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Toni Talks about PT Today

Nursing Isn't the Problem

Published October 30, 2013 2:21 PM by Toni Patt

There's an ongoing struggle between PTs and nursing over who is responsible for getting patients out of bed. Both agree patients need to get out of bed. Easily transferred patients get out of bed regularly. The disagreement arises over max and total-assist transfers. There's nothing therapeutic about a mechanical lift transfer. Being out of bed is the therapy, not getting there. Every facility I've worked at has provided annual training to nursing on how to perform those transfers. And every time one needs to be performed, they seem to forget how.

As a PT, I put the blame on nursing. They've been trained. The responsibility should be shared. The unspoken assumption is that pressure is being put on nursing to help us out. That assumption isn't always true. I work in a relatively small facility. Nursing never gets anyone out of bed. Instead they've been told to call our technician to do so. This didn't come from nursing administration. Nor did it come from facility administration. It came from our rehab manager.

It seems our manager is more concerned with getting along, and I assume, remaining in the position. Rather than attempting to stop the practice, it is encouraged. If I refuse to get someone up, she calls the tech and instructs him to do so without notifying me. If nursing wants someone up, the tech is instructed to do so for them. When an order is written for someone to be out of bed who isn't on caseload, the same tech is called.

Naturally there are some consequences to this practice. The tech is so busy getting patients up for nursing, he's unable to assist the therapists with treatments. It then falls on the rehab staff to do the work of two people. Sometimes all I need is someone to follow with a chair while someone ambulates, but if the tech is busy that may not happen.

I've never experienced anything like this. Even the worst managers seemed to have a grasp on this. It's especially frustrating to hear her at our regular meetings talking about how this isn't acceptable. There is a simple solution. Instruct the tech to stop getting up people not on caseload and being at nursing's beck and call. Then enforce it. That's all. It would take the word "no" and meaning it. While there have been several discussions, not once has she actually stopped the practice.

Thus nursing will never get anyone out of bed. Our tech will. The ridiculousness of the situation becomes apparent whenever the tech is off. No one gets out of bed. It isn't nursing's fault if no one is holding them accountable and telling them no. But it does cut down on the strife within the facility.

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This is a problem in all areas I have worked in the last 34 years. It has been said that my employer (Acute care ) is going to have a check list built into the order portion of the computer program in which nursing has to mobilize the pt before getting the Dr. to order P.T. or O.T. 1st is rolling then supine to sit then ambulation. I can't wait but I have heard nurses say "My pts will all flunk and I will get PT ordered" We all can only be responsible for ourselves I guess.

Joy, Acute Physical Therapy - LPTA, Marymount Hosp. November 4, 2013 9:09 PM
Garfield Hts. OH

And I thought this happened only at the facilities I worked at.  This seems to be a universal problem in SNF's without an easy solution.

One nurse told me they have a responsibility to keep the patients pain free and as long as the patients are in bed they are accomplishing that goal in their nursing care plan.  I reluctantly agree with this thought processing from their perspective.

From a therapeutic stand point it makes no sense to keep patients in bed 20 hours a day but cares are more easily accomplished by nursing staff when the patients are supine.  

You are fortunate to have a tech, most facilities have eliminated this position.  Keep the tech busy with tightening the screws on the walkers (it is a patient safety issue) or scrubbing therapy balls to prevent the spread of infection so when nursing asks you can tell them your tech is engaged in other activities.   If a few RUG levels are missed because the patients are not up and ready it may remind the facility how important therapy is.  

As a side note,  one facility used to get patients up but not dressed and we were not allowed to bring patients out of their room in a gown.  So part of the therapy time included ADL's and the other part was used for working specifically towards the goals.  

Jason Marketti October 31, 2013 12:36 AM

I sincerely agree with you about getting residents up. We don't have a rehab tech and each individual therapist or assistant has to beg and plead with CNAs to get TD or Max pts out of bed so we can do "real" therapy with them. Using a lift isn't reimbursable because nursing staff can do it, so it's not really considered a skilled therapy. Maybe if we educated and demo to new staff members how to do it, then that might be, but we don't do that every day.

Also, we are so constrained by Medicare rules and productivity that we need nursing staff to get on board with helping getting residents up. My tactic is to win them over with kindness and it seems to work. If it's the weekend, though, and therapy isn't there, then what are they to do about getting pts up then?

On the other hand, if they are on caseload and have OT orders, I really think OTs and COTAs should help get pts out of bed too if that's in their POC. Not all the time, mind you, but to consistently see that the pt can do it and work towards being more indep. OTs are supposed to work on bed mobs, UB/LB dressing, core stability, toileting/hygiene needs, etc. BADLs. But the OTs and COTAs I work with would rather "simulate" these things in the gym when they could actually do it in their rooms. They also don't come in to work until 930-10am when all the residents are already up. I find myself doing more ADLs with residents which I don't mind, but it makes me question why I didn't go into OT school instead of PT...

Anyway, it's all very frustrating and there will be no fixing anything because our industry is people. People are flawed. There is no fixing that. And who really pays for it are the residents, which is very disheartening. I'm a team player. I get residents up or lay on the sugar coating for nursing to help.

Tina PTA October 30, 2013 10:40 PM

A possible solution is for nursing to have their own lift team as part of resorative nursing. When you d/c the pt from therapy put it in the pt's careplan to have restorative nursing get them up and back to bed as continued transfer trainng after you dc/ them from therapy.

This same issue has been going on since I started doing therapy in 1984.

The Veteran administration has  a 40# lifting restriction and uses lifts. Some of the new lifts allow the pt to assist with transfer so they get the benefits of participating.

Judy October 30, 2013 9:59 PM
Delray Beach FL

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