big reason why some people prefer to deal with non–mental health professionals. They feel less manipulated, which is common experience for people in the mental health system.
The only rationale for security staff giving medication is in a crisis. I'll let security come near me because I know what they're about, whereas my treatment staff wear a lot of hats – sometimes they're my best friend, sometimes they're my therapist, sometimes they're just delivering dinner. Security is security is security as a rule. But if I've painted myself into a corner and the only way the job is going to get done is to comply with my wish then go ahead. If I want the janitor to give the medications because that's the only way I'll take it, that's fine.
But on a day-to-day basis, security shouldn't give medication because security is security, nursing is nursing, pharmacy is pharmacy. Everybody has their own hats to wear, certain jobs to do. You can't mess with that for the purpose of messing with that. I know that sounds a little harsh, but it is what it is. Never mind the pragmatic part of getting security staff to come and give the medication.
Let's look at why this situation would come up. Why would someone ask security to give them their medication? It could be something innocent – maybe this security guard is nice looking, or maybe the person doesn't like certain staff members who can give the medication, or isn't comfortable with them. So the answer means sussing out exactly what's going on with the person but still validating them, making them feel okay. If you have that kind of atmosphere then the person wouldn't be requesting that security staff give them their medication. If the person doesn't like the nursing staff or whomever it is that dispenses medication, there needs to be more respect and open dialogue.
Whether security staff can give clients medication depends on the situation. For example, it might be appropriate if this is the only way to get the person to take their medication and a nurse is present to supervise the administration. The nurse may not be handing the medication to the person, but is basically responsible for administering and recording it. It is the scope of practice of the nurse or registered practical nurse to do the actual administration, partly to see whether the client is having any reaction to the medication.
A client asking security staff to give them their medication almost becomes a self-administration. We do have self-administration programs, but usually they are for clients who are getting ready to be discharged into the community. You are teaching them to be on their own and to take their medication. Self-administration doesn't usually happen in the way this security scenario suggests, where the person basically says "I refuse to take the medications from anybody else."
Still, this situation could be considered similar to a self-administration, where the nurse supervises and records the administration. It's a little different from administration itself, and even the definitions of administration are a little tricky. If you look at it from an inpatient versus outpatient perspective, the inpatient's point of view is quite simple: You bring the medication to the inpatient, you open the package, you give the medication to the patient with a cup of water. It's obvious that this is administration.
But if you hand a client a blister pack from which the client pokes out the medication, you're not exactly administering – you're watching or coaching the client to have their medication. This means there can be rare occasions where it's appropriate for security staff to dispense medication, but there have to be safeguards and a written process.
Accreditation Canada is very specific about having a process. It doesn't indicate what the process is, but it is very specific that you must have a process for self-administration. The process must be written out and pass through the appropriate committees for discussion and recommendations. I could see security staff giving medication occasionally, but I would not want it to be typical practice.
The bottom line is that it would not be appropriate, reasonable or lawful for security staff to administer medication by any route to a patient, even if the patient requests it. Medications can only be administered by a regulated health care professional who has the appropriate competence to do so, following the appropriate health care practitioner's prescription. The medication would be administered with full and free informed consent either by the capable patient or the incapable patient's substitute decision-maker.
Security staff do not possess the qualifications, competencies or lawful authority to administer medications. Indeed, administering medication to an actively suicidal person may also result in charges of serious breach of the law, such as assisting a vulnerable person to commit suicide or even committing murder where this act results in the person's death.
Assuming that the client or the appropriate substitute decision-maker has already consented to the medication, it should be offered to the client by a trained, professionally responsible health care worker, that is, an assigned nurse or the medication prescriber or delegate. Security staff typically do not have the professional or occupational responsibility or authority for direct provision of medications.
But another question remains: Why does this client prefer receiving medication from security staff? Does the client not like or trust the assigned nurses? Or does the person feel disrespected or frightened by them? If that is the case, the situation needs to change. In the interim, another clinician, such as a nursing supervisor or on-call physician, can be asked to give the client the medication.
Of course, if the client is capable and makes an informed choice to decline medication, this choice should be honoured and the client's reasons understood. But if the client is incapable of making treatment decisions and declines medication consented to by a substitute decision-maker, it remains important to understand the client's reasons and share them with the substitute decision-maker so the treatment plan can be revised if necessary.