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%.
Last weekend I ran my second half-marathon. In hindsight, I'm pleased with my performance, having finished 4 minutes faster than last year's half. When I signed up for the run this year, however, I originally set the lofty goal of running the full marathon. I gave myself four months to train and established a week-by-week running regime to reach my goal. The first two months went well -- I didn't miss a training run and was easily increasing the mileage. Then life happened. Between unexpectedly switching jobs and a hard-hitting flu bug sweeping through the household, somewhere between week 8 or 10, the plan jumped the tracks.
When I came to terms with the fact that I would have to "downgrade" to running the half-marathon vs. the full, I was initially disappointed in myself. It was then I realized there are many times in the physical therapy setting when I have to recommend that a patient downgrades a short- or long-term goal. Despite the concerted efforts of the patient, the primary PT and myself, sometimes reaching a particular functional goal becomes unrealistic. If a patient has to return to ambulating with a front-wheeled walker versus the four-wheeled rolling walker due to increased weakness as a result of a health decline -- that's simply the more realistic and safer choice.
I'll explain to the patient that goals are established in the plan of care by the PT to reach his highest function and independence. The goals are assessed weekly and adjusted accordingly. There are even times when patients far surpass a short-term goal and surprise everyone on their rehab team, including themselves. Whichever the outcome, the only way to "fail" is to give up and not participate entirely. Perhaps a gait goal was never fully met and maybe I'll never run a full marathon -- but when the effort was made and the goal modified and reached, people should not be disappointed in themselves.
I recently had a routine but painful dental procedure performed by my good-natured dentist. As I sat, gripping the armrests of the exam chair, the dentist attempted to distract me (in vain) with small talk about my family and the "crazy Spring weather we're having" -- as he proceeded to insert a sharp tool into my gum line.
His distraction techniques did not work on this patient, however. As I knew how uncomfortable I was about to become and the last thing I wanted to part take in at that moment was casual banter about the increased rainfall.
It's moments like these that help me reflect on my own ability to distract patients in moments of therapy-induced pain. Patients with ORIF procedures or hip and knee replacements maintain a steady, high level of pain for many days and sometimes weeks post op. Despite diligent pre-medication, therapy can seem like necessary torture at times.
My therapeutic style is brutal honesty with the patient. Before we do the first ankle pump, I like to give the "game plan" for the therapy session, so the patient knows there will be a beginning (bed exercises), middle (transfer training) and end (gait training -- then ice!). I find that if patients feel like they have some control over their therapy, they can persevere and complete the session.
Without a doubt, I also distract with conversation. Supine exercises and seated rest breaks between gait-training bouts are the perfect opportunity to engage patients on their favorite interests, whether it's family, job, sports or their dogs. I have many, many in-depth discussions about people's pets. I think patients feel more at ease when disclosing details of their lives that are most important to them, especially if it brings them comfort and pride when they're feeling the most vulnerable.
Personally I think ignoring or not recognizing someone's pain, whether in the role of clinician or patient, can strain the relationship and ultimately the outcome of the therapy session. I've found that learning how to finesse the art of distraction (and honesty) has had positive outcomes for my patients throughout the years. How do you "distract" patients through a tough therapy treatment?
Last month I was lucky enough to celebrate turning the age of 40. One would assume, as I did, that working with the geriatric population on a daily basis for years by this point would give me a healthy perspective on aging. In general, I like to think it has -- especially experiencing the resiliency of the human body and spirit. However, reaching this personal milestone came with a large dose of unexpected anxiety and stress.
I've always felt age is a subjective description of one's self -- having met 30-year-old patients who behave like they're in a 75-year-old body and 90-year-olds who don't look a day over 65. As we all know, lifestyle and genetics hold a tight grip when it comes to "aging gracefully." Maybe this is the reason I, for lack of a better description, "flipped out" as my birthday drew near.
My midlife crisis at least had a healthy theme to it. A few months before my birthday, I began swimming laps three times a week, which I hadn't done in 20 years. I also learned to rock climb and signed up to run a full marathon. I was obviously feeling energetic and very ambitious... also compensating for not having enough funds to buy a cute sports car.
For me, turning 40 was "the beginning of the end of life," which is a completely ridiculous and naive way of viewing age. But alas, that's how I felt. Luckily, working with my patients -- the above 75 set -- left me feeling humbled and appreciative. When a few patients learned it was my birthday and asked my age, I received a lot of: "Forty was the best time of my life," "If I could only go back to that age" and "You're still so young, dear." One of the best pieces of advice I received was from a 90-year-old resident, who told me "just don't stop moving." Frankly, those are some of the wisest words I've heard in all my 40 years to date.
I'm pleased to report, my birthday panic has completely gone -- funny how that happens when you learn to accept the inevitable. The good news is that I'm still training for that marathon and continue my swimming every Saturday. Best of all, working in skilled nursing every day allows me to keep that healthy aging perspective in check -- and appreciate life.