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Value of the Nursing Assistant in Palliative Care

Journal of Hospice & Palliative Nursing: June 2019 - Volume 21 - Issue 3 - p E13–E14
doi: 10.1097/NJH.0000000000000571
DEPARTMENTS: HPNA Position Statement
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It is the position of the Hospice and Palliative Nurses Association (HPNA) that

  • Nursing and health care organizations recognize that care provided by nursing assistants is critical to achieving established goals of care for patients with serious illnesses and their families.
  • Registered nurses recognize that nursing assistants are a vital and important member of the palliative care team. Nursing assistants deliver care that assists the registered nurse in accomplishing the patient’s and family’s goals and plan of care.
  • Health care institutions and organizations must ensure that nursing assistants in all settings receive adequate educational preparation and continuing education to care for patients with serious illnesses and their families.
  • Nurses and administrators in all palliative care settings must advocate for and ensure the inclusion and recognition of nursing assistants as key members of the interdisciplinary team who are valued and deserving of competitive wages.
  • Specialty certification of the hospice and palliative nursing assistant is a means for recognition and advancement of this essential component of the palliative interdisciplinary team.
  • Individuals developing policies, procedures, and protocols must ensure the role of the hospice and palliative nursing assistant is consistent with individual state nurse practice acts, the Statement on the Scope and Standards for Hospice and Palliative Nursing Assistant Practice, and Hospice and Palliative Nursing Assistant Competencies.
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Nursing assistants are essential members of the palliative health care team who play a central role in providing care to patients and families coping with serious illnesses. Other interdisciplinary team members rely on hospice and palliative nursing assistants for their observations and reports in developing and implementing a plan of care for patients and their families.

The nursing assistant assumes primary responsibility for providing personal care and assisting patients with activities of daily living. Nursing assistants practice across all palliative care settings, including long-term care, acute care, home care, and so on. In some of these settings, nursing assistants provide up to 90% of hands-on patient care.1

Because of their intense, consistent, and frequent interactions with patients and families, nursing assistants may be the first providers to observe the physical, psychosocial, and spiritual symptoms common in patients experiencing serious illnesses. Nursing assistants witness and experience the profound grief that accompanies the dying process and the loss of loved ones.

Hospice and palliative nursing assistants are integral to the interdisciplinary team, providing comprehensive physical, psychological, social, and spiritual care within their knowledge and skills,2 in addition to all functions permissible by state law. Because they work so closely with patients, the attitudes of nursing assistants toward certain therapies, such as administration of opioids and medically administered nutrition and hydration, are communicated either directly or indirectly to patients and families; therefore, nursing assistants must be educated about reasons for implementing, changing, stopping, or removing therapies. They must also be encouraged to reflect on and understand how their beliefs and values may impact patients and families. Nursing assistants must be informed about the decision-making processes for patients in their care so they can support and reinforce the patient’s plan of care.

Nursing assistants can contribute substantially to both treatment planning and implementation of the care plan. However, their expertise in observing and reporting relevant patient and family information and providing hands-on personal care is not consistently recognized across settings. To be actively involved in planning and providing quality palliative care, nursing assistants need to possess a thorough knowledge of palliative care concepts and practices. In addition, their experience and insights must be recognized and validated by the interdisciplinary team.3 Nursing assistants who are educated and involved in the team care-planning process experience greater job satisfaction, which could decrease job turnover that threatens the quality and consistency of end-of-life care.4

Many nursing assistants are deeply committed to their work in palliative care and strive to maintain a very high standard of care. However, nursing assistants frequently receive low wages and have burdensome workloads.5 Lack of appreciation and respect also contributes to job dissatisfaction and turnover, causing nursing assistants to feel personally and professionally dismissed.3,6-8 These factors negatively influence the quality of palliative care as well as patient and family satisfaction.1 Opportunities for advancement and professional growth have been suggested as remedies to this dilemma in health care.9

In recognition and support of their important role in providing palliative care, the Hospice and Palliative Credentialing Center provides hospice and palliative nursing assistants the opportunity to achieve certification. Such certification verifies the mastery of the key knowledge and skills required for performance as a palliative nursing assistant. In addition to being the sole certification body offering specialty certification for nursing assistants, Hospice and Palliative Credentialing Center also presents a Certified Hospice and Palliative Nursing Assistant of the Year Award.10

Along with the rest of the interdisciplinary team, HPNA includes nursing assistants as valued members. As a professional nursing organization, HPNA is unique in its inclusion of nursing assistants in its membership, its recognition of the specialized skills and clinical contributions of hospice and palliative nursing assistants, and its offering of continuing education for nursing assistants.

The Hospice and Palliative Nurses Foundation offers certification scholarships, HPNA-sponsored conference scholarships, and educational scholarships for nursing assistants.11

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Nursing: “The protection, promotion, and optimization of health and abilities; prevention of illness and injury; facilitation of healing; alleviation of suffering through the diagnosis and treatment of human response; and advocacy in the care of individuals, families, communities, and populations.”12

Nursing assistant: Members of the interdisciplinary team that assist patients with daily tasks and provide bedside care—including basic nursing procedures—all under the supervision of a registered nurse or licensed practical/vocational nurse according to regulatory boards as applicable.13

Palliative care: “Patient and family-centered care that optimizes quality of life by anticipating, preventing, and treating suffering. Palliative care throughout the continuum of illness involves addressing physical, intellectual, emotional, social, and spiritual needs to facilitate patient autonomy, access to information, and choice.14(pp9)

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1. Aubry F, Etheridge F, Couturier Y. Facilitating change among nursing assistants in long term care. Online J Issues Nurs. 2012;18(1).
2. Martinez JM, Chichin ER, Lentz J, et al. Statement on the Scope and Standards of Hospice and Palliative Nursing Assistant Practice. 2nd ed. Pittsburgh, PA: Hospice and Palliative Nurses Association; 2010.
3. Bishop CE, Squillace MR, Meagher J, Anderson WL, Wiener JM. Nursing home work practices and nursing assistants’ job satisfaction. Gerontologist. 2009;49(5):611–622.
4. Sutermaster DJ, ed. Introduction. In: Core Curriculum for the Hospice and Palliative Nursing Assistant. 3rd ed. Pittsburgh, PA: Hospice and Palliative Nurses Association; 2015:vii–viii.
5. Head BA, Washington KT, Myers J. Job satisfaction, intent to stay, and recommended job improvements: the palliative nursing assistant speaks. J Palliat Med. 2013;16(11):1356–1361.
6. Bishop CE, Weinberg DB, Leutz W, Dossa A, Pfefferle SG, Zincavage RM. Nursing assistants’ job commitment: effect of nursing home organizational factors and impact on resident well-being. Gerontologist. 2008;48(spec no 1):36–45.
7. Wiener JM, Squillace MR, Anderson WL, Khatutsky G. Why do they stay? Job tenure among certified nursing assistants in nursing homes. Gerontologist. 2009;49(2):198–210.
8. Wholihan D, Anderson R. Empowering nursing assistants to improve end-of-life care. J Hosp Palliat Nurs. 2013;15(1):24–32.
9. Castle NG, Engberg J, Anderson R, Men A. Job satisfaction of nurse aides in nursing homes: intent to leave and turnover. Gerontologist. 2007;47(2):193–204.
10. Certified Hospice and Palliative Nursing Assistant. Advancing Expert Care website. Accessed June 26, 2015.
11. Awards & Recognition. Advancing Expert Care website. Accessed June 26, 2015.
12. What is nursing? American Nurses Association website. Accessed March 15, 2018.
13. Nurse Aide/Assistant. Explore Health Careers website. Accessed March 20, 2018.
14. National Consensus Project for Quality Palliative Care. Clinical Practice Guidelines for Quality Palliative Care. 3rd ed. Pittsburgh, PA: National Consensus Project; 2013.
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MAY 2018

This position statement reflects the bioethics standards or best available clinical evidence at the time of writing or revisions. This position statement is based on evidence that reflects patients with advanced illnesses and may not be applicable in all palliative circumstances.

Copyright © 2005, 2009, 2012, 2013, 2018 by the Hospice and Palliative Nurses Association

© 2019 by The Hospice and Palliative Nurses Association.