CNA	Certified nursing assistant, certified nurse aide
LNA	Licensed nursing assistant
LPN	Licensed practical nurse
LVN	Licensed vocational nurse
NATCEP	Nursing assistant training and competency evaluation program
NCSBN	National Council of State Boards of Nursing
OBRA	Omnibus Budget Reconciliation Act of 1987
RN	Registered nurse
RNA	Registered nurse aide

Federal and state laws and nursing center policies combine to define the roles and functions of each health team member. Everyone must protect residents from harm. To do so, you need to know:

• What you can and cannot do

• Your legal limits

Laws, job descriptions, and the person’s condition shape your work. So does the amount of supervision you need.

History and current trends

For decades, nursing assistants have helped nurses with basic nursing care. Often called nurse’s aides, they gave baths and made beds. They helped with grooming, elimination, and other needs. Their work was similar in hospitals and nursing centers. Until the 1980s, training was not required by law. Nurses gave on-the-job training. Some hospitals, nursing centers, and schools offered nursing assistant courses.

Before the 1980s, team nursing was common. A registered nurse (RN) was the team leader. The RN assigned care to nurses and nursing assistants. Care was assigned according to each person’s needs and condition. It also depended on the staff member’s education and experiences.

Primary nursing was common in the 1980s. RNs planned and gave care. Many hospitals only hired RNs. Meanwhile, nursing centers relied on nursing assistants for resident care.

Home care increased during the 1980s. Prospective payment systems limit health care payments (Chapter 1). To reduce care costs, hospital stays also are limited. Therefore patients are discharged earlier than in the past. Often they are still quite ill and need home care.

Efforts to reduce health care costs include:

• Hospital closings. Many do not make enough money to stay open.

• Hospital mergers. Hospitals merge to share resources and to avoid the same costly services. For example, one hospital offers heart surgery. The other serves women and children.

• Health care systems. Agencies join together as one provider of care. A system often has hospitals, nursing centers, and home care agencies. It also has hospice settings, ambulance services, and doctors. For example, a hospital patient needs long-term care. The person transfers from the hospital to a system nursing center. The person is transported by the system-owned ambulance service. After rehabilitation, the person returns home. The system-owned home care agency provides needed services in the home setting. The person’s care stays within the system from the hospital to the home setting.

• Managed care. Insurers have contracts with doctors, hospitals, and health care systems for reduced rates. See Chapter 1.

• Staffing mix. Hospitals hire RNs, licensed practical nurses/licensed vocational nurses (LPNs/LVNs), and nursing assistants. Most hospitals require a state-approved nursing assistant training and competency evaluation for employment. More training is given for tasks not in the training program.

Federal and state laws

The U.S. Congress makes federal laws that all 50 states must follow. State legislatures make state laws. For example, the New York legislature makes state laws for New York. The Texas legislature makes state laws for Texas. You must know the federal and state laws that affect your work. They provide direction for what you can do.

See Chapter 4 for other laws affecting your work.

Nurse practice acts

Each state has a nurse practice act. It protects the public’s welfare and safety by regulating nursing practice in that state. A nurse practice act:

• Defines RN and LPN/LVN.

• Describes the scope of practice for RNs and LPNs/LVNs.

• Describes education and licensing requirements for RNs and LPNs/LVNs.

• Protects the public from persons practicing nursing without a license. Persons who do not meet the state’s requirements cannot perform nursing functions.

The law allows for denying, revoking, or suspending a nursing license. The purpose is to protect the public from unsafe nurses. Reasons include:

• Being convicted of a crime in any state

• Selling or distributing drugs

• Using the person’s drugs for oneself

• Placing a person in danger from the over-use of alcohol or drugs

• Demonstrating grossly negligent nursing practice

• Being convicted of abusing or neglecting children or older persons

• Violating a nurse practice act and its rules and regulations

• Demonstrating incompetent behaviors

• Aiding or assisting another person to violate a nurse practice act and its rules and regulations

• Making medical diagnoses

• Prescribing drugs and treatments

Nursing assistants

A state’s nurse practice act is used to decide what nursing assistants can do. Some nurse practice acts also regulate nursing assistant roles, functions, education, and certification requirements. Other states have separate laws for nursing assistants.

Legal and advisory opinions about nursing assistants are based on the state’s nurse practice act. So are any state laws about their roles and functions. If you do something beyond the legal limits of your role, you could be practicing nursing without a license. This creates serious legal problems for you and the nurse supervising your work.

Nursing assistants must be able to function with skill and safety. Like nurses, nursing assistants can have their certification (p. 22) denied, revoked, or suspended. The National Council of State Boards of Nursing (NCSBN) lists these reasons for doing so:

• Substance abuse or dependency.

• Abandoning, abusing, or neglecting a resident.

• Fraud or deceit. Examples include:

• Filing false personal information

• Providing false information when applying for initial certification or to have it re-instated

• Violating professional boundaries (Chapter 4).

• Giving unsafe care.

• Performing acts beyond the nursing assistant role.

• Misappropriation (stealing, theft) or mis-using property.

• Obtaining money or property from a resident. Fraud, falsely representing oneself, and through force are examples.

• Having been convicted of a crime. Examples include murder, assault, kidnapping, rape or sexual assault, robbery, sexual crimes involving children, criminal mistreatment of children or a vulnerable adult (Chapter 4), drug trafficking, embezzlement (to take a person’s property for one’s own use), theft, and arson (starting fires).

• Failing to conform to the standards of nursing assistants (p. 25).

• Putting residents at risk for harm.

• Violating a resident’s privacy.

• Failing to maintain the confidentiality of resident information.

The omnibus budget reconciliation act of 1987

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.

OBRA sets minimum training and competency evaluation requirements for nursing assistants. Each state must have a nursing assistant training and competency evaluation program (NATCEP). A nursing assistant must successfully complete a NATCEP to work in a nursing center, hospital long-term care unit, or home care agency receiving Medicare funds.

The training program

OBRA requires at least 75 hours of instruction. Some states have more hours. At least 16 hours of supervised practical training are required. Such training occurs in a laboratory or clinical setting (Fig. 3-1, p. 22). Students perform nursing care and tasks on another person. A nurse supervises this practical training (clinical practicum or clinical experience).

Fig. 3-1 Nursing assistant training program. A, Students study in a classroom setting. B, An instructor demonstrates a skill in a laboratory setting.

The training program includes the knowledge and skills needed to give basic nursing care. Areas of study include:

• Communication

• Infection control

• Safety and emergency procedures

• Residents’ rights

• Basic nursing skills

• Personal care skills

• Feeding methods

• Elimination procedures

• Skin care

• Transferring, positioning, and turning methods

• Dressing

• Helping the person walk

• Range-of-motion exercises

• Signs and symptoms of common diseases

• How to care for cognitively impaired persons (those who have problems with thinking and memory)

Competency evaluation

The competency evaluation has a written test and a skills test (Appendix A, p. 722). The written test has multiple-choice questions. Each has 4 choices. Only 1 answer is correct. The number of questions varies from state to state.

The skills test involves performing nursing skills. You will perform certain skills learned in your training program.

You take the competency evaluation after your training program. Your instructor tells you when and where the tests are given. He or she helps you complete the application. There is a fee for the evaluation. If working in a nursing center, the employer pays this fee. You are told the place and time of the tests after your application is processed. Some states give a choice of test dates and sites.

Your training prepares you for the competency evaluation. If you listen, study hard, and practice safe care, you should do well. If the first attempt was not successful, you can retest. OBRA allows at least 3 attempts to successfully complete the evaluation.

Nursing assistant registry

OBRA requires a nursing assistant registry in each state. It is an official record or listing of persons who have successfully completed that state’s approved NATCEP. The registry has information about each nursing assistant:

• Full name, including maiden name and any married names.

• Last known home address.

• Registry number and the date it expires.

• Date of birth.

• Last known employer, date hired, and date employment ended.

• Date the competency evaluation was passed.

• Information about findings of abuse, neglect, or dishonest use of property. It includes the nature of the offense and supporting evidence. If a hearing was held, the date and its outcome are included. The person has the right to include a statement disputing the finding. All information stays in the registry for at least 5 years.

Any agency (hospital, nursing center, home care agency) can access registry information. You also receive a copy of your registry information. The copy is provided when the first entry is made and when information is changed or added. You can correct wrong information.

Other OBRA requirements

Retraining and a new competency evaluation program are required for nursing assistants who have not worked for 24 months. It does not matter how long you worked as a nursing assistant. What matters is how long you did not work. States can require:

• A new competency evaluation

• Both retraining and a new competency evaluation

Nursing centers must provide 12 hours of educational programs to nursing assistants every year. Performance reviews also are required. That is, your work is evaluated. These requirements help ensure that you have the current knowledge and skills to give safe, effective care.

See Teamwork and Time Management: Other OBRA Requirements.

TEAMWORK AND TIME MANAGEMENT

Other OBRA Requirements

Educational programs in nursing centers are commonly called in-service programs or in-service training. Some are required; others are optional. Program announcements and schedules are posted on bulletin boards on nursing units, in staff locker rooms and lounges, and by the time clock. Some are included with your paycheck. Know where your agency posts in-service information. Check those areas often.

Such training is scheduled before your shift begins, during your shift, or after your shift. If scheduled before work, plan to arrive early. If scheduled after work, plan to stay late. Arrange for transportation and childcare as needed (Chapter 5).

If the program is during your shift, plan with your co-workers. Some staff stay on the unit while others attend the program. Staff on the unit tend to all residents. A person may have special care needs while you are off the unit. Share this information with the staff who will provide such care. When you return to the unit, thank your co-workers for helping you. Help your co-workers when they leave the unit to attend in-service programs.