February 2018

News 3/2018

19 February 2018

Impairment Committee Report: Management of controlled scheduled medicines/substances in healthcare establishments to minimize errors and abuse caused by improper control

1. Introduction
In healthcare establishments, registered nurses have a duty to control various medications, including controlled scheduled medicines and substances, i.e. those scheduled 5, 6 and 7.
The shortage of qualified professional nurses in wards has the implication that ‘other categories’ of nurses are expected to participate in the co-checking of these medicines or substances. This has at times led to a departure from the policies and procedures governing the control of medicines and as such, lower categories of nurses and unauthorised personnel are sometimes left to check and administer these drugs on their own, without supervision.

2. Purpose
This Impairment Committee Report serves to reaffirm that nursing management has a duty to ensure that controlled scheduled medicines are properly managed, from the time these are ordered until they are administered to patients as prescribed by a medical practitioner, following proper policies and procedures.

3. Background
The Impairment Committee of the South African Nursing Council (SANC) has noted with concern a degree of negligence in the manner in which controlled scheduled medicines are managed in some healthcare establishments (both public and private).
The Impairment Committee, which is one of the standing committees established in terms of section 51 of the Nursing Act, 2005 (Act No.33 of 2005), is appointed to manage nurse practitioners (registered in terms of section 31 (1)(a-e) of the Act) who are deemed unfit to practice nursing due to disability or impairment. Cases of medicine and substance abuse are referred to the Committee, and it is frequently established that nurse practitioners have had access to drugs in the following ways:

	Nurse practitioners being allowed to check and administer controlled scheduled medicines alone;
	The keys of cupboards containing controlled scheduled medicine were not kept in the appropriate manner;
	The amount of a medicine or injections remaining was supposed to be discarded, but the nurse in question appropriated it for her own use, because she handled the discarding process alone, and therefore had the opportunity
	Controlled scheduled medicines are not properly checked during every shift change, leaving discrepancies to go unnoticed;
	Prescribed medicines being administered recklessly, without counting/keeping record of the quantities of medicine having been administered to patients.

o This information was forthcoming from nurse practitioners who, for example, were involved in car accidents or have had major operations (including caesarean sections) and were prescribed Pethidine, which led them to or contributed to their addiction

4. Management of controlled medicines, schedules 5,6 and 7, in hospital departments and wards:

4.1 Hospitals must adhere to policies and procedures in place to:

• Prevent;
• Detect; and
• Report any diversion (such as stealing and falsifying of records) of controlled medicines.

	4.2 It remains the obligation of the registered nurse/midwife to ensure that all controlled scheduled medicines are ordered, controlled, administered and disposed of in terms of the given protocols, policies and procedures of the institution.
	4.3 The registered nurse in charge of a nursing unit and/or shift remains accountable and responsible.
	4.4 Enrolled nurses/nursing auxiliaries MUST NOT be allowed to keep the keys to the controlled medicines and substance cupboard and to check and administer scheduled medicines alone.
	4.5 Unregistered staff (care workers and general workers) should not be involved in the administration of controlled scheduled medicines, or any medication.
	4.6 Without a prescription by a doctor, there can be no administration of controlled scheduled medicines, except where a protocol is followed and in an emergency situation. The person in charge will remain accountable

Note that the following are warning signs of nurses who may be abusing medicines and substances:

	Health care users receiving the maximum prescribed dose of a pain injection (e.g. 100mg Pethidine), yet still experiencing increased pain;
	Scheduled medicine to be discarded being kept in a syringe for no apparent reason;
	A nurse frequently borrowing scheduled medicines from other wards or visiting the wards/healthcare establishments at awkward times;
	A nurse asking colleagues to countersign in the register for scheduled medicines which they did not witness being dispensed;
	Inaccurate recording and fraudulent entries;
	Erasing or ‘overwriting’ of drug book entries, instead of following standard operating procedures;
	Often volunteering to administer scheduled medications;
	Frequently offering to count scheduled medicines, to make sure the count is correct.

5. Legal obligations of the nursing service manager/ unit manager
Nursing service management must oversee the scheduled medicine control processes or procedures to ensure that all healthcare providers working in their healthcare establishment are strictly following these in terms of the given legislation.
It is therefore important that nursing management ensure adherence to the standards as laid down by:

	The Medicines Control Council;
	The National Drug Policy for South Africa;
	The rules relating to Good Pharmacy Practice in South Africa;
	The Medicines and Related Substances Act, 1965 (Act 101 of 1965).

Behaviours indicative of Controlled Medicine abuse

These may include, but are not limited to the following:

	A noticeable decrease in attendance at work, increased absence or reporting late for work
	A noticeable decrease or inconsistency regarding work performance.
	Mood swings.
	Deterioration in personal appearance.
	May be sleepy or dozing off while on duty.
	Not interested in interaction with others, or being withdrawn.
	Memory lapse or euphoric recall of events.
	May have ‘pin point’ pupils, shaky hands or tremors.
	Smelling of alcohol, or mouthwash/breath mints to mask the alcohol smell.

Common group of Controlled Scheduled Medicines abused by health practitioners

Like anyone, nurses can and do use many different types of medication. Some are legitimate prescriptions issued after consultation with medical doctors. Some, like pain or allergy medication can be bought over the counter.

Those used in health establishments fall within the following categories:

	Barbiturates, benzodiazepines and tranquilizers, such as Diazepam;
	Prescription painkillers, such as opiates;
	Sedatives, such as Propofol or Diprivan;
	Appetite suppressants and narcotic analgesics.

A LIST OF SCHEDULED SUSTANCES IS AVAILABLE IN THE MEDICINES AND RELATED SUBSTANCES ACT NO. 101 OF 1965.

Some SUBSTANCES are recreational, such as:

	Alcohol;
	Marijuana and other ‘street drugs’.

Getting Help

Most public and private health establishments have Employee Assisted Programs to support their staff, including assistance for nurses with substance abuse problems.
The South African Nursing Council, like other health statutory bodies, offers an alternative to discipline program for nurse practitioners who demonstrate signs of impairment in terms of section 51 of the Nursing Act, 2005 ( Act 33 of 2005).

To contact the SANC please use the following information

Postage or hand delivery	Tel No. 27+12 420 1008/426 9547
The South African Nursing Council 602 Cecilia Makiwane Building Arcadia, 0083	Email: gash@sanc.co.za or skubayi@sanc.co.za

References

	‘Scheduling of Medicine guidelines’– Medicine Control Council;
	Medicine and Related Substances Act, 1965 (Act No. 101 Of 1965);
	Nursing Act, 2005 (Act No. 33 of 2005);
	‘Good Pharmacy Practice Manual’ – South African Pharmacy Council;
	‘Safe Management of Controlled Drugs: A guide to good practice in secondary care (England)’ – British Department of Health;
	www.rehabcenterrankings.com/drug-addiction-in-healthcare-professionals;
	www.nevadanursingboard.org/ discipline/chemically-dependent-nurses/.

Circular 1/2018

1 February 2018

TO:	National Department of Health
	Provincial Departments of Health
	Nursing Education Institutions
	All Relevant Stakeholders

Phasing out of ‘legacy’ qualifications

1. PURPOSE

The purpose of this document is to update the National Department of Health, Provincial Departments of Health, Nursing Education Institutions (NEIs) and relevant stakeholders about the following matters pertaining to nursing education and training:

•	Phasing out of the ‘legacy’ qualifications in 2019;
•	Removal of the names of certain Nursing Education Institutions, that were previously approved to offer the following phased out nursing programmes, from the South African Nursing Council (SANC) website:

– Course leading to Enrolment as a Nurse (Government Notice Regulation No. 2175 of November 1993); and

– Course leading to Enrolment as a Nursing Auxiliary (Government Notice Regulation No. 2176 of November 1993);

•	• Registration of learners/students undergoing Nursing Education and Training programmes; and
•	• Maintenance of registration or enrolment for learners/students who are pursuing basic/ undergraduate or additional/post-graduate ‘legacy’ qualifications.

2. PHASING OUT OF THE ‘LEGACY’ NURSING QUALIFICATIONS

Based on:
a) Circular 13 of 2014, wherein the South African Nursing Council (SANC) informed Nursing Education Institutions and stakeholders that the ‘legacy’ nursing qualifications in point 1 above would no longer be offered after 30 June 2015 (duly gazetted as per Government Notice No. R928 of 09 October 2015); and
b) Circular 7 of 2016, issued in December 2016, informing all NEIs and stakeholders about the process of the phasing out of ‘legacy’ nursing qualifications and implementation of the Higher Education Qualifications Sub-Framework (HEQSF)-aligned nursing qualifications, the SANC has phased out those two legacy programmes, namely:

•	Course leading to Enrolment as a Nurse (Government Notice Regulation No. 2175 of November 1993); and
•	Course leading to Enrolment as a Nursing Auxiliary (Government Notice Regulation No. 2176 of November 1993).

In a Board Notice published in Government Gazette No. R. 801 of 06 July 2016, the Minister of Higher Education and Training, declared that the last enrolment date for first time entering students into academic programmes that are not aligned to the Higher Education Qualifications Sub-framework (HEQSF), will be 31 December 2019.

The implications of the phasing out of the ‘legacy’ nursing programmes for the affected NEIs are as follows:

•	Adherence to their approved numbers of students per intake;
•	Adherence to their approved number of intakes per year;
•	Adherence to their intake month/s; and
•	No learner/student will be registered with the SANC if the NEIs did not adhere to all of the above stipulations.

The SANC wishes to remind all NEI’s that are affected in respect of the above-mentioned programmes that May 2018 is the last examination date for the two-year programme leading to Enrolment as a Nurse, and that no further examinations for this programme shall be undertaken by the SANC.

3. REMOVAL OF NAMES OF NURSING EDUCATION INSTITUTIONS FROM THE SOUTH AFRICAN NURSING COUNCIL (SANC) WEBSITE

Institutions that are accredited by the SANC to offer nursing programmes are published on the SANC website in order to provide the public with up-to-date information. Prospective students and the general public are encouraged to visit the SANC website to verify the name of the institution where they want to register for a nursing programme, in order to ensure that they do not apply at bogus schools.

Noting that displaying the names of NEIs that are no longer offering any nursing programme(s) on the SANC website could create confusion for potential nursing students who want to register for nursing programmes, the Council of the South African Nursing Council at its meeting held on 29-30 November 2017 took the following resolutions:

•	The names of NEIs that were only approved for those nursing programmes that have already been phased out, will be removed from the SANC website, as the NEIs no longer offer programmes for which they are accredited by the SANC. Such removal is effected in the interest of the public.
•	Henceforth, there shall be two (02) separate lists of NEIs displayed on the SANC website, namely:

– NEI’s that were only accredited for the ‘legacy’ programmes that are currently being phased out; and
– NEIs accredited for the ‘new’ nursing programmes.

4. REGISTRATION OF LEARNERS/STUDENTS UNDERGOING NURSING EDUCATION AND TRAINING PROGRAMMES

In terms of section 32(1) of the Nursing Act No. 33 of 2005, “a person undergoing education and training in nursing must apply to the Council to be registered as a learner nurse or a learner midwife”.

The responsibility to register learners / students resides with the Head/ Person in charge of the NEI as provided for in section 32(3) of the Act, as follows:

“The person in charge of a Nursing Education Institution must, within 30 days, notify and furnish to the Council information prescribed by the Council in respect of each learner who has commenced, completed, transferred to or abandoned a nursing education and training programme”. (Our emphasis added.)

These provisions in the Act are applicable to all students, both under-graduates and post-graduates.

The provisions also place increased responsibility on the persons in charge of health facilities that are used as clinical facilities by different NEIs, as provided for in section 32(5) of the Act, as follows: “A health establishment must not allow access to clinical facilities for training purposes to anyone who is not registered in terms of this Act.’’

Currently some Higher Education Institutions are not compliant with these provisions, especially in respect of students undergoing nursing programmes in Clinical Nursing Science leading to registration of an additional qualification (Government Notice No. R212 of 1993). This gives rise to many actual and potential challenges, including but not limited to the following:

•	Health facilities will not allow access to clinical facilities for training purposes to anyone who is not registered, in terms of this Act.
•	A Learner/ Student database which is incomplete and inaccurate; and
•	Registration as practitioners after completion of the learning programme may legitimately be refused.

All NEIs are therefore reminded of these provisions and are urged to comply with them in respect of ALL learners/students. Failure to comply will render learners/students illegible to access clinical facilities, and result in refusal by the SANC to grant a registration certificate on completion of education and training.

5. MAINTENANCE OF ENROLMENT OR REGISTRATION FOR LEARNERS/STUDENTS WHO ARE PURSUING UNDERGRADUATE (BASIC) OR POSTGRADUATE (ADDITIONAL QUALIFICATIONS) STUDIES

This Circular serves as a reminder that all learners/students who are pursuing basic studies or additional qualifications must maintain their enrolment/registration with the SANC, failing which the education and training that was done while a learner/student was removed from the register/roll will be considered null and void.

IMPLEMENTATION DATE: This Circular becomes implementable on the date of issue.

For further information on this Circular, you are advised to contact the Senior Manager: Education and Training, Ms SJ Nxumalo at (012) 420 1022 or at jnxumalo@sanc.co.za

Kind regards,

(Signed)

Ms S Mchunu
Registrar and CEO
South African Nursing Council