Clinical Narratives

Clinical Objectives Narratives

Narrative Self-Refection

Michael Brown

Introduction:

I would like to share with you the course of my clinical experience. Over the course of my 15 week journey at the Cumberland Diagnostic Treatment Center, located in the Fort Green section of Brooklyn, I had the opportunity to learn, teach, lead and follow. I learned a great deal about a community and people in need. I taught some very receptive clients about self care and the importance of managing their clinical conditions. I was able to lead by providing demonstrations in the use of medical equipment ( Accucheck  devices, sphygmomanometers etc.) that, in turn, enabled the clients to become empowered and take control of their conditions. I followed by listening as they shared with me their personal journey, describing their struggles and triumphs along the way. During this time, I achieved the 9 objectives outlined below.

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

This objective was achieved out of a constant diligence to and respect for my patients, and out of a sincere determination to uphold the dignity of my profession. In the clinical setting there was clear evidence of how vulnerable our clients were. Some clients came to the clinic with a reluctance to fully disclose their health state. However, as we developed a professional and empathetic relationship, trust was built. As the trust between the client and clinical team grew, so did the willingness of the client to share more completely their illnesses as well as their life’s journey. Maintaining a professional rapport but cordial with my clients allowed me to gain a more complete history and thereby advocate for appropriate care. The setting was always quiet and confidential. The nurse that I shadowed, was always mindful of the patient’s right to HIPPA. She displayed a level of professionalism that was well recognized by the patients and staff alike.

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

Providing care to such an eclectic group with such a wide range of conditions can be challenging. Out of those challenges however, came vast learning opportunities. One of those opportunities came in the form of client “X”,  a 39 year old African American male of Caribbean descent who arrived in the Unites States over 8 years ago. He came to the clinic with a complaint of generalized weakness, 30 pound weight loss in the past 6 weeks and loss of appetite for the past 3 weeks. He also stated that he had been living with different friends for the past 3years but was now living in a men’s shelter as of 6 months ago. He had not seen a doctor since the time he arrived to this country. He appeared dehydrated, with dry skin and sunken eyes. His only form of identification was a weather  worn pass port baring his picture and a partially eroded date of birth. He had no insurance but desperately needed medical care. Another challenge was to get him the needed insurance without a fully readable form of identification. In seeing the seriousness of the clients condition, we took the opportunity to engage the care manager and physician in order to expedite treatment and care options. As result of the great efforts of the care team, the patient was provided the urgently needed care. In addition, the persistence in ensuring that the client received a complete work up was crucial. The results of tests done revealed that he had full blown AIDS but is now been provided full insurance coverage and has been placed in a setting where he is being given the utmost care.

OBJECTIVE 3: Effectively communicate with diverse groups and disciplines using a variety of strategies regarding the health needs of individual and families in the community setting. 

            Effective communication has been essential throughout not only the course of my clinical but in every aspect of everything I do. Communication is the common thread that ties us to the varying needs of the variety of patients we encounter. At times, I have had to exercise the use of the CYRA com phone system in order to clearly give and receive information to and from the clients. The CYRACOM is essentially a language bank that is accessed via telephone. The licensed interpreters translate medical information to layman’s terms to the patients. This is among the few acceptable means of communication between the provider and a client whose dialect (language) may be different from English. Other means of providing information to and receiving information from the client included demonstrations and return demonstrations as well as verbal feed back in the form of explanation of the information provided. The clinic also had take home items that assisted patients with compliance. A pill box, for example, was an item that was provided to and elderly client in the early stages of Alzheimer’s. She arrived with her daughter, who stated that her mom had a forgetful tendency and would sometimes miss taking her medications. In realizing the potential danger and the opportunity to provide something that would benefit this client, the nurse gave the pill box to the client and provided instructions to the daughter and mother on it’s use. On return to the clinic the family was very appreciative, and boasted that medications were now being taken on time without missing a dose.

One of the critical things recognized when communicating is understanding where the client is at the time communication is being attempted. At times I’ve had to stand in silence while the client gathered themselves. The patience and understanding displayed more than paid off. As a result of attempting to understand, not just the immediate complaint but the client as a whole, much more was gained from the experience. A trusting relationship was developed because the patients understood that I cared about them, not just the sum of their complaints. By taking into account their individuality I was more easily able to dissolve barriers and get to the heart of the matter.

OBJECTIVE 4: Establish an environment conductive to learning and use a plan for learners based on evidence-based practice.

Once the communication barriers were dissolved, a constructive plan for treating the client’s health condition could be established. Through the use of evidenced based practice (Best Practice), we were able to select specific treatment regimens that catered to the needs to a particular client. Because the prescribed care plan is supported by clear evidence we were assured that with compliance to the plan, a return to optimal health would be achieved. Through the teaching techniques employed, demonstrations, videos and distribution of pamphlets, the patient provided the necessary feedback that were clues to the provider about the likelihood of compliance.  Instructions were provided in a quiet and private setting free of distractions. The clients were allowed to express themselves freely and ask questions accordingly.

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

The system used at Cumberland Medical Center is Quadromed. It is a computerized integrated medical record and documentation system. We were able to access pertinent medical information and facilitate the coordination of clinical services. The computerized system allowed for clinical appointments to be immediately made after a patient discharge. Although some appointments were not urgent, the convenience to the patient was that they did not have to go to another area in order to have an appointment made.

OBJECTIVE 6: Demonstrate a commitment to professional development.

            I believe strongly in the development of my profession. I have returned to after not taking classes for over 7 years. I am determined, and yes committed to following this journey through to the end. I endeavor to inspire and I will challenge my peers who have been hesitant to take the leap, to not only get their feet wet, but dive full on and surface with a degree higher than the one they started with. I am grateful to those who believed in me and to those by whom I am inspired. I had the pleasure of conversing with a certain professor who said “You have a quality. You should consider teaching. You can make a difference.” The sentences are not very long in words, but I assure you,  they are immeasurable in their impact. It is my belief that you are no better to your self until you’ve made a difference to someone else. Through a commitment to my personal professional development I can in some way assist in clearing a path to help build my profession overall.

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

Over the years I have seen just how important it is to exercise the use of nursing practice standards to guide actions when caring for those we serve. Often times complaints are generated and these usually stem from non-adherence to those standards. It is refreshing to see how well versed my colleagues in the Cumberland Diagnostic Treatment Center are, and the attention paid to clinical excellence. In spite of staffing challenges the commitment to the clients is undoubted. As I participated in the care of the patients, side by side with my colleague RN, I watched as she implemented her plan of care with a careful precision and quiet dignity. I was proud to be a nurse all over again. She exemplified the best of us and showed just how much our ANA guidelines mean to our profession.

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

            As I reviewed the heading, I realized just how often and how seamlessly these actions occurred in the clinic during my time there. One of the more pronounced times of course, involved our client that experienced the significant weight loss, loss of appetite and was subsequently diagnosed with the AIDS virus. Although the findings were unfortunate,  the finding was without question…life saving. The rapid action of the RN, MD, Social Services and yes the billing department, helped to foster a smooth transition of a man without care to a client fully care for. That’s big. Kudos to the team. I am proud to have been a part of it. The elements of many of the things we spoke of earlier came into play to make this happen. For example, the was the use of technology to effectively communicate and collaborate with the care team and devise a complete plan of care guided by evidenced based practice and standards set forth by the ANA. This patient

benefited because we did what we do best. Provide outstanding care.

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

It is unfortunate but it is also the reality. There is a significant impact to the care and services provided to the residents of this clinic. By it’s nature, the Cumberland Clinic is a care center that serves the underprivileged. It is a clinic dead in earnest, quietly suffering their own ails. While we often sway to mention the impact of economics and politics on the clients, we must, at least from time to time, recognize the impact on the dedicated staff that serve this community. Staffing challenges are a big factor in the administration of care to the patients. Nurses are expected to do more with less and maintain the same high standard of care at all times. For the short term this might work, but in the long run both provider and patient could potentially suffer. The external as well as the internal customer must be taken into account in order provide optimal sustained care. There stands the chance of burnout on a large scale if staffing targets are not adhered to. The socioeconomic and political influences have already impacted this facility greatly. I recognized that, from time to time only provider was available for a more than 4 hour span during the morning clinic hours. The nursing staff also worked short on a daily basis. I was glad to have been able to provide the much needed assistance to my colleagues. Aside from the national politics that affected the clinic, the obvious internal politics made situations no less difficult. The hiring process described to me revealed gaps that left the staff at a great disadvantage. Staff that had retired for over nine months had not been replaced in spite of repeated request of the staff for additional help. Added to this, the influx of patients that steadily increased in numbers made situations even more taxing. The demographic breakdown consisted of primarily Haitian American, Caribbean American and to a lesser amount Hispanic American persons. All clients regardless of their circumstance were treated without bias. All but a few were insured by Medicare, Medicaid or both. While there I saw no self pay customers. In essence, this resilient group, nurses, providers and patients seemed to show no sign of bowing to their circumstance.  The providers remain committed and the patients come back, both understanding of the situation, and appreciative of the professional high quality care provided to them.

Conclusion:

            This was yet another stop in my professional journey. It was my pleasure to have been able to share it with you. I have gained a lot through this experience. I have developed a deeper understanding and appreciation of what it means to be a community nurse. They are truly the front line and interface between the community and the hospital. The clinic nurse is deserving of a great deal of respect. Not only do they help, by delivering high quality care with professionalism to the members of the community, in the community, they do this with significantly limited resources. These experiences have definitely helped me to grow, professionally, but personally as well.

 

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