My nursing career began as a medical assistant/transcriptionist and proceeded to work as an acute care nurse in a community hospital. This was followed by home care and school nursing, to where I am employed now as a chemotherapy nurse in an outpatient center. During the past 22 years, I also volunteered within my community and internationally.
My volunteer activities included working with the Child Abuse Prevention Services from 2001-2003 educating children and school personnel regarding signs and symptoms of child abuse, the services available and proper protocol to follow when reporting suspected abuse. In 2002 I assisted in providing warmth, food, and encouragement to walkers participating in the Avon 3-day Walk for Breast Cancer. In 2009 I volunteered in my community as a member of the Long Beach Soup Kitchen, preparing and serving lunch to hungry children and adults. In 2013 I worked with Island Impact Ministries Breast Cancer Outreach in the Dominican Republic where I performed breast exams, provided education to the Dominican women, and assisted with breast surgery at Ricardo Limondo Hospital alongside other medical professionals from the United States.
In 2012, in my first role as a chemotherapy nurse in the outpatient setting, I procured my Oncology Nursing Certification through the Oncology Nursing Certification Corporation. This certification could only be obtained after spending 1000 hours employed in the oncology setting and passing a 3 hour exam which covers a vast subject matter of oncological nursing including, but not limited to health promotion, disease prevention, screening, early detection, advanced care planning, epidemiology, survivorship, end-of-life care; standards, scope and legal concerns; professional performance and quality of practice. etiology and symptoms, palliative care; psychosocial dimensions of care related to cultural diversity, including spiritual and religious concerns; financial concerns; body image issues; learning styles and barriers; coping mechanisms and social relationships; and support-related concerns.
My learning and experience in different settings have helped develop and shape my practice to what it is now. I have also strived to ensure that my experience is beneficial not only in collaborating with colleagues but also to enhance patient outcomes.
Standards and Codes of Professional Nursing Relevant to Community Health Nursing
Throughout my experience as a Registered Nurse (RN), I have learned the purpose and utilization of the standards and codes of professional nursing relevant to community health nursing. As a community health RN, I have learned to apply the American Nurses Association Standards of Practice and Professional Performance (ANA, 2010). As a community health RN, the standards are critical to providing quality care to the patients. My Associate in Applied Science (AAS) and my studies in pursuit of my Bachelor of Science in Nursing have enhanced my understanding and application of the standards concerning assessment, diagnosis, identification of outcomes, planning, implementation, and evaluation of care in the community.
With my first role in the healthcare continuum being a medical transcriptionist and assistant within a cardiology practice as well as in a gastroenterology practice, I employed both practice and professional performance standards. Being a witness to doctor-patient communication in the outpatient setting highlighted what I saw as a need for disease prevention education, and this aligned with Standard 7 of Professional Performance which states that an RN should enhance the quality and effectiveness of the nursing practice (ANA, 2010). While the doctors I worked with treated the patients with warmth and respect, they did not have the time to thoroughly discuss disease prevention, symptomatology, and lifestyle changes necessary to combat or prevent disease. As such, I utilized Standard 10 of Professional Performance which requires an RN to exercise collegiality by interacting with and contributing to the professional development of peers. Although I worked as an assistant, the treatment accorded by the doctors to the patients enlightened me on the standards to prioritize in my practice.
As I progressed in my career as a RN for a medical oncology unit in the acute care setting, I continued utilizing standards of practice adequately, advanced my knowledge through education and research and ascertained my evidence-based practice (EBP). At the time, the concept of EBP was not as common as it is now. In that role of hospital nurse, I was privy to the benefit of an interdisciplinary approach in the acute care setting. I learned to develop goals and work towards them for the best interests of the patients. From this part of my career, I discovered that communication, respect, patient autonomy, and adequate education are essential standards of practice that Registered Nurses should ensure in their practice.
Provision of Evidence-Based Care Incorporating Models, Concepts, and Principles Central to Community Health Nursing Practice
Progress in my career led me to home care and school nursing, roles that serve as the arch of my career in nursing practice. Serving as a homecare nurse for eleven years between 2003 and 2014 was an experience that helped me understand that cultural competency is a key concept in Evidence-Based Practice (EBP) to meet the diverse needs of the local population. EBP in community health nursing, based on my experience, is supported by cultural competency whereby the RN is required to be sensitive to and aware of the diverse cultures in the community. As a community RN providing home care, I anchored and developed my beliefs on cultural awareness which enhanced my cultural competency to enable me to provide care to this diverse population. In this phase of my career, I developed my standards of practice further as I realized that assessments were not only physical but also spiritual and emotional for them to be holistic. My experience as a home care nurse taught me the value in first establishing a trusting relationship with each patient and their family. I found in the acute care setting patients were more apt to be trusting of the nurses and doctors that came into their room. This blind trust of the RN did not apply to the home care RN, and I had to earn the patient’s trust by communicating, being compassionate and empathetic towards them.
Looking back, I believe that the difference between acute care and home care patients in trusting the nurses and doctors is based on the role played by the nurse as well as the level of dependency. In the acute care setting, patients are dependent on the nurse and feel more of a visitor role; whereas in the home, the nurse is a visitor to the more independent patient. Without the foundation of trust, my efforts at educating and advocating for my homecare patient were naught. As a result, I learned that trust was also a crucial concept in EBP since the basis of home care is on EBP interventions and patient-centeredness which focus on patient preferences, beliefs, and values. Observance of cultural traditions such as taking off shoes at the door, the act of looking or not looking a patient in the eye, appreciation of holistic treatments within the family, and observing a family's hierarchy will enable that trust to be established. To develop the trust, I learned to assess the patient and family routines, values, and beliefs, and respect them while trying to fit in for them to feel comfortable in my presence. The importance of establishing trusting nurse-patient relationship was solidified during my experience as a homecare nurse.
For me to ascertain my EBP, I had to practice strictly within the scope of my practice as RN. As such, I was not certified to prescribe over the counter (OTC) medications to patients, and I had to inquire with the doctors first. Although the aspect surprised patients, I had to develop a mantra by which I would work with as I progressed in my career. Similarly, I ensured that patient education was provided regarding medications or disease management and prevention not only to foster a trusting environment but also as an EBP concept. Patient education is critical to the continuum of care as it ensures patients are aware of what they are experiencing and the purpose of medications and treatments. As a home care nurse, I also developed the skill of treating patients with respect and dignity as key aspects for patient-centered care. Finally, as I ascertained my EBP further, I educated patients and families on disease prevention strategies such as handwashing, proper cleansing of soiled materials, and basic tenets of wound care to improve community health and wellbeing. I provided information regarding local resources available to the patient or to make appropriate referrals to local agencies. While educating the patient and family, I believe I was providing education for their community as well.
I discovered through my studies towards my Bachelor of Science in Nursing (BSN) that I naturally incorporate Jean Watson’s Theory of Human Caring in my practice (Yeter, 2015). I first learned of Watson's ten carative factors, also know as Ten Caritas, in my online studies and realized I was unintentionally utilizing them in my role as a homecare nurse. The ten Caritas represent the core concept for nursing and are based on knowledge, clinical competency, and the intention to heal. My nursing practice naturally incorporates Watson’s theory. The use of this theory in my practice is a good illustration of research-informed practice which is an essential concept in EBP. As an RN, nursing theories are critical to day-to-day practice and clinical decision making in providing patient care (Yeter, 2015). As a home care nurse, I realized that I had a primary role in providing quality and patient-centered care to improve patient outcomes, experience, safety, and satisfaction (Yeter, 2015). I believe Watson's theory and concepts are essential to community health nursing. Watson's Ten Caritas focus on the nurse, the transpersonal caring relationship, and the caring process. The caring process is equivalent to intervention, as it requires mutuality of both patient (family) and nurse (Watson & Brewer, 2015). Watson's caring process empowers the patient, thereby developing their self-care ability. Self-care is tantamount to disease prevention, and disease prevention is both a long-term and a short-term goal of the community health nurse (Yeter, 2015).
The concepts and principles in Jean Watson's Theory of Human Caring supported my EBP in nursing as a home care nurse throughout my career in community health nursing. For community health and wellbeing to be promoted, I realized that EBP and research are critical to identifying effective interventions to health problems experienced by the populations.
Collaboration with Peers, other Healthcare Professionals, and Community Members for Health Promotion and Prevention of Diseases
Throughout my career, I discovered that collaboration with peers, other healthcare professionals such as nurses and doctors, and community members was critical to improving health outcomes for the patients and the community entirely. I was involved in interdisciplinary teams that sought to enhance disease prevention and health promotion strategies in the community. Collaborating with the community members enhanced the understanding of the cultural beliefs and values that influence health in the community (Kumar & Preetha, 2013). As earlier noted, cultural competency is a crucial principle of EBP in a diverse community, and collaborating with community members made it easier to learn their cultural beliefs and values. I enjoyed the collaboration with the interdisciplinary team and community because every member brought significant knowledge regarding the patients and the community, which was essential for the improvement of community health. Essentially, health promotion strategies and initiatives were enhanced by the collaboration as every party sought to promote community health and wellbeing. Hospice nursing is where I worked most closely with the interdisciplinary team. I learned from the aides’ tricks to provide added comfort to the bedbound patient; from social work the priceless gift of silently holding someone’s hand; and from the pastoral team the blessing of praying with the patient/family; the hospice doctors explained the vain and oftentimes detrimental effect of eating when the body is dying.
Health promotion is primary prevention of the patient and/or community to avoid the display of illness or disease (Kumar & Preetha, 2013). With many years of nursing practice as a RN, I have learned a nutritious diet, adequate hydration, a personalized activity schedule, and annual assessments are important components in health promotion (Kumar & Preetha, 2013). The Center for Disease Control (CDC) National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP) reports that "chronic diseases are responsible for 7 in 10 deaths each year, and treating people with chronic diseases accounts for most of your nations health care costs" (CDC.gov, 2018). Based on this report, I have focused on utilizing my role as a community health nurse to promote health aspects concerning chronic diseases and prevention measures. Patient education has been an appropriate avenue to inform the community on the need for lifestyle changes like healthy diets, smoking cessation, and quitting alcohol and other drugs. The internet has helped to create public awareness of risk-taking behaviors, but my role of the community health nurse in the home care setting allowed me to provide my patients with EBP's that would elicit better health outcomes. Such EBPs include physical activity, lifestyle changes, and frequent doctor visits for a checkup.
Informing my patients of available screenings related to age, family, history, and environmental factors while giving quick tips on personal assessments (i.e., get to know your bowel movement, urine output, etc.) have become routine in my practice as a professional registered nurse. In my view, this is part of health promotion as patients get to know where and when to get screened for particular diseases. I have learned that the patient more easily retains simple, short, relatable tips, which I will frequently provide. Through my professional experience, I have learned the benefit of meeting a patient where they are at present—rather than where they "should" be. Setting small easily attainable goals such as increasing water consumption or calling the doctor if a change from the norm is noted has proven to be effective tools in health promotion and disease prevention. The more in-depth a patient enquires, the more information I will provide at that moment (this is especially true of the pediatric population). I have also learned through my experiences to assess for knowledge retention on subsequent visits by asking questions on the issues that have been handled before based on a patient’s medical records as well as previously given health tips.
Family or Community Advocacy in the Role of the Professional Nurse
My work as a hospice care nurse was my most rewarding. Death is a universal equalizer. It pervades social status, age, and geography. To be able to accompany a patient and their support system in this process of death with dignity has been my greatest honor, and I took it upon my role to advocate for their comfort and wishes.
I focused on advocating for the comfort of the patients in hospice for them to experience maximum peace and dignity in their final days. During team meetings, I was keen to understand how certain illnesses progress towards the path of death, and the medications that are most effective for providing a peaceful death experience, such as atropine, lorazaepm, and morphine. As such, I encouraged the primary caregiver(s) to advocate for the patient when the patient was unable. There are many misconceptions regarding the use of medications to provide comfort to the dying patient and I found that proper education for the caregiver and support system regarding these medications allowed for the patient and family to experience a peaceful, harmonious death. An adequate education of medication purpose during end of life transitioning enabled the caregiver to advocate for the patient as well. My hospice experience has allowed me to be more of a comfort to my patients in their fear of death and dying (Hebert, Moore & Rooney, 2013). Because of my past work experiences, as well as my staying current on nursing literature and EBP, I can inform my patient and their support system that cancer pain is real and in the end stages of cancer the goal of pain relief should trump the fear of addiction (Hebert et al., 2013). I focused on ensuring that the patients could get pain medications to control cancer pain as well medications to alleviate anxiety and respiratory issues.
My experiences as a hospice nurse influence my advocacy skills as a Registered Nurse, and I continue advocating for the needs and rights of all my patients. Being so close to death made me realize the value and importance of life. As a result, I continue to advocate for my patients and their supports systems in my current role as a chemotherapy infusion nurse. In this role I frequently encounter patients suffering from cancer and the respective treatments given while trying to balance living with quality of life. When my institution formed a Supportive Care Committee I was quick to join. The Supportive Care Committee provides a platform for me to advocate for all patients within my cancer center, not just the ones I work with. While the Supportive Care Committee seeks to provide palliative care throughout the treatment spectrum, we avoid the term palliative because patients perceive palliative as akin to hospice, while supportive care highlights our desire to provide patients with quality of life throughout their journey with us at Memorial Sloan Kettering Cancer Center (MSKCC).
Reflective Practice with a Focus on Human Dignity and Diversity
The vast experiences I have in community health nursing have made me into a nurse who excels at developing individualized care plans, utilizing appropriate resources, and acting as a liaison with the interdisciplinary team to increase communication and ensure optimal patient outcomes. Any outcome that does not include the respect of the cultural aspect of the patient is not optimal. Dignity is ensured when diversity is acknowledged and respected. My experiences have also enhanced the value with which I hold human dignity and diversity as the community comprises of people with various cultural beliefs and values concerning health and death. Through my experience as home care and hospice nurse, I have learned to put more value on the quality of life as perceived by each patient, rather than my personal view. I believe all patients should be treated with dignity in their end-of-life stage. It was during my employment as a hospice care nurse that I developed my own mission statement. I adhere to this mission statement not only in my working life, but my personal life as well. My mission is to meet the physical, emotional, and spiritual needs of my patients so that I may provide them an opportunity to live or die with dignity. I work to ensure dignity for all patients within my professional institution by being a member of the Supportive Care Committee. Through my professional experiences and my review of current nursing literature I am able to provide feedback to appropriate personnel regarding our companies policies and procedures