This blog post was written by Holly Harmon, RN, MBA, LNHA, Senior Director of Clinical Services, American Health Care Association and was included in the current issue of PX Alert, HealthStream's quarterly e-newsletter devoted to the wide range of challenges, situations, and issues that have an impact on the patient experience.
Nursing is a profession that offers a great variety of settings to work, including physician office, specialty clinic, school, hospital, home health, skilled nursing and rehabilitation center, retirement community, and many more. This article will focus on nurses transitioning from acute care to post-acute care, specifically skilled nursing and rehabilitation centers. The skilled nursing and rehabilitation aspect of the care continuum serves a vast population that is growing in acuity, including individuals with geriatric complexities and comorbidities. The needs of individuals staying or living in skilled nursing and rehabilitation centers offer the nurse an opportunity to develop or advance unique skills in this specialty practice within post-acute care.
There are four key characteristics representing an assortment of skills and qualities that are important to consider when nurses are transitioning from acute care to post-acute care:
1. Delegation & Empowerment – In skilled nursing and rehabilitation centers, the largest proportion of direct-care staff is typically nursing assistants. Nursing assistants are often referred to as the “eyes and ears” of the nurse. A nurse working in a skilled nursing and rehabilitation center may have two to three times as many residents or patients on his or her assignment than in acute care. Effectively meeting the needs of each resident requires delegation and empowerment between the nurse and nursing assistants. The nurse sets the tone for the working relationship with the nursing assistants, which affects outcomes for the residents or patients. The nurse needs to know the parameters of delegation as determined by the Board of Nursing, licensing and certification standards, and organization policy.
Great care is more likely when nurses demonstrate and acknowledge the true value of the nursing assistants’ work. This occurs when nurses empower nursing assistants and other staff, encouraging them to do what they do best for the benefit of the residents or patients they are serving. Successful empowerment requires mutual respect; being a positive role model; active listening; seeing the possibilities, talents, and skills that exist in each staff member; providing feedback; and developing trust. Nurses who recognize and utilize the invaluable contributions of nursing assistants and other members of the team will find the most success and satisfaction in their practice.
2. Autonomy – Skilled nursing and rehabilitation centers have less on-site resources than acute care. For example, typically there is not 24/7, on-site physician presence in skilled nursing or rehabilitation centers. As a result, nurses transitioning from acute care to post-acute care will experience changes in workflow and decision-making. Autonomy in skilled nursing and rehabilitation centers is viewed by many highly skilled nurses as a benefit to the job. It provides enhanced opportunity to incorporate the nurse’s unique knowledge and expertise into practice through heightened influence and decision-making.
With autonomy also comes great responsibility to effectively practice assessment, monitoring, intervention, evaluation, and critical thinking skills. For example, nurses are key to preventing avoidable hospital readmissions through effective management of acute change in condition, including early identification, assessment, and communication with the physician or other providers. Nurses in this setting must be vigilant in assessing and examining their own skills, updating and refreshing their own competencies, and reflecting on opportunities for improvement.
3. Leadership & Coordination of Services – The nurse is a key player in coordination of care in skilled nursing and rehabilitation centers. Nurses and nursing assistants are typically the only group of staff who work 24/7 in a skilled nursing and rehabilitation center, whereas acute care often has other disciplines working around the clock. A nurse’s leadership skills are important to facilitate communication with families who visit at all hours, ensure continuity of care from shift to shift, and lead direct-care staff in problem-solving when challenges arise. Nurses are often on their own to practice innovative problem-solving and seek solutions to best meet each individual resident’s needs. Nurses often will be confronted with conflict between staff, or between a resident or patient and their family member, thus warranting a need for effective communication, negotiation, and conflict resolution skills.
Skilled nursing and rehabilitation centers are highly regulated, which has shaped a complex healthcare environment where documentation, outcomes, and experiences of residents or their families drive positive or adverse consequences for the center. The nurse’s role is critical to facilitate continuity across the interdisciplinary team through collaboration with each team member, including social services, activities, nutrition, therapy, pharmacy, physician, family, resident, and others. It is important for the nurse to recognize the contributions that each of these interdisciplinary team members brings, and engage them as needed to enhance quality of care and quality of life for individuals.
4. Facilitation of Home Environment, Healthy Relationships, and Quality of Life – Nurses transitioning from acute care to skilled nursing and rehabilitation centers must be conscious of balancing the medical model with the needs of residents who are likely to call this setting “home.” In many cases, this will be a resident’s home for the rest of their life or a temporary home for someone who is in the center for a short term stay of three or four weeks. Creating a meaningful life for a long-stay resident with all the comforts of home will differ from the needs of a short-stay resident who requires short-term rehab and pain management in order to return home. Regardless, the length of stay is typically longer in a skilled nursing and rehabilitation center than in acute care, which raises the importance of a home environment to the resident’s quality of life and quality of care.
Developing healthy relationships between the staff, resident, and family is critical for many reasons. Nurses working in skilled nursing and rehabilitation centers have greater opportunity than in acute care to develop relationships with residents and families. Valuable information can be learned about the resident to better meet his or her needs or preferences. Knowing the person opens endless opportunities for further improving quality of life and quality of care, and also becomes valuable when confronted with a challenging situation, such as an illness that affects the resident’s behavioral expressions. Knowing the resident, their likes and dislikes, and the small and large things that bring meaning and purpose to their life can be the difference in providing effective non-pharmacological interventions that resolve the problem with no adverse effects.
A valuable resource is the Nurse Competencies for Nursing Home Culture Change developed by an interdisciplinary expert panel of leaders in culture change and gerontological nursing. This panel was convened in 2008 by the Hartford Institute for Geriatric Nursing in collaboration with the Coalition of Geriatric Nursing Organizations and Pioneer Network. This tool identifies and supports the 10 competencies that are most critical for nurses to be successful in creating and sustaining person-directed care.
There is great opportunity for nurses to contribute to, and benefit from, working in skilled nursing and rehabilitation centers. The experience of working with a diverse interdisciplinary team, practicing at a heightened level of autonomy, and demonstrating leadership and coordination of services to benefit residents by directly impacting their quality of life and quality of care, is a gift to the profession of nursing. The relationships that develop and learning that is gained from knowing each person as an individual, and understanding the meaning and purpose that shapes each one of us, is impactful in a way that validates why many nurses chose nursing as a profession. This is what inspires the devoted nurses who have chosen skilled nursing and rehabilitation care as their specialty.
About the Author
Holly Harmon, RN, MBA, LNHA, is the senior director of Clinical Services at the American Health Care Association. She has more than 18 years of experience working in healthcare, including post-acute care, long-term care, and assisted-living care.
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