Journal of Gerontological Nursing

IDENTIFYING CLUES TO INFECTIONS IN NURSING HOME RESIDENTS: The Role of the Nurses' Aide

Marguerite McMillan Jackson, RN, MS, CIC, FAAN; Kimberly Schafer, MS

Abstract

Nurses' aides (NAs) in nursing homes provide 80% to 90% of the direct care to residents (Institute of Medicine, 1986), and for many reasons it is unlikely that this wiU change.

During the past decade there has been a clear trend for hospitalized elderly to be discharged to nursing homes earUer than in the past (Lewis, 1987; Tresch, 1988), with a variety of conditions that previously would have merited prolonged stay in the acute care faculty. Many more persons who are admitted and live in nursing homes have multiple complex problems than they did even 5 to 10 years ago. With this change in resident acuity, it is increasingly important for the NA to develop skills to recognize "clues" to potential problems (eg, early signs and symptoms of infection). The consequences of failing to recognize a resident problem promptly can often result in rapid progression of a condition such as an infection.

In addition to improving skills for early recognition of "clues" to problems, the NA also should promptly communicate this information to licensed staff in language that wÜl lead to appropriate interventions for the resident. One result of this improved early recognition and communication could be a decrease in resident transfers to acute care facilities. This hypothesis has not been tested for NAs, but did prove to be the case in facilities employing geriatric nurse practitioners (GNPs), whose presence in the nursing homes undoubtedly led to earUer recognition of problems and prompt intervention thereafter (Garrard, 1990; Kane 1989).

Other results of developing improved resident care skills in NAs should be improved self-esteem, reduced burnout, and less frustration when NAs beUeve the observations and information they provide are noted by decision makers - who then use the information to improve resident care. Considerable attention was given to these issues in the Institute of Medicine Report (1986).

Several researchers have addressed ways to improve the working conditions for the NA by suggesting the foUowing: job redesign and restructure (Bowers, 1992; Brannon, 1988); increased attention to social support (ChappeU, 1992); better understanding of the personal background from which the NA comes to work in the nursing home (Tellis-Nyak, 1989); and analysis of factors that affect turnover and work satisfaction (CaudiU, 1989; Waxman, 1984). Holtz (1982) also found that supervision, achievement, and responsibüity ranked high among factors important in influencing NAs to stay with their jobs. Few investigators have studied the mechanisms of communication among care providers in nursing homes, even though Gottesman (1970) identified the central position of the NA in the nursing home over two decades ago, and observed that communication was restricted.

BACKGROUND FOR THIS STUDY

A prospective study of intensive surveillance for nursing-home associated infections in 666 residents of a 300-bed nursing home in San Diego was conducted from August 1984 through May 1987. The study was funded by a National Institute of Aging's Teaching Nursing Home Award to the University of California San Diego and San Diego State University (UCSD/SDSU). The methodology used and results have been published elsewhere (Jackson, 1992). Whüe this large study was in progress, interviews with NAs were also conducted at the same nursing home in the faU of 1986. An article published in 1989 described information obtained from the interviews about the influence of folk knowledge, cultural background, and personal Ufe experiences on the NA's choices of words and descriptions of problems, using pneumonia as an example (Jackson, 1989).

FINDINGS FROM THE INTERVIEWS WITH NURSES7 AIDES

Demographic information about the 50 NAs interviewed is presented in Table 1. Data were coUected using a structured interview with both forced-choice and open-ended questions. The goals…

Nurses' aides (NAs) in nursing homes provide 80% to 90% of the direct care to residents (Institute of Medicine, 1986), and for many reasons it is unlikely that this wiU change.

During the past decade there has been a clear trend for hospitalized elderly to be discharged to nursing homes earUer than in the past (Lewis, 1987; Tresch, 1988), with a variety of conditions that previously would have merited prolonged stay in the acute care faculty. Many more persons who are admitted and live in nursing homes have multiple complex problems than they did even 5 to 10 years ago. With this change in resident acuity, it is increasingly important for the NA to develop skills to recognize "clues" to potential problems (eg, early signs and symptoms of infection). The consequences of failing to recognize a resident problem promptly can often result in rapid progression of a condition such as an infection.

In addition to improving skills for early recognition of "clues" to problems, the NA also should promptly communicate this information to licensed staff in language that wÜl lead to appropriate interventions for the resident. One result of this improved early recognition and communication could be a decrease in resident transfers to acute care facilities. This hypothesis has not been tested for NAs, but did prove to be the case in facilities employing geriatric nurse practitioners (GNPs), whose presence in the nursing homes undoubtedly led to earUer recognition of problems and prompt intervention thereafter (Garrard, 1990; Kane 1989).

Other results of developing improved resident care skills in NAs should be improved self-esteem, reduced burnout, and less frustration when NAs beUeve the observations and information they provide are noted by decision makers - who then use the information to improve resident care. Considerable attention was given to these issues in the Institute of Medicine Report (1986).

Several researchers have addressed ways to improve the working conditions for the NA by suggesting the foUowing: job redesign and restructure (Bowers, 1992; Brannon, 1988); increased attention to social support (ChappeU, 1992); better understanding of the personal background from which the NA comes to work in the nursing home (Tellis-Nyak, 1989); and analysis of factors that affect turnover and work satisfaction (CaudiU, 1989; Waxman, 1984). Holtz (1982) also found that supervision, achievement, and responsibüity ranked high among factors important in influencing NAs to stay with their jobs. Few investigators have studied the mechanisms of communication among care providers in nursing homes, even though Gottesman (1970) identified the central position of the NA in the nursing home over two decades ago, and observed that communication was restricted.

BACKGROUND FOR THIS STUDY

A prospective study of intensive surveillance for nursing-home associated infections in 666 residents of a 300-bed nursing home in San Diego was conducted from August 1984 through May 1987. The study was funded by a National Institute of Aging's Teaching Nursing Home Award to the University of California San Diego and San Diego State University (UCSD/SDSU). The methodology used and results have been published elsewhere (Jackson, 1992). Whüe this large study was in progress, interviews with NAs were also conducted at the same nursing home in the faU of 1986. An article published in 1989 described information obtained from the interviews about the influence of folk knowledge, cultural background, and personal Ufe experiences on the NA's choices of words and descriptions of problems, using pneumonia as an example (Jackson, 1989).

FINDINGS FROM THE INTERVIEWS WITH NURSES7 AIDES

Demographic information about the 50 NAs interviewed is presented in Table 1. Data were coUected using a structured interview with both forced-choice and open-ended questions. The goals of the interviews were to learn more about the foUowing:

* Decision making by NAs;

* Language used to describe conditions in patients (Table 2);

* Priority assignment for different conditions when compared to one another (Table 3); and

* Perceptions about information flow within the institution (Figure 1).

In addition, the responses by NAs about infections in specific residents were compared with the information obtained by the geriatric nurse practitioners (GNPs) about the same residents seen during the same 2-week period (Table 4).

DISCUSSION

The demographic characteristics (Table 1) of the NAs are fairly typical of this work force in many nursing homes in the United States; that is, the vast majority are female (94%), and over three quarters (78%) are between the ages of 21 and 40. Two thirds are nonwhites with a broad range of years of experience, both as an NA and in the study facility. Eleven of the NAs reported being students, but none were in nursing programs. All of the NAs reported being certified. Many had completed the certification program offered by the study facility, which provided 50 hours of classroom instruction and 100 hours of supervised clinical experience whüe the person worked there. It was surprising that so few of the NAs were aware of the UCSD/ SDSU research study, because two or three study GNPs had been at the nursing home daily - on both the day and evening shifts - for more than 2 years. In fact, only five of the NAs recognized the name of the supervising nurse practitioner for the UCSD/ SDSU study, even though she had provided inservice programs a number of times.

Table 2 lists the five exact terms used most frequently in response to the question, "What different types of sign or symptom of infection do you consider serious enough to teU the charge nurse?" The interviewer stated the type of infection; each NA could provide more than one response for each type of infection. The terms used most frequently appear to reflect those on standard textbook lists of signs /symptoms of infection taught in many types of training programs.

However, when these terms are analyzed in the context of the nursing home environment, some problems emerge. For example, when asked about pneumonia, in addition to the six terms listed in Table 2, there were 37 other signs/symptoms named one to four times by the NAs. Although most NAs named more than one sign/ symptom, it is interesting mat 30% mentioned temperature and an additional 12% mentioned high temperature. However, the institutional policy for temperature measurement required only once per month notation on most residents unless there was a "problem." Thus, if the NA used temperature as a major indication ("clue") for pneumonia, the absence of the measurement - except once per month - made it unlikely that many cases of pneumonia would be identified using the most frequently stated "clue."

The most commonly mentioned signs /symptoms of bladder infection were burning, pain, and frequency; however, many of the residents were cognitively impaired and unable to express these symptoms. Again, signs such as odor and color change, although mentioned less frequently, would be more Ukely to be recognized by the NA.

To determine congruence among possible infections identified by NAs and those identified by the GNTs, information recorded in the interviews was compared with information recorded by the GNPs about the same residents during the same 2-week period immediately prior to the interview. The mean number of days between interviews with the NA and resident evaluation by the GNP was 1.76 days (range 0 to 3 days).

The findings (Table 4) suggest there was consistent agreement when there were no signs/symptoms (or "clues") of infection (Group I); however, there were usually serious problems in recognizing and /or interpreting signs/symptoms of infection when infection was present. There was agreement between the NA and GNP for only four infections (Group II). In Group III, the most commonly identified infections by the NAs were "colds" which were described with terminology for "clues" consistent with the language and culture of the NA. Language used by the NAs to describe these problems was more likely to reflect terms family members would use to communicate with one another rather than terms associated with a formal training program in nursing care.

Table

TABLE 1Demographic Characteristics of Nurses' Aides Interviewed

TABLE 1

Demographic Characteristics of Nurses' Aides Interviewed

Table

TABLE 2Signs /Symptoms of Infection Nurses' Aides Consider Serious Enough to Warrant Notification of Charge Nurse*

TABLE 2

Signs /Symptoms of Infection Nurses' Aides Consider Serious Enough to Warrant Notification of Charge Nurse*

It is possible that the GNP may have missed some of the infections in Group ?? (eg, URIs) due to the interval between the interview and his or her evaluation of the resident. To verify whether this was true, as part of the study, the resident's medical record was reviewed for the time interval in question. In none of the cases in Group ?? was information recorded documenting the problems identified by the NA to the interviewer. Thus, either the problems were not considered important enough to record, or were not communicated by the NA at all.

In Group TV, it is also likely that the term "cold" is a term broadly applied by NAs to changes in resident condition where the etiology of the change may be unknown to the NA. That is, the NA notes that something is "different" about the resident; what the difference is caused by is unclear. This can lead to problems in communication when the NA relays the information to Ucensed personnel that the resident has a "cold." The nurse receiving the information may consider it nonspecific and not requiring intervention, or the nurse may contact the resident's physician by telephone and obtain an intervention that may or may not be related to the resident's pathology. Unless the Ucensed personnel evaluate the resident and provide feedback to the NA, the NA may be likely to beUeve his or her observation is ignored, and extinguish such reporting over tune.

In Group V, aU of the infections documented by the GNPs presented with signs /symptoms for which "clues" should have been recognized by the NA during his or her daily care of the resident. It is interesting that while many NAs were able to give textbook descriptions of signs/ symptoms of 7 of 14 of these infections in Table 2 (URI, UTI, pneumonia), the "clues" were apparently missed when present in the individual resident. In addition, several of these infections benefit from interventions (treatments) that are clearly more effective if initiated early in the clinical course rather than when the infection progresses.

Table

TABLE 3Nurses' Aide-Ranked Importante of Conditions in Random Pairs*

TABLE 3

Nurses' Aide-Ranked Importante of Conditions in Random Pairs*

These interview data also substantiate findings from a previous study (Jackson, 1992), in which the most common nursing home-associated infections identified by the GNPs were at the respiratory site. That study and several others (Irvine, 1984; Mott, 1988; Zimmer, 1988) have shown that infection is also a major reason for admission of nursing home residents to acute care hospitals. It is well known that many infections can be adequately managed in the nursing home if they are recognized early, but that once the resident becomes acutely ill, he or she may require acute care hospital management. In the pilot study of financial incentives paid by Medicare to facilities and responsible physicians to evaluate and care for acutely ill nursing home patients, acute bacterial infection was the most common category of episode, occurring in 46% of cases (Zimmer, 1988).

Table 3 represents interview data intended to provide information about the importance of care priorities as evaluated by NAs. For each pair of conditions listed, the NA was asked to choose the more important consideration in caring for residents. Sequence and pairing of options was randomly derived from a list of possible options. Acute events such as falls, chest pain, and change in mental status were always selected more often than the alternative. Whether or not signs/ symptoms of infection rated higher than the alternative seemed to depend on what the alternative choice was. Thus, it appeared from the data that most NAs had some ability to choose between two alternatives and usually selected the choice that would probably have been selected by a licensed person had they been asked to compare the same list and prioritize the options.

Figure 1 is a schematic of the flow of information and decision making within a typical nursing home. The NA is placed at the top of a decision tree that has several branches. The term "clue" is used in the Figure to describe any sign or symptom, either physical or mental, that is at variance to what is normal for the resident. The NA's ability to identify "clues" in the first place is strongly influenced by his or her familiarity with the resident and the continuity provided by having a consistent care assignment. As mothers of infants use subtle changes in behavior as "clues" to illness in their children, our interview data suggest that NAs use similar lay knowledge in interpreting changes in behavior or condition of residents in their care.

Because of the hierarchical nature of most nursing homes, NAs have little independence and autonomy and are usually required to report all findings to licensed staff (RN or LVN) who are responsible for making decisions about whether to intervene and /or to notify the physician. In most states, licensure regulations for nursing homes also limit the authority for licensed personnel. Contact is required - and is usually made by telephone - with the patient's physician for even simple problems. The physician usually makes a decision based on information conveyed over the phone by the licensed personnel.

As Figure 1 depicts, the RN/LVN may or may not choose to examine the resident personally. Factors that may influence this decision include the nature of the problem as described by the NA, the staffing ratio for the shift and resulting workload for the RN, the perceived urgency of the problem, the time of day or night and how that relates to the demands of the shift, and whether the physician would be likely to do anything with the information. An additional important point in making the decision to intervene is whether the licensure, certification, and/or funding agencies consider this type of problem one for which lack of intervention can result in citations, fines, or altered reimbursement decisions (eg, development of a new decubitus ulcer).

Table

TABLE 4Comparison of Nurses' Aide (NA) and Geriatric Nurse Practitioner (GNP) Patient Assessments*

TABLE 4

Comparison of Nurses' Aide (NA) and Geriatric Nurse Practitioner (GNP) Patient Assessments*

The physician's options for the resident are directly influenced by the language used by the RN/LVN in describing the situation, and short of exarrtining the resident personally (rarely practical), an intervention can be directed over the telephone. Factors that influence the physician's decision include how well he or she knows the resident and his or her family, the funding source for the resident and the covered options available, the preference of the resident/ family regarding aggressive versus comfort or terminal care, the urgency of me problem, and whether staff at the nursing home have the skills to manage the problem there. Availability of diagnostic laboratory and/or radiographic facilities may also influence whether the physician believes transfer to an acute care hospital is necessary.

The pathway on the right side of Figure 1 is used when the NA does not recognize or articulate a "clue" and no intervention is initiated until the resident's condition worsens. This can happen for a number of reasons, including the following:

* Unf amiliarity of the NA with the resident and lack of adequate knowledge/experience with the resident to know what is "normal" for the resident;

* Lack of adequate knowledge of signs/symptoms of problems that, if identified and managed early, are unlikely to progress with serious sequelae; and

* Lack of adequate skills to identify deviations from normal.

Of course, other skills are required to prioritize the importance of problems and to avoid "crying wolf" about every problem that occurs. The ability to prioritize work was identified as an important variable in evaluating turnover by NAs in a study by Bowers and Becker (1992) and in job redesign in the study by Brannon and colleagues (1988).

In summary, Figure 1 depicts the pivotal position of the NA in the care of nursing home residents. The NA can trigger a series of responses that each have different consequences. Our interviews suggest that the language used by NAs to communicate within the nursing home hierarchy is probably much more strongly influenced by cultural background, folk knowledge, and personal experiences than by educational materials presented during training sessions.

Even though the NA may know the textbook list of signs and symptoms of infection, he or she may not identify "clues" to infection in the individual resident. If a "clue" to infection is identified by the NA, the term used for it may be at variance to the textbook term licensed personnel expect to hear. Clearly, the outcome for the resident is strongly influenced by what the NA believes, sees, and does for the resident, and says to others in the nursing home hierarchy. Yet, NAs are the lowest paid, occupy the lowest status positions in the hierarchy, and experience the highest turnover of anyone in the nursing home industry (Waxman, 1984; Institute of Medicine, 1986; Caudill, 1989).

MEETING EDUCATION AND TRAINING NEEDS

These interview data also suggest that NAs generally have some ability to learn to identify "clues" and prioritize problems, and that such information can influence outcomes for residents. Yet there were serious gaps between what the NAs had learned in textbook terms, application of that information in the practice setting, and communication of the information within the nursing home hierarchy.

A number of educational approaches have been suggested over the years to teach NAs the information important to the care of nursing home residents. Some of the most insightful work was done by Crawford, Waxman, and Carner (1983) who noted that the major educational shortcoming of existing framing programs in nursing homes was the failure to recognize and address the special educational needs of NAs. Programs typically emphasized training needs as perceived by others - administrators and charge nurses - and seldom requested input from the NAs themselves. When asked about the content for framing programs, most NAs expressed interest in "learning more about basic nursing skills," with "learning more about physical illness" and "learning more about mental illness" coming in second and a distant third.

Prior to Waxman's study, useful background information about the political and economic implications of training nursing home aides was reviewed by Hyerstay (1978), and problems frequently expressed about training programs, trainers, and content provided were reviewed by Almquist and Bales (1980).

A number of subsequent researchers have used Waxman's work to design training programs for NAs (Burgio, 1990).

Some examples pertinent to our data include the study by Cohn, Horgas, and Marsiske (1990), who used the topic of resident behavior management to develop skills in observation and action for NAs. The success of the training program suggested that NAs could learn behavioral strategies in reducing disruptive resident behavior, and that routine training in and support for NAs in learning behavioral options could be very useful.

A comprehensive study of improving nursing home care through training and job redesign was recently conducted in Pennsylvania (Spore, 1991; Smyer, 1991). This intervention study was designed to demonstrate NAs' knowledge of mental health strategies through skills training, and to improve job motivation through job redesign. Knowledge and job perceptions influencing motivation did change after the interventions, but performance did not.

Spore and Smyer suggested several possible reasons. For example, the theoretical model for the study hypothesized that work performance would improve with increased knowledge and motivation; however, adequacy of the model is likely only where the work environment is conducive to change and the opportunity to improve performance is supported by management and practice changes.

CONCLUSIONS

Although the findings presented here are from a single nursing home in a large metropolitan city, they suggest a way to look at the role of the NA that may be applicable to many other situations. Some possible ways to use these findings include the following suggestions:

First, it is important to recognize the pivotal position of NAs as the most likely persons to initially recognize "clues" to resident problems for which early intervention could theoretically improve the quality of and reduce the costs of care.

Second, if this pivotal position for NAs is acknowledged, it is essential for NA training programs to teach how to identify "clues" that may suggest problems, and how to communicate this information within the nursing home hierarchy so that it is heard and understood.

Third, if NAs are taught to recognize and communicate "clues" to licensed staff, and appropriate interventions are then initiated promptly in the nursing home, it is likely that quality of care for residents can be improved at reduced cost (eg, managing infections within the nursing home rather than in an acute care hospital is one example that is both feasible and cost-effective).

Finally, if early "clue" recognition and communication skills are to be integrated into NA training programs, it is essential to provide educators with the knowledge, skills, and abilities required to teach them. This will be both a challenge and an opportunity, requiring creativity and innovation. The American Health Care Association is revising its training materials to be consistent with these suggestions (Casey, 1994). Training program development also is likely to benefit from input from NAs who, as frontline care providers, may have ideas that are both practical and reasonable. Although this may require the nursing home hierarchy to view the NA differently than in the past, the consequences of not changing this view are likely to continue to be serious and costly.

The challenge to improve the work environment of the nursing home so that it is conducive to improved NA performance will be of increasing importance as we move into the next century - with more elderly people, fewer resources per capita, and increasing regulatory demands to reduce complications in residents and improve safety for care providers.

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TABLE 1

Demographic Characteristics of Nurses' Aides Interviewed

TABLE 2

Signs /Symptoms of Infection Nurses' Aides Consider Serious Enough to Warrant Notification of Charge Nurse*

TABLE 3

Nurses' Aide-Ranked Importante of Conditions in Random Pairs*

TABLE 4

Comparison of Nurses' Aide (NA) and Geriatric Nurse Practitioner (GNP) Patient Assessments*

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