1. The Nursing Assistant Chapter 2, part A
Federal and state laws and agency policies combine to define the roles and functions of each health team member.
Chapter 2, part A
The Nursing Assistant

2. CARE TEAM PROVIDERS
____ Medical Social Worker (MSW)
____ Occupational Therapist (OT)
_____ Physical Therapist (PT)
_____ Physician or Doctor
_____ Registered Dietitian (RD)
_____ Speech-Language Pathologist (SLP)
_____ Activities Director
HOW THEY WORK
A. Diagnoses disease or disability & prescribes treatment
B. Administers therapy in the form of heat, cold, massage, ultrasound, electricity, & exercise to muscles, bones, & joints.
C. Teaches exercises to help the resident improve or overcome speech problems.
D. Trains residents to compensate for disabililities during ADLs & other activities.
E. Creates diets for residents with special needs.
F. Helps residents get support services, such as counseling.
G. Helps residents socialize & stay active.

3. How they work together to provide nursing care
Nursing Care Team Providers
How they work together to provide nursing care
A. The care team revolves around this person & his or her condition, treatment, & progress.
B. Performs delegated tasks, such as taking vital signs, providing personal care, & reporting observations to other team members.
C. Licensed professional who has completed 1 -2 years of education & is able to administer medications & give treatments.
D. Licensed professional who has completed years of education who coordinates, manages, & provides skilled nursing care.
___ Registered Nurse (RN)
___ Licensed Practical Nurse (LPN/LVN)
___ Nursing Assistant (NA or CNA)
___ Resident

4. HISTORY & CURRENT TRENDS
Until the 1980s, training was not required by law.
Before the 1980s, team nursing was common.
Primary nursing was common in the 1980s.
Home care increased during the 1980s.
Efforts to reduce health care costs include:
Hospital closings
Hospital mergers
Health care systems
Managed care
Staffing mix
Patient-focused care
With team nursing, care was assigned according to each person’s needs and condition. It also depended on the staff member’s education and experiences.
With primary nursing, registered nurses (RNs) planned and gave care. Many hospitals only hired RNs. Nursing homes relied on nursing assistants for resident care.
Prospective payment systems limit health care payments. Patients are discharged earlier than in the past. Often they are still quite ill and need home care.

5. Each state has a nurse practice act which: Defines RN and LPN/LVN
FEDERAL AND STATE LAWS
Each state has a nurse practice act which:
Defines RN and LPN/LVN
Some acts also define nursing assistant.
Describes the scope of practice for RNs and LPNs/LVNs
Describes education and licensing requirements for RNs and LPNs/LVNs
Protects the public
from persons practicing nursing without a license
Allows for denying, revoking, and suspending a nursing license
Nurse practice acts protect the public’s welfare and safety.
The law protects the public from unsafe nurses.

6. Role of nursing assistants
Some nurse practice acts also regulate nursing assistant roles, functions, education, and certification requirements.
In other states, there are separate laws for nursing assistants.
If you do something beyond the legal limits of your role, you could be practicing nursing without a license.
Legal and advisory opinions about nursing assistants are based on the state’s nurse practice act.
State laws about nursing assistant roles and functions are based on the state’s nurse practice act.
Nursing assistants must be able to function with reasonable skill and safety.
Nursing assistants can have their certification, license, or registration denied, revoked, or suspended.

7. Omnibus
Budget
Reconciliation
Act of 1987
OBRA

8. X Remember: OBRA, NOT OPRA, OBRA Omnibus Budget Reconciliation Act

9. OBRA
Its purpose is to improve the quality of life of nursing center residents.
This law sets minimum training and competency evaluation requirements for nursing assistants.
Each state must have a nursing assistant training and competency evaluation program (NATCEP).
The nursing assistant training and competency evaluation program must be successfully completed by nursing assistants working in nursing centers, hospital long-term care units, and home care agencies receiving medicare funds.
OBRA (Omnibus Budget Reconciliation Act):
law originally passed in 1987; includes minimum standards for nursing assistant training, staffing requirements, resident assessment instructions, and information on rights for residents

10. OBRA requires at least 75 hours of instruction.
The training program
OBRA requires at least 75 hours of instruction.
National minimum requirement: 75
Illinois requires 80
There must be at least 16 hours of supervised practical training.
National minimum requirement:16
Illinois requires 40
Competency evaluation
The competency evaluation has a written test and a skills test.
OBRA allows at least 3 attempts to successfully complete the evaluation.
Some states require more than 75 hours. State of Illinois requires 80 hours of theory and 40 hours of clinical practice.
Students perform nursing care and procedures on another person during the practical training.
A nurse supervises this practical training.
The written test has multiple-choice questions.
The number of questions varies from state to state.
The skills test involves performing nursing skills.
There is a fee for the evaluation.
If you work in a nursing center, the employer pays this fee.

11. Nursing assistant training programs require student practice in a
laboratory setting

12. Performance reviews also are required.
Retraining and a new competency evaluation program are required for nursing assistants who have not worked for 24 months.
Agencies covered under OBRA must provide 12 hours of educational programs to nursing assistants every year.
Performance reviews also are required.
States can require:
A new competency evaluation
Both retraining and a new competency evaluation
These requirements help ensure that nursing assistants have current knowledge and skills to give safe, effective care.
Each state NATCEP (Nurse Aide Training and Competency Evaluation Program) must meet OBRA (Omnibus Budget Reconciliation Act of 1987) requirements.
If you want to work in another state, contact the state agency responsible for NATCEPs and the nursing assistant registry.

13. OBRA requires a nursing assistant registry in each state.
It is an official record or listing of persons who have successfully completed that state’s state-approved NATCEP.
The registry has information about each nursing assistant.
All information stays in the registry for at least 5 years.
Any agency can access registry information.
You receive a copy of your registry information.
You can correct wrong information.
NATCEP (Nurse Aide Training and Competency Evaluation Program):
part of OBRA that sets minimum requirements for nursing assistants for training and testing.
After completion: CNA (certified nursing assistant/aide)
LNA-licensed nursing assistant / aide
RNA- registered nursing assistant/ aide

14. To protect persons from harm, you must understand: What you can do
What you cannot do
The legal limits of your role
This is also called scope of practice.
The National Council of State Boards of Nursing (NCSBN) calls it range of functions.
Licensed nurses supervise your work.
You assist them in giving care.
The following are a list of tasks that are generally considered within the scope of a CNA practice:
A nursing task is the nursing care or a nursing function, procedure, activity, or work that can be delegated to nursing assistants when it does not require an RN’s professional knowledge or judgment.
Review the rules in Box 2-1 on p. 16 in the textbook.

15. Serving meal trays and feeding residents
Helping residents dress and undress
Helping residents with mouth care, bathing, shaving, & backrubs
Keeping living areas clean & neat; making beds
Assisting residents to move around safely
Taking vital signs
Caring for supplies & equipment
Describe the nursing assistant’s role

16. Before you perform a nursing task, make sure that:
Your state allows nursing assistants to do so
It is in your job description
You have the necessary education & training
A nurse is available to answer questions and to supervise you
Review the contents of Box 2-2 on p. 17 in the textbook.
Review the Focus on Long-Term Care and Home Care: Roles and Responsibilities Box on p. 17 in the textbook.
OBRA defines the basic range of functions for nursing assistants. All NATCEPs include those functions. Some states allow other functions.
Review the contents of Box 2-3 on p. 17 in the textbook.

17. You must know what you can do in the state in which you are working.
State laws and rules limit nursing assistant functions.
No agency or nurse can expand your range of functions beyond what is allowed by your state’s laws and rules.
“The nurse told me to do it” won’t stand up in a court of law.

18. A job description describes what the agency expects you to do
Identifies educational requirements
Always obtain a written job description when you apply for a job.
Ask questions about it during your job interview.
Before accepting a job:
Tell the employer about functions you did not learn
Advise the employer of functions you cannot do for moral or religious reasons
Clearly understand what is expected

19. Do not take a job that requires you to:
Act beyond the legal limits of your role
Function beyond your training limits
Perform acts that are against your morals or religion
You need to know:
What you can safely do
The things you should never do
Your job description
The ethical and legal aspects of your role
No one can force you to do something beyond the legal limits of your role.

20. The person must be competent to perform a task in a given situation.
Delegate means to authorize another person to perform a nursing task in a certain situation.
The person must be competent to perform a task in a given situation.
Nurse practice acts give nurses:
Certain responsibilities
Legal authority to perform nursing actions
A responsibility is the duty or obligation to perform some act or function.

21. RNs can delegate nursing tasks to LPNs/LVNs and nursing assistants.
In some states, LPNs/LVNs can delegate tasks to nursing assistants.
Delegation decisions must protect the person’s health and safety.
The delegating nurse is legally accountable for the nursing task.
The RN is accountable for all nursing care.
Nursing assistants cannot delegate.
RNs and licensed practical nurses (LPNs)/licensed vocational nurses (LVNs) can only delegate:
Tasks within their scope of practice
Tasks that are in the nursing assistant’s job description
The delegating nurse must make sure that the task was completed safely and correctly.

22. Nursing care planning process
Assessment: getting info
Diagnosis: id problems & needs
Planning: id goal of care
Implementa-tion: steps in care plan
Evaluation: observations, unexpected outcomes, & changes
Nursing care
planning process

23. Care plan - should identify all of the following:
Resident’s health & physical condition
Resident’s diagnosis & treatment
Resident’s goals & expectations

24. Chain of command
Describes the line of authority & helps ensure that residents receive proper care.
Also protects employees & employer from liability (being held responsible for harming someone else).
If a resident is harmed by a CNA who is doing what was in the care plan & according to policy & procedure, the CNA may not be held responsible.
If a resident is harmed by a CNA who is not following the care plan, he could be held responsible.
To make delegation decisions, the nurse follows a process.
The person’s needs, the nursing task, and the staff member doing the task must fit.
Delegation decisions must result in the best care for the person.
The nurse may face serious legal problems for a bad decision.
If you perform a task that places the person at risk, you also can face serious legal problems.
Review the Focus on Long-Term Care and Home Care: Communication Box on p. 23 in the textbook.
Steps delegation: RN will assess resident- ---plan : is it safe to do it-if safe ( proceed) / if no ( stopped)-communicate to CNA (explain in details what need to be done)-CNA decide her if comfortable to do it (go or don’t do it)----complete the task----supervision---evaluation

25. Which of the following statements is true of the chain of command?
It describes the line of authority in a facility.
It is the same as the care team.
It details the survey process for a facility.
Nursing assistants are at the top of the chain.
Liability is a legal term that means
the line of authority in a facility.
ignoring a resident’s call light.
someone who can be held responsible for harming someone else.
a task that a person was not trained for.

26. Why is it important not to do tasks that are not assigned to you?
You may be assigned more work if you perform additional tasks.
You may put yourself or someone else in danger.
You may need to pay for additional training.
You may have to start arriving at work earlier.

27. What is one reason that other members of the care team will show great interest in the work that you do?
They may not trust you.
You will be working under the authority of other’s licenses.
They may not have much respect for nursing assistants.
To avoid having to pay you if you make a mistake.

28. TRUE or FALSE
___ The purpose of the care plan is to give suggestions for care, which the CNA can customize for each resident.
___ Activities that are not listed on the care plan should not be performed.
___ Care planning does not involve the resident’s input or feelings.
___ Sometimes even simple observations that CNAs make about residents are very important.

29. Nursing process
Descriptions
A. Deciding if goals were met
B. Getting information about the resident & reviewing this information
C. Identifying health problems & resident needs
D. Putting the plan into action
E. Resident’s needs are met
F. Setting goals & creating a care plan
___Assessment
___Diagnosis
___Planning
___Implementatio n
____Evaluation
___Goal

30. The right circumstances –Is the resident stable?
The NCSBN’s Five Rights of Delegation is another way to view the delegation process.
The right task - Is there a match between the resident’s needs & the CNA’s skills, abilities, & experience?
The right circumstances –Is the resident stable?
The right person – Is the CNA the right person for the job?
The right directions and communication – Can the nurse give appropriate direction & communication?
The right supervision – Is the nurse available for to give supervision, support, & help that the CNA needs?
Can the task be delegated?
What are the person’s physical, mental, emotional, and spiritual needs at this time?
Do you have the training and experience to safely perform the task for this person?
Did the nurse give clear directions?
Is the nurse available to guide, direct, and evaluate the care you give?

31. Your role in delegation
You must protect the person from harm.
You either agree or refuse to do a delegated task.
Accepting a task
When you agree to perform a task, you are responsible for your own actions.
You must complete the task safely.
Report to the nurse what you did and the observations you made.
Asking questions and asking for help when you need it will help you to provide better care.
Use the Five Rights of Delegation in Box 2-4 on p. 24 in the textbook to decide to agree or refuse to do a delegated task.
Describe the Residents for Whom You Will Care: It is more important to understand each individual in your care than to understand the entire population
Reasons to refuse task: beyond your legal limits, not your job description,
Not prepared to perform task, task could harm pt, don’t know how to use supplies, not ethical/legal, against agency policy,

32. Refuse to perform a task when:
The task is beyond the legal limits of your role.
The task is not in your job description.
You were not prepared to perform the task.
The task could harm the person.
The person’s condition has changed.
You do not know how to use the supplies or equipment.
Directions are not ethical or legal.
Directions are against agency policies.
Directions are unclear or incomplete.
A nurse is not available for supervision.
You have the right to say “no.”

33. Things a CNA should never do.
*Memorize this list for the certification exam
Never take oral or telephone orders from doctors. (Find a nurse promptly.)
Never perform sterile procedures. (You can assist by opening packages, but can’t perform sterile procedures)
Never tell a person or family a diagnosis or treatment plan (doctor’s responsibility, nurse can clarify what the doctor said).

34. Never diagnose or prescribe treatments or drugs for anyone (only doctors can diagnose & prescribe)
Never supervise other nursing assistants or assistive personnel (this is a nurse’s responsibility).
Never ignore an order or request to do something you can’t do (You must inform the nurse promptly why you can’t do it. You cannot neglect the person’s care)

35. Never insert or remove tubes or objects into body openings.
Never, ever, ever GIVE MEDICATIONS: not orally, not rectally, not rectally or vaginally or by injection. Not by application to skin either.
Never insert or remove tubes or objects into body openings.
No catheters into a person’s bladder
No feeding tube into a person’s nose or esophagus
No breathing tubes into a person’s trachea
No blood draws or IV starts
No enemas or suppositories or rectal tubes unless specified in your job description & legal in your state

36. Never, ever ignore an order or a request to do something.
Tell the nurse about your concerns.
You must have sound reasons for refusing a task.
Failing to provide needed care is a violation of law, know as neglect.
Share your concerns about a delegated task with the nurse. The nurse can:
Answer your questions
Demonstrate the task
Show you how to use supplies and equipment
Help you as needed
Observe you while you perform the task
Check on you often
Arrange for needed training

37. But that’s for our next unit...