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MARGUERITE M. JACKSON

W hen a nurses' aide says "Mrs. Jones has a cold" or "there is a bruise on Mr.

Smith's toe," do licensed staff in nursing homes respond differently than they would if the nurses' aide said "Mrs. Jones has difficulty breathing and sounds very con- gested" or "Mr. Smith's big toe is blacker today than it was yester- day"?

The situations described with the first set of words suggest minimal in- tervention. However, the same situa- tions described with the second set of

words suggest possible congestive failure or pneumonia for Ms. Jones and gangrene for Mr. Smith. The in- terventions that would be required for these problems are more immedi- ate and aggressive than for a cold or for a bruise.

The way nurses' aides communi- cate information about the patient to licensed staff strongly influences both the nature and the speed of the assessment and intervention for the patient. For the past five years, as part of a larger study of nosoeomial infections in 666 nursing home pa- tients, we have investigated how care decisions are made in nursing

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homes. Researchers at the Universi- ty of California in San Diego and San Diego State University have been studying the words nurses' aides choose to describe patient conditions and how those words are interpreted

Marguerite M. Jackson, RN, MS, CIC, is the director of the Medical Center epidemiology unit and assistant clinical professor of commu- nity and family medicine at the University of California, San Diego. This study was funded in pan by the National Institute on Aging and the University of California Academic Geriat- ric Resource Program. Dorothy Fraser was the supervising nurse practitioner. The author thanks Bonnie Burkhardt, Maureen Jones, and Rita Hatch for their work.

244 Geriatric Nursing September/October 1989

by other staff members. In the large study, each patient was

evaluated weekly or biweekly by a nurse practitioner who recorded 9bervations in progress notes and on computer forms for statistical analy- sis.

In a smaller study, 50 nurses' aides in a large nursing home in San Diego agreed to be interviewed about care of their patients. Using both forced- choice and open-ended questions, we asked the nurses' aides about the lan- guage they used to describe condi- tions in 125 interactions with 81 pa- tients enrolled in the largenursing home study of nosocomial infec- tions.

Responses from the aides were then compared with information ob- tained by .the nurse practitioners from the same patients at about the same time. This was done to validate whether or ilnot the same problems were identified in patients by the nurses' aides and nurse practition- ers.

A Cold is a Cold?

Folk knowledge, cultural back- ground, and personal life experiences influenced the nurses' aides' choices of words and descriptions of prob- lems, whereas the nurse practitioners recorded problems in professional terms.

For example, the word "cold" is a common term used in many English- speaking cultures for general fatigue, malaise, "aches," "sniffles," and oth- er conditions that are each at vari- ance to normal for the individual. In professional terms, "difficulty breathing" has a different meaning than "congested," and each term prompts different types of assess- ment and intervention.

Similarly, the lay term, "bruise," has a different etiology and prompts a different intervention for the pro- fessional than does "a toe that is blacker today than yesterday." Yet, to the nurses' aide using lay language, "bruise" may be the only word that closely approximates a description of a gangrenous toe.

Experience Helps

The ability of nurses" aides to iden- tify variations from normal in the

first place was strongly influenced by his or her familiarity with the patient and the continuity provided by.hav- ing a .consistently assigner patient load. The aide's amount of experi- ence also made a big difference in their familiarity with various condi- tions and their physical signs. (See "'What is pneumonia?" at right.)

If the nurses' aide does not report a change in the patients' condition, in- tervention may be delayed and the condition may worsen. Even when a nurses" aide reports the problem, however, the nurse may choose not to examine the patient or report it to the physician.

How the aide describes the nature and urgency of the problem greatly influences the nurse's decision--as does the time of day or night, the smiling and demands of the unit, and the likelihood that the physician will do anything with the information or that the intervention will change anything. Sometimes, another factor is whether the regulatory agencies consider the problem one for which lack of intervention can result in cita- tions, fines, or reimbursement de- nials. (For example, new pressure ulcers are reviewed critically by li- censure evaluators in many states.)

The Trigger for Treatment

Nurses' aides provide 80 to 90 per- cent of direct care in nursing homes and, generally, they have little inde- pendence but have the longest con- tact with patients. This gives them a pivotal position in making decisions about care for nursing home patients. What nurses' aides report can prompt a nurse to further assess, and possibly intervene. What effect does all this have on patient care?

It's possible to develop education- al materials for nurses' aides and li- censed staff that focus on using the same language to describe similar problems. It is also important for nursing home administrators to rec- ognize the pivotal role of the nurses' aide in prompting a whole series of

interventions that affects patient out- come. It's important to reward nurses' aides for early problem iden- tification that triggers licensed staff to begin early intervention for cor- rectable problems. GN

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Geriatric Nursing September/October 1989 245