PROFESSIONAL E-PORTFOLIO REFLECTION
IRINA GLUSHKINA
Community health nursing is one of the oldest specialty nursing practices that combines professional clinical nursing with public health and community practice. The community health nurse serves as a liaison between the patients, their families, physicians, social workers and government officials. The nursing focus is in the community health is not an individual client and family but rather populations that imposes additional challenges for the nurse.
The goal of the community health nursing is to affect the health of the community, provide organizational structure and support to its members, and allocate resources. The nurse assesses the risks, plans interventions and addresses the needs of the community. Healthy community consists of the healthy citizens, therefore health and illness are considered not individual issues but community issues. Home health care is a big part of the community health nursing and serves to maximize clients’ independence outside institutions, decrease hospitalizations and rehospitalization and to minimize the effects of existing disabilities.
Community health clinical experience took place at the Visiting Nurses Services of New York, a home health care agency that provides a variety of services to clients in different communities. It was a great clinical experience combined with opportunity to work independently outside acute-care setting. Home visits posed many challenges to the nurse including transportation, availability of caregiver, resources and occurred in the variety of settings in the community. Documentation was an important part of home visits to ensure the proper quality of care and billing. Corroboration with other members of health care team was required to manage clients’ care. The following is the description of the met objectives in the community health setting.
Objective 1: Demonstrates individual professionalism through personal behaviors and appearance.
Maintains client confidentiality.
All patient information was kept strictly confidential during clinical visits and on the pre- and post-conferences. Patient- related issues were discussed only with the members of the health care team directly involved in patient care. Family members’ involvement in care was discussed with the patient priory. Documentation with sensitive information was collected on the post-conference. Electronic records were secured with the three lines of passwords changed every few weeks according to HIPAA compliance plan.
Assumes responsibility for own learning.
All aspects that required clarification regarding patient care, disease management, surgical procedures and agency protocols were discussed with the clinical professor and the clinical facilitator. Literature and textbooks were searched when needed for evidence-based practice methods to improve patient care and to maintain professional growth.
Prepares for clinical learning.
Pre-conferences were conducted before each home visit. During the pre-conference the case was discussed with the clinical professor, clinical facilitator and the fellow student. The main objectives were stated and the reason for home visit was clarified. On the post-conference the outcomes were documented electronically, the patient physical and cognitive status, family involvement were discussed, physician and other disciplines’ referrals were made accordingly.
Completes assignments within designated time frame.
There were no written assignments given during the clinical time.
Seeks guidance appropriately.
As with any other organization the assigned home care agency has its own procedures and protocols that are expected to be followed by all employees and students. During the orientation this policy was emphasized. Students were instructed to seek guidance at all times regarding any matter that needed clarification. For example, before answering patient questions about different types of long-term programs in the agency and the number of given hours for the home health aide, the clinical facilitator was consulted for additional information. Any skilled nursing in question such as permission to perform blood glucose stick or the wound care without physician orders first had to be approved and permission received accordingly.
Participates actively in clinical conferences.
Pre- and post-clinical conferences were among the most important aspects in the home care experience. In the pre-conferences, the patient information was given, the patient was contacted and informed about the upcoming visit, and the contents of the visit were discussed with the clinical professor and clinical facilitator. Two students made a visit alternating, conducting and documenting the patient’s care to allow for proper assessment and evaluation of each student. Active participation of both students in the pre- and post-conferences was required in order to make a visit, provide for sufficient documentation and to facilitate learning.
Attends clinical punctually and in accordance with school policy.
All clinical visits were attended strictly from 8:30 a.m. till 12:30 p.m.
Dresses professionally.
The dress code for clinical visits included white shirt and black pants. No sneakers, jeans or jewelry were allowed. I consistently followed the policy.
Objective 2: Employ analytical reasoning and critical thinking skills when providing care to individuals and families in the community setting.
Uses client interviews, nursing and medical records, staff nurses and other health professionals to collect client information.
All patient information was stored electronically, and visits were made with the computers to allow for easy access and storage of the data. Additional information regarding any changes in the patient status, insurance or hospitalizations, was obtained through direct patient or family interviews, physicians’, social workers or other health care professionals contacts. Primary nurses for the patients were contacted as needed to clarify any discrepancies. Home health aide agencies were also used to collect any missing data regarding the patient.
Assesses the impact of developmental, emotional, cultural, religious and spiritual influences on theclient’s health status.
Patient’s physical and cognitive condition depends on variety of factors that were assessed during the visits to modify the care according to patients’ individual needs. One patient with intellectual disability required continuous supervision, management of medications and diet. Teaching for this patient was limited, and the caregiver was additionally instructed on care. All elderly patients were assessed for signs and symptoms of depression that adversely impact compliance with treatment regimen. Culture was also taken into consideration because many patients used complementary and alternative medicine, folk medicine and were accustomed to certain diets.
Collects significant data relevant to client’s self-care needs.
During the assessment, all pertinent patient information was collected and recorded. This information included vital signs, any change in physical or mental status, change in medications, orders, follow ups with physician, caregiver availability, ability to perform personal care, instrumental activities of daily living and activities of daily living independently. The environment was assessed for safety. Based on this data it was determined if additional support was needed and how many hours will be sufficient to keep patient safe at home.
Completes physical assessment of selected clients.
All body systems were checked during physical assessment including cardio-vascular, neuromuscular, gastro-intestinal, genito-urinary and integumentary systems. Additional assessment was required for certain diagnoses such as congestive heart failure that included edema description and measurements, weight monitoring, heart rate and respiratory rate ranges. Patients with diabetes mellitus diagnosis required blood glucose measurements if physician order was present.
Prioritizes care based on analysis of data.
Home visits were done according to a plan of care and were based on nursing assessment. If the primary reason for a visit was wound care, then after complete physical assessment the wound care was performed. If it was nursing observation and teaching the nurse would instruct patient and caregiver on disease management, medication teaching and other issues.
Applies priority-setting in planning nursing interventions.
Nursing interventions were individualized according to each patient’s needs and the reason for the visit. There were no emergency situations during the home visits. In case of emergency ABC (airway, breathing, and circulation) would guide nursing interventions.
Implements safe, appropriate nursing interventions in a timely manner.
When the patient with the diagnosis of congestive heart failure gained more than 4 lbs. in one week, the physician was contacted and additional dose of medication was administered to the patient.
Administers medications and treatments safely.
All wound care orders were done strictly according to physician orders. If the wound care needed to be changed the physician was contacted and new treatment obtained. No medications were prepoured or administered during clinical visits.
Evaluates the outcomes of nursing care.
Medications managements and diet teaching, wound care and safety instructions and other teaching done at each visit were assessed continuously. Based on these evaluations the nurse would determine if additional visits were necessary reach the outcomes.
Is reflective about practice. Modify client care as indicated by evaluation of client outcomes.
The wound care was assessed at each visit and modified accordingly if the treatment didn’t facilitate healing.
Utilizes principles of personal safety when working in the community setting.
All students made visits in pairs, dressed appropriately without jewelry. Computers were kept in the bags at all times and taken out only inside the home. Standard and universal precautions were followed at each visit.
Objective 3: Effectively communicates 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.
Therapeutic communication skills were employed during all clinical visits. The patient had DM and was not compliant with life style changes that included adherence to 1800 cal ADA diet, medication regimen and exercise program. The patient was approached with the friendly attitude. The difficulty of the task was acknowledged. Patient was explained the consequences of non-compliance and informed that it would take time, motivation and help to complete adjustment. Family and friends were strongly encouraged to participate and assist patient with the task.
Utilizes appropriate channels of communication.
There is an organizational hierarchy in the agency to be followed by all employees. During the visit patient stated that she just came back from the hospital after the surgery. Clinical facilitator was contacted because the patient should have been placed on hold due to Medicare insurance to avoid double billing. Clinical facilitator contacted the Director of Community and Supervisor regarding further steps.
Communicates clearly and effectively with instructor, peers and the health care team.
On each pre-conference instructor assigned patient to two students and determined who will lead the team, do assessment and complete documentation. The leader would have to contact physician as needed, report clinical findings and nursing interventions to clinical facilitator and discuss the case with fellow student.
Communicates significant data to instructor and the health care team.
All minor and major data was reported to the clinical instructor and health care team. After surgical procedure wound care orders were confirmed with referring physician. Primary care physician was notified about the surgical procedure and patient status and follow up appointment was set up. Clinical findings were reported to the instructor and the clinical facilitator.
Adapts communication skills to the developmental needs of the client.
Physical and cognitive condition of the patients was considered during all visits. Diabetic teaching of the elderly client included short and simple instructions, limited use of terminology and frequent repetitions. On the first visit the patient was instructed on foot care, on the second on medication management in order to prevent information overload and promote compliance.
Reports and documents assessments and nursing interventions accurately.
All information was electronically documented including any changes in the treatment, phone conversations with physician or physician office, follow-ups, patient response to treatment, family involvement. All details or changes were included in the documentation to provide high quality of care. Electronic documentation allows viewing of the records from different locations.
Objective 4: Establish environment conductive 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.
Individual plan of care was developed for each patient based on diagnosis and patient’s physical and cognitive status. Patients with congestive heart failure were given weight log booklets to monitor daily weights, patients with diabetes were given blood glucose booklets. Teaching instructions were provided at each visit and reinforced on consecutive visits.
Establish environment conductive to learning.
In order to facilitate learning and improve adherence and compliance the nurse should establish environment suitable for learning. Patient’s physical and cognitive status was assessed prior to teaching. Caregiver involvement was encouraged at all times especially for patients with dementia. A patient with poor vision was provided written instructions with greater font, patient with hearing impairment required better articulation, slower speech and face-to-face position with the nurse. Patients who experienced pain were unable to learn and required pain management prior to learning session.
Evaluates client/family learning outcomes.
Learning outcomes were evaluated during the visit and reinforcement provided as needed. Patient newly diagnosed with DM required teaching on diabetic diet, medication management, exercise program, diabetic foot care. If learning outcomes were not met the nurse continued teaching, encouraged family involvement, assessed patient for a need of additional methods of learning.
Objective 5: Utilizes informational technology when managing individual and families in the community.
Utilizes principles of nursing informatics in the clinical area.
All data was integrated and computerized to assist nurses to manage patients in the community. The nurses work in the field with the computers, have uninterrupted internet access that facilitates decision-making in the community setting. Patient had a new medication. The nurse was able to use drugs.com and obtain up-to-date information on it.
Maintains strict confidentiality with clients records.
Students were allowed to use computers only during clinical visits and were required to return them after post-conference. Each computer was made to be accessible by only two assigned students. Each student had 3 personal passwords to enter the software and to complete documentation.
Objective 6: Demonstrates a commitment to professional development.
Uses appropriate current literature in planning care for clients in the community setting.
In order to ensure that care provided is based on latest evidence-based practice the nurse should engage in continuous professional development. Patient had great toe wound consisting of 100 % eschar. Current evidence-based practice suggests that eschar serves as a natural barrier to granulation tissue and should not be removed to allow for faster regeneration of new tissues. The wound care orders were discussed with wound care specialist and physician.
Assumes responsibility for lifelong learning.
Development of new technologies and evidence-based practice methods in the clinical settings required all nurses to maintain their professional status by continuing education, participating in the research, conferences, obtaining certifications and keeping up-to-date with current medical literature. I’m planning to apply to graduate school and become a public health nurse.
Engages in self-evaluation.
One clinical visit was conducted with the clinical instructor. After the visit was completed the student was asked to perform self-evaluation and identify areas that needed improvement.
Is committed to adjusting to the challenges of independent practice in the community health nursing.
There are many challenges that nurse faces working in the community health setting. All decisions regarding patient care are based on nursing assessment, availability of resources , physician orders and agency protocols. During the visit for wound care no place for preparation of wound care supplies was available in the cluttered environment and some supplies were not delivered. The nurse had to improvise and find a way to perform wound care using clean technique and use available materials to dress the wound.
Objective 7: Incorporates professional nursing standards and accountability into practice.
Utilizes American Nurses Association Standards in clinical practice.
ANA standards guided nursing care during clinical visits. All patients were treated with compassion and respect regardless of social, economic, personal attributes or the nature of health problems. Some patients lived in private houses, others in projects but all patients were treated in equal manner.
Complies with agency standards of practice.
Agency procedures and protocols were to be followed at all times. If the patient had PICC line and nurse went in to do wound care, according to agency protocols the nurse was not allowed to care for the PICC line site. It was responsibility of the nurse to contact the supervisor and arrange an appointment with the nurse who specializes in PICC line insertion and care.
Is accountable for actions in the clinical area.
The nurse was accountable for nursing interventions provided to the patient. Patient had a wound care. The nurse was accountable for performing wound care according to physician orders, assess the wound care healing status and contact MD as needed to change the treatment. The nurse was accountable for the outcomes of nursing interventions.
Is aware of the assigned agency’s mission.
The mission statement of VNSNY agency 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.
- · To be a leader in the development of innovative services that enable people to function as independently as possible in their community.
- · To shape health care policies that support beneficial home- and community-based services.
- · To continue our tradition of charitable and compassionate care, within the resources available.
Objective 8: Collaborate with clients, significant support persons and members of the health care team.
Collaborates effectively with health care team to address client problems.
Resumption of care was done after patient was released from the hospital. During the visit the nurse contacted the referring physician to reconcile wound care orders and medications and informed the patient’s primary care physician of surgical procedure patient underwent and current physical and cognitive status.
Coordinates client-care based on client needs and therapeutic interventions.
The patient had a wound and caregiver was not available to perform daily wound care. The nurse coordinated care based on current situation and arranged daily skilled nursing for the patient to perform the wound care.
Identifies health care resources for client/families.
The patient was homebound due to physical and cognitive status. The nurse arranged physician and psychiatrist home visits to accommodate the patient.
Guides clients/families to make appropriate lifestyle and treatment choices.
One of the goals in the community health nursing is the promotion of healthy lifestyle. The nurse implements nursing interventions to affect behavior. The patient with diabetes mellitus was instructed on disease management and strongly encouraged to make lifestyle changes to control the disease and to prevent serious complications such as heart disease, kidney failure, blindness and others. The patient was informed that adherence to diabetic diet, medication management and exercise program will postpone insulin therapy and prevent morbidity and mortality.
Assist clients to make connections to other community agencies.
Patients were informed that after a few months of CHHA short-term services the long-term programs were available. VNSNY offers a wide range of long-term care programs to accommodate patients’ needs including Lombardi housekeeping service. Patients were also instructed on availability of CASA government-based program for long-term care needs.
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.
Patients and their families were informed about the cuts affecting the reimbursement by Medicare and Medicaid insurances, growing numbers of managed care insurances that limited the services provided by health care professionals. Economic changes affected the number of physical therapy visits available to patients, durable medical equipment supplies, dispense of certain medications by pharmacies.
Begin to identify solutions to complex problems in the clinical area.
If the patient with complex health care needs had no available caregiver to provide assistance and supervision alternative solutions had to be found such as nursing home placement.
Acts as change agent in advocating to appropriate health care resources for client/families.
Patients who required assistance with obtaining insurance such as Medicaid were referred to social work department for help.
Community health nursing experience gave me a better understanding of people I provided care for. I saw places they lived and the way they lived. I was involved in the family dynamics and relationships. I realized what a great impact culture has on human behavior and how it affects health. I encountered many gaps in the health care system that limit the use and access to services for many people. Despite a variety of available governmental programs many are still uninsured and don’t have primary care physician. With this experience began my understanding of the concepts of community and health along with opportunities and challenges it faces.
