1. Competency Model for Professional Rehabilitation Nursing
Behavioral Scenario
for
Competency 4.2: Implement an Interprofessional Holistic Plan of Care
Nanci Steinebach, RN, BSN, CRRN, CCM & Kristen Mauk, PhD, DNP, CRRN, GCNS-BC, GNP-BC, ACHPN, FAAN
Copyright©2015, Association of Rehabilitation Nurses

2. Competency 4.2: Implement an Interprofessional Holistic Plan of Care
Description/Scope: The rehabilitation nurse develops a plan of care for diverse clients, which prescribes strategies, alternatives, and interventions to attain desired outcomes
Identifies client problems that need care planning
Contributes to interprofessional team in establishing patient-centered goals
Implements the interventions established in the interprofessional plan of care
Evaluates effectiveness of nursing interventions in the interprofessional plan of care
Beginner Proficiency Level Descriptors
Copyright©2015, Association of Rehabilitation Nurses

3. Behavioral Scenario
The night nurse is performing hourly turning rounds on the spinal cord unit of an inpatient rehabilitation hospital. She enters the room of a new 28-year old male patient diagnosed with a C3-4 complete fracture resulting in tetraplegia from sliding into third base at a baseball game.
The patient is crying and says to the nurse, “Why me? Why did God let this this happen to me? I wish I never lived. I don’t think I can do this.”
Copyright©2015, Association of Rehabilitation Nurses

4. Path 1 – Not Proficient
The nurse explains to the patient why she is there and why she needs to assist him with turning every two hours. She recognizes that he is upset and not sleeping, but states that he should get some rest, as he has a big day in therapy scheduled tomorrow. After asking if there is anything else he needs, he replies “no”, and she leaves the room. The nurse notes his crying in the record and gives report to the day nurse to report this in team conference.
Copyright©2015, Association of Rehabilitation Nurses

5. Path 1 – Not Proficient Observations & Outcomes
The nurse implemented the interprofessional POC by making turning rounds to prevent skin breakdown and complications. She appropriately noted that the patient was crying and asked if he needed anything additional before leaving the room. The nurse also passed this information along to the RN on the next shift to report in team conference. However, the nurse did not demonstrate a proficient level of expertise since she did not recognize the need to collaborate with additional members of the interprofessional team to provide the highest quality of care based on best available evidence.
Understanding the importance of implementing an interprofessional holistic plan of care is essential to best rehabilitation nursing practice. The more seasoned nurse recognizes the roles and value of various team members and knows how to appropriately involve them in the interprofessional POC. By updating the POC to include recreational therapy, psychology, peer support, and spiritual care, the patient receives the benefit of many professionals working together toward a common goal of successful adaptation.
Copyright©2015, Association of Rehabilitation Nurses

6. Path 1 – Not Proficient Observations & Outcomes (Cont.)
3. The nurse should develop her skills at implementing an interprofessional plan of care. This includes recognizing the roles of each team member, knowing when to make appropriate referrals, acting as the nursing expert on the team, and helping to establish team goals that are patient-centered. This type of interprofessional care results in better patient outcomes.
Copyright©2015, Association of Rehabilitation Nurses

7. Path 2 - Proficient
The nurse states, “I can see you are upset. Would you like to talk about it?” She sits down next to the patient and listens to the patient voice concerns about no longer playing sports, questioning his faith in God, and his worries that he will no longer be the father and husband he was before. The nurse provides reassurance to the patient, realizes that depression and spiritual distress may be common following a SCI such as this, and that additional team members can help to address some of these issues. The nurse updates the plan of care (POC) to include additional team members.
Copyright©2015, Association of Rehabilitation Nurses

8. Path 2 – Proficient (Cont.)
The rehab nurse consults with rec therapy to talk to the patient about adaptive sports, assures that a psychology consult is ordered for an evaluation/depression screening, contacts the hospital chaplain for spiritual care support, provides the physiatrist and psychologist with an update, and s the peer support network that a new patient might need some consultation. She discusses the POC updates with the dayshift nurse going to team conference tomorrow, and makes a suggestion that the team establish some interprofessional goals related to the patient’s coping, spiritual distress, and long-term desire to play sports again.
Copyright©2015, Association of Rehabilitation Nurses

9. Path 2 – Proficient Observations & Outcomes
The proficient nurse contributes specific nursing observations to the team and collaborates with the interprofessional team to establish patient-centered goals.
Rather than just attending to the basic needs of this patient while rounding, the proficient nurse took time to sit at his bedside and listen to his concerns. Then, she addressed those issues by using her knowledge of the interprofessional team and facilitating that team goals be established for the POC.
In this case, the nurse recognized the value of additional team members and knew which persons should be incorporated into the POC. She appropriately made the contacts and followed through with the next shift RN to communicate this information.
Copyright©2015, Association of Rehabilitation Nurses

10. What Did You Observe? How did the outcomes of this scenario differ?
Proficient Nurse
- Took time to therapeutically listen to the patient
- Contributed specific nursing knowledge to the POC
- Used knowledge about the rehab team to request consultation and also provide consultation to the interprofessional team
- Understood that depression and spiritual distress can be common after SCI and that an interprofessional approach provides the best outcomes
Non-Proficient Nurse
- Provided basic care, but avoided additional communication to identify patient concerns related to his crying
- Did not recognize the common sequelae related to coping after SCI
- Did not use an interprofessional approach to care by engaging additional team members in the POC
Copyright©2015, Association of Rehabilitation Nurses

11. Takeaways
Implementing a holistic interprofessional plan of care promotes quality of life and positive patient outcomes.
A holistic approach to care involves biopsychosocial and spiritual components which require a team approach.
The new rehabilitation nurse should recognize his/her important role on the interprofessional team and appropriate contributions toward to the interprofessional POC.
Copyright©2015, Association of Rehabilitation Nurses