My clinical rotation this semester is at a Community Center providing health care to low socioeconomic population, with minimum or no medical insurance. There is a team of primary care physicians, NPs,PAs , social and behavioral health workers, a pediatrician and many helpful Medical Assistants as well as front desk staff and back office coordinators. All working well together. Clinical Experience Paper Example

Clinical Experience Paper

As an advanced practice nurse one is expected to acquire particular competencies relating to the population focus that one will take care of as well as general competencies that each and every advanced practice nurse requires to have. Amongst those factors and competencies to be met are the AACN Essentials of Masters education for advanced practice nurses, population-Focused Nurse Practitioner Competencies for Family/ Across the Lifespan, and the NONPF Nurse Practitioner Core Competencies (DeCapua, 2019). After learning from the classroom, the NP is expected to go for clinical rotation or practicum where these competencies can be demonstrated in practice under the supervision of a preceptor. The purpose of this paper is to outline such an experience during a clinical rotation at a Community Center for a marginalized and disadvantaged population demographic.

The Facility

The facility chosen is a Community Center at the grassroots level that offers basic primary care and some additional specialty care to a poor marginalized population that either has limited healthcare cover or no healthcare insurance at all. The population covered is a low socioeconomic status community which is also affected by other social determinants of health. Apart from low socioeconomic status, these other social determinants of health include low educational achievement, poor living conditions and sanitation, and lack of access to quality healthcare services (Powell, 2016). Despite the low level of the healthcare facility, there is a formidable team of healthcare professionals at the facility to look after the population.

The above team of healthcare professionals includes nurse practitioners (NPs), physician assistants (PAs), primary care physicians, a pediatrician, social workers, behavioral health workers, and nurse assistants. There are also other supportive employees such as front and back office staff as well as cleaners. All these professionals work together in the spirit of interprofessional collaboration to provide multidisciplinary care to the patients. There is effective communication and transformational leadership (Choi et al., 2016) that is motivating the employees and empowering them to deliver only the best care possible despite the resource-limited settings.

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The Patient Case Chosen

The patient chosen for this case study was a 45 year-old African American male who had a medical history of obesity, hypertension, hyperlipidemia, and type II diabetes mellitus. He was born and grew up in the same community and has been affected all this time by the social determinants of health listed above. He has been followed up and treated at the same Community Center ever since the above diagnoses were made. In actual fact, all those diagnoses were made at the same Community Center. At the time of our encounter he was being managed on both lifestyle strategies of exercise and diet as well as medications. This is after the trial of the lifestyle measures alone as per clinical guidelines failed (Kaplan, 2016; MacDonald & Pescatello, 2018). The medications he was on included:

• Metformin 500 mg PO BID
• Sitagliptin (Januvia) 100 mg orally OD
• Losartan 100 mg PO OD
• Hydrochlorothiazide (HCTZ) 25 mg orally PO OD, and
• Atorvastatin 20 mg PO OD

Patient-Centered Care

During the time that I was there on clinical rotation and interacted with the above patient, his preferences as well as those of his family were assessed properly and extensively. This was done by way of carrying out a thorough history taking and physical examination through a follow up interview. He was fully involved together with his family in the planning for his care which had to be reviewed as the body mass index (BMI) was no falling despite exercise and dietary measures. Since the family is crucial in diet adherence and encouragement to exercise, they were fully involved and were given the required health education. Clinical Experience Paper Example

There were indeed cultural considerations and diversity considerations to take into account. This is because the community is overwhelmingly African American and so cultural sensitivity was a priority so that the patient and their family did not feel that they were being treated differently (McFarland & Wehbe-Alamah, 2019). A number of barriers to care were also identified. These included low purchasing power that prevented the patient from affording a regular supply of fresh fruits and vegetables, low educational achievement that made it slightly difficult for the patient to understand some of the concepts used to deliver the health education and promotion, and a misplaced perception that overweight and obesity is actually good health.

Teamwork and Collaboration

My initial encounter with my preceptor was very memorable. She is the one who welcomed me in person and took me round the facility during orientation. She introduced me to all the staff and welcomed me to the Community Center. Being a very experienced family nurse practitioner of ten years herself, I felt in safe hands and took to the clinical placement with a lot of zeal. Before commencing, she sat down with me and we set some ground rules. These included punctuality, respect for patient’s privacy and autonomy, and teamwork with the rest of the employees or staff at the center. The communication strategies that worked well for me were active listening, attention to body language, and eye contact. I however felt that we could have improved on the amount of time we spent on familiarizing ourselves with the patients and establishing rapport. The Community Center was so busy that the time allocated for this was very limited and I thought the patients felt rushed.

Evidence-Based Practice (EBP)

To formulate a plan of care for this patient, all the current interventions were questioned through clinical inquiry. Several PICOT questions were formulated by the team and evidence that is current was searched from research databases such as CINAHL, ProQuest, Cochrane, and PubMed. The interventions that had the most and current scholarly evidence were then applied (Melnyk & Fineout-Overholt, 2019). This process also involved consulting the most current clinical guidelines for managing obesity, hypertension, hyperlipidemia, and type II diabetes. I understood that the evidence was appropriate for this patient because the PICOT questions formulated addressed the specific circumstances of the patient. As such, the results of the evidence search were specific to this particular patient.

Continuous Quality Improvement (QI)

According to the Institute of Medicine (IOM), quality care has to meet six domains of quality care. That is the care has to be timely, efficient, effective, patient-centered, equitable, and safe (AHRQ, 2018). The encounter for this patient met all of these except that I felt they could have been timelier. He had been on care for close to a year and a half and his BMI kept on going up. What went right for the patient is that his weight started reducing after the social worker started paying him home visits to ensure that he stuck to the exercise and diet regime. It would therefore appear that he had not been adhering all along to the diet and exercise prescriptions. What could have been done differently is that the home visitations could have started immediately contact was established.

Safety

The risks identified for this patient included risk of a cardiovascular event such as myocardial infarction, risk of stroke, and risk of microvascular diabetes complications such as nephropathy and retinopathy (Hammer & McPhee, 2018). Addressing these risks today requires that the patient is closely monitored to make sure he is compliant to the treatment plan. The issue of medication reconciliation for this patient does not present a big problem given that he has never been seen at a different facility with a different provider. The factor that places the patient at highest risk is his high BMI, the hypertension, and the hyperlipidemia. This is because they are predisposing factors to heart attack or myocardial infarction. What can go wrong is a sudden heart attack. What could have been done to further address this is to take the patient through a program of psychotherapy to change his thoughts and behaviors. Clinical Experience Paper Example

Informatics

The technological innovations that were used for this patient included mainly the electronic health record (EHR) system that had his medical data and the clinical decision support (CDS) system integrated in the EHR system (Holmström et al., 2020; McGonigle & Mastrian, 2017). The technology was indeed helpful because the EHR provided easy retrieval of the patient’s data and the CDS helped in fostering care coordination by preventing fragmentation. The additional technology that would have been helpful to this patient and the care team is telehealth. This would have enabled remote monitoring even when he is at home.

Plan for Improvement

The best plan for improvement that immediately comes to mind concerning this patient is the incorporation of telemedicine to assist in delivering care to him. There is enough evidence that this technological intervention is effective and efficient for such a patient who is poor and also non-adherent to interventions (McGonigle & Mastrian, 2017). The only drawback is that the poverty of the patient does not allow him to have a reliable Internet connection all the time. Also, the Community Center still does not have a telehealth program due to cost issues.

Conclusion

My clinical rotation at the rural Community Center was indeed memorable. Having outlined the case f one of the patients with whom I had a clinical encounter, I can confidently say that I more than achieved my practicum objectives for the semester. This was also possible because of the good chemistry that I had with my preceptor.

References

Agency for Healthcare Research and Quality [AHRQ] (2018). Six domains of health care quality. https://www.ahrq.gov/talkingquality/measures/six-domains.html

Choi, S.L., Goh, C.F., Adam, M.B.H., & Tan, O.K. (2016). Transformational leadership, empowerment, and job satisfaction: The mediating role of employee empowerment. Human Resources for Health, 14(1), 73. https://doi.org/10.1186/s12960-016-0171-2

DeCapua, M. (2019). What are the NP core competencies? https://www.nursepractitionerschools.com/faq/what-are-the-np-core-competencies/

Hammer, D.G., & McPhee, S.J. (Eds). (2018). Pathophysiology of disease: An introduction to clinical medicine, 8^th ed. McGraw-Hill Education.

Holmström, I.K., Kaminsky, E., Lindberg, Y., Spangler, D., & Winblad, U. (2020). Registered Nurses’ experiences of using a clinical decision support system for triage of emergency calls: A qualitative interview study. Journal of Advanced Nursing, 76(11), 3104–3112. http://dx.doi.org/10.1111/jan.14542

Kaplan, N.M. (2016). Hypertension highlights: The many benefits of exercise. Journal of the American Society of Hypertension, 10(4), 280-281. https://doi.org/10.1016/j.jash.2016.01.016

MacDonald, H.V. & Pescatello, L.S. (2018). Exercise prescription for hypertension: New advances for optimizing blood pressure benefits. Lifestyle in Heart Health and Disease, 115-136. https://doi.org/10.1016/B978-0-12-811279-3.00009-4

McFarland, M.R. & Wehbe-Alamah, H.B. (2019). Leininger’s theory of culture care diversity and universality: An overview with a historical retrospective and a view toward the future. Journal of Transcultural Nursing, 9(6), 1-18. http://dx.doi.org/10.1177/1043659619867134

McGonigle, D., & Mastrian, K.G. (2017). Nursing informatics and the foundation of knowledge, 4^th ed. Jones & Bartlett Learning.

Melnyk, B.M., & Fineout-Overholt, E. (2019). Evidence-based practice in nursing & healthcare: A guide to best practice, 4^th ed. Wolters Kluwer.

Powell, D.L. (2016). Social determinants of health: Cultural competence is not enough. Creative Nursing, 24(1), 5-10. http://dx.doi.org/10.1891/1078-4535.22.1.5

Clinical Experience Paper Example