Competency Model for Professional Rehabilitation Nursing Behavioral Scenario for Competency 1.3: Provide Client and Caregiver Education in Relation to Disability, Chronic Illness, and Health Management (DCIHM) Kristen L. Mauk, PhD, DNP, CRRN, GCNS-BC, GNP-BC, ACHPN, FAAN & Kim Maas, BSN, CRRN, CBIS Copyright©2015, Association of Rehabilitation Nurses

Competency 1.3: Provide Client and Caregiver Education in Relation to Disability, Chronic Illness, and Health Management (DCIHM) Description/Scope: Uses the nursing process to provide DCIHM to provide education for individuals, families, interdisciplinary teams, and communities. Areas of education include but are not limited to ADL management, mobility, communication, safety, and disease management. Assesses/determines learning needs and readiness to learn of the client and caregiver for DCIHM “literacy” Supports established goals for the client and caregiver Utilizes standard rehabilitation education related to DCIHM Utilizes “teach-back” to evaluate client and family learning Beginner Proficiency Level Descriptors Copyright©2015, Association of Rehabilitation Nurses

Behavioral Scenario A nurse enters the room of a patient that is due to be discharged the next day. The patient is a 37 year old male who was in a motor vehicle accident and sustained a traumatic brain injury and multiple fractures. The fractures are since healed and he has full weight-bearing; however, the psychoemotional effects of his brain injury are still apparent. His wife is at the bedside and expressing concerns about his upcoming discharge. His wife reports that she runs a daycare in the home and this is their only income at this time. She is concerned about her husband’s continued irritability and verbal outbursts when too much environmental stimulation is present. They also have a son of their own, and the patient has been verbally aggressive with him as well. The patient is currently on Cymbalta daily. Copyright©2015, Association of Rehabilitation Nurses

Path 1 – Not Proficient The nurse continues to walk into the room with little eye contact with patient and wife. She approaches the bedside and discusses the need to finish up discharge paperwork. She explains that she needs to get this done before the next shift comes in so he is ready to be discharged at the hospital’s stated discharge time. The patient’s wife expresses concerns about her husband’s irritability again. The nurse brings her computer near them and goes over the last team conference notes. The notes conclude with the team agreeing that the patient has met his goals and is ready to go home. The nurse also states that the physician says it is time for the patient to be discharged. His wife nods and acknowledges the note, but starts to get tearful and express her doubts of being able to manage everything at home while working. The nurse tells her not to worry and that her husband would not be going home if the team didn't think they were both ready. The nurse then says that she needs to check on another patient and she will be back soon to finish up the paperwork. Copyright©2015, Association of Rehabilitation Nurses

Path 1 – Not Proficient Observations & Outcomes The nurse does review the last team notes to assist in reassuring the patient's wife he is ready to go home. She does this by acknowledging he has reached his goals for inpatient rehab. However, the nurse is not proficient in addressing the concerns about overstimulation and irritability. She does not attempt to educate the wife on ways to decrease stimulation to assist in making home transition easier. She also does not address the medications he is on and whether or not they can be adjusted. The nurse is too concerned with getting her paperwork done. The nurse needs to increase her proficiency in providing education to her patients by using principles of patient-centered care and therapeutic listening. She should have realized that the wife was asking for help and reassurance and that this presented a teachable moment. By failing to educate the wife about common behaviors, how to control the environment to minimize stimulation, the medication regimen, and strategies to cope with behaviors, the nurse is not helping the patient and family to have the best outcomes after discharge. Copyright©2015, Association of Rehabilitation Nurses

Path 2 - Proficient The nurse says to the wife, “I understand that this is an adjustment in getting ready to take your husband home after his brain injury. Let’s talk about your specific concerns”. The nurse listens carefully to the wife and then states that she will be back with some written information about managing behavior after brain injury and the contact number for a support group in the area. The nurse returns with this information and takes time with the wife to role play a scenario in which the patient loses his temper in front of their son. She demonstrates the best strategies for handling this behavior and repeats the scenario for the wife to demonstrate “teach-back”. The nurse also discusses other options for the wife that might be more feasible than running a day-care in their home, and some choices for respite for her. After their educational session, the wife says, “I feel so much better now. I think I just needed to have more information. It looks like I need to make some changes on how I handle things”. Copyright©2015, Association of Rehabilitation Nurses

Path 2 – Proficient Observations & Outcomes The nurse at a beginning level of proficiency considered the patient’s wife and her goals for discharge. The nurse was able to determine that the wife needed additional education in several areas. She used standard educational tools and methods including a brochure and support group information, the teach-back method via role-playing to handle difficult behaviors, and discussion about medications. The nurse also demonstrated some intermediate competencies in that she individualized the educational plan and provided tailored education. To further increase her proficiency level, this nurse could have adapted the plan of care in advance to include the needed teaching versus waiting until just before discharge. An expert rehab nurse would have anticipated long-term needs of this patient and family, provided consultation ahead of time to determine the wife’s fears and concerns, and modified educational materials to meet the wife’s needs. Copyright©2015, Association of Rehabilitation Nurses

What Did You Observe? How did the outcomes of this scenario differ? Proficient Nurse - Took time to listen to the wife’s concerns and tailored her educational plan accordingly - Used the teach-back method to help the wife practice new skills - Used her rehab knowledge to educate the wife about behavior, environmental control, and medications - Non-Proficient Nurse - Focused on finishing her documentation above listening to the wife’s concerns - Provided minimal education that was not tailored to the patient/wife’s needs - Did not share the needed knowledge for this patient before discharge Copyright©2015, Association of Rehabilitation Nurses

Takeaways The new rehab nurse should demonstrate at least a beginning proficiency level in this competency by listening to the patient and family goals prior to discharge and providing needed education. Establishing a tailored educational plan takes prior planning. Rehabilitation nurses can foster more positive patient outcomes through appropriate education that is based on current standards and includes the items that family members and patients both want and need to know for a successful home transition. Copyright©2015, Association of Rehabilitation Nurses