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Perspectives: Challenges of Mentoring a Brain-Injured Peer
As a rehabilitation nurse, I find it a challenge to care for a traumatic brain-injured patient, no matter what occupation that person performs. It is an even greater challenge to care for a peer who is brain-injured. I took on that challenge and succeeded in managing and teaching the patient and family, but I never thought I would be asked to mentor this patient 18 months later as a nursing peer. Here is our story.
I first met Polly (not her real name) when she was Rancho Scale Level 3–4. She was very sleepy, quiet, and not agitated. She would wake for short periods, then fall back to sleep. Her parents took turns staying with and supporting her. Gradually, she awoke and healing rapidly progressed, influencing her ability to accomplish activities of daily living (ADLs) and mobility skills.
After she finished inpatient rehabilitation, she graduated to the Comprehensive Outpatient Rehabilitation Program (CORP) with high cognition impairments. Her parents supervised her at home and assisted with the care of her young child. Polly progressed from CORP to one of our facility’s specialty programs—the Head Injury Re-entry Program (HIRE). She was assessed by HIRE staff for potential job training and placement opportunities.
While in the HIRE program, Polly voiced her desire to resume her nursing career. It was at this point that I was asked to mentor her while assessing her abilities to manage patient care. A meeting was scheduled to set up the parameters for this mentoring. Those who were involved and planned the program were Polly, Polly’s job coach, the inpatient program manager, the nurse manager, the program educator, and myself. Throughout this meeting, Polly took notes and asked a number of seemingly insightful questions about what expectations she needed to meet to resume her career.
After the meeting, I spoke with her job coach and educator to voice my concerns about Polly. Although she looked and acted as though she could manage patients, I wondered about her high-cognitive processing capabilities. The job coach explained that Polly insisted on trying to get back into nursing, saying, “She really needs to see if she can do it without panic and anxiety.”
The educator and I set up her mentoring experience on the unit as if she were a new staff member. The plan consisted of having her shadow the mentor and then take on a patient caseload gradually over a 4-week period. My role was not only to assess her abilities daily, but also to meet with the job coach and Polly weekly to evaluate the plan. At the end of the month, I would make recommendations to the whole team as to whether Polly should move forward and resume nursing. I felt quite anxious about being responsible for determining whether somebody could resume their lifelong dream of working as a nurse.
During the first week, Polly shadowed me and observed me doing assessments, organizing and prioritizing my daily workload, giving and receiving report, and attending team conferences. During this week, Polly was very focused on asking questions about other disciplines’ roles and other hospital programs, rather than on nursing, and this concerned me. At times, she was very difficult to redirect back into observing patient care, and I shared this concern with her job coach.
During the second week, Polly was assigned to one patient and attended that patient through all of the therapies. She was amazed about all of the therapies the paient had to do, and did not recall her own rehabilitation. She was asking questions pertinent to a rehabilitation patient’s care, such as bowel and bladder management. At the end of each day, Polly and I would review her documentation; it appeared very fragmented. I shared with her some ideas regarding how to better organize her documentation. By the end of the week, Polly had taken on two patients and, along with the patient care technician (PCT), was managing their care fairly well. I shared this information with her job coach.
During week three, Polly took on three patients, but it was obvious from her nonverbal behavior that she was anxious. I encouraged her to go back to managing two patients, but she insisted on trying to manage three. She had a lot of difficulty pulling and organizing their medications, as well as scanning to the right when reading the medication record. She had to bring the medication record close to her face. All of this information was shared with her job coach, who validated the challenges she faced in organizing medication administration with the HIRE therapists.
When it came, it was hard to believe that we were into week four of Polly’s mentoring experience. The job coach was present daily to observe closely Polly’s skills and behaviors. I noticed that she began the first day of the week by arranging her assignment sheet differently—placing the high patient room numbers first, rather than going from lowest to highest. She seemed more distracted and anxious and complained that her jaw hurt. We discussed the daily routine, and she set off for the medication room while I met with her job coach.
The job coach and I had difficulty locating her after we had finished our talk. When I checked the med room, Polly was not there, and the medications were still in the drawers. The PCT also was looking for her, as she had not given any report about the patients’ activities. We finally did find her doing a patient assessment, which we had not discussed when organizing the day’s activities. She became so focused on a patient’s blood pressure that I found it impossible to redirect her in reprioritizing her patient care. Her gestures and facial expressions demonstrated how very distracted and anxious she was becoming. The job coach was present throughout this whole ordeal. I finally was able to get her into the med room so that we could regroup her patient care. But when I turned around, she was gone again. We found her feeding a patient, though she was supposed to be administering medications.
The job coach, Polly, and I then sat down to talk. I voiced my concerns about the increase in Polly’s distractability, impulsivity, and anxiety. Polly stated that she was having difficulty because the routine was not the same all the time. I thought to myself that no two days are ever the same for a nurse.
As I reflected on the past four weeks with Polly, I became even more concerned that having to manage patients in an acute medical situation might become too overwhelming for her. During the mentoring process, I could see that Polly had poor insight, disorganized documentation skills, and limited scanning ability. She was easily distracted, became increasingly impulsive, and began complaining of more physical symptoms. Her ability to think critically was not being demonstrated. I noticed that my own frustration was increasing as I feared for Polly and her patients’ safety. I shared all of this with the job coach, the neuropsychologist, and the educator. We decided to set up a meeting to discuss with Polly all of these concerns and to bring this mentoring experience to a close.
The day came for our meeting. There I sat with the job coach and the educator, facing Polly. I shared several times, in different ways, my concerns about her being able to resume her nursing career and keep her patients safe. She could not seem to process that the recommendation was “no” to her continuing as a nurse, and kept interjecting ideas about working in another kind of nursing setting. Finally, the job coach intervened by stating that she would help Polly investigate other nonnursing jobs. Polly became very tearful, as did I, the job coach, and the educator. Polly left the meeting and I sat there, numb. The job coach looked at me and said “She did not understand and process anything we said.”
This mentoring experience was one of the hardest challenges I have had to encounter. It hurt to have to recommend to a nursing peer and former patient that she could not continue practicing nursing and, more importantly, that she was not safe. Rehabilitation nursing is a specialty that encourages patients to achieve their goals, but also strives to keep them safe. In Polly’s case, safety became the more important goal.
Jennifer A. Spalding, RN CRRN, is a clinical nurse I, Inpatient Rehab, at Miami Valley Hospital in Dayton, OH. Address correspondence to Jennifer Spalding, 2517 Montbello Circle, Kettering, OH 45440.
This article won first place in the Rehabilitation Nursing 2004 Writers’ Contest.