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This textbook is an open educational resource (OER) with CC-BY licensing aligned with Wisconsin Technical College System’s Nursing Assistant program (30-543-300). The Nursing Assistant program prepares students for employment as nursing assistants as well as for entry to other health-related programs. It is recognized by the Wisconsin Department of Health Services as a nurse aide training program. Upon successful completion of a Nursing Assistant program, the student is eligible to take the Wisconsin Nursing Assistant competency evaluation for inclusion on the Wisconsin Nurse Aide Registry and employment in nursing homes, hospitals, home health agencies, hospices, community based residential facilities, assisted living centers, and homes for the developmentally disabled. Chippewa Valley Technical College created this OER with funding from the Higher Education Emergency Relief Fund (HEERF) by using Open RN workflows, remixing Open RN OER textbooks, and creating new content. The Open RN project has published five OER nursing textbooks that have been widely adopted across the United States and is funded by a $2.5 million grant from the Department of Education. More information about the Open RN project can be found at cvtc.edu/OpenRN. This online book is free and can also be downloaded in multiple formats for offline use. The online version is required to complete interactive learning activities included in each chapter. The following video provides a quick overview of how to navigate the online version. One or more interactive elements has been excluded from this version of the text. You can view them online here: https:/ wtcs.pressbooks.pub/nurseassist/?p=4#oembed-1 Introduction | 1

Preface Developing Author The developing author remixed existing open educational resources and developed original content. Myra Sandquist Reuter, MA, BSN, RN, Chippewa Valley Technical College Editors Kimberly Ernstmeyer, MSN, RN, CNE, CHSE, APNP-BC, Chippewa Valley Technical College Dr. Elizabeth Christman, DNP, RN, CNE Graphics Editor Nic Ashman, MLIS, Librarian, Chippewa Valley Technical College Contributors Tammy Casey, RN, Chippewa Valley Technical College Landon Cerny, Creative Multimedia Specialist, Chippewa Valley Technical College Jane Flesher, MST, Proofreader, Chippewa Valley Technical College Joshua Myers, Web Developer, Chippewa Valley Technical College Vince Mussehl, MLIS, Open RN Lead Librarian, Chippewa Valley Technical College Dominic Slauson, Open RN Instructional Technologist Amanda Yule, BSN, RN, Chippewa Valley Technical College Reviewers Lynn Barton, MSN, RN, Oregon Coast Community College Dr. Kathleen Capone, MS, RN, CNE, EdD, Nurses International Tammy Casey, RN, Chippewa Valley Technical College Tamara Davis, MSN, RN, Chippewa Valley Technical College 2 | Preface

Marie E. Dusio, MS, RN, Madison Area Technical College Stacey Grimm, BSN, RN, Lakeshore Technical College Magdalena Handy, RN, South Texas College Jill Henry, RN, Southwest Wisconsin Technical College Dr. Amy Olson, DNP, RN, Mayo Clinic Celee Schuch, Certified Nursing Assistant and Nursing Student, St. Catherine University Cynthia Theys, MSN, RN, MSOLQ, Northeast Wisconsin Technical College Gerri Van Oss, BSN, RN, Lakeshore Technical College Dr. Nancy Whitehead, PhD, RN, APNP, Milwaukee Area Technical College Amanda Yule, BSN, RN, Chippewa Valley Technical College Licensing/Terms of Use This textbook is licensed under a Creative Commons Attribution 4.0 International (CC-BY) license unless otherwise indicated, which means that you are free to: • SHARE – copy and redistribute the material in any medium or format • ADAPT – remix, transform, and build upon the material for any purpose, even commercially The licensor cannot revoke these freedoms as long as you follow the license terms. • Attribution: You must give appropriate credit, provide a link to the license, and indicate if any changes were made. You may do so in any reasonable manner, but not in any way that suggests the licensor endorses you or your use. • No Additional Restrictions: You may not apply legal terms or technological measures that legally restrict others from doing anything the license permits. • Notice: You do not have to comply with the license for elements of the material in the public domain or where your use is permitted by an applicable exception or limitation. Preface | 3

• No Warranties Are Given: The license may not give you all of the permissions necessary for your intended use. For example, other rights such as publicity, privacy, or moral rights may limit how you use the material. Attribution Content for this textbook was adapted from the following open educational resources. For specific reference information about what was used and/or changed in this adaptation, please refer to the footnotes at the bottom of each page of the book. • Nursing Fundamentals by Chippewa Valley Technical College is licensed under CC BY 4.0 • Nursing Skills by Chippewa Valley Technical College is licensed under CC BY 4.0 • Nursing Pharmacology by Chippewa Valley Technical College is licensed under CC BY 4.0 • Nursing: Mental Health and Community Concepts by Chippewa Valley Technical College is licensed under CC BY 4.0 • Human Relations by LibreTexts is licensed under CC BY-NC-SA 4.0 • Microbiology by OpenStax is licensed under CC BY 4.0. Access for free at https://openstax.org/books/microbiology/pages/1-introduction • Introduction to Infection Prevention and Control Practices for the Interprofessional Learner by Hughes, Kenmir, St-Amant, Cosgrove, & Sharpe is licensed under CC BY-NC 4.0 • Anatomy and Physiology by Boundless is licensed under CC BY-SA 4.0 • Human Nutrition by University of Hawai‘i at Mānoa Food Science and Human Nutrition Program is licensed under CC BY 4.0 • Nursing Care at the End of Life by Lowey is licensed under CC BY-NC-SA 4.0 • StatPearls by McNeil-Masuka and Boyer is licensed under CC BY 4.0 • StatPearls by Waheed, Kudaravalli, and Hotwagner is licensed under CC BY 4.0 • Introduction to Sensation and Perception by Students of PSY 3031 and 4 | Preface

edited by Dr. Cheryl Olman is licensed under CC BY 4.0 • Introduction to Social Work at Ferris State University by Department of Social Work is licensed under CC BY 4.0 • What is the Individuals With Disabilities Education Act? by University of Washington is licensed under CC BY-NC-SA 3.0 • Psychology by Jeffrey C. Levy is licensed under CC BY 4.0 • Understanding and Supporting Learners With Disabilities by Paula Lombardi is licensed under CC BY-NC-SA 4.0 • Abnormal Psychology by Lumen Learning is licensed under CC BY 4.0 • A Long Goodbye: Ed and Mary’s Journey With Lewy Body Dementia by James Cook University is licensed under CC BY-NC-ND 4.0 • StatPearls by Khan and De Jesus is licensed under CC BY 4.0 • Opening Eyes Onto Inclusion and Diversity by Carter (Ed.) is licensed under CC BY-NC 4.0 • The Scholarship of Writing in Nursing Education: 1st Canadian Edition by Lapum, St-Amant, Hughes, Tan, Bogdan, Dimaranan, Frantzke, and Savicevic is licensed under CC BY-SA 4.0 Suggested attribution statement: Reuter-Sandquist, Myra. (2022). Nursing Assistant (K. Ernstmeyer and E. Christman, Eds.) by Chippewa Valley Technical College is licensed under CC BY 4.0 Preface | 5

Foundational Concepts Nursing assistants (NAs), also called nursing aides, are important members of the health care team. NAs work under the supervision of licensed practical/ vocational nurses (LPNs/VNs) and registered nurses (RNs). NAs provide basic care and help patients* with activities of daily living. They typically perform the following tasks 1 : • Clean and bathe patients • Help patients use the toilet and dress • Turn, reposition, and transfer patients between beds and wheelchairs • Listen to and record patients’ health concerns and report that information to nurses • Measure patients’ vital signs, such as temperature • Serve meals and help patients eat * Note: The terms patient, client, and resident are used interchangeably throughout this book to represent the people cared for by nursing assistants. Definitions of these terms are discussed in Chapter 2.6, “Health Care Settings.” Each state defines the actions and skills that nursing assistants can perform in health care facilities, also referred to as their scope of practice. Job descriptions in health care agencies also list specific expectations and duties for NAs within that facility. Depending on the NA’s level of training, the facility, and the state law in which they work, nursing assistants may also dispense medication. These actions and associated skills checkoffs will be discussed throughout this book. 1. Bureau of Labor Statistics, U.S. Department of Labor. Occupational Outlook Handbook, Nursing Assistants and Orderlies. https://www.bls.gov/ooh/healthcare/nursing-assistants.htm 6 | Foundational Concepts

View the following YouTube video about Nursing Assistants 2 : Certified Nursing Assistant Career. In 2020, nursing assistants were employed in 1.4 million jobs in many types of health care facilities. The largest employers of nursing assistants were as follows 3 : • Skilled nursing facilities: 37% • Hospitals: 30% • Assisted-living facilities: 11% • Home health care agencies: 6% • Government agencies: 4% Skilled nursing facilities (commonly referred to as “nursing homes”) provide inpatient services to patients who require medical, nursing, or rehabilitative services but do not provide the level of care or treatment available in a hospital. Assisted-living facilities are living arrangements where people live on their own in a residential facility but additional personal care services such as meals, housekeeping, transportation, and assistance with activities of daily living are available. Residents in assisted living facilities typically pay monthly rent with additional fees for requested services. Home health care agencies provide skilled nursing care, physical therapy, occupational therapy, speech therapy, and personal care in an individual’s home. 4 “Health care settings” are further discussed in Chapter 2. Overall employment of nursing assistants is projected to grow eight percent from 2020 to 2030. As the baby-boom population ages, nursing assistants will 2. WVHCA. (2012, July 27). Certified nursing assistant career [Video]. YouTube. All rights reserved. https://youtu.be/ fRjNpjxnjYo 3. Bureau of Labor Statistics, U.S. Department of Labor. Occupational Outlook Handbook, Nursing Assistants and Orderlies. https://www.bls.gov/ooh/healthcare/nursing-assistants.htm 4. Centers for Medicare & Medicaid Services. https://www.cms.gov Foundational Concepts | 7

help care for an increasing number of older adults who have chronic or progressive diseases, such as heart disease and diabetes. Client preferences and shifts in federal and state funding are also increasing the demand for home and community-based long-term care, which should lead to increased opportunities for nursing assistants in home health and community rehabilitation services. 5 . Nursing assistants may work full time or part time. Because health care facilities provide patient care at all hours, nursing assistants often work nights, weekends, and holidays. 6 Becoming a Nursing Assistant To become a nursing assistant, an individual must complete a state-approved education program and pass their state’s competency exam. A stateapproved education program includes classroom instruction on nursing assistant principles, as well as supervised clinical work. These educational programs are available in high schools, community colleges, vocational and technical schools, hospitals, and nursing homes. Nursing assistants who pass their state’s competency exam are placed on a state registry. They must be on this state registry to work in a skilled nursing facility. 7 Professional Qualities of a Nursing Assistant As personal caregivers, nursing assistants must demonstrate professional qualities, including communication skills, compassion, patience, and physical stamina 8 : 5. Bureau of Labor Statistics, U.S. Department of Labor. Occupational Outlook Handbook, Nursing Assistants and Orderlies. https://www.bls.gov/ooh/healthcare/nursing-assistants.htm 6. Bureau of Labor Statistics, U.S. Department of Labor. Occupational Outlook Handbook, Nursing Assistants and Orderlies. https://www.bls.gov/ooh/healthcare/nursing-assistants.htm 7. Bureau of Labor Statistics, U.S. Department of Labor. Occupational Outlook Handbook, Nursing Assistants and Orderlies. https://www.bls.gov/ooh/healthcare/nursing-assistants.htm 8. Bureau of Labor Statistics, U.S. Department of Labor. Occupational Outlook Handbook, Nursing Assistants and Orderlies. https://www.bls.gov/ooh/healthcare/nursing-assistants.htm 8 | Foundational Concepts

• Communication skills. Nursing assistants must listen and respond to patients’ concerns. They must appropriately share observed patient information with nurses and other health care workers caring for that patient. Communicating professionally in a health care setting is discussed in Chapter 1. • Empathy. Nursing assistants care for people who are sick, injured, debilitated, cognitively impaired, or need assistance for other reasons. A compassionate attitude is required to do this type of work. • Physical stamina. Nursing assistants spend much of their time on their feet performing tasks such as lifting or moving patients. It is important to be in good physical condition to safely perform these tasks and avoid injury to oneself or others. “Body mechanics and safe equipment use” are discussed in Chapter 3. • Professionalism. Repetitive tasks of cleaning, feeding, and bathing patients can be stressful. Nursing assistants must complete these tasks with professionalism. Nursing assistants have one of the highest rates of injuries and illnesses of all occupations from lifting and moving patients and other physically demanding tasks. Nursing assistants typically complete a brief period of onthe-job training to learn about their specific employer’s equipment, policies, and procedures, as well as training in how to properly lift people to reduce the risk of injuries. 9 Professionalism What does professionalism mean? Being professional means delivering patient care in a manner that is ethical, respectful, competent, knowledgeable, and caring. Professional nursing assistants are committed to promoting clients’ dignity and well-being, as well as displaying high 9. Bureau of Labor Statistics, U.S. Department of Labor. Occupational Outlook Handbook, Nursing Assistants and Orderlies. https://www.bls.gov/ooh/healthcare/nursing-assistants.htm Foundational Concepts | 9

standards of professional behavior. 10 Good hygiene principles as a health care professional include the following: • Wear clean scrubs every shift. Scrubs should be wrinkle-free and the correct size for a professional appearance. • Keep your hair clean and neatly combed. Long hair should be pulled back for safety and infection control purposes. • Keep nails clean and trimmed short. Most agencies do not permit nail polish or artificial nails. Long nails and nail polish harbor microorganisms that can spread infection. • Get plenty of sleep before coming to work so you are alert at work. • Wear comfortable, closed-toe shoes with nonskid soles. • Do not wear jewelry for safety and infection control purposes. Some 10. Miller-Hoover, S. (2018). I said what? Professionalism for the CNA. RN.com.https://www.rn.com/featured-stories/ professionalism-cna/#:~:text=Professional%20CNAs%20are%20resp[/footnote] Professional behavior includes communicating respectfully with clients, their family members, and other health care team members and introducing oneself before beginning care. It also includes being a professional employee, such as performing hand hygiene, exhibiting good personal hygiene and appearance, being dependable and on time for work, and completing one’s assigned tasks in an accurate and timely manner. Professionalism includes understanding and working within one's scope of practice and being a lifelong learner to continue to provide excellent care as the health care environment changes. “Demonstrating professionalism in the workplace” is further discussed in Chapter 2. Initiating and Concluding Personal Cares When initiating care with a client, it is important to begin by introducing oneself. When initiating care with patients, it is essential to first provide privacy and then introduce yourself and explain what will be occurring. Providing privacy means taking actions such as talking with the patient privately in a room with the door shut. When concluding care, it is also important to ask if the resident needs anything else, as well as ensuring safety measures are in place. These routine actions are further discussed in “Pre- and Post-Procedural Steps” in Chapter 5. Before initiating care and after performing care, it is vital to perform good hand hygiene. Using hand hygiene is a simple but effective way to prevent the spread of infection when performed correctly and at the appropriate times. More details about using effective hand hygiene and preventing the spread of infection are discussed in the “Precautions Used to Prevent the Spread of Infection” in Chapter 4. Maintaining Good Hygiene and Personal Appearance Managing your personal hygiene with good grooming habits is a component of professionalism that contributes to patient satisfaction and prevents the spread of infection.[footnote]Miller-Hoover, S. (2018). I said what? Professionalism for the CNA. RN.com. https://www.rn.com/featured-stories/professionalism-cna/#:~:text=Professional%20CNAs%20are%20resp 10 | Foundational Concepts

agencies permit wedding rings. • Do not wear perfume or strong-smelling deodorants or powders. Strong odors can cause nausea, headaches, or allergic reactions in some patients, especially if they are not feeling well. • Follow agency policies regarding tattoos and piercings. • Always wear your name badge while at work. • Wear a watch with a second hand that is easily cleaned. • Carry a pen and paper in your pocket for taking client care notes to report or document. • Use effective coping skills to deal with stress at work, home, and school. • Notify your supervisor if you are not feeling well. Overview of This Book The chapters in this book discuss the following competencies that a student must demonstrate to successfully become a certified nursing assistant: • Chapter 1: Communicate Professionally Within a Health Care Setting • Chapter 2: Demonstrate Professionalism in the Workplace • Chapter 3: Maintain a Safe Health Care Environment • Chapter 4: Adhere to Principles of Infection Control • Chapter 5: Provide for Personal Care Needs of Clients • Chapter 6: Provide for Basic Nursing Care Needs • Chapter 7: Demonstrate Reporting and Documentation of Client Data • Chapter 8: Utilize Principles of Mobility to Assist Clients • Chapter 9: Promote Independence Through Rehabilitation/Restorative Care • Chapter 10: Provide Care for Clients Experiencing Acute and Chronic Health Conditions • Chapter 11: Apply Knowledge of Body Systems to Client Care Foundational Concepts | 11

1.1 Introduction to Communicate Professionally Within A Health Care Setting Learning Objectives • Interact professionally with clients, families, and coworkers • Display appropriate verbal and nonverbal communication skills in the health care setting • Establish therapeutic relationships with clients and their family members • Respond to clients exhibiting disruptive behaviors • Respond to aggressive behavior • Establish effective working relationships with supervisors and peers • Demonstrate effective reporting and documentation • Assist clients to meet spiritual needs • Adapt care and communication to meet the psychological needs of the aging client • Demonstrate empathy for the emotional needs and mental health of diverse clients • Apply effective coping strategies Effective communication is a vital skill for nursing assistants. Nursing assistants communicate professionally with patients and other health care team members throughout every shift. This chapter will review the communication process, discuss strategies for adapting communication based on the needs of the client and health care team, and introduce guidelines for documentation and reporting. 1.1 Introduction to Communicate Professionally Within A Health Care Setting | 15

1.2 The Communication Process Communication is a process by which information is exchanged between individuals through a common system of symbols, signs, or behavior. 1 In the health care setting, good communication is the foundation to trusting relationships that improve client outcomes. It is the gateway to providing holistic care. Holistic care addresses a client’s physical, emotional, social, and spiritual needs. 2 The communication process involves a sender, the message, and a receiver. See Figure 1.1 3 for an illustration of the communication process. Figure 1.1 The Communication Process Verbal Messages There are many aspects of the communication process that can alter the delivery and interpretation of the message. These aspects relate to the language and experience of both the sender and receiver, referred to as semantics. People typically make reference to things they are familiar with, including landmarks, popular culture, and slang. Barriers can occur even 1. Merriam-Webster. Communication. https://www.merriam-webster.com/dictionary/communication 2. Jasemi, M., Valizadeh, L., Zamanzadeh, V., & Keogh, B. (2017). A concept analysis of holistic care by hybrid model. Indian Journal of Palliative Care, 23(1), 71–80. https://doi.org/10.4103/0973-1075.197960 3. “Communication Process” by Meredith Pomietlo for Chippewa Valley Technical College is licensed under CC BY 4.0 16 | 1.2 The Communication Process

when both parties in the conversation speak the same language. For example, if you asked a person who has never used the Internet to “Google it,” they would have no idea what that means. Nonverbal Messages Nonverbal messages, also referred to as body language, greatly impact the conversational process. Nonverbal communication includes body language and facial expressions, tone of voice, and pace of the conversation. See Figure 1.2 4 for an illustration of body language communicating a message. Nonverbal communication can have a tremendous impact on the communication experience and may be much more powerful than the verbal message itself. You may have previously learned that 80% of communication is nonverbal communication. The importance of nonverbal communication during conversation has been broken down further, estimating that 55% of communication is body language, 38% is tone of voice, and 7% is the actual words spoken. 5 If the sender or receiver appears disinterested or distracted, the message or interpretation may become distorted or missed. 4. “Boulder_Worldcup_Vienna_29-05-2010a_semifinals090_Akiyo_Noguchi,_Anna_Stöhr.jpg” by Manfred Werner - Tsui is licensed under CC BY-SA 3.0 5. Thompson, J. (2011). Is nonverbal communication a numbers game? Psychology Today. https://www.psychologytoday.com/us/blog/beyond-words/201109/is-nonverbal-communication-numbers-game 1.2 The Communication Process | 17

Figure 1.2 Body Language Health care professionals assess receivers’ preferred methods of communication and individual characteristics that might influence communication and then adapt communication to meet the receivers’ needs. For example, nursing assistants adapt verbal instructions for adult patients with cognitive disabilities. Although the information provided might be similar to that provided to a patient without disabilities, the way the information is provided is adapted based on the patient’s developmental level. A nursing assistant may ask a cognitively intact person, “What do you want for lunch?” but adapt this information for someone with impaired cognitive function by offering a choice, such as “Do you want a sandwich or soup for lunch?” This adaptation allows the cognitively impaired patient to make a choice without being confused or overwhelmed by too many options. 6 Read more about developmental levels in the “Human Needs and Developmental Stages” section of this chapter. Communication Styles In addition to using verbal and nonverbal communication, people 6. This work is a derivative of Nursing Fundamentals by Chippewa Valley Technical College and is licensed under CC BY 4.0 18 | 1.2 The Communication Process

communicate with others using one of three styles. A passive communicator puts the rights of others before their own. Passive communicators tend to be apologetic or sound tentative when they speak and often do not speak up if they feel as if they are being wronged. Aggressive communicators, on the other hand, come across as advocating for their own rights despite possibly violating the rights of others when communicating. They tend to communicate in a way that tells others their feelings don’t matter. Assertive communicators respect the rights of others while also standing up for their own ideas and rights when communicating. An assertive person is direct, but not insulting or offensive. 7 Assertive communication refers to a way of conveying information that describes the facts and the sender’s feelings without disrespecting the receiver’s feelings. Assertive communication is different from aggressive communication because it uses “I” messages, such as “I feel…,” “I understand…,” or “Help me to understand…,” to address issues instead of using “you” messages that can cause the receiver to feel as though they are being verbally attacked. Using assertive communication is an effective way to solve problems with patients, coworkers, and health care team members. For example, instead of using aggressive communication to say to a coworker, “You always leave your patients’ rooms a mess! I dread following you on the next shift,” an assertive communicator would use “I” messages. The assertive communicator might say, “I feel frustrated spending the first part of my shift decluttering patients’ rooms. Help me understand the reasons why you don’t empty the wastebaskets and clean up the rooms by the end of your shift.” 8 Overcoming Communication Barriers It is important to reflect on personal factors that influence your ability to communicate with others effectively. There are many factors that can distort the message you are trying to communicate, resulting in your message not being perceived by the receiver in the way you intended. When 7. This work is a derivative of Human Relations by LibreTexts and is licensed under CC BY-NC-SA 4.0 8. This work is a derivative of Nursing Fundamentals by Chippewa Valley Technical College and is licensed under CC BY 4.0 1.2 The Communication Process | 19

communicating, it is important to seek feedback that your message is clearly understood. 9 Nursing assistants must be aware of these potential barriers and try to reduce their impact by continually seeking feedback and checking understanding. Review common communication barriers in the following box. Common Barriers to Communication in Health Care 10 • Jargon: Avoid using medical terminology, complicated wording, or unfamiliar words. When communicating with patients, explain information in common language that is easy to understand. Consider any generational, geographical, or background information that may change the perception or understanding of your message. • Lack of attention: It is easy to become task-centered rather than person-centered when caring for multiple residents. When entering a patient’s room, remember to use preprocedural steps and mindfully focus on the person in front of you to give them your full attention. Patients should feel as if they are the center of your attention when you are with them, no matter how many other things you have going on. • Noise and other distractions: Health care environments can be very noisy with people talking in the room or hallway, the TV blaring, alarms beeping, and pages occurring overhead. Create a calm, quiet environment when communicating with patients by closing doors to the hallway, reducing the volume of the TV, or moving to a 9. This work is a derivative of Nursing Fundamentals by Chippewa Valley Technical College and is licensed under CC BY 4.0 10. SkillsYouNeed. (n.d.). Barriers to effective communication. https://www.skillsyouneed.com/ips/barrierscommunication.html 20 | 1.2 The Communication Process

quieter area, if possible. • Light: A room that is too dark or too light can create communication barriers. Ensure the lighting is appropriate according to the patient’s preference. • Hearing and speech problems: If your patient has hearing or speech problems, implement strategies to enhance communication, including assistive devices such as eyeglasses, hearing aids, and any communication aids such as whiteboards, photobooks, or microphones. • Language differences: If English is not your patient’s primary language, it is important to seek a medical interpreter and provide written handouts in the patient’s preferred language when possible. Most agencies have access to an interpreter service available by phone if they are not available on-site. • Differences in cultural beliefs: The norms of social interaction vary greatly in different cultures, as well as the ways that emotions are expressed. For example, the concept of personal space varies among people from different cultural backgrounds. Some people prefer to stand very close to one another when speaking whereas others prefer a distance of a few feet. Additionally, some patients are stoic about pain whereas others are more verbally expressive when in pain. • Psychological barriers: Psychological states of the sender and the receiver affect how the message is sent, received, and perceived. Consider what the receiver may be experiencing in the health care setting and what may change your delivery of your message. Being rushed, distracted, and overwhelmed are just a few things that can affect your message and its understanding. 1.2 The Communication Process | 21

• Physiological barriers: It is important to be aware of patients’ potential physiological barriers when communicating. For example, if a patient is in pain, they are less likely to hear and remember what was said. If the patient is receiving pain medication, be aware these medications may alter their comprehension and response. • Physical barriers for nonverbal communication: Providing information via email or text is often less effective than face-to-face communication. The inability to view the nonverbal communication associated with a message, such as tone of voice, facial expressions, and general body language, often causes misinterpretation of the message by the receiver. When possible, it is best to deliver important information to others using face-to-face communication so that nonverbal communication is included with the message. • Differences in perceptions and viewpoints: Everyone has their own beliefs and perspectives and wants to feel “heard.” When patients feel their beliefs or perspectives are not valued, they often become disengaged from the conversation or their plan of care. Information should be provided in a nonjudgmental manner, even if the patient’s perspectives, viewpoints, and beliefs are different from your own. 22 | 1.2 The Communication Process

1.3 Communication Within the Health Care Team Communicating With Staff The resident is at the center of the health care team. As a nursing assistant, most of your duties will involve interaction regarding nursing services among other CNAs, LPNs, and RNs. It is important to establish a good relationship with coworkers to ensure quality resident care. Improper communication can affect the team’s ability to provide holistic care. The health care team will be discussed further in Chapter 2. Good communication starts by respecting those you work with and using the communication skills previously discussed to grow a trusting relationship. Knowing and fulfilling your duties, documenting and reporting the completion of these duties, and functioning in a consistent and dependable manner are keys to creating strong, professional relationships within your team. These expectations for good communication may seem challenging as an inexperienced nursing assistant, but they can be achieved by organizing your responsibilities and managing your time. This begins by arriving on time for your shift, being dressed appropriately, being prepared to start working when your shift starts, and reviewing your assigned residents’ plans of care at the beginning of the shift. Items to review in the plan of care include the following: • Resident’s name and location • Activity level and transfer status • Assistance required for activities of daily living (ADLs) • Diet and fluid orders (see Chapter 6 for more information) • Elimination needs Transfer status refers to the assistance the patient requires to be moved from one location to another, such as from the bed to a chair. Activities of daily living (ADLs) are daily basic tasks that are fundamental to everyday functioning (e.g., hygiene, elimination, dressing, eating, ambulating/moving). 1.3 Communication Within the Health Care Team | 23

Diet and fluid orders refer to what the resident is permitted to eat and drink. Elimination needs refer to assistance the resident requires for urinating and passing stool. For example, a resident requires assistance to the toilet and uses incontinence pads. After reviewing the cares you will be providing to your assigned patients during your shift, discuss a timeline with your coworkers that meets residents’ schedules and allows for the coordination of cares that require more than one caregiver. For example, one resident may require a two-person assist when transferring from the bed to the chair. Schedules for activities, treatments, labs, appointments, or other services should also be reviewed so that cares can be organized around these schedules. As resident cares are completed, they must be documented in a timely manner and reported to nursing staff. Prepare a concise report to share with the nurse for each of your assigned clients. The report should include the time cares were provided and any observations or changes noted in the resident. Read more about documentation and reporting in the “Documenting and Reporting” section at the end of this chapter. Communicating With the Client, Families, and Loved Ones Therapeutic communication is a type of professional communication used with patients. It is defined as the purposeful, interpersonal, informationtransmitting process through words and behaviors based on both parties’ knowledge, attitudes, and skills that leads to patient understanding and participation. 1 Therapeutic communication techniques have been used by nurses since Florence Nightingale, who insisted on the importance of building trusting relationships with patients. She believed in the therapeutic healing that results from nurses’ presence with patients. 2 Since then, several 1. Abdolrahimi, M., Ghiyasvandian, S., Zakerimoghadam, M., & Ebadi, A. (2017). Therapeutic communication in nursing students: A Walker & Avant concept analysis. Electronic Physician, 9(8), 4968–4977. https://doi.org/10.19082/4968 2. Karimi, H., & Masoudi Alavi, N. (2015). Florence Nightingale: The mother of nursing. Nursing and Midwifery Studies, 4(2), e29475. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4557413/ 24 | 1.3 Communication Within the Health Care Team

professional nursing associations have highlighted therapeutic communication as one of the most vital elements in nursing. 3 Nursing assistants also implement therapeutic communication with patients. Read an example of a nursing student effectively using therapeutic communication with patients in the following box. An Example of Nursing Student Using Therapeutic Communication 4 , 5 Figure 1.3 Attending Behaviors Ms. Z. is a nursing student who enjoys interacting with patients. When she goes to patients’ rooms, she greets them and 3. This work is a derivative of Nursing Fundamentals by Chippewa Valley Technical College and is licensed under CC BY 4.0 4. Abdolrahimi, M., Ghiyasvandian, S., Zakerimoghadam, M., & Ebadi, A. (2017). Therapeutic communication in nursing students: A Walker & Avant concept analysis. Electronic Physician, 9(8), 4968–4977. https://doi.org/10.19082/4968 5. “beautiful african nurse taking care of senior patient in wheelchair” by agilemktg1 is in the Public Domain 1.3 Communication Within the Health Care Team | 25

introduces herself and her role in a calm tone. She kindly asks patients about their problems and notices their reactions. She does her best to solve their problems and answer their questions. Patients perceive that she wants to help them. She treats patients professionally by respecting boundaries and listening to them in a nonjudgmental manner. She addresses communication barriers and respects patients’ cultural beliefs. She notices patients’ health literacy and ensures they understand her messages and patient education. As a result, patients trust her and feel as if she cares about them, so they feel comfortable sharing their health care needs with her. There are several components included in therapeutic communication. The health care professional uses active listening and attending behaviors to demonstrate they are interested in understanding what the patient is saying. Touch is used to professionally communicate caring, and specific therapeutic techniques are used to encourage the patient to share their thoughts, concerns, and feelings. Active Listening and Attending Behaviors Listening is obviously an important part of communication. A well-known phrase from a Greek philosopher named Epictetus is, “We have two ears and one mouth so we can listen twice as much as we speak.” It is important to actively listen to patients and not use competitive or passive listening. Competitive listening occurs when we are primarily focused on sharing our own point of view instead of listening to someone else. Passive listening occurs when we are not interested in listening to the other person or we assume we correctly understand what the person is communicating without verifying their message. During active listening, we communicate verbally and nonverbally that we are interested in what the other person is saying and also verify our understanding with the speaker. For example, an active 26 | 1.3 Communication Within the Health Care Team

listening technique is to restate what the person said and verify our understanding is correct, such as, “I hear you saying you are hesitant to go to physical therapy because you are afraid of falling. Is that correct?” This feedback process is the main difference between passive listening and active listening. 6 Touch Touch is a powerful way to professionally communicate caring and compassion if done respectfully while being aware of the patient’s cultural beliefs. NAs commonly use professional touch when assessing, expressing concern, or comforting patients. For example, simply holding a patient’s hand during a painful procedure can be very effective in providing comfort. See Figure 1.4 7 for an image of a nurse using touch as a therapeutic technique when caring for a patient. 6. This work is a derivative of Human Relations by LibreTexts and is licensed under CC BY-NC-SA 4.0 7. “Flickr_-_Official_U.S._Navy_Imagery_-_A_nurse_examines_a_newborn_baby..jpg” by Official Navy Page from United States of America MC2 John O'Neill Herrera/U.S. Navy is licensed in the Public Domain 1.3 Communication Within the Health Care Team | 27

Figure 1.4 Using Touch as a Therapeutic Technique Therapeutic Communication Techniques Therapeutic communication techniques are specific methods used to provide patients with support and information while focusing on their concerns. Nursing assistants help patients complete activities of daily living and meet goals in their plan of care based on their needs, values, skills, and abilities. It is important to recognize the autonomy of the patient to make their own decisions, maintain a nonjudgmental attitude, and avoid interrupting. Depending on the developmental stage and educational needs of the patient, appropriate terminology should be used to promote patient understanding and rapport. When using therapeutic communication, health care professionals often ask open-ended questions, repeat information, or use silence to prompt patients to process their concerns. Table 1.3a describes a variety of therapeutic communication techniques. Table 1.3a Therapeutic Communication Techniques 8 8. American Nurse. (n.d.). 17 therapeutic communication techniques. https://www.myamericannurse.com/therapeuticcommunication-techniques/ 28 | 1.3 Communication Within the Health Care Team

Therapeutic Technique Description Active Listening By using nonverbal and verbal cues such as nodding and saying, “I see,” health care professionals can encourage patients to continue talking. Active listening involves showing interest in what patients have to say, acknowledging that you’re listening and understanding, and engaging with them throughout the conversation. General leads such as “What happened next?” can be used to guide the conversation or propel it forward. Using Silence At times, it’s useful to not speak at all. Deliberate silence can give patients an opportunity to think through and process what comes next in the conversation. It may also give them the time and space they need to broach a new topic. Providing Acceptance Sometimes it is important to acknowledge a patient’s message and affirm they’ve been heard. Acceptance isn’t necessarily the same thing as agreement; it can be enough to simply make eye contact and say, “I hear what you are saying.” Patients who feel their health care professionals are listening to them and taking them seriously are more likely to be receptive to care. Giving Recognition Recognition acknowledges a patient’s behavior and highlights it. For example, saying something such as “I noticed you ate all of your breakfast today” draws attention to the action and encourages it. Offering Self Hospital stays can be lonely and stressful at times. When health care professionals make time to be present with their patients, it communicates they value them and are willing to give them time and attention. Offering to simply sit with patients for a few minutes is a powerful way to create a caring connection. Giving Broad Openings/ Open-Ended Questions Therapeutic communication is often most effective when patients direct the flow of conversation and decide what to talk about. For example, giving patients a broad opening such as “What’s on your mind today?” or “What would you like to talk about?” is a good way to allow patients an opportunity to discuss what’s on their mind. Seeking Clarification Similar to active listening, asking patients for clarification when they say something confusing or ambiguous is important. Saying something such as “I’m not sure I understand. Can you explain more to me?” helps health care professionals ensure they understand what’s actually being said and can help patients process their ideas more thoroughly. Placing the Event in Time or Sequence Asking questions about when certain events occurred in relation to other events can help patients (and health care professionals) get a clearer sense of the whole picture. It forces patients to think about the sequence of events and may prompt them to remember something they otherwise wouldn’t. 1.3 Communication Within the Health Care Team | 29

Making Observations Making observations about the appearance, demeanor, or behavior of patients can help draw attention to areas that may indicate a problem. For example, making an observation that they haven’t been eating much may lead to the discovery of a new symptom. Encouraging Descriptions of Perception For patients experiencing sensory issues or hallucinations, it can be helpful to ask about these perceptions in an encouraging, nonjudgmental way. Phrases such as “What do you hear now?” or “What do you see?” give patients a prompt to explain what they’re perceiving without casting their perceptions in a negative light. Encouraging Comparisons Patients often draw upon previous experiences to deal with current problems. By encouraging them to make comparisons to situations they have coped with before, health care professionals can help patients discover solutions to their problems. Summarizing It is often useful to summarize what patients have said. This demonstrates you are listening and allows you to verify information. Ending a summary with a phrase such as “Does that sound correct?” gives patients explicit permission to make corrections if they’re necessary. Reflecting Patients often ask health care professionals for advice about what they should do about particular problems. Instead of offering advice, health care professionals can ask patients to reflect on what they think they should do, which encourages them to be accountable for their own actions and helps them come up with solutions themselves. Focusing Sometimes during a conversation, patients mention something particularly important. When this happens, health care professionals can focus on this statement and prompt patients to discuss it further. Patients don’t always have an objective perspective on what is relevant to their case, but as impartial observers, health care professionals may be able to pick out the topics on which to focus. Confronting Health care professionals should only use this technique after they have established trust and rapport with the client. In some situations, it can be vital to disagree with patients, present them with reality, or challenge their assumptions. Confrontation, when used correctly, can help patients break destructive routines or understand the state of their current situation. Voicing Doubt Voicing doubt can be a gentler way to call attention to incorrect or delusional ideas and perceptions of patients when appropriate. For example, when appropriate, a health care worker may say to a patient experiencing visual hallucinations, “I know you said you are seeing spiders on the walls, but I don’t see any spiders.” 30 | 1.3 Communication Within the Health Care Team

Offering Hope and Humor Because hospitals can be stressful places for patients, sharing hope that they can persevere through their current situation or lightening the mood with humor can quickly establish rapport. This technique can help move patients in a more positive state of mind. However, it is important to tailor humor to the patient’s sense of humor. In addition to the therapeutic techniques listed in Table 1.3a, health care professionals should genuinely communicate with patients with empathy. Communicating honestly, genuinely, and authentically is powerful. It opens the door to establishing true connections with others. 9 Communicating with empathy can be described as providing “unconditional positive regard.” Research has demonstrated that when health care professionals communicate with empathy, there is improved patient healing, reduced symptoms of depression, and decreased medical errors. 10 Nontherapeutic Responses Health care professionals must be aware of potential barriers to communication. In addition to the common communication barriers discussed in the “Communication Styles” subsection of this chapter, there are several nontherapeutic responses to avoid. These nontherapeutic responses often block the patient’s communication of their feelings or ideas. See Table 1.3b for a description of nontherapeutic responses. 11 Table 1.3b Nontherapeutic Responses 12 9. Balchan, M. (2016, February 16). The magic of genuine communication. http://michaelbalchan.com/communication/ 10. Morrison, E. (2019). Empathetic communication in healthcare. EM Consulting. https://work.cibhs.org/sites/main/files/ file-attachments/empathic_communication_in_healthcare_workbook.pdf?1594162691 11. Burke, A. (2021). Therapeutic communication: NCLEX-RN. RegisteredNursing.org. https://www.registerednursing.org/ nclex/therapeutic-communication/ 12. Burke, A. (2021). Therapeutic communication: NCLEX-RN. RegisteredNursing.org. https://www.registerednursing.org/ nclex/therapeutic-communication/ 1.3 Communication Within the Health Care Team | 31

Nontherapeutic Response Description Asking Personal Questions Asking personal questions that are not relevant to the situation is not professional or appropriate. Don’t ask questions just to satisfy your curiosity. For example, asking, “Why have you and Mary never married?” is not appropriate. A more therapeutic question would be, “How would you describe your relationship with Mary?” Giving Personal Opinions Giving personal opinions takes away the decision-making from the patient. Effective problem-solving must be accomplished by the patient and not the NA. For example, stating, “If I were you, I’d put your father in a nursing home” is not therapeutic. Instead, it is more therapeutic to say, “Let’s talk about what options are available to your father.” Changing the Subject Changing the subject when someone is trying to communicate with you demonstrates lack of empathy and blocks further communication. It seems to say that you don’t care about what they are sharing. For example, stating, “Let’s not talk about your insurance problems; it’s time for your walk now” is not therapeutic. A more therapeutic response would be, “After your walk, let’s talk more about your concerns about insurance so I can help find assistance for you.” Stating Generalizations and Stereotypes Generalizations and stereotypes can threaten relationships with patients. For example, it is not therapeutic to state a stereotype like, “Older adults are always confused.” It is better to focus on the patient’s concern and ask, “Tell me more about your concerns about your wife’s confusion.” Providing False Reassurances When a patient is seriously ill or distressed, it is tempting to offer false hope with statements such as “You’ll be fine,” or “Don’t worry; everything will be alright.” These comments tend to discourage further expressions of feelings by the patient. A more therapeutic response would be, “It must be difficult not to know what the surgeon will find. What can I do to help?” Showing Sympathy Sympathy focuses on the health care professional’s feelings rather than the patient. Saying “I’m so sorry about your amputation; I can’t imagine losing a leg” shows pity rather than trying to help the patient cope with the situation. A more therapeutic response would be, “The loss of your leg is a major change; how do you think this will affect your life?” Asking “Why” Questions It can be tempting to ask a patient to explain “why” they believe, feel, or act in a certain way. However, patients and family members can interpret “why” questions as accusations and become defensive. It is best to phrase a question by avoiding the word “why.” For example, instead of asking, “Why are you so upset?” it is better to rephrase the statement as, “You seem upset. What’s on your mind?” 32 | 1.3 Communication Within the Health Care Team

Approving or Disapproving Health care professionals should not impose their own attitudes, values, beliefs, and moral standards on patients or family members. Judgmental messages contain terms such as “should,” “shouldn’t,” “ought to,” “good,” “bad,” “right,” or “wrong.” Agreeing or disagreeing sends the subtle message that health care professionals have the right to make value judgments about the patient’s decisions. Approving implies that the behavior being praised is the only acceptable one, and disapproving implies that the patient must meet the listener’s expectations or standards. Instead, health care professionals should help the patient explore their own beliefs and decisions. For example, it is nontherapeutic to state, “You shouldn’t schedule elective surgery; there are too many risks involved.” A more therapeutic response would be, “So you are considering elective surgery. Tell me more about it…” This response gives the patient a chance to express their ideas or feelings without fear of being judged. Giving Defensive Responses When patients or family members express criticism, health care professionals should actively listen. Listening does not imply agreement. To discover reasons for the patient’s anger or dissatisfaction, health care professionals should listen without criticism, avoid being defensive or accusatory, and attempt to defuse anger. For example, it is not therapeutic to state, “No one here would intentionally lie to you.” Instead, a more therapeutic response would be, “You believe people have been dishonest with you. Tell me more about what happened.” (After obtaining additional information, the health care worker may decide to follow the chain of command at the agency and report the patient’s concerns to the nurse supervisor for follow-up.) Providing Passive or Aggressive Responses Passive responses serve to avoid conflict or sidestep issues, whereas aggressive responses provoke confrontation. Health care workers should use assertive communication. Arguing Challenging or arguing against patient perceptions denies that they are real and valid to the other person. They imply that the other person is lying, misinformed, or uneducated. The skillful health care professional can provide alternative information or present reality in a way that avoids argument. For example, it is not therapeutic to state, “How can you say you didn’t sleep a wink when I heard you snoring all night long!” A more therapeutic response would be, “You don’t feel rested this morning? Let’s talk about ways to improve your sleep so you feel more rested.” Strategies for Effective Communication In addition to overcoming common communication barriers, using active listening and therapeutic communication techniques, and avoiding 1.3 Communication Within the Health Care Team | 33

nontherapeutic responses, there are additional strategies for promoting effective communication when providing patient-centered care. Specific questions to ask patients are as follows 13 : • What concerns do you have about your plan of care? • What questions do you have about your daily routine? • Did I answer your question(s) clearly, or is there additional information you would like? Listen closely for feedback from patients. Feedback provides an opportunity to improve patient understanding, improve the patient-care experience, and provide high-quality care. Other suggestions for effective communication with clients include the following: • Read the care plan carefully and access any social history available. If family members or friends visit and it seems appropriate, talk with them about the client without intruding or taking up a lot of their time together. This information helps you build trust and care for the client based on their preferences and life history. For example, you might learn the resident lived on a farm most of their life and enjoyed taking care of their horses. Striking up conversations about horses is a way to build rapport with this client. • Review any changes in routine or in the plan of care for assisting with ADLs with the client to improve understanding and participation. • If there are questions you can’t answer, be sure to report to the nurse so someone can follow up with the client. Check back with the client to ensure they have had their questions answered. • Observe nonverbal communication from clients. Do they seem to interact during care, or is it something that they are merely tolerating and just trying to get through each day? Find an approach so they are comfortable with receiving care. 13. Smith, L. L. (2018, June 12). Strategies for effective patient communication. American Nurse. https://www.myamericannurse.com/strategies-for-effective-patient-communication/ 34 | 1.3 Communication Within the Health Care Team

Adapting Your Communication When communicating with patients, their family members, and other caregivers, note your audience and adapt your message based on characteristics such as age, developmental level, cognitive abilities, and any communication disorders. For patients with language differences, it is vital to provide trained medical interpreters when important information is communicated. Adapting communication according to an individual’s age and developmental level includes the following strategies 14 : • When communicating with children, speak calmly and gently. It is often helpful to demonstrate what will be done during a procedure on a doll or stuffed animal. To establish trust, try using play or drawing pictures. • When communicating with adolescents, give freedom to make choices within established limits. • When communicating with older adults, be aware of potential vision and hearing impairments that commonly occur and address these barriers accordingly. For example, if a patient has glasses and/or hearing aids, be sure these devices are in place before communicating. Strategies for Communicating With Patients With Impaired Hearing, Vision, and Speech In addition to adapting your communication to your audience, there are additional strategies to use with individuals who have impaired hearing, vision, or speech. Impaired Hearing 15 14. Butcher, H., Bulechek, G., Dochterman, J., & Wagner, C. (2018). Nursing interventions classification (NIC). Elsevier, pp. 115-116. 15. Butcher, H., Bulechek, G., Dochterman, J., & Wagner, C. (2018). Nursing interventions classification (NIC). Elsevier, pp. 115-116. 1.3 Communication Within the Health Care Team | 35

• Gain the person’s attention before speaking (e.g., through touch) • Minimize background noise • Position yourself 2-3 feet away from the patient • Facilitate lip-reading by facing the person directly in a well-lit environment • Use gestures, when necessary • Listen attentively, allowing the person adequate time to process communication and respond • Refrain from shouting at the person • Ask the person to suggest strategies for improved communication (e.g., speaking toward a better ear, moving to well-lit area, and speaking in a lower-pitched tone) • Face the person directly, establish eye contact, and avoid turning away mid-sentence • Simplify language (e.g., do not use slang but do use short, simple sentences), as appropriate • Read the care plan for information on the preferred method of communicating (whiteboards, pictures, etc.) • Assist the person using any devices such as hearing aids or voice amplifiers • Report any changes to the nurse Impaired Vision 16 • Identify yourself when entering the person’s space • Ensure the patient’s eyeglasses are cleaned and stored properly when not in use, and assist the patient in wearing them during waking hours • Provide adequate room lighting • Minimize glare (e.g., offer sunglasses, draw window covering, position with face away from window) • Provide educational materials in large print as available • Read pertinent information to the patient 16. Butcher, H., Bulechek, G., Dochterman, J., & Wagner, C. (2018). Nursing interventions classification (NIC). Elsevier, pp. 115-116. 36 | 1.3 Communication Within the Health Care Team

• Provide magnifying devices • Report any changes to the nurse Impaired Speech 17 Some patients may have problems processing what they are hearing or in responding to questions due to dementia, brain injuries, or prior strokes. This difficulty is referred to as aphasia. There are different types of aphasia. People with expressive aphasia understand speech and know what they want to say, but frequently speak in short phrases that are produced with great effort. For example, they may intend to say, “I would like to go to the bathroom,” but instead the words, “Bathroom, Go,” are expressed. People with receptive aphasia often speak in long sentences, but what they say may not make sense. They are unable to understand both verbal and written language. Aphasia often causes the person to become frustrated when they cannot communicate their needs. Review the following evidence-based strategies to enhance communication with a person with impaired speech 18 : • Modify the environment to minimize excess noise and decrease emotional distress • Phrase questions so the patient can answer using a simple “Yes” or “No,” being aware that patients with expressive aphasia may provide automatic responses that are incorrect • Monitor the patient for frustration, anger, depression, or other responses to impaired speech capabilities • Provide alternative methods of speech communication (e.g., writing tablet, flash cards, eye blinking, communication board with pictures and letters, hand signals or gestures, or computer) • Adjust your communication style to meet the needs of the patient (e.g., stand in front of the patient while speaking, listen attentively, present one idea or thought at a time, speak slowly but avoid shouting, use written 17. Butcher, H., Bulechek, G., Dochterman, J., & Wagner, C. (2018). Nursing interventions classification (NIC). Elsevier, pp. 115-116. 18. Butcher, H., Bulechek, G., Dochterman, J., & Wagner, C. (2018). Nursing interventions classification (NIC). Elsevier, pp. 115-116. 1.3 Communication Within the Health Care Team | 37

communication, or solicit the family’s assistance in understanding the patient’s speech) • Ensure the call light is within reach • Repeat what the client said to ensure accuracy • Instruct the client to speak slowly • Read the care plan for instructions from the speech therapist • Report any changes to the nurse Responding to Challenging Situations Being a care provider is a very rewarding career, but it also includes dealing with challenging situations. Using strong communication techniques can deescalate situations and put patients, loved ones, and staff at ease. It is impossible to predict what behavior you may encounter as a health care worker, but having a solid basis of communication techniques can prepare you to better handle unique situations. Memory Impairment and Behavioral Health Issues As a nursing assistant, you will likely encounter older adults with varying degrees of memory impairment. Older adults are defined as adults aged 65 years old or older. 19 Residents with memory issues often become confused and can feel overwhelmed by everyday situations. For those with impaired cognitive functioning like dementia, it may not be possible to reorient them to the current time and place or to move them on from thoughts that are not based in the current situation. Aphasia and confusion can cause frustration that can result in agitation or aggression. Agitation refers to behaviors that fall along a continuum ranging from verbal threats and motor restlessness to harmful aggressive and destructive behaviors. Mild agitation includes symptoms such as irritability, oppositional behavior, inappropriate language, and pacing. Severely agitated patients are at immediate risk of harming themselves or others through assaultive or self-injurious behavior, and they 19. HealthyPeople.gov. (n.d.). Older adults. Office of Disease Prevention and Health Promotion. https://www.healthypeople.gov/2020/topics-objectives/topic/older-adults 38 | 1.3 Communication Within the Health Care Team

are capable of causing property damage. 20 Aggression is an act of attacking without provocation. 21 Agitation and aggression will be discussed in more detail in Chapter 10, but general guidelines to prevent aggression and agitation include the following: • Keep the environment calm and as quiet as possible. • Build trusting relationships by learning resident preferences and routines. • Gather information from family members and loved ones about the patient’s background and beliefs. • Offer choices to allow the patient to communicate preferences, but do not cause them to be overwhelmed with too many decisions. • Stick to a daily routine for ADLs, meals, and activities. • Empathize with the resident and understand that challenging behavior is often communication of emotion due to cognitive impairment and not a choice. • Practice validation therapy. Validation therapy is a method of therapeutic communication used to connect with someone who has moderate- to late-stage dementia and avoid agitation. It places more emphasis on the emotional aspect of a conversation and less on the factual content, thereby imparting respect to the person, their feelings, and their beliefs. Validation may require you to agree with a statement that has been made, even though the statement is neither true or real, because to the person with dementia, it feels both true and real. 22 For example, if the resident with dementia believes they are waiting to catch the bus and is intent on doing so, sit with them by the window as if you are waiting for a bus and continue to have interaction with them until they are no longer concerned with the bus. • Redirect behavior if appropriate. For example, suggest alternative activities such as walking around the facility, looking at photos, listening to music, or other activities the resident enjoys. 20. ScienceDirect. (n.d.). Agitation. https://www.sciencedirect.com/topics/immunology-and-microbiology/agitation 21. Merriam-Webster. Aggression. https://www.merriam-webster.com/dictionary/aggression 22. Hoyt, J. (Ed.). (2020, January 27). Validation therapy in dementia care. SeniorLiving.org. https://www.seniorliving.org/ health/validation-therapy/ 1.3 Communication Within the Health Care Team | 39

• Focus on safety for residents experiencing delusions or hallucinations. Delusions are unshakable beliefs in something that isn’t true or based on reality. For example, a resident may refuse to eat breakfast because they have a delusion that staff are trying to poison them. Hallucinations are sensing things such as visions, sounds, or smells that seem real but are not. For example, a resident may refuse to enter a room because they have hallucinations of big spiders crawling on the walls. If a patient is having delusions or hallucinations, never contradict them or tell them what they perceive isn’t real. Instead, empathize with them and do whatever is possible to help them feel safe. For example, offer to move to another area or investigate what the resident is concerned about. Dealing With Stress The stress response is a common psychological barrier to effective communication. It can affect the message sent by the sender or the reception by the receiver. The stress response is a common reaction to life events, such as a health care worker feeling overwhelmed with tasks to complete for multiple patients or a patient feeling stressed when admitted to a hospital or receiving a new diagnosis. Symptoms of the stress response include irritability, sweaty palms, a racing heart, difficulty concentrating, and impaired sleep. It is important to recognize symptoms of the stress response in ourselves and our patients and use strategies to manage the stress response when communicating. There are several stress management strategies to use to manage the stress response 23 : • Use relaxation breathing to become aware of one’s breathing. This technique includes taking deep breaths in through the nose and blowing it out through the mouth. This process is repeated at least three times in succession and then as often as needed throughout the day. 23. American Psychological Association. (2019, November 1). Healthy ways to handle life's stressors. https://www.apa.org/ topics/stress/tips 40 | 1.3 Communication Within the Health Care Team

• Make healthy diet choices. Avoid caffeine, nicotine, and junk food because these items can increase feelings of anxiety or being on edge. • Make time for exercise. Exercise stimulates the release of natural endorphins that reduce the body’s stress response and also helps to improve sleep. • Get enough sleep. Set aside at least 30 minutes before going to bed to wind down from the busyness of the day. Avoid using electronic devices like cell phones before bedtime because the backlight can affect sleep. • Use progressive relaxation. There are several types of progressive relaxation techniques that focus on reducing muscle tension and using mental imagery to induce calmness. Progressive relaxation generally includes the following steps: ◦ Start by lying down somewhere comfortable and firm, like a rug or mat on the floor. Get yourself comfortable. ◦ Relax and try to let your mind go blank. Breathe slowly, deeply, and comfortably, while gradually and consciously relaxing all your muscles, one by one. ◦ Work around the body one main muscle area at a time, breathing deeply, calmly, and evenly. For each muscle group, clench the muscles tightly and hold for a few seconds, and then relax them completely. Repeat the process, noticing how it feels. Do this for each of your feet, calves, thighs, buttocks, stomach, arms, hands, shoulders, and face. Managing Clients’ and Family Members’ Stress Being cared for by strangers can feel very challenging to clients. Residents in long-term care settings have frequently experienced major physical and/or cognitive changes that caused a loss of their independence and sometimes some of their autonomy. Autonomy is each individual’s right to selfdetermination and decision-making based on their unique values, beliefs, and preferences. It is important for the nursing assistant to empathize with these losses and the new reality that residents must become accustomed to when 1.3 Communication Within the Health Care Team | 41

moving into a long-term care facility. Reflect on the exercise in the following box to understand a resident’s feelings during their transition: Reflection Activity When you wake up in the morning, imagine that you cannot get out of bed on your own. Think about putting on your call light as you need to use the restroom and having to wait until someone is available to help. As you look around the room, you see some of your belongings, but many are no longer there. The floor is clean but bare; your recliner is nearby but you can’t move into it. You wish you could go to the kitchen to have coffee with your partner, but they are no longer around. You miss your pet that used to sleep with you each night. Finally, an aide arrives, and although they are friendly, it is another new face that will help you to the bathroom and with other care needs. Clients usually become more comfortable with their new reality as they become familiar with a new routine and their new home. It is important to remember that emotions related to loneliness, feeling like a burden, and loss of independence can arise at any time. The nursing assistant can help residents adjust to their new environment in the following ways: • Greet clients by their preferred name and introduce yourself. • Ask clients their preferences for their care. Always communicate what you will be doing next and allow the resident to redirect or refuse care. • Provide privacy when assisting with cares. • Use confidentiality when documenting information or reporting to other members of the health care team. • Treat belongings carefully and with respect and remember the client’s room is their home. • Listen to the resident and address concerns if they arise. If you cannot adequately address the resident’s concerns, communicate these 42 | 1.3 Communication Within the Health Care Team

concerns to the nurse or supervisor. Family members and other loved ones may have questions and concerns about the resident’s care. Read more information about managing their concerns in the following “Dealing With Conflict” section. Dealing With Conflict Health care professionals provide personal care at integral times in the lives of patients. The demands of caregiving and the associated rapid decisionmaking process can create stress for health care team members, patients, family members, and other loved ones. Managing care and making decisions can cause conflict among all involved. As a nursing assistant, it is important to be aware of your role and responsibility when managing conflict. When a patient does not want to participate in care necessary to support their proper hygiene or health maintenance, the nursing assistant can use effective communication to encourage actions and promote desired outcomes. When a resident declines care, here are some actions the nursing assistant may use that respect their choices but allow care standards to be met: • Re-approach the resident at a later time. • Offer an alternative method. For example, a resident may not want to shower or take a bath but would be willing to have a full bed bath, allowing them to stay covered and warm throughout care. • Remind the resident what may occur if care is not provided, such as higher risk of infection, open areas in the skin, odor, etc. • Encourage as much control and independence as possible. Allow the resident to direct the process if able and offer as many choices as are appropriate. Family members and other supports may have concerns about the plan of care for a resident. This may be due to lack of medical knowledge, little experience with the procedures of health care facilities, or a feeling of 1.3 Communication Within the Health Care Team | 43

helplessness in regard to their loved one’s situation. The nursing assistant should listen to and acknowledge these concerns. Following confidentiality guidelines, interventions included in the plan of care can be discussed if the resident has permitted disclosure of this information. However, the nursing assistant should only disclose information when they have confirmed the resident has permitted disclosure. It may be beneficial for family members or others involved to discuss concerns with the nurse or unit supervisor and possibly schedule a care conference with the health care team to resolve their concerns. In this instance, the aide should understand that any anger directed at them may be a result of the situation rather than a reflection of anything they have personally done. Conflicts among coworkers can also be addressed with assertive communication techniques. As discussed in the “Communication Styles” subsection, using assertive communication is the best approach to address workplace conflict and a respectful way to make one’s viewpoints known. Communication should start between the two parties that have the conflict before involving other staff. It is best to think about the situation and develop a potential solution before approaching the coworker. Frame the situation from your perspective using “I” messages. If the situation is especially tense, it may be beneficial to allow some time between the experience and the discussion to reduce stress and think more logically about the conflict. A typical time frame is to wait one day to think logically about a conflict before addressing it, often referred to as the “24-hour Rule.” If you have discussed your concerns with the coworker and offered a potential solution without any resolution in the situation, it is appropriate to notify your supervisor for additional assistance at that time. See an example of conflict resolution in the following box. Example of Conflict Resolution A nursing assistant becomes frustrated with a coworker who works on the previous shift when they continue to neglect to 44 | 1.3 Communication Within the Health Care Team

empty the wastebaskets and tidy up the residents’ rooms before the end of their shift. When it became apparent this was a pattern of behavior and not an isolated incident due to an exceedingly busy shift, the nursing assistant approached the coworker and said, “I feel frustrated when I start my shift with full wastebaskets and untidy rooms for the residents you care for. Can you help me understand why these things aren’t accomplished by the end of your shift? It works for me to clean up the room when I am finished assisting the resident. That way I don’t forget to come back, and the residents seem to appreciate it as well.” The coworker apologized for this oversight and committed to completing these tasks before leaving at the end of their shift. 1.3 Communication Within the Health Care Team | 45

1.4 Human Needs and Developmental Stages It is important to understand human needs and developmental stages to communicate effectively and provide holistic care. Maslow’s Hierarchy of Needs Maslow’s Hierarchy of Needs was created in 1943 by American psychologist Abraham Maslow. Maslow’s theory is based on the ranking of the importance of human needs and the belief that human actions are based on motivation to meet these needs. See an illustration of Maslow’s Hierarchy of Needs in Figure 1.5. 1 Figure 1.5 Maslow’s Hierarchy of Needs Maslow’s theory states that unless the basic needs in the lower levels of the hierarchy are met, humans cannot experience the higher levels of 1. “Maslow%27s_Hierarchy_of_Needs2.svg” by Androidmarsexpress is licensed under CC.BY-SA 4.0 1.4 Human Needs and Developmental Stages | 47

psychological and self-fulfillment needs. The levels of Maslow’s Hierarchy of Needs have the following definitions 2 : 1. Physiological needs: This is the most important level with basic needs humans must have to stay alive and function, including air, food, drink, shelter, clothing, warmth, sex, and sleep. 2. Safety needs: People want to experience order, predictability, and control in their lives. This includes emotional security, freedom from fear, and health and well-being (such as safety against falls and injury). For new residents in a long-term care facility, this level includes becoming comfortable in familiar surroundings as opposed to feeling apprehension when experiencing a new environment. 3. Love and belongingness: After physiological and safety needs have been fulfilled, the third level of human needs is social and involves feelings of belongingness. Belongingness refers to a human emotional need for interpersonal relationships, connectedness, and being part of a group. A group may mean biological families, friends, or other supporters. It may also include physical intimacy and romantic relationships. 4. Esteem needs: Esteem needs include self-worth and feelings of accomplishment and respect. It includes how one views oneself and the feeling of contributing to something of importance. 5. Self-actualization: Self-actualization is the highest level and refers to the realization of a person’s potential and self-fulfillment. This level refers to the desire to attain life goals and being truly satisfied in being the most one can be. Maslow theorized that one cannot attain a higher level in any of these categories if the levels below are not met. For example, one is not motivated by a sense of belonging if they are focused on obtaining basic needs such as food, water, and shelter. The hierarchy is subjective because each individual determines what each level means for them. For instance, for one person, safety may mean living in the neighborhood where they grew up, whereas for 2. McLeod, S. (2020, March 20). Maslow’s hierarchy of needs. Simply Psychology. https://www.simplypsychology.org/ maslow.html 48 | 1.4 Human Needs and Developmental Stages

another individual it means having a daily routine. Belongingness to one person may mean being a part of a community group whereas to another it may mean having one very close friend. Self-esteem and feelings of accomplishment may be defined by one person as successfully graduating from high school, whereas to another it is defined by being able to run a mile without stopping. Self-actualization is defined by each individual and can mean things such as being a good parent, graduating from college, or achieving one’s dream of becoming a nurse. The levels of belongingness and self-actualization also include a person’s spirituality and how they find meaning and purpose in life. Spirituality is often mistakenly equated with religion, but spirituality is a broader concept that includes how people seek meaning and purpose in life, as well as establish relationships with family, their community, nature, and/or a higher power. 3 Maslow’s Hierarchy of Needs is a good basis for providing holistic care and communicating with clients based on their needs and preferences. For example, in nursing, priorities of care are based on physiological needs and safety. Additionally, knowing that a newly admitted resident may have difficulty reaching a higher level of needs if their basic needs are not met is a good starting point for providing care. Strategies that integrate Maslow’s Hierarchy of Needs when providing care to residents include the following: • Following the nursing plan of care to meet physiological needs. • Implementing fall precautions to keep residents safe. • Answering call lights promptly and consistently providing a calm, comfortable environment to make residents feel secure. • Respecting residents’ belongings and asking their preferences for grooming, bathing, and meals to satisfy self-esteem needs. • Encouraging interaction among residents with similar interests to 3. Puchalski, C. M., Vitillo, R., Hull, S. K., & Reller, N. (2014). Improving the spiritual dimension of whole person care: Reaching national and international consensus. Journal of Palliative Medicine, 17(6), 642–656. https://doi.org/10.1089/ jpm.2014.9427 1.4 Human Needs and Developmental Stages | 49

promote a feeling of belongingness. • Offering to bring residents to on-site religious activities or referring them to social services for a chaplain visit to promote self-actualization and a feeling of belongingness. Maslow’s Hierarchy of Needs can also be applied to the work environment to enhance professionalism by doing the following: • Offering assistance to coworkers when able to promote a feeling of security and belongingness and also maintaining residents’ physiological needs and safety as a team. • Participating fully in the reporting and documentation process of the facility to meet residents’ physiological and safety needs. • Accurately following training and agency policies and procedures to encourage feelings of self-esteem in the health care worker. • Being accountable for one’s actions and job responsibilities to promote a feeling of self-actualization by meeting one’s potential. Erikson’s Stages of Development Another psychologist named Erik Erikson created a theory of psychosocial development that also describes how one’s personality is developed. It theorizes there are eight stages of development based on a person’s chronological age. Development occurs based on the main conflict or challenge confronted during that period of time. Each stage can create either a virtue/strength or a maladaptive tendency. Erikson proposed that those who have a stronger sense of identity from resolving these conflicts over time have fewer conflicts within themselves and with others and, subsequently, a decreased level of anxiety. 4 Erikson’s stages of development are defined as trust versus mistrust, autonomy versus shame, initiative versus guilt, industry versus inferiority, 4. This work is a derivative of StatPearls by Orenstein and Lewis and is licensed under CC BY 4.0 50 | 1.4 Human Needs and Developmental Stages

identity versus identity confusion, intimacy versus isolation, generativity versus stagnation, and integrity versus despair 5 : • Trust vs. Mistrust The first stage establishes trust (or mistrust) that basic needs, such as nourishment and affection, will be met. Trust is the basis of our development during infancy (birth to 12 months). Infants are dependent on their caregivers, so caregivers who are responsive and sensitive to their infant’s needs help their baby to develop a sense of trust; their baby will see the world as a safe, predictable place. Unresponsive caregivers who do not meet their baby’s needs can engender feelings of anxiety, fear, and mistrust; their baby may see the world as unpredictable. 6 • Autonomy vs. Shame Toddlers begin to explore their world and learn that they can control their actions and act on the environment to get results. They begin to show clear preferences for certain elements of the environment, such as food, toys, and clothing. A toddler’s main task is to resolve the issue of autonomy versus shame and doubt by working to establish independence. For example, we might observe a budding sense of autonomy in a two-year-old child who wants to choose her clothes and dress herself. Although her outfits might not be appropriate for the situation, her input in such basic decisions has an effect on her sense of independence. If denied the opportunity to act on her environment, she may begin to doubt her abilities, which could lead to low self-esteem and feelings of shame. 7 • Initiative vs. Guilt 5. This work is a derivative of Psychology 2e by OpenStax and is licensed under CC BY 4.0. Access for free at https://openstax.org/books/psychology-2e/pages/1-introduction 6. This work is a derivative of Psychology 2e by OpenStax and is licensed under CC BY 4.0. Access for free at https://openstax.org/books/psychology-2e/pages/1-introduction 7. This work is a derivative of Psychology 2e by OpenStax and is licensed under CC BY 4.0. Access for free at https://openstax.org/books/psychology-2e/pages/1-introduction 1.4 Human Needs and Developmental Stages | 51

Once children reach the preschool stage (ages 3–6 years), they are capable of initiating activities and asserting control over their world through social interactions and play. By learning to plan and achieve goals while interacting with others, preschool children can master this task. Those who do will develop self-confidence and feel a sense of purpose. Those who are unsuccessful at this stage may develop feelings of guilt. 8 • Industry vs. Inferiority During the elementary school stage (ages 7–11), children begin to compare themselves to their peers to see how they measure up. They either develop a sense of pride and accomplishment in their schoolwork, sports, social activities, and family life, or they feel inferior and inadequate when they don’t measure up. 9 • Identity vs. Identity Confusion In adolescence (ages 12–18), children develop a sense of self. Adolescents struggle with questions such as “Who am I?” and “What do I want to do with my life?” Along the way, most adolescents try on many different selves to see which ones fit. Adolescents who are successful at this stage have a strong sense of identity and are able to remain true to their beliefs and values in the face of problems and other people’s perspectives. Teens who do not make a conscious search for identity or those who are pressured to conform to their parents’ ideas for the future may have a weak sense of self and experience role confusion as they are unsure of their identity and confused about the future. 10 • Intimacy vs. Isolation 8. This work is a derivative of Psychology 2e by OpenStax and is licensed under CC BY 4.0. Access for free at https://openstax.org/books/psychology-2e/pages/1-introduction 9. This work is a derivative of Psychology 2e by OpenStax and is licensed under CC BY 4.0. Access for free at https://openstax.org/books/psychology-2e/pages/1-introduction 10. This work is a derivative of Psychology 2e by OpenStax and is licensed under CC BY 4.0. Access for free at https://openstax.org/books/psychology-2e/pages/1-introduction 52 | 1.4 Human Needs and Developmental Stages

People in early adulthood (i.e., 20s through early 40s) are ready to share their lives with others after they have developed a sense of self. Adults who do not develop a positive self-concept in adolescence may experience feelings of loneliness and emotional isolation. 11 • Generativity vs. Stagnation When people reach their 40s, they enter a time period known as middle adulthood that extends to the mid-60s. The social task of middle adulthood is generativity versus stagnation. Generativity involves finding your life’s work and contributing to the development of others, through activities such as volunteering, mentoring, and raising children. Those who do not master this task may experience stagnation, having little connection with others and little interest in productivity and self-improvement. 12 • Integrity vs. Despair The mid-60s to the end of life is a period of development known as late adulthood. People in late adulthood reflect on their lives and feel either a sense of satisfaction or a sense of failure. People who feel proud of their accomplishments feel a sense of integrity and often look back on their lives with few regrets. However, people who are not successful at this stage may feel as if their life has been wasted. They focus on what “would have,” “should have,” or “could have” been. They face the end of their lives with feelings of bitterness, depression, and despair. 13 By combining Maslow’s and Erickson’s theories of development and motivation, we can begin to understand why some patients need more 11. This work is a derivative of Psychology 2e by OpenStax and is licensed under CC BY 4.0. Access for free at https://openstax.org/books/psychology-2e/pages/1-introduction 12. This work is a derivative of Psychology 2e by OpenStax and is licensed under CC BY 4.0. Access for free at https://openstax.org/books/psychology-2e/pages/1-introduction 13. This work is a derivative of Psychology 2e by OpenStax and is licensed under CC BY 4.0. Access for free at https://openstax.org/books/psychology-2e/pages/1-introduction 1.4 Human Needs and Developmental Stages | 53

encouragement, space, or time to allow caregivers to provide assistance with their ADLs to maintain physical and emotional health. View the following YouTube video 14 for more information about Erikson’s theory of development: Erikson’s Psychosocial Development | Individuals and Society. Assisting With Spiritual Needs When clients experience a serious illness or injury, they often grapple with the existential question, “Why is this happening to me?” This question can be a sign of spiritual distress defined as, “A state of suffering related to the inability to experience meaning in life through connections with self, others, the world, or a superior being.” Spiritual well-being is a pattern of experiencing meaning and purpose in life through connectedness with self, others, art, music, literature, nature, and/or a power greater than oneself. Spirituality is often mistakenly equated with religion, but spirituality is a broader concept. Elements of spirituality include faith, meaning, love, belonging, forgiveness, and connectedness. 15 Spirituality and religion can change over a person’s lifetime and vary greatly between people. Some people who are very spiritual may not belong to a specific religion. Religion is frequently defined as an institutionalized set of beliefs and practices. Many religions have specific rules about food, religious rituals, clothing, and touching. Supporting these rules when they are meaningful part of a resident’s spirituality is an effective way to support the resident and maintain a caring, professional relationship. The nursing assistant should discuss these aspects with the nurse to assure they support the plan of care 14. Desai, S. (2014, February 25). Erikson’s psychosocial development | Individuals and society | MCAT | Khan Academy [Video]. YouTube. Licensed under CC BY-NC-SA. https://youtu.be/SIoKwUcmivk 15. Herdman, T. H., & Kamitsuru, S. (Eds.). (2018). Nursing diagnoses: Definitions and classification, 2018-2020. Thieme Publishers New York, pp. 365, 372-377. 54 | 1.4 Human Needs and Developmental Stages

for the resident and encourage other staff members to provide support. Many nursing homes and assisted living facilities offer religious or spiritual opportunities through their Activities departments. Many hospitals, nursing homes, assisted living facilities, and hospices employ professionally trained chaplains to assist with the spiritual, religious, and emotional needs of clients, family members, and staff. In these settings, chaplains support and encourage people of all religious faiths and cultures and customize their approach to each individual’s background, age, and medical condition. Chaplains can meet with any individual regardless of their belief, or lack of belief, in a higher power and can be very helpful in reducing anxiety and distress. 16 NAs may suggest chaplain services for their clients. An important way to assist a client with their spiritual well-being is to ask them what they need to feel supported in their faith and then try to accommodate their requests, if possible. Explain that spiritual health helps the healing process. For example, perhaps they would like to speak to their clergy, spend some quiet time in meditation or prayer without interruption, or go to the on-site chapel. Many agencies have chaplains onsite that can be offered to patients as a spiritual resource. 17 If the client or family member requests a nursing assistant to pray with them, it is acceptable to pray with them or find someone who will. Some nursing assistants may feel reluctant to pray with patients when they are asked for various reasons; they may feel underprepared, uncomfortable, or unsure if they are “allowed to.” Nursing assistants, nurses, and other health care team members are encouraged to pray with their patients to support their spiritual health, as long as the focus is on the patient’s preferences and beliefs, not their own preferences. Having a short, simple prayer ready that is appropriate for any faith may help a health care professional feel prepared for this situation. However, if the nursing assistant does not feel comfortable praying 16. This work is a derivative of Nursing Fundamentals by Chippewa Valley Technical College and is licensed under CC BY 4.0 17. This work is a derivative of Nursing Fundamentals by Chippewa Valley Technical College and is licensed under CC BY 4.0 1.4 Human Needs and Developmental Stages | 55

with the patient as requested, the nurse should be notified so the chaplain can be requested to participate in prayer with the patient. 18 It is important to support clients within their own faith tradition, but it is not appropriate for the nursing assistant to take this opportunity to attempt to persuade a patient towards a preferred religion or belief system. The role of the nursing assistant is to respect and support the client’s values and beliefs, not promote the nursing assistant’s values and beliefs. 19 18. This work is a derivative of Nursing Fundamentals by Chippewa Valley Technical College and is licensed under CC BY 4.0 19. This work is a derivative of Nursing Fundamentals by Chippewa Valley Technical College and is licensed under CC BY 4.0 56 | 1.4 Human Needs and Developmental Stages

1.5 Documenting and Reporting Guidelines for Documentation Accurate documentation and reporting are vital to proper client care. Reporting is oral communication between care providers that follows a structured format and typically occurs at the start and end of every shift or whenever there is a significant change in the resident. Documentation is a legal record of patient care completed in a paper chart or electronic health record (EHR). It is also referred to as charting. Checklists and flowcharts completed in the resident’s room may also become part of the paper chart. Documentation is used in a court of law to prove patient care was completed if a lawsuit is filed, with the rule of thumb being, “If it wasn’t documented, it wasn’t done.” Documentation is also reviewed by other health care team members to provide holistic care. Accurate documentation should follow these guidelines: • The client’s chart is confidential and should only be shared with those directly involved in care. If using paper, cover information with a blank sheet. When using technology, be sure screens are visible only to you and log out after each use. Never share security measures like passwords or PIN with anyone else. • Document as soon as any care is completed. • Include date, time, and signature per facility policy. • Use facts, not opinions. An opinion is, “The resident doesn’t like their food.” Instead, a fact should be charted, such as, “The resident refused their meal and stated they were not hungry.” • Use measuring tools, such as a graduated cylinder or a tape measure, whenever possible to provide accurate data. If you do have to estimate, provide a comparison such as, “Drainage noted on the bandage was the size of a quarter.” • If you chart on paper, always use a black pen. If you make a mistake, draw only one line through the entry, write the word “mistaken entry,” and add your initials. Do not use correction fluid or completely black out the entry. 1.5 Documenting and Reporting | 57

Long-term care facilities are required to complete additional documentation called a Minimum Data Set (MDS). The MDS is a standardized assessment tool for all residents of long-term care facilities certified to receive reimbursement by Medicare or Medicaid. The MDS is completed by a registered nurse who reviews documentation by nursing assistants to complete some parts of the MDS. Accurate documentation is vital so that facilities are appropriately reimbursed for the services provided to clients. The MDS nurse will review the nursing assistant’s documentation pertaining to a resident’s sensory abilities, specifically their communication skills, hearing, and vision. For this reason, documentation must be accurate and thorough regarding assistive devices, the amount of assistance required, and skin observations. For example, devices for communication, such as whiteboards, photo books, charts, hearing aids, or glasses, must be appropriately documented, as well as the amount of assistance required for dressing, bathing, eating, toileting, repositioning in bed, transferring, and ambulating. Skin observations made during cares should also be thoroughly documented so they can be included in MDS reporting. View the MDS PDF from the Centers for Medicaid and Medicare Services. Guidelines for Reporting Reporting client information to other nursing assistants or to a nurse for follow-up is an important part of meeting client needs and providing competent care. When providing an oral report, be mindful of confidentiality and where the report is given so no one overhears private information. Appropriate places for reporting include a closed room, a nurse’s station away from resident rooms and common areas, or in a private resident’s room with the door closed. Throughout this textbook, specific information that should be documented 58 | 1.5 Documenting and Reporting

and reported will be noted. Generally, a nursing assistant should report any physical changes in a client that seem unusual or behavior that is out of the ordinary for that person. Examples that require immediate notification to the nurse may include the following: • Strong odors from urine, oral care, or wounds • Reddened, warm, or open skin areas • Difficulty breathing or chest pain Objective information includes information about a client that can be observed through the four senses of sight, touch, hearing, or smell. This information is referred to as signs. Objective information can be verified by another individual and often includes measuring tools such as a scale, thermometer, specimen cup, or graduated cylinder. An example of objective information is the client’s temperature was 98.6 degrees Fahrenheit. Subjective information is information reported to you by clients or their family members. This information is referred to as symptoms. It is documented by using the exact wording reported with quotation marks. An example of subjective information is the resident stating, “I have a headache.” Military Time Military time is used to record the time care is provided and any other pertinent information for the resident. It avoids confusion between daytime and nighttime hours because it does not require a.m. or p.m. Each hour of the day has its own number from 1 to 24 and no colons are used. Beginning at 1:00 p.m., simply add 12 to the hour. For example, 1:46 p.m. is written as 1346. For morning hours up to 9:59 p.m., add a zero in front of the hour. For example, 9:24 a.m. is written as 0924. Midnight is documented as either 2400 or 0000. When reporting in military time, morning hours are pronounced beginning with “zero” or “O.” For example, 7:00 a.m. is pronounced “zero seven hundred” 1.5 Documenting and Reporting | 59

or “oh seven hundred.” The time of 2:43 p.m. is pronounced “fourteen fortythree.” See Figure 1.6 1 below for conversion from civilian to military time. Figure 1.6 Military Time 1. “Military Time Clock 3I3A0711.jpg” by Deanna Hoyord for Chippewa Valley Technical College is licensed under CC BY 4.0 60 | 1.5 Documenting and Reporting

1.6 Learning Activities An interactive H5P element has been excluded from this version of the text. You can view it online here: https:/ wtcs.pressbooks.pub/nurseassist/?p=145#h5p-1 An interactive H5P element has been excluded from this version of the text. You can view it online here: https:/ wtcs.pressbooks.pub/nurseassist/?p=145#h5p-2 An interactive H5P element has been excluded from this version of the text. You can view it online here: https:/ wtcs.pressbooks.pub/nurseassist/?p=145#h5p-3 An interactive H5P element has been excluded from this version of the text. You can view it online here: https:/ wtcs.pressbooks.pub/nurseassist/?p=145#h5p-4 1.6 Learning Activities | 61

I Glossary Active listening: Listening while communicating verbally and nonverbally that we are interested in what the other person is saying and also verifying our understanding with the speaker. Activities of daily living (ADLs): Daily basic tasks that are fundamental to everyday functioning (e.g., hygiene, elimination, dressing, eating, ambulating/ moving). Aggression: The act of attacking without provocation. Aggressive communicators: Individuals who come across as advocating for their own rights when communicating despite possibly violating the rights of others. Agitation: Behaviors that fall along a continuum ranging from verbal threats and motor restlessness to harmful aggressive and destructive behaviors. Aphasia: A condition with difficulty processing what one is hearing or responding to questions due to dementia, brain injuries, or strokes. Assertive communication: A way of conveying information that describes the facts and the sender’s feelings without disrespecting the receiver’s feelings. Assertive communicators: Individuals who respect the rights of others while also standing up for their own ideas and rights when communicating. Autonomy: Each individual’s right to self-determination and decision-making based on their unique values, beliefs, and preferences. Belongingness: A human emotional need for interpersonal relationships, connectedness, and being part of a group. Communication: A process by which information is exchanged between individuals through a common system of symbols, signs, or behavior. I Glossary | 63

Competitive listening: Listening that occurs when we are primarily focused on sharing our own point of view instead of listening to someone else. Delusions: Unshakable beliefs in something that isn’t true or based on reality. Diet and fluid orders: Orders regarding what the resident is permitted to eat and drink. Documentation: A legal record of patient care completed in a paper chart or electronic health record (EHR). Elimination needs: Assistance the resident requires for urinating and passing stool. Hallucinations: A condition where a person senses things such as visions, sounds, or smells that seem real but are not. Holistic care: Health care that addresses a patient’s physical, emotional, social, and spiritual needs. Maslow’s Hierarchy of Needs: A theory stating that unless basic human needs within a hierarchy are met, humans cannot experience higher levels of psychological and self-fulfillment needs. Military time: A standard for recording time that avoids confusion between daytime and nighttime hours because each hour of the day is represented by a number ranging from 00:00 to 24:59. Minimum Data Set (MDS): A standardized assessment tool for all residents of long-term care facilities certified to receive reimbursement by Medicare or Medicaid. Nonverbal communication: Communication that includes body language and facial expressions, tone of voice, and pace of the conversation. Objective information: Anything that can be observed through sight, touch, hearing, or smell, referred to as “signs.” An example of objective information is the client’s temperature was 98.6 degrees Fahrenheit. 64 | I Glossary

Older adults: Adults aged 65 years old or older. Passive communicator: Individuals who put the rights of others before their own when communicating. Passive listening: Listening that occurs when we are not interested in listening to the other person or we assume we correctly understand what the person is communicating without verifying their message. Progressive relaxation: Stress management techniques that focus on reducing muscle tension and using mental imagery to induce calmness. Relaxation breathing: A stress management technique focused on becoming aware of one’s breathing. Reporting: Oral communication between care providers that follows a structured format and typically occurs at the start and end of every shift. Signs: Objective information obtained through the senses of sight, hearing, smell, or touch. Stress response: The body’s response to stress that can include irritability, sweaty palms, a racing heart, difficulty concentrating, and impaired sleep. Subjective information: Information reported by clients or their family members referred to as “symptoms.” An example of subjective information is the resident stating, “I have a headache.” Symptoms: Subjective information reported by clients or their family members. Symptoms are documented by using quotes around the exact words expressed by the client or their family member. For example, the client reported, “I have a headache.” Therapeutic communication: A type of professional communication used with patients defined as the purposeful, interpersonal, informationtransmitting process through words and behaviors based on both parties’ knowledge, attitudes, and skills that leads to patient understanding and participation. I Glossary | 65

Transfer status: Assistance the patient requires to be moved from one location to another, such as from the bed to a chair. Validation therapy: A method of therapeutic communication used to connect with someone who has moderate to late-stage dementia and avoid agitation. 66 | I Glossary

2.1 Introduction to Demonstrate Professionalism in the Workplace Learning Objectives • Function within and uphold the ethical and legal responsibilities of the nursing assistant • Carry out assignments • Develop job-seeking and keeping skills • Protect rights of clients • Treat all clients respectfully regardless of social, ethnic, or religious background • Apply strategies to cope with caregiver stress • Differentiate the nursing assistant role in a variety of health care settings In this chapter you will learn about professional responsibilities associated with becoming a licensed nursing assistant. Resident rights are at the forefront of providing care to ensure quality of life for dependent individuals. You will become familiar with the agencies involved in regulation of longterm care, legislative acts that uphold resident rights, and the nursing assistant scope of practice. You will gain awareness about your role within the health care team, the facility, and the nursing process, as well as the variety of health care settings in which you may work as a nursing assistant. 2.1 Introduction to Demonstrate Professionalism in the Workplace | 69

2.2 Ethical and Legal Responsibilities of the Nursing Assistant Ethical Responsibilities of the Nursing Assistant Nursing assistants should treat all clients equally and with compassion and respect for their inherent dignity, worth, and unique attributes. They should promote clients’ rights and safety to assist in achieving the best possible health and functioning. Read more about resident rights in the box later in this section. As a student or a newly employed nursing assistant, you may find yourself in circumstances where you observe unethical behaviors exhibited by other agency staff. Examples of unethical behavior to avoid are as follows 1 : • Using a personal cell phone in patient care areas • Not responding to call lights promptly when you are available to do so • Ignoring the phone(s) assigned to you • Using agency computers for personal use • Avoiding clients because of their ethnicity, beliefs, demeanors, or other individual characteristics • Avoiding work by sitting in empty patient rooms or the break room during on-time work hours • Accepting gifts or gratuities from clients or their family members • Sharing clients’ personal information with others who are not providing direct care • Stealing items from clients or the health care agency Governing Agencies When you work as a nursing assistant, you are helping vulnerable populations. Vulnerable populations include patients who are children, older adults, minorities, socially disadvantaged, underinsured, or those with certain 1. Miller-Hoover, S. (2018). I said what? Professionalism for the CNA. RN.com. https://www.rn.com/featured-stories/ professionalismcna/#:~:text=Professional%20CNAs%20are%20responsible%2C%20trustworthy,and%20being%20a%20team%20player 70 | 2.2 Ethical and Legal Responsibilities of the Nursing Assistant

medical conditions. Members of vulnerable populations often have health conditions that are exacerbated by inadequate health care. 2 As a result, there are many governing agencies involved in the care of these clients to ensure their needs are met. Federal agencies that regulate and provide guidelines for health care include the following: • Centers for Medicare and Medicaid (CMS): The CMS provides health care funding for qualifying members. Medicare is health care funding available to anyone over the age of 65, as well as those who have a permanent disability or kidney failure. There are four types of coverage that Medicare provides: care in hospitals and nursing homes (Part A); medical appointments, services, and equipment (Part B); additional services provided by private companies (Part C); and prescription drug coverage (Part D). Medicaid is health care funding available for individuals with low incomes and is provided at both the federal and state level. Both Medicare and Medicaid may cover services for resident care based on each individual’s needs. 3 , 4 • Centers for Disease Control (CDC): The CDC provides guidance for facilities related to infection and disease control. 5 • Food and Drug Administration (FDA): The FDA protects public health by ensuring the safety of medications, biological products, medical devices, cosmetics, products that emit radiation, and the food supply. It also regulates tobacco products and helps the public get the accurate, science-based information they need to use medical products and foods to maintain and improve their health. 6 • Occupational Safety and Health Administration (OSHA): OSHA ensures 2. Waisel, D. B. (2013). Vulnerable populations. Current Opinion in Anaesthesiology, 26(2), 186-192. https://doi.org/10.1097/ aco.0b013e32835e8c17 3. Medicare.gov. U.S. Centers for Medicare and Medicaid Services. https://www.medicare.gov/ 4. Medicaid.gov. U.S. Centers for Medicare and Medicaid Services. https://www.medicaid.gov/ 5. Centers for Disease Control and Prevention. (2021, September 24). About CDC 24-7. https://www.cdc.gov/about/ default.htm 6. U.S. Food & Drug Administration. (2018, March 28). What we do. https://www.fda.gov/about-fda/what-we-do 2.2 Ethical and Legal Responsibilities of the Nursing Assistant | 71

safe and healthy working conditions for workers by setting and enforcing standards and by providing training, outreach, education, and assistance. 7 Every state has a Department of Health Services (DHS) that works with local counties, health care providers, and community partners. The DHS provides services that aid and protect the state’s citizens, such as alcohol and drug abuse prevention programs, mental health programs, public health services, disability determination, implementation of long-term care, and regulation of state nursing homes, along with numerous other services. Read more about Wisconsin’s Department of Health Services at the About the Department of Health Services (DHS) web page. Federal Health Care Acts In addition to government agencies, there are federal laws that directly affect health care. The Health Insurance Portability and Accountability Act of 1996 (HIPAA) required the creation of national standards to protect sensitive patient health information from being disclosed without the patient’s consent or knowledge. The HIPAA security rule requires the following: • Ensure the confidentiality, integrity, and availability of all protected health information (PHI) • Detect and safeguard against anticipated threats to the security of the information • Protect against anticipated impermissible uses or disclosures • Certify compliance by their workforce As a nursing assistant, this means that you must legally keep any information 7. Occupational Safety & Health Administration. (n.d.). About OSHA. United States Department of Labor. https://www.osha.gov/aboutosha 72 | 2.2 Ethical and Legal Responsibilities of the Nursing Assistant

regarding the care of your clients confidential, including documentation, care plans, and shift reports. Refer to the “Guidelines for Reporting” subsection in Chapter 1 for more details about confidential reports. Read more about HIPAA at the CDC’s Health Insurance Portability and Accountability Act of 1996 (HIPAA) web page. The Omnibus Reconciliation Act of 1987 (OBRA) set forth new provisions for Medicare and Medicaid related to new standards for care in the nursing home setting. One major provision was a requirement for nurse aide training. It required that new nurse aides train for a minimum of 75 hours and pass a competency evaluation and that each state records a registry for nurse aides who have passed the competency evaluation. It also focused on improving quality of life for residents in long-term care (LTC), focusing on patientcentered care and meeting the preferences of each individual in making decisions regarding their care. 8 Read more about long-term care settings in the “Health Care Settings” section of this chapter. During patient-centered care, an individual’s specific health needs and desired health outcomes are the driving forces behind all health care decisions. Patients are partners with the health care team members, and health care professionals treat patients not only from a clinical perspective, but also from an emotional, mental, spiritual, social, and financial perspective. 9 The Older Americans Act (OAA) was passed in 1965 in response to concern by policymakers about a lack of community social services for older persons. The original legislation established authority for grants to states for community planning and social services, research and development projects, and personnel training in the field of aging. It also includes states’ Long-Term Care 8. Kelly, M. (1989). The omnibus budget reconciliation act of 1987. A policy analysis. The Nursing Clinics of North America, 24(3), 791-794. https://pubmed.ncbi.nlm.nih.gov/2671955/ 9. NEJM Catalyst. (2017, January 1). What is patient-centered care? Massachusetts Medical Society. https://catalyst.nejm.org/doi/full/10.1056/CAT.17.0559 2.2 Ethical and Legal Responsibilities of the Nursing Assistant | 73

(LTC) Ombudsman programs that work to resolve problems related to the health, safety, welfare, and rights of individuals who live in LTC facilities, such as nursing homes, assisted living facilities, and other residential care communities. The OAA act requires the following of ombudsman programs 10 : • Identify, investigate, and resolve complaints made by or on behalf of residents • Provide information to residents about long-term services and supports • Ensure that residents have regular and timely access to ombudsman services • Represent the interests of residents to governmental agencies and seek administrative, legal, and other remedies to protect residents • Analyze, comment on, and recommend changes in laws and regulations pertaining to the health, safety, welfare, and rights of residents Resident Rights As a health care regulator, the CMS ensures residents know and understand their rights and these rights are upheld. Resident rights are the most important aspect of providing care. It is essential for health care workers to protect the dignity of residents and enhance their quality of life. A concise list of resident rights that are protected in long-term care and other settings is described in the following box. Resident Rights in Long-Term Care and Other Settings 11 • Be treated with respect • Participate in activities 10. Administration for Community Living. (2021, November 24). Long-term care ombudsman program. https://acl.gov/ programs/Protecting-Rights-and-Preventing-Abuse/Long-term-Care-Ombudsman-Program 11. Centers for Medicare & Medicaid Services. (n.d.). Residents' rights & quality of care. https://www.cms.gov/nursinghomes/patients-caregivers/residents-rights-quality-care 74 | 2.2 Ethical and Legal Responsibilities of the Nursing Assistant

• Be free from discrimination, restraints, abuse, and neglect • Make complaints • Receive proper medical care • Make decisions regarding one’s care with the involvement of family and loved ones if desired • Have one’s representative notified of care and complications • Receive information about services and fees • Manage one’s money • Receive privacy and proper living arrangements • Spend time with visitors • Receive social services • Be protected against unfair transfers or discharges • Have the ability to leave the facility when health status allows, either temporarily or permanently • Create or participate in groups These guidelines should be at the forefront of your mind with any resident interaction. It is important for NAs to remember that it can be difficult for residents to accept being dependent on a caregiver for completing their ADLs. This feeling of dependency can cause them to lose self-esteem or even lead to depression. Refer back to the exercise in the “Managing Clients’ and Family Members’ Stress” subsection in Chapter 1 to recall how to empathize with residents. If a resident has a request, you should make accommodations to meet their needs as appropriate. If you are unsure how to meet their request, consult with your supervising nurse. The only reason a resident preference should not be granted would be due to safety or infection control concern. For example, if a resident wants to have a candle in their room, the risk of fire would not allow this request, but an alternative would be an electric candle. If a resident wanted to use a hair dryer but their roommate could possibly burn themselves due to altered safety awareness, the facility 2.2 Ethical and Legal Responsibilities of the Nursing Assistant | 75

should work to find a secure place where the resident could use the hair dryer. For more information, read the Your Rights and Protections as a Nursing Home Resident PDF. Learning Activity Resident rights quiz: Resident Rights Quizlet Elder Abuse and Neglect As discussed in the “Resident Rights” section, clients are to be free from abuse and neglect. Elder abuse is an intentional act, or failure to act, that causes or creates a risk of harm to someone age 60 or older. The abuse occurs at the hands of a caregiver or a person the older adult trusts. Neglect refers to a failure to provide care for oneself or to someone for whom you are enlisted to care. Review Table 2.2 for types of abuse and neglect and signs or symptoms that you should report to the nurse. Table 2.2 Types of Abuse and Signs or Symptoms to Report 12 , 13 12. Centers for Disease Control and Prevention. (2021, June 2). Preventing elder abuse. https://www.cdc.gov/ violenceprevention/elderabuse/fastfact.html 13. Washington State Department of Social and Health Services. (n.d.). Self-neglect. https://www.dshs.wa.gov/node/ 2444/#signs 76 | 2.2 Ethical and Legal Responsibilities of the Nursing Assistant

Type of Abuse Definition Signs or Symptoms Physical Illness, pain, injury, functional impairment, distress, or death as a result of the intentional use of physical force. This includes acts such as hitting, kicking, pushing, slapping, and burning. Bruising, fractures, burns, or any other unexplainable injury. The abused person may isolate themselves, withdraw from conversation, or change behavior when the abuser is present. Sexual Forced or unwanted sexual interaction of any kind. This may include unwanted sexual contact, penetration, or noncontact acts such as sexual harassment. Injury to genital areas, rashes, infections, bleeding or discharge from genitals, torn clothing, and behavioral changes listed under “Physical” abuse “Signs or Symptoms.” Emotional or Psychological Verbal or nonverbal behaviors that inflict anguish, mental pain, fear, or distress on an older adult. Examples include humiliation or disrespect, verbal and nonverbal threats, control of one’s actions, harassment, or isolation from other loved ones. Depression, anxiety, loss of self-confidence or motivation, or feelings of failure. Financial Illegal, unauthorized, or improper use of an older adult’s money, benefits, belongings, property, or assets for the benefit of someone other than the older adult. Missing items; going without food, medications, or other necessities; or excessive use of cash if they cannot account for the spending. Neglect Failure to meet an older adult’s basic needs, including food, water, shelter, clothing, hygiene, and essential medical care. Weight loss, skin breakdown, infection, confusion, hallucinations, dehydration, soiled linens and clothing, odors, or poor oral care. Self-Neglect Lack of self-care that threatens personal health and safety, including a failure to seek help for care. See “Signs or Symptoms” listed under “Neglect.” Nursing assistants and other health care professionals are referred to as mandated reporters because they are required by state law to report suspected neglect or abuse of the elderly, vulnerable adults, and children. As a caregiver, you are required to report any signs or symptoms that are suspicious for abuse or neglect to the nurse. At the time of the finding, you must stay with the resident until you can ensure that no further abuse or 2.2 Ethical and Legal Responsibilities of the Nursing Assistant | 77

neglect occurs, even if you are in a facility. If a resident reports any abuse, you are obligated to inform the nurse, charge nurse, or an administrator, regardless of the cognitive function of the person reporting so that an investigation can be performed. The Survey Process Each state’s Department of Health Services (DHS) conducts surveys of longterm care (LTC) facilities under the guidelines provided by the CMS. Standard surveys typically occur at least one time per year. During a survey, DHS employees observe care provided to residents, watch preparation and serving of food, review resident care plans and facility documentation, interview residents and families, and look at every aspect of the facility. The surveyors are ensuring that all aspects of residents’ physical, emotional, social, and spiritual needs are met. If you are a nurse aide being observed or interviewed, it is important to only provide facts. If you do not know the answer to a question, respond that you do not know the answer and explain that you will find an answer as soon as possible. You can offer things like, “I need to check my care plan for that information,” or “I would ask the nurse for clarification,” as appropriate to the question. 14 If a problem or discrepancy is discovered during a survey, the facility receives a citation from the surveyors. At the end of the survey process, DHS will conduct an exit interview with the Administrator, Director of Nursing (DON), and other facility leadership. When residents are found to be at a high risk for adverse events, the surveyors will ask the facility to create a plan to correct the issues. DHS will make a return visit in a few weeks to follow up on the implementation. DHS may also conduct a survey if they have received several complaints from residents or family members or if certain events occur such as elopement of a resident or an accident with a major injury. Elopement is defined as an event 14. Institute of Medicine (US), Committee on Nursing Home Regulation. (1986). Improving the quality of care in nursing homes. National Academies Press (US); 1986. 4, Monitoring nursing home performance. https://www.ncbi.nlm.nih.gov/books/NBK217555/ 78 | 2.2 Ethical and Legal Responsibilities of the Nursing Assistant

when a resident who is incapable of protecting themselves from harm is able to successfully leave the facility unsupervised and unnoticed and possibly enter into harm’s way. 15 The results of a survey must be made available to the public. They must be posted at the entrance to the facility, along with information on how to contact the ombudsmen. They are also available electronically at medicare.gov. Read ratings of nursing homes and survey results: Medicare.gov Provider Comparison Tool. 15. Institute of Medicine (US), Committee on Nursing Home Regulation. (1986). Improving the quality of care in nursing homes. National Academies Press (US); 1986. 4, Monitoring nursing home performance. https://www.ncbi.nlm.nih.gov/books/NBK217555/ 2.2 Ethical and Legal Responsibilities of the Nursing Assistant | 79

2.3 Members of the Health Care Team and Nursing Home Structure As illustrated in Figure 2.1 1 below, the resident and their family members are at the center of holistic care. We know from Chapter 1 that holistic care includes physical, emotional, social, and spiritual well-being. A holistic approach focuses on a person’s wellness and not just their physical illness or condition. Each member of the health care team provides holistic care to achieve the best possible health outcomes for clients and improve their quality of life. Responsibilities of the health care team members are as follows: • Physicians and health care providers diagnose conditions and prescribe medications and treatments. • Nursing service members include registered nurses (RNs), licensed practical nurses/vocational nurses (LPNs/VNs), certified medical technicians (CMTs), and nursing assistants (RNAs, LNAs, CNAs). The nursing team implements nursing care plans based on the nursing process and provider orders. The nursing supervisor/charge nurse/unit manager supports the nursing staff and may assist in providing resident care or treatments. Staff/Floor nurses provide nursing care to residents. Nursing assistants perform assigned or delegated nursing tasks such as assisting with ADLs and reporting any changes in a resident’s condition. • Social Services, such as social workers and case managers, assist with emotional and personal problems, benefit coordination, and any discharge or transfer needs to other facilities. • Therapists, such as physical therapy (PT), occupational therapy (OT), and speech therapy (ST), assist residents in recovering from an illness to return to and maintain function. Therapy roles are further outlined in Chapter 9. 1. This image is a derivative of “img4.jpg” by Branden Morton. This image is included on the basis of Fair Use. 80 | 2.3 Members of the Health Care Team and Nursing Home Structure

Figure 2.1 Members of the Health Care Team Each department and member of the health care team is essential for quality resident care. Although there are a variety of certifications, skills, and abilities present within the health care team, each component is a valued resource. Your part in the team as a nursing assistant is to understand team member roles and responsibilities, coordinate with the appropriate team members when needed, and respect and support each team member’s efforts. You should expect the same treatment from other health care team members regardless of their educational background, title, or job duties. While the health care team provides care for residents in the nursing home, other departments and individuals oversee business and non-health care operations for the facility. A nursing assistant should have an understanding of the non-medical aspects necessary to meet resident needs. Non-health care responsibilities of team members in a nursing home include the following: • Administrator: Oversees federal and state regulation compliance and manages non-medical aspects of the facility, such as finance. • Medical Director: Consults on medical aspects of care, such as infection control and quality of care. • Director of Nursing (DON): Manages all aspects of nursing staffing, 2.3 Members of the Health Care Team and Nursing Home Structure | 81

policies, and procedures. • Assistant DON: Assists with managing nursing staff and implementing policies and procedures. • Staff Development Coordinator (SDC): Trains nursing employees and provides continuing education. • Minimum Data Set (MDS) Coordinator: Assesses resident needs and reports to CMS for reimbursement. • Business Office: Oversees billing and other financial aspects. • Housekeeping and Maintenance: Maintains the facility and equipment and keeps the environment clean and safe. • Activities Director: Oversees any activities staff members provide and plans events for resident enjoyment related to hobbies or interests. • Dietary Director: Oversees dietary staff to deliver nutritional and fluid needs of residents. See Figure 2.2 2 for an illustration of the general structure of a LTC facility. Figure 2.2 General Structure of a LTC Facility 2. “General Structure of a LTC Facility” by Myra Sandquist-Reuter for Chippewa Valley Technical College is licensed under CC BY 4.0 82 | 2.3 Members of the Health Care Team and Nursing Home Structure

2.4 The Nursing Process The nursing process is a critical thinking model based on a systematic approach to patient-centered care that nurses use to perform clinical reasoning and make clinical judgments when providing patient care. The nursing process is based on the Standards of Professional Nursing Practice established by the American Nurses Association (ANA). These standards are authoritative statements of the actions and behaviors that all registered nurses, regardless of role, population, specialty, and setting, are expected to perform competently. 1 The mnemonic ADOPIE is an easy way to remember the ANA Standards and the nursing process, with each letter referring to the six components of the nursing process: Assessment, Diagnosis, Outcomes Identification, Planning, Implementation, and Evaluation. See an illustration of the cyclical nursing process in Figure 2.3. 2 Figure 2.3 The Nursing Process Assessment The Assessment component of the nursing process is defined as, “The registered nurse collects pertinent data and information relative to the health 1. American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association. 2. “The Nursing Process” by Kim Ernstmeyer at Chippewa Valley Technical College is licensed under CC BY 4.0 2.4 The Nursing Process | 83

care consumer’s health or the situation.” 3 A nursing assessment includes physiological data, as well as psychological, sociocultural, spiritual, economic, and lifestyle data. Nursing assistants should observe and report things to the nurse that they notice when providing care, such as reddened or open skin, confusion, increased swelling, or reports of pain. 4 Diagnosis The Diagnosis phase of the nursing process is defined as, “The registered nurse analyzes the assessment data to determine actual or potential diagnoses, problems, and issues.” 5 A nursing diagnosis is the nurse’s clinical judgment about the client’s response to actual or potential health conditions or needs. Nursing diagnoses are the basis for the nursing care plans and are different than medical diagnoses. 6 Outcomes Identification The Outcomes Identification phase of the nursing process is defined as, “The registered nurse identifies expected outcomes for a plan individualized to the health care consumer or the situation.” 7 The nurse sets measurable and achievable short- and long-term goals and specific outcomes in collaboration with the patient based on their assessment data and nursing diagnoses. 8 Nurses may communicate expected outcomes to nursing assistants, such as, “The client will walk at least 100 feet today.” 3. American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association. 4. This work is a derivative of Nursing Fundamentals by Chippewa Valley Technical College and is licensed under CC BY 4.0 5. American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association. 6. This work is a derivative of Nursing Fundamentals by Chippewa Valley Technical College and is licensed under CC BY 4.0 7. American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association. 8. This work is a derivative of Nursing Fundamentals by Chippewa Valley Technical College and is licensed under CC BY 4.0 84 | 2.4 The Nursing Process

Planning The Planning phase of the nursing process is defined as, “The registered nurse develops a collaborative plan encompassing strategies to achieve expected outcomes.” Assessment data, nursing diagnoses, and goals are used to select evidence-based nursing interventions customized to each patient’s needs and concerns. Goals and nursing interventions are documented in the patient’s nursing care plan so that nurses, as well as other health professionals, have access to it for continuity of care. 9 Nursing Care Plans Nursing care plans are part of the Planning step of the nursing process. A nursing care plan is a type of documentation created by registered nurses (RNs) that describes the individualized planning and delivery of nursing care for each specific patient using the nursing process. Nursing care plans guide the care provided to each patient across shifts so care is consistent among health care personnel. Some nursing interventions can be assigned or delegated to licensed practical nurses (LPNs) or nursing assistants with the RN’s supervision. 10 Although nursing assistants do not create or edit care plans, they review this document to know what care should be provided to each client within their scope of practice. Implementation The Implementation phase of the nursing process is defined as, “The nurse implements the identified plan.” 11 Nursing interventions are implemented or delegated with supervision according to the care plan to assure continuity of care across multiple nurses and health professionals caring for the patient. Interventions are also documented in the patient’s medical record as they are 9. This work is a derivative of Nursing Fundamentals by Chippewa Valley Technical College and is licensed under CC BY 4.0 10. This work is a derivative of Nursing Fundamentals by Chippewa Valley Technical College and is licensed under CC BY 4.0 11. American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association. 2.4 The Nursing Process | 85

completed. 12 The nursing assistant’s largest responsibility during the nursing process is safely implementing their delegated interventions in the nursing care plan. Evaluation The Evaluation phase of the nursing process is defined as, “The registered nurse evaluates progress toward attainment of goals and outcomes.” 13 During evaluation, nurses assess the patient and compare the findings against the initial assessment to determine the effectiveness of the interventions and overall nursing care plan. Both the patient’s status and the effectiveness of the nursing care must be continuously evaluated and modified as needed. To assist the nurse in evaluation, nursing assistants must report any changes in patient condition or new observations related to new interventions. Because nursing assistants spend the most time with the residents, it is important to communicate with the nurse if asked to implement an intervention that is known to be ineffective with a resident so a different, more effective alternative can be identified. Benefits of Using the Nursing Process Using the nursing process has many benefits for all members of the health care team. The benefits of using the nursing process include the following 14 : • Promotes quality patient care • Decreases omissions and duplications • Provides a guide for all staff involved to provide consistent and responsive care • Encourages collaborative management of a patient’s health care problems 12. This work is a derivative of Nursing Fundamentals by Chippewa Valley Technical College and is licensed under CC BY 4.0 13. American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association. 14. This work is a derivative of Nursing Fundamentals by Chippewa Valley Technical College and is licensed under CC BY 4.0 86 | 2.4 The Nursing Process

• Improves patient safety • Improves patient satisfaction • Identifies a patient’s goals and strategies to attain them • Increases the likelihood of achieving positive patient outcomes • Saves time, energy, and frustration by creating a care plan or path to follow 2.4 The Nursing Process | 87

2.5 Scope of Practice Scope of practice is defined as services that a trained health professional is deemed competent to perform and permitted to undertake according to the terms of their state professional license. 1 Different states have some variability in what nursing assistants can legally perform based on their licensure. It is important to check state DHS regulations to know exactly what skills and care you are able to legally provide as a nurse aide. The CMS defines acceptable scope of practice for nursing aides at the federal level. Federal regulation 42 CFR § 483 lists nine tasks that are allowable by each state. These tasks are as follows 2 : • Personal care skills • Safety/emergency procedures • Basic nursing skills • Infection control • Communication and interpersonal skills • Care of cognitively impaired residents • Basic restorative care • Mental health and social service needs • Residents’ rights As you learned in the “Nursing Process” section of this chapter, many tasks in the Implementation phase can be assigned or delegated by the registered nurse (RN) to the nurse aide. To keep you and your residents safe, use the 4 S’s to verify that you are performing within your scope of practice when accepting delegated or assigned tasks: Scope, Supervision, Safety, and Supplies. It is important that you ask yourself these questions before performing any cares for a resident: 1. This work is a derivative of Nursing Fundamentals by Chippewa Valley Technical College and is licensed under CC BY 4.0 2. McMullen, T. L., Resnick, B., Chin-Hansen, J., Geiger-Brown, J. M., Miller, N., & Rubenstein, R. (2015). Certified nurse aide scope of practice: State-by-state differences in allowable delegated activities. Journal of the American Medical Directors Association, 16(1), 20-24. https://doi.org/10.1016/j.jamda.2014.07.003 88 | 2.5 Scope of Practice

• Scope: Is this task within my scope of practice as defined by my state licensure? If it is a skill or task that you did not perform for evaluation by your instructor during your nursing assistant course, it may not be legal for you to carry out under your licensure. However, some states allow facilities to provide additional training on skills to improve resident care. • Supervision: Do I have supervision available? Each task delegated to you must be clear and supervised. If you are unsure of exactly what you need to perform, you should have an RN supervisor to whom you can direct questions. Supervision can be in person or via telephone. • Safety: Am I safe to perform the task? Patient safety is vital. Even though you may have competently demonstrated a skill when you took your certification course, there may be tasks that you do not perform consistently depending on your care setting. For example, if you haven’t recently used a mechanical lift, you may need additional training before you can safely perform this transfer technique with a resident. • Supplies: Do I have the supplies I need? If you do not have the proper equipment needed for the task, it is unsafe to perform it. Supplies may include personal protective equipment (PPE) for infection control, transfer equipment and mobility aids, or personal items needed for resident grooming and hygiene. 2.5 Scope of Practice | 89

2.6 Health Care Settings Caregivers who provide assistance in activities of daily living (ADLs) work in a variety of settings. When an individual is no longer able to independently care for oneself, the level of care needed is what determines where they reside. For example, an individual who is able to perform most of their ADLs but needs assistance with meals and laundry may live in an assisted living facility, but someone who needs more assistance with daily ADLs may live in a nursing home. As you become more familiar with health care delivery, you will discover what type of setting will be the best fit for you. Some settings require licensure for nurse aides while others will provide training at the agency level. Table 2.6 outlines the different types of settings where health care can be delivered. Terms such as patients, clients, residents, and members are used interchangeably for people for whom nursing assistants provide care. In general, people receiving care in hospitals are referred to as “patients,” people who live long-term care facilities are referred to as “residents,” and people receiving outpatient care are often referred to as a “clients” or “members.” Table 2.6 Health Care Settings 90 | 2.6 Health Care Settings

Care Setting Type of Care Provided Typical Patient Room Environment What are Users Called? Who Provides ADLs? Hospital 24-hour care is provided with access to physicians and other providers, RNs, speech therapists, physical therapists, occupational therapists, respiratory therapists, social workers, registered dietitians, and chaplains for spiritual care. Hospitals provide acute and specialty care for patients, as well as emergency and urgent care. Some hospitals provide home health and hospice services. Larger hospitals provide various types of labs and diagnostic tests on site. Anyone with emergent or urgent health care concerns is appropriate to be served in the hospital setting. Designed for short stays with sterile and clean environments. Rooms are typically made for one patient and contain multiple pieces of medical equipment to avoid HIPAA and infection control concerns. Many disposable or one-time use items are used to avoid cross-contamination. Patients Patient Care Assistants (PCAs) or Certified Nursing Assistants (CNAs); licensure is required. 2.6 Health Care Settings | 91

Long-term Care (LTC) or Nursing Home (NH) 24-hour skilled care is provided for people who are no longer eligible for hospital care but are unable to care for themselves at home. An RN is always on site. Residents may be admitted due to physical limitations in mobility, management of chronic conditions or medication, or both. Typically, older adults with chronic conditions such as physical disabilities, heart disease, prior strokes, diabetes, history of major fractures, or are otherwise unsafe at home. A long-term care facility, commonly referred to as nursing home or rehabilitation center, is where a person lives. The facility typically has both private and shared rooms, and residents are encouraged to have their own belongings. Rooms are accessible for various mobility needs but are more homelike than a hospital setting. Residents Certified Nursing Assistants (CNAs); licensure is required at facilities that are funded by Medicare and Medicaid. Assisted Living Care is provided that can be scheduled, such as medication assistance, grooming, showering, meal preparation, cleaning, and laundry. On-demand care, such as assistance with toileting or getting from one place to another, is not included. Typically, residents are 65 years or older and are more independent than in other LTC facilities. They are medically stable but need some oversight for safety and home maintenance. As their assistance needs change, they can be moved to a different area if necessary. Each room is like an apartment with a small kitchen and entry doors that lock. Residents Daily Living Assistants (DLAs) or CNAs; licensure is not required. 92 | 2.6 Health Care Settings

Group Home/ Adult Family Home Provides daily care and maintenance with mostly an oversight on safety. Typically, adults with developmental disabilities or moderate dementia, or those recovering from substance use disorders. Residents have a bedroom and access to the whole house. Each state provides a maximum capacity per house, but group homes typically have 4-6 residents. Residents or clients Daily Living Assistants (DLAs) or CNAs; licensure is not required. Home Health Any assistance (nursing or ADLs) provided in someone’s home. Can be short-term assistance for things like wound care or IV therapy or long-term assistance with medication management, cleaning, shopping, etc. Care is provided in the client’s home. Patient, client, or member Daily Living Assistants (DLAs) or CNAs; licensure is not required. Hospice Assistance provided for palliative or end-of-life care. Those who are terminally ill and/or have a life expectancy of six months or less. Care is available 24 hours, 7 days a week in a resident’s home, LTC facility, or hospital unit. Patient, client, or member Daily Living Assistants (DLAs) or CNAs; licensure is not required. 2.6 Health Care Settings | 93

2.7 Job-Seeking and Keeping Skills After completing your coursework, the next step to becoming an employed nursing assistant is to find employment opportunities. You can use local resources, such as newspapers or workforce entities, websites, or social media pages of local health care facilities, or conduct your own search online. After you have completed your clinical experiences, keep in mind the type of facility you prefer to work in and seek out those opportunities for greater job satisfaction. As discussed in “The Survey Process” subsection of this chapter, you can review the survey data of nursing homes to determine their current quality ratings. It is also important to consider staffing ratios when applying for a job. Staffing ratios refer to the number of patients assigned each shift to nurses and nursing aides. Working for a facility with good staffing ratios can positively impact your stress level and work-life balance, making this an important characteristic to consider. You should create a resume to submit with your job application. A resume is a factual presentation of yourself that lists your various skills and accomplishments. The goal of your resume is to make an employer want to interview you. Your resume should include your contact information, education, licenses or certifications, and your work experience. You can include skills attained during your nursing assistant training that will pertain directly to the position for which you are applying. You may want to add any honors, awards, or volunteer experiences that would be helpful in highlighting your skills for the position you are seeking. You should also have 2-3 professional references available. References are people who have supervised you in previous jobs or instructors who have observed your skills. Be sure to ask individuals if you can use them as a reference before giving their contact information to your prospective employer. 1 When you receive a request from a potential employer for an interview, there are many things you can do to prepare yourself. Look at the job description 1. Chippewa Valley Technical College. (n.d.). Career planning. https://www.cvtc.edu/experience-cvtc/student-services/ career-planning 94 | 2.7 Job-Seeking and Keeping Skills

and be able to specifically state how you can meet the requirements of the job. It is helpful to have someone ask you practice questions. During an interview you are also considering if the facility is a good fit for you. You may want to consider asking for a tour of the facility to observe the environment. Think of questions you want to know about the job such as the following: • How long is the orientation period? • What hours will I be expected to work? • How will I be evaluated? On the day of the interview, be sure to arrive 10-15 minutes early and have your cell phone silenced. When you meet the person with whom you will interview, make good eye contact and shake hands if appropriate. Speak confidently and truthfully about your abilities. Additionally, you should follow these grooming guidelines: • Shower, brush your teeth, groom your hair, and trim your nails. • Wear clean, professional attire without wrinkles, words, or logos. • If you wear a skirt or dress, make sure it is knee-length or below. • Do not wear shorts or jeans. • Wear closed-toed shoes that are in good condition. • Keep makeup and jewelry to a minimum. • Use deodorant but no cologne or perfume. These are all grooming expectations of health care professionals, and it is important to display these qualities the first time you meet your prospective employer. After you are hired, refer to the areas discussed in “Communication Within the Health Care Team” to meet the needs of your residents and build professional relationships with other staff. Based on the facility’s policies, you will have periodic evaluations with your supervisor to discuss your job performance. It is good to reflect on your own performance before the evaluation and be open to any opportunities discussed to improve your care. Be sure to keep your certification and any other training requirements 2.7 Job-Seeking and Keeping Skills | 95

current so you do not have a lapse in your availability to your residents and peers. Being a caregiver and helping others can be extremely rewarding, but at times it can also be challenging. Be sure to take care of yourself by getting proper rest, exercise, and nutritional intake. If you don’t feel well, you can’t take care of others. Refer to information on “Dealing With Stress” in Chapter 1 as to how you can keep yourself mentally healthy to meet the demands of your job. 96 | 2.7 Job-Seeking and Keeping Skills

2.8 Learning Activities An interactive H5P element has been excluded from this version of the text. You can view it online here: https:/ wtcs.pressbooks.pub/nurseassist/?p=189#h5p-5 An interactive H5P element has been excluded from this version of the text. You can view it online here: https:/ wtcs.pressbooks.pub/nurseassist/?p=189#h5p-6 An interactive H5P element has been excluded from this version of the text. You can view it online here: https:/ wtcs.pressbooks.pub/nurseassist/?p=189#h5p-7 An interactive H5P element has been excluded from this version of the text. You can view it online here: https:/ wtcs.pressbooks.pub/nurseassist/?p=189#h5p-8 2.8 Learning Activities | 97

II Glossary Citation: A problem or discrepancy found during a survey of a facility by the Department of Health Services. Elder abuse: An intentional act, or failure to act, that causes or creates a risk of harm to someone 60 or older. The abuse occurs at the hands of a caregiver or a person the older adult trusts. Elopement: An event when a resident who is incapable of protecting themselves from harm is able to successfully leave the facility unsupervised and unnoticed and possibly enter into harm’s way. Health Insurance Portability and Accountability Act of 1996 (HIPAA): Legislation that required the creation of national standards to protect sensitive patient health information from being disclosed without the patient’s consent or knowledge. Mandated reporter: Nursing assistants and other health care professionals are referred to as mandated reporters because they are required by state law to report suspected neglect or abuse of the elderly, vulnerable adults, and children. As a caregiver, you are required to report any signs or symptoms that are suspicious for abuse or neglect to the nurse. Neglect: Failure to provide care to oneself or to someone for whom you are enlisted to care. Nursing care plan: A type of documentation created by registered nurses (RNs) that describes the individualized planning and delivery of nursing care for each specific patient using the nursing process. Nursing process: A critical thinking model based on a systematic approach to patient-centered care that nurses use to perform clinical reasoning and make clinical judgments when providing patient care. The nursing process is based on the Standards of Professional Nursing Practice established by the American Nurses Association (ANA). The mnemonic ADOPIE is an easy way to remember the ANA Standards and the six components of the nursing 98 | II Glossary

process: Assessment, Diagnosis, Outcomes Identification, Planning, Implementation, and Evaluation. 1 Patient-centered care: A model of health care where an individual’s specific health needs and desired health outcomes are the driving force behind all health care decisions. Patients are partners with the health care team members, and health care professionals treat patients not only from a clinical perspective, but also from an emotional, mental, spiritual, social, and financial perspective. Resume: A factual presentation of yourself that lists your various skills and accomplishments. Scope of practice: Services that a trained health professional is deemed competent to perform and permitted to undertake according to the terms of their professional license. 2 Staffing ratios: The number of patients assigned each shift to nurses and nursing aides. Survey: An evaluative visit by state Department of Health Services (DHS) employees to observe care provided to residents, watch preparation and serving of food, review resident care plans and facility documentation, interview residents and families, and look at every aspect of the facility. The surveyors are ensuring that each aspect of residents’ physical, emotional, social, and spiritual needs are met. Vulnerable populations: Patients who are children, older adults, minorities, socially disadvantaged, underinsured, or those with certain medical conditions. Members of vulnerable populations often have health conditions that are exacerbated by unnecessarily inadequate health care. 3 1. This work is a derivative of Nursing Fundamentals by Chippewa Valley Technical College and is licensed under CC BY 4.0 2. This work is a derivative of Nursing Fundamentals by Chippewa Valley Technical College and is licensed under CC BY 4.0 3. Waisel, D. B. (2013). Vulnerable populations. Current Opinion in Anesthesiology, 26(2), 186-192. https://doi.org/10.1097/ aco.0b013e32835e8c17 II Glossary | 99

3.1 Introduction to Maintain a Safe Health Care Environment Learning Objectives • Maintain a safe, clean, comfortable, therapeutic environment • Respond appropriately in emergency situations • Perform airway clearance maneuver • Apply principles of body mechanics • Demonstrate safe use and maintenance of equipment and supplies • Make an occupied and unoccupied bed Nursing assistants must provide safe, clean, comfortable environments and safely use equipment and supplies. This chapter will review common emergency situations and provide guidelines on how a nursing aide should respond. A typical nursing home environment will be described, and strategies for helping residents transition from living independently to residing in a facility will also be discussed. Proper equipment and body mechanics for lifting residents will also be described to help keep you and those you care for safe. 3.1 Introduction to Maintain a Safe Health Care Environment | 103

3.2 Emergency Situations Nursing assistants must be prepared to respond to emergency situations when providing patient care. Common situations requiring immediate emergency response include heart attacks (myocardial infarctions), strokes (cerebrovascular accidents), seizures, falls, fires, and choking. Heart Attack or Myocardial Infarction (MI) Myocardial infarction (MI) is the medical term for what is commonly referred to as a “heart attack.” It is caused by a lack of blood flow and oxygen to a region of the heart, resulting in the death of cardiac muscle cells. An MI is typically caused by a blocked coronary artery that occurs when the buildup of plaque creates a clot or when a piece of the plaque breaks off and travels to a smaller vessel, creating a blockage. When the cardiac muscle cells are starved of oxygen and begin to die during an MI, there is typically a sudden onset of severe pain called angina beneath the sternum. This pain often radiates down the left arm or into the jaw. However, some patients (especially female patients) may not experience severe pain but instead experience symptoms that feel like indigestion. Patients may also have associated symptoms like difficulty catching their breath referred to as shortness of breath (SOB), sweating, anxiety, irregular heartbeats, nausea, vomiting, or fainting. Symptoms should be immediately reported to the nurse for emergency assessment and treatment to preserve as much of the heart as possible. 1 See Figure 3.1 2 for an illustration of a male experiencing a myocardial infarction. 1. This work is a derivative of Nursing Pharmacology by Chippewa Valley Technical College and is licensed under CC BY 4.0 2. “A man having a Heart Attack.png” by https://www.myupchar.com/en is licensed under CC BY-SA 4.0. 104 | 3.2 Emergency Situations

Figure 3.1 Myocardial Infarction View the following supplementary TED-Ed video 3 with additional information on heart attacks: What Happens During a Heart Attack? – Krishna Sudhir. Stroke or Cerebrovascular Attack (CVA) A cerebrovascular attack (CVA), often referred to as a “stroke” or “brain attack,” is caused by a lack of blood flow and oxygen to the brain, resulting in the death of brain cells within a few minutes. Similar to the cause of a heart attack, the lack of blood flow is often caused by a blockage in an artery, but in the case of a stroke, the artery is located in the brain. Strokes can also be caused by a blood vessel in the brain rupturing and bleeding, called a hemorrhagic stroke. Risk factors for strokes include smoking, high blood pressure, and cardiac arrhythmias (i.e., irregularities in heart rate and/or rhythm). Lack of blood flow to the brain for more than a few minutes causes irreversible brain damage. The longer a person goes without treatment for a 3. TED-Ed. (2017, February 14). What happens during a heart attack? - Krishna Sudhir [Video]. YouTube. All rights reserved. https://youtu.be/3_PYnWVoUzM 3.2 Emergency Situations | 105

stroke, the more damage that occurs to their brain cells. Damaged brain cells can result in paralysis, cognitive impairment, difficulty speaking and understanding words, and mood swings. For this reason, it is important to recognize early signs of a stroke and obtain rapid emergency treatment. The treatment for a stroke depends on the cause. Eighty percent of strokes occur due to a blockage of an artery in the brain. Strokes caused by a blockage are treated with thrombolytic medication (such as tPA) to dissolve the clot. See Figure 3.2 4 for an image of a stroke caused by a blockage. Hemorrhagic strokes occur due to a ruptured vessel in the brain. These types of strokes often require surgery to stop the bleeding. Stroke treatments work best if the symptoms of a stroke are recognized early and emergency treatment occurs within three hours of the onset of symptoms. 5 Figure 3.2 Stroke Strokes typically affect one side of the brain based on where the blood flow was disrupted. Because of the brain’s anatomy, the symptoms of a stroke occur on the opposite side of the body as the affected side of the brain. For example, if a stroke occurs in the left side of the brain, the right side of the body will be affected, resulting in signs and symptoms occurring only on the 4. “Stroke Diagram” by ConstructionDealMkting is licensed under CC BY 2.0 5. Centers for Disease Control and Prevention. (2020, August 28). Stroke. https://www.cdc.gov/stroke/ signs_symptoms.htm 106 | 3.2 Emergency Situations

right side of the body. This unilaterality (i.e., one-sidedness) of symptoms is important to recognize and report to the nurse. The FAST acronym is used to remember early signs of a stroke: • F: Facial drooping • A: Arm weakness (unilateral) • S: Slurred speech • T: Time, meaning the quicker the response, the better the outcome Given the central role and vital importance the brain is to life, it is critical that its blood supply remains uninterrupted. If blood flow is interrupted, even for just a few seconds, a transient ischemic attack (TIA), also called ministroke, may occur. A TIA is a temporary period of symptoms similar to those of a stroke, but they usually last only a few minutes, and they don’t cause permanent brain damage. However, TIAs can be a warning sign for a future stroke and should be reported to the nurse. View a YouTube video 6 from the Centers for Disease Control and Prevention (CDC): Recognizing the Signs and Symptoms of Stroke Seizure A seizure is a transient occurrence of signs and/or symptoms due to abnormal activity in neurons in the brain. During a seizure, large numbers of brain cells are abnormally activated at the same time, like an electrical storm in the brain. This abnormal neuronal activity often affects a person’s consciousness and causes abnormal muscle movements. 6. Centers for Disease Control and Prevention (CDC). (2015, October, 26). Recognize the Signs and Symptoms of Stroke. [Video]. YouTube. All rights reserved. https://youtu.be/cx5G1VdC9UA 3.2 Emergency Situations | 107

Seizures are generally described in two major groups: generalized seizures and focal seizures. The difference between the types of seizures is in how and where they begin in the brain. 7 Many symptoms can occur during a seizure. They are classified as motor or nonmotor symptoms. Motor symptoms include the following 8 : • Sustained rhythmic jerking movements (clonic) • Muscles becoming limp or weak (atonic) • Body, arms, or legs becoming stiff or tense (tonic) • Brief twitching (myoclonus) Nonmotor symptoms are as follows 9 : • Staring spells (absence seizures) • Changes in sensation, emotions, thinking, or autonomic functions (nonmotor symptoms) • Lack of movement (behavioral arrest) When reporting a seizure to the nurse, include the following three descriptions 10 : • The time the seizure started • The person’s level of awareness during the seizure • The movements that occurred during the seizure If a resident has seizure disorder, it is typically noted in the nursing care plan. If you witness the beginning of a seizure, prepare to take quick action to reduce the chance of injury. For example, if the person is standing, the seizure can cause them to fall. You may not be able to stop the fall but try to guide them to the floor if possible. After they are on the floor, protect their head 7. Epilepsy Foundation. (2020). Types of seizures. https://www.epilepsy.com/learn/types-seizures 8. Epilepsy Foundation. (2020). Types of seizures. https://www.epilepsy.com/learn/types-seizures 9. Epilepsy Foundation. (2020). Types of seizures. https://www.epilepsy.com/learn/types-seizures 10. Epilepsy Foundation. (2020). Types of seizures. https://www.epilepsy.com/learn/types-seizures 108 | 3.2 Emergency Situations

from directly hitting the floor by placing a pillow or your leg underneath their head. During the seizure, the person may bite their tongue or gag. However, do not place anything in their mouth because this will increase the risk of choking. Immediately notify the nurse if you observe the start of a seizure and note the time it started. When the seizure has ended, carefully assist the person into bed. Due to the trauma experienced during the seizure, it is typical for the person to sleep for several hours. Some individuals with seizure disorders may also receive antianxiety medication to prevent another seizure from occurring. View the Epilepsy Foundation’s YouTube video 11 of a person experiencing a seizure: Wendy says #ShareMySeizure. View the Epilepsy Foundation’s YouTube video to learn more about seizure first aid 12 : Responding to Seizures: Care and Comfort First Aid. Falls and Fall Prevention Falls are common in adults aged 65 years and older. In the United States, about a third of older adults who live at home and about half of people living in nursing homes fall at least once a year. There are many factors that increase the risk of falling in older adults. These risk factors include mobility problems, balance disorders, chronic illnesses, and impaired vision. Many falls cause injury, ranging from mild bruising to broken bones, head injuries, and even death. In fact, falls are a leading cause of death in older adults. 11. Epilepsy Foundation. (2016, November 16). Wendy says #ShareMySeizure (30 sec) [Video]. YouTube. All rights reserved. https://youtu.be/KYQXSam1kww 12. Epilepsy Foundation. (2015, November 17). Responding to seizures: Care and comfort first aid [Video]. YouTube. All rights reserved. https://youtu.be/PAl9LDq9yas 3.2 Emergency Situations | 109

If you enter a room and discover a resident has fallen, do not move them unless they are in immediate danger of further injury. Notify the nurse as soon as you observe the situation so the resident can be assessed and treated. Typically, a mechanical lift will be used to raise the resident from the floor to prevent injury to themselves and staff. As a nursing assistant, there are several actions you can take to prevent falls. Keep the environment clean and free of clutter that can cause imbalance while a resident is ambulating (i.e., walking). If a spill is noted on the floor, it should be cleaned up immediately. Whenever residents are standing or walking, be sure they are wearing nonskid footwear (i.e., shoes or socks with rubberized soles). Use ordered assistive devices, such as gait belts and walkers, when moving a resident. If a resident wears glasses or hearing aids, make sure they are functioning, clean, and properly fitted for the resident so the resident can safely assess their surroundings when moving. 13 Additional information on fall risk and preventing falls can be found in Chapter 9. Fire In Chapter 2 you learned about agencies that govern health care, such as the Occupational Safety and Health Administration (OSHA). OSHA provides fire regulations and guidelines for every place of employment. This knowledge is essential for keeping residents safe in health care settings due to their limited mobility. Compliance to these regulations when responding to fires is commonly reviewed during the survey process. The response to a fire can be remembered by the RACE and PASS acronyms. See Figure 3.3 14 for using the PASS method with a fire extinguisher. • R: Rescue anyone in immediate danger from the fire if it doesn’t endanger your life. • A: Activate the alarm by pulling the nearest fire alarm or calling 911. 13. MedlinePlus [Internet]. Bethesda (MD): National Library of Medicine (US). Stroke signs and symptoms; [reviewed 2020, Aug 28; cited 2021, Dec 3]. https://medlineplus.gov/lab-tests/fall-risk-assessment/ 14. “RACE-Safety--Arvin61r58.png” by unknown at Freesvg.org is licensed under CC0 1.0 110 | 3.2 Emergency Situations