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According to reports from the tribunal, Adelaide Kweyama, a black nurse from South Africa, was advised by an NHS manager to “bleach her skin” so that she would “come back white and the patient will be nice to you.” This occurred after she had reported racial abuse from a patient who feigned inability to communicate in English. Ms. Kweyama, who was employed as an agency nurse at an immigrant removal centre in Heathrow, expressed shock at the comment. The senior nurse further remarked to a colleague that she was tired of employees claiming to be unwell and suggested Ms. Kweyama should “go and bleach her skin.”

Subsequently, Ms. Kweyama experienced racial abuse from male detainees at the centre who called her derogatory names. Despite raising concerns and filing incident reports, she felt unsupported by her managers. Following a separate incident where a detainee was racially abusive towards her, she was again told by the senior nurse to “bleach her skin.” This incident left Ms. Kweyama feeling depressed, prompting her to email her agency, Athona, stating her inability to continue working at the Heathrow centre due to emotional and psychological distress.

Despite her complaints of racial abuse and lack of support from the NHS Trust, Ms. Kweyama’s contract was terminated, with the reasoning cited as concerns about her mental health based on her statement. The tribunal concluded that Ms. Kweyama had been subjected to race-related harassment and victimization, both by her boss’s remarks and the termination of her agency role. However, her claim of direct race discrimination was dismissed. A hearing to determine remedies will be scheduled later.

What is your take on this crucial matter?

Source: MAIL online



Detective Constable Emma Maders of GMP’s Criminal Investigation Department stated that Petula Hatzer, residing on Mortlake Drive in Manchester, had been sentenced to 1 year and 1 month in prison after admitting to 10 counts of fraud by false representation and 1 count of Fraud by Abuse of position at Minshull Street Crown Court on March 13, 2024.

Hatzer, who had been caring for the victim for approximately 17 years, was arrested in 2021 following allegations made to the police by another caregiver. This caregiver had expressed concerns in October 2020 about Hatzer opening credit card and catalogue accounts in the victim’s name over several years. The victim, who is extremely vulnerable and receives round-the-clock care, had never possessed the capacity to open such accounts.

After receiving the report, detectives initiated an investigation and discovered evidence of 10 accounts opened in the victim’s name. Hatzer was subsequently arrested, and various credit cards and letters were seized from her home. During initial questioning, she admitted to the fraudulent activities but showed little remorse. Subsequent interviews yielded no comments from Hatzer.

DC Maders described the crime as particularly distressing, emphasizing that Hatzer, in her role as a trusted caregiver, had exploited the victim’s identity for personal financial gain. Hatzer not only opened fraudulent accounts but also accessed the victim’s existing bank account, depriving her of funds intended for daily necessities.

The impact on the victim’s family was profound, as Hatzer had been considered a part of their family. DC Maders assured continued support for the family, acknowledging the emotional trauma they experienced. She urged community members to report similar instances of exploitation, emphasizing the importance of protecting vulnerable individuals.




It was explained that the Objective Structured Clinical Examination, commonly known as the OSCE, serves as the conclusive assessment required by the NMC for overseas nurses seeking registration as nurses in the UK. The most recent iteration of the OSCE, as of 2021, mandates ten stations where candidate nurses are observed while demonstrating their skills and knowledge. This process bears resemblance to the return demonstration tests undergone by Filipino nurses in the Philippines, albeit with the distinction that UK OSCE candidates are obliged to verbalize each step demonstrated during the examination. The previous version of the OSCE, referred to as the Legacy OSCE, comprising merely six stations, is anticipated by the NMC to remain in effect only until July 31, 2022. For overseas nurses, the OSCE stands as the primary obstacle they must surmount upon embarking on their nursing journey in the UK.

The online Filipino nursing community has shared numerous success stories regarding the OSCE and offered abundant content on strategies for passing it with flying colours. However, there is minimal discussion about the consequences of failing the OSCE.

It was clarified that the OSCE, according to its grading criteria, yields either a pass or fail outcome, devoid of any numerical scoring akin to the Philippine Nursing Licensure Exam. Candidates receive their OSCE results via email within a few days following the examination.

Regarding a pass outcome, it signifies a favourable result leading to subsequent registration with the Nursing and Midwifery Council of the UK, thereby granting overseas nurses’ eligibility for a qualified nurse’s salary, albeit with heightened responsibilities, typically corresponding to Band 5 within the NHS. Furthermore, registration necessitates the payment of an annual fee; failure to comply risks the loss of nursing practice rights. Registration must also undergo revalidation every three years to avoid suspension or revocation of the nursing license in the UK.

In the event of a failure, the situation is more nuanced than a simple pass. A partial failure may occur if a candidate overlooks minor details during the examination, resulting in failure only in the specific section or station. A partial failure necessitates a resit of the same station under identical circumstances, albeit at a reduced fee. Conversely, a complete failure mandates a comprehensive resit of the entire OSCE, incurring the full examination cost.

Discussions with experienced Filipino UK nurses who underwent OSCE resits revealed that NHS trusts generally offer support for candidates undergoing resits, covering fees and providing additional training and study time for a second attempt. However, support might diminish beyond the second attempt, with trusts often indicating that failure to pass on the second try could halt the employment process, potentially leading to Home Office intervention and curtailment of residency rights.

To avoid OSCE failure, several tips were suggested, including ample practice, time management, utilization of learning resources, familiarity with marking criteria, calming techniques, and acclimatization to the new environment. Despite its familiarity to Filipino nurses, thorough preparation remains crucial for OSCE success, as it represents the final step toward fulfilling the dream of becoming a registered UK nurse.

Source: Filipino UK Nurses Community



Abena, a migrant worker from southern Africa, recounted how she had been repeatedly raped by her manager at a UK care home but felt unable to report him to the police out of fear of losing her job and her visa.

Bernice, from the Caribbean, shared her experience of being sexually harassed by her landlord in the accommodation arranged by her employer, who sponsored her work in the UK.

Chidera, a live-in carer from Ghana, recalled a time when she went nearly four months without a day off. After complaining to a manager, she was threatened with dismissal and having her visa revoked.

These are just a few of the stories shared by migrant care workers who travelled to the UK to fill vacancies but found themselves exploited and silenced. The Bureau of Investigative Journalism (TBIJ), collaborating with Citizens Advice, gathered testimonies from almost 175 individuals working for approximately 80 care providers via the health and care worker visa. Their accounts revealed a pervasive fear among this crucial section of the social care workforce to raise concerns about labour abuses, largely due to the visa system tying their right to stay and work in the UK to their employers. Any complaint, even if upheld, could trigger a countdown, leaving them with barely two months to avoid the risk of deportation.

Kayley Hignell, interim director of policy at Citizens Advice, expressed deep concern, stating, “We work on a lot of difficult issues at Citizens Advice, but this is one of the most heartbreaking because of our limited ability to help people find a way forward.”

Andrew Gwynne MP, the shadow minister for social care, echoed these sentiments, emphasizing the government’s failure to address the crisis in social care and the urgent need to prevent the exploitation of overseas workers.

Early last year, staff at Citizens Advice observed an uptick in calls from individuals on the health and care worker visa in the UK, prompting the organization to collect information to assess the extent of the problem. A total of 150 workers provided evidence, though the true number affected is believed to be much higher.

The charity shared anonymized details about the callers with TBIJ as part of an investigation into exploitative working conditions faced by migrants in the UK.

In their accounts to Citizens Advice and TBIJ, care workers described experiencing various forms of exploitation, including wage theft, exorbitant recruitment fees, reduced hours, and destitution due to poor working conditions in the care sector. One recurring theme was the feeling of being trapped due to visa arrangements penalizing whistleblowing, with workers dependent on their employers for their right to remain and work in the UK.

Approximately 30% of those mistreated at work admitted to being afraid to raise concerns about their managers or employers, fearing reprisals such as losing their jobs and visas, as well as threats to their safety.

Abena, for instance, disclosed to Citizens Advice that she had been raped by her care home manager but chose not to involve the police, fearing repercussions. Bernice, who experienced sexual harassment from her landlord while employed as a carer, similarly refrained from lodging a complaint due to the risk of job loss outlined in her contract.

A Home Office spokesperson condemned the exploitation of health and care worker visa holders, pledging to crack down on illegal activity in the labour market.

The situation underscores a glaring power imbalance, with workers feeling powerless to speak out against abuses for fear of losing their livelihoods and facing deportation. Efforts to address this issue are imperative to safeguard the rights and well-being of migrant care workers in the UK.

source: The Bureau of Investigative Journalism



A major provider of home care services in the UK has revealed that it is facing exorbitant expenses by paying migrant workers to stay idle due to delays in the renewal of immigration permits by the Home Office.

Last year, thousands of overseas care workers were invited to the UK to address the 152,000 vacancies in the sector. However, following instances of exploitation by scammers and certain care providers, allegations of modern slavery surfaced, prompting the government to tighten regulations.

As part of the regulatory changes, care workers are no longer permitted to bring their families to the UK as of March 2024.

These developments coincide with the issuance of 106,000 visas to carers by the government in 2023.

CEO Darren Stapelberg of Grosvenor Healthcare expressed frustration, stating, “The sponsorship process has swung from being overly permissive to nearly impossible. Despite the ease with which individuals were sponsored previously, the current system is making it extremely challenging to bring in new staff and renew existing contracts.”

Currently, Grosvenor Healthcare is reducing wages for 30 of its migrant workers, with plans to do the same for an additional 90 soon.

Stapelberg lamented the loss of eleven workers who returned home, noting, “We’re losing valuable contributors to our society precisely when there’s a dire shortage of staff.”

In response, a spokesperson from the Home Office stated, “Our guidelines ensure that individuals who have applied for visa extensions are entitled to the same benefits as their initial permits. Sponsors must demonstrate the existence of genuine job vacancies at the time of application. Applications lacking evidence of available work are not approved.”

Jane Townson, CEO of the Homecare Association, highlighted the challenges faced by ethically operating providers in sponsoring migrant workers due to the Home Office’s refusal to grant certificates of sponsorship. She emphasized the impracticality of guaranteeing hours in advance due to fluctuating care needs, resulting in workers being sent home and providers forfeiting hours of care.

Townson urged for a more balanced approach from UK Visas and Immigration to prevent further strain on health and care services.



In a recent announcement, the government unveiled a plan aimed at achieving the most significant reduction in net migration ever and addressing issues of abuse within the immigration system. The Home Secretary, James Cleverly, outlined the plan, emphasizing its impact on limiting migration levels and enhancing the integrity of the UK health service.

The comprehensive package includes measures to restrict the influx of dependents into the UK, raise minimum salaries for overseas workers and sponsors, and combat exploitation within the immigration system.

The Health and Care Worker visa will undergo tightening, with restrictions on overseas care workers bringing dependents to the UK. Care providers in England will now only be able to sponsor migrant workers engaged in activities regulated by the Care Quality Commission.

Effective from the upcoming spring, the government plans to raise the earning threshold for overseas workers by nearly 50%, from £26,200 to £38,700. Simultaneously, the minimum income required for British citizens and settled individuals sponsoring family members will also increase. These adjustments aim to encourage businesses to prioritize British talent and align salaries with industry averages.

To counter cut-price labour from overseas, the government will eliminate the 20% salary discount for shortage occupations and introduce an Immigration Salary List. The list will be reviewed by the Migration Advisory Committee to align with increased salary thresholds, reducing the number of occupations eligible.

Additionally, the Migration Advisory Committee will review the Graduate visa route to prevent abuse and ensure it aligns with the UK’s best interests. These measures complement the government’s efforts to curb the rise in students bringing dependents to the UK.

The government attributes the feasibility of these measures to its Back to Work Plan, which prioritizes growing the domestic workforce. Home Secretary James Cleverly stressed the need for action, asserting that the plan is designed to address high net migration, protect British workers, and alleviate strain on public services.

In conjunction with measures to reduce migration, the government has decided to increase the annual Immigration Health Surcharge from £624 to £1,035, aiming for a fair financial contribution from migrants to support public services, including the NHS.

Cleverly acknowledges the high proportion of visas issued to workers and their dependents and underscores the importance of addressing concerns about non-compliance and exploitation in the adult social care sector. These measures come in response to the temporary inclusion of carers in the immigration system to meet urgent labour shortages during the COVID-19 pandemic.

Lastly, the government’s earlier measures to reduce student visas will come into force in January 2024, restricting the rights of international students to bring dependents and limiting their ability to switch to work routes before completing their studies.

Source: UK Home Office



A registered nurse, Catherine Hudson, and assistant practitioner, Charlotte Wilmot, have been sentenced to seven and three years in jail, respectively, for administering drugs to patients at Blackpool Victoria Hospital between April 2017 and November 2018. The purpose of drugging the patients was purportedly to “keep them quiet and compliant,” creating what the individuals involved referred to as an “easy life” during their work shifts.

The pair, who also joked about causing harm to a patient via text messages, administered drugs like Zopiclone without a clinical need. During sentencing, Judge Robert Altham highlighted the severity of the breach of trust, stating, “You were in a position of trust and responsibility. You offended against vulnerable people in your care over a significant period. You were the lead offender.”

In addition to the jail sentences for Hudson and Wilmot, Ms. Hudson’s partner, former nurse Marek Grabienowski, was sentenced to 14 months for conspiring to steal drugs from his employer and perverting the course of justice. Matthew Pover and Victoria Holehouse also faced legal consequences.

Judge Altham emphasized the betrayal of trust and the potential harm caused, especially to elderly stroke patients, due to the inappropriate sedation. Detective Chief Inspector Jill Johnston of Lancashire Police expressed concern over the lack of care and compassion displayed by Hudson and Wilmot, emphasizing that their actions posed serious risks and undermined the fundamental principles of patient safety and dignity within healthcare.

The incident has raised concerns about the potential impact on public confidence in the NHS, with Detective Chief Inspector Johnston stating, “Everyone should be safe in the hospital, receive the care they need, and be treated with dignity and respect.”

Source: Nursing Notes




  • Enter the patient room, check for scene safety, and ensure the scene is safe to approach.
  • Protect the privacy and dignity of the patient by closing curtains, windows and doors.
  • Perform hand rub using the seven steps of hand hygiene recommended by WHO.
  • Introduce yourself as ‘name of candidate’ an attending nurse.
  • Obtain patient information, including name, date of birth, Hospital number and confirm details with ID tag.
  • Assess the patient’s current condition and comfort level.
  • Explain the purpose of the procedure: collecting a urine sample from the catheter for culture.
  • Inquire about the need for a chaperone (usually not required).
  • Ask about allergies and pain.
  • Inform the patient about the procedure duration and offer assistance if needed.
  • Confirm the non-painful nature of the procedure, explaining the urine withdrawal process as 10 ml of urine would be withdrawn from the sampling port using a 10/20 ml syringe
  • Assemble necessary items, and assure the patient of assistance if needed by using the call bell.

Required Articles:

– Syringe (10ml or 20ml)

– Universal specimen container

– Disinfectant wipes

– Chlorhexidine wipes (black)

– Sharps container

– Non-traumatic clamp (if required)

– Microbiology bag (if required)

– Lab form (if required)

  • Put on apron and gloves after performing hand rub.
  • Confirm cleanliness of the trolley with the examiner.
  • Clamp the urinary catheter a few cm distal to the sampling port. Tell patient if any discomfort or fullness of bladder he should call you to unclamp the catheter in normal scenario.
  • Perform hand washing using WHO-recommended seven steps and dry.
  • Assemble required items in the kidney tray or trolley as stated.
  • Approach the patient, confirm comfort, and proceed with the procedure.
  • Wear gloves, place an incontinent pad under the sampling port, and wipe the port for 30 seconds.
  • Open the syringe, withdraw urine, and demonstrate to the examiner.
  • If using a needle and syringe, follow proper insertion and withdrawal techniques.
  • Open the sample bottle, pour urine without touching, close the bottle, and place it in the bag.
  • Dispose of the used syringe in the kidney tray or clinical waste.
  • Wipe the port again with an alcohol swab and let it dry.
  • Remove the incontinent pad and discard it.
  • Unclamp the catheter.
  • Discard gloves into the waste and needle and syringe into the sharps container (if used).
  • Inform the patient that the procedure is complete and inquire about comfort.
  • Explain the next steps, such as sending the sample to the laboratory or refrigerating it.
  • Provide the call bell to the patient for assistance.
  • Retrieve the trolley, discard waste, clean it, and prepare for the next use.
  • Fill out the culture form, document the procedure, and observe the colour and nature of urine.
  • Open the curtains and perform a final hand washing before leaving the room.


– Failure if the sample is taken from the incorrect port (leg bag emptying port or water balloon port).


Emphasize the importance of stating the condition of the urine, unclamping the catheter, and wiping the sampling port twice. Documentation is not necessary as per the pre-documented scenario.

Things to Note:

  • Scene safety
  • Privacy
  • Hand hygiene (Verbalize)
  • Purpose of visit
  • Explain procedure & gain consent
  • Validate the articles
  • Hand hygiene (Verbalize)
  • Ensure no visible urine in the tube
  • Hand hygiene, apron, and gloves
  • Clamp and ensure enough urine collected
  • Change apron, gloves, and hand hygiene
  • Clean the collection port
  • Collect urine (needleless or syringe and needle)
  • Transfer it to the container
  • Discard the needle and syringe into the sharps container if required
  • Re-clean the collection port
  • Unclamp
  • Discard apron and gloves
  • Communicate, educate, comfort, and provide the call bell
  • Conclusion statements


Nurse: Good day, Pratima. I’m here to gather a urine sample from your catheter. Is it convenient for us to proceed at this moment?

Pratima: Yes, it’s fine.

Nurse: Excellent. I’ll prepare the necessary equipment for the procedure. Before I go, do you need anything or are you comfortable?

Pratima: I’m fine, thank you.

Nurse: Great. Here’s the call bell. If you need assistance, just press the button.

Nurse: Assessor, may I confirm that this tray has been cleaned with soap and water after its last use?

Assessor: Yes.

Nurse: Perfect. Here’s the universal container (sample bottle) intact and in date, alcohol wipes intact and within date, and a 10ml syringe for specimen withdrawal. The non-traumatic clamp may already be attached to the catheter.

“Hello again, Pratima. Are you in a comfortable position?”

Pratima: Yes.

Nurse: Alright. Can I proceed with the sample collection?

(Perform hand hygiene, apron, and gloves)

Nurse: May I raise your clothing slightly? (Moves the cloth upward to expose the collection port)

“Now, I’ll clamp the catheter and wait a few minutes for the urine to collect.”

(Changes apron and gloves)

“I’ll now clean the sample port with an alcohol wipe for 30 seconds and let it dry for another 30 seconds. Assessor, I assume there’s enough urine in the catheter.”

“Now, I’ll insert the sterile syringe into the sample port at a 90-degree angle (or needle at a 45-degree angle) and withdraw 10 ml of the specimen. I’ll transfer the sample from the syringe to the specimen bottle without touching the edges. And close the lid.”

Nurse: Pratima, I’ve collected 10 ml of urine from your catheter. I’m going to unclamp the catheter and clean the sampling port for another 30 seconds. After that, I’ll send the sample to the lab immediately. Do you have any concerns or questions?

Pratima: No.

Nurse: Alright, Pratima. I’ll be around for a bit. If you need anything, press the call button, and I’ll come to assist you.

Conclusion Statements

Nurse: Assessor, I’ve collected the urine sample and will send it to the lab right away. Before sending, I’ll ensure that the container is labelled correctly and then send it to the microbiology lab. I will then discard the used items and make them ready for next use

Thank you






Implementation Station is the third stage within the APIE framework, with a designated time limit of 15 minutes. This station involves interacting with either a real patient or a manikin.

During this phase, participants are tasked with the administration of oral medication, armed with a comprehensive drug chart detailing crucial information such as weight, height, allergies, stat medications, PRN medications, and regular medications. The patient or mannequin assigned here is the same as in the assessment and planning station. In this role-playing scenario, participants are expected to draw upon their skills and knowledge to administer oral medications accurately. Additionally, they must ascertain the patient’s potential allergic reactions to any prescribed medication.

Typically, a prescription chart will contain three or four medicines, among which there might be one the patient is allergic to or one with an incorrect prescription or dose. Participants are required to identify and omit these problematic drugs, administering only those that are due and clearly specified.

Key considerations during the Implementation Station include:

1. Articulating and explaining the prescription aloud while preparing the medicine.

2. Verifying the validity of the prescription and reporting any errors to the prescriber.

3. Confirming the timeliness of medication administration, taking into account the patient’s allergy status. If an allergy is identified, omit the medication with the appropriate code and report the prescription’s illegibility to the prescriber.

4. Checking the prescribed route of administration, and if it is not oral, stating the intention to administer the specific medicine after completing the oral medications.

5. Consulting the British National Formulary (BNF) before administering any drug to obtain essential drug details.

6. Investigating if there are precautions to be observed before administering a specific medicine, with a list of medicines and their required precautions available in the course room.

7. Confirming whether the medicine has been previously administered, particularly for PRN medicines, to avoid potential overdose. Additionally, verifying oxygen and IV therapy by cross-referencing the prescription, dose, and batch number.

Furthermore, participants must ensure adherence to the ten rights of medication administration:

1. Right Patient

2. Right Drug

3. Right Dose

4. Right Route

5. Right Time

6. Right Patient Education

7. Right Documentation

8. Right to Refuse

9. Right Evaluation

10. Right Assessment


Begin by entering the patient’s room and assess the scene for safety, ensuring it is safe to approach.

Maintain the patient’s privacy and dignity by closing curtains and the door.

Perform hand washing using the seven steps of WHO hand hygiene.

Introduce yourself, stating, “Hello, I’m [your name], your attending nurse today.”

Request the patient’s name and inquire about their preferred name.

Ask for the patient’s date of birth.

Verify the patient’s details by cross-checking with their ID tag, specifically checking their full name, date of birth, and hospital number.

Inform the patient of your purpose: “I am here to administer your medications due at [specified time].”

Inquire about any medication allergies, and if applicable, ask about the reaction to those medications.

Check if the patient is currently experiencing pain and, if so, inquire about the pain level on a scale of zero to ten.

Determine if the patient requires pain medication and explain that you will check the medication chart for any prescribed prn pain medication.

Ask about any swallowing difficulties and whether the patient has had something to eat.

Inquire if the patient needs to use the toilet and inform them that the procedure will take approximately 15 minutes.

Ensure the patient is in a comfortable position.

Inform the patient that you will check the drug trolley for their medications and invite them to call or use the call bell if needed.

Perform hand hygiene, don PPE and unlock the drug trolley, and inspect the medications.

Read aloud the medication chart, including patient details, admission information, and relevant medical data. Thus; Patient name, DOB, Hospital number, Admission date, Consultant name, prescriber’s bleep number, Height, Weight to help calculate drug dosage eg: weight below 50 kg Tab Paracetamol cannot be administered.

Pay special attention to any allergic medications mentioned in the chart.

If oxygen is prescribed and the patient is using nasal cannula, assess oxygen saturation, and adjust as necessary.

Check the prn medication section for previous administrations; if a pain medication has been given within the past 4 hours, withhold it.

Review regular medications, omitting any wrongly prescribed, illegible, or omitted medications, and document with appropriate codes.

Before administering the first drug, verify the patient’s identity using their ID band, checking their name, date of birth, and hospital number.

Explain the purpose of the medication to the patient and mention any major side effects using BNF.

While handling the tablet, check for expiry both outside and inside the container on the literature, transfer it directly to a cup without touching, and provide it to the patient with water or juice.

Confirm that the patient has swallowed the medication.

Administer medications one by one, signing after each administration.

In the event of an error, verbalize what actions to be taken in real-life scenarios.

When striking off an entry, use a single line, put your signature below, and verbalize the action taken.

Ensure that not administered medications are clearly listed at the back of the medication chart with appropriate reasons, avoiding the use of codes (e.g., patient already received pain medication, incorrect dose, or wrong timing).

After administering all medications, conduct a recheck if time permits, lock the medication trolley, express your intention to clean and prepare it for subsequent use.

Inform the patient that all prescribed medications have been administered.

Hand over the call bell to the patient, emphasizing its use in case of adverse reactions such as breathing difficulties or rashes, reassuring immediate assistance.

Restore the room to its original state by opening the curtains.

Discard PPE and used items. Do hand hygiene using the seven steps of WHO, and exit the room.


Prioritize patient identification again before drug administration.

Inquire about any swallowing difficulties and confirm the patient has swallowed the medication.

Remain vigilant for allergies, patient weight, and accuracy of prescriptions.

Adhere to a minimum four-hour gap between successive administrations of similar pain medications, such as Paracetamol.

Be mindful of stat medications already administered.

Seek clarification from the examiner regarding oxygen saturation during oxygen therapy. Verify blood sugar levels before dispensing anti-diabetic medications and assess blood pressure and pulse rate levels before administering anti-hypertensive medications.

If uncertain about any prescribed medication, refrain from administration, verbalize the reason for hesitation, and communicate your intention to consult with the doctor before proceeding.

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