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Caregiver and Nurse Hopes for Recoveryof Patients with Acquired Brain Injury 3

Great Rehabilitation Nurses CombineArt and Science to Create Magic 13Delegation Knowledge and PracticeAmong Rehabilitation Nurses 16

Nurses with Sensory Disabilities: TheirPerceptions and Characteristics 25

Improving Physical Activity andFunction in Overweight and ObeseAdults with Osteoarthritis of the Knee:A Feasibility Study 32

Advancing the care of persons with chronic illness and disability

January/February 2011 Volume 36 • No. 1

NURSING


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3 Caregiver and Nurse Hopes

for Recovery of Patients with

Acquired Brain Injury

Mary Catherine Gebhardt, PhD RN CRRN

Linda A. McGehee, PhD RN

Cecelia Gatson Grindel, PhD RN CMSRN

FAAN

Linda Testani-Dufour, MS RN CRRN

13 Great Rehabilitation Nurses

Combine Art and Science to

Create Magic

Donald D. Kautz, PhD RN CNRN CRRN CNE

16 Delegation Knowledge and

Practice Among Rehabilitation

Nurses

Mary Joe White, PhD RN

Ann Gutierrez, MSN RN CBIS CRRN

Kerry Davis, BSN RN CBIS CRRN

Rhonda Olson, MS RN CRRN

Celeste McLaughlin, MS CNS RN CRRN

25 Nurses with Sensory Disabilities:

Their Perceptions and

Characteristics

Leslie Neal-Boylan, PhD CRRN APRN-BC

Kristopher Fennie, PhD MSC MPH

Sara Baldauf-Wagner, MS APRN-BC CNM

MSN

32 Improving Physical Activity and

Function in Overweight and

Obese Adults with Osteoarthritis

of the Knee: A Feasibility Study

Elizabeth A. Schlenk, PhD RN Jennifer L. Lias, MS MPT

Susan M. Sereika, PhD

Jaqueline Dunbar-Jacob, PhD RN FAAN

C. Kent Kwoh, MD

ContentsJanuary/February

Volume 36, Number 1

EDITORElaine Tilka Miller, PhD RN

CRRN FAHA FAANUniversity of Cincinnat

College of NursingCincinnati, OH

EDITORIAL BOARD Joan P. Alverzo, PhD CRRN

Kessler Institute foRehabilitation

West Orange, N

Carole Ann Bach, PhD RN CRRN Jeanette C. Rudy School o

Nursing, Cumberland UniversityLebanon, TN

Anne Deutsch, PhD RN CRRNRehabilitation Institute o

ChicagoChicago, IL

Janice L. Hinkle, PhD RN CNRNCatholic University of America

Washington, DC

Cynthia S. Jacelon, PhD RN CRRNUniversity of Massachusetts–

AmhersAmherst, MA

Donald Kautz, PhD RN CNRNCRRN CNE

UNC Greensboro School oNursing

Greensboro, NC

Rosemarie B. King, PhD RN FAHANorthwestern University

Chicago, IL

Cheryl A. Lehman, PhD RN BCCRRNUniversity of Texas Health

Science Center at San AntonioSan Antonio, TX

Barbara Lutz, PhD RN CRRNUniversity of Florida

College of NursingGainesville, FL

Audrey Nelson, PhD RN FAAN James A. Haley Veterans’ Hospita

Tampa, FL

Gail Powell-Cope, PhD ARNPFAAN

James A. Haley Veterans’ HospitaTampa, FL

STAFFExecutive Directo

Karen NasonManaging Edito

Rachel Frank

Designe Jill Coope

Editorial AssistanGail Pannozzo

Director of SaleKathryn M. Checea

Senior Sales ManageTerri Berkowitz

Rehabilitation Nursing is the official publication of the Association of Rehabilitation Nurses and is a refereed journal. Journal articles express the authors’views only and are not necessarily the official policy of ARN. Information for authors is available from the editorial office of Rehabilitation Nursing. The asso-ciation reserves the right to accept, reject, or alter all editorial and advertising material submitted for publication. Advertising published in the journal doesnot imply endorsement of products and services.

Copyright © 2011 by the Association of Rehabilitation Nurses. All rights reserved. Rehabilitation Nursing (USPS 465810/ISSN 0278-4807) is published sixtimes yearly by the Association of Rehabilitation Nurses, 4700 W. Lake Avenue, Glenview, IL 60025-1485, 800.229.7530, 847.375.4710. Subscription: Nonmembersubscribers to the journal have a choice of subscription levels: regular or premium. Regular subscribers receive the online edition of the journal and premiumsubscribers receive both online a print editions. ARN members receive both online and print editions of the journal as a member benefit. Individual subscriber(U.S.): $120 (regular), $150 (premium); individual subscriber (international): $195 (regular), $240 (premium); institutional subscriber (U.S.): $175 (regular), $220(premium); institutional subscriber (international): $195 (regular), $240 (premium). Back issues available at $25 a copy. No replacements because of nonreceiptwill be made after 60 days has elapsed. Address all subscription correspondence to Circulation Department, Rehabilitation Nursing, 4700 W. Lake Avenue,Glenview, IL 60025-1485. Include label from magazine or entire old address on change requests and allow 6 weeks for change. Periodicals postage paid atGlenview, IL 60025 and additional mailing offices. POSTMASTER: Send address changes to Rehabilitation Nursing, 4700 W. Lake Avenue, Glenview, IL 60025-1485. Rehabilitation Nursing is indexed in Index Medicus/MEDLINE, Cumulative Index to Nursing & Allied Health Literature (CINAHL), and UnCover. Microfilm ofsingle articles or complete issues available from University Microfilms International, 300 N. Zeeb Road, Ann Arbor, MI 48106.

Members of the Association of Rehabilitation Nurses receive a subscription to Rehabilitation Nursing as a benefit of membership.

INFORMATION FOR AUTHORSGuidelines for writing for Rehabilitation Nursing can be obtained by contacting RNJ /Information for Authors, 4700 W. Lake Avenue,Glenview, IL 60025-1485, 800.229.7530, 847.375.4710, fax 847.375.6441, e-mail [email protected], website www.rehabnurse.org.

Features

Departments

Association ofRehabilitation Nurses

REHABILITATIONNURSING

2 Editorial


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2 Rehabilitation Nursing • Vol. 36, No. 1 • January/February

Rehabilitation NURSING

Safe After 60

Elaine Tilka Miller,

PhD RN CRRN FAHA

FAAN

Editor

Editorial

Helen, a spunky 88-year-old widow, was excited

to go out to dinner with her daughter and grand-

daughter. While she was rushing to put on herfavorite coat she tripped on the hall rug and came

crashing down to the hard, slate floor. Suddenly,

the anticipated fun-filled evening was replaced

with severe pain in her left leg and side, while

blood flowed down her forehead from hitting the

door as she fell. Unfortunately, this is a common

scenario as our population ages. In many instanc-

es, a fall may lead to a sequence of changes (e.g.,

injury, decreased functional ability, transitioning

from an independent living situation to one with

more assistance) that have a profound influence

on the lives of older adults and their families.

Approximately 30% of community-dwellingadults 65 years and older will fall in a given year;

adults 80 years and older are at greatest risk and ex-

perience falls at a rate of 1 in 2 (Gillespie et al., 2009).

Of those who fall, 66% are likely to fall again within

6 months. Moreover, injuries from falls are associated

with increased mortality, decreased functional abili-

ties, and reduced quality of life (Sterling, O’Connor,

& Bonadies, 2001). In 2006 falls among older adults

resulted in approximately 17,000 deaths and 1.84 mil-

lion visits to emergency departments in the United

States (Stevens et al., 2006). In addition to the person-

al costs associated with falls, the economic costs are

substantial; direct medical costs in 2000 alone totaledmore than $19 billion and are projected to be $240

billion by 2040 (Stevens et al.). Given these multiple

high personal and financial costs and rapidly expand-

ing numbers of older adults, the National Center for

Injury Prevention and Control (NCIPC) at the Center

for Disease Control and Prevention (CDC) recently

made older adult fall prevention a central priority in

its research agenda (NCIPC, 2009).

Because Helen lives in a small community setting,

she was taken to an urgent care facility rather than

a hospital-based emergency room. In both the Unit-

ed States and the United Kingdom, approximately

30%–50% of individuals are not taken to a hospital

when they fall (Weiss, Chong, Ong, Earnest, & Bal-

ash, 2003). Although with this type of care the injury

is treated, the underlying fall risk factors frequently

are not assessed. As a result, prevention strategies

to reduce the major fall risk factors (e.g., poor mus-

cle strength and tone, limited exercise, loss of bone

mass, impaired vision, medications limiting menta

alertness, and environmental hazards that contribute

to more than 30% of falls) are not considered or addressed (Gillespie et al., 2009).

In most cases, fall-prevention programs are target

ed to older adults who are hospitalized for their fall

related injuries. However, fall-prevention programs

and general health education should begin long

before adults experience initial falls. Framed within

the context of “safe after 60,” older adults must in-

creasingly learn more about normal aging changes

that may place them at greater risk for falls. Along

with recognizing key contributors to increased fal

risk, older adults must take more responsibility for

performing those behaviors that minimize the likeli-

hood of falls. A recent review of the fall-preventionevidence by Costello and Edelstein (2008) for com-

munity dwelling older adults revealed the following

• Multifocused interdisciplinary fall-prevention

programs (e.g., health and fall risk assessment

with referral, home visit assessment, exercise,

and balance training) appear to be effective for

older adults with a previous fall history.

• Medication and vision assessment, referral,

follow-up, and adjustments should occur for all

older adults and those at greatest risk for falls.

• Exercise alone is effective in reducing falls

and should include a combination of muscle

strengthening, balance, or endurance trainingfor at least 12 weeks.

• Home hazard assessment and modications

may be benecial in reducing initial and

subsequent falls.

Rehabilitation nurses must remain cognizant

that fall-prevention strategies are applicable to the

nonhospitalized, community-dwelling older adul

as well as those who are hospitalized. Be proactive

and educate older adults about actions that will mini

mize their risk for falls. Recognize that patients who

have fallen and are not hospitalized are more likely

to fall again and probably have not received any for

mal fall-prevention interventions. Whether you are a

nurse in a doctor’s office, a clinic, hospital, or urgen

care waiting room, or attending a family event, take

advantage of every teachable moment to educate al

older adults (60 years and older) and their families

regarding feasible actions to reduce potential falls.

continued on page 42


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Rehabilitation Nursing • Vol. 36, No. 1 • January/February 3


KEY WORDS

brain injury

caregiver

hope


From the moment of admission and throughout

the rehabilitation process, caregivers of patients

with an acquired brain injury (ABI) develop

hopes for the recovery and future of the patient.

Research suggests that over time caregivers adapt

their hopes based on the progress of the family

member (Herth, 1993); however, little data exist to

document this process. At the same time, rehabili-

tation nurses have reported that there is incongru-

ity in their hopes for the recovery of the patients

and those of the caregivers. No literature could

be found to support the reported incongruity or

the effect this incongruity might have on patient

outcomes. Without a clear understanding of the

similarities and differences related to the hopes

that caregivers and nurses have, it is difficult to

plan realistic patient care for discharge and devel-

op pragmatic plans for the future of the patient

with ABI. Consequently, the purpose of this study

was threefold: (a) explore the caregiver’s hope for

recovery of his or her family member who has

experienced an ABI; (b) compare the nurse’s hopesfor the patient with ABI to those of the caregiver;

and (c) identify what caregivers and nurses do to

maintain hope for recovery during the rehabilita-

tion process.

This article will focus on the results of interviews

with caregivers and primary nurses that describe and

compare their hopes for the patient at the time of ad-

mission. Rehabilitation nurses who understand the

hopes of the caregiver for his or her family member

with ABI can design effective interventions that meet

both the needs of the patient and the caregiver. As a

result, these interventions will be founded on realis-

tic, measurable nursing goals that also take into ac-

count the caregiver’s hopes to maximize the patient’s

recovery.

Literature Review

Stotland (1969) recognized that hope motivates

individuals to act and achieve. In the absence

of hope, the individual is often dull and listless.

Stotland defined hopefulness as high expectations

of success and hopelessness as low expectations of

success. Bland and Darlington (2002) distinguish

hope from wishful thinking, noting that in a hope-

ful situation there is the potential for the outcome

to be achieved. Dufault and Martocchio (1985)

describe a model of hope that includes a distinction

between general hopefulness and hope for spe-

cific outcomes. Family caregivers described having

“attainable expectations” as a source that serves

to increase hope (Herth, 1993). Caregivers who

have reasonable expectations are able to redefine

expectations as needed. In evolving circumstancessuch as the recovery process of an individual with

ABI, flexibility in altering one’s expectations was

necessary to engage hope in the context of an ever-

changing situation (Herth). These findings suggest

that guiding caregivers in setting realistic expecta-

tions for the family member with ABI supports the

caregiver’s hope.

Herth (1993) found that hope was a buffer for

stress and a requirement for effective coping. In ad-

dition, caregivers in this study described hope as

“continually unfolding and changing in response

From the moment an adolescent with acquired brain injury (ABI) is admitted to the hospital, his or her caregiver develops

hopes for the recovery and future of the patient; however, rehabilitation nurses have reported that these hopes are not al -

ways congruent with the nurse’s observations of the adolescent’s progression. The purpose of this study was threefold: (1)

explore the caregiver’s hope for recovery of his or her family member who has experienced an ABI, (2) compare the nurse’s

hopes for the patient with ABI to those of the caregiver, and (3) identify what caregivers and nurses do to maintain hope

for recovery during the rehabilitation process. This qualitative study validated that in some cases there was a disconnect

between caregivers’ and nurses’ hopes for recovery. Four themes related to the caregiver’s maintenance of hope were identi-

fied: “the importance of family,” “taking one day at a time,” “knowing the patient better,” and “spiritual strength brings me

through.” Enhancing the perceptual congruence between nurse and caregiver hope during rehabilitation will ultimately

improve patient outcomes.


Caregiver and Nurse Hopesfor Recovery of Patients with

Acquired Brain Injury Mary Catherine Gebhardt, PhD RN CRRN • Linda A. McGehee, PhD RN • Cecelia GatsonGrindel, PhD RN CMSRN FAAN • Linda Testani-Dufour, MSN RN CRRN

FREE CE OFFERING

FOR ARN MEMBERS

Log on to www.rehabnurse.

org and visit the Education

page for more details


6/48


to life situations” (p. 544). In their study of family

caregivers, Bland and Darlington (2002) identified

a range of sources of hope that come from internal

and external sources. External sources identified in-

cluded family, friends, professionals, and, sometimes,

the family member suffering from an illness. Inter-nal sources came “from within” and were generally

associated with the caregivers’ religious beliefs and

practices. Herth (1993) labeled these internal and ex-

ternal sources as hope-fostering strategies. Identifying

sources of hope will assist caregivers in developing

strategies that maintain hope while setting realistic

recovery goals during the rehabilitation of their fam-

ily member with an ABI .

Researchers have documented that the physical

and psychological health of the caregiver is often al-

tered by the caregiving experience (Gerkensmeyer,

Perkins, Scott, & Wu, 2008; Halm & Bakas, 2007; Holt-

slander, 2008; Hong & Kim, 2008; Teel, Duncan, & Lai,2001; Wennman-Larsen & Tishelman, 2002). Most

research on caregiver health has centered on spouse

and child caregivers of persons with a terminal or

long-term illness. In this study, the sample included

parents and grandparents of adolescents who experi-

enced traumatic brain injury and were hospitalized in

a rehabilitation center. These caregivers did not have

experience with long-term home care for their family

member with ABI.

The literature is void of prospective research that

examines the caregiver’s and rehabilitation nurse’s

hopes and expectations for an adolescent who has

an ABI. This study expands the science of nursing

knowledge on this topic and provides a framework

for the development of interventions that merge the

caregiver’s hopes with the reality of the day-to-day

recovery progression and the adolescent’s long-term

potential for recovery.

Methodology

This study used triangulation of data from multiple

sources (i.e., nurses, family caregivers) and multiple

methods (i.e., interviews, surveys) to gather infor-

mation related to hope for recovery of patients with

ABI. Researchers asked caregivers of 21 patients

with ABI admitted for inpatient rehabilitation to

participate in an interview and complete surveys on

personal hope and hope for the family member with

ABI. The interviews and completion of the surveys

by caregivers occurred within 2 weeks of patients’

admission to inpatient rehabilitation. In addition,

caregiver, patient, and nurse demographics and

patient clinical data were collected. Interviews with

patients’ primary nurses occurred within 2 weeks

of admission. Most caregivers visited their family

member every day. Therefore, researchers were able

to arrange the interview for both the caregiver and

the nurse to take place on a day when the nurse was

working, avoiding the risk of data contamination

from discussion of the interview between the nurse

and caregiver.

SampleThe caregiver was defined as the person the family

identified as the individual who would provide the

majority of care (e.g., parent, guardian, significant

other) for the patient with ABI after discharge. Care-

givers in this study included parents, grandparents,

and stepparents. The caregiver criteria for selection

included being able to speak and read English at an

8th grade level and being older than 18 years old.

The patients were individuals who had sustained

an ABI and been admitted to an inpatient rehabilita-

tion facility. To be included in the study, patients were

between 15 and 21 years old, unmarried, and whose

primary/permanent residence was the home of theirparents or guardian. The patients were stratified into

two groups. Group 1 included ABI patients admitted

at a Rancho Level I, II, or III. All patients at levels I,

II, or III require total nursing care. The ABI patients

assigned to Group 2 were admitted at a Rancho Level

IV, V, or VI. Patients at these levels require assistance

with activities of daily living (Rancho Los Amigos

National Rehabilitation Center, 2002). See Table 1 for

a description of Rancho Los Amigos Levels of Cogni-

tive Functioning Classification Guidelines. The recov-

ery for patients who were classified at Rancho Levels

I–III was expected to be significantly different than for

those patients listed at Rancho Levels IV–VI. Because

of the lower cognitive functioning of patients admit-

ted at Rancho levels I–III, recovery was projected to

be limited if it occurred at all. It was anticipated that

over time caregivers in the two groups would have

different hopes for patients based on the perception

of the severity of patients’ brain injuries.

The nurse selected for the interview was the pri-

mary nurse who had been assigned responsibility for

the overall care of the patient. Typically, this nurse

coordinated care for the patient and was the nursing

representative for the patient in team meetings.

Location

The location for this study was a major Southeastern

catastrophic care hospital. This large free-standing

hospital is devoted to the medical care and rehabili-

tation of people with spinal cord injury and disease,

ABI, multiple sclerosis, and other neuromuscular

problems. The facility has 100 beds, including an

eight-bed intensive care unit and a 20-bed ABI unit.

Each year, more than 850 patients are admitted to the

hospital. The average patient admitted to this facility

is male, 18–35 years old, and injured in a car accident.

The length of stay varies but ranges from 3–5 weeks.

Caregiver and Nurse Hopes for Recovery of Patients with AcquiredBrain Injury


7/48


Instruments

Caregivers and nurses participated in semistruc-

tured interviews within 2 weeks of a patient’s

admission to the rehabilitation center. At the time

of the interview, caregivers and nurses completed

demographic forms. Patient background and clini-

cal data were collected from the chart. During the

interview, caregivers were asked about the trauma

that caused the ABI, how they were dealing with

the situation, what their hopes were for the family

member, and what his or her perceptions were of

the staff’s goals for the patient. Nurses were asked

questions regarding their hopes for the patient and

those of the caregivers. Interview guides can be

found in Box 1.

Demographic information collected from the care-

givers include age, race, gender, marital status, educa-

tion, annual household income, number of persons

living in a household, past caregiving experiences,

relationship to the patient, perceived perception of

personal health, level of fatigue and spirituality, per-

ception of concurrent losses, and occupations of the

caregiver and patient. The nurse demographic data

form requested information about age, gender, educa-

tion, years of nursing experience, years of rehabilita-

tion nursing experience, and information related to

nursing certifications.

The clinical data collected from the patient’s chart

include age, gender, cause of injury, rehabilitation di-

agnosis, date of injury, date of admission to the inpa-

tient rehabilitation hospital, date of initial conference

between the caregiver and the physician overseeing

care, anticipated date of discharge, admission Ran-

cho Level, and goals identified by the caregiver upon

admission.

Table 1. Rancho Los Amigos Levels of Cognitive Functioning

Classification Guidelines

Rancho Level Patient Behaviors

Rancho I Patients elicit no response when presented with visual, auditory, tactile, proprioceptive,

vestibular, or painful stimuli.

Rancho II Patients begin to respond to sounds, sight, touch, or movement. They may respond slowly,inconsistently, or after a delay.

Rancho III Patient may be awake on and off during the day and make more movements than before.They may react more specifically to what they see, hear, or feel. They may begin to recognizefamily and friends.

Rancho IV Patients remain confused or agitated. They may be frightened and not understand what ishappening around them. They have difficulty following directions.

Rancho V Patients are confused, inappropriate, and non-agitated. They may be able to pay attention fora few minutes.

Rancho VI Patients are confused and appropriate and require moderate assistance. They will rememberthe main points from a conversation but forget and confuse the details.

(Rancho Los Amigos National Rehabilitation Center, 2002)

Box 1. Guides for Interviewing the Caregiver and the Primary Care

Nurse

Interview Guide for Caregiver • Please tell me about what happened to your loved one (son, daughter, grandchild).

• How are you dealing with these changes that are occurring in your life as a result of this event? • Please tell me about your hopes (goals) for (patient’s name) future. • What are your thoughts about how you will manage if (name) does not meet these goals? • What do you think the staff’s goals are for (name)? • Based on the information you have received from the staff, to what extent do you think (name) will be able to

meet the goals you have for (him/her)?

Interview Guide for Nurse • Describe your hopes (goals) for the patient’s (name) future. • Based on your rehabilitation expertise, to what extent do you think your goals for the patient (name) are

achievable? • Describe the goals the family has for the patient (name). • Based on your rehabilitation expertise, to what extent do you think the caregiver’s goals for the patient are

achievable?


8/48



Procedure

The clinical nurse specialist (CNS) for the ABI unit,

in consultation with the primary care nurse, identi-

fied eligible participants. The CNS or primary nurse

requested permission from the caregiver for the

researchers to contact the caregiver. With permis-sion, the researcher contacted the caregiver within

the first week after the patient had been admitted

to the rehabilitation setting and set up a time to

meet the caregiver to discuss the study. If the care-

giver was willing to participate, researchers obtained

consent and the interview and questionnaires were

completed during this meeting. Interviews were

conducted in a quiet, private location convenient for

the caregiver. The interviews were audio recorded

and given a unique identifier to ensure confidenti-

ality. Each interview lasted approximately 1 hour.

Following the interview, the caregiver completed the

demographic data form and received a gift certificatein appreciation for their participation. Audio record-

ings were transcribed verbatim as soon as possible

following the interview.

The CNS of the rehabilitation facility provided

the researchers with the names of the primary nurses

responsible for each participant. With the primary

nurse’s permission, the researcher was given contact

information to arrange a date, time, and location for

an interview. During this meeting, usually the same

day as the interview with the caregiver, the researcher

explained the study, obtained consent, and conducted

the interview at a private location convenient for each

nurse. The interviews were audio recorded and given

a unique identifier to ensure confidentiality. Each in-

terview lasted less than 1 hour. Following the inter-

view, the nurse completed a demographic data form.

Whenever possible, the same researcher interviewed

the caregiver and primary nurse for a patient. Follow-

ing the interview, researchers offered each nurse an

honorarium in appreciation of their participation.

The researchers coded the transcribed interviews for

themes associated with the nature of hope. This process

of coding began with three researchers considering each

interview independently. The researchers then met to

compare the themes they identified. If one researcherfound a theme not identified by the others, it was dis-

cussed. For a theme to be presented in this report, all

three researchers agreed on its presence and meaning.

Another method used to increase trustworthiness in-

volved the researchers becoming very familiar with

the data (Miles & Huberman, 1994), which they ac-

complished by conducting and reading the interviews

(in addition to coding all the interviews). Finally, the

themes and findings were reported to the nurses at the

rehabilitation center. The nurses validated the findings

in their interviews.

The caregivers’ and primary nurses’ goals were

described as they related to hopefulness for recov-

ery over the course of the study. Nursing hopes were

compared to those of the caregivers for similarities

and differences. During the interviews, caregivers and

nurses were asked about what helped them maintainhope throughout the recovery process. Themes identi-

fied from the data included “the importance of fam-

ily,” “taking one day at a time,” “knowing the patient

better,” and “spiritual strength brings me through.”

Findings

Sample

On average, caregivers were 45 years of age (SD =

6.94), primarily White, female, and married. Most

were parents of the patient; however, a grandparent

and a stepparent also participated. The majority of

caregivers had more than a high school education,

worked in a service or professional capacity, andhad a household income of >$50,000 (Table 2).

The average age of the adolescent patients was

17.76 years (SD = 1.44). They were primarily White,

male, and had suffered a brain injury due to a mo-

tor vehicle accident. Other causes of injury included

a gunshot wound to the head and sports-related in-

jury. Rancho Levels for the patients ranged from II–VI

(Table 3). The average age of the primary nurses was

45.07 years (SD = 9.63); they were female and had an

associate or bachelor’s degree in nursing. Most of the

nurses had been a nurse for more than 11 years, and

had more than 6 years of rehabilitation nursing expe-

rience (Table 4).

Research Objective 1: Exploring

Caregivers’ Hopes

When asked about what they hoped their loved ones

would be doing in a year, all of the caregivers who

were interviewed were able to express the hopes

they had related to their loved ones’ futures. The

hopes expressed by caregivers primarily dealt with

completing high school, trade school, or college if the

loved one was in school prior to the incident. If the

loved one was employed prior to the injury, the care-

giver hoped that the patient would be able to regain

employment. The mother of a 16-year-old RanchoLevel V female patient said, “[I hope she’ll] be back

at school. I anticipate she’ll be back in.” The mother

of an 18-year-old Rancho Level V male patient said,

“I hope he’ll be back at college.” Another mother

said, “Hopefully she’ll be, you know, at least in cos-

metology school. Hopefully she’ll be graduated from

that in a year” (Mother of an 18-year-old female,

Rancho Level V patient). Another patient, an 18-year-

old Rancho Level VI male, had been repairing golf

carts prior to the accident. His mother said, “He will


9/48


probably still be working at the golf cart place. [He’ll]

be hanging out with his friends. Probably fishing.”

Caregivers expressed hopes that the loved one

would be resuming the preexisting activities 1 year

after the injury. The caregivers did not express many

hopes for attainment of specific activities of daily liv-ing, and inferred these activities were an automatic

expectation. For example, if their loved one was going

to be back at school or work, naturally they would be

continent and independent in all activities of daily

living—it was an assumption, an expectation.

Research Objective 2: Comparison of

Caregiver Hope and Nurse Hope

In addressing the second aim, the caregivers and

the nurses often expressed similar hopes and expec-

tations for the patient. This was particularly true for

situations in which the patient was admitted with a

higher Rancho score. When describing their hopes,caregivers focused on their hopes for the patient’s

future. As this mother noted,

I’m hoping that she’ll be as close to the [person]

that we had before the accident as possible. I do

understand that she won’t be 100% because of

the injuries, but getting her as close to that is...

our goal. Hoping that she will be well enough

to be back at school…I hope she’ll be as much

on her own as she can possibly be. (Mother of a

16-year-old Rancho Level V female patient)

The primary nurse of the same patient presented

hopes similar to the caregiver’s. The nurse stated, “I

think she’ll be able to…get back to baseline.”Nurses would often address specific markers

of progress such as toileting and showering, yet the

Table 2. Caregiver Demographic

Information

Mean (SD) RangeAge 45.1 years (6.94) 36–66 years

n (%)RaceWhite 20 95.2Black 1 4.8

GenderFemale 20 95.2Male 1 4.8

Marital StatusMarried 17 81.0Single 1 4.8Divorced 3 14.3

EducationChose not to answer 1 4.8Grade/high school 5 25.0

Trade/some college 7 35.0College graduate 8 40.0

OccupationService/labor 8 38.2Homemaker 3 14.2Professional 8 38.2Business 1 4.8Unemployed 1 4.8

Relationship to PatientParent 19 88.9Relative 1 5.6Stepmother 1 5.6

Household Income$100,000 5 23.8

Table 3. Patient Demographic and Clinical Data

Mean (SD) Range

Patient Age 17.76 years (1.44) 15–20 years

n %

RaceWhite 20 95.2

Black 1 4.8

Gender

Female 7 33.3Male 14 66.7

Cause of Acute Brain InjuryMotor vehicle accident 18 85.7

Gunshot 2 9.6

Sport-related injury 1 4.7

Rancho LevelIII 9 42.9

IV 3 14.3

V 2 9.5

VI 7 33.3


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caregivers did not typically express the same markers.

A primary nurse of a male Rancho Level VI patient

had these specific hopes for recovery: “[I hope he’ll

be able to recover] to a level where he can do things

for himself as far as like going to the bathroom, being

able to feed himself…” The mother of this patient

had hopes that included getting back to college andhaving a normal life and future. These seemingly

different hopes may be related to the fact that nurses

focus on specific aspects of daily living. Nurses’

hopes are measurable and attainable. They want the

outcomes to be attainable during the hospital stay.

However, the parents envision the patient back in his

or her home or school environment; the hospital is

merely a temporary phase. Caregivers’ hopes are long

term and reflect the normalcy of life as they knew it

before the accident. For caregivers, the specific skills

of going to the bathroom and feeding oneself tend to

be assumed and do not need mentioning. Caregivers

hope the patient will be attending college; therefore,toileting and eating are a foregone conclusion.

The hopes expressed by the caregiver and the

primary nurse were dissimilar in other situations as

well. One mother was very specific about hopes for

her daughter’s future. This mother talked about her

hopes not changing from the hopes she had prior to

the accident. The mother stated: “She’s going to col-

lege…she wants to play soccer…we certainly hope,

we’re going to try for it…she wants to do something

in medicine, like a nurse or nurse practitioner...yes,

it’s realistic” (Mother of a 16-year-old Rancho Level

V female patient). The primary nurse of this same pa-

tient had very different hopes. The nurse was quick to

note the patient’s deficits and how these would limit

her abilities. This nurse did not indicate that college

was something she hoped for in the future of this par-

ticular patient. The nurse stated,

Hopefully she will be able to speak for herself.She’s got a right-sided weakness. It’s hard to

know what’s going on in her mind since we’re

not getting any verbalization. She’s getting her

continence…[back]…asking for the bedpan.”

Family members were quick to acknowledge even

the smallest accomplishments. In a few cases, care-

givers reported an accomplishment that the nurse

could not validate as meaningful. For example, the

mother of a 16-year-old Rancho Level V female pa-

tient said “She’s asking me questions and she’s a lot

more alert…more orientated and can remember day-

to-day things.” The nurse for this patient was not sure

the patient was oriented. She explained, “[We don’tknow] if she’s got all her wits about her.” One of the

nurses of an 18-year-old Rancho Level III male patient

summed it up well. This nurse realized the parents

thought they were seeing things the nurses were not

seeing. She said, “…Sometimes you see what you

want to see…it’s sad, but I don’t see that he’s gonna

emerge.…They [the parents] say he does [respond]

with them, but the rest of us, none of us have seen

it.” This presents a difficult situation for all involved.

Caregivers are “seeing” recovery while the nurses are

trying to document their observations and make an


Table 4. Nurse Demographic Data

Mean (SD ) RangeNurse Age 45.07 years (9.63) 30–58 years

n %

GenderFemale 12 85.7Male 2 14.3

EducationDiploma/LPN 2 14.3Associate 6 42.9Bachelor 5 35.7Master’s 1 7.1

Years of Nursing Experience0–2.99 years 3 21.43–5.99 years 1 7.16–10.99 years 2 14.311–15.99 years 1 7.1More than 16 years 7 50.0

Years of Rehabilitation Nursing Experience

0–2.99 years 5 35.73–5.99 years 1 7.16–10.99 years 3 21.411–15.99 years 3 21.4More than 16 years 2 14.3

Note. Some RNs were primary care nurses for more than one patient.


11/48


12/48


behaviors were similar to preinjury activities and

that the nurses thought her son was worse than she

believed him to be. She sensed these behaviors as nor-

mal, which allowed her to maintain hope for recovery.

I guess because I’ve always been around him

and he’s been ADD [attention deficit disorder]all of his life. So nothing has really changed for

us, other than the fact that he’s got part of his

skull missing. From everything that he’s been

through, maybe they [the nurses] thought he

would have been worse than [he is].” (Mother of

an 18-year-old Rancho Level VI male patient)

Parents thought their inside knowledge helped

them see progress when nurses and staff did not. In

fact, sometimes nurses thought patients were talking

about things that did not make sense but the caregiver

was able to provide insight that indicated the patient

was actually remembering events that had occurred

in the past. For nurses, sometimes parents’ insideknowledge was helpful for understanding some of

the behaviors they were seeing. Nurses also recog-

nized that sometimes parents’ inside knowledge was

not always useful and did not elicit any new infor-

mation. However, caregivers’ ability to see progress

supported their hope for recovery of their loved one.

Spiritual Strength Brings Me Through. Caregivers

consistently noted that a strong sense of spirituality

helped them maintain hope. They noted their sense

of spirituality gave them added strength. It was no

longer necessary to have all the answers, but rather

their sense of spirituality allowed them to believe

they were part of some larger plan.

My full belief and my full thought process

through all of this is, “There’s a reason he’s still

alive and there was a reason why this hap-

pened.” Why? I don’t know. That’s not for me to

question. It’s simply mine to be grateful for and

take advantage of the opportunity to do or to see

or to help the plan finish its way out, and that’s

the way I look at it. (Mother of an 18-year-old

Rancho Level IV male patient)

This expression of gratefulness indicated the

mother’s sense of renewed hope for a future.

Another spiritual component that helped caregiv-ers maintain hope was the camaraderie associated

with a strong sense of spirituality. Caregivers would

note the ability to call others with a similar sense of

spirituality, and this sense of togetherness helped

maintain hope and the feeling that things were going

to be okay. The following is one mother’s description

of this camaraderie:

I just have a real big faith…church and God, you

know, just the faith that brought me through a

lot… Then I called my mom, and we prayed, and

I thought, okay, I can make it, all I have to go on

is my faith in God.” (Mother of an 18-year-old

Rancho Level VI male patient)

After she was able to communicate with another

spiritually connected person, she was able to maintain

hope. She was able to get through the tough times and

support her son in his recovery.The importance of spirituality in the lives of these

caregivers was borne out by their responses to a sur-

vey question assessing its importance: 18 caregivers

(85.7%) indicated that spirituality was very important,

one caregiver (4.8%) declared it was important, and

two caregivers (9.5%) felt it was somewhat important.

Discussion

All of the caregivers had hopes for the recovery

of their family member and were willing to share

those hopes. In many cases, the caregivers’ hopes

were generally realistic. As described by Dufault

and Martocchio (1985), who noted a model of hopeaddressing “specific” hopes, caregivers in this study

identified hopes for specific future outcomes for the

patient (e.g., attending college or vocational school,

being independent). In most cases, caregivers and

nurses shared common hopes and expectations for

the patients. However, the nurses were often much

more pragmatic when describing patient expecta-

tions; for example, they would identify specific

activities of daily living (e.g. toileting, brushing teeth,

combing hair, showering) that the patient needed to

master. It was evident that caregivers’ hopes were

strengthened by the accomplishments of their loved

ones. These accomplishments allowed the caregiver

to adapt their hopes as recovery occurred, support-

ing Herth’s (1993) research.

What are the potential consequences when care-

givers and nurses have dissimilar hopes and expec-

tations for the patient? If this incongruence is short

term, wherein the caregiver simply needs more time

to redefine his or her expectations, there may be no

consequences. However, if this disconnect is not re-

solved, at what point does the caregiver’s inability to

accept the limitations of the patient become dysfunc-

tional? The incongruence in hopes could potentially

become a crisis if it interferes with the formulationand implementation of appropriate discharge plans.

In such cases, the rehabilitation nurse needs to play a

pivotal role in identifying the problem, conferring with

the rehabilitation team, and participating in the imple-

mentation and monitoring of strategies meant to help

the caregiver and family members focus on discharge

plans that meet the needs of their loved one.

Caregivers in this study identified both internal

and external sources of hope as described by Bland

and Darlington (2002), who noted a model of hope

addressing “specific” hopes. Family and friends were



13/48


crucial supporters of caregivers and patients, so much

so that caregivers and nurses felt this external support

was therapeutic for the patients. During interviews,

caregivers frequently mentioned looking forward to

having their family member placed closer to home

so that both the adolescent and the caregiver could benefit from having other family and friends nearby.

Several caregivers commented on how important it

would be for their adolescents’ friends to visit.

Recovery from ABI is a slow process. Both care-

givers and nurses recognized that “taking one day

at a time” was helpful. Caregivers would share the

daily accomplishments that their family member had

achieved by putting these achievements in the context

of the adolescent’s deficits the day or week before.

These caregivers had faced the life-threatening crisis

of the ABI; now they were involved in the recovery

phase. They had transitioned from minute-by-minute

and hour-by-hour fear for the life of their family member to the day-to-day “baby steps” that their adolescent

could accomplish. The realization of these accomplish-

ments allowed caregivers and nurses to maintain hope

for recovery. If things were better today than they were

yesterday, then caregivers and nurses felt hopes were

realistic and therefore maintained.

Because caregivers knew the patient better than

staff members did, they were quick to clarify nurses’

perceptions that were inaccurate. In cases for which

this need for clarification was described, it was ap-

parent that the caregivers wanted to ensure the staff

members had the correct interpretation of the situa-

tion. It was important that the staff did not assign a

negative interpretation to the circumstance. As noted

earlier, one caregiver needed the staff to know that her

adolescent had been studying Shakespeare and that

his ramblings were a part his school-life reality. She

did not want the staff to think he was confused. Open

dialogue between the caregiver and the nursing staff

was helpful for clarifying the state of the patient’s cog-

nition and connectedness to recent reality. Exchanges

between caregivers and staff highlight the importance

and benefits of good communication.

Caregivers identified a source of hope that came

“from within,” which is very similar to Emblen’s (1992)definition of spirituality as the “inner dimension of be-

ing human attuned to the most valuable aspect of life

that motivates and guides one’s significant choices.”

Caregivers noted their spiritual strength helped them

move on and guided them throughout the recovery

process. Their spiritual beliefs were a source of strength

and support for them (Bland & Darlington, 2002). This

finding was supported by both qualitative and quan-

titative data.

Limitations

This convenience sample did not include any caregiv-

ers whose adolescent had experienced an ABI with

resultant Rancho Levels I or II. It is possible that their

stories may have been different than those presented

here. Also, the convenience sample was drawn frompatients in one rehabilitation center in the Southeast.

Implications for Clinical Practice

Rehabilitation nurses can support patients’ prog-

ress by advocating for family-centered care and

by encouraging caregivers’ enthusiastic and active

involvement in the rehabilitation process. Open

communication between the caregiver and the nurse

can be fostered so that nurses have an accurate assess-

ment of the patient’s progress. This study validated

the practice of rehabilitation centers welcoming fam-

ily and friends of patients when the patient is not in

therapy. Both caregivers and nurses stated that fam-ily involvement enhanced patients’ progress. Finally,

caregivers noted that spirituality was a support for

them. Because nurses work more closely with the

patient and caregiver than other healthcare providers,

they are in a unique position to support caregivers

with their spiritual needs and explore the potential

for referrals or contacts to spiritual advisers.

Implications for Research

Further research is needed to explore the conse-

quences of situations in which the caregiver and

the nurse do not have similar hopes for the patient.

When differences in caregivers’ perceptions serious-

ly impede a patient’s discharge or placement, inter-

ventions that resolve the conflict should be exam-

ined. Studies that examine the effect of families’ and

friends’ involvement in patients’ progress are war-

ranted. Research exploring different involvement

types and how they affect patient outcomes would

help determine the best interventions for improving

patient outcomes. Also recommended are studies

that examine the effect that a personal sense of

spirituality can have on the well-being of caregivers

throughout the patient’s recovery from ABI.

Rehabilitation nurses reported a difference be-tween the hopes and expectations of caregivers of

patients with ABI and the nurses who care for them.

This study validated that, in some cases, a difference

in perception did exist. Enhancing the perceptual

congruence between nurses and caregivers during

rehabilitation will ultimately improve patient out-

comes. This research expanded the knowledge about

the experiences of caregivers of adolescents with an

ABI and sets the framework for nurses to design in-

terventions that support the development of realistic

hopes during the many phases of recovery.


14/48


Acknowledgments

This study was partially funded by the Rehabilita-

tion Nursing Foundation of the Association of Reha-

bilitation Nurses and the Georgia State University’s

College of Health and Human Sciences Intramural

Grant Program. We would like to acknowledge thesupport of the nurses and staff at the Shepherd Cen-

ter, and we would like to thank the caregivers who

graciously shared their experience with us.

About the Authors Mary Catherine Gebhardt, PhD RN CRRN, is an assistant professor at Georgia State University in Atlanta, GA. Addresscorrespondence to her at [email protected].

Linda A. McGehee, PhD RN, is director of StrengtheningSurveillance and Response in Central Africa at the NationalFoundation for the Centers for Disease control and Preventionin Atlanta, GA.

Cecelia Gatson Grindel, PhD RN CMSRN FAAN, is associ-ate director for academic affairs at Georgia State Universityin Atlanta, GA.

Linda Testani-Dufour, MSN RN CRRN, is a clinical managerof the Post Acute Brain Injury Unit at Shephard Center in

Atlanta, GA.

ReferencesBland, R., & Darlington, Y. (2002). The nature and sources of

hope: Perspectives of family caregivers of people with seri-ous mental illness. Perspectives in Psychiatric Care, 38, 61–68.

Dufault, K., & Martocchio, B. C. (1985). Symposium on com-passionate care and the dying experience. Hope: its spheresand dimensions. Nursing Clinics of North America, 20(2),379–391.

Emblen, J. D. (1992). Religion and spirituality defined accord-ing to current use in nursing literature. Journal of ProfessionalNursing, 8, 41–47.

Gerkensmeyer, J. E., Perkins, S. M., Scott, E. L., & Wu, J. (2008).Depressive symptoms among primary caregivers of chil-dren with mental health needs: Mediating and moderatingvariables. Archives of Psychiatric Nursing, 22(3), 135–146.

Halm, M. A., & Bakas, T. (2007). Factors associated withcaregiver depressive symptoms, outcomes, and perceivedphysical health after coronary artery bypass surgery.

Journal of Cardiovascular Nursing, 22(6), 508–515.

Herth, K. (1993). Hope in the family caregiver of terminally illpeople. Journal of Advanced Nursing, 18, 538–548.

Holtslander, L. F. (2008). Caring for bereaved family care-givers: Analyzing the context of care. Clinical Journal ofOncology Nursing, 12(3), 501–506.

Hong, G. R., & Kim, H. (2008). Family caregiver burden byrelationship to care recipient with dementia in Korea.

Geriatric Nursing, 29(4), 267–274.Miles, M. B., & Huberman, A. M. (1994). Qualitative data analy-sis: An expanded sourcebook . London: Sage.

Rancho Los Amigos National Rehabilitation Center. (2002).Family guide to the levels of cognitive functioning.Retrieved January 18, 2006, from www.rancho.org/patient_education/bi_cognition.pdf.

Stotland, E. (1969). The psychology of hope. San Francisco, CA: Jossey-Bass Publishers.

Teel, C. S., Duncan, P., & Lai, S. M. (2001). Caregiving experi-ences after stroke. Nursing Research, 50(1), 53–60.

Wennman-Larsen, A. & Tishelman, C. (2002). Advanced homecare for cancer patients at the end of life: A qualitativestudy of hopes and expectations of family caregivers.Scandinavian Journal of Caring Sciences, 16, 240–247.


Earn nursing contact hoursRehabilitation Nursing is pleased to offer readersthe opportunity to earn nursing contact hoursfor its continuing education articles by taking aposttest through the ARN website. The posttest consists ofquestions based on this article, plus several assessmentquestions (e.g., how long did it take you to read the articleand complete the posttest?). A passing score onthe posttest and completion of the assessment questionsyield one nursing contact hour for each article.

To earn contact hours, go to www.rehabnurse.organd select the “Education” page. There you can read thearticle again, or go directly to the posttest assessment byselecting “RNJ online CE.” The cost for credit is $10 perarticle. You will be asked for a credit card or online pay-ment service number.

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Great Rehabilitation NursesCombine Art and Science to

Create MagicDonald D. Kautz, PhD RN CNRN CRRN CNENote. This article was the basis for Dr. Kautz’s keynote address at the 2010 ARN Educational Conference

in Orlando, FL.

I believe that rehabilitation nurses have the poten-

tial to create and experience “magic” every day in

their practice. Some nurses might be offended by

the word “magic” because they associate magic

with being dark, secretive, or perhaps evil. The

magic to which I am referring encompasses the

captivating, powerful, moving, and cherished

moments that nurses create and experience.I have been a rehabilitation nurse for more than

30 years, and I know that great rehabilitation nurses

routinely incorporate the art and science of nursing

into their practice. No nurse is a “great” nurse all

of the time—that would be impossible. But all of us

have great moments, and in these moments we com-

bine research-based best practices with our own ex-

periences of working with patients and their families.

This is when the magic occurs. I would like to tell you

about a time when magic occurred for me and for a

patient with whom I was working.

I was the neuroscience clinical nurse specialist at

a tertiary care level 1 trauma center affiliated with a

preeminent medical school and university. Sally, who

was in her 20s, had become a C5-6 quadriplegic as the

result of a vehicular crash. She also had undergone

a left upper arm amputation as a result of the crash.

She was a married mother of three small children and

her home was several hours from the medical center;

her family rarely was able to visit. When I first met

Sally, she was still in the intensive care unit (ICU),

had just been weaned from the ventilator, and was

in a halo brace. The ICU nurses asked me to see her

because she was extremely anxious and demanding.

She also was experiencing severe neck and shoulderpain and phantom pain in her left arm. Because of

the halo brace, she could not see the residual limb

of her left arm and often complained that the nurses

had positioned her so that she was lying on her left

wrist and hand. The nurses could see that the arm

was gone but Sally could not, and she had very little

feeling in either arm other than the pain from her

C5-6 injury.

I had worked for years on an acute spinal cord

injury rehabilitation unit, so I had learned several in-

terventions that might help Sally. Some interventions

were based on science; others I had learned from ex-

perience and these skills represented the “art” of be-

ing an experienced rehabilitation nurse (Kautz, 2008).

Based on my experience, I believed that Sally may

cope better if she could be distracted from the hor-

ror of being a new quadriplegic and if she could feel

more in control of her care (Consortium for Spinal

Cord Medicine, 2008). Despite her condition, I knewshe could control some aspects of her care. I called

the physical therapy department and got her a pair

of prism glasses so she could increase her scope of vi-

sion and watch television. I believed that as she could

see more of what was happening around her, she also

would feel more in control of her care. I had learned

at an ARN conference that shoulder positioning was

a key factor in promoting comfort in new quadriple-

gics, especially those in a halo brace. I worked with

the ICU staff and showed them how they could po-

sition her residual limb in different positions using

towels and pillows (Fries, 2005). Sally’s job was to

focus on the best positions for her left stump and

right arm when she was on either her right or left

side. Sally was a willing participant in these efforts

and quickly found that she could stay an hour or two

on each side by varying her arm positions.

I also implemented the science of rehabilitation

nursing, especially in relieving Sally’s pain and anx-

iety. A new quadriplegic patient experiences three

types of acute pains as well as chronic pain over time.

Somatic pain (sharp and stabbing) results from the in-

jury and fusion surgery, visceral pain (ache) from im-

mobility, and neuropathic pain (burning and tingling)

from the spinal cord injury, all of which require dif-ferent treatments (Institute for Clinical Systems Im-

provement, 2008). This acute pain will continue and

become chronic pain. I decided it would be best to

treat all three types of acute pain, begin treatment

for chronic pain, and treat anxiety. I asked the physi-

cians to start her on around-the-clock nonsteroidal

anti-inflammatory (NSAID) medications for her pain

caused by inflammation and a histamine (H2) blocker

to prevent peptic ulcers associated with the NSAID.

They also agreed to start her on an around-the-clock

small dose of Valium to help with her anxiety and

KEY WORDS

comprehensive pain management

evidence-based practice

nurse-patient relations

problem patients

rehabilitation nursing

safe patient handling

spinal cord injury


16/48


Great Rehabilitation Nurses Combine Art and Science to CreateMagic

provide additional muscle-relaxant effects. Even

though Sally still was in spinal shock and did not

have spasms, the physicians also agreed to start her

on baclofen (Lioresal) so that by the time her spasms

started, the medication would have reached a thera-

peutic level (Birns & Fitzpatrick, 2008). Amitriptyline(Elavil) was initiated for her neurogenic pain even

though it would take several weeks to become effec-

tive. The nurses told me in the following days that

a “miracle” had occurred for Sally, and that Sally’s

interventions were “magic.”

When I returned to work after being gone for a few

days, Sally had been transferred out of the ICU to the

general neuroscience nursing unit. As I walked down

the hall, I heard Sally calling out a nurse’s name. I

went in to see her and she said, “Please come here

quick, I need you.” I walked over to her bed and she

said, “Please scratch my nose, it itches.” Then she

said, “The nurses all hate me. They stand outside myroom ignoring me and laughing at me.” I had worked

with these nurses for some time and knew full well

that none of them would do this. I told Sally I would

be back in a few minutes, and then I went to the con-

ference room to talk with these nurses. They said that

Sally knew all of their voices and would constantly

call out to them, even though she had a call ball that

she could ring on her own. (A call ball is a call light

mechanism placed inside a tennis ball that is sus-

pened by a patient’s head, shoulder, or arm so he or

she can “bump” it and call the nurse.) After one of

them went in, the requests would be for nonpriority

tasks such as scratching her itching nose or rearrang-

ing her bedside table.

These nurses also told me that they were starting to

get Sally up in a wheelchair; while doing so, she would

complain of being dizzy and panic, fearing that she

was going to fall. I agreed to go in and help her get out

of bed and into the wheelchair. Indeed, Sally told me

too that she was going to get dizzy and fall. I explained

how I would transfer her and told her that I had years

of experience transferring patients and knew all the

tricks to make her comfortable, so she agreed.

Now I was able to use art and science again. I put

on Sally’s thromboembolic deterrent (TED) hose and

abdominal binder before getting her up. I asked her

to take several deep breaths and explained to her that

the TED hose, abdominal binder, and deep breaths

would combat the orthostatic hypotension (and re-

sulting dizziness) she would experience when tran-

sitioning from lying to sitting (Consortium for Spinal

Cord Medicine, 2008). Next I raised the head of her

bed, talking with her the entire time. She replied with

amazement that she was not dizzy. Here it was, an-

other moment of magic. I swung her legs out over the

edge of the bed, and she again said she was not dizzy.

Then, much to her horror, I transferred her by myself

from the bed to her wheelchair using a sliding board.

I had assured her several times that I could do this

without hurting either of us, but she still panicked

and complained throughout the transfer. I got her

situated in the partially reclined wheelchair with thearm and feet rests in place and a lapboard across her

lap and her right arm comfortably placed. To prevent

injury to patients and nurses, the type of transfer I

used with Sally is no longer recommended. The cur-

rent recommendations for turning and transferring

patients to prevent nurse injuries are to use evidence-

based safe patient handling guidelines (Nelson, Mo-

tacki, & Menzel, 2009; Waters & Rockefeller, 2010).

I could not believe her reaction to the transfer. She

kept saying over and over, “Help me, I am going to

fall. I am falling.” The sensation of falling is thought to

be caused by the halo brace, which creates a feeling of

floating (Consortium of Spinal Cord Medicine, 2008).Only a few things are “certain” in nursing, and one

of them is that a C5-6 quadriplegic patient in a halo

brace, positioned correctly in a reclining wheelchair

(as Sally was), is not going to fall. I pulled a chair up

beside her and assured her I was not going anywhere

and would sit and talk with her for the entire 30 min-

utes she was going to sit in the chair. Sitting calmly

with anxious patients, listening to their concerns,

teaching them about their illness, and showing them

new ways to cope can often be helpful (Levigne &

Kautz, 2010). In this case, my calm presence, listening,

and assurances did not help. Sally kept repeating, “I

am falling, I am falling, I am going to fall. Please, do

something….”

I don’t know how long I sat there reassuring her,

but it seemed like an eternity. I started to cry. Sally

said, “What’s wrong?” I replied, “Sally, you are kill-

ing me.” She was taken aback. Then, she started to

laugh. This is the first time anyone working with

her remembered her laughing. She kept saying, “I

am killing you?” and laughed. We talked, and after

30 minutes, I put her back to bed. Her laughing was

a turning point for her, and so another moment of

magic had occurred.

I came to visit Sally a number of times during the

next several days. The nursing staff had begun get-

ting her up several times a day, transferring her to

the wheelchair, and taking her outside and to other

places she wanted to go. Although her anxiety had

decreased, she still was demanding to be turned often

and still wanted someone to scratch her nose and per-

form other tasks. On Thursday, she was transferred

to the spinal cord unit at a nearby rehabilitation fa-

cility for a comprehensive spinal cord rehabilitation

program (I had worked there for many years before

coming to the medical center).


17/48


I called the rehabilitation facility on Friday after-

noon to inquire about how she was doing. I talked

to a nurse with whom I had worked for years. She

said, “Sally? Sally is not here. Don, I’m ashamed of

you. You didn’t notice that one thigh was much larger

than the other? She has a deep vein thrombosis (DVT).We sent her back to you for heparin therapy.” I hung

up the phone. I knew she was not back on the neu-

roscience unit. After checking, I discovered she had

been put on one of the medical floors and her anti-

coagulation was being managed by a medical team.

I went down and talked with Sally, the medical resi-

dent, and the nursing staff about any questions they

might have. I also brought Sally a call ball that she

could “ring” with her chin so she could call the nurses

(Fries, 2005), and then I went home for the weekend.

On Monday, when I came back in, I had some early

morning commitments and was not able to get up to

the medical floor to see Sally until around 10:30. As Iwalked down the hall, I saw that the call light above

her door was on. “Typical,” I thought. I walked into

the room, and to my surprise Sally had an elderly

roommate. Sally was in the bed farthest from the door

and was turned on her side away from the door. I

walked around the side of the bed to face her. She

said, “Hi. What time is it?” I told her it was 10:30. She

said, “Oh, the nurses said they were going to come

in and turn me at 9:30. They must have gotten busy.

Can you do me a favor? Please take Ms. ‘Smith’ in

the next bed to the bathroom.” I took Ms. Smith to

the bathroom, and then I turned Sally. I said, “Sally,

what happened to you? You are not the same person

that left here last Thursday.” She replied, “When I

got to the rehab facility, the first thing they asked me

was what my goals for rehab were. I hadn’t thought

about that. I decided it was time for me to get on with

my life. I am a mother. Mothers don’t ask for help

all the time. Mothers are the ones who do things for

others.” Another moment of magic! Changing focus

from what has been lost to focusing on the future has

been identified as a key element in the maintaining of

hope for those with new spinal cord injuries (Lohne

& Severinsson, 2004).

I learned lessons from Sally that I continue to usein my practice. First, we all need a change of venue

now and then. For Sally, it was transferring to the re-

habilitation unit, and then back to the medical unit

on the same day. No one on the medical unit knew

Sally, and both Sally and her caregivers got a new

start. Second, Sally got a roommate. She had some-

one to focus on other than herself. Sally was a mother

who was used to caring for others, and the roommate

was just what Sally needed. Finally, we all need goals,

and when we help our patients to see their goals, we

empower them to create their own future (Kautz,

2008). What magic!

Sally experienced two additional kinds of magic.

First, she did not recognize the effect I was having on

her. I was the clinical nurse specialist, consulting with

the nurses and doctors. The interventions that workedfor her were interventions put in place by the nursing

staff, not me. I am sure she does not remember me—

why should she? She never really knew who I was. I

was just one of the many faces she came into contact

with in a sea of caregivers. But even though Sally does

not remember me, she changed my life forever. And

that is the second piece of magic. Sally did not know

the effect she had on me. This is the true magic we

create and experience as rehabilitation nurses. We

may never know who we have a profound effect on,

and, likewise, our patients may never know the life-

changing effects they have on us. This magic keeps us

coming back to work day after day. My hope in shar-ing Sally’s story is that you will remember your own

“Sally,” that these memories will remind you why you

became a rehabilitation nurse, and the memories will

help you remember that you are a great rehabilitation

nurse. I also hope that you will continue to use the art

and science of rehabilitation nursing every day to cre-

ate these magical moments. Although we never know

when magic might occur, magic will occur more often

if we purposefully use art and science every day. And

when we share these moments with each other, we

create hope for the future of nursing.

Acknowledgments

The author gratefully acknowledges the editorial

assistance of Elizabeth Tornquist with this manu-

script.

About the AuthorDonald D. Kautz, PhD RN CNRN CRRN CNE, is a directorof the Hickory Outreach Program and associate professor ofnursing at University of North Carolina Greensboro School ofNursing in Greensboro, NC. Address correspondence to himat [email protected].

References

Birns, J., & Fitzpatrick, M. (2008). Management of spastic-ity: A brief overview of educational and pharmacologicaltherapies. British Journal of Neuroscience Nursing, 4, 370–373.

Consortium for Spinal Cord Medicine. (2008). Early acutemanagement in adults with spinal cord injury: A clini-cal practice guideline for health-care professionals.Retrieved October 8, 2010, from www.pva.org/site/PageServer?pagename=pubs_main#CPG.

Fries, J. M. (2005). Critical rehabilitation of the patient withspinal cord injury. Critical Care Nursing Quarterly, 28, 179–187.

Institute for Clinical Systems Improvement. (2009). Healthcare guideline: Assessment and management of chronic pain

continued on page 24


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KEY WORDS

delegation

Nurse Practice Act

registered nurse

unlicensed assistive personnel

Delegation Knowledge andPractice Among Rehabilitation

Nurses Mary Joe White, PhD RN • Ann Gutierrez, MSN RN CBIS CRRN • Kerry Davis, BSN RN CBIS CRRN • Rhonda Olson, MS RN CRRN • Celeste McLaughlin, MS CNS RN CRRN

Delegation is an essential process that allows nurses to function more effectively and efficicently. The Association of

Rehabilitation Nurses’ (ARN) Southeast Texas Chapter research committee developed a survey to study registered nurses

(RN) practices and knowledge of delegation to unlicensed assistive personnel. State boards of nursing determine delegation

practices, so the survey was sent only to Texas ARN members. Benners’ Novice to Expert theory was used to study delega-

tion practices based on years of experience, certification, and education. Survey Monkey was used with a questionnaire

developed by the research committee. Descriptive statistics analyzed data from the survey’s 73 respondents, and chi-square

measured significance of differences based on years of experience and certification (yes or no). Data show that delegation

knowledge does not necessarily translate to practice, especially when looking at specific tasks performed by certified reha-

bilitation registered nurses (CRRNs) and non-CRRNs. The data support continued study of this important issue; 93.7%of respondents say delegation requires further discussion.

Leadership in practice is an important nursing

issue. Delegation is one leadership tool nurses use

in professional practice. Knowledge regarding tasks

that can be delegated—and to whom—is critical in

rehabilitation nursing practice. Florence Nightingale

said, “But in both hospitals and private houses, let

whoever is in charge keep this simple question in

her head: not how can I always do this right thing

myself, but how can I provide for this right thing to

be always done?” (National Council of State Boardsof Nursing [NCSBN], 2005, p. 3).

The nursing profession faces critical shortages

compounded by an aging nurse population and an

increased need for nursing services due to chang-

ing demographics. The NCSBN states that “the

profession of nursing must determine how to con-

tinue providing safe, effective nursing care with de-

creased numbers of nurses caring for an increased

number of clients” (2005, p. 3). The American Nurses

Association (ANA) recognizes that unlicensed assis-

tive personnel (UAP) are necessary to help nurses in

their practice (ANA, 1992, 2007). “More than ever,

nurses need to work effectively with assistive person-

nel. The abilities to delegate, assign, and supervise

are critical competencies for the 21st century nurse”

(ANA & NCSBN, 2006, p. 1).

Numerous researchers have addressed the fine

art of delegation. According to one report, “delega-

tion is essentially a management tool for working

through people to complete tasks” (ANA & Coalition

of Nursing Futures, 1997, p. 5). A more recent article

states, “delegation is the act of assigning a task or a

series of tasks to another while retaining responsibility

for the outcome” (Haynes, Boese, & Butcher, 2004,

p. 442). According to the NCSBN, “All decisions re-

lated to the delegation of nursing tasks must be based

on the fundamental principles of protection of the

health, safety, and welfare of the public that is the

underlying principle of nursing regulation” (2005,

p.5). The Council also states that “decisions to del-

egate nursing tasks/functions/activities are based

on the needs of clients, the stability of client condi-

tions, the competency of the task, the predictabilityof the outcome, and the available resources to meet

the needs and the judgment of the nurse” (2005, p. 5).

Each state regulates delegation for professional

nursing in its Nurse Practice Act (NPA; Habgood,

2000; McInnis & Parsons, 2009; Reising & Allen, 2007).

For example, in 2001 the 77th Texas Legislative Session

passed House Bill 456 to review and make recom-

mendations regarding delegation for nursing care to

people with functional disabilities in independent liv-

ing environments and acute care settings. According

to the NCSBN, 48 state boards refer to delegation in

their NPA (2005). As a process, delegation, when used

appropriately, can result in effective time management

and safe, efficient nursing care (Bittner & Gravlin,

2009; Kleinman & Saccomano, 2006; Sheets, 2005).

Nurses must know the context of their state NPA,

standards of practice, and organizational policies to

delegate appropriately. In the context of the nursing

shortage, delegation is of paramount importance.

Rehabilitation nurses need to understand and

practice delegation in a consistent manner (ANA,

2007; ANA & NCSBN, 2006). The Association of

Rehabilitation Nurses (ARN) supports rehabilitation


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nurses’ use of UAP to achieve patient care goals.

According to ARN, “All care provided by the UAP

should be delegated by a registered nurse and based

on the patient’s written plan of care and the UAP’s

demonstration of a level of competency” (1994, p. 1).

Purpose

According to Kelly (2008), delegation is more than

a learned skill. Nursing professionals need to dis-

cuss the concerns, knowledge, and responsibilities

associated with delegation. To clearly understand

delegation issues for rehabilitation nurses, a Texas

ARN chapter initiated a study to determine the

practice and knowledge of delegation by ARN

members in the state. The following research ques-

tions were posed:

1. What tasks do rehabilitation nurses in Texas

delegate to the UAP?

2. What knowledge do these nurses have, ac-cording to the Board of Nursing for Texas, of

tasks that can be delegated?

3. How does practice of delegation compare to

knowledge of delegation for this group of

nurses?

4. Does certication or years of experience have

any influence on RN knowledge and practice

of delegation?

Methods of Study

ARN’s Texas chapter research committee developed

a questionnaire for this descriptive study using

Benner’s Theory of Novice to Expert (Benner, 1984).

Benner’s theory supports expertise in nursing that

correlates with experience; nurses begin as novices

and progress to experts through experience in the

workforce. One of the present study’s questions

sought to determine whether experience increased

nurses’ knowledge of delegation policies and prac-

tice. According to previous research, “identification

of clinical grasp and clinical forethought enriched

the understanding of clinical judgment” (Tomey &

Alligood, 2002, p. 170).

Content validity was established through expert

review. The questionnaire was administered to sever-al ARN members with varying levels of expertise (ed-

ucator, administrator, staff nurse). This test resulted in

revisions to the final questionnaire. A letter was sent

to the national ARN Board requesting e-mail address-

es for all of the ARN members in Texas. Prospective

participants received a letter that included details

about the project and an assurance that they were

free to choose whether or not to participate and that

any responses would be anonymous and reported

as aggregate data. The national ARN Board granted

us permission to use the list for the project. Survey

Monkey was used to send out the questionnaire and

collect data. There were no direct risks or benefits to

survey participants. Using Survey Monkey, 243 peo-

ple were sent an e-mail message with a cover letter

explaining the study and the questionnaire. Twelve

messages were returned, with six recipients asking to be removed from the list. There were 73 respondents;

with a response rate of 32.4%.

Data Analysis

The Statistical Package for Social Sciences was used

for data analysis. The data were compiled using

percentages and a tally of responses. The results were

reviewed by the research team. Chi-square was used

to determine significant differences between groups.

Literature Review

Throughout the literature review, the committee

referred to the Texas NPA. Rules 224.4 and 225.4in the Texas NPA define delegation as authorizing

an unlicensed person to provide nursing services

while retaining accountability for how the unli-

censed person performs the task (Texas Board of

Nursing, 2003). The Texas NPA definition does not

include situations in which an unlicensed person

is directly assisting an RN by carrying out nursing

tasks in the presence of an RN.

According to the Texas Board of Nursing, how

one delegates differs from Rules 224.1 and 225.1.

Rule 224.1 applies to situations in which a client has

an acute health condition that is unstable or unpre-

dictable in an acute care environment in which nurs-

ing services are continuously provided including,

but not limited to, hospitals, rehabilitation centers,

skilled nursing facilities, clinics, and private physi-

cian offices (Board of Nurse Examiners for the State of

Texas, 2007). According to this rule, the tasks that can

be delegated to UAP are noninvasive and nonsterile

treatments; the collecting, reporting, and documenta-

tion of data (i.e., vital signs, intake and output, height,

weight, patient or family comments and behaviors);

assistance with ambulation, positioning, and turning;

providing personal hygiene; feeding; and other activi-

ties of daily living. Tasks that usually are not withinthe scope of sound, professional judgment for nurs-

es to delegate according to this rule include sterile

procedures, nonsterile wound procedures, invasive

procedures such as inserting tubes into a body cavity

and/or instilling substances into an indwelling tube,

and care of broken skin other than minor abrasions

or cuts (Board of Nurse Examiners for State of Texas).

Rule 225.1 applies to situations in which a client

resides in an independent-living environment and

the task is to achieve a stable, predictable condition

as defined by Rule 225.4 (Board of Nurse Examiners


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