Leon Antoine RN, AAS
New York City College of Technology
NUR 4010 OL30 Fall 2015
Community Health Nursing
Dr Aida Eagues
November, 27 2015
Reflections Along The Way
Introduction
The following reflection is a compilation of thoughts addressing the clinical objectives while on clinical rotation at 190 Stanton Place, New York, NY 10002 and 255 East Broadway, New York, NY 10002. As a BSN student, enrolled in NUR 4010 HD22, performance at the assigned clinical sites was measured by the outlined objectives discussed below. The following is a reflection on the objectives, after ten weeks of interaction with the residents and members of the Community Access team, at the assigned location.
Objective 1: Demonstrates individual professionalism through personal behaviors and appearance
I have been told first impression is lasting so throughout my visit to the clinical sites I have maintained a casual professional look. This I think was important since it established a sense of organization and “got it together” if you know what I mean. At this stage, as professionals we are responsible for ourselves and to some extent others. So I maintained a self driven focus on task using the nursing process format as a check and balance to ensure preparation, timely completion and continuous self evaluation. All task were done on time, even though I felt at times they did not follow the path planned. This was so with not being able to accompany one of the resident to an optometry visit because of a prior engagement. Professor McGirr set me straight on this aspect of the job reminding me that motion in any direction requires the continued willingness of the client which changes with time. The clinical site directors have also proven to be an invaluable resource. Their advice and guidance, together with the instruction from the professor, have made meeting and dialoguing with the residents less formidable. Engaging with the clients made getting to the sites on time easy since you anticipated the outcome of the next encounter. Always, I arrived at the sites before time, however I would have to literally pull myself away and run to the subway station in order to arrive at post conference on time.
Objective 2: Employ analytical reasoning and critical thinking skills when providing care to individuals and families in the community setting.
The experience at the sites required wearing your thinking cap constantly. Coming up with a point of entry to engage the residents, keeping them involved and interesting, to me was always challenging. I tried not to undervalue the experience reducing it to an aimless discourse. Keeping the communication open and casual while at the same time assessing the information and engendering goal visualization to me was always the challenge. For example, while conversing with the client about her desire to stop smoking K2 and find a job. How was I to use her concerns as a entry point to also focus on her hygiene needs, (she looked disheveled) without discouraging future encounters. Or how do you help the client to refocus on stated goals when they fell off the proverbial wagon, after a profound affirmation of ceasing an activity they deemed harmful. These challenges were even made more daunting in an environment where the stated undesirable activity placed the client and you at risk. This was self evident in the case where the common meeting area was the site of smoking K2 and drinking alcohol amidst individuals under the influence of substance abuse. Despite caring for the client the need of personal safety trumped the goal of the day to have a tobacco harm reduction forum, we were out of there to return when the environment was much safer.
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.
Certainly, my communication skills were challenged in the diverse settings of the clinical site. It was not the comfort of reminisce with geriatric about their past or sharing the joy of new discoveries with toddlers. Each client entered the discourse with their own unique mental health challenge. Therefore, the level of dialogue had to be tailored to suit the individual’s needs. However, using open ended questions and occasionally summarizing what was said proved to be an effective strategy to keep the conversation going. At times, refocusing technique was important in keeping the discussion within context. What comes to mind is a round table conversation with three residents where one was obsessing about her mother “don’t play”, while another was interesting in describing her retail job experiences and the third was engaged in getting the female facilitator’s phone number. Refocusing the discourse truly required therapeutic communication skills, which at times was truly a challenge. Of course, communicating with peers, site team members and Professor McGirr was welcoming since the discourse was academic requiring very little therapeutic skills. This was the case since all parties were seeking the same common goal.Also, this was even easier when charting or reporting finding orally to the site managers.
Objective 4: Establish environment conducive to learning and use a plan for learners based on evidence-based practice.
4.Cognizance of the residents’ needs it was important to keep the learning objectives, of any planned learning activity, at a basic level. The residents, secondary to their history of mental illness, homelessness and substance abuse, would not be engaged by the formal lesson plan format. Therefore , an informal casual setting, usually at the lounge table, was preferred. At times, individualized 10 minutes chat sessions, focusing on the resident’s interest, was most effective. Monthly group forum, per the surveyed topic of interest was planned. Participation incentives, like gift cards , donuts and other snacks, were given to ensure attendance and encourage participation at the sessions. Through participation by open dialogue assessment of the goals were made possible. The tenets of motivational interviewing, mainly empathic listening, agenda(goals) setting and eliciting change talk were used when planning the various activities(session). Also, mere attendance was an achieved goal at our site.
Objective 5: Utilize informational technology when managing individual and families in the community.
The concern of confidentiality was pivotal to site directors and clients (even though they never mentioned it). The use of the Community Access Network as a means of acquiring and sharing information was helpful. However, Safe-guarding patient’s health information(PHI) was always reinforced and provided with the required attention at each sites. This was duly noted when the door was always shut when discussing any situation arising with the client during the week. This was adhered to through the complete anonymity of clients in reports at post conference.
Objective 6. Demonstrate a commitment to professional development.
Using Motivational Interview technique to engender changes was new to me. The overwhelming literature reviews on its use made me aware of the mass amount of evidence base practices waiting to be used by nurses in their clinical practice. Continuing educations has evolved into life skills studies which during this assignment was important. Using Cochrane data base has open up a virtual box of peoples, travels and discoveries along the way. To me this was one of the new challenges. Searching for evidences to support the thrust of the open forum or, to lend strength to the main observable community problem, has been tedious but rewarding as one learn to stand on the existing body of knowledge. It was good not having to reinvent the wheel and better to know you can rely on the ones’ who had gone before’. Their incites would be used to guide current and future nursing practice.
Objective 7. Incorporate professional nursing standards and accountability into practice.
Being summoned by a resident for a consult on entering the site, before even taking off my coat was a gratifying moment. I thought someone must be doing something right. Then the sail was deflated when the question was popped, ” can you lend me ten dollars?” Saying no, was the beginning of establishing professional boundaries. Yet, maintaining client-nurse relationship with these type of boundaries made it challenging at the start. The nurse persona went beyond the stethoscope, pressure cuff and the Q & A sessions. It was upheld by limits, boundaries, integrity, trust, confidentiality and veracity. Therefore saying no, with an explanation, though difficult, was possible due to the stated agency policies and nursing standards. Having ones decision validated by the site director, professor and peer made adherence to the stated standards easier.
Objective 8. Collaborate with clients, significant support persons and members of the health care team.
It was clear from the inception that the other members of the teams, at the transitional homes, were seeing the student nurses not as learners but as participating team members. This meant that in this arena suggested solution, from the nursing perspective, must be offered by the student nurse. At first, this was daunting but after the initial meeting with the residents and the sites coordinators some of the assessed needs became quite apparent. The needs for dialogue on the impact smoking habits, proper nutrition, compliance with follow up medical appointments and sexuality were identified on the top of the list. Therapeutic discussion both at a personal and group level was initiated. Residents were guided into identifying harmful smoking and eating related behaviors. Open discussion on smoking harm reduction, in a nonjudgmental atmosphere, was initiated. Goals setting guidance in all of the accessed needs was provided by the student nurse and other members of the team.
Objective 9. Recognize the impact of economic, political, social and demographic forces that affect the delivery of health care services.
Lower Manhattan, the area where the residents live, is going through a renaissance of sought. To live in this are requires greater income due to the increase prices. Since most of the displaced residents in the transitional communities received fixed stipends from social security they are at disjoint in their new high price neighborhood. This disparity is also reflected in their access to affordable healthcare. To alleviate the socioeconomic disparities requires rallying the stakeholders to see the residents as members of the community, not mental health junkies, and assists to improve their lives by having a tare pricing system supported by tax right off of the lost profit. Also, becoming aware of the complex Patient Protection and Affordability ACT (ObamaCare) and how it can best be access to meet the health care needs of the residents is mandatory. Honestly, as a student nurse at the clinical sites you could not help feeling inept when wondering how health care delivery could be brought to the homes of residents who often are non compliance with follow up visits with their PCPs. Is it possible to bring the proverbial mountain to their homes? The answer to this, and other teething problems, would solve many of the existing disparities experienced by this vulnerable population.
Summary
The assigned clinical sites, with all of the hurdles, is in a sense a microcosms of the challenges faced by the community health nurse. The student nurse is immediately exposed to the vicissitudes of problems faced by individuals with a history of mental health illness in their attempt to reclaim their rightful place in society.
