Holistic, Person-Centered Care

What is holistic, person-centered care? In short, it means caring for a

person as a whole person. A holistic approach to care doesn’t reduce a
person to their ailment or which specific aspects of their body require
treatment. Instead a holistic approach treats each person in the entirety of
their person, with a recognition that ailment or treatment that highlights one
area of one’s body impacts a person’s whole life. When thinking about
wellness and healing, the whole person should be the focus, not just their arm
or back.

Person-centered means that the person receiving care is at the center of

that care; they are in control of it. A person-centered approach to care means
that the care team does everything they can to maximize the person’s
autonomy and agency. Receiving medical care should feel empowering, but
all too often a person is left in the dark, doesn’t know what is happening to
them, or is not put in control of their own care.

A person who is already vulnerable should not also have to advocate for their
needs to the very people who are supposed to help them, but unless medical
professionals conscientiously exercise techniques rooted in holistic, person-
centered care practices, a person receiving care may continue to feel that
receiving care exacerbates their vulnerability rather than alleviates it.
Throughout the text, readers will be asked to consider specific cases of
caregiving through the lens of holistic, person-centered care.

In order to provide holistic, person-centered care, NAs will need to use critical
thinking skills. What is critical thinking? Critical thinking occurs any time
somebody closely analyzes something in order to form a judgment, such as
whether they like it and why or what to do next about a situation. Applying a
theory or conceptual framework to a real-world scenario is also an act of
critical thinking.

NAs apply critical thinking in every step of their job. Whether making
observations about a change in a resident’s condition, determining the safest
way to perform a task, or considering circumstances from the resident’s point
of view in order to demonstrate empathy and understanding, NAs deploy
critical thinking at every moment.
Critical thinking begins with:

 assessing the situation

 observing all relevant factors
 weighing options
 acting based on reasoning

The Big Three

Part of critical thinking for NAs involves always applying the Big Three to
one’s assigned responsibilities and care tasks. What is the Big Three? “The
Big Three” refers to three essential frameworks for NAs to keep in mind at all
times; Residents’ Rights, Safety, and Infection Control. We will go into the
specifics of each of these frameworks throughout the course of the texts.

We highlight these three frameworks for NAs because they are each relevant
to everything a NA does. An important part of critical thinking as a nursing
assistant is habitually asking oneself “Are the resident’s rights being protected
in my actions right now? Am I performing this task in the safest way possible?
Am I following the steps necessary to prevent infection?” throughout each part
of one’s job. Like holistic, person-centered care, the Big Three are analytical
frameworks and habits of thought that nursing assistants learn to use in a
near-automatic way. We will continue to discuss the Big Three and its
application throughout the whole text.

What is a Nursing Assistant (NA)? What do NAs do?

Nursing assistants (NAs), also referred to as Certified Nursing Assistants
(CNAs), are the first line of care in a variety of different medical care settings.
Nursing assistants play an essential role in hospitals, assisted living facilities,
home healthcare, and other medical contexts where patients or residents
require assistance with their activities of daily living (ADLs).

ADLs include activities like brushing one’s teeth, getting dressed, eating,
showering, and walking. In other words, an ADL is any activity that somebody
does daily or near-daily in their routine. It can be easy for somebody who does
not need assistance not to think about their ADLs, but for somebody
who does need assistance with daily tasks, a compassionate and
understanding hand to do the helping can make a big impact on someone’s
sense of wellbeing, life-satisfaction, and dignity.

NAs tend to provide the most regular and hands-on care of all the members
on the care team,

so it is important that they observe closely and take note of any changes in
residents’ physical and mental condition to report back to the care team.
Talking and listening is an important part of gathering information about a
resident’s health, so getting to know specific residents and becoming familiar
with their personalities can be an important part of providing holistic care.

NAs can provide emotional and spiritual support to residents in addition to

providing basic assistance for ADLs. Listening and speaking with residents in
a way that communicates an understanding of them as a whole person can
provide residents with a sense of companionship and community.

NAs are an invaluable member of the care team; the value of NAs to a
person’s care can’t really be overstated. An attentive and caring NA can be
the difference between a positive and a negative care outcome, or between
somebody’s life and death.

The qualities of NAs

Nursing assistants to be empathetic, patient, and understanding with the

people to whom they are providing care. What is an empathetic person? A
person who practices empathy is able to put themselves in someone else’s
shoes. They are able to use their own life experiences to relate to and identify
with the experiences of others.
It is important for everyone to practice using empathy, but it is especially
important for NAs and anyone else who regularly cares for vulnerable adults.
Practicing empathy every day trains us to see that everybody’s lives and
experiences are equally as valuable as one’s own; as a nursing assistant, it
will be part of your job to make sure that residents are treated in accordance
with their inherent value as human beings.

“Smiling caregiver embracing happy senior woman in

nursing home(opens in new tab)” by agilemktg1(opens in new tab) is marked with Public Domain Mark
1.0(opens in new tab).

Nursing assistants should also be conscientious, courteous, and

accountable in their work. Being conscientious in this case means always
doing your work to the best of your ability by being present, careful, observant,
aware, thoughtful, and responsible in every situation.

Being courteous means showing basic respect to one’s team mates, and to
the people being cared for. Accountability means taking responsibility for
one’s work, and for one’s mistakes; an accountable person always seeks to
improve.

Being conscientious as a NA also means being trustworthy and completely

honest, especially when it comes to being honest about what you don’t know
or when you’ve made a mistake. It means that your healthcare team and your
residents’ families can depend on you.

Courtesy is an important part of providing conscientious care; a nursing

assistant provides courteous care when they respect everyone as individuals
regardless of their beliefs, lifestyle, or identity. It means caring for somebody
with the knowledge that they are a person deserving of dignity. This means
that NAs must work to be unprejudiced and treat everyone in their care with
kindness and equal standing.
Do’s and Don’ts

It is important to know some basic rules about being a nursing assistant.

Nursing assistants must remain within their scope of practice to protect the
person receiving care from accidents, and to protect themselves and their
team from liability[1].

 NAs are assistants to the nurse. Nurses assign, supervise, and delegate
all of the NA’s work. NAs should only do the work that has been
delegated to them.
 A nurse makes the decisions on what care a person should receive.
NAs should always review the care plan with the nurse before
proceeding.
 NAs should only perform tasks they have been trained to do and that
their state and job description allow for. They should never perform a
task if uncomfortable or unconfident performing it unless being guided
by a nurse. NAs must always ask for help if unsure of their ability to
safely do the delegated task.
 NAs need to know their own limitations. If they don’t know their own
limitations, everybody is at risk; if something goes wrong then the
person being caring for could suffer the consequences of a mistake, the
NA may lose their job and license, and the rest of the nursing team may
be investigated for negligence. Everybody relies on one another in a
care team, and in a setting where everybody relies on one another,
being honest and trusting your team to support you is essential for the
health of the person you are caring for.

The Organization and Operation of Care in Different

Settings[2]
Contexts

Nursing assistants are essential members of care teams in a variety of

different healthcare contexts. Because nursing assistants most often work
in long-term care contexts, that will be the focus of this text.

“Long-term care” is a general term used for facilities that provide 24-hour
skilled medical care;
long-term care facilities exist for people who are unable to stay in the hospital
but who need more intensive care than can be provided at home. Long-term
care is often necessary for people with chronic health conditions, or a health
condition that takes place over a long period of time. NAs should treat a
resident’s space as a guest would the home of a friendly host.

Assisted living facilities are places where staff can help a resident with
whatever they may need. The residents in assisted living facilities do not
usually need intensive medical care, but do require assistance with some
ADLs due to restricted mobility and aging. If a resident develops higher care
needs, some assisted living facilities may move them to a specialized wing for
more attention and access to skilled care.

Hospitals are where somebody receives short-term skilled care. Someone

may go to a hospital for a surgery, an emergency wound or burn, for a blood
infusion, or any number of other medical problems.

Someone is placed in hospice care when they have a terminal condition;

somebody’s condition is labeled “terminal” when it is likely going to be the
cause of their immanent death, usually anticipated in less than six months.

The care team

What is a healthcare team? A patient’s healthcare team consists of all of the

healthcare workers assigned to that patient’s recovery and care. Many
different kinds of healthcare workers will be on your care teams, and each one
brings specialized knowledge, skills, and talents to meet the varied needs of
the person receiving care. Please read through this non-exhaustive list of
some of the roles that you will encounter on your future healthcare teams.

Nursing assistants play one essential role on their care teams, but what are
some of the other roles most often assigned to a care team.

 Registered Nurse (RN): RNs are people who have successfully

completed a state-licensed nursing program and passed the requisite
state exam. They have a variety of responsibilities depending on the
context including hands-on care and dispensing medication. They work
as staff nurses, nurse supervisors and managers, directors of nursing,
administrators, or instructors. With further study, RNs can become
nurse practitioners or clinical nurse specialists.
 Licensed Practical or Licensed Vocational Nurse (LPN/LVN): an
LPN/LVN provides basic nursing care and must possess a license. They
 may be supervised by RNs, doctors, and dentists. An LPN/LVN has
fewer responsibilities and functions than an RN.
 Physician/doctor (MD): Provides prescriptions and diagnoses, and
performs certain kinds of medical procedures. There are many different
kinds of doctors specializing in various ailments or bodily systems.
 Physician’s Assistant (PA): PAs assist doctors in diagnosing illness and
prescribing treatment.
 Physical therapist (PT or DPT): A PT is somebody with extensive
training on the body’s physical systems and administering treatment
meant to ease pain, maintain mobility, or improve breathing and
circulation.
 Speech-language pathologist (SLP): An SLP is trained to diagnose
speech and language disorder and constructs a treatment plan to
address it.
 Registered dietitian nutritionist (RDN): An RDN creates nutrition plans
for patients or residents with particular dietary needs, whether due to a
specific illness or in the interest of overall health.
 Respiratory therapist (RT): An RT is somebody trained to provide
treatment to people with respiratory illness.
 Medical social worker (MSW): An MSW is a health professional trained
to help patients address the social support aspects of their care and
recovery. A graduate degree and state licensure are required to perform
this role.
 Ombudsman: An Ombudsman is a person who addresses patient and
resident complaints about the facility from a fair and neutral perspective;
they are often affiliated with the state, rather than directly affiliated with
the healthcare facility. An Ombudsman’s role is to help people address
situations of injustice and conflict from a perspective of fairness and
patient advocacy.

The patient and their family are essential members of the care team. The
person receiving care must be included in conversations about the direction of
the care; their family should also be included as a member of the care team,
because they will most likely be the ones caring for the person once they
leave the hospital or facility.
“doctor/nurse team photo(opens in new tab)” by ReSurge International(opens
in new tab) is licensed under CC BY-NC-ND 2.0(opens in new tab).

Continuity of care amongst the healthcare team is vital, as is continuity of

care between what care the patient receives at the medical facility and the
care received at home. Effective coordination between members of the care
team is essential for a successful recovery. Healthcare team members need
to communicate with one another effectively to provide high-quality care.

The nursing team is a specific subgroup of the healthcare team made up of

RNs, LPNs/LVNs, and nursing assistants. Each member of the nursing team
focuses on the physical social, emotional, and spiritual needs of the person
and family.

Everybody on the care team performs a specific and important role. However,
even though each role is specific and carries particular responsibilities,
expertise, and obligations, everyone on the care team is working
collaboratively towards the same end: the person’s health, recovery, and
maximum quality of life. Because everyone works collaboratively, giving and
insisting on respect is a practice NAs should become comfortable with.

The Legal Dimension of Caregiving

Resident Rights

What are Resident Rights? Residents' Rights are the dimension of the Big
Three that addresses what kinds of services, conditions, and treatment are
legally and ethically required for people living in long-term care and assisted
living facilities[3].

Laws and ethics are different things, though they can overlap. Laws are rules
and regulations that a government passes; healthcare professionals are
subject to healthcare laws made at the federal and state level.

The most sweeping healthcare law enacted at the federal level is

the Omnibus Budget Reconciliation Act of 1987 , which continued to be
revised and improved since its passage.

Ethics is the question of right and wrong, and how to design rules to
determine them. Healthcare agencies and facilities often have a code of ethics
that details what they consider to be ethical and unethical behavior in the
workplace.

National Ombudsmen Resource Center. (2021, October 6). Residents’ rights:

Your life, your care, your choice [Video]. Youtube.
[Link]

While workplaces will have their own codes of conduct, these are some
general Ethics guidelines for future NAs.
  Always maintain confidentiality; it is absolutely necessary to keep the
information of those in your care as private as possible. Only share
things that are relevant to the person’s care, and only with the particular
members of the care team.
 Always be honest in your communications with persons receiving care,
the other members on the nursing team, and in your documentation.
This goes hand in hand with being trustworthy and reliable; always
show up for work on time, and always let your supervisor know if you
are having any problems or difficulties.
 Never arrive at work under the influence of intoxicating substances.
 Never be prejudiced or biased in your interactions with persons in your
care or in interactions with colleagues. Prejudice and bias occurs when
we make judgments about somebody based on a single aspect of their
personality or appearance, such as perceived sex and gender, ethnicity,
race, taste in clothing, etc.
 Medical racism, or the ways in which health conditions and healthcare
outcomes are partially determined by a person’s race, is a pervasive
issue in healthcare today. Hoffman et al. (2016) found that 73% of the
medical professionals they surveyed held at least one false belief about
biological differences between white and Black people.

 They also found that false beliefs about biological difference based on
race had a significant impact on how likely a healthcare professional
was to believe a Black person’s description of their pain levels, and
whether Black person communicating their pain receives effective
treatment[4]. This basic insight that the prejudices of caregivers impact
care outcomes applies to other forms of prejudice too, like sexism and
fatphobia.
 Patience is a virtue, especially when providing care. NAs should always
be patient with the persons in their care. Healthcare settings are often
stressful places; NAs need to be able to help someone through pain and
the trials of recovery without becoming frustrated or rushing them.
 Always read and follow the workplace code of ethics closely.

Understanding the laws and codes of ethics is important. It is also important to

understand why such laws and ethics are in place. People receiving care are
often vulnerable. Laws and codes of ethics are necessary measures to ensure
that vulnerable people are not taken advantage of or easily mistreated. NAs
should always follow the spirit and motivation of such laws and ethics in
addition to abiding by their minimum standards; we have all been or will be
vulnerable at different points in our lives, but NAs are in the unique position to
turn an awareness of vulnerability into attentive and empowering care.

The Nurse Practice Act

Each state has a Nurse Practice Act that defines the scope of practice for
nurses and nursing assistants, delineates their education and licensing
requirements, and outlines the requirements for revoking or suspending a
license.

These laws are put in place to protect people from unqualified or unsafe
healthcare workers; these laws are also in the interest of nurses, whose own
health and professional status are protected. State laws about nursing
assistants are based on that state’s Nurse Practice Act, and describe what it
means for a nursing assistant to function with safety, skill, and accountability.
What is a Healthcare Worker Registry? As part of the Omnibus Reconciliation Act of 1987, NAs
are added to a state-wide registry once they have completed their requisite training and meet
competency requirements. The Illinois Healthcare Worker Registry can be found
at [Link] The Healthcare Worker Registry is a
comprehensive resource containing a list of every certified medical professional by name. Other
information such as sex, race, height, certification status, and the date of most recent
background check is also listed[5].

HIPAA

The Health Insurance Portability and Accountability Act of 1996

(HIPAA) is a law passed at the federal level that establishes rules about what
healthcare and insurance agencies can do with individuals’ protected health
information (PHI). PHI is any identifying information about a person’s health
plan, healthcare history, or any conditions or treatments they may have or will
undergo[6].

The two most important elements of HIPAA for nursing assistants to know are
the Privacy Rule and the Security Rule. The Privacy Rule was added to
HIPAA in 2000, and sets national standards for the protection of private health
information. The Security Rule was published in HIPAA in 2003 and outlines
standards for protecting the “confidentiality, integrity, and availability of
electronic health information”[7].
The reason for a higher level of concern regarding the privacy and integrity of
PHI comes from the security risk posed by progresses in computer
technology; as it became easier to use technology to steal a person’s
healthcare information, it became more important to pass regulation to ensure
that any identifying information is kept safe and private.

NATCEP

What is NATCEP? NATCEP stands for the Nurse Aide Training and
Competency Evaluation Program. It was implemented as a result of OBRA’s
passage. OBRA was necessary because of the poor, negligent, and
sometimes abusive conditions present in long-term care and assisted living
facilities up to that point. To address this, the federal government legislated
minimum standards of care, including minimum standards of education for
nurse assistants.

NATCEP requires at least 75 hours of combined theoretical and hands-on

instruction and successful completion of a competency evaluation before a
nursing assistant can legally work. NATCEP also mandates at least 12 hours
of continuing education for nursing assistants each year to keep skills sharp
and current.

NAs must continue working as a NA in some capacity if they want to keep

their certification. If a nursing assistant goes 24 consecutive months without
providing professional care for pay they will have to re-take the requisite
written competency exam to reacquire certification. It is in one’s best interest
not to let NA certification expire; not only can it be time-consuming or costly to
become re-certified, it may also cause potential employers to doubt
someone’s professionalism.

Resident Rights; their importance and enforcement

Residents’ Rights are basic quality of life standards that long-term care
residents always have a legitimate claim to because they are human beings
and because they are protected by federal and state law.

Protecting Resident Rights is necessary and grows from a general concern for
human rights, with the added recognitions that vulnerable elders have
historically not had their human rights protected. Adults who are already
vulnerable due to age and disability may be even more vulnerable when they
reside in long-term care and aren’t in a position to advocate for themselves.
OBRA, or the Omnibus Budget Reconciliation Act of 1987, is a federal law
that was put in place to protect residents in long-term care facilities from
reported patterns of abuse, neglect, and substandard care. OBRA establishes
some policies intended to increase the accountability and standards of long-
term care facilities and puts minimum certification requirements in place for
NAs.

OBRA has been updated multiple times since 1987, with its most recent
update occurring in 2016 when the Center for Medicare and Medicaid
Services implemented additional safety and resident rights requirements for
long-term care facilities if they want to access federal funds. OBRA goes
hand-in-hand with the Elder Justice Act of 2010, a comprehensive piece of
legislation at the federal level passed to protect residents in long-term care
facilities from abuse, neglect, and exploitation.

Legislation like OBRA and the Elder Justice Act apply to nursing assistants
because it establishes baseline educational, certification, and registration
requirements. It is also part of what defines the NA scope of practice.

According to the Illinois Department on Aging, residents in long-term care

facilities have a specific set of rights that long-term care facilities are required
to uphold[8].

 Residents have a right to dignity and respect. This means that residents have a
right to make their own choice, a right to treatment that promotes quality of life,
and a right to equal access to care.
 Residents have a right to safety; this means that residents have a right to be free
from abuse, neglect, and exploitation. Residents have a right to complain
without fear of retaliation and discrimination. Residents have a right to quality
physical and mental health services, and a clean, comfortable, and homelike
environment. Residents have a right to be free from chemical or physical
restraint; residents can only be given mood or thought altering medication with
their permission.
 Residents have the right to participate in their own care. This means that they
may attend care conferences, may see and request changes to the care plan,
choose their own doctor, make a living will, refuse treatments, and move out of
the facility. Residents have a right to be fully informed and empowered in their
own care.
 Residents have a right to confidentiality and privacy. They are entitled to a knock
before facility staff enter, a right to private visits at any hour as long as they
don’t infringe on other residents’ rights, a right to control who has access to
their information, and a right to privacy and access to mail and telephone
services.
  Residents have a right to their personal money, even if their personal money is
managed by their facility. They also have a right to their personal property;
facilities must take steps to keep residents’ personal property safe and secure.
 Residents have a right to be fully informed about the expected and actual costs
of their care; they also have a right to be provided with accurate information
about Medicare and Medicaid. Residents also have a right to advanced
directives, which are documents that gives instructions on care should the
resident be unresponsive or unable to make their own medical decisions.
 Residents also have a right to stay in their facility, unless in case of certain
exceptions. If a facility wants to involuntarily discharge a resident, they must
meet some requirements; first, there must be some reason that the resident
can no longer receive care at this facility, such as being a danger to themselves
or others, an unmeetable care need, improved condition, unpaid bills, or facility
closure. If a facility wants to evict a resident, they must provide notice at least
21 days in advance, provide information on the appealing the decision to the
Illinois Department of Public Health, and provide a mailing envelope for the
appeal.

If you suspect that your workplace is violating any of these rights, you should
discuss it with your supervisor and bring the problem up with the resident
council. The resident council is a group of residents who meet to discuss
issues with their facility and advocate for improvements on behalf of residents.

If you or the resident council need further help solving the problem, you may
want to contact your state’s long term care Ombudsman program or file a
complaint with the Department of Public Health[9].

A coworker of yours notices that Miss Marvin enjoys the private company of
men in her room. Recently, Miss Marvin has also been enjoying the private
company of women, and once one of her visitors didn't leave until late in the
evening. You don't have much interest in the intimate lives of the residents,
but your coworker finds gossiping about the comings and goings of the
various residents' visitors very entertaining. You think your coworker may be
casually discussing these things with other people in addition to you. What
would you do in this situation? Is your coworker doing something wrong?
Why?
Policy, Procedure, and Job Description

A policy is a course of action that is meant to be taken every time in

response to particular situations. A healthcare facility may have a policy on
workplace attire, on sharing details of a person’s recovery with their family, or
on the appropriate use of psychiatric medication, to give a few examples.

A procedure is a specific method or way of doing something. A healthcare

facility will have procedures on how to change a bed, how to fill out a medical
chart, and on how to properly remove PPE like gloves and masks.

NAs must closely follow all of their workplace policies and procedures. Failure
to do so could make them or their supervisors liable any resulting negative
consequences. Policies and procedures are in place to protect the patient, the
healthcare professionals, and the healthcare facility; it is in everyone’s best
interest, including one’s own, to follow policies and procedures to the letter.

Some policies and procedures are mandated and overseen by federal and
state governments, while others are specific to the workplace. If you have a
question about your workplace’s policies and procedures, always ask your
supervisor or consult the document where they can be found.

A job description refers to one’s clearly defined duties and responsibilities. Job
descriptions may be written by government legislation, agencies, and specific
workplaces. If a nursing assistant is asked to do something that is not in their
job description, they should refrain from performing the task and discuss it
with their supervisor.

Federal and state agencies may perform oversight on long-term care facilities
by hosting surveys; a survey is when a federal or state oversight body reviews
the work done by a long-term care facility to ensure that minimum legal
standards are consistently met. These surveys will assess whether residents
are receiving satisfactory care and whether their needs are being met. In
doing so they will talk with staff, residents, and families, as well as review all
charts and documentation done by the staff.

A NA’s role during a survey is the same as it always is – provide quality care,
pay attention to the Big Three, and be professional and honest. If an oversight
agency finds a problem with a facility, they will issue a citation; depending on
the severity, a citation may result in the care facility being forced to correct the
issue, being fined, or loss of license, certification, and accreditation. NAs
should always be honest if an auditor asks them questions about their facility.
Abuse and Neglect

Before OBRA’s passage, abusive and neglectful treatment of residents was

significantly more common than it is today. Sadly, in spite of necessary
legislation, the problem does still persist.

Residents have a right to be free from abuse and neglect. Abuse is

purposeful mistreatment and can come in many forms, physical, financial, or
psychological. Neglect is a form of mistreatment that occurs when a
vulnerable person’s needs are not met while in the responsible party’s care;
neglect or negligence can result in harm to a person, which then makes it
malpractice.

Every resident is every NA’s responsibility. NAs work to make sure that
everyone in their care has as high a quality of life as possible every day. A
high quality of life, understood in terms of the residents’ rights outlined above,
is not compatible with suffering abuse[10].

Elder abuse can come from different sources. Residents are especially
vulnerable to abuse from staff members, and potentially from other residents.
Residents may also be abused by family members who visit or take the
resident elsewhere. It is important for NAs to recognize the possibility of
abuse and to observe any potential warning signs that a resident is being
abused.

There are many signs of potential abuse and neglect; unexplained injuries
(especially if reoccurring), weight loss and dehydration, fear and anxiety
around a particular caregiver, uncleanliness, a caregiver or family member
withholding privacy, and call lights left unanswered are all potential indicators
that a resident is suffering from abuse or neglect.

NAs are mandatory reporters, which means that they are legally obligated
to report suspected abuse or neglect. The NA can alert the nurse to their
concerns with or without discussing it with the resident first. When reporting,
the NA should tell the nurse and give as many details as possible; they should
also assist the resident if the resident decides to make a formal complaint.

Remember, residents have a right to be free from retaliation; if a resident

complains and a staff member appears to punish them for it, the nursing
assistant should report this behavior as soon as possible.
What would you do?
Imagine that you are working as a nurse’s assistant in a long-term care facility. You
regularly care for Mr. Jones, and have a good sense of his personality. He is talkative
with you, is forgetful but lucid most days, and is comfortable with a casual touch on the
hand or the arm (you know this because he told you after you asked). However recently
you have noticed some changes in Mr. Jones’ demeanor. In the last month he has
become more withdrawn and disoriented, less willing to eat and participate in social life,
and he recoiled the few times you have touched his hand during conversation. Today he
said something concerning: when you brought up the upcoming weekend, he said that
he wished you would still come to work so he “wouldn’t have to spend as much time
with that other aide.” You’ve observed him while assisting with ADLs and did not notice
any marks or physical causes for concern. How would you proceed with this situation?
Would you tell the nurse immediately, or try and talk with Mr. Jones first? How would
you approach that discussion? Spend 5 minutes writing, and share with a friend or
classmate.

Professional Communication
Professional communication for NAs looks different depending on the context
it occurs in; professional communication means something different when
talking with a nurse than when communicating with a resident[11].

The communication that goes on as a function of caring for patients and

residents is some of the most significant communication that happens in
healthcare settings. In other words, the members of the care team have to
communicate with one another in order to organize and provide care, and
their ability to communicate effectively matters a lot for their ability to
successfully care for someone. Professional communication between
members of a care team about patient care will utilize three important
frameworks and procedures: the nursing Chain of Command, the Nursing
Process, and reporting and recording.

The Chain of Command

The Chain of Command refers to the authority and responsibility that

different nursing staff carry relative to one another. NAs are at the “bottom” of
the Chain of Command; this has nothing to do with how important they are to
a person’s care, and simply means that they are not permitted
to delegate tasks to or supervise anyone. Rather, tasks are
delegated to them, and they are supervised by a nurse with more
responsibilities and liabilities who is “higher” on the chain of command.
A facility’s Director of Nursing (DON) is responsible for the whole nursing staff.
The DON has a team of staff involved at higher-order levels of staff
development and care management, who have responsibility over nursing
supervisors and charge nurses that manage many units or a single unit
respectively.

Staff nurses, or RNs and LPNs, are next in the Chain of Command and are
responsible over the nursing assistants. NAs report to the RN that they are
assigned to.

It is part of the work of employers to provide their NAs with the education and
mentorship necessary to do their work. NAs should always feel comfortable
asking for help or additional instructions from people who oversee their work
and training.

Delegation

When an RN gives the NA a request or an order, they are delegating

something to them. This implicates them both in that care task. NAs are liable
for their own actions; this means they are responsible for them. However,
NA’s actions are also a liability in the sense that other people, like supervising
nurses, may be held responsible for them as well.

Delegation occurs when a particular member of the care team with a higher
level of supervision and responsibility than the NA on the nursing Chain of
Command asks them to perform a task. Tasks must be properly delegated, in
the sense that they are delegated by the correct person to the correct person
An NA should only be delegated tasks that are within their job description and
they can legally perform; NAs may also be asked to assist nurses with more
complicated tasks. RNs can delegate tasks to LPNs and NAs, LPNs can
delegate tasks to NAs, and NAs cannot delegate any tasks.

The National Council of State Boards of Nursing (NCSBN) describes the Five
Rights of Delegation[12] as:

 Right Task
 Right Circumstance
 Right Person
 Right Direction/Communication
 Right Supervision/Evaluation
These “rights” are in place to ensure that when a task is delegated, it is the
correct care task, delegated properly by the relevant person, in the best
interest of the patient, and is performed by the right person with the proper
oversight. It is part of the NAs responsibility to know when they are being
delegated a task that they should not perform. This is vital, because a NA,
RN, or another member of the nursing team may be held responsible for
improperly delegated tasks[13].

NAs can either agree or refuse to perform a delegated task. Protecting the
patient from harm is always the NA’s first priority; if the NA does not feel they
can safely perform the delegated task, they should refuse it so the nurse can
delegate it to somebody who can safely and legally perform it.

NAs should only perform tasks that are within their scope of practice. The
NA’s scope of practice is determined by the state, the agency the NA works
for, and the NA’s supervising nurse. However, no agency or nurse can expand
the NA’s scope of practice beyond legal boundaries or beyond the boundaries
of responsible caregiving.

It is important never to ignore a request. If a NA is not comfortable with

performing a delegated task, it is important that they communicate with their
supervisor or someone who can hear their concerns. Some reasons for
refusing a task may be that the directions aren’t ethical or are not within the
legal boundaries of the NA role, the task falls outside the NA scope of
practice, directions may go against agency policies, directions are unclear or
incomplete, or a nurse may not be available to supervise the NA’s
performance.
Quick Question
Imagine that you are at work as a NA, and your supervising nurse asks you to perform a
care task that is within the technical scope of your practice, but that you haven’t been
trained on how to perform. The floor is very busy right now, so when you raise your
concern, the nurse says “It’s a simple task, just go ahead and do it.” You are still
uncomfortable with the situation. What should you do? Which of the Five Rights might
be at jeopardy in this situation?

The Nursing Process: Assess, Diagnose, Plan, Implement,

Evaluate

Nursing care is a highly organized process, which means that in order to do it

well every time all members of the nursing team need to proceed
methodically. The nursing process is a step-by-step method that nurses use
to determine what may be wrong with a patient and how best to move forward
with their care.

Assessment: Assessment means, in short, gathering information about the

patient. Nurses or N.A.s nay do this by reviewing a medical chart, talking with
the patient, performing a physical assessment of some kind, and by using
your five senses to take note and observe.

Nursing assistants play an important role in the assessment phase of the

nursing process because they often have the most hands-on interaction with
the patient, and are therefore best positioned to take note of changes in their
condition.

NAs should take note of objective information by writing down what they can
gather from their senses; they should also note any subjective information, or
things they learn by speaking with the patient or their families. For example,
objective information is noticing that a patient has jaundice; subjective
information would be when they tell you that their stomach hurts.

When observing a patient as part of assessment, try and take note of their
orientation (awareness and grasp of reality), vital signs, changes in ability, or
any other changes in physical condition or mood. Assessment is an ongoing
process, and continues for as long as the patient is in the nursing team’s care.

Diagnosis: When a medical professional makes a diagnosis, they are making

an official declaration of what they believe is wrong with the patient. Nurses
can give diagnoses of problems that can be treated with nursing measures.
Nursing diagnoses are not medical diagnoses, because a medical diagnosis
must be made by a doctor. A nursing diagnosis can be made by a nurse, and
describes a health problem that can be treated by a nurse. A nursing
diagnosis may have to do with an issue of the body, but it may also address
the emotional, social, or spiritual dimensions of a person’s care.

Planning: Planning occurs when the nursing team decides how to proceed
with care. Planning with the nursing team may involve the delegation of tasks
and duties, prioritizing some aspects of care over others, and aligning your
care goals as a team. While the RN ultimately decides on the plan,
everybody’s input (especially the patient and their family’s) input is essential.
Goals are what is desired for a person’s care, and usually indicate an “if all
goes well” mentality, aiming at a person’s highest anticipated level of being
and function. Goals are important because they promote healing and
recovery. When prioritizing actions in the planning phase, consider which
needs are most threatening, which steps are time-sensitive, staff availability to
perform the tasks, and the holistic needs and wants of the patient.
Prioritization is an exceptionally important skill for a NA to develop, because it
is important to the organization of a patient’s care and because it is essential
for efficient time-management on the job.

Implementation: The implementation step is the action phase of the nursing

process. It is when the interventions determined in the planning phase are put
into effect. The tasks in need of implementation may range from basic and
simple to highly complicated and requiring multiple people. Reporting and
recording of the care should only occur after the care has actually been
administered. It is important to continue observing and taking note throughout
the entirety of the nursing process, because the assessment phase never
ends. Continued observation is necessary in case any changes need to be
made to the care plan.

Evaluation: Evaluation occurs when the care team determines how

successful the intervention was. Goals set during the planning phase may be
met completely, partially, or not at all. Once progress has been evaluated, the
nursing team returns to the assessment stage to continue the patient’s care
and begin the process over again.

Reporting and Recording

When an NA reports something to the nurse, they deliver information verbally.

When an NA records something, that means the information was written and
is included in the patient’s chart. It is important to make sure that both of these
steps are completed.

When reporting, a NA has only officially reported something when they speak
to their supervising nurse, not simply another person above them in the Chain
of Command.

When verbally reporting the NA should be prompt, thorough, and accurate.

This means correctly noting all relevant information, without including so many
unnecessary details that the record is burdensome and time consuming. All
record entries should include the patient’s name, room, and bed number, and
the time that the observation was made or care was given.

The NA should report and record only what they did and the care they
provided, as well as any noticeable changes to the patient’s condition. The
report should also include the time when the NA left the area.
When recording, an NA should write information in the patient’s medical
record. A medical record, or chart, is a permanent legal document that
medical institutions keep on their patients. It contains descriptions of a
patient’s condition, relevant details of their medical history, notes on the care
plan and treatment, consent forms, progress notes, and details of any
changes the patient has undergone since entering into care.

The NA should record anything that they do to, with, or for the patient; this is
an essential element of maintaining the continuity of care within the nursing
team.

A popular saying in the nursing profession is that “if it wasn’t recorded, it didn’t
happen.” While ironic, this saying expresses the extent to which a nursing
team relies on a patient’s medical record to coordinate their care. All
documentation should occur only after the care has been administered,
neither during nor before.

Record-keeping may be different from one healthcare setting to the next.

While most employers now use an electronic system, some may use a written
or a mixed record-keeping system. When charting by hand, always use blank
ink, and only record facts rather than opinions. It is important to follow the
agency’s rules on documentation. If a NA make a mistake on a chart, they
should never erase it or correct it, though they should cross it out and enter
the correct information. NAs should follow their facility or agency’s policy for
correcting a mistake made on a medical record.

Incident Reporting and Recording

An incident is a problem, accident, or unforeseen event in a patient’s care, or

an accident or injury that impacts any employee or visitor. An incident report is
a report that objectively documents what happened and what the response to
the situation was. This is important so workplaces can be made safer, and so
incidents do not further impact anybody’s care.

NAs should always fill out an incident report if they are injured while on the
job; if an incident occurs in a patient’s care, a nurse will usually fill out the
incident report and may ask for input from the NA. The incident report should
include only factual observations and events from an objective perspective.
NAs should never let anybody talk them out of filing an incident report.
When completing an incident report, NAs should include exactly what they
observed, list the time of occurrence, list any observations of the person and
what state they are in, and describe the person’s reaction to the situation.
Facilities will usually have a specific form for NAs to fill out. NAs should report
the incident to the nurse before filling out an incident report form, especially if
the incident involves a patient, because the nurse may want to complete the
form themself.

Start and End-of-Shift Reporting

Start-of-shift reports are gatherings of the care team at the start of a shift to
get up-to-speed on the patients in their care. NAs will be present at start-of-
shifts reports, during which the nurse from the previous shift will discuss any
changes to patients’ conditions and updated care plans, as well as any
discharges or new admissions. It is also where NAs will receive their
assignments for that shift.

At end-of-shift reports, NAs should report any changes to their supervising

nurse, so they can be included in the next start-of-shift report. Before finishing
tasks and going to end-of-shift reporting, NAs should make sure that patients
or residents have anything they may need. NAs can offer them the restroom,
make sure that necessities are within easy reach, and reposition them. Shift
changes will likely be the longest time patients or residents are left unattended
during the day, so it is important to make sure that they will be safe and their
needs taken into account for that time.
Critical thinking is an essential skill for nursing assistants. NAs will rely on critical
thinking when making observations for reporting and recording. Why is critical thinking
such an important skill when reporting and recording? Write for 5 minutes, then share
your response with a friend or classmate.

Professionalism

It is essential that nursing assistants keep themselves well-groomed, diligently

attend to their hygiene, and dress in accordance with the standards of their
workplace. NAs should always be aware of their workplace’s dress code. NAs
should abstain from wearing large jewelry or any adornments, such as long
nails, that could get in the way of performing hands on work or catch on an
object unintentionally. NAs should remove unnecessary jewelry, but are
encouraged to wear a small, waterproof watch to keep track of the time.
Remove the watch when washing hands so that no areas are missed.
NAs should refrain from using artificial fragrances like perfume and cologne.
Instead, consider a lightly or unscented deodorant. People receiving care may
have sensitivities to smell, so refraining from fragrance is one way you can
practice empathy and courtesy before even arriving at work.

It is important for NAs to conduct themselves in a professional manner. This

can mean being punctual, limiting cell-phone use, never reporting to work
under the influence, using appropriate language, maintaining positive relations
with coworkers, and listening to and applying feedback. NAs should always
discuss workplace standards of professionalism with their supervisor, as
expectations can change depending on where one works.