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Nursing Leadership Collaboration for Rehabilitation of Polytrauma Patients
This article describes a variety of nursing issues that emerged over a 3-year period on polytrauma rehabilitation nursing units and the leadership roles and strategies that were used to meet the rehabilitation needs of newly injured servicemembers who served in Operation Enduring Freedom (OEF) in Afghanistan and Operation Iraqi Freedom (OIF). Nursing’s leadership responsibilities focus on three primary areas: patient advocacy, family centeredness, and advocacy for staff. Collaboration among the four national polytrauma rehabilitation centers (PRCs) run by the U.S. Department of Veterans Affairs has enhanced the skill set for nursing staff members. These rehabilitation nurses possess the strong skills necessary to assess complex patient cases involving blast injuries, as well as strengthened interpersonal competencies in family dynamics, family education, and team function.
The U.S. Department of Veterans Affairs (DVA) has established four polytrauma rehabilitation centers (PRCs) to meet the needs of newly injured servicemembers serving in Operation Enduring Freedom (OEF) in Afghanistan and Operation Iraqi Freedom (OIF). Polytrauma centers were established by Public Law 108-422, Section 302, in November 2004 to address the rehabilitation needs of brain-injured servicemembers (U.S. DVA, Veterans Health Administration, 2005). The PRCs—VA medical centers with long histories of caring for patients with traumatic brain injuries (TBIs)—are located in Tampa, FL; Richmond, VA; Minneapolis, MN; and Palo Alto, CA. Polytrauma is defined as “injury to the brain in addition to other body parts or systems resulting in physical, cognitive, psychological, or psychosocial impairments and functional disability. Injury to the brain is the impairment which guides the course of rehabilitation” (U.S. DVA, Veterans Health Administration, 2005). Rehabilitation nursing needs at these facilities are more complex because of the multiple injuries resulting from improvised explosive devices (IEDs) and highly effective, rapid medical and surgical interventions. Interventions to achieve rapid stabilization are administered at the point of combat and servicemembers are subsequently airlifted to Landstuhl, Germany, within 24 hours. They are then transported to a U.S.-based military treatment facility (MTF) within 48–72 hours, most frequently Walter Reed Army Medical Center or Bethesda Naval Hospital. Wounded servicemembers receive intensive care for multiple wounds and, when ready for rehabilitation, are admitted to one of the four VA PRCs. On average, injured servicemembers have five impairments, which may include brain injury, amputation, infection, posttraumatic stress disorder (PTSD), vision and/or hearing loss, pain, and wounds.
Treating polytrauma requires significant collaboration among caregiving team members to meet the needs of servicemembers and their families at the PRCs. For example, each PRC has designated military liaisons (active-duty servicemembers assigned to the VA polytrauma unit) who help patients transition from military to VA care. Although the liaisons were designated as support personnel, role conflicts emerged, as well as questions regarding patient confidentiality (e.g., Are liaisons members of the treatment team?) and ambiguity related to expectations. The concept of “team” was expanded to include the military liaisons because they had access to critical military information about patients’ injuries, status, and resources.
Nurse executives at the PRCs scheduled conference calls to share lessons learned and work together to address similar issues. This communication proved beneficial. Each center had experienced a “significant event” such as an unexpected death or a family complaint to a high-level authority. These events had resulted in external review or media and congressional attention, and leadership struggled with how to support staff while remaining responsive to the core issues; executives had to control and sort out staff pressures and mitigate the impact on 24-hour nursing caregivers. Leaders shared various patient education orientation strategies and tools and useful reference materials and Web sites for helping staff and families understand the brain-injury experience. A shared Intranet site on polytrauma nursing was created to serve as an educational reference for VA nurses caring for these injured men and women.
Collaboration extended to interagency team members. Understanding the roles of various coordinators who assisted servicemembers transition from MTFs was necessary to ensure that nursing care needs were communicated clearly to receiving nurses at the VA. It is important for receiving VA nurses to have a comprehensive understanding of the servicemember’s clinical status, specialized treatments and procedures, and family needs. An MTF nursing position eventually was created to ensure that patients’ nursing needs would be successfully communicated to PRCs. PRC nursing leaders were involved in delineating the position’s responsibilities, selecting the certified rehabilitation nurses, and creating the hand-off tool used to communicate between facilities. This collaboration helped foster a seamless transition between the VA and MTFs.
The shift to a truly patient-centered approach is a cultural change that leadership must nurture. It is leadership’s responsibility to promote teams that are highly coordinated and include all team members. One site, James A. Haley Veterans’ Hospital in Tampa, FL, uses the knowledge and key concepts (i.e., patient centeredness, team vitality, safety and reliability, value-added processes) introduced by the national Transforming Care at the Bedside Project (Rutherford, Lee, & Greiner, 2004).
Although MTFs and VA care are both part of the federal government, the transition in care between the two is not necessarily a simple process. Despite the long-standing relationships between the organizations in caring for patients with TBI, transitions may be complicated by cultural mores when treating active-duty servicemembers. The military is a hierarchical organization; MTFs have active-duty (as well as civilian) staff caring for injured people. Rank, strong affiliations with military units, and continued active-duty status accompany injured servicemembers into the PRCs. Staff address injured servicemembers by their military rank because they are still on active duty; the expectation is that an injured person will work toward getting better and return to the job. Young men and women who are brain injured frequently express rage or act impulsively; for example, they may try to drive when not cleared to do so. The presence of a military liaison in uniform serves as a reminder of behavioral standards and minimizes aggressive behaviors. A servicemember’s allegiance remains with the military and his or her “buddies” (those injured or back in Iraq), and some servicemembers do return to work in the military. VA nurses are not required to have a military history and, therefore, many PRC nurses are unfamiliar with this culture or the finer points of military rankings. Nursing units have used posters to illustrate the titles and ranks of Marine, Navy, Army, Air Force, and Coast Guard personnel, which proved helpful for nurses and family members when high-level military visitors were in the patient care area.
Nursing leadership must dissolve differences between nursing settings, and program boundaries need to be fluid to meet patient needs. After initial rehabilitation, for example, additional PTSD symptoms may appear that require behavioral intervention. After his or her PTSD treatment needs are reduced, a patient can again focus on rehabilitation. When transferring a rehabilitation patient to an intensive care setting to treat a complication, acute care staff risk excluding the family in patient care. It is important for nursing leadership to clarify the extent of a family’s engagement in patient care from the beginning to avoid staff-family conflict after an emergent transfer. In addition, nursing and other rehabilitation disciplines need to continue the necessary rehabilitation therapies. Nurses must educate families that changes in treatment settings for specialized surgery and recovery or for other reasons frequently occur during the rehabilitation process.
Early on, care for polytrauma patients appropriately is focused in the polytrauma rehabilitation unit. The complexity of patient injuries and patients’ fragile conditions eventually necessitate a system-wide approach to health care, however. Patients may transfer between units for planned treatments or unexpected complications. Key roles for rehabilitation nurses and team members include meeting with patients and families to ensure continuity of care in each new setting, helping the nursing staff meet the unique needs of each family, and assessing and reassessing patients for rehabilitation needs. This direct interaction builds families’ confidence during these transitions and strengthens their faith in the rehabilitation process and the organizational commitment to meeting patient and family needs.
Leadership opportunities emerge when traditions and assumptions are challenged by patients and families. Leaders need to help staff members see rules and regulations from the perspective of patients and their families. For example, when visiting hours were reassessed by one PRC, leadership had to make quick adjustments to satisfy patient needs. Because of the family-centered focus at military facilities—beginning at the Landstuhl Regional Medical Center in Germany—it was clear that family involvement was an expectation, not a timed event. The polytrauma units quickly amended family visitation policies; families were granted 24/7 access to patients in all settings, except psychiatry. Units had to adjust to accommodate the presence of young children and infants and maintain a therapeutic healing environment. The new policy also prompted staff to examine the degree of patient/family-centered activities. The Wednesday bingo games, VA food options, and pass rules no longer met the needs of millennium-generation patients and families. Rehabilitation had to be very active and frequently took place off site. Recreation can include the latest rehabilitation technology, horseback riding, biking, and sailing. This variety increases the workload for nursing staff, who frequently must assess patients before and after they take part in an activity and ensure medications and treatments are continued. Treatment also includes access to the Internet, games, and family and patient cookouts.
Caring for severely injured servicemembers raises ethical and legal questions for nursing and interdisciplinary staff. One of the most difficult issues for staff members is recognizing a family’s desire to heal their loved one while remaining realistic about the patient’s potential long-term outcome. Experienced rehabilitation nurses can balance this dichotomy, but new staff members must adjust to it. And although the clinical outcomes of many seriously injured young men and women have been dramatic, for others, progress frequently is measured over a long period of time and is delayed by a series of complications such as a return for a cranioplasty or reconstructive surgery. Patient progress occurs over a period of years, not just during the initial months.
Determining family authority for medical decision making must happen shortly after patients are admitted to the PRC. If complications arise, it is vital that a legal healthcare decision maker has been established. The family member who accompanies an injured servicemember frequently is his or her parent, not a spouse, because spouses have childcare obligations and can visit only intermittently. Staff members are caught in disagreements between the family member with legal authority and the family member who is present; they may be unsure about the right person with whom to communicate. When these conflicts arise, staff members need to identify the legal decision-making authority and decide how to handle the others involved. One solution practiced by PRCs has been to designate alternate visitation weeks between spouses and mothers. Another idea is to appoint a legal guardian to make decisions for servicemembers, which eliminates the decision-making conflict between parents and spouses.
Families who stay with their loved ones experience stress that extends for months, not just weeks. The younger generation may require family advocacy that involves finding temporary housing, addressing personal healthcare needs such as arranging pregnancy care and child care, and addressing needs for additional income. Nurses must understand that families face many pressures that extend beyond concerns about the patient, and the appropriate staff must be engaged to help resolve these issues.
A component of team function at PRCs is including family members and patients as important members of the rehabilitation team. When managing a catastrophic event, the importance of dealing with complex family dynamics cannot be overestimated. Many of these patients have been engaged in a fight for survival. Lee Woodruff described her experience with her husband: “The ups and downs of Bob’s medical ride were like bad airplane turbulence. Each time we throttled up, we were hit with fresh bad news. Pneumonia, sepsis, bacterial infection: I kept reaching for something—anything—positive to hold on to” (Woodruff & Woodruff, 2007, p. 162). After a servicemember reaches a PRC, the road to recovery remains uncertain. The ambiguity of recovery, at whatever level of treatment, remains.
Transitioning from an acute medical facility to a rehabilitation facility is a major change for families. It is difficult for families to shift their patient care focus from survival to rehabilitation (and uncertain treatment outcomes). Their prayers for survival have been answered, but now they must face the reality that their loved one will be living with various deficits. This shift requires staff to rethink the pace of family education. Sharing patient education strategies helped all PRCs improve the timing of family education.
Many returning servicemembers belong to the millennium generation, which spans 1982–2000. They were born during a time of great technological advances and globalization, which includes instant access to information via the Web, digital imagery, and cable television. It is a generation that tends to be group oriented and outspoken. Their parents ardently watch over them (Howe & Strauss, 2004). This complicates nurses’ advocacy role. Many injured servicemembers had only recently left their parental home for the first time. Families may have had strong feelings about the servicemember’s decision to join the military. If the injured servicemember recently had married, the spouse/parental relationships were often influential, and the nursing staff experienced tension during family conflicts. Setting boundaries for family members is an initial intervention available to nurses in this situation.
Boss (2006) suggests that stress from ambiguous loss is the cause of conflict. Ambiguous loss is defined as the situation in which a loved one is perceived as physically present and psychologically absent. The result for the family is paralysis—decisions and family events are put on hold. Nurses are acutely aware of families’ pain and want to help, but the degree of stress due to ambiguous loss requires the intervention of a certified family systems expert, usually a social worker or psychologist. Boss recommends that nursing staff keep communication open with the family and assign appropriate tasks (e.g., designing a patient memory board with family pictures) to family members to more effectively engage them in the recovery process.
Members of the millennium generation expect to have Internet access and instant communication. The CaringBridge Web site is an example of a way to meet the connectivity needs for this generation and their parents. It is used by family members of a loved one who has experienced catastrophic injury or illness. CaringBridge, a not-for-profit organization primarily supported by donations from users, allows people to electronically keep in touch with family and friends during significant life events. Most families use this site to write daily journal entries in which they share the progress, joys, and frustrations of their recovery journey. The site reduces the number of phone calls made to extended family and friends, yet provides a forum in which people can offer their prayers, love, and support with routine updates. Millennials who are used to receiving instant results also may use the site to express their anger or frustration with healthcare providers or discuss their perception of the insensitivity of bureaucracies.
Helping families manage their recovery expectations entails maintaining a delicate balance between realistic goal setting and tempering overly optimistic expectations for outcomes. Although the initial recovery trajectory has some predictability, gradual improvements generally happen 1–3 years after initial injuries occur, shattering traditional views about recovery. The interdisciplinary team must skillfully navigate the ongoing balance between hope and reality.
Goal setting is a process during which families and staff can agree on a patient’s goals for the next 1 or 2 weeks. Setting goals reveals a family’s expectations, which often are unrealistic. At the PRCs, team members and families listed their goals side by side on a piece of paper throughout the week. At least once every 2 weeks, they met to set and mutually agree upon a goal, which then was documented on the same piece of paper. The differences written on the paper helped the family be more realistic regarding the steps needed to achieve goals. This process keeps communication open and allows families to actively participate in the care-planning process.
Properly timing TBI family education is important because initial orientation information frequently is not fully retained. Over time, a friendly approach to education has evolved to a more formal hand-off structure. Working with liaisons at the MTF, family needs are proactively identified, assuring that Maslow’s hierarchy of needs are met (e.g., that caring for basic human needs of housing, child care, physiological and psychological safety before the rehabilitation transition of the family unit can occur; Maslow, 1998). Education about transitioning from an acute facility to a rehabilitation setting requires clear communication. Otherwise, families will expect the acute-care viewpoint and have difficulty with rehabilitation goals. Videoconferencing between the MTF and the PRC before a transfer occurs has greatly eased the transition for families, allowing both groups to prepare, giving staff the opportunity to welcome the patient and family, and giving families the opportunity to meet staff who will be involved in care.
Family readiness to assimilate information must be determined. Rather than sequential classes, families have indicated they want all information about the injuries and treatment at once, using the information as a resource over a period of time. One site developed an extensive briefing book for families on traumatic brain injury that is now used by all four sites.
Family involvement has progressed from family participation to family partnership. A patient’s mother may encourage and lead the holiday decorating event. Direct-care activities such as bathing, feeding, or suctioning are shared between staff and family members after assessing the family members’ desire to engage in direct-care activities. Family members of newly injured patients frequently are transitioned into the PRC by existing family groups. This level of family interaction represents a major shift for the nursing staff, moving from control of the nursing care environment to sharing with families and patients.
Nurses serve as advocates for all patients, which can cause conflict when a new patient group has strong external advocates such as congressmen, military officials, and VA central office leaders. Initially, PRC nurses felt that active-duty servicemembers were receiving “special treatment” compared to veterans. After congressional and high-ranking military staff visited newly injured service members, hospitalized veterans reported they felt like second-class veterans. It was important for nursing leadership to communicate these concerns to hospital leadership and work to have such visits include hospitalized veterans as well. Communicating this observation to other senior leadership members helped balance the high expectations for exceptional care for polytrauma patients. This nursing concern was evident when staff nurses recommended the “Every Veteran is a VIP” initiative at the nursing strategic planning retreat. This action reflects nurses’ professional and ethical expectation of advocacy for all patients.
Advocating on behalf of nursing staff requires listening carefully to what staff members are saying. Comments regarding lack of team support after 4 pm, the perception of being rushed, the provision of “special” care to active-duty patients, and concerns regarding fairness and intensity of family involvement suggested that staff needed support to voice their concerns. Various strategies were required to meet these needs, and education was a key component of staff advocacy. Meeting with staff members to allow them a forum to voice their concerns was critical during the early stages of PRC operation and when negative feedback was received thereafter.
Creating a new nursing role at one site helped staff. A mental health (clinical specialist) nurse liaison position was introduced to specifically help staff manage complex family situations, create stress-reducing interventions, and be available for individual and group problem-solving sessions. Staff members were provided a forum to safely express their concerns about the ever-present family, their personal stress in caring for young patients, and their frustration regarding the transition in rehabilitation nursing care. Learning to interpret “the same level of care” to mean “the same care, but different due to generational needs” was another essential intervention implemented to support the staff transition care for a new patient population.
The leadership advocacy role must balance staff needs as well as patient and family needs in a politically sensitive environment. Staff must be supported, yet the transition to caring for a younger, recently war-injured patient population needed to occur at the PRCs. It is expected that the DVA will do a better job of meeting the needs of today’s veterans than veterans of the Vietnam era. Outreach, screening, and early interventions for stress-related reactions and ineffective coping now are priorities for OEF and OIF servicemembers. In addition, caring for millennium-generation patients has created new demands on nursing and other clinical staff. Because instant communication and feedback are expectations for this population, dealing with government bureaucracies such as the DVA and Department of Defense create frustrations for servicemembers and their families. These frustrations, in addition to the normal stages of coping with a catastrophic injury, have the potential to become highly charged.
Nurse leaders advocated for additional resources to meet the new nursing requirements. Advocacy translated into factoring in time for nursing staff interaction with families during scheduled shifts. Another example was providing sitters, such as nursing assistants, for close observation of agitated patients. The intensity of family involvement necessitated safe spaces for staff to break away from a unit. With the complexity of patient care, an advanced practice nurse provided daily consultation for staff on new and unique care issues and just-in-time education.
In a setting in which family members have the business cards of congressmen and senators, high-ranking military officers, VA central office leaders, governors, and presidential staff, meeting patient and family needs takes on new meaning. Collaboration among team members on plans of care is critical. Numerous specialty physicians are involved in making rounds with the attending physician, necessitating clear, open, and frequent communication between the attending physician and nursing staff. Communication breakdowns in the PRCs result in external inquiries regarding help and intervention. This high level of visibility made any mistake linked to a PRC subject to an external review. When reviews took place, leadership buffered staff from the findings. Softening feedback, creating systematic plans for improvement, and involving staff in planning have been essential leadership strategies used to support staff.
In a time of uncertainty, the development of a new specialty—polytrauma care—provided significant growth for PRC nursing staff, leaders, and the entire organization. Working with a new patient population—in terms of age and injury complexity—has created an environment in which past assumptions have been reexamined. Becoming a patient- and family-centric organization requires a willingness to rethink the status quo, learn from external examination, and embrace feedback from families and other patient advocates. It requires a learning environment that supports nursing staff and interdisciplinary teams as they move toward a new way of practicing—as partners in the journey of these rehabilitation patients and their families.
About the Authors
Sandra K. Janzen, MS RN NEA-BC, is associate director of patient care/nursing services at James A. Haley VA Hospital in Tampa, FL. Address correspondence to her at firstname.lastname@example.org.
Alice S. Naqvi Mugler, MS RN, is magnet project coordinator at Santa Clara Valley Medical Center at VA Palo Alto Health Care System in Palo Alto, CA.
Boss, P. (2006). Loss, trauma, and resilience: Therapeutic work with ambiguous loss. New York: W.W. Norton.
CaringBridge. (n.d.). About CaringBridge. Retrieved May 6, 2008, from www.caringbridge.org/about/htm.
Howe, N., & Strauss, W. (2004). Millennials rising: The next great generation. New York: Vintage.
Maslow, A. (1998). Toward a psychology of being (3rd ed.). New York: John Wiley & Sons.
Rutherford, P., Lee, B. & Greiner, A. (2004). Transforming care at the bedside: IHI innovation series white paper. Retrieved May 6, 2007, from www.ihi.org/IHI/Results/WhitePapers/TransformingCareattheBedsideWhitePaper.htm.
United States Department of Veterans Affairs, Veterans Health Administration. (2005). Veterans Health Administration directive 2005-024: Polytrauma rehabilitation centers. Washington, DC: Author.