Chapter 3

1. Chapter 3 The Nursing Assistant

2. Federal and State Laws (cont’d) • The Omnibus Budget Reconciliation Act of 1987 (OBRA) is a federal law. • Its purpose is to improve the quality of life of nursing center residents. • This law sets minimum training and competency evaluation requirements for nursing assistants. • Each state must have a nursing assistant training and competency evaluation program (NATCEP).

3. Federal and State Laws (cont’d) • The training program • OBRA requires at least 75 hours of instruction. • Includes classroom and at least 16 hours of supervised practical training • Provides the knowledge and skills needed to give basic nursing care • Competency evaluation • Includes a written test and a skills test • OBRA allows at least 3 attempts to successfully complete the evaluation.

4. Federal and State Laws (cont’d) • Nursing Assistant Registry • Official record or listing of persons who have successfully completed that state’s approved NATCEP • The registry has information about each nursing assistant. • All information stays in the registry for at least 5 years. • Any agency can access registry information. • You receive a copy of your registry information. • You can correct wrong information.

5. Federal and State Laws (cont’d) • Other OBRA requirements • Retraining and a new competency evaluation program are required for nursing assistants who have not worked for 24 months. • Agencies covered under OBRA must provide 12 hours of educational programs to nursing assistants every year. • Performance reviews also are required.

6. Certification • Each State’s NATCEP must meet OBRA requirements. • Nursing assistants can have their certification (licenses, registration) denied, revoked, or suspended. • To work in another state you must meet that state’s NATCEP requirements: • Apply to the state agency responsible for NATCEPs and the nursing assistant registry. • Your application is reviewed. • Certification (a license, registration) is granted if requirements are met.

7. Delegation • Delegate means to authorize another person to perform a nursing task in a certain situation. • The person must be competent to perform a task in a given situation.

8. Delegation (cont’d) • Who can delegate • RNs can delegate nursing tasks to LPNs/LVNs and nursing assistants. • In some states, LPNs/LVNs can delegate tasks to nursing assistants. • Delegation must protect health and safety. • Nursing assistants cannot delegate.

9. Delegation (cont’d) • The National Council of State Boards of Nursing (NCSBN) describes four steps in the delegation process. • Step 1—Assess and plan is done by the nurse. • Step 2—Communication involves the nurse and you. • Step 3—Surveillance and supervision; the nurse observes the care you give. • Step 4—Evaluation and feedback is done by the nurse.

10. Delegation (cont’d) • The NCSBN’s Five Rights of Delegation is another way to view the delegation process. • The right task • The right circumstances • The right person • The right directions and communication • The right supervision

11. Delegation (cont’d) • Your role in delegation • You must protect the person from harm. • You either agree or refuse to do a delegated task. • Accepting a task • When you agree to perform a task, you are responsible for your own actions. • You must complete the task safely. • Report to the nurse what you did and the observations you made.

12. Delegation (cont’d) • Refusing a task • The task is beyond the legal limits of your role. • The task is not in your job description. • You were not prepared to perform the task. • The task could harm the person. • The person’s condition has changed. • You do not know how to use the supplies or equipment. • Directions are not ethical or legal. • Directions are against agency policies. • Directions are unclear or incomplete. • A nurse is not available for supervision.

13. Delegation (cont’d) • Never ignore an order or a request to do something. • Tell the nurse about your concerns. • You must have sound reasons for refusing a task.

14. Chapter 4 Ethics and Laws

15. Seatwork • Among your tablemates, please describe the difference between ethics and laws. • Ethics is concerned with what you should and should not do. • The law is concerned with what you can and cannot do. • A law is a rule that is made by a government body. • Laws are enforced by government bodies. • Ethics deal with morals and what is the right thing to do. • Professional groups have code of ethics.

16. Introduction • The following serve to protect patients and residents from harm: • Nurse practice acts (State & Federal) • Your training and job description • Safe delegation • A complex set of rules and standards of conduct

17. Ethical Aspects • Ethics is knowledge of what is right conduct and wrong conduct. • Morals are involved. • It deals with choices or judgments about what should or should not be done. • Ethical behavior involves not being prejudiced or biased. • Ethical problems involve making choices. • Professional groups have codes of ethics.

18. Ethical Aspects (cont’d) • Boundaries • Professional boundaries separate helpful behaviors from behaviors that are not helpful. The following can occur when you are over-involved or under-involved with the person. • Boundary crossing—A brief act or behavior outside of the helpful zone • Boundary violation—An act or behavior that meets your needs, not the person’s needs • Professional sexual misconduct—An act, behavior, or comment that is sexual in nature

19. Ethical Aspects (cont’d) • Boundary signs are acts, behaviors, or thoughts that warn of a boundary crossing or violation. • Be alert to these signs. • Some violations and some types of sexual misconduct also are crimes.

20. Legal Aspects • Ethics • What you should or should not do • Laws • Tell you what you can and cannot do • A law is a rule of conduct made by a government body. • Criminal—generally offenses against the public and society • Civil—concerned with relationships between people

21. Legal Aspects (cont’d) • Torts • A wrong committed against a person or the person’s property • Part of civil law • Unintentional—harm was not intended • Intentional—harm was intended

22. Legal Aspects (cont’d) • Unintentional tort • Negligence • Malpractice is negligence by a professional person. • Intentional tort • Defamation—injuring a person’s name and reputation by making false statements • Libel—made in print • Slander—made orally

23. Legal Aspects (cont’d) • Intentional torts (cont’d) • False imprisonment—unlawful restraint or restriction of a person’s freedom of movement • Invasion of privacy—private affairs exposed or made public without consent • Health Insurance Portability and Accountability Act of 1996 (HIPAA) • Fraud—saying or doing something to trick, fool, or deceive a person • Assault and battery—may result in both civil and criminal charges

24. Legal Aspects (cont’d) • Informed consent • Consent is informed when the person clearly understands: • Reason for treatment, procedure, or care measure • What will be done • How it will be done • Who will do it • The expected outcomes • Other treatment, procedure, or care options • The effects of not having the treatment, procedure, or care measure

25. Legal Aspects (cont’d) • Wills • You can ethically and legally witness the signing of a will. • You can refuse to witness the signing of a will. • You must politely refuse to prepare a will. • Know your agency’s policy before you agree to witness a will. • If you have questions, ask the nurse.

26. Reporting Abuse • Elements of abuse • Willful infliction of injury • Unreasonable confinement • Intimidation • Punishment • Depriving the person (or the person’s caregiver) of the goods or services needed to attain or maintain well-being • Involuntary seclusion

27. Reporting Abuse (cont’d) • Abuse is a crime. • It can occur at home or in a health care agency. • All persons must be protected including those in a coma. • The abuser is usually a family member or caregiver. • Both men and women are abusers. • Both men and women are abused. • Many states, accrediting agencies, and OBRA do not allow agencies to employ persons who were convicted of abuse, neglect, or mistreatment.

28. Reporting Abuse (cont’d) • Vulnerable adults • Persons 18 years old or older who have disabilities or conditions that make them at risk to be wounded, attacked, or damaged • They have problems caring for or protecting themselves due to: • A mental, emotional, physical, or developmental disability • Brain damage • Changes from aging

29. Reporting Abuse (cont’d) • Elder abuse—any knowing, intentional, or negligent act by a caregiver or any other person to an older adult • Forms of elder abuse • Physical abuse • Neglect • Verbal abuse • Involuntary seclusion • Emotional or mental abuse • Sexual abuse • Abandonment • Financial exploitation or misappropriation • Federal and state laws require the reporting of elder abuse.

30. Reporting Abuse (cont’d) • Child abuse and neglect • May involve the following: • A child 18 years old or younger • Any recent act or failure to act on the part of a parent or caregiver • The act or failure to act results in death, serious physical or emotional harm, sexual abuse, or exploitation. • The act or failure to act presents a likely or immediate risk for harm.

31. Reporting Abuse (cont’d) • Types of child abuse and neglect • Physical abuse • Physical or emotional neglect • Sexual abuse • Rape or sexual assault • Molestation • Incest • Child pornography • Child prostitution • Emotional abuse • Substance abuse • Abandonment

32. Reporting Abuse (cont’d) • Report any changes in the child’s body or behavior. • Child and parent behaviors may signal a problem. • The child may be quiet and withdrawn. • The child may fear adults. • Sometimes children are afraid to go home. • Sudden behavior changes are common. • Bed-wetting, thumb-sucking, loss of appetite, poor grades, running away • Some children attempt suicide.

33. Reporting Abuse (cont’d) • Child abuse is complex. • Parents give different stories about what happened. • Frequent emergency room visits are common. • All states require the reporting of suspected child abuse. • If you suspect child abuse, share your concerns with the nurse. • Give as much detail as you can.

34. Reporting Abuse (cont’d) • Domestic abuse (domestic violence) occurs in relationships. • One partner has power and control over the other through abuse. • Abuse may be physical, sexual, verbal, economic, or social. • Usually more than one type of abuse is present. • Patients and residents can suffer from domestic abuse. • State laws vary about reporting domestic abuse. • If you suspect domestic abuse, share your concerns with the nurse.