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Clinical Narrative: Better to Light a Single Candle
The following is a clinical narrative that describes one nurse’s attempt to motivate a patient who had recently sustained an injury that caused quadriplegia and the practice implications that arose from “silo” thinking between disciplines.
“I don’t want to f*&%#ing do anything!” It was 8 o’clock on a Saturday morning, and I had just gone in to meet my patient. Mr. A was a 27-year-old male who recently had been transferred to us from another hospital after being in a severe motor vehicle crash that included ejection and loss of consciousness. He sustained spinal cord fractures and became quadriplegic. He also had a tracheostomy, a gastric feeding tube, healing abrasions, and a major attitude problem. He was, quite understandably, angry, bitter, depressed, and frightened. His whole life had changed forever, and he stated he saw no reason to go on. He was transferred to our acute rehabilitation unit and consistently refused every therapy. His appetite was poor, and we were becoming concerned about his hydration status. I decided to take him as a patient one quiet weekend, partly to see if I could find a way to motivate him and partly because no one else volunteered when I was making patient assignments.
“Come on, Mr. A, you have me all to yourself for 8 hours on a beautiful sunny day. Isn’t there anything you’d like to do?” I asked. More swearing, more refusals, more frustration was all this man could muster. He didn’t want the blinds opened, the lights turned on, or to eat any of his breakfast. He let me take his vital signs and give him his medicines via the gastric tube and then ordered me out of his room. It was my turn to refuse. I shut the door and sat there in the dark with him. After a few minutes he opened his eyes and asked if I was getting paid to do this. I laughed and said yes, I had gone for a run that morning and was tired, so sitting around all day while getting paid sounded great. I thought I saw a glimmer of a smile (it could have just been a shadow), and so I launched into a description of the balmy July temperatures that morning, the smell of the roses, and the sound of the birds singing. And Mr. A started to cry. He said he hadn’t been outside since the accident 3 months earlier and that he was sick of being in hospitals, sick of being a quad, sick of being in bed, and sick of everything. I let him rant and then I said, “So let’s go outside.” He started to refuse, and I said, “Look, I can’t change everything that’s happened, and I have no idea how your future will play out, but for today, for now, I can make this a little better.” And then a small miracle happened. He agreed to get up.
I started with breakfast and managed to get him to eat (and drink) about half of it. He mentioned his mom was coming to see him in the next day or two (she was an ICU nurse, working 12-hour shifts all in a row to maximize the time she could spend with him), and I wanted to get him bathed and shaved. I recruited the help of the weekend physical therapist to help me get him into the Hoyer lift, and while he was up I asked the doctor to take a look at his back and sacral area, where it had been reported he had an evolving decubitus. We found no evidence of a pressure ulcer, and we were able to prop him in a shower chair and give him a long hot shower and shampoo. He started crying again and said it was the first time his hair had been washed in months. I asked the physical therapist to help me move him from the shower chair to a reclining wheelchair so he could shave and brush his teeth. The therapist then asked if he could work with him for a little while, and for the first time Mr. A didn’t refuse.
I checked the doctor’s orders and confirmed the patient could be out of bed as tolerated. I got some sunscreen from the recreation therapists, found some sunglasses, and got a portable vital signs machine. I told Mr. A that before we went outside we should take a little tour of the unit (it was the first time he had been out of his room), and I showed him our communal dining room. The big screen TV was on, and some of the patients were watching a baseball game, so Mr. A agreed to have his lunch in there. He started to refuse everything on his tray, and I told him I would make him anything he wanted that was consistent with his diet order, but if I made it he was going to eat it. (I think I gave him the “wasting food is a sin” lecture I give to my kids.) He ate 100% and drank two cartons of milk. I checked his vital signs and confirmed his medical stability (with spinal cord patients, autonomic dysreflexia is a constant concern), and then I made good on my promise. Mr. A, coated in sunscreen and wearing his cool shades, went outside on our patio. I took the vital signs machine with me and some light blankets in case he became chilled or overheated (spinal cord patients have trouble regulating their temperatures). The incredible peace on Mr. A’s face was so rewarding! We didn’t chat very much, but just relaxed and enjoyed the calm. I kept taking his blood pressure and temperature, but I could tell just by looking at him that he was stable. No diaphoresis, no headaches or chest pain/shortness of breath, no skin color changes or goose bumps—just plain old relaxation. After about 15 minutes I told him we would have to go back inside because it was time for my lunch and I didn’t know if anyone else would be able to stay with him. He opened his eyes and begged me to just let him stay a few minutes more, suggesting that it would be good for me to eat outside on such a nice day! Again he made me laugh, and I couldn’t argue with such sound logic, so I got my lunch and an extra pudding and juice for Mr. A and went back out to our little patio. Vital signs every five minutes remained normotensive, his temperature was euthermic, and Mr. A was happy. We were outside for about 30 minutes, and he was out of bed for about 3 hours. He was cooperative and pleasant with both recreation therapy and nursing for the rest of the shift, and I went home pleased and satisfied and hopeful about Mr. A’s rehab stay with us.
Imagine how surprised I was when I came back to work on Monday morning and learned that the therapists were upset that I had gotten Mr. A out of bed. They were concerned that I had used an inappropriate wheelchair (they had just ordered him one that was not expected to arrive for several days), that he wasn’t stable enough to tolerate being upright or even reclined, that his pressure sore would get worse, and that nurses didn’t know the correct way to prop him up. Even when presented with the documentation by physicians and nurses that none of these things occurred, there remained a schism between nursing and therapy as to the best course for Mr. A. This example of “silo” thinking and the resulting defensiveness between disciplines prevented us from presenting a unified approach with Mr. A. He was no longer allowed to go outside, and he once again began to refuse therapy. After 10 days a decision was made to transfer him to another unit. He was subsequently placed on suicide watch.
The interdisciplinary team approach is the gold standard for effective rehabilitation, but, as with any team, communication and collaboration are essential for success. Collaboration can be difficult because many rehabilitation professionals have only a minimal understanding of the scope of practice of other disciplines. Overlap can lead to confusion and conflict as well as “turf wars.” To promote better communication and a more coordinated service delivery, our rehabilitation team instituted a series of both formal and informal team-building sessions with a focus on communication and maintaining a high standard of performance. A consultant was brought in to facilitate a workshop on conflict and change, and weekly interdisciplinary team meetings were restructured to promote an overall philosophy of collaboration. Although the process was far from perfect, the institutional support helped enable team members to make changes and recommit to providing exceptional patient care that reflected the concept of setting and achieving individualized rehabilitation goals. The above story illustrates an important issue in rehabilitation care and the implications that arise when therapists and nurses either resolve or ignore the inevitable disagreements and conflicts that will always be a part of rehabilitation.
About the Author
Sandra Stafford Cecil, MSN RN CEN CRRN, is the assistant nurse manager on the polytrauma unit of the Palo Alto Veterans Administration Hospital in Palo Alto, CA. Address corredspondence to her at firstname.lastname@example.org.