1. Competency Model for Professional Rehabilitation Nursing Scenarios for Education Competency 3.1 Promote Accountability for Care Wendy Wintersgill, MSN, RN, CRRN, ACNS-BC

2. Competency 3.1 Promote Accountability for Care Description & Scope: Accountability for care is the continuous, multi-dimensional process that promotes ethical, cost-effective client and family- centered quality outcomes in persons with disability and chronic illness. Delivers safe, ethical, quality care for the client and family Collects unit data that addresses practice issues affecting quality outcomes Demonstrates awareness of how client/staff variables affect the quality of the processes of the unit Beginner Proficient Level Descriptors

3. Behavioral Scenario Copyright©2015, Association of Rehabilitation Nurses Mr. Cantarez is 68 years of age and was admitted to the IRF yesterday afternoon after a stroke. He speaks little English. When approached by the nurse he speaks rapidly and loudly. Mr. Cantarez has a reddened area at the base of his spine and his right elbow. He has mild right sided weakness and is complaining of right sided shoulder pain. The nurse caring for Mr. Cantarez is a novice who has been on the unit for six months. He knows the rehab routine and the importance of therapy minutes. He took report, passed his morning medications and is ready to get his patients to the rehab gym.

4. Path 1 – Not Proficient Wanting to get Mr. Cantarez to the gym on time, he looks at the white board in the patient’s room and sees that no one has updated it with the patient’s mobility status. He gets the translation phone and dials in to speak via a translator. He continues to do a mobility assessment and determines that Mr. Cantarez is a gait belt assist. Since no gait belt is in the room, the nurse tries a low-pivot transfer and notices Mr. Cantarez wince during the activity. Mr. Cantarez is whisked down the hall to get to therapy on time. Realizing that he forgot to ask the translator to rate Mr. Cantarez’ s pain, he asks the diet clerk who speaks Spanish to translate for a pain assessment. The pain is a 6. He gets Mr. Cantarez to the gym and goes back to the unit for pain medicine. He passes the charge nurse on the way who asks, “Is everything okay?” The nurse answers, “Just fine…” and continues on his way to medicate his patient. Copyright©2015, Association of Rehabilitation Nurses

5. Path 1 – Not Proficient Observations & Outcomes 1.A rehabilitation nurse always asks the level of assistance needed to safely mobilize a patient. He should have received this information in report. If the level of assistance wasn’t provided, a proficient rehab nurse would have asked. He wasn’t prepared to provide safe, high quality care. 2.Realizing his mistake, he does the right thing by using a translation line to perform a mobility assessment. The assessment findings tell him that the patient is a gait belt assist. He needs a gait belt but none is available. Having taken the time to use the translation line, he is rushed and transfers the patient without the proper device adding strain to a subluxed shoulder. 3.The wincing reminds him to assess his patient’s pain. Asking a diet clerk who is not a certified medical translator was inappropriate. The clerk may know Mr. Cantarez from the largely Latin community, violating Mr. Cantarez’ s privacy. Additionally, he did not localize or have a description of Mr. Cantarez’ s pain. He assumes the pain is in the shoulder and is preparing to medicate based only on a score. The pain may have been from seated pressure on his lower spine. Overall, the care provided was based on the novice nurse rushing to get his patient to the gym on time rather than being patient centered for quality outcomes. 4.Accountability begins with the nurse patient relationship that may have been harmed in this scenario. Novice nurses need to be self-aware, know their limits, and allow their peers to step in to help. The nurse completely forgot about the safe patient handling equipment missing from the patient’s room. This could have been addressed by the charge nurse had it been communicated. He also forgot to update the whiteboard in the patient’s room with the patient’s mobility status. Copyright©2015, Association of Rehabilitation Nurses

6. Path 2 - Proficient The charge nurse learns from two other nurses that gait belts are missing from patient rooms. She takes the initiative to check every room and replaces each missing belt. She sends a message to the Unit Based Quality Team and asks to be placed on the agenda for their meeting next week stating that the purpose of her request is to talk about the missing gait belts and propose doing a weekly monitor to ensure that staff have the proper equipment at the point of care. Later, she sees Mr. Cantarez who is now very tired. She asks his nurse to help her put Mr. Cantarez in his bed. She sees that the whiteboard isn’t updated and calls the language line to perform a mobility assessment. The novice nurse says, “ He’s a gait belt assist.” The charge nurse says, look at him, and proceeds to do a new mobility assessment. Mr. Cantarez is too tired to participate. Together, they safely transfer Mr. Cantarez back to bed using a chair sling lift. Once Mr. Cantarez is safe in his bed the charge nurse takes the novice nurse aside and reminds him that Mr. Cantarez had received pain medication, and spent the last hour being evaluated by PT & OT. She also adds that stroke itself causes fatigue while the body is working to restore itself. After summarizing the changes in Mr. Cantarez, she finishes with, “Always re-assess when there is a change in your patient’s condition.” The charge nurse updates the white board to read, Use Transfer Sling when Fatigued. Copyright©2015, Association of Rehabilitation Nurses

7. Path 2 – Proficient Observations & Outcomes 1.The proficient nurse gathers and shares her analysis of unit data that affects the quality of client –centered care and takes ownership of the path forward for change and improvement. 2.The proficient nurse leader stops what she is doing and re-prioritizes to meet the patient’s needs and to support her peers. 3.The proficient nurse identifies factors that influence the provision of quality care and client and family outcomes. Copyright©2015, Association of Rehabilitation Nurses

8. What Did You Observe? How did the outcomes of this scenario differ? Proficient Nurse - - Puts the patient first - -Demonstrates proficient assessment according to the standards and scope of practice - -Provides constructive feedback to support the professional growth and development of her novice partner - - Initiates an environmental analysis, implements changes as appropriate that impact the provision of safe and quality care Non-Proficient Nurse - Puts their needs ahead of the patients - Unethically uses an employee translator - Assessment is disorganized and incomplete - Fails to recognize his own limitations - Forgets about the barriers he encountered when caring for his patient and leaves the environment unprepared for the next nurse Copyright©2015, Association of Rehabilitation Nurses

9. Takeaways 1.It is critical that nurses recognize their own limitations. 2.Accountability for care can take a variety of forms and venues. 3.Nurses wishing to become proficient in this competency should actively identify factors that influence the provision of quality care and client and family centered outcomes; also, contribute to unit-based quality improvement activities including the analysis of unit data that affect quality client- centered outcomes. 4.Advanced practice nurses would additionally be expected to analyze data from multiple sources that impact the provision of safe and quality care and implements changes as appropriate; as well as to contribute to the evaluation of the environment in monitoring and measuring the efficacy of organizational quality outcomes. Copyright©2015, Association of Rehabilitation Nurses