Step by step

By Laura Raines

Pulse editor

Erica Garofalo sums up her role as a rehabilitation nurse in the spinal cord injury unit at Shepherd Center in Atlanta with two words: “hope and faith.”

Patients come from all over the country to Shepherd Center, one of the nation’s leading catastrophic care hospitals, in many conditions.

“When you admit them, you’re seeing them at their worst,” said Garofalo, BSN, CRRN, MHA. “You know they have so much potential, but they don’t know it yet.”

What she loves best about being a rehab nurse is helping patients fulfill that potential and seeing them achieve better outcomes. Garofalo said she gets goose bumps and sometimes cries at patient graduation ceremonies, which are held in the therapy gym.

Every patient recieves a diploma, a mortarboard and a commemorative T-shirt. Many patients give heartfelt speeches about how Shepherd Center changed their lives.

“It’s very gratifying when patients thank you on their way out the door, and [it’s] rewarding when they come back to update you on their progress” she said. “I still keep in contact with my first patient on Facebook and through e-mail.”

Between a patient’s admission and discharge, rehab nurses put in plenty of care, compassion, education and hard work. These patients require a team of doctors, therapists, counselors and technicians, but it’s usually a rehab nurse who coordinates the care.

While her primary focus is on helping patients achieve bowel and bladder independence, Garofalo goes on rounds with doctors every morning. She gives updates on patient progress, confers with therapists, helps patients practice new skills and educates patients and their families.

About 35 percent of the nurses at Shepherd Center hold rehab nursing certification (CRRN) and all of them have FIM (Functional Independent Measurement) certification, which is used to measure progress toward goals.

“It’s very emotional when patients don’t meet their personal expectations,” Garofalo said. “But we have a saying at Shepherd, ‘Never say never and never say can’t.’

“In 13 years, I’ve seen so many injuries and none are exactly the same. You never know how a patient will progress, but if something isn’t working we’ll find different ways to accomplish goals.”

She loves all aspects of her job, but especially when she accompanies patients on field trips for learning how to use adaptive equipment, community reintegration and enjoyment.

“In what other job would you get to go hunting and see your patient carry a turkey home on his lap?” she said. “We’ve taken patients on ventilators and feeding tubes to ballgames and the zoo. We’ve gone bowling and fishing. There are no limitations here. If we haven’t tried it, we will.”

Whether working in the field or the hospital, rehab nurses are nurses first.

“We check vitals, give medications, research drug interactions, suction tracheotomy tubes, give tube feedings, pack wounds, draw blood, and remove PICC [peripherally inserted central catheter] lines. You name it, we do it,” said Chaketa Brittain, RN, a nurse on Shepherd Center’s brain injury floor.

“We’re also detectives. Sometimes we have to put all the puzzle pieces together to figure out what’s going on with our patients and their families,” she added.

Brittain has only been a nurse for two years, but the rehab role comes naturally.

“My son suffers from a brain injury,” she said. “Doctors found that he had a brain tumor when he was 8, and removing it left him [mentally disabled]. He’s 22 now, just graduated from high school and is in a day program.”

Recently, Brittain calmed an angry father with the words, “I know that you’re upset because you are grieving.”

“He began to cry and then we could talk,” she said. “It’s easy for me to practice what I know and love, as a rehab nurse.”

In caring for patients during their three-month stays (on average), Brittain forms strong bonds with them and their families.

“I’ve walked a mile in their shoes and it feels good to be helping others, to be guiding them toward the best care,” she said.

The best approach is holistic, says Sharon Layton, RN, BS, CRRN, a nurse in the inpatient rehabilitation unit at WellStar Kennestone Hospital in Marietta.

“As rehab nurses, we coordinate everything about the patient medically, emotionally, functionally and educationally,” Layton said. “We’re constantly asking ourselves what we need to teach our patients.

“If they’ve been sent here for therapy, they are medically stable, but anything can happen. One of our biggest challenges is dealing with medical emergencies.”

With shorter hospital stays and more-acute patients, Layton said that the rehabilitation team is often asked to do the impossible.

“Sometimes we do it — getting a patient to where he needs to be in three days instead of nine or 10 days,” she said.

Layton tracks her patients’ schedules on a huge board that shows how they are progressing and what they’re doing every minute of the day.

Awarded as a top performer by the Uniform Data System for its best practices and outcomes in 2008 and 2009, WellStar Kennestone’s rehab unit places its patients with the same team of nurses and therapists each day for continuity of care.

“We all get to know each other and they get to know us, and it builds trust,” Layton said. “Trust is a big part of rehabilitation. There’s a lot of fear when you don’t know who’ll be looking after you or what you’ll be doing.”

Recently, she saw that fear in the eyes of a 91-year-old patient.

“Your initial impression with the patient has to be good,” Layton said. “I told her that she’d probably heard rumors about how hard physical therapy would be but that as her nurse, I was here to tell her the real story.

“I explained that we would design a treatment plan just for her — one that would fit her condition and limitations — and that there would be pain medication to make therapy easier and rest breaks. But I also told her what she’d be doing, and how we’d help her. You have to hit that line between being too soft or too hard.”

Rehab nurses have to adopt a unique mindset, said Kristina Lowe, RN, a veteran of 26 years in the field.

“My biggest challenge at first was not to do things for my patients that they should be doing for themselves,” Lowe said. “It takes more time and patience to do things that way, but it serves no purpose if we do it for them.”

Instead, Lowe has learned to give brief and to-the-point instructions so patients know what’s happening and what’s expected. She also carefully monitors pain medication.

“If their pain is managed, they can sleep better and do more and get better quicker,” she said.

Lowe finds it rewarding when patients reach milestones, and she gets excited when they take a first step, walk 150 yards or climb the stairs. She finds it fulfilling to watch a patient go from not being able to get out of bed to walking to the bathroom alone.

“I love this job because you get to put your energy and care and love into someone, and you can see the results,” she said. “You know you’re helping them to go back and live life to the fullest.

“I think one of our biggest roles is cheerleader. We’re the ones saying, ‘I know you can do this.’ ”