Narrative Self-Reflection
My clinical took place on Wednesdays between the hours of 8:30am and 12:40pm at Greenpoint Community Health Center, an affiliate of Woodhull Medical Center. It was based in a community in which a majority of the population were of Polish, Russian, or Hispanic culture. It was a very busy location, and I had the opportunity to participate in many of the daily operations, which I found to be quite interesting and fulfilling. I had very rarely visited the neighborhood in which this site was located, so I found the new area very intriguing and stimulating.
Objective 1: Demonstrates individual professionalism through personal behaviors and appearance.
I maintained patient confidentiality by providing patient privacy during assessments and discussions with patients. Space was very limited at my clinical site, but my tactics to ensure privacy and maintain confidentiality included keeping room doors closed or drawing curtains. Furthermore, while in the waiting area, patients addressed by a number which prevented knowledge of their names.
I assumed responsibility for my own learning during my time at Greenpoint Community Health Center by asking questions and familiarizing myself with the sites policies and procedures. There were several times I came across or overheard discussions about procedures, diagnoses, medications, and treatments that I had no previous experience with, so I would inquire with another nurse. Many topics and issues that were discussed during staff meetings that were unique to community nursing, so I had to investigate these differences and become accustomed to working in this setting. My preparations for clinical learning included completing all assigned readings prior to attending clinical, and clarifying my understanding of the content covered, as well as, jotting down notes and questions throughout the day to review prior to my next visit.
All of my assignments were completed within the designated time frame. I focus on each assigned task and complete each in a timely fashion. If I had difficulty progressing with my assignments or found it difficult to do so within a certain time frame, I would seek guidance from another RN at my facility. As previously noted, I would attend a staff meeting at the start of each clinical day, which would include the RNs, physicians, and administration. Existing issues, planned solutions and future goals were the objectives, and on occasion there would be a visitor from central office to discuss newly implemented policies or procedures and provide the staff with in-services. I learned a lot of useful information about community nursing during these staff meetings, and gained a realistic insight into the realistic relationships that exist between staff members.
Each clinical day I would arrive at least 15 minutes early, so I had time to look over notes and/or questions that I may have had from the week prior, to better equip myself with the days proceedings. I take pride in my appearance, making sure to wear professional clothing – slacks and a blouse – with my hair tied away from my face, donning minimal jewelry and makeup, and with nails clean and appropriately manicured. I maintain a good sense of hygiene, and presented myself in a professional manner to both staff and patients.
Objective 2: Employ analytical reasoning and critical thinking skills when providing care to individuals and families in the community setting.
Opportunities to perform client interviews on my own were slim, but when I did I would collect client information from numerous sources, including existing medical records, and other RNs. I never used physicians or family members to collect client information on my own, but I did have many opportunities to observe other RNs do so. I assessed the developmental, emotional, and cultural influences on client’s health status, which ranged from infants to those over 65 years old. The wide age range allowed me to recognize the impact of the level of development with only minimal difficulty. Unfortunately, I never performed a full spiritual assessment because of time constraints, but would quickly inquire about their beliefs and acknowledge any representative items they may have been wearing. I would inquire about the different religions commonly seen at this site with fellow staff members. Many of the clients practiced Catholicism or Judaism, the latter being still somewhat unfamiliar to me, so I had to continue to research information about it.
Since the ages of clients were spread out over such a wide spectrum, self-care needs were very diverse. I was able to inquire about the self-care needs of clients I had the opportunity to assess, which I did by speaking to the client, the client’s family member or caretaker. I inquired about physical activity levels, and their abilities to walk, bathe, cook, and feed themselves. If I recognized discrepancies, I would inquire about what changes they could implement that would be helpful, and tried to identify any other needs. I did not have the opportunity to assess a new patient, which is when a comprehensive assessment is done, and my time with returning patients with was very limited, and policy only permitted focused assessments. Returning clients were assessed for “high-risk” diagnoses, including hypertension, diabetes, and depression. All other returning clients, those visiting for follow-up appointments were seen by the PCT’s for vital sign measurement and then by their physician.
Data collected during assessments often dictated my next move. Patients who were showing acute symptoms and high-risk patients (returning clients with a history of hypertension, depression, and/or diabetes) were of first priority. My nursing interventions were always overseen by another RN, so my interventions were in conjunction with hers. We would discuss different options and work as a team to arrive at an ideal selection, which frequently was patient teaching about hypertension and diabetes. Time constraints made teaching difficult, so I had to practice delivering the needed information in different ways to find the best way of doing so. My assigned facility did not permit me to administer medications to clients, but I did get to observe other nurses do so. Many patients received vaccines, and had their blood glucose levels monitored. I had the opportunity of observing several different RNs administer medications and each had a different style. There were a few medications that I was not familiar with, so I would ask about them and take into account the different routes and administration sites. Each time I performed patient teaching I would confirm their understanding by asking them to reiterate the information I provided them with. Over the course of my weeks at Greenpoint Community Health Center, I have had to reevaluate my patient teaching tactics and continuously adjust to find the best fit for my patients.
Several staff meetings about maintaining personal and patient safety were held while I have been working at this site. On my first day, I was oriented to the safety policy, the location of alarms, and fire exits and extinguishers. I had the opportunity to experience fire and safety drills that were implemented by central office. Staff was also in-serviced by Hospital Police on patient violence.
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 communicated therapeutically with the individuals and families at Greenpoint Community Health Center by making sure to be present during each interaction. I would do my best to provide them with privacy, but it was very rarely quiet. I would sit across from my clients, and maintain a calm, positive demeanor would often help them feel comfortable and engage them in conversations. I would adjust my eye contact with them accordingly. I found many of the male clients I interacted with would avert their eyes during discussions about their health. Language proved to be a communication barrier at my facility because many of the clients speak Russian, Polish, or Spanish. I relied heavily on other nurses who were fluent in these languages to actively communicate with numerous patients. This site is only equipped with one CyraCom phone, so it made sense that many of the staff were fluent in the common languages spoken by the clients.
I have consistently communicated with my professor, peers, and the healthcare team on a weekly basis. I have shared clinical experiences and my many concerns, issues, and have asked many questions. Communication with my peers and professor has taken place in-person, over the phone and by email. My communications with the health care team, as well as, any interaction with clients has been strictly in-person. All significant data was communicated to the healthcare team, such as the new identification of a high-risk patient or the identification of an unknown medication. The various age groups called for ability to communicate effectively with different developmental levels, however, many of the clients I worked with were adults. There were several times that I had to communicate with younger individuals and those over the age of 65, so I needed to adjust my word usage, tone, and speed accordingly. I was unable to actively document due to facility policy, but I was able to observe the use of QuadroMed, the electronic documentation system. Several nurses also took the time to show me how to access this system, navigate it and document the different information.
Objective 4: Establish environment conducive to learning and use a plan for learners based on evidence-based practice.
Most of my nursing interventions were to plan and teach about the facilities common high-risk issues, specifically diabetes and hypertension. Due to the time constraints I would often ask these clients what they knew about their diagnosis, and then plan my teaching around their existing knowledge. I would reinforce all of the information, but focus more time on what was either totally unknown or not fully clear. I would also have to plan to have an interpreter if necessary, which was often a fellow nurse fluent in the client’s primary language. Space was limited, but I would try my hardest to provide clients with an environment that was conducive to learning in a limited amount of time. Each time I would provide them with a seat in front of me, and draw a curtain for privacy. The curtain would muffle some of the noise, but it is almost impossible to provide complete quiet, so I would have to adjust my tone accordingly. It is imperative to ask the client to repeat the information provided and demonstrate any procedures for evaluation of their understanding.
Objective 5: Utilize informational technology when managing individual and families in the community.
I didn’t have the opportunity to work directly with the client’s electronic records, but I did observe the use of them and was given tutorials on how to enter and find data. It was important to maintain strict confidentiality when using the electronic client records, therefore all screens were donned with screen protectors and all nurses and staff made sure to lock the computers when they were done using them. Each computer was locked with a password that was unique to each staff member and requested each use.
Objective 6: Demonstrate a commitment to professional development.
When I would plan my teaching lessons about diabetes, hypertension, and depression, I used the information that was provided in the most updated databases. I made sure that the information discussed correlated with the data provided on the informational brochures provided to the clients. I keep myself updated about treatment modalities by doing research – nursing databases, textbooks, and information booklets. The healthcare industry and clients are ever changing, and it is my responsibility as a professional to remain updated with the latest knowledge and information so I can provide adequate, quality care.
I continuously evaluate my knowledge level, skills and interactions with patients. Each interaction is unique and I take something away from all of them. I use my past experience to think of ways to make future interactions more productive. This clinical experience had made me aware of the many differences in nursing within the community, specifically the many challenges – limitations in space and resources, time constraints, healthcare teams that may be lacking, etc. – and I have adjusted to these changes, but I have much more learning ahead of me. I know that I must remain open to the possibility of ending up with a job in the community, therefore I have remained committed to learning about, experiencing, and adjusting to the different challenges presented in this setting.
Objectives 7: Incorporate professional nursing standards and accountability into practice.
I am slowly learning all of the standards set by the American Nurses Association, and incorporating them into my clinical practice, especially within the community setting. I am extremely cautious with remaining within my scope of practice, which can be difficult at a community clinic. I was provided with the facility’s expectations in the beginning of my semester, and am being continuously monitored for my compliance with their set standards. I have not had any personal issues thus far.
I maintain accountability for all of my actions at my facility. My performance has not been perfect, especially since I do not have much experience working in the community setting, but I have taken responsibility for my shortcomings and have been actively working to strengthen my skill. One of my issues that I have been working on is my ability to communicate actively with clients that do not speak English or use it as a second language. In the beginning, I used to be very uncomfortable – because I could not speak their language and because I was in their community – but I have acknowledge my deficits and have been working to become more comfortable. I have become familiar with the translating services provided by my facility.
I am aware of the clinic’s mission, which is the same as the other facilities that are part of the New York City Health and Hospital Corporation. It is committed to provide equal, quality care regardless of ability to pay, as well as, “promote and protect,” and to work actively with other heath care workers and within communities. I feel I have done an adequate job extending this mission into the community and to the clients I have worked with.
Objective 8: Collaborate with clients, significant support persons and members of the health care team.
I actively work with other members of the health care team to address client problems. There have been issues with medications, understanding diagnoses, and deciding on treatment modalities. I have worked alongside other RNs in passing this knowledge to the physicians and working with the client directly to strengthen their knowledge, understanding, and confidence. I was not allowed to coordinate the client-care on my own, but I would do so alongside another RN. Occasionally, patients saw PCTs for vital sign measurement and would then meet with the doctor. However, if a client was experiencing acute symptoms, documented as a “high-risk” patient, or “special needs” then they would have to meet with an RN for an assessment prior to seeing the physician. Also, each patient was offered HIV testing by the RNs and would be sent to the phlebotomist if interested. There was an AIDS/HIV counselor on-site to better address any questions or concerns. I met with her in my first weeks at Greenpoint Community Health Center to get a better understanding of the resources she provided to clients. However, if a patient reported to be HIV/AIDS positive or received a diagnosis at my site, they were referred to another facility that has staff specifically trained and equipped for teaching and treatment.
I had many opportunities to hear other RNs discuss the different resources within the community that were available for clients. Most of the time they were identified during patient teaching sessions, and included smoking cessation programs, weight loss programs, Narcotics Anonymous, and Alcoholics Anonymous. I spoke with nurses about new applications that were available on most smart phones that help track calorie intake and calories burned through physical activity. I suggested that they should be offered as options alongside more traditional methods and programs. My knowledge of the community is still pretty bleak, so I have never directly recommended community agencies or resources to clients.
Objective 9: Recognize the impact of economic, political, social and demographic forces that affect the delivery of health care services.
There are many gaps in the health care system that has become apparent while working in the community at Greenpoint Community Health Center. Things like time constraints, language barriers, and the unavailability and scarcity of updated resources in all of the needed languages seriously impact the quality of care provided by the health care team. These also negatively affect perceived care by the client. The limited space can make interactions uncomfortable and frustrating to both clients and providers. There have been numerous times at my site that frustrations were running high due to the lack of space and privacy, and it was clearly noted in interactions – both nurse-client and amongst staff.
Many patients who come in to receive vaccinations for either themselves or their children witness that the vaccines are coming from one of two refrigerators – one for those patients who receive Medicaid benefits, and one for those with private insurance. The two refrigerators have caused so much commotion amongst the clients – they often have worries and concerns that the vaccinations are not the same in quality – which has posed as a barrier in the nurse-client relationship.
My clinical site is in dire need of resources. Updated information brochures about common diagnoses, such as hypertension, diabetes, and depression should be available in each language that is commonly spoken by the facility’s clients. I have discussed options with a few local businesses in the area and visited two health fairs in search of help. I was able to obtain the contact information for some businesses and individuals that can provide the site with adequate resources, and they are more than willing to do so. I have provided my sites nurse manager with their information.
Overall, my experience at this location was a very fulfilling one. I had the opportunity to meet and work alongside many great people that were very kind and more than willing to offer me advice and guidance. I enjoyed being able to work within the community, especially since I had only previously worked within large, acute care facilities. I was surprised at how comfortable I was in this environment, and how quickly I was able to transition. Lastly, I really enjoyed the diverse atmosphere, and being challenged by both staff and the limitations brought on by working in a community setting.
