Rehab nursing-the good/bad/ugly?

shellhurles · Mar 12, 2009

I am an ER nurse and I moved into a supervisor position at an acute care rehabilitation hospital. That is all we do. I am going to tell you, it is the most back breaking physical nursing there is. It by far does not compare to what you experience in the ER. It's so different because of what it requires of you and your back. These are for the most part dependent patients requiring 2-3 assist for almost everything. It kind of like being a PT/OT/ST and combining that with nursing. My nurses are in my office almost on a daily basis complaining of what they have to do. Of course I have other issues that feed into this but I know from where I came from ---- the ER---- I would not ever take a job as a rehab nurse. I'm not trying to speak badly about it but I would prefer the pace of the ER and patient load there more than I would on the rehab floor. It at times feels like it is just a slightly faster paced nursing home. I battle the ever present staffing issues as do other areas of nursing......and at least 1 x a month someone is calling off becasue they 'hurt' their back at home doing something which probably extended from their role here at the rehab hospital.

PAERRN20 · Mar 12, 2009

Thanks for the information. It's nice to hear from another ER nurse regarding rehab.

I haven't applied for a specific position...I'm still keeping my eyes peeled for an opening. I don't hate the ER, but I don't love it either.

How is the stress level compared to the ER?

shellhurles · Mar 14, 2009

It's a different type of stress. Not quite the adrenaline rush of the ER. I kind of look at is as a faster paced nursing home because we have the patients for an average stay of 13 days before they move on. It's mainly the geriatric population. It's just more demanding physically on your body. Truthfully, I would be bored if I had to be on the floor and not in the position I have. The stress presents itself with the number of patients per nurse assignment, staffing issues, MDs who hate being on call (still typical of other nursing areas like the ER). Your ER experience puts you far ahead of the nurse who has only done rehab. I think the rehab language has been the most difficult peice......FIM scores, understanding the 10 tasks associated with toileting, etc. Your skills become more of one that helps the patients FUNCTIONAL capacity. We want the pateint to return home not to a nuring home or skilled facility. It is interesting.....it is challenging. It is more fulfilling becuase you get to see the actual moment that patient gets to go home finally---after their lengthy stay in the acute care hospital then their stay in rehab.

hope this helps you!

ayla2004, ASN, RN · Mar 14, 2009

Im a Uk new grad working in acute rehab ortho/medical geriatric population.

whats a FIM score and what are the 10 tasks of toileting?

oh i google FIM we do most of these assesments but don't have a tool.

meluhn · Mar 14, 2009

I am a CRRN and have been working in acute rehab for 3 years now. It is very back breaking. My unit is similar to a med-surg floor only the patients are all dressed in clothes when you want to do your assessment and they're always running off to rehab and you can't get their meds into them before they go. They often go very hypotensive on you because of all the activity they are not used to in their fragile states. We have codes and rapid responses weekly to monthly on my floor. Other than that it is alot of busy work--passing lots of meds etc. There is so much charting you wouldn't even believe it. We have to chart for every patient assessment, meds, PPS(similar to fims) which is a functional assessment, vitals, education, 3 nurses notes, and cosign newly ordered meds in the computer. The meds are heavy, lots of prn pain meds. All day doctors are running in and writing orders. The good thing about it is you have your patients there for sometimes weeks at a time (Which can also be a bad thing)and you get to know them and generally they leave in better shape then when they came in. We also have patient care techs that do everything from EKGs to bs and blood draws and take care of all the AM care so we don't have to. It is a hopeful proactive place.The teamwork with the therapists is great. I happen to work with an awesome bunch of physiatrists who really consider you part of the team and act like your opinion matters. I love it but I also hate it some days, but I think that goes for anywhere you work in nursing. I started out full time and I only made it 3 months and had to go per diem. I never, ever, have gotten out on time. It is truly hard work. I would rather be in the ER personally. I just hate the drudgery of meds and charting and would rather be doing something different all the time.

We do have alot of medically complex patients too. We do pretty much anything a medsurg floor does, blood transfusions, heparin drips, etc. We are always sending people to the er.

oramar · Mar 14, 2009

What might come as a shock is the complex medical problems of the patients. Though I think a ER nurse would be better able to deal with that. Used to be you would get healthy people in their 40s, 50s and 60s on no meds and with no other medical problems who were recovering from hip or knee replacements. They were pretty easy patients. However, the vast majority of the patients now days are quite elderly and have a lot of medical problems. Insurances including medicare do not even think knee replacement qualifies you for rehab anymore. They think the uncomplicated knee patients and sometimes even the uncomplicated hip patients should rehab at home or as outpatients. Toward the end of my stint on rehab only double knee replacements and very elderly or very sick knee replacements were getting admitted. The insurances were also getting a little particular about hip repairs and replacement. In my opinion the renal patients were the most complicated but the people who had multiple transplants could get pretty tricky also. It has been a couple years since I did rehab, my guess it is only getting tougher. By the way I liked it and my extensive med/surg experience really came in handy.

shellhurles · Mar 14, 2009

FIM scores are 18 different areas of funactional capacity that we rate the patients on. The lower the score, the less independent they are. the goal is to have the FIM score change from lower to higher by the end of their stay. This change to a higher level indicates basically that rehab has worked to improve their functional capacity and we get paid based upon this FIM score change. If FIM scores are not accurate, then the change may not be accurate, then we may not get paid for all or part of the stay.

As far as the tasks of toileting that we rate according to percentage the patient performs themselves without cues, reminders or help in any way:

pt stands

pt unbuttons or unzips pants

pt pulls pants down

pt sits on toilet

pt cleans self

pt flushes toilet

pt stands up

pt pulls pants up

pt button or zips up pants

....only 9 task but that is the breakdown of just 1 area the FIM scores look at.

PAERRN20 · Mar 14, 2009

Thank you all very much! You have given me many things to consider.

OldPhatMC · Mar 14, 2009

I've been a rehab nurse for the last year. Before that, I was an EMS provider and worked med-surg.

The gratifying part of rehab nursing is that you do see miracles every day. Someone who comes in completely lacking impulse control from a bad brain injury will start healing.. sometimes dramatically... and return to a decent amount of function. I love that part.

What I have a harder time with is that the rehab hospital setting is not equipped a lot of times to deal with medically fragile patients. We're getting criticized a lot by management for shipping out MI, SBO, DVT... pick an acute syndrome and we've got to put them in an ambulance to send them to the acute hospital. Our hospital has no capacity for heparin or cardiac drips, no PCA or IV pain meds, and only Basic Life Support capacities in the "Red Cart". It gets frustrating when we can't really can't get stat labs, and the physicians get all crankypants over being called at night.

Most frustrating are the career rehab/nursing home nurses that have no sense of urgency. If I have a patient with vomiting and abdominal distension, I want to start pushing the issue NOW to the doctor, not sit there and "let's wait until the PA comes in" or worse "I'm not going to call the doctor about that".

I think rehab nursing is a good waypoint. I think we all could benefit from doing some time in as rehab nurses, but as a career, you'd have to find some part of the job that incites a little passion. I can't say that I have.

Sorry for being a negative Nelly. The job needs people with acute level expertise. The problem is that the reality of variable, distressed, fragile patients hasn't caught up with the American system of third party payment. So on paper, you should not be seeing very sick patients. But in practice you will.

OldPhatMC, RN Sends.

meluhn · Mar 14, 2009

Most frustrating are the career rehab/nursing home nurses that have no sense of urgency. If I have a patient with vomiting and abdominal distension, I want to start pushing the issue NOW to the doctor, not sit there and "let's wait until the PA comes in" or worse "I'm not going to call the doctor about that".
I think rehab nursing is a good waypoint. I think we all could benefit from doing some time in as rehab nurses, but as a career, you'd have to find some part of the job that incites a little passion. I can't say that I have.
Sorry for being a negative Nelly. The job needs people with acute level expertise. The problem is that the reality of variable, distressed, fragile patients hasn't caught up with the American system of third party payment. So on paper, you should not be seeing very sick patients. But in practice you will.
OldPhatMC, RN Sends.

I must point out that there is a difference between subacute units in LTC facilities and acute rehab facilities such as the one I work in. I work in a rehab unit that only hires RNs in a hospital (that uses LPNs). We use all the facilities of the hospital-dietary, lab, pharmacy, xray, endo etc. If we need a stat CXR or CT scan or anything stat, we get it. OldPhatMC is right, the nursing home subacute units have similar patients that can be very complex but they do not have the facilities to handle it and many are staffed by LPNs although some try to get RNs only. Another difference is nurse:patient ratios. I would never recommend LTC/subacute for this reason, to patients or nurses. Although they have improved in recent years, I have worked on subacute with 25-30 patients assigned to me. I was literally risking my license everyday. :bluecry1:I hated it. They had high acuity hospital pts but tried to staff like a nursing home. They have improved but the nurse still takes 12-15 patients. In acute rehab I have a max of 8, usually 6 or 7 on day shift.

ayla2004, ASN, RN · Mar 14, 2009

Waht my ward lacks at time is full time presnet on the ward medical coverage as pt are assumed to be stable. We do have one part time SHO(resident we are a teaching hospital)and use cover from 2 other wards and on call services.

Patients do become unwell and develpo exhib other contions cardiac, HAP, DVT etc

i would hate to do my job in one of out commiunty based reahb units without oncall cover a full crash chart and acess to ct and mri onsite.