PAMELA K. RANDOLPH, RN, MSSHEILA A. SORRENTINO, PHD, RN

JUNE 2010

Inconsistencies Between Nurse Aide Programs and the Need for

Uniformity in Education, Evaluation, and Endorsement

Objectives

Assess similarities and differences between state requirements (Assessment and Nursing Diagnoses).

Discuss approaches to mitigating mobility issues for nursing assistants (Planning).

Describe and evaluate one state’s approach to nursing assistant endorsement (Implementation and Evaluation).

HISTORICAL OVERVIEW:

ILLINOIS AND OTHER STATESOMNIBUS BUDGET RECONCILIATION ACT OF 1987

Assessment

Nursing Assistant Profile

Average hourly rate $11.46 Lowest 10%—less than $8.34 per hour (less than $19,000

annual full-time) Middle 50%—between $9.71 and $13.76 per hour Highest 10%—more than $15.97 per hour

Many work and average of 30 hours/week Reduces annualized earning to below $15,000

28% live in poverty and rely on public benefits30 to 35% of single-parents receive food stamps

Many rely on publicly funded health careOver 90% are female

12 to 23% are foreign-born; about 1/3 are naturalized citizens28 to 35% have some college educationOver 40 titles used in the industry

State Board of NursingState Board of Nursing Dept. of Health, Public Health, or SimilarDept. of Health, Public Health, or Similar

Arizona Colorado District of Columbia Kentucky Maryland Nevada New Hampshire Oregon South Dakota Vermont Virgin Islands Virginia Wyoming

Alabama Montana California Nebraska Connecticut New Jersey Delaware New Mexico Florida New York Idaho North Carolina Illinois North Dakota Indiana Ohio Kansas Oklahoma

Maine Pennsylvania Massachusetts South Carolina Michigan Tennessee Montana West Virginia Minnesota Wisconsin Mississippi Missouri

Responsible Agency

Responsible Agency (cont.)

Other Arkansas Dept of Human Services—Div. of Long-term Care Georgia Health Partnership-GMCF Hawaii Dept of Commerce & Consumer Affairs Iowa Dept. of Inspections & Appeals—Health Facilities

Division Louisiana State Board of Examiners for Nursing Facility

Administrators or Louisiana Dept. of Health and Hospitals Rhode Island Dept. of Health Professionals Texas Dept. of Aging & Disability Services Utah Health Technology Certification Center Washington Aging & Adult Services Administration

Residential Care Services Division

Program Hours—120+ Hours

State Required Hours Clinical Hours

Maine 180 70

Missouri 175 100

California 150 100

Delaware 150 75

Oregon 150 75

Alaska 140 80

Arizona 120 40

District of Columbia 120 45

Florida 120 40

Illinois 120 40

Virginia 120 40

West Virginia 120 55

Wisconsin 120 32

Program Hours—76 to 119 Hours

State Required Hours Clinical Hours

Indiana 105 75

Connecticut 100 50

Hawaii 100 70

Maryland 100 40

New Hampshire 100 60

New York 100 30

Rhode Island 100 20

Arkansas 90 16

Kansas 90 45

New Jersey 90 40

Georgia 85 24

Washington 85 50

Program Hours—76 to 119 Hours (cont.)

Louisiana 80 40

Pennsylvania 80 37.5

South Carolina 80 40

Utah 80 16

Vermont 80 30

Program Hours—75 Hours

State Required Hours Clinical Hours

Alabama 75 16

Colorado 75 16

Iowa 75 30

Kentucky 75 16

Massachusetts 75 16

Michigan 75 16

Minnesota 75 16

Mississippi 75 16

Montana 75 25

Nebraska 75 16

Nevada 75 16

New Mexico 75 16

Program Hours—75 Hours

State Required Hours Clinical Hours

North Carolina 75 16

North Dakota 75 16

Ohio 75 16

Oklahoma 75 16

South Dakota 75 16

Tennessee 75 35

Texas 75 24

Wyoming 75 48

Testing Services

Pearson Vue—21 statesProMetric—10 statesDiversified—13 statesOther

Illinois Indiana Iowa Kansas Kentucky Maine Massachusetts Missouri Nebraska

Competency Evaluation: Written Test

Written test: required passing score Low—65% Mid—75% High—80% Pass/fail

Competency Evaluation: Written Test (cont.)

Test questions (some states do not specify a time) 55 with 2 hours for completion 60 with 2 hours for completion 70 with 90 minutes for completion 72 with 90 minutes for completion 75 with 90 minutes for completion 77 with 90 minutes for completion 79 with 90 minutes for completion 85 with 90 minutes for completion 100 with no time specified

Competency Evaluation: Skills Tested

Abdominal thrust Ambulation Ambulation with gait belt Ambulation with walker (or

cane) Antiembolic stockings Apply warm or cold compress Assist with bedpan Back rub Bedpan Bedpan and output Bedpan/fracture pan and

output Bed bath (face, arm, hand, and

underarm) Bed bath (partial) Bed bath (full) Blood pressure Brief application

Catheter care for indwelling urinary catheter

Catheter care for female Change of position Change of position with

backrub Convert ounces to mLs Denture care Dressing Dressing/undressing Dress a resident who has a

weak arm Dressing bedridden resident Feeding Feeding a dependent resident Fingernail care Fluid intake

Competency Evaluation: Skills Tested (cont.)

Foot care Gown and gloves Hair and nail care Handwashing Height and weight Making an occupied bed Making an unoccupied

bed/closed Measure and record

contents of urinary drainage bag

Measure and record weight Measure and record urinary

output Mechanical lift

Mouth care (brushing teeth) Mouth care to a resident

who has dentures Mouth care of comatose

resident Moving and positioning a

resident Nail care (one hand) Obstructed airway Oxygen Passing fresh water Passive range-of-motion

exercises to lower extremity (hip, knee, ankle)

Passive range-of-motion exercises to upper extremity (shoulder, elbow, wrist, and fingers)

Competency Evaluation: Skills Tested (cont.)

Perineal care (female) Perineal care (female who is

incontinent of urine) Perineal care (male) Perineal care for

uncircumcised male Position Foley

catheter/bag/tubingPosition for an enema

Position resident for meals Position resident on side Positioning and alignment

(Fowler’s, lateral, supine) Pressure ulcer prevention

Range-of-motion elbow Range-of-motion hip and knee Range-of-motion hip Range-of-motion shoulder Range-of-motion wrist Restraints Shaving Transfer Transfer from bed to

wheelchair using transfer belt and pivot transfer technique

Transferring from bed to wheelchair/one man pivot

Vital signs (TPR) Vital signs (T (oral/axillary)PR

Common Skills

BathingBedmaking

Occupied/UnoccupiedDressingHandwashing (may be pre- and post-procedure steps)Mouth care

Brushing teeth Comatose person Person with denture

Range-of-motionPositioningTransferVital signs—TPR

Skills Comparison—Handwashing

Pearson Vue 10 steps 15 seconds

ProMetric 7 to 9 steps 15 seconds; 10 seconds for Michigan

Diversified 12 steps No time specified for some states; 15 seconds for

others

Skills Comparison—Feeding

Pearson Vue 14 steps 1 key step

Client is in upright sitting position (45-90 degrees)

ProMetric 19 steps

Diversified 19 steps 2 key steps

Positioning upright at least a 45 degree angle. Candidate within 25% of solids; within 30 mL of fluids

consumed.

Skills Comparison—Perineal Care (Female)

Pearson Vue 18 steps 2 key steps

Washes from front to back with clean area of washcloth for each stroke

Rinses from front to back with clean area of a clean washcloth for each stroke

ProMetric (to incontinent female) 23 steps No key steps

Diversified 31 steps No key steps

Competency Evaluation Costs

Written and skills: $59 to $176.50Re-test written: $19 to $45.50Re-test skills: $55 to $119

Legal Titles for Nursing Assistants

CNA—certified nursing assistant; certified nurse aide

LNA— licensed nursing assistantRNA—registered nurse aideSTNA—state tested nurse aideNurse aideNursing assistantGeriatric nursing assistantNursing home nurse aide

STUDENTSINSTRUCTORSEMPLOYERS

GENERAL PUBLICCANDIDATES SEEKING ENDORSEMENT

Nursing Diagnoses

Nursing Diagnoses

Anxiety Comfort, Impaired Confusion, Acute Confusion, Chronic Confusion, Risk for Acute Coping, Defensive Coping, Ineffective Decisional Conflict Human Dignity, Risk for

Compromised Fatigue Fear Hopelessness Insomnia

Knowledge, Deficient Knowledge, Readiness for

Enhanced Powerlessness Powerlessness, Risk For Self-Esteem, Chronic Low Self-Esteem, Situational

Low Self-Esteem, Situational

Low, Risk for Sleep Deprivation Sleep Pattern, Disturbed Sleep, Readiness for

Enhanced Stress Overload

IS IT NECESSARY OR DESIRABLE TO HAVE UNIFORMITY IN NURSING ASSISTANT EDUCATION,

EVALUATION, AND ENDORSEMENT?

Planning

Planning

Minimum requirements-quickest way to uniformity is to seek the lowest common denominator—lowers all standards

Increasing requirements—how much? Differing ideas among states

Grandfathering—always needed—across state lines?

Other Minimum requirements—what about other settings—acute care, assisted living

Positive Aspects

Resolves endorsement issues, time, and costsIncreases interstate mobilityResolves range of function issuesLessens confusion Increases respect

Negative Aspects

CHANGE!Agreement on what/how to standardize will

take effort an planningIncrease costs to facilitiesMajor curricular revisionsMay require legislative action—lobbyists for

LTC may opposeAvailability of clinical sites for more hoursLabor market needsStates’ rights

One state’s response to varying standardsEndorsement in Arizona

Implementation and Evaluation

Arizona Variances

Title is CNARequire 120 hour programTesting by D and S TechnologiesRenewal on birthday month every 2 yearsRequire practice of 160 hours of nursing

assistant practice hours within the past 2 years to renew

Endorsement Process

Complete ApplicationSubmit fingerprint card—need our ownFeesDocumentation of legal presence in USVerification of current inclusion in the

registry Provide address/contact of all registries in US Provide form to send to the state registry to verify

status

Education Options

Board approved CNA programProof of a 120 hour CNA programProof of a 75-119 hour CNA program plus working as

a nursing assistant for an additional 45 hoursProof of graduation from RN/LPN program (foreign

or domestic) or Proof of completion of a part of a nursing program that

contained didactic content relating to LTC clients and 40 hours of LTC clinical

Proof of 100 hours military health care training

Practice Requirement Options

Currently working doing nursing assistant activities even if title is different

Has worked performing nursing assistant activities for 160 hours in past two years even if title is different

Or completed a NA program in the past 2 years

Challenges

Lapsed NA certificate/registry If has continuously worked performing NA tasks, we

will endorse (at least 160 hours every 2 years) If never worked needs to retake course

Challenges

Recently completed a 75 hour course in another jurisdiction and never worked Can enroll as an Advanced Placement Student in an

approved course Can accumulate work hours doing CNA duties in a

non-CNA position Can ask the original course to allow him/her to

complete additional long term care clinical to make up to 120 hours

Can ask the Board to make an exception

Uniformity

From a State Board of Nursing Perspective, uniformity is desired if: Education is appropriate to job duties and evidence-

based Endorsement/Renewal requirements ensure

competency Protection of the public is ensured Preserves state authority over discipline

Bibliography

An introduction to the national nursing assistant survey, U.S. Department of Health and Human Services, series 1, number 44, March 2007.

Bureau of Labor Statistics, U.S. Department of Labor, Occupational Outlook Handbook, 2010-2011.

Nursing Aides, Home Health Aides, and Related Health Care occupations—national and local workforce shortages and associated data needs, February 2004, National Center for Health Workforce Analyses, Bureau of health professions, Health resources and services administration.

Rosen J: Getting to the bottom of CNA turnover, McKnight’s Long Term Care News, December 01, 2008

PAMELA RANDOLPH

Arizona State Board of Nursing602-771-7800

prandolph@azbn.govSHEILA A. SORRENTINO

623-551-9477sheilasorrentino@aol.com

Contact Information