Competency Model for Professional Rehabilitation Nursing Behavioral Scenario
Competency Model for Professional Rehabilitation Nursing Behavioral Scenario for Competency 2. 3: Promote and Facilitate Safe and Effective Care Transitions Mary Ullrich, MSN, RN, CRRN & Kristen L. Mauk, Ph. D, DNP, RN, CRRN, GCNS-BC, GNP-BC, FAAN Copyright© 2015, Association of Rehabilitation Nurses
Competency 2. 3: Promote and Facilitate Safe and Effective Care Transitions Description/Scope: Optimal collaboration and coordination among clients, families and healthcare professionals to promote the safe and timely transition across care settings. Beginner Proficiency Level Descriptors Assesses the client and family regarding cultural values and health literacy as applicable to care transitions Participates in the development of an interprofessional plan for care transitions Contributes to the development and implementation of the goals for care transitions Participates in the care conference that evaluates the care transition plan Copyright© 2015, Association of Rehabilitation Nurses
Behavioral Scenario Carl is 72 years old and suffered a left middle cerebral artery infarct. He has a history of heart failure, DM, HTN and obesity. Pre-morbidly, Carl was inconsistent in keeping his check-up appointments with his physician unless he felt poorly. He developed a PE while on the inpatient rehab unit. He is currently requiring maximum assistance with his bladder and bowel programs to be continent. He lived alone prior to the infarct. His son and daughter-in-law have agreed to take Carl to their home after discharge. Copyright© 2015, Association of Rehabilitation Nurses
Path 1 – Not Proficient Carl’s nurse was thinking ahead to discharge and knowing Carl could not give his own insulin, she taught his son how to administer the insulin. She provided handouts regarding heart failure, diabetes, and information regarding his medications. She provided information to the family regarding Carl’s follow-up appointments with his physicians. She reported in team conference that there were no longer any barriers to Carl’s discharge, as his family teaching had been completed. Carl was continent of bowel and bladder, and therapists were working with the family on transfers. Copyright© 2015, Association of Rehabilitation Nurses
Path 1 – Not Proficient Observations & Outcomes 1. The rehab nurse did identify some of Carl’s learning needs in preparation for home discharge when she taught the son how to administer Carl’s insulin to him. Additionally, the nurse provided written information on his chronic conditions and medications. However, the nurse reported no barriers to discharge and that the family teaching was complete. This stopped short of meeting the competencies for a beginning level. 2. In order to master the beginning level of competency in this domain, the rehab nurse should have also assessed Carl‘s and his family’s health literacy, gained more information about the transition to home and who would be family caregivers, provided thorough instruction about Carl’s follow-up care, helped the family to develop some reasonable short and long-term goals, and involved any additional team members for a safer and more effective transition to the home environment. Copyright© 2015, Association of Rehabilitation Nurses
Path 2 - Proficient Concerned regarding Carl’s transition to home, his nurse took the time to talk to Carl with his son and daughter-in-law regarding Carl’s needs once home. Carl had a scheduled follow up visit with his PCP for 3 weeks after discharge, but transportation was a concern, as his daughter-in-law felt uncomfortable transferring Carl to a car. Having had a complicated hospitalization in acute care as well as in the rehab setting, the nurse assisted Carl and his son in creating a paper Personal Health Record for all of the healthcare providers Carl would see post discharge. She instructed the family in insulin administration as well as blood pressure monitoring. She created a list of signs and symptoms for Carl and his family to be aware of that would warrant a call to the physician or a trip to the ER. Knowing that Carl uses a urinal for bladder continence, the nurse discussed options for the nighttime hours. In team conference, Carl’s nurse requested the Home Health RN to follow him for diabetes and heart failure monitoring. She requested a Home Health Aide to work with Carl’s daughter-in-law to learn how to provide basic care to Carl. A bedside commode was requested to assist with bowel continence and PT was asked to help family learn to transfer Carl to the BSC. She asked the social worker to assist in finding transportation for Carl to his physicians appointments. Copyright© 2015, Association of Rehabilitation Nurses
Path 2 – Proficient Observations & Outcomes 1. The rehabilitation nurse who meets the beginner level of competency, as in this scenario, used all of her resources to provide thorough education in order to assure a smooth transition to home. She identified the family’s values and concerns, taking time to address specific needs regarding transferring, medication, monitoring, and follow-up. She also discussed continence strategies, and involved home health care staff, the PT, and social worker in securing help at home and transportation to appointments as needed. 2. Intermediate and proficient rehab nurses would additionally engage in activities such as coordinating and facilitating an interprofessional plan of care as well as using data to evaluate the effectiveness of care transitions to manage and improve programs at a systems level. Copyright© 2015, Association of Rehabilitation Nurses
What Did You Observe? How did the outcomes of this scenario differ? Proficient Nurse - The nurse who was competent at the beginner level identified some of the challenges Carl would face with his health maintenance after discharge. - She assisted Carl and his family in problem solving some specific health concerns. - The rehab nurse sought the assistance of team members in providing resources and training for the family. Non-Proficient Nurse - The non-proficient nurse provided discharge information to Carl and his family. - However, anticipating obstacles to maintaining his health after discharge were not addressed. - The nurse also did not sufficiently address the health literacy of the patient and family, nor effectively communicate additional teaching and resource needs for a smooth and safe transition home. Copyright© 2015, Association of Rehabilitation Nurses
Takeaways The focus of rehabilitation nurses is quality of life for each individual we care for. It is important to understand know our patients and their families so that we can anticipate future obstacles to health maintenance. By identifying potential threats to their well being and using all available resources within the interprofessional team to facilitate smooth care transitions, we can then provide our patients and families with the necessary tools and resources to maintain their quality of life. Copyright© 2015, Association of Rehabilitation Nurses
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