Who's monitoring resident health?

I'M SO GLAD WE WERE ABLE TO GET MOTHER ADMITTED HERE," says the daughter of a newly admitted resident. "I was so worried about her living alone. She wasn't eating right and I don't think she was taking her medication correctly. She's probably losing weight. She has been having more difficulty with her walking and I was afraid she'd fall and injure herself. I'm thankful that she'll be in a safer place here with all of you to check on her regularly and make sure that she's alright. And by the way, will you be her nurse?" "No," is the reply. "Kathy Brown is her nurse. I'm just the CAN."

This staff person is not just the CNA (certified nurse's aide)! This person is a very important part of the interdisciplinary nursing team. She and her CNA colleagues provide 80 to 90 percent of the direct care residents receive and make up the majority of direct-care personnel in a nursing home. [1] Therefore, they play an important role in meeting the needs of the resident and the expectations of the family in providing that "safer place" through their provision of care and regular monitoring of the resident's health status.

But this CNA is also part of a group in short supply. There are 1.6 million residents in 17,000 nursing homes nationwide but not enough CNAs to meet the need. [2] Their work is physically challenging. It can be simultaneously emotionally demanding and emotionally satisfying. The average pay is lower than that in the hospital setting. And, the turnover rate ranges anywhere from 38 percent to 143 percent. [3]

THE MAKING OF A CNA

A nurse's aide is "one who provides nursing or nursing-related services to residents but is not a licensed health professional" according to federal regulation 483.75. [4] The distinction between CNA and licensed professional is not always clear to consumers, or even other health care workers. This confusion is fostered through the variety of titles, preparation programs, and licensure levels of RNs and LPN/LVNs.

CNAs serve as the supplemental eyes, ears, and hands of licensed nurses. Much of the basic day-to-day care of residents--bathing, dressing, eating, toileting, and transferring--is delegated to them. They frequently are responsible for routinely checking vital signs and providing skin care. Their contact with residents is more constant than that of other staff members. The CNA reports observations made while performing these duties to the nurse. The nurse then uses those reports to further assess residents and make appropriate care-plan decisions. This makes the CNA's input crucial to helping residents attain or maintain their highest level of functioning.

CNAs must meet training and competency evaluation requirements implemented under the Omnibus Budget Reconciliation Act of 1987 (OBRA). According to federal regulation 483.152, the training program must be state approved and include courses on communication and interpersonal skills, infection control, safety and emergency procedures, promoting resident independence, respecting resident rights, basic nursing and personal care skills, care of the cognitively impaired, basic restorative services, and basics of mental health and social services. [4]

After satisfactorily passing the testing component, the CNA is placed on the OBRA-required state registry. Other accepted methods of eligibility for competency testing are completing a nursing arts course as a nursing student, a military training program with CNA courses, or a nursing program in a foreign country. For example, in Minnesota, according to Dena Dunkel of that state's Nursing Assistant Registry, persons in the categories mentioned above may either complete the 75-hour NA training program or may opt to attempt the testout. She cautions, however, that "there are some nursing homes that will not hire 'testout' candidates and there are some states that will not allow 'testouts' to transfer to their registry."

Jude Franko, RN, who instructs CNA trainees at St. Paul (Minn.) Technical College says that she and fellow instructors emphasize the importance of monitoring the health status of residents throughout the CNA curriculum. "The [CNA] must understand the normal aging process so there is a baseline against which to compare anything out of the ordinary. Then this 'normal' must be individualized for each resident," says Franko. This allows the CNA to recognize what would be unusual for that particular resident. As the trainee progresses through each unit, she (or he) learns what to expect and what not to expect.

ALL IN A SHIFT'S WORK

The CNA must constantly keep herself alert to changes in the resident as she is providing care. When bathing or dressing a resident, the CNA observes the resident's mobility and whether there is any discomfort. Skin and scalp condition is checked. The CNA checks for pressure ulcers, noting skin condition, especially when there is incontinence or constipation. Bowel and bladder elimination and characteristics of the resident's stool and urine are noted. During oral care, the CNA checks the resident's mouth and teeth or dentures. While ambulating or transferring the resident, the CNA notes what the resident can and cannot do independently. She observes the resident walking, noting the resident's gait and checking for signs of dizziness. The CNA also notes how vision or hearing deficits are affecting the resident's ability to function and their impact on the resident's safety.

Nutrition Care Alerts, guides developed by nutrition and long term care experts and distributed through the Nutrition Screening Initiative, acknowledge the role of the CNA in preventing unintended weight loss, dehydration, pressure ulcers, and feeding-tube complications. [5] The guides provide CNAs with warning signs and action steps that detail specific interventions and monitoring of residents.

The CNA records meal and snack intake, measures and records weight, and looks for weight-loss warning signs such as mouth pain, ill-fitting dentures, difficulty using adaptive utensils, and difficulty chewing or swallowing. Fluid intake and the condition of the mouth, lips, and urine are monitored for signs of dehydration. The CNA must note complaints of nausea or vomiting, diarrhea, and constipation or cramping in tube-fed residents, as well as any redness or pain around the tube site.

Throughout the work shift the CNA must check for environmental hazards such as malfunctioning equipment, infection-control practices and problems, and compromises to resident rights and privacy. She must identify the resident who is unable to speak up or defend himself and modify communication patterns depending on his level of cognitive impairment. The CNA's reports to the nurse must be regular or, in the event of an emergency, immediate.

TOOLS THAT MAKE THE MOST OF YOUR CNA

Much is expected of the CNA by the resident, the family, the supervising nurse, and the facility, hut adequate systems must be in place for the CNA to function optimally. What are these systems? These are the important ones:

Orientation and continuing education. Staff shortages may tempt administrators to press newly hired CNAs into full service quickly. But a good orientation can make the difference between retention or quick turnover. The CNA needs to become familiar with the facility and its policies and procedures. This includes knowledge of equipment and supplies, safety rules, and infection control. The job description should be reviewed so it is clearly understood what is expected and how the CNA fits into the organizational structure. Assignment of a mentor and inclusion into groups helps the new CNA get acquainted and feel accepted. It may also enhance socialization, a factor CNAs identified in a study carried out by Atchison as being important to their job satisfaction. [6]

A minimum of 12 hours of continuing education per year must he provided by the facility under OBRA requirements. The goal is to ensure the continuing competence of the CNA in addressing resident needs. According to federal regulation 483.75, the content must be specific to the CNAs' learning needs as identified in their performance appraisal. [4]

Appropriate delegation and supervision. Delegation occurs when authority to carry out a particular task is transferred to an individual qualified to do it. In the nursing home setting, the licensed nurse is delegating selected tasks to the CNA according to ability and facility policy. While the nurse is accountable for the delegation, the CNA is accountable for accepting and carrying out the task. [7]

Clear communication is an important component of delegation. Directions should be specific and complete. The nurse, while respecting the CNA's abilities, should not assume that she knows everything about the task being delegated. While the CNA's daily assignment sheet should reflect what the resident's care plan is, especially interventions and desired outcomes, additional information will help the CNA understand the rationale.

Providing evaluation and follow-up is inherent in supervision and should be done in a respectful manner. CNAs sometimes feel put down during the feedback process. Effective feedback deals with issues not personalities, solicits the CNA's opinions in problem-solving, and recognizes successful efforts?

TECHNOLOGY NEEDS TO BE SUPPORTIVE

The CNA should be held accountable for accurately recording information such as resident weight, routine care, food and fluid intake, elimination patterns, and vital signs. Easily-accessed, user-friendly flowsheets will facilitate this.

The CNA's workload must be realistic. Administrators must regularly assess workloads and adequacy of staffing to avoid staff frustration and compromises to the safety and security of residents.

Updated and properly functioning equipment makes the CNA more effective when assisting and maintaining the safety of residents. Equipment needs to be checked by maintenance staff regularly to avoid injury to residents and staff and to ensure accuracy when used. This includes lifts, tubs, wheelchairs, monitors and adaptive equipment, scales, and thermometers. At the same time, the CNA must know the proper procedure for reporting defective equipment.

Technology that provides for quick communication and assistance ranges from basic nurse-call systems monitored from a central location to systems that allow the CNA to immediately communicate with other staff. These systems enable the CNA to call for help in the event of an emergency or on shifts where fewer staff is available without having to leave the resident in a compromised position. Devices that alert the GNA to a resident getting up unaided or needing a position change also facilitate more effective care.

Just a CNA? No. The CNA is an essential member of the interdisciplinary team providing compassionate and competent care. And the desired outcome is the safe and secure setting expected by any newly admitted resident and his or her family. With the trend toward facilities using outcome achievement to compare their performance against other facilities, the CNA's role in monitoring health status is increasingly important to the facility's success.

Woodbury, Minn.-based Janice K. Olson, RN, MS, MEd, is a member of CLTC's advisory board.

References:

(1.) Wunderlich G, Sloan F, Davis C. Nursing Staff in Hospitals and Nursing Homes: Is it Adequate? Washington, DC: Institute of Medicine, 1996.

(2.) Measures of Nursing Home Implementation. www.hcfa.gov/medicaid/reports/ rpfall00.pdf

(3.) American Health Care Association Health Services Research and Evaluation, Staffing of Nursing Services in Long Term Care: Present Issues and Prospects for the Future. February 2001.

(4.) Minnesota Health & Housing Alliance, The Really Big Book of Nursing Home Regulations, 3rd edition. September, 2000.

(5.) Nutrition Care Alerts. www.ahca.org/quality/care-alert/care-alert/care-alerts.pdf

(6.) Atchison. J. Perceived job satisfaction factors of nursing assistants employed in midwest nursing homes. Geriatric Nursing. 1998;19(3):135.

(7.) Hansten R, Washburn M. Delegating to UAPs: Making it work. NurseWeek. 2001;2(3):21.