The Roles and Responsibilities of the Nursing Assistant 

Your Role and Responsibilities 
Your role is to provide personal care and assistance to the elder  client who might receive health-care services in a variety of settings. Although you can work  in various settings, such as hospitals, clinics, physicians’ offices, or clients’ homes, the practice  focus of this text is on the long-term care setting. If you practice in a hospital or clinical setting,  you can substitute the term patient for all references of resident in this chapter. You can  also substitute the title patient care assistant or technician for the title of nursing assistant/aide. 
Regardless of your practice setting or your title, your job or position description outlines your  responsibilities and duties in detail. The most important tasks you perform are direct personal  care of the client referred to as the resident. 

Job Responsibilities 
Tasks listed on your job description can vary from one facility to another but often include  personal care, including, but not limited to 
- Activities of daily living (ADLs): Personal care activities performed by residents  every day, which include bathing, grooming, dressing, eating and hydrating, toileting,  ambulating, and exercising. 
- Measurement and client observation: Measuring, recording, and reporting resident  vital signs (temperature, pulse, respiration, and blood pressure), height and weight,  intake and output, meal consumption, changes in resident’s condition, collecting  laboratory specimens, and applying resident restraints. 
- Procedures outlined in facility procedure manual and performed under the  supervision of a licensed nurse: Performing skills including instilling enemas;  applying non-sterile dressings; applying ice packs; attending to skin and oral needs; and  admitting, transferring, and discharging patients. 
- Infection control: Adhering to facility care standards; that is, preventing and isolating  client infection through handwashing, care and handling of contaminated objects,  isolation procedures, and observing and reporting environmental situations that might  spread infection. 
- Assisting with client ambulation, movement, and exercise: Lifting, moving, and  transporting residents from one position to another, from one room to another, or  from one facility to another. Assisting the resident to maintain or regain normal  range of motion and body strength, and assisting physical exercise to maintain  musculoskeletal function and general well-being. 
- Environmental care and safety: Making residents’ living conditions as comfortable  and safe as possible by keeping the residents’ rooms clean and tidy, making beds and 

Personal Qualities 
- arranging residents’ furniture, adjusting room temperature and lighting, removing 
- potential safety hazards or sources of personal injury, such as spills or objects left on the floor, removing refuse and caring for plants, and performing CPR and resident 
- evacuation in case of fire or other environmental threats. 
- Communication: Verbal or written communication with clients, visitors, and health- care team members; observing and recording resident care or information; and answering  the telephone and taking messages. 

Other Tasks and Duties 
Other tasks and duties that fall under the responsibility of the nursing assistant include the  following: 
- Protecting residents’ rights, privacy, confidentiality, and dignity 
- Following safety rules, adhering to legal and ethical standards of care 
- Complying with all agency policies 
- Promoting client safety and well-being 
- Participating in facility efforts to provide quality care and performance improvement  activities 
- Continuing staff education 
- Performing post-mortem procedures 

Job Limitations 
You must work under the direction of a licensed nurse or doctor. Your job responsibilities are  limited to those specified in your job description. Limitations often include giving medications  (includes applying prescription skin creams, lotions, or ointments), taking orders from a doctor,  and performing any procedures prohibited by law or by the employing facility. When in doubt  about performing any function or task for which you are unfamiliar or unsure, consult your  immediate supervisor. In medicine, the adage 'Do no harm' applies to your practice as well. 

Personal Qualities 
Honesty is one of the most important qualities you can bring to your job. Second only to  knowing your job well and being accountable for what you do is being truthful in your  interactions with others. Accepting your own limitations is another example of being truthful. 
These qualities are essential to effective, lawful practice. 

Caring means having a sincere regard for the safety and well-being of all residents in your  care and being willing to care for them and about them. You can be the most skillful nursing  assistant in the facility, but if you do not care about what happens to the residents, you are  in the wrong job. The time you spend with residents other than the time required is a good  way to evaluate your caring characteristics. Spending time with residents is only one way to  evaluate caring behaviors, but it is an effective job performance measure. The following caring  characteristics are the hallmark of the exemplary employee: 
- Being considerate of others, both residents and coworkers, is very important if you are to  be an effective nursing assistant. 
- Being empathetic; that is, seeing yourself in others’ situations without pitying them is  also a very important attribute you must possess. Consideration for other peoples’  feelings is also an important personal quality for effective practice. This means being  aware of the effect of what you say and how you say it; cooperating with coworkers  to help support them and the facility when short-staffed is another example of being  considerate. 
- Having respect for other people is important, especially when their values, culture,  language, or beliefs differ from your own. Honesty, empathy, sincerity, and caring  behaviors are all part of legal and ethical practice—basic but crucial expectations of  your employer. Values, culture, and language considerations are included in subsequent  chapters. 
- Dependability is a basic expectation of your employer. Coming to work when scheduled  and on time demonstrates your commitment to your job and to the residents. Doing  what you commit to do and doing it consistently also help to demonstrate your  dependability. 
- Flexibility and dependability go hand in hand. Despite the best assignment plan, 'stuff  happens,' meaning you might be reassigned to another unit or group of residents or  staff you do not know. You must be able to accept this normal disruption in your work  schedule and make the best of the situation. 
- Accountability is a key quality you bring to your work. You must care for all residents in  a variety of conditions and situations that you have been prepared to handle, and you  are expected to perform your duties in the way you have been trained to perform them. 
Should you have any questions or concerns about your assignment, you should discuss  them privately with your supervisor. 
- Self-responsibility is required for your own health and safety. Wearing personal  protective equipment (PPE), using effective body mechanics when moving and lifting  clients, maintaining a safe workspace, organizing your work to conserve energy, and  maintaining a healthy life style are examples of those actions you must take to protect  yourself and promote your own well-being. 

The Nursing Assistant as a Member  of the Health-Care Team 
You are one of the most important members of the health-care team, working with other  nursing staff as well as technicians, therapists, health-care providers (physicians or nurse  practitioners), dieticians, social workers, the clergy, support staff, and administration to help  meet the mission of the facility whose goal is to provide the very best care possible to all  residents. Each of the following nursing staff members contributes to the well-being of the  residents: 
- Registered Nurse (RN): The RN is responsible for carrying out both the medical  plan of care prescribed by the physician as well as the nursing care plan developed  by the nursing staff. The RN assesses each resident and modifies the nursing care as  needed to help meet the patient’s needs. The RN also works with other therapists and  staff to ensure the well-being of each resident. He or she assigns unlicensed assistive  staff members to each day’s personal care activities and supervises the work. The RN  works under the supervision of the Director of Nursing and is accountable for his  or her practice according to the state’s nurse practice act, which outlines the practice  competencies as well as limitations of the practice. The RN might supervise other RNs, LPNs, or unlicensed assistive personnel (UAPs). 
- Licensed Practical Nurse (LPN): Like the RN, the LPN carries out the medical and  nursing plans of care for assigned residents but works under the supervision of the RN. 
The LPN performs treatments, administers medications, and documents care given  according to a prescribed scope of practice set by the board of nursing or other licensing  agency of the state in which the LPN practices. The LPN might supervise UAPs as  well. His or her duties can be expanded with additional training and credentialing. 
- Nursing Assistant/Nurse Aide (CNA) or Patient Care Assistant/Technician  (PCA/PCT): The CNA (or PCA/PCT) performs care and carries out duties under  the supervision of the RN or LPN. The CNA (or PCA/PCT) is in a unique position  as a first responder at the bedside. He or she becomes the eyes, ears, and hands of  the licensed nurse, often being the first team member to identify resident needs and  problems that can become life threatening. 
As a CNA, you spend more time with residents than any other team member. Because of your  close interactions with residents, you befriend them and become their advocates, meaning you  communicate their needs when they might not be able to. 
You can also serve as the first line of defense for residents in situations that might threaten  their health or well-being. For example, you will often be the first team member to notice a  change in the resident’s vital signs that can signal an infection. You might also be the first to notice a skin irritation, a warning sign of a developing bedsore. Because you spend so much  time with a resident, you might be the first team member to notice subtle changes in behavior  that could point to a serious infection. These are only a few examples of the unique role you  play on the health-care team. 

Other Team Members 
- Dietician (RD): Licensed professional who plans client’s diet according to physician  order to assure the client receives required nutrients to maintain or restore health. 
- Physical Therapist (RPT): Licensed professional who follows physician order to  maintain musculoskeletal function to help ensure client mobility and other physical  abilities to promote physical well-being. 
- Respiratory Therapist (RT): Licensed professional who carries out physician order to  maintain, promote, or regain respiratory functions. Therapy may include medications  via aerosol delivery system. 
- Social Worker (LMHP or LSW): Licensed professional who provides guidance to  secure social services (housing, insurance, agency assistance) to promote psychosocial  health; secures necessary social assistance to promote, maintain, or gain social  independence for clients. 

Being a Team Player 
As a team member, you carry out duties assigned to you by the RN or LPN. While you are  responsible for completing assignments for specific residents in a timely manner, you also assist  other team members with their assignments when you have completed your own or when urgent  help is needed. Cooperating willingly to assist coworkers is an expectation of any employer but  is particularly important in the long-term care facility. An isolated approach to your work is  not only unmanageable but also potentially harmful to you and the residents. An example of  working alone is lifting, moving, or assisting the resident to ambulate by yourself. The resident  will feel safer if two or more staff members assist with this task. You also protect yourself, other  workers, and the resident from injury by asking for help when you need it. 
Working well with others is a hallmark of an efficient and effective nursing assistant. Your  coworkers will more likely offer to help you if you assist them with enthusiasm and a can-do  approach. Your supervisor will welcome your cooperation with assignments when carried out  cheerfully and to the best of your ability. If you have a concern about an assignment or with a  situation involving your coworker’s approach to cooperation and teamwork, discuss it privately  with your immediate supervisor. 
Being a team player also means being able to accept constructive criticism, especially from  your supervisor. Listening to your superior’s feedback without being defensive helps you to improve your performance and contribute to your job satisfaction. Always follow the  facility’s chain of command when resolving work-related issues, especially for work conflicts  or other disagreements that are bound to occur. It is important for you to consult with your  supervisor about any situations that will potentially interfere with resident welfare or that will  compromise your own values and well-being. 

Communication and Interpersonal Skills 

Needed for Effective CNA Practice 
Being able to express yourself verbally and in writing is a skill you learn and apply throughout  your health-care career. Likewise, forming positive working relationships with your coworkers  and building effective interpersonal relationships with residents are essential elements in  effective CNA practice. Communication skills involve listening, responding, and documenting  what residents tell you about themselves and their unique needs. Active listening—that is,  listening to residents without being distracted by your own thoughts—is key to acknowledging  them as worthy human beings who deserve your attention. This skill is called listening with a 'third' ear. Your skill in observing what is omitted in conversation with residents will cue you  to their unexpressed needs. 

Verbal communication skills include speaking clearly at a level residents can understand—that  is, avoiding medical jargon; asking open-ended questions that discourage a yes/no response;  using phrases to encourage further exploration of thoughts and feelings: 'Oh?,' 'Tell me  more,' and so on; and clarifying the message you receive: 'Let me see if I understand what you  mean…,' 'Is this what I hear you say…?,' and so on. 
Communication barriers can occur in practice. Try to avoid the following pitfalls when  communicating with the resident: asking close-ended questions that prompt a yes/no answer;  speaking 'over the resident’s head,' using medical terms or other language that he or she cannot  understand; and responding to him or her with advice, criticism, or sarcasm. Responses to the  resident that begins with 'You should/shouldn’t…' or 'Why?' are not only demeaning but  encourage defensiveness and limit further communication. This reluctance to communicate  can be hazardous for the resident and a detriment to an effective relationship with you. 
It is important to recognize communication barriers that interfere with effective interpersonal  relationships with residents and to seek guidance and help from your supervisor to solve any  communication problem you might encounter. Use an interpreter or family member to assist  you in talking with the resident whose primary language is not English, and be patient with the  resident who struggles to understand your language. Cultural barriers can also interfere with  effective communication, especially if the resident’s culture is very different from your own. 
Nonverbal gestures like avoiding eye contact might be viewed by the resident as offensive or  disrespectful. Other cues to barriers include personal space (for example, standing too close  to the resident), smiling or other facial expressions that do not match the verbal message, and your conversational tone or body posture. For example, smiling when talking to a resident  might imply your agreement. At the same time, standing with your arms crossed over your  chest and leaning away from the resident is a message that you, indeed, do not agree with him  or her. At best, this message is confusing if not disrespectful. Admitting your own limitations  and working to improve your communication skills are positive steps to building meaningful  relationships. 
Equally important to effective interpersonal relationships with residents is the need to maintain  resident safety through clear communication. Countless stories abound regarding accidental  resident injury or neglect that resulted from failure to communicate. Examples include failure  to explain the dangers of walking without assistance for residents with mobility problems,  misunderstanding or lack of sufficient information for family members regarding restrictions  to their resident’s diabetic diet that led to hyperglycemia, or residents becoming upset with a  change in their care plan due to faulty interpretation of the nursing staff’s instructions. Barriers  to communication also include those linked to the senses (vision, hearing, and other sensory  deficits). Speaking clearly, slowly, and directly to the hearing-impaired resident is important to  ensure his or her understanding of your verbal communication. Offering large-print reading  materials or other assistance to the resident who is visually impaired is equally important. 
Some residents have a decreased sensation to pain and temperature changes. Specific details  regarding working with impaired residents are covered in subsequent chapters. 
Reporting conversations between you and the resident is also important to maintain his or her  safety and well-being. This includes changes in resident condition, his or her specific requests,  concerns or evaluations regarding care, safety considerations, and other pertinent observations. 
Recording observations, measurements, and personal care of the resident is an important  nursing assistant function. Charting and other resident documentation requires knowledge of  medical terminology and abbreviations, proper spelling and grammar, and basic computation  skills. For example, measuring intake and output requires mathematics/addition with results  expressed in milliliters, not household measures. Recording 'I & O' is acceptable terminology  for charting. Factual recording is required because your personal opinion has no purpose in  communication. Although observation is the first step to assuring resident safety, you must  record and report any resident responses to care or change in condition promptly to your  supervisor. Consult your supervisor for help with documentation to ensure completeness,  objectivity, and accuracy. Remember, you can never overcommunicate! 

Legal and Ethical Considerations  in Practice 
Your job description is based on laws and rules for nursing assistant practice set by government  agencies. As long as you follow those rules when carrying out your duties and observe the  law, you are not liable for your performance. Liability means being responsible for providing 

Resident Rights 
care according to an accepted standard. If you perform duties outside your job description  or perform appropriate duties incorrectly that result in harm to a resident, you can be found  liable. Examples of liable acts include the following: 
- Abuse: A threat or actual physical or mental harm to a resident. 
- Aiding and abetting: Participating in an unlawful act or observing it and not reporting  it. For example, observing sexual harassment of a resident and not reporting it. 
- Assault: Threat or actual touching of a resident without permission. 
- Battery: Unlawful personal violence toward a resident; for example, bathing a resident  without his or her permission. 
- False imprisonment: Preventing a resident from moving freely about, with or without  force, against the resident’s wishes. 
- Invasion of privacy: Failing to keep the resident’s affairs confidential or exposing the  resident’s body when performing care. 
- Involuntary seclusion: Keeping a resident isolated from others as a form of  punishment. 
- Neglect: Accidently or deliberately ignoring the needs of a resident that results in  harm or injury. 
- Negligence: Either neglecting to act in the manner in which you were taught, or  omitting care or performing care incorrectly that results in harm to a resident. 
- Theft: Taking something that does not belong to you. 

Resident Rights 
In 1973 the American Hospital Association (AHA) issued a policy for all patients called 'A Patient’s Bill of Rights.' Soon after that publication, a guide for long-term residents was  developed, called 'Resident’s Bill of Rights.' Although both bills are similar, the Resident’s Bill of Rights contains additional considerations for residents in long-term care settings. 

By law, all nursing homes must have written policies describing residents’ rights and must  make them available to any resident. The following outlines the issues addressed in the bill of  rights; namely, that every resident has the right to the following: 
- Be informed about the facility’s services and charges: The services of the nursing  home and all charges involved with the services should be made available and fully  explained to every resident. Likewise, charges that are not covered by Medicare or 

Medicaid should also be included in the notice of services; this includes those services  not covered by the basic charges for facility rates. 

- Be informed about one’s medical condition: Unless the physician notes in the  medical record that to be informed of his or her medical condition is not in his or her  best interest, every resident deserves to be apprised of his or her medical condition. 

Be truthful with your answers to residents’ questions about their condition, being  careful to inform them of what you observe only. An example of this is answering the  resident’s questions about vital signs or output. The RN or doctor should answer the  resident’s medical condition questions because you cannot answer medical questions  that you have not been prepared to answer. It is your responsibility to report the  resident’s request for information to your supervisor. 
- Participate in the plan of care: Every resident must have the opportunity to participate  in his or her plan of care or to refuse care or treatment. Despite your belief that a  procedure or care activity will be helpful to residents, be very careful that you do not  force them to participate against their wishes. This includes assisting other staff to do  the same. Failure to observe this resident right is an example of assault, battery, and  invasion of privacy. 
- Choose one’s own physician: Every resident has the right to determine his or her  own physician and pharmacy. Remember, your personal opinion is unimportant in this  situation. Refer the resident to the RN or social worker for assistance. 
- Manage one’s own personal finances: Residents can manage their own finances  or appoint someone else (power of attorney) to manage them. If authorized by the  resident to manage funds, the manager must report the resident’s financial status as  directed and provide all receipts for business transactions. Avoid handling the resident’s  money or valuables (for example, inventory of personal items when admitted to the  facility) without a witness. 
- Privacy, dignity, and respect: Privacy, dignity, and respect for each resident are of the  utmost importance. Privacy includes visitation for married couples. Close the door to  assure couples are alone and are not interrupted; knock before entering the room. Each  caregiver must knock before entering the patient’s/resident’s room EVERY TIME the  caregiver enters. Remember, the room is the patient’s/client’s personal space and, thus,  must be respected. Part of providing respect is to address the resident by his or her  formal name until given permission to use a first name. 
- Use one’s own clothing and possessions: Unless hazardous, or potentially infringing  on other residents’ rights, each resident has the right to wear his or her own clothing  and use his or her own possessions. 
- Be free from abuse and restraints: Residents must be protected from mental and  physical abuse, which can include unauthorized use of restraints. Except as authorized  in writing by a physician for a specified and limited time, or when necessary to protect  the individual from hurting himself/herself or others, residents must be free from  chemical or physical restraints that cause them to be unable to freely move about. 

Resident Rights 
Mental abuse refers to any threat to the resident’s psychological well-being that results  in psychological or emotional distress. This can include financial exploitation or verbal  assault. Depriving residents of any of their rights listed here is considered mental  abuse. 
Physical abuse includes hitting or rough handling of a resident. Withholding food  or fluids or failure to change a wet bed are forms of physical abuse. Sexual abuse is  a form of physical abuse and involves threats or physical contact for sexual favor or  control. Fondling or inappropriately touching a resident, rape, sexual assault, or sexual  molestation are examples of sexual abuse. Sexual harassment, or making unwelcomed  sexually explicit or implied statements to residents, is abusive and could become  grounds for resident grievance or legal action. 

Watch for signs or other clues of resident abuse that might include the following: 
- Skin tears or bruises, especially in the genital area 
- Frequent crying or periods of sadness or withdrawal 
- Personality changes 
- Refusal to carry out ADLs 
- Fear of touch 
- Anxiety or nervousness 
- Refusal of certain visitors, including spouse or family members 

You have a moral, ethical, and legal duty to report suspicion of abuse. Be as factual  as possible, avoiding assumptions and expressing personal opinions about what you  observe. Do not worry if your suspicions are unfounded. Your sincere attempt to  protect the resident outweighs any fears you might have. In all cases, follow the  facility policy for reporting abuse concerns. Abuse hotlines might also be available for  reporting suspicions of abuse. An Ombudsmen Committee might also be available as  a source for investigating abuse complaints. An Ombudsmen Committee is a group  of concerned citizens, usually appointed by the state governor, to investigate all  complaints of abuse. The committee members are not affiliated with a health-care  facility. The originator of the abuse complaint, whether a fellow citizen or a health-care  provider, is kept confidential. 
- Grievance without retaliation: Residents should be able to express concerns, make  recommendations about facility services or care, and consult with outside sources to  resolve conflicts involved in their care without fear of criticism, discrimination, or  other acts of vengeance by the facility or its staff. 
- Be discharged or transferred only for specific reasons: Residents might be  transferred or discharged from a facility only for medical reasons, for their welfare or the welfare of other residents, or for nonpayment, which excludes becoming Medicaid eligible. If transfer or discharge is planned, the resident or representative must be notified in writing within 30 days of the change. 

- Access to 
- Receive or refuse any visitor (includes family members) 
- Visiting hours, posted in public places 
- Confidential communication with visitors, including help with personal, social, or  legal services 
- Claim own rights and benefits through consultation with others for the purpose of  legal action, organizational activity, or other forms of representation 

Ethics 
Ethics is often linked with legalities when determining right and lawful behavior in health  care. Ethics is a branch of philosophy dealing with the good, bad, right, and wrong thing to  do in human interactions and the principles that help guide professionals in terms of what  ought to be done in certain situations. Ethical principles, or standards, help guide you in your  work. Examples cited include beneficence, or doing good for others. Confidentiality is another  principle that you follow to keep residents’ matters private. Nonmaleficence, or 'do no harm,'  underscores the need to not cause undo harm to a resident, or to provide safe and effective  care. Veracity, or truthfulness, means speaking the truth consistently and dependably. 
Health-care professionals such as nurses adhere to a published code of ethics, which admonishes  them to practice in an ethical manner at all times. Such guiding principles help form  a practice framework on which nurses can build. A description of ethical behavior is to 'do  the right thing when nobody else is looking.' This could be evidenced by refusing to accept  money, gifts, or favors from residents or their families; avoiding shortcuts in job performance;  maintaining a positive attitude about the facility; and treating residents’ belongings with care. 
Ethical problems occur when your 'inner ethical voice' conflicts with a situation that causes  you to struggle with the right course of action to maintain your values, often reflected in  ethical principles. Ethical dilemmas abound in today’s world, especially in health care. Specific  examples of ethical dilemmas regarding residents in long-term care mirror those of clients in  other health-care settings, such as quality-of-life issues, death and dying, access to health care,  and euthanasia. Solutions can become quite weighty but need not be solved alone. As a health  team member, you can seek guidance from your supervisor and other professionals, including  the clergy, to sort out all available alternatives in an ethical situation. Use your resources wisely  in this regard and remember that you are not experiencing the situation alone.