Creative staffing ensures continuity of patient care

Aim is around-the-clock reinforcement of goals

When two rehab nursing aides decided to become therapy aides at Lourdes Regional Rehab Center in Camden, NJ, the supervisory staff realized there was a gap between nursing and therapy orientation and practice.

They found that instead of helping the patients learn to do for themselves, as is the case in therapy, the former nursing aides were working with patients from a nursing perspective in which they had to do everything quickly.

"There is a gap between what our nursing assistants learn and do in the nursing environment, where they need to do things quickly, and on the therapy floor, where they assist the therapists with two patients an hour," reports Tammy Feuer, MA, CCC, administrator of rehabilitation and postacute services.

On the nursing floor, for instance, when all patients are getting up and dressed at the same time, speed may become an issue that takes priority over therapeutic goals. So, instead of helping patients ambulate or dress themselves with assistance, the aides tend to do it for them.

That’s why the hospital administration has looked at ways to make sure the therapy goals are reinforced by all staff, even on weekends and evenings.

Having both therapy and nursing aides helps

"As patients become more medically acute, nurses become so involved in medical care that they don’t have time for rehab nursing techniques. We are trying to find efficient ways to carry out mobility and activities of daily living goals on the nursing unit," Feuer says.

The hospital has therapy aides who assist on the therapy floor weekdays and nursing aides who assist on the nursing floor around the clock, seven days a week. Physical therapy and occupational therapy students from local schools work as therapy aides on weekends.

The hospital originally set out to cross-train aides to work as both therapy aides and nursing aides. "We want our people to be flexible so they can go to the area of greatest need, but more than flexibility, [that need] is to achieve carry-over of therapy goals on the nursing unit," Feuer says.

However, they ran into some resistance when therapy aides balked at working on weekends and saw nursing assistants as doing more toileting than ambulating. "We backed off for a while. It’s still a good concept, and we still are looking at how to carry it out," she says.

Here are a few ways the hospital is working to increase communication between shifts:

Changes in shift times. In the past, the therapy aides worked 8 a.m. to 4 p.m., and the nursing aides changed shifts at 7 a.m., 3 p.m., and 11 p.m.

The nursing aide shifts were changed to run from 8 a.m. to 4 p.m., 4 p.m. to midnight, and midnight to 8 a.m. The move will make it easier to rotate aides between therapy and nursing on weekdays. In addition, it will help with the nursing shift changes because the aides remain on shift during the nursing report and are available to answer lights and attend to patient needs.

Evening rehab nursing tech. A staff member who has worked both as a nurse’s aide and as a therapy aide now works from 4:30 p.m. until 9:30 p.m. Monday through Saturday. She’s not counted in the nursing care numbers, but she is an additional employee whose primary function is to carry out therapy goals. For example, she works with activities of daily living during dinner, helps patients with adaptive devices in the shower, and helps them work on their undressing techniques at bedtime.

"Her primary focus is to work with the occupational therapy and physical therapy plan of care," Feuer says.

Sunday nights are more family-oriented and patients don’t shower, so there isn’t the need for the extra help with showers and other activities of daily living, she says. The evening rehab tech is training the nursing aides to help the patients meet their therapy goals.

Extra staff during crunch times. The rehab tech is on hand for dinner, showers, and undressing Monday through Saturday. The day shift nursing aides arrive an extra half-hour before the night shift leaves, which gives double coverage for the morning crunch time.

At Lourdes, the regular staff work eight hours with a half-hour meal break and get paid for 7½ hours. The day aides work 8½ hours and are paid for eight.

"It’s not a big increase in patient care hours, but it makes a big difference because we have extra hands when we need them," Feuer says.

One-on-one training in transferring patients. When a patient who needs moderate or greater assistance is admitted to the nursing unit, a therapist trains a nurse and an aide on the day and evening shift on how to transfer the patient. The goal is to have the nurses trained on transferring the patient within 24 hours of admission.

When nurses transfer patients, they strive to do it quickly. When therapists transfer patients, they concentrate on making sure it is done accurately and with the functionality of the patients in mind.

The hospital has always had an orientation session in which the therapists demonstrated how to transfer each kind of patient. The new method makes it more meaningful because the nurses learn what is needed with each individual patient. "It’s a patient they know and can ask questions. It really means something, as opposed to the first days of orientation, when they don’t know the patients," Feuer says.

Nurses may use two or three staff for a difficult transfer, but the therapist may be able to do it alone. "It’s possible that this training will help with efficiency, too," she adds.

The training also gives therapists a chance to observe what kinds of problems the nursing staff encounter when they transfer patients, and it allows therapists to solve problems on the patient floors.

Feuer says she hopes an added benefit will be a reduction in workers’ compensation injuries because the nurses will learn firsthand how to transfer a patient safely. Traditionally, the nursing units have experienced far more back injuries than the therapy units, she says.