Nursing Assistant

🧭 Overview

🧠 One-sentence thesis

Effective communication—adapted to each patient's needs and delivered through verbal, nonverbal, and assertive methods—is the foundation of trusting relationships and holistic care in health care settings.

📌 Key points (3–5)

• Communication is a process: involves a sender, a message, and a receiver; both verbal and nonverbal elements shape how the message is understood.
• Nonverbal communication dominates: approximately 55% body language, 38% tone of voice, and only 7% actual words—so facial expressions, posture, and tone matter more than the words themselves.
• Assertive vs. passive vs. aggressive: assertive communicators respect others' rights while standing up for their own (using "I" messages); passive communicators put others first and may not speak up; aggressive communicators may violate others' rights.
• Common confusion: assertive ≠ aggressive—assertive uses "I feel…" to describe facts and feelings without attacking the receiver; aggressive uses "you" messages that feel like verbal attacks.
• Adapt communication to the receiver: health care professionals assess each patient's characteristics (cognitive level, language, culture, physical barriers) and tailor their communication accordingly.

🗣️ The communication process

🗣️ What communication is

Communication: a process by which information is exchanged between individuals through a common system of symbols, signs, or behavior.

• In health care, good communication builds trusting relationships and improves client outcomes.
• It is the gateway to holistic care: addressing physical, emotional, social, and spiritual needs.
• The process involves three elements: sender, message, and receiver.

📝 Verbal messages and semantics

• Semantics: the language and experience of both sender and receiver.
• People reference things they are familiar with—landmarks, popular culture, slang.
• Barriers can occur even when both parties speak the same language.
• Example: asking someone who has never used the Internet to "Google it" would confuse them because they lack that reference.

🤐 Nonverbal messages (body language)

Nonverbal communication: includes body language and facial expressions, tone of voice, and pace of the conversation.

• Nonverbal communication can be much more powerful than the verbal message itself.
• Research estimates:
  • 55% of communication is body language
  • 38% is tone of voice
  • 7% is the actual words spoken
• If the sender or receiver appears disinterested or distracted, the message may become distorted or missed.
• Example: crossed arms, lack of eye contact, or a hurried tone can change how the message is received, even if the words are polite.

🎭 Communication styles

🎭 Three styles: passive, aggressive, assertive

Style	Definition	Characteristics
Passive	Puts the rights of others before their own	Apologetic, tentative, often does not speak up when wronged
Aggressive	Advocates for own rights, possibly violating others' rights	Tells others their feelings don't matter; direct but insulting or offensive
Assertive	Respects others' rights while standing up for own ideas and rights	Direct but not insulting; uses "I" messages

✅ Assertive communication in practice

Assertive communication: a way of conveying information that describes the facts and the sender's feelings without disrespecting the receiver's feelings.

• Uses "I" messages: "I feel…," "I understand…," "Help me to understand…"
• Avoids "you" messages that make the receiver feel verbally attacked.
• Example (aggressive): "You always leave your patients' rooms a mess! I dread following you on the next shift."
• Example (assertive): "I feel frustrated spending the first part of my shift decluttering patients' rooms. Help me understand the reasons why you don't empty the wastebaskets and clean up the rooms by the end of your shift."
• Don't confuse: assertive communication is not aggressive—it addresses issues without attacking the person.

🚧 Overcoming communication barriers

🚧 Why barriers matter

• Many factors can distort the message, so it is not perceived by the receiver in the way the sender intended.
• Nursing assistants must be aware of potential barriers and continually seek feedback to check understanding.

🧩 Common barriers in health care

🧩 Language and attention barriers

• Jargon: avoid medical terminology and complicated wording; explain information in common language; consider generational, geographical, or background differences.
• Lack of attention: easy to become task-centered rather than person-centered; use preprocedural steps and mindfully focus on the person in front of you; patients should feel they are the center of your attention.

🧩 Environmental barriers

• Noise and distractions: health care environments are noisy (talking, TV, alarms, pages); create a calm, quiet environment by closing doors, reducing TV volume, or moving to a quieter area.
• Light: a room that is too dark or too light can create barriers; ensure lighting is appropriate according to the patient's preference.

🧩 Sensory and language barriers

• Hearing and speech problems: implement strategies such as assistive devices (eyeglasses, hearing aids, whiteboards, photobooks, microphones).
• Language differences: if English is not the patient's primary language, seek a medical interpreter and provide written handouts in the patient's preferred language; most agencies have phone interpreter services.

🧩 Cultural and psychological barriers

• Differences in cultural beliefs: norms of social interaction and emotional expression vary greatly; personal space preferences differ; some patients are stoic about pain, others are more verbally expressive.
• Psychological barriers: psychological states of sender and receiver affect how the message is sent, received, and perceived; being rushed, distracted, or overwhelmed can affect the message and its understanding.

🧩 Physiological and physical barriers

• Physiological barriers: if a patient is in pain, they are less likely to hear and remember what was said; pain medications may alter comprehension and response.
• Physical barriers for nonverbal communication: email or text is often less effective than face-to-face communication; inability to view tone of voice, facial expressions, and body language often causes misinterpretation; deliver important information face-to-face when possible.

🧩 Perception barriers

• Differences in perceptions and viewpoints: everyone has their own beliefs and perspectives and wants to feel "heard"; when patients feel their beliefs are not valued, they often become disengaged; provide information in a nonjudgmental manner, even if the patient's perspectives differ from your own.

🏥 Adapting communication to patient needs

🏥 Assessing and adapting

• Health care professionals assess receivers' preferred methods of communication and individual characteristics that might influence communication.
• Then they adapt communication to meet the receivers' needs.

🏥 Example: cognitive disabilities

• Verbal instructions for adult patients with cognitive disabilities are adapted.
• The information provided might be similar to that for a patient without disabilities, but the way the information is provided is adapted based on the patient's developmental level.
• Example (cognitively intact): "What do you want for lunch?"
• Example (cognitively impaired): "Do you want a sandwich or soup for lunch?"
• This adaptation allows the cognitively impaired patient to make a choice without being confused or overwhelmed by too many options.

👥 Communication within the health care team

👥 Communicating with staff

• The resident is at the center of the health care team.
• Most nursing assistant duties involve interaction regarding nursing services among other CNAs, LPNs, and RNs.
• Improper communication can affect the team's ability to provide holistic care.

👥 Building professional relationships

• Good communication starts by respecting those you work with and using the communication skills discussed.
• Keys to creating strong, professional relationships:
  • Know and fulfill your duties
  • Document and report the completion of these duties
  • Function in a consistent and dependable manner

👥 Organizing responsibilities

• Arrive on time for your shift, dressed appropriately, and prepared to start working when your shift starts.
• Review your assigned residents' plans of care at the beginning of the shift.

👥 Items to review in the plan of care

• Resident's name and location
• Activity level and transfer status

  Transfer status: the assistance the patient requires to be moved from one location to another (e.g., from bed to chair).

• Assistance required for activities of daily living (ADLs)

  Activities of daily living (ADLs): daily basic tasks fundamental to everyday functioning (e.g., hygiene, elimination, dressing, eating, ambulating/moving).

• Diet and fluid orders

  Diet and fluid orders: what the resident is permitted to eat and drink.

• Elimination needs

  Elimination needs: assistance the resident requires for urinating and passing stool (e.g., assistance to the toilet, incontinence pads).

👥 Coordinating care

• After reviewing the cares you will provide during your shift, discuss a timeline with your coworkers.
• The timeline should meet residents' schedules and allow for coordination of cares that require more than one caregiver.
• Example: one resident may require a two-person assist when transferring from bed to chair; schedules must be coordinated.

🧭 Overview

🧠 One-sentence thesis

Effective communication within the health care team and with patients requires therapeutic techniques, active listening, and organized care coordination to build trust and ensure quality resident care.

📌 Key points (3–5)

• Therapeutic communication is purposeful, professional communication that builds trust and encourages patient understanding and participation.
• Active listening vs passive/competitive listening: active listening involves verifying understanding and showing interest, not just hearing words or waiting to speak.
• Therapeutic techniques include open-ended questions, silence, reflection, and empathy; nontherapeutic responses like giving personal opinions or asking "why" questions block communication.
• Common confusion: sympathy vs empathy—sympathy focuses on the caregiver's feelings ("I'm so sorry"), while empathy focuses on understanding the patient's experience and helping them cope.
• Organizing care through reviewing plans of care, coordinating with coworkers, and timely documentation creates strong professional relationships and ensures holistic care.

🤝 Building Professional Relationships with Coworkers

🤝 Why team communication matters

• CNAs interact with other CNAs, LPNs, and RNs regarding nursing services.
• Improper communication affects the team's ability to provide holistic care.
• Good relationships with coworkers are essential for quality resident care.

🔑 Keys to strong professional relationships

• Respect those you work with and use good communication skills to grow trust.
• Know and fulfill your duties: complete assigned tasks consistently.
• Document and report completion of duties in a timely manner.
• Function consistently and dependably: reliability builds trust within the team.

🗓️ Organizing responsibilities and managing time

Start each shift prepared:

• Arrive on time, dressed appropriately, ready to work when the shift starts.
• Review assigned residents' plans of care at the beginning of the shift.

Items to review in the plan of care:

• Resident's name and location
• Activity level and transfer status
• Assistance required for ADLs
• Diet and fluid orders
• Elimination needs

Transfer status: the assistance the patient requires to be moved from one location to another, such as from bed to chair.

Activities of daily living (ADLs): daily basic tasks fundamental to everyday functioning (e.g., hygiene, elimination, dressing, eating, ambulating/moving).

Diet and fluid orders: what the resident is permitted to eat and drink.

Elimination needs: assistance the resident requires for urinating and passing stool (e.g., assistance to toilet, incontinence pads).

📋 Coordinating care with coworkers

• After reviewing assigned cares, discuss a timeline with coworkers.
• Coordinate schedules to meet residents' needs and activities that require multiple caregivers.
• Example: a resident may require a two-person assist when transferring from bed to chair.
• Review schedules for activities, treatments, labs, appointments, or other services so cares can be organized around them.

📝 Documentation and reporting

• Document completed cares in a timely manner.
• Report to nursing staff with a concise report for each assigned client.
• Include: time cares were provided, observations, and any changes noted in the resident.

💬 Therapeutic Communication with Patients

💬 What therapeutic communication is

Therapeutic communication: a type of professional communication used with patients, defined as the purposeful, interpersonal, information-transmitting process through words and behaviors based on both parties' knowledge, attitudes, and skills that leads to patient understanding and participation.

• Used by nurses since Florence Nightingale, who emphasized building trusting relationships and the therapeutic healing from nurses' presence.
• Professional nursing associations highlight it as one of the most vital elements in nursing.
• Nursing assistants also implement therapeutic communication with patients.

🎯 Core components of therapeutic communication

1. Active listening and attending behaviors: demonstrate interest in understanding what the patient is saying.
2. Touch: professionally communicate caring.
3. Specific therapeutic techniques: encourage patients to share thoughts, concerns, and feelings.

👂 Active Listening and Attending Behaviors

👂 Three types of listening

Type	Description	Problem
Competitive listening	Primarily focused on sharing your own point of view	Not truly listening to the other person
Passive listening	Not interested or assuming you understand without verifying	No feedback to confirm understanding
Active listening	Communicate verbally and nonverbally that you are interested; verify understanding	✓ Correct approach

✅ How active listening works

• Communicate interest both verbally and nonverbally.
• Verify understanding with the speaker—this is the main difference from passive listening.
• Example: "I hear you saying you are hesitant to go to physical therapy because you are afraid of falling. Is that correct?"
• This feedback process ensures accurate understanding.

Don't confuse: Hearing someone speak (passive) vs. actively confirming what they mean and showing engagement (active).

🤲 Using Touch Therapeutically

🤲 When and how to use touch

• Touch is a powerful way to professionally communicate caring and compassion.
• Must be done respectfully and with awareness of the patient's cultural beliefs.
• NAs commonly use professional touch when assessing, expressing concern, or comforting patients.
• Example: holding a patient's hand during a painful procedure can provide comfort.

🛠️ Therapeutic Communication Techniques

🛠️ General principles

• Provide patients with support and information while focusing on their concerns.
• Help patients complete ADLs and meet goals based on their needs, values, skills, and abilities.
• Recognize the patient's autonomy to make their own decisions.
• Maintain a nonjudgmental attitude and avoid interrupting.
• Use appropriate terminology for the patient's developmental stage and educational needs.

🗣️ Key therapeutic techniques

Technique	How it works	Example
Active Listening	Use nonverbal/verbal cues (nodding, "I see") to encourage talking; use general leads	"What happened next?"
Using Silence	Give patients time to think, process, or broach a new topic	Deliberate pauses in conversation
Providing Acceptance	Acknowledge the message and affirm they've been heard (not necessarily agreement)	"I hear what you are saying"
Giving Recognition	Acknowledge and highlight a patient's behavior	"I noticed you ate all of your breakfast today"
Offering Self	Be present with patients; communicate you value them	Sitting with a patient for a few minutes
Giving Broad Openings / Open-Ended Questions	Let patients direct the conversation	"What's on your mind today?"
Seeking Clarification	Ask for explanation when something is confusing or ambiguous	"I'm not sure I understand. Can you explain more?"
Placing the Event in Time or Sequence	Ask when events occurred in relation to other events	Helps clarify the whole picture
Making Observations	Draw attention to appearance, demeanor, or behavior	"I notice you haven't been eating much"
Encouraging Descriptions of Perception	Ask about sensory issues or hallucinations in a nonjudgmental way	"What do you hear now?"
Encouraging Comparisons	Help patients draw on previous experiences to cope with current problems	"How does this compare to when…?"
Summarizing	Recap what patients have said; verify information	"Does that sound correct?"
Reflecting	Ask patients what they think they should do instead of giving advice	Encourages accountability and self-solutions
Focusing	Prompt patients to discuss something particularly important they mentioned	Helps patients explore relevant topics
Confronting	Disagree, present reality, or challenge assumptions (only after trust is established)	Helps break destructive routines
Voicing Doubt	Gently call attention to incorrect or delusional ideas when appropriate	"I know you said you see spiders, but I don't see any"
Offering Hope and Humor	Share hope or lighten the mood (tailored to patient's sense of humor)	Moves patients to a more positive state

💙 Communicating with empathy

• Communicate honestly, genuinely, and authentically—this is powerful for establishing true connections.
• Provide "unconditional positive regard".
• Research shows empathy improves patient healing, reduces depression symptoms, and decreases medical errors.

Don't confuse: Empathy vs. sympathy (see nontherapeutic responses below).

🚫 Nontherapeutic Responses to Avoid

🚫 What blocks communication

Nontherapeutic responses block the patient's communication of feelings or ideas. Avoid these:

Nontherapeutic Response	Why it's a problem	Therapeutic alternative
Asking Personal Questions	Not relevant or professional; satisfies curiosity, not care needs	"How would you describe your relationship with Mary?" (not "Why have you never married?")
Giving Personal Opinions	Takes away patient's decision-making	"Let's talk about what options are available" (not "If I were you, I'd…")
Changing the Subject	Shows lack of empathy; blocks further communication	"After your walk, let's talk more about your insurance concerns" (not "Let's not talk about that now")
Stating Generalizations and Stereotypes	Threatens relationships	Focus on the patient's specific concern, not stereotypes like "Older adults are always confused"
Providing False Reassurances	Discourages further expression of feelings	"It must be difficult not knowing. What can I do to help?" (not "You'll be fine")
Showing Sympathy	Focuses on caregiver's feelings, not helping patient cope	"How do you think this will affect your life?" (not "I'm so sorry; I can't imagine…")
Asking "Why" Questions	Can sound like accusations; patients become defensive	"You seem upset. What's on your mind?" (not "Why are you so upset?")
Approving or Disapproving	Imposes caregiver's values; judgmental (uses "should," "good," "bad," "right," "wrong")	Help patient explore their own beliefs: "Tell me more about it…" (not "You shouldn't…")
Giving Defensive Responses	(Text cuts off; implies defensiveness blocks communication)	(Not specified in excerpt)

🔍 Sympathy vs empathy clarified

• Sympathy: "I'm so sorry about your amputation; I can't imagine losing a leg" → focuses on the caregiver's feelings, shows pity.
• Empathy: "The loss of your leg is a major change; how do you think this will affect your life?" → helps the patient cope with the situation.

Example: False reassurance like "Don't worry; everything will be alright" is nontherapeutic because it discourages the patient from expressing feelings. Better: "It must be difficult not to know what the surgeon will find. What can I do to help?"

🧭 Overview

🧠 One-sentence thesis

Effective communication in health care requires avoiding nontherapeutic responses, adapting to each patient's needs, and using evidence-based strategies to manage stress and challenging behaviors while respecting patient autonomy.

📌 Key points (3–5)

• Nontherapeutic responses to avoid: false reassurance, sympathy vs empathy, "why" questions, judgmental language, defensive reactions, passive/aggressive responses, and arguing.
• Adaptation is essential: communication must be tailored to age, developmental level, cognitive abilities, and sensory impairments (hearing, vision, speech).
• Validation over correction: for patients with dementia, validation therapy emphasizes emotional connection rather than factual correction to prevent agitation.
• Common confusion: sympathy vs empathy—sympathy focuses on the caregiver's feelings ("I'm so sorry"), while empathy focuses on helping the patient cope with their situation.
• Stress management matters: both health care workers and patients experience stress responses that impair communication; relaxation techniques and healthy habits help manage this barrier.

🚫 Nontherapeutic Communication Patterns

🚫 False reassurance

• Phrases like "Everything will be alright" or "Don't worry" discourage patients from expressing their feelings.
• These comments focus on the caregiver's discomfort rather than the patient's needs.
• Therapeutic alternative: Acknowledge the difficulty and offer support.
• Example: Instead of "You will be alright," say "It must be difficult not to know what the surgeon will find. What can I do to help?"

💔 Sympathy vs empathy

Sympathy focuses on the health care professional's feelings rather than the patient.

• Sympathy shows pity ("I'm so sorry about your amputation; I can't imagine losing a leg").
• Empathy helps the patient cope with their situation.
• Therapeutic alternative: "The loss of your leg is a major change; how do you think this will affect your life?"
• Don't confuse: Sympathy = caregiver's feelings; Empathy = patient's coping.

❓ "Why" questions and judgmental language

• "Why" questions can sound like accusations and make patients defensive.
• Judgmental terms include "should," "shouldn't," "ought to," "good," "bad," "right," or "wrong."
• Approving or disapproving implies the caregiver has the right to judge the patient's decisions.
• Therapeutic alternative: Rephrase without "why" and avoid judgment.
• Example: Instead of "Why are you so upset?" say "You seem upset. What's on your mind?"
• Example: Instead of "You shouldn't schedule elective surgery; there are too many risks," say "So you are considering elective surgery. Tell me more about it…"

🛡️ Defensive and argumentative responses

• When patients criticize, health care workers should listen actively without becoming defensive.
• Listening does not imply agreement; it helps discover reasons for dissatisfaction.
• Arguing denies that patient perceptions are real and valid to them.
• Therapeutic alternative: Acknowledge the patient's perception and gather more information.
• Example: Instead of "No one here would intentionally lie to you," say "You believe people have been dishonest with you. Tell me more about what happened."
• Example: Instead of "How can you say you didn't sleep a wink when I heard you snoring!" say "You don't feel rested this morning? Let's talk about ways to improve your sleep."

🎯 Adapting Communication to Patient Needs

👶 Age and developmental considerations

Age Group	Strategy
Children	Speak calmly and gently; demonstrate procedures on dolls/stuffed animals; use play or drawing to establish trust
Adolescents	Give freedom to make choices within established limits
Older adults	Address potential vision and hearing impairments; ensure glasses and hearing aids are in place before communicating

👂 Impaired hearing strategies

• Gain attention before speaking (e.g., through touch).
• Minimize background noise.
• Position yourself 2-3 feet away.
• Face the person directly in well-lit environment to facilitate lip-reading.
• Do not shout—instead, speak in a lower-pitched tone.
• Ask the person to suggest their preferred communication strategies.
• Use gestures when necessary.
• Allow adequate time to process and respond.

👁️ Impaired vision strategies

• Identify yourself when entering the person's space.
• Ensure eyeglasses are cleaned and worn during waking hours.
• Provide adequate lighting and minimize glare.
• Provide large-print materials or read information aloud.
• Offer magnifying devices.

🗣️ Impaired speech strategies

Aphasia: difficulty processing what they are hearing or responding to questions due to dementia, brain injuries, or prior strokes.

Types of aphasia:

• Expressive aphasia: Understand speech and know what they want to say, but speak in short phrases with great effort (e.g., "Bathroom, Go" instead of "I would like to go to the bathroom").
• Receptive aphasia: Speak in long sentences that may not make sense; unable to understand verbal and written language.

Evidence-based strategies:

• Minimize excess noise and emotional distress.
• Phrase questions for simple "Yes" or "No" answers (but be aware automatic responses may be incorrect).
• Provide alternative communication methods: writing tablet, flash cards, eye blinking, communication boards, hand signals, computer.
• Adjust communication style: stand in front, listen attentively, present one idea at a time, speak slowly without shouting.
• Ensure call light is within reach.
• Repeat what the client said to ensure accuracy.
• Read care plan for speech therapist instructions.

🧠 Managing Memory Impairment and Behavioral Challenges

🧠 Understanding agitation and aggression

Older adults: adults aged 65 years old or older.

Agitation: behaviors that fall along a continuum ranging from verbal threats and motor restlessness to harmful aggressive and destructive behaviors.

Aggression: an act of attacking without provocation.

• Mild agitation: irritability, oppositional behavior, inappropriate language, pacing.
• Severe agitation: immediate risk of harming self or others, assaultive behavior, property damage.
• Challenging behavior is often communication of emotion due to cognitive impairment, not a choice.

🛡️ Prevention strategies

• Keep environment calm and quiet.
• Build trusting relationships by learning resident preferences and routines.
• Gather information from family about background and beliefs.
• Offer choices without overwhelming with too many decisions.
• Stick to daily routine for ADLs, meals, and activities.
• Empathize and understand that behavior communicates emotion.

✅ Validation therapy

Validation therapy: a method of therapeutic communication used to connect with someone who has moderate- to late-stage dementia and avoid agitation; places more emphasis on the emotional aspect of a conversation and less on the factual content, thereby imparting respect to the person, their feelings, and their beliefs.

• May require agreeing with a statement that is neither true nor real, because to the person with dementia, it feels both true and real.
• Don't confuse: This is not lying—it's respecting the emotional reality of someone with cognitive impairment.
• Example: If a resident believes they are waiting for a bus, sit with them by the window as if waiting for a bus and interact until they are no longer concerned.
• Redirect to alternative activities when appropriate: walking, looking at photos, listening to music.

👻 Delusions and hallucinations

Delusions: unshakable beliefs in something that isn't true or based on reality.

Hallucinations: sensing things such as visions, sounds, or smells that seem real but are not.

• Example of delusion: refusing to eat because of belief that staff are trying to poison them.
• Example of hallucination: refusing to enter a room because of visions of spiders on walls.
• Never contradict or tell them what they perceive isn't real.
• Instead: empathize and help them feel safe; offer to move to another area or investigate their concern.

😰 Managing Stress Responses

😰 Recognizing the stress response

Stress response: symptoms include irritability, sweaty palms, racing heart, difficulty concentrating, and impaired sleep.

• Common psychological barrier to effective communication.
• Can affect both sender and receiver of messages.
• Occurs in health care workers feeling overwhelmed and patients facing hospitalization or new diagnoses.

🧘 Stress management strategies

Relaxation breathing:

• Take deep breaths in through nose, blow out through mouth.
• Repeat at least three times in succession.
• Use as often as needed throughout the day.

Healthy lifestyle choices:

• Avoid caffeine, nicotine, and junk food (increase anxiety).
• Make time for exercise (stimulates endorphins, improves sleep).
• Get enough sleep: set aside 30 minutes to wind down before bed; avoid electronic devices before bedtime.

Progressive relaxation:

• Lie down somewhere comfortable and firm.
• Breathe slowly, deeply, and comfortably.
• Work around the body one muscle area at a time.
• Clench muscles tightly, hold for a few seconds, then relax completely.
• Repeat for feet, calves, thighs, buttocks, stomach, arms, hands, shoulders, and face.

🏥 Understanding residents' stress and loss

Autonomy: each individual's right to self-determination and decision-making based on their unique values, beliefs, and preferences.

• Residents in long-term care have often experienced major physical/cognitive changes causing loss of independence and autonomy.
• Moving into a facility means adjusting to a new reality: needing help with basic tasks, unfamiliar surroundings, separation from loved ones and pets.
• Emotions related to loneliness, feeling like a burden, and loss of independence can arise at any time.
• Nursing assistants should empathize with these losses and help residents adjust to their new environment.

📋 Effective Communication Strategies

📋 Key questions to ask patients

• What concerns do you have about your plan of care?
• What questions do you have about your daily routine?
• Did I answer your question(s) clearly, or is there additional information you would like?

📋 Building rapport and trust

• Read the care plan carefully and access social history.
• Talk with family members and friends when appropriate to learn about the client's preferences and life history.
• Example: Learning a resident lived on a farm and enjoyed horses helps build rapport through conversations about horses.
• Review changes in routine or care plan with the client to improve understanding and participation.
• Report questions you can't answer to the nurse; check back to ensure questions were answered.
• Observe nonverbal communication: Do they interact during care or merely tolerate it?

🧭 Overview

🧠 One-sentence thesis

The excerpt does not contain substantive content related to infection control principles; instead, it covers stress management techniques, communication strategies for managing client and family concerns, conflict resolution, Maslow's Hierarchy of Needs, and Erikson's Stages of Development.

📌 Key points (3–5)

• Stress management: Progressive muscle relaxation is a technique for managing stress by tensing and relaxing muscle groups sequentially.
• Client autonomy and adjustment: Residents in long-term care experience loss of independence and autonomy; nursing assistants can help by respecting preferences, providing privacy, and listening to concerns.
• Conflict resolution: Use assertive communication, "I" messages, and the 24-hour Rule when addressing conflicts with coworkers; involve supervisors only after direct discussion.
• Maslow's Hierarchy of Needs: Basic physiological and safety needs must be met before higher-level needs (belongingness, esteem, self-actualization) can be addressed.
• Erikson's Stages of Development: Psychosocial development occurs through eight age-based stages, each involving a central conflict that shapes personality and identity.

⚠️ Content Notice

⚠️ Mismatch between title and excerpt

The chapter title indicates the content should focus on infection control principles, but the provided excerpt does not contain information about infection control, hand hygiene, personal protective equipment, sterilization, or related topics.

📄 What the excerpt actually covers

The excerpt discusses:

• Stress management techniques for nursing assistants
• Communication strategies for supporting residents and families
• Conflict resolution in healthcare settings
• Maslow's Hierarchy of Needs theory
• Erikson's Stages of Development theory

The following notes reflect the actual content of the excerpt, not infection control principles.

🧘 Stress Management for Nursing Assistants

🧘 Progressive muscle relaxation technique

The excerpt describes a method for managing stress through physical relaxation:

• Work through one muscle group at a time
• Breathe deeply, calmly, and evenly throughout
• Clench muscles tightly and hold for a few seconds
• Then relax them completely
• Repeat the process and notice how it feels

💪 Muscle groups to target

The technique should be applied to:

• Feet, calves, thighs
• Buttocks, stomach
• Arms, hands, shoulders
• Face

Why this matters: Nursing assistants experience stress from caregiving demands and rapid decision-making; this technique provides a structured way to reduce physical tension.

🏥 Managing Clients' and Family Members' Stress

🏥 Understanding residents' challenges

Autonomy: each individual's right to self-determination and decision-making based on their unique values, beliefs, and preferences.

Residents in long-term care settings face:

• Major physical and/or cognitive changes
• Loss of independence and sometimes autonomy
• Being cared for by strangers
• Adjustment to a new environment

Example: The excerpt includes a reflection exercise where the reader imagines waking up unable to get out of bed independently, waiting for help to use the restroom, seeing only some belongings in an unfamiliar room, missing a partner and pet, and being assisted by unfamiliar aides.

🤝 How nursing assistants can help residents adjust

• Greet clients by their preferred name and introduce yourself
• Ask clients their preferences for their care
• Always communicate what you will be doing next
• Allow the resident to redirect or refuse care
• Provide privacy when assisting with cares
• Use confidentiality when documenting or reporting
• Treat belongings carefully and with respect
• Remember the client's room is their home
• Listen to the resident and address concerns
• Communicate concerns to the nurse or supervisor if you cannot adequately address them

Why this matters: Emotions related to loneliness, feeling like a burden, and loss of independence can arise at any time, even after residents become comfortable with their routine.

🗣️ Dealing With Conflict

🗣️ When residents decline care

If a patient does not want to participate in necessary care, the nursing assistant may:

• Re-approach the resident at a later time
• Offer an alternative method (e.g., full bed bath instead of shower, allowing them to stay covered and warm)
• Remind the resident what may occur if care is not provided (higher risk of infection, open areas in the skin, odor, etc.)
• Encourage as much control and independence as possible
• Allow the resident to direct the process if able
• Offer as many choices as are appropriate

Goal: Respect residents' choices while meeting care standards.

👨‍👩‍👧 Managing family concerns

Family members and other supports may have concerns due to:

• Lack of medical knowledge
• Little experience with health care facility procedures
• Feeling of helplessness regarding their loved one's situation

What the nursing assistant should do:

• Listen to and acknowledge concerns
• Follow confidentiality guidelines
• Discuss interventions in the plan of care only if the resident has permitted disclosure
• Confirm the resident has permitted disclosure before disclosing information
• Suggest family members discuss concerns with the nurse or unit supervisor
• Possibly schedule a care conference with the health care team

Don't confuse: Anger directed at the aide may be a result of the situation rather than a reflection of anything the aide has personally done.

🤝 Conflict resolution among coworkers

The excerpt recommends using assertive communication to address workplace conflict:

Steps for resolving conflict:

1. Start communication between the two parties that have the conflict before involving other staff
2. Think about the situation and develop a potential solution before approaching the coworker
3. Frame the situation from your perspective using "I" messages
4. If the situation is especially tense, allow time between the experience and the discussion to reduce stress and think logically
5. Apply the 24-hour Rule: wait one day to think logically about a conflict before addressing it
6. If discussion and a potential solution do not resolve the situation, notify your supervisor for additional assistance

Example: A nursing assistant became frustrated with a coworker who continued to neglect emptying wastebaskets and tidying residents' rooms before the end of their shift. After recognizing this was a pattern, the assistant approached the coworker and said, "I feel frustrated when I start my shift with full wastebaskets and untidy rooms for the residents you care for. Can you help me understand why these things aren't accomplished by the end of your shift? It works for me to clean up the room when I am finished assisting the resident. That way I don't forget to come back, and the residents seem to appreciate it as well." The coworker apologized and committed to completing these tasks.

🏔️ Maslow's Hierarchy of Needs

🏔️ Overview of the theory

Maslow's Hierarchy of Needs: created in 1943 by American psychologist Abraham Maslow; based on the ranking of the importance of human needs and the belief that human actions are based on motivation to meet these needs.

Core principle: Unless the basic needs in the lower levels of the hierarchy are met, humans cannot experience the higher levels of psychological and self-fulfillment needs.

📊 The five levels

Level	Definition	Examples
1. Physiological needs	Most important level with basic needs humans must have to stay alive and function	Air, food, drink, shelter, clothing, warmth, sex, sleep
2. Safety needs	Order, predictability, and control in life	Emotional security, freedom from fear, health and well-being (safety against falls and injury), familiar surroundings
3. Love and belongingness	Social needs and feelings of belongingness	Interpersonal relationships, connectedness, being part of a group (biological families, friends, supporters), physical intimacy, romantic relationships
4. Esteem needs	Self-worth and feelings of accomplishment and respect	How one views oneself, feeling of contributing to something of importance
5. Self-actualization	Highest level; realization of a person's potential and self-fulfillment	Desire to attain life goals, being truly satisfied in being the most one can be

Belongingness: a human emotional need for interpersonal relationships, connectedness, and being part of a group.

🧩 Key characteristics of the hierarchy

• One cannot attain a higher level if the levels below are not met: For example, one is not motivated by a sense of belonging if they are focused on obtaining basic needs such as food, water, and shelter.
• The hierarchy is subjective: Each individual determines what each level means for them.
  • Safety may mean living in a familiar neighborhood for one person, or having a daily routine for another.
  • Belongingness may mean being part of a community group or having one very close friend.
  • Self-esteem may be defined as graduating from high school or running a mile without stopping.
  • Self-actualization may mean being a good parent, graduating from college, or achieving one's dream of becoming a nurse.

🙏 Spirituality in the hierarchy

The levels of belongingness and self-actualization include a person's spirituality and how they find meaning and purpose in life.

Don't confuse: Spirituality is often mistakenly equated with religion, but spirituality is a broader concept that includes how people seek meaning and purpose in life, as well as establish relationships with family, their community, nature, and/or a higher power.

🏥 Applying Maslow's Hierarchy to resident care

Strategies that integrate Maslow's Hierarchy of Needs when providing care:

• Follow the nursing plan of care to meet physiological needs
• Implement fall precautions to keep residents safe
• Answer call lights promptly and consistently provide a calm, comfortable environment to make residents feel secure
• Respect residents' belongings and ask their preferences for grooming, bathing, and meals to satisfy self-esteem needs
• Encourage interaction among residents with similar interests to promote a feeling of belongingness
• Offer to bring residents to on-site religious activities or refer them to social services for a chaplain visit to promote self-actualization and belongingness

Why this matters: Maslow's Hierarchy of Needs is a good basis for providing holistic care and communicating with clients based on their needs and preferences. In nursing, priorities of care are based on physiological needs and safety. Knowing that a newly admitted resident may have difficulty reaching a higher level of needs if their basic needs are not met is a good starting point for providing care.

💼 Applying Maslow's Hierarchy to the work environment

To enhance professionalism:

• Offer assistance to coworkers when able to promote a feeling of security and belongingness and maintain residents' physiological needs and safety as a team
• Participate fully in the reporting and documentation process to meet residents' physiological and safety needs
• Accurately follow training and agency policies and procedures to encourage feelings of self-esteem in the health care worker
• Be accountable for one's actions and job responsibilities to promote a feeling of self-actualization by meeting one's potential

🌱 Erikson's Stages of Development

🌱 Overview of the theory

Erik Erikson created a theory of psychosocial development that describes how one's personality is developed:

• Eight stages of development based on a person's chronological age
• Development occurs based on the main conflict or challenge confronted during that period of time
• Each stage can create either a virtue/strength or a maladaptive tendency

Core principle: Those who have a stronger sense of identity from resolving these conflicts over time have fewer conflicts within themselves and with others and, subsequently, a decreased level of anxiety.

👶 Stage 1: Trust vs. Mistrust (Infancy, birth to 12 months)

Central task: Establish trust (or mistrust) that basic needs, such as nourishment and affection, will be met.

• If caregivers are responsive and sensitive: The infant develops a sense of trust and sees the world as a safe, predictable place.
• If caregivers are unresponsive: The infant may develop feelings of anxiety, fear, and mistrust and see the world as unpredictable.

Why this matters: Trust is the basis of our development during infancy; infants are dependent on their caregivers.

🚶 Stage 2: Autonomy vs. Shame (Toddlerhood, ages 1–3)

Autonomy (in this context): independence and the ability to control one's actions and act on the environment to get results.

Central task: Resolve the issue of autonomy versus shame and doubt by working to establish independence.

• Toddlers begin to explore their world and show clear preferences for certain elements of the environment (food, toys, clothing).
• Example: A two-year-old child wants to choose her clothes and dress herself. Although her outfits might not be appropriate for the situation, her input in such basic decisions has an effect on her sense of independence.
• If denied the opportunity to act on her environment: She may begin to doubt her abilities, which could lead to low self-esteem and feelings of shame.

🎨 Stage 3: Initiative vs. Guilt (Preschool, ages 3–6)

Central task: Initiate activities and assert control over the world through social interactions and play.

• Preschool children are capable of initiating activities and asserting control.
• If successful: They learn to plan and achieve goals while interacting with others, develop self-confidence, and feel a sense of purpose.
• If unsuccessful: They may develop feelings of guilt.

📚 Stage 4: Industry vs. Inferiority (Elementary school, ages 7–11)

Central task: Compare themselves to peers and develop a sense of pride and accomplishment or feel inferior.

• Children begin to compare themselves to their peers to see how they measure up.
• If successful: They develop a sense of pride and accomplishment in their schoolwork, sports, social activities, and family life.
• If unsuccessful: They feel inferior and inadequate when they don't measure up.

🔍 Stage 5: Identity vs. Identity Confusion (Adolescence, ages 12–18)

Central task: Develop a sense of self and answer questions like "Who am I?" and "What do I want to do with my life?"

• Most adolescents try on many different selves to see which ones fit.
• If successful: They have a strong sense of identity and are able to remain true to their beliefs and values in the face of problems and other people's perspectives.
• If unsuccessful: Teens who do not make a conscious search for identity or who are pressured to conform to their parents' ideas for the future may have a weak sense of self and experience role confusion as they are unsure of their identity and confused about the future.

💑 Stage 6: Intimacy vs. Isolation (Early adulthood, 20s through early 40s)

Central task: Share lives with others after developing a sense of self.

• People in early adulthood are ready to share their lives with others after they have developed a sense of self.
• If unsuccessful: Adults who do not develop a positive self-concept in adolescence may experience feelings of loneliness and emotional isolation.

🌳 Stage 7: Generativity vs. Stagnation (Middle adulthood, 40s to mid-60s)

Central task: Find your life's work and contribute to the development of others.

• Generativity involves finding your life's work and contributing to the development of others, through activities such as volunteering, mentoring, and raising children.
• If unsuccessful: Those who do not master this task may experience stagnation, having little connection with others and little interest in productivity and self-improvement.

🏆 Stage 8: Integrity vs. Despair (Late adulthood, mid-60s to end of life)

Note: The excerpt is cut off and does not provide the full description of this stage.

🧭 Overview

🧠 One-sentence thesis

Understanding developmental stages and spiritual needs helps nursing assistants provide holistic care, while accurate documentation and reporting ensure legal protection and continuity of care.

📌 Key points (3–5)

• Erikson's developmental stages: Adolescents through late adulthood face specific psychosocial tasks (identity, intimacy, generativity, integrity) that affect how they respond to care.
• Spirituality vs. religion: Spirituality is broader than religion and includes meaning, connectedness, and purpose; nursing assistants must support clients' beliefs without imposing their own.
• Documentation is legal evidence: "If it wasn't documented, it wasn't done"—accurate, factual charting protects both client and caregiver.
• Common confusion: Objective (signs) vs. subjective (symptoms) information—signs are observable through the senses; symptoms are what the client reports in their own words.
• Military time eliminates confusion: Each hour has a unique number (0000–2400), avoiding a.m./p.m. errors.

🌱 Developmental stages in care

🧑‍🎓 Identity vs. Role Confusion (Adolescence)

Adolescents struggle with "Who am I?" and "What do I want to do with my life?"

• Teens try on different identities to see which fit.
• Success: Strong sense of identity; able to stay true to beliefs despite pressure.
• Struggle: Weak sense of self or role confusion when pressured to conform or when they don't actively search for identity.
• Care implication: Adolescent clients may need more space or encouragement as they navigate identity questions during illness.

💞 Intimacy vs. Isolation (Early Adulthood)

• Age range: 20s through early 40s.
• Task: Ready to share life with others after developing a sense of self.
• Risk: Those who didn't develop positive self-concept in adolescence may experience loneliness and emotional isolation.
• Example: A young adult client may need support connecting with family or friends during recovery.

🌳 Generativity vs. Stagnation (Middle Adulthood)

• Age range: 40s to mid-60s.
• Task: Finding life's work and contributing to others through volunteering, mentoring, or raising children.
• Risk: Stagnation—little connection with others, little interest in productivity or self-improvement.
• Care implication: Middle-aged clients may benefit from activities that allow them to feel productive or helpful.

🪴 Integrity vs. Despair (Late Adulthood)

• Age range: Mid-60s to end of life.
• Task: Reflecting on life with satisfaction or failure.
• Success: Sense of integrity, few regrets, pride in accomplishments.
• Struggle: Feeling life was wasted; focus on "would have, should have, could have"; bitterness, depression, despair.
• Care implication: Older clients facing serious illness may grapple with existential questions; combining Maslow's and Erikson's theories helps caregivers understand why some need more time, encouragement, or space.

🕊️ Assisting with spiritual needs

🕊️ What spirituality means

Spiritual well-being: a pattern of experiencing meaning and purpose in life through connectedness with self, others, art, music, literature, nature, and/or a power greater than oneself.

• Don't confuse spirituality with religion: Spirituality is broader; elements include faith, meaning, love, belonging, forgiveness, and connectedness.
• Some very spiritual people may not belong to any specific religion.
• Spirituality and religion can change over a lifetime and vary greatly between people.

🙏 What religion involves

Religion: an institutionalized set of beliefs and practices.

• Many religions have specific rules about food, rituals, clothing, and touching.
• Nursing assistant role: Support these rules when they are meaningful to the resident; discuss with the nurse to align with the care plan.
• Example: A resident may need uninterrupted time for prayer or meditation, or may request specific dietary accommodations.

😟 Spiritual distress

Spiritual distress: a state of suffering related to the inability to experience meaning in life through connections with self, others, the world, or a superior being.

• Clients with serious illness or injury often ask, "Why is this happening to me?"—a sign of spiritual distress.
• How to help: Ask what they need to feel supported in their faith; explain that spiritual health helps healing.
• Options: speak to clergy, quiet time for meditation/prayer, visit the chapel, or meet with a chaplain.

🤝 Chaplains and prayer

• Many facilities employ professionally trained chaplains to assist with spiritual, religious, and emotional needs of clients, families, and staff.
• Chaplains support people of all faiths and cultures and customize their approach; they can help anyone, regardless of belief in a higher power.
• If a client requests prayer: It is acceptable to pray with them or find someone who will, as long as the focus is on the patient's preferences and beliefs, not the nursing assistant's own.
• If uncomfortable: Notify the nurse so a chaplain can be requested.
• Important boundary: Do not attempt to persuade a patient toward your preferred religion or belief system; the role is to respect and support the client's values, not promote your own.

📝 Documentation and reporting

📝 What documentation and reporting are

Reporting: oral communication between care providers that follows a structured format, typically at the start and end of every shift or when there is a significant change.

Documentation: a legal record of patient care completed in a paper chart or electronic health record (EHR); also called charting.

• Legal rule: "If it wasn't documented, it wasn't done."
• Documentation is used in court to prove care was completed if a lawsuit is filed.
• It is also reviewed by other health care team members to provide holistic care.

✅ Guidelines for accurate documentation

Guideline	What it means
Confidentiality	Share charts only with those directly involved in care; cover paper with blank sheet; log out of screens; never share passwords.
Timeliness	Document as soon as care is completed.
Signature	Include date, time, and signature per facility policy.
Facts, not opinions	Opinion: "The resident doesn't like their food." Fact: "The resident refused their meal and stated they were not hungry."
Measurements	Use graduated cylinders, tape measures, etc.; if estimating, provide comparison (e.g., "drainage the size of a quarter").
Paper corrections	Use black pen; draw one line through mistake, write "mistaken entry," add initials; do not use correction fluid or black out.

📊 Minimum Data Set (MDS)

MDS: a standardized assessment tool for all residents of long-term care facilities certified to receive Medicare or Medicaid reimbursement.

• Completed by a registered nurse who reviews nursing assistant documentation.
• Why accuracy matters: Facilities are reimbursed based on MDS data.
• What NAs must document thoroughly:
  • Sensory abilities: communication skills, hearing, vision.
  • Assistive devices: whiteboards, photo books, hearing aids, glasses.
  • Amount of assistance required: dressing, bathing, eating, toileting, repositioning, transferring, ambulating.
  • Skin observations made during care.

🗣️ Guidelines for reporting

• Confidentiality: Report in closed rooms, nurse's stations away from resident areas, or private resident rooms with doors closed.
• What to report immediately: Strong odors (urine, oral, wounds), reddened/warm/open skin, difficulty breathing, chest pain.
• General rule: Report any physical changes or behavior that is unusual or out of the ordinary for that person.

🔍 Objective vs. subjective information

Type	Definition	Also called	Example
Objective	Information observed through sight, touch, hearing, or smell; can be verified by another person; often uses measuring tools.	Signs	"The client's temperature was 98.6°F."
Subjective	Information reported by clients or family members; documented using exact wording with quotation marks.	Symptoms	The resident stated, "I have a headache."

⏰ Military time

Military time: a standard for recording time that avoids confusion between daytime and nighttime hours; each hour has its own number from 0000 to 2400; no colons are used.

• How to convert: For 1:00 p.m. onward, add 12 to the hour (e.g., 1:46 p.m. = 1346).
• Morning hours: Add a zero in front (e.g., 9:24 a.m. = 0924).
• Midnight: 2400 or 0000.
• Pronunciation: Morning hours start with "zero" or "O" (e.g., 7:00 a.m. = "zero seven hundred"); afternoon hours use the full number (e.g., 2:43 p.m. = "fourteen forty-three").
• Example: Avoid confusion—"1400" is always 2:00 p.m., never 2:00 a.m.

🧭 Overview

🧠 One-sentence thesis

Understanding developmental stages and spiritual needs helps nursing assistants provide individualized care that supports both physical and emotional well-being across the lifespan.

📌 Key points (3–5)

• Developmental stages shape care needs: Adolescents through late adulthood face distinct psychosocial tasks (identity, intimacy, generativity, integrity) that influence how they respond to illness and caregiving.
• Spiritual distress vs. spiritual well-being: Serious illness often triggers existential questions; spiritual well-being comes from meaning, purpose, and connectedness, not necessarily religion.
• Common confusion: Spirituality ≠ religion—spirituality is broader (faith, meaning, love, belonging, forgiveness, connectedness), while religion is an institutionalized set of beliefs and practices.
• Supporting spiritual needs: Ask what the client needs, accommodate requests when possible, respect religious rules (food, rituals, clothing, touching), and offer chaplain services.
• Prayer boundaries: NAs may pray with patients if requested and comfortable, but must focus on the patient's beliefs, not promote their own; if uncomfortable, notify the nurse to request a chaplain.

🧑 Developmental stages in adulthood

🔍 Identity vs. Role Confusion (Adolescence)

• Core question: "Who am I?" and "What do I want to do with my life?"
• Adolescents try on many different selves to see which ones fit.
• Success outcome: Strong sense of identity; able to remain true to beliefs and values despite problems and others' perspectives.
• Failure outcome: Weak sense of self and role confusion—unsure of identity and confused about the future, especially if they don't make a conscious search or are pressured to conform to parents' ideas.

💞 Intimacy vs. Isolation (Early Adulthood)

• Age range: 20s through early 40s.
• Core task: Ready to share lives with others after developing a sense of self.
• Failure outcome: Adults who did not develop a positive self-concept in adolescence may experience loneliness and emotional isolation.
• Don't confuse: This stage builds on the previous one—without identity, intimacy is harder to achieve.

🌱 Generativity vs. Stagnation (Middle Adulthood)

• Age range: 40s to mid-60s.

Generativity: finding your life's work and contributing to the development of others, through activities such as volunteering, mentoring, and raising children.

• Success outcome: Engagement in productivity, self-improvement, and connection with others.
• Failure outcome: Stagnation—little connection with others and little interest in productivity and self-improvement.
• Example: A person in their 50s who mentors younger colleagues or volunteers in the community is demonstrating generativity.

🪞 Integrity vs. Despair (Late Adulthood)

• Age range: Mid-60s to end of life.
• Core task: Reflecting on life and evaluating satisfaction or failure.
• Success outcome: Sense of integrity—feeling proud of accomplishments, looking back with few regrets.
• Failure outcome: Feeling life has been wasted; focusing on "would have," "should have," or "could have" been; facing end of life with bitterness, depression, and despair.

🔗 Why developmental stages matter for nursing care

• Combining Maslow's and Erikson's theories helps explain why some patients need more encouragement, space, or time to allow caregivers to provide assistance with ADLs to maintain physical and emotional health.
• Understanding a patient's developmental stage helps tailor care to their psychosocial needs, not just physical needs.

🕊️ Understanding spiritual needs

🤔 Spiritual distress in illness

• When clients experience serious illness or injury, they often grapple with the existential question: "Why is this happening to me?"
• This question can be a sign of spiritual distress.

Spiritual distress: a state of suffering related to the inability to experience meaning in life through connections with self, others, the world, or a superior being.

🌟 Spiritual well-being vs. religion

Concept	Definition	Key elements
Spiritual well-being	A pattern of experiencing meaning and purpose in life through connectedness	Faith, meaning, love, belonging, forgiveness, connectedness with self, others, art, music, literature, nature, and/or a power greater than oneself
Religion	An institutionalized set of beliefs and practices	Specific rules about food, religious rituals, clothing, and touching

• Common confusion: Spirituality is often mistakenly equated with religion, but spirituality is a broader concept.
• Some people who are very spiritual may not belong to a specific religion.
• Spirituality and religion can change over a person's lifetime and vary greatly between people.

🤲 Supporting spiritual needs in practice

🗣️ Asking and accommodating

• Most important step: Ask clients what they need to feel supported in their faith, then try to accommodate their requests if possible.
• Explain that spiritual health helps the healing process.
• Example requests: speak to clergy, spend quiet time in meditation or prayer without interruption, go to the on-site chapel.

🏥 Using available resources

• Many agencies have chaplains onsite that can be offered to patients as a spiritual resource.
• Chaplains are professionally trained to assist with spiritual, religious, and emotional needs of clients, family members, and staff.
• Chaplains support people of all religious faiths and cultures and customize their approach to each individual's background, age, and medical condition.
• Chaplains can meet with any individual regardless of their belief, or lack of belief, in a higher power and can be very helpful in reducing anxiety and distress.
• NAs may suggest chaplain services for their clients.

🙏 Praying with patients

When it's appropriate:

• If the client or family member requests a nursing assistant to pray with them, it is acceptable to pray with them or find someone who will.
• NAs, nurses, and other health care team members are encouraged to pray with their patients to support their spiritual health.

Important boundaries:

• The focus must be on the patient's preferences and beliefs, not the NA's own preferences.
• Having a short, simple prayer ready that is appropriate for any faith may help a health care professional feel prepared.
• If the NA does not feel comfortable praying with the patient as requested, the nurse should be notified so the chaplain can be requested to participate.

What is NOT appropriate:

• It is not appropriate for the NA to take this opportunity to attempt to persuade a patient towards a preferred religion or belief system.
• The role of the NA is to respect and support the client's values and beliefs, not promote the NA's values and beliefs.

🍽️ Respecting religious rules

• Many religions have specific rules about food, religious rituals, clothing, and touching.
• Supporting these rules when they are a meaningful part of a resident's spirituality is an effective way to support the resident and maintain a caring, professional relationship.
• The NA should discuss these aspects with the nurse to assure they support the plan of care for the resident and encourage other staff members to provide support.
• Many nursing homes and assisted living facilities offer religious or spiritual opportunities through their Activities departments.

🧭 Overview

🧠 One-sentence thesis

Accurate documentation and reporting are vital legal and clinical tools that prove care was delivered, guide holistic treatment, and ensure proper reimbursement, following the principle "if it wasn't documented, it wasn't done."

📌 Key points (3–5)

• Documentation vs reporting: documentation is a written legal record (paper or electronic), while reporting is structured oral communication between care providers.
• Legal importance: documentation serves as proof in court that care was completed; it becomes the legal record of what happened.
• Objective vs subjective data: objective information (signs) can be observed and measured; subjective information (symptoms) comes from what the client reports in their own words.
• Common confusion: don't confuse facts with opinions—chart what you observe or measure, not your interpretation (e.g., "refused meal" not "doesn't like food").
• MDS requirement: long-term care facilities must complete standardized Minimum Data Set assessments using nursing assistant documentation for Medicare/Medicaid reimbursement.

📝 Core Documentation Principles

📝 What documentation is

Documentation: a legal record of patient care completed in a paper chart or electronic health record (EHR), also referred to as charting.

• Includes checklists and flowcharts completed in the resident's room
• Used in court to prove care was completed if a lawsuit is filed
• Reviewed by other health care team members to provide holistic care
• The fundamental rule: "If it wasn't documented, it wasn't done"

🗣️ What reporting is

Reporting: oral communication between care providers that follows a structured format and typically occurs at the start and end of every shift or whenever there is a significant change in the resident.

• Happens verbally, not in writing
• Must be done in private locations to protect confidentiality
• Appropriate places: closed room, nurse's station away from resident areas, or private resident room with door closed

✅ Guidelines for Accurate Documentation

🔒 Confidentiality and security

• The client's chart is confidential and should only be shared with those directly involved in care
• If using paper, cover information with a blank sheet
• When using technology, ensure screens are visible only to you and log out after each use
• Never share security measures like passwords or PIN with anyone else

⏰ Timing and format

• Document as soon as any care is completed
• Include date, time, and signature per facility policy
• Use military time to avoid confusion between daytime and nighttime hours

🖊️ Paper documentation rules

• Always use a black pen
• If you make a mistake, draw only one line through the entry
• Write the word "mistaken entry" and add your initials
• Do not use correction fluid or completely black out the entry

📊 Facts vs opinions

• Use facts, not opinions
• Opinion example (wrong): "The resident doesn't like their food"
• Fact example (correct): "The resident refused their meal and stated they were not hungry"
• Use measuring tools (graduated cylinder, tape measure) whenever possible to provide accurate data
• If you must estimate, provide a comparison: "Drainage noted on the bandage was the size of a quarter"

🔍 Types of Information to Document

👁️ Objective information

Objective information: information about a client that can be observed through the four senses of sight, touch, hearing, or smell; also referred to as signs.

• Can be verified by another individual
• Often includes measuring tools: scale, thermometer, specimen cup, graduated cylinder
• Example: "The client's temperature was 98.6 degrees Fahrenheit"

💬 Subjective information

Subjective information: information reported to you by clients or their family members; also referred to as symptoms.

• Must be documented using the exact wording reported with quotation marks
• Example: The resident stating, "I have a headache"
• Don't confuse: objective data is what you observe; subjective data is what the client tells you

🏥 Special Documentation Requirements

📋 Minimum Data Set (MDS)

Minimum Data Set (MDS): a standardized assessment tool for all residents of long-term care facilities certified to receive reimbursement by Medicare or Medicaid.

• Completed by a registered nurse who reviews nursing assistant documentation
• Accurate documentation is vital so facilities are appropriately reimbursed
• The MDS nurse reviews nursing assistant documentation for:
  • Sensory abilities (communication skills, hearing, vision)
  • Assistive devices (whiteboards, photo books, charts, hearing aids, glasses)
  • Amount of assistance required (dressing, bathing, eating, toileting, repositioning, transferring, ambulating)
  • Skin observations made during care

🚨 What requires immediate reporting to the nurse

Throughout care, nursing assistants should report any physical changes or behavior that is unusual or out of the ordinary. Examples requiring immediate notification:

• Strong odors from urine, oral care, or wounds
• Reddened, warm, or open skin areas
• Difficulty breathing or chest pain

⏱️ Military Time System

⏱️ How military time works

Military time: a time system used to record when care is provided and other pertinent information, avoiding confusion between daytime and nighttime hours because it does not require a.m. or p.m.

• Each hour has its own number from 1 to 24
• No colons are used
• Beginning at 1:00 p.m., simply add 12 to the hour
  • Example: 1:46 p.m. is written as 1346
• For morning hours up to 9:59 a.m., add a zero in front of the hour
  • Example: 9:24 a.m. is written as 0924
• Midnight is documented as either 2400 or 0000

🗣️ Pronouncing military time

• Morning hours are pronounced beginning with "zero" or "O"
  • Example: 7:00 a.m. is pronounced "zero seven hundred" or "oh seven hundred"
• Afternoon/evening hours use the full number
  • Example: 2:43 p.m. is pronounced "fourteen forty-three"

🧭 Overview

🧠 One-sentence thesis

Nursing assistants must uphold ethical standards, comply with federal regulations and laws that protect vulnerable populations, and ensure resident rights are respected in all care settings.

📌 Key points (3–5)

• Ethical behavior: Nursing assistants must treat all clients with compassion, respect, and dignity while avoiding unethical behaviors like misusing work time, accepting gifts, or breaching confidentiality.
• Governing agencies: Multiple federal and state agencies (CMS, CDC, FDA, OSHA, DHS) regulate health care to protect vulnerable populations including older adults, children, and socially disadvantaged individuals.
• Federal laws: HIPAA protects patient information confidentiality; OBRA established nurse aide training standards and patient-centered care; OAA created ombudsman programs for long-term care residents.
• Resident rights: The most important aspect of care is protecting residents' rights to respect, participation, freedom from abuse, proper medical care, and decision-making autonomy.
• Common confusion: Understanding the difference between Medicare (for those 65+ or with disabilities) and Medicaid (for low-income individuals)—both may cover resident care but have different eligibility criteria.

🛡️ Ethical foundations of nursing assistant practice

🤝 Core ethical principles

Nursing assistants should treat all clients equally and with compassion and respect for their inherent dignity, worth, and unique attributes.

• The primary ethical duty is promoting clients' rights and safety to help them achieve the best possible health and functioning.
• Equal treatment means providing care regardless of ethnicity, beliefs, demeanors, or other individual characteristics.
• Don't confuse: Treating everyone equally does not mean ignoring individual preferences—patient-centered care requires respecting each person's unique needs and choices.

⚠️ Unethical behaviors to avoid

Common examples of unethical conduct include:

• Misuse of work time: Using personal cell phones in patient care areas, sitting in empty rooms or break rooms during work hours, ignoring call lights or assigned phones when available
• Inappropriate boundaries: Accepting gifts or gratuities from clients or family members
• Privacy violations: Sharing clients' personal information with those not providing direct care
• Discrimination: Avoiding clients because of their ethnicity, beliefs, demeanors, or other characteristics
• Misuse of resources: Using agency computers for personal use, stealing items from clients or the facility

Example: A nursing assistant who ignores a call light because they dislike a particular resident's demeanor is violating both ethical standards and the resident's right to proper care.

🏛️ Governing agencies and regulatory framework

🏥 Federal regulatory agencies

Agency	Primary Role	Impact on Nursing Assistants
CMS (Centers for Medicare & Medicaid)	Provides health care funding and ensures resident rights	Regulates care standards; nursing assistants must understand coverage rules
CDC (Centers for Disease Control)	Provides infection and disease control guidance	Nursing assistants must follow CDC protocols for safety
FDA (Food and Drug Administration)	Ensures safety of medications, medical devices, food supply, and tobacco products	Affects what products can be used in care settings
OSHA (Occupational Safety and Health Administration)	Ensures safe and healthy working conditions through standards, training, and enforcement	Protects nursing assistants' workplace safety

🏛️ State-level regulation

• Every state has a Department of Health Services (DHS) that works with local counties, health care providers, and community partners.
• DHS provides services including mental health programs, public health services, disability determination, long-term care implementation, and nursing home regulation.
• State agencies work in coordination with federal agencies to protect citizens.

👥 Vulnerable populations

Vulnerable populations include patients who are children, older adults, minorities, socially disadvantaged, underinsured, or those with certain medical conditions.

• These populations often have health conditions exacerbated by inadequate health care.
• The extensive regulatory framework exists specifically to protect these vulnerable groups.
• Nursing assistants play a direct role in ensuring vulnerable individuals receive appropriate, respectful care.

📜 Federal health care laws

🔒 HIPAA (Health Insurance Portability and Accountability Act of 1996)

HIPAA required the creation of national standards to protect sensitive patient health information from being disclosed without the patient's consent or knowledge.

The HIPAA security rule requires:

• Ensure confidentiality, integrity, and availability of all protected health information (PHI)
• Detect and safeguard against anticipated threats to information security
• Protect against anticipated impermissible uses or disclosures
• Certify compliance by the workforce

What this means for nursing assistants:

• You must legally keep all information regarding client care confidential
• This includes documentation, care plans, and shift reports
• Sharing information with anyone not directly involved in care is a violation

Example: Discussing a resident's medical condition with a friend or family member (even without naming the resident) violates HIPAA if that person is not involved in the resident's care.

🏠 OBRA (Omnibus Reconciliation Act of 1987)

OBRA set forth new provisions for Medicare and Medicaid related to new standards for care in the nursing home setting.

Major provisions:

• Nurse aide training requirement: Minimum of 75 hours of training and passing a competency evaluation
• State registry: Each state must maintain a registry of nurse aides who have passed the competency evaluation
• Patient-centered care focus: Improving quality of life for residents in long-term care by meeting individual preferences in care decisions

Patient-centered care definition:

An individual's specific health needs and desired health outcomes are the driving forces behind all health care decisions.

• Patients are partners with the health care team
• Treatment addresses not only clinical needs but also emotional, mental, spiritual, social, and financial perspectives
• Don't confuse: Patient-centered care is not just being nice—it means the patient's preferences actively drive care decisions.

👴 OAA (Older Americans Act of 1965)

Passed in response to lack of community social services for older persons.

Key components:

• Authority for grants to states for community planning and social services
• Research and development projects
• Personnel training in the field of aging
• Long-Term Care Ombudsman programs: Work to resolve problems related to health, safety, welfare, and rights of individuals in LTC facilities

Ombudsman program requirements:

• Identify, investigate, and resolve complaints made by or on behalf of residents
• Provide information about long-term services and supports
• Ensure residents have regular and timely access to ombudsman services
• Represent residents' interests to governmental agencies
• Analyze and recommend changes in laws and regulations pertaining to residents' rights

🎯 Resident rights

🌟 Core resident rights

Resident rights are the most important aspect of providing care.

Essential for health care workers:

• Protect the dignity of residents
• Enhance their quality of life
• These rights are protected by CMS as a health care regulator

📋 Protected rights in long-term care

Key rights that nursing assistants must uphold:

• Respect and dignity: Be treated with respect
• Participation: Participate in activities
• Safety and freedom: Be free from discrimination, restraints, abuse, and neglect
• Voice: Make complaints
• Medical care: Receive proper medical care
• Decision-making: Make decisions about their own care

Why these matter: Each right directly impacts a resident's quality of life and sense of autonomy. Violating any of these rights is both unethical and potentially illegal.

Example: A resident has the right to refuse a bath even if the nursing assistant believes it is necessary—respecting this choice upholds the resident's autonomy and right to make decisions.

🔑 Medicare vs. Medicaid distinction

Program	Eligibility	Coverage Type
Medicare	Anyone over 65, permanent disability, or kidney failure	Part A (hospitals/nursing homes), Part B (medical appointments/services/equipment), Part C (private company services), Part D (prescription drugs)
Medicaid	Individuals with low incomes	Provided at both federal and state level

• Both programs may cover services for resident care based on individual needs
• Understanding the difference helps nursing assistants recognize what services may be available to different residents

🧭 Overview

🧠 One-sentence thesis

Nursing assistants must uphold resident rights, recognize and report abuse or neglect as mandated reporters, and understand the survey process that ensures quality care in long-term care facilities.

📌 Key points (3–5)

• Resident rights are central: residents have the right to respect, participation, freedom from abuse, proper care, and decision-making involvement—these rights must guide every interaction.
• Mandated reporting obligation: nursing assistants are legally required to report any suspected abuse or neglect (physical, sexual, emotional, financial, or neglect) to the nurse immediately.
• Survey process ensures compliance: state Department of Health Services conducts annual surveys to verify that facilities meet residents' physical, emotional, social, and spiritual needs.
• Common confusion: dependency vs. dignity—residents may feel loss of self-esteem when dependent on caregivers for ADLs; NAs must accommodate preferences unless safety or infection control is at risk.
• Ombudsman programs: these programs identify, investigate, and resolve complaints to protect residents' health, safety, welfare, and rights.

🛡️ Resident Rights and Dignity

🛡️ Core resident rights

Resident rights: the protections that ensure residents are treated with respect, participate in care decisions, and are free from discrimination, restraints, abuse, and neglect.

The excerpt lists comprehensive rights protected in long-term care:

• Be treated with respect and participate in activities
• Be free from discrimination, restraints, abuse, and neglect
• Make complaints and receive proper medical care
• Make decisions regarding care with family involvement if desired
• Receive privacy, proper living arrangements, and social services
• Manage one's money and spend time with visitors
• Be protected against unfair transfers or discharges
• Have the ability to leave the facility temporarily or permanently when health allows
• Create or participate in groups

🤝 Respecting resident autonomy

• It is difficult for residents to accept dependency on caregivers for completing ADLs.
• This dependency can cause loss of self-esteem or depression.
• NAs should make accommodations to meet resident requests as appropriate.
• When to consult: if unsure how to meet a request, consult the supervising nurse.
• Only exception: deny a preference only if there is a safety or infection control concern.

Example: A resident wants a candle in their room → fire risk prevents this, but an electric candle is an acceptable alternative. A resident wants to use a hair dryer but their roommate has altered safety awareness → find a secure place where the resident can use the dryer safely.

🧠 Don't confuse: preference vs. safety

• Resident preferences should be granted unless there is a clear safety or infection control risk.
• The goal is to balance autonomy with protection, not to deny requests arbitrarily.

🚨 Elder Abuse and Neglect

🚨 Definitions

Elder abuse: an intentional act, or failure to act, that causes or creates a risk of harm to someone age 60 or older, occurring at the hands of a caregiver or a person the older adult trusts.

Neglect: a failure to provide care for oneself or to someone for whom you are enlisted to care.

🔍 Types of abuse and signs to report

Type of Abuse	Definition	Signs or Symptoms
Physical	Illness, pain, injury, functional impairment, distress, or death from intentional use of physical force (hitting, kicking, pushing, slapping, burning)	Bruising, fractures, burns, unexplainable injury; isolation, withdrawal, behavior change when abuser is present
Sexual	Forced or unwanted sexual interaction (contact, penetration, or noncontact acts like harassment)	Injury to genital areas, rashes, infections, bleeding or discharge, torn clothing, behavioral changes
Emotional/Psychological	Verbal or nonverbal behaviors that inflict anguish, mental pain, fear, or distress (humiliation, threats, control, harassment, isolation)	Depression, anxiety, loss of self-confidence or motivation, feelings of failure
Financial	Illegal, unauthorized, or improper use of an older adult's money, benefits, belongings, property, or assets	Missing items, going without food/medications/necessities, excessive unaccounted cash use
Neglect	Failure to meet basic needs (food, water, shelter, clothing, hygiene, essential medical care)	Weight loss, skin breakdown, infection, confusion, hallucinations, dehydration, soiled linens/clothing, odors, poor oral care
Self-Neglect	Lack of self-care that threatens personal health and safety, including failure to seek help	Same signs as neglect

📢 Mandated reporter responsibilities

Mandated reporters: health care professionals required by state law to report suspected neglect or abuse of the elderly, vulnerable adults, and children.

• Immediate action: stay with the resident until you can ensure no further abuse or neglect occurs, even in a facility.
• Reporting obligation: inform the nurse, charge nurse, or administrator of any signs, symptoms, or resident reports of abuse.
• No exceptions: report regardless of the cognitive function of the person reporting so that an investigation can be performed.

⚠️ Don't confuse: suspicion vs. proof

• You are not required to prove abuse occurred; you must report any suspicious signs or symptoms.
• The investigation will determine the facts.

🔍 The Survey Process

🔍 What surveys are

Survey: an inspection conducted by state Department of Health Services (DHS) under CMS guidelines to ensure long-term care facilities meet all aspects of residents' physical, emotional, social, and spiritual needs.

• Standard surveys occur at least once per year.
• DHS employees observe care, watch food preparation and serving, review care plans and documentation, interview residents and families, and examine every aspect of the facility.

🗣️ How to respond during a survey

• Provide facts only: if you are observed or interviewed, give factual information.
• If you don't know: respond that you do not know and explain how you will find the answer.
• Appropriate responses: "I need to check my care plan for that information" or "I would ask the nurse for clarification."

📋 Citations and follow-up

Citation: a formal notice of a problem or discrepancy discovered during a survey.

• At the end of the survey, DHS conducts an exit interview with the Administrator, Director of Nursing, and other facility leadership.
• If residents are at high risk for adverse events, surveyors ask the facility to create a corrective plan.
• DHS makes a return visit in a few weeks to follow up on implementation.

🚪 Complaint-driven and event-driven surveys

• DHS may also conduct surveys if they receive several complaints from residents or family members.
• Certain events trigger surveys, such as:
  • Elopement: when a resident incapable of protecting themselves successfully leaves the facility unsupervised and unnoticed, possibly entering harm's way.
  • Accidents with major injury.

📢 Public access to survey results

• Survey results must be made available to the public.
• They must be posted at the facility entrance, along with information on how to contact the ombudsmen.
• They are also available electronically at medicare.gov.

🏛️ Ombudsman Programs

🏛️ Role of the Long-Term Care Ombudsman

The Older Americans Act (OAA) requires ombudsman programs to:

• Identify, investigate, and resolve complaints made by or on behalf of residents.
• Provide information to residents about long-term services and supports.
• Ensure residents have regular and timely access to ombudsman services.
• Represent residents' interests to governmental agencies and seek administrative, legal, and other remedies to protect residents.
• Analyze, comment on, and recommend changes in laws and regulations pertaining to residents' health, safety, welfare, and rights.

🤝 Why ombudsmen matter

• They work to resolve problems related to health, safety, welfare, and rights of individuals in LTC facilities (nursing homes, assisted living, other residential care communities).
• They serve as advocates for residents who may not be able to advocate for themselves.

🧭 Overview

🧠 One-sentence thesis

The nursing process provides a systematic framework for patient-centered care that guides registered nurses in assessment through evaluation, while scope of practice and care plans ensure that nursing assistants safely implement delegated tasks within their legal boundaries across various health care settings.

📌 Key points (3–5)

• The nursing process (ADOPIE): A six-step critical thinking model—Assessment, Diagnosis, Outcomes Identification, Planning, Implementation, Evaluation—that structures nursing care delivery.
• Scope of practice boundaries: Nursing assistants must verify tasks fall within state licensure using the 4 S's (Scope, Supervision, Safety, Supplies) before accepting delegated work.
• Nursing care plans guide consistency: RN-created care plans document individualized interventions so all team members provide consistent care across shifts.
• Common confusion: Nursing assistants don't create care plans but must review and implement them; their largest responsibility is in the Implementation phase.
• Different settings, different terms: Hospitals have "patients" and require CNAs; nursing homes have "residents" and require CNAs; assisted living has "residents" but may not require licensure.

🏥 Long-term care facility structure

🏢 Key leadership roles

Long-term care facilities have a hierarchical structure with distinct roles:

Role	Primary responsibility
Administrator	Federal/state compliance; non-medical aspects (finance)
Medical Director	Consults on medical aspects (infection control, quality)
Director of Nursing (DON)	Manages all nursing staffing, policies, procedures
Assistant DON	Assists with nursing staff management
Staff Development Coordinator (SDC)	Trains employees and provides continuing education
MDS Coordinator	Assesses resident needs and reports to CMS for reimbursement

🔧 Support departments

• Business Office: Billing and financial aspects
• Housekeeping and Maintenance: Facility upkeep, equipment maintenance, clean/safe environment
• Activities Director: Plans events related to resident hobbies and interests
• Dietary Director: Oversees nutritional and fluid needs delivery

🔄 The nursing process (ADOPIE)

📋 Assessment

"The registered nurse collects pertinent data and information relative to the health care consumer's health or the situation."

• Includes physiological, psychological, sociocultural, spiritual, economic, and lifestyle data.
• Nursing assistant role: Observe and report findings (reddened/open skin, confusion, increased swelling, pain reports) to the nurse.
• This is data collection, not diagnosis.

🔍 Diagnosis

"The registered nurse analyzes the assessment data to determine actual or potential diagnoses, problems, and issues."

• A nursing diagnosis is the nurse's clinical judgment about the client's response to health conditions or needs.
• Don't confuse: Nursing diagnoses differ from medical diagnoses; they form the basis for nursing care plans.
• This step is performed by RNs, not nursing assistants.

🎯 Outcomes Identification

"The registered nurse identifies expected outcomes for a plan individualized to the health care consumer or the situation."

• The nurse sets measurable and achievable short- and long-term goals in collaboration with the patient.
• Example: "The client will walk at least 100 feet today."
• Nursing assistants may be informed of these expected outcomes to guide their care.

📝 Planning

"The registered nurse develops a collaborative plan encompassing strategies to achieve expected outcomes."

• Uses assessment data, nursing diagnoses, and goals to select evidence-based interventions.
• Nursing care plans document goals and interventions for continuity of care across shifts and health professionals.
• Some interventions can be delegated to LPNs or nursing assistants with RN supervision.
• Nursing assistant role: Review care plans to know what care to provide within their scope.

⚙️ Implementation

"The nurse implements the identified plan."

• Nursing interventions are carried out or delegated according to the care plan.
• Interventions are documented in the medical record as completed.
• Nursing assistant's largest responsibility: Safely implementing delegated interventions from the nursing care plan.

📊 Evaluation

"The registered nurse evaluates progress toward attainment of goals and outcomes."

• Nurses compare current findings against initial assessment to determine intervention effectiveness.
• Both patient status and care plan effectiveness are continuously evaluated and modified.
• Nursing assistant role: Report changes in patient condition or new observations; communicate if an intervention is known to be ineffective with a resident so alternatives can be identified.
• Nursing assistants spend the most time with residents, making their feedback crucial.

✅ Benefits of the nursing process

• Promotes quality patient care
• Decreases omissions and duplications
• Provides a guide for consistent and responsive care
• Encourages collaborative management
• Improves patient safety and satisfaction
• Identifies patient goals and strategies
• Increases likelihood of positive outcomes
• Saves time, energy, and frustration

🔐 Scope of practice and the 4 S's

📜 What scope of practice means

Scope of practice: services that a trained health professional is deemed competent to perform and permitted to undertake according to the terms of their state professional license.

• Different states have variability in what nursing assistants can legally perform.
• Check state DHS regulations to know exactly what skills you can legally provide.

🇺🇸 Federal CMS standards

Federal regulation 42 CFR § 483 lists nine allowable task categories:

1. Personal care skills
2. Safety/emergency procedures
3. Basic nursing skills
4. Infection control
5. Communication and interpersonal skills
6. Care of cognitively impaired residents
7. Basic restorative care
8. Mental health and social service needs
9. Residents' rights

🛡️ The 4 S's verification framework

Before accepting delegated or assigned tasks, ask yourself:

S	Question	Why it matters
Scope	Is this within my state licensure scope?	If you didn't perform it for evaluation during training, it may not be legal under your license (though some states allow facility-provided additional training)
Supervision	Do I have supervision available?	Each delegated task must be clear and supervised; you need an RN supervisor for questions (in person or by phone)
Safety	Am I safe to perform this task?	Even if you demonstrated competency during certification, infrequent use (e.g., mechanical lift) may require additional training
Supplies	Do I have the proper equipment?	Without proper equipment (PPE, transfer equipment, mobility aids, personal items), performing the task is unsafe

Example: If you haven't recently used a mechanical lift, even though you passed that skill during certification, you may need additional training before safely performing that transfer technique with a resident.

🏢 Health care settings comparison

🏥 Hospital setting

• Type of care: 24-hour acute and specialty care with access to physicians, RNs, therapists, social workers, dietitians, chaplains
• Who is served: Anyone with emergent or urgent health care concerns
• Environment: Short stays; sterile/clean; typically one patient per room; multiple medical equipment pieces; many disposable items to avoid cross-contamination
• What users are called: Patients
• Who provides ADLs: Patient Care Assistants (PCAs) or Certified Nursing Assistants (CNAs); licensure required

🏘️ Long-term care (LTC) or nursing home

• Type of care: 24-hour skilled care for people unable to care for themselves at home; RN always on site
• Who is served: Typically older adults with chronic conditions (physical disabilities, heart disease, prior strokes, diabetes, major fractures) or otherwise unsafe at home
• Environment: Where a person lives; private and shared rooms; residents encouraged to have own belongings; homelike but accessible for mobility needs
• What users are called: Residents
• Who provides ADLs: Certified Nursing Assistants (CNAs); licensure required at Medicare/Medicaid-funded facilities

🏠 Assisted living

• Type of care: Scheduled care (medication assistance, grooming, showering, meal prep, cleaning, laundry); no on-demand care like toileting assistance
• Who is served: Typically 65+ years, more independent, medically stable but need oversight for safety and home maintenance
• Environment: Apartment-like with small kitchen and locking entry doors
• What users are called: Residents
• Who provides ADLs: Daily Living Assistants (DLAs) or CNAs; licensure not required

🏡 Group home/adult family home

• Type of care: Daily care and maintenance with mostly safety oversight
• Who is served: Adults with developmental disabilities, moderate dementia, or recovering from substance use disorders
• Environment: Residents have a bedroom and access to whole house; typically 4-6 residents per house (state maximum capacity varies)
• What users are called: Residents or clients
• Who provides ADLs: Daily Living Assistants (DLAs) or CNAs; licensure not required

🏠 Home health

• Type of care: Any assistance (nursing or ADLs) provided in someone's home; can be short-term (wound care, IV therapy) or long-term (medication management, cleaning, shopping)
• Environment: Care provided in the client's home
• What users are called: Patient, client, or member
• Who provides ADLs: Daily Living Assistants (DLAs) or CNAs; licensure not required

🕊️ Hospice

• Type of care: Palliative or end-of-life care
• Who is served: Terminally ill and/or life expectancy of six months or less
• Environment: Care available 24/7 in resident's home, LTC facility, or hospital unit
• What users are called: Patient, client, or member
• Who provides ADLs: Daily Living Assistants (DLAs) or CNAs; licensure not required

💼 Job-seeking and professional success

📄 Creating your resume

Resume: a factual presentation of yourself that lists your various skills and accomplishments.

Goal: Make an employer want to interview you.

What to include:

• Contact information
• Education
• Licenses or certifications
• Work experience
• Skills from nursing assistant training pertinent to the position
• Optional: honors, awards, volunteer experiences

References: Have 2-3 professional references (supervisors from previous jobs or instructors who observed your skills); ask permission before giving their contact information.

🎤 Interview preparation

Before the interview:

• Review the job description and be able to state how you meet requirements
• Practice with someone asking you questions
• Prepare questions to ask, such as:
  • How long is the orientation period?
  • What hours will I be expected to work?
  • How will I be evaluated?
• Consider requesting a facility tour to observe the environment

Day of interview:

• Arrive 10-15 minutes early
• Silence cell phone
• Make good eye contact and shake hands if appropriate
• Speak confidently and truthfully

Grooming guidelines (these are ongoing health care professional expectations):

• Shower, brush teeth, groom hair, trim nails
• Wear clean, professional attire without wrinkles, words, or logos
• Skirts/dresses should be knee-length or below
• No shorts or jeans
• Closed-toed shoes in good condition
• Minimal makeup and jewelry
• Use deodorant but no cologne or perfume

🌟 Maintaining employment success

• Staffing ratios: Consider the number of patients assigned per shift to nurses and aides; good ratios positively impact stress and work-life balance.
• Periodic evaluations: Reflect on your own performance before supervisor evaluations; be open to improvement opportunities.
• Keep certifications current: Maintain certification and training requirements to avoid lapses in availability.
• Self-care: Get proper rest, exercise, and nutrition—if you don't feel well, you can't care for others.
• Refer to stress management techniques to maintain mental health for job demands.

🧭 Overview

🧠 One-sentence thesis

Nursing assistants must understand the organizational structure of long-term care facilities, apply the nursing process framework to deliver patient-centered care, and maintain safe environments through proper body mechanics, emergency response, and infection control practices.

📌 Key points (3–5)

• Nursing process (ADOPIE): A systematic six-step framework—Assessment, Diagnosis, Outcomes Identification, Planning, Implementation, Evaluation—guides all nursing care delivery.
• Nursing assistant's primary role: Implementing delegated interventions from the care plan and reporting observations to nurses, especially during Assessment and Evaluation phases.
• Emergency response: Recognize and respond to heart attacks (angina, SOB), strokes (FAST signs), seizures, falls, fires (RACE/PASS), and choking (Heimlich maneuver).
• Common confusion: Scope of practice varies by state; use the "4 S's" (Scope, Supervision, Safety, Supplies) to verify you can legally and safely perform a delegated task.
• Injury prevention: Work-related musculoskeletal symptoms (WRMS) affect 88% of nurse aides; use proper body mechanics (ABC: Alignment, Base of support, Center of gravity) and lifting equipment to prevent injury.

🏥 Long-term care facility structure

🏢 Key leadership roles

Long-term care facilities have a hierarchical structure with distinct roles:

Role	Responsibility
Administrator	Oversees federal/state compliance and non-medical operations (finance)
Medical Director	Consults on medical aspects (infection control, quality of care)
Director of Nursing (DON)	Manages all nursing staffing, policies, and procedures
Assistant DON	Assists with nursing staff management and policy implementation
Staff Development Coordinator (SDC)	Trains nursing employees and provides continuing education
MDS Coordinator	Assesses resident needs and reports to CMS for reimbursement

🔧 Support services

• Business Office: Handles billing and financial aspects
• Housekeeping/Maintenance: Maintains facility, equipment, and cleanliness
• Activities Director: Plans events related to resident hobbies and interests
• Dietary Director: Oversees nutritional and fluid needs delivery

🔄 The nursing process (ADOPIE)

📋 What the nursing process is

The nursing process: a critical thinking model based on a systematic approach to patient-centered care that nurses use to perform clinical reasoning and make clinical judgments.

• Based on American Nurses Association (ANA) Standards of Professional Nursing Practice
• Applies to all registered nurses regardless of role, population, specialty, or setting
• The mnemonic ADOPIE helps remember the six components
• It is a cyclical process—evaluation leads back to reassessment

🔍 Assessment

"The registered nurse collects pertinent data and information relative to the health care consumer's health or the situation."

• Includes physiological, psychological, sociocultural, spiritual, economic, and lifestyle data
• Nursing assistant role: Observe and report findings such as reddened/open skin, confusion, increased swelling, or pain reports
• Example: A nursing assistant notices a resident has new redness on their heel and reports it to the nurse

🩺 Diagnosis

"The registered nurse analyzes the assessment data to determine actual or potential diagnoses, problems, and issues."

• A nursing diagnosis is the nurse's clinical judgment about the client's response to health conditions
• Different from medical diagnoses
• Forms the basis for nursing care plans
• Nursing assistant role: Does not create diagnoses but should understand they guide the care plan

🎯 Outcomes Identification

"The registered nurse identifies expected outcomes for a plan individualized to the health care consumer or the situation."

• Nurse sets measurable, achievable short- and long-term goals in collaboration with the patient
• Based on assessment data and nursing diagnoses
• Example outcome communicated to nursing assistant: "The client will walk at least 100 feet today"

📝 Planning

"The registered nurse develops a collaborative plan encompassing strategies to achieve expected outcomes."

• Uses assessment data, nursing diagnoses, and goals to select evidence-based interventions
• Customized to each patient's needs and concerns
• Documented in the nursing care plan for continuity of care across shifts

📋 Nursing care plans

Nursing care plans: documentation created by RNs that describes individualized planning and delivery of nursing care for each specific patient using the nursing process.

• Guide care provided across shifts for consistency
• Some interventions can be assigned/delegated to LPNs or nursing assistants with RN supervision
• Nursing assistant role: Review care plans to know what care to provide within their scope of practice
• Don't confuse: Nursing assistants do not create or edit care plans, but they must follow them

⚙️ Implementation

"The nurse implements the identified plan."

• Nursing interventions are implemented or delegated with supervision according to the care plan
• Interventions are documented in the medical record as completed
• Nursing assistant's largest responsibility: Safely implementing delegated interventions in the nursing care plan

📊 Evaluation

"The registered nurse evaluates progress toward attainment of goals and outcomes."

• Nurses assess the patient and compare findings against initial assessment
• Determines effectiveness of interventions and overall care plan
• Both patient status and care effectiveness must be continuously evaluated and modified
• Nursing assistant role: Report any changes in patient condition or observations related to interventions; communicate if an intervention is known to be ineffective with a resident

✅ Benefits of using the nursing process

• Promotes quality patient care
• Decreases omissions and duplications
• Provides consistent and responsive care guide for all staff
• Encourages collaborative management of health care problems
• Improves patient safety and satisfaction
• Identifies patient goals and strategies to attain them
• Increases likelihood of achieving positive outcomes
• Saves time, energy, and frustration

⚖️ Scope of practice and the 4 S's

📜 What scope of practice means

Scope of practice: services that a trained health professional is deemed competent to perform and permitted to undertake according to the terms of their state professional license.

• Varies by state—check state DHS regulations for what nursing assistants can legally perform
• Federal regulation 42 CFR § 483 lists nine allowable task categories at the federal level

📋 Nine federal task categories for nursing aides

1. Personal care skills
2. Safety/emergency procedures
3. Basic nursing skills
4. Infection control
5. Communication and interpersonal skills
6. Care of cognitively impaired residents
7. Basic restorative care
8. Mental health and social service needs
9. Residents' rights

✔️ The 4 S's verification method

Before accepting delegated or assigned tasks, ask yourself:

S	Question	Why it matters
Scope	Is this within my state licensure scope?	If you didn't perform it for evaluation during training, it may not be legal under your licensure (though some states allow facility-provided additional training)
Supervision	Do I have supervision available?	Each delegated task must be clear and supervised; you need an RN to direct questions to (in person or by phone)
Safety	Am I safe to perform the task?	Even if you demonstrated competency during certification, skills you don't perform consistently may require additional training (e.g., mechanical lift)
Supplies	Do I have proper equipment?	Without proper equipment (PPE, transfer equipment, mobility aids, personal items), it is unsafe to perform the task

Don't confuse: Just because a task is within your scope doesn't mean you should perform it without verifying supervision, safety, and supplies.

🏥 Health care settings

🏢 Types of care settings

Different settings require different levels of care and have different licensure requirements:

Setting	Type of Care	Typical Users	What Users Are Called	Who Provides ADLs	Licensure Required?
Hospital	24-hour acute/specialty care with access to physicians, RNs, therapists, labs	Anyone with emergent/urgent concerns	Patients	PCAs or CNAs	Yes
Long-term Care/Nursing Home	24-hour skilled care; RN always on site	Older adults with chronic conditions, physical disabilities, unsafe at home	Residents	CNAs	Yes (Medicare/Medicaid funded)
Assisted Living	Scheduled care (medication, grooming, meals, cleaning); not on-demand care	65+ years, more independent, medically stable	Residents	DLAs or CNAs	No
Group Home/Adult Family Home	Daily care and safety oversight	Adults with developmental disabilities, moderate dementia, or recovering from substance use	Residents or clients	DLAs or CNAs	No
Home Health	Nursing or ADL assistance in client's home	Short-term (wound care, IV) or long-term (medication, cleaning, shopping)	Patient, client, or member	DLAs or CNAs	No
Hospice	Palliative/end-of-life care, 24/7 availability	Terminally ill, life expectancy ≤6 months	Patient, client, or member	DLAs or CNAs	No

🏠 Environment differences

• Hospital: Short stays, sterile, one-patient rooms, medical equipment, disposable items
• Nursing home: Long-term residence, private/shared rooms, residents' own belongings, homelike but accessible
• Assisted living: Apartment-like with small kitchen and locking doors
• Group home: Bedroom plus access to whole house (typically 4-6 residents)

🚨 Emergency situations

❤️ Heart attack (Myocardial Infarction - MI)

Myocardial infarction (MI): lack of blood flow and oxygen to the heart, resulting in death of cardiac muscle cells.

Cause: Blocked coronary artery from plaque buildup creating a clot

Key symptoms:

• Sudden severe pain (angina) beneath sternum, often radiating to left arm or jaw
• Some patients (especially females) may experience indigestion-like symptoms instead
• Associated symptoms: shortness of breath (SOB), sweating, anxiety, irregular heartbeats, nausea, vomiting, fainting

Action: Immediately report symptoms to nurse for emergency assessment and treatment

🧠 Stroke (Cerebrovascular Attack - CVA)

Cerebrovascular attack (CVA): lack of blood flow and oxygen to the brain, resulting in death of brain cells within minutes.

Causes:

• Blockage in brain artery (80% of strokes)
• Ruptured blood vessel in brain (hemorrhagic stroke)

Risk factors: Smoking, high blood pressure, cardiac arrhythmias

Why speed matters: Brain damage is irreversible after a few minutes; treatment works best within three hours of symptom onset

Treatment depends on cause:

• Blockage strokes: thrombolytic medication (tPA) to dissolve clot
• Hemorrhagic strokes: surgery to stop bleeding

🎯 FAST acronym for stroke recognition

Letter	Sign	What to observe
F	Facial drooping	One side of face droops
A	Arm weakness	Unilateral (one-sided) weakness
S	Slurred speech	Difficulty speaking or understanding
T	Time	Quicker response = better outcome

Important: Symptoms occur on the opposite side of the body from the affected brain side (e.g., left brain stroke causes right-side symptoms)

⚡ Transient Ischemic Attack (TIA)

Transient ischemic attack (TIA): temporary period of stroke-like symptoms lasting only a few minutes without permanent brain damage.

• Also called "ministroke"
• Warning sign for future stroke
• Should be reported to nurse

🌀 Seizure

Seizure: transient occurrence of signs/symptoms due to abnormal neuronal activity in the brain.

What happens: Large numbers of brain cells activate abnormally at the same time (like an electrical storm)

Two major groups:

• Generalized seizures
• Focal seizures
• Difference is in how and where they begin in the brain

Motor symptoms:

• Sustained rhythmic jerking (clonic)
• Muscles becoming limp/weak (atonic)
• Body/arms/legs becoming stiff/tense (tonic)
• Brief twitching (myoclonus)

Nonmotor symptoms:

• Staring spells (absence seizures)
• Changes in sensation, emotions, thinking, or autonomic functions
• Lack of movement (behavioral arrest)

🆘 Seizure response actions

If you witness the beginning:

1. If standing, guide person to floor (may not be able to stop fall)
2. Protect head from hitting floor (place pillow or your leg underneath)
3. Do NOT place anything in their mouth (increases choking risk)
4. Immediately notify nurse and note the time started
5. After seizure ends, carefully assist person into bed
6. Expect person to sleep for several hours

What to report to nurse:

• Time seizure started
• Person's level of awareness during seizure
• Movements that occurred during seizure

🤕 Falls and fall prevention

Statistics: About 1/3 of older adults at home and about 1/2 in nursing homes fall at least once yearly

Risk factors: Mobility problems, balance disorders, chronic illnesses, impaired vision

Consequences: Range from mild bruising to broken bones, head injuries, and death (falls are a leading cause of death in older adults)

If you discover a fallen resident:

• Do NOT move them unless in immediate danger
• Notify nurse immediately for assessment
• Typically a mechanical lift will be used to raise them from floor

Prevention actions:

• Keep environment clean and clutter-free
• Clean spills immediately
• Ensure residents wear nonskid footwear (rubberized soles) when standing/walking
• Use ordered assistive devices (gait belts, walkers)
• Ensure glasses and hearing aids are functioning, clean, and properly fitted

🔥 Fire response: RACE and PASS

RACE acronym:

• Rescue: Anyone in immediate danger (if it doesn't endanger your life)
• Activate: Pull nearest fire alarm or call 911
• Contain: Close all doors and windows
• Extinguish: Use fire extinguisher if fire is small (PASS method); otherwise Evacuate

PASS method for fire extinguisher:

• Pull: The pin on the extinguisher
• Aim: Nozzle at the base of the fire
• Squeeze: Or press the handle
• Sweep: Side to side at the base of the flame until fire appears out

🍽️ Choking and Heimlich maneuver

Risk: Over half of choking deaths occur in people over 70; food is often responsible, especially for those with difficulty swallowing or dentures

When to act: If person can't cough, speak, or breathe, they need immediate help

Heimlich maneuver steps (not for children under 1):

1. Stand behind victim with one leg forward between their legs (or lean them forward if in wheelchair)
2. For a child, move to their level and keep head to one side
3. Reach around abdomen and locate navel
4. Place thumb side of fist against abdomen just above navel
5. Grasp fist with other hand and thrust inward and upward with quick jerks
6. For pregnant victims or anyone you can't get arms around, give chest thrusts (avoid squeezing ribs)
7. Continue thrusts until victim expels object or becomes unresponsive
8. If person becomes unconscious, perform standard CPR with chest compressions and rescue breaths
9. After choking stops, seek medical attention

🏠 Resident environment and transition

🌡️ SPICES framework for well-being

SPICES: an acronym for observing aspects affecting older adult well-being—Sleep, Problems eating, Incontinence, Confusion, Evidence of falls, Skin breakdown.

Letter	Aspect	What to observe/do
S	Sleep	Older adults need 7-9 hours; control noise, lighting, temperature; report sleep disturbances (snoring, gasping, not feeling rested)
P	Problems eating	Report chewing/swallowing issues and food preferences; insufficient intake leads to skin breakdown, infection, functional decline
I	Incontinence	Offer toileting every 2 hours and on request; check incontinence products every 2 hours, especially for residents with communication problems
C	Confusion	Report new onset confusion (can indicate infection); example: not knowing day/location when normally oriented
E	Evidence of falls	Report new weakness, difficulty transferring, or changes in walking ability
S	Skin breakdown	Reposition immobile residents every 2 hours; provide proper hygiene to keep incontinent residents clean and dry

🏡 Transitioning to nursing home

What residents experience:

• Abrupt change in living environment (privacy, size, personal belongings)
• Cannot follow typical home schedule (though accommodations should be made)
• Often have recent major change in cognitive or physical functioning
• Adjusting to needing assistance with previously independent activities (walking, eating, self-care)

Actions to help transition:

• Staff member should greet individual and loved ones at entry
• Room should be prepared (sanitized, bed made) before arrival
• Introduce resident to staff and identify who is responsible for which care needs
• Provide facility tour
• Show where to find daily schedule of events/activities
• Assist in organizing belongings and arranging room to fit preferences
• Introduce roommate if sharing a room
• If possible, arrange a resident mentor (another resident who can answer questions and encourage interaction)

📋 Admission procedures

• Complete written inventory of resident's belongings (typically done by nurse aide)
• Inventory documents all personal items brought to facility

💪 Body mechanics and injury prevention

📊 Work-related injury statistics

• 88% of nurse aides report at least one work-related musculoskeletal symptom (WRMS)
• Lower back is most commonly affected, followed by arms and shoulders
• Nursing assistants rank first for occupational back sprains/strains (above construction workers and garbage collectors)
• WRMS from nurse aides account for over 50% of all musculoskeletal injuries in the U.S.

Causes: Manual handling of clients, heavy physical loads, frequent awkward positions, repetitive movements

🔤 ABC of proper body mechanics

ABC mnemonic: Alignment, Base of support, Center of gravity

Alignment (good posture):

• Imaginary line should be drawable straight down through center of body
• Both sides of body are mirror images
• Body parts lined up naturally: arms at sides, palms forward, feet pointed forward and slightly apart
• Guidelines: Maintain correct alignment when lifting; keep object close to body; point feet and body in direction of movement; do NOT twist at waist

Base of support:

• Good base improves balance; imbalance creates awkward positioning leading to injury
• Create strong base by placing feet about shoulder width apart (or slightly wider than hips)

Center of gravity:

• Where most weight is concentrated (pelvis when standing)
• Maintaining low center of gravity provides stable base and improves balance
• When lifting: Keep center of gravity low with good base by bending at knees with feet shoulder width apart
• Keep resident or object as close to your body as possible
• Face the person/object you're moving and use both sides of body equally

Example: Safer body mechanics = good alignment + base of support + load close to center of gravity + bending knees

🏋️ Lifting equipment

• Facilities have specialized equipment to assist in lifting/transferring clients
• Significantly reduces risk of lifting injuries
• Manufacturers provide specific instructions for safe use and maintenance
• Must receive extensive training during facility orientation

Orientation should include:

• Familiarity with all parts of device
• Requirements for mobility status of residents who will use device
• Potential risks to residents and caregivers while using device

🛏️ Bed making

🧼 Infection control guidelines for bed making

• Never allow linens to touch your uniform
• Do NOT transfer linens from one room to another
• Do NOT place soiled linens on floor
• If linens touch floor, place in soiled laundry (do not use)
• Do NOT shake linens (spreads airborne pathogens)
• Store clean linens in closed closet or covered cart

📝 When to change linens

• At least weekly
• Whenever they become soiled

🛏️ Unoccupied bed procedure highlights

• Gather supplies and perform routine pre-procedure steps (knock, hand hygiene, introduce self, identify resident, provide privacy, explain procedure)
• Don gloves before handling soiled linens
• Check for personal belongings before removing linens
• Roll soiled linens to middle of bed and place in linen bag
• Remove gloves and perform hand hygiene
• Sanitize bed if soiled
• Place fitted sheet with seams against mattress (away from resident)
• Smooth sheet to prevent wrinkles (can injure fragile skin)
• Place lift sheet where shoulders to hips will be
• Place soaker pad/waterproof barrier on top of lift sheet
• Make mitered corners at foot of bed for flat sheet and bedspread/blanket
• Place pillow with open end of pillowcase facing away from door
• Post-procedure: hand hygiene, check comfort, ensure bed low and locked, place call light within reach, open door/curtain, hand hygiene, report abnormal findings

🛏️ Occupied bed procedure highlights

• Similar to unoccupied bed but with resident in bed
• Use side rails for safety
• Roll resident toward side rail using lift sheet
• Roll soiled linens to middle and under resident
• Work on one side, then move to opposite side
• Pull through clean linens ensuring no wrinkles
• Keep resident covered with new flat sheet while removing old linens
• Make toe pleat to prevent pressure on feet
• Exchange pillows while maintaining cleanliness

💼 Job-seeking and keeping skills

🔍 Finding employment

Resources:

• Local newspapers
• Workforce entities
• Facility websites and social media pages
• Online searches
• Review survey data of nursing homes for quality ratings
• Consider staffing ratios (number of patients assigned per shift to nurses and aides—impacts stress level and work-life balance)

📄 Resume creation

Resume: a factual presentation of yourself that lists your various skills and accomplishments.

Should include:

• Contact information
• Education
• Licenses or certifications
• Work experience
• Skills from nursing assistant training pertinent to position
• Honors, awards, or volunteer experiences (if helpful)
• 2-3 professional references (people who supervised you or instructors who observed your skills—ask permission first)

🎤 Interview preparation

• Review job description and state how you meet requirements
• Practice with someone asking you questions
• Prepare questions about the job (orientation length, expected hours, evaluation process)
• Request facility tour to observe environment

Day of interview:

• Arrive 10-15 minutes early
• Silence cell phone
• Make good eye contact and shake hands if appropriate
• Speak confidently and truthfully

Grooming guidelines:

• Shower, brush teeth, groom hair, trim nails
• Wear clean, professional attire without wrinkles, words, or logos
• Skirt/dress should be knee-length or below
• No shorts or jeans
• Closed-toed shoes in good condition
• Minimal makeup and jewelry
• Deodorant but no cologne/perfume

🌟 After being hired

• Build professional relationships with staff
• Periodic evaluations with supervisor to discuss performance
• Reflect on your own performance before evaluations
• Be open to improvement opportunities
• Keep certification and training requirements current
• Take care of yourself: proper rest, exercise, nutritional intake
• Refer to stress management techniques when needed