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Home > Simulations > Simulation 7: Mexican Immigrant

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

Facilitator directions

Main focus

  1. On-site two HCPs to jointly prioritize patient care issues
  2. Identify and understand cultural barriers that could influence patient compliance and plan for care
  3. Communicate with NP regarding patient's anxiety over shoulder impairments regarding rehab versus surgery
  4. Determine Plan of Care with patient and her husband

Performance measures

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

Skills/tasks/procedures

  1. Team planning
  2. Situational Awareness/Cultural considerations
  3. Family Involvement
  4. Accessing Resources
  5. Decision Making

Imbedded challenges

  1. OT/PT team plan to perform joint initial assessment of new patient with Dx of frozen shoulder speaks primarily Spanish with limited English
  2. 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
  3. OT/PT to decide with patient whether or not to include husband in the initial assessment and discussion of POC
  4. OT/PT to communicate with NP regarding plan of care; rehab versus surgery and patient and husband disagreement about POC
  5. 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.

Learner roles

  1. OT
  2. PT
  3. NP- by phone (can be confederate)

Confederate roles and scripting

Role Tone Timing Of Participation Lines / Comments
Husband

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

Throughout scenario

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"

Patient information

Senora Ladonna Chavez

Name: Senora Ladonna Chavez
Age: 55
Weight: 165 lbs
Height: 5'6"
Gender: Female
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.

Social history

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.

Technician staging

Staged For Learners Available For Learners To Use

Simulated Patient

Gender: Female

Clothing: Street clothes

Position: Sitting on plinth, exam table or in chair

Female

Street Clothes

Holding (R) arm

Expresses pain and discomfort

Apprehensive about moving (R) UE

Environment Outpatient rehabilitation clinic
Equipment

Plinth or exam table

Rolling stool

Goniometer

Reflex hammer

Xrays None

Progression of events

Simulated Patient Actions Performance Measures

Cues

Confederates In and Out

0-10 minutes

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..."

  • OT/PT have preplanned progression of initial assessment
  • OT/PT initiate focused assessment to include: chief complaint, history of pain, medical and surgical history, ADLs, functional abilities, vital signs, ROM, strength (B) UEs
  • OT/PT to decide to include the patient's husband in the initial assessment

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

10-20 minutes

Mental Status:

Tone: slightly agitated

Script

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"

  • OT/PT decide together whether or not to contact the nurse practitioner via phone
  • OT/PT/NP to consult regarding Mrs. Chavez POC
  • OT/PT to broker comprise with Mr. and Mrs. Chavez for rehab for 6 weeks prior to making a decision about surgery

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
Opening

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?

Please explain.

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?
Documentation

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?

Leadership

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?

Closing

What would we do differently next time?

Any other questions or comments?

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