Scenario #7: Mexican Immigrant, Senora Ladonna Chavez
Learner Group: OT, PT, NP (NP by phone, can be learner or confederates)
Environment: Outpatient Rehab Clinic
Authors: Karen Panzarella
- On-site two HCPs to jointly prioritize patient care issues
- Identify and understand cultural barriers that could influence patient compliance and plan for care
- Communicate with NP regarding patient's anxiety over shoulder impairments regarding rehab versus surgery
- Determine Plan of Care with patient and her husband
|1||T||OT/PT to plan how to perform initial assessment|
|1||T||OT/PT initiate focused assessment to include: interview with patient, UE ROM, Strength, sensation, vital signs, etc.|
|1||C||OT/PT discuss involving the patient's husband in the rehab process|
|1||B||OT/PT contact NP to discuss patient's and patient's husband's disagreement about rehab versus surgery|
|1||C||OT/PT/NP to create a plan of care for patient, her husband and home follow through|
- Team planning
- Situational Awareness/Cultural considerations
- Family Involvement
- Accessing Resources
- Decision Making
- OT/PT team plan to perform joint initial assessment of new patient with Dx of frozen shoulder speaks primarily Spanish with limited English
- Pt. portraying "marianismo" and stating that she is very concerned about her inability to fulfill her role as caretaker to her grandchildren and parents, is anxious that her husband wants her to have surgery and she wants to try rehabilitation first
- OT/PT to decide with patient whether or not to include husband in the initial assessment and discussion of POC
- OT/PT to communicate with NP regarding plan of care; rehab versus surgery and patient and husband disagreement about POC
- OT/PT/NP to team conference with patient and husband regarding POC for rehabilitation prior to considering surgical intervention
Synopsis of scenario
55 year old Hispanic female who is attending outpatient PT and OT for an initial assessment for a (R) frozen shoulder, pt. is (R) hand dominant. Patient was diagnosed with a (R) frozen shoulder 2 weeks ago from her primary care Nurse Practitioner. Patient has been complaining of pain and lack of mobility in the (R) shoulder for the past 2 months and her inability to perform ADLs and family role. Patient expresses concern that her husband, who is in the waiting room, does not think she should have rehab but instead have surgery so she can get better more quickly. Patient is displaying marianismo and her husband presents as wanting to control the decisions of her care, both appear anxious.
- NP- by phone (can be confederate)
Confederate roles and scripting
|Role||Tone||Timing Of Participation||Lines / Comments|
Speaks limited English, Spanish is primary language
Complains that is wife is unable to cook and clean for the past 2 months, he wants her to get better quickly and would like her to have surgery instead of wasting time with rehabilitation
Is sitting in the waiting room until called upon by HCP
"my wife cannot cook or clean or take care of the house, for over 2 months because of her shoulder pain"
"we need to get this taken care of quickly, she should have surgery"
"my parents are living with us and they need care and my wife is in too much pain to help them"
|NP||Professional||Phone call||"I have been the primary care provider for Mrs. Chavez for several years. Her husband makes most of the decisions for her and the family. I am recommending rehab for her shoulder although her husband wants her to have surgery. He is concerned that her pain has been going on for over 2 months. I explained to them both that having rehab for a month or so may eliminate the need for surgery and should be tried before surgery"|
Name: Senora Ladonna Chavez
Weight: 165 lbs
Religion: Roman Catholic
Support: Husband and 4 adult children, 5 grandchildren and aging parents
Past Medical History: Diabetes x 5 years controlled with Metformin and diet. 2 c-section births, hysterectomy 2 years ago, gallbladder removal 8 years ago, irritable bowel syndrome
Meds: metformin, daily fiber, OTC vitamins and herbs
History of present illness
Patient began experiencing pain in her (R) shoulder approximately 2 months ago, has lost motion progressively and pain has increased, pt. has been treating with ice and herbs, hoping it would improve.
Home maker and care taker of aging parents and grandchildren. Active in church and community events.
Report to participants
Mrs. Chavez is here for her initial visit for an OT and PT evaluation for a diagnosis of frozen shoulder. She has been referred from her primary care NP. You are to work together to complete the initial assessment and make a recommendation to her and her husband for a plan of care. You will 5 minutes to preplan before addressing Mrs. Chavez.
|Staged For Learners||Available For Learners To Use|
Clothing: Street clothes
Position: Sitting on plinth, exam table or in chair
Holding (R) arm
Expresses pain and discomfort
Apprehensive about moving (R) UE
|Environment||Outpatient rehabilitation clinic|
Plinth or exam table
Progression of events
|Simulated Patient Actions||Performance Measures||
Confederates In and Out
Mental status: slightly anxious
Script: "I have pain in my shoulder and I cannot cook or clean or take care of my family" "please help me so I can take care of my grandchildren and my parents"
Other: SP expresses "my husband is concerned that I cannot take care of the house or my family, he wants me to have surgery but I would like to try rehab first, he makes all the decisions, you may have to speak with him as well, he is in the waiting room..."
Patient will be holding (R) UE and expressing pain and discomfort
Patient expresses concern over not being able to fulfill her role at home
Patient expresses concern that her husband wants her to have surgery but she wants to try rehab
Patient's ROM of (R) arm will be limited to 90 degrees of flexion and abduction with pain, internal and external rotation only 10 degrees
Tone: slightly agitated
SP: "My doctor, the Nurse Practitioner, Miss Roberta, said I should try rehab first, I am afraid to have surgery right now", "here is the prescription from her"
Husband: "She won't listen to me, She never listens." " I am the Man, I do not want this to go on any longer, she cannot take care of our house and family", "maybe you should call Miss Roberta and talk with her about the plan"
SP gives OT/PT written script from NP with order for OT/PT evaluation and treatment for (R) frozen shoulder
NP to be able via phone
Integrated debriefing guide
|Threads||Performance Measures||Debriefing Prompt|
Give us a quick summary of what happened.
What went well?
What didn't go so well?
|Team Planning||OT/PT to plan how to perform initial assessment||
Was the preplanning session helpful?
What are the benefits of performing the initial assessment jointly? What are some of the draw backs?
|Understand clinical presentation||
How are you sure of this diagnosis?
how does a script from a referring HCP impact upon your clinical decisions?
What signs and symptoms would you expect for this type of patient?
What signs and symptoms were present?
How did the patient describe his/her symptoms?
What other presentations can produce similar symptoms?
|Identify contributing factors||
What co-morbidities were present?
What risk factors were present?
|Identify correct intervention / treatment||OT/PT to verify appropriate diagnosis of frozen shoulder||
What is the accepted standard of care for this type of patient?
How was it used?
What other options for care would be reasonable?
What other clinical resources could be accessed?
|Recognize a concern during patient interview||OT/PT discuss involving the patient's husband in the rehab process||
What was concerning at this point?
|Understand cultural implications||
What cultural influences may be present?
Are there any inherent risk factors for this population?
What does "marianismo" pt. stating that she is very concerned about her inability to fulfill her role as caretaker to her grandchildren and parents have to do with this case and POC
|Assessment||OT/PT initiate focused assessment to include: interview with patient, UE ROM, Strength, sensation, vital signs, etc.||What specific assessments are important to consider with this type of patient?|
What is important to document?
Whom documents what?
|Decision Making Prioritization||
What information was necessary to make a decision? What cultural considerations need to be explored?
How were decisions made?
What resources could be accessed?
|Communication||OT/PT contact NP to discuss patient's and patient's husband's disagreement about rehab versus surgery||
When is it helpful to contact a referring provider?
What additional information do you need to proceed with this case?
What information do you want from the primary NP?
What are some ways we could improve on sharing information?
How does the NP differ from the primary MD?
|Situational Awareness||Cultural Considerations||
How might the concept of marianismo" conflict with a rehab program? How might it enhance a rehab program?
What are strategies for keeping the big picture in view?
When was there a clear leader?
Did everyone know their role?
How were the roles delegated?
How could the workload be divided up differently?
|Professional Behavior||To patient, family, and NP||
How were we coming across?
What was the team performance like?
What would happen if the "regular" team was not present? What are some strategies for managing difficult interactions?
What was the conflict and how was it managed?
What would we do differently next time?
Any other questions or comments?