NUR 4010 FA 2013

Tina R. Mahler

Narrative Self-Reflection

            In the following self-evaluation I am going to report on whether I met expected behavior objectives for my clinical experience this semester. I was assigned to the diabetes clinic at Bellevue Hospital Center. I observed diabetes educators as they interacted with clients, participating slightly in those interactions. The nurse educator behaved as a mentor towards me, teaching me as much as she could. I found this to be a premier educational experience. The element of repetition and the format of diabetes educator’s mode of teaching was a wonderful element of reinforcement of learning for me.

Objective 1: Demonstrates individual professionalism through personal behaviors and appearance.

Maintains client confidentiality. In my blogs I described clients’ situations without disclosing names.

Assumes responsibility for own learning. I asked if I could have whatever literature was available. I was very attentive to every detail spoken and took down notes from memory that I later re-read.

Prepares for clinical learning. I wanted to study everything about diabetes, but I haven’t done that yet.

Completes assignments within designated time frame. I missed more than one blog but made up all the blogs at the end.

Seeks guidance appropriately. I did not function independently in the diabetes clinic but was always in the company of a nurse educator. The diabetes educator would ask at the end of the client sessions whether there was anything I would like to add, and it was at that point that I would make a comment or pose a question. The diabetes educator would then take up that question and, reformulating it, pose the question to the client.

Participates actively in clinical conferences. I participated actively in clinical conferences.

Attends clinical punctually and in accordance with school policy. I attended clinicals punctually, arriving at 8:30 a.m.

Dresses professionally. I dressed in my lab coat with the school insignia on the sleeve. The lab coat was very clean. Some days I wore a little make up and always had my school ID pinned to my pocket. I wore a black skirt, white blouse, and comfortable shoes.

Objective 2: Employ analytical reasoning and critical thinking skills when providing care to individuals and families in the community setting.

Uses client interview, nursing and medical records, staff nurses and other health professionals to collect client information. I myself did not have access to the nursing and medical records which were computerized. Before the client came in, the diabetes educator would tell me relevant aspects of the client’s profile. During the interviews with the clients I was very observant and attentive and arrived at assessments of each client.

Assesses the impact of developmental, emotional, cultural, religious and spiritual influences on the client’s health status. A memorable example of this is a woman who spoke Spanish and a little English. As she entered, she did not respond to a greeting and had an expression that was like stone, shutting out others. In the course of the meeting, she broke down crying, and she said that she had been under a lot of stress because of incidents that had occurred at home, meaning at home in her country. She said she was the only one of her family in this country. Her “sugars” had been out of control for the past few months because of the stresses in her life, she said, but this had not been the case previously. My judgment was that she may or may not have been here legally and was under the stresses of those of an immigrant besides the stresses that she mentioned. It was possible that the diabetes educator was a person she thought she could tell her problems to, and emotions that had been pent up came pouring out suddenly. The diabetes educator told her that there was psychological counseling available and that if she needed such, she should call her.

Collects significant data relevant to client’s self-care needs. My means of assessment was the history the nurse educator told me and my observations. An assessment needed to be made about whether a woman would be a candidate to participate in a study in the use of texting by daily blood glucose values and then receiving a phone calls as to the number of insulin units to be taken. This study was for first time insulin users to accelerate titration of their insulin. The woman did not have a cell phone and did not know how to text. A cell phone would be provided. I said that if she understood the value of the study to herself, she might be willing to learn to text.

Prioritizes care based on analysis of data. The diabetes educator spent considerable time reviewing each case the day before she was to meet with clients. She deliberately followed an almost identical format with each client. This way she made sure not to miss important points. She first asked the client about which medications they were taking and asked them how they were taking the medication. She then reviewed the record of blood glucose checks. In one case the patient was beginning to have kidney failure, and the diabetes educator went over with him the foods he should not eat because of their potassium content. The only other way the diabetes educator might vary her routine was if the client had had an episode of low blood sugar. Then she would review what measures the client should take. If, on the other hand, a client had had no incidences of low blood sugar, this would not be emphasized. If a client was a newly diagnosed diabetic, a first-time insulin user, or could not read and write, the script would be different.

Applies priority-setting in planning nursing interventions. I was not doing much intervention. I had an observational and learning role. The nurse educator had an outline in mind which she applied to every client. She did not want to vary that outline because this is her way of remembering what topics to touch upon. The diabetes educator went over notes in the record that had been entered by other providers, I assume primarily by the primary doctor. For instance, when a couple came in, the diabetes educator already knew that it was the woman who would be giving her husband insulin.

Implements safe, appropriate nursing interventions in a timely manner. I was not doing much intervention. The nurse diabetes educator’s primarily function was to ensure safe and proper use of the medications and on the clients’ understanding of the medications.

Administers medications and treatments safely. I did not administer medications or treatments. I understand the importance of administering medications safely. I hope that I would more than double check the prescriptions and whether they were appropriate. The diabetes educator would discuss the amount of insulin that would be taken, at what time of day in relation to meal times, and the number of pills.

Evaluates the outcomes of nursing care. The way outcomes were evaluated was clients were asked how they were going to take their medication, what they were going to do if their sugar was too low, and what they were going to do if they had any questions.

Is reflective about practice. Modify client care as indicated by evaluation of client outcomes. Client outcomes in diabetes education are measured by A1C results. A1C is tested every three months. Because diabetes is largely a matter of self-care, the diabetes educator has to help clients be reflective about their insulin intake in relation to meal times and contents of meals and snacking. The nurse educator was being reflective about practice when she discussed with me her plans for patients.

Utilizes principles of personal safety when working in the community setting.  I received the flu shot early on the semester, as soon as I learned it was available.

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.

Utilizes therapeutic communication skills with individuals and families in the community setting. My understanding of therapeutic communication skills is that the nurse should use open-ended questions to gather information. I had an opportunity to ask the nurse educator to ask a client what she eats for breakfast, lunch, and dinner. Then I asked, do people drink vegetable juice in her home country. The client gave a very full description not only of what she had recently had to eat, but of her likes and dislikes, and of the food customs when she was a child in her home country. I hoped that by self-reflection the client would be moved to her own realizations.

Utilizes appropriate channels of communication. I spoke through the diabetes educator, not directly to the client, so that I maintained the communication between the client and the diabetes educator on matters of substance. I did not follow this rule, though, when I was merely being sociable and friendly.

Communicates clearly and effectively with instructor, peers and the healthcare team. During the course I had the phone numbers of other students. When I needed to, I communicated with the instructors. I did not want to burden one of the instructors when she was going through a bout of illness and found another channel to get the information I needed. The instructors were very easy to communicate with so that made it easy. I believe I could have been cooler under pressure during several days when I couldn’t figure out where to post assignments. If I had communicated with the instructor early on, I could have saved time. From the feedback I got from the instructors and the healthcare team, I was usually understood. This was not always the case with peers to whom I was not always able to get my ideas across.

Communicates significant data to instructor and the health care team. I communicated an idea that I had for a service learning project early on in the course. If I had had the idea fully developed when I brought it up, it might have been taken up as a possible project idea.

Adapts communication skills to the developmental needs of the client. Most clients were were elderly, and many spoke little English, their primary language being Spanish. I spoke using very simple language. A number of times I used Spanish words. In one case I said no es facil. I wanted to say that being a diabetic is not easy.

Reports and documents assessments and nursing interventions accurately. I hope I approached accuracy in my blogs, although in the earlier blogs I also included self-reflection as well. As blogging continued, I adopted more of a style I noticed other students using that was more objective. If I was going to be reporting and documenting, I would have to be entirely objective and not put in my own reactions.

Objective 4: Establish environment conducive to learning and use a plan for learners based on evidence-based practice.

 Develops and implements a teaching plan for an adult and/or family in the community setting. Through my observations, I extracted the main points of the diabetes educator’s teaching plan. The diabetes educator asks questions, and after gathering the information, she makes corrections. Then there is questioning at the end to review if the patient understood what was taught. There is also attention given to the blood glucose checking that the patient had recorded. The nurse asks why certain numbers are low or high and asks about the times the patient is doing the checking. She might find errors in what the patient is doing, such as the patient might be checking the blood glucose after a meal rather than before or the patient should not only check the same time every day but should vary the times. In teaching an adult, it is important to give lavish praise just as much as if one were speaking to a small child. This is appreciated by the client and is not thought to be overdone.

Establish environment conducive to learning. The environment in the diabetic educator’s office is conducive to learning because there are enough chairs there, and the door is closed so it is quiet. The education is one-on-one.

Evaluates client/family learning outcomes. The questions asked at the end of the meeting are very similar to the questions asked at the beginning.

Objective 5: Utilize informational technology when managing individual and families in the community.

Utilize principles of nursing informatics in the clinical area. The diabetes educator showed me the websites that give information to clients. One was pictorial so that people who do not speak English well, visual learners, or the deaf may learn about administering the medications from pictures. Also there is a website that gives information entirely in Spanish.

Maintain strict confidentiality with client records. This is greatly needed. I did not handle client records.

Objective 6: Demonstrates a commitment to professional development.

Uses appropriate current literature in planning care for clients in the community setting. I cannot say that I was spending this semester reading up on diabetes literature. I collected and read the literature available in the clinic. I can say with confidence that in the course of my studies, I have achieved facility in finding and evaluating current research.

Assumes responsibility for lifelong learning. I am an independent learner, interested in nursing and medical topics as well as topics in the humanities.

Engages in self-evaluation. I have recently purchased a journal to which I add an entry every few days. I believe that writing a journal will be useful in improving not only my practice but also my personal decision making going forward.

Is committed to adjusting to the challenges of independent practice in community health nursing. I think that in independent practice one would have to be quite knowledgeable and have a broad information base. I believe other courses I am taking, pathophysiology and case management, are relevant towards achieving expertise, and I plan to continue delving into those areas.

Objective 7: Incorporate professional nursing standards and accountability into practice.

Utilizes American Nurses Association Standards in clinical practice. My understanding of the ANA’s standards of practice is that they are in large part based on the nursing process. For instance, one of the ANA’s standards of practice is that education continues as long as a nurse continues to practice. As part of this, the nurse needs to identify his/her learning needs. I have identified certain learning needs based on my clinical experience. The majority of patients who came to the diabetes clinic were Spanish speaking. I hope to achieve a better speaking ability of Spanish by perhaps enrolling in an adult education course. I hope also to enroll in a certified nurse diabetes educator course.

Two of the ANA’s standards of practice are assessment and diagnosis. I have already mentioned assessment and diagnosis in the context of diabetes education. Another area of the course where assessment and diagnosis came into play was the group service learning project. We decided to adopt data available at Bellevue Hospital Center’s website regarding assessment and diagnosis of the communities’ needs. Approximately 50% of BHC’s outpatients (excluding visitors to the emergency room) reside in 27 different zip codes. The identified priorities were (1) mental illness, (2) diabetes, (3) hypertension, (4) substance abuse, (5) health literacy, (6) cancer, (7) obesity, and (8) HIV/AIDS/STDs.

Another ANA standard is goals. One of the goals of our service learning project was to increase health literacy about influenza and the flu shot among the college students.

Another ANA standard is planning. In our service learning project, I put forth ideas for a Plan B.

Another ANA standard is implementation. I participated in the health fair by canvassing the college dining room and speaking to groups of students.

Another ANA standard is coordination. I coordinated my activities with the other group members satisfactorily. Some of this was done via discussion board. Much of this coordination was enabled by the skills of the group leader.

Another ANA standard is evaluation. In reviewing the outcome of our service learning project, I perceived a number of important lessons that could be derived. Our original concept was not doable for the reason that permission to conduct the event on the premises of the hosting institution was not forthcoming. Before committing to a project, we could have consulted with someone at a high level of the organization to find out what need they might have of us. Second of all, it is my belief that when we changed the venue where the implementation was to take place, we needed to alter our goals to put more of an emphasis on education (health literacy). One reason for this is that the community of students at New York City College of Technology is different from the population of patients at Bellevue Hospital Center. They are a young, relatively healthy population. In fact, we found that most of the student population at the college were disinterested in getting the flu shot, although some were ready to discuss the pros and cons of the flu shot.

Therefore, I think our project should have been designed primarily as an awareness/informational campaign.

Complies with agency standards of practice. I would imagine that they would be closely aligned with those of the American Nurses’ Association.

Is accountable for actions in the clinical area. I understand that accountability means to be answerable to oneself and others for one’s actions. I understand the code of ethics that is grounded in moral principles that is the basis of accountability.

Is aware of the assigned agency’s mission. I know that Bellevue Hospital Center proudly expresses a commitment toward providing quality care regardless of the individual’s immigration or financial status.

Objective 8. Collaborate with clients, significant support persons and members of the health care team.

Collaborates effectively with healthcare team to address client problems. I collaborated with the nurses so that their work would proceed as efficiently as possible.

Coordinates client-care based on client needs and therapeutic interventions. I made suggestions and made contributions to making the clients feel comfortable and welcome.

Identifies healthcare resources for client/families. The nurse educator on one occasion informed a client of the availability of psychological counseling services.

Guides clients/families to make appropriate lifestyle and treatment choices. I wanted to discuss lifestyle aspects of diabetes self-care but was constrained by the fact that I played mostly an ancillary role. I was a student nurse and a guest at the facility. The job belonged to the nurse educator.

Assists clients to make connections to other community agencies. I did not assist clients in making connections to other community agencies, as this was not part of my clinical.

Objective 9. Recognize the impact of economic, political, social and demographic forces that affect the delivery of health care services.

Recognize gaps in care system. I recognized certain gaps in the care system. There may have been a few instances when the nurse educator could have elicited more of a return response from the patient to be a hundred percent sure of the patient’s understanding. Diet is explained to a newly diagnosed diabetic but is not revisited much as a topic, in my opinion. Most of the emphasis was on the safe use of the medications and monitoring of blood glucose levels. Also rarely discussed were side effects and long term effects of medications.

Begin to identify solutions to complex problems in the clinical area. The group education that they have is wonderful. A doctor, two pharmacy students, a nurse educator, and a nutritionist meet three hours a week for four hours a week with a number of clients, and various aspects of health are discussed. During the conferences, patients are free to consult one-on-one with the professionals. The problem is that this group education is available only to a select number of individuals and only to English-speaking clients. There are nine clients in the group. This program needs to be expanded. Spanish-speaking groups could be conducted with an interpreter present.

Another problem is patients missing appointments. The diabetes educator may sit an entire day with only some patients showing up. The patients do not even call to cancel the appointments. This is a waste of resources. An assistant should be assigned the task of calling up patients to remind them of appointments.

Acts as change agent in advocating to appropriate healthcare resources for client/families. I believe that there should be centers available for the undocumented Hispanic immigrants to receive training in diabetes self-care, education in diet and other aspects of lifestyle, and guidance in where to receive low cost medical care and pharmaceuticals. The Mexican government through its consulates should contribute towards the care of immigrants from that country, especially of the undocumented. Health insurance could be made available to those who have immediate family residing in Mexico. I would like to learn how to influence elected officials in this regards.

Conclusion.

The magnitude of the contribution that Bellevue Hospital Center is making toward society, and its approach towards providing quality care to all without question of income or immigration status is a humanitarian gesture that is rare to see. I am proud of the city and state that I live in that supports such an institution. I am impressed with the nurse educators. One nurse educator, working there for 35 years, has just retired. She and a doctor were reminiscing about how many people they helped over the years. These professionals are true humanitarians devoted to the people. Above all, clients need to be helped to help themselves. Whatever lifestyle improvements can be made should be. More can be done in this direction even though it is complicated to address lifestyle. It is much easier to talk about the details of medicines. There is broad, evidence-based knowledge available about diet and physical activity. Nutrition does not only have to be the purview of the nutritionist.

This semester’s clinical experience has given me the desire to continue in the field of community health nursing.

 

 

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