Anyone involved with care of the chronically ill knows the extensive influence of registered nurses who staff and coordinate patient care. Too often their efforts become an endless treadmill of meals, medicine, and maintenance.
Five years ago, the Intermediate Care Unit at the Veterans Administration Medical Center in Roseburg, Oregon was typical of many nursing homes. A 75-bed unit held chronically ill patients with severe parkinsonism, debilitating cerebral vascular accidents, Alzheimers disease, Huntington's chorea, and other serious neurological disorders requiring back breaking care. Many of these patients had been hospitalized for years. The frustrated nursing staff kept busy with endless rounds of feeding, changing linens and pajamas, applying restraints, inserting catheters, and administering medications. Care was custodial and morale low resulting in resignations and requests for transfer.
Today, patients are walking about, dressed in personal clothes, planning holiday parties, going on picnics, and deep sea fishing. Several work in sheltered workshops. Best of all, the majority of patients are being discharged from the hospital to nursing homes, foster homes, or their own family homes.
As Hospital Nursing Education Coordinator, I was amazed at the impact nurses had on improving patient care and felt their success could be achieved in other health care settings. This is the reason for telling their story.
Preparing for Change
The physician in charge of the unit retired. Other physicians were not attracted to the uninviting group of patients offering little hope of cure or recovery, so it seemed timely to explore other methods of management. Since the patients' needs were primarily personal care and rehabilitation, things nurses could provide, the chief nurse* proposed organizing a Nurse Administered Unit. Instead of one physician responsible for 75 patients, each patient would retain the physician who transfered him or her to the unit. Specially trained nurse practitioners and a highly qualified nursing coordinator would provide the link between medical and therapy personnel.
Using the holistic concept, incorporating a concern for the whole person, the nurses began moving from diagnoses and treatment to identifying patients' assets, working with strengths rather than deficits. This meant allowing patients the freedom to try to surpass constricting diagnostic labels; to watch for clues in patients' readiness to try new activities; and to motivate patients in a variety of ways to improve the quality of their lives.
The following goals were formed to express the philosophy of holistic care as it pertained to this group of patients:
1. Assist patients to function at their highest levels by retraining existing skills.
2. Help patients compensate for lost skills.
3. Increase patients' abilities to achieve self-care.
4. Improve patients' self-esteem and regain a sense of identity by participating in individualized programs and activities.
5. Plan for discharge home or other community setting.
Reorganizing the Unit
The unit coordinatorf began working closely with the chief nurse to analyze ways of achieving the unit's goals in a systematic fashion. Staffing was adjusted to meet increased demands for assisting patients with independent activities, A 6 AM- 2:30 PM shift brought personnel to assist with shower and dressing activities. A 1 PM- 9:30 PM shift added staff during the critical socialization hours in the afternoon, dinner, and bedtime.
The total nursing staff included the following:
- One RN unit coordinator;
- Two RN patient group leaders-day tour, rotating tours if needed;
- Eight RN staff nurses-rotating day, evening, and night tours;
- Eight LPNs utilized for medications and special care-rotating all tours; and
- Fifteen nursing assistants- ranging from orientees to highly experienced personnel-rotating all tours.
Two nurse practitioners were the most significant addition to the nurse administered unit. They had recently completed an intensive training program and received state certification. Their preparation included classes in physical assessment and many hours of practice with a physician to learn the skills of observing physical changes and making decisions about medications, diagnostic tests and nursing treatment. Usually nurse practitioners are found in outpatient departments and clinics, but these two nurses chose to work on a difficult patient unit.
The nurse practitioners, unit coordinator and key staff nurses began an indepth analysis of the 75 patients. All available data was reviewed such as diagnosis, length of time on unit, current strengths and capabilities, daily behavior, activities of daily living done by the patient, family background and availability, religion, current medications and treatments, and potential for discharge. Looking at the type of nursing care required, patients were separated into the following three groups:
1. Patients with potential for rehabilitation and already performing some activities of daily living with possibilities for future discharge. Designated as Group Two.
2. Patients capable of some increased independence if allowed to wear regular clothes, have bowel and bladder control, and ambulate in a protected area. Designated as Group One.
3. Patients requiring total care for severe, progressive conditions including neurological disorders, cancer, and complex infections. Designated as Group Three.
Twenty-seven beds were designated for Group Two patients allowing maximum freedom and space for rehabilitation activities. The area closest to the nursing station was chosen for 34 Group One patients since it offered large areas for dining and recreational activities as well as a locked door providing a protected environment. Patients could leave the unit but were accompanied by one of the nursing staff for walks, picnics, and other daily activities. The remaining rooms with 14 beds were chosen for Group Three patients requiring intensive bed care.
Early in the reorganization, the nurse practitioners assisted the staff in developing a bladder and bowel training program. By decreasing the amount of cathartics and stool softeners, changing diets to include prune j uice and bran with breakfast, adding cranberry juice as nourishment, and establishing a toileting schedule, incontinent patients gradually became almost totally continent.
Encouraged by the success of bladder and bowel training, the staff gained confidence. When a laundry mix-up brought a pair of bib overalls to the ward, one of the patients was assisted to wear them. It seemed miraculous how regular clothing restored this man's pride in appearance. Gould changes in patients' behavior be more significant to recovery than a diagnosis or room number?
New ideas flowed in earnest. Why not ask family members to bring suitable clothing? Why have special feeding chairs when dining tables and chairs are available? Why not have colorful curtains on the windows and plants, fish, clocks, music, and activities to stimulate awareness?
Max Smith (fictitious name) was a prime example of the care required by Group Two patients. Max was a paraplegic with an ileo-loop bladder who had been in a variety of nursing homes for the past 14 years. Every nurse and therapist knew Max had no desire to become more independent or be discharged. His care was demanding and he criticized everything the staff tried to do. An acute episode of pneumonia left him in critical condition on another hospital unit. After a lengthy convalescence, he requested to return to the nurse administered unit. This time he appeared with massive decubiti, bowel problems, severe depression, and a 20 lb weight loss. The nursing team tackled a hopeless task, calling on new ideas from every member of the staff and therapy departments. The result- Max was able to accept his first job in over 14 years in a rehabilitation center for the handicapped.
A swallowing team was formed by the nurse practitioners, occupational therapist, dietician and RN group leader to work with patients like Frank Mitchell (fictitious name). Frank was transferred to the Special Care Section in Group Three shortly after its organization. His previous cerebral vascular accidents left him with many complications and he was given only two weeks to live. A weeping dermatitis covered his entire body and he we fed through a nasogastric tube connected to a food pump. Extremely agitated, Frank resisted initial communication when the staff tried to approach him. His wife said she hoped he would not have to go through another painful rehabilitation.
Again the situation seemed hopeless. Nurses and nursing assistants on all three tours, being highly sensitive to the patient's condition, began developing a rapport with him. As their caring hands soothed his skin and encouraging voices make him aware of his surroundings, he became less agitated and slowly his skin began to improve. Frank regained enough strength for the swallowing team to start its program of developing licking and tasting stimuli so the nasogastric tube could be removed. Three months later, Frank was able to eat his favorite food, mashed potatoes and gravy. His wife on seeing this, burst into tears of joy.
Huntington chorea patients presented a unique challenge. At one point, five were on Group Two in various stages of the disease. Their dramatic choreiform body movements led to construction of custom built upholstered side rails. Special sheepskin leg protectors allowed them to sit in chairs. Bean bag chairs and an exercise mat were tried to allow maximum movement in a protective environment. One patient, a former newsman, was obsessed with the memory of typing and mailing in his copy to meet a deadline. Although he couldn't physically accomplish this task, the staff felt he should be allowed to have his old typewriter on the unit. It was brought out of storage and he was encouraged to use it. Another patient showed interest in billiards. A nursing assistant dared to try the impossible by helping the patient stand at a pool table and successfully hold a cue stick.
Patients in Group One needed five main areas of activity; learning and using daily living skills, reality stimulus., muscle and joint strengthening, diversional stimulus related to prior aptitudes and job skills and recreational stimulus. Small groups of patients with similar activity needs were placed together so personnel could become instructor/coaches. One example of this was a simple exercise program conducted by a nursing assistant in which patients tossed a ball or did simple calisthenics.
Reality orientation had its greatest impact when combined with recreational activities. When interest was expressed in fishing, a charter fishing trip was organized for nine patients and three staff members in Group One. Several salmon were caught and it was suggested they be used at a barbecue for patients back at the hospital. This stimulated all kinds of patient activity like making invitations, flower arrangements, and decorations. One of the "fishermen" who had previously spoken only one word and had to be restrained when admitted to the unit, gave the following welcoming speech to guests at the luncheon. "Welcome. I went fishing. I didn't catch a fish but I'm sure going to eat some."
Every holiday provided another excuse for reality stimulus. This started when some of the staff mentioned how little contact patients had with their families and how sad it was to be alone at Christmas. A Christmas party was planned with the staff searching old records for family names and addresses, helping patients send invitations, getting community groups to help patients select and wrap gifts, planning refreshments and music. The day of the party was filled with nervousness. How would outsiders feel? How would the patients react? The party was a success with family members coming from several states. Feet began tapping to the rhythm of the music and one patient, previously confined to a wheelchair and unable to walk without assistance, unexpectedly reached towards his wife, got up, and began dancing with her. Old memories came alive!
Severely ill patients with last stage neurological disorders, terminal cancer, and draining wounds requiring isolation were among those receiving care in the 14-bed special care section. RNs, LPNs, and Nursing Assistants with advanced training in sterile technique and other complex procedures were assigned to this area. Potential pressure sores were identified and monitored through the use of nursing care plans with the result that bed patients, comotose for months, never developed skin breakdowns. Special sensory stimuli were obtained including colorful mobiles, pictures, clocks, calendars, soft music, and a soothing towel bath.ij;
Communication between personnel in all patient groups was considered crucial. Peer reports were started at the change of shift with RNs reporting to RN's, LPNs, and nursing assistants receiving report from their peers going off duty. Following these reports, walking rounds were made by the total group, including the nurse practitioners, to each bedside or day room. Nursing care plans, used by staff on all tours of duty, were updated during rounds and became permanent parts of the patients' records.
Weekly interdisciplinary conferences were another vital means of communication and planning. All services were invited, including a physician representative, pharmacist, dietician, occupational therapist, physical therapist, and others. Each service was notified of new patients admitted to the unit by Tuesday to provide adequate preparation before the Friday conference. Staff nurses brought input from LPNs and nursing assistants. Nurse practitioners prepared their assessments. A total of five or six patients were reviewed, with each participant allowed five minutes of uninterrupted time. Openend discussions followed to develop future plans and the unit coordinator, acting as moderator, summarized discussions. In this way, new patients as well as all other unit patients received review from the diverse group involved in their care.
Working with Physicians
Now that each patient retained the physician who transferred him to the Unit, it was necessary to replace unit routines with coordinated, individualized care. The Nurse Practitioners provided the liaison for the nurse administered unit. Clinical privileges were developed with key physicians, the unit coordinator, nurse practitioners, and the chief nurse. These written statements permitted the practitioners to independently order diagnostic tests such as electrocardiographs, pulmonary function, serum blood levels, blood chemistries, parasitology, and microbiology. They could order noninvasive xrays and interpret more complex diagnostic tests. Standing orders were developed, allowing the nurse practitioners to order medications for short-term use when needed for pain, cold symptoms, bowel problems, gastric distress, sleep, and simple abrasions. These medications could be given up to 48 hours without counter signature by a physician.
Once privileges and standing orders were established, the practitioners divided the unit with one working exclusively on group One. They began by reviewing patients' transfer orders. The transferring physician continued to be in charge of the patients' care but daily decisions could often be made by the nurse practitioners. Signs and symptoms were brought to their attention by any observant member of the nursing staff. With current input, plus direct observation, the practitioners could make immediate changes in treatment or order diagnostic tests at critically needed times. In situations not covered by clinical privileges and standing orders, they consulted the physicians for further direction. Physicians continued to see their patients at least every 30 days to write a progress note and update medication orders. At the end of the patient's hospitalization, the practitioners wrote the discharge summary.
The majority of doctors gradually accepted the nurse practitioners largely because they were seen as nonthreatening collaborators. Clinical privileges and standing orders were clearly written, making it easier for physicians to accept nurses making independent decisions. In addition, physicians found it easier to make their decisions based on sound facts supplied by the practitioners.
Results After the First Year of Operation
Evaluating the unit's progress, the following statistics showed an interesting development:
1. The majority of patients were dressed in personal clothes, walked about, went on picnics, had parties, and, for many, the first family attention in years.
2. Of the patients, 28% were discharged to their own homes. Another 48% were discharged to nursing homes or other facilities requiring greater independence.
3. Physicians accepted the nurse practitioner role and became more interested in patient welfare.
4. Pharmacy reductions saved $349 month in less need for sedatives, tranquilizers and cathartics.
5. A $ 1,500 restraint order was cancelled.
6. An order for 27 feeder chairs was cancelled saving $2,500.
7. Multidisciplinary conferences offered a forum for planning care and produced significant results.
8. Nursing personnel were learn- ing to observe patients' readiness for greater independence and felt pride in patient's accomplishments.
This nursing staff's experience can be replicated in other health care settings, particularly in chronic disease centers and most nursing homes. Every registered nurse employed in these institutions should be encouraged to get short-term physical assessment training. According to Ingeborg Mauksch, a pioneer in the nurse practitioner movement, basic assessment skills will be a part of the basic preparation of all nurses in the future.1
At Roseburg, we asked the nurse practitioners to teach selected assessment skills to other hospital nurses so patient concerns could be met more scientifically. At first reluctant to add activities that would take them from direct patient involvement, the nurse administered unit practitioners and two other nurse practitioners in the outpatient department began planning program content. Many nurses, including the education coordinator, expected to start learning to listen through a stethoscope. Instead, these practitioners taught us how to listen to patients.
The first series of classes was an intensive, 11-hour course on interviewing which required a brief patient interview during theintitial eight-hour segment and two completed written interviews prior to the follow-up afternoon session three weeks later. One nursing supervisor summarized her experience by saying, "I never knew a patient could teach me so much."
This initial program led to several others on head to toe assessment and introduction to lung and bowel assessment. It was hoped nurses would be motivated to continue self-study and enroll in more extensive physical assessment programs.
Information about community and state-wide continuing education programs on physical assessment is available from inservice educators at nearby hospitals. Shorter courses can be coordinated by inservice educators for one or more nursing homes. In addition, the American Journal of Nursing Company offers an 18-unit Patient Assessment series in programmed instruction format which can be studied individually or in a group.
Nurses in Nursing Homes and similar care centers often make independent judgments in the absence of physicians and therapists. Why not give them the training and authority to order or perform and analyze certain laboratory tests? Physicians would be provided with more specific information upon which to base judgments and nurses could give more scientific care. Standing orders for frequently needed drugs would permit nurses to start giving medications when first needed by patients rather than waiting for a crisis or giving a variety of drugs like sedatives and stool softeners on routine schedules.
Collaboration of key nursing home physicians, administrators and registered nurses might initiate regrouping of patients based on degree of independence and nursing care requirements. It is easier to provide physical activities and rehabilitative programs to similar clusters of patients. Nurses aides and licensed practical nurses, like their counterparts on the nurse administered unit, can become vital contributors to improving patient care when given the chance to work in an open accepting administrative climate that welcomes their suggestions.
Interdisciplinary conferences can be held in nursing homes on a modified basis. Conferences might be held monthly instead of weekly and include representative consultants and physicians currently on the staff. A cook or consulting dietician might represent food service and a member of the nursing staff could review medication usage and other patient care procedures. A member of the administrative staff could discuss organizational and budget factors.
Family involvement can dramatically personalize institutional care. Relatives and friends could be contacted to learn more about patients' previous occupations and interests. The nurse administered unit staff started a scrapbook with snapshots brought by family members showing patients in their productive years. This helped bring patients' potential strengths into sharper focus, giving incentive to starting bladder and bowel training as well as novel reality orientation programs.
Perhaps the ultimate positive change for the chronically ill in institutions would be to add a nurse practitioner, either full- or parttime, to the staff. Their specific training prepares them for admission screening and discharge planning, assessing constantly changing needs and achievements, working with other nursing personnel to adapt patient care and collaborating with physicians. The Kellogg Foundation recently funded a project being conducted by the Mountain States Health Corporation to add a geriatric nurse practitioner to 25 rural and urban nursing homes in five Northwest states. At this writing, the practitioners have graduated from university based programs and recently begun working in the health facilities.2
One group of nurses dared to improve patient care in a seemingly hopeless situation. The challenge was there. The need was immediate. The goals were achievable. They did it. So can others.
- 1. Mauksch I:Critica! issues of the nurse practitioner movement. Nurse Practitioner Nov-Dec:15, 1978.
- 2. Gerdes J, Pratt S: In anticipation of the geriatric nurse pracitioner. Nurse Practitioner Nov-Dec:14, 39. 1978.
- Fink DL: Holistic health: Implications (or health planning. Am J Health Plan 1:2331, July, 1976.
- Gerdes JW. Pratt SC: In anticipation of the geriatric nurse practitioner. Nurse Practitioner Nov-Dec:14, 39, 1978.
- Levine E: What do we know about nurse practitioners? Am j Nurs Nov: 1799-1803, 1977.
- Mauksch IG: Critical issues of the nurse practitioner movement. Nurse Practitioner Nov-Dec:15, 35-36, 1978.
- Shortridge L, Habif L, Smith M, et al: Opportunity to learn physical assessment in a continuing education course. J Con tin Educ Nurs 8(4):6-ll, 1977.
- Stillman PL, Gibson J, Levin-son Det al:The nurse practitioner as a teacher of physical examination skills. J Med Educ 53:119124, Feb 1978.