Chapter 2: The nursing assistant and the care team

Learning objectives Describe how the care team works together to provide care Explain the nursing assistant’s role Explain professionalism in regards to the nurse assistant Describe proper personal grooming Differentiate between chain of command and scope of practice Discuss the resident care plan in regards to its purpose Describe the nursing process Describe the Five Rights of Delegation Demonstrate how to manage time and assignments

Members of the care team Nursing Assistant (NA) or Certified Nursing Assistant (CNA) Registered Nurse (RN) Licensed Practical Nurse (LPN)/Licensed Vocational Nurse (LVN) Physician or doctor (MD – medical doctor or DO – doctor of osteopathy) Physical Therapist (PT) Occupational Therapist (OT) Speech-Language Pathologist (SLP) Registered Dietitian (RDT) Medical Social Worker (MSW) Activities Director Resident and Resident’s Family Residents have diverse needs and problems, so there is a diverse care team of professionals to help care for them. Let’s look at the members of the care team: The nursing assistant (NA) performs assigned tasks like taking vital signs or assisting with activities of daily living (ADLs). NAs must have at least 75 hours of training and NAs spend more time with residents than other team members, so they are the “eyes and ears” of the team. Observing and reporting changes in the resident’s condition or abilities is a very important role of the NA. The registered nurse (RN) coordinates, manages, and provides skilled nursing care in the long-term care setting. A registered nurse also assigns tasks and supervises daily care of residents by nursing assistants RNs are licensed professionals with two- to four-year nursing degrees who have passed a licensing examination. Additionally, RNs may seek additional education in a specialty area. The licensed practical nurse (sometimes called the licensed vocational nurse) administers medications and gives treatments. LPNs may also supervise nursing assistants’ daily care of residents LPNs have one to two years of education and have passed a licensing examination. A doctor’s role on the health team is to diagnose disease or disability, and to prescribe treatment. Doctors have received a bachelor’s degree and then completed four years of medical school. Upon completion of medical school, doctors often attend specialized training programs. A physical therapist (PT) evaluates a person and develops a treatment plan to increase movement, improve circulation, promote healing, reduce pain, prevent disability, and help the resident regain or maintain mobility. The treatment plan can include various methods of treatment. A PT has completed a three-year doctoral program (generally after completed a bachelor’s degree), and must pass both state and national licensing exams prior to practicing physical therapy. An occupational therapist (OT) helps residents learn to adapt to disabilities, often training them to perform ADLs. This may include the use of assistive or adaptive devices. OTs assess residents’ needs and plan treatment accordingly. Occupational Therapists have a minimum of a master’s degree and have to pass a national certification examination in order to practice. Most also must be licensed in their state, as well. Speech-language pathologists (SLP) are often referred to as speech therapists. These professionals identify communication disorders, address factors involved in recovery, and develop a plan of care to meet recovery goals. They can also evaluate a resident’s ability to swallow food and drink. SLPs must have a master’s degree to practice and most states require they be licensed or certified, as well. A registered dietician (RDT) creates diets for residents with special needs in order to improve health and manage illness. RDTs have completed a bachelor’s degree and may also have completed a postgraduate degree. Most states require that RDTs be licensed or certified. A medical social worker (MSW) determines residents’ needs and helps them get support services they may need. The resident may need help setting up appointments and getting transportation to and from these appointments. He or she may need clothing or other personal items. The MSW helps with these kinds of things. Often times, MSWs hold a master’s degree in social work. The activities director plans activities for residents to help them socialize and stay physically and mentally active. Doing so helps increase the residents’ quality of life and prevents further physical or mental decline. Activities directors may have a bachelor’s degree, associates degree, or may have qualifying work experience. Another title given to activities directors is “recreational therapist” depending on education and work experience. The resident and his or her family are important members of the care team. Residents have the right to make decisions about their care, and family members may be involved in this decision making process. The care team is resident-focused in that the care team revolves around the resident and his or her condition, treatment, and progress. Without the resident, there is no care team.

Nursing assistant’s role Performing assigned nursing tasks Providing personal care or assisting with self-care The NA has two primary roles in the care of residents: 1) Performing assigned nursing tasks and 2) Providing personal care or assisting with self-care. Assigned nursing tasks may include taking vital signs. Providing personal care includes helping residents with toileting needs, assisting residents to move around safely, keeping residents’ living areas neat and clean, encouraging residents to eat and drink, caring for supplies and equipment, helping residents dress, making beds, giving backrubs, and helping residents with mouth care. Nursing assistants are not allowed to insert or remove tubes, change sterile dressings, or give tube feedings. Only nurse assistants who have undergone training programs in medication administration are allowed to give medications. This is only permitted in some states. Usually the nurse administers medications. While caring for residents, nurse assistants are responsible for observing and reporting any changes in the resident’s condition. Another responsibility of the nurse assistant is to chart, or document, important information about the resident. The nurse assistant is an important member of the health team as he or she spends the most time with the residents.

Professionalism and professional behavior Professional vs. Personal Professionalism and the nurse assistant: Compassionate Honest Tactful Conscientious Dependable Respectful Unprejudiced Tolerant Professional means having to do with work, while personal refers to life outside a job and includes family, friends, and home life. Professionalism refers to proper workplace behavior and includes being compassionate, honest, tactful, conscientious, dependable, respectful, unprejudiced, and tolerant. To be compassionate means being caring, concerned, considerate, and understanding. The NA is both empathetic (identifying with the feelings of others) and sympathetic (sharing in the feelings and difficulties of others). NAs must also be honest; they must tell the truth. Residents need to be able to trust NAs and employers rely on NAs to be truthful when reporting and recording observations. Being tactful means showing sensitivity and having a sense of what is appropriate when interacting with others. NAs must be conscientious. To be conscientious means to be alert, observant, accurate, and responsible. Other members of the care team make important decisions based on the data collected by the NA (vital signs, for example). This data must be accurately obtained and recorded in order to look out for the resident’s well-being. NAs must be dependable. This means keeping commitments: arriving to work on time, skillfully doing assigned tasks, avoiding too many absences, and helping peers when needed. Being respectful means honoring other people’s individuality (age, religion, culture, feelings, practices, and beliefs). NAs must be respectful of both residents and other members of the care team. NAs will work with people from many different backgrounds. Quality care must be provided to all residents, regardless of age, gender, sexual orientation, religion, race, ethnicity, or condition. Being tolerant means respecting others’ beliefs and practices and not judging them. NAs should provide quality care to a resident even if the NA doesn’t agree with what the resident or his or her family does or has done. NAs are expected to act professionally, providing quality care to residents in their care.

Personal Grooming habits Do: Bathe or shower daily using deodorant or antiperspirant Brush teeth frequently Keep hair clean, neatly brushed, and tied back Keep facial hair short, clean, and neat Dress neatly in a clean, pressed uniform Wear comfortable, clean, closed-toed shoes Keep fingernails short, smooth, and clean Wear little or no make-up Don’t: Wear perfume or cologne Wear a uniform that is Too tight or too baggy Torn or stained Too revealing Wear large jewelry Have visible tattoos and body piercings Wear artificial nails, extenders, or overlays Regular personal grooming makes a person feel good about himself or herself, and affects how confident residents feel about the care a person gives. Professional nursing assistants have the following personal grooming habits: Do bathe or shower daily using deodorant or antiperspirant. Do brush your teeth frequently and floss as needed. Do keep your hair clean and neatly brushed or combed. Long hair should be tied back. Do keep facial hair short, clean, and neat. Dress neatly in a clean and pressed uniform and be sure to wear comfortable, clean, closed-toed shoes. Be sure to keep fingernails short, smooth, and clean. When looking at the palm-side of your hand, you should not be able to see your fingernails. If you can, they are too long and should be cut. Wear little to no make-up. You should not wear cologne or perfume as some residents are intolerant of some odors. Do not wear a uniform that is too tight or too baggy, is torn or stained, or is too revealing (like short skirts, low-cut blouses, or see-through fabrics). Don’t wear large jewelry, except a water-proof watch). Jewelry can harbor bacteria and spread infection. Do not have visible tattoos and body piercings and don’t wear artificial nails, extenders, or overlays as these can spread infections. These are some basic personal grooming habits for the professional nurse assistant. Be sure to follow any specific rules your facility has regarding appearance.

Chain of command and scope of practice Liability Scope of practice Nursing assistants are given instructions by a nurse. The nurse is following the instructions of the physician or other member of the care team. This is the chain of command and describes a line of authority making sure residents get proper healthcare and that employees and employers are protected from liability. Liability is a legal term that means someone can be held responsible for harming someone else. Here is an example: Let’s say that a resident is hurt while being cared for by the nursing assistant. The NA followed both the care plan and the facility’s policy and procedure. The NA could not be held liable (or responsible) for the resident’s injury. If the NA did something that was not on the resident’s care plan or did not follow the facility’s policy or procedure, he or she could be held responsible for the resident’s injury. Just as it is important for the NA to understand the chain of command at his or her workplace, it is important for the NA to understand his or her scope of practice. While NAs must be certified in most states, they are not licensed. NAs work under the authority of the licenses of other healthcare professionals. For this reason, these professionals will show great interest in what nursing assistants do and how they do it. Each licensed professional works with his or her scope of practice which defines the tasks that he or she is legally allowed to do and how to do them correctly. Laws and regulations about what nursing assistants can and cannot do vary from state to state. However, there are several tasks that are always outside the scope of practice of a nursing assistant. NAs do not: administer medications Honor a request to do something outside the scope of practice, not listed on the care plan, or not on the assignment sheet Perform procedures that require sterile technique Diagnose illnesses or prescribe treatments or medications Tell the resident or the faily the diagnosis or the medical treatment plan As previously discussed, each state has defined the scope of practice of the nurse assistant. Additionally, facilities may have additional tasks which they do not allow NAs to perform. Nurse assistants must follow the chain of command and work within their scope of practice to provide quality care and avoid legal implications.

Resident care plan The nursing care plan is developed and individualized by the nurse or doctor for each resident to help them achieve the goals of care. The care plan should involve input from the resident and/or his or her family. The care plan lists the tasks that team members must perform. Activities not on the care plan should not be performed. Factors considered when formulating a care plan include the resident’s health and physical condition, diagnosis and treatment, and goals or expectations. It is important that nurse assistants report any change in the patient’s condition. It may be necessary to revise the care plan in response to these changes. Also, NAs may be asked to come to care planning meetings as they have a lot of valuable information that will help in the care planning process.

The nursing process Assessment Diagnosis Planning Implementation Evaluation To communicate with other healthcare team members and to help plan and evaluate the resident’s care needs, nurses use the nursing process (Assessment, diagnosis, planning, implementation, and evaluation). Assessment involves getting information about the resident from many sources including medical history, physical assessment, and environment, and reviewing this information. Diagnosis involves identifying the health problems after looking at all the resident’s needs. The nurse then makes a plan, setting goals and creating a care plan to meet the resident’s needs. The plan is then implemented and evaluated to determine whether the goals are being met. The nursing process constantly changes as new information is collected and reported. The nursing assistant’s accurate observations and reports are an important part of planning and evaluating care.

The five rights of delegation Right Task Right Circumstance Right Person Right Direction/Communication Right Supervision/Evaluation To delegate is to authorize another person to perform a nursing task in a certain situation. It transfers responsibility for that task from one person to another. While the nurse is ultimately responsible for the care of those under his or her care, it would be impossible for the nurse to complete all required tasks for each resident. Just like this cartoon depicts, it is important that the nurse delegates some responsibilities to the NA. There are five things that must be true, or “right”, for a task to be delegated to the NA. The first, “right task”, means that the task must both meet the residents needs and the nursing assistant’s skills, abilities, and experience. The “right circumstances” involve the stability of the resident – taking into account the resident’s physical, mental, emotional, and spiritual needs at the time the task is to be completed. Given the circumstances, is it reasonable to delegate the task to a NA? Along with this, making sure that the NA is the “right person” to complete the job is important. Does the NA have the right training and experience to safely perform the task for the resident? Have you been provided the “Right Direction/Communication”? The nurse should tell you what to do and when to do it. He or she should also tell you what observations to make and when to report on them. The nurse should give you the opportunity to ask questions, should you have them. Finally, “right supervision/evaluation” means that the nurse will be available to guide you as you perform the task and will evaluate the care that you give. He or she should be available to demonstrate the task and answer any questions you may have. The nurse should also assess the resident’s response to the task and evaluate how well you performed the task. The nurse should provide feedback to you regarding what you did well and how to improve your work. This helps you learn and improve the care you provide. Don’t be afraid to tell the nurse if you are concerned that you lack the skills to perform a task or feel it is outside of your scope of practice. Making sure that the task being delegated to you meets these five “rights” of delegation can assure that you are working within your scope of practice to provide great care for your residents.

Time and assignment management Plan ahead Prioritize Make a schedule Combine activities Get help Nursing assistants will have many jobs delegated to them and it will be important that you develop strong time management skills to help you manage your assignment each day. Here are some tips to helping you manage your time effectively: Plan ahead - Even though planning may seem to take up some of your valuable time, it is an important step to help you make the best use of your time and assure that all assigned tasks are completed. The nurse will make the NA’s work assignments based on the needs of the residents and the availability of staff. Taking the time to sit down and list everything that must be done on a shift for the assigned residents will help your shift go more smoothly and assure each resident in your care is receiving the care that he or she needs. Prioritize – Once the planning for the shift has been completed, the NA should decide (sometimes with the help of the nurse) which tasks are most important and complete those first. Make a schedule – This, too, may be part of the planning process for the NA. Some NAs find it helpful to write out the hours of the day and fill in what needs to be done and when. Combine activities – Whenever possible, complete two tasks at one time. This might mean talking to a resident about whether or not he or she would like to take part in that day’s activities while you are helping to dress them in the morning. Doing so would avoid the NA having to seek out the resident to ask him or her later in the day which would save time (be more efficient). Get help – It is impossible for a NA to do everything. NAs will need help to ensure the residents receive safe, quality care. Do not be afraid to ask for help! Using these tips will help you to provide great care to residents in an efficient manner. Many of these tips may be helpful in your personal life, too.

Review Members of the care team Nursing assistant’s role Professionalism and professional behavior Personal grooming habits Chain of command and scope of practice Resident care plan The nursing process The five rights of delegation Time and assignment management This chapter discussed the members of the care team and the nurse assistant’s role within that team. The term professionalism was discussed and professional behavior was outlined. Personal grooming habits required by policy at most healthcare institutions were described. Differentiation between the chain of command and scope of practice was made. The nursing process and the resident care plan were described and the five rights of delegation were defined. Finally, tips for time and assignment management were shared.