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
SRNA	State registered nurse aide
STNA	State tested nurse aide

Federal and state laws and agency policies combine to define your roles and functions. To protect patients and residents from harm, you need to know:

• What you can and cannot do

• Rules and standards of conduct affecting your work

• Your role 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 in hospitals and nursing centers with basic nursing care. Often called nurse’s aides, they helped with bathing, grooming, elimination, bedmaking, and other needs. Until the 1980s, training was not required by law. Nurses gave on-the-job training. Some hospitals, nursing centers, and schools offered courses.

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

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

Home care increased during the 1980s. With prospective payment systems, health care payments were limited (Chapter 1). To reduce costs, hospital stays were shorter. Discharged hospital patients often needed care at home.

Managing health care costs is a growing concern. Efforts to reduce costs include:

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

• Hospital mergers. Hospitals share resources and avoid the same costly services. For example, 1 hospital offers heart surgery. The other serves children.

• Health care systems. Agencies join together as 1 provider of care. See Chapter 1.

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

• 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 learned in the training program.

• Patient-focused care. Services are moved from departments to the bedside. Staff are cross-trained to perform basic skills of other health team members. For example, a blood test is ordered. The nurse tells the unit secretary, who calls the laboratory. A laboratory technician goes to the patient’s room to draw the blood sample. Many people are involved. With patient-focused care, a nursing team member draws the blood. Fewer staff provide services, which lowers cost.

Federal and State Laws

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

See Chapter 5 for other laws affecting your work.

Nurse Practice Acts

Each state has a nurse practice act. A nurse practice act:

• Defines RN and LPN/LVN and their scope of practice.

• Describes RN and LPN/LVN education and licensing requirements.

• 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 intent is to protect the public from unsafe nurses. Reasons include:

• Being convicted of a crime in any state

• Selling or distributing drugs

• Using a 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.

Nurse practice acts are used to decide what nursing assistants can do. Some also regulate nursing assistant roles, functions, education, and certification requirements. Other states have separate laws for nursing assistants.

If you do something beyond the legal limits of your role, you could be practicing nursing without a license. This means serious legal problems for you, your supervisor, and your employer.

You must be able to function with skill and safety. Like nurses, you can have your certification (license, registration) denied, revoked, or suspended. (See “Certification.”)

The Omnibus Budget Reconciliation Act of 1987

The Omnibus Budget Reconciliation Act of 1987 (OBRA) is a federal law. It applies to all 50 states.

OBRA sets minimum requirements for nursing assistant training and evaluation. 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 require more hours. Classroom and at least 16 hours of supervised practical training are required (Fig. 3-1). Practical training (clinical practicum or clinical experience) occurs in a laboratory or clinical setting. Students perform nursing tasks on another person. A nurse supervises this training.

FIGURE 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 and 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

• Caring for cognitively impaired persons (those with thinking and memory problems)

See Focus on Communication: The Training Program.

Focus on Communication

The Training Program

Student clinical experiences commonly take place in a real clinical setting. Care is practiced on patients or residents. The patient or resident has the right to know who you are. When you meet the person, introduce yourself. Tell the person you are a student. For example: “Hello. My name is Jenna Smith. I am a nursing assistant student. I will be working with your nurse, Mr. Kline, today.”

Competency Evaluation.

The competency evaluation has a written test and a skills test (Appendix A, p. 873).

• 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 certain skills learned in your training program.

You take the competency evaluation after your training program. Your instructor knows the testing service used in your state and when and where the tests are given. You complete the application in writing or on-line. The evaluation has a fee. If working in a nursing center, the employer pays the fee. Otherwise you pay the fee.

You are told the place and time of the test 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 re-test. OBRA allows at least 3 attempts to successfully complete the evaluation.

Each testing service has a candidate handbook. Review the handbook carefully as you prepare for the competency 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 health care agency can access registry information. You also receive a copy of your registry information. The copy is sent when the first entry is made and when information is changed or added. You can correct wrong information.

Certification.

Certification is the official recognition by a state that standards or requirements have been met. After successfully completing your state’s NATCEP, you have the title used in your state.