Section 2.3: The Interdisciplinary Healthcare Team & Scope of Practice

Section 2.3: The Interdisciplinary Healthcare Team & Scope of Practice

The Interdisciplinary Healthcare Team

Providing quality care in long-term care facilities requires the cooperation of diverse professionals, collectively known as the interdisciplinary healthcare team. Each member brings specialized expertise to address the physical, emotional, social, and spiritual needs of the resident. The team meets regularly to develop, review, and update the resident care plan, which is a comprehensive guide tailored to each individual resident's goals and needs.

Key Roles within the Interdisciplinary Team:

• Physician or Advanced Practice Provider (Nurse Practitioner/Physician Assistant): Diagnoses medical conditions, prescribes medications, orders treatments, and directs the overall medical care plan.
• Registered Nurse (RN): Assesses the resident's physical and mental status, coordinates the interdisciplinary team, administers specialized treatments, develops care plans, and supervises Licensed Practical Nurses (LPNs) and CNAs.
• Licensed Practical Nurse (LPN): Administers medications, performs dressing changes, monitors vital signs, reports changes to the RN, and provides direct resident care under RN supervision.
• Certified Nursing Assistant (CNA) / Direct Care Worker (DCW): Provides hands-on personal care (Activities of Daily Living) and basic nursing procedures. CNAs are the "eyes and ears" of the team because they spend the most direct time with residents, making them the first to observe subtle changes in condition.
• Physical Therapist (PT): Focuses on restoring or improving mobility, strength, balance, and gross motor skills, particularly after an illness, stroke, or surgery.
• Occupational Therapist (OT): Helps residents regain independence in performing daily living skills (e.g., dressing, grooming, eating) using adaptive equipment if necessary.
• Speech-Language Pathologist (SLP): Identifies, evaluates, and treats residents with speech, language, communication, or swallowing disorders (dysphagia).
• Medical Social Worker (MSW): Assists with admission and discharge planning, coordinates financial resources, and provides counseling and support to residents and their families.

Role and Responsibility Comparison

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CNA Scope of Practice and Prohibited Tasks

A professional's scope of practice refers to the tasks and procedures they are legally permitted to perform under their state certification. For CNAs, this scope is defined by state regulations and facility policies. Performing tasks outside your scope of practice is illegal, constitutes a safety hazard, and can lead to immediate termination, registry revocation, and potential criminal charges.

Tasks Inside the CNA Scope of Practice:

• Assisting with Activities of Daily Living (ADLs) such as bathing, dressing, eating, grooming, toileting, and perineal care.
• Measuring and recording vital signs (temperature, pulse, respiration, blood pressure) and pain levels.
• Measuring and documenting fluid intake and output (I&O) and food consumption.
• Assisting with positioning, turning, transferring, and ambulating residents.
• Applying clean, dry dressings to intact skin (e.g., a simple adhesive bandage over a minor scrape, if permitted by facility policy).
• Promoting resident safety by keeping pathways clear, applying call lights, and adhering to infection control guidelines.

Tasks Strictly Prohibited for CNAs:

• Medication Administration: CNAs must never administer medications of any kind. This includes swallowing oral medications, applying prescription creams, putting in eye drops, or crushing pills. (Note: Only certified medication aides, CMAs, who have completed additional training and certification in Iowa, may administer medications under nurse supervision).
• Sterile Procedures: CNAs must never perform sterile techniques, such as inserting or removing urinary catheters, or changing sterile surgical dressings.
• Tube Feedings: CNAs must never administer formula or flush nasogastric (NG) tubes or gastrostomy (G) tubes.
• Taking Physician Orders: CNAs must never accept verbal, telephone, or written orders directly from a physician or provider. If a physician attempts to give you an order, politely direct them to the nurse.
• Assessment and Diagnosis: CNAs cannot perform nursing assessments or diagnose a resident's medical condition. A CNA can report a symptom (e.g., "Mrs. Jones' right heel is red and warm"), but cannot diagnose it (e.g., "Mrs. Jones has a stage 1 pressure injury").

The Direct Directive Rule:

Even if a licensed nurse instructs you to perform a task outside your scope of practice (e.g., "Can you apply this medicated cream to Mr. Green's hip?"), you must refuse. The nurse's instruction does not shield you from legal liability if you perform a prohibited task.

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The Delegation Process & The Five Rights

Delegation is the transfer of responsibility for the performance of a specific nursing activity from a licensed nurse to a nursing assistant. While the CNA performs the task, the nurse retains ultimate accountability for the outcomes.

To delegate safely, nurses and CNAs must adhere to the Five Rights of Delegation:

1. Right Task: The task must be one that is safe to delegate and permitted by facility policy and the CNA scope of practice.
2. Right Circumstance: The resident's condition must be stable. If a resident's status is changing or unpredictable, the nurse must perform the task.
3. Right Person: The nurse must ensure that the specific CNA has the training, competency, and confidence to perform the task safely.
4. Right Direction/Communication: The nurse must provide clear, concise, and specific instructions, including what data to collect, when to perform the task, and what abnormal findings to report immediately.
5. Right Supervision/Evaluation: The nurse must monitor the CNA, assist if necessary, and evaluate the resident's response to the delegated care.

When to Refuse a Task:

You have a professional duty to refuse a delegated task if:

• It is outside your scope of practice.
• You have not been trained or evaluated on how to perform the task.
• You do not have the proper equipment to perform the task safely.
• The resident's condition is unstable or the instructions are unclear.
• The task violates facility policy.

How to Refuse: Politely explain to the nurse why you are refusing (e.g., "I cannot apply that prescription cream because it is outside my scope of practice as a CNA"). Never simply ignore the request.

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Iowa Direct Care Worker Registry Maintenance

In Iowa, the Direct Care Worker (DCW) Registry, managed by the Iowa Department of Inspections, Appeals, and Licensing (DIAL), maintains the official records of all individuals certified to work as nursing assistants in the state.

To work as a CNA in any Iowa licensed nursing facility (under Iowa Administrative Code 441 Chapter 81), your status on the registry must be "Active."

Registry Retention Rules:

• The 24-Month Rule: To maintain active status, a CNA must perform at least 8 hours of direct care services for financial compensation under the supervision of a licensed nurse (RN or LPN) within a rolling 24-month period.
• Volunteer Work Exclusion: Volunteer or unpaid work does not qualify to keep your certification active. You must be paid for the services rendered.
• Lapse in Active Status: If a CNA does not meet the 8-hour requirement, their registry status lapses to "Inactive." To regain active status, the individual must retake and pass both the state written and skills competency exams.
• Background Checks and Sanctions: Iowa law requires facilities to check the DCW registry and the abuse registries before hiring. Any substantiated finding of resident abuse, neglect, or misappropriation of resident property on the registry results in a permanent lifetime ban from working in licensed long-term care facilities in Iowa.