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Greensboro Nursing Students Reach Out to Elders in Poverty

Monday November 10, 2008
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The University of North Carolina at Greensboro School of Nursing community-based nursing centers provide a service-learning clinical experience that also sends home a message to students about their competence and the essence of nursing. By practicing as community health nurses, faculty and students in the BSN and adult and gerontological nurse practioner programs encompass the roles of case finder, caregiver, client advocate, and health resource coordinator.

"At first, [students] ask, 'If I'm not passing meds or following orders, what will I do in a clinic for a semester?' and I tell them, 'You're going to practice nursing,'" says Jayne Lutz, RN, MS, PCHCNS-BC, a clinical associate professor in community practice. "By their senior year, they've spent so long carrying out physicians' orders in hospital settings [that] they've almost forgotten why they went into nursing and that we have a body of knowledge, roles, and expertise to offer clients that's separate and often independent of the medical model. At semester's end, they're surprised how much they know."

During a two-decade partnership with the Greensboro Housing Authority, the school's students have provided weekly free on-site nursing center health clinics at Greensboro's low-income housing and community centers, and visited clients who can't come to them.

UNCG's nursing clinics at Hall Towers, Gateway Plaza, and Hampton Homes serve about 500 patients, primarily widowed or divorced women over age 70. Many are disabled, and most have three or more chronic illnesses.

"We've had to scrounge for 50-cent capillary blood glucose strips because we have a lot of diabetics who can't afford them, and although clients request more cholesterol screenings, we can only afford one per person per semester," says Lutz, the program's co-founder. "The folks we serve truly live in poverty."

Residents now recognize the white coats worn by nurses and students, and often open their doors to say hello, ask advice, or request a quick blood pressure check. Because there's a higher rate of crime near the community center clinics, students making nearby home visits travel in pairs and keep in cell-phone contact with instructors.

Students and faculty have identified life-threatening conditions during routine clinic visits. "We found a grade 3 systolic murmur in a man who said he had no problems or medications, and it turned out he had moderately advanced aortic stenosis that required considerable treatment," says Lois Lewis Voncannon, APRN-BC, clinical associate professor. They've noticed atrial fibrillation and other cardiac irregularities that might have led to strokes and heart attacks without treatment, edema indicative of congestive heart failure, and early obstruction through decreased bowel sounds.

They've also caught problems when clinic regulars didn't show up and the students searched them out. "One lady had a temp over 101, horrible cough, and pneumonia," says Voncannon. "She was blind and deaf. I don't know what would've happened without us."

The students assess patients' general health status, blood pressure, weight loss or gain, and medication adherence; screen for blood sugar, cholesterol, and urinary tract infections; and provide foot care. "That's new to most students, yet necessary in holistic care," says Lutz. "Many elderly people can neither see nor reach their feet, which are pivotal to maintain mobility and independence."

Undergraduates focus on wellness; if they suspect a health problem, they can refer residents to graduates, who practice on different days. Nurse practitioner students focus on physical assessment, early case findings, and the aging process. They may refer residents to a primary care provider or back to undergraduates for follow-up care. If a resident is sick, students can arrange physician appointments and transportation if needed.

Each clinic is open weekly on a specific day for about four hours. It may stay open longer, depending on the number of students available and the day's caseload, typically 10 to 15 clinic patients and 20 to 25 outreach visits.

Lutz, Voncannon and some other faculty keep the clinics running year-round during holidays, semester breaks, and summer. "I don't think it's ethical to accustom elders to expect services, and then run them on the academic calendar, so if there are no students, there's no clinic," says Lutz. Although some faculty are now paid to teach an RN to BSN summer course on caring for vulnerable populations (created, in part, to keep the clinics open), initially they volunteered their time.

The clinics at the high-rise complexes are based in former apartments; the community center clinic has two small exam rooms and a waiting area. The close quarters allow plenty of professional show and tell. Students improve skills, including physical and environmental assessing, interviewing, teaching, case management, home visiting, clinic operation, and counseling.

"Nursing students need to be taught communication skills beyond the classroom because it's difficult to do in clinical settings" while carrying out other actions, says Lutz. "They need to see an experienced nurse accomplish both, and we need settings besides psych where they can have patient interactions."

The clinics also have a significant impact on how students will communicate with physicians as fellow professionals. "In the hospital, students aren't allowed to take physician orders directly. But here they talk directly to doctors in a proactive professional role," says Lutz. "The physicians know us and take calls, and they're very responsive."

In addition to calling physicians with their concerns, students also provide patients with written reports of their visits and results. "Some physicians now expect and ask for notes from our [students], and others ask students to call with weekly reports," says Lutz. "I think it helps them see nurses in a different way, as valued partners in patient care."

Wendy Bonifazi, RN, CLS, APR, is a senior staff writer with Nursing Spectrum.

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