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

2. Introduction
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
Federal and state laws and agency policies combine to define the roles and functions of each health team member.
Everyone must protect patients and residents from harm.
Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

3. History and Current Trends
Prior to the 1980s
Training was not required by law.
Team nursing was common.
During the 1980s
Primary nursing was common.
Home care increased.
Nursing assistants (often called nurse’s aides) have helped nurses with basic nursing care for decades.
Until the 1980s nurses gave on-the-job training to nursing assistants. Some hospitals, nursing centers, and schools offered nursing assistant courses.
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 hired only RNs. Nursing homes relied on nursing assistants for resident care.
Home care increased due to prospective payment systems’ limit on health care payments. Patients were discharged earlier than in the past. Often they were still quite ill and needed home care.
Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

4. History and Current Trends (cont’d)
Efforts to reduce health care costs include:
Hospital closings
Hospital mergers
Health care systems
Managed care
Staffing mix
Patient-focused care
Many hospitals do not make enough money to stay open.
Mergers happen to share resources and avoid the same costly services (e.g., one hospital will offer heart surgery while the other serves women and children).
Agencies join together as one provider of care.
Insurers have contracts with doctors, hospitals, and health care systems for reduced rates.
Hospitals hire RNs, LPNs/LVNs, and nursing assistants.
Services are moved from departments to the bedside. Staff members are cross-trained to perform the basic skills of other health team members, which results in faster service by fewer staff members.
Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

5. 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
Allows for denying, revoking, and suspending a nursing license
The U.S. Congress makes federal laws for all 50 states to follow. State legislatures make state laws.
You must know the federal and state laws that affect your work.
Nurse practice acts protect the public’s welfare and safety.
The law protects the public from unsafe nurses.
Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

6. Federal and State Laws (cont’d)
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.
A nursing assistant must be able to function with reasonable skill and safety.
A nursing assistant can have his or her certification, license, or registration denied, revoked, or suspended.
Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

7. 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.
Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

8. 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.
Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

9. 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
Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

10. 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.
Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

11. 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.
Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

12. Roles and Responsibilities
Scope of practice/Range of functions
Legal limits of your role
Varies among states and agencies
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.
Nurse practice acts, OBRA, state laws, and legal advisory opinions direct what you can do.
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.
Box 3-3 on p. 26 in the Textbook describes the limits of your role—the tasks that you should never do.
Know what you can do in the state in which you are working. State laws and rules limit nursing assistant functions.
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.
Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

13. Roles and Responsibilities (cont’d)
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 p. 26 in the Textbook.
Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

14. Roles and Responsibilities (cont’d)
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.
Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

15. Roles and Responsibilities (cont’d)
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.
Sometimes jobs are threatened for refusing to follow a nurse’s orders. Often staff obey out of fear.
Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

16. 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.
Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

17. 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.
Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

18. 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.
Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

19. 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?
Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

20. 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.
Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

21. 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.
Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

22. 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
Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.