Practical Strategies for the Day Service Nurse

1. Practical Strategies for theDay Service Nurse • A REVIEW of NURSING SYSTEMS, PROCESSES • and COMPETENCIES • Robert Peters, RN • Day Service Nursing Coordinator • AHRC-New York City

2. History of IDD • Historically people with handicaps (physical, mental and intellectual conditions) occupied 'deviant' status • Object of dread, ridicule, evil/possessed person, sub-human, diseased. • Stigma remains to some degree, diseased organism treated with so-called "medical model" • “Historical ghosts” – fears, prenatal testing

3. History of IDD • Europe 1800 Jean-Marc Itard met Victoire of Aveyron, the so-called "Wild Boy of Aveyron," and began what is regarded as the first documented case of special education. • United States in the 19th and 20th centuries, "feeblemindedness" • and "mental deficiency“ • 1851, New York State Asylum established - eventually known as the Syracuse State School, then Syracuse Developmental Disabilities Services Office. • ‘Institutions,' 'schools,' or 'colonies,' originally called, operated a philosophy of treatment and training, relatively normal living conditions, educated residents, and provided opportunities for work on the grounds.

4. History of IDD • Early 20th century, things get worse – dumping grounds • Philosophy of eugenics – “Social Darwinism” • Sterilization of IDD, especially women, strongly advocated by medicine and government • Germany, euthanasia became official medical policy sometime around 1920 • US, euthanasia practiced and advocated early 20th cent. • 1940’s American Psychiatric Association editorial endorsed legal euthanasia of mentally retarded children and the provision of psychotherapy to parents to relieve them of their guilt!

5. History of IDD • 1930’s 1940’s depression, WWII, fiscal resources dried up, institutions had fewer staff who were less trained. AMAP. Beginning to get very crowded, but no children younger than five admitted • 1945 - LetchworthVillage (130 buildings!) 20-30% overcrowded, 200 children sleeping in living rooms and on mattresses on the floors. • 1945 State Schools begin admitting children under five. • Late 40’s - as soon as the facilities at Willowbrook State • School were available, limited numbers of infants could begin to be admitted • 1952 – Willowbrook opens, reaches 6000 individuals

6. History of IDD • 1940’-1950’s: parent groups begin to form, dividing into • community-based groups and institutional-based groups • First charitable organizations begin to form: • NYSARC - 1949 • UCP – 1949 • Lifespire – 1951 • YAI – 1957 • Heartshare – 1970’s • Parents groups, parental initiative and parental power

7. 1948 some parents try to found “nursery school” Jan 1949, AHRC “founded” “It would seem that the pent up energies of many years propel us forward and we move with a motion and volition beyond our control." - Joseph T. Weingold, 1950 1953 nursery for preschoolers 1954, sheltered workshop 1957 day center, school, clinic and recreation 1959 OMRDD formed AHRC History

8. 1970, group residence 1971, camp 1972, Geraldo 1970’s, de-institutionalization 1970’s, day treatment centers proliferate 1977 early intervention 1980’s, Medicaid waiver 1990, Americans with Disabilities Act AHRC History

9. 1985, Sibling program 1986, “HIRE” - supported work project that involves job training and placement in competitive employment 1988, Bronx Seniors program 1995, community services TBI 2006, Director of Individualized Supports – person centered planning 2008 , College – Kingsborough Community, CSI 2009 , Without Walls – all 5 boroughs AHRC History

10. Educational Services (early intervention through high school – autism) Day Services Camping & Recreation – weekends, trips etc. Service Coordination - MSC Employment & Business Services – supported job, jobs in the community Residential Services, many types, includes skilled 24/h nursing, respite In-Home Services Family & Clinical Services – counseling, psych testing, OT/PT/speech Department Individual Services & Supports – person centered planning Legal - Guardianship and Advocacy Sobriety Today the agency:

11. Day Treatment centers (in which abilities of the individual to function more independently and in the community are fostered) Vocational workshops (wherein structured work environments are offered for those who need them) Day Habilitation (a goals-oriented program involving recreation, education, culture, community exploration, voluntarism and work) – both site based and “Without Walls” Employment and Business Services – competitive and supported employment settings, spun off day service Managed care – do the same, or more, with less – remain hopefully optimistic Day services

12. Larger centers: 228 people with 2 RN’s, 190 with 1 RN Small center: 50-80 people, RN covers 2 or more sites, on call very important Smaller center: colleges (non-certified) have about 20 students each, RN only assigned to review physicals, create protective oversight plans and do trainings Non-center: “Without Walls”, non-certified, 1 RN oversees Focus being IN THE COMMUNITY Day services

13. Nurse Practice Act – Art 139 of Education Law ADM-2003-01 : Nursing Supervision of Unlicensed Direct Care Staff Other OPWDD regulations, ADM, memos, alerts, guidelines “Nursing in OPWDD” (67 pages), October 2012 – talks about frequency of visits, nursing ratio 1:50 or less, plans of nursing services (PONS), required orientation within 3 months of hire – RESIDENTIAL CENTRIC Nursing Regulations – Day Services

14. How ADM-2003-01 is a CORE DOCUMENT for the day programs: Applicability --- intention RN decides what can be delegated and to whom RN must supervise unlicensed staff in nursing delegation RN must be on call for supervision Nursing plans Staff trained on conditions Diabetes care, RN must have OPWDD training and annual update Nursing Regulations – Day Services

15. What does apply? 624 regulations – Incident reports, abuse-neglect, Justice Center, medication errors, reports of death. 633 regulations – rights, confidentiality, access to care, supervision responsibilities, staff training, first aid, CPR, emergencies, medical treatment, TB, meds-AMAP, OTC’s, other medication rules, DNR, HIV 633: Self medication assessment, use the RES one or complete, done for people who live at home and take meds at program Nursing Regulations – Day Services

16. What does apply? 635 regulations – finance, reimbursement, environment (building, life safety code) “Dignity of Risk” – provide choices with reasonable and available options What does apply? – annual physical exams (see handout), other medical, health and safety information Challenge to know the current health status, assess risk and provide nursing oversight Nursing Regulations – Day Services

17. So why even have nurses in the day programs? Tradition – they were included based on the “school model” Reality, it’s not just Band-Aids and “hand washing” ADM 2003-01 makes it clear that they are required unless the program does not give meds, delegate any tasks, perform any nursing procedures, or require any specialized training – not real More individuals with diverse health status in the community Triage and chronic disease management Saves money, if not for the agency paying salary, for families and society Nurse is part of the continuum of care, for people living at home, the day program nurse may be key to the person’s health Nursing Regulations – Day Services

18. Day Hab Plan – includes safeguards necessary to provide for the person’s health and safety while participating in the habilitation service. Protective Oversight Plans (aka the POP): Medical Alerts Allergies Special Diets Support for Safe Eating Adaptive Equipment Behaviors of Concern Supervision/support needs in the community/program Likes/Preferences AND Dislikes/what doesn’t work Fire Safety Transportation Safety (also notes “travel training”) Day services – nursing plans

19. Protective Oversight Plans (POP) are reviewed by all new staff, annually reviewed, must be reviewed immediately if there is a change in the POP Staff training on the POP must be documented Staff must know the POP for the people that they support and care for A lot of responsibility for non-nurses, day program nurses must provide both good supervision of staff and encouragement to know their people and the person’s safety needs at all times Staff can always go back and review and re-review the POP, annual trainings should reference who has what in the day program Day services – nursing plans

20. Enhanced Protective Oversight Plans (EPOP) – for special “behavior of concern,” “level of supervision required,” and/or “preventive/supportive strategies” “Health Emergency Profile” (HEP) aka “nursing assessment” is part of the “Ready To Go” packet Protocols (detailed care plans) will be attached to the POP if needed. AND the POP will cite the Protocol(See attached protocol) if applicable Day services – nursing plans

21. Day services – Medical protocols

22. Individualized Medical PROTOCOLS: Asthma protocol Bowel monitoring protocol Case management protocol* Catherization protocol Diabetes protocol Epipen protocol Helmet protocol Ostomy device protocol Restraints protocol Day services – Medical protocols

23. Individualized Medical PROTOCOLS (Continued) Safe Eating protocol – Dysphagia Seizure protocol Skin Surface Check protocol Temporary or OTHER protocol Transfer protocol Urinary device protocol Day services – Medical protocols

24. Medical PROTOCOLS can either be completed by the RN based on MD orders or received “as a protocol” form the residence, MD, SLP, PT etc. Day services uses standardized templates Some templates adjust elements, for example the Seizure Protocol can include if the person has: VNS magnet and how to use Oral clonazepam after X amount of minutes Diastat rectal gel after X amount of minutes Variable time within to call 911 (the standard being 5 minutes) Day services – Medical protocols

25. Staff must be trained on the protocol Only AMAP’s would be trained on medication specific protocols. Anyone can be trained to use Epipen, must be explained POP would say: “Must see nurse or AMAP if….” or “Person must always have an AMAP when going on trips” or “PRN medications must always be taken out with the person” Day services – Medical protocols

26. Some protocols are designated NURSE ONLY, and might not be delegated Catherizations, tube feedings or tube meds (even though permissible) Some Diabetes Protocols (complexity, diabetes pumps) Case management (done by the nurse only, appointments can be delegated) While some protocols really should be delegated to non-nursing staff, emptying of urine and colostomy bags – toileting Day services – Medical protocols

35. Protocols must be reviewed annually (in-service trainings) OR when new staff care for the person Any changes to a protocol (based on an MD order) = that the POP might need to be revised, the protocol re-written and staff re-trained on the updated protocol When one part changes all parts are set in motion Protocols and Protective Oversight Plans are a lot for staff to remember and can be a challenge to follow, support and encourage your staff in being the eyes, ears and hearts that we need them to be Day services – Medical protocols

36. New hire agency (OSHA etc.) and department orientation Agency trainings (AMAP, dysphagia, diabetes management, CPR, first aid) Annual in-service trainings: Hot/cold weather Seizures Diabetes Skin injury checks Triage for the non-nurse (head injury, falls injury forms) And as needed: Diastat, Epipen, Glucagon, Ostomy care, VNS, Aging, Alzheimer's, psychotropic’s, flu and colds, nutritional concerns Nursing – Supporting DSPs

37. AMAP supervision (pouring's with the RN present, in addition to re-cert) Daily AMAP observations if AMAP’s give meds those days Dysphagia supervision Flu vaccine free to staff Staff meeting updates Nurse meeting with site supervisors (see Team Meetings for Nurses and Directors) ISP meetings – attends with DSP as needed Personal relationships, nursing advice Day Services – Staff Support

38. Nurse must support DSP code of ethics: (see handout) Person-centered support Promote physical and emotional well-being Integrity and responsibility Confidentiality Justice, fairness and equity Respect Relationships Self-determination Advocacy Day Services – Staff Support

39. Nurse must support DSP core competencies for SUPPORTING GOOD HEALTH: (see handout) Team work Teach/support positive behaviors Meal planning, food prep Knows medical, physical, psychological, dental needs Prevents illness & disease, teaches person Responds to S&S illness/injury and knows emergency procedures Safe clean environment Documents and protects health information Understands/implements good health practices Day Services – Staff Support

40. Day service and residential nurses “Unity is plural and, at minimum, is two.” – Buckminster Fuller

41. Day service and residential nurses Review of Survey Monkey questionnaire, discussed at AHRC Nurses Meeting 9/19/14

42. Day service and residential nurses • Seeing each other as collaborators – taking care of the same person • Avoiding un-necessary CONFLICT • Shared challenges: new admissions more medically challenging, more challenging behaviors, more risk, more work loads • Nurses work in isolation, without peer support or other clinicians on a daily basis, dealing with emotional boundaries • Job description highly regimented-detailed, limited room for innovation, sharing and experimentation

43. Strategies for supporting “shared individuals” • Collaboration between residential nurses and day program (all environments) is not a luxury but a necessity • Remain person centered • Go Zen and Pema! • Use the nursing process, discuss • the area where clarity is needed, • try to resolve on professional • level, seek help as needed • Remember – we both nurses!

44. Strategies for supporting “shared individuals” • Meet and communicate with “the other nurse” – bond as nurses, focus on the real problem • Regularly meet with other nurses at your agency, or at zone meetings, at trainings, professional organization (NYSNA) – reach out, network, ask to see what others do • Seek consultations from administrators, compliance, medical directors, nurse educators, other nursing peers, “human rights” committee, other “team” members • Is there any medical or nursing research that may assist resolution • “Take the initiative. Go to work, and above all co-operate and don't hold back on one another or try to gain at the expense of another.” – Buckminster Fuller

45. Day Program communication challenges: Intra site relationships (co-workers) Intra agency relationships (other departments) Inter agency relationships (outside agencies, DDSO) Relationship with family Relationship with guardian, CAB, other Relationship with other care providers, clinicians Relationship with the person Communication

46. Work towards collaboration with residence, family etc. Changing the culture of communication Teamwork Training together Mutual respect Communication

47. Use an expected and known agenda Use a team meeting approach Share nursing decision making – collaborate nursing judgment Communication is key to advocacy and coordination of care “Don't fight forces, use them” – Buckminster Fuller Communication

48. Improving Clinically focused RELATIONSHIPS Take pride in your practice Communicate effectively Embrace a team approach Speak up when you notice a problem or error Avoid negative behaviors Know the context Have a sense of humor Make the goal - UNDERSTANDING Communication

49. Normal bowel function: Normal frequency of bowel movements can range from 3 times a day to 3 times a week. Doctors often define constipation as a stool (or bowel movement) frequency of less than 3 times a week. Discomfort may be reported or observed as straining, hard stool, or feelings that client is unable to empty the bowel. Normal stool in an adult or child (not infant) is brown, soft and formed. White or clay-colored stool, black/tarry stool, bloody, thin ribbon-like stool, narrow/pencil-shaped stool, hard or liquid stool is usually considered abnormal. Case Study 1 – Bowel Monitoring

50. People with chronic constipation report they feel that they have a lower quality of life. People who have only one or two bowel movements per week are more likely to have obesity, diabetes, diverticulosis, hemorrhoids, and colon cancer. Constipation may lead to complications including fecal impaction, ulceration, bowel obstruction, sigmoid volvulus (the bowel twisting in a loop), incontinence of stool, rectal prolapse, urinary retention, possible dizziness (and falls). Increasing intestinal distension (stretching of the intestines) may lead to loss of blood flow to the bowel, perforation, and tissue death. Untreated, a bowel obstruction can cause hypovolemic or septic shock and death. Case Study 1 – Bowel Monitoring