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Chapter 1

The Nursing Assistant Working in Long-Term Care

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Resident-Focused Care

Your focus is the resident—the person needing care. You must provide quality care and promote the

person’s quality of life and independence.• Independence means not relying on or requiring care

from others.

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Long-Term Care Centers

Long-term care centers provide health care to persons who cannot care for themselves at home but do not need hospital care.

Board and care homes (residential care facilities) provide rooms, meals, and laundry to a few independent residents in a home-like setting.

Assisted living residences (ALRs) provide housing, personal care, support services, health care, and activities in a home-like setting.

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Nursing Centers

Nursing centers (nursing facility [NF], nursing home) provide health care and nursing care to persons who need regular or continuous care. Licensed nurses are required. Skilled nursing facilities (SNFs) provide health care and

nursing care for residents who have many or severe health problems or who need rehabilitation.

Purposes and goals include:

• Promoting physical and mental health

• Treating chronic illness

• Preventing communicable diseases

• Providing rehabilitation or restorative care

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Nursing Center Organizational Structure

Nursing center organization Nursing centers are owned by an individual, a

corporation, or county health departments. Each center has an administrator.

• The department directors report to the administrator.

By law, nursing centers must have a medical director.

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Nursing Service Organization

Nursing service The director of nursing (DON) is responsible for

the entire nursing staff. Nurse managers (usually registered nurses

[RNs]) assist the DON. Staff RNs report to the charge nurse. Licensed practical nurses (LPNs)/licensed

vocational nurses (LVNs) report to staff RNs or to the charge nurse.

You report to the nurse supervising your work. Nursing education staff (staff development) is part

of nursing science.

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The Nursing Team

The nursing team involves those who provide nursing care. RNs, LPNs/LVNs, and nursing assistants

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The Interdisciplinary Health Care Team

Involves the many health care workers whose skills and knowledge focus on the person’s total care The overall goal is quality resident care. Coordinated care is needed. An RN leads the team.

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Paying for Health Care

Private insurance is bought by individuals and families.

Group insurance is bought by groups or organizations for individuals.

Medicare is a federal health insurance program for persons 65 years of age or older. Part A Part B

Medicaid is a health care payment program sponsored by the federal government and operated by the states.

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Prospective Means Before Care

Prospective payment systems Diagnosis-related groups (DRGs) are for hospital

costs. Resource utilization groups (RUGs) are for SNF

payments. Case mix groups (CMGs) are used for

rehabilitation centers. Managed care limits:

• The choice of where to go for health care

• The care that doctors provide

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11

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12

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13

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14

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15

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16

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17

Meeting Standards

Standards for nursing centers are set by: Federal and state governments Accrediting agencies

A center must meet standards for: Licensure (issued by the state) Certification Accreditation

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The Survey Process & Your Role

The survey process: Surveys are done to see if the center meets set

standards. You must:

• Provide quality care

• Protect the person’s rights

• Provide for the person’s and your own safety

• Help keep the center clean and safe

• Conduct yourself in a professional manner

• Have good work ethics

• Follow center policies and procedures

• Answer questions honestly and completely

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Nursing Assistant Duties

To protect residents from harm, you need to know:What you can and cannot doWhat is right conduct and wrong conductYour legal limits

Your work is shaped by:LawsJob descriptionsThe person’s conditionThe amount of supervision you need

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History and Current Trends

Until the 1980s, nursing assistant 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 were made to reduce health care costs.

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Federal and State Laws

You must know the state and federal laws that affect your work.

Each state has a nurse practice act that: Defines RN and LPN/LVN 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 revoking or suspending a nurse’s

license

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Nurse Practice Act and Nursing Assistants

Nursing assistants A state’s nurse practice act is used to decide what nursing

assistants can do. The Omnibus Budget Reconciliation Act of 1987

(OBRA) applies to all states. It sets minimum training and competency evaluation

requirements for nursing assistants. It requires each state to have a nursing assistant training

and competency evaluation program (NATCEP). The training program

• OBRA requires at least 75 hours of instruction.

• There must be 16 hours of supervised practical training.

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OBRA Basics

Competency evaluation The competency evaluation has a written test and a skills test. The written test has multiple choice questions. The skills test involves performing nursing skills.

The nursing assistant registry is an official record of persons who have successfully completed a state-approved NATCEP.

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.

Other OBRA requirements Retraining and a new competency evaluation program for

nursing assistants who have not worked for 24 months 12 hours of educational programs for nursing assistants every

year Performance reviews

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Certification

After successfully completing your state’s NATCEP, you have the title used in your state. Certified nursing assistant (CNA) or certified nurse

aide (CNA)Licensed nursing assistant (LNA) Registered nurse aide (RNA)

Nursing assistants can have their certification (licenses, registration) denied, revoked, or suspended.

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Working in Another State

To work in another state, you must meet that state’s registry requirements.

To do so, contact the state agency responsible for NATCEPs and the nursing assistant registry.

Then apply to the state agency to be a CNA (LNA, RNA).

Your application is reviewed to see if you meet the state’s requirements.

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Roles and Responsibilities

The following direct what you can do: Nurse practice acts OBRA State laws Legal and advisory opinions

To protect persons from harm, you must understand: What you can do What you cannot do The legal limits of your role

• In some states, this is called scope of practice.

• The National Council of State Boards of Nursing (NCSBN) calls it range of functions.

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Roles and Responsibilities (Cont’d)

Licensed nurses supervise your work. You assist in giving care. You also perform nursing tasks. 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 and training. A nurse is available to answer questions and

supervise you.

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Nursing Assistant Standards

OBRA defines the basic range of functions for nursing assistants.

All NATCEPs include those functions. Some states allow other functions.

NATCEPs also prepare nursing assistants to meet those standards.

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Job Description

The job description: Is a list of responsibilities the center expects you

to perform It also states educational requirements

Always request a written job description when you apply for a job.

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

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Know Your Limits

No one can force you to do something beyond the legal limits of your role.

You must understand: Your roles and responsibilities The functions you can safely perform The things you should never do Your job description The ethical and legal aspects of your role

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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. Who can delegate?

RNs can delegate tasks to LPNs/LVNs and nursing assistants.

In some states, LPNs/LVNs can delegate tasks to nursing assistants.

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The Delegation Process

The National Council of State Boards of Nursing (NCSBN) describes the delegation process in four steps.

Assess and plan: The nurse needs to understand the person’s need.

Communication: The nurse must provide clear and complete directions.

Surveillance and supervision: The nurse must make sure that you complete the task correctly.

Evaluation and feedback: The nurse decides if the delegation was successful.

The Five Rights of Delegation (according to the NCSBN) The right task The right circumstances The right person The right directions and communication The right supervision

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Accepting a Task

When you agree to perform a task: You are responsible for your own actions. You must complete the task safely. You must ask for help when you are unsure or

have questions about a task. You must report to the nurse what you did and the

observations you made.

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Refusing a Task

You should 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 center policies. Directions are unclear or incomplete. A nurse is not available for supervision.

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Quality of Life

Nursing center care is always focused on the resident.

Residents should be allowed to do as much for themselves as safely possible.

The work you do is important for the person’s quality of life.

Your current training is just the start of a lifetime of learning and possibilities.

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