The Role of Nursing Assistive Personnel in the Rehabilitation Setting

It is recognized that nursing assistive personnel (NAP) make a significant contribution to the care and welfare of patients in a variety of clinical settings, including rehabilitation. It is the American Nurses Association’s (ANA) belief that "the utilization of NAPs in the provision of specific aspects of direct and indirect patient care, as the result of delegation and direction by a registered nurse (RN) in accordance with state nurse practice acts, is an appropriate, safe, and resource-efficient method of providing nursing care.” (ANA, 2007). The Center for American Nurses (2006) position statement, Registered Nurse Utilization of Nursing Assistive Personnel, recognizes that NAPs provide “support services which are required for the provision of quality patient care, as health care changes and the registered nurse shortages demand adaptations in the manner care is provided…”

The Association of Rehabilitation Nurses (ARN) further supports the ANA position, finding that utilization of NAPs (formerly known as unlicensed assistive personnel) is necessary for the registered rehabilitation nurse "to achieve the goal of assisting individuals in the restoration and maintenance of maximal physical, psychosocial, and spiritual health" (ARN, 1994, p.1).

Recommended Qualifications

• High school diploma or equivalent
• Nurse's aide training certificate or a minimum of 4 weeks of documented on-the-job training
• Completion of a basic cardiopulmonary resuscitation course
• Demonstrated initial and ongoing task competencies based on training, skills, and abilities

Scope of Care

According to the International Council of Nurses’ (ICN) position statement, Assistive or Support Nursing Personnel, “the delegation of nursing care and the supervision of assistive nursing personnel is the responsibility of nurses” and “the role, preparation, standards, and practice of assistive nursing personnel must be defined, monitored, and directed by registered nurses” (ICN, 2000, p. 1). This responsibility is based on the nursing scope and standard of practice prescribed by the individual state nurse practice acts and regulations.

In settings or states where the job responsibilities for NAPs are subject to state regulation, the tasks delegated by the RN shall not exceed any restrictions set forth by the state. The delegation of tasks should be assigned based on The Five Rights of Delegation – right task, right circumstances, right person, right directions and communication, and the right supervision and evaluation (National Council of State Boards of Nursing, 1997).

All care provided by NAPs should be delegated and supervised by an RN and based on a patient's written plan of care and the NAPs demonstrated level of competency. The tasks that may be delegated to the NAP can be divided into two categories―a basic and a secondary skill set. The basic skills consist of those tasks that support a patient's activities of daily living, hygiene, and nutrition as well as those tasks that support professional nursing assessments. The secondary skills consist of those tasks that require additional training and demonstration of competence prior to being performed by the NAP and are dependent upon each individual state’s practice acts.

Basic Skill Set

• Obtaining and documenting vital signs, including temperature, pulse, respirations, and blood pressure and pain level (and notifying the professional nurse when these values are outside of established parameters)
• Bathing, grooming, toileting, dressing and undressing
• Feeding and assisting with fluid and nutritional intake, including following dietary and fluid guidelines and aspiration precautions
• Mobility assistance including ambulation, transfers, positioning, range of motion, and positioning precautions. Lifts, moves and transports clients, using proper body mechanics or lifting devices.
• Performs all job responsibilities in accordance with prescribed safety and infection control procedures including thorough hand washing, use of disposable gloves where indicated, and proper disposal of soiled materials
• Observing urine color and smell  and documenting input and output
• Observes and documents bowel movements
• Applying external catheters and maintaining and cleaning urinary drainage bags
• Provides orientation as indicated
• Displaying behavioral management skills, including positive reinforcement and adherence to behavior management program structure
• Applying prescribed orthotics, prosthetics, and other mobility devices and observing for skin breakdown
• Notifying  professions of any changes in clinical or functional status as appropriate
• Observing patient behaviors and reporting observations to the registered nurse
• Assisting in socialization activities and reporting the level of patient participation to the registered nurse
• Performing other assigned duties or tasks within the state’s legal parameters
• Provides care that maintains skin integrity to prevent pressure ulcers, skin tears and other damage by changing incontinent clients, turning, repositioning immobile clients, and applying moisturizers to fragile skin, etc. Observes for skin integrity for irritation, bruising, and redness and reporting observations to registered nurse
• Assists in maintaining a safe, neat and clean environment; reports environmental deficiencies to the registered nurse, such as lighting or equipment problems
• Supports and implements specific procedures and programs for safety, including universal precautions and safe work practices, established fire/safety/disaster plans, risk management, and security; reports issues as necessary
• Assists in patient fall prevention as necessary, such as frequent rounds, scheduled toileting, use of wheelchair or bed alarms.
• Performs post mortem care
• Apply oxygen as per direction from RN, including connect/disconnect tubing
• Communicate both verbally and in writing, pertinent observations and information in order to maintain a complete record of care for the patient.
• Identify and report any unusual signs and symptoms either observed, heard or reported by patient to the nurse in a timely manner
• Collect and label any patient specimens in the presence of the patient in accordance with established procedure
• Collect and test blood specimens for glucose level using a blood glucose monitor and report results to RN immediately

Refer to your state’s individual practice act for current information.

Setting

Care can be provided by NAPs under the supervision of an RN in institutional, residential, outpatient, and community settings. These settings include, but are not limited to, acute care facilities, rehabilitation facilities, skilled nursing facilities, or nursing homes, residential facilities, day care agencies, or private residences.

References

American Nurses Association. (1992, November). Position Statement on Registered Nurse Utilization of

 Unlicensed Assistive Personnel. Washington, DC: Author.

American Nurses Association. (2007). Position Statement on Utilization of Nursing Assistive Personnel in

 All Settings. Washington, DC: Author.

Association of Rehabilitation Nurses. (1994, May). Registered Nurse Utilization of Unlicensed Assistive

 Personnel. Skokie, IL: Author.

Center for American Nurses. (2006). Registered Nurse Utilization of Nursing Assistive Personnel:

 Statement for Adoption.  Retrieved from http://www.centerforamericannurses.org/positions/.

International Council of Nurses. (2000). Assistive or Support Nursing Personnel. Retrieved from http://www.icn.ch/psassistive.htm.

National Council of State Boards of Nursing, Inc. (1997). The Five Rights of Delegation. Retrieved from http://ncsbn.org/fiverights.pdf.

Approved by the ARN Board of Directors July 1995; Revised October 2003; Revised October 2007; Revised March 2014; Reviewed April 2017.