CNA Notes
Healthcare Yesterday and Today
Florence Nightingale:
Known as the founder of modern nursing.
Worked in a field hospital during the Crimean War in the 1850s.
Used statistics to link sanitary conditions and the spread of infectious diseases, establishing the scientific basis of nursing.
Emphasized compassionate care and brought the basics of care to nursing and public health.
Believed the nurse's role was to help the individual make the fullest recovery possible.
Considered the environment in patient care, emphasizing its importance in regaining health.
Identified necessary aspects for nursing practice: bedmaking, patient cleanliness, physical/intellectual/mental well-being activities, proper food and water intake, documentation, and room cleanliness.
These aspects form the basics of nursing assistant training.
By addressing these needs, nursing assistants can improve clients' recovery and quality of life.
Early Healthcare in the United States:
Lack of medical schools, standardized training, licensing boards, or regulating bodies.
Doctors often came from various backgrounds (tailors, clergymen, barmen, or barbers).
Healthcare primarily involved herbal and home remedies.
Patients or their families paid for services; if unable, family members provided care.
Almshouses, funded by community donations or religious orders, served as places for the poor, elderly, homeless, and insane.
Medical students trained in almshouses, mainly through apprenticeships with doctors.
Beginning of Modern Healthcare (mid-1800s):
Public health concept emerged, focusing on educating groups about healthy living and preventing illness.
Example: teaching communities about sewage systems and clean water to prevent illness.
Public health interventions reduced infectious illness rates (e.g., smallpox, cholera).
Shift from deaths mainly caused by infectious illnesses to chronic illnesses (e.g., heart disease, arthritis).
Modernization of Medicine (early 1900s):
Scientists identified causes of illness, prevention methods, and better treatments, establishing a scientific basis for medicine.
Medical schools became more demanding, with longer training and scientific teaching.
Late 1900s: medicine became highly organized with extensive training, licensing, and regulation for doctors.
Increase in specialty healthcare providers (specialty surgery, cancer care) and expansion of physical therapy, occupational therapy, and specialty nursing degrees.
The Cost of Healthcare:
Increased complexity of healthcare led to rising costs.
Hospitals became organized entities, specializing in specific groups or diseases (burn victims, cancer patients, pediatrics).
Healthcare became a large, costly part of the economy.
Health insurance became standard after World War II, based on workers' compensation plans.
Workers' compensation evolved to cover lost wages and healthcare costs, leading to modern-day group insurance plans.
Medicare (1965): Health insurance for older adults and some younger people with disabilities, funded through federal taxes.
Medicaid (1965): Health insurance for eligible individuals and families (disabled, low-income), funded by federal and state taxes.
Rising costs due to technology, specialty services, older population with chronic illnesses, and research for new treatments.
Managed Care Organizations (MCOs) emerged to control costs by limiting charges and services.
Payment systems initiated by MCOs led to increased outpatient surgeries, shorter hospital stays, and limited choices for consumers.
Healthcare Today:
Healthcare costs rising faster than inflation.
Expensive for employers to offer insurance; premiums too high for individuals/families.
Premiums: Monthly cost for healthcare plan, often deducted from paycheck.
Cost-saving measures: co-pays (specific dollar amount/percentage per service), deductibles (set amount paid before insurance coverage starts).
National healthcare plans expanded to cover military veterans/families and some families above the poverty level (Medicaid).
Medicare prescription drug plan added in 2006.
Uninsured individuals increase healthcare costs for everyone due to unpaid emergency care costs.
Who Is Your Client?:
Clients are healthcare consumers utilizing the system.
Nursing assistants are widely employed due to cost-containment strategies.
Opportunities in hospitals, community settings, and specialty facilities.
Training focuses on basic care; on-the-job training familiarizes with specific populations (older adults, children, infants, postsurgical clients).
Each contact with a client has the potential to affect the facility positively or negatively.
Consumerism in America:
Healthcare driven by consumerism, where consumers drive choice and increase the number of choices.
Doctors/hospitals advertise to attract business; facilities focus on customer service.
Environment of healthcare agencies designed to appeal to consumers.
Consumers often have information but not necessarily knowledge; nursing assistants may need to help clients/families understand healthcare.
Clients play an active role in their care.
Nursing assistants need to explain more, listen more, and allow time for conversation and consumer choice that is best for themselves and their situation.
Home Healthcare Versus Facility Care:
Historically, care was provided at home.
Modern hospitals centralized care but rising costs and MCOs decreased hospital stays.
Increase in outpatient surgeries (same-day admission/discharge) to control costs.
Long-term care facilities (nursing homes) offer skilled nursing care for longer periods at a lower cost.
Clients transferred to long-term care for ongoing treatment after short hospital stays.
Assisted-living facilities bridge the gap between independent living and nursing homes at lower costs.
Home health services offer nursing care, personal care, and therapies in the client's home, reimbursed through Medicare/insurance.
Home healthcare shifts caregiving from hospital/nursing home staff to client/family.
Why the Nursing Assistant Needs to Know These Trends:
Clients are more involved in their care and expect more from services.
Clients are more aware of healthcare resources and treatment options.
Adapt care to clients who actively participate, respecting their choices.
Communicate with supervisors to update care plans or intervene when needed.
Involve family members if requested.
Use strong customer service skills.
Play a role in controlling costs by using supplies efficiently, preventing contamination, and properly storing labeled items.
The Nursing Assistant Role: Where You Fit In!
Work Settings for the Nursing Assistant:
More employment choices available than in the past.
Acute Care Settings:
Provide short-term care for immediate illnesses or injuries (e.g., emergency departments, hospitals, surgical clinics).
Clients referred to as "patients."
Goal: address immediate healthcare needs and stabilize the patient's condition with medication, surgery, and/or therapy.
Various healthcare professionals work in acute care settings (nurses, doctors, surgeons, social workers, pharmacists, health unit coordinators, nursing assistants, paramedics).
Hospital care is the most expensive type of healthcare, so patients are discharged as soon as safely possible.
Patients needing additional care may be discharged to subacute care, long-term care, or assisted-living facilities.
The Joint Commission accredits and surveys most acute care facilities, required by most states for Medicaid/Medicare funding.
The Joint Commission surveys facilities every 3 years (unannounced) to verify compliance with federal regulations.
Noncompliant facilities face fees and risk losing Medicare/Medicaid funding.
Typical duties: taking vital signs, walking patients, measuring intake/output, bathing/positioning patients, preparing patients for surgery, and helping patients after surgery.
Nursing assistants need to be flexible and work at a fast pace with changing assignments.
Subacute or Rehabilitation Facility:
Treats patients requiring 24-hour skilled nursing care but who are medically stable.
Designed for longer stays with a focus on patient education to prevent future hospitalizations and return to prior function.
Can be housed within acute care facilities (swing bed units) or long-term care facilities (Medicare units).
Regulated based on location: Joint Commission (within a hospital) or state regulators following OBRA regulations (within a long-term care facility).
Funding sources: Medicare, Medicaid, insurance, or private funds.
Nursing assistant duties vary based on unit focus but often involve helping with personal care needs, strengthening exercises, walking, and encouraging independence.
Daily assignments do not vary as much as in the hospital setting, but the patient population continuously rotates.
Long-Term Care:
Also known as nursing homes or skilled nursing facilities (SNFs), employ many nursing assistants.
Clients are known as "residents."
Goal: provide skilled nursing care for a long period due to chronic illness (e.g., dementia) or short-term rehabilitation.
Typical staff includes nursing assistants, nurses, activity aides, housekeeping staff, and dietary aides.
Nursing home care is less expensive than acute care with funding from Medicaid, Medicare, insurance, and private funds.
Average cost ranges between 5,000 and 6,000 per month.
Regulated by the Omnibus Budget Reconciliation Act (OBRA) of 1987, mandating regulations for resident care/rights and nursing assistant training.
Noncompliant facilities lose Medicare/Medicaid funding.
Residents have access to an ombudsman who protects their rights and investigates complaints.
Nursing homes have annual unannounced surveys from the state (typically from the Health and Human Services Department).
State representatives monitor daily caregiving, facility policies, and nursing care; additional surveys occur due to complaints.
Noncompliant facilities receive citations or fines based on rule violations and potential harm.
Citations causing immediate harm prevent the facility from accepting nursing assistant students for training for 24 months.
Typical duties: assisting with daily tasks (bathing, grooming, eating, positioning, walking residents) and caring for social/emotional needs.
This setting provides a homelike atmosphere and regular daily assignments; nursing assistants get to know residents well and become an extension of their family.
Assisted-Living Communities:
Also known as assisted-living facilities, community-based residential facilities (CBRF), or residential care apartment complexes (RCAC).
RCAC offers minimal care comparable to senior apartment living.
Assisted living bridges the gap between independent living and healthcare facilities (nursing homes).
Staff provide basic help with bathing, cooking, and cleaning; residents may be older adults or people with developmental disabilities.
Level of care varies depending on the facility.
More cost-effective than long-term care, approximately 50%-75% of the cost of a nursing home per month.
Some facilities have a nurse on staff or on call, but not 24 hours a day.
Most facilities do not require certified nursing assistants, though the certification is valuable.
Staff members are often referred to as "personal care workers."
Regulated by state governments with varying regulations; surveyed by the state every 1-2 years (or due to a complaint).
Duties vary based on whether working in a CBRF or RCAC; may include helping with activities of daily living (bathing, mobility), meal prep/service, and light housekeeping.
Some personnel are trained on the job to deliver medications.
Home Healthcare:
Services have expanded since the advent of MCOs; transitioning a client back home is more cost-effective and comfortable.
Possible only if clients can care for themselves or family members can help with daily care needs.
Clients often require nursing care, therapy, or both, provided at home on fixed schedules (one to three times per week, or as frequent as once or twice daily).
Medicare often pays for home healthcare as a temporary service until prior ability is restored or progress plateaus.
Federal legislation governs home healthcare and hospice services by linking documentation/outcomes to Medicare payments.
Private home care service businesses offer light housekeeping, errand running, cooking, companionship, and personal care.
Clients pay out-of-pocket or receive support from social support programs.
Employees are typically not required to be certified nursing assistants, but certification is an asset.
Ideal for individuals who like to take their time with clients and enjoy one-on-one interaction.
Duties include daily caregiving (bathing, toileting, assisting with range-of-motion exercises) and light housekeeping.
Hospice Services:
Specialty end-of-life care for individuals with less than 6 months to live.
Services can be provided in a hospice facility, nursing home, assisted-living center, or client's home.
Recipients are referred to as "clients," "residents," or "patients."
Goal: assist the client and family through the dying process by making the client comfortable rather than trying to cure.
Team members: social workers, nurses, nursing assistants, clergy, and volunteers.
Nursing assistants help with daily hygiene needs and provide emotional support for the client and family; requires emotional stability, tact, compassion, and composure.
Respite Services:
Also called adult day-care services, operate during normal business hours.
Recipients referred to as "clients."
Goal: provide a safe and stimulating environment for older adults and developmentally disabled clients over 18, giving primary caregivers a needed break.
Facility placement is avoided, and services are expanding with the growing older adult population.
States independently regulate these agencies.
The National Adult Day Services Association (NADSA) sets forth voluntary standards.
Services offered can include activities (crafts, games), socializing, meals/snacks, personal care needs, some healthcare services, and exercises; transportation may be available.
Another opportunity for nursing assistants to use training in a more relaxed and slow-paced environment.
Members of the Healthcare Team:
Nursing assistants are vital members of the healthcare team.
Positions are expected to increase by 17% between 2014 and 2024 (U.S. Bureau of Labor Statistics, 2015), particularly in home healthcare and assisted living.
The role provides many opportunities in healthcare, either as a career or a stepping stone.
The diversity of the team depends on the area of practice but includes providers, nursing staff, management teams, therapists, activity department staff, nutritionists, social workers, support/office staff, billing department staff, community volunteers, public health department staff, and radiology/imaging staff.
Scope of Practice for the Nursing Assistant:
Includes skills, responsibilities, and actions permitted and expected to follow after completing training.
Training programs regulated by state and federal codes to ensure consistency.
Responsibility to know the scope of practice to avoid harming clients or facing legal trouble.
Includes providing basic personal care, restorative tasks, emotional support, dementia care, and assisting with daily living activities.
Does not include delivering medications, placing indwelling medical devices (catheters), or changing a plan of care.
Chain of Command:
A hierarchical route of communication from one member of the healthcare team to the next ensures there is only one cook in the kitchen at one time.
The chain will vary depending on facility type.
Typically involves receiving delegated tasks from the nurse, not directly from the provider.
Questions or reports should go to the nurse, who then consults the provider if needed.
Follow a