Nursing Fundamentals: Introduction and Scope of Practice

The Crimean War serves as a significant historical marker for the beginning of formalized nursing processes. During this period, observations regarding infection and the transmission of diseases from one individual to another began to shape medical practices.
Early medical environments lacked the modern understanding of germ theory. Surgeries and amputations were frequently performed with tools, such as saws, that were used on multiple patients without any form of sterilization or cleaning in between.
The lack of hygiene protocols meant that bacteria growing on medical tools were directly transferred into the wounds of subsequent patients, leading to widespread infection and death.
While the history of nursing and infection control is foundational, it is often treated as background knowledge in modern nursing education and is typically not included on certification boards or the final exams for CNAs.

Professionalism is a requirement in the healthcare workplace that exists independently of personal feelings. Healthcare workers are expected to maintain professional behavior regardless of whether they like their colleagues or not.
The concept of a standard of care entails providing the same quality and level of treatment to every individual. Whether a caregiver is looking after one person or a hundred, the standard dictates that every patient receives identical, high-quality care.
The Omnibus Budget Reconciliation Act (OBRA) is a critical piece of legislation that establishes these standards. For those in nursing homes, OBRA mandates a specific level and amount of care that they are entitled to receive.

OBRA sets the legal standards for the education and certification of Certified Nursing Assistants (CNAs). It regulates the requirements necessary for a CNA to obtain and maintain their license.
National standards ensure consistency across state lines. Similar to how the ACT provides a standardized measure for high school graduates across states like Mississippi, New York, or Oregon, OBRA ensures that training standards for CNAs are uniform regardless of location.
Training programs are strictly hourly-based. For example, if a program is mandated to provide $90$ hours of training, the full $90$ hours must be completed. Instructors cannot reduce these hours, as doing so would fail to meet the standard set by OBRA.
Competency is determined through on-the-job training and the completion of a specific skills checklist to ensure the trainee is deemed competent in all required tasks.

To become eligible for state exams and eventual certification, students must be entered into the Nurse Aide Registry upon completion of their program. The registry requires legal documentation, including:
- Legal first name and last name.
- Telephone number.
- Personal email address (educational or school emails are generally avoided to ensure long-term access).
Completion dates for the program are entered into the registry to establish eligibility for certification exams.
Reciprocity, as discussed on $\text{page } 19$ , allows CNAs to transfer their certification from one state to another, such as moving from Mississippi to Alabama or Texas.
While reciprocity is a broad principle, some states require additional steps, such as paying a specific certification fee. For example, moving to California may involve different expectations or administrative costs compared to other states.

The healthcare team is composed of different roles with distinct scopes of practice based on their level of education and responsibility.
Registered Nurses (RNs) possess the highest level of education and responsibility among the floor nursing staff. In long-term care facilities, the RN typically serves as the supervisor. They are responsible for making assignments and delegating work.
Licensed Practical Nurses (LPNs) have a more limited scope than RNs. If a nursing assistant questions a direction given by an LPN, the next person in the chain of command is the RN.
CNAs must operate strictly within their defined scope of practice to protect themselves and their patients. If a doctor, nurse practitioner, or nurse asks a CNA to perform a task outside their scope, the CNA must decline and state that the task is not within their scope of practice.

Specific tasks are legally classified as being beyond the scope of a nursing assistant, as outlined on $\text{page } 23$ :
- Administering medications, which includes the administration of oxygen.
- Adjusting oxygen flow rates (e.g., turning a dial to $2\text{ liters}$ ) is prohibited because following a medical order for oxygen requires the ability to monitor for specific clinical signs that are outside of a CNA's training.
- Receiving verbal orders from physicians, particularly over the telephone. Only licensed nurses (LPN/RN) can accept verbal orders from a doctor who is off-site.
- Diagnosing illnesses or prescribing medications.
- Supervising other nursing assistants, unless the individual has been officially promoted to a specific supervisory title.
- Performing procedures that require sterile technique, such as wound dressings. While a CNA can assist a nurse (e.g., during a bed bath if a dressing comes off), they cannot independently apply a new sterile bandage or perform a wet-to-dry dressing change.
- Inserting or removing tubes, including those in the bladder (catheters) or the esophagus (feeding tubes).
In the case of an ostomy, a CNA may empty or manipulate the bag, but the attachment around the ostomy must be measured, cut, and fitted by a licensed nurse.

The five rights of delegation are designed to ensure that patients receive the proper standard of care. These include:
- The right person.
- The right circumstance.
- The right direction.
- The right supervision.
A CNA's job description should align with their scope of practice and typically includes the following responsibilities:
- Providing assistance with Activities of Daily Living (ADLs).
- Maintaining the dignity and privacy of all residents.
- Assisting with personal needs while encouraging independence and well-being.
- Documenting all delivered services and noting any significant changes in a resident's condition.
- Reporting health and well-being concerns to the assistant living administrator.
- Protecting the confidentiality of all resident information at all times.
- Serving meals in a gracious manner that respects the nutritional needs and dignity of the residents.

Question: If a doctor calls on the phone at midnight and wants to give an order, can a CNA take it if the doctor says they will sign it later?
Response: No. As a CNA, you cannot accept verbal orders. You must refuse, even if someone suggests they will sign it after the fact. Only a nurse (LPN or RN) is authorized to accept those orders.
Question: Regarding sterile dressings, if a bandage comes off in the shower, can we just re-bandage it?
Response: No. If a sterile dressing comes off, there is no harm in warm water touching the area, but the CNA cannot re-bandage it. It must remain open until a nurse comes in to perform the wet dressing and redress the wound properly. The CNA can only assist the nurse in this process.