Professional Boundaries

In this article, I want to present a concept that should be well understood by all CNA’s. Here, we’re going to discuss what can happen when we become overly attached to a resident, or their family and the implications this has upon the facility.

One of the better changes for some LTC facilities is consistent staffing. However, this staffing model has created some unintended consequences.

CNA’s develop long term relationships with those we are charged to care for. We grow to love them and will do all the little “extras” for them. Usually this doesn’t present a problem for anyone. But there are times when our relationships become unhealthy- for us, for the resident, for the other residents we’re assigned to; to our peers and to the facility we work for.

Over Attachment
In nursing homes, CNA’s can become too attached to a certain resident, in different ways. The CNA will be very upset if they are not assigned to care for this resident, or, will use their relationship with this resident as an excuse for being exempted from floating to other units. The CNA might spend inordinate amounts of time with this resident, and therefore shortchange the others assigned to him/her. The aide will always cater to this residents’ every whim before all others. This resident will have more needs than all others as well- and these “needs” will increase as times moves along.

Sometimes, the resident develops a fondness for an aide that isn’t healthy. The resident becomes dependent upon the aide’s presence to be happy. He or she refuses to allow other aides to work with him/her. Residents have “bad” days when their favorite aide isn’t at work. I have seen residents who believe they are “in love” with their favorite aides, especially those with mild dementia. I’ve also seen aides who care for patients in short term rehab centers develop “crushes” on these patients. The age difference between patient and aide isn’t that far apart.

Other assigned residents are neglected. Often. Or, the needs of these residents are tended to by the CNA’s peers. This creates a problem for everyone. Resentment sets in and working relationships suffer.

Being Objective
A huge problem with this arrangement, as it’s often called, is when the aide loses his or her ability to be objective. This is a serious concern. We must be able to truthfully report the conditions of our residents. This includes, but isn’t limited to, the residents progress or decline in all areas: Ability to speak, bath, dress, feed self, walk- are all very important. The CNA who is too close to certain residents isn’t able to accurately describe the resident’s true abilities.

This effects the resident directly: A resident who cannot really dress herself can be assessed as being able to do so. This might end up in a care plan…and other aides who work with this poor resident will get frustrated at THEIR ability to motivate this resident. Families are told their loved one can still dress herself when in fact she cannot, and hasn’t been able to perform this task for awhile.

We have professional boundaries
CNA’s are considered to be the professionals in the care giver-patient relationship. A CNA is expected to maintain a therapeutic relationship and not anything else. We have the upper hand because of our knowledge and skills. We are responsible for the care we deliver. Within the ethical discussions on this subject, the care giver always has power over the patient. Many times these relationships are for the benefit of the care giver and not the patient.

When the care becomes intertwined with personal friendships and over-advocacy, it’s not healthy. What is OVER ADVOCACY? It’s when we demand residents be given care, therapies and attention they don’t truly need. This is often where over attachment to a resident’s family starts. This is another whole problem- and the legal implications are high.

Ask yourself these questions. And be honest. If you can answer more than two of these with a YES, then YOU are crossing the professional boundaries. And setting yourself up for a lot of trouble.

* Have you ever spent off-duty time with a patient/family?

* Do you keep secrets with patients/family?

* Do you become defensive when someone questions your interaction with a patient/family?

* Have you ever given gifts to or received them from a patient/family?

* Have you felt possessive of a patient/family, thinking that only you could provide the care the patient needs?

* Have you ever flirted with a patient?

* Have you chosen sides with a patient against his or her family and other staff?

If you find that you’re overly attached, how to manage that? It’s not easy. The first step is recognizing you have a problem. Then, its a matter of distancing yourself from the resident. For some aides this is best done gradually. For others, a total cut off is appropriate. Many times, when the bosses see these problems, they’ll assign the aide to another unit altogether, effectively ending the relationship. I don’t think this is a good way to do this.

A CNA can ask for a change with their assignment. Being open and honest about this will almost always result in getting the changes you seek. Part of being PROFESSIONAL means keeping staffing issues to yourself. The urge to tell the resident, or the family, a change has taken place might be very high. Its best to leave these discussions with the nurse. And, after the resident and/or their family is informed, THEY will prod the CNA for information. Again, professional boundaries must take precedent over individual staff needs.

A note about being attached to resident families.
It’s not as common as resident-CNA friendships. But its much more dangerous. And, many times these relationships are initiated by the CNA.

Often times:
A family will block out all others in the facility and depend upon the aide for all communication. The aide will be put into situations they are not trained and educated to handle. Every word the aide speaks will be heard and recalled. If the aide doesn’t have the right information, or misspeaks, a lot of trouble can arise, legally.

The aide will become a spy, for the family. CNA’s are privy to some information that is private and confidential. The levels of care for other residents is an example. When we have over bearing families seeking information from aides who are all to willing to share, it creates huge management problems. It sets the stage for a turbulent relationship between the FACILITY and the family.
Some aides like to think families have some super power over a facility. This is simply not true. Government regulation and oversight have “power”; as do legal standards.

Other aides will use the family in an effort to be assigned to the resident they want. From my experience, these residents are almost always the ones who are considered “easy to do”– and the aide is simply seeking a guarantee of being assigned to this resident. There has been some evidence of aides seeking permanent assignment to certain residents in hopes of getting some monetary award. These situations are always unethical. The aides involved in this should be terminated from employment and barred from working as aides ever again. They are opportunists.

No matter whether a CNA is overly attached to a resident or their family, it’s not usually healthy. Most times the only way to stop the problems associated with these relationships is to separate the aide and resident. Perhaps, consistent staffing would better serve all if the assignments changed every so often. A couple times a year and all aides would be required to change no matter what family requests are. We all want what is best for the residents. Sometimes though, in order to insure this is happening equally across the board, we have to make adjustments and changes.

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What is reciprocity : By Federal and State Laws, you must pass a State prescribed course and test in order to work as a nursing assistant in a nursing home. You also cannot work as a nursing assistant in a nursing home in any state unless you are approved by that state.

If you already are Licensed, Certified, Registered or State Approved in your own State and want to move to another state, you will need to request reciprocity. This means that you are asking the new state to recognize the approval you received from your home state.

How to request reciprocity

1. The first step is to contact the Nurse Aide Registry in your home state and request a “Application for Enrollment By Reciprocity”. Ask them if you should send the completed form to them or to the state to which you are moving.

2. Then contact the other state and ask them the same thing. Some nursing assistants have been able to fax their request directly to the state they are moving into rather than with their home state. Do not take chances, ask. Be sure to get the name of those who talk with you and their phone numbers. Call them by name while you are talking so they remember you.

3. If the agency in your new state says it is acceptable for you to fax or mail info, then do this right away. Be sure to clarify the fax number and the mailing address. Then fax or mail your info to the attention of the person you spoke to. Ask them what items you will need to fax or mail but be prepared to send at least the following:

  • Copy of your Social Security Card
  • Copy of your drivers license (or other photo ID)
  • Copy of your present State approval
  • Copy of a recent pay stub or something to document that you have worked in a nursing home in the past two years.

Tell them where you are moving from and where to and where they can send the new card.
They may ask for other info as well

4. When you send your info, include a brief note to thank the person who took time to talk with you and ask them to call you if they need more information.

Automated lines

When you call, you may get an automated line. Most automated lines are free 800 numbers and can provide some good information. Do listen and be prepared to write down numbers, but also always try to get a connection to a real person.


Every nursing home in the country must be prepared to provide for training and testing for their nursing assistants, and should have information about the training and testing sites that are local to you. In some states, the training and testing is conducted by nursing homes, some use community colleges and still others use independent agencies. The best way to get information about the training and testing programs in your area is to talk to a trainer or DON in your area. If this does not provide the needed information, contact the Area Agency on Aging or the NATP agency in your state.

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Everything You Want To Know About Being A CNA

You’re thinking about becoming a Certified Nursing Assistant. You’re excited and want more information about this career. Some questions you might have deserve answers, and here we will try to do that.

1) What is a CNA?
A Certified Nursing Assistant is a member of the health care team. Always working under the direction of a nurse (RN or LPN/LVN) the CNA provides hands on nursing care to patients, residents, clients and customers in a variety of health care settings. CNA’s typically provide assistance with bathing, dressing, eating, toileting and oral care to people who cannot do these tasks alone. Also, the CNA is often the person who gets the vital signs, weights and height measurements.

The CNA has a high school diploma or GED.

2) Why be a CNA?
If you’re looking at a career in nursing, being a CNA is a great way to really test yourself on this goal. Being a CNA exposes you to many members of the health care team: You get to see nurses, physical and occupational therapists, doctors, med techs and assistants in action. You’ll soon know whether you have what it takes to further yourself in nursing; perhaps you’ll decide to move to another field of work within health care.
If you’re looking for a quick job to pay bills for a few months becoming a CNA might not be the right choice for you. Going through the training is hard work; being charged with caring for sick people isn’t something to be taken with a grain of salt. You have to the will and desire to help people…you’ll need patience and compassion. You have to be committed to a physically demanding job, with little tolerance for poor work ethic.

Career CNA: You won’t get rich doing this for a living. But you will gather experiences not often found in any other career. You’ll have pride over many accomplishments and you’ll make friends with people you would otherwise never meet. Being a CNA is one of the few careers where one can say they truly give it all for little in return. On the downside, your body will pay you back in a bad way if you don’t take care of it. You’re apt to hurt your back. If you get sick, plan to be at work regardless- and plan on getting sick more often than other people get in other careers. As stated above, the pay is not going to be rewarding- but the other rewards are priceless.

CNA’s don’t earn a high salary. You should be very aware of this. Many of who have been doing this for a long time notice new aides coming into the field, who get disillusioned over the pay. We’re paid by the hour; that rate is dependent upon several factors which include how much experience one has; what region of the country one works in and where employment is at.

In general, CNA’s who work in long term care settings (nursing homes, assisted living) earn the least; those who work for staffing agencies and hospitals earn the most. Belonging to a union also has an impact upon pay. Overall, wages for aides range from 7.00/hr for a brand new CNA at an assisted living center, to $20.00/hr for a CNA with 20 plus yrs experience, working for an agency. Average wages are in the area of 13.00 to 18.00/hr in all settings. Like I said you’re not going to get wealthy doing this work.

3) Where can CNA’s work?
In any setting provided there is a nurse to oversee the CNA’s practice. This is very important to remember. Always, CNA’s work under the direction of a licensed nurse. Don’t let anyone tell you otherwise. This is per federal and state statute, and it’s to protect the public. Only a licensed nurse can delegate duties to CNA’s. Doctors and therapists cannot. Families cannot. CNA’s cannot delegate to CNA’s.

Always keep this in mind- legally a CNA cannot practice on their own. Many aides place ads in newspapers offering their services as a CNA. This is illegal in all states! It’s okay to offer care giving services. Its okay to use your experience as a CNA; but it’s never good to claim yourself a CNA who is providing the services. When you do this, you’re delegating. And breaking the law. Be careful with this.

CNA’s are found on the payrolls at:

Nursing Homes
Home Health Care Agencies
Assisted Living Facilities
Staffing Agencies
Doctor Offices/Practice Groups
Day Care Centers and Schools
Medical Clinics
Urgent Care Centers

An interesting note on potential sources of employment: The role of the CNA is mandated by the Federal government for nursing homes only. Other health care settings are not required by law to hire CNA’s…this includes hospitals, assisted living facilities and doctor’s offices (although not common). While all of these places do hire CNA’s, for good reason, they don’t have to.

4) How does one become a CNA?
Once you’ve decided this is the work you want, set out to locate a training program. Many nursing homes offer the training; the Red Cross does classes too- contact your local chapter. Tech colleges are another source where training is offered. Some high schools also provide classes- but mostly for students and not others. More and more, small private for profit schools are popping up all over the country. Offering a variety of specialty training, a CNA program is often part of this.

Costs of training programs vary by region and by the source. College classes are the most expensive followed closely by these Medical Ed schools; the costs including books is around $1500.00. One thing to remember when choosing a program is to make sure it is approved by your State board of Nursing or whatever State agency is charged with approving curriculum. This is vital to know. It does no good to take a course that isn’t approved.

Another important thing to know: Stay away from online and correspondence courses for Nursing Assistants. While these are great for basic knowledge most of these are not approved by most states. People who suddenly find themselves taking care of an elderly parent benefit most from these courses- not those with a serious interest in this as a career. You need clinical hours- real, hands on training in order to perform this work. You don’t get this with the online/mail order courses.

5) What Can I Expect During Training?
Plan on anywhere from 3 weeks of full time classes and clinical hours, to 8 weeks part time. You can expect to be challenged. Your knowledge will increase a lot. Some of the topics typically covered in a CNA course include:
Patient/Resident Rights
The Roles and Responsibilities of the Health Care Team
Legal Issues for Nursing Staff pertaining to the CNA
Medical Terminology
Infection Control
Medical Unit Environment- Safety and Proper Body Mechanics
Emergencies: Some states require CPR to be a part of this
Communication Skills
Documentation Skills
Patient Care: Vital Signs, bathing, dressing, moving patients, feeding, oral care, grooming skills
Patient Room Upkeep
…among many other skills. Most CNA courses cover the typical requirements and education you will need to be successful working in nursing homes, acute and sub-acute care centers, perhaps some rehab and restorative nursing instruction is covered as well. You will learn about caring for adults, children and babies. Some of this will include caring for people who are dying, and, how to provide postmortem (after death) care. Most CNA courses do not cover all the skills required for employment at hospitals. Most of these places offer their own special orientation for this purpose.

You should expect to do a lot of reading, and take many quizzes to test your new knowledge. You should know that 100% of your attendance is very critical to your success in any CNA program. Clinical hours refer to the portion of your training that takes you into the actual heath care setting- usually the nursing home. Here, you will be given an assignment of residents (not more than one in most cases). You will be expected to use your newly learned skills to show your instructor you can apply them on real people.

6) What happens after my training is completed?
Your instructor will assist you with scheduling a Competency exam administered by your state. This exam is mandatory and you must pass it. It will test your knowledge and competency with skills. Once passed, you are certified. In some states, you don’t need to wait to work however…there is a federal ruling that allows nursing assistants to work while waiting to take their exams, for up to four months. Many places won’t allow you to do this, for legal reasons.

The Exam is done in two parts: A written portion and a clinical portion. The written test is usually not too difficult- and this web site offers sample questions for you to practice. The clinical part is a bit harder. You have to bring a friend with you in order to complete this portion. The friend will serve as your patient, whom you demonstrate to the examiner, your skills. Bring a gait belt with you for use during your clinical exam.

The important skills the examiner will watch for will include infection control (hand washing– gloves!), patient safety privacy and dignity. Remember to close the privacy curtain. Remember to identify yourself to your “patient”, and remember to identify the patient! You will be asked to perform several tasks- usually up to five skills, but no less than three skills. These might include a full or partial bed bath; offering a urinal or bedpan; a transfer into a wheelchair; a complete or partial set of vital signs; making an occupied bed…any skill you learned in your training is apt to chosen by the examiner. Be prepared but don’t sweat and lose sleep over this. Your training should provide you with the competence you need to pass the exam.

You will be told on the spot if you pass or fail. The examiner realizes you are nervous and will expect some jitters from you. Mistakes are not the end of it; if you realize you made a mistake ask if you can re-demonstrate. Often this is allowed. If you do fail, ask about re-scheduling another test. Each state has different rules about how often a test can be re done and whether both portions need to be re-done.

Next, please read the following posts about other important information you will need in order to effectively work as a CNA. This info will provide you with details about aspects of this work you must take seriously.

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In my experience working as a CNA in a nursing home, I rarely heard the term “Nursing Process”; I often heard about care plans- but that was about as descriptive as things would get. I remember asking a nurse- “Just what is a care plan, anyway?”- and she didn’t know how to answer me! So I have spent a long time researching this elusive term- “Nursing Process”- and trying to figure out exactly where the CNA fits in with it.

First, the medical team is broken into several layers. At the top is the patient- who has an illness, or condition requiring on going care. The Doctors are next- we all know they are well educated and have spent years learning how to diagnose and treat problems, illnesses, disease etc. Doctors, Physician Assistants and Nurse Practitioners are the only person within the medical team who can actually diagnose. We have doctors, nurses and then us- CNA’s!

So this brings us to the next point: A patient, client, resident is admitted to a nursing unit. This can be in a hospital, nursing home, rehab center, even to the patient’s own home. Nurses are called upon to perform several steps to assist with the healthful and positive outcomes for these patients. The nursing process is a relatively new thing; in the 1960′s team based nursing came into fashion, but nurses had no way to let other team members know what to do with patients.
A process, based upon what scientists use, was developed. Over the years this process has been refined to what we know today.

The nursing process is divided into five steps.
1) Assessment
2) Nursing Diagnoses
3) Planning
4) Intervention
5) Evaluation

Where does the work of the CNA fall here, you may ask yourself? Let’s see if we can find some pretty common things CNA’s are asked to do, that are a part of helping the nurses with this process. It is assumed here that the patient/resident/client has a top level diagnoses from an MD, and a treatment plan is in place from the MD. This plan would include medications, treatments, special diets, procedures ordered by a doctor.

Step One: Assessment

Assessment involves continuous data collection to identify a patient’s actual and potential health problems. This data should be as objective as possible, and nurses should be as non-judgmental as possible as well. To perform the assessment, nurses should:
· Get Nursing History from patient
· Perform a physical examination
· Review lab and medical information

The nursing history is mostly subjective data. Often, the patient’s perception of his health problems makes up a large portion of the health history. Nurses should find out how the patient coped with a similar illness, what interventions worked, didn’t work etc.

A physical exam is the next step. This is where the CNA often assists the nurse. When we are asked to get heights and weights, vital signs, record food/fluid intake and output, it is almost always for the purpose of assessment. Although CNA’s do not make assessments, nurses depend upon us to report timely and accurate data. Things we see, smell, hear, feel and touch should be reported.

Nurses should perform a thorough exam by doing the following:
· Body Inspection- observation of patient- direct and indirect
· Palpation- feeling body regions for masses, smoothness, and muscle tone
· Percussion-using fingers in a tapping motion to feel for abnormal sounds over body regions
· Auscultation- listening for sounds over body regions such as lungs, bowels…

Nurses are taught skills to perform a physical assessment in their schools.

Step Two: Nursing Diagnoses

Nurses are licensed to identify and treat certain human reactions and potential health problems associated with the illness, disease etc.
As we see, nurses have a huge responsibility when it comes to giving accurate diagnoses of a health/potential health problem. All the care given is based upon the proper Dx, the proper plan of care being written and the right interventions.
Based upon all the data collected- both subjective and objective, the nurse next will form a nursing diagnoses drawing from the above list of possible problems.

It is these terms in the list that we will often see when we look at a care plan. It isn’t something that comes lightly for nurses- this is one of the big reasons they need a college degree. Assessment is a big part of being a nurse, and it is an even bigger part of what we, CNA’s, do. It is absolutely vital that we report back accurate information. The care a patient gets, and hence the outcome of his health, depends upon good sound information.

Step Three: Care Planning
The Care Plan is a term we should all be familiar with. We all should know that the care plan is the bible for nursing care of patients, but what else should we know about this document? It is a legal document promising care being delivered as written; the nurse can get into huge amounts of trouble if her care plan isn’t followed. The care plan is designed to assist team members in delivering high quality, consistent care that is needed. Time spent performing tasks and care that is not needed results in wastes of money, resources. Effective care plans take into account unit staffing patterns, patient wishes and abilities, and should reflect who the patient is. A good nurse will seek the opinion of the CNA when writing the care plan. CNA’s can offer invaluable insights into the patient’s abilities and desires. All facilities should encourage CNA participation in care plan conferences.

Cookie cutter care plans are easily recognizable:
· they have the same nursing Dx
· they have the same interventions for all patients (seen often in nursing homes, where all residents have been known to be on a two hour bladder program)
· they don’t work!

A good care plan will be specific, realistic, clear and brief. It doesn’t need to be a long novel.
Anyone who is expected to deliver care from a care plan should be able to read the plan and understand it, including the patient when applicable, as well as the patient’s family.

Step Four: Interventions
This is where the CNA really comes into play! Often, the interventions are WHAT we do. All that turning, repositioning, toileting- are all interventions listed in the care plan. Also, a great amount of the documenting we do is designed to assist the nurse with evaluating these interventions. So it really makes sense to document accurately- in time- if an intervention IS NOT working, it will be noted (and perhaps removed from future care plans). Interventions can be anything from special baths to back rubs to repositioning, to toileting, to using special creams and lotions, to offering certain supplements. Often, an intervention must have an MD order along with it. This is kind of strange I think- if nurses are allowed to formulate their own Dx then they shouldn’t need an MD’s order to carry out some of the treatments to reach the goals. The most important part a CNA can play in this intervention stage is to accurately report all reactions to the interventions. Be as specific and objective as possible.

Step Five: Evaluation
This is the final step in the nursing process. This is the time when nurses look at their care plans and check to see if the plan has “worked” in solving the patients’ health issues, concerns, etc. As stated before, a good plan will work and a poor plan will not. Nurses will check to see if the interventions have been effective- they look at subjective as well as objective data. This is when they will see your good documentation! For example, if a patient were incontinent, and the patient wasn’t so until recent illness, the nurse might try a timed program approach to help the patient gain control again. IF the initial voiding assessments, done by the CNA, were not accurate (i.e.- CNA just wrote in times she guessed patient voided)- and the nurse put the resident on a two-hour program…when patient actually needed to go every hour- you can see how this intervention would fail.

The nursing process doesn’t end here- it continues until the patient is discharged or passes on or whatever. Sometimes a patient goes home with a care plan, and this is especially challenging for staff. If the nurse never saw the home environment, then chances are good that the care plan won’t work. Usually home health nurses do the plans for this population.

Some thoughts to ponder…
As I said in the beginning of this page, I never knew what the nursing process was. I still have my books from my CNA classes, and I have several newer additions. It wasn’t until very recently that CNA’s were taught this process. This is too bad. I fear there are too many CNA’s out there who do not have a clue how important their work is. All the work, the documenting- would certainly take on a new meaning if CNA’s really understood their role, within the nursing process, as a whole. It would make a good in-service for any facility to offer: Nursing Process- What Is it?

Even of greater concern for me is the apparent lack of concern on the part of nurses who are charged with this process. Never mind those who don’t seem to know what it is, but what about those who DO know, yet follow their own approaches to deliver care. Hmm. I challenge all CNA’s to hold their nurses up to the standard when it comes to the Nursing Process. After all, if our work is to have any meaning at all, then the Process should be the standard. When a new patient is admitted onto a unit you work on, watch to see if a complete physical assessment is done by the nurse; see if any of the things you are asked to do may have a part in the assessment. Ask questions. Expect answers that make sense to you. A lot is at stake here, the patient’s well-being. See if all your good documenting is worthwhile. Ask the nurses what will become of the notes you have written- those flow sheets should become a tool, not some paper put into a chart.

See if the system really works, or if it is just another process that is meaningless.


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First, make sure you understand the nursing process and how CNA’s fit in with it.

When we think about it, CNA’s are the eyes, ears, hands and nose of the nurses. We use these senses when providing care and with the right skill, we can assist the nurse with valuable patient information that may avert a serious problem. Things get confusing though when we make judgments about the things we’re seeing, feeling, smelling and hearing.

There are two types of observations.
Subjective and objective.

Objective observations are fact. They are measurable.
• Vital Signs
• Bruises
• Open Areas and other skin conditions
• Blood in urine
• Urine output from a cath

Objective observations are reported in the same manner by many people. They are not biased and they do not rely on statements and guesswork.

Subjective observations are made by the patient:
• “I have a headache”
• “I feel sick to my stomach”
• “My sugar levels are off”

Subjective observations are reported by the patient and are just as important as objective observations, except they are not measurable. The nurses need to know when patients have complaints such as those listed above; the nurse can assess the patient and determine what course of treatment or intervention is needed. CNA’s cannot pass judgment on these statements.
It’s not in our role to do so. Our job is to REPORT the statements, accurately and without added
flair. I often see CNA’s report observations- with their own opinion added in. This isn’t necessary and it’s not good to do. Just the basics is all that is needed. If you’re asked for more information, like, “What do you think is going on?” then by all means give your opinion. But don’t offer it up front as part of the observation.

Examples of CNA statements that are not correct:
“Mrs. Smith says she has a headache. She does this whenever it’s her bath time!”
“When I went to assist Mrs. Smith with her bath she stated that she had a headache.”

“Mr. Jones ambulated ten feet today; he said his foot hurt…yesterday he was fine and walked a hundred feet and his foot didn’t hurt! He’s being lazy.”
“Mr. Jones ambulated ten feet today.”

“Ms. Hawthorne had a really loose BM and it smells like C Diff.”
“Ms. Hawthorne had a loose BM that was very foul smelling.”

I think we get the picture here. Many of the things we know from experience with our work turn out to be true. Ms. Hawthorne probably does have C Diff…we can tell by the odor. BUT it’s not up to us to report that as fact. Are we absolutely sure Mr. Jones is being lazy? What makes us assume that? IS it possible that his foot really does hurt? As CNA’s, our job is NOT to make assumptions and diagnose conditions. We observe, we report. It’s pretty simple. No need to embellish our reports with our own opinions. We’re not always right.

How we observe
Using our eyes we see things:
• Broken skin, open areas, cuts, bruises
• Blood- in urine, in and around the mouth
• Changes in the patient’s ability to walk, speak, eat

Using our hands we feel things:
• Pulse
• Skin temperature (warm, cool)
• Lumps and bumps under the skin

Using our ears we hear things:
• B/P readings
• Respiration problems (wheezing, coughing)
• Patient’s statements

Using our noses we smell things:
• Body odors
• Foreign odors not normal to what we are doing (gas and oil, chemicals and the like)

Observations must be accurate.
Observations must be made in a timely manner and the nurse must be notified of unusual findings.
Observations must be free of our opinions and bias.
Report patient statements word for word…directly quoted. Don’t add your own thoughts.

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Legal Standards

These are guidelines to lawful behavior. When laws are not obeyed you can be prosecuted and found liable (responsible) for injury and damages. Legal guilt can result in fines and imprisonment, as well as loss of certification/license to work as a CNA.

Laws are passed by local, state and federal governments. All citizens are expected to obey these laws…when you disobey a law you are liable for fines and/or imprisonment. CNA’s can avoid this by:
• Knowing and staying within their state’s scope of practice rules.
• Do only those tasks and skills you have been taught; if you’re asked to do tasks you have not been trained to do ask for guidance (and if necessary seek the advice of your supervisor).
• Carry out your tasks and procedures carefully and only as you were taught.
• Keep up to date with your skills and education and in-service requirements.
• In questionable situations, seek the advice of your supervisor.
• Make sure you fully understand your assignment and what is expected of you
• Know your facility policies and procedures and follow them.
• Do no harm to your patients.
• Respect the personal property of your patients

Legal Definitions and Examples
As a CNA the legal issues you might encounter and witness would be negligence, theft, defamation, false imprisonment, assault, battery and abuse. You need to understand what these are.

The failure to provide a degree of care that others would consider reasonable under the circumstances; when injury results to your patient. Negligence is often caused by rushing around to get your work done and by not thinking FIRST.
• YOU give a patient a bath…and don’t check the water temp first. The patient is burned.
• YOU place a tray of food in front of a patient and don’t check the menu; the tray belonged to another patient. The patient who got the tray eats the wrong consistency food and chokes.
• YOU transfer a patient by yourself even though the care plans states two staff should be present for the transfer. You drop the patient.

One would think this is pretty simple. It should be but often isn’t. Taking ANYTHING that doesn’t belong to you is considered theft. It doesn’t matter how cheap or expensive the item is. When you see another person take something that isn’t their’s, and you fail to report this, you are guilty of aiding and abetting the crime. Keep your standards high. We need all the honest people we can get in this work- don’t be scared or indifferent to report theft you witness. I’ve seen aides take wash clothes, briefs, deodorants, soaps ect from their facility (for their own personal use at home). I’ve also seen aides steal jewelry and clothing from patients. It’s NEVER acceptable to do this. EVER.

This means making statements about another person, either verbally (slander) or in writing (libel)
when the character of that person is injured. Examples would be you telling a co-worker wrongful and inaccurate information about patients. I’ve seen this happen: We had an admission coming and the chart was available to all of us. The patient had Crohn’s Disease. One of the aides I worked with at that time went around and told everyone this patient had C-Diff. Not a good thing to do. Unless you know something to be actual fact, (and even then make sure you hear it from a reliable source), keep your mouth SHUT. And never put anything like this in writing.

False Imprisonment
This is an area many nursing staff have trouble understanding. It’s not just about restraints. It’s about a mindset. It is defined as restraining a person’s movements or actions without the proper authorization. Patients have rights and we must respect these rights. In the hospital setting, a patient CAN leave the hospital without a doctor’s permission. They can also leave a nursing home/assisted living home. Under very few circumstances can we interfere with this right. If you do, it’s called false imprisonment.

Physical Restraints
Using them requires a doctor’s order. Threatening to use them is considered false imprisonment.

Physical restraints are defined as any manual or physical device, material, or equipment attached to or near to the patients body, that:
• A patient cannot easily remove
• Restricts movement of ANY and ALL body parts
• Restricts the patient from accessing their own body or parts of their body
Examples of physical restraints:
• Wrist, Arm, Leg and Ankle restraints
• Vests
• Jackets
• Hand Mitts
• Geri chairs, recliners
• Seatbelts, safety belts
• Bed rails and the pads sometimes used on them
• In some populations the use of certain clothing would be considered a restraint: For example, donning a one piece undershirt on a child to prevent him from having access to his body. Or, a long sleeved shirt to prevent access to an IV site.

Also, many practices are considered a restraint. When a patient doesn’t have the physical strength to remove a device it is a restraint.
• When a patient doesn’t have the strength to sit up from a low rise sofa, for example, this practice is considered a restraint.
• Tucking in blankets and sheets so tightly the resident cannot move is considered a restraint. Using Velcro and tape to secure sheets is also a restraint.
• A lap tray being used with a wheelchair is a restraint if the patient cannot remove it.
• Using recliners and Geri chairs, tilted back, is a restraint.
• Moving chairs and beds so close to a wall that it prevents a patient from rising is a restraint.
• Placing a patient up into a table so close they cannot move their chair is a restraint.

In short, any action or device (designed for the sole purpose or something put together by you) that prevents the free movement of body parts is a physical restraint.
Some patients require splints and other appliances to maintain alignment and posture. These are restraints as well, but are often referred to as enablers because they assist the patient with ADL’s.
The patient may not be able to remove the splints, but it’s not an overt restraint. An MD order is always in place for these items.

Many medications are considered restraints. This is called chemical restraining and it is a very different thing than physical restraints. Nurses and doctors must understand the ramifications of using meds to induce sleep, states of relaxation, pain control that could be considered restraining activity.

Assault and Battery
There is some confusion about the meanings of these terms. Assault means purposely attempting to touch the body of another person without their permission, and threatening to do so. Battery is when you actually doing this. These terms are not all about hitting and hurting patients like so many of us have been taught.
Every task we perform is done so with the patient’s informed consent. This means the patient needs to know what it is we want to do, why, the benefits of the task-and they have to agree to it.
Informed consent can be withdrawn at any time and we must honor this. More and more patients are taking their healthcare into their own hands these days, and many will question the value of treatments. In spite of our best efforts to explain the need for treatments, the patient always retain the right to refuse. If you continue with the treatment you are guilty of battery. And threatening to get the nurse or others to assist you with said treatments is battery as well. You must report to the nurse any and all refusals of care by your patients, but do so quietly and not within hearing distance of the patient. Let the nurse handle the situation from this point forward.

To avoid being charged with battery:

• Tell the patient what you plan to do
• Make sure the patient understands what you’re saying
• Asking the patient if they have any questions or concerns
• Allowing the patient some time to think about this
• If the patient refuses, don’t push the issue. Quietly report the refusal to the nurse and document facts only.
• NEVER carry out the refused treatment

In our work we will come across a lot of coercion– which is forcing a patient to do something against their will. Unfortunately, it’s a problem within nursing in general. We always think we know what is best. This happens more with patients who are confused, mentally incapacitated or those with dementia. Almost always, these patients are not their own legal guardian, their family is. This makes it difficult for us to do our job at times because the patient is still refusing the care but we have to do it anyway- because the family has consented on behalf of the patient. It’s ALWAYS best to try to get the patient to cooperate with us vs. a full struggle. It really helps to wait and come back later when a confused patient refuses care. They tell us to always assume the patient would want our care if they were not confused so we have to think of things differently. It’s a hard spot to be in.

Abuse: Doing harm to a patient. Abusing a patient is ethically wrong as well as legally wrong. Ethical standards require us to do no harm and legal standards enforce this through laws. There are severe penalties if you’re found guilty.

Abuse is defined as the act (or failure to act) that is non accidental and causes or could cause harm or death to a patient. It’s not just about hitting here. It’s also about mental abuse, verbal abuse and other more subtle forms. Abuse comes in many shapes:
• Physical
• Verbal
• Emotional
• Sexual
• Involuntary seclusion

Physical Abuse:
• Handling the patient roughly
• Hitting, slapping, punching, kicking, pinching a patient
• Performing the wrong treatment on the patient

Verbal Abuse:
• Swearing when you’re dealing with the patient
• Raising your voice, yelling
• Calling the patient unpleasant names
• Teasing the patient
• Embarrassing the patient at anytime
• Using gestures
• Making threats
• Use of inappropriate words/terms to describe a patient’s race or nationality

Sexual Abuse:
Using physical means and verbal threats to force patients to perform sexual acts.
In most states sexual abuse is ANY behavior that is seductive, sexually demeaning, harassing. As with Sexual Harassment policies, this harassment need only be considered as such by the patient without regard to your intentions. Be careful. THINK before your interactions with patients (and everyone else for that matter). Be considerate of your patient’s values and morals.

Emotional/Psychological Abuse:
THIS can be the worst kind of abuse because it’s typically ongoing and subtle.
• Causing a patient to be afraid of you (through threats, actions, attitude, and body language)
• Threatening the patient
• Threatening to withhold treatment
• Threatening to tell others about the patient’s condition
• Making fun of the patient
• Belittling the patient (and this would include all those cute little nicknames we tend to have)
• Calling the attention of others to the patient’s behavior.

Involuntary Seclusion
I see this happen a lot in nursing homes. A resident is being noisy and disruptive so we remove them to another area. This is another one of those hard spots to be in- trying to balance the needs of the larger group of residents without violating the rights of one. A good care plan, communication with everyone, documentation and other interventions should really be in place to prevent the resident from having outbursts in the first place. The nurse should always be the one who directs you to remove a resident. Don’t ever make this decision on your own.

Other forms of involuntary seclusion:
• Closing the door to the patient’s room when they want it kept open
• Placing a patient in a wheelchair away from others
• Leaving a patient without a means to communicate- removing the call bell for example

Abuse by Others
There are times when we will witness another CNA or nurse do harm to a patient, as described above in all the various forms. Often the CNA/nurse will not realize they are doing these things. It doesn’t matter whether she knows better or not. The abuse MUST be reported. As soon as it occurs, not at the end of the shift, the next day or next week. All healthcare workers are required by law to report actual or suspected abuse. When you don’t report, you’re just as guilty.

Sometimes it is a member of the patient’s family who abuses them. This is difficult to see happen, to suspect is happening. Again if you suspect this you are required to report it to the nurse. I’ve seen nursing home residents go out on a day trip with a family member and return to the facility with bruises and cuts; or with complaints of hunger and thirst. These things caused me to suspect some sort of abuse or neglect and I reported the findings to the nurses. I made sure they came down and looked at the bruises and cuts firsthand as well.

Neglect is failing to provide the services, care and treatments necessary to avoid physical harm, mental anguish or mental illness. Neglect can be intentional or unintentional. Neglect is against the law no matter what. CNA’s are not expected to decide if neglect has occurred- that is the nurses job. However, you must report signs of neglect. Some examples of neglect we might see on the job:

• Routine hygiene and care not being provided. Patients not being repositioned, bathed, toileted, ROM exercises not being performed according to the care plan.
• Patients not being given enough time to eat
• Patients not being offered water and snacks

Invasion of Privacy
This is an area where every CNA should put themselves in the patients’ shoes. Would you like it if someone went around talking about your medical condition to anyone? How would you feel if you were in a hospital room and the nurse came in, started to do a treatment without closing the privacy curtain? You wouldn’t like these things at all. Most people don’t. Every patient has a right to expect their medical information will be kept confidential and that only those who NEED to know will have access to this information.

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