Creating New Jobs and Delegating Responsibilities

As discussed in previous chapters, efficient use of the workforce will require more delegation of job duties in the coming years. This delegation has a cascading effect, with specific tasks being handed off to people in various professions and occupations, depending on the situation, which allows each worker to be used at his or her highest level of skill. The combination of the need to delegate additional duties and the desire of some direct-care workers to assume more responsibilities creates opportunities to restructure workforce assignments in ways that are potentially more satisfying for direct-care workers.

In some new models, direct-care worker roles may become much broader. For example, the Green House model described in Chapter 3 gives a more expansive role to direct-care workers. Under that model, frontline caregivers take responsibility for a broader range of tasks that include personal care, cooking, housekeeping, and making sure that residents spend time according to their preferences.

In other cases, direct-care workers take on specific tasks that require a higher level of skill than is usually expected of them. One example of this is the delegation of medication administration duties from RNs, as discussed in Chapter 4. Although there have been some concerns raised regarding patient safety, some RNs who have assessed the delegation of these responsibilities to CNAs have argued that CNAs may be able to deliver medications with greater accuracy because they face fewer distractions than RNs (Reinhard et al., 2003). If so, giving this responsibility to CNAs has the potential to increase efficiency, benefit patients, and facilitate the recruitment and retention of direct-care workers. Similarly, having home health aides assume responsibility for medication administration from RNs could help decrease the need for RN visits to homes.

If direct-care workers are to assume these increased responsibilities, they may in turn need to delegate certain of their own tasks. One example of this is the use of feeding assistants in the long-term care setting. Nurse aide training includes instruction in how to assist older adults with eating and hydration, and this is one of the primary responsibilities of CNAs. In 2003, however, CMS issued regulations allowing states to permit long-term care facilities participating in Medicare or Medicaid to use paid feeding assistants to supplement CNA services under certain conditions. Requirements for feeding assistants include the successful completion of a minimum of 8 hours of training in a state-approved course. The use of the feeding assistant has been controversial, but a preliminary analysis found that the quality of feeding done by feeding assistants was comparable to the quality of feeding by CNAs and, furthermore, that facilities did not decrease CNA hours in response (Kasprak, 2007; Simmons et al., 2007).

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