CorrectCare

The author (left) teaches psychiatric aides how to measure heart rate during the CNA training.

Facility and Client Profile The St. Louis Psychiatric Rehabilitation Center is a 212-bed forensic facility operated by the Missouri Department of Mental Health. It is accredited by the Joint Commission and certified by the Centers for Medicare and Medicaid Services. An intermediate and long-term inpatient facility, SLPRC treats adults with severe mental illnesses, many of whom have been involuntarily committed by the court system.    In March 2007, an analysis of client records revealed that the average stay is six to seven years. Crimes committed are diverse, but at least 33% involved some type of an assault. Demographically, 88% of the clients were men and 32% were in their 50s.    Nearly half (47%) were dually diagnosed with schizophrenia and substance abuse, and 32% have a global assessment of functioning (GAF) score from 41 to 50, which denotes severe symptoms (e.g., suicidal ideation, severe obsessional rituals) or a serious impairment in social, occupational or academic functioning. Changing Client Physical Profiles In comparing records of clients discharged between 2000 and 2006 with those in March 2007, the analysis showed that the current clients typically had more medical diagnoses, especially heart disease, diabetes, obesity and other chronic conditions. Overweight is worsened by the fact that many of these patients get little exercise, and many take antipsychotic drugs that cause weight gain. Well over 50% of the clients smoke cigarettes.

Homegrown Human Capital:
One Facility’s Response to Its
Nursing Shortage
By Gwen Boyd, BSN, MA, CCHP

Like many states, Missouri is experiencing a significant shortage of registered nurses. This shortage is felt in every health care facility, public and private alike. Still, it is no secret that many state-operated facilities have shortages far worse than in the private sector. Despite the stability of state employment and abundant benefits, these facilities can’t compete in terms of wages and resources, not to mention extravagant lures such as large sign-on bonuses, total tuition or loan reimbursements and other incentives.

However, one state facility has developed a homegrown solution that not only helps the nurses during this critical time but also invests in its workforce by upgrading the skills necessary to meet the challenging care needs of the clients. This approach could help other state facilities deal with their own nursing shortages.

Rising Need for Skilled Care
The St. Louis Psychiatric Rehabilitation Center is a 212-bed inpatient facility operated by the Missouri Department of Mental Health. SLPRC treats adults with severe mental illnesses. About 80% of our clients come from the criminal justice system and were involuntarily committed by the court system. (See box at right to learn more about SLPRC.)

As the average age of our clients has increased, along with the severity of their mental illnesses and medical diagnoses, so too have their needs for assistance with activities of daily living (bathing, grooming, feeding, etc.). Some of the nurses said that SLPRC is beginning to look like a nursing home, with the advent of indwelling urinary catheters, a gastrotomy tube, tracheostomy care and periodic use of canes, walkers and wheelchairs.

Evolution of a Solution
Faced with this changing psychiatric client profile, the growing demand for nursing care and fewer nurses due to attrition, SLPRC had to find a way to meet these challenges without an influx of new financial resources. Recognizing that employees are our greatest asset, we assessed our human capital and tapped into it.

The psychiatric aides are an invaluable resource. These paraprofessionals outnumber the nursing staff by roughly 4 to 1, and in many instances they interact directly with the clients the most. However, they were in need of an opportunity to upgrade their skills.

So in 2005, we launched a certified nurse aide program for the psychiatric aides. As a former nursing home inspector, I was familiar with long-term care regulations and the nurse aide training programs in nursing homes certified by the Centers for Medicare and Medicaid and licensed by the Missouri Department of Health and Senior Services. I applied the same concept to SLPRC, with some modifications. This is the first program of its kind to be offered in a Missouri mental health facility.

To set up the program, I attended a two-day seminar to become a qualified instructor and examiner. I then made application and received permission from the Department of Health and Senior Services for SLPRC to become an on-site training agency.

Other expenses were moderate and included training tapes, manuals and a manikin. Each CNA candidate paid the $50 exam fee.

The CNA training consists of a 16-hour orientation module with emphasis on the needs of geriatric patients —including emergency care, infection control and prevention of abuse and neglect—and 100 hours of on-the-job training in basic nursing. The basic nursing skills include vital signs, signs and symptoms of hyper- and hypoglycemia, ambulation, range of motion, normal signs of aging, incontinence care, nutrition, food sanitation, promotion of self-care and basic anatomy and physiology.

The psychiatric aides also are educated on mentoring, leadership, team building, effective communication, conflict resolution and basic psychiatric forensic nursing (including substance abuse awareness and suicide prevention). In 2007, we added basic computer skills to enable the students to complete their competency tests.

Positive Outcomes
By June 2007, 19 psychiatric aides had completed the training program. The results of a post-training survey showed that 100% of the aides rated the experience as excellent, and many commented that they learned a lot and that their job performance had improved. The director of nursing noticed improvements in the aides’ skills and their ability to identify changes in client conditions before physical and/or mental decline.

Besides enhancing competency— and morale—these newly learned portable skills enable the aides to earn extra money by moonlighting as a CNA, one of Missouri’s fastest growing occupations.

Recently, after examining her first group of CNA candidates from SLPRC, one RN examiner said, “This is the best group I’ve ever seen … they’re so organized and meticulous … I’m really impressed! They should be in nursing school.”

Bright Prospects
The post-training surveys of the new CNAs showed that 58% planned to further their education in the field of nursing and 74% planned to remain with SLPRC until retirement. Based on the training they’ve already received, it would be a seamless transition for these aides to integrate into the nursing field since the seed for continuous learning has been planted. In fact, internal SLPRC policies are already in place to provide educational leave time and tuition reimbursement, although these benefits are currently underused.

Other homegrown nursing solutions might include internal training and use of certified medication technicians (who must first be CNAs), and improved marketing of an already generous state employee benefits package to attract new nurses.

Clearly, in cultivating our psychiatric aides by giving them CNA training, our facility has enabled those aides to better care for clients with increasing skilled care needs. This will help to relieve the burden on licensed nursing staff to provide skilled care.

— About the author: Gwen Boyd, BSN, MA, CCHP, is the nurse educator at the St. Louis (MO) Psychiatric Rehabilitation Center. She may be reached by e-mail at gwen.boyd@dmh.mo.gov.

[This article first appeared in the Summer 2007 issue of CorrectCare.]