1 Module 1 – Introduction to Healthcare
Introduction to Healthcare
Learning Objectives
- Define the role of nursing assistants and articulate what makes a good nursing assistant
- Demonstrate understanding of how healthcare is organized in different settings
- Demonstrate understanding of the legal aspects of caring for residents as a nursing assistant
- Demonstrate professional communication
Welcome!
Welcome to Caregiving for the Human Condition, an Open Educational Resource (OER) for nursing assistant training. Congratulations on taking this next step in your professional life as a caregiver. Whether you want to be a career nursing assistant or use this as a stepping-off point for further credentials, Illinois (and the rest of the world) is lucky to have dedicated, caring individuals like you who want to make a career out of helping people become and stay well.
Holistic, Person-Centered Care
This goal of this text is to serve as instructional material for nursing assistant training with a focus on providing holistic, person-centered care in geriatric long-term care facilities, although its contents will be broadly applicable across caregiving contexts. What is holistic, person-centered care? In short, it means caring for a person as a whole person. A holistic approach to care doesn’t reduce a person to their ailment or which specific aspects of their body require treatment. Instead a holistic approach treats each person in the entirety of their person, with a recognition that ailment or treatment that highlights one area of one’s body impacts a person’s whole life. When thinking about wellness and healing, the whole person should be the focus, not just their arm or back.
Person-centered means that the person receiving care is at the center of that care; they are in control of it. A person-centered approach to care means that the care team does everything they can to maximize the person’s autonomy and agency. Receiving medical care should feel empowering, but all too often a person is left in the dark, doesn’t know what is happening to them, or is not put in control of their own care.
A person who is already vulnerable should not also have to advocate for their needs to the very people who are supposed to help them, but unless medical professionals conscientiously exercise techniques rooted in holistic, person-centered care practices, a person receiving care may continue to feel that receiving care exacerbates their vulnerability rather than alleviates it. Throughout the text, readers will be asked to consider specific cases of caregiving through the lens of holistic, person-centered care.
In order to provide holistic, person-centered care, NAs will need to use critical thinking skills. What is critical thinking? Critical thinking occurs any time somebody closely analyzes something in order to form a judgment, such as whether they like it and why or what to do next about a situation. Applying a theory or conceptual framework to a real-world scenario is also an act of critical thinking.
NAs apply critical thinking in every step of their job. Whether making observations about a change in a resident’s condition, determining the safest way to perform a task, or considering circumstances from the resident’s point of view in order to demonstrate empathy and understanding, NAs deploy critical thinking at every moment.
Critical thinking begins with:
- assessing the situation
- observing all relevant factors
- weighing options
- acting based on reasoning
Throughout the text the reader will be asked to engage in critical thinking scenarios, where you will consider a situation and respond to it in a way that demonstrates critical thinking skills that align with the content of the chapter.
The Big Three
Part of critical thinking for NAs involves always applying the Big Three to one’s assigned responsibilities and care tasks. What is the Big Three? “The Big Three” refers to three essential frameworks for NAs to keep in mind at all times; Residents’ Rights, Safety, and Infection Control. We will go into the specifics of each of these frameworks throughout the course of the texts.
We highlight these three frameworks for NAs because they are each relevant to everything a NA does. An important part of critical thinking as a nursing assistant is habitually asking oneself “Are the resident’s rights being protected in my actions right now? Am I performing this task in the safest way possible? Am I following the steps necessary to prevent infection?” throughout each part of one’s job. Like holistic, person-centered care, the Big Three are analytical frameworks and habits of thought that nursing assistants learn to use in a near-automatic way. We will continue to discuss the Big Three and its application throughout the whole text.
What is a Nursing Assistant (NA)? What do NAs do?
Nursing assistants (NAs), also referred to as Certified Nursing Assistants (CNAs), are the first line of care in a variety of different medical care settings. Nursing assistants play an essential role in hospitals, assisted living facilities, home healthcare, and other medical contexts where patients or residents require assistance with their activities of daily living (ADLs).
ADLs include activities like brushing one’s teeth, getting dressed, eating, showering, and walking. In other words, an ADL is any activity that somebody does daily or near-daily in their routine. It can be easy for somebody who does not need assistance not to think about their ADLs, but for somebody who does need assistance with daily tasks, a compassionate and understanding hand to do the helping can make a big impact on someone’s sense of wellbeing, life-satisfaction, and dignity.
NAs tend to provide the most regular and hands-on care of all the members on the care team,
so it is important that they observe closely and take note of any changes in residents’ physical and mental condition to report back to the care team. Talking and listening is an important part of gathering information about a resident’s health, so getting to know specific residents and becoming familiar with their personalities can be an important part of providing holistic care.
NAs can provide emotional and spiritual support to residents in addition to providing basic assistance for ADLs. Listening and speaking with residents in a way that communicates an understanding of them as a whole person can provide residents with a sense of companionship and community.
NAs are an invaluable member of the care team; the value of NAs to a person’s care can’t really be overstated. An attentive and caring NA can be the difference between a positive and a negative care outcome, or between somebody’s life and death.
The qualities of NAs
Nursing assistants to be empathetic, patient, and understanding with the people to whom they are providing care. What is an empathetic person? A person who practices empathy is able to put themselves in someone else’s shoes. They are able to use their own life experiences to relate to and identify with the experiences of others.
It is important for everyone to practice using empathy, but it is especially important for NAs and anyone else who regularly cares for vulnerable adults. Practicing empathy every day trains us to see that everybody’s lives and experiences are equally as valuable as one’s own; as a nursing assistant, it will be part of your job to make sure that residents are treated in accordance with their inherent value as human beings.
Nursing assistants should also be conscientious, courteous, and accountable in their work. Being conscientious in this case means always doing your work to the best of your ability by being present, careful, observant, aware, thoughtful, and responsible in every situation.
Being courteous means showing basic respect to one’s team mates, and to the people being cared for. Accountability means taking responsibility for one’s work, and for one’s mistakes; an accountable person always seeks to improve.
Being conscientious as a NA also means being trustworthy and completely honest, especially when it comes to being honest about what you don’t know or when you’ve made a mistake. It means that your healthcare team and your residents’ families can depend on you.
Courtesy is an important part of providing conscientious care; a nursing assistant provides courteous care when they respect everyone as individuals regardless of their beliefs, lifestyle, or identity. It means caring for somebody with the knowledge that they are a person deserving of dignity. This means that NAs must work to be unprejudiced and treat everyone in their care with kindness and equal standing.
Do’s and Don’ts
It is important to know some basic rules about being a nursing assistant. Nursing assistants must remain within their scope of practice to protect the person receiving care from accidents, and to protect themselves and their team from liability[1].
- NAs are assistants to the nurse. Nurses assign, supervise, and delegate all of the NA’s work. NAs should only do the work that has been delegated to them.
- A nurse makes the decisions on what care a person should receive. NAs should always review the care plan with the nurse before proceeding.
- NAs should only perform tasks they have been trained to do and that their state and job description allow for. They should never perform a task if uncomfortable or unconfident performing it unless being guided by a nurse. NAs must always ask for help if unsure of their ability to safely do the delegated task.
- NAs need to know their own limitations. If they don’t know their own limitations, everybody is at risk; if something goes wrong then the person being caring for could suffer the consequences of a mistake, the NA may lose their job and license, and the rest of the nursing team may be investigated for negligence. Everybody relies on one another in a care team, and in a setting where everybody relies on one another, being honest and trusting your team to support you is essential for the health of the person you are caring for.
Nursing Assistant “No”s
While the particulars of the NA job description may vary from state to state or from workplace to workplace, there are a few things that NAs should never do.
- Never give drugs
- Never insert or remove tubes or objects from a body
- Never take verbal or phone orders from a doctor
- Never perform procedures that require sterile technique
- Never tell the family or person the diagnosis or medical or surgical treatment plans. These are conversations that they should have with the nurse or doctor.
- Never supervise others, including other NAs. NAs should never perform a supervisory role.
- NAs should never ignore an order or request while following the chain of command.
Quick Questions
What is critical thinking, and why is it a particularly important skill for nursing assistants to exercise? When will nursing assistants need to use critical thinking? Spend 5 minutes writing a response, and share with a friend or classmate.
The Organization and Operation of Care in Different Settings[2]
Contexts
Nursing assistants are essential members of care teams in a variety of different healthcare contexts. Because nursing assistants most often work in long-term care contexts, that will be the focus of this text.
“Long-term care” is a general term used for facilities that provide 24-hour skilled medical care;
long-term care facilities exist for people who are unable to stay in the hospital but who need more intensive care than can be provided at home. Long-term care is often necessary for people with chronic health conditions, or a health condition that takes place over a long period of time. NAs should treat a resident’s space as a guest would the home of a friendly host.
Assisted living facilities are places where staff can help a resident with whatever they may need. The residents in assisted living facilities do not usually need intensive medical care, but do require assistance with some ADLs due to restricted mobility and aging. If a resident develops higher care needs, some assisted living facilities may move them to a specialized wing for more attention and access to skilled care.
Hospitals are where somebody receives short-term skilled care. Someone may go to a hospital for a surgery, an emergency wound or burn, for a blood infusion, or any number of other medical problems.
Someone is placed in hospice care when they have a terminal condition; somebody’s condition is labeled “terminal” when it is likely going to be the cause of their immanent death, usually anticipated in less than six months.
The care team
What is a healthcare team? A patient’s healthcare team consists of all of the healthcare workers assigned to that patient’s recovery and care. Many different kinds of healthcare workers will be on your care teams, and each one brings specialized knowledge, skills, and talents to meet the varied needs of the person receiving care. Please read through this non-exhaustive list of some of the roles that you will encounter on your future healthcare teams.
Nursing assistants play one essential role on their care teams, but what are some of the other roles most often assigned to a care team.
- Registered Nurse (RN): RNs are people who have successfully completed a state-licensed nursing program and passed the requisite state exam. They have a variety of responsibilities depending on the context including hands-on care and dispensing medication. They work as staff nurses, nurse supervisors and managers, directors of nursing, administrators, or instructors. With further study, RNs can become nurse practitioners or clinical nurse specialists.
- Licensed Practical or Licensed Vocational Nurse (LPN/LVN): an LPN/LVN provides basic nursing care and must possess a license. They may be supervised by RNs, doctors, and dentists. An LPN/LVN has fewer responsibilities and functions than an RN.
- Physician/doctor (MD): Provides prescriptions and diagnoses, and performs certain kinds of medical procedures. There are many different kinds of doctors specializing in various ailments or bodily systems.
- Physician’s Assistant (PA): PAs assist doctors in diagnosing illness and prescribing treatment.
- Physical therapist (PT or DPT): A PT is somebody with extensive training on the body’s physical systems and administering treatment meant to ease pain, maintain mobility, or improve breathing and circulation.
- Speech-language pathologist (SLP): An SLP is trained to diagnose speech and language disorder and constructs a treatment plan to address it.
- Registered dietitian nutritionist (RDN): An RDN creates nutrition plans for patients or residents with particular dietary needs, whether due to a specific illness or in the interest of overall health.
- Respiratory therapist (RT): An RT is somebody trained to provide treatment to people with respiratory illness.
- Medical social worker (MSW): An MSW is a health professional trained to help patients address the social support aspects of their care and recovery. A graduate degree and state licensure are required to perform this role.
- Ombudsman: An Ombudsman is a person who addresses patient and resident complaints about the facility from a fair and neutral perspective; they are often affiliated with the state, rather than directly affiliated with the healthcare facility. An Ombudsman’s role is to help people address situations of injustice and conflict from a perspective of fairness and patient advocacy.
The patient and their family are essential members of the care team. The person receiving care must be included in conversations about the direction of the care; their family should also be included as a member of the care team, because they will most likely be the ones caring for the person once they leave the hospital or facility.
“doctor/nurse team photo” by ReSurge International is licensed under CC BY-NC-ND 2.0.
Continuity of care amongst the healthcare team is vital, as is continuity of care between what care the patient receives at the medical facility and the care received at home. Effective coordination between members of the care team is essential for a successful recovery. Healthcare team members need to communicate with one another effectively to provide high-quality care.
The nursing team is a specific subgroup of the healthcare team made up of RNs, LPNs/LVNs, and nursing assistants. Each member of the nursing team focuses on the physical social, emotional, and spiritual needs of the person and family.
Everybody on the care team performs a specific and important role. However, even though each role is specific and carries particular responsibilities, expertise, and obligations, everyone on the care team is working collaboratively towards the same end: the person’s health, recovery, and maximum quality of life. Because everyone works collaboratively, giving and insisting on respect is a practice NAs should become comfortable with.
The Legal Dimension of Caregiving
Resident Rights
What are Resident Rights? Residents' Rights are the dimension of the Big Three that addresses what kinds of services, conditions, and treatment are legally and ethically required for people living in long-term care and assisted living facilities[3].
Laws and ethics are different things, though they can overlap. Laws are rules and regulations that a government passes; healthcare professionals are subject to healthcare laws made at the federal and state level.
The most sweeping healthcare law enacted at the federal level is the Omnibus Budget Reconciliation Act of 1987, which continued to be revised and improved since its passage.
Ethics is the question of right and wrong, and how to design rules to determine them. Healthcare agencies and facilities often have a code of ethics that details what they consider to be ethical and unethical behavior in the workplace.
National Ombudsmen Resource Center. (2021, October 6). Residents’ rights: Your life, your care, your choice [Video]. Youtube. https://www.youtube.com/watch?v=34Z0LYhLtIs
While workplaces will have their own codes of conduct, these are some geEthicsneral guidelines for future NAs.
- Always maintain confidentiality; it is absolutely necessary to keep the information of those in your care as private as possible. Only share things that are relevant to the person’s care, and only with the particular members of the care team.
- Always be honest in your communications with persons receiving care, the other members on the nursing team, and in your documentation. This goes hand in hand with being trustworthy and reliable; always show up for work on time, and always let your supervisor know if you are having any problems or difficulties.
- Never arrive at work under the influence of intoxicating substances.
- Never be prejudiced or biased in your interactions with persons in your care or in interactions with colleagues. Prejudice and bias occurs when we make judgments about somebody based on a single aspect of their personality or appearance, such as perceived sex and gender, ethnicity, race, taste in clothing, etc.
- Medical racism, or the ways in which health conditions and healthcare outcomes are partially determined by a person’s race, is a pervasive issue in healthcare today. Hoffman et al. (2016) found that 73% of the medical professionals they surveyed held at least one false belief about biological differences between white and Black people.
They also found that false beliefs about biological difference based on race had a significant impact on how likely a healthcare professional was to believe a Black person’s description of their pain levels, and whether Black person communicating their pain receives effective treatment[4]. This basic insight that the prejudices of caregivers impact care outcomes applies to other forms of prejudice too, like sexism and fatphobia.
- Patience is a virtue, especially when providing care. NAs should always be patient with the persons in their care. Healthcare settings are often stressful places; NAs need to be able to help someone through pain and the trials of recovery without becoming frustrated or rushing them.
- Always read and follow the workplace code of ethics closely.
Understanding the laws and codes of ethics is important. It is also important to understand why such laws and ethics are in place. People receiving care are often vulnerable. Laws and codes of ethics are necessary measures to ensure that vulnerable people are not taken advantage of or easily mistreated. NAs should always follow the spirit and motivation of such laws and ethics in addition to abiding by their minimum standards; we have all been or will be vulnerable at different points in our lives, but NAs are in the unique position to turn an awareness of vulnerability into attentive and empowering care.
Quick Question
What is the relationship between Residents’ Rights and ethics? Why is following ethical conduct important for maintaining Residents’ Rights? Write for 5 minutes and share with a friend or a classmate.
The Nurse Practice Act
Each state has a Nurse Practice Act that defines the scope of practice for nurses and nursing assistants, delineates their education and licensing requirements, and outlines the requirements for revoking or suspending a license.
These laws are put in place to protect people from unqualified or unsafe healthcare workers; these laws are also in the interest of nurses, whose own health and professional status are protected. State laws about nursing assistants are based on that state’s Nurse Practice Act, and describe what it means for a nursing assistant to function with safety, skill, and accountability.
HIPAA
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is a law passed at the federal level that establishes rules about what healthcare and insurance agencies can do with individuals’ protected health information (PHI). PHI is any identifying information about a person’s health plan, healthcare history, or any conditions or treatments they may have or will undergo[6].
The two most important elements of HIPAA for nursing assistants to know are the Privacy Rule and the Security Rule. The Privacy Rule was added to HIPAA in 2000, and sets national standards for the protection of private health information. The Security Rule was published in HIPAA in 2003 and outlines standards for protecting the “confidentiality, integrity, and availability of electronic health information”[7].
The reason for a higher level of concern regarding the privacy and integrity of PHI comes from the security risk posed by progresses in computer technology; as it became easier to use technology to steal a person’s healthcare information, it became more important to pass regulation to ensure that any identifying information is kept safe and private.
NATCEP
What is NATCEP? NATCEP stands for the Nurse Aide Training and Competency Evaluation Program. It was implemented as a result of OBRA’s passage. OBRA was necessary because of the poor, negligent, and sometimes abusive conditions present in long-term care and assisted living facilities up to that point. To address this, the federal government legislated minimum standards of care, including minimum standards of education for nurse assistants.
NATCEP requires at least 75 hours of combined theoretical and hands-on instruction and successful completion of a competency evaluation before a nursing assistant can legally work. NATCEP also mandates at least 12 hours of continuing education for nursing assistants each year to keep skills sharp and current.
NAs must continue working as a NA in some capacity if they want to keep their certification. If a nursing assistant goes 24 consecutive months without providing professional care for pay they will have to re-take the requisite written competency exam to reacquire certification. It is in one’s best interest not to let NA certification expire; not only can it be time-consuming or costly to become re-certified, it may also cause potential employers to doubt someone’s professionalism.
Resident Rights; their importance and enforcement
Residents’ Rights are basic quality of life standards that long-term care residents always have a legitimate claim to because they are human beings and because they are protected by federal and state law.
Protecting Resident Rights is necessary and grows from a general concern for human rights, with the added recognitions that vulnerable elders have historically not had their human rights protected. Adults who are already vulnerable due to age and disability may be even more vulnerable when they reside in long-term care and aren’t in a position to advocate for themselves.
OBRA, or the Omnibus Budget Reconciliation Act of 1987, is a federal law that was put in place to protect residents in long-term care facilities from reported patterns of abuse, neglect, and substandard care. OBRA establishes some policies intended to increase the accountability and standards of long-term care facilities and puts minimum certification requirements in place for NAs.
OBRA has been updated multiple times since 1987, with its most recent update occurring in 2016 when the Center for Medicare and Medicaid Services implemented additional safety and resident rights requirements for long-term care facilities if they want to access federal funds. OBRA goes hand-in-hand with the Elder Justice Act of 2010, a comprehensive piece of legislation at the federal level passed to protect residents in long-term care facilities from abuse, neglect, and exploitation.
Legislation like OBRA and the Elder Justice Act apply to nursing assistants because it establishes baseline educational, certification, and registration requirements. It is also part of what defines the NA scope of practice.
According to the Illinois Department on Aging, residents in long-term care facilities have a specific set of rights that long-term care facilities are required to uphold[8].
- Residents have a right to dignity and respect. This means that residents have a right to make their own choice, a right to treatment that promotes quality of life, and a right to equal access to care.
- Residents have a right to safety; this means that residents have a right to be free from abuse, neglect, and exploitation. Residents have a right to complain without fear of retaliation and discrimination. Residents have a right to quality physical and mental health services, and a clean, comfortable, and homelike environment. Residents have a right to be free from chemical or physical restraint; residents can only be given mood or thought altering medication with their permission.
- Residents have the right to participate in their own care. This means that they may attend care conferences, may see and request changes to the care plan, choose their own doctor, make a living will, refuse treatments, and move out of the facility. Residents have a right to be fully informed and empowered in their own care.
- Residents have a right to confidentiality and privacy. They are entitled to a knock before facility staff enter, a right to private visits at any hour as long as they don’t infringe on other residents’ rights, a right to control who has access to their information, and a right to privacy and access to mail and telephone services.
- Residents have a right to their personal money, even if their personal money is managed by their facility. They also have a right to their personal property; facilities must take steps to keep residents’ personal property safe and secure.
- Residents have a right to be fully informed about the expected and actual costs of their care; they also have a right to be provided with accurate information about Medicare and Medicaid. Residents also have a right to advanced directives, which are documents that gives instructions on care should the resident be unresponsive or unable to make their own medical decisions.
- Residents also have a right to stay in their facility, unless in case of certain exceptions. If a facility wants to involuntarily discharge a resident, they must meet some requirements; first, there must be some reason that the resident can no longer receive care at this facility, such as being a danger to themselves or others, an unmeetable care need, improved condition, unpaid bills, or facility closure. If a facility wants to evict a resident, they must provide notice at least 21 days in advance, provide information on the appealing the decision to the Illinois Department of Public Health, and provide a mailing envelope for the appeal.
If you suspect that your workplace is violating any of these rights, you should discuss it with your supervisor and bring the problem up with the resident council. The resident council is a group of residents who meet to discuss issues with their facility and advocate for improvements on behalf of residents.
If you or the resident council need further help solving the problem, you may want to contact your state’s long term care Ombudsman program or file a complaint with the Department of Public Health[9].
Policy, Procedure, and Job Description
A policy is a course of action that is meant to be taken every time in response to particular situations. A healthcare facility may have a policy on workplace attire, on sharing details of a person’s recovery with their family, or on the appropriate use of psychiatric medication, to give a few examples.
A procedure is a specific method or way of doing something. A healthcare facility will have procedures on how to change a bed, how to fill out a medical chart, and on how to properly remove PPE like gloves and masks.
NAs must closely follow all of their workplace policies and procedures. Failure to do so could make them or their supervisors liable any resulting negative consequences. Policies and procedures are in place to protect the patient, the healthcare professionals, and the healthcare facility; it is in everyone’s best interest, including one’s own, to follow policies and procedures to the letter.
Some policies and procedures are mandated and overseen by federal and state governments, while others are specific to the workplace. If you have a question about your workplace’s policies and procedures, always ask your supervisor or consult the document where they can be found.
A job description refers to one’s clearly defined duties and responsibilities. Job descriptions may be written by government legislation, agencies, and specific workplaces. If a nursing assistant is asked to do something that is not in their job description, they should refrain from performing the task and discuss it with their supervisor.
Federal and state agencies may perform oversight on long-term care facilities by hosting surveys; a survey is when a federal or state oversight body reviews the work done by a long-term care facility to ensure that minimum legal standards are consistently met. These surveys will assess whether residents are receiving satisfactory care and whether their needs are being met. In doing so they will talk with staff, residents, and families, as well as review all charts and documentation done by the staff.
A NA’s role during a survey is the same as it always is – provide quality care, pay attention to the Big Three, and be professional and honest. If an oversight agency finds a problem with a facility, they will issue a citation; depending on the severity, a citation may result in the care facility being forced to correct the issue, being fined, or loss of license, certification, and accreditation. NAs should always be honest if an auditor asks them questions about their facility.
Abuse and Neglect
Before OBRA’s passage, abusive and neglectful treatment of residents was significantly more common than it is today. Sadly, in spite of necessary legislation, the problem does still persist.
Residents have a right to be free from abuse and neglect. Abuse is purposeful mistreatment and can come in many forms, physical, financial, or psychological. Neglect is a form of mistreatment that occurs when a vulnerable person’s needs are not met while in the responsible party’s care; neglect or negligence can result in harm to a person, which then makes it malpractice.
Every resident is every NA’s responsibility. NAs work to make sure that everyone in their care has as high a quality of life as possible every day. A high quality of life, understood in terms of the residents’ rights outlined above, is not compatible with suffering abuse[10].
Elder abuse can come from different sources. Residents are especially vulnerable to abuse from staff members, and potentially from other residents. Residents may also be abused by family members who visit or take the resident elsewhere. It is important for NAs to recognize the possibility of abuse and to observe any potential warning signs that a resident is being abused.
There are many signs of potential abuse and neglect; unexplained injuries (especially if reoccurring), weight loss and dehydration, fear and anxiety around a particular caregiver, uncleanliness, a caregiver or family member withholding privacy, and call lights left unanswered are all potential indicators that a resident is suffering from abuse or neglect.
NAs are mandatory reporters, which means that they are legally obligated to report suspected abuse or neglect. The NA can alert the nurse to their concerns with or without discussing it with the resident first. When reporting, the NA should tell the nurse and give as many details as possible; they should also assist the resident if the resident decides to make a formal complaint.
Remember, residents have a right to be free from retaliation; if a resident complains and a staff member appears to punish them for it, the nursing assistant should report this behavior as soon as possible.
What would you do?
Imagine that you are working as a nurse’s assistant in a long-term care facility. You regularly care for Mr. Jones, and have a good sense of his personality. He is talkative with you, is forgetful but lucid most days, and is comfortable with a casual touch on the hand or the arm (you know this because he told you after you asked). However recently you have noticed some changes in Mr. Jones’ demeanor. In the last month he has become more withdrawn and disoriented, less willing to eat and participate in social life, and he recoiled the few times you have touched his hand during conversation. Today he said something concerning: when you brought up the upcoming weekend, he said that he wished you would still come to work so he “wouldn’t have to spend as much time with that other aide.” You’ve observed him while assisting with ADLs and did not notice any marks or physical causes for concern. How would you proceed with this situation? Would you tell the nurse immediately, or try and talk with Mr. Jones first? How would you approach that discussion? Spend 5 minutes writing, and share with a friend or classmate.
Professional Communication
Professional communication for NAs looks different depending on the context it occurs in; professional communication means something different when talking with a nurse than when communicating with a resident[11].
The communication that goes on as a function of caring for patients and residents is some of the most significant communication that happens in healthcare settings. In other words, the members of the care team have to communicate with one another in order to organize and provide care, and their ability to communicate effectively matters a lot for their ability to successfully care for someone. Professional communication between members of a care team about patient care will utilize three important frameworks and procedures: the nursing Chain of Command, the Nursing Process, and reporting and recording.
The Chain of Command
The Chain of Command refers to the authority and responsibility that different nursing staff carry relative to one another. NAs are at the “bottom” of the Chain of Command; this has nothing to do with how important they are to a person’s care, and simply means that they are not permitted to delegate tasks to or supervise anyone. Rather, tasks are delegated to them, and they are supervised by a nurse with more responsibilities and liabilities who is “higher” on the chain of command.
A facility’s Director of Nursing (DON) is responsible for the whole nursing staff. The DON has a team of staff involved at higher-order levels of staff development and care management, who have responsibility over nursing supervisors and charge nurses that manage many units or a single unit respectively.
Staff nurses, or RNs and LPNs, are next in the Chain of Command and are responsible over the nursing assistants. NAs report to the RN that they are assigned to.
It is part of the work of employers to provide their NAs with the education and mentorship necessary to do their work. NAs should always feel comfortable asking for help or additional instructions from people who oversee their work and training.
Delegation
When an RN gives the NA a request or an order, they are delegating something to them. This implicates them both in that care task. NAs are liable for their own actions; this means they are responsible for them. However, NA’s actions are also a liability in the sense that other people, like supervising nurses, may be held responsible for them as well.
Delegation occurs when a particular member of the care team with a higher level of supervision and responsibility than the NA on the nursing Chain of Command asks them to perform a task. Tasks must be properly delegated, in the sense that they are delegated by the correct person to the correct person An NA should only be delegated tasks that are within their job description and they can legally perform; NAs may also be asked to assist nurses with more complicated tasks. RNs can delegate tasks to LPNs and NAs, LPNs can delegate tasks to NAs, and NAs cannot delegate any tasks.
The National Council of State Boards of Nursing (NCSBN) describes the Five Rights of Delegation[12] as:
- Right Task
- Right Circumstance
- Right Person
- Right Direction/Communication
- Right Supervision/Evaluation
These “rights” are in place to ensure that when a task is delegated, it is the correct care task, delegated properly by the relevant person, in the best interest of the patient, and is performed by the right person with the proper oversight. It is part of the NAs responsibility to know when they are being delegated a task that they should not perform. This is vital, because a NA, RN, or another member of the nursing team may be held responsible for improperly delegated tasks[13].
NAs can either agree or refuse to perform a delegated task. Protecting the patient from harm is always the NA’s first priority; if the NA does not feel they can safely perform the delegated task, they should refuse it so the nurse can delegate it to somebody who can safely and legally perform it.
NAs should only perform tasks that are within their scope of practice. The NA’s scope of practice is determined by the state, the agency the NA works for, and the NA’s supervising nurse. However, no agency or nurse can expand the NA’s scope of practice beyond legal boundaries or beyond the boundaries of responsible caregiving.
It is important never to ignore a request. If a NA is not comfortable with performing a delegated task, it is important that they communicate with their supervisor or someone who can hear their concerns. Some reasons for refusing a task may be that the directions aren’t ethical or are not within the legal boundaries of the NA role, the task falls outside the NA scope of practice, directions may go against agency policies, directions are unclear or incomplete, or a nurse may not be available to supervise the NA’s performance.
Quick Question
Imagine that you are at work as a NA, and your supervising nurse asks you to perform a care task that is within the technical scope of your practice, but that you haven’t been trained on how to perform. The floor is very busy right now, so when you raise your concern, the nurse says “It’s a simple task, just go ahead and do it.” You are still uncomfortable with the situation. What should you do? Which of the Five Rights might be at jeopardy in this situation?
The Nursing Process: Assess, Diagnose, Plan, Implement, Evaluate
Nursing care is a highly organized process, which means that in order to do it well every time all members of the nursing team need to proceed methodically. The nursing process is a step-by-step method that nurses use to determine what may be wrong with a patient and how best to move forward with their care.
Assessment: Assessment means, in short, gathering information about the patient. Nurses or N.A.s nay do this by reviewing a medical chart, talking with the patient, performing a physical assessment of some kind, and by using your five senses to take note and observe.
Nursing assistants play an important role in the assessment phase of the nursing process because they often have the most hands-on interaction with the patient, and are therefore best positioned to take note of changes in their condition.
NAs should take note of objective information by writing down what they can gather from their senses; they should also note any subjective information, or things they learn by speaking with the patient or their families. For example, objective information is noticing that a patient has jaundice; subjective information would be when they tell you that their stomach hurts.
When observing a patient as part of assessment, try and take note of their orientation (awareness and grasp of reality), vital signs, changes in ability, or any other changes in physical condition or mood. Assessment is an ongoing process, and continues for as long as the patient is in the nursing team’s care.
Diagnosis: When a medical professional makes a diagnosis, they are making an official declaration of what they believe is wrong with the patient. Nurses can give diagnoses of problems that can be treated with nursing measures. Nursing diagnoses are not medical diagnoses, because a medical diagnosis must be made by a doctor. A nursing diagnosis can be made by a nurse, and describes a health problem that can be treated by a nurse. A nursing diagnosis may have to do with an issue of the body, but it may also address the emotional, social, or spiritual dimensions of a person’s care.
Planning: Planning occurs when the nursing team decides how to proceed with care. Planning with the nursing team may involve the delegation of tasks and duties, prioritizing some aspects of care over others, and aligning your care goals as a team. While the RN ultimately decides on the plan, everybody’s input (especially the patient and their family’s) input is essential. Goals are what is desired for a person’s care, and usually indicate an “if all goes well” mentality, aiming at a person’s highest anticipated level of being and function. Goals are important because they promote healing and recovery. When prioritizing actions in the planning phase, consider which needs are most threatening, which steps are time-sensitive, staff availability to perform the tasks, and the holistic needs and wants of the patient. Prioritization is an exceptionally important skill for a NA to develop, because it is important to the organization of a patient’s care and because it is essential for efficient time-management on the job.
Implementation: The implementation step is the action phase of the nursing process. It is when the interventions determined in the planning phase are put into effect. The tasks in need of implementation may range from basic and simple to highly complicated and requiring multiple people. Reporting and recording of the care should only occur after the care has actually been administered. It is important to continue observing and taking note throughout the entirety of the nursing process, because the assessment phase never ends. Continued observation is necessary in case any changes need to be made to the care plan.
Evaluation: Evaluation occurs when the care team determines how successful the intervention was. Goals set during the planning phase may be met completely, partially, or not at all. Once progress has been evaluated, the nursing team returns to the assessment stage to continue the patient’s care and begin the process over again.
Reporting and Recording
When an NA reports something to the nurse, they deliver information verbally. When an NA records something, that means the information was written and is included in the patient’s chart. It is important to make sure that both of these steps are completed.
When reporting, a NA has only officially reported something when they speak to their supervising nurse, not simply another person above them in the Chain of Command.
When verbally reporting the NA should be prompt, thorough, and accurate. This means correctly noting all relevant information, without including so many unnecessary details that the record is burdensome and time consuming. All record entries should include the patient’s name, room, and bed number, and the time that the observation was made or care was given.
The NA should report and record only what they did and the care they provided, as well as any noticeable changes to the patient’s condition. The report should also include the time when the NA left the area.
When recording, an NA should write information in the patient’s medical record. A medical record, or chart, is a permanent legal document that medical institutions keep on their patients. It contains descriptions of a patient’s condition, relevant details of their medical history, notes on the care plan and treatment, consent forms, progress notes, and details of any changes the patient has undergone since entering into care.
The NA should record anything that they do to, with, or for the patient; this is an essential element of maintaining the continuity of care within the nursing team.
A popular saying in the nursing profession is that “if it wasn’t recorded, it didn’t happen.” While ironic, this saying expresses the extent to which a nursing team relies on a patient’s medical record to coordinate their care. All documentation should occur only after the care has been administered, neither during nor before.
Record-keeping may be different from one healthcare setting to the next. While most employers now use an electronic system, some may use a written or a mixed record-keeping system. When charting by hand, always use blank ink, and only record facts rather than opinions. It is important to follow the agency’s rules on documentation. If a NA make a mistake on a chart, they should never erase it or correct it, though they should cross it out and enter the correct information. NAs should follow their facility or agency’s policy for correcting a mistake made on a medical record.
Incident Reporting and Recording
An incident is a problem, accident, or unforeseen event in a patient’s care, or an accident or injury that impacts any employee or visitor. An incident report is a report that objectively documents what happened and what the response to the situation was. This is important so workplaces can be made safer, and so incidents do not further impact anybody’s care.
NAs should always fill out an incident report if they are injured while on the job; if an incident occurs in a patient’s care, a nurse will usually fill out the incident report and may ask for input from the NA. The incident report should include only factual observations and events from an objective perspective. NAs should never let anybody talk them out of filing an incident report.
When completing an incident report, NAs should include exactly what they observed, list the time of occurrence, list any observations of the person and what state they are in, and describe the person’s reaction to the situation. Facilities will usually have a specific form for NAs to fill out. NAs should report the incident to the nurse before filling out an incident report form, especially if the incident involves a patient, because the nurse may want to complete the form themself.
Start and End-of-Shift Reporting
Start-of-shift reports are gatherings of the care team at the start of a shift to get up-to-speed on the patients in their care. NAs will be present at start-of-shifts reports, during which the nurse from the previous shift will discuss any changes to patients’ conditions and updated care plans, as well as any discharges or new admissions. It is also where NAs will receive their assignments for that shift.
At end-of-shift reports, NAs should report any changes to their supervising nurse, so they can be included in the next start-of-shift report. Before finishing tasks and going to end-of-shift reporting, NAs should make sure that patients or residents have anything they may need. NAs can offer them the restroom, make sure that necessities are within easy reach, and reposition them. Shift changes will likely be the longest time patients or residents are left unattended during the day, so it is important to make sure that they will be safe and their needs taken into account for that time.
Critical thinking is an essential skill for nursing assistants. NAs will rely on critical thinking when making observations for reporting and recording. Why is critical thinking such an important skill when reporting and recording? Write for 5 minutes, then share your response with a friend or classmate.
Professionalism
It is essential that nursing assistants keep themselves well-groomed, diligently attend to their hygiene, and dress in accordance with the standards of their workplace. NAs should always be aware of their workplace’s dress code. NAs should abstain from wearing large jewelry or any adornments, such as long nails, that could get in the way of performing hands on work or catch on an object unintentionally. NAs should remove unnecessary jewelry, but are encouraged to wear a small, waterproof watch to keep track of the time. Remove the watch when washing hands so that no areas are missed.
NAs should refrain from using artificial fragrances like perfume and cologne. Instead, consider a lightly or unscented deodorant. People receiving care may have sensitivities to smell, so refraining from fragrance is one way you can practice empathy and courtesy before even arriving at work.
It is important for NAs to conduct themselves in a professional manner. This can mean being punctual, limiting cell-phone use, never reporting to work under the influence, using appropriate language, maintaining positive relations with coworkers, and listening to and applying feedback. NAs should always discuss workplace standards of professionalism with their supervisor, as expectations can change depending on where one works.
Key Takeaways
- Nursing assistants (NAs) are the first line of care. NAs provide the most direct and daily care of the different members on the care team, so it is important that their caregiving be holistic, person-centered, and performed with empathy and conscientiousness.
- Residents have a set of specific and legally enforced rights, including rights to safety, dignity and respect, and participation and agency in their own care. When NAs observe the violation of Residents’ Rights they should report this to their supervisor or a state ombudsman.
- NAs will have their tasks delegated to them in accordance with the facility Chain of Command. NAs are responsible understanding their scope of practice and determining whether delegated tasks are included in it. NAs should always ask for assistance if they are unsure about performing a delegated task.
- The Nursing Process: Assess, Diagnose, Plan, Implement, Evaluate, Assess again
- Reporting and recording are essential practices. NAs should always follow workplace reporting and recording procedures. The combination of critical thinking and observation skills are important for good reporting and recording.
Comprehension Questions
1) Which of these are ADLs? Select all that apply.
a. Brushing one’s teeth
b. Showering
c. Going to the movie theater
d. Getting dressed
e. Voting in a city council election
f. Meditative breathing exercises
2) Which of these qualities are necessary for providing holistic, person-centered care?
a. Respecting someone’s personal choices and individuality
b. Telling confessional stories in order to build rapport
c. Attending to someone’s physical, psychological, social, and spiritual needs
d. Making somebody second-guess themselves about treatment the NA doesn’t agree with
3) What are qualities that nursing assistants must cultivate? Select all that apply. With a friend or classmate, discuss what each (correct) answer means to you, and for your role as a nursing assistant.
a. Funny
b. Punctual
c. Empathetic
d. Accountable
e. Creative
f. Attentive
g. Patient
4) Respond to the following sentences with T (true) or F (false).
____ Nurses make decisions about the care someone will receive and then delegate to NAs
____ If unsure about performing a care task, NAs should give it a shot and see how it goes
____ NAs should avoid telling a person’s family about their loved one’s diagnosis, and should instead leave it up to the nurse or doctor
____ NAs can decide whether or not they will respond to an order or request from the chain of command
5) Edna is an elder who recently needed to sell her house for her financial security. She also found it difficult to use the stairs, and reach everything in her kitchen. Edna’s husband died five years ago, and her children live in different states. She has a good memory, but has trouble with cooking, and mostly stays in her home. What care facility would Edna benefit from the most?
a. A hospital
b. Hospice care
c. An assisted living facility
d. A nursing home
6) OBRA and NATCEP require which of the following?
a. NAs must shower before work
b. NAs must be registered with their state’s Healthcare Worker Registry
c. NAs must report observations or suspicions of abuse and neglect
d. NAs must act within the clearly defined scope of practice
7) What are the “Five Rights of Delegation”? What does each “right” involve?
8) What are the four basic steps necessary for critical thinking? Why are they all important? Is critical thinking something that can be done with others? If so, how?
9) What does it mean for NAs to be understanding, empathetic, and accountable in their work? How do these qualities relate to the Big Three? Try to relate them to at least two elements of the Big Three.
10) What are the 5 steps in the nursing process? What does each step involve?
11) What does it mean for nursing assistants to practice professionalism? What is the connection between professionalism, providing good care, and being a good team member?
12) Cassandra is working as a nursing assistant; she is assigned to a new resident named Mrs. Gupta, who is known for her being chatty and enjoying company. Cassandra says “Couldn’t I be assigned to someone else? I can never understand people with those accents anyways.” Which qualities of a good nursing assistant does Cassandra’s response not demonstrate? How could she have responded differently?
13) Drew, a nursing assistant, is helping a resident eat their dinner. Drew notices that his shift ends in 10 minutes, and he still has a lot of work to do before the shift change. He says to the resident, “Could you eat faster, please? Or maybe you could do the last bit here yourself? I have some things I need to do before my shift ends.” How could Drew have demonstrated more patience and empathy in this situation? Does Drew’s comment go against any of the Big Three?
- Miller-Hoover, S. (2018). I said what? Professionalism for the CNA. RN.com. https://www.rn.com/featured-stories/professionalism-cna/#:~:text=Professional%20CNAs%20are%20responsible%2C%20trustworthy,and%20being%20a%20team%20player ↵
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- Nursing Assistant, Chapter 2 by Chippewa Valley Technical College is licensed under a Creative Commons Attribution 4.0 International License, except where otherwise noted. ↵
- Hoffman, K. M., Trawalter, S., Axt, J. R., & Oliver, M. N. (2016). Racial bias in pain assessment and treatment recommendations, and false beliefs about biological differences between blacks and whites. PNAS, 13(16). https://doi.org/10.1073/pnas.1516047113 ↵
- Illinois Department of Public Health. (n.d.). Retrieved February 15, 2023, from https://dph.illinois.gov/topics-services/health-care-regulation/health-care-worker-registry/cna-facts.html ↵
- U.S. Department of Health and Human Services. (2022, October). Summary of the HIPAA privacy room. U.S. Department of Health and Human Services. https://www.hhs.gov/hipaa/for-professionals/privacy/laws-regulations/index.html ↵
- U.S. Department of Health and Human Services. (2022, October). Summary of the HIPAA privacy room. U.S. Department of Health and Human Services. https://www.hhs.gov/hipaa/for-professionals/privacy/laws-regulations/index.html ↵
- Illinois Legal Aid. (2021, February 25). Understanding nursing home resident's rights. https://www.illinoislegalaid.org/legal-information/understanding-nursing-home-residents-rights ↵
- For more information on residents’ rights, consider looking through some of the brochures and reports published by the Illinois Department on Aging: https://ilaging.illinois.gov/programs/ltcombudsman/residents-rights-in-long-term-care-facilities1.html ↵
- Centers for Disease Control and Prevention. (2021, June 2). Preventing elder abuse. https://www.cdc.gov/violenceprevention/elderabuse/fastfact.html ↵
- Nursing Assistant, Chapter 1 by Chippewa Valley Technical College is licensed under a Creative Commons Attribution 4.0 International License, except where otherwise noted. ↵
- American Nurses Association and NCSBN. (2019). National guidelines for nursing delegation.https://www.ncsbn.org/NGND-PosPaper_06.pdf ↵
- For more detailed information on delegation in nursing contexts, check out this resource: https://med.libretexts.org/Bookshelves/Nursing/Nursing_Management_and_Professional_Concepts_(OpenRN)/03%3A_Delegation_and_Supervision/3.04%3A_Delegation ↵
Caring for a whole person, including their psychological, emotional, and spiritual needs, and prioritizing their autonomy and agency in the care process.
An approach to care rooted in the autonomy, choice, and empowerment of the person receiving care
Understanding all sides of a situation before making a judgement using reason and careful consideration
Safety, Residents' Rights, and Infection Control. These are three frameworks that NAs should use to structure their critical thinking in caregiving contexts.
An assistant to the registered nurse. They are the first line of care, and provide holistic care in the form of emotional and spiritual support, in addition to physical care. NAs should always act with empathy and conscientiousness.
daily activities that a person needs to do to stay well, including daily hygiene, eating, dressing and undressing, and ambulating or other recreation
The quality of being able to imagine how somebody else is impacted by something. True empathy leads to compassion.
The ability to imagine another's experience, and to incorporate your understanding of their experience into how you care for them
Thoughtful and self-aware about communicating with others. Being conscientious means caring with intention.
Taking responsibility for one's mistakes, and always seeking to improve
The set of actions that a particular nurse or nursing worker can perform given their legally defined role, their agency and facility job description, and their training.
The teams of facility staff responsible for a patient or resident's care, recovery, and overall quality of life.
24-hour skilled medical care provided for extended periods of time.
Residence where medical staff are always available to assist residents, but where residents do not need the level of intensive and attentive care required in a long-term care facility.
Care that someone receives in a facility for people with terminal conditions, or conditions for which the prognosis is a relatively immanent death, usually less than six months from admission to hospice care.
Caregiving that is well-organized, correctly executed, and that maintains effective communication among all members of the care team, including the person's family.
A sub-team within the care team comprised of nursing staff
The ethically and legally defined minimum standards of care that all residents are entitled to.
Rules created and enforced by the government
Also known as OBRA, this act set minimum quality of care standards in assisted living facilities
Using an understanding of right and wrong to create rules about moral behavior.
Respecting another person's right to privacy
State laws that define the scope of practice for nursing roles
A federal law that outlines the acceptable use of a person's private health information (PHI).
The Omnibus Reconciliation Act of 1987 is a sweeping reform to the legally required minimum standards of care for long-term care and assisted living facilities.
A course of action set by a facility that clearly describes what procedures to follow and when and how to follow them
Purposeful mistreatment
Habitually failing to meet someone's basic needs
People who are legally obligated to report suspected or observed abuse and nglect
The hierarchical ordering of responsibility and delegation in healthcare facilities
Delegation refers to the process of members of the care team assigning care tasks to other care team members.
The methodical approach nurses use to determine the proper course of care and put it into practice
Also called a chart, the medical record is a permanent legal document healthcare facilities are obligated to keep that documents all of the care a person received and when they received it.
A form that needs to filled out any time an accident or injury occurs in a healthcare facility of any kind