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									The Use of Aesthetic Knowledge in the
Management of Brain Injury Patients
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                                                                                                                           Keywords
                                                                        brain injury, traumatic brain injury, nursing intuition, coma,
                                                                       brain injury agitation, nursing management, ICP, brain injury
Joan Alverzo, MSN CRRN                                                      recovery, brain injury nursing, brain injury rehabilitation

A patient’s recovery from a brain injury (BI) is unpre-                affords an opportunity for nurses to help patients and their
dictable and requires flexible nursing strategies for each             families negotiate the course of recovery with greater success.
stage of recovery. Empirical knowledge provides a frame-
work for delivering nursing care based on scientific princi-           Joan Alverzo is vice president of clinical support services
ples. Aesthetic knowledge, including intuition, provides a             and chief nurse executive at the Kessler Rehabilitation Cor-
further opportunity to know and understand BI patients and             poration in West Orange, NJ. Address correspondence to
their responses as they progress along the trajectory of re-           Joan Alverzo, Kessler Rehabilitation Corporation, 300 Ex-
covery. Incorporating both empirical and aesthetic knowl-              ecutive Drive, West Orange, NJ 07052, or e-mail jalverzo@
edge into the nursing plan of care for this population                 kessler-rehab.com.

    After a brain injury (BI), a patient’s course of recovery is not   challenges to nursing, and nursing care can clearly be enhanced
always predictable. Although there has been extensive research         by integrating an aesthetic approach during these phases of re-
into patient outcomes after BI, the recovery process for each pa-      covery. Patients are described, and nursing strategies for both the
tient is unique. Successful nursing management traditionally           patient and the family are proposed, from both empirical and aes-
has rested upon the body of scientific and empirical knowledge         thetic perspectives for each level of recovery (Table 1).
about BI that leads to observations and interventions that are
critical to recovery. It is, however, equally important to ac-         Theoretical framework
knowledge the key role that aesthetic knowledge plays in the               Nursing theorists and researchers have examined the empir-
provision of high-quality nursing care. Aesthetic knowledge,           ical as well as the aesthetic nature of nursing. Barbara Carper
sometimes referred to as the art of nursing (Benner & Tanner,          (1978) first proposed four fundamental patterns of knowing; em-
1987), allows nurses to truly know and empathize with their pa-        pirics, aesthetics, personal knowledge, and ethics. Empirics is
tients. Incorporating both the science and art of nursing into the     the traditional science of nursing based on facts that are orga-
care of BI patients provides a broad framework for negotiating         nized into laws and theories. Aesthetic knowledge is considered
the challenging course of recovery.                                    the art of nursing, and includes intuition. While early nursing
    Each year, approximately 7 million people in the United            research focused on developing a body of scientific knowledge
States suffer a traumatic BI, with 550,000 of these people sus-        as a foundation for nursing, interest in the area of aesthetic knowl-
taining moderate to severe injuries (McNair, 1999). Patients           edge eventually developed. Building on Carper’s work, Benner
also sustain a BI through nontraumatic means, such as brain tu-        and Tanner (1987) identified intuition, defined as understand-
mors, cerebral aneurysms, and anoxic encephalopathy. All these         ing without rationale, as a central source of aesthetic knowledge
BI patients are categorized and managed using the Rancho Los           that has a direct impact on practice.
Amigos Scale (Rancho Scale) (Hagen, 1999), which identifies                Benner and Tanner further described intuition as a form of non-
10 levels of recovery, from a complete absence of response (lev-       analytical reasoning in which patterns and relations provide a
el 1), to independent, purposeful, and appropriate (level 10).         holistic understanding of a situation. They described intuitive judg-
    While BI patients generally evolve from coma to arousal and        ment in terms of six components: pattern recognition, similarity
then to awareness, the length of time in each level, as well as the    recognition, commonsense understanding, skilled know-how, a
order of progression, varies (Galski, Palasz, Bruno, & Walker,         sense of salience, and deliberative rationality. In this framework,
1994). Patients’ progress may plateau or even deteriorate, along       intuition modifies clinical decision-making, so that judgment is
the recovery trajectory, and not every patient progresses through      based on more than empirical knowledge. Benner and Tanner pro-
every stage. Each level of recovery presents different challenges      posed a model for the expert nurse that integrates empirical knowl-
to nursing, and requires creative strategies for managing the as-      edge or rational calculation with intuitive judgment. As nurses
sociated patient behaviors.                                            progress from novice to expert, it is their intuition that most con-
    This article provides an overview of nursing strategies for man-   tributes to their expanded knowledge base (Benner, 1984).
aging recovering BI patients to promote better patient outcomes.           Several subsequent models have integrated intuition into nurs-
Using the Rancho Scale, three levels of recovery are reviewed:         ing decision-making. The integrated model of clinical judgment
level 2—coma; level 3—localized response; and level 4—con-             (Gordon, Murphy, Candee, & Hiltunen, 1994) proposes that clini-
fused, agitated. These three levels represent some of the greatest     cal decision-making is based on diagnostic, therapeutic, and ethical



                                                                             Rehabilitation Nursing • Volume 29, Number 3 • May/June 2004 85
Aesthetic Knowledge in Nursing Care of BI Patients



     Table 1. Empiric and Aesthetic Nursing Interventions for BI Patients

       Level of Recovery*                          Empirical Approach                             Aesthetic Approach
       Coma                                        •   Meticulously support of all body systems   • Coordinate care with patterns and
       (Level 2)                                                                                    rhythm of coma cycle
                                                   •   Manage oxygen/CO2 levels
                                                   •   Manage pain                                • Support and coach family members at
                                                                                                    the bedside based on observed pat-
                                                   •   Manage blood pressure                        terns/relationships
                                                   •   Monitor ICP                                • Modify care based on patient response, in-
                                                   •   Modify tracheal suctioning to minimize       cluding subtle observations and changes
                                                       anoxia                                       to enhance the patient’s sense of safety
                                                                                                  • Manage the environment to promote
                                                                                                    periods of rest and activity

       Localized Response                          • Continue support of all body systems         • Establish a relationship with the patient
       (Level 3)                                   • Provide structured environment                 based on personal connection
                                                   • Initiate social greetings and orient pa-     • Observe patterns of responsiveness ac-
                                                     tients to their surroundings                   cording to time of day and who is inter-
                                                                                                    acting with the patient
                                                   • Mitigate risk of injury
                                                                                                  • Support the sleep-wake cycle by mini-
                                                   • Provide explanations of care                   mizing interruptions, visitors, and
                                                   • Manage activities and people to mini-          group activities
                                                     mize disruption of daily schedule

       Confused, Agitated                          • Reduce environmental stimuli                 • Observe and track sleep patterns and
       (Level 4)                                   • Limit noise, background music, or TV           periods of agitation, noting potential
                                                                                                    factors that precipitate agitation
                                                   • Limit interactions with patient to one-
                                                     on-one format, when possible                 • Match patient roommates based on ob-
                                                                                                    served relationships
                                                   • Use consistent care providers
                                                                                                  • Identify visitors who may precipitate
                                                   • Provide consistent approach to patient         agitation and coach them on an alter-
                                                     by all care providers                          nate approach
                                                   • Cohort patient with other BI patients on     • Educate family on expected behaviors
                                                     a dedicated unit                               and establish a relationship that reduces
                                                   • Minimize use of restraints                     their stress and promotes use of humor
                                                   • Observe effects of medications and             as coping strategy
                                                     report to physician

  *Levels and descriptions based upon the Rancho Los Amigos Scale


reasoning. Within each sphere of reasoning, intuition may play              stimuli (Hagan, 1999). The coma period is highly stressful for
a significant part. Acknowledging intuition as a key component              family members as well as for nurses and other care providers.
of nursing expertise and clinical decision-making has been a cen-           An ongoing pressure for families and clinical staff is the knowl-
tral focus of several nurse researchers (McCutcheon & Pincombe,             edge that the longer the coma lasts, the worse the outcome will
2001; Herbig, Bussing, & Ewert, 2001). Integration of both the              be (Jeanett, Teasdale, & Braakmann, 1976).
empirical and aesthetic perspectives into the therapeutic plan for              From an empirical perspective, nursing care is directed towards
BI patients can enrich the quality of nursing care as well as re-           meticulous attention to all body systems and the overall prevention
sult in improved patient outcomes.                                          of complications. The continuous nursing oversight of respiratory
                                                                            function, skin integrity, fluid balance, elimination, and other body
Levels of recovery—Coma                                                     functions requires the integration of nursing science to provide a
    Coma is defined as a state of being unarousable (Plum & Pos-            balance between body systems and to compensate for dysfunction.
ner, 1980), and generally refers to a Glasgow Coma Scale (GCS)              The Guidelines for the Management of Severe Head Injury (1995)
score of 8 or for a duration of 6 or more hours (Teasdale &                 evaluates evidence-based practice and provides guidelines for patient
Jeanett, 1974). The Rancho Scale for coma is Level 2, described             management to improve outcomes, including parameters for mon-
as the absence of observable change in response to stimuli, or a            itoring and/or maintaining blood pressure, intracranial pressure
delayed generalized reflex response to pain or other repeated               (ICP) monitoring, hyperventiliation, and PaCO2 levels.



86   Rehabilitation Nursing • Volume 29, Number 3 • May/June 2004
    From an aesthetic perspective, the scenario unfolding at the         Levels of recovery—Localized response
bedside is dramatic. Nurses are called upon not only to man-                 Emerging from coma is a critical time in a BI patient’s recov-
age the patient, but also the family and visitors who are trying         ery. The Rancho stage of recovery here is Level 3, localized re-
to cope with a tragic situation. Intuition can be an important           sponse to stimuli (Hagan, 1999). This period is characterized by
tool for the nurse who must decide where to focus attention and          varying responsiveness to both tactile and verbal stimuli, as well as
how to intervene. The nurse’s ability to identify patterns and           inconsistent ability to correctly answer “yes” or “no” to questions.
relationships among family members and the patient, as well              Some of the variability of responses is associated with the patient’s
as to apply commonsense understanding in formulating an ap-              sleep-wake cycle. The challenge nurses face managing this level of
proach to providing support, can affect substantially the stress         recovery is complicated by the family’s need to see positive changes.
levels of all involved. Identifying family members or visitors           Families anticipate the awakening, which they believe will mark
who can provide context and support for the family as a whole            the patient’s reconnection with the world and with their previous
ultimately will benefit the patient, as family members modify            relationships. The variability of patient responsiveness makes this
their behaviors.                                                         a very stressful time for families as well as for nurses.
    Empirical research into factors that increase ICP has focused            The team focus during this phase of recovery is protection and
on head positioning (Sullivan, 2000), as well as on the effect of        nurturing of the patient. Nursing management of all body sys-
pain (Mitchell, 1986), auditory stimuli (Davis & Gimenez, 2003),         tems continues as it did during the coma period, but the level of
and tracheal suctioning (Hall, 1997). Mitchell (1986) reviewed           interaction between the nurse and patient is expanded. The em-
nursing activities associated with increased ICP and concluded           pirical basis for interactions now is to reorient the patient to the
that environmental stimuli, painful stimuli, spacing of nursing          environment, and provide a context and structure to his or her
activities, and tracheal suctioning may have significant effects.        daily activities (Galski et al., 1994). Every interaction with a pa-
Although there are some conflicting results from studies into fac-       tient requires a verbal greeting, providing an opportunity for the
tors that increase ICP, all agree that managing ICP is a central         patient to respond, ongoing explanation of the care being given,
objective after BI because it has an impact on patient outcome.          and evaluation of the patient’s responses during treatment. Pro-
    A clinical nurse whose practice is evidence-based will inte-         tecting the patient during this phase includes mitigating risk of
grate these scientific findings into the care of a comatose patient.     injury, creating a safe room environment, and acting on the pa-
The use of nursing intuition, however, to decide how and when            tient’s behalf to manage the people and activities that interrupt
to intervene or modify care greatly enhances the effectiveness           the daily schedule (Flannery, 1998). Establishing a sense of safe-
of these strategies (McCutcheon & Pincombe, 2001). Activities            ty and security for a patient also requires that both family and
can be synchronized with the patient’s rhythm and response. For          clinicans respect the patient’s vulnerability (Flannery, 1998).
example, a nurse may sense that a well-intentioned family mem-               While nursing care is centered around incorporating empir-
ber who is overzealous in his or her attempts to awaken a co-            ical knowledge into the plan of care, the effectiveness of the care
matose patient, is inadvertently increasing ICP. The ability to          plan can be enhanced by incorporating aesthetic knowledge of
intervene and redirect a family member in a supportive manner            the patient’s self-aware participation in his or her recovery dur-
may be crucial to the preservation of that patient’s neurological        ing this phase (Benner & Tanner, 1987). The intuitive connection
function.                                                                of nurse with patient during care delivery is central to the pa-
    Another area of nursing research has focused on investigating        tient’s reconnection with the world. Observing patterns of re-
recollections of patients who awaken from coma. One study focused        sponsiveness based on the time of day, and who is interacting
on understanding patients’ experiences from an aesthetic perspec-        with the patient, is important in maximizing opportunities for
tive (Lusardi & Schwartz-Barcott, 1996). Several common themes           effective interactions. Nurses are in a position to coach and di-
of coma recollection were identified in this study, including feeling    rect members of the team, including the family. The nurse’s in-
like a prisoner, sensory stimuli, including auditory and olfactory;      teractions with the patient can provide the family with a model
death; and guilt. Patients’ recollections of coma may be based on the    for how to establish or reestablish relationships during this time.
actions and activities of family members and visitors as well as the         One challenge during this phase of recovery may be the fam-
nursing staff and other healthcare team members (Tosch, 1988).           ily’s desire to return the patient to a higher level of functioning
    A central tenet of nursing is to mitigate negative experiences for   through persistent tactile and verbal stimulation, sometimes
patients. Based on the themes identified in research by Lusardi and      around the clock. Often, large numbers of simultaneous visitors
Schwartz-Barcott (1996) and Tosch (1988), nursing interventions          may attempt to engage the patient. It is important that nurses
should be directed at reducing negative experiences such as feel-        provide some direction for the family and other visitors during
ings of imprisonment or guilt. This goal may be accomplished by          this time. Respecting the sleep-wake cycle of the patient is im-
coaching family members to provide the patient with a sense of           portant (Davis, 2000), and stimulation from one person rather
safety and security during coma. Intuitive judgment, including a         than multiple stimuli may be preferred. It is important to em-
sense of the salience, or meaning, of obscure gestures (Benner &         phasize that the recovery process needs to be supported, rather
Tanner, 1987), is necessary to detect subtle indications that the pa-    than directed.
tient is experiencing fear or anxiety, and to intervene. The role of
intuition in care delivery, along with understanding the response of     Level of recovery—Confused, agitated
a coma patient to stimuli, enhances the effectiveness of nursing in-         Once a patient has fully awakened from coma, the next stage
terventions and may contribute to a more positive outcome.               of recovery is characterized by confusion and agitation. This is



                                                                               Rehabilitation Nursing • Volume 29, Number 3 • May/June 2004 87
Aesthetic Knowledge in Nursing Care of BI Patients


Level 4 on the Rancho Scale. It is characterized by restlessness              Protecting the safety of patients, visitors, and staff is central
and heightened activity that is often nonpurposeful (Hagan,               to this phase of recovery. Cohorting patients in a dedicated unit
1999). This is an unpredictable phase of recovery that may be-            is highly desirable (Flannery, 1998). Managing an agitated pa-
gin at any time and may last from several hours to several weeks          tient in an open environment is difficult, and often leads to the
or months. The patient may exhibit mood swings and impulsiv-              excessive use of restraints. The use of restraints other than jack-
ity (Galski et al., 1994). Overall, this is one of the most chal-         et or chest restraints should be minimized because they may con-
lenging phases of recovery for nursing staff because of the safe-         tribute to agitation. Patients may pull at tubes or lines, but cre-
ty issues that apply to the patient as well as to other patients,         ative wrapping of the area may minimize the need for using wrist
visitors, and clinical staff.                                             restraints. The use of medications to manage agitation is an op-
    From an empirical perspective, the team approach for this             tion to be considered, but there is always concern about any se-
stage is to reduce confusion and agitation. Many of the strate-           dating effects or other undesirable effects that may interfere with
gies for nurses now are related to managing the environment               recovery. Again, the nurse is in a position to provide the most
(Corrigan & Mysiw, 1988). Reducing the amount of stimuli in               comprehensive feedback regarding both the behavior and the ef-
the environment is important. The playing of background mu-               fect of medications intended to manage the behavior.
sic, televisions, or radios generally is not advisable because com-           This stage of recovery is particularly stressful to clinical staff
peting stimuli can be distressing for the patient. For families,          and family members because of the safety risks and the range
this stage of recovery is particularly difficult because they are         of possible patient behaviors. Generally, patients lack impulse
often alarmed by the patient’s behavior and may have difficul-            control, and so engage in behaviors that most people suppress,
ty making the transition from trying to awaken and stimulate the          such as overt sexual expression. It is important that family mem-
patient to reducing stimuli.                                              bers be well educated about this stage of recovery, and that they
    The nurse’s critical role during this period is to establish, with    maintain a sense of humor. Nurses can bond with family and
the team, guidelines for managing the environment and patient             other team members by keeping patient behaviors in perspec-
behaviors. The neuropsychologist leads the development of a               tive, and by using humor to lighten a potentially embarassing
behavioral plan, but before that plan can be drafted, a detailed          situation. Remembering that this stage of recovery is general-
picture of the patient and his or her behaviors must be provid-           ly time-limited helps all team and family members to endure
ed. The nurse can provide a 24-hour picture of the patient, in-           its stresses. Using intuition to recognize family stress may pro-
cluding sleep and agitation patterns (Flannery, 1998). Nurses’            vide an opportunity for nurses to intervene early and manage
observations often may be intuitive in that they may be based             the situation.
on detection of subtle stimuli that may be precipitating an agi-
tated response from a patient. This aesthetic or intuitive knowl-         Conclusion
edge of the patient can be critical in establishing a successful             Recovery from BI is a complex, unpredictable process. Un-
behavioral plan.                                                          derstanding that recovery needs to be supported, rather than di-
    Other nursing strategies alo have had a demonstrated impact           rected, provides nurses a framework for providing care. Beyond
on patients who are confused and agitated. First, consistency in          the empirical nursing interventions that form a foundation for
who provides care is important in limiting patient confusion.             nursing care, however, aesthetic or intuitive knowledge of the
Sometimes, for no apparent reason, a patient will have a strong           patient and where they are in their recovery is essential. The
negative reaction to another person. In such instances, the most          nurse is in the best position on the team to observe behaviors
important action to take is to remove that person as a care provider      and to provide insight to clinical staff and family members that
for that patient. In addition, care providers should have a consis-       will ensure a consistent and effective approach to care. Inte-
tent approach to patients, such as first greeting a patient from a dis-   grating scientific knowledge about BI recovery with aesthetic
tance and then giving the patient an opportunity to respond be-           knowledge about each patient will promote more positive pa-
fore proceeding. Respecting a patient’s personal space is critical        tient outcomes, and will support effective interactions between
during this phase of recovery, for reasons of safety as well as to        the clinical team, the family, and the recovering BI patient.
minimize any sense a patient may have of being threatened.
    Managing the patient’s environment has value from a scien-            References
                                                                          Benner, P., (1984). From Novice to Expert. Menlo Park, CA: Addison
tific perspective in that it reduces agitation and confusion (Fuller         Wesley.
& Young, 1984). From an aesthetic viewpoint, the nurse must               Benner, P., & Tanner, C. (1987). How expert nurses use intuition. Ameri-
be attuned to more subtle factors that may either increase or de-            can Journal of Nursing, 87, 23–31.
crease agitation. Determining whether the patient can tolerate a          Carper, B.A. (1978). Fundamental patterns of knowing in nursing. Ad-
roommate, and who that roommate should be, is important.                     vances in Nursing Science, 1(1), 13–23.
                                                                          Corrigan, J.D., & Mysiw, W.J. (1988). Agitation following traumatic head
Sources of noise should be identified and modified according to              injury: equivocal evidence for a discreet stage of cognitive recovery.
the patient’s responses. Managing the flow of visitors is very               Archives of Physical Medicine and Rehabilitation, 69, 487–492.
challenging during this phase of recovery. Visitors should be             Davis, A.E. (2000). Cognitive impairments following traumatic brain in-
limited to one or two people at a time, generally close family               jury. Etiologies and interventions. Critical Care Nursing Clinics of
                                                                             North America, 12(4), 447–456.
members or close friends. Group visits should be discouraged.             Davis, A.E., & Gimenez, A. (2003). Cognitive-behavioral recovery in co-
Again, the nurse must be attuned intuitively to visitors who may             matose patients following auditory sensory stimulation. Journal of Neu-
agitate the patient, and should intervene to rectify the situation.          roscience Nursing, 35(4), 202–209.




88   Rehabilitation Nursing • Volume 29, Number 3 • May/June 2004
Flannery, J. (1998). Using the levels of cognitive functioning assessment        Sullivan, J. (2000). Positioning of patients with severe traumatic brain in-
   scale with patients with traumatic brain injury in an acute care setting.        jury: Research-based practice. Journal of Neuroscience Nurses, 32,
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Fuller, C. & Young, C. (1984). Levels of cognitive functioning: A basis for      Teasdale, B., & Jeanett, B. (1974). Assessment of coma and impaired con-
   nursing care of the head-injured person. Rehabilitation Nursing, 9,              sciousness. Lancet, 2(7872), 81–84.
   30–31.                                                                        Tosch, P. (1988). Patients’ recollections of their posttraumatic coma. Jour-
Galski, T., Palasz, J., Bruno, R.L., & Walker, J. (1994). Predicting physical       nal of Neuroscience Nursing, 20, 223–228.
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Gordon, M., Murphy, C.P., Candee, D., & Hiltunen, E. (1994). Clinical              Earn nursing contact hours
   judgement: An integrated model. Advances in Nursing Science, 16(4),                 Rehabilitation Nursing is pleased to of-
   55–70.
The Brain Trauma Foundation and The American Association of Neurolog-              fer readers the opportunity to earn nursing
   ical Surgeons. (1995). Guidelines for the management of severe head             contact hours for its continuing education
   injury.                                                                         articles by taking a posttest through the
Hagan, C. (1999). Rehabilitation in managed care: Controlling costs, en-           ARN Web site. The posttest consists of
   suring quality. Gaithersburg, MD: Aspen Publishers.
Hall, C.A. (1997). Patient management in head injury care: A nursing per-
                                                                                   questions based on this article, plus sever-
   spective. Intensive Critical Care Nursing, 3, 329–337.                          al assessment questions (e.g., how long did it take you to
Herbig, B., Bussing, A., & Ewert, T. (2001). The role of tacit knowledge in        read the article and complete the posttest?). A passing score
   the work context of nursing. Journal of Advanced Nursing, 34,                   of 88% on the posttest and completion of the assessment
   687–695.                                                                        questions yield one nursing contact hour for each article.
Jeanett, B., Teasdale, G., & Braakmann, R. (1976). Predicting outcome in
   individual patients after severe head injury. Lancet, 1, 1031–1034.                 To earn contact hours, go to www.rehabnurse.org, and
Lusardi, P.T., & Schwartz-Barcott, D. (1996). Making sense of it: a neuro-         select “Continuing Education.” There you can read the arti-
   interactional model of meaning emergence in critically ill ventilated pa-       cle again, or go directly to the posttest assessment. The cost
   tients. Journal of Advanced Nursing, 23, 896–903.
McCutcheon, H.H., & Pincombe, J. (2001). Intuition: an important tool in
                                                                                   for credit is $9 per article. You will be asked for a credit card
   the practice of nursing. Journal of Advanced Nursing, 35, 342–348.              or online payment service number.
Mitchell, P.H. (1986). Intracranial hypertension: influence of nursing care            The Association of Rehabilitation Nurses is accredited
   activities. Nursing Clinics of North America, 21, 563–576.                      as a provider of continuing nursing education by the Amer-
McNair, N.D. (1999). Traumatic brain injury. Neuroscience Nursing for a
   New Millennium, 34, 637–659.                                                    ican Nurses Credentialing Center’s Commission on Ac-
Plum, F., & Posner, J.B. (1980). The diagnosis of stupor and coma.                 creditation (ANCC COA).
   Philadelphia, PA: F.A. Davis Company.



Clinical Consultation
continued from page 77
encouraged a patient to participate in ther-          concerns, can help improve compliance                   nications: The issue of patients rights. In G.
apy may not work after a few weeks. A                 and overall treatment success.                          Servellen, Communication skills for the
                                                                                                              health care professional: concepts and tech-
previously employed strategy should not                                                                       niques. Sudbury, MA: Jones and Bartlett.
be discarded, however, since it may be ef-            John M. Tomkowiak is the director of                 Kreuter, M.W., Chheda, S.G., & Bull, F.C.
fective in another situation or at another            psychiatry and director, year 3 and 4 at                (2000). How does physician advice influence
time. A good assessment of the patient’s              Florida State University College of                     patient behavior? Evidence for a priming ef-
pain, fatigue, or level of distraction can            Medicine in Tallahassee, FL.                            fect. Archives of Family Medicine, 9, 426-433.
                                                                                                           Lim, M. (2002). Questioning the voluntary nature
play a critical role in the selection of the                                                                  of informed consent. American Medical As-
                                                      Anne J. Gunderson is an assistant profes-
appropriate strategy by the nurse.                                                                            sociation. Retrieved December 28, 2003, from
                                                      sor in the Department of Geriatrics at
    Understanding the nature of autonomy              Florida State University College of
                                                                                                              http://www.ama-assn.org/ama/pub/category/
and the concepts of coercion and manip-                                                                       8926.html
                                                      Medicine in Tallahassee, FL.                         Nelson, R.M., & Merz, J.F. (2002). Voluntari-
ulation will help nurses avoid unethical be-                                                                  ness of consent for research: an empirical and
havior when dealing with a patient’s re-              Address correspondence to Anne Gunder-                  conceptual review. Medical Care, 40, Supple-
fusal to participate in his or her therapy. A         son, Department of Geriatrics, Florida                  ment V-69-V-80.
patient’s willingness to be informed, abil-                                                                Shiel, A., Burn, J.P., Henry, D., Clark, J., Wil-
                                                      University College of Medicine, Tallahas-               son, B.A., Burnett, M.E., and McLellan, D.
ity to receive and process information and            see, FL 32306-4300, or e-mail anne.                     (2001). The effects of increased rehabilitation
to express his or her wishes can affect their         gunderson@med.fsu.edu.                                  therapy after brain injury: Results of a
decision-making. Other factors that can                                                                       prospective controlled trial. Clinical Rehabili-
influence patient attitudes toward therapy            References                                              tation, 15, 501-514.
include type of illness, culture, age, edu-           Beauchamp, T.L., & Childress, J.F. (2001). Prin-     Resnick, B. (2002). Geriatric rehabilitation: The
                                                         ciples of Bioethics (5th ed.). New York: Ox-         influence of efficacy beliefs and motivation.
cation, and socioeconomic status. Appre-                 ford University Press.                               Rehabilitation Nursing, 27, 52-59.
ciating the reasons for a patient’s refusals,         Davis, A. J., and Aroskar, M.A. (1997). The priv-
as well as strategies for addressing patient             ileged nature of patient and provider commu-




                                                                                       Rehabilitation Nursing • Volume 29, Number 3 • May/June 2004 89

								
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