Rehabilitation nursing role withininterdisciplinary teamwork: the

perspectives from nurses,patients, therapists

and doctors

Jenny Liu

Introduction: • Patients requiring rehabilitation often have multiple or

complex physical, emotional and psychosocial problems. None of the professional disciplines within the healthcare team have expertise in all of these areas. While numerous works have been completed regarding the rehabilitation nursing role within the international context, there was insufficient literature discussing the rehabilitation nursing role within interdisciplinary teamwork (IDT) and the nurses’ interaction with other team members, especially from other disciplines’ and patients’ perspectives.

Research Objectives:• 1) To explore and determine the perceptions of the

rehabilitation nursing role at an inpatient rehabilitation service from the patients’, nurses’, therapists’ and doctors’ perspectives.

• 2) To identify areas of potential overlap between rehabilitation nurses and other team members within the inpatient rehabilitation service.

• 3) To identify opportunities for potential development of the rehabilitation nursing role within interdisciplinary teamwork at an inpatient rehabilitation service.

Research Design: • General Inductive Methodology of qualitative

research, which derived from grounded theory, was utilised in this study.

• Semi-structured interviews were conducted with 15 participants, which included five nurses, five patients, three therapists and two doctors.

• The general inductive analysis approach was used to analyse the data.

Method• The Study setting: inpatient rehabilitation service-Rehab

Plus, Auckland, New Zealand• Research design: • Methodology: General Inductive Methodology of

qualitative research• Semi-structured interview• Sampling, Study Population and Sample size:• Purposeful sampling, recruitment, There were five nurses,

three allied health staff, five patients and two doctors from Rehab Plus were selected and interviewed.

• a flowchart summarising the process of conducting the qualitative study.

Findings:

• Seven themes were identified and developed from the study findings: 1) the rehabilitation nursing role; 2) attitude; 3) environment; 4) communication; 5) interdisciplinary teamwork; 6) patient’s goals and patient-centred care7) service efficiency.

Seven themes identified from the current research

Rehabilitation Nursing Role

Section 5.2

Rehabilitation Nursing

AttitudeSection 5.3

EnvironmentSection 5.4

CommunicationSection 5.5

Interdisciplinary TeamworkSection 5.6

Patient goals and Patient-centred Care

Section 5.7

Service EfficiencySection 5.8

Research Findings• The research defined the rehabilitation nursing role

from the aspects of medical nursing, rehabilitation nursing and nurses within the team.

• With the rehabilitation teamwork model, the team members from different disciplines allowed and accepted the role blurring and role overlap during interdisciplinary teamwork.

Demographic characteristics of rehabilitation nurses

Nurse 1 Nurse 2 Nurse 3 Nurse 4 Nurse 5

Gender Male Female Female Female Female

Age group 30-39 60+ 40-49 50-59 40-49

Ethnicity NZ Maori NZ European Other

European

Malaysian NZ European

Country trained New Zealand New Zealand United Kingdom England New Zealand

Qualifications RN EN RN RN RN

Post Graduate (PG)

study

PG

Certificate in

Education

PG diploma in

rehab (Otago)

PG Certificate in

rehab (Otago)

Clinical

study days and case

study

One PG rehab

paper

Years of qualification

14 19 29 30 20

Years of rehab

experience 12 19 9 10 12

Level on PDRPRN 3 EN 4 RN 4 RN 4 RN 4

Demographic characteristics of patientsPatient 1 Patient 2 Patient 3 Patient 4 Patient 5

Gender Female Male Male Female Female

Age group 50-59 60-65 60-65 50-59 40-49

Ethnicity NZ European Maori &

European

Samoan Other European NZ European

Diagnosis Pathological

Fracture Right

Femur; gamma

nail fixation;

Metastatic

breast Cancer

Ischemic

Stroke- R)

MCA

subcortical

Diabetic sepsis

R) foot

R) BKA

On

haemodialysis

Avascular

Necrosis of R)

hip;

R) THJR;

Rheumatoid

Arthritis (RA)

colitis; Peritonitis;

R) hemicolectomy;

Deconditioning

Refeeding

syndrome, from

TPN to NG feeding+

oral

Chronic wound

Colostomy bag

Main Reason

for rehab

Fracture Stroke Amputation R) THJR

RA

De-conditioning

LOS when

interviewed

3 weeks 6 weeks 4 weeks 6 weeks 3 weeks

Demographic characteristics of Allied Health staff

AH 1 AH 2 AH 3

Gender Female Female Female

Ago groups 30-39 20-29 20-29

Ethnicity Germany NZ European NZ European

Country trained Germany New Zealand New Zealand

Qualification

(Disciplines)

SLT PT OT

Post graduate

study

Masters degree N/A N/A

Years of qualification 7 6 5

Years of rehab

experience

3 3 < 1

Demographic characteristics of doctors

Doctor 1 Doctor 2

Gender Male Female

Age group 50-59 30-39

Ethnicity Arabic Asian

Country trained Egypt, UK, New Zealand New Zealand

Qualifications MB. BCh., MSc., FAFRM

(RACP)

MB. BCh

Position at Rehab + Consultant in Rehabilitation

medicine

Rehabilitation registrar

Years of qualification 35 6

Years of rehab experience 14 1

Themes, codes arising from analysis of interviews with participantsTHEMES CODES

Theme 1 the rehabilitation

nursing role

Traditional nursing, “basic nursing”, “pure nursing”, “nursing nursing”; Holistic nursing care

Rehab nursing

Working within the team

Theme 2 Attitude Positive attitude to patients’ care

Positive attitude to nursing role

Some challenge or negative attitude

Theme 3 Environment Environment geographically

Rehab milieu: the environment created and maintained by staff, warm safe, supportive environment

Theme 4 Communication Communication between team members, patients and family

The methods of communication

The work environment and facilitation of communication

Room for improvement

Theme 5 Interdisciplinary

teamwork

Patient’s holistic care needs an interdisciplinary team

How the IDT works

The interaction between team members

Theme 6 Patients’ Goals

and patient-

centred care

Goal setting: patient’s goals, patient’s wants

Patient-centred care: ICF model, holistic care

IDT work together towards patient’s goals

Theme 7 Service efficiency Excellent service and nursing care, good feedback

The rehabilitation nursing role - medical nursing

Medical

and

holistic nursing:

Nurses’

perspectives

Medical nursing: monitor medical conditions, meet patients’ medical needs;

observations, medications; nursing assessment, manage clinical issues, pick up

any medical issues and report to doctors. Manage IV trolley, emergency trolley

and medical related equipment and environment.

Physical care: hygiene, skin care, prevention of further breakdown, ensure nutrition intake,

toileting issues, bowel management, incontinent issues; pain management, wound

management, diabetes care, assist mobility

Emotional support: get family involved, support patient and family, refer to psychologist

and doctors for emotional support

Patients’ perspectives Physical care: Hygiene, showering, toileting, pain, medication, make bed, assist with

mobility, get out of bed, put in the bed, nutrition, wound care, skin care, dress

Emotional: nurse is the first person to ask, frontline, be there, listen to the patients,

empathise with patients, overall wellbeing, primacy of nurse-patient relationship

AH’s perspectives “Nursing” nursing: wound care, stump dressing, medication, pressure sores, skin care,

showers, toileting, nutrition.

Doctors perspectives Pure nursing: monitor and assess patient’s medical aspects and report to doctors and the

rest of team, meet patient morbidities and rehab needs, support and assist doctors job

the rehabilitation nursing - rehab nursingRehab

nursing

Nurses

perspectives

Functional rehab: from doing for patients to educating and supervising patients to do for themselves,

self medication, do as much as they can do

Rehabilitation specific nursing work: Find out patients’ goals and work towards their goals,

attending patients’ meetings, facilitate weekend leaves, safe discharges.

Empower and enable patients: motivate patients, empower and enable them to regain their

independence; Education, teaching and training patients and family, and giving back control of their

lives.

Patients’

perspectives

Work together with patients: following instruction from PT, OT, encouraging and prompting self-

care, support, positive reinforcement, infection control, create a warm and safe environment

Confused with rehab nursing role: serve the meals, cleaning messy tables, Some nursing roles could

be done by HCA, nurse aid, then nurses have more time for nursing care or patients care.

AHs’

perspectives

See self more in a training role, not just helping or doing for patients, they support the rehab process,

help and train patients to be independent, rehab shower, rehab breakfast. Education around smoking

cessation, sit down with patients, teach self medicating.

Doctors’

perspectives

Play important role in the rehab environment. Contribute to the whole rehab process, follow

instructions from PT/OT, walk patients, daily functional goals, educate patients and families, supervise

medication, mobility and transfers, smoking cessation, inflection control, sexuality

The rehabilitation nursing role - work within the IDTWork

within the

IDT

Nurses’

perspectives

Facilitator: get patients ready for therapies; work with or assist doctor’s job; follow

instructions from therapists

Senior nurse role: management level, bed management, manage referrals, new

admissions, training staff, health promotion, continue education with IDT, coordinating,

manage staff, manage clinical issues

Role blurring or role confusing

Patients’ perspec Nurses work with therapists; follow instruction from therapists

AHs’ perspectives Engage goal setting, nurse do all sorts of things, they train, teach patients to use

walking aids, education re prevention of strokes, smoking cessation, key working issues,

discharge planning

Engage teamwork: interdisciplinary working in the team, role blurring, do a little bit of

other disciplines’ jobs, to be OT/SLT/PT’s eyes after hours

Blurring of roles: Nursing staff undertake roles that are traditionally outside of the

scope of nursing, enhanced potential to evolve from IDT to transdisciplinary model

(especially regarding equipment use)

Doctors

perspectives

Working as a team: Key workers give nurses power to coordinate patients’ rehab

programmes, link between the core team and families, coordinate and meet patients’

needs, finalise the discharge report, outcome measures-FIM, form relationship support

patients and family, support other team members job

Theme 2: attitudeNurse’s perception: Positive attitude regarding nursing role

Positive attitude regarding patients’ care

Some challenges from negative or difficult patients

Patients’ attitude Rehab nurses are positive and interested in patients

Patients are proud of themselves making progress; they appreciate nursing

care and positive reinforcement received

Doctors perception Very friendly, rehab orientated nursing team

Nurses were too shy or at second position; need to be more visible; need to

be upfront and acknowledge the value of the contribution of nursing

Therapists’ perception Nurse’s caring nature with patients.

Theme 3: environment

Nurses’

perception

Work environment purpose built-physically or geographically

Work environment with people- warm, supportive atmosphere

RTC programme; well organised ward; more rehab environment.

Patients’

perceptionPositive, friendly, safe warm environment

meet nurses and other patients, and talk with them

small things count

Doctors’

perspectiveThe large team office and the soft side of rehabilitation environment

i.e. ICF model

Therapists’

perspectiveRooms for social things would be nice.

Theme 4: CommunicationNurses’

perception:

Open to each other; communicate with each other; be respectful and honest; communicate

with family; family involved meetings; family may assist patients once discharged home

With the big office open and all the therapists in the same office, enhance the

communication between team members.

Patients’

perception:

Nurses are the first people to ask about everything; communication within teams very good,

you don’t have to explain to nurses, they already know from handover or reading the notes;

Some communication gaps: staff name badges too small, need to introduce self more than

once; need to know patient’s specific rehab needs

AHs’

perspectiv

e

Nursing vs patient: nurses sit down with patients talking about medication; seeking help

from SLT with looking at medication.

between IDT; big office; ICF model; relationships between teams; joint sessions; quick

catch up on top of regular meetings/nurses’ input in patient meetings

Doctors’

perception

quite good; two way communication; direct and lateral communication between all core

team members every day; able to communicate if any problems; large team office; meet

frequently; working in close proximity facilitates process

Theme 5: interdisciplinary teamworkNurses’

perceptionPatients’ holistic care requires that the IDT works together; it works extremely well for

patients’ benefit

facilitate the goal-setting process

Staff feel supported from IDT and enjoy working together as a team towards patients’

goals.

Patients’ perception: Patients recognise most of core team members; they all do specific jobs; Nurses are the

first people to ask about everything.

Doctors’ perception: Big office and regular meetings facilitate good communication between team members,

respect. Nurses need to be more proactive and to be part of the IDT, play more prominent

and obvious role in a more assertive way

PT/nurse Interaction: PT recognise nurses’ rehab role; integrate rehab into daily life functions;

work together and share knowledge with nurses in certain areas

SLT’s role interaction with

nurse role:Cognition, memory, education, key working stuff, discharge planning. SLT workers

collaborate with nurses to solve problems, teach people communication strategies,

comfortable using the white board and are able to swallow safely. People are happy to

share their roles

Interdisciplinary teamwork (Cont…)

Nurse support SLT: Nurses are present 24hours , observe patients when they are fatigued, any problems

such as swallowing report to SLT; Nurses need ask SLT help for communication

impaired patients

SLT/ PT Seating, problems with eating and drinking.

OT /IDT: PTs, OTs,

SLTs,Nurses, Social

workers

OT/PT: working on general mobility and upper limb issues, patients’ independence

around home.

OT/SW: the level of home help; D/C planning of accommodation.

OT/SLT: cognitive therapy tasks, any cognitive issues or communication problems,

functional rehab.

OT/Nurses: working on facilitating patients’ independence of personal care. If there

were more joint AH/ nurse sessions then teamwork would be improved.

Interactions or role overlap within IDT membersDisciplines Interaction or role overlap

Nurses/doctors

(medical or rehab

related tasks)

Medical aspects of care, observation and monitoring patients’ condition and report to doctors;

follow doctors’ orders re medication or medical related tasks. pain, wound, bowels, continence

management, diabetes care, rehab related tasks

Nurses/ SLT

(working together

with patients with

communication,

swallowing,

cognition, memory

problems)

Work together with patient’s communication, swallowing, cognition, memory, key working tasks

and discharge planning.

Educate patients regarding fall risks, medication, smoking cessation etc. , enable them to

participate in rehab programme

Nurses are present 24hours; SLTs need nurses’ observation regarding patients’ problems such as

swallowing when they are fatigued. Nurses need help from SLTs for communication impaired

patients.

Nurses/OT

(working closely on

facilitating patients’

independence of

personal cares)

Rehab shower, rehab breakfast, toileting, and education about procedures. Joint sessions

introduced, so OTs/nurses work together rather than nurses just take directions from OT.

Nurses run their everyday tasks on a daily basis and make good observations and know patients

more. They are OTs’ eyes after hours and highlight patient’s needs to OTs.

Interactions or role overlap within IDT members (Cont…)Nurses/PT

(Working

together on

patient’s mobility,

equipment,

wound healing,

medication,

diabetes foot

cares etc.)

Mobility: patients’ transfers, stairs, manual handling skills.

Equipment i.e. Roho cushions, orthotics, splints, hoists

Medication, pain killers, BP medications

Wound healing, especially amputee stump wounds, pressure sores etc.

Diabetes patients, the sensations test and diabetes foot care etc.

As patients may be different between gym and day, nurses can feedback to PTs for any

issues after hours.

SLT/OT The function activities involve the level of communication, A lot of overlap between SLTs

and OTs with the cognitive therapy tasks, and to help patients return to their previous

function.

PT/OT OTs and PTs often work together because they both work on patients’ general mobility and

independence around the home. They also cross over regarding the upper limb tasks.

SLT/PT They work together regarding patients’ seating, patients’ eating and drinking stuff.

Theme 6: patients’ goals and patient-centred care

Nurses’

perspectives

The whole idea is based on the patients. The patients are the centre of the core team. The

ICF model facilitates patients’ individualised and holistic care.

goal setting is a major part, family is important with the patient rehab journey, especially

with weekend leave and safe discharge.

Goal setting: make sure it’s patient’s goals and wants, not health professionals’ goals and

wants. Core team helps patients to set up realistic goals and work towards them assisting

them to achieve their goals.

Patients’

perspectives

Individualised care, tailored for patients, negotiation and partnership with patients.

Patients have core team work for them, own nurse, PT/OT/SLT/social worker.

Start road to go home, gain knowledge about my medical problem, want to be

independent at home and come back to visit.

Doctors’ perspectives

Goal setting by patients and family directs their rehab programmes; IDT focus on rehab

intervention to help patients get their goals and achieve their goals. Utilising the ICF

model, with regular meetings, core team ensure patients’ holistic care met.

AHs’ perspectives We work together towards patients’ goals; looking at what patients want to achieve and

working towards that.

Theme 7: Service efficiencyNurses’ perspectives We provide good service and nursing care to patients; have good feedback from patients and family; we

provide a lot of support to patients. Nursing staff more stable than AH staff, nurses have a stronger voice

in the IDT. RTC improves things for nurses

Lots of pressure from management, and more complex patients, multi morbidity, unstable patients,

homeless patients, funding issues, uncertain future planning, cutting costs, stressful to staff, patients and

family.

We need to promote ourselves more to gain more recognition, better communication. Nurses need do

post graduate rehabilitation papers, do more modern research; we need education and ongoing education

with staff regarding the goal setting, the IDT, the ICF model, keyworking.

Doctors’ perspectives Regular communication between team members. the allied health team and nursing team very mobile

and rotating, on-going regular in-service, presentations, on-going teaching and education, orientation of

new staff, introduce rehabilitation framework within the ICF model, FIM training; efficacy working on

shortening LOS.

Therapists’

perspectives

We have quite a high level of cares. Lots of paper work has been put in place to continue to improve our

service

New nurses introduced to cover the ward, in order to release more nurses to attend inservice training.

More joint sessions between nurses and therapists, joint social activities.

Patient’s perspectives The overall cares to the patients is very good.

Someone trained to do meals, toileting, showering (i.e. HCA) need to be employed to free nurse’s time

Conclusion: • The present study identified a new

interdisciplinary teamwork model, where the nurses step in to work closely with patients and families and to be an integral conduit between the patient/family and other members of the IDT.

the interdisciplinary team model portrayed by literature

PATIENTand

FAMILY

Physiotherapist

Occupational Therapist

Dietician

Doctor

Psychologist

Pharmacist

Social Worker

Speech-language therapist

Nurse

Nurses step in to take more responsibilities within interdisciplinary teamwork

PATIENTand

FAMILY

Physiotherapist

Occupational Therapist

Dietician

Doctor

Psychologist

Pharmacist

Social Worker

Speech-language therapist

Nurse

Nurse

the new interdisciplinary teamwork model at Rehab Plus

PATIENTand

FAMILY

Physiotherapist

Occupational Therapist

Dietician

Doctor

Psychologist

Pharmacist

Social Worker

Speech-language therapist

Nurse

• At Rehab Plus, Nurses are more actively involved in patients’ rehabilitation processes and coordinated the patients’ care by connecting and coordinating the interdisciplinary team members’ work, as well as doing some other disciplines’ jobs to optimise patients’ care within existing service constraints.

Conclusion and implications

This research has explored the rehabilitation nursing role within interdisciplinary teamwork from nurses’, patients’, therapists’ and doctors’ perspectives in a specialist rehabilitation centre in Auckland.

Following analysis using the GIM process, seven main themes were identified from the data. The research findings explored the research questions by defining the rehabilitation nursing role from medical nursing, rehabilitation nursing and nurses within the team.

The results of the present study suggested that within the rehabilitation teamwork model,

the team members from different disciplines accepted and enjoyed the role blurring and

role overlap during the interdisciplinary teamwork.

ImplicationsRehabilitation nurses working within the interdisciplinary team allowed and accepted role

blurring and role overlap with other team members.

This research identified a new interdisciplinary teamwork model within the unit where the

nurses step in to work closely with patients and families, and be the eyes and hands of other

disciplines after hours.

The rehabilitation nurses are the essence and soul of the IDT. They are the communication centre

and the connection centre, They coordinate patients’ care by connecting and coordinating the IDT members’ jobs, as well as they cross the professional boundaries and do a little bit of other disciplines’ jobs to meet patients’ needs. They create and maintain a warm home like and rehabilitative environment for patients and team members..

With their 24 hour presence, nursing staff pick up any issues or any care gaps between other professionals and automatically fill the gap and fix the problems. they are the glue to hold the

team together and patch up if any gaps occur. They are the pivot of the IDT family.

Implications (Cont…)

The patients are the priority and are treated as the core of the core team. It is vital for the team members to work together like a family, to have a shared vision and respect each other and work together to maximise the benefits of recovery and assist patients to achieve their goals.

Implication from the studyThe results indicated that during rehabilitation practice, health professionals’ attitudes towards rehabilitation and patients are very important. The work environment included the physical environment (such as the interdisciplinary team office facilitates the team members’ communication), and the work environment which included the interdependence and relationship with other team members and patients. A healthy work environment will promote healthier employees, which includes improving employee attitudes, enhancing a generally satisfying place to work and increasing productivity.

Implication from the study• Ongoing education and further study were highlighted from the current

research. The nursing staff need to promote themselves more and gain more recognition and a stronger voice within the team. The new staff need to be orientated to the ICF model, the interdisciplinary rehabilitation team framework and post graduate study. Another implication from the study could be more joint sessions between team members and some joint social events to facilitate staff closer relationships between the staff and to establish a strong team member relationship to facilitate teamwork.

• The nurses’ multi-faceted roles implied that some nursing roles, such as assisting patients with toileting, and hygiene and skin care could be done by someone trained to be able to do basic physical and hygiene care to free the nursing staff to do more skilled jobs. This approach indicated a cost effective way to provide high quality nursing care.

LimitationsThe present research was a small study and only involved one rehabilitation centre in New Zealand. Since all the participants were recruited from the same setting with a small sample of nurses, patients, AH staff and doctors over a particular period, it is challenging to apply the findings to other areas.

Limitation from the research methodology: This research setting is the researcher’s workplace, it may raise some potential issues of researcher credibility of the research findings. However, the research process transparency was maintained by communicating and disseminating the research proposal amongst staff and managers, and involving them in the selection of participants. Returning transcripts to the interviewees was another action taken for reflexivity.

The current research did not involve social workers, psychologists, dieticians and rehab assitant, who were also important team members in that rehabilitation centre.

References