In the Spring 2017 semester, I was able to spend time learning about Community based nursing at the Penn South Program for Seniors in Chelsea, New York. Working in this clinical site allowed me to grow as a person and a nurse. I learned to subdue biases, learned to be more open, and surprised myself with how much I had matured since my first week of clinical here. I believe that I have achieved all of my clinical objectives in this course. These objectives included health promotion, disease prevention, maintenance of health, professional expectations and accountability of practice.
Objective 1: Demonstrates individual professionalism through personal behaviors and appearance.
I demonstrated my professionalism through personal behaviors by always showing up to clinical prepared. Showing up prepared meant I was on-time, had all the necessary tools for the day (phone, pen, blood pressure machine, stethoscope), and dressed professionally. Not being able to wear scrubs meant that I had to prepare all my outfits the night before and make sure that each item was pressed and free from lint.
I maintained client confidentiality by not discussing my client’s information in any public spaces or with anyone note related to my clinical class or social workers within the Penn South Program for Seniors. I also did not fill out any paperwork in spaces where others could peek over my shoulders and at the end of every clinical day, I would return my client’s folder to my instructor who had them locked up in the social work office. I would prepare myself for clinical learning by taking time to see the social workers for my patients and speak up when I had questions. The only way to have them answered is to ask them of course! I was surprised to see how much I had participated in conversation this semester, especially in pre and post-conference as I am usually a very quiet person. I realized that actively participating gave me more insight on clinical experiences.
Objective 2: Employ analytical reasoning and critical thinking skills when providing care to individuals and families in the community setting.
Using motivational interviewing skills, I had my client agree to learn about the medications she was taking and their indications and side effects. When I first met her, I noticed a large plastic bin full of medication bottles and asked her what medications she was taking. She replied “I don’t know. That you would have to ask my girls. They prepare it and I take it!” I knew that this was a large problem because someone who is on polypharmacy should be aware of what they are taking. With deeper digging, I realized that my clients emotional state played a large part in her willingness to learn about her medications. Her husband passed 6 years ago and she became depressed. Since then she has given up on many things such as travel. After she suffered a stroke in 2011, she gave up on travel completely! She became bed-bound and hasn’t left her apartment since she was discharged home from the hospital.
Based on the data I collected, I realized that medication education was one goal I wanted to focus on. The second main goal was to improve her mood and decrease her feelings of loneliness during my short visits with her. When I would assess the patient, I would continue my conversation with her and build rapport. It was through this mindless conversation that I could really pick at her brain and have her open-up about her feelings of depression. I remember the first time I met her she said “There is nothing in this world that could get me to leave this apartment. I love it here. This is where I am comfortable.” She was in denial about her depression and isolation. By the end of the semester she had changed her mind. She said to me “I am jealous of you. You can get up from that chair, walk out the door, and go wherever you want in this world. And me? I’m stuck here.”
Objective 3: Effectively communicate with diverse groups and disciplines using a variety of strategies regarding the health needs of individuals and families in the community setting.
Communication played a large part of clinical. First, I had to communicate with my patient and her aide to figure out what needed to be reassessed and changed. The aides complained that they had nowhere to rest during the day besides a small chair in the kitchen area. We contacted my patient’s power of attorney to see if anything could be arranged.
I was able to communicate with my clinical instructor and peers as well. We held great conversations during pre-conference about our patients and objectives for the day. We also spent a lot of time talking about changes to health insurance and how it would affect our patients and our careers. I documented weekly on my assessment for my patient and wrote notes detailing my work for the day.
Lastly, I spoke with the social worker very often to follow-up on doctors appointments and issues that I had contacting my initial patient who unfortunately dropped out of the Penn South Program for Seniors. It was also the social worker who helped me figure out why my patient was not answering her phone one day when I planned to make a visit. I knew it was unusual when my patient didn’t answer her phone because she always had her bills next to her on a small box. When I reported it to the social worker, she got in contact with my patient’s attorney who told us she had passed away during the week of Spring Break.
Objective 4: Establish environment conducive to learning and use a plan for learners based on evidence-based practice.
For our service learning project, my group created a PowerPoint titled “Time Counts: Spot a Stroke – Save a Life”. We held a small presentation for a group of 8 people. We had an informal pre-test where a majority of the group said that a stroke meant that the brain was not receiving oxygen. Throughout the PowerPoint, we stopped and answered any questions the participants had before moving on. This really allowed the participants to learn and asking if they had questions helped to clarify the information provided to them.
At the end of the presentation, 100% of the participants showed an increase in knowledge on the signs and symptoms of stroke and early interventions. The knowledge increased by ten-fold. I was so glad to see that everyone had benefitted from the presentation and that the participants were so engaged in conversation with my clinical group.
Objective 5: Utilize informational technology when managing individual and families in the community.
Although I did not use any type of electronic documentation in clinical, I did keep an organized folder for my client’s information and the nursing notes that I completed weekly. This included notes about my patient’s baseline vitals, multi-system assessment including skin, neurological, musculoskeletal, etc. I documented on any changes and if there were any changes I reported them to my clinical instructor and the patient’s social worker immediately. I maintained strict confidentiality by not sharing any information about my patient outside of the clinical area and kept her information locked in the social work office when I had finished my documentation.
Objective 6: Demonstrate a commitment to professional development. Nursing is a profession of lifelong learning.
I used current literature to further my learning. If I had any questions or needed to clarify anything such as signs and symptoms of medication, I would look them up in my medication drug guide. I would read up to date articles and read the most recent volume of the ANA Magazine. After every clinical day, I would go over what I had assessed, the interventions carried out, and brainstormed what I could do during my follow-up visit. This tied in with my nursing diagnosis.
The challenges that I faced in independent practice of community health nursing this semester is bad weather and patients not wanting me to visit. After the snowstorm, I took the train and put on my rain boots and walked over 4 avenues of ice to get to clinical. The weather was freezing cold and the wind burned my face as it blew by. Also, the first patient I was assigned refused to see me for 4 weeks. She would be in a hurry to get off the phone and would not let me conduct a phone interview. Eventually, I was assigned another patient, but I spent lots of time documenting our phone conversations and speaking with the social workers to solve this issue.
Objective 7: Incorporate professional nursing standards and accountability into practice. I was held accountable for my actions in the clinical area.
From my first impression to the nursing interventions I provided for my patient, I followed all the American Nurses Association Standards and the standards of the agency I was working with. I stayed within my scope of practice as a RN- student and utilized assessment, diagnosis, outcomes identification, planning, implementation, and evaluation. Following these steps lead my patient and I to the highest level of achievement for my clients desired goal. I also followed the code of ethics and respected my patient’s wishes and provided quality care regardless of age, race, sex, ethnicity, sexual orientation, economic status, etc. I utilized resources and conducted research to support my evidence-based practice in the field.
Objective 8: Collaborate with clients, significant support persons and members of the health care team.
I collaborated with my patient and her healthcare team which included her doctor, social worker and home health aides. We communicated efficiently and concluded that it was necessary for her to learn about her medications, their indications, and their side effects. I found out that my patient was taking hypertension medications without checking her blood pressure first. I recommended that she should take her blood pressure before taking medication to check that her blood pressure wasn’t too low to begin with. I taught her how to check her own pulse and gave her a coupon to Rite Aid for $20 dollars off an Omron blood pressure cuff. I also referred her to the CDC and American Heart Association websites for more information on hypertension.
Objective 9: Recognize the impact of economic, political, social, and demographic forces that effect the delivery of health care services.
Stigmas play a large part in how we deliver health care. Mental illness, homelessness, race, age, gender, sexual orientation, religion, wealth, and even the location you’re in all have large stigmas and biases attached to them. In my professional opinion, I believe that it is best to leave these biases at the door when we enter our workplaces and treat everyone with the same respect and dignity. The quality of care provided should not fluctuated between patients because of pre-conceived biases.
With changes being made to Obama Care and a change of Political Party in the White House, I think that many people are worried that they may not be covered and will not have access to affordable health care in the future. As a person that is not wealthy, this makes me fearful of the consequences that will occur when the health reform takes place. As a nurse, it makes me feel empowered to sign as many protests and petitions as possible and to get the word out there to anyone who will listen. It also makes me worried for my patients who will have to make difficult decisions about what healthcare services they will be able to afford and have access to. In a world where people suffer from multiple comorbidities, which are caused by demographic, social, economic, and even genetic forces, it is difficult for me to believe that the President of the United States wants to cut back on health insurance and exclude coverage pre-existing conditions.
This semester has really shaped me to become a better professional. I have grown and matured greatly with this course. After going out into the community and seeing patients, I have a greater understanding of the lives of patients outside of a health care facility. I can see and experience the stress and issues of my patients and incorporate that into my plan of care. What I really appreciate learning the most is not to buy into stigmas and biases. Both interfere with my plan of care for the patient and in the end, it is a lose-lose situation. The patient will not open-up to you and you will not be able to meet your desired goal. I have also grown as an individual and it is evidenced by my abilities to see past a person’s appearance or reputation and getting to know them through an open mind.