Preparing the nursing staff for the unexpected.

The last question a nursing home administrator or DON wants to answer is "What could you have done to prevent this?" Today, nursing home residents--especially those admitted directly from hospitals--are more medically fragile than ever before. And one seemingly insignificant event can push them over the line from stable to critical, lucid to confused.

The key to preventing emergencies--both medical and nonmedical--and handling them safely and effectively when they occur, is ongoing staff education. And this involves using more than a few "tricks of the trade."

First and foremost, though, this requires commitment from the top down. Staff education should be viewed as a necessary means to an end: providing the highest possible quality of care in the safest environment. Any costs incurred are an investment in that goal.

Orientation

Emergency protocol education begins during orientation. Unfortunately, orientation is often the first casualty of a high turnover rate; nurses may be put out on the floor after only limited orientation.

At Northland Terrace Medical Center for Subacute Care and Rehabilitation, a 260-bed Ohio facility with adult ventilator, pediatric and subacute rehabilitation, and hospice units, all new nursing employees spend an initial four days in orientation learning the mandatories of risk management -- from fire alarms to wandering patients. For RNs and LPNs, this is followed with a three-day documentation class and four to six weeks of on-the-job training (depending upon the experience level of the employee).

Nursing assistants receive two weeks of training in the state-tested requirements, followed by an additional two-week on-the-job orientation.

All levels of nursing staff are encouraged to use their powers of observation and to carefully document any change in condition. To assist with this task, Northland provides their nurses with a written Physician Notification Protocol which outlines the signs, symptoms, and laboratory results that require immediate physician notification.

Nurses also receive laminated cards detailing specific assessment tasks for the respiratory, genitourinary, neurological, and musculoskeletal systems, as well as those for residents exhibiting pain, fever, lethargy, and confusion.

These assessments are reviewed with the staff on an as-needed basis by nurse managers and annually in a formal inservice.

Also, on the back of each nurse's and nursing assistant's name tag where it is always at hand, is the acronym R.A.C.E.: Rescue, Alarm, Contain fire, Evacuate, with steps of protocol for the wandering patient, fire, and severe weather.

Inservice Innovations

Inservice attendance should of course be a requirement of employment for any nursing staff. But nurses, who may already feel overworked, may view such a requirement as an additional source of stress.

To put inservices in a more positive light, DONs and staff development personnel should work together to make them innovative and creative, and to make attendance as convenient as possible.

For example, rather than asking staff to attend inservices during their off hours, the programs should be made available during their regular working hours, with someone assigned to cover their workload while they attend. For the staff developer, this means working some weekends and nights.

"Innovative" doesn't have to mean expensive. More often than not, professionals will volunteer their time to help educate staff. This is especially important to the nursing home interested in providing subacute care, since the staff must be educated in emergency and nonemergency procedures well before the first resident is admitted.

The medical director, consulting physicians and specialists, nurse practitioners and physician assistants are invaluable sources of patient care information. Northland's nurses make weekly rounds with medical specialists: the pulmonologist on the pulmonary unit, and the neurologist on the subacute rehabilitation unit.

Furthermore, the hospital discharging patients to the nursing home is usually willing to provide a nurse specialist to conduct inservices on special apparatus and procedures. Pharmaceutical companies and other vendors are also always willing to teach staff about the use of their medications and equipment.

Also at Northland, CPR training is required for all levels of nursing. By sending the staff development director for certification in CPR instruction, the course can be offered to other employees in-house, year round.

It is, of course, both unrealistic and unwise to rely on formal inservicing to meet all educational needs. This is where creativity comes in:

* Staff development and nursing management personnel should be encouraged to provide on-the-spot education, addressing problems, and potential problems when they arise and explaining the importance of performing the task correctly.

* Informal inservices on the unit are especially helpful and well received. Northland staff development personnel make rounds on each of the facility's units and give frequent ten-minute inservices on everything from positioning residents to dehydration, reaching all the staff.

* Something as simple as video taping the staff performing various tasks can be an effective and enjoyable teaching tool. Similar to an athlete watching an instant replay, nurses can observe themselves at work and discuss the positive and negative aspects of their performance.

* Inservices with guest speakers from the community are among the best attended. This was the case at Northland Terrace when the local TV meteorologist came in to conduct the tornado inservice.

* Poster sessions with brief tests for continuing education are both creative and informative. And setting up several "learning stations," each with a different task to master, is an effective way to break the monotony of the traditional classroom experience.

One of this year's staff development goals at Northland is to initiate annual competency testing on all equipment, from thermometers to hypothermia machines. RNs and LPNs will "test out" on several stations, each set up to test the nurses' skill on a different piece of equipment. Those who fail will be reinstructed one-on-one, after which, they must pass a retest or face possible dismissal.

All in all, the DON who assumes her nursing staff is competent to meet all the challenges posed by today's nursing home environment is making a potentially serious mistake. It is nursing management's responsibility to make certain that the staff knows what they want them to know and performs up to the standards they expect. But, along the way, the learning experience can be made stimulating, and even enjoyable.

Sue Longhenry, MS, RN, has been director of nursing at Northland Terrace in Columbus, Ohio since 1986. She has an additional six years experience as a Director of Nursing, Assistant Director of Nursing, Patient Care Coordinator, Practical Nurse Clinical Instructor, Charge Nurse, and Staff Nurse in long-term and acute care facilities. She has received the Ohio Health Care Association's Director of Nursing of the Year Award, is currently President of the NADONA/LTC and has spoken frequently at national conventions such as AHCA and AMDA.

Table. The acronym R.A.C.E.: Rescue, Alarm, Contain Fire, Evacuate is placed on the back of each nurse's and nursing assistant's name tag where it is always at hand.

"Captain Thermo" -- Fire

R.A.C.E.

R -- Rescue A -- Activate Alarm C -- Contain Fire E -- Extinguish or Evacuate Dial 9-911 for Fire/Police

Resident Missing? Notify Head Nurse Charge nurse immediately

Tornado Watch 1. Clear off window sills 2. Crack windows open

Code RED-Tornado Warning

1. Remove patients into halls. Close doors.

2. Patients unable to be taken into halls -- Push beds close to doors, cover faces with blankets, pull curtains. Keep doors open.

3. U4 & U5-Do not put patients in Front Hall

4. No patients in lounge or "T" hallways.

5. Rehab -- Move to Clinic 2

6. PEDS -- Move to activities Room

7. Dining Room -- Pts to U1 & U2