Ch 3 the nurse assistant

Chapter 3
The Nursing Assistant
Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

• To protect patients and residents from harm, you need to
know:
• What you can and cannot do
• Your legal limits
• The following shape your work:
• Laws
• Job descriptions
• The person’s condition
• The amount of supervision you need
Introduction
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History and Current Trends
• Prior to the 1980s
• Training was not required by law.
• Team nursing was common
• care was assigned according to each person’s needs and condition.
• depended on the staff member’s education and experiences.
• nurses gave on-the-job training to nursing assistants.
• Some hospitals, nursing centers, and schools offered nursing assistant
courses
• During the 1980s
• Primary nursing was common - registered nurses (RNs) planned and
gave care
• Home care increased due to prospective payment systems’ limit on
health care payments resulting in still ill patients going home.
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History and Current Trends
• Efforts to reduce health care costs include:
• Hospital closings – many didn’t make enough to stay open
• Hospital mergers – to share resources between specialty hospitals
• Health care systems – created as agencies join as single provider
• Managed care – Insurers have contracts with doctors, hospitals
• Staffing mix – move to mix of RNs, LPNs and NAs
• Patient-focused care – services moved from department to bedside,
and many staff cross-trained to perform basic skills of other
members.
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Federal and State Laws
• Each state has a nurse practice act that:
• Defines RN and LPN/LVN
• Some acts also define nursing assistants.
• 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 or unsafe professionals
• Allows for denying, revoking, and suspending a nursing license
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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.
• A nursing assistant must be able to function with reasonable skill
and safety
• If you do something beyond the legal limits of your role, you could
be practicing nursing without a license.
• A nurse aide can have his or her certification, license or registration
denied, revoked, or suspended.
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Federal Laws
• The Omnibus Budget Reconciliation Act of 1987 (OBRA) is a
federal law.
• 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).
• Nursing assistants working in nursing centers, hospital long-term care
units, and home care agencies receiving Medicare funds must
successfully complete a training program.
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Nurse Aide Training Programs
• OBRA requires:
• at least 75 hours of instruction.
• Includes classroom, skills laboratory & at least 16 hours of
supervised practical training
• Provides the knowledge and skills needed to give basic nursing care
• Competency evaluation
• Includes a multiple choice written test and a skills test
• OBRA allows at least 3 attempts to successfully complete the
evaluation.
• If employed by an LTC, employer pays evaluation fee.
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Nursing Assistant Registry
• Official record or listing of persons who have successfully completed
that state’s 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.
• Registry information includes:
• Full name, including maiden name and any married names
• Last known home address
• Registry number and date of expiration
• Date of birth
• Last known employer, date hired, and date employment ended
• Date the competency evaluation was passed
• Information about findings of abuse, neglect, or dishonest use of property

Other OBRA requirements
• 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.
• Each State’s NATCEP must meet OBRA requirements
• If you want to work in another state, contact the state agency
responsible for NATCEPs and the nursing assistant registry.

Certification
• Each state has its own competency evaluation review
program.
• After successfully completing your state’s NATCEP, you
have the title used in your state (CNA, LNA, RNA).
• To work in another state you must meet that state’s
NATCEP requirements:
• Apply to the state agency responsible for NATCEPs and the
nursing assistant registry.
• Your application is reviewed.
• Certification (a license, registration) is granted if requirements
are met.

Roles and Responsibilities
A nursing task is the nursing care or nursing function, procedure, activity, or
work that can be delegated to nursing assistants when the professional
knowledge or judgment of an RN is not required.
•Scope of practice/Range of functions
• Legal limits of your role
• Varies among states and agencies
• An agency can further limit what you can do, so can a nurse based
on the person’s needs.
• No agency or nurse can expand your range of functions beyond
what your state’s laws and rules allow.
• Protects persons from harm
•Licensed nurses supervise your work.
• You assist them in giving care.
• You perform nursing tasks.
• Before performing a task, make sure it is allowed by your state, it is
in your job description, you have the necessary education and
training, and a nurse is available to supervise and answer questions.

Nursing Assistant Standards
• OBRA defines a basic range of functions.
• All NATCEPs include these functions.
• NATCEPs prepare nursing assistants to meet the standards.
• Some states allow other functions. Review the contents of Box 3-4 on
page 26 in the textbook.
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• Job description
• Describes what the agency expects you to do
• States 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.
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• Do not take a job that requires you to:
• Act beyond the legal limits of your role
• Function beyond your training limits
• No one can force you to do something beyond the legal limits of
your role, or threaten your job if you refuse.
• 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

Delegation
• Delegate means to authorize another person to perform a
nursing task in a certain 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.
• RNs are responsible for supervising LPNs/LVNs and nursing assistants
—only RNs can carry out this responsibility.
• Delegation is one responsibility of the RN
• The person must be competent to perform a task in a given situation.

Delegation
• Who can delegate
• RNs can delegate nursing tasks to LPNs/LVNs and nursing
assistants.
• In some states, LPNs/LVNs can delegate tasks to nursing
assistants.
• RN and LPN can only delegate tasks within their scope of
practice
• Tasks must be within the NA’s job description
• The delegating nurse is legally accountable
• Delegation must protect health and safety.
• Nursing assistants cannot delegate, but may ask for help.
• RNs are accountable for all nursing care.
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Steps of Delegation
• The National Council of State Boards of Nursing
(NCSBN) describes four steps in the delegation
process.
• Step 1—Assess and plan is done by the nurse.
• Step 2—Communication involves the nurse and you.
• Step 3—Surveillance and supervision; the nurse observes
the care you give.
• Step 4—Evaluation and feedback is done by the nurse.
• 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.

Delegation
• The NCSBN’s Five Rights of Delegation is another
way to view the delegation process.
• The right task
• The right circumstances
• The right person
• The right directions and communication
• The right supervision
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Five Rights of Delegation
• Questions to Ask:
• 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?
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NA’s Role in Delegation
• Use the Five Rights of Delegation to agree or refuse a task
• 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.
• You must ask for help when you are unsure or have questions about a
task delegated to you.
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Delegation – The NA’s right to say No
• Sometimes refusing to follow the nurse’s directions is your right and duty
• Refusing a task
• 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.

Delegation
• Never ignore an order or a request to do something.
• Share your concerns about a delegated task with the nurse.
• You must have sound reasons for refusing a task.
• 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

Ch 3 the nurse assistant

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