1. Competency Model for Professional Rehabilitation Nursing
Behavioral Scenario
for
Competency 1.2: Implement Nursing and Interprofessional Interventions Based on Best Evidence to Manage the Client’s Disability and/or Chronic Illness
Rebecca S. Koszalinski PhD, RN, CRRN, CMSRN
Copyright©2015, Association of Rehabilitation Nurses

2. Competency 1.2: Implement Nursing and Interprofessional Interventions Based on Best Evidence to Manage the Client’s Disability and/or Chronic Illness
Description/Scope: Use of evidence-based interventions to manage common disabilities and chronic illness, such as TBI, stroke, SCI, amputation, neuromuscular disorders, etc.
Uses established guidelines to assess an individual’s function and health management needs
Follows an established plan of care (POC) with the client and family
Documents responses to standard interventions
Beginner Proficiency Level Descriptors
Copyright©2015, Association of Rehabilitation Nurses

3. Behavioral Scenario
A nurse enters the room of a patient who is completing his rehabilitation locally so he can be near his family. He suffered Mild Traumatic Brain Injury (MTBI) in military service when his jeep flipped and he was thrown. His family members, who are greatly involved in his plan of care, say that he seems “different”. The patient is generally cooperative, but is anxious to leave the facility. He also frequently exhibits impulsive behaviors.
Additionally, his vestibular system is affected so that he sometimes experiences dizziness. He is identified as a fall risk in his personalized plan of care. A gait belt is supposed to be worn at all times (except when sleeping) and he should always wear non-slip socks when out of bed. The nurse from the last shift reported that he was “belligerent”. She adds that the patient wants to get up to use the restroom instead of using the urinal hanging on his side rail.
Copyright©2015, Association of Rehabilitation Nurses

4. Path 1 – Not Proficient
The nurse introduces himself to the patient as the patient fidgets in his bed. Suddenly the patient blurts out, “I need to get up right now”. Before the nurse can respond, the patient throws his blankets off and swings his legs out of the bed. The nurse quickly steps forward to block the patient as the patient lurches to his feet. The nurse instinctively grabs the patient’s arm and attempts to steer the patient to the restroom. However, the patient is not wearing a gait belt or non-slip socks. As a result of these safety errors, the patient slips and falls to the floor. Further injury occurs when the nurse tries to pull the patient back to his feet and is subsequently pulled to the floor. The nurse reports a mild back strain and leaves to have it examined after the patient is safely back in bed. The plan of care is not updated and the nurse leaves the facility before completing the required documentation.
Copyright©2015, Association of Rehabilitation Nurses

5. Path 1 – Not Proficient Observations & Outcomes
The nurse did not know and did not follow established evidence-based guidelines for working safely and competently with patients who are fall risks and/or have experienced MTBI. As a result, both the patient and nurse were at risk for injury.
The impacts/consequences of not being proficient include further injury to the patient and a potential setback in the patient’s progress , which could require additional time and costs. The nurse could suffer injury, resulting in diagnostic tests, unanticipated time off work and temporary loss of full pay. The nurse could be disciplined for not being aware of safety measures, using ineffective communication, poor body mechanics and limited critical thinking skills. Lastly, the nurse could suffer permanent disability.
Steps to achieve beginner proficiency include becoming aware of resources and guidelines, such as the Agency for Healthcare Research and Quality (AHRQ) National Clearinghouse Guidelines, so that the nurse can anticipate care needs in the rehabilitation population. Other resources include the individualized plan of care, supervisors and colleagues.
Copyright©2015, Association of Rehabilitation Nurses

6. Path 2 - Proficient
The nurse introduces himself to the patient as the patient fidgets in his bed. As he introduces himself, the nurse assesses the patient and quickly notes agitation. Suddenly the patient blurts out, “I need to get up right now!” The nurse is knowledgeable about the Agency for Healthcare Research and Quality (AHRQ) National Clearinghouse Guidelines for best practices and so is aware of how to work with a patient with increased fall risk and MTBI. The nurse continues to speak calmly to the patient while reaching for the non-slip socks on the side table and the gait belt on the chair. This action and calm communication provides both clear direction and reassurance to the patient. Once both safety measures are properly applied, the nurse skillfully assists the patient to the restroom and the patient successfully uses the toilet. The nurse then documents the nurse-led intervention including the patient’s success. This new information is added to the individualized plan of care.
Copyright©2015, Association of Rehabilitation Nurses

7. Path 2 – Proficient Observations & Outcomes
The behaviors that this nurse is exhibiting display competence, confidence, and proficiency. The nurse sets limits and provides clear direction for the patient in order to alleviate the patient’s agitation and stress. The nurse appreciates the report of the patient being “belligerent” but does not simply accept this second hand assessment. Instead, this nurse looks for the source of his agitation and learns that the patient wants to void independently and in the restroom. This nurse demonstrates critical thinking and therefore is able to safely and successfully assist the patient.
The positive outcomes of being proficient include patient safety, patient empowerment and clear nurse-patient communication.
The nurse may continue to increase proficiency by engaging in best practices in the facility and by using insight and creativity to identify gaps in assessment strategies. The nurse can collaborate with clients, patients, family and the interprofessional team to develop a plan of care with attainable rehabilitation goals, and evaluate and document clients responses to interventions. Lastly, the nurse can continue to adjust the plan of care as needed for best outcomes.
Copyright©2015, Association of Rehabilitation Nurses

8. What Did You Observe? How did the outcomes of this scenario differ?
Proficient Nurse
- Proactively assessed the situation
- Safely employed best practices to maximize outcome and minimize risk
- Empowered the patient with calm and clear communication
Non-Proficient Nurse
- Reacted to the situation with intuition instead of insight
- Did not know and did not use evidence-based best practices
- Greatly increased risk for injury to both patient and nurse
Copyright©2015, Association of Rehabilitation Nurses

9. Takeaways
Evidenced-based practice should strongly inform nursing practice. For the beginning nurse in particular, the use of evidenced-based practice helps to increase proficiency through the development and use of critical thinking skills.
Understanding and following the plan of care helps to ensure that care is consistent and can result in better outcomes for the patient.
Documenting all interventions and patient responses to those interventions keeps the interprofessional team on the same page. This can facilitate smoother care transitions and optimize an individualized plan of care.
Copyright©2015, Association of Rehabilitation Nurses