Person-Centered Care

In the last module we introduced the concept of holistic, person-centered care. What does it mean to care for someone holistically? To do something holistically means to guide one’s actions and responses with attention to the whole, rather than to a part or a section. This translates to medical caregiving because even though residents or patients may have a specific problem or ailment, we recognize that a problem with one part of a person’s body can still impact their whole experience, whether physical, spiritual, psychological, or social^[1].

For example, a person experiencing chronic pain may not be able to socialize as much as they want to, and so their mental and social wellbeing suffers along with their physical wellbeing. Similarly, maintaining one’s mental, spiritual, and social health can be an important part of healing or managing a physical ailment. When we talk about holistic care, we recognize that caregiving is about the whole of a person, and that all aspects of a person are impacted by a medical condition.

It is important for nursing assistants to practice holistic care; failing to practice holistic care may result in a medical professional harming a person in one way at the same time as they try to help them in another. Holistic care understands that a person’s physical, psychological, social, and spiritual needs are interrelated.

As a person loses parts of their normal functioning, whether due to illness, disability, or old age, anger can be a common response. It is necessary for NAs to treat everybody they care for with dignity and respect, and to keep them informed about their care as the NA provides it.

If a person being cared for becomes upset or angry, it is necessary to respond with a calm and professional demeanor; NAs should not argue, and make sure to listen and allow space for silence.

When caring for a person, NAs should emphasize their abilities in interaction, rather than disabilities. If a person can perform a task themselves, such as washing their hands or dressing themselves, that option should be made available to them. NAs should always allow time and be patient with the people they care for; even if a person can only do something at a much slower pace than the NA, the NA should still give someone the opportunity to complete the task themself at their own pace.

Person-centered care and holistic care are closely related. While holistic care means caring for the entirety of a person (not just the part or system impacted by a diagnosed condition), person-centered care means that the person’s care plan is guided by their own goals for treatment and that their desires for care and care outcomes are respected as much as possible. Person-centered care involves empowering a person to make as many of their own care decisions as possible; it means encouraging their autonomy and agency, and proceeding with the understanding providing care should always be meeting the goals and needs of the person themself.

Maslow’s Hierarchy of Needs

Maslow’s Hierarchy of Needs is a framework for interpreting and understanding human needs, and is useful when applied to care in a holistic way. Humans have a wide variety of needs, whether they are basic physic needs or psycho-social needs. Basic physical needs include things like food and water, movement, sleep, freedom from pain, and shelter. Psycho-social needs are more varied, and include feeling safe and secure, feeling loved, and maintaining self-worth. Maslow’s Hierarchy divides the schema of human needs into roughly five layers representing kinds of human need, each of which is necessary for the full experience of the next. These kinds of needs are basic physical needs, safety and security needs, the need for love, the need for self-esteem and self-regard, and the need for self-actualization.

“Maslow’s Hierarchy of Needs” by Chiquo is licensed under CC BY-SA 4.0.

In 1943, Abraham Maslow came up with a psychological theory of human need where our needs are structured like a pyramid, with more basic needs on lower (and hence more structurally necessary) tiers of the pyramid. “Maslow’s Hierarchy of Needs” can be a useful way of thinking about that some needs like having friends and having self-esteem depend on more basic needs like comfort, oxygen, or nutrients.

The bottom tier of the pyramid is physical needs. The physical needs Maslow has in mind here are basically things that a person could not survive without; food, water, air, movement, etc. NAs can make sure a resident meets their basic needs by encouraging and helping them to eat and drink, assisting them with eliminating waste, and making sure they rest and move enough.

The second tier of the pyramid is safety and security. A person needs an environment that is free from danger, and provides protection. It is important that a person has a consistent environment they can call their own. An NA can help a someone feel safe and secure in their new residence by being understanding if the person they are caring for displays anxiety or confusion; moving out of one’s home for long-term medical care is a stressful situation; NAs can be compassionate and patient, and do what they can to cultivate a home-like atmosphere for residents or patients. NAs can also provide a listening ear, and help to reassure residents that they are safe.

The third tier is Maslow’s pyramid is our human need for love. Our need for love includes other

psychosocial needs, like our need for acceptance and a sense of belonging. When people enter  an assisted-living facility, they may feel distant from their loved ones, or have recently lost a loved one. It can be difficult for a person to acclimate to a new living environment, particularly when it involves living amongst strangers. It is normal for someone to miss their established routines.

The fourth tier of the pyramid is a person’s need for esteem, both self-esteem and social esteem. People need to feel valued by themselves and feel that they are valued by others. It is important for a person to feel that their presence matters.

Nursing assistants can help residents meet their esteem needs by telling a resident that they think highly of them, spending enjoyable time with them, and praising their successes. NAs can also help residents maintain a sense of self-esteem by encouraging as much independence as possible, and praising a resident’s successes. Such comments can help someone maintain a sense of dignity and self-esteem.

The fifth type of need a human has on this model is for self-actualization. Self-actualization refers to a person’s striving to reach their “ideal self,” whether through acts of creativity, play, charity, socializing, or some other form of positive engagement with the world. Examples might include painting, dancing, or writing letters.

Self-actualization refers to our pursuit of the activities that we have chosen as expressions of our authentic self, or the activities that we engage in while pursuing an expression of our authentic self.  NAs can help residents pursue self-actualization by encouraging and showing interest in their pursuits, and facilitating connections with other residents with compatible self-actualization activities.

It’s all connected

When a person enters an assisted living facility, it can accompany a sense of loss of one’s identity, independence, mobility, social connections, and sense of connection to the world. When a person’s psychosocial needs go unmet, other aspects of their health can suffer. Nursing assistants should keep the full spectrum of human need in mind as they provide care, since it is necessary for providing holistic care and helping residents maintain their highest possible quality of life.

When somebody experiences disability, whether for the first time or because of a lifelong condition, their reactions may include angry, demanding, inappropriate, or aggressive behavior. NAs can’t avoid residents, however if a resident acts in such a way that puts themselves or others at risk of danger then an intervention may be needed to correct the behavior. Until such an event, NAs should be patient and accommodating with residents who are angry with their circumstances, empower them with as much autonomy as possible, and meet any abrasiveness with a kind and dignifying demeanor.

Respecting people from different cultures, religions, and backgrounds

Culture and language

When interacting with residents, it is important to approach them with a sense of basic respect. This kind of respect is considered “basic” because it will be consistent across all the residents an NA cares for. Always interact with residents as complex adult human beings; never infantilize them with one’s words, tone of voice, or body language. Always provide them with courtesy and respect.

“Culture” refers to a group’s shared behaviors, attitudes, assumption, beliefs, and values. Culture closely relates to the way that any person’s worldview is shaped by the social context they grow up in. The world contains significant cultural plurality, and each culture shapes peoples’ worldviews in unique ways. Culture can correspond to, but is not the same as, one’s nationality, ethnicity, region, or even one’s own friend group or family.

Cultural competency

Within an assisted living facility there may be a substantial amount of cultural diversity, or people from a wide array of different cultural backgrounds. Cultural competency refers to a person’s ability to comfortably and skillfully communicate with people from different cultures; a lot of cultural competency comes down to being flexible, attentive, and nonjudgmental.

Culturally competent nursing is an important aspect of caregiving in a pluralistic community. A NA should be able to learn things about each resident’s cultural background and apply that information to their caregiving.

Johnson & Johnson Nursing. (2018, December 3). Becoming a culturally competent nurse [Video]. Youtube. https://www.youtube.com/watch?v=r62Zp99U67Y

NAs must always interact with the people they care for with an attitude of acceptance and nonjudgement. Because culture influences the ways that people seek and discuss healthcare, NAs should try to become familiar with the cultural backgrounds of the residents they care for.

Some residents will be excited to share different aspects of their culture with you, so NAs can ask about family, friends, and cultural traditions; others may be more reticent or less enthusiastic, so sometimes NAs may need to do a little bit of research or use their critical thinking skills to understand how a resident’s cultural background may inform their attitudes and preferences.

When NAs are culturally competent and sensitive to difference it improves the quality of their care and makes the experience of providing care to a diverse population that much more interesting and rewarding. Cultural competence is necessary because it improves patient care outcomes; providing culturally and linguistically appropriate services (CLAS) means providing care that is effective, appropriate, and understandable for the person receiving care^[2].

Resident Rights

Residents have a right to communicate with someone in their own language. If a facility does not have someone who is capable of communicating with a resident in the resident’s own language, then they will need to hire an interpreter. If a facility fails to meet this requirement, then they will be in violation of OBRA.

If you feel that an interpreter or translator is needed for a resident to communicate with ease and convenience, they tell the nurse right away^[3].

Religion and spirituality

There are a wide variety of different religions in the world, and a modern day assisted living facility may represent a good number of them. NAs will interact with believers from many different religious traditions. A resident’s religion and spirituality can be important to them, and may play a key role in maintaining a hopeful and positive attitude throughout the duration of their care. NAs must always treat residents’ religious beliefs, needs, and practices with respect.

“Q introduces bill banning religious symbols” by Prachatai is licensed under CC BY-NC-ND 2.0.

NAs should never adopt a judgmental attitude toward a resident’s religious beliefs or practices; an essential element of cultural competency is learning how humble oneself and practice empathy to better understand and accept the way someone from a different cultural or religious background experiences the world. Always be accepting and helpful about a resident’s religious needs.

A resident’s religion may have an impact on how they receive care. For example, some religions like Islam and Judaism maintain a dietary code (called Halal and Kosher, respectively) that can impact what a resident will eat. Other religions may have other rules about the kinds of medical care someone is permitted to receive; for example, Jehovah’s Witnesses do not accept blood transfusions or products derived from blood.

The flip side of considering how a person’s religious beliefs can impact care is that not everyone practices their religion in the same way; even if the NA knows something about a resident’s stated religion, it is important not to make assumptions about a given resident’s personal relationship to religion and spirituality.

Knowing something about different religions such as Christianity, Islam, Judaism, Buddhism, and Hinduism can help NAs understand their residents’ worldviews and experiences.

It can also help them when conversing with residents, and in discussing spiritually laden topics like death and dying and the meaningfulness of life. Understanding some doctrinal aspects of a resident’s religion, such as beliefs after the afterlife or the existence of the soul, can be helpful in conversing with them and tending to their emotional and spiritual needs.

Religion can be an important source of community for people. Residents have a right to practice their own religion and, when possible, to practice it with others. If a resident needs help accessing spiritual resources, religious leaders, or a community of religious practice, the NA should tell the nurse so arrangements can be made to meet the person’s full scope of human needs.

NAs should never judge a resident for their beliefs or for how they choose to practice their beliefs. NAs should never try to change a resident’s religious beliefs, push them into any kind of religious activity, discuss your own personal beliefs, or interfere with a religious practice in any way.

Race and Ethnicity

Race is a form of classifying people based on shared observable characteristics like skin color. Ethnicity refers to grouping people based on a common heritage, language, social customs, and national origins. A person’s race and ethnic background can have an impact on how they understand themselves and how they relate to other people. However, neither race nor ethnicity provide somebody with certain information. race and ethnicity should never be the basis of an assumption about a person.

Race and ethnicity can influence how a person relates to things like work and rest, and how

they speak and use language. A person’s experience as a member of a particular race or ethnicity, especially if that race or ethnicity is regularly stereotyped by dominant cultural narratives, may condition how they interact with others.

Racism occurs when a racial minority is discriminated against or treated in a one-dimensional way based on their perceived race.  Prejudice occurs when someone judges another person based on preconceived notions about a group that the person apparently belongs to. All racism is prejudice, but not all prejudice is racism.

Medical racism occurs when someone experiences a negative health outcome due to their race. Medical racism occurs at a personal level when an individual’s racism or implicit bias negatively impacts someone’s care. Medical racism occurs on a systemic level when a whole population’s health and access to medical care is negatively impacted by racism. Medical racism is still a problem in the healthcare system today^[4]. Medical racism of both kinds remains a pervasive problem in healthcare today^[5].

NAs must be careful never to adopt a racist or prejudiced attitude about any of the residents in their care. NAs should make sure to see each resident as a complex individual, and not to make any assumption about residents based on race, ethnicity, or culture.

Implicit bias

Implicit bias refers to the unintentional biases that we all carry within us as part of living in an unequal society; people are unaware of their implicit biases, even as they impact their behavior and interpersonal interactions. Somebody can be consciously committed to social justice and still hold implicit biases, or unconscious negative attitudes and judgments, that cause them to behave in discriminatory ways.

NAs can make healthcare settings more socially just by attending to their own implicit biases. When having a negative response to a resident that occupies a marginalized social position, NAs can ask themself “where is this response of mine coming from? what can I do to address these negative feelings in a way that lets me be more thoughtful and reflective?”^[6]. NAs should advocate for residents who they believe may be suffering from biased treatment.

Sexuality and Gender

Residents have a Right to be respected and affirmed in their sexuality and gender identities. This means that NAs must be equipped to respect, value, and interact in an affirming way with residents who occupy a variety of gender and sexual identities. NAs should learn something about the LGBTQ+ (lesbian, gay, bisexual, transgender, queer, and more) community so that when they care for a member of that community they can do so in a way that is affirming. This is necessary when practicing holistic, person-centered care.

“Sexuality” refers to how one experiences physical, emotional, and amorous attraction to other

people. One is considered “heterosexual” if they are exclusively attracted to members of the opposite sex, and “gay” or “homosexual” when exclusively attracted to members of the same sex. “Bisexual” and “pansexual” are both terms that indicate attraction to people of multiple or all sexes and gender-presentations.

“Gender” refers to one’s experienced sense of themselves in relation to other people and the world at large; some examples of gender identity categories are man, woman, and nonbinary, though terminology is broad and can vary from person to person.

Gender is distinct from one’s sex organs – if somebody is assigned male or female at birth because of their sexual morphology, such assignment is ultimately unimportant to how that person may come to think of their own gender; a person’s sexual morphology is especially irrelevant to anybody other than that person. Never ask a transgender person (or anybody) for details about their anatomy or comment on their anatomy.

“File:A TransGender-Symbol Plain2.png” is licensed under CC BY-SA 2.0.

“Transgender” is the term used to describe a person who does not identify with the gender they were assigned at birth. If a person discovers that they are transgender, they may decide to transition and live their life in a way that reflects their inner truth. Nobody should ever use the term “transgendered,” because because being transgender is not a disease and is not something that happens to a person, but is one aspect of who a person is.

Transitioning can be a difficult process; it is also usually joyful and affirming. NAs should support transgender residents at any stage of their transition, and always refer to residents using the language and pronouns residents choose for themselves.

Resident Rights: Dignity & Respect

Treating members of the LGBTQ+ community with dignity and respect in healthcare settings is an essential aspect of providing good holistic, person-centered care. When interacting with gay or bisexual persons, it is important to maintain the positive, accepting, and empathetic attitude that the NA adopts with all of their residents.

Sometimes, people may respond to differences in sexuality or gender in negative ways without meaning to or even realizing it, such as with feelings of annoyance or even unintentional disgust. These unconscious reactions are examples of feelings motivated by implicit bias, and everyone experiences implicit bias in some form to some degree. The important part is in how we all respond to our implicit bias – ideally, with critical self-reflection and by making sure that it doesn’t find its way into our actions and behavior.

NAs can be respectful towards LGBTQ+ people in pretty much the same ways that they respect people of different religions, ethnicities, and cultural backgrounds. NAs must respect the rights of residents to lead a life that they identify with, and one that is really theirs. NAs should do everything they can to help residents adopt a sense of ownership and agency over their circumstances. Ultimately, NAs should interact with residents in a way that always emanates from the recognition of their inherent worth as a person with a right to make their own decisions.

Changes associated with aging

The human life cycle, or the arc of olife cycleur lives from birth until death, is commonly thought of as occurring in different “stages” that connote changes in one’s physiology, psychology, and sociality. Infancy, toddler, childhood, preadolescence, and adolescence are all early stages of the human life cycle^[7].

An adolescent becomes an adult around age 18, and is then considered a young adult until about age 40. Middle adulthood generally lasts from around ages 40 until 65. Once a person is no longer in the middle adulthood stage of the life cycle, they are elderly, or in late adulthood.

Different people respond to aging in different ways. How they respond depends on factors like their health, previous life experiences, financial circumstances, education, and social support network. Some people may find that old age suits them, while others may find themselves feeling lonely, alienated, or insecure. Many people experience both.

Elderly adults will likely work less or not at all, have less income, experience diminished mobility and energy, may require frequent medical care, and may need to enter an assisted living facility or move in with younger family members.

People at this stage of life may be coping with the deaths of friends and loved ones, and may be coming to terms with their own mortality. All of these factors can contribute to decreased life satisfaction and wellbeing.

To meet their holistic needs, elderly folks may have to put extra effort into a fulfilling social life by picking up new hobbies, volunteering, and staying active in community organizations. Staying connected to others is vital, especially because growing old sometimes involves diminished social connections, and can result in feelings of loneliness and loss of meaning. When caring for older adults in long-term care facilities, NAs should encourage them to be social and engaged in community activities.

Changes in a person’s physiological systems with age

As people age, their bodies undergo changes. These changes happen to “systems” in the body, such as the nervous system or the circulatory system^[8]. A bodily system is a set of body parts and processes that play a specific role in keeping somebody healthy.

Gastrointestinal system: The gastrointestinal system refers to how a body takes in food, processes it for energy, and expels what goes unused as waste. As a person ages, their gastrointestinal system undergoes changes.

• Their sense of taste becomes less sensitive, so they may prefer foods with salt and/or sugar. Good oral hygiene and denture care can help to improve the taste of food.
• Chewing and swallowing may become more difficult (dysphagia), and the production of digestive fluids such as saliva decreases.
• The person’s body may absorb fewer nutrients from the food they eat, and the whole process of digestion will be slower. Peristalsis, or the contracting muscular movement of food through the body from esophagus through waste disposal, decreases with age, which can slow or belabor the digestive process.

Urinary system: The urinary system is responsible for filtering the blood as disposing of the waste in liquid form. As a person ages, their urinary system becomes weaker and more susceptible to infection.

• Kidneys filter blood less efficiently, which can slow urinary output and increase blood toxin levels.
• The bladder muscle weakens, so it can hold less urine.
• Urination may happen more frequently, but the bladder may not empty completely.
• Older adults are at high risk for urinary tract infections.
• Older adults have to remain well hydrated to maintain a healthy urinary system. Good hydration is essential for preventing urinary tract infections.

Reproductive system: A person’s reproductive changes as they age will depend on whether they have a penis and testes or a vagina, uterus, and ovaries. For someone with a penis and testes, normal age-related changes include…

• Enlargement of the prostate gland
• Decreased number and efficacy of sperm, and slowed sexual responsiveness.

For someone with with ovaries normal changes include…

• Decreased production of the hormones estrogen and progesterone, which leads to weakened bones and can result in more severe skeletal complications.
• Drying and thinning of the vaginal walls
• Menopause is the end of an ovulating person’s ability to reproduce, and usually occurs between ages 45 and 55.

Integumentary system: The integumentary system refers to our outer layer of protection, composed of fat and living and dead skin cells. As a person ages…

• They have less fatty tissue, which can make them feel cold and result in sagging skin.
• Wrinkles form as the skin loses elasticity, and the skin can become dryer and thinner. This may cause a resident’s skin to be particularly itchy.
• Because an elderly person’s skin can tear or puncture easily, NAs should exercise gentleness and caution when handling bandages and wound dressings.
• As a person’s hair distribution changes, perhaps losing hair on their head and acquiring it in other areas such as the face, back, and chest, they may experience a loss of identity or self-esteem. NAs should do what they can to help residents address these physical changes in the way they want, or talk about it with them in a kind and supportive manner.

Circulatory system: The circulatory system is responsible for pumping blood through the human body, which delivers oxygen and nutrients, and removes toxins and waste. As a person ages…

• A person’s heart weakens and pumps blood less efficiently.
• The combination of less efficient blood pumping with narrowed and inelastic blood vessels, also due to age, results in decreased blood flow and diminished oxygen delivery.
• Weakened blood vessels mean that an elderly person may bleed more quickly and easily, and their blood may take longer to clot.

Image by Medical Heritage Library, Inc. is licensed under CC BY-NC-SA 2.0.

Respiratory system: The respiratory system is responsible for taking in oxygen, distributing oxygen to the blood cells for distribution, and disposing of the body’s carbon dioxide. As someone ages…

• Their lungs, diaphragm, and other components of the respiratory system weaken.
• They may have more difficulty breathing and experience increased susceptibility to respiratory illness.
• Their lungs and chest muscles become weaker and decrease in capacity, and their airways lose some elasticity.
• They may experience dyspnea, or difficulty breathing.

Musculoskeletal system: The musculoskeletal system consists of muscles, bones, tendons, and ligaments; tendons and ligaments are connective tissues that keep the muscles, bones, joints, and cartilage working together. As someone ages…

• Their muscles weaken, and their bones become brittle due to decreased calcium.
• They may literally shrink due to a contraction of the vertebrae and spine, and they will lose some range of motion as joints and muscles stiffen.
• As mobility decreases, regular activity and a nutrient-rich diet are especially important. NAs should encourage residents to be active, help prevent them from falling, and support them during ambulation.

Nervous system: The nervous system is the system of nerves that conduct our movements through their connection to the brain; it includes the brain, and everything the brain performs. As a person ages…

• They lose nerve cells, and their senses may weaken or become less receptive.
• Weakened senses can result in loss of vision, hearing, smell, taste, and a diminished sensitivity to touch.
• Memory loss occurs, especially short-term and task memory, sleep patterns change, and physical reflexes may also slow.
• Dizziness can occur as a result of diminished blood flow to the brain.

Visual and auditory systems: Older adults experience changes to their ability to see and hear. As a person ages…

• Their eyes tend to dry out because of decreased tear secretion.
• Vision becomes less clear, and it can be difficult to see without adequate direct lighting.
• Older adults tend to become more far-sighted with age; someone who didn’t need glasses at all may find that they now require reading glasses.
• Our eye lenses all yellow with age, which can impact color perception and differentiation; as older adults lose color differentiation, they should be prompted to distinguish their medications by means other than color.
• The ear drum atrophies, which means it gradually becomes weaker.
• Less ear wax is produced, but it is harder and thicker than a young person’s, and so may need to be removed by a nurse or a doctor to prevent hearing obstruction.
• Residents may require hearing aids; hearing aids must be cleaned and placed in the appropriate container.

Endocrine system: The endocrine system regulates a person’s hormones. Hormones are involved in some way in most human health processes, from digesting food to regulating mood. A person’s hormones alter as they age.

• People undergo changes in the production of testosterone, estrogen, and progesterone.
• Physical stress, in the form of cortisol and other stress-related hormones, becomes more difficult for a person to process. They may have increased difficulty regulating their emotions.
• The body produces less insulin, which makes it more difficult for a person to process and metabolize sugars.

Immune system: A person’s immune system exists to clean the body of external stuff, such as microbes or viruses, some of which may be harmful to our organism. As a person ages…

• Their immune system weaken, which makes them less able to fight off infection and illness.

Feelings about changes associated with aging

Some people enjoy the aging process. However, more commonly, someone may feel anxiety, dread, or loss of overall life satisfaction as their body changes. Some of the changes listed above produce physical and emotional discomfort, and present obstacles to spending time with loved ones or engaging in activities that give joy and meaning to one’s life. An aging person may respond to these changes with frustration, depression, and even anger.

NAs should always respond to a resident’s complaints about aging with kindness, empathy, and understanding. It may also be helpful to make sure that a resident’s basic needs are always met. Ultimately the best thing nursing assistants can do is provide a listening ear, and make sure that the person has all of their basic care needs met.

Communication Skills

Communication is, at its most basic, the exchange of information. People exchange information in many ways, though most of the ways NAs will communicate is face-to-face and in person. When using verbal communication, or spoken and written communication, NAs should be as clear, direct, and kind as they can. Good communication improves patient outcomes, and makes someone feel cared for and attended to.

The ACH Online. (2014, April 24). The importance of communication in healthcare: The time is now [Video]. Youtube. https://www.youtube.com/watch?v=b7YwrHNylTg

NAs need to practice active listening, which means keeping one’s full attention on the person they are communicating with and remaining fully present in that interaction.

Someone practicing active listening will show they are engaged with their body and eyes by leaning forward and being responsive through nods and smiles; they will also use responsive phrases (“I see,” “Oh my,” “So what happened?”), and will stay on topic. It is important for residents to feel that people are interested in what they have to say.

When communicating with residents, some general strategies will be useful:

• Always listen closely, and really listen in a way that brings an awareness of the whole person to the conversation.
• When practicing active listening, paraphrasing the other’s response can be a helpful tool because it shows them you are attentive, and it can help to clarify exactly what each person means.
• Direct questions are often useful because they set an explicit subject of conversation, while an open-ended question may help begin conversation by letting the resident determine the topic. Yes/no questions should be avoided, since they tend to end rather than begin conversation.

  Never assume they can’t hear

  Always assume that a resident can hear what is said around them, even if you suspect that they cannot. Even if someone appears unconscious, they may have some degree of situational awareness. When performing care tasks the NA should always describe what they will do prior to doing it.

When conversing with residents NAs should try and include everyone present in the conversation; if an NA is conversing with Mr. Johnson and Ms. Chou, then both residents should be regular participants in the discussion; staff should never conduct conversation amongst themselves while a resident is in the room, since it will come across as indifferent and uncaring. Instead, involve residents in conversation.

When communicating information to residents, such as the steps of a task or the items on a menu, NAs should ask follow-up questions, such as “Can you tell me what we’re about to do?” or “What does poutine come with again?” to make sure the resident understands. Yes/no questions are not particularly useful for gauging someone’s understanding, because they can respond “yes” without fully understanding the topic.

Communication styles vary from person to person

Everybody has different communication styles for verbal and nonverbal communication. The way a person communicates and wants to be communicated with is shaped by one’s past experiences, their family, the environment they are in, their feelings and mood on a given day, and other things. NAs should be attentive to a resident’s tone, mood, and body language when determining how a resident would like to be communicated with on that day.

Someone’s culture can play an influential role in their communication styles. For example, the use of eye contact in communication is commonplace in some areas of the world, but in others direct eye contact can be taken as rude or abrasive.

Deference for elders is another culturally informed dimension of communication. In some cultures, young people are expected to show a high degree of respect for their elders, while other cultures may have less formal courtesy norms.

NAs should refer to residents by their last name preceded by Mr., Ms./Mrs., or Mx. (pronounced “mix”), until a resident requests or grants permission to be referred to by a different name. NAs should respect resident’s wishes on what they would like to be called, and how they would like to be communicated with.

Using touch in communication

NAs will touch residents as part of performing basic care tasks such as helping to wash, dress, or move. In addition to medical care, touch may be one way that NAs provide holistic care through comfort and emotional support.

Physical touch is an important example of interpersonal communication that varies with cultural background; it can communicate happiness, empathy, or a simple sense of presence. However, comfort levels with such touch vary. Some residents may appreciate touch on the hand, arm, or back, or may ask for a hug. Other residents may be uncomfortable with any social touch and would prefer to only be touched when necessary for care.

Asking “is it alright if I touch your hand or arm sometimes when we are speaking” is a useful step if the NA is unsure how a resident feels about casual communicabody languagetive touch. Paying attention to a resident’s body language can also provide information on their comfort with touch; if someone becomes stiff or slightly pulls away when touched, they may be communicating their discomfort using their body language.

NAs should only engage in social touch that they can tell is wanted by both parties; that means that NAs should not engage in any forms of touch that make them uncomfortable or that make the resident uncomfortable.

Some forms of touch are never appropriate, such as sitting on laps, kissing, any touch of even remotely sexual nature, or anything that appears unwelcome and unprompted.

If a resident touches a NA inappropriately, the NA should set a clear and explicit verbal boundary and make sure that the boundary is understood by the resident. If the inappropriate behavior continues, the NA should alert the RN to find a workable solution. Touch should always be an expression of a friendly and professional connection NAs have with a resident, never something that produces feelings of discomfort or unease.

Barriers to communication

NAs may experience barriers to communication in their workplace, whether between themselves and a resident or between staff members. A barrier is anything that makes communication more difficult or impossible than it would be under ideal circumstances. Some barriers to communication between NAs and residents are environmental or medical, and some barriers are psycho-social or due to a mismatch of communication styles^[9].

Environmental and medical barriers

Environmental barriers are features of one’s environment than can impact straightforward communication. For example, maybe the resident is on the other side of the room and the NA will need to move closer to have a clear conversation. Perhaps they forgot to turn their hearing aid on, or it has a low battery.

When speaking with older adults, it is helpful to stand directly in front of them, speak slowly and clearly, and make distinct mouth and facial movements. Never whisper, shout, or mumble – instead, enunciate words and speak at a clear (and reasonable) volume.

Hearing impairments

When a resident has impaired hearing, NAs may need to change the way they communicate with them.

• Never approach a hearing-impaired resident from behind. Place oneself in front of them and get their attention before speaking.
• Make sure that your own face is well-lit, and speak clearly and distinctly.
• Sometimes the NA may need to use written communication with hearing-impaired residents. When communicating with writing, it is best to use short sentences with yes/no answers and to print in large letters.
• Do not make exaggerated movements to explain something. Some gesturing is often helpful when communicating with anyone, but excessive gesturing when communicating with a person with impaired hearing can come across as condescending.
• Residents have a right to effective communication. If somebody requires an ASL interpreter in order to communicate effectively in a healthcare context, then an interpreter must be provided. When speaking to someone through an interpreter, you are still having a conversation with the person (not their interpreter); look at the person directly and maintain eye contact throughout the conversation, and refer to them by name.

Visual impairments

People with visual impairments may need specific communication strategies.

• NAs should always identify themselves to the resident, and narrate the activities they perform before and as they do them.
• Visual impairment can make someone more susceptible to falls, so maintaining good spatial awareness is key. NAs should avoid moving objects around a room unless necessary, and should tell the resident when they do.
• When entering a new space, describe the room in terms of the face of a clock; “there is a plush chair in the corner at 1 o’clock, and a group of people playing cards at a table nearby at about 9 o’clock.”
• If a resident uses eyeglasses, make sure they are clean and fit properly. Be careful and gentle when handling a resident’s eyewear

Difficulties with speaking

Sometimes a resident may be difficult to understand, whether because of the words and phrases they use or because of some medical or physical obstacle to clear speech. Communicating with people who speak in ways one is unused to can take practice, but with careful listening and good communication practices it becomes easy with time.

NAs can ask such residents to repeat themselves, or to rephrase their meaning or explain in a different way. NAs can then reflect and rephrase what the resident tells them with responses like “so what I am hearing is…” or “I think you are experiencing…, does this sound right to you?” These are strategies that grow from an attention to active listening.

Residents with speech and language disorders  may have difficulty forming words, or they may be unable to create or comprehend conventional language. A person with a speech and language disorder may use assistive technology, such as an augmented and alternative communication (AAC) device. NAs must take the time to learn the communication strategies that are most effective for residents, including the use of assistive devices.

Social barriers

Language barriers

Residents have a right to speak with someone in their own language. If a resident needs a certified interpreter to communicate, the facility is required to provide one in-person or by phone.

When an interpreter is not always necessary but the NA still needs to navigate a language barrier, they should speak slowly and as clearly as possible. They should note when the resident appears to genuinely understand as opposed to when they say they understand but still seem to experience some confusion.

NAs may need to utilize gestures, pictures, translation technology, and other ways of communicating in addition to spoken language. The NA should be patient and kind throughout the process, never condescending or frustrated.

Effective communication

NAs should be conscious of appropriate, professional, and effective ways of communicating with residents^[10].

• Avoid using slang and profanity, even if a resident engages in those things. Such language is not in line with professional communication norms and expectations.
• Avoid using clichés and platitudes, such as “I’m sure it’ll all work out” or “it’s all part of the plan.” This shows that somebody is not really interested in listening.
• Residents will need somebody to listen to their concerns, fears, and worries; NAs should be a listening ear, ask how they can support the resident, and never belittle or minimize their worries.
• Avoid responding to resident wishes or requests with “why?”, since such responses can shut down conversation or make a respondent defensive. If a resident makes a choice about how they would like to spend their time, it does not necessarily need to be scrutinized.
  • Sometimes the NA will need to ask a follow-up question in cases where a resident’s behavior may be out of the norm or indicate an underlying change; for example, refraining from taking a walk may indicate fatigue, or choosing not to socialize may indicate a sense of loneliness. When the NA notices something like this, they should frame their question in terms like “I noticed you seem low-energy today, how are you feeling?” instead of “why aren’t you sitting with your friends?”.
• Avoid yes/no questions – questions that only have yes or no answers can shut down conversation, and prevent nuance. Instead, frame questions in an open-ended way. An example may be asking “what are your favorite fruits?” rather than “do you like blackberries?”

NAs should never offer a medical opinion or give medical advice. Always defer to the nurse. It is not within the scope of the NA practice, and could be dangerous and irresponsible.

Nonverbal communication

Nonverbal communication can be a barrier to communication when someone is unaware of their body language. NAs should exercise conscious body language to show the resident that they are being listened to.

• Leave arms uncrossed
• Lean in slightly
• Look at the resident when they are speaking
• Nod one’s head to indicate interest and engagement

NAs should also pay close attention to residents’ nonverbal communication; for example, even if a resident tells you that they are comfortable, their facial expression or constant shifting may indicate that they are in pain.

The opening and closing procedure

Residents have a right to be informed about their care, every time care is provided. Performing the opening procedure and closing procedure whenever you give care is an important part of effective communication with residents, and helps protect their rights to dignity and respect.

The opening procedure involves some steps NAs should perform every time they give care, to prepare themselves and to prepare the resident. The closing procedure is a process done after giving care that involves making sure the resident is comfortable and has their needs met, and that care is documented.

Opening procedure

Do these tasks every time you give care.

1. Wash hands for at least 30 seconds. Do not shake dry. Do not touch contaminated surfaces between washing hands and giving care.
2. Assemble the equipment. Make sure that you have everything you need within easy reach.
3. Knock and pause before entering the resident’s room. This gives them a moment to prepare for an interaction.
4. Introduce yourself and verify the resident’s identity. A resident’s identity ought to be verified in multiple ways, such as by asking them their name and reading the name on their patient ID. This is to ensure that the right care is going to the correct resident.
5. Ask visitors to leave, unless the resident explicitly requests their presence.
6. Ensure privacy for the resident. This can be done by closing their door and closing the privacy curtain around their bed.
7. Explain the procedure, answer any questions, and make sure the resident understands the care they will receive.

After going through the opening procedure, NAs can proceed with their assigned care.

Closing procedure

After giving the assigned care, nursing assistants will go through the closing procedure to make sure the resident is comfortable and has everything they need before the NA leaves. After completing care, make sure to go through the following steps.

1. Position the resident comfortably in their chair or in bed.
2. Remove and discard gloves and other protective equipment, except your face mask.
3. Wash your hands.
4. Return the bed to an appropriate position, usually its lowest setting.
5. Place the signal cord/call light within easy reach.
6. Check the resident’s room and general environment for safety concerns. Make sure the resident is safe and remove potential risk factors.
7. Open the privacy curtains.
8. Care for the equipment as needed, such as rinsing measuring cups or cleaning the bedpan.
9. Wash your hands (again).
10. Invite the person’s visitors back into the room if it is appropriate.
11. Report the task to the nurse, if necessary.
12. Document all care given, the resident’s response to care, and any other relevant observations in the patient’s chart.

The steps of the closing procedure will be done at the end of every care task.

Making each step of the opening and closing procedure a habit will make good handwashing routine. Having a handwashing routine built into care tasks is an important measure towards preventing the spread of infections in the workplace.

Video by Allie Tiller is licensed under CC BY-NC 4.0

Communication on the Care Team

Good communication is essential between all members of a care team, staff, and facility^[11].

Good communication is necessary for giving high-quality care. Consistent dialogue and careful documentation amongst the care team leads to more attentive caregiving and better quality of life for residents

Good communication is essential for coordinating care because everyone needs to be on the same page about a lot of important information that they can only learn from each other, and from the resident. In some cases, good communication and documentation is also ethically and legally required. For example, care teams must hold care conferences

Regular and detailed communication between NAs and other nursing staff is necessary because they are always working together with common goals and shared responsibilities.

When communicating about care or reporting one’s observations, NAs should try and speak in terms of fact statements. Fact statements are declarations of things that are definitely true; an example of a fact is “Mx. Gupta weighs 150 pounds; she is two and a half pounds lighter than she was last week” or “Mx. Gupta usually drinks tea in the afternoon.”

An opinion is something someone thinks, and that may be true or false or a matter of personal taste. Examples of opinions are “Mx. Gupta looks like she may need to use the restroom” or “Ms. Gupta has seemed more tired than usual lately.”

Both factual and opinion observations are useful for a care team. NAs have a valuable perspective that RNs, doctors, and other medical professionals will want to take into account beyond strictly fact statements. NAs should be careful to distinguish when they are providing an opinion from when they are providing a fact.

Comprehension Questions

1) Please list the different kinds of needs discussed in Maslow’s Hierarchy of needs in their order of fundamentality, or from the bottom – up on the pyramid. After listing the need, please provide two examples of each kind of need. Think about the way that you meet these needs in your own life, and how you can meet them in others’ lives.

2) Respond to the following sentences with T (true) or F (false).

___ A person’s physical needs must be met before psychosocial can be fully met.

___ Needs listed higher on Maslow’s hierarchy do not impact the needs below them.

___ Feeling a sense of safety and belonging is not important to healthcare outcomes.

___ Feeling secure in one’s identity and social esteem are important needs.

___ Aging and moving into an assisted living or long-term care facility can make it difficult for someone to independently meet all of their psychosocial needs.

3) Is a person’s right to effective communication in their own language a physical need, a psychosocial need, or both? Why?

4) What is culture? Select the correct answer for the context.

a. A colony of growing bacteria

b. Diversity

c. Shared beliefs, attitudes, values, and behaviors in a group or subgroup

d. A person’s nationality

e. The way someone sees the world

5) What goes in to giving culturally competent care? Select all that apply.

a) Actively listening to someone and asking what they need, instead of making assumptions about them.

b) Being really good at guessing where someone is from.

c) Adopting an attitude of acceptance and nonjudgment.

d) Loving Mexican food.

e) Advocating for a person’s right to access culturally appropriate food, language services, religious services, and culturally relevant community.

6) Respond to the following sentences with T (true) or F (false).

___ A person’s religion is irrelevant to providing them with effective care.

___ Healthcare team members must be accepting of residents’ religious beliefs.

___ If you know of a superior religion, it is good to try and convert the residents in your care. They’ll be better off for it.

___ Everybody has implicit bias; the important part is to reflect on your own biases, and approach care from a place of acceptance and compassion for everyone.

___ When a transgender resident decides to transition, NAs get to decide if they will call the resident by their chosen name and gender pronouns.

___ A resident’s right to dignity and respect includes a right to equitable care, to have their identity honored, and to have their individuality cherished by the people caring for them.

7) What are some psycho-social changes commonly experienced by older adults? Select all that apply.

a. Less income due to leaving the workforce or working less

b. Increased activity levels due to more free time

c. Coping with the deaths of friends and loved ones, and reckoning with one’s own mortality

d. It becomes easier to meet one’s holistic needs by participating in the community

e. Decreased independence due to financial circumstances, losing a spouse, or moving into a family member’s home or an assisted living facility

8) What are some physical changes commonly experienced by older adults? Select all that apply.

a. Sense of taste becomes more sensitive

b. The bladder muscles weaken, which means someone may have to urinate suddenly and urgently

c. The skin becomes thinner and more fragile

d. The heart becomes stronger and pumps blood more efficiently

e. Mobility decreases and muscles weaken and bones become more brittle

f. Eyesight and hearing become less sensitive

g. The immune system becomes stronger and more capable of fighting infection

9) Respond to the following sentences with T (true) or F (false).

___ Active listening requires giving someone your full attention.

___ Yes/no questions are useful for determining whether someone understands what you’re telling them. The best question to use is “do you understand?”

___ NAs should always avoid touching a resident on the hand or shoulder during conversation. Friendly touch is never appropriate or useful during care.

___ Writing in a patient’s chart is one important form of communication.

___ Nonverbal communication usually does not provide someone with useful information.

___ Candor is an important quality to have in communication amongst the care team. Candor means that you tiptoe around difficult topics to keep everybody in a good mood.

___ Effective communication on the care team, both written and verbal, is essential to providing high-quality care.

10) Please list the steps of the opening and closing procedures.

11) You think a resident may be in pain; she is making a strained facial expressing, clenching her teeth, and clutching her shoulder. You are hurriedly tidying the resident’s space when you ask “are in pain right now?” The resident slightly smiles, shakes her head, and says “I’m fine.” You say “okay,” gather your things, and leave. What barriers to communication are present in this interaction? How could you have handled things differently?

12) What are some potential sources of anxiety for a resident in long-term care? What are some ways that anxiety presents itself? What are some strategies that you can use as a nursing assistant to communicate effectively with an anxious resident? Discuss at least three different approaches.

13) Compassion is obviously necessary in all of the healthcare team’s interactions with patients. Why is compassion necessary in a nursing assistant’s interactions with other members of the care team? How should you balance compassion and candor when communicating with your colleagues? What is the relationship between compassion and being a responsible team member (ie, showing up on time, completing your assigned tasks, asking for help)?