Course

First of all, opening steps are known by a number of differing names such as pre-steps, opening procedures and beginning steps. The opening steps are the specific sequence of actions a nursing assistant takes prior to starting a direct care procedural skill. The closing steps, which are also called post-steps, closing procedures and ending steps, are the actions a nursing assistant takes to end the skill. 

The opening and closing steps are regarded as indirect care skills. While direct care focuses on the correct performance of patient care procedures, the indirect care skills revolve around maintaining the safety, cleanliness and comfort of the patient care environment. Indirect care skills are defined as a series of steps to promote "patients’ safety and protection, infection control, communication, and the ability to meet needs and comfort" (Stone Academy, 2020). After all, it does not matter that the nursing assistant correctly gave a bed bath if she left the patient's door wide open and used contaminated supplies throughout the process. 

Both the opening and the closing steps place a heavy emphasis on hand hygiene since the dirty hands of a nursing assistant might potentially contaminate the patient's clean supplies, resulting in a preventable healthcare-acquired infection. Also called nosocomial infections, healthcare-acquired infections are ones that patients contract while being treated. Healthcare-acquired infections occur in all care settings, "including hospitals, surgical centers, ambulatory clinics, and long-term care facilities such as nursing homes and rehabilitation facilities" (PatientCareLink, 2020). 

Infections can lead to poor outcomes such as disease, amputation and death in susceptible patients, so nursing assistants must adhere to infection prevention practices on a routine basis. When performing opening steps, one of the indirect care skills is to wash the hands prior to gathering clean supplies. Moreover, when performing the closing steps, the nursing assistant is required to perform hand hygiene. This is because proper hand hygiene is the single most effective action a nursing assistant can take to stop the spread of infectious microbes. 

Thus, the opening and closing steps are important because they incorporate all of the aspects that improve patients' outcomes and experiences such as infection prevention, communication, ethical principles, safety and comfort. In addition, nursing assistants must display proficiency in performing the opening and closing steps in order to obtain a passing result on the skills evaluation section of most CNA certifying examinations in many states.   

• Knock
• Introduce Oneself
• Identify the Patient
• Describe the Skill
• Obtain Consent
• Provide Privacy
• Wash Hands
• Gather Clean Supplies

Always keep in mind that the opening steps require solid communication skills on the part of the nursing assistant. A typical opening statement will sound very similar to this: "Knock, knock. Good morning, Mrs. Thompson! My name is Rebecca and I will be your nursing assistant today. I am going to transfer you from the bed into your wheelchair. Is that okay? Alright! I am going to provide you with some privacy, wash my hands, gather the supplies and get started in just a moment."

• Knock: this measure is related directly to the concept of privacy. Patients have the right to privacy (Hartman Publishing, 2014). Before starting any procedural skill, the first thing the nursing assistant must do is knock and await permission to enter the patient’s room. 
• Introduce Oneself: this step is related to the concept of comfort. Patients have the right to know the names of all people who provide their care (Hartman Publishing, 2014). Therefore, the nursing assistant must introduce herself. Additionally, a friendly introduction establishes pleasant rapport, leading the patient to feel more comfortable with his or her caregiver. 
• Identify the Patient: this step is related to the concept of safety. The nursing assistant must ensure he performs the right skill on the right patient. Identifying the patient prior to starting all direct care skills ensures procedure are performed on the correct individuals for whom the acticivites were prescribed. 
• Describe the Skill: this step pertains to the concept of comfort. The more the patient knows about what the nursing assistant plans to do, the more comfortable and reassured he or she will feel. In addition, patients have a right to know what care you intend to provide (Hartman Publishing, 2014). 
• Obtain Consent: this revolves around the concept of comfort. Patients have the right to refuse care. They also have the right to instruct the nursing assistant to perform the care at a later time in the day or evening. A nursing assistant can obtain consent by simply asking the patient, "Is it okay if I do this?" 
• Provide Privacy: of course, this step is related to the concept of privacy. The nursing assistant must uphold the patient's privacy while performing procedural skills. Privacy can be provided by closing the patient's door in a private room. It is also acceptable to provide privacy by closing a privacy screen or pulling a privacy curtain in a semiprivate room if the patient has a roommate. 
• Wash Hands: this is directly related to the concept of infection control. Disease-causing microbes are easily spread to patients through providing care with unclean hands. Therefore, the nursing assistant must perform hand hygiene prior to touching supplies and performing patient care procedures. 
• Gather Clean Supplies: this pertains to infection control. It is assumed that the nursing assistant has washed her hands immediately prior to this step. Now that the nursing assistant's hands are clean, she can gather the supplies without cross-contaminating them.

The closing steps, also known as post-steps, closing procedures and ending steps, are the deliberate actions a nursing assistant takes in order to end the skill. Even though a meticulous knowledge of the closing steps is imperative to pass the hands-on skills evaluation section of nursing assistant certification examinations in most states, these measures also have a multitude of use in real-world patient care settings.

The closing steps should be the very last steps the nursing assistant takes after completing any patient care skill (Tanner, 2020). Prior to ending a procedural skill at the state certification exam to become a certified nurse aide, the test taker must take eight specific actions as part of the closing. These steps include asking about comfort, ensuring a clean environment, confirming the bed is in a low position, placing the call light within easy reach, removing privacy measures, washing one's hands, documenting, and announcing that the skill is complete.

The closing steps also pertain to the four interrelated concepts of safety, privacy, comfort and infection control. To imbed these integral concepts into memory, continue to use the acronym P.I.C.S., which stands for Privacy + Infection Control + Comfort + Safety. The individual measures that make up the closing steps are listed below.

• Ask About Comfort
• Ensure a Clean Environment
• Confirm the Bed is in a Low Position
• Place the Call Light Within Easy Reach
• Remove Privacy Measures
• Wash Hands
• Document the Skill
• Announce, "Skill Complete."

Be mindful that successful execution of the closing steps requires reasonably good communication skills. A customary closing statement in a patient care setting should sound very similar to this: "Is there anything else you need before I leave your room, Mrs. Thompson? Your bed is in a low position, your call light is within reach, and I am going to remove privacy measures at this time. I will now wash my hands and document. The skill is complete."

Keep in mind that not all procedural skills will require documentation when taking the skills evaluation portion of the state certification examination to become a certified nursing assistant. In fact, only five skills require documentation. These five skills are weight, blood pressure, radial pulse, respiration rate and measurement of urinary output.

There are a number of clear-cut rationales for performing the closing steps. To recap, the closing steps revolve closely around the four patient care concepts of safety, privacy, comfort and infection control. Continue to utilize the acronym P.I.C.S., which stands for Privacy + Infection Control + Comfort + Safety. The individual measures that make up the closing steps are listed below.

• Ask About Comfort: this step pertains to the concept of comfort. A major part of the nursing assistant's job is maintaining the patient's comfort. This can be achieved by fulfilling requests for the television remote, reading material, room temperature adjustments, snacks, additional blankets, and so forth.
• Ensure a Clean Environment: this is related to the two concepts of safety and infection control. The nursing assistant ensures a clean environment by keeping clutter to a minimum so the patient does not trip and fall over shoes or electrical cords. A clutter-free environment maximizes safety by reducing the chance for falls. Cleanliness also means wiping filthy side rails and nightstands to minimize the amount of disease-causing germs on surfaces, thereby promoting infection control.
• Confirm the Bed is in a Low Position: this step maintains safety. If the patient happens to roll out of bed, injuries are minimized or nonexistent if the bed is in the lowest possible position. Therefore, the nursing assistant is keeping patients safe by ensuring the bed is in a low position prior to leaving the room.
• Place the Call Light Within Easy Reach: this step is related to safety. The call light, also known as a call bell or signaling device, allows residents to communicate with members of staff as necessary (Hartman Publishing, 2014). Patients who have no way to contact staff might attempt to climb out of bed unassisted, resulting in a preventable fall. 
• Remove Privacy Measures: this closing step pertains to the concepts of comfort and privacy. Some patients will feel more comfortable with their doors closed all day, but most will want their doors opened after the nursing assistant has finished performing procedures. 
• Wash Hands: this step is directly related to infection control. It is generally assumed that the nursing assistant has contaminated his hands while delivering care, even if gloves had been worn. Therefore, he must perform hand hygiene to ensure that his hands are clean before leaving the room.
• Document the Skill: this step pertains to the concept of safety. Other care providers read the nursing assistant's documentation and depend on it to know what has been done for the patient throughout the span of each work shift. If skills and procedures are not documented, this could lead to dangerous duplication of efforts and wasted time.
• Announce, "Skill Complete." - this step is mainly for the comfort of the evaluator who will be grading the skills portion of the nursing assistant state examination. The evaluator prefers to know when each skill has ended, so the nursing assistant needs to announce, "Skill complete."

Hand hygiene is important at specific times during the opening and closing steps. Specifically, the nursing assistant must wash his hands immediately before gathering the clean supplies during the opening steps. Additionally, the nursing assistant must wash his hands must wash his hands immediately before documenting during the closing steps. Hand-washing must be done in this order for particular reasons which will be explained below.

So, why does the nursing assistant wash his hands before obtaining clean supplies during the opening steps? There are a number of rationales. If the nursing assistant's hands are unwashed, he will contaminate the clean supplies. Also, he has touched a germy door knob, screen or curtain while providing privacy. He may have even touched other contaminated surfaces such as a nightstand, call light or side rails on the patient's bed. Therefore, the nursing assistant must wash his hands before gathering supplies.

During the closing steps, why does the nursing assistant wash his hands before documenting? Again, there are several rationales. It is assumed that the nursing assistant will be taking the inkpen home that is used to chart, so his hands must be clean before he touches things that come home with him. This includes pens, keys, lunchboxes, cellular phones, and other personal items. Also, the nursing assistant's hands must be clean before he enters the rooms of other patients, so he must wash his hands.

Hartman Publishing. (2014). Nursing Assistant Care - The Basics (4th Ed.). Albuquerque, NM: Hartman.

PatientCareLink. (2020). Healthcare-Acquired Infections. Retrieved April 26, 2020 from https://patientcarelink.org/improving-patient-care/healthcare-acquired-infections-hais/

Stone Academy. (2020). 20 Must-Have CNA Skills. Retrieved April 26, 2020 from https://www.stone.edu/cna-skills/

Tanner, D. (2020). Closing Steps for CNA/Caregiver Skills. Caregiverology. Retrieved April 26, 2020 from https://www.caregiverology.com/cna-closing-steps.html