NUR 4010 FA 2013

Alison Miller

Introduction
My Community Health Nursing clinical placement was at Bellevue Hospital Center, in the dermatology clinic. I had a great experience and learned so much in my 14 weeks there. The following is a self-evaluation based on certain clinical, professional, educational, and personal objectives.

Objective #1: Demonstrates individual professionalism through personal behaviors and appearance
Every Tuesday at 9 am I went to the fourth floor in the “B” building, dressed in the required uniform of dark pants, dress shoes, light colored shirt, and lab coat. I participated in the staff meetings that occur before the shift starts, by explaining what I had learned. Tuesdays at Bellevue are the Hansen’s Disease (HD) clinic, so I had to learn about the disease in order to assist the staff. I asked many questions and had to do a bit of research in advance to prepare. Patient confidentiality is important when dealing with a disease as taboo as HD, so I treated the patients at the HD clinic with respect and handled their cases with privacy. I wrote blogs on the Blackboard blog site, in a timely fashion, in accordance with the course parameters.

Objective #2: Employ analytical reasoning and critical thinking skills when providing care to individuals and families in the community setting
One of the most helpful ways that I learned about HD was by speaking with the patients themselves. I learned about their personal history of the disease, and read in their charts about the treatments that they received. Dr. Levis, the attending physician of the clinic, and Lydia, his nurse, also educated me about the signs, symptoms, and treatment of HD. The life of an HD patient can be taken over by the disease, so I had to assess how it affected the whole person. I did this by speaking with patients and asking them about their personal histories, feelings about treatment, and barriers to their adherence to treatment. It was important, as well, to identify how well they self-manage their disease, because HD requires a great deal of self-inspection, lifestyle changes, and symptom reporting. I found that the greatest barrier to adherence is that HD patients must wear safe and supportive footwear, and many of the female patients did not like the fashion options of safe and supportive footwear. I saw a few female patients that had developed foot ulcers due to wearing inappropriate footwear such as high heels or sandals. I also inspected the skin of patients with the multibacilliary type of HD, in which erythematous patches appear on the trunk, arms, and legs. One of my functions in the clinic was to call patients in for treatment, and to triage patients occasionally based on how long their wound care would take. I assisted with the wound care by removing bandages and casts, cleaning wounds, applying barrier creams and wound dressings, and re-casting the dressings. The clinic is very busy, so we had to move quickly, but always in a safe and efficient manner. I evaluated outcomes of nursing care by seeing the patients’ wounds in the clinic each week, and observing their healing. I did not modify care related to outcomes in this clinical. I utilized safety by donning PPE every time I did wound care.

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
I utilized therapeutic communication skills with patients when I spoke to them about their personal histories and diseases with caring and professionalism. I utilized appropriate channels of communication by speaking with the nurses first before speaking with anyone else about care. I communicated with my instructor and peers clearly over email and blackboard to organize our service-learning project. I communicated significant data to the healthcare team by reporting anything that I thought was important while performing wound care. I adapted my communication when speaking with clients of different cultures who spoke different languages with different educational backgrounds appropriately. I used translation where necessary. I reported any findings during wound care to the physical therapist and nurses who, in turn, documented them in the EMR.

Objective #4: Establish environment conducive to learning and use a plan for learners based on evidence-based practice
The literature for HD suggests that the best way for HD patients to prevent infections secondary to injury related to neuropathy is to wear appropriate footwear. Based on these findings, I used my teaching skills in the clinic to educate patients on the footwear that they should purchase. I came up against some resistance with some fashion-forward Brazilian patients who did not like the idea of wearing comfortable yet unattractive footwear. I ensured that the environment was conducive to learning by working with them to come up with options that would provide both safety and fashion. I evaluated the success of my outcomes by watching one patient come in the next week wearing more sensible shoes.

Objective #5: Utilize informational technology when managing individuals and families in the community
I was not permitted my own access to the Bellevue EMR, but I did have many opportunities to observe and contribute to each patient’s EMR whose care I was involved in. I maintained strict confidentiality with these records by depositing any printed paperwork in the shredding bin after I was finished using it.

Objective #6: Demonstrate a commitment to professional development
I used nursing and medical journals while preparing for learning and for patient teaching in my clinical placement. I have assumed responsibility for lifelong learning, not just because I have chosen the field of nursing where this is necessary, but also because I want my career to evolve with the direction in which nursing is going. I constantly evaluate my knowledge, practice, and learning style so that I may be a better nurse, more culturally competent, and a more effective patient educator. I commit to adjust to the challenges of independent practice in community health nursing every day. As a case manager in the community, it is an integral function of my job.

Objective #7: Incorporate professional nursing standards and accountability into practice
I utilize the ANA standards of practice in my Bellevue clinical by reviewing the scope of my practice there and adhering to the principles. I comply with agency policies and practice by asking what is expected of me and by following the directions of my superiors. I am fully accountable for my actions in the clinic, as I am doing wound care and teaching, and must ensure the privacy and safety of my patients. If this is not done, it is my license as a Registered Nurse that is at risk. The mission of Bellevue Hospital Center is that of HHC; “to provide comprehensive health services to all New Yorkers regardless of the ability to pay.”

Objective #8: Collaborate with clients, significant support persons, and members of the health care team
I collaborate with the health care team in the Bellevue dermatology clinic to address client problems on every shift. I consult with the PCAs and the physical therapist to discuss wounds of certain patients, and the course of action for healing. I coordinate client-care based on client needs and therapeutic intervention by creating care plans and teaching that will be effective and appropriate for each patient. I base my planning on language, culture, values, and past history. I find resources for patients to access appropriate support in the community, such as stores to find supportive yet attractive footwear. I guide my patients to make appropriate lifestyle choices such as quitting smoking and losing weight. Smoking and obesity are health issues alone, but compounded with HD can be fatal. I did not assist clients to make connections to other community agencies, as this was not part of my clinical. There is social work available for them to handle this.

Objective #9: Recognize the impact of economic, political, social, and demographic forces that affect the delivery of heath care services
I recognize that there are gaps in the healthcare system, however treatment for HD worldwide is unique, as it is paid for entirely by Novartis and The Novartis Foundation for Sustainable Development. Many of the other patients that utilize the dermatology clinic are on Medicaid, and those that are not pay on a sliding-scale fee. The latter group may have great difficulty keeping up with payments, especially if they utilize clinic resources frequently. Additionally, many supplies are very expensive for wound care, and non-HD wound patients without adequate insurance coverage may have trouble paying for the supplies they so desperately need. Some solutions may be getting those patients without adequate coverage SSI or Medicare benefits if possible to help pay for care and supplies. If I worked at Bellevue as a nurse, I would most certainly advocate for this population that falls between the cracks to have more affordable options to treat their wounds. I would also advocate for primary prevention and teaching so wounds are less of a problem for these patients and others in the future.

Conclusions
Overall, my experience at Bellevue was a rewarding and highly insightful one. I learned a great deal about a global disease that I had no previous knowledge of, and was able to participate in the treatment of its victims. I honed my skills in patient teaching as well as developed new ones in wound care. Working with the HD community and the larger one of Bellevue patients inspired me to further develop skills necessary for working in community health nursing.

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