Wednesday September 3rd 2014

The future is now

Rehabilitation nurses well-prepared for care coordination, team focus

Rehabilitation RNs work together to help a young patient in a halo brace regain abilities and prevent complications. Photo courtesy of Association of Rehabilitation Nurses
Staff nurse Joanne Pugh and case manager Susan Wirt are both longtime RNs who can easily step into the role of “nurse of the future” as called for in the Institute of Medicine report on nursing and other health reform initiatives. They are experts in working on interdisciplinary teams, are strong problem solvers and communicators, and they don’t shy away from taking the lead on efforts to ensure that their patients get the right — and best — care.
They work in a specialty that allows them to assist patients in their journey from serious injury or illness to a life that may not be the same but still full. They are among the 10,000 nurses who are certified in rehabilitation nursing.
As president of the Association of Rehabilitation Nurses (ARN), Michelle Camicia, MSN, CRRN, is on a mission to build greater awareness among nurses and the public about her specialty.
“Rehabilitation nursing is more of a philosophy than a scope of practice,” said Camicia, director of Rehabilitation Operations at Kaiser Foundation Center in California and an ANA\California (ANA\C) member. “We work in many different roles and settings, including acute rehabilitation hospitals, long-term care and home health care.”
Depending on the role, rehabilitation nurses can specialize in working with pediatric patients needing complex care, older adults or people who have pain management needs, for example. Their patient population also can run the gamut from patients or clients who have spinal cord injuries to traumatic brain injuries to developmental congenital disorders, such as spina bifida.
They all base their practice, however, on key rehabilitative and restorative principles.
According to ARN, rehabilitation nurses put those principles into practice by effectively managing complex health care issues; collaborating with other professionals and disciplines, such as occupational or speech therapy; providing patients and their caregivers with needed education; setting patients’ goals that are aimed at maximizing independence; and establishing plans of care that maintain patients’ optimal wellness.
Because of their strong skill set, rehabilitation nurses are well-prepared to take on the many opportunities opening up through the Affordable Care Act, such as those that focus on care coordination and preventing complications in people living with chronic and complex conditions, according to Camicia.
A closer look at acute rehab
A rehabilitation nurse works with assistive equipment to help her patient transfer. Photo courtesy of Association of Rehabilitation Nurses
In her 27 years working on acute rehabilitation units, Joanne Pugh, BSN, CRRN, an ANA\C member and now a staff nurse at Kaiser, has seen it all and has learned to never prejudge. She has taken care of many patients with spinal cord injuries, including a young woman who had a car accident and a young man who had been shot. She also has worked with many patients with traumatic brain injuries, strokes and complications from diabetes.
“Patients often come in and they are devastated, and so are their families,” Pugh said. “These patients have just gone through a major life change. They are at their lowest point. Spinal cord injury patients, for example, think their lives are over and that they can’t do anything anymore.
“As staff nurses, we begin working with individuals and their families soon after the onset of their injury, and we focus on what they can do, their abilities. We support and teach our patients about their condition and strategies to help them adapt, which empowers them so they can function as independently as possible. And we do caregiver training.”
Some patients initially fear doing any tasks by themselves.
“I always say to a patient, ‘I know this is scary, especially if it is the first time,’” said Pugh, who finds her specialty incredibly rewarding. “‘But if you want to live an independent life, you need to start doing things for yourself. I’ll be your assistant and be with you all along the way.’
“After they do an activity once, like giving themselves a heparin injection or perform a self-cath, they realize they can do it and it’s not so bad.”
A typical day shift for Pugh is fast-paced. She performs many of the same tasks that are done in an acute care hospital setting, along with rehabilitative-specific assessments and care, such as cathing patients, trach care, and getting patients up and dressed for therapy.
“Every week I have a team conference with the physician and others involved in a patient’s care, such as a physical therapist, an occupational therapist and a psychologist, to evaluate goals and maybe set new ones. It’s really a team approach. I back them up, and they back me up.” (The same team also meets with the patient and family at different times.)
Camicia added that rehabilitation nurses often serve as the hub of a wheel, providing information and coordinating care among the other disciplines — the spokes in that wheel.
“Advocacy is also a huge role for us,” she said. “We serve as the patient’s advocate when addressing issues with other members of the health care team and sometimes with a patient’s own family. We always want to make sure that all patients are getting the right care in the right place at the right time.”
Managing their cases
Susan Wirt, BSN, RN, CRRN, CCM, started her 35-year career in adult critical care but then transitioned into rehabilitation nursing to help patients deal with the post-acute effects of their injury or illness. She currently works independently as a case manager, working with individual patients as well as insurance companies and health care facilities.
“My clients have been through acute rehab and are back in their communities,” said Wirt, the immediate past president of ARN, an organizational affiliate of ANA and an ANA member. “I figure out how they can be well and healthy despite their chronic conditions. People who are getting the ongoing care they need will experience fewer re-hospitalizations.”
Sometimes, however, Wirt visits patients and their families while they are still in acute rehabilitation facilities.
“When patients are in the midst of a catastrophic situation, they are thinking life or death,” Wirt said. “I let them know that I’m there for their support, someone whom they can lean on.
“I often initially focus on improving the flow of communication, educating families, individuals and even health care teams about services that are available or needs that still must be addressed. I also will identify community resources and facilities, so patients can be in the best place — whether it’s a transitional facility or at home — after they are discharged and make informed decisions about their ongoing care.”
Frequently she goes to the homes of patients who soon will be discharged to determine if there are any barriers or durable medical equipment required and then ensure that those issues are addressed. For example, she will consider whether ramps are needed to get inside the home, any scatter rugs to be removed or a cordless phone to be ordered. She also will consider whether the clients are independent with their activities of daily living but must have assistance with meal preparation.
Many of her clients are in rural areas of Virginia and surrounding states. That can add to the challenges of finding resources, including specialists whom clients must see, and her own travel time. Wirt has followed some clients for many years, accompanying them to health care appointments and making sure that they are staying at the maximal level of their health.
She even has researched and subsequently found a lightweight portable shower chair for one of her longtime clients, a lay minister and paraplegic who had been forced to stay at certain hotels instead of with members of his congregation, as he had pre-injury. That kind of flexibility is something that Wirt wants for all her clients, so they enjoy many of the same things they used to do before any constraints occurred.
As the baby boomer generation ages and health care continues to reform, Wirt sees more opportunities in case management.
“Nurses are best at case management, and rehabilitation nurses are particularly well-suited for this role,” Wirt said.
That said, Camicia believes that rehabilitation nursing practice can extend to all nurses.
“Every nurse can practice the philosophy and concepts of rehabilitation nursing wherever they work,” Camicia said. “Falls prevention, behavior management, improving mobility — these are basic to our specialty practice but they apply to all settings.”
For more information on rehabilitation nursing, go to www.rehabnurse.org.
— Susan Trossman is the senior reporter for The American Nurse.
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