Unnamed: 0
int64 12
658
| 0
stringlengths 202
3.08k
|
---|---|
12 | 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
|
13 | 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
|
14 | 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
|
15 | • 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
|
16 | 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
|
17 | 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
|
18 | 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
|
19 | 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
|
20 | • 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
|
21 | 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
|
22 | 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
|
26 | 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
|
27 | 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
|
28 | 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
|
29 | 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
|
30 | 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
|
31 | 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
|
32 | 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
|
33 | • 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
|
34 | 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
|
35 | 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
|
36 | 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
|
37 | 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
|
38 | 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
|
39 | 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
|
40 | 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
|
41 | 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
|
42 | 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
|
43 | 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
|
44 | 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
|
45 | 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
|
46 | 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
|
47 | • 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
|
48 | • 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
|
49 | 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
|
50 | 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
|
51 | • 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
|
52 | • 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
|
53 | 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
|
54 | 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
|
55 | 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
|
56 | 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
|
58 | 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
|
59 | 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
|
60 | 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
|
61 | 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
|
62 | 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
|
63 | 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
|
64 | 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
|
65 | 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
|
66 | 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
|
67 | 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
|
68 | 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
|
69 | 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
|
70 | 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
|
71 | 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
|
72 | 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
|
74 | 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
|
75 | 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
|
76 | 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
|
77 | 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
|
80 | 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
|
81 | 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
|
82 | 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
|
83 | 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
|
84 | 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
|
85 | (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
|
86 | • 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
|
87 | 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
|
88 | 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
|
89 | 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
|
90 | 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
|
91 | 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
|
92 | 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
|
93 | 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
|
94 | 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
|
95 | 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
|
96 | 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
|
97 | 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
|
98 | • 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
|
99 | 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
|
100 | • 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
|
101 | 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
|
102 | 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
|
103 | 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
|
104 | 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
|
105 | 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
|
106 | 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
|
107 | 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
|
108 | 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
|
109 | 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
|
110 | 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
|
114 | 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
|
115 | 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
|
116 | 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
|
117 | 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
|
118 | 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
|
119 | 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
|
120 | 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
|
121 | 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
|