Pessisimism is not often looked at as a strength, but it is a useful approach. If one is only planning for the best, then the best better happen. Recognizing the possibility of, and planning for, the worst case scenario does several things. One, it keeps you well prepared. If the worst comes to pass, then you are ready for it. But you are also ready for any alternatives, and planning for the worst challenges you to find the best and most far reaching solutions. Even if they are not used now, they can be adapted for other situations. Another way pessimism pervades is to look at the entire workload as it hangs over the looming deadline. This creates a positive stress that forces you to devise ways of prioritizing, chunking, and forcing yourself to meet targets and keep moving rather than get bogged down.

One strength that can be a great asset to a nurse is humility. A nurse definitely has to be confident and assertive, but should also know his/her limits. After going through the nursing curriculum, one learns very quickly that one person does not, and can not, know everything, and has to rely on others. We rely on classmates to explain things the text is not clear on, to give rationales for answers, and for quick advice and assistance in clinical. That last part is crucial. What nurse can say he/she was never given any assistance from anyone? Yet somehow, there are nurses in the field who refuse assistance when asked, or will say they learned on their own. Even if that were the case, then the question can be rephrased as what nurse has never wanted or needed assistance at some point. By being willing to ask for assistance, a nurse can recognize faults and deficits, show deference towards more experienced colleagues and superiors, and show a willingness to learn and adapt. Likewise, a willingness to help others when asked helps build trust and lay the groundwork for future collaboration.

Another strength that is needed for success is a willingness to learn and improve. Some practicioners get set in their ways. They cling to what they learned in training and how they learned it. While it is important to keep a firm foundation, the reality is that knowledge and technology are constantly advancing. The standard practices of today may well be obsolete not long from now. New graduates enter the field with new techniques and new medications that will go against what veteran practicioners are accustomed to. It is important to keep in mind, even after 5, 10, or 20 years, that you too were once that new graduate. Keeping an open mind can also help keep the profession fresh and stave off burnout, as each day and each encounter would be viewed as a possible learning experience and not just another day at the office.

One of the key differences between the associate and baccalaureate programs is scope. Coursework in the associate program is focused on specific disciplines, and is technically rooted. Advancing to the baccalaureate program was an eye opener because the focus has shifted to the broader picture. It is no longer about assessing a particular patient at a particular time, but on looking at the population as a whole, seeing the case from the risk factors and culture and community influences through care and return to the community. The role of advocate takes on a whole new meaning because it is no longer a question of providing an extra blanket for the night on the unit but on alerting lawmakers to the need to funnel funding into programs to provide blankets to needy children or families in schools and community centers.

At the same time, there has also been the realization that a nurse also has to be an advocate for himself. I recall one session in psychiatric clinical where it was mentioned that nobody puts their head out into the hallway and calls, “Doctor”, but rather the call bell, patients, and families are calling “Nurse”. It is incumbent then to not only represent the profession and uphold its ideals, but seek ways to further advance it. As medicine continues to become more complex, nursing has to not only grow but change to meet current and future demands. There is far more reliance on specialists and other professionals to execute some of the tasks associated with care, but it falls on the nurse to act as the go between and tie the disciplines together. This also falls in line with the bigger picture of nursing as a profession; assessing not only the patient but nursing itself- the scope of practice, the rationales for interventions, the overlaps with other functions in the continuum of healthcare, and the changes on the horizon due to social, political, and economic shifts.

Another key learning point comes from the broadness of nursing. The traditional view of a white uniform dutifully standing next to a hospital bed is still commonly found, to be sure. But there are many other ways and capacities to address healthcare.  We are only beginning to realize that medicine is not limited to the acute treatment of an emergent condition. As the concept of health continues to change, so will the role of nurse, and those in or looking to enter the field will need to assert a voice in shaping what the final form will be. This, ultimately, is the purpose of advancing nursing education beyond the essential clinical skills needed to perform at the bedside. Many students, including myself, have questioned the validity of the baccalaureate program, with the argument that if the classwork is not geared towards learning and mastering assessment skills or practicing clinical procedure, then there is little use for it. But you to come to realize that the purpose is not to train the new nurse for the immediate position, but to see the larger picture of advocating for oneself and the profession rather than just for the patient.

Getting back to the argument, a nurse can treat patients without a syringe and an iv bag. Especially in the primary preventative care model healthcare is trying to move to, the key interventions will be providing education on identifying and modifying risk factors, or managing medications and activity regimens. This is where the “big picture” view comes into play. Also in this regard, the nurse becomes a salesperson, trying to get the client to buy into the care plan. In some ways, this is even more challenging. The person rolling on the ground in excruciating pain is not likely to question the nurse’s interventions or rationales. The one who believes himself to be in good health will need some convincing. Experience will teach the means of managing this situation more than any book will, but the books will lay the groundwork for experience to do its magic.

What does it mean to be a nurse?

A person is perhaps no more vulnerable than at a time of illness. The individual is physically limited in some way, may be confused, may be scared, and these feelings can extend to the person’s support system if any exists. In the midst of this uncertainty, there must be someone to serve as an anchor. As the personnel who spends the most time at the bedside, who interfaces most with the patient, who advocates for the patient and caregivers, it is the nurse who fills this role. In essence, the nurse takes the complicated science of medicine and makes it human.

A number of people of written about and formulated nursing philosophies. Ultimately, though, a person’s outlook will be shaped by experience, and while some parts of a philosophy are fixed, others are fluid. Core values, such as approaching each patient as a person and not an illness, as offering a service to someone in a time of need, of following through on requests, do not change over time. But another key to both survival and success in nursing is an understanding that the profession, and therefore the practitioner, must be open to change. The way to do this is to approach the profession, and the bedside, with humility. Nobody has all of the answers, all of the supplies and skills, and nobody has gotten to where they are without any help whatsoever from anyone whatsoever. Be willing to listen to and constantly learn from colleagues, from supervisors, and from patients and families, rather than place all trust in oneself. Another means of expressing humility is through continuing education. There are common everyday items that are indispensable today yet did not exist a few decades ago, as there are now treatments that for years were only dreamed of. Imagine what awaits in the years to come. So one cannot approach nursing as another every day job. Rather, the nurse, whether one fresh out of school or one with 30 years experience, has to remain the child in the candy store- wanting it all but not knowing where to start. This will keep the profession fresh, and keep the nurse in a position to grow rather than stagnate.

There have been several instances that have demonstrated this concept to me. Without giving too much information- even here the long arm and eye of HIPPA loom- I recall in my first semester a patient who did not want me to care for her, but in the middle of our time there, after several failed attempts to assess her and discuss her care, I poked my head in and casually asked if she wanted any change of gown or water. After bringing her a new pair of socks, her entire demeanor changed, and we spent the rest of the shift talking, and suddenly she was asking me to conduct all my assessments and confiding personal information to me. In my psych clinical, there was a difficult patient in the hallway, and staff was considering calling a code. The patient suddenly came running up to me, of all people, and said he wanted to talk to me. My professor was cautioning me not to, but I figured I might as well give it a go. After a few minutes with him, it turns out all he wanted was a blanket. My clinical professor complimented me on managing a challenging situation, but really all I did was listen, something apparently nobody else was. On a med-surg unit, one of my most memorable, and most successful days came caring for a patient with a gastric tube who mentioned he had trouble breathing from time to time. I explained the purpose of his tubes and taught him to use an incentive spirometer. The point, here, is that my greatest lesson in nursing school is that it is not the big, complex procedures, but rather the simplest and most basic interventions that prove the most effective.

The goal of attending clinical is to gain practical experience to supplement and put into actual use the information in the text. Along the way, the goals are professional development, sharpening assessment and critical thinking skills, further utilizing and integrating new technology into practice, and gaining experience in collaborating with colleagues and staff. This semester I was assigned to the geriatric clinic at Woodhull, and overall it was a valuable experience. Throughout the semester, I was able to gain new insight into professional practice and get a feel for outpatient and ambulatory nursing.

When attending clinical sites in previous courses, the day was already in full flux, all care had been assigned and delegated, and I just became another cog in the wheel. However, this semester, I feel more a part of the team. The geriatric clinic does not open until 9. When I arrive, so are the rest of the staff. We go through the daily walkthrough, checking the cart, checking med counts, attending the huddle, and reviewing the paperwork for the upcoming day. It has added an entire new layer onto my nursing experience. My interactions with the rest of the staff are not confined to tasks and vital signs and meds, but rather we can also share personal information about our lives. This goes a long way towards building teamwork and making the staff a more cohesive unit, where the rest of the staff are not just their respective titles and functions, but people, which again is different from other clinical experiences I’ve had in this program. Also, the clinic has a social worker and a lawyer, helping to get more ready access to services and resources, as opposed to on a unit where referrals would have to be made for these services. However, while the clinic may provide quicker and easier access to social services, referrals for specialists are not as forthcoming. Referrals can easily be arranged, but the wait time for some services may be months. Often, we ask clients if they have an outside provider to refer them to for a shorter wait or even advise them to go to the ER for specialty treatment.

Each clinical site is to some extent a reflection of the neighborhood it is located in. This allows you to gain insight into some of the specific health and community issues of the population served. In addition, the geriatric clinic is an outpatient facility. Unlike a typical med surg or psych unit where I would only interact with the more acute cases, in an outpatient setting I can get a wider feel for the general health problems of the neighborhood. Woodhull Hospital serves a population that is mostly Hispanic. While Hispanic itself can be seen as an umbrella term covering several smaller subgroups, nonetheless there are a number of similarities. This allows assessment questions and patient teaching to be more focused to the population. It also means that when a new client enters, you have a better idea of how to go about assessing and phrasing questions.

This semester has given me plenty of experience in dealing with a specific population- elderly Hispanics with diabetes and/ or hypertension. It has therefore also provided me with an opportunity to become more culturally competent in dealing with these clients and others I will encounter in the future. I’ve been able to pinpoint some specific practices and foods that I can target in teaching plans. Based on information given in interviews with clients, after a while you can also begin to develop some area or culturally specific questions to ask new or returning clients that would not be asked otherwise. By the same token, I’ve also had to identify a major limitation in myself- the ability to communicate with non English clients. Doing clinicals at Coney Island, I cared for several Russian speaking clients, but was always able to find a classmate to act as a translator. While I never learned any medical or nursing terminology, I have enough experience with Chinese to at least break the ice and give the client a general idea of what I am trying to say and do. And while I’m nowhere near fluent, most are surprised and appreciative that I speak any Chinese at all. But this semester, it has been frustrating at times to be forced to take a back seat in patient interviews and teaching sessions because I have no Spanish ability. Perhaps that would be something to look into, both as a personal and professional growth opportunity. If we are to try and be empathetic to our patients, it is essential that we can listen and understand their complaints, but also placate their fears if they do not understand the barrage of technical information being thrown at them about potentially devastating illnesses.

The clinics at Woodhull use a PCMH system. Before a patient comes for a visit, a red flag will appear if any labs or diagnostics are missing or incomplete and allows us at the clinic to contact the patient. This helps streamline care. The goal was for the clinic to be entirely paperless in 2015. Here it is 2017 and the printer and copier are still two of the busiest workers in the clinic. It goes to show that for all the benefits of technology and for all the leadership meetings and project and process planning, implementation is a different matter. At any rate, truth be told, while the new spreadsheets do contain some new categories of information, I feel the old method was superior. The columns were more organized, and information from multiple patients could fit on one sheet, as opposed to the new system where only two patients have their labs and prior appointments on a page. With a little tinkering, the old spreadsheets could easily be modified to include a few more columns for data, and could also be set up for a specific doctor on a specific day, making the paperwork much more organized and reduced. I even mentioned this to the RN of the clinic and the supervisor when she came in to stress that going forward the new sheets were used, as staff were continuing to print them out using the old format. Still, just follow the institutional guidelines and policy, and let the rest fall into place. As professionals, we should strive to find areas of improvement, but need to remain compliant with the policies of the hospital.

The clinic screens each patient for diabetes, hypertension, and depression. Standardized questions using a Likert scale are given to clients for the depression screening. As an outpatient clinic, assessments are thus limited to vitals and fingersticks, with a more in depth history taken for new clients. Some clients may come in with complaints of new or worsening symptoms, but these patients will be referred to the providers, who in turn refer them to specialists, or are brought to the emergency department if abnormal results are obtained on repeat attempts. But despite any limitations in assessments or interventions can be offset by the formation of more permanent relationships with the clients. All patients are scheduled to return for follow up appointments every three months, and some more frequently. Over time, staff can get to know this particular client, his or her traits, any other issues or concerns regarding care, and use the more intimate knowledge to tailor more specific teaching plans and recommendations. Compare that to a med surg unit, where you may see a patient for a few days before discharge, but then are unlikely to see the client again.