NRNP 6654 Week 11 Reflection Example

Reflection: Three Plans From This Term That Each Assumed the Person Would Come Back at a Set Time to a Set Place

Student Name

College of Nursing, Walden University

NRNP 6654: Psychiatric Mental Health Advanced Practice Nursing Care of Vulnerable/Special Populations

Instructor Name

Month Day, Year

Reflection: Three Plans From This Term That Each Assumed the Person Would Come Back at a Set Time to a Set Place

Three Specimens

The three sentences below are constructed for this reflection, one standing for each of three earlier pieces of mine. They are specimens of a pattern, not quotations.

From the trauma-informed intake (week 5), in its first draft: "We will finish the rest of the history when she returns in two weeks."

From the shelter care plan (week 6), in its first draft: "Patient to attend clinic on the 14th at 10:00; reminder call the day before."

From the program proposal (week 10), in its first draft: "Patients will be scheduled for monthly medication management visits."

The Pattern, Found in the Specimens

Read one at a time, each sentence is ordinary. Read together, they share an assumption I did not write down: that the person would be at a known place, at a known time, two weeks or a month later, reachable by a phone that still worked. The first defers half the assessment to a visit that may not happen. The second fixes a date, an hour, and a phone call. The third builds a whole service around a monthly calendar. In each, the plan's clinical content was sound, and the part that failed was the part I never looked at: whether the person could return. The evidence I had cited in those same papers pointed the other way. I had quoted a study showing that more than half of homeless adults had changed their phone number within three months (Rhoades et al., 2017), and then written a plan that relied on a reminder call.

Why This One Was Comfortable

This was the easy constraint to forget because it is one I never meet. My own life runs on a calendar, a phone number I have had for ten years, and a car. A return visit is not an obstacle for me, so it did not register as one in a plan for someone else. The constraints I did notice, such as privacy in a day room or storing medicine at a front desk, were ones I could see from the clinic. Return is invisible from the clinic, because the people who cannot return are, by definition, not there to be seen.

The omission is not peculiar to me. In a study in which unannounced standardized patients visited 111 internal medicine physicians, physicians probed contextual red flags, such as transportation needs or economic situation, less often than biomedical ones, 51% compared with 63%, and produced an error-free plan in only 22% of encounters complicated by a contextual factor (Weiner et al., 2010). My plans made the same kind of error: medically reasonable, and wrong for the person's life.

Nothing From the Placement Record

Preceptor evaluations, logged hours, and placement documentation play no part here. The material under examination is my own writing from this term, because that is where the assumption can be seen and dated, and because a placement record would describe what I did rather than what I planned.

One Piece, Revisited

The week 6 care plan is the one I would change most, and the revised version shows how. Its follow-up line now ties the next visit to the shelter's own weekly clinic afternoon, moves the reminder from her phone to a person she sees every day and a card in her pocket, and names the case manager as a second way to find her. Nothing in the clinical content changed. What changed is that the plan now asks, for every next step, where the person will be and how we will find them. The same question would have changed the other two: the intake would gather what is needed today and treat a second visit as a bonus, and the proposal would offer walk-in follow-up at several sites rather than monthly appointments. In a population where a third of people with prescriptions report being unable to take them as prescribed (Kushel et al., 2001), a plan that assumes return is a plan that assumes the problem away.

What I Will Check From Now On

Before finishing any plan, I will read each step and ask two questions: where will this person be when this step happens, and how will we reach them if they are not where we expect? If I cannot answer both, the step is not finished.

I will also stop treating a missed step as information about the person until I have checked it against the plan. When someone does not return, the first question in my note will be whether the plan gave them a realistic way to, and only then whether something about their illness or choices kept them away. That order matters, because the second question is the easier one to write down, and I have now seen how readily I reach for the easier one.

References

Kushel, M. B., Vittinghoff, E., & Haas, J. S. (2001). Factors associated with the health care utilization of homeless persons. JAMA, 285(2), 200-206. https://doi.org/10.1001/jama.285.2.200

Rhoades, H., Wenzel, S. L., Rice, E., Winetrobe, H., & Henwood, B. (2017). No digital divide? Technology use among homeless adults. Journal of Social Distress and the Homeless, 26(1), 73-77. https://doi.org/10.1080/10530789.2017.1305140

Weiner, S. J., Schwartz, A., Weaver, F., Goldberg, J., Yudkowsky, R., Sharma, G., Binns-Calvey, A., Preyss, B., Schapira, M. M., Persell, S. D., Jacobs, E., & Abrams, R. I. (2010). Contextual errors and failures in individualizing patient care: A multicenter study. Annals of Internal Medicine, 153(2), 69-75. https://doi.org/10.7326/0003-4819-153-2-201007200-00002