Unit 2; On the Job: Being a Nursing Assistant

Terms in this set (67)

Each discipline requires a specified course of study. Most require state licensing or certification from a professional association. Requirements vary from state to state for some disciplines.

Patient - The most important member of the team. The patient has input into the planning and implementation of care. The family may participate if the patient gives permission or if the patient is unable to participate.

Physician - Licensed to diagnose and treat disease and prescribe medications. Many specialty areas require additional education.

Clinical Nurse Specialist (CNS) - An advanced-practice registered nurse whose care focuses on a very specific patient population (e.g., medical, surgical, diabetic, geriatric, etc.).

Nurse Practitioner (NP) - A registered nurse with advanced education and experience that enables the NP to diagnose and manage common illnesses, either independently or as part of a team. A nurse practitioner can prescribe medications in most states.

Physician Assistant (PA) - A professional who is licensed to practice medicine only with physician supervision. PAs conduct physical exams, order and interpret tests, assist in surgery, and can write prescriptions in most states. PAs are educated in the medical model and their activities are designed to complement physician practice.

Registered Nurse (RN) - Licensed to make assessments and plan, implement, and evaluate nursing care. Supervises other nursing staff. Many specialty areas within nursing require additional education.

Licensed Practical Nurse (LPN or LVN) - Licensed to provide direct patient care under the supervision of a registered nurse. Called licensed vocational nurse in Texas and California.

Nursing Assistant - Has completed a state-approved course, has passed a competency examination, and is certified to provide direct patient care under the supervision of a licensed nurse.

Nutrition Assistant (Feeding Assistant) - After completing an approved class, may assist stable, long-term care facility residents with intake of food and fluids, under the direction of a licensed nurse.

Medication Aide (MA) - A certified nursing assistant who has taken additional classes in medication administration and passed a state examination. Allowed to give medications under the supervision of a licensed nurse. About 30 states permit medication aides to practice in various health care settings.

Restorative Assistant (RNA) - A certified nursing assistant who has additional education in restorative nursing care. Assists patients to attain and maintain their highest level of function, and prevents physical deformities.
Nursing assistants must know the scope of their duties and the laws governing their practice. Each state identifies the duties and responsibilities of the assistant, and defines the education and level of competency required for safe practice.

In 1987, Congress passed a federal law that regulates the education and certification of nursing assistants. That law is called the Omnibus Budget Reconciliation Act (OBRA). OBRA established the minimum requirements for nursing assistant programs. All persons working as nursing assistants must complete a competency evaluation program or approved course. The education of nursing assistants is under the jurisdiction of each state, guided by federal regulations.

The National Council of State Boards of Nursing, Inc., developed the Nurse Aide Training and Competency Evaluation Program (NATCEP). NATCEP meets the requirements of OBRA, and serves as a guide for registering and awarding credentials to nursing assistants. NATCEP lists the skills to be achieved. Programs may exceed these minimums.

The nursing assistant class must include a minimum of 75 hours of theory and practice. Some states require 80 to 175 program hours in written or oral and clinical skills in several areas:
- Basic nursing skills, including infection control
- Basic restorative services
- Mental health and social service needs
- Personal care skills
- Resident rights and good communication
- Safety and emergency care

Other rules that affect nursing assistant practice require:
- Successful completion of a competency evaluation program.
Assistants who have completed the program have at least three opportunities to pass the state test.
- Completion of a new program or retesting by nursing assistants who have not given nursing care for pay for a continuous 24-month period.
- Continuing education (12 to 24 hours per year, in some states).

Become familiar with the rules for nursing assistant practice in your state and facility and be sure you meet the requirements. In some states and facilities, you may be required to take special classes before being allowed to work on the nursing unit. For example, your facility may require you to complete a cardiopulmonary resuscitation (CPR) class. Some states require additional classes to learn about abuse of elderly and disabled persons.
For many years, health care workers based their practice on "whatever worked," including intuition, education, and past experience. Scientific evidence and research were largely nonexistent. The lack of research led to home remedies, unqualified caregivers, treatments and cures that were not always effective, and treatments that were harmful in some cases. Over time, the nursing community realized that professional practice must be validated and confirmed by scientific evidence.

Evidence-based practice (EBP) is an approach that guides decision-making by identifying evidence for a treatment or particular way of doing things, then rating that practice according to the strength of the evidence.
This approach opposes the use of tradition and rules of thumb. With EBP, workers consider individual patient variables when selecting approaches to patient care. The goal of EBP is to improve patient outcomes by eliminating scientifically unsound, unsafe, and risky practices. Research must be done and solid evidence of effectiveness must be present for a method to be included in EBP. The EBP approach encourages professionals to use the strongest and best evidence possible when making clinical decisions. EBP involves developing guidelines for best practices based on the strength of the evidence instead of tradition, gut feelings, or rules of thumb (estimation). Professionals also use EBP for developing procedures, practices, and guidelines, and for educating health care workers. This results in safe, cost-effective patient care. The information and procedures you are learning in your nursing assistant class have been proven valid and effective, based on the strength of the available evidence.
Before delegating a task, the nurse must decide if delegation is appropriate. Appropriate delegation assures that:
- The nursing assistant is permitted to perform the procedure in the facility. The nursing assistant has been taught to perform the procedure correctly. If asked, the assistant can demonstrate the procedure safely and efficiently.
- The patient does not need frequent nursing assessments during the procedure.
- The nurse believes the patient's response to the procedure is reasonably predictable. In the nurse's opinion, the nursing assistant will obtain the same or similar results from performing the procedure as an RN would.
- The nurse is certain that delegating the activity to a nursing assistant is not against the law.

The National Council of State Boards of Nursing has developed a guide called the "Five Rights of Delegation." Nurses use this list to help them delegate correctly. Reading this list will help you learn if a delegation is appropriate. The rights are:
- Right Task—the task is one that can legally be done by a nursing assistant who has been taught the proper way to do the procedure. Further, your instructor or other licensed nurse must have checked your competency in the procedure and approved you to perform it on patients. You must be permitted to perform the procedure according to your state law and facility policy.
- Right Circumstances—the nursing assistant understands the purpose of the procedure, can perform it safely, and has the right supplies or equipment to perform the procedure safely.
- Right Person—the right person delegates the right task to the right nursing assistant, to be performed on the right patient.
- Right Direction/Communication—the nurse delegating the activity has given complete instructions, has described the procedure clearly, and has identified the limits (if any) and expected outcome(s) of the procedure. Always ask for directions if you do not understand your assignment.
- Right Supervision—the nurse delegating the activity has answered the nursing assistant's questions and is available to manage changes in the patient's condition. The nursing assistant reports completion of the task and the patient's response to the nurse who delegated the activity.

In some situations, delegating even simple activities is inappropriate. For example, the nursing assistant routinely takes the vital signs of stable patients. However, assigning a nursing assistant to take the vital signs of an unstable patient may be an inappropriate delegation. In this situation, the patient needs the assessment skills of a licensed nurse. Do not feel offended if the nurse takes the vital signs or performs other patient care duties in a situation like this.
As you can see, delegating activities is a serious matter for nurses. When you accept the responsibility for a delegated task, you are responsible for your own actions. If you think that performing a procedure is unsafe for the patient, discuss your feelings with the RN. Report your observations about the patient's condition, and be prepared to explain why you are uncomfortable about doing the procedure. Ask for help, if necessary.

You may refuse a delegation if you believe that a procedure is not within your legal scope of practice, if you have not been taught and approved to perform it, or if you believe that the activity will harm the patient. If you are unsure how to carry out a procedure, inform the nurse. Do not feel embarrassed. It is better to ask for help than to make an error and injure a patient. Likewise, if you do not understand the instructions, or do not have the proper supplies, you may also refuse until the problem has been addressed. However, you must explain the reason for your refusal to the RN. He or she can probably resolve your concerns, enabling you to safely complete the activity. Do not refuse because you do not have time, or because the procedure is unpleasant.

Good communication is the key to successful delegation and patient safety. Be honest, tactful, and sensitive. If honest communications are ineffective, you can use the chain of command to address the problem with the next person in line. If you are assigned to a task, your supervisor assumes that you will do it. Never ignore an assignment. If you cannot complete the activity, discuss the situation with your supervisor.
Successful time management is a key to nursing assistant success. You cannot master time management skills in the classroom. However, you can practice and use good organizational skills in the skills lab and clinical portions of your class until they become automatic. This will translate to good organization on the nursing unit. Mastering good organization and time management skills helps you work more efficiently, and reduces stress. Once mastered, organizational skills become a part of you, and you will not have to think about them. A bonus is that these skills are also very useful at home and in your personal life.

Time is a borrowed commodity. Once used, it is gone and cannot be replaced or reclaimed. You can only manage yourself in relation to time. Each day begins with 86,400 seconds, 1440 minutes, or 24 hours. This equals 168 hours each week.
If you work an 8-hour shift, you have:
- 28,800 seconds or 480 minutes in which to get your work done each day.
If you work a 12-hour shift, you have:
- 43,200 seconds or 600 minutes in which to get your work done each day.

The total time available for getting your work done is set by your employer. You can only control how you use that time. Cutting corners, skipping breaks, and working longer hours are not good techniques for managing time, and may cause ethical and legal problems for you. At best, managing time in this manner is stressful. At worst, it is dangerous. You manage the time available. It does not manage you. Do this by working smarter, not harder.
If you do not manage your time, others will do it for you. This can be both difficult and stressful. Making rounds is an important part of your time management strategy. Making regular rounds will save you many trips up and down the hallway, and give you a more complete picture of patient needs. Patients and their families will feel confident and secure in your ability. Setting priorities and focusing on efficiency are key assets in developing good time management skills. Avoid losing your focus. Ensuring quality care and patient safety are your top priorities. Perfecting good organization and time management skills will make a difference in your personal life and the care you give.
- Establish and develop a systematic daily routine for things.
-- Make rounds as soon as possible after report to identify patient needs and problems. Meet immediate needs during this round, such as assisting with toileting.
-- Develop your plan for each patient while making rounds.
- Practice good communication skills with patients and families while making rounds; this will save you time and prevent them from calling you to the room later.
Let them know you are on top of things. Ask questions and obtain patient input on the plan you are mentally formulating.
-- Stop to visit briefly with concerned family members. Do not wait for them to seek you out. This may seem like a time waster, but it promotes satisfaction, gains support, and may end up saving you time. Offer simple information to families. For example, "Your mother ate
a good breakfast today," "The night nurse said your father had a restful night," or "Your auntie really enjoyed her visit from the church members yesterday."
-- Families usually know the patient well. They may offer important information about the patient. Do not be timid about asking for their opinion. For example, "Does he seem stronger to you?"
-- Avoid becoming defensive if family members express concerns about patient conditions. Report concerns, observations, and needs to the nurse after you have made rounds on all your patients. Listen to what patients have to say. Tell them what you will do about their concern, and give them a follow-up time if needed, such as, "I will let you know tomorrow." Thank them for sharing their concerns. Keep the nurse informed.
- Determine which patients need frequent monitoring.
-- Monitoring is simple oversight, such as looking in on or speaking with a patient, taking or reviewing vital signs, watching for new problems and changes in condition, and addressing known problems.
Develop a personal plan for organizing your time by following these suggestions:
- Plan and organize your work. Be sure the plan is realistic.
-- Write down your plan; make a new "to do" list every day. Putting the plan in writing is important.
- List your main goals for the day. Your goals will help ensure that the most important tasks are done. Review each item on your list and ask yourself it makes the best use of your time.
-- Goals without deadlines are dreams. Set realistic and achievable deadlines.
-- Everything designated as a top priority must be completed immediately.
-- Next-level priorities must be done a few minutes after top priorities are finished.
- Schedule your breaks into the plan. Take breaks at the assigned times. These are important to reduce stress and prevent injury. Avoid overloading yourself. Avoid taking work with you on your breaks.
- Be flexible. Expect the unexpected. Accept that you may have to change your plan if conditions and patient needs change.
-- Accept that your priorities may change.
-- Identify "no options" activities. These are things that must be done during your shift, without exception.
- Identify events that must be done by specific times, and distinguish them from things you can take care of later.
- Identify the what, where, when, why, who, and how of your priorities; this will help you devise a strategy and plan for completing your priority items.
- You control the timing of events for which you are responsible.
- Emergencies, new admissions, and patient or family demands are imposed on you by others, and you cannot control them. Accept this as a fact, and learn to remain calm when things change suddenly. On most days, these things will not be a burden if you do a good job organizing and managing your time regarding events you can control.
- Focus on the patients' needs instead of tasks that must be done; by focusing on needs, you will complete the necessary tasks with far less stress.
- Avoid repetition. Plan to do like jobs at the same time. Do them right the first time to avoid having to redo them.
- Plan to do things simultaneously. For example, you must remain in the patient's room while she washes at the sink. Use that time productively! Make the bed or do another task instead of waiting impatiently.
- When you have a task to complete, set a time limit for yourself. Be reasonable.
-- Avoid becoming distracted. Focus on the task at hand.
- Break tasks and responsibilities into smaller, more manageable pieces, if possible.
- Constantly evaluate your efficiency and time management skills and work on improving them.

Try to break your own record on time-consuming tasks. If a job takes 30 minutes today, try to get it done in 29 minutes tomorrow. Save a few seconds to a minute a day until you have streamlined the task as much as possible. One caveat, however: Avoid cutting corners for the sake of saving time.

The time you save is not worth the price you will pay for harming a patient or making a major error. If cutting corners is the only way you feel you can save time, try a different routine.

Before beginning a task, organize what you will need:
- When beginning a project, gather and organize your supplies in advance.
- Take everything you will need into the patient's room at once so you do not waste time and energy making trips up and down the hall to retrieve forgotten items.
- Communicate with peers, colleagues, and others throughout your shift. Good communication helps ensure success.
-- Be tactful and polite in all communications.
-- Treat others with dignity, respect, and integrity.
- Be assertive.
-- Help others when you can. Do not be afraid to ask for help when you need it.
- Avoid wasting time; remain organized so you make good use of your time.
- Note whether patients are sick, unstable, or displaying behavior problems; develop a plan for nursing assistant action. Keep the nurse informed.
-- Take the blinders off! Continue to make important observations as you circulate around the unit.
Many facilities allow workers to select the type and style of their uniforms. Traditionally, patients could identify workers' job positions by their uniforms, which included caps. Today, it is difficult to distinguish one worker from another. It is no wonder that patients may be confused. Because of this, some facilities require personnel to wear a name badge or photo identification tag while on the job. The name badge may state only your first name and title. Some facilities do not list workers' last names on name badges, as a security measure.

Wear your uniform only when you are on duty. If your facility provides an area for changing your uniform, take advantage of it. If not, wear a cover-up as you travel to and from work so you will not spread germs. When you get home, remove your uniform, fold it inside out, and put it in the laundry. This keeps the dirtiest part of your uniform away from other clothes. Wear a fresh uniform that is clean and in good repair each day. Stockings and socks should be freshly laundered. Clean shoes and shoelaces daily. You will be less fatigued if your shoes give proper support to the feet and fit well.

Remember that your appearance reflects your pride in yourself and your work. Well-groomed nursing assistants who pay attention to their appearance project a positive image and send a nonverbal message that says they have the same pride and caring attitude toward their work. If you are well groomed and have good personal habits, patients will feel more secure, and other staff will regard you as mature and reliable.
Change is ongoing in the health care industry. Learn to accept this as a fact from the outset of your health care career. New competitors build facilities and take away established customers (patients); technology changes; new research reveals different methods of patient care; changes in laws alter the way services are given; patients have high expectations. Change is never really finished. It can be very disruptive, unpredictable, and difficult for everyone. Venturing into unknown territory can be threatening. Workers faced with change may feel stressed and insecure, believing that change will expose their shortcomings. When workers resist change, negative attitudes cause turmoil for others.

The ability to cope with change is an asset that all workers must master. Try these strategies:
- Learn all you can about the change and your responsibilities.
- Try to understand the need for and value of the change.
- Find ways of adapting to the change.
- Be open-minded and flexible.
- Cooperate with others and be a team player.
- Adjust your attitude. View change as an opportunity for new challenges, growth, and accomplishment.
- Keep your sense of humor. Make change fun. Try to have a good time despite the discomfort you feel.
- Compensate for the stress by making time for activities you enjoy.

Remember the old adage: "Change is inevitable, but growth is optional." Viewing each change as an opportunity for growth will do more than help you survive. Having a positive attitude and using change as an opportunity for growth will help you thrive in the ever-changing workplace.
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