Dr. David B. Adams – Psychological Blog

Psychology of Illness, Pain, Anxiety and Depression

The Nurse Case Manager

When the nurse is not permitted to interact with the patient, she can only rely upon records that indicate that care is progressing, the fact that the employer has alternative work, and a written description of that work. I feel it is mandatory that a nurse case manager have the opportunity to directly interact with patients rather than rely upon records to obtain a total picture of the patient (who most often has no idea why they have never met their nurse firsthand; they assume it is for lack of interest or compassion).

If the patient has one or more surgeons, each is comfortable only addressing the tissue damage that relates to their specialty. A hand surgeon does not address a knee complaint. If the patient is seeing three, four or more physicians for a range of injury-related damages, someone (the nurse case manager and I) must be conversant with all aspects of their care. Someone must have the complete picture of the patient within the context of job, injury and care.

Additionally, I am also required to know what the patient was like prior to injury, what co-morbid conditions were at play and ultimately to what level of psychological function the patient will ultimately return.

What looks appropriate for the patient on paper frequently has nothing to do with total functional capacity (TFC).

If I am one of four clinicians treating the patient, what typically happens is that I am asked to address TFC after the others have signed off on a job description based upon their specialty area. There is the clear expectation that I will also find the patient capable of the job. But with severe physical and emotional trauma, especially in those who have been violated and/or disfigured by another individual, you have problems that extend beyond the boundaries of physical functional capacity.

You need to know if the patient feels safe or does s/he feel vulnerable to others who may resemble the perpetrator. Does s/he feel that s/he can (ever) function in the presence of others or will s/he be continually the object of curiosity or even rejection or disgust. Can s/he function in a setting that resembles, in some way, the setting in which the injury occurred.

It is possible to determine a patient’s capacity for alternate work based upon records if the injury follows a relatively simple and predictable path. But all too often, the situation is inordinately more complex and requires that the nurse have first hand exposure to the patient. Most nurses I know would agree with that view.”

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