Following a skill and grade-mix review in 1997, a plan for providing a 24-hour approach to rehabilitation was introduced at Linden Lodge, a 29-bed adult neuro-rehabilitation unit at Nottingham City Hospital.
Before this, the multidisciplinary team worked closely together, having already established a single case-note system, one common uniform and shared team offices.
These factors were fundamental in supporting the change.
Through this round-the-clock approach, we aimed to create interdisciplinary teamworking in the rehabilitation of patients.This was achieved by breaking down barriers and establishing better understanding between team members with the sharing of skills across traditional boundaries.
The changes were a response to several factors, including patient complaints over the lack of therapy input, particularly in the evenings and at weekends, and the desire to move further towards a 24-hour culture, ensuring patient rehabilitation programmes continued day and night.
The first stage of the changes began in October 1997 and featured a 30 per cent increase in therapy staffing levels, a 30 per cent reduction in trained nurses, upgrading of all nursing auxiliary staff to rehabilitation assistants, jointly managed by therapists and nurses, and the introduction of shift working for therapy staff.
The second stage began in June 1998 with a project management approach to further implementation of changes in staffing and working practices.The overall aim was to provide input by therapists 12 hours a day, with additional cover on a Saturday morning; to develop the role of the trained nurse into a specialist role; and to increase the role of the rehabilitation assistants to support nursing and therapy staff.
The aim was to reduce complaints from patients and reduce their length of stay, while improving clinical outcomes.For staff, the aims were to reduce sickness absence, increase their involvement in the management of the unit and improve job satisfaction.A number of measures were taken before the start date of the project, including the number of treatment goals attained, staff sickness rates and back injury reporting by staff.These have all improved.Despite patients now being discharged on average one month earlier, all measures of a quality service are improving.Back pain incident reporting has reduced to below the level it was before making the changes.
Staff satisfaction surveys were carried out in 1998 and again in 1999.A questionnaire used closed questions and rating scales together with opportunities for comments. It included themes of changes in roles, teaching/training, support, motivation and commitment, patient care, and organisation of the unit.
Patient satisfaction surveys have been conducted annually for the past three years.All were carried out on our behalf by the community health council.Patients were asked a variety of questions relating to such topics as treatment and care, staffing levels and therapy intervention.There has been a significant improvement in the patients' rating of staffing levels and in the amount of therapy received.The amount patients feel involved and informed about their treatment and care has risen from 80 per cent in 1998 to 93 per cent in 1999.
The results indicate that the changes have been effective in meeting the needs of both patients and staff.Examples are the reduction in length of stay from 117 days to 89, and complaints reduced from an average of seven a year to zero.Current developments include using and developing the Northwick Park dependency measure, supporting rehabilitation assistants through the completion of competency booklets, and collecting outcomes data using the therapy outcomes measure.
As a result of the surveys, recommendations and changes include a review of training needs, further improvement in communication, and clinical supervision for staff.
Areas that have been identified as needing further develpment include evidence-based practice, service standards, an outreach service and a clinical, practice nurse post.
Although the change began before the implementation of clinical governance, many elements meet clinical governance criteria.Establishing an inter-professional system of teamworking has also enabled us to set up a clinical governance steering group.This will oversee the re-auditing of the measures through the multidisciplinary clinical audit and riskmanagement groups.
1 Embling S.Exploring multidisciplinary teamwork.Brit J Therapy and Rehabilitation 1995; 2 (3): 142-144.
2 Enderby P.Therapy Outcome Measures .London: Singular Publishing Group, 1998.
Penny Spreadbury is therapy services manager, Linden Lodge rehabilitation unit and Kay Riley is unit manager/divisional specialty manager, Nottingham City Hospital trust.