Unlicensed Assistive Personnel In Healthcare

Healthcare Systems and Unlicensed Assistive Personnel

Who are Unlicensed Assistive Personnel,Research Publication  About Unlicensed Persons,Unlicensed Personnel in Acute Care,Institutional Redesigning of Job Design and Responsibilities,Reduction In RN and Induction of UAP,Task Delegation and Supervision of UAP,Main Concerns of RN as Compare to UAP,Nursing Research.

Who are Unlicensed Assistive Personnel

    Unlicensed assistive personnel (UAP) are an “unlicensed individual who is trained to function in an assistive role to the licensed nurse” (American Nurses Association, 1992). UAPS provide direct and indirect patient care that has been delegated and is supervised by a registered nurse. 

    Known by a variety of names and practicing in distinctly different sites Patient Care Assistant (PCA), Nurse Extender (NE), or nurse partner in acute care; Certified Nurse Assistant (CNA) in nursing homes; Resident Assistant (RA) in assisted living residences; Personal Care Attendant (PCA) or Home Care Aide (HCA) in home care; aid, orderly, etc. Job qualifications, training, and nursing activities vary widely. 

    The purpose of this entry is to describe recent studies about UAPS conducted by nurse researchers.

Research Publication  About Unlincensed Persons 

    There is a dearth of published information about the content, duration, and effectiveness of UAP training in acute and home care (including assisted living). In the nursing home (NH) sector, mandatory education and training curricula are set by the federal government and can be no less than 75 hours. 

    Topics include personal care of the elderly person (ie, activities of daily living [ADLs]), communication and culture, age related changes, resident rights, and death and dying. RA Burns (1995) reported that this curriculum was sufficient for standard care, but additional hours were needed for CNA-delivered care in subacute special care units. 

    In assisted living (AL) and home care, each state regulates training and curricula. In acute care, it is institution directed and ranges from 1.5 to 6 weeks, including on unit orientation (Barczak & Spunt, 1999). 

    There is considerable variation in level of education required; only some hospitals require that UAPs have a high school diploma (Bernreuter & Cardona, 1997). A medication administration training program for aides in Maryland AL facilities attributed to the successful completion rate and scores on the final examination to high school education (Spellbring & Ryan, 2003). 

    A study of the relationship between literacy skills and job performance found that NH aide literacy was between 5th and 6th grade level (Benjamin, 1995). It is unknown whether or how this might affect reading and comprehension of a written nursing plan of care in any setting.

Unlicensed Personnel in Acute Care

    In their review of studies of UAP implementation in acute care, Bernreuter and Cardona (1997) noted that nurse managers and staff nurses feel that UAPs lack ADL and supportive skills, but had been adequately trained in technical skills. 

    Yet, some nurses feel that training is inadequate, inconsistent, relies too heavily on unit training, and fails to teach UAPs how to recognize patient problems.

    In most NHs, CNAs constitute 70% of the nursing staff. This has been standard practice for decades although some states regulate the CNA-to-resident ratio. Primary nursing was never a delivery model. 

    The workload for NH CNAs has increased due to staffing cutbacks associated with reimbursement, the nursing shortage, and higher acuity residents. 

    However, quality of care is compromised and turn over increases when CNAs lack time to deliver care, are unsure how to prioritize, and “cut corners” (Bowers & Becker, 1992; Foner, 1994). 

    Nurses and CNAS disagree about the likelihood of implementing individualized care plans (a goal of care), but both groups agree that barriers include inadequate staffing and poor communication (Walker, T., Porter, Gruman, & Michalski, 1999). 

    Hartig (1998) reported that CNAs' and RNs' assessments of residents' functional status were highly correlated but also found that institutionally ascribed “expert” CNAs were performing nursing tasks that exceeded their training and education.

Institutional Redesigning of Job Design and Responsibilities 

    Hospital restructuring, job redesign, and adding UAPS to the skill mix in acute care are attributed to cost containment, managed care, and more recently the shortage of licensed professional nurses. 

    Proponents argue that UAPS free nurses to meet “higher-level” patient care needs. As such, UAPs are assuming more of the bedside, task-based care. In some settings, UAPs draw blood, take and interpret EKGs, suction and administer respiratory treatments, and perform catheterization. 

    More commonly in acute care than in nursing homes, and most probably in home care, UAPs take blood pressures, perform catheterization, nasopharyngeal and tracheostomy suctioning and trach care, phlebotomy, and enteral tube feeding (Barzak & Spunt, 1999).

Reduction In RN and Induction of UAP

    An American Nurses Association (ANA) statement to the IOM (Institute of Medicine, 1996) held that reducing RNs and adding UAPS increased costs in many cases related to training UAPs and training RNs for delegation and supervisory roles. 

    The anticipated cost-savings by using UAPS in the delivery of nursing care is equivocal; some studies report reduced costs, others report increased costs, and others are budget neutral (Huston, 1997; McClung, 2000). 

    Most studies fail to incorporate or calculate UAP turnover and training costs, off-unit time for RNs to learn delegation and management skills, and cost reductions (or increases) among ancillary services if UAPs assume, for example, responsibilities for blood specimen collection or food tray distribution (Bernreuter & Cardona, 1997; Zimmerman, 2000). 

    The absence of an accepted methodology to calculate productivity and the failure to recognize variables that could have an impact on costs, productivity, and quality weaken the validity of findings of virtually all studies of cost-effectiveness of UAPs in acute care.

    Not surprisingly, UAPS want to be treated with respect, thanked for doing a good job or going the extra mile, and not be thought of as interested only in their paycheck (Burke, Summers, & Thompson, 2001). 

    Responding to an investigator designed survey (validity and reliability not reported), CNAs felt that poor team communication and negative staff attitudes were barriers to improved care (Curry, Porter, Michalski, & Gruman, 2000). 

    They also felt that they were not respected by other team members and that their suggestions about individualized care were not valued or given a try. These findings were similar to those reported in a study to implement a prompted voiding program in a nursing home in which CNAs were directly responsible (Lekan-Rutledge, Palmer, & Belyea, 1998). 

    Nursing home CNAs feel that communication within the health care team and decisions about care should include the CNAs who, after all, spend more time with the resident than the licensed nurses (Harrington, Carillo, & Wellin, 2001).

Task Delegation and Supervision of UAP 

    Nurses feel they are not prepared to delegate or supervise and are concerned about their legal liability and loss of protection under the collective bargaining provisions of the National Labor Relations Act once they are designated as a supervisor (Huston, 2001). 

    Most, but not all, boards of nursing of the 50 states have guidelines for UAP supervision by RNs, but few boards use the ANA or National Council of State Board's (NCSBN) definitions of delegation or assignment (Thomas, 5. A., Barter , & McLaughlin, 2000). 

    Most state boards created their own definitions and parameters for delegation and had no plans to standardize UAP training curriculum.

Main Concerns of RN as Compare to UAP

    The single largest concern of RNs in institutional settings is the relationship between staff mix and quality of care; this is echoed by consumers as well (Zimmerman, 2000). 

    Notwithstanding that UAPS are responsible for accurate observation, reporting, and documentation of patient status, and are accountable for the nursing tasks delegated to them, several studies found that as the number of RNs in hospital staffing decreased and were replaced by UAPS, adverse clinical outcomes increased (Blegen, Goode, & Reede, 1998; Eastwood & Schechtman, 1999; Houston, 2001; IOM, 1996; Kovner & Gergen, 1998; Zimmerman, 2000). 

    Among the negative outcomes were medication errors, inappropriate use of physical restraints, pressure ulcers, increased mortality rates, patient falls, and postsurgical complications (eg, pneumonia, UTI). 

    Huston suggested that her finding of less effective pain relief for hospitalized patients with diagnostic related grouping (DRG) 209 (joint and limb reattachment) who were receiving nurse administered analgesia might be attributed to changes in the staffing mix. 

    On the other hand, MJ Ventura (1999) reported that hospital RNs felt that UAPS contributed to quality of care.

Nursing Research 

    Sophisticated research designs are needed to look at the complex relationships and factors with a multilevel nursing staff, the most prominent being delegation, achievement needs, communication and interpersonal relations, competency and performance evaluation, and cost effectiveness. 

    Virtually nothing is known about the number of UAPS who choose to study professional nursing (RN and LPN) and the barriers and facilitators to that movement. Studies of delegation must account for the variables embedded in resources and systems that can affect outcomes.