Last month, I began working with a unique and challenging patient at my facility. The person in question had not been out of bed since early spring, had serious comorbidities including permanent ROM limitation of most joints, chronic pain and (not surprisingly) was of a bariatric size. Having read this patient's POC goals, I was already frustrated without even one treatment session being completed.
Bed mobility without hand rail assistance? Static seated balance -- edge of bed? This person was a two person max assist for log rolling in bed with trace trunk stability -- how was I going to help him meet this goal? Obviously, this treatment session was a bigger undertaking than I could handle, literally. I would need a second and possibly third person to assist me with providing just functional (and safe) positioning techniques in supine.
The understaffed and overworked CNAs would help of course, but didn't have the luxury of an hour to assist with the patient's seated balance. However, very often I'll incorporate the patient's bed mobility training with functional tasks such as donning/doffing clothes and hygiene care along with the aide staff -- who are more than delighted to have an extra hand offered by therapy.
In this case, I tapped my colleague in the gym office, a COTA who was just as frustrated with how she was going to approach this patient's treatment. Interestingly enough, she told me that she had not participated in many co-treatment sessions with PT in her career. I was stunned because it was a daily occurrence for me at my former facility.
This patient was the perfect candidate for a PT/OT co-treat: significant weakness both in upper and lower extremity, low endurance to complete two separate skilled therapies in one day and the multiple-person assist he required. I reviewed what my focus would be for that treatment (bed mobility and LE therapeutic exercise) and she communicated the OT goals (increase UE ROM and core strength). With this clear delineation between our goals, we were able to assist each other when necessary and offer an effective co-treatment session that served the patient and both therapy disciplines' POC.
As this patient became stronger, his pain was reduced and his activity tolerance increased. After a few weeks, the COTA and I began initiating our treatment sessions separately in the morning (occupational) and afternoon (physical therapy). Had our two therapy disciplines not joined forces in those early weeks, the patient wouldn't have progressed as far as he has today or perhaps not at all. Every patient has individual challenges when it comes to therapy, but I've found (when appropriate) that teaming up with other therapists (whether OT or speech) can lead to successful outcomes for everyone.
I recently had a conversation with a small group of close friends and former colleagues who also happen to be PTAs. As we're all kindred spirits at this point, having worked closely together in a SNF setting for years -- we laughed and commiserated over our shared experiences. One of my friends posed the question to us all regarding our opinions on working with a patient who is "end of life."
She explained how conflicted she felt as a therapist when having to approach a patient for therapy who is ready to "let go." She mentioned in one particular case, the patient was in her 90s, had lived a full life (with her spouse and peers already passed), and was ready to stop fighting so she could move on herself. This PTA was expected to "work" with this patient for 65 minutes -- as she lay supine in bed.
In the long-term care facility where I work, if a patient has medically declined to the point of "end-of-life," her doctor and nursing staff will recommend hospice services or "comfort measures," which essentially places this person on therapy-hold. Rightly so, but this isn't always the case.
I and each of my colleagues discussed having had a session with patients who were not on hospice -- yet passed on the next day or even later that evening after their therapy session. Typically, these are extremely ill patients and in severe pain/discomfort, so it comes as no surprise when we hear the news the following day. As my friend pointed out, this is cold comfort knowing we had them performing PT during their last hours left on earth.
My personal opinion is that if a patient is agreeable to therapy, my job is to provide this service and I certainly adjust accordingly depending on the patient's endurance and tolerance level. If a patient declines therapy and displays signs of increased fatigue, lethargy and pain, the nursing staff is notified and the refusal is thoroughly documented. As well, I'll notify the primary PT and in some cases my director of rehab.
All of my PTA friends did agree that sometimes, just the opportunity to spend a few minutes with patients as they enter this last phase of life can offer them support and comfort -- whether therapeutically billable or not. In the end, I trust that utilizing my clinical skills and a dose of compassion will lead me to make the appropriate therapy (or non-therapy) choices for these patients.
Over the past few years, I've written many-a-blog on the subject of patients refusing therapy. I've discussed different approach techniques and tactics, depending on the patient, which might help improve compliance.
This week, I was the recipient of (arguably) the most creative "decline" as to why a patient could not do therapy. As I approached this 80-year-old woman who was seated on the edge of her bed, and requested we "go for a walk down the hall," she simply declined stating she couldn't possibly due to her "pregnancy." Granted, the patient has a dementia diagnosis but even so -- that was the first time I heard that particular excuse in skilled nursing therapy.
This experience had me thinking about other creative types of refusals I've received from patients over the years and I thought it might be interesting to share:
The Procrastinator: These are the patients who request for therapy to come back an hour or two later than their scheduled session. Only to do this all day long and ultimately not work with PT at all.
The Possum: Patients who feign sleep despite the fact that you can see their eyelids move as you call their name.
The King/Queen of Pain: The patients who state they cannot participate in therapy because they are in 10/10 pain as they casually walk across the room to answer their phone.
The Avoider: These are the patients who will participate in every activity the facility has to offer (bingo, puzzles, prayer circle, even OT and Speech)... other than PT. Typically never in their room and very hard to track down for therapy.
Mr./Mrs. Popularity: On occasion we'll see a patient who has so many visits from family and friends, therapy literally has to take a number just to fit in an hour's worth of skilled services.
This is obviously a generalization and many times patients display a mix of "all of the above" behaviors. With all my patients, I spend time educating on the benefits of physical therapy and conversely, the risks of not participating -- whether we make it to the therapy gym or not. Do any of these patients sound familiar to you? What is the most colorful decline you've ever received?
I recently was looking for a good read at the library -- anything that would pique my interest and whisk me into a riveting story that related to my life in no way. As it turned out, I passed on the gritty crime fiction novels and historical fiction (my fave!) and picked up a book on caregiving for people with dementia.
I was immediately hooked as I began to read the no-nonsense approach techniques for caring and treating family members or "clients" with this diagnosis. A close friend (also a PTA) called me on 8:30 a.m. that following Sunday, to find me power-reading through this book, only to chuckle that she was "impressed with my commitment" -- to my patients.
I'm not touting that this book is the "definitive text" on managing difficult patients with dementia -- but I do feel that I was eager to learn more about the disease process and approaches that will enable myself and the patient to have a successful therapy session. Currently half the patients in my caseload live on a secured dementia unit. Having more of a knowledge base on this diagnosis and skills to effectively communicate is pivotal for increasing their safety and quality of life.
When I arrived back to the secured unit of the facility on Monday morning, my first impressions were of how "non-effectively" the aide, nursing and housekeeping staff were communicating with the residents. The most glaring example being how people with dementia will "mirror" the emotions of their caregivers. If a CNA becomes angry and frustrated, that person will find the patient expressing the same behavior in response.
In a discussion with my rehab colleagues later, and citing the previous interaction I witnessed with the aide and patient, we were all in agreement that all staff should receive mandatory dementia training. I'm certainly no expert because I read one book on the subject, but I do feel more informed and prepared to care for my patients.
If staff, along with myself, received monthly or even yearly in-service training, we would all benefit -- but especially the patients. As a therapist in a long-term care facility with a specific secured dementia unit, I feel obligated to seek continuing education opportunities to learn more about dementia. However, for the caregiver staff who aren't expected to seek supplemental education -- mandatory dementia training should be offered.
I've recently blogged about the potential closing of the long-term care/skilled nursing facility where I work. Although there has been no formal announcement from the administration, census continues to slow and hours have been cut from all departments -- for the exception of rehab. Due to the fact that we continue to generate revenue for the facility and are required by state law to provide skilled services to the residents, physical therapy continues to be an important presence in the building, albeit with smaller daily caseload of patients.
Typically I would have seven to eight patients on my daily schedule -- currently, I have four to five. Combined with a contract guaranteeing me a full-time position (at least 32 hours per week), my days are left with a few hours to fill. With the encouragement of my rehab director, I spend a large portion of my days screening patients, auditing wheelchairs and assistive devices, contributing to committee meetings, and providing CNA training for safer transfers. All of these activities are non-billable and although I record the time I've spent with each individual task, do not count toward my "productivity" percentage.
Watching my productivity numbers drop is alarming due to the many years spent in skilled nursing facilities where I chased a mark of 80-90% each day. However, I am just as busy if not quite as stressed. I believe the decreased stress has led me to make better clinical decisions and has given me the opportunity to branch out in my role of a PTA. It makes me speculate about how much better the quality of therapy our patients receive would be if therapists did not have the productivity "noose" around our necks each day. Will this last for my rehab department? Of course not. Eventually, efficiency of the therapy staff will become top priority again as more patients are added to caseload.
In this interim period, though, I will take advantage of the "low-productivity" expectations, with a full understanding that this is a unique opportunity to hone my therapeutic skills and learn more without the pressure of the clock.
During the first week of PTA school, our director announced that the median age of the class was 33.5 years old. We students, spanning from age 20-55, had come from all walks of life. I remember a few fellow classmates had just received BS degrees from 4-year colleges and others were entering physical therapy as a fourth or fifth job incarnation.
This age breakdown discussion was completed with my director announcing that "within a few years" the program would include 18-year-old students. His prophecy was correct and an 18-year-old did enter the program within the following year's cohort.
How can one graduate from an accredited PTA program by the age of 18, you may ask? The same junior college that runs the program also offers a "Running Start" program for high school students that allows them to take general education college courses in lieu of college prep classes at their high school.
Therefore, a studious and focused 16-year-old can earn credits toward an associate's degree as well as her diploma. A 17-year-old student can easily complete the prerequisite courses and apply to the PTA program before she even turns 18.
The question the program director posed to the class, which has been proven over the years since, is the following: Does an 18-year-old PTA have enough life experience or "people skills" to be a successful clinician? As well, will it be more difficult for a younger PTA to secure a job versus another "older" prospected hire?
I like to think a smart, energetic PTA (who also happens to be a teenager) would be a perfect fit for certain PT clinics and facilities. Depending on the clientele, an 18-year-old might be the best choice for the job, bringing youthful energy and enthusiasm. Not to mention their neurons are firing quicker than most (well, at least mine).
Ultimately, the old adage "Live your age, don't act your age" can apply to my young counterparts just as much my patients. I've met more than a few mature and responsible teens, as I have careless and disinterested middle-age folks in the medical profession over the years.
What's your opinion regarding the young and ambitious PTAs graduating today? Would you hire a fresh-faced 18-year-old PTA in your clinic or facility? If you are a "young" PTA, what has your professional experience been like so far? I would love to hear from you!
In a typical therapy session, I attempt to fit in the most important tasks I feel the patient needs to focus on for that day. Therapeutic exercise, gait training and pain management modality -- it can be challenging to fit the session goals into the allotted 45 minutes to an hour. Then there are times when the patient is so weak and ill, bed-level exercises and bed mobility are the only options for therapy. In these cases, extensive rest breaks due to increased fatigue and education regarding importance of movement with healing can be filled during the treatment time -- which is duly documented.
One documentation "gray area" I find when working with a patient, particularly one who is new to my schedule, is billing for the time where I'm "building rapport." There are many instances where, after introducing myself to a patient, I'll attempt to engage the person in a topic of interest. Any discussion of family/job/dog/sports/music (etc.) can and usually help relax the patient and begins to build our therapist-patient relationship. These "chats" can last up to 10 minutes or more before any skilled therapy begins.
Throughout the session, I find having irrelevant conversations off topic of the patient's medical condition can lead to an overall more productive treatment. In some cases, the amount of activity is lower but the quality and effort are increased because the patient is less stressed. When I finally sit down to document for that session, I'll chart that extensive rest breaks were taken and encouragement was provided. Personally, I don't actually state that a portion of the treatment time was dedicated to "building rapport," but I've read notes where those exact words were used by other clinicians.
I'm not about to stop engaging my patients in discussions that bring them comfort and some enjoyment, but it definitely can be a balancing act. Keeping a person focused on the therapy session just as much as the talk of his favorite NFL team, it can be challenging but necessary. As well, appropriately billing for therapy treatment is my responsibility as the patient's PTA.
Over the past 4 months, I've been acclimating to a new PTA job -- as I've described at length in some of my previous blogs. The work itself is similar to my previous PTA position in a skilled nursing setting but the environment is completely different. Initially, the slower-paced, smaller rehab department of a long-term care center was a huge adjustment from my previous facility's large rehab-staffed SNF. Most days, my former facility felt like a frantic stressed-out, corporate-run pressure cooker, which was a difficult environment to thrive in as a therapist -- not to mention give quality treatments to patients.
However, that previous job was a stable one, where I had accrued benefits and paid vacation over the years. The decision to leave and move on to another, smaller, independent facility was a difficult one -- especially leaving fantastic colleagues who I've worked and collaborated with for almost 3 years. Unfortunately, my job choice "gamble" has not worked out as I hoped. Although my new facility has a long history of good service, as (un)luck and incredibly horrible timing would have it, a closure at this location is imminent.
As I begrudgingly throw my hat into the next job search, I question if my decision to leave my initial stressful SNF was the right one. Maybe or maybe not, but change and adapting to that change is only making me a more savvy PTA. During the next interview process, I'll have questions for the rehab management that I've never thought to ask before. Including but not limited to: How will this rehabilitation department be growing and improving over the next year?
Have you accepted a "promising" job opportunity only to have it fail miserably? Are you inclined to work in a stable job and not take a risk? I would love to hear reader opinions and experiences.
Last week my 10-year-old daughter pointed to her leg and asked "What's this bone called, Mom?" Specifically, she was pointing to a bony prominence on the lateral aspect of her lower leg and wondering why her friend had a "bigger bump" than herself. I quickly responded "Well, that's your..." and in that moment I realized two facts: I could name all the muscles associated with the lower extremity but I could not recall the name of that bone.
As a parent, when confronted with a question that I don't readily feel I can answer sufficiently, I try to spin a "teaching moment" for my kids and myself. In this case, "Let's look it up!" I told my daughter and her friend. As luck (or positional irony) would have it, I had recently unpacked a box of my physical therapy textbooks from school including a beloved original anatomy text that was sitting in the kitchen.
As I fished through the pages looking for the knee chapter, I remembered how arduous the anatomy class was for me back in my first semester of PTA school. The rote memorization of the OIAN of muscles and general frustration of trying to understand the shoulder joint. As if by osmosis of simply holding the anatomy book, I recalled the bony prominence in question: fibular head.
That's right -- I had completely forgotten the name for the fibula. More than disappointing considering I've been a PTA for a number of years now. I did a quick checklist of all the major bones of the extremities and spine that I could identify -- not too bad. But I wasn't going to pat myself on the back -- I forgot the fibula after all. The fact is my anatomy skills are rusty.
Just like I tell my patients, if you don't use it -- you'll lose it. In their case, I'm referring to the ability to walk if they don't attempt to stand, but the same can be applied to anything including anatomy knowledge. I simply don't treat many orthopedic patients in my SNF/long-term care facility. My focus is improving balance, transfers and gait safety. The majority of my patients are end-of-life and/or have an advanced dementia diagnosis. My approach and communication skills are strong because they have to be to work with that particular population. My recall of the carpal ligaments? Not so much.
I now have my old anatomy textbook at the ready at work, including a very helpful anatomy app on my phone that was reviewed and recommended by ADVANCE recently. I also plan on taking a few continuing ed courses that focus on specific joint rehab I feel the need to review. The "unidentified bump" debacle was an important reminder that I'll need to be responsible for maintaining my knowledge and skill level regardless of the setting where I work. As well, I won't have to pause when locating the fibular head anytime soon.
I have found there are a few skill sets PTAs might find useful in their careers that are not covered in the PTA program curriculum. The techniques relate mostly to skilled nursing PT, as that's been my setting since I graduated, but can certainly translate to home health or inpatient/acute physical therapy.
The first and most often demonstrated (during my typical day) is toilet transfer training. I would also include bedside commode (BSC) transfer under this skill. Perhaps due to occupational therapy's ownership of bathroom ADLs of all kinds, this particular transfer was never discussed in class. That's just my theory and I'm probably completely off the mark (side note: I love OTs!). As it turns out, I perform toilet transfers multiple times a day to work toward a safer, functional transfer. Quite often, the primary PT will set a toilet or BSC t/f as one of the patient's short-term goals.
Speaking of transfers not discussed in PTA school: car transfers. Again, here is a functional transfer I regularly include in therapy sessions that involve the patient and family/friends. Typically everyone involved is eager to learn and motivated since the result is the patient's increased safety and independence (and ability to leave the facility -- which is a huge incentive for them).
Last but certainly not least, wheelchair management training. Although we did indeed have thorough training in wheelchair fitting in class, I was never taught how to adjust the brakes, attach anti-tippers or raise/lower the wheel height. All of which I've had to learn and perform on almost a daily basis. Disclaimer: both SNF rehab departments I've worked in did not employ a rehab aide who could also perform these maintenance services. However, I find knowing how a wheelchair is constructed and can be modified only makes me a better clinician for my patients. Not to mention, sometimes I'm the only person there to fix it.
Let's face the facts: On-the-job training post-PTA program profoundly trumps the basic skills you learn in school. An accredited PTA program offers a stunning amount of information in a concise, accelerated time frame. I still recall my instructor stating that it was impossible to teach us every skill we'll require for our patients and he was absolutely right, of course. But a few extra optional labs in the handicap-accessible bathrooms might've been beneficial.
"I have a positive attitude and I surround myself with positive people. I eat cleanly and have a bowel movement every day -- it makes a difference (wink)."
This wise statement was given to me by a 98-year-old patient when I asked her, "What is the secret to aging gracefully?" This particular person did not use an assistive device, walked faster than me and had better posture than anyone I knew, regardless of age.
Over the past few years, my PT caseload had been predominately made up of the geriatric population. Since I started in skilled nursing therapy, a day hasn't gone by where I haven't learned something from my patients about the human condition. Whether witnessing the steadfast resiliency of an 80-plus-year-old recovering from a pelvic fracture or the gentle wilting of spirit with a person suffering from dementia -- each day holds lessons that I might not have been able to experience if not for physical therapy.
I find treating the geriatric patient as rewarding as a high-level athlete. Typically, my patients are dedicated, respectful to their plan of care and tough-as-nails (there are always those exceptions to the rule, though). As well, there's an absence of the sense of entitlement many other younger patients from different generations carry to their treatment session.
Working in a skilled nursing/long-term care setting with this age group has enabled me to take a hard look at my lifestyle and attitude. What can I do today that will improve my health and quality of life when I'm 90? That is if I'm lucky enough to reach my ninth decade. Personally I've attempted to reduce the level of stress I allow in my life, move my body as much as I can and, as my 98-year-old patient sagely stated -- stay positive.
Summer is in full swing as we head into July. The kids are out of school, the sun is out (even in the drippy Pacific Northwest that I call home) and everyone has earmarked their week/s of vacation in the coming month or two. Working full-time in any job, really, warrants at least a week of mental and physical relaxation outside the "office." In the skilled nursing setting -- between efficiency scrutiny and challenging patient caseloads, those vacation days can be a lifeline or at least an oasis to recharge my energy and outlook.
This year, however, I've accrued no vacation days due to starting a new job a few months ago and having to wait a year before I can take a "paid" vacation day per contract outlines. Although I do get paid holidays, those days are considered typical working days if they fall on Monday through Friday. This means, other than taking a sick day when I am or (more often than not) my kids are ill, I won't see a paid vacation day until the summer of 2015. Let me just emphasize that taking a few days off to nurse a sick child is no vacation, by any stretch of the imagination.
Do I appreciate that my employer offers paid vacation? Absolutely! In fact, post-one year of employment, I'll receive 15 days to enjoy throughout that following year. In the interim, I'm monopolizing my weekend days with mini road trips and "stay-cations," kids in tow. A few extra days tacked onto these weekends would be ideal, but for now I'm finding the peace and reenergizing rest I need close to home. As well, this is giving me the time and motivation to schedule the next big family trip. When summer rolls round next year, this PTA will be relaxing far from home or facility pressures, preferably on an uneventful beach that only follows island time.
Recently, in the middle of a treatment session, I had a patient worriedly ask me if the skilled nursing facility where we were working was "going out of business." Considering how random the question was, but more importantly how concerned the patient seemed, I attempted to ease his mind with the truthful answer of the facility's stable future.
I followed this up with a question about where he heard this information. The patient then stated he knew of employees' hours being cut and general nervous malaise spreading throughout the staff.
How would a patient know of staff members having garnished hours? Either an employee of the facility felt the need to share this type of information to the patient or (more likely than not) the patient overheard a conversation between staff. Whichever might have been the case, this additional stress is the last worry a patient should be concerned with.
When in the therapy gym or the busy hallways of the SNF, information between therapists and other healthcare staff is exchanged constantly. How easy is it to "vent" frustrations to each other -- whether about a specific patient, colleague or facility practice? Very simply human nature, of course. I find "discussing" my day with colleagues to be an imperative stress reducer -- when patients are not present and in the privacy of a closed therapy gym, that is. One unguarded and disparaging comment in front of an unassuming patient can potentially lead to days of confusion and anxiety for him.
Working in healthcare can be incredibly stressful -- as we all know. In addition, our patients can be compromised with pain, depression and anxiety of their own. Guarding our private conversations from patients is just another safety measure to insure patient comfort and confidence in their care team. Not to mention, avoid those awkward conversations.
There are many motivating techniques as PT/PTAs we can utilize with our patients to encourage participation and compliance with their plan of care. I like to think my ability to discuss a wide range of topics (Halibut fishing? NFL stats? Crochet patterns?) can angle me into getting an extra ther-ex set of mini squats. Despite my varied repartee with patients, I've found nothing as truly motivating as having family present during a session.
Having worked with the young 18-30-year-old to the end-of-life geriatric patient, I can tell you from my experience, when a spouse, parent or child is observing or in many cases participating during the treatment, the patient (in most cases) exerts more energy and simply tries harder than if it were a regular one-on-one session. This does not exclude patients with cognitive impairments. I've seen patients with advanced dementia, who are typically agitated and nonverbal become (physically and emotionally) calm and even carry on conversations with their family members. This results in a vastly more productive therapy session than the average with that person.
With a few beautiful exceptions, most patients don't have family members present during their daily treatments because it just isn't realistic. Most patients have therapy 5-7 days a week and their close family members work or often don't have transportation to the facility (this is a major obstacle for spouses who don't drive anymore). When the opportunity arises and a family member happens to visit during the patient's scheduled therapy hour, I highly encourage that person attending. Often family and friends feel like they're "intruding" or "disrupting" their loved one's therapy session. I'll take that opportunity to educate the family on the importance of their presence and encouragement.
Unfortunately, there are instances where family members are so incredibly uncomfortable witnessing their loved ones weak and ill -- they can't leave the patient's room fast enough as I enter to begin therapy. But when the opportunity arises, those family and friends can be incorporated into a therapeutic session. I never pass up the chance to suggest they observe or, even better, encourage them to participate in the therapy session. The cathartic love that family brings into therapy can be the most successful tool for a person's recovery.
Once upon a time, not but a short few months ago, I worked in a large corporate-run skilled nursing facility where the productivity of the rehab staff was considered top priority. Even above the recovery of the patients, you may ask? Almost -- with productivity expectations a very close second. Every week our rehab meeting would lead with our director addressing our "team" productivity percentage average.
My days were spent running from one patient to another -- furiously, scheduling my patients back-to-back, so I would only "lose" 2-5 minutes between each treatment session. An unexpected family visit or unscheduled out-of-facility MD appointment for one of my patients could sabotage my productivity for the day. I would half-joke with my colleagues that I could pinpoint the exact time of day when my productivity dropped from 90 to 70%.
With that type of atmosphere, I would get anxious during my "downtime" between treatments, sometimes breaking off a quick casual conversation with a patient or family member because I had to track down my next patient. When spending just a few extra minutes with a person can be the highlight of his session or at the very least build a rapport of trust.
You can imagine my shock when I began my current job at another skilled nursing/long-term care facility where I was told productivity was not their driving focus. Due to the fact that this rehab department was "in transition" -- the expectation was to deliver quality therapy as they build up their rehab unit over the next few months. As the only PTA and one of only three therapists making up the team, there's still quite a lot of building to be done.
Although I don't have the "productivity police" looming over my head on a daily basis anymore, I continue to be shrewd with my timing and often feel my pulse quicken when a treatment is delayed unexpectedly. I have no doubt when the new rehab department is in full swing and the gym is bustling with patients and therapists, our productivity will be scrutinized more than it is now. But until then, I'll enjoy rapport-building and helping patients reach their goals vs. my minutes reaching 90%.