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Self Reflection for Community Health Nursing

Sarana Alexander Community Health Nursing NUR 4010 Section 8522 Spring 2012   INTRODUCTION As a matriculated student in the clinical component of Community Health Nursing within the RN to BSN program at New York City College of Technology, I attended clinical at Visiting Nurse Service of New York in Brooklyn. On the first day of Clinical, I was paired with a visiting nurse whom I shadowed in the field to observe her during the assessment of her clients. For the duration of clinical, I partnered with fellow students to complete field visits for assigned clients. The following objectives and ways in which I’ve met them, serves as a self reflection of the past weeks at VNSNY. Objective 1:    Demonstrates individual professionalism through personal behaviors and appearance. 1.  Maintains client confidentiality I adhered to HIPPA guidelines and ensured that screen saver was on or computer was turned off when leaving the work station. I also followed the policies and procedures of VNSNY such as utilizing assigned ID, password and pin number when using computerized documentation of client’s personal information. 2.  Assumes responsibility for own learning Read textbook, power points and referred to nursing journal articles in an effort to gain information that would guide my nursing judgment and assessment abilities as a Community Health Nurse. There were times when I viewed module/visual aid to gain further knowledge on diagnosis of my assigned client. 3.  Prepares for clinical learning Before doing field visits for my assigned clients, I reviewed their chart via the computerized system. For instance, if a client with diabetes was assigned to me, I would look at the past nurses notes, coordinator of care notes and plan of care to determine what the goal for my visit would be. Maybe the previous nurse charted that client does not have adequate knowledge about diabetic management, hence from this data, I can focus my visit with the client on diabetic teaching. 4.  Completes assignments within designated time frame The nurse Educator at VNSNY did a presentation about Mobility Assessment in the home and my Clinical Professor requested that we sent her an email, stating at least one objective of the presentation and how it was met. Whenever blogs were posted to our Lecture Professor via blackboard, a copy had to be forwarded to our Clinical Professor’s email. I submitted all assignments and blogs to my clinical professor, as requested, before the deadline. 5.   Seeks guidance appropriately Whenever I needed clarification or had an inquiry regarding clients care, I communicated with my instructor and VNS educator. 6.  Participates actively in clinical conferences I engaged in conversations and reported findings related to client’s health, with my fellow classmates, Clinical Professor and VNSNY Nurse Educator before and after field visits. 7.  Attends clinical punctually and in accordance with school Policy During the semester I reported to VNSNY office for the scheduled time of 8:30am every Wednesday. I had no lateness or absence. 8.  Dresses professionally I also adhered to the professional dress code of black shoes, black pants and white shirt as mandated by school Policy. Objective 2:    Employ analytical reasoning and critical thinking skills when providing care to individuals and families in the community setting 1.  Uses client interview, nursing and medical records, staff nurses and other health professionals to collect client information I reviewed the COC (Coordinator of Care) notes, demographics, Plan of Care via computerized charting for assigned clients. I interviewed clients and family members to gain information about client’s health status, social support, financial support and need for paraprofessional assistance. I also conversed with appropriate personnel at VNSNY and other members of the interdisciplinary team in order to gather client’s information. 2.  Assesses the impact of developmental, emotional, cultural, religious and spiritual influences on the client’s health status I was mindful of my own cultural beliefs to prevent biases and I respected the cultural practices of the clients because I know culture plays a great part in planning care for every client. In terms of emotional health, clients who were depressed, I ensured that they were compliant with medication regimen, they were keeping appointments with therapists and that they weren’t having any suicidal ideation. 3.  Collects significant data relevant to client’s self-care needs I observed clients in their home environment and interviewed family members in order to determine how independent of ADLS client is. Those who had a Home Attendant or any type of paraprofessional, I was able to inquire about the clients ability to perform self care and the level of assistance needed in order to develop a care plan specifically geared towards clients needs. 4.  Completes a physical assessment of selected clients I was able to perform head to toe physical assessment for each client. Vital signs were obtained and documented. The lower extremities especially of clients with heart problems (CHF) and those with diabetes were assessed for edema, temperature, color and skin integrity. Appropriate measurements were taken and recorded in computerized patient chart. 5.  Prioritizes care based on analysis of data All the clients assigned to my care, had many co morbidities, however priority was given to the fist diagnosis on the clients list, as per VNSNY policy. This method is used by the institution to assist nurses in knowing the priority diagnosis for their clients. However, based on my assessment in the home, if there are any changes to client’s health status or client needs teaching in another area, I would perform that role. 6.  Applies priority-setting in planning nursing interventions One of my clients had CHF as her primary diagnosis, therefore this was given priority. During the visit, particular attention was given to client’s ability to weigh herself, maintain a weight log and her ability to comply with medication regimen and MD appointments. 7.  Implements safe, appropriate nursing interventions in a timely manner My partner and I evaluated one of our clients with diabetes and dementia. We found out that the family has problems preparing medications and ensuring that the client takes the medications at the right time and as prepared by the family. We detected signs of care giver role strain and that client does not trust her children to give her medication. As an advocate and collaborator of care for this client, we requested a referral for behavioral health evaluation and the situation was reported to client’s regular nurse at VNSNY. 8.  Administers medications and treatments safely At VNSNY, I did not have the opportunity to give PO medications; however, I performed one wound care. Client had a decubitus ulcer on sacrum and needed skilled nursing care. I followed MD orders which stated cleanse with dermal wound cleanser and apply Tegaderm. The wound was measured, staged and assessed for granulation or necrotic tissue, tunneling and drainage. 9. Evaluates the outcomes of nursing care After each field visit, once I provided teaching to the client, I evaluated the outcomes of my teaching through return demonstration from client and also having them verbalize what was understood. This helped me to determine whether the information I communicated to the client was understood. 10.  Is reflective about practice. Modify client care as indicated by evaluation of client outcomes The following is an example of how I was able to modify care for one of the clients I was assigned to. From the prior nurse’s report, the client’s goal for the preceding nurse’s visit was to be able to perform the blood sugar test accurately and keep a log of readings. This client had diagnosis of diabetes and early stage dementia. I observed client performing the glucometer test and also looked at her log reports which were accurately recorded. Client was able to perform these tasks correctly, however we found out that client doesn’t trust her children with preparing her medication so the family has problems prepouring medications for client and ensuring that she takes the right medication. I spoke to assigned nurse for this client and a referral was sent to behavioral health and medications will be prepoured weekly for the client by VNS Nurse. 11. Utilizes principles of personal safety when working in the community setting I maintained universal precautions by washing my hands when entering and leaving clients home. I wore gloves when dealing with blood or bodily fluids. I remained very observant and aware of the areas I went to for client’s visits. At VNS we were instructed about bag technique, which I utilized in all my visits. 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. 1. Utilizes therapeutic communication skills with individuals  and families in the community setting I used therapeutic communication and active listening with clients. I maintained eye contact, paid attention to client’s nonverbal cues and used motivational interviewing to allow clients to make decisions without being coerced. 2. Utilizes appropriate channels of communication One of my client’s spoke only Chinese language and there wasn’t any translator available at that specific time in VNS.  I called client on the phone to schedule visit time but there was a barrier to communication. I remembered that one of my classmates spoke the language, so I kindly asked her to schedule the appointment for me and ask client whether it was possible to have a family member present who speaks English, to assist in translation. 3. Communicates clearly and effectively with instructor, peers and the health care team Throughout my clinical sessions at VNS, I communicated with all members of the interdisciplinary team regarding clients care. This included my instructor, peers, VNS educator, client’s regular nurse, therapist and physician. 4. Communicates significant data to instructor and the health care team One of my clients had diagnosis of decubitus ulcer on her sacrum, which required skilled nursing care. Based on my assessment and my measurements of the wound, there was discrepancy between my findings and the data that the last nurse documented. I informed my instructor and the VNS educator that client didn’t have one, but two ulcers with different characteristics than what was documented on clients computerized chart. We got in contact with the nurse and the clients chart was updated. 5. Adapts communication skills to the developmental needs of the client During every visit, I assessed client’s developmental level and literacy. I avoided using medical terms or jargons that clients would not understand. 6. Reports and documents assessments and nursing interventions accurately For every visit, I wrote narrative note on client’s computerized chart and accounted for all interventions, teaching, assessment and measurements performed. Before using my assigned pin to sign out of the system, every narrative note was reviewed and approved by the instructor and VNS Educator. Objective 4:   Establish environment conducive to learning and use a plan for learners based on evidence-based practice 1. Develops and implements a teaching plan for an adult and/or family in the community setting One of my clients had Guillan Barre, so I implemented teaching for client and his private aid. I was able to provide him with signs and symptoms that warrant immediate medical attention. Client was able to verbalize what he understood from the teaching. 2. Establish environment conducive to learning When providing teaching to client, I ensured that all distractions example the television was turned off to allow for an environment suitable for learning. If client had pets, especially dogs, I asked client to kindly put the dog in the bedroom or form some barrier between dog, client and RN. 3. Evaluates client/family learning outcomes Based on questions I asked clients, their family members and paraprofessionals, I was able to assess how much information they knew and in what areas more teaching was needed. Objective 5:  Utilize informational technology when managing individual and families in the community. 1. Utilize principles of nursing informatics in the clinical area All the medical records of client’s receiving services from VNSNY are computerized, hence on the first day of clinical the nurse educator gave a very detailed orientation to the program, especially since it was new and their own nurses were in the process of learning it also.The program is very intense but user friendly. I was responsible for charting all the field visits I did under the respective client’s computerized chart. 2. Maintain strict confidentiality with client records I adhered to HIPPA guidelines and ensured that screen saver was on or computer was turned off when leaving the work station. I also followed the policies and procedures of VNSNY such as utilizing assigned ID, password and pin number when using computerized documentation of client’s personal information. Objective 6.  Demonstrate a commitment to professional development 1.  Uses appropriate current literature in planning care for clients in the community setting I read textbook, powerpoints and performed literature review of nursing journal articles via MEDLINE OR PUBMED in order to gain information to assist in planning care for my clients. 2. Assumes responsibility for lifelong learning There is a large source of nursing information available through databases, journals and books. As a health care provider, I must stay informed and do research in order to find evidence based practice to support my clinical practice. 3.  Engages in self-evaluation  After every visit, I do self searching in order to identify my strengths and weaknesses and find ways to improve my professionalism and knowledge. 4.   Is committed to adjusting to the challenges of independent practice in community health nursing Community health nursing is very challenging since you’re independent in the field and sometimes you have to improvise and use critical thinking skills. However, no matter the field, we have to perform care for our clients and use our critical thinking and judgment.  Objective 7.  Incorporate professional nursing standards and accountability into practice 1.  Utilizes American Nurses Association Standards in clinical practice In order to provide quality care to my assigned clients, I ensured that whatever tasks or duties I performed was within my nursing scope of practice and that I followed nursing code of ethics. For example, I respected my client’s right to confidentiality and privacy, right to self determination and I always reminded myself that I am accountable for all my nursing judgment and actions. 2.  Complies with agency standards of practice I followed the code of ethics, I always tried to fulfill my professional responsibilities and I provided both individual and family centered care. 3.  Is accountable for actions in the clinical area There was one instance where my partner and I forgot to get the signature of the client during the field visit. We acknowledged that we forgot, took accountability for our mistake and reported it to the instructors. 4.  Is aware of the assigned agency‘s mission One of the VNSNY mission statements is, “To promote the health and well-being of patients and families by providing high-quality, cost-effective health care in the home and community.” Objective 8. Collaborate with clients, significant support persons and members of the health care team 1. Collaborates effectively with health care team to address client problems I communicated with instructor, peers, VNS educator, client case coordinator, nurses and doctors. One of my client needed assistance with medication administration, so I spoke to the regular nurse about possibly offering client service of prepouring medication weekly since client gets confused due to dementia and client doesn’t trust her children to prepour her medication. 2. Coordinates client-care based on client needs and therapeutic interventions Performed care and gave interventions specific to each client’s needs. For example, the clients who needed wound care; I followed the MD orders for that specific client. One of the orders for my client was written incorrectly so I intervened by speaking to the clients MD and nurse to clarify the orders. 3. Identifies health care resources for client/families One of my clients who have dementia is not able to take her medications correctly. The family usually performs that task, but the client does not trust her children to do so. As an advocate for the client, I requested that VNS get involved by assigning a nurse to prepour the medications weekly in a pill box which will make it easier for client to self administer. Client and family was also referred to behavioral health services. 4.  Guides clients/families to make appropriate lifestyle and treatment choices A 30 year old male client has ESRD. After assessing the client, I realize that his family prepares meals and assist with medication, so I decided to get the family involved in the teaching plan. I focused my teaching on diet and medication. Client and family were very appreciative that we focused on daily meal plans and what to avoid in his diet. 5.  Assist clients to make connections to other community agencies This objective was not achieved during my clinical sessions. Objective 9.  Recognize the impact of economic, political, social and demographic forces that affect the delivery of health care services 1.  Recognize gaps in care system As a result of this clinical experience thus far I’ve learnt how different types of insurance will affect the delivery of the health services that clients receive. The nurse has to be mindful of what insurance the client has because in that way she/he will be able to determine what services the client is eligible for. 2. Begin to identify solutions to complex problems in the clinical area I have encountered a situation where a client with Guillan Barre really needed PT; however he was having difficulty getting to his appointments at the outpatient clinic. I thought that a good solution would be to get Access A Ride services for the client. However, after reviewing clients insurance, and speaking with client’s coordinator at VNS, I found out that we could not him with transportation since he is not receiving PT from VNS. This was very sad, but I was told that there was nothing we could do in that case. I had to tell the client that he would have to continue taking a cab to his appointments. 3. Acts as change agent in advocating to appropriate health care resources for client/families There was one situation thus far where I acted as a catalyst for change. The client with dementia who doesn’t want family involved in helping with medication because of trust issues, I reported this to client nurse and was able to request prepouring services for this client. CONCLUSION During this semester, I had the opportunity to perform the roles and duties of a Community Health Nurse with one of the most prestigious Certified Home Care Agencies; VNSNY. I had the chance to fulfill most of the required objectives for the clinical component of this course. I found that the Lecture and clinical portion of this course was very cohesive because whatever was taught in class by the Professor was exhibited in clinical. My Clinical Professor and Nurse Educator at VNS were very supportive and made sure that we had the opportunity to be a CHN for an entire semester. As a CHN, I was an advocate, collaborator, manager, leader, Educator and a Researcher. I must say that it was a wonderful experience, resources were made available for us, professionalism was maintained and I truly learnt a lot about Community Nursing.