1. Competency Model for Professional Rehabilitation Nursing Behavioral Scenario for Competency 3.4: Empower Clients to Self-Advocate Mary Ullrich, MSN, RN, CRRN & Kristen L. Mauk, PhD, DNP, RN, CRRN, GCNS-BC, ACHPN, GNP-BC, FAAN Copyright©2015, Association of Rehabilitation Nurses

2. Competency 3.4: Empower Clients to Self-Advocate Description/Scope: Client advocacy is the safeguarding of a client’s autonomy, acting on behalf of the client, and empowering the client through education, collaboration, and support for individuals living with chronic illness and/or disability (DCIHM). Respects and values client and family autonomy in their health-related choices Provides information to client and families that they need to make informed decisions about care Demonstrates awareness of developing conflicts on the unit between clients, families, and caregivers Beginner Proficiency Level Descriptors Copyright©2015, Association of Rehabilitation Nurses

3. Behavioral Scenario Fred is a 76 year old male who has been on the rehabilitation unit for a left middle cerebral artery (MCA) stroke (CVA). He has been progressing quite well with self-care and mobility issues; however, he remains NPO due to dysphagia. He currently has a nasogastric tube in place and has worked hard with the Speech Language Pathologist to improve his ability to eat again. In Team Conference today a discharge date for the following week was set. It was determined Fred would require a G-tube placed for nutritional prior to going home, as Fred has not made enough progress in swallowing safely. After the Team Conference, the physician spoke to Fred about G-tube placement and the reasons why it was determined this intervention is required. Copyright©2015, Association of Rehabilitation Nurses

4. Path 1 – Not Proficient Sally, Fred’s primary nurse, entered Fred’s room after the physician spoke to him about G-tube placement. Sally indicated she wanted to start soon with education for Fred and his wife regarding the use and care of the G-tube. At that point, Fred informed Sally he had no intention of having the tube placed. Sally stated that although she respects and understands Fred’s feelings regarding this, the issue is really out of everyone’s hands because, ethically speaking, eating is harmful to him right now and it is the team’s responsibility to keep him safe. Later in the shift, Sally saw Fred’s wife entering the unit for her daily visit with Fred. Sally told the wife it was important for Fred to have the G- tube and could she please talk Fred into having the procedure done. Copyright©2015, Association of Rehabilitation Nurses

5. Path 1 – Not Proficient Observations & Outcomes 1.The novice nurse understood the patient’s need for autonomy, but quickly denied him his right to decision-making through informed consent. 2.The novice nurse also attempted to solicit Fred’s wife in talking him out of the decision he had made without understanding that Fred’s wife deserved information and education as well. 3.The not-proficient nurse in this case did not initiate consultation with team members who could provide additional education and information, thus failing to empower Fred’s decision-making. Copyright©2015, Association of Rehabilitation Nurses

6. Path 2 - Proficient The proficient nurse first asked Fred why he was opposed to having the G-tube placed. Fred stated life was not worth living if he could not taste and swallow his food. The nurse provided additional information to Fred that he could still continue speech therapy and that patients often progress enough to later have the G-tube removed. The speech therapist and the clinical nurse specialist were asked to provide additional education to Fred and his wife. However, Fred was still adamant that he did not want a G-tube. Acknowledging Fred’s right to make that decision, the nurse contacted the patients care team for a discussion. Members of the team presented information to Fred and his wife regarding the health effects of Fred’s decision. The nurse anticipated discourse within the nursing and therapy teams regarding the potential that Fred might discharge home without a G-tube. She contacted a member of the Ethics Committee to discuss the ethical principle of autonomy with the clinicians in regards to Fred’s situation. The following week, Fred discharged home without the G-tube. Copyright©2015, Association of Rehabilitation Nurses

7. Path 2 – Proficient Observations & Outcomes 1.The proficient nurse allowed the patient to verbalize his reasons for not wanting the G-tube. This allowed her to provide the appropriate interventions for Fred and his wife for informed decision making. 2.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 interprofessional team to communicate Fred’s wishes. 3.The proficient nurse also anticipated difficulty with acceptance of Fred’s decision from her colleagues and arranged education and discussion of their feelings regarding Fred’s decision. 4.Although the outcome of this scenario was still Fred’s refusal of G-tube placement, the proficient nurse assured that his decision was both informed and supported. Copyright©2015, Association of Rehabilitation Nurses

8. 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 even with additional education, the patient still had a right to be empowered to make an informed decision about having a G-tube placed Non-Proficient Nurse - Provided basic care, but avoided additional communication to identify patient concerns related to his resistance to the G-tube placement -Did not recognize the need for additional education and information - Did not use an interprofessional approach to care by engaging additional team members in the POC Copyright©2015, Association of Rehabilitation Nurses

9. Takeaways The beauty of rehabilitation is in the team approach to assisting the patient to attain a quality of life that is self-determined. When ethical issues arise in the care of our patients, it is critical to work as a team to support and empower clients toward self-advocacy. This is done through education and collaboration. Support in the form of discussion and education to the team members is also vital to their ability to support the patient in his decision. Copyright©2015, Association of Rehabilitation Nurses