Often we hear the terms Restorative Nursing and Rehabilitation Nursing- the two terms are confused and intermixed in conversations and services. While similar, there are a few major differences between the two:

Rehab is a higher level of skilled care. Services are always provided by licensed staff- physical and occupational therapists and their assistants; Speech-Language Professionals, Nurses and others. Services are billed for by the hour. Government and insurance plans will only reimburse services delivered by licensed professionals. The use of CNA’s in Rehab is limited- and any care they provide is not “billable”. This means services provided by a CNA are not paid for. In Rehab, the CNA is not considered a professional.

Restorative care, on the other hand, is provided by nursing staff, including CNA’s. It is provided 24 hours a day, 7 days a week. Nurses can assess residents for needs and create special programs designed to restore or maintain the residents’ current and previous levels of physical health.

People are discharged from hospitals with complex medical conditions and needs. As is often the case, these people are admitted to nursing homes for rehab. Doctors write orders for PT, OT and other rehab services. The newly admitted resident is usually at the nursing home just for rehab- and they expect to return to their homes or other places they were residing at once the therapies end. Other residents need nursing care as well as rehab, and these folks make up the majority of the population we see in the nursing home setting. These people don’t return to their homes, sadly.

The PT and others develop specialized programs for the rehab resident: ROM/Exercises, Ambulation, Positioning…self care skills, teaching the use of adapted equipments. The resident will either meet the goals and no longer need the services, or they will not meet the goals and services end because a lack of improvement.

This is where Restorative Nursing comes into the picture.

Some nursing homes chose to have a dedicated Restorative Program; others do not. Those that don’t usually expect ALL the staff to follow basic, generic guild lines for ALL the residents. While this sounds good, it’s not. These are not true Restorative Programs and they are not individualized for each resident. This one size fits all form of delivery is a poor substitution for the real thing, which offers so much more. The real thing involves nurses assessing each resident for potential problems in almost all areas of need. For those residents coming off of REHAB, the wise nurse will confer with the residents’ therapists and develop on going, daily living programming that is carried out by nursing staff.

Restorative skills assessment may include but is not limited to:

* range of motion exercises
* ambulation and transfers
* splint and brace application
* toileting programming
* fall risk assessment and prevention
* feeding
* communication
* dressing.

Resident and staff restorative specific education and goal setting is provided. A restorative plan of care reflects the resident’s goals and desired outcomes and is formulated and implemented in order to improve or maintain optimal wellness and functional potential of each resident.

Dedicated Restorative Programs can be creative and meaningful and have a real purpose. One facility I know of has teams of staff that address different areas of resident well being:

* Positioning Group. Develop individualized procedures whereby nursing staff can easily and consistently follow through on residents’ positioning needs to prevent contractures (deformities or distortions caused by permanent shortening of muscle or scar tissue); minimize pain, stiffness and edema; facilitate independent self-care; increase socialization; and maximize skin integrity and ability to interact with the environment.

* Skin Integrity Group. Identify residents at risk for skin breakdown, falls and poor sitting posture, and provide such residents with mechanical supports and positioning techniques and/or devices.

The facility called upon the professional skills of a PT and an OT to help develop these groups. Nurses, aides, Activity Staff, Dietary Staff were all members of these groups. By far, the groups were made up of mostly of CNA’s though, since they are the ones expected to deliver much of the programming. This method is very inclusive and requires ALL the aides to participate in the Restorative Process, which I personally believe is the best route to take.

Some duties of the RNA might include:
Provides direct restorative care and delegated formalized therapy tasks as assigned in order to continuing on-going formalized therapy program.

Receives specific instruction from nursing on restorative nursing techniques through nursing orders.

Restorative Nursing Assistants, RNA’s, are not required by any government agency. Nor are they specially paid for…so any facility that utilized an RNA often pulls this person out of the regular CNA pool rotation. The justification behind this is pretty bland: The work the RNA does equals the increased workload for the other CNA’s who no longer are expected to do certain elements of their job. We all know CNA’s never have to time to do much more than HALF of what they should be doing. So this is pretty lame.

Instead of having one or two “special aides” assigned to these tasks, it makes much more sense to have the job description of CNA changed to RNA or what ever title suits the facility best. Here’s how one facility did just this.

Of course the CNA (s) will need some training to become familiar with the tasks expected of them in the role of an RNA. I cannot imagine this would be too difficult to manage: A PT or OT and an RN could come together and come up with a pretty inclusive and extensive in service for teaching.
THIS IS AN EXCELLENT book and resource for anyone interested in Restorative Skills Teaching.

Also, have a look at what other places offer for RNA training- to give you ideas of what content might be needed for teaching the CNA’s.

The Association of Rehabilitation Nurses offers a training manual for Restorative Aides as well.

And here’s a company that hosts seminars on how to develop a Restorative Program.