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Five-point guide focuses staff’s attention on patients’ needs
Home health aides and certified nursing assistants (CNAs) are in an ideal position to alert nurses to patient needs — if they can astutely observe symptoms and changes in patients and clearly communicate them to others. A special training module for aides and CNAs focuses on honing those observation and communication skills. It’s part of a palliative care program being developed by Alexandria, VA-based MKHP Associates, LLC, says Mary Hamil Parker, PhD, principal investigator for the project.
MKHP has received a grant from the National Cancer Institute of the National Institutes of Health to develop training modules for health professionals, paraprofessionals, volunteers, and family caregivers in the area of palliative care, which seeks to manage the symptoms of patients who cannot be cured of their diseases.
Along with recognizing such symptoms as pain and immobility, home health aides and nursing assistants play a vital role in seeing how the symptoms affect the quality of patients’ lives and letting nurses know when problems arise. "We’re finding that home health aides and CNAs and even some experienced hospice aides need training on how to observe and report symptoms in a way that looks at the needs of the patient in all domains of care: physical, psychological, social, and spiritual," she says. "Their training is task-focused, and what we’re teaching is affective behavior. You look at not simply, How do you give a bed bath?’ but, How do you help the person achieve what they wish to achieve that day?’
"Palliative care is not only reporting the fact that somebody has pain, but also that there’s disruption with the family and that family dynamics might be contributing to the patient’s suffering — or the patient’s suffering might be contributing to problems with the family," Parker says. "All of that is the dynamic in which palliative care takes place."
The training module offers home health aides and CNAs a five-point guide to observing and communicating changes in the patient’s condition, keeping the four domains in mind. "We hope people will learn to use this as a way of organizing and presenting information," Parker says.
The guide lays out these five steps:
1. Be alert to a problem or change, through observation or by speaking to the patient or family. "That should probably be the first responsibility of any home health aide or CNA, to observe and report a problem or change with the patients," Parker says.
2. Find out how long the problem or change has been going on.
3. Observe how the symptom or change has affected the patient’s or family’s usual ability to do what they want to do.
4. Determine what remedies have been tried. "Patients and families do try things. Some of them work and some of them don’t," she says.
5. Determine who or what may be able to help.
"We [have had] a very positive response from home health aides and CNAs that we’ve trained and also nursing supervisors and others, because they find this method of organizing information empowering," Parker says. "They say, Now, somebody’s told me how to do it.’"
As part of the training, Parker presents case studies, asking participants to use the five-point guide to make observations about the patient. Here is an example of a case study:
Mr. A has been experiencing more frequent episodes of shortness of breath over the past week. In the past 12 hours, the problem has worsened. When you arrive, Mr. A is still in bed and short of breath. He says, "I can’t do anything. I’m tired of not feeling well." You notice that his breathing is shallow and his pulse rapid. The window is open, and a fan is blowing air on him. He has turned up his oxygen setting to 4 liters per minute.
In that instance, a participant might make the following observations using the five-point guide:
1. Observed change. Mr. A’s increased shortness of breath is a change.
2. How long has this been going on? In the past 12 hours, or since last night.
3. How has it affected the patient’s ability? Mr. A is unable to get out of bed.
4. What has been tried? Somebody has figured that increased air circulation might help and has opened the window and turned on a fan. Mr. A himself has turned up his oxygen setting.
5. Who or what may be able to help? Usually, when a home health aide sees a patient is having a medical problem, his or her immediate responsibility is to call a nurse, Parker says.
The approach also can be used in connection with pain management, even in situations in which the patient can’t verbally express what he or she is feeling. In this case study, a home health aide is attending a 75-year-old man who has suffered a stroke:
Mr. D takes a baby aspirin daily and is working hard to regain his functioning, but he has difficulty speaking. His aide notices that when he tries to sit up in bed, he grunts and makes a face.
He does the same thing during range-of-motion exercises, even when she tries positioning him in a chair to make him comfortable. Today, he is refusing to exercise. She decides she needs to report her observations to the nurse, using the five-point guide for communication.
1. Observed change. Mr. D grunts and makes a face when he tries to sit up. He does the same thing when he tries to do range-of-motion exercises. Today, he’s refusing to exercise.
2. How long has it been going on? The refusal to exercise began today.
3. How has the symptom affected the patient’s ability? He doesn’t want to do his exercises or move. If he doesn’t continue his exercises and grow stronger, his recovery from the stroke might be impaired.
4. What has been tried? She has tried positioning him in a chair, but today he doesn’t want to move.
5. Who or what may be able to help? The aide "is thinking through these five points: I need to tell the nurse that Mr. D is having more pain.’ That’s the process that she’d mentally go through," Parker says.
The training module provides home health aides and CNAs with more specific questions in the area of reporting pain. That information can help them give a detailed account of what a patient is experiencing.
Parker says it’s vital for the aides and CNAs to use the exact words patients use to describe their pain — "aches all the time," "worse with breathing," "worse when I move," "comes and goes," "cramp," "spasm," "burning," and "stabbing," for example. Those words can give doctors and nurses the description they need to identify the type of pain.
"It’s very important to understand a new pain may mean something different and need a different kind of treatment from the kind they’re normally getting," she says.
The following case study illustrates the questions aides and CNAs should ask when confronted with a patient experiencing pain:
Mrs. C. has advanced lung cancer. When you arrive, she is sitting in a chair in a hunched-over position. She’s rubbing the area under her right arm and around the back, almost reaching back to her spine.
She says, "This pain is different. It’s very deep, inside there, and it aches worse than the usual pain at that spot. It even hurts when I take a deep breath. It started about eight hours ago. When I take my pain medication, it goes to a four [on the pain scale], but after three hours, it’s back to an eight again.
o Where is the pain? The words Mrs. C used were "deep inside" and "aches." It extends under her right arm and around the side of her waist to her back, indicating pleural pain.
o Is it at more than one site? No.
• What does the pain feel like? It’s "different" it hurts when she breathes. It aches "worse than the usual pain at that spot."
o How bad is the pain at each site? Mrs. C rates it as eight on the pain scale.
o What makes the pain better or worse? The medication helps for a while. Moving makes it worse. Breathing makes it worse.
o What activity can she do or not do because of the pain? She can’t get up from her chair. She can’t move easily.
o Has the pain changed in any way? Mrs. C says this pain is different.
o Is she taking medication? Yes.
o How long does it take for relief to start? In this case, we don’t know. The aide needs to ask Mrs. C that question.
o Does the medication reduce pain? Yes, from an eight to a four.
o How long does the relief last? Three hours.
o Is the patient having side effects from medication? That question needs to be asked. Parker points out, for example, that constipation is common among patients using opioids.
o Is the patient having any problem getting medication? Parker says this is an important question, especially in rural areas or situations in which patients can’t get out to get medication and there’s no one to get it for them.
"What we’re doing is teaching people an orderly process of thinking about what they’re going to tell someone," Parker says. "That’s what they find empowering about this."
She says the palliative care training also includes modules on topics such as communicating with patients and family at the end of life and dealing with food and fluid issues. Modules, some of which still are in the process of being written, will be available in CD-ROM or diskette format. A facilitator could use a computer and a Microsoft PowerPoint presentation to present it to a class.
Eventually, Parker says, the training may offer certification for palliative care caregivers, based on a 16- to 18-hour program.
• Mary Hamil Parker, PhD, Principal Investigator, Project No. R42CA73284-03, National Cancer Institute, National Institutes of Health. Contact her at the Institute for Palliative Care Training, 112 S. Pitt St., Alexandria, VA 22314. Phone: (703) 519-8621. Fax: (703) 683-3759. E-mail: email@example.com.