A Sense of Community
service-driven clinical placements - spring/summer 2009
By Joshua Jensen
"Community health is fundamentally about community context. Thus, we owe it to our students to put them in a context where they are poised to contribute as well as learn," begins Clinical Assistant Professor Adele Pike, who, along with Clinical Instructor Judith Pirolli, organizes the community health clinical courses that undergraduate nursing students take their senior year. "Boston College's Jesuit mission pushes us to take on a social justice perspective. This perspective demands that we find a pathway to meaningful involvement in the community," adds Pirolli.
For Boston College nursing students, the clinical experience is an opportunity to apply theory in the areas of health promotion, disease prevention, continuity and coordination of case, and long-term care. But according to Pike, student-learning outcomes are only half of the equation for a successful community health program. An ideal placement, she says, is one where students are contributing to the mission of the organization and making a lasting positive impact on the individuals and communities that they are serving.
To achieve this, Pike and Pirolli are building long-term, sustainable partnerships with the community organizations where they place Boston College students. Pike is an experienced partnership builder: in 2004, she established the Center for Excellence in Home Care Practice and Education, a collaborative effort between the Connell School and the Visiting Nurse Association of Boston (VNAB). Pike's work on this effort has resulted in benefits for both organizations, including access to clinical placements for Boston College students, and access to cutting-edge nursing knowledge for VNAB staff.
It is this partnership that is serving as a model for new and existing clinical health sites. The three partnerships presented here—Cathedral Cares, Casa Myrna Vazquez, and Carelink—are examples of the range of organizations with which the community health faculty are building new models of learning—models where giving back to the local community is as important a goal as student learning outcomes.
Clinical Instructor Lynn Finn runs Cathedral Cares, a parish nursing outreach program at the Church of the Holy Cross in Boston's South End. This program offers community health services to parishioners and other members of the community surrounding the cathedral. Many think of the South End as an affluent neighborhood, home to Boston's trendiest restaurants and nightlife, but the reality is quite different. Many of the cathedral's parishioners come from nearby Villa Victoria, a subsidized housing complex with a predominantly Latino population. Finn reports that 90% of the students that attend the nearby Blackstone School are below the poverty line.
While Finn does plan some traditional wellness programs that she cites as "typical parish nursing" fare, she is also committed to providing strong clinical services to the community. "We screen for blood sugar, cholesterol, anemia. We do a lot of health education around these topics." Regular services are available in the cathedral, but Finn knows the value of getting into the community, so she also runs regular programs at Villa Victoria and the Irish Immigration Center.
From Finn's perspective, she couldn't accomplish this without Boston College students. Finn places three students each semester at Cathedral Cares, as well as additional students at the Blackstone School and nearby Boston Medical Center. The students work hand-in-hand with Finn, organizing the Cathedral Cares programs and advocating on behalf of their clients. The students do a significant amount of the work, as virtually all of the Cathedral Cares staff—including Finn—are volunteers. Finn operates with the help of approximately 10 nurses, one physician's assistant, and a small team of non clinical volunteers.
Finn is quick to point out the concrete impact her students have on the community. They have helped organize health clinics at various sites, including a large-scale flu vaccination effort where students administered over 600 vaccinations.
While this type of work may seem straightforward at first, Finn notes that in practice, many of the cases are quite complex and can require untangling. "It's not uncommon for the students to encounter someone who for one reason or another just isn't taking their medication. Either they don't have the money or they don't have the appropriate dose. The students will get on the phone and follow the patient's experience through the medical system until they figure out where the knot is. Their role is to untangle it and try to get the person back on course."
Students experience the challenges of working with patients for whom English is not their primary language—approximately 50% of the Villa Victoria residents are Spanish-speaking, and a significant number speak primarily Chinese, Portuguese, or Haitian Creole—which further complicates the work, but also provides a real-world context that many students haven't experienced before this placement.
In addition to the clinical work, students also have the opportunity to understand the challenges of running a community health program such as Cathedral Cares. Many of the challenges that Finn faces are budget and logistics related, but end up having a real impact on her ability to reach the community. Finn notes, "The winter was so bad this year in Boston. Father O'Leary met with us and said, ‘I've spent over $40,000 clearing sidewalks and I'm out of money.' Of course, people can't come and see us if they can't make their way safely." Finn's students also learn the challenges and costs of outreach. She wrestles with basic costs such as printing signs for health fairs and taking out small ads in the local newspaper.
For Finn, these challenges are simply another learning opportunity for her students. This past November, a Boston College connection led Finn and her students to CatholicTV, which is based in Boston. Students Sarah Zumsande and Alexandra Dziama were guests on This is the Day, where they shared information about flu prevention, and promoted an upcoming flu clinic at the cathedral.
Finn explains the importance of the CatholicTV audience. "When I was a visiting nurse, in nearly every house that I went into, CatholicTV was on. And people would say, ‘Don't come to give me my insulin during Mass.' We were always trying to work around the Mass, so I know it's very, very popular in a lot of households. I thought that if we could get health teaching on the TV, that's a lot of households that you're going to reach." For Finn, her students, and her colleagues at Cathedral Cares, it's the impact of their community outreach that is the reward.
Francisco Rodriguez gets his cholesterol checked by Michelle Bruno '09 at a Cathedral Cares health fair, while Clinical Instructor Lynn Finn looks on.
casa myrna vazquez
Grassroots organizers founded Casa Myrna Vazquez in the 1970s in response to stories of local South End women experiencing abuse by their husbands or partners. Today, the organization has evolved into a key resource for survivors of domestic violence seeking emergency shelter, transitional housing, and other supportive services, including legal advocacy, counseling, and housing search assistance, as well as education and outreach about domestic violence. Additionally, Casa Myrna operates the 24/7 toll-free, multilingual, statewide hotline SafeLink (877-785-2020). Just this past year, Judith Pirolli and Adele Pike approached Casa Myrna Vazquez, seeking creative ways to partner with the organization.
This spring, a clinical pilot was launched. Clinical Instructor Nancy Crouse was recruited to work with the staff at Casa Myrna Vazquez to find a meaningful role for nursing students. An expert in psychiatric nursing in the community setting, Crouse immediately saw the value of this partnership as a learning experience for her students. "All kinds of light bulbs were going off in my head. Domestic violence affects many different systems related to an individual. How does it affect just their general health? Then how does it affect socioeconomic status? How does it affect emotional status?"
Seeing a clear learning potential for their students, Crouse, Pirolli, and Pike were eager to explore how to craft a partnership that would benefit Casa Myrna Vazquez. They met with Casa Myrna's Education and Prevention Specialist, Amanda Wolfe, to explore the value nursing students could bring to the organization, even at a very basic level. Crouse explains, "She was interested in how the students might work with the children in the shelter, who need extra support given what's going on with their parents. They have been uprooted from familiar surroundings and faces, and their school life may have been disrupted. They may have issues with nutrition. Their mothers often don't have time to think about these things because their energies are going in so many different directions."
Crouse also emphasizes the importance of community health in a shelter or transitional setting, because of challenges accessing other forms of healthcare. "Everyone is talking about improving access to health insurance, which is an important step. But even if an individual or family has insurance, there is no guarantee they will have the ability to access appropriate care. If you're moving around a lot because you've lost your apartment or are in a shelter, do you even have a pediatrician or primary care physician?" Crouse sees community health nurses, including student nurses from Boston College, as advocates and educators for the survivors and families who need these vital services.
Even with this potential, Crouse still faces a large barrier that makes this placement different from all others: because of issues of safety and confidentiality, she is not able to go to the placement with the students, or observe their work directly. For this reason, Crouse planned for a lot of time outside of the placement to check in with the students, and has many questions: "What have you seen? What's going on? What do you think the needs are? What have people been saying to you?" In addition, Crouse is in regular communication with the students' supervisor at Casa Myrna Vazquez, and thus is able to provide the guidance that is a key component of a strong clinical placement.
Laura Flaherty and Mary Kelly are the two students placed with Casa Myrna Vazquez this semester. Each completed 40 hours of training, organized by the Greater Boston Domestic Violence Volunteer Consortium, to ensure their safety and effectiveness in the domestic violence setting. Flaherty was positive about the experience. "I learned so much about domestic violence, crisis intervention, and empowering survivors. The training that I received will certainly impact my nursing career. I wish that my fellow nursing students would have the opportunity to undergo the same training."
Following this intensive training, Flaherty and Kelly went to work in a Casa Myrna Vazquez shelter, educating children and families on issues like the importance of hand washing and nutrition—seemingly small-scope issues but with a significant health impact. Crouse put much thought into choosing the right issues for her students to address. "I did question what kinds of things the clients there would most benefit from, as well as how the nursing role fits into the health of these individuals and the health of the overall community in a domestic violence shelter setting."
Crouse, Pirolli, and Pike are already thinking about building this partnership for long-term success, and they aren't afraid to think outside the traditional framework of clinical placement. For example, early on in their conversations with Boston College, Casa Myrna noted an interest in having a nursing presence year-round, possibly bringing in additional nursing schools or incorporating nurses into their regular staff. The community health clinical faculty are supportive of these goals, and have expressed a willingness to help the organization use the Boston College relationship as a way to explore their broader goal of expanding their services to the community.
Crouse sees this type of creative partnering as a unique benefit that Boston College can offer to the sites where community health students have their clinical placements. "These relationships offer us an opportunity to show these agencies and organizations what community nursing is about, and how community health nurses can contribute to their organizations, both as student nurses and as professionals. It's exciting to start something new."
Clinical Instructor Nancy Crouse meets regularly with the students placed at Casa Myrna Vazquez, Mary Kelly '09 and Laura Flaherty '09. Due to confidentiality, Crouse cannot accompany them to the placement site, but she plays an active role in helping the students plan visits.
Clinical Instructor Mary McColgan runs a Carelink program at Catholic Charities' Visiting Nurse Services (VNS) at the Labouré Center in South Boston. Carelink allows elders with chronic diseases to remain safely in their homes, often after a hospitalization. McColgan explains, "Medicare and health insurance only offer home care reimbursement up to a certain point, and then, many elders are left on their own even though they aren't quite ready. Carelink fills that gap."
McColgan's program director at Catholic Charities, Priscilla Green, came up with the idea for starting a Carelink program at Labouré, based on programs developed by the Visiting Nurse Association of Central Connecticut and the Neighborhood Visiting Nurses Association of Chester County, Pennsylvania. Green contacted Adele Pike asking for BC's help in establishing the program. She, Adele Pike, and McColgan worked together and piloted the idea with a group of graduate students last year. The program was a success. Mary McColgan, a nurse in the employ of Labouré's Home Care, was recruited, hired, and oriented to the Boston College clinical faculty last fall.
Unlike more traditional clinical placements, the Carelink program is highly autonomous, and students are the core service providers. While McColgan starts the semester going with the students, the goal by the end of the semester is for them to feel comfortable going on a home visit by themselves. Students are nervous at first, but McColgan reminds them that she is just a phone call away if they have a question or a concern.
Students work with patients to help them manage their chronic diseases and avoid relapse or hospitalization. They address issues such as dietary management and when and how to take medications. They also address issues of home safety, such as fall risk, and how to get up and change positions slowly.
Many of the issues that the Boston College students address would be minor for most healthy individuals, but are potentially life threatening for their patients. McColgan tells a story of a woman who couldn't open her pill bottle because of severe arthritis. "She kept calling the pharmacy to give her a twist-off bottle cap, and it just wasn't happening. One of the students took this on, and was able to make it happen. This patient is a nurse, completely capable of advocating for herself. There are many others who aren't as capable who need this kind of help."
The Carelink placement has proved as transformational for the students as it has for their patients. The home care setting offers a different experience than the students have had in their previous clinical placements. McColgan highlights the differences. "They're not in a structure of a hospital. The patient is in total control. They're using manual blood pressure cuffs; we don't have any automated equipment. We're right back to the basics."
McColgan coaches the students on their communication skills, helping them become more at ease talking with people about their health issues. Working in a personal environment, students see the financial struggles and other barriers that some of the patients face. Some situations illustrate the value of a good support system family and friends can provide, and others show the challenges faced by those without strong supports.
The Boston College students also bring creativity to the work, notes McColgan. "People have trouble reading because they can't see that well. One student drew a picture to illustrate a no-salt diet, showing things the patient should avoid as a reminder. I'm planning on taking that example to some of the other nurses to see if we can use it for home visits."
In addition to learning valuable skills, McColgan notes that the students find hope in their work. "Many students don't realize that people can live at home independently, even with some fairly severe disabilities. One woman couldn't even stand up straight; she was bent over at an almost 90 degree angle and uses a cane to walk. She inspired the students, because she is still extremely independent and lives at home safely."
Given initial success, McColgan is hopeful that she will be able to expand the Carelink program. She says that word is already spreading in the South Boston community. "Initially patients were a bit reluctant to take advantage of Carelink, because they were worried I was trying to put them into a nursing home. Once I talked a couple of them into it, they've been telling their friends, and interest has expanded."
McColgan is interested in examining the data, to understand objectively how the Carelink program is making a difference. She's interested in understanding how many of their clients have stayed healthy, how they are doing with medication compliance, and if they are avoiding falls. As for the students, she can already see the impact. "To see them so hesitant at first, and then to see them at the end of their placement, when they are able to do a home visit on their own . . . it's really amazing."
Photo at top: As part of the Carelink program, Samantha Shortell '09 visits patient Rita Carmichael, a former nurse, in her home.