R.N. head nurses manage hospital and nursing home units on a twenty-four-hour basis. So, even when off duty, they are responsible for the delivery of all nursing care services. Head nurses direct and schedule daily, weekly, and monthly work tasks for nurses and nursing assistants.
Nursing Department Personnel
Hospital-based R.N. team leaders work for and with head nurses to supervise, inform, and instruct licensed nurses (part-time R.N.s and L.RN.s), and C.N.A.s.
Nursing home-based R.N. head nurses and charge nurses (licensed nurses who work evening and night shifts), work together to inform all staff members about patient care issues. Head nurses supervise, inform, and instruct licensed nurses and nursing assistants. Charge nurses supervise nursing assistants during evening and night-shift hours.
Community home health agency R.N. nurse managers and nurse supervisors share similar duties as colleagues who work for hospitals and nursing homes. They are available to supervise, advice, and assist L.RN.s and home health aides on each twenty-four-hour basis.
Public health nurses (P.H.N.s) are R.N.s who have gained additional education about public health policies and issues that concern patient care practices. They supervise work tasks performed by L.RN.s and nursing assistants who work with them in clinics and schools and teach families in their homes.
Visiting nurses are R.N.s who work for visiting nurse services (VNS). They provide nursing care services for patients in their homes and supervise nursing assistants who work with them.
Organizational Plan
A typical hierarchical organizational plan in a hospital and nursing home nursing department would be as follows:
Board of Directors
Administrator
Medical Director
Director of Nurses
R.N. Supervisors (responsible for shift supervision or nursing staffs)
Head Nurses (responsible for nursing unit supervision)
R.N. Staff Nurses L.P.N. Staff Nurses Nursing Assistants
INFORMATIONAL SYSTEMS IN NURSING
Informational systems are vehicles nurses use to communicate in a universal effort to provide competent nursing care services. There are three major types of informational systems: the nursing process, patient care plans, and shift-to-shift reports.
The Nursing Process
The nursing process is a four-part system designed to identify patient problems, plan solutions, implement them, and evaluate their positive/ negative effects on patients' health conditions. The following fictional scenario describes a scene at a community hospital where a certified nursing assistant and her team leader used the nursing process.
Patient Care Plans
Patient care plans are systematic designs developed for each patient based on data collection and discussions with others. Care plans are in a constant state of revision as nurses communicate with other nurses, nursing assistants, and other health care providers in a cooperative effort. Each patient's particular health problems and nursing care solutions are listed in the care plan. A seven year old who has an earache presents a different set of problems and solutions than does an eighty-five year old who has the flu.
Shift-to-Shift Reports
Nurses use shift-to-shift reports in all patient care settings to maintain high levels of patient safety and ensure quality nursing care services. Nurses from two shifts, outgoing and incoming, meet in staff rooms (also called break rooms) to engage in purposeful conversation about the patients they care for. The nurse in charge of the outgoing shift presides during shift reports. She uses the nursing process and patient care plans to discuss pertinent issues and positive/negative occurrences.
In many hospitals and nursing homes, overlapping shift hours enable staffs going off duty to care for patients while staffs going on duty participate in the report. In home health care situations, home health aides from two shifts engage in shift-to-shift reports, calling their R.N. supervisor whenever they are in doubt.
Computers as Informational Tools
Nurses use computers to input or access patient care plans and other pertinent information. In some workplaces, nursing assistants are taught how to access informational (flow) sheets that concern bath lists, vital sign sheets, individual toileting schedules, and other daily patient care information. Confidential information is programmed so that only staff members with clearance can access these data. Patient care plans and shift reports can be developed through the use of computers. However, shift reports and the use of computers, as informational tools, should never take precedence over the need for nurses and nursing assistants to interact with their patients.
A Case Scenario
Mr. Andrews, aged sixty-two, had an angiogram at a hospital that specializes in the care of people with heart problems. His angiogram was negative, and Mr. Andrews was taken from the diagnostic area to a third floor nursing unit, where he was to be observed for a period of six hours. After that time, he was to be discharged to go home and rest.
At 5:00 P.M. the head nurse advised Mr. Andrews that an R.N. would assess his health condition at 6:30 and discharge procedures would begin. By 7:00, Mr. Andrews had not been assessed by a nurse. He asked his wife to find out why. She approached the nursing unit desk, waited until a nurse was finished using a computer, and inquired about R.N. assistance. This nurse said, "We are discussing patients in a shift report and will assess your husband when the report is over." By 7:30 Mr. Andrews's health condition had not yet been evaluated, and he was unable to be discharged from the nursing unit. He became agitated and requested his wife's assistance to dress. After calming him down, she left the room and approached the nurse assigned to his care. This nurse was at a computer terminal showing a nurse assistant how to access a vital signs flow sheet. When interrupted, she told Mrs. Andrews she would be in to see her husband in a few minutes. Time passed, and Mr. Andrews took control of the situation. Assisted by his wife, he dressed and prepared to leave the hospital. When the assigned R.N. became aware of his intent, she said she would notify his doctor. Mr. Andrews repeated what he was told by the head nurse and added, "If there were changes in the discharge schedule I should have been advised." Before the situation escalated further, another R.N. intervened insisting that Mr. Andrews received and signed his discharge instructions. The next day Mr. Andrews informed his doctor of the situation. Mrs. Andrews called the hospital's director of nursing services to report her displeasure with R.N. attitudes. This negative situation for patient and staff members could have been avoided in two ways. First, Mr. Andrews should have been advised that discharge time would not be completed by 7:30 P.M. Second, the need for communication through shift report and computer access should not have taken precedence over the need for a nurse to communicate with her patient.
Nursing Assistant Job Tasks
Nursing assistant job tasks relate to patients' activities of daily living (ADLs). Patients/residents/clients need varying degrees of assistance when eating, toileting, bathing, dressing, and moving about. At first glance, assisting with patient ADLs appear to involve simple job tasks. In reality, assistance with ADLs involve complex issues that require an aptitude to assist others, the ability to learn, and the ability to use nursing knowledge and nursing skills to perform job tasks. For instance, if a nursing assistant served a food tray to a person who could not eat independently and did not notice this patient's inability to eat without assistance; it would be evident that the nursing assistant did not have the aptitude to be working as a health care provider.
The completion of nursing assistant job tasks requires a personal aptitude to complete tasks in a competent manner by knowing how to integrate policies and procedures through communication, infection control, and patient safety techniques.
The task of one ADL, assisting patients at mealtimes, includes the need to use a variety of facts, skills, knowledge, and common sense. Prior knowledge concerns "need to know" information: which type of therapeutic diets have been ordered, are patients able to eat without assistance, or do patients need partial or full assistance? Which patients are being monitored for food intake at mealtimes because of weight gain/loss? Which patients are being monitored for fluid intake and output because of pre-existing health problems? Which patients have difficulty swallowing and/or choke easily?
FICTIONAL SCENARIOS
The following scenarios are fictional accounts of this ADL.
C.N.A. Luis Carrero works for Mercy Hospital. It is noon, and he serves a lunch tray to a patient whom he has not cared for before. Mr. Carrero notes that the patient is being fed by artificial means and does not require a tray. He reports the situation to the R.N. team leader and asks for further instructions. After a short conference, he places the tray on the return-to-kitchen cart, washes his hands, and prepares to deliver a second food tray. Mr. Carrero knows this patient, but he still compares her name bracelet with the name on the food tray. This young woman, recovering from injuries sustained in an auto accident, can move her upper extremities independently. She pushes the food tray away. 'Take this tray," she says. "I am not hungry." Aware that trying to convince her to eat would be futile, Mr. Carrero removes the tray from her view. After all patients have received their trays he returns to this patient and initiates therapeutic communication techniques. She responds by crying. Mr. Carrero holds her hand and gives her tissues to wipe her tears. Within a short time the patient is in control again. Mr. Carrero explains how eating will help her to heal faster. He places the tray where she can reach it. The patient begins to eat, and, smiling, he washes his hands and leaves her room.
In the first situation, Mr. Carrero was unsure of how to proceed. He consulted with the team leader for further instructions. He washed his hands between serving food trays to ensure that he was following infection control guidelines. In the second situation, he made sure that the patient had received the correct diet from the hospital's kitchen. When he served the tray, the patient's condition alerted him that he was dealing with a person who needed to eat to promote healing. He initiated nursing actions by giving her some time and used therapeutic communication techniques and empathic nursing actions that encouraged her to vent her feelings. He supported this young woman in her sad moments, and, in a kind but firm manner, he encouraged her to eat.
C.N.A. Cynthia Steiner works for Daleford Nursing Home and is assisting an elderly resident to eat her lunch. This woman is in a weakened condition and requires the assistance of feeding devices (i.e., plates that do not slide, cups that do not spill). She has recently lost weight and needs to be encouraged and assisted to eat. She positions the woman in her geri-chair, sets up her food tray, and provides her with the assistive feeding devices (ordered and provided by the home's occupational therapist). Ms. Steiner leaves this resident unsupervised because this nursing unit is short staffed and she is needed to assist other residents. Within a few minutes, she notes the resident in the geri-chair has her hand on her throat, a signal that Ms. Steiner recognizes as a universal sign of choking. She asks the resident, "Can you speak?" The resident does not respond and Ms. Steiner notes that she is turning blue. She takes immediate action by using the Heimlich maneuver, an emergency procedure to assist choking victims. When mealtime is over and all residents are safe and comfortable, the head nurse and day shift supervisor meet with the staff. They decide that residents who are in weakened physical conditions warrant constant supervision at mealtimes, even when short-staffed conditions exist.
Ms. Steiner had prior nursing care information about the resident she was assisting at mealtime. She knew that this elderly woman needed assistance with body movement and in-chair positioning and required supervision when using assistive feeding devices. Her intent to help coworkers care for other residents created an emergency situation that could have resulted in a resident's death.
Assisting Clients in their Homes
Nursing assistants working for community home health agencies (home care, adult day care, etc.) exchange notes with colleagues who work for hospitals and nursing homes. Home health aides work independently and learn to pay special attention to home safety procedures because most accidents occur in the home. Their training curriculums also include subjects about meal planning, shopping, and meal preparation.
Nursing assistant job tasks involve complex caring issues that need to be addressed and discussed as often as necessary. Nursing assistants are legally responsible to perform job tasks safely, to ask questions when in doubt, and to refuse to perform job tasks without receiving prior instruction and supervision by licensed nurses.
Work Assignments
Nursing work assignments are developed and used in similar ways in hospitals, nursing homes, community health care settings, and wherever nursing staffs care for patients. Head nurses and their designees develop work assignments by dividing work tasks, according to each staff member's level of education, training, and life experience. For example, a new C.N.A. working in a hospital would not be assigned to patients with complex health problems. Experienced C.N.A.'s would complete some assignments and would be expected to monitor some types of technological machines, report malfunctions, and ask for nurse assistance whenever necessary. Nurse assistants should not perform work tasks without prior training or nurse supervision.
Work Processes
Nursing departments use similar work process guidelines adapted for individual work places. Work process guidelines include: policies and procedures, objectives and goals, and quality assurance issues. Information about work process guidelines should be available on nursing units and in nursing administration offices. When unsure about guidelines, contact a staff resource person and ask questions.
Policies define and explain why job tasks are important. Procedures describe and explain how job tasks are to be performed. A hand-washing policy explains the importance of hand washing as an infection control measure. A hand-washing procedure lists steps that describe the most correct way to wash your hands.
Nursing objectives are professional aims about nursing care practices. There are two universal objectives that all nurses' value --first, to give safe, consistent, and competent nursing care services to patients and second, to work in therapeutic and friendly work environments that support the healing process. Therapeutic work environments exist whenever nurses and nursing assistants set aside personal problems and personality differences to help those who cannot help themselves.
Nursing Department Meetings
The objective of nursing department meetings is to share information about patient issues and employer/employee problems. DNSs interact with staff by sharing pertinent information. For example, at one nursing department meeting, nurses and nursing assistants expressed their concern about short-staffed working conditions that caused harried work processes and dissatisfied patients. They pointed out that short-staffed situations compromised safety and the delivery of quality nursing care services. The DNS actively listened to group statements and then asked for corrective suggestions. He thanked the participants and told them that their suggestions would be included in his plan of correction to alleviate staff shortages.
Quality Assurance Systems
Quality assurance is a system of checks and balances designed to support nursing's objective to provide quality nursing care services. This system uses investigative methods to determine whether nurses and nurse assistants are providing competent, efficient, and effective care. Its problem-solving characteristics serve as a useful tool for review of nursing care outcomes. Quality assurance is supported by informational systems.
Quality Assurance Committees
The majority of health care businesses have established quality assurance committees to investigate internal problems and solutions. Nursing assistants are valued and viable committee members. Committees investigate small and large problems that involve all departments, such as faulty systems of communication or safety problems.
Nursing Assistant Job Descriptions
Nursing assistant job descriptions identify, define, and explain N.A. job tasks that are performed within their scope of practice at individual health care institutions such as hospitals, nursing homes, home health agencies, and adult day care centers. Sample job descriptions follow below.
Sample Hospital Job Description
First Street Community Hospital
Job Title: Certified Nursing Assistant
Department: Nursing
Supervisor: Director of Nurses Job Summary: Assists licensed nurses to provide caring services for patients in a hospital setting.
Job Duties: Director of Nurses Interacts with patients, families, visitors, and staff in a positive manner; assists patients to perform activities of daily living (eating, dressing, toileting, bathing, and moving about); makes beds and cleans patients' personal areas and care equipment.; performs special job tasks that include, but are not limited to, measuring patients' vital signs; glucometer testing; assisting patients with health conditions that include infectious diseases, physical and mental disabilities, and patients who require restorative and rehabilitative nursing care. (Job tasks may be expanded after additional training has been completed.) She follows nursing department policies and procedures, patients' rights and abuse laws, and other quality assurance guidelines. Attends and participates at departmental meetings and required in-service training sessions.
Working Conditions: Works in a clean, safe, sometimes stressful indoor environment; may be subjected to unpleasant odors while caring for diseased (including infectious diseases) and sick patients of all ages; works with the physically and mentally disabled and those with memory loss.
Sample Nursing Home Job Description
Hearth Commons Nursing Home
Job Title: Certified Nursing Assistant
Department: Nursing
Supervisor: Director of Nurses
Job Summary: Assists licensed nurses to care for residents in a nursing home setting.
Job Duties: Certified Nursing Assistant interacts with residents, families, visitors, and staff in a positive manner; assists residents to perform their activities of daily living (eating, dressing, bathing, toileting, and moving about).
Makes beds, cleans residents' personal spaces and care equipment, performs rehabilitative and restorative nursing care tasks; cares for residents with mental and physical disabilities and residents with infectious diseases; follows nursing department guidelines and quality assurance issues.
Certified Nursing Assistant is knowledgeable of personal responsibilities as they concern residents' rights, resident abuse laws, infection control, safety, fire safety, disaster plans, and legal responsibilities.
She performs special job tasks -- measures vital signs, measures height and weight, collects specimens; performs other nursing department job duties at the discretion and direction of the director of nurses. Attends and participates in departmental meetings and required in-service training sessions.
Working Conditions: She works in a clean, safe, sometimes stressful environment; works with a large population of elderly residents; cares for the diseased, including those with infectious diseases, the physically and mentally disabled, and those with other infirmities.
Sample Home Health Agency Job Description
Your-House Home Health Care
Job Title: Home Health Aide
Department: Nursing
Supervisor: Director of Nurses
Job Summary: Home Health Aide assists clients at home to perform activities of daily living (eating, toileting, dressing, and mobility needs); follows the daily care plan that has been developed by the nursing supervisor; contacts supervisor to report changes in each client's condition or whenever in doubt.
Job Tasks: Home Health Aide assists with physical care (activities of daily living and special skin care), performs special skills (vital signs, specimen collection, glucometer testing), measures height and weight, monitors the effects of rehabilitative and restorative nursing services, and uses rehabilitation equipment (mechanical [Hoyer] lifters, slide boards, and wheelchairs); monitors wound care and changes simple dressings; assists new mothers with baby care tasks; assists clients by completing light housekeeping duties, shopping, preparing meals, and accompanying clients to doctors' appointments. Aide is expected to perform other job tasks, as instructed by the director of nurses.
Working Conditions: Job assignments include indoor and outdoor tasks. Aide cares for people of many age groups, those with physical diseases (including infectious diseases), and clients with physical and mental disabilities; must be willing to work independently, sometimes in isolated settings without daily nursing supervision.
Legal Issues and the Role of the Nursing Assistant
It is the responsibility of nursing personnel to keep patients safe from harm. Safety issues concern the correct implementation of communication techniques, patients' rights laws, patient abuse laws, infection control practices, and confidentiality in all interactions with patients. In addition, nursing assistants are expected to know how to perform as-signed job tasks and ask for clarification and instruction whenever in doubt. Legally, nursing assistants are expected to work within their scope of practice.
