Professional Nursing 

Fall 2016

October 6^th of this year has marked one full year that I have been a full time nurse practicing in a medical institution. It has been both extremely rough and enlightening, as most novice nurses would agree, trying to get over that hurdle of newness while adjusting to a profession where so much is expected of you. In my nursing school, we were taught Jean Watson’s philosophy/model of caring. This philosophy of caring is how most people think a nurse should be, and in turn also what I expected of myself to project to the world at all times. I have learned that the practice of caring is very central to nursing, and the act itself also promotes health when “administered” meticulously to those who need it. While I appreciate Jean Watson’s philosophy and agree that as a nurse we are the absolute embodiment of the ideal; I have realized that my own philosophy has been centered on patience.

In my very first job, I worked on a very busy and fast paced medical step-down unit. During my evaluation, my head nurse who had hired me told me that I was not cut out for that unit because I cared too much. As brutally honest and contradicting to the profession as this statement seemed, she meant more good than harm and I took it as a compliment. I had what I saw most people lacked on the unit, and that was patience. The patience I had with my patients manifested itself as being caring. I disliked the idea of pushing medications and moving on to the next person, functioning robotically with no feelings. Anyone who has practice nursing clinically knows what little time is available to spend with each and every patient. This can become frustrating at times because that time being “patient” with our patients, we see as interrupting “more important” things such as documenting. This has become a very sad reality for most nurses.

I remember in high school one of my teachers would constantly tell us “patience is a virtue”. As I grew older I found myself repeating this saying but never truly understanding what that virtue was. However, later on I remember reading a book and seeing a quote by Aristotle that stated, “ patience is bitter, but its fruit is sweet”, this made a lot more sense to me and I agreed with it. Life requires us to be patient in all aspects of it, and it has become the philosophy that I have chosen to adopt in my nursing career. It is important to be patient because you never know the difference or impact you can have on someone’s life by taking that extra time.

I have come to realize that on my not so busy days, when life affords me the opportunity to spend the extra time with a patient by having more meaningful conversations or just overall being able to put my best foot forward, this is when I feel I am living up to my true potential as a nurse. I believe and value what I was taught in school, as well as the stereotypes and expectations that nurses try live up to, which is the theory of caring. However, I have also witnessed what stepping outside of oneself and giving that extra five minutes to someone who simply wants to be acknowledged can do. The capacity to tolerate this simple act is what being patient is all about. The best part about this is, most patients will recognize your efforts and commend you on them, letting you know the difference it might have made in their lives. This is what is important to me; and I hope to live as a nurse who has enough patience for her patients.

Communication in Nursing

Summer 2016

Journal #4

July 27^th marked a day that I will never forget. It was the day I experienced my first death of a patient. Rewinding back to two days prior, that previous Monday, was the day I had my first interaction with the patient. The interaction took place at Maimonides hospital on a Progressive Care Unit.

The patient was a 74-year-old male Jewish patient, who was under the care of another nurse on that Monday, July 25^th. I was standing by my district documenting my notes when a lady walked up to me asking if I can please help her father transfer to the bedside commode. I responded promptly even though I had heard previously from other nurses about how “nasty” of an attitude the patient had; and also that he had thrown a urinal at a nurse the week before. Regardless of this fact, patient care comes first. I walked into the room, which was filled with the patient’s wife, daughter, son, and father. The patient screamed “OH SHE CAN’T HELP ME, I NEED MY OWN NURSE.” I nervously smiled then introduced my self, and explained to the patient that his nurse was currently on a break and that I will help how I can. This patient was about 5 feet 11inches tall and about 230 pounds, and was extremely verbal about his feelings of not wanting me to help him. However, he kept saying he needed to use the commode as soon as possible. I kept on a brave face, and told the patient that I want to help and that I just needed to get him out of the tangled wires first. He repeatedly insisted that he did not want my help; his family however was very friendly and kept telling him that I was only trying to help. As frustrated as I was with this patient, I kept a smile on my face, which in my head would help the patient recognize that sometimes people really do want to help. I figured this gesture would slightly change his attitude, however it did not, so I kept detangling his wires. As I was about to help him up off the chair and on to the commode, his nurse walked in and said, “it’s okay Monique, I got it”. The patient then sneered and said, “I told her she couldn’t help me”, but the son was nice enough to say “thank you very much, we appreciate you trying to help”. I walked out of the room thinking to myself thank God he was not my patient. A lot of times as nurses, we try to put our best food forward, and the effort we make to be the greatest of help to others go unrecognized.

Two days later I got assigned to this patient. All I could think about was how ungrateful he was and how hectic my day will probably be with him. I decided to try my friendly approach, and hoped for the best. I walked in to the room to find the patient sitting on his chair looking out of the window. I introduced myself, and asked him how his night was. He responded calmly, and quite friendly, which I was taken aback by. For the next three hours, in between my assessment and administering his medications, he was making jokes with me and engaging in different “small talks” which was a complete shock to me.

That morning, the patient was scheduled for a procedure, and when escort came for him and we had gotten him onto the stretcher he began to have distressed breathing and kept saying he did not feel well, and was nauseous. To make a long story short, he became tachycardic, tachypneic, short of breath, and cyanotic and a code had to be called. 55 minutes later, resuscitation was not successful and the patient was pronounced dead at 12:26pm.

As I look back at this story, as sad as I get about it. I am most proud about how well I communicated with this patient. No one saw his death coming, and all people remembered him for was the bad attitude he had. However, I saw a nicer side him before he died, and I am happy that I did not let my previous experience with him change how I cared for him on that present day. As human beings we tend to want to treat people how they treat us, or we block communication and disconnect from our patients because of their “nasty attitude”. However God had his plans for that day, and I believe the communication that took place between my patient and I was great for the both of us. We learned about this in class, about our Mental Model, and how we often prejudge or treat people based on how they treat us or what we know previously know about them. However I knew better than to let this block my communication, so I did better.

PS: I later found out that the patient died from a massive pulmonary embolism.

Community Health

Spring 2016

Blog #3. NYSIM and Bellevue Hospital Centers, 462 First Avenue, New York, New York 10016. Wednesday, March 27, 2016, 8:00am – 12:00pm.

Before going to the NYSIM Center, I was somewhat apprehensive because I thought about all the times I had to work with mannequins for simulation in school, and how terrifying it was messing up in front of your classmates and the professor. However when we were told we were dealing with “live actors”, I also reflected on my previous experience during the associates nursing program working with actual people for simulation, which was essentially a fun learning experience. What I liked about the NYSIM experience was doing it with three other classmates, verses working by yourself or with just a partner. Working with more people left us with less room for mistakes, and had more minds thinking than just having one or two individuals thinking alone. This made thinking easier and less stressful because while one or two people were thinking of questions to ask, others were thinking of interventions to implement during this emergency situation. However, having a lot of people in a group can be just as bad as it was good. In one scenario, having a bigger group was not ideal because of the type of client we were dealing with. We lacked organization, and everyone was asking questions all at once and become flustered and ill prepared to help because the client was somewhat aggressive and overly demanding. As a team, we should have planned more appropriately and assigned different task to each member in the group to avoid not getting the job done and implementing the proper care. This proved to be our biggest weakness collaborating as a group.

My biggest weakness as an individual was assessing the situation without having in mind the background and history of the client. I was comfortable with the COPD, the asthma baby, and the cardiac clients; however, I was thrown off by the hypoglycemic client. I was too focused on her being hyperglycemic as the scenario stated that I paid less attention to the actual symptoms presented in order for us to implement care. This made me realize I need to sharpen my critical thinking skills as well as my “nurses common sense” awareness.

What I learned about myself was my ability to be the calm voice in chaos. I felt with the patients panicking about being out of oxygen and the mother being anxious about her baby, I was able to remain unruffled while repeatedly reminding the clients that they were safe and that help is on the way. In the meantime, my classmates were able to ask other appropriate questions about the client’s history and also assess the safeness of the environment.

I think it would be a great idea to include live actor simulation into the class curriculum for the future, however, I do not feel is it has to be done at the NYSIM center. I felt the professors played great actors for the scenarios, so having this done at the school can prove to be as good a learning experience as it was at Bellevue. It would also be some what “cool” to have group work where students come up with their own scenarios and play it out in front of the class, and have the class assess what illness or disease was being played out, and then working collectively as a group to give ideas on the plans and interventions that should be brought out in each case. This gives us autonomy as a class, and would make us less anxious about what to expect.

All in all, working and dealing with actual people makes a big difference than working with mannequins, and I believe it allows us to think better on our feet as if we were really in a community or hospital setting. Overall, I enjoyed the activity and the experience, and it allows us as students to feel more comfortable working with “real people”, helping us to gain the confidence we need for the working world.

SERVICE LEARNING PROJECT SELF REFLECTION

Clinical Site: Our Lady of Refuge Church

Objective 1: Demonstrates individual professionalism through personal behaviors appearance

During my clinical rotation at Our Lady of refuge Church at the weekly food pantry, my classmates and I conducted weekly blood pressure screening and BMI measurements. I maintained client confidentiality by complying with laws and regulations of HIPPA and the American Nurses Association code of ethics. As a patient advocate, I ensured privacy by speaking with and educating clients in privacy and away from the eyes and ears of other people partaking in screening. On our weekly recording sheet, we ensured that certain personal and demographical information was folded over and hidden, therefore, unseen by other clients. I assumed responsibility for my own learning by being aware of the pantry’s weekly objective, and also setting up the BMI measurement station. This was also a part of preparing for our clinical learning. My classmates and I would first meet with our clinical professor and the Community Nurse from Lutheran hospital to do a quick run through of what we would accomplish that day; as well as gather the products being handed out at the pantry and checking the nutrition facts to prepare for client teaching. Completing clinical assignments within a designated time frame is important because as a student, I am responsible for my works content and being accountable for handing it in, in a timely fashion. It is important as a new nurse to always seek the appropriate guidance, and I do so by turning to senior nurses (the community health nurse Susan, and the clinical Instructor Gellar); by asking appropriate questions, and gaining the proper knowledge, while implementing the proper clinical skills to ensure clients gets the best patient centered care. I participated in clinical conferences by answering questions, giving feedback, making suggestions, and working along with my student peers and volunteers at the clinical site. As a professional and a student, it was my duty and in my best interest that I was punctual in my attendance in accordance with the schools policy and I was certain to also put my best foot forward in dressing professionally each week, even though the food pantry was a very casual setting.

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

When providing care to the clients, we used simple interview to ask basic questions that focused on our objectives. Based on the answers the clients provided, we then employed analytical reasoning and critical thinking skills as far as obesity and high blood pressures were concerned. We did not have access to client’s personal medical records or direct contact with their primary health care providers. Upon assessment of the clients needs, it was apparent that culture and country of origin had a very strong impact on a client’s health status. Some clients believed that medications offered in the United States were not as potent and effective as medications offered in their country. So assessing barriers to learning was a big part helping our clients with noncompliance and achieving their maximum level of health. My classmates and I did not collect data as it related to our client’s self-care needs.  No complete head to toe physicals were completed on our clients, only blood pressure screening and BMI measurements. However, a few clients pointed out to us that they wish we had blood glucose monitoring at the food pantry. Prioritizing care based on collected data was crucial in our clinical setting. If a patient had extremely high blood pressure, we would ensure to repeat the measurements and emphasize the importance of complying with home BP medications, going to the emergency room, or following up with their primary health care provider. This went hand in hand with our nursing interventions, we would ask the patient about any related symptoms to high BP, educating on getting up slowly, and providing nutrition facts especially as it related to eating can meals which are loaded with sodium and preservatives. We did this in a safe and timely manner and with emphasis on follow up care, so patients can also recognize the seriousness of hypertension and obesity. My classmates and I did not participate in any medication administration. We evaluated nursing outcomes based on client’s feedback and improvement or lack of improvement based on weekly-recorded BP and weight measurements. This allows us to reflect on our practice, and lets us know if modifications are necessary based on our evaluations and progression in good health of client outcomes.  I instituted principles of personal safety in the community setting when helping patients to get on and off scales when measuring BMI. A lot of clients were elderly, and needed someone to help them with balancing when getting on and off the scale.

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

As a nurse, therapeutic communication is extremely important and necessary. It ensures that client feels comfortable with sharing their personal information with a “stranger”. It also enhances effective communication with individuals and their families because they become aware that we recognize them as a person and we want to act in their best interest. Listening, giving personal space, making eye contact, answering questions appropriately, and asking open ended questions made clients feel more comfortable and willing to offer personal information. It was imperative that we communicated significant data such as extremely high blood pressures to our clinical instructor and the community health nurse. They would then emphasize to the client the need to go to the hospital or follow up with their personal doctor. We adapted the proper communication skills needed, especially therapeutically, which enhanced care between the client and as student care providers. On our weekly recording sheet, we made sure to document what advice was given to the patient such as “follow up with PCP”, “continue medication regime”, “Continue daily exercise”, these interventions allows us to look back and ask clients what were their outcomes, and this lets us know how effective they were based on our evaluation.

Objective 4: Establish environment conducive to learning and use a plan for learners based on evidence- based practice

A formal teaching plan was not implemented to our clients, however teaching materials were handed out to clients weekly. This included nutrition facts based on food given out at the pantry. A cooking class was also conducted for the students and the volunteers. We learned how to make certain meals from foods that are given out at the pantry often such as beans and tomatoes. We were taught the benefits of these foods to pass on the information to the clients we serve. We also handed out a paper that had a list of senior centers in and around that neighborhood that they could visit to possibly become members of. Since a lot of the clients were from low-income households, we figured they could benefit from this service for free meals and daily activities. The environment was not very conducive to learning, but when clients were truly interested, we took the time to step them to the side and teach them whatever it was they were interested in learning. Often times clients were solely interested in receiving the food and leaving. Learning outcomes were established as the clients and families demonstrated the knowledge and understanding they gained from the information we enforced weekly.

Objective 5: Use informational technology when managing individual and families in the community

In our clinical setting, we did not utilize and did not find it necessary to incorporate principles of nursing informatics. All our information and data collected was recorded on paper and handed to the Community health nurse for patient confidentiality and data collection. However, we maintained strict confidentiality with client records, and teachings. This ensured their personal safety, and increased their desire to return for weekly screening, while sharing important information we need to provide the best care to them.

Objective 6: Demonstrate a community to professional development

 We incorporated current literature in planning care for our clients in the community setting by handing out up date pamphlets with information from the American Heart Association. Staying up to date ensures that we are enlisting the proper evidence based practice to our clients, keeping us confident in the information we provide. I assume responsibility for life long learning by continuing my education and keeping up to date on recent research and scholarly articles that support current care for clients. As a student and as a nurse, ongoing self-evaluation is needed in patient based client care. We have to continuously restructure how we handle patients and how we give them care based on the information at hand. Self-evaluation allows me to recognize my strength and my weaknesses and keeps me afloat of what I need to improve or what I need to continue to do. Knowing my strength and weaknesses helps me enhance my capabilities when it comes to applying my critical, theoretical, and clinical skills, which are all needed for my future within practicing this profession. Working in this community setting is helping me in my personal and professional development. I am not yet working independently, but it provides a framework and a blueprint which sets the groundwork upon which I accept the challenges to perform independently in the future. I am also well aware of the adjustments that are continuously made in the world of nursing.

Objective 7: Incorporate professional nursing standards and accountability into practice

It is extremely important that as a nurse we follow standards of clinical practice as they are set by the American Nurses Association; this entails providing adequate and safe patient care to the best of our ability and acting as a prudent nurse would. In doing so we foster the highest standards of care for the safety of the public. I believe I uphold these goals and standards, and I take pride in my responsibility and accountability that comes with the territory. I did this to the best of my ability, displaying much professionalism in my clinical setting. Working with Our Lady of Refuge associated with Lutheran Medical Center, the hospital’s mission is stated as “NYU Lutheran exists to serve its neighbors.  We are dedicated to caring for whole persons throughout whole communities.  As a stabilizing foundation for these communities, Lutheran is committed to meeting our neighbors’ changing physical, emotional, spiritual, intellectual and social needs”. I believe working with this elderly, low income, immigrant community mirrors the face of this mission, and we are exercising our power to help foster and meet the needs of this community.

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

At the food pantry, we did not get to collaborate with members of an interdisciplinary team; however we worked with volunteers who handed out canned foods and green produce, we worked alongside with Susan the community health nurse who is aware of the populations needs and shortcomings, in addition to this we worked with the person who applies for city grants and orders the food for the pantry. As “visitors” we had to be open minded, and allow them to show us how everything is done, before lending a helping hand. At the end of the day, each person working in the best interest of the clients had one goal in mind; and we were all able to collaborate effectively in achieving these goals. Our effective collaboration afforded us the opportunity to help meet patients needs by teaching about Hypertension and non compliance; with our therapeutic interventions, we were able to coordinate the best client based care we could implement. Most of the clients who visited the food pantry stated that they had primary care providers, and often told us when they last visited or when they will visit their doctor. A few clients were skeptical of telling their personal information, but we often informed them that if they needed emergency help they could not be turned down by community hospitals. Our main goal for this service learning project was to help facilitate these clients in being more compliant with medications secondary to hypertension, helping them make better meal choices with the food options offered at the pantry, and teaching them how to be partners in their own healthcare. My classmates and I achieve this through weekly reinforcement and education. The more we encouraged clients to take part in their healthcare, the more they stayed on top of weekly screenings. Even though they had no control of what foods were available at the pantry, we encouraged them to watch serving size, and ways to decrease sodium intake in certain canned foods. Most of them were receptive to our teachings. Within the first month of screenings at Our Lady of Refuge, we thought it would be a good idea to hand out Senior Center information to the clients. We thought this would be a great community agency for them to connect with because it also provides food and a place to be involved with other members of the community on a daily basis.

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

We must accept that there are numerous gaps in the healthcare system. Delivery of care is disrupted by many reasons, they include but are not limited to household income, immigration status, lack of health insurance, age, language barriers, mental and physical disabilities, preexisting morbidities, socioeconomic status, location, and the biggest one is lack of correct information. To overcome these disparities and close in on these gaps, we must inform the public. Providing the proper education in promoting self-wellness and living healthy lifestyle is the most effective way to ensure that the less fortunate can overcome certain disadvantages. As a patient advocate, as stated above it is my job to help inform the public and act in their best interest. This is all apart of providing high quality patient centered care.  It is extremely unfortunate that certain individuals lack the help they need because circumstances keep them from getting the resources they need. Health care providers must work alongside politicians and community leaders to lobby for patients rights and resources. Health care providers are at the forefront of the fight for equality in healthcare, and it is with this knowledge and power can the pendulum be swung in the right direction.