NURS 6710 Week 11 reflection example

The Visits That Never Counted: How One Urgent Care Nurse Stopped Treating Each Wheeze as a Closed Event

Student Name

College of Nursing, Walden University

NURS 6710: Public Health Nursing Theory and Practice

Instructor Name

Month Day, Year

The Visits That Never Counted: How One Urgent Care Nurse Stopped Treating Each Wheeze as a Closed Event

The Habit as It Stood

For six years I have worked in an urgent care center, and for most of those years I have treated each child with a wheeze as a complete event. A child arrives, I assess work of breathing and oxygen saturation, the provider orders a nebulized bronchodilator and often a steroid, I teach the parent about the inhaler and spacer, and the child goes home. The chart closes. By the next shift, that child has become one line in a daily count the clinic never looks at again. If the same child returned three weeks later, I might recognize the name, but I had no reason to ask whether the child down the hall came from the same street. I thought of this as good nursing, and in the room it was. What I did not see was that the room was the only place I was looking.

This habit is not unusual in acute care. Our work is organized around the visit: we are paid per visit, staffed per visit and measured on how quickly each visit ends. Nothing in the shift asks me to look across visits, and nothing in my training before this course suggested I should.

What Disturbed It

The moment that changed my thinking came in the third week, while I was examining the asthma figure quoted for our composite corridor. The figure came from state hospital discharge data, and when I listed what its numerator left out, the first item was urgent care. I wrote a line noting that the count omits any visit ending before a child reaches an emergency department, and only then realized I was describing my own work. Every child I have treated for asthma in six years is missing from the figure the county uses to describe childhood asthma. If our clinic sees a group of children from one neighborhood who never go to the emergency department because we manage them first, the state's figure makes that neighborhood look healthier than it is.

That realization was uncomfortable in a useful way. My clinic was not just outside the data; it was one of the reasons the data were incomplete. And I held information, where children lived and how often they returned, that no one else in the county was looking at.

The Competency That Names the Change

The community and public health nursing competencies developed by the Quad Council Coalition, now maintained by the Council of Public Health Nursing Organizations, organize public health nursing practice into eight domains (Quad Council Coalition Competency Review Task Force, 2018). The first, assessment and analytic skills, expects nurses to describe the health status of populations using data, to recognize the limits of that data and to use it to make decisions. The competencies were revised through a consensus process to reflect practice across settings (Campbell et al., 2020), and they are written in tiers, so that a nurse at the front line is expected to apply them in their own work, not only in a health department.

Before this course, I would have said that domain belonged to epidemiologists. Now I see that at the first tier, it describes something I can do with records I already keep. I cannot run a surveillance system, and I have no training in the statistics an epidemiologist would apply to a pattern like this. What I can do is notice when the same area keeps appearing, and I can recognize that my clinic's visits describe a population and that the description is missing from the county's picture.

The New Habit

The change I have made is small and specific. Once a month, I review our asthma visits for children under 18 over the previous month, using fields our clinic already records: date, age, ZIP code and whether the child has been seen for asthma before in the past year. I sort the list by ZIP code and look for two things: children with repeat visits and areas that appear more than their population would suggest. I do this with the clinic manager's approval and without taking any identifying information out of the record system. The first review took about forty minutes; the second, twenty.

The second review found four children with two or more visits in a month, three of them from the same ZIP code. None of them had an asthma action plan on file with us. That is not proof of anything, but it is a question, and before this course I would not have known it was there to ask. Asthma action plans are a recommended part of asthma management (National Asthma Education and Prevention Program, 2007), and a repeat visit without one is a gap I can close.

The Constraint

The constraint is time. The review happens outside patient care, and I have no protected hours to act on what it shows: calling families, contacting school nurses or sharing the pattern with the county health department. For now, I flag repeat-visit children for the provider at their next visit and make sure each family leaves with an action plan. I have asked the clinic manager whether a summary of repeat visits by area, with no names, could be shared with the county's asthma program each quarter. That request is pending. If it is approved, our clinic's visits would stop being invisible, and the county's picture of childhood asthma would be more complete by at least one clinic.

What I Carry Forward

I still treat the child in front of me as if nothing else mattered, because in that moment nothing else does. But I no longer close the chart and forget the street. The course taught me several frameworks, and I will not remember all of them. What I will keep is the habit of asking who is missing from a number, and knowing that sometimes the answer is my own patients. The synthesis I finished last week put children's asthma first for the corridor, and the repeat-visit list from my clinic is exactly the kind of evidence that priority will need.

References

Campbell, L. A., Harmon, M. J., Joyce, B. L., & Little, S. H. (2020). Quad Council Coalition community/public health nursing competencies: Building consensus through collaboration. Public Health Nursing, 37(1), 96-112. https://doi.org/10.1111/phn.12666

National Asthma Education and Prevention Program. (2007). Expert panel report 3: Guidelines for the diagnosis and management of asthma (NIH Publication No. 07-4051). National Heart, Lung, and Blood Institute.

Quad Council Coalition Competency Review Task Force. (2018). Community/public health nursing competencies. Quad Council Coalition of Public Health Nursing Organizations.