Use nursing rehab techs to maximize licensed staff
In-house program trains staff
A new position of nursing rehab tech (NRT) has helped maximize the time of licensed staff at the Rehabilitation Institute at Santa Barbara (CA) and continues to provide quality care while controlling costs.
NRTs are certified nursing assistants (CNAs) trained to do about 70 additional tasks that historically have been done by licensed staff. These include blood glucose monitoring, positioning affected extremities, dressing simple wounds, starting and discontinuing tube feeding, wrapping amputee stumps, using a passive motion machine, and applying stabilization devices. (For pointers on setting up an NRT program, see story, p. 172.)
"We decided that based on shorter lengths of stay, higher acuity, and fewer licensed staff, we needed a creative way to ensure quality of care and help the organization stay viable," says Maggie Wordell, RN, CRRN, director of education, who coordinated the training course.
During the past four years, the Rehab-ilitation Institute’s staff skill mix has changed from 70% licensed and 30% unlicensed to a 55% to 45% mix, according to Melinda Staveley, MS, RN, vice president of clinical services/nurse executive.
During the latest budget year, the nursing department was actually able to add full-time equivalency positions by increasing the percentage of unlicensed staff and by absorbing the position of director of nursing into the vice president of clinical services position.
The 45-bed rehab hospital employs nine nursing rehab techs and 10 certified nursing assistants. The hospital nursing staff is divided into teams, each of which cares for a group of six to 10 patients. Each team includes a registered nurse and one or two unlicensed staff, depending on the caseload and acuity of the patients.
"This has been a highly successful program. The NRTs have expressed high job satisfaction, and our licensed staff are delighted," Wordell reports.
The NRTs are assigned to all three shifts at the hospital. They continue to do the traditional CNA tasks as well as additional duties for which they are trained as NRTs.
The registered nurse remains responsible for the tasks she delegates to the NRTs. The techs cannot do assessments and cannot do a task, even if it is part of their training, unless the nurse delegates it.
Choose assignments carefully
At the beginning of every shift, the nurses assign the NRTs their tasks for that day. The NRTs are not allowed to ask someone else to do their assigned jobs if they are busy. Only the RN can delegate.
Initially, the registered nurses questioned the nursing rehab tech program because it meant they would have to delegate skills that took them years to learn, Wordell says.
The skills the NRTs learn are the same skills that nurses teach patients and family members to perform after discharge. "That’s how we could sell the program to our nursing staff," she says.
Now nurses have learned to value the NRTs and say their day is far more stressful if an NRT isn’t assigned to their team, Wordell reports.
Learning to delegate
After the first NRTs had been working for a while, Wordell surveyed the nursing staff and the NRTs to see if the RNs were delegating the tasks for which the NRTs had been trained.
The team leadership worked with the licensed nurses to encourage them to delegate the tasks they were not assigning to the NRTs, Wordell says. For instance, most nurses were not delegating wound care because many of the wounds were complex and needed to be handled by a licensed person. They were encouraged to do the complex treatment, such as irrigating the wound themselves, then assign the NRT to apply the dressings.
The training program includes 40 hours of classroom teaching and demonstrations over a five-day period and a three-month preceptorship. The CNAs who are trained to be NRTs are paid for their classroom time. Their positions on the floor are filled by per-diem staff.
After a week of classroom training, the NRT candidates must pass a lengthy examination with a score of at least 80%.
Then they go through a three-month clinical orientation during which they are paired with a preceptor who is responsible for making sure the candidate is trained in all of the NRT skills.
Nurses who are preceptors for the NRTs attended an eight-hour preceptor class on adult learning and teaching skills. During the three-month orientation period, the CNAs must perform their regular responsibilities as well as learning and practicing the additional skills. They must demonstrate a skill three times with 100% competency before they are considered competent in that skill. Preceptors meet weekly with their assigned NRT candidates to discuss how the program is progressing.
When all the NRT candidates have completed their competencies, the hospital acknowledges their achievement. NRTs get a 10% pay raise and are given the title of nursing rehab tech.
Each year, the NRTs must pass competency evaluations in selected skills. Criteria are based on seldom-used, problem-prone, and high-risk procedures, Wordell says.
Nurses choose delegation tasks
To develop the class, Wordell, the director of nursing, and the nurse managers studied the California Board of Registered Nursing guidelines for assistive personnel and compiled a list of all the skills that would qualify under the requirements. Nurses were asked to give their input on tasks they felt comfortable delegating.
Wordell created the curriculum, using input from all disciplines as well as nursing. She chose staff members with expertise in each topic on the skill list and worked with them to devise the course content and objectives.
When the program began, the hospital administration gave all the CNAs the opportunity to apply for the program.
Candidates went through a lengthy admissions process before the first group of six were chosen for the program. (For details on the job qualifications, see chart, p. 170.)
"They worked their way through the application process, and by the time they had completed it, we had a good idea if they were capable of taking the class," Wordell says.
[Editor’s note: The Rehabilitation Institute at Santa Barbara is available for consultation on its nursing rehab tech program and will customize the program for other organizations. For more information, call Maggie Wordell at (805) 683-3788, ext. 111, or Meaghen Lewis at ext. 113.]
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