In the inpatient rehab setting, group therapy activities can be one of the most engaging and meaningful ways to provide treatment to move toward someone’s individualized goals. However, this mode of therapy is often an intimidating thing to approach for many therapists. In the hustle and bustle of the day, we are all trying to efficiently and effectively get to our individual treatments… and our perception is often that there is not enough time and not enough room to fit a whole group of patients into an already busy schedule. But… with a little bit of creativity and scheduling gymnastics, group therapy activities can bring a lot of fun and enjoyment to a sometimes painful and emotionally exhausting situation!
How will group therapy activities help… really?
Maintaining participation despite increasing disability:
Group therapy activities can provide an outlet for your patients to be involved and enjoy daily life despite the barriers and limitations that they are currently working through. Being in the hospital and going through rehab can be a very isolating situation, despite having many people all around caring for you. No matter what your patient’s current level of ability may be, participating in a group can bring meaning to the day through opportunities to use the skills that are present and build on skills that are falling short. Group therapy activities also allow for a more enriched environment for people with cognitive challenges to learn and practice skills. Therapists at times feel that having cognitive impairment would lead to a patient being inappropriate for group participation, however having cognitive impairment is a great reason to include someone in a group!
Receive feedback and strategies from group members and leaders:
When in the setting of a functional group activity, your patients will be able to learn from the experiences of others and apply strategies that other people use to their own unique challenges. Whatever the individual impairment each of them has or whatever their individual goals are, they will be able to help each other move forward through the feedback that they give and the feedback that they are able to get from the other participants.
Group problem solving helps to normalize the use of compensatory strategies:
Depending on what the focus of the group is, this mode of therapy also allows people from different levels of ability and people with different impairment to come together and problem solve through barriers they are facing. Your patients may need to use compensatory strategies in order to facilitate independence… and seeing other people using similar strategies and work through the same struggles, can be a powerful way to normalize a different way of doing things!
Peer support and socialization:
Being around people who are going through similar situations can be a powerful support! Group therapy activities allows the patients to be in a setting where they can socialize with other people going through the same or similar experiences, sympathize with each other, share their own story, encourage each other, and simply interact with people who aren’t caring for them.
Provides training opportunities through various modes of learning:
As most of us know, we all don’t learn in the exact same way. Some people are visual learners, some are auditory, and some are kinesthetic learners. Sometimes a combination of learning modes is what someone needs. Group therapy activities provides each type of learner with what is most meaningful to them. The visual learner will be able to see the facilitator demonstrate and will be able to watch the other participants complete the skill. The auditory learner will have opportunity to listen to the instructions for task completion as well as the open conversation that happens when problem solving occurs. And the kinesthetic learner will be able to have hands-on practice.
Improves patient engagement in the overall rehab process:
Patients always know when group therapy is scheduled! They often find these sessions very meaningful and fun! This helps to improve their engagement in the rest of their rehab process as well. They become more in tune with the rest of their schedule, with planning discharge, and they start to help to identify barriers they should be working on in order to get home safely.
And when it comes down to it… group therapy will certainly help improve your patients’ outcomes! They will improve in the functional tasks that you have incorporated into the groups, and they will be less likely to have falls and re-hospitalization because you’ve addressed the individual challenges they will have once discharged.
What should the group focus on???
When coming up with a group focus, it is important to remember that you want the group to have as much meaning to the patients as possible. This will allow them to be more engaged in the group itself and engaged in the process of the group helping them get closer to their individualized goals. So, ideally a group should be either ‘barrier-centered’ or ‘outcomes-centered’.
As we work with our patient to plan their discharge, we are constantly identifying barriers that they may encounter along the way. Common barriers we encounter are patients that live alone and do not have adequate support, patients who are ‘partial weight bearing’ and have a full flight of steps to enter their home, or other safety or cognitive impairment that would limit the patient’s ability to perform tasks independently.
Most of the functional activities in rehab that are tracked from admission to discharge can be turned into an engaging group! Groups that focus on outcomes could include upper body and lower body dressing, walking, stairs, walking on uneven surfaces, car transfers, etc. These are all activities that you will be training your patients in anyway in order to track your outcomes and this would be a great opportunity to get a group of patients together in order to work through their individual impairments to move them closer to meeting their individualized goals for that particular outcome.
Let’s explore a few examples of barrier-centered groups as well as outcome-centered groups! This is not a complete list… but will hopefully get your creative juices flowing!
Kitchen safety group –
If your patient lives alone or has limited support, they will likely need to access the kitchen and be able to identify how to safely operate appliances and safely maneuver around the space itself. A kitchen safety group is a very engaging and meaningful way to achieve improvement in patient’s safety awareness around kitchen tasks. A way that you can accomplish this is by setting up a kitchen space with several different unsafe scenarios – examples could be electrical cords lying in the sink, paper or cloth on the burners of the stove, metal in the microwave, the oven door being left wide open, water on the floor. Then you ask your group to go through and identify some of the safety hazards and give suggestions for solutions in order to maintain safety. This gives the opportunity for the group to have open discussion and build off of the feedback that each one gives to the situation.
The second stage in running this group, after all of the hazards have been identified and corrected… Would be to walk the participants through scenarios that they may encounter on a daily basis. These could include carrying items around the kitchen or out of the kitchen, reaching for items out of the refrigerator or a cabinet, getting items ready to prepare a meal, etc. Introduce different strategies to optimally set up the countertops or cabinets so that reaching frequently used items would be easier and therefore safer for the patients to access. You could also introduce different pieces of equipment that would be useful in kitchen mobility scenarios – such as walker baskets, bags, or trays. You would demonstrate how you would carry or transport various items throughout the kitchen in a safe manner while still being able to hold on to the walker with both hands.
This kind of group and these scenarios in it can be easily translated into other rooms in the house – you can take the same template and create a bathroom safety group or a general home mobility group.
Medication Management –
Another example of a barrier-centered group activity could be medication management. If someone lives alone or their caregivers would not be able to manage this on a consistent basis, this may come up as a barrier for them to be safely discharged home. Doing these sorts of activities in a group setting could help the patients learn different strategies from each other that have worked for each individual, and also facilitate a setting where they could problem solve various errors that are made during the group. Each participant could have a weekly pill organizer and the group facilitator would go through step-by-step instructions on different things that the patient would have to do in order to successfully organize their medication for the week. As they go through, the patients can have a discussion on strategies that they use and help each other to work through difficulties that they may have.
After everyone organizes their pills… You could then ask questions like, “What are some other ways that you could make sure your medications are taken each day at the right time?”, “If you accidentally spill your pill bottles or your pill organizer… Do you have a strategy in place that would help you identify what pill is what medication?” Then you could talk about different ways that they could better identify what exactly all of their medications are and what the pills look like, so there are no medication errors if the pills get mixed up or dropped. Patients often have systems in place that work for them and through sharing these experiences in a group setting they could help somebody else overcome this type of barrier in order to discharge home safely.
Elevations Group –
When we talk about outcomes centered groups… As mentioned previously this could encompass anything from dressing, transfers, walking, stairs and elevations. One engaging and functional example would be running a group with a focus on the stairs, curb, and ramp. The group facilitator can demonstrate all the various ways that the patient may need to climb the stairs or manage uneven surfaces. So depending on each individual’s needs and circumstances, the facilitator will demonstrate step-to and reciprocal stepping patterns, using two railings, using one railing, coming down the stairs backwards, folding a walker and carrying it up and down the stairs, and even hopping up and down the steps if the patient has weight-bearing restrictions.
Demonstrating all of these variations could help the patients to understand how to safely maneuver on the stairs if they encounter a set of stairs that might be different from their own. They could also learn from the performance of the other patients as each takes their turn being trained on the stairs. Sometimes errors are made and it can be very meaningful to point them out in real time and talk through how to more safely and effectively complete the activity so that the group can be a part of a problem-solving discussion. And then the same sort of demonstration would happen on the ramp and the curb. The facilitator can demonstrate various ways that the patients may need to handle those elevations.
Lower Body Dressing –
Another functional outcome that would be a meaningful group focus could be the use of adaptive equipment with lower body dressing. There are times when patients are hesitant to use the equipment because they may think that it is not really completing the activity in a normal way. Or they may think that the equipment is too cumbersome, or it takes too long… However, completing this activity in a group setting and demonstrating the use of all the adaptive equipment during the group can be a great way for the patients to feel more comfortable and more competent with the compensatory strategies. So, this would be a matter of demonstration and then having the patients perform the activity with the opportunity to learn different strategies from the facilitator and from the other group participants.
Once you start to think through ways to build groups that are focused on barriers and outcomes, it’s easy to expand on them and come up with more and more ways to create engaging and meaningful group therapy activities! Yoga, although more of an impairment centered group, can be a great way to introduce your patients to how useful group learning can be!
Check out ‘Update Your Care Plan: Balance Rehab’ to find out how to incorporate Yoga into your patients’ home exercise programs as well!
Interested in more clinical tips, articles, and resources for your practice? Sign up for our bi-weekly mailing list below! We promise to treat your inbox with the respect and love it deserves 🙂
As an experienced clinician there are certain things that are expected of you – good time management, evidenced based treatment, and mentoring of students. Now all of those items can be very daunting at times (productivity requirements I’m looking AT YOU), but all three of those things evolve with experience. Here, we look at student supervision- and give you some tips for success!
New clinicians aren’t expected to be stellar at those things, but it is expected that you start working towards being efficient and effective in those areas. One of the most intimidating things as a new clinician can be mentoring graduate student clinicians. Each discipline – PT, OT, and SLP all have their own separate requirements for clinical student supervision, but there are some things that are universal between the disciplines. We all want our graduate clinicians to leave their placements feeling more educated and empowered, but how exactly do we do that? How do we mentor our students so they develop their clinical skills and strong sense of self in the process?
Our professional organizations can definitely provide some guidance and direction. It is strongly encouraged to consult them if you are a first-time clinical supervisor. For discipline specific requirements please see the following links- They not only provide information on requirements for supervising students, but also offer some continuing education courses about effective student supervision!
- APTA: https://www.apta.org/apta-magazine/2018/05/01/compliance-matters-supervision-requirements-for-ptas-and-physical-therapy-students
Your employer can also be a great source of support and information when mentoring students. Some employers have their own “training” programs/education series that needed to be completed prior to accepting a student that can provide you with some effective tools to keep in your student supervision toolbox.
In addition, more senior staff can be a great sounding board when preparing to accept a student – there are some things that can only be learned from experience (i.e., making mistakes) and more senior therapists in your department can help prevent you from making the same blunders they did way back when. One of the many benefits of working on an interdisciplinary team is the ability to bounce ideas off of your colleagues and verbalize your thought process to someone other than yourself on your car ride home.
How can you set yourself (and your student) to succeed during a clinical placement? Review the following tips to set yourself (and your student) up for a productive, enriching clinical experience that will leave both of you feeling like better clinicians.
This seems pretty straight forward and basic, but ensure you have a contact name, number, and email of the person at the school that is responsible for coordinating and monitoring student placements. With each new placement, the student coordinator should be sending on an outline of the program, a supervision manual for what is expected of their students, and various forms for both you and the student to complete and send back during the course of the placement. Familiarize yourself with the school’s program and be sure to mark important dates down on your calendar. Keeping track of due dates will help you guide your supervision of the student and also ensure that the student is meeting the needed “benchmarks” during their placement.
Time goes by quite quickly during placements, and you do not want time to get away from you – especially if the student is needing more intensive supervision and assistance or if you anticipate the placement will need to be extended beyond the original end date in order to be deemed as successful. Take the time to contact the school ahead of time and get to know the student coordinator. It is never a bad idea to invite the coordinator to your site (if feasible) for a tour and a chance to sit down and chat about both parties’ expectations – not every placement site is going to be a good fit for every student (and that’s ok!). You want to know who to contact in the event things start to go downhill and you need some extra guidance to help the student get back on course.
Under most ‘normal’ circumstances you will be getting the student’s contact information ahead of their placement start. Take the time to contact the student and setup an in-person meeting at the facility (if feasible), a Zoom call, or just a regular old fashioned phone call. Email is great for most things, but in this situation you cannot really get a great sense of someone via email. Some facilities permit student interviews prior to being accepted for a placement but not every site has that kind of process.
When speaking with your student for the first time, be sure to ask them what their expectations of the placement are and what they are hoping to get out of it. Ask them their strengths and weaknesses and also ask them what their learning style is. By the time students are at this point in their education they should know how they learn best and it is important they communicate that to you (their supervisor) so you know how to best explain things and relay information effectively. Most importantly, ask them how they prefer to receive feedback about their clinical performance. Some students are ‘in the moment’ people and like to know right away what is working and what is not. Others prefer delayed feedback at the end of the day. Also be sure to ask if they would like to receive their feedback verbally or written – keeping a feedback journal is helpful for those who prefer the chance to back and review things at a later time when they are able to give it their full attention.
The foundation for any successful relationship whether it be personal or work related is communication. If your student does not know they are doing something wrong they are not going to be able to fix it. The same goes for the supervisor – you being the supervisor need to make it clear that you need to know when things are not going well. If we do not know there is a problem then we are not going to be able to help the student navigate out of the situation.
Make yourself approachable and available – that is easier said than done but you need to make communicating with you a positive empowering experience so that your student will not hesitate to come to you throughout the course of the placement. You are meant to be a mentor, teacher, and resource – not a scary supervillain who is out to destroy someone’s self-esteem.
We have all been told at least 1,000 times – if you did not document it than it did not happen. This is especially important in those situations in which the student is not performing as well as they are expected to be. Contacting the school early is key and keeping a paper trail of that communication and action plans is of the upmost importance. Writing out some kind of remediation plan that the student needs to adhere to in order to continue to advance in the clinical placement is a very clear-cut way to outline what the student needs to change and do in order to be successful. You want to ensure that all of your bases are covered in the event that the student is unable to pass the placement – you need the data to back up your recommendations for a failing grade, the need to extend or even repeat the placement. Most schools and programs will have some kind of remediation plan or policy that needs to be followed.
Documentation is not only for those students who are struggling – it can also be an effective teaching tool for those students who are moving along just fine. Some learners find it helpful to have objective and measurable goals written down (much like our patients) so they know what they need to be working towards in order to keep advancing their skills. Almost like a clinical “to do” list – it is very satisfying to check items off of a “to do” list especially when mastering clinical skills are involved.
In order to make progress with your student supervision/mentoring skills you need to reflect on your own performance. Not everything you do is going to be great and you need to be able to recognize when you need to adjust your course of action. If your student is not progressing as they should be under your supervision take a moment and reflect on what you are doing and ask yourself questions such as “Am I communicating effectively? Am I demonstrating clinical skills in a way the student is understanding? Am I making myself available enough to my student for questions and concerns? Am I giving adequate feedback?” You need to keep in mind that you are the “leader” in this situation – you are being expected to set the example for your student. If they see you not being able to recognize when you need to change your approach, they are going to be less likely to change theirs when things are not working.
Student supervision can be a really great, challenging, and rewarding experience. All in all, it will make you better clinician and keep you on your toes with the most recent research and advances in your field. All of our fields only advance when we grow, and we grow by adding new clinicians to the fold every year!
Interested in more clinical tips, articles, and resources for your practice? Sign up for our bi-weekly mailing list below! We promise to treat your inbox with the respect and love it deserves
Have you ever wondered if there is anything that you can do to be happier at your job?
If the answer is ‘Heck yes!’…you are not alone.
Rates of burnout and job dissatisfaction, especially among healthcare professionals, are higher than ever. The number of providers looking to transition to non-clinical careers has skyrocketed and many of us admit to spending much of our day being unhappy with our current work situation.
The key to long term, job satisfaction ultimately comes down to a compilation of factors.
Are you doing something that aligns with your mission, aspiration, and purpose in life?
Does your role provide a good work life balance?
Do you feel respected by your organization and feel a sense of autonomy in your day to day?
If the above sounds like a pipe dream at the moment, don’t worry!
The good news is there are a number of things that you can start doing today that are proven to improve your levels of happiness even in your current situation.
Try these 10 strategies to feel happier at your job today!
1. Smile and Laugh
Next time you are having a rough day at work, try putting a smile on your face. Your body is not able to tell the difference between a genuine smile or laughter and if you are faking it. Turning up the corners of your mouth or having a good laugh (even if it’s forced) has been proven to trick the body into elevating your mood!
2. Practice Gratitude
Giving thanks can make you happier. Whether it is recalling past experiences, relishing in current good fortune, or feeling optimistic about the future, positive psychology research strongly and consistently associates gratitude with greater levels of happiness.
Boost your mood by expanding upon feelings of gratitude in a journal or thank you letter. Gratitude can also be contagious, shown to be a benefit to both parties involved when spoken out loud and expressed.
3. Stay Hydrated
By the time your body says drink up you are already suffering from mild dehydration. The sensation of thirst is triggered by a 1-2% water body loss, the amount that naturally occurs during our daily routine. This same amount has been proven to have a significant detrimental impact on our mood by slowing circulation to the brain and altering the way that we think and feel.
Try re-committing to your daily water intake and watch your mood improve!
4. Be Mindful
Practicing mindful awareness, or deliberately slowing down to focus on our present moment experiences has consistently been shown to increase happiness. An awareness of what is going on within and around you moment to moment may help you to notice more positive experiences throughout your day.
The second facet of mindfulness is acceptance. By simply observing our experiences and meeting them with curiosity vs. judgement we can begin to sit with both the negative as well as the positive.
Awareness and acceptance of the present moment can increase happiness by reducing the need for life to be a certain way, making even our stressful moments more tolerable.
5. Find a Workplace Bestie
Research strongly supports that having friends at work significantly increases employee happiness and engagement. Even though it’s easy to get sucked into work mode, it may be worth trying out some techniques to build stronger relationships in the office and seeking out that workplace bestie.
6. Hold Boundaries
Overwhelm at work is most often not a consequence of being lazy or weak. Individuals who are striving for excellence tend to take it all on their shoulders and may have a difficult time delegating or saying no.
Learning to say no and holding strong to the boundaries of your time and emotional energy has been shown to reduce stress and improve confidence and happiness.
7. Take Breaks
Whether it’s a five minute stretch break, your lunch break, or your yearly family vacation, taking breaks from work will make you happier at your job. Working without proper rest increases stress, which can have a detrimental impact on your system over time.
Taking breaks from work has been shown to improve positive affect, increase job satisfaction and improve mood. This simple trick not only makes you happier, but often increases productivity and creativity as well.
8. Use Positive Affirmations
Positive affirmations are a self awareness strategy used to help shift a negative thought into something more positive. Over time, the neuroplastic nature of your brain may actually begin to see these statements as truth and in the short term they can be helpful for increasing happiness at work by helping to direct you towards a healthy habit for managing stress.
For example, you might replace a negative or anxious thought with “I have the skills and strategies needed to make it through a difficult day”.
A few well placed deep breaths throughout your day can do wonders for decreasing the stress response. When existing long term in fight or flight mode we are more reactive and our threshold for dealing with difficult situations decreases significantly.
Practicing mindful breathing is proven to help activate the parasympathetic nervous system, immediately calming the body and the mind. Re-setting the nervous system and reducing stress can leave more room for positive emotions and interactions to take hold.
10. Savor Positive Emotions
Our brains are designed to pay attention to the negative, particularly in the healthcare environment where noticing a subtle change in patient status can be the difference between life or death. Although imperative to our work and patient safety, if we remain hyper-vigilant to those things that can be threatening to us, we may actually miss out or forget about experiences that are positive or pleasurable.
The work of positivity researcher Barbara Fredrickson suggests that we need to be proactive in recognizing and savoring positive emotions. Even if they are fleeting, we all have moments of positivity throughout our day. Working to shift our attention to recognize and celebrate these experiences can be crucial in increasing happiness.
Try making a mental note to tell your partner the story of a patient’s success at the end of the day. Choose to journal about a moment where you felt really confident and capable in your job rather than solely speaking of the frustrations and worries.
We spend so many hours of our lives at work that it seems like a waste to spend them being unhappy. Becoming happier at your job can be influenced by your internal dialogue just as much as external factors.
Whether you’re having a bad week or still waiting to land your dream job, start increasing your happiness by implementing one of these strategies into your work life today.
Kristen Bingaman writes about being happier at your job and other topics at her site, The Resilient Rehab Mama! Kristen is a Physical Therapist who is passionate about the health and well being of healthcare families. As a Mom, Registered Yoga Instructor and Certified Health and Wellness Coach, she loves sharing her holistic approach to helping healthcare providers foster resilience both at work and at home. Her Facebook group, Resilient Healthcare Families is a resource for Healthcare Providers committed to fostering resilience during difficult times, striving to adapt and grow together.
Like this article? Sign up to our mailing list for a weekly education right to your inbox! We promise to treat your email with the respect and love it deserves 🙂
Edema management. It is not something that you can expect at every hospital… inpatient rehab… or even outpatient facility. Yet, I doubt there are many clinicians who wouldn’t agree- this is a big issue for our patients!
Edema is one of the most chronically underdressed issues, particularly in rehab. The reasons for this are many! It can be masked by other issues, such as medical fragility; it can hide in plain sight, for those who have had slowly worsening chronic swelling; or it can simply be written off as ‘not my area’, by therapists, nurses, and physicians. And a dedicated edema management program? Usually nowhere to be found!
This combination adds to the problem of edema. Under-recognized as an issue, it often is left to slowly progress over time, adding in a host of complicating factors along the way. Untreated edema will contribute to a lack of mobility; a higher risk for skin infections and breakdown; decreased independence and ability to engage in the community, and more. In fact, addressing edema can be incredibly helpful! Here, we can prevent our clients from entering this ‘vicious cycle’ of progressive disability and impairment.
And yet- it isn’t! But maybe, that should change.
Many in-patient rehabilitation facilities have dedicated programs for the wellness of their clients; such as brain injury/stroke/disease-specific care/palliative. These specialized services empower the clinicians and provide resources to the clients to have a more successful outcome. A specialized edema management program, however, are less commonplace – even though edema is a debilitating issue for many patients.
Edema can occur from an orthopedic injury, be neurological in nature, or even congenital. Patients who present to inpatient rehab post-surgery, CVA, or trauma, are likely to have issues with swelling. A process wherein that edema is identified, addressed as part of the plan of care, and continued follow up support given, results in far better outcomes for the patient and carer.
Setting up any type of program is intimidating- and an edema management program is no different. Let’s have a look at the reasons we should be advocating for this service, and how you can be instrumental in setting up this service in-house!
So why should we include edema management in the plan of care?
Firstly, the clinical reasons:
Mobility. The person is clearly more likely to be able to move around, walk for longer, and transfer in and out of bed if they are not struggling with heavy and edematous limbs. Stiffness and discomfort experienced with edematous limbs, also makes it more difficult for our patients to move around. They may be discouraged from ambulation by how strenuous they may find walking on heavy and stiff limbs.
This, naturally, does not help with their goals in rehab. It also impairs their chronic edema issues, and will compound upon the lack of circulation and muscle strength. In a nutshell: Swelling -> less walking -> more swelling!!
Related to this point- treating the person’s swelling is going to improve their skin integrity, aid with wound healing, and decrease the number of infections that they contract. Chronic edema is known to be a cause of cellulitis and erysipelas, both of which can continue to recur if the swelling is untreated. Wounds do not heal as quickly and as well as they might when the circulation around the wound is impaired. Additionally, stagnating lymphatic fluid leads to a cascade of unusual skin conditions, predisposing your client to skin breakdown and infections.
Footwear considerations are also key. A person with chronic and worsening edema is likely to have difficulties finding and maintaining proper footwear. This has a functional impact on their community involvement, and leave them at risk for skin breakdown and injury. Our patients should be able to don their shoes to be an active part of their community and to protect their feet- but many people with undertreated edema resort to wearing cast shoes or some other suboptimal option for community engagement. A common goal in inpatient rehab (for both OT and PT) is applying footwear/walking in shoes.
Now: the non-clinical reasons!
Aside from the clinical reasons to treat edema (of which we have so many!), there are also a host of administrative reasons to begin to address this issue. We all are working in a system, which we should strive to make as efficient and fair as possible, with best outcomes. Providing sub-standard care is unethical, AND inefficient!
From an administrative point of view- first in line is the reduction of re-admissions. We are sure to have fewer re-admissions and a higher quality of health if the patient is at a lesser risk of infections with improved skin integrity. It is also important to note that chronic edema has a progressive nature and will not just “go away by itself” if ignored. Thus, it is important to address it early on in their rehab stay, and make sure our patients are aware of the warning signs.
Additionally- it will set you and your facility apart from other places. The lack of knowledge of edema and the means to treat it in the healthcare is astounding! As clinicians, we are in a fantastic position to advocate for and educate our patients (and ourselves!), to prevent the continual worsening of edema. As we know it can lead to permanent disability, we should be educating healthcare workers all around us to recognize that this is not a transient symptom.
Patient satisfaction is, of course, hand-in-glove in addressing the areas mentioned here! Your patients are going to be so appreciative of the attention given to an issue that may have previously been completely unaddressed, and the more positive outcomes that will arrive with the treatment. Anecdotally, I have found that my patients are so grateful to be heard and treated for this condition, saying things like “I didn’t know I could do anything for this” “No one was ever listening to me about this” and “I can’t believe how much better I feel”.
Lastly, and importantly when it comes to getting the resources and support of your administration, is the marketability of a program like this. Referring doctors, referring facilities, and liaisons will be able to advertise and refer appropriate patients when there are the systems to address the areas they need.
Right! I’m convinced. But where do I start?
First- you should begin by up-skilling in the area of edema management.
Getting some practical skills that you will need in the area of edema management will be crucial in setting up a successful program- this is, after all, a clinical intervention- and you should have the clinical knowhow to support the program. There are several options to upskill- once of which is to become a certified lymphedema therapist (CLT). Becoming a CLT will provide you with a lot of clinical skills and background, intensive practice in manual drainage techniques and compression bandaging. If your facility is investing in its staff, in terms of continuous professional development and program set-up, they may pay for, or reimburse, your registration fees.
Of course, getting the certification is not mandatory for treating these issues. Edema treatment is well within the scope of Physical and Occupational Therapists and nurses! Check out Edema Management in In-Patient Rehabilitation for a comprehensive seminar that focuses specifically on how to incorporate these skills into your practice.
Second- do your assessment of need.
Do an audit, a chart review, or even a straw poll of the patients that you and your colleagues are currently seeing. Would any of them benefit from an program such as this one being in house? Do they have swelling, pain, skin issues, wounds that could be treated if an edema management program was set up? I have found, when working in in-patient rehab, that 70-80% of my patients would benefit to some degree. Swelling, skin issues, and high risk conditions such as diabetes will all be appropriate for preventative care, if not treatment.
Gaining this information will strengthen the need for your program, and get extra support from your colleagues and administrators. It will also provide a baseline that you can point to, of people who need services that are not provided.
Thirdly- Educate your staff and colleagues.
Educating your team as to what you wish to add is crucial. Change can be challenging, as especially with a condition as poorly understood as edema. By including your therapy, nursing, and admin team from the start- it can be tackled together! Educate your team about: the misconceptions of edema; the people who will be appropriate for this program; and what interventions your program will include. Explain the different bandage materials that you will be using, so that floor staff will have a heads up! You will want to clearly delineate what is expected and what will be changing, and how you can be contacted for further insights or if there are any issues.
If possible, try to assemble a sub team that can help set up your program, handle issues, and help you educate. Include wound care, nursing, RNT, PT, OT and anyone else you think would be a great advocate!
Fourthly- set up your program and examine what you need.
In order to begin your program, you will require supplies, resources, assessment tools, and informational packets. I always recommend that people run a smaller, easy-to-manage pilot group to begin with- 10 patients, who all have LE needs, for example. Prepare the order for supplies, the HEPs and plans, and any other tools you need for this group. Note your documentation and admin requirements. Make sure you are using subjective and objective outcome measures to track their progress, and take photographs as much as is possible!
It may be worth exporting their results onto a chart, or writing up a comprehensive report. This way, you can track their results and figure out what worked best. Pointing to their outcomes will also provide support for your program! If you need further supplies or more expensive equipment in the future; having this data will be invaluable.
Setting up an Edema Management Program will not be easy- but I guarantee, it will change your practice forever! This under-recognized and mismanaged condition only complicates the lives of our patients. Having a dedicated service will maximize your outcomes! No matter where you work- you’ll see the need.
If you found this program development article helpful, you’ll love our popular and engaging seminar on the topic of Edema Management. Check it out and read more right here: Edema Management in In-patient Rehabilitation!
Interested in more clinical tips, articles, and resources for your practice? Sign up for our bi-weekly mailing list below! We promise to treat your inbox with the respect and love it deserves 🙂
After a stroke, a person usually has a long road of rehabilitation ahead of them before they can get back to their “normal life”. One of the first things they want to know is when they can get behind the wheel again. As therapists, this is not usually the first question that comes to our minds. We are too busy breaking down their current disability into all its various impairments, so we can make appropriate goals and piece things together in order to help them become more independent with moving around and with basic needs of daily life. However, to the patient…driving is often something that will make or break how they perceive the quality of their life after recovery from a stroke.
After a CVA, there are several abilities that should be intact in order to be cleared to return to driving. Here, we discuss the skills needed to return to driving post-stroke, and some considerations you may want to think about, as a clinician.
Return to driving after a stroke is a topic you may continuously educate your client about. Keep in mind, that all along the rehab journey, you may use the impairments observed in your patient as opportunities to educate them about the return to driving process. You don’t want to avoid the subject or wait until the very end of their stay to talk about it. For example, if they are unable to feel their right lower leg, you could say… “Mr. Smith, remember since we normally use our right foot to operate the pedals in the car, this could be one of the challenges to overcome before you’re able to get back on the road. We will continue to monitor it here and facilitate recovery, but if you still have this impairment by the time you think you’re ready to drive… we may need a driver rehab specialist to look into what modifications are available to ensure everyone’s safety.” (Rinse and repeat for any other impairment.) OK – let’s dive in!
Stroke Impairments that will affect driving ability:
This may seem like an obvious barrier to on-road driving, but we must ensure that our patients have adequate cognitive skills after stroke recovery to handle the predictable and unpredictable conditions that pop up during a road trip.
Attention/Concentration: There are so many distractions for any driver on the road… When you mix in a variety of impairments that come along with stroke, it’s a whole new ball game! If your patient has impairments in attention, they are most likely not going to be successful with any part of driving a vehicle. Sustained attention is needed to keep our eyes on the road, keep our foot on the gas pedal at a certain pressure, wait for the light to turn green, etc. If your patient has impairments in sustained attention, they will most likely not be able to focus on those basic pieces of driving just listed. They will be easily distracted and will not be able to effectively complete the task. Selective attention while driving may come into play when driving through a heavy rainstorm or hale storm. Being able to tune out the visual and auditory stimuli of those severe weather conditions and being able to maintain focus on operating the vehicle is essential! A combination of alternating and divided attention happens throughout the process of driving. At times, the driver will need to use divided attention and “pay attention” to many different things all at once (i.e. – oncoming traffic, operating the turn signals or wipers, listening to the radio or GPS, etc.) and at other times one will need to use alternating attention (i.e. – looking both ways before turning left, where your full attention needs to be placed on looking left, then looking right). As you can see, without intact attention… driving will be almost impossible!
Memory: Do you remember how to drive? Do you remember where you turned? Will you remember to take your keys out of the car? So many things to remember! One main thing to consider when talking about memory and return to driving after stroke, is if the person can remember the modifications or different safely recommendations that you or other clinicians may be making after their stroke. They may be able to remember the “normal” way of doing things, however after a stroke there are usually many modifications to daily life that are being recommended.
Decision making/Problem Solving/Judgement: Being able to make appropriate decisions and problem solve through unforeseen situations while driving is crucial! The light turns yellow… you must determine if you have enough time to go through or if you should stop. The car in front of you is going too slowly… you must decide if it is safe to pass them. You have a quarter tank of gas left… you must decide the best time to stop for gas. The car in front of you stops short… you must decide if swerving to the shoulder is the right move. The list goes on!
Strength & Range of Motion: Stroke often leaves people with asymmetrical strength, sometimes limited range of motion, and even atypical tone (either hyper or hypo). If their right leg has been affected, their ability to push on the gas and brake pedals and move between them will be impaired. Steering the wheel with one hand is certainly possible, but there are many things to consider regarding training and modification in order to make this safe. And a consideration for anyone getting behind the wheel (post-stroke or otherwise) is their ability to adequately turn their head to look in their blind spot.
Sensation & Proprioception: Imagine that feeling you get when you sit on your foot too long and it completely “falls asleep”. Now imagine you immediately hop in the driver’s seat and attempt to accelerate up to a stop sign then slow down and come to a stop… without the ability to feel your foot or where it may be located. It would be challenging to say the least… and that is just the tip of the ice burg of what a person may be experiencing after stroke.
Balance & Coordination: You may have great strength and flexibility. You may be able to feel every inch of every limb. But when you try to move your foot from the gas pedal to the brake pedal… you over or undershoot every time. When you try to make a smooth turn with the steering wheel, the movements are choppy and not uniform. You can imagine how this would impact safe driving!
Reaction Time: Along with being able to place your foot directly on the brake pedal when needed, a driver needs to complete this maneuver quickly at times. There’s a certain amount of anticipation that occurs with braking, however we cannot always predict if someone will stop suddenly in front of us, or if a car pulls out to turn without looking, or if a pedestrian or animal wanders out into the road. All of these circumstances require a driver to react quickly! After stroke, processing of sensory information and assessment of the environment may be a bit slower… and therefore production of the needed motor response with also be delayed. Adequate reaction time is needed to ensure safety of everyone involved… and seconds count!
Visual Acuity: Many people drive and wear glasses. Requiring correction of vision does not eliminate anyone as a driver, however after stroke we would want to make sure that vision is still adequate to see everything necessary to drive safely. Street signs, GPS, pedestrians, lines on the road, other cars, and anything else in the environment… we all have to be able to see what we are doing and what is ahead of us and around us. Visual acuity requirements to drive vary by state, so make sure to know what your state requires in order to assist your patients to assess baseline and get an idea of where they stand.
Visual Fields (Peripheral vision): Depending on where the stroke occurs, it could bring with it some other visual difficulties, such as field cuts. There are already certain areas considered to be “blind spots” in driving… however is a person’s visual fields are not all intact this will leave them with a larger “blind spot” they may have to compensate for. When we drive, most of our visual attention is forward, on the road ahead. But it is important to be able to rely on peripheral vision to alert us of danger and see things coming in order to act appropriately.
Oculomotor function: As mentioned above, most of the time we are looking straight ahead while we drive. However throughout the time a driver is behind the wheel, they are required to quickly move eyes from one target to another (saccades), stay focused on a street sign while the car is in motion (smooth pursuit), or stay focused on any number of things in the environment while the car is moving and/or their head is moving (VOR). If a patient has any kind of oculomotor dysfunction after stroke, they will not last very long in the driver seat without becoming dizzy or nauseous.
What’s the next step to getting behind the wheel?
Provide Preliminary results:
As you can see, there are many roadblocks a person can have to getting back to driving after stroke. Many times, clinicians will defer to the physician when patients ask if they can start driving again. And this is mostly due to simply not knowing how to answer the question. But, if you break it down by impairment, you really can provide the patient with a lot of useful information! Become familiar with what rehab driving school will be assessing and start to work on the areas that your patient struggles with. Many of the things looked at are the impairments listed above. Then talk to your patient about where they may fall short. Be open and honest about what you are seeing and encourage them to follow up with a rehab driving school to determine if there are any modifications related to their specific impairments that would be appropriate.
Refer to Driver Rehab:
Rehab driving school is where you will find the experts… the Driver Rehab Specialists. A Driver Rehab Specialist is a professional who plans, develops, coordinates, and implements driving services for individuals with disabilities. This could be a member of the allied health community or a driving instructor who has taken courses related to the field or obtained a credential in driving rehab. A great resource to find an OT Driver Rehab Specialist has been put together by the AOTA. Information about where to find driving school and Driver Rehab Specialists (including general information about the credential) can be found on the Association for Driver Rehabilitation Specialists website. Read this insightful article for more information, if you are interested in becoming a Driver Rehab Specialist.
When it comes to getting our patients back to living their best lives, we can always take a step toward their goals… driving included! Start with what you know. Evaluate their abilities post-stroke, and educate them about what is generally needed for driving. Then drill down to where they may struggle most and refer them on to the experts for a more comprehensive assessment and recommendation.
For more great ways to help your patients meet their goals after stroke, check out our course ‘Inpatient Stroke Rehab: 14 Strategies to get your Patient Home.’ This powerful and practical 7- credit course will supercharge your practice with those post-stroke, and help you get the most desired outcomes possible!
Like this article? Sign up to our mailing list for a weekly education right to your inbox! We promise to treat your email with the respect and love it deserves 🙂
Do you have a robust oral care program in your facility? If not- your patients may well be suffering the consequences!
Take a moment and think about your morning routine – you get out of bed, hop into the bathroom, and probably brush your teeth as soon you are able to get the toothpaste out of the medicine cabinet.
Also, think about the products you use. Chances are you have a preferred brand of toothpaste, toothbrush, floss, and mouthwash. Think about how your mouth feels first thing in the morning, and how satisfying it is to wash away that terrible overnight taste with some high-quality oral care products on your own choosing. Now, consider being sick in the hospital and not having access to your preferred bands of oral care items or even having the physical ability to do your own teeth brushing.
Imagine not being able to communicate to someone that you would like to brush your teeth, or need to wash a bad taste out of your mouth…
As we know, effective oral care has a large host of benefits for our patients; most commonly, decreased occurrences of hospital acquired pneumonia. Our patients are already battling enough while hospitalized – if we can prevent pneumonia then we need to! But- getting that essential oral care completed can be a bigger challenge then we realize. As clinicians we have a ‘check list’ of items we need to get accomplished when we work with our patients. More often than not, oral care is completed during an activity of daily living (ADL) with occupational therapy (OT) or with nursing staff members. It can also be completed in a speech therapy session with a speech-language pathologist (SLP). Rarely, a physical therapist (PT) has been known to brush some teeth prior to gait training- but those occurrences are few and far between (we still love our PTs though!).
So the questions must be asked… Who on the team is responsible for completing oral care with a patient? Does it always have to be the nurse? What items should you be using to complete oral care? Can patients who are NPO or on thickened liquids still brush their teeth? How do we as clinicians ensure that our patients are getting proper oral hygiene consistently? Well the answer is… ORAL CARE PROGRAM!
There is a laundry list of things that must be considered prior to formulating and implementing an oral care program. These are some of my tips to get you started on your oral care program journey! This information won’t give you exact step by step instructions on what oral care program or protocol to use but will instead give you things you need to consider while formulating your program. You need to remember like much like everything else, oral care programs are not a ‘one size fits all’ item. They need to be tailored to your specific work setting and patient population. Get ready to use those clinical reasoning skills!
Check out these tips to get your oral care program off the ground!
1. Assemble an interdisciplinary team. As therapists, we like to think that our input is the most important and valuable, but that is not the case. The best programs (regardless of focus) are ones that are molded by a team of nursing and therapy. Therapy is not present 24/7 365… in all honesty it is the nursing staff of a given facility that spends the most time with the patient. Nursing is mostly responsible for ADLs and the documentation that comes along with it. By having a diverse group of individuals on your team you will get input from all points of view. What works for therapy may not necessarily work for nursing and vice versa. By having all departments represented your chances of having a successful program increase.
2. Analyze your current process. Take apart your current oral care process (if you have one) piece by piece and see what works and what does not. This may be a good opportunity to interview staff and tease out what their barriers are. Getting honest feedback will help you build a more realistic and successful program. Also look at the current way oral care is documented in your medical record. Is it cumbersome and hard to find? Is it even being documented at all? Looking at compliance for your current process will help you develop your new one and prevent you from implementing ineffective processes and interventions.
3. Look at your oral care inventory. Take stock of what items you have readily available to you for your oral care program and investigate if you are able to expand your inventory. Basic toothbrush, toothpaste, and alcohol-free mouthwash are all an absolute must and there is a solid chance you have them stocked and ready to go. Consider if you would like to add any other items to your stockpile. Suctioning toothbrushes (if you have wall suction available) are wonderful for patients who are NPO or on thickened liquids and then even come with their own packet of alcohol-free mouth rinse. Tongue rakes are also a great addition to your oral care arsenal and are useful in the management of thrush. Having things such as dental floss and lip balm are a nice way to round out your inventory of oral care products. Not to be forgotten are our denture cleaning supplies – denture tabs and cups are items that should be readily available to you. Knowing what you have and what you would like to acquire prior to formulating your program will help you maximize your budget and avoid an unnecessary ordering. (Side note: get a head lamp. You’ll thank me later)
4. Do your research! This time one seems like a no brainer, but it is important to highlight taking ample time to research what evidenced based protocols are out there and what could possibly be a good fit for your facility. Many items are floating around in cyber space but do your due diligence and see which ones are the most up to date. Using a formalized assessment tool such as the Oral Health Assessment Tool (OHAT) may be a good driving force for your program as it is objective, measurable, and easy/timely to administer. The OHAT also makes clinical recommendations based on the patient’s score which make formulating a program a little less painful. Check out this link, for more information on the OHAT!
5. Consider how you want to educate your staff. This is incredibly important as the people completing the new oral care protocol with the patients will need to know when, how, and why. Taking the time to orchestrate a thorough, formal staff education program will help with a smoother rollout and compliance from staff members. Perfection right from the start should not be expected. Instead, be proactive and schedule follow up education sessions and in-services to ensure staff carryover and compliance. Be sure to periodically audit you program and see if and where any breakdowns are occurring so you can address them. If those items continue to be a pain point for your program you need to be willing to tweak your program to make it more effective.
Establishing any new program at a healthcare facility can be a daunting and overwhelming process. Always remember to take a step back and remember why you are doing what you are doing – for the betterment of your patients. Check in and think about how you would feel if you were unable to brush your teeth when and how you wanted. It will make developing this program more seamless and meaningful. BRUSH THOSE TEETH. No one wants pneumonia.
Interested in learning more about the ethical and social barriers related to dysphagia? You will love our 3- cont. ed hour seminar, Life with Dysphagia: Knocking down Social & Ethical Barriers! This course will teach you fantastic tools to focus on the unseen consequences of dysphagia, and provide you with the tools to empower your patients and caregivers with swallowing issues.
Interested in more clinical tips, articles, and resources for your practice? Sign up for our bi-weekly mailing list below! We promise to treat your inbox with the respect and love it deserves 🙂
Dining club, dining program, supervised dining… these initiatives go by many names, but it might surprise you to learn what a POWERFUL effect they could have in your facility!
Take a minute and think about your own eating habits. Now, I’m not talking about what kind of food you eat, how often you snack, or whatever diet you’re currently attempting to adhere to – I’m referring to where you eat, how you eat, and who you eat with.
On the whole, people tend to eat with one or more people. Eating is a very social activity. In fact, the University of Oxford published research in 2017 showing: the more often people eat with others, the more likely they are to feel happy and satisfied with their lives.
Now, apply this thinking… to where you work.
Take a moment and consider the patients you’re currently working with – where are they eating their meals? Are they alone? Are they eating in their wheelchairs, or their beds? Now, I want you to consider their intake – is it good? Are their nutritional needs being met? Are they losing weight? Lastly, consider their dietary needs – do they have dysphagia? Can they feed themselves? Now consider the answers you gave to those questions – dare any red flags being raised to you?
In a traditional long term care facility or nursing home, there is usually a centrally located main dining room, and then other smaller day rooms on the individual units that are utilized for mealtimes. It is common practice to have the more independent residents eat meals in the main dining room (if they choose) and then have the residents who require much more assistance with mealtime eat either in their rooms or in the smaller day rooms on the unit.
Is this the same for inpatient rehabilitation? In-patient rehab is usually more focused on a return to independence, or the previous level of function. Yet, dining outside of their room can be a major blind spot for therapy and nursing staff. Perhaps this may be because it isn’t always clear ‘whose role’ it should be!
Let me ask you some questions…
- Is there a dining room program facilitated at your facility?
- Are you overwhelmed at the idea of starting such a program?
- Are your patients losing out, for want of a program like this??
If any of the above are true… Fear not! We’re going to discuss some top tips as to how to get a dining room program initiated at your facility.
How will it look?
First and foremost, think about what you want your dining room to look like. This means, how you want the tables arranged, and what patients would you like participating in the program. It is often beneficial to break up the dining room into three sections – speech treatment area, direct supervision area, and independent/social dining area.
Designating tables into these sections, assists staff members with knowing who needs the most amount of supervision or assistance. For example, if a patient is assigned to the independent/social dining area, the staff members who are distributing meals know those individuals are able to set themselves up, and do not have any dysphagia diet restrictions or strategies.
How will we communicate about it?
Next, consider how you want to communicate to other staff members who is currently participating in the dining room program. A good suggestion is to put out a daily list of which patients eat where. Some items to include on that list are: name of the patient (remember – do NOT use room numbers as identifiers in place of patient names!), dysphagia diet level (if applicable), dysphagia strategies (alternate liquids and solids, etc.), any type of adaptive equipment, and any type of feeding assistance they may require. Ensure that all staff involved with mealtimes receive a copy of that list or know where to find a copy. Providing a list to the dietary staff is also important. They should know where to distribute meal trays, and so there is not any delay in someone getting their meal.
How can we involve the whole team?
Lastly, be sure to conduct thorough education of all departments regarding the dining room program. It’s very important to highlight the ‘why’ behind implementation of a new program. Change can be tough for people to adapt to. Highlighting the benefits of a new program will assist with staff compliance, and ‘buy in’. It is also important to empower staff to make altered diets appealing for the patients. Referring to something as “baby food” or “mush” is not going to make the patient feel good about their meals.
Dining room programs are a true team effort, and the responsibility cannot solely fall on one department’s shoulders. At the end of the day, this is being done to benefit the patient, not to make anyone’s job harder! Remembering how much we care for our patients can be the raison d’etre for many working in in-patient facilities!
So let’s say you’re having difficulty getting your new dining room program off the ground – what can you do? Well, be sure to highlight the benefits of a dining room program, which we are about to get in to!
Improved patient safety.
By having patients that have dysphagia (swallowing difficulty) closely supervised while eating, it can ensure increased use of compensatory swallowing strategies and quicker identification of new swallowing problems. Also, do people usually eat their meals of the day while laying down in bed? More often than not, NO THEY DO NOT! Being upright in a wheelchair or standard chair can assist with the good positioning needed for safe and effective eating.
Some patients need cues and encouragement to persist with their meals. That type of encouragement cannot be effectively provided if the patient is eating alone in their room. It also gives a more accurate picture of a patient’s meal intake. Some of our patient will “accidentally” throw portions (or all) of their meals away or give their meals away to visiting family or to their roommates. Having those patients eat meals in the dining room with supervision gives us a more accurate picture of how much, or little, they’re eating.
As mentioned in the beginning of this article, people who eat meals surrounded by other people have an increase in life satisfaction. Most social activities are built around food – dinners out, happy hours, brunches, etc. Take a moment and think about yourself – do you eat alone if given the option, or do you choose to eat with a group of people and socialize? Now, it is nice to occasionally eat alone but on the whole we are all very social creatures who enjoy the company of others. It gives our patients the chance to interact with other people in a natural setting and have an organic non prompted conversation.
What if you have trouble getting patients to buy into your dining room program? Be sure to highlight the items that were just listed, but also be sure to stress that it is a part of their rehabilitation program. Also emphasize the importance of trying to establish and maintain a more “normal” routine while being in rehab. It is easy for someone to fall into a bad habit of eating in bed and not keeping a schedule when they are not at home in their normal environment. Ultimately, we cannot force sometime to participate in a dining room program… but we can make a pretty appealing case as to why they should!
As mentioned throughout, a dining room program is a true interdisciplinary team effort. All people involved in patient care need to be on board and need to keep in mind that programs such as one like this is ultimately going to improve patient outcomes. Wouldn’t you like the option to eat with other people who know what you are currently experiencing and socialize a little? Remember, if it is something you would like to have offered to you, please be sure to offer it to your patients. Food tastes much better when shared with others (metaphorically speaking, of course!).
Want to learn more about dysphagia, and the social and ethical implications of management? You will love ‘Life With Dysphagia: Knocking Down Social and Ethical Barriers‘, a 0.3 ASHA/0.3 AOTA CEU, self-paced seminar that will take you through the lesser known conundrums of dysphagia, and arm you with the tools to manage it. Come see why this course is an SLP/OT favorite!
If you work in the field of rehab, you already know… this is a whole specialty unto itself! In-patient physical rehabilitation comes with a very unique set of challenges, demands, and skills. Of course, it also comes with fantastic rewards- any clinician who works in rehab knows that amazing feeling of accomplishment that comes when a patient you saw come in at a dependent level progresses to being able to walk, talk, and look after themselves. Watching someone you cared for walk out the door independently is one of the best feelings any nurse can have!
I always feel like working in rehab is a well-kept secret. You get to work with a team of other rehab specialists- like the physiatrist, Occupational and Physical therapists, and Speech and Language Pathology; to see innovative and amazing equipment being used to help people become more independent in a million ways, from communication, to toileting, to taking their own meds.
The role of the nurse is critical in physical rehab. Rehab nurses are pivotal in working with a patient around the clock to help them implement the new skills they are learning, encourage and facilitate them in being as independent as possible, or helping them to adapt to an altered lifestyle. The nurse can see what many other professionals won’t- such as how the client is coping outside of therapy sessions, at night, or without guidance. Working closely with, and educating, the family and caregivers is also a key area for nursing.
The physical therapist may be assisting the client to get stronger; the occupational therapist facilitating more independence; and the speech therapist working on swallow and cognition issues- but the nurse will help bring it all together. The learning curve to be a nurse working in rehab is pretty steep!
Yet, many nurses find themselves working in rehab without any specialized or advanced training at all; and can quickly become overwhelmed or aggravated by the demands of the setting.
Becoming a Certified Rehab Registered Nurse (CRRN®) can be the perfect answer to some of these issues. Gaining your CRRN credential will show your dedication to working in the field of rehab, your commitment to the rehab model or wellness, and increase your marketability as a seasoned and experienced rehab professional!
Why become a CRRN?
1. Do it for your patient!
Taking the CRRN prep course and exam will make sure that you are completely up to date with the newest innovations and evidence in rehab nursing practice! It is hard to keep up with the current literature, but the course goes beyond just exam prep- it is 12 contact hours of continuing ed, and reviews performance areas across the spectrum, rehab-specific needs of practice and how to empower independence in your client.
The prep course covers many aspects of nursing process and theory, and how to apply these to functional health. Additionally, you will learn how to use your skills to promote community re-integration, and about the legislative, economic, ethical and legal issues involved in rehab.
2. Do it for your team!
Show your dedication to the team! Becoming a CRRN adds weight to your role as a rehab nurse. The insight and expertise that a rehab nurse brings to the table is unlike any other professional, and is invaluable to the working of the interdisciplinary team.
Your employer will value your credential- having specialized and upskilled staff on bard looks good for them! It helps to show the company’s ongoing commitment to providing the best care to the patient, and their support to the team. Having the most up-to-date, dedicated nurses on staff is a goal of any great organization!
3. Do it for yourself!
Invest in your career by attaining this credential. It will be helpful on a daily basis in your practice as a nurse in the rehab setting, but may also serve as a bridge to furthering your career in leadership, teaching, or management roles.
Becoming a CRRN® shows to the world that you are dedicated to the rehab philosophy of nursing- building clients and patients to become as independent and functional in their communities. It shows to your colleagues and team that you are serious in this role, and striving to continuously improve your practice!
Lastly, it validates your experience, the skills and knowledge that you have already built in your career in rehab thus far. You have worked hard- this is the recognition you deserve!
The CRRN credential is awarded through the Association of Rehab Nurses (ARN), and currently has more than 13,000 current certificants. If you want to learn more about the CRRN exam, make sure to visit the ARN website, and check out the exam process!
Like this article? Sign up to our mailing list for a weekly education right to your inbox! We promise to treat your email with the respect and love it deserves 🙂
If you work with patients recovering from a Traumatic Brain Injury (TBI), you know that on occasion they may need a bit of behavior modification for- agitation. TBI symptoms can have quite a wide range, including physical impairments, cognitive impairments, and social/emotional challenges. Usually at some point in the rehab process with TBI, you will see unwanted and disruptive behaviors come and go. Knowing how to approach the agitated patient and de-escalate the situation is key in order to be able to move forward with your goals for their care.
Why agitation happens in Traumatic Brain Injury:
One reason that agitation happens in the Traumatic Brain Injury population is that it can be part of the recovery process. When someone sustains a TBI, they will start to go through stages of recovery that are characterized by the Rancho Levels of Cognitive Functioning.
Per the Rancho Scale- if someone is at a Cognitive Level I (no response), they do not respond to any outside stimuli. They are essentially in a coma. When they move into Cognitive Level II (generalized response), they will start to slowly and inconsistently respond to stimuli. Cognitive Level III (localized response) is characterized by the person’s ability to react more specifically to what they see, hear, and feel; they may begin to be awake on and off throughout the day; start to recognize family and friends and start to follow simple commands. And Cognitive Level IV (agitated and confused) is where most clinicians run into trouble.
At Cognitive Level IV, the person will appear very frightened and confused; they may not understand how they feel or what is going on around them; they will have a hard time following instructions and may overreact by hitting and screaming; and they will be very focused on their basic needs. This stage seems to last forever when you’re helping them through it, but in reality, will run its course and they will move into the next stage within a relatively short time period.
There are four more Cognitive Levels the person can move through, with the last one being Cognitive Level VIII (purposeful and appropriate). This person may still have some lingering difficulties but will be aware of them and be able to apply compensatory strategies to function in day to day life. For a great description of all the levels as well as what family and friends can do to help at each level, check out this great resource.
Outside of the natural healing process, another reason someone with a traumatic brain injury experiences agitation- could be the same reason that we may also become agitated. They’ve been triggered!
Now, this may look much different than your average trigger and people who have not sustained a TBI may have the ability to effectively use coping strategies and work through it. Your patient will not be able to self-regulate very well at this point and they may not even be able to communicate that something is bothering them. Some triggers for a person with TBI may be:
There are several reasons a person with TBI could be experiencing pain. A likely culprit could be persistent headache. We know that even mild TBI symptoms consist of headache, so in someone that has sustained a severe TBI, this could be exacerbated further.
There may also be other orthopedic sources of pain depending on the mechanism of their injury. Fractures, surgical incisions, and other wounds could be causing ongoing pain for your patient.
Some non-verbal signs and symptoms of pain include restlessness, moaning, labored breathing, and agitation. Since this person may not be able to communicate this specifically, it’s important to speak with the patient’s physician to find out if any medical interventions would be appropriate to include for pain management.
Some patients in this stage of recovery have a few add-ons that can be rather uncomfortable – such as helmets, PEG tubes, trachs, IVs, oxygen, etc. These are not things that they likely had prior to sustaining a TBI and these types of medical devices are usually uncomfortable to deal with for anyone – with or without a TBI! These patients are going to feel this discomfort… not be able to communicate the discomfort… and most likely be confused as to what it is and why it is there to begin with. Understandable that this may cause a bit of agitation for someone post brain injury!
Eating, sleeping, and using the bathroom are often things that a patient after TBI needs assistance with. If they are NPO, they may still have a feeling of hunger and want nothing more than to be given something to eat. And when they can’t have it, this could cause agitation. If they are on a PO diet, they may not like the texture or not like the food choices and this will cause agitation as well. The person with TBI may not be sleeping well or may have their days and nights mixed up. So, when you are trying to do any kind of treatment with them, they end up being too tired… and end up agitated. They also may now have difficulty with continence. They have an uncomfortable feeling in their body, but they are not quite sure what it means or how to communicate it or they have an accident and become uncomfortable due to being soiled. They are not able to anticipate these types of issues or problem solve their way through them… so they become agitated!
Loud noises, bright lights, crowded areas, temperature changes, among other things can overwhelm a patient’s system and cause them to go into an agitated state. This could be easily identified by tracking the circumstances that are present when agitation occurs and seeing what sets them off. This could even include people that are in their environment – sometimes there are certain personalities that clash or even the tone of a person’s voice could be too loud or is perceived as noxious by the patient after TBI.
As the title of Cognitive Level IV states, these patients will be confused and agitated. They often require frequent reorientation to place, time, and situation and often perseverate on wanting to leave or go home. They don’t remember who you are, where they are, why they are there… and this can be scary! They want to leave and when they are not permitted to do so, this could escalate the situation.
To learn more about resources available to the patients and families affected by TBI, check out the Brain Injury Association of America.
There are many other things that could cause agitation in someone recovering from a Traumatic Brain Injury, and the most important thing is to pay attention and recognize patterns of behavior that may be occurring, so you can put an appropriate behavior modification in place and help them through the recovery process. It’s important to respond to brain injury-related agitation consistently and professionally.
Try these 3 tried-and-true strategies to help you and your patients through this challenging stage!
Strategy 1: Stay present, stay calm, and don’t argue
Ok, so that may sound like three separate strategies… but they are all related to building rapport, building trust, and teaching your patient what your expectations are. Staying present means that you don’t leave and end the session simply because your patient is agitated and is yelling at you. They may be trying to refuse therapy and yelling for you to get out of their room… but however counterintuitive it may seem at the time – the best thing to do is stay with them and “ride the storm.”
Here is an example of how the same scenario can be handled different ways and why staying present and calm will be the best choice in the long run.
Imagine the simple scenario described above. You go into your patient’s room at their scheduled time and they start yelling, refusing, maybe even threatening to throw something at you.
- If you…Leave and mark that session as missed, you have taught the patient that they are not expected to participate in your plan of care for them. They simply have to act out a bit and they will be able to get out of participating. Even when they move past the confused and agitated stage and progress with their recovery, they will be less likely to want to participate with you as this has now become a learned behavior and they may not feel that you expect much from them.
- If you… Start to argue and correct the inappropriate behavior, you have taught the patient that you are a source of anxiety for them. You are not someone they can be vulnerable with and they will not tend to trust you. It doesn’t matter in that moment if what they are saying is completely wrong – in their mind, they are right and if you try to correct them by arguing with them you will only heighten their level of agitation. It’s very much worth doing a self-assessment when we speak to any of our patients, as we may not always come across how we intend to.
- BUT: If you… Stay present, stay calm, and don’t argue you will get the best result by far! This requires extreme patience and is very difficult to do at times. But if you remain calm and continually reorient them and redirect them to the situation and what your purpose is, they will eventually learn that you can be trusted and they will learn that you expect them to participate in your session during the scheduled time. This may not happen during the first attempt, this may not happen during the second attempt… but if you ride it out with them, they will come around! Some examples of things you may say are as follows:
“Mr. Smith, I see you’re upset. You are in rehab because you have a brain injury. This is your therapy time. I’m going to stay here with you. Let me know when you’re ready.”
This allows you to show empathy by acknowledging that something is wrong. You are reorienting them to the situation by reminding them why they are there and what time it is. You are reassuring them that this time with them is important to you and that you are going to follow through. And you hand them a small amount of control back – they will tell you when they are ready instead of you telling them to do something now.
“Mr. Smith, this is your therapy session. I’m here with you until 1:30. We need to work on [x, y, and z] during this session. What would you like to work on first?”
Here you are telling them what to expect while you are there. They now have an end time, which makes your purpose and presence more concrete. They don’t have to wonder how long they have to work. You let them know what your goals for the session are, which again makes the session feel more concrete. And you allow them to have a choice. You are there for a specific reason, but you are not going to run things – you are allowing them to direct how the session goes as long as you accomplish [x, y, and z].
“Mr. Smith, please don’t speak to me that way. I am being polite to you, please be polite to me. I am your therapist. You are in rehab because you had a brain injury. I’m here to help you get better so you can go home.”
Now, you may see how this could come across as argumentative given that you’re telling them not to do something. However, if delivered in a calm and even tone this is quite effective in pointing out the inappropriateness of how they are acting. There is nothing wrong with calling them out on what they’re doing as long as it’s approached the right way. This type of cueing may even take a few practice runs in the mirror or some role playing with co-workers. This will also reorient them to why they are there and what the “end game” is… going home – which may be motivating to some patients.
You will know what the exact wording needs to be based on the needs of your patient. The main thing to remember is to stay present and calm and work to build the trust and rapport you need to help them stay calm and be present in their own recovery. While you are using these strategies, there may be some down time and “waiting it out” when not much “therapy” is going on. But this is well worth the time spent in the beginning in order to get the outcomes you’re looking for in the end. You will gradually teach the patient how to treat you by remaining consistent and continually reorienting and redirecting them.
Strategy 2: Provide Structure
When someone sustains a TBI and is going through the cognitive stages of recovery, they are confused at times, disoriented to time and place, don’t always remember who their caregivers are or what they’ve done throughout the day. Since they are unable to organize and process all of this information, it can be useful to provide structure to them in a few different ways. Helping them keep track of things will give them a sense of comfort and security and may help prevent agitation before it occurs.
- Calendar – Having a monthly calendar readily available is going to provide an easy and consistent way to reorient the patient to time and also keep track of activities and appointments that are coming up. Often times, if unexpected things happen to or around a person with a TBI… this could send them into a tailspin! They usually have very little flexibility of thinking due their injury (and depending on what stage of recovery they are in) and the more concrete you make their day, the information you present to them, their environment… the more chance you have of holding back the anxiety and agitation. Giving them the ability to anticipate things that fall outside the realm of a “normal day” will be a life saver!
- Daily Schedule – You don’t want to leave the day to chance. Your patient has lost so much control over their bodies and their lives, that a simple thing like knowing what to expect throughout the day will help them feel more settled and less anxious. They will know what to expect and have more time to process the information and complete whatever preparation they may need to. A great place to start is their therapy schedule. Coordinate with all the therapists and with nursing to see when each therapy would fit best in the day for that particular patient. Write it down and provide it to the patient, so they always know when to expect you. And if this has to change for any reason, make sure to tell them ahead of time! As they start to recover and are able to participate in more high-level activities, you can add other things to their daily routine. These things may be a wake up and bed time, morning and evening routine, making a call to a family member, going on a community outing, going to an appointment, etc. The more they know in regards to how the day will unfold, the better. And since it is written down, they won’t have the pressure of trying to remember what is next. They can look at it as many times as they need to.
- The Care Team – As much as possible, try to have the same therapists, nurses, aides, etc. work with the patient on an ongoing basis. As mentioned previously, these patients (especially if they are at a Cognitive Level IV) will be confused and disoriented and will be fairly untrusting at first of the people trying to care for them. Seeing the same faces day in and day out, building trust, and establishing expectations will be key in preventing and de-escalating episodes of agitation. And on the clinician side of this factor, it is much easier for us to know how to approach someone, how to anticipate needs, what strategies work (and which ones don’t) if we are the ones seeing them each day. If the patient with a TBI has to get to know a different clinician each day for their whole recovery period and those clinicians have to try their best to get to know everything that is going to make the session or treatment go as efficiently as possible… progress is going to be rather slow, if not non-existent. Consistency and structure in the care team is what you want to strive for.
The three examples above are some of the more natural ways you can incorporate structure when you’re starting to formulate your plan. They are a good place to start, but any type of structure you can provide will be helpful in decreasing brain injury-related agitation and helping your patient with TBI feel more confident in themselves, and with what they see around them. Try to always give instructions in a concrete way, so nothing is left to chance and provide information in writing (if they are able to read and comprehend) so they can review it at will.
Strategy 3: Make a Plan & Meet their needs
So, this may seem oversimplified. Meet their needs. As healthcare professionals, we want to make a difference and help people… we always strive to meet the needs of the patients we work with. However, when you’re working with the TBI population and you are at the point where behavior modification is needed – it may not be so obvious what their needs are!
Step 1: Identify triggers – When your patient with a Traumatic Brain Injury starts to have episodes of agitation, you want to carefully track what preceded the episode, what is in and around their environment, who is caring for them, etc. By paying close attention to these sorts of things, you can easily identify what undoubtedly sets them off. There will still be times that the agitation seems to be insidious, but for the most part you will be able to find out what circumstances are troublesome for that specific patient. This type of tracking is best done with input from the interdisciplinary team. So, if your facility has a daily huddle or a daily clinical meeting – this type of information should be brought up then so everyone has the opportunity to ask questions that are relevant to them and that others may not have thought about. Sample questions that should be explored are:
- Were they found to be incontinent? Were they wet or soiled?
- Were they in the same position for a long time? Could they have been uncomfortable?
- Did they feel too hot or too cold?
- Were there any loud noises? Or other environmental irritants?
- Was someone trying to work with them when the behavior started to escalate? Or were they alone?
- When was the last time they ate? (if not NPO)
There are a whole host of other questions to ask depending on the needs and circumstances of the patient and the episode of agitation. But having a quick discussion as a team will be the fastest way to identify what is triggering them.
Step 2: Identify needs – Once the triggers are identified, you can more easily identify what the patient needs. If the patient seems to always be found as incontinent when the agitation ramps up, they may need to be toileted more often. If the patient seems to get restless after a certain amount of time in their chair, they may need rest breaks in bed. If they seem calm in their room but hate being in the therapy gym with other people, they may need a quiet space to start treatment in. If light seems to bother them, sunglasses may be in order! If they are constantly asking for something to eat, maybe giving them double portions at their meals would be appropriate.
These patients will have needs, just like all the other patients that we work with. Unfortunately, agitation is the person with brain injury ‘s way of saying they need something, or something is wrong. Once we identify why they are acting out, we will know what to do!
Step 3: Make a plan – All the information discussed above will go into a behavior modification plan. This plan should be easily accessible to all clinicians caring for the patient and should be initiated as soon as possible. You can include things like:
- Names of people on their care team
- Names of caregivers or contacts
- Therapy schedule and/or out of bed schedule
- Toileting schedule
- Environmental modifications
- Triggers of agitation
- Strategies for de-escalation
- What types of external memory aides are being used
- Any other special instructions
As your patient with a TBI moves through recovery, there are going to be times that are challenging and there are going to be behaviors you observe that are irrational and sometimes quite explosive! Agitation in brain injury is not uncommon… however no one (you or the patient) has to simply suffer through this time. If we take a step back and make sure we are building trust and rapport, providing structure, and meeting their needs… we can all experience a smoother transition through the Rancho Levels of Cognitive Function.
If you are interested in learning more about assessment and treatment of Mild TBI, check out ‘Practical Approaches to Concussion Management‘! This powerful seminar provides skills and tools to be able to assess, treat and manage concussion and the complications that may arise from it.
There is a solid chance you’ve heard the phrase ‘trust your gut.’ As a rehabilitation professional, you probably know when there’s something *not quite right* with your patient. It’s our job to be an advocate for the patient, and to communicate our concerns to the physiatrist and attending physician. But how can you make sure that your concerns are communicated well, and acted upon?
Unfortunately, many of our colleagues (and probably ourselves) have been put into this uncomfortable position. How do you advocate for your patient, and not only be heard, but be actually listened to (and taken seriously)? Consider the following five points to assist you with communicating your concerns effectively.
Having a “bad feeling” just is not enough to justify further diagnostic testing, stat lab draws, or even a transfer to the acute care emergency department for further evaluation. As a rehabilitation clinician, you need data to support your therapeutic interventions, goals, and recommendations and you also need it when communicating a change in status to the physician.
You may be asking yourself, “What kind of changes do I need to observe? What is considered significant?” Something to keep on your radar is increased weakness. If you notice that your patient has increased weakness, especially on one side of the body it could indicate a new (or evolving) CVA or other neurological issue. It is likely that if a patient is experiencing increased weakness, their functional status will also change, meaning their transfers may require more assistance, they may not be able to ambulate, and their ability to perform ADLs will also diminish.
Something else to take notice of would be a change in the patient’s speech and language. If a patient is noted to have an increase in slurred speech, or an increase in word finding it could indicate an acute neurological change.
You may also note a change in the patient’s ability to swallow and their ability to feed themselves to go along with the change in communication abilities. A change in cognition is also something to be attuned to.
An increase in overall confusion can be indicative of a brewing infection – most often a UTI or something like dehydration. It would be beneficial to check the patient’s most recent lab results, and recent record of food/liquid intake. This is especially important for patients on altered diets as there is a known link between thickened liquids and dehydration.
There are, of course, a lot of other changes that can take place with our patients, but the ones mentioned are some of the most common ones that pop up.
Re-administering some assessment items to illustrate a decline in status is also helpful in building your case. For example, the Orientation Log is a 10 point serial assessment of orientation for anyone who is confused. The Orientation Log can be used to document progress, or decline, from day to day. Read more about the Orientation Log, and its uses, here.
For example, if you approach the physician, and indicate that your patient scored 25 points out of a possible 30 points on assessment, but is now scoring 15 points, it presents a clearer picture when discussing the patients decline in status. Saying “I think they are more confused” is not going to help your cause – we could ask ourselves, “do you THINK, or do you KNOW?”
We want to be the best advocate to our patient that we can be, and skilled documentation is a huge part of this.
Documenting concrete functional changes in your daily note (regardless of how large or small), as well as keeping some notes for yourself are going to be helpful when pleading your case to the physician. If you work in a facility or setting where daily notes are not required (believe it or not, they do exist) start writing a daily note in the chart where applicable.
Do your best to paint a picture of the patient’s current functional status, and functional decline. Also document any interdisciplinary team communication regarding the patient’s status, including any communication with the physician(s) you may have. You need to remember that if you did not document it, it did not happen. CREATE THAT PAPER TRAIL.
Further improve your communication by reading: 5 Things to Think About when Educating Caregivers.
Look at the big picture – is the patient having increased difficulty or a functional decline in other disciplines? Communicate with your fellow team members – other therapists, nurses, and allied health professionals (respiratory therapy, registered dietitian, nursing aides, therapeutic recreation etc.) and see if they are noticing the changes that you are noticing. Has there been a functional decline during their sessions, or interviews? Has the patient’s nutritional intake declined? Have they needed more oxygen support during the day or overnight? Do they need more assistance with activities of daily living, or are they now incontinent?
Ensuring that the entire care team is on the same page is going to be key when approaching the physician with your concerns. If the decline seems to be only specific to your discipline, take a step back and look at what you’re doing – maybe you changed the way you are cueing them and don’t realize it, or maybe the time of day you’re scheduled to work with them is impacting their performance.
EMPOWER THE PATIENT
Talk to your patient and ask them how they are feeling if they are able to accurately and effectively communicate with you. Make them part of the conversation about their care. Remember: it’s THEIR plan of care, and you can also help the patient advocate on their own behalf.
Encourage them to communicate with their physician(s) about how they are feeling, and what they are noticing. More often than not, patients do not want to ‘bother’ the physicians because they feel they have more pressing issues and other patients to manage. We need to empower our patients to speak up! Their physician cannot help them if they do not know what is wrong. Also, as therapists, we traditionally spend more time with the patient then the physicians do, and patient may be more inclined to speak with us about their concerns then the physician. It may be helpful to be present (if you are able) when the physician rounds on the patient to help facilitate the conversation between the patient and the physician about what items have changed for them over the course of their care. Your presence can help give your patient the confidence to advocate for themselves.
You have done your due diligence, and you have all of the concrete evidence you need to approach the physician(s) about a change in your patient’s status and condition. Now, as satisfying as running, yelling, and waving your hands at them would be, you cannot take that approach if you want to be taken seriously!
Monitor your tone, rate, volume, and body language. You don’t want to seem accusatory or rushed, but you do need to communicate confidently. This seems silly to some, but you need to be professional as possible when communicating your concerns. Use good eye contact, professional jargon, and monitor your volume, rate, and tone. Not all physicians may be receptive to concerns, and some still feel that things are only a problem if they recognize them as a problem. You cannot control how someone is going to receive your concerns… you can only control how you present them. Some great tips on improving your overall communication skills are here! Check it out for a list of 10 items that can assist you with being an effective communicator.
Demonstrating solid clinical reasoning skills and good communication skills will help you build trust with your facility physicians. The more your physicians trust you, the more likely they will be to take your concerns more seriously when they arise. Being proactive, demonstrating active listening, and being open to their suggestions will also assist with building a solid physician/clinician relationship. At the end of the day, we’re all here for the betterment of the patients and we can’t take things personally if the physician does not go with our particular recommendation.
At the end of the day, you cannot make someone listen to you. Communication is a two way street, and you need to ensure that you are using every tool in your box to be heard. You need to feel confident that you are doing everything within your power to be an effective patient advocate, and to communicate changes in functional status when they arise. Trust your intuition and do your due diligence. Your patients and colleagues will thank you for it… and do not forget to DOCUMENT!
Interested in becoming a more effective patient advocate? Check out our Certified Brain Injury Specialist Training Course! Obtaining your CBIS sets you apart from your peers and show that you are committed to keeping your clinical skills with the ABI population sharp. It can inspire confidence in your patients and their families and give you the tools you need to assist your patients recover.
Grab these Say This, Not That cheat sheets!!
Grab these three guides- of what (and what not) to say in order to: Maintain Dignity; Respect Emotional Aspects; and Increase Intake! These tools are incredibly helpful in education and implementation, and for kitchen staff, caregivers, and your team.