Nursing Assistant Ethics, Resident Rights, and Nursing Process

Ethical responsibilities and rights in nursing assistance

  • Nursing assistants should treat all clients equally with compassion and respect for their inherent dignity, worth, and unique attributes. They should promote clients' rights and safety to assist in achieving the best possible health and functioning. Read more about resident rights in the box later in this section.
  • When observing unethical behaviors by other staff, avoid the following examples:
    • Using personal cell phones in patient care areas; not responding to call lights promptly when available
    • Ignoring phones assigned to you; using agency computers for personal use
    • Avoiding clients because of ethnicity, beliefs, or other characteristics; avoiding work by sitting in empty rooms or break room during on-time hours
    • Accepting gifts or gratuities from clients or family members
    • Sharing clients’ personal information with non-caregiving staff; stealing items from clients or the health care agency
    • Governing agencies (implied unethical practices at the agency level)
  • Working as a nursing assistant means helping vulnerable populations.
  • Vulnerable populations include: children, older adults, minorities, socially disadvantaged, underinsured, or those with certain medical conditions.
  • These populations may have health conditions worsened by inadequate health care. Many governing agencies ensure needs are met (federal emphasis below).

Governing agencies and federal health care acts

  • Federal agencies that regulate and provide guidelines for health care include:
    • Centers for Medicare and Medicaid Services (CMS): provides health care funding for qualifying members. \text{CMS}
    • Medicare: funding for people over 65 or with permanent disability or kidney failure; four types of coverage: Part A (inpatient hospital/long-term care), Part B (medical services and equipment), Part C (Medicare Advantage via private plans), Part D (prescription drugs).
    • Medicaid: funding for individuals with low income; joint federal/state program; coverage varies by state.
  • Other federal agencies:
    • Centers for Disease Control (CDC): infection and disease control guidance for facilities.
    • Food and Drug Administration (FDA): safety of medications, devices, cosmetics, and related products; regulates tobacco and provides accurate information on medical products and foods.
    • Occupational Safety and Health Administration (OSHA): ensures safe and healthy working conditions; sets/enforces standards, provides training.
  • State-level health oversight:
    • Each state has a Department of Health Services (DHS) that works with counties and providers to protect citizens (e.g., public health services, long-term care regulation).
  • Wisconsin example: DHS provides resources about the Department of Health Services (About the Department of Health Services) and long-term care regulation.

Federal health care acts and major provisions

  • HIPAA (Health Insurance Portability and Accountability Act of 1996): national standards to protect sensitive patient health information (PHI) from disclosure without consent.
    • The HIPAA Security Rule requires: ext{confidentiality}, \text{integrity}, \text{availability of PHI}; detect and safeguard against anticipated threats; protect against impermissible uses/disclosures; certify compliance by workforce.
    • As a nursing assistant, legally keep client information confidential (care, plans, shift reports).
  • OBRA (Omnibus Reconciliation Act of 1987): introduced new standards for Medicare/Medicaid related to nursing home care.
    • Key provision: nurse aide training minimum of 75 hours and a competency evaluation; each state records a registry of nurse aides who passed the competency evaluation.
    • Emphasized improving quality of life and patient-centered care in long-term care (LTC).
    • Focus on meeting residents’ preferences and involving them in decisions about their care.
  • Older Americans Act (1965): established grants to states for community planning, social services, research, and aging workforce development; includes ombudsman programs for LTC residents to resolve health, safety, welfare, and rights issues and encourage advocacy.

Patient-centered and holistic care

  • Patient-centered care aims to address health needs across physical, emotional, mental, spiritual, social, and financial dimensions.
  • The care team approaches residents with holistic care, recognizing each member contributes to best outcomes and quality of life.
  • Roles within the health care team:
    • Physicians/health care providers diagnose and prescribe treatments.
    • Nursing team includes RNs, LPNs/LVNs, CMTS (certified medical technicians), CNAs/RNAs/LNAs.
    • Nursing staff implement care plans per nursing process and orders.
    • Nursing supervisor/charge nurse provides oversight and may assist with direct resident care.
    • Social services (social workers, case managers) assist with emotional issues, benefits, discharge planning.
    • Therapists (PT, OT, ST) help residents recover function and maintain independence.
    • All team members contribute to holistic outcomes; coordination and respect among team members is essential.
  • Nonmedical oversight: facilities have administrative and support roles that interact with medical care but focus on operations and resident environment (see below).

Nonhealth care responsibilities in facilities

  • Administrative and support roles include:
    • Administrator: oversees regulatory compliance and nonmedical facility operations (finances).
    • Medical Director: medical oversight, infection control, and quality of care.
    • Director of Nursing (DON): manages nursing staffing, policies, and procedures.
    • Assistant DON: assists with nursing management.
    • Staff Development Coordinator (SDC): trains staff and provides continuing education.
    • Minimum Data Set (MDS) Coordinator: assesses resident needs; reports to CMS for reimbursement.
    • Business Office: handles billing and financial matters.
    • Housekeeping and Maintenance: facility cleanliness and equipment safety.
    • Activities Director: plans resident activities.
    • Dietary Director: oversees dietary staff and nutritional care.

The nursing process and scope of practice

  • The nursing process is a critical-thinking model for patient-centered care and clinical judgment. It follows ANA standards of professional nursing practice.
  • The process is often captured by the mnemonic ADOPIE or as described in this chapter as ATABE (as presented in the text):
    • Assessment
    • Diagnosis
    • Outcomes Identification
    • Planning
    • Implementation
    • Evaluation
  • Components:
    • Assessment: RN collects relevant data (physiological, psychological, sociocultural, spiritual, economic, and lifestyle).
    • Nursing assistant observations: report changes to the nurse (e.g., reddened skin, swelling, pain, confusion).
    • Diagnosis: RN analyzes data to determine actual/potential diagnoses; nursing diagnoses guide care plans and differ from medical diagnoses.
    • Outcomes Identification: RN sets measurable, achievable short- and long-term goals in collaboration with patient.
    • Planning: develop a collaborative plan with evidence-based interventions; document in the nursing care plan to ensure continuity.
    • Nursing care plans: document ongoing care and specify delegated interventions to LPNs or CNAs under RN supervision.
    • Implementation: perform delegated interventions with supervision; document actions in the medical record.
    • Evaluation: RN assesses progress toward goals; adjust plan as needed; CNAs report changes and may implement alternative interventions if asked.
  • Benefits of the nursing process include improved quality and safety, reduced omissions/duplications, collaborative care, patient satisfaction, and more efficient care planning (cite ANA, 2021).
  • Scope of practice:
    • Defined as services a trained professional is competent to perform under state licensure; variability exists by state.
    • Federal baseline: 42 CFR § 483 lists nine tasks allowable by states; examples include:
    • Personal care skills
    • Safety/emergency procedures
    • Basic nursing skills
    • Infection control
    • Communication and interpersonal skills
    • Care of cognitively impaired residents
    • Basic restorative care
    • Mental health and social services needs
    • Residents’ rights
    • Tasks in the implementation phase can be delegated by the RN to CNAs under supervision.
    • The four S’s to verify before accepting delegated tasks:
    • Scope: is the task within your licensure and state-defined scope?
    • Supervision: is supervision available and clearly defined (in-person or via telecommunication)?
    • Safety: is it safe to perform the task given current condition and skills?
    • Supplies: are the necessary tools/equipment available?
  • Practical guidance for performing cares:
    • If unsure, ask the RN supervisor for clarification.
    • If a task was not taught during training or is legally restricted, do not perform it unless additional facility training is provided.

Types of care settings and roles for CNAs

  • Settings and provider roles vary; some require licensure, others provide agency-level training.
  • Care settings and typical observations:
    • Hospital: 24-hour care with on-site physicians and specialists; focus on acute care; sterile environment; high use of disposable items; HIPAA and infection control emphasize.
    • Long-term care (LTC) / Nursing Home: 24-hour skilled care; RN on-site; focus on chronic condition management and safety.
    • Assisted Living: more independence; scheduled assistance (medication help, grooming, meals); not always 24-hour nursing.
    • Group Home / Adult Family Home: daily living assistance with safety oversight; typically 4–6 residents; licensure varies by state.
    • Home Health: care provided in the client’s home; can be short-term or long-term; CNA duties adjusted to home setting.
    • Hospice: palliative or end-of-life care; 24/7 availability for comfort and support.
  • Terminology: patients, residents, clients, and members are used interchangeably depending on the setting.

Job-seeking, grooming, and professional expectations

  • After coursework, seek employment via local resources (newspapers, workforce boards, facility pages, online searches).
  • Review facility survey data to gauge quality rating before applying.
  • Grooming guidelines for professional appearance:
    • Shower, brush teeth, neat hair, trimmed nails; clean, wrinkle-free attire without logos; knee-length dress/skirt; closed-toe shoes; minimal makeup and jewelry; no cologne/perfume; deodorant only.
  • After hire:
    • Communicate effectively with health care team; meet resident needs; seek periodic evaluations with supervisor; keep certifications and trainings current; manage personal well-being to sustain caregiving role (stress management resources).

Resident rights and abuse prevention

  • CMS ensures residents know and understand their rights; protecting dignity and quality of life is central.
  • Resident rights (summary):
    • Be treated with respect; participate with family if desired; have representative notified of care and complications; receive information about services and fees; manage personal finances;
    • Receive privacy and appropriate living arrangements; spend time with visitors; receive social services; be protected against unfair transfers or discharges; have the ability to leave the facility when health permits; form or join groups.
  • Empathy and resident independence: accepting dependence on a caregiver can affect self-esteem and mood; empathize with residents and make appropriate accommodations while maintaining safety.
  • If a resident has a request, attempt accommodations; consult the supervising nurse if unsure; safety or infection control concerns override request (e.g., candle in room vs electric candle; location for hair dryer due to roommate safety).
  • Long-term care rights resources: read more in the Rights and Protections as a Nursing Home Resident documentation.
  • Elder abuse and neglect: protect residents from abuse and neglect; elder abuse is intentional harm or risk by a caregiver or trusted person; neglect is failure to provide care.
  • Table 2.2 (types of abuse and signs – summarized):
    • Physical abuse: signs include illness, pain, injuries, distress; behavior changes; hidden or unexplained injuries.
    • Sexual abuse: forced or unwanted sexual contact; signs include genital injuries, infections, changes in behavior.
    • Financial abuse: misuse of an older adult’s money or belongings; signs include missing items, unexplained cash use, or unusual spending.
    • Neglect: failure to meet basic needs (food, water, shelter, hygiene, medical care); signs include weight loss, skin breakdown, dehydration, soiled linens.
    • Self-neglect: resident neglect of self-care that threatens health/safety; signs align with neglect listed above.
  • Mandated reporters: CNAs and other professionals are legally required to report suspected elder/child neglect or abuse to the nurse; stay with the resident after reporting to ensure safety; report concerns to the nurse, charge nurse, or administrator for investigation.

The survey process and accountability

  • States (e.g., DHS) conduct regular surveys of LTC facilities according to CMS guidelines.
  • Surveys typically occur at least once per year; inspectors observe care, food preparation/serving, review care plans, interview residents and families, and review documentation.
  • If issues are found, citations are issued; an exit interview with facility leadership is held; facilities must develop corrective plans; DHS may return for follow-up.
  • If there are multiple complaints or serious incidents (e.g., elopement, major injury), surveys may be triggered; elopement is when a resident incapable of self-protection leaves the facility unsupervised.
  • Survey results and ratings are public (e.g., medicare.gov provider comparison tool).

The care team and interaction dynamics

  • The health care team is diverse, with each member contributing essential skills to resident care. The CNA’s role is to understand team members’ responsibilities, coordinate with appropriate colleagues, and respect each team member’s contributions.
  • Expect respectful treatment in return, regardless of educational background or job title.
  • Nonmedical facility operations require coordination with administrators and department heads to ensure comprehensive resident care.

Practical scenarios and ongoing learning

  • If residents request outcomes (e.g., activity participation, schedule changes), collaborate with the nurse to determine feasible accommodations that meet safety and infection-control criteria.
  • Recognize the emotional impact of dependent living; apply empathy and appropriate de-escalation techniques when addressing resident concerns.
  • Maintain ongoing professional development and self-care to sustain caregiving quality and personal well-being.

Quick references (key ideas to memorize)

  • Resident rights list (summary): be treated with respect; participate with family; informed about services/fees; privacy; visit freedom; social services; protection from unjust transfers/discharges; ability to leave; participate in groups.

  • OBRA training requirement: 75 hours of nurse aide training + competency evaluation; state registry.

  • HIPAA core protections: confidentiality, integrity, availability of PHI; safeguard against threats; lawful disclosures with consent.

  • 42 CFR \textbf{§} 483: nine tasks allowable by states (e.g., personal care, safety, basic nursing, infection control, communication, cognitive care, restorative care, mental health and social services, residents’ rights).

  • CNA scope: perform delegated tasks under RN supervision; verify scope, supervision, safety, and supplies (the 4 S’s).

  • Nursing process cycle: Assessment → Diagnosis → Outcomes Identification → Planning → Implementation → Evaluation (ATABE/ADOPIE as described in the text).

  • Holistic care focus: address physical, emotional, social, spiritual well-being; everyone on the care team contributes to outcomes.

  • For further reading: explore sections on resident rights, patient-centered care, elder abuse signs, and the survey process to understand how care quality is monitored and improved.

This set of notes consolidates ethical responsibilities, regulatory frameworks, resident rights, care processes, team roles, care settings, and practical guidelines to prepare for exams and real-world practice.