1. Chapter 3
The Nursing Assistant

2. Federal and State Laws (cont’d)
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).
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.

3. Federal and State Laws (cont’d)
The training program
OBRA requires at least 75 hours of instruction.
Includes classroom and at least 16 hours of supervised practical training
Provides the knowledge and skills needed to give basic nursing care
Competency evaluation
Includes 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.
Students perform tasks on another person in a laboratory or clinical setting 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.

4. Federal and State Laws (cont’d)
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.
OBRA requires a nursing assistant registry in each state.
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

5. Federal and State Laws (cont’d)
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.
States can require new competency evaluation or both re-training and a new competency evaluation.
These requirements help ensure that nursing assistants have current knowledge and skills to give safe, effective care.
Each state’s 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.

6. Certification Each State’s NATCEP must meet OBRA requirements.
Nursing assistants can have their certification (licenses, registration) denied, revoked, or suspended.
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.
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).
Review Box 3-1 on p. 25 in the Textbook for reasons for losing certification, a license, or registration.

7. Delegation
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.
RNs are responsible for supervising LPNs/LVNs and nursing assistants—only RNs can carry out this responsibility.

8. Delegation (cont’d) 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.
Delegation must protect health and safety.
Nursing assistants cannot delegate.
RNs and licensed practical nurses (LPNs)/licensed vocational nurses (LVNs):
Can only delegate tasks within their scope of practice
Can only delegate tasks that are in the nursing assistant’s job description
Must make sure the task was completed safely and correctly
Are responsible for the delegated task; the delegating nurse is legally accountable
The RN is accountable for all nursing care.
Nursing assistants cannot delegate any task to other nursing assistants. They may ask someone to help but they cannot ask or tell someone to do their work.

9. Delegation (cont’d)
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.
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. 30 in the Textbook.

10. Delegation (cont’d)
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
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?

11. Delegation (cont’d) 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.
Use the Five Rights of Delegation in Box 3-5 on p. 32 in the Textbook to decide to agree or refuse to do a delegated task.
What you do or fail to do can harm the person. Ask for help when you are unsure or have questions about a task.

12. Delegation (cont’d) 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.
You have the right to say “no.”
Sometimes refusing to follow the nurse’s directions is your right and duty.
Use common sense. This protects you and the person.
Ask yourself if what you are doing is safe for the person.

13. Delegation (cont’d)
Never ignore an order or a request to do something.
Tell the nurse about your concerns.
You must have sound reasons for refusing a task.
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

14. Chapter 4
Ethics and Laws

15. Seatwork
Among your tablemates, please describe the difference between ethics and laws.
Ethics is concerned with what you should and should not do.
The law is concerned with what you can and cannot do.
A law is a rule that is made by a government body.
Laws are enforced by government bodies.
Ethics deal with morals and what is the right thing to do.
Professional groups have code of ethics.

16. Introduction
The following serve to protect patients and residents from harm:
Nurse practice acts (State & Federal)
Your training and job description
Safe delegation
A complex set of rules and standards of conduct
The ethical and legal aspects of care are formed by a complex set of rules and standards of conduct.

17. Ethical Aspects
Ethics is knowledge of what is right conduct and wrong conduct.
Morals are involved.
It deals with choices or judgments about what should or should not be done.
Ethical behavior involves not being prejudiced or biased.
Ethical problems involve making choices.
Professional groups have codes of ethics.
An ethical person:
Behaves and acts in the right way
Does not cause a person harm
To be prejudiced or biased means to make judgments and have views before knowing the facts.
Do not judge the person by your values and standards.
Do not avoid persons whose standards and values differ from your own.
You must decide what is the right thing to do.
The ANA and the NFLPN have code of ethics for RNS and LPNs/LVNs. Review the contents of Box 4-1 on p. 35 in the Textbook.

18. Ethical Aspects (cont’d)
Boundaries
Professional boundaries separate helpful behaviors from behaviors that are not helpful. The following can occur when you are over-involved or under-involved with the person.
Boundary crossing—A brief act or behavior outside of the helpful zone
Boundary violation—An act or behavior that meets your needs, not the person’s needs
Professional sexual misconduct—An act, behavior, or comment that is sexual in nature
A boundary limits or separates something.
As a nursing assistant, professional boundaries are formed as you help patients, residents, and families.
Boundary crossing: the act may be thoughtless or something you did not mean to do.
Boundary violation: the act or behavior is not ethical; it violates the code of conduct. Examples include abuse, giving a lot of information about yourself, keeping secrets with the person.
Professional sexual misconduct is present even if the person consents or makes the first move.

19. Ethical Aspects (cont’d)
Boundary signs are acts, behaviors, or thoughts that warn of a boundary crossing or violation.
Be alert to these signs.
Some violations and some types of sexual misconduct also are crimes.
To maintain professional boundaries:
Review the code of conduct in Box 4-1 on p. 35 in the Textbook.
Follow the rules in Box 4-2 on p. 36 in the Textbook.
Review the contents of Box 4-3 on p. 36 in the Textbook.
Review the Focus on Communication: Professional Boundaries Box on p. 36 in the Textbook.

20. Legal Aspects Ethics Laws What you should or should not do
Tell you what you can and cannot do
A law is a rule of conduct made by a government body.
Criminal—generally offenses against the public and society
Civil—concerned with relationships between people
The U.S. and state legislatures make laws.
Enforced by the government, laws protect the public welfare.
An act that violates a criminal law is called a crime.
A person found guilty of a crime is fined or sent to prison.
Civil laws are those that involve contracts and nursing practice.
A person found guilty of breaking a civil law usually has to pay a sum of money to the injured person.

21. Legal Aspects (cont’d)
Torts
A wrong committed against a person or the person’s property
Part of civil law
Unintentional—harm was not intended
Intentional—harm was intended

22. Legal Aspects (cont’d)
Unintentional tort
Negligence
Malpractice is negligence by a professional person.
Intentional tort
Defamation—injuring a person’s name and reputation by making false statements
Libel—made in print
Slander—made orally
Unintentional tort: the negligent person did not act in a reasonable and careful manner. As a result, a person or the person’s property was harmed.
The person causing the harm did not intend or mean to cause harm.
What you do or do not do can lead to a lawsuit if harm results to the person or property of another.
You are legally responsible (liable) for your own actions.
Intentional tort: the act is done on purpose and is meant to be harmful.
Never make false statements about a patient, resident, family member, co-worker, or any other person.
Examples of defamation are implying or suggesting a person uses drugs, saying a person is insane or mentally ill, or implying or suggesting a person steals money from the staff.

23. Legal Aspects (cont’d)
Intentional torts (cont’d)
False imprisonment—unlawful restraint or restriction of a person’s freedom of movement
Invasion of privacy—private affairs exposed or made public without consent
Health Insurance Portability and Accountability Act of (HIPAA)
Fraud—saying or doing something to trick, fool, or deceive a person
Assault and battery—may result in both civil and criminal charges
Examples of false imprisonment are threatening to restrain a person, restraining a person, or preventing a person from leaving the agency.
You must treat the person with respect and ensure privacy.
Only staff involved in the person’s care should see, handle, or examine his or her body.
Review the contents of Box 4-4 on p. 38 in the Textbook.
HIPAA protects the privacy and security of a person’s health information. Failure to follow HIPAA rules can result in fines, penalties, and criminal action including jail time.
Fraud is telling a person or family that you are a nurse, so is giving wrong or incomplete information on a job application.
Assault is intentionally attempting or threatening to touch a person’s body without consent and battery is actually touching a person’s body without his or her consent.
Consent is the important factor in assault and battery. The person has the right to withdraw consent at any time.

24. Legal Aspects (cont’d)
Informed consent
Consent is informed when the person clearly understands:
Reason for treatment, procedure, or care measure
What will be done
How it will be done
Who will do it
The expected outcomes
Other treatment, procedure, or care options
The effects of not having the treatment, procedure, or care measure
A person has the right to decide what will be done to his or her body and who can touch his or her body.
The doctor is responsible for informing the person about all aspects of treatment.
A responsible party may give informed consent for a person unable to do so. This can be a wife, husband, parent, daughter, son, or legal representative.

25. Legal Aspects (cont’d)
Wills
You can ethically and legally witness the signing of a will.
You can refuse to witness the signing of a will.
You must politely refuse to prepare a will.
Know your agency’s policy before you agree to witness a will.
If you have questions, ask the nurse.
A will is a legal document of how a person wants property distributed after death.
Do not witness the signing of a will if you are named in the will.
If you are a witness, be prepared to testify that the person:
Was of sound mind when the will was signed
Stated that the document was his or her last will
If you witness a will, tell the nurse.

26. Reporting Abuse Elements of abuse Willful infliction of injury
Unreasonable confinement
Intimidation
Punishment
Depriving the person (or the person’s caregiver) of the goods or services needed to attain or maintain well-being
Involuntary seclusion
Abuse is the intentional mistreatment or harm of another person.
Abuse causes physical harm, pain, or mental anguish.

27. Reporting Abuse (cont’d)
Abuse is a crime.
It can occur at home or in a health care agency.
All persons must be protected including those in a coma.
The abuser is usually a family member or caregiver.
Both men and women are abusers.
Both men and women are abused.
Many states, accrediting agencies, and OBRA do not allow agencies to employ persons who were convicted of abuse, neglect, or mistreatment.
The abuser can be a friend, neighbor, landlord, or other person.
Before hiring a person:
The agency must thoroughly check the applicant’s work history.
All references are checked.
Efforts must be made to find out about any criminal records.
The agency checks the nursing assistant registry for findings of abuse, neglect, or mistreatment and of mis-using or stealing a person’s property.

28. Reporting Abuse (cont’d)
Vulnerable adults
Persons 18 years old or older who have disabilities or conditions that make them at risk to be wounded, attacked, or damaged
They have problems caring for or protecting themselves due to:
A mental, emotional, physical, or developmental disability
Brain damage
Changes from aging
Patients and residents, regardless of age, are considered vulnerable.
Older persons and children are at risk for abuse.
Review the Focus on Long-Term Care and Home Care: Vulnerable Adults Box on p. 40 in the Textbook.

29. Reporting Abuse (cont’d)
Elder abuse—any knowing, intentional, or negligent act by a caregiver or any other person to an older adult
Forms of elder abuse
Physical abuse
Neglect
Verbal abuse
Involuntary seclusion
Emotional or mental abuse
Sexual abuse
Abandonment
Financial exploitation or misappropriation
Federal and state laws require the reporting of elder abuse.
A negligent act causes harm or serious risk of harm.
Review the signs of elder abuse in Box 4-5 on p. 41 in the Textbook.
If abuse is suspected, it must be reported.
If you suspect abuse, discuss the matter and your observations with the nurse. Give as many details as possible.
Review the contents of Box 4-6 on p. 41 in the Textbook.
Review the Focus on Long-Term Care and Home Care: Elder Abuse Box on p. 42 in the Textbook.

30. Reporting Abuse (cont’d)
Child abuse and neglect
May involve the following:
A child 18 years old or younger
Any recent act or failure to act on the part of a parent or caregiver
The act or failure to act results in death, serious physical or emotional harm, sexual abuse, or exploitation.
The act or failure to act presents a likely or immediate risk for harm.
Child abuse and neglect occurs at every social level: low-, middle-, and high-income families. The abuser’s education level may be low to high.
The abuser is often a household member: parent, a parent’s partner, brother or sister, nanny.
Usually an abuser is someone the family knows.
Risk factors include stress, family crisis (divorce, unemployment, moving, poverty, crowded living conditions), drug or alcohol abuse, abuser history of being abused as a child, discipline beliefs that include physical punishment, lack of emotional attachment to the child, a child with birth defects or chronic illness, a child with personality or behaviors that the abuser considers “different” or not acceptable, unrealistic expectations for the child’s behavior or performance, families that move often and do not have family or friends nearby.

31. Reporting Abuse (cont’d)
Types of child abuse and neglect
Physical abuse
Physical or emotional neglect
Sexual abuse
Rape or sexual assault
Molestation
Incest
Child pornography
Child prostitution
Emotional abuse
Substance abuse
Abandonment
Child abuse and neglect has many forms. Often more than one type is present.
Physical abuse is injuring the child on purpose.
Physical neglect means depriving the child of food, clothing, shelter, and medical care. Emotional neglect is not meeting the child’s need for affection and attention.
Sexual abuse is using, persuading, or forcing a child to engage in sexual conduct.
Emotional abuse is injuring the child mentally.
Substance abuse is part of child abuse and neglect in some states. It involves: exposing a child to the making, selling, and or distributing of a controlled substance and any equipment and related activities, the selling, distributing, or giving drugs or alcohol to a child, using a controlled substance by a caregiver that impairs his or her ability to adequately care for the child.
Abandonment is when a parent’s identity or whereabouts are unknown.

32. Reporting Abuse (cont’d)
Report any changes in the child’s body or behavior.
Child and parent behaviors may signal a problem.
The child may be quiet and withdrawn.
The child may fear adults.
Sometimes children are afraid to go home.
Sudden behavior changes are common.
Bed-wetting, thumb-sucking, loss of appetite, poor grades, running away
Some children attempt suicide.
Review the contents of Box 4-7 on p. 43 in the Textbook.
The health team must be alert for signs and symptoms of child abuse.

33. Reporting Abuse (cont’d)
Child abuse is complex.
Parents give different stories about what happened.
Frequent emergency room visits are common.
All states require the reporting of suspected child abuse.
If you suspect child abuse, share your concerns with the nurse.
Give as much detail as you can.
Parents blame injuries on play accidents or other children.
You must be alert for signs and symptoms of child abuse.
All states require reporting of suspected child abuse. However, someone should not be falsely accused.
Share your concerns with the nurse. The nurse contacts health team members and child protection agencies as needed.

34. Reporting Abuse (cont’d)
Domestic abuse (domestic violence) occurs in relationships.
One partner has power and control over the other through abuse.
Abuse may be physical, sexual, verbal, economic, or social.
Usually more than one type of abuse is present.
Patients and residents can suffer from domestic abuse.
State laws vary about reporting domestic abuse.
If you suspect domestic abuse, share your concerns with the nurse.
Domestic abuse is also called domestic violence, intimate partner abuse, partner abuse, and spousal abuse.
Domestic abuse is a safety issue.
The victim often hides the abuse. He or she may protect the abuser.
The health team has an ethical duty to give information about safety and community resources.
Review the Focus on Long-Term Care and Home Care: Domestic Abuse Box on p. 44 in the Textbook.