My Journey to the Community

By M. Oneha

My drive each morning takes me along the coast of the windward side of the island of O`ahu to the community of Waimānalo. I work at a community health center, whose mission is to “provide the highest level of primary and preventive health services, with special attention to the needs of Native Hawaiians and the medically underserved, and improving the health and wellness of individuals and their `ohana regardless of their ability to pay.” My journey in nursing didn’t start off in the community, it was the furthest from my mind as a new graduate. Stories of pain, loss, joy, behavior changes, and new insights are experienced by nurses on a daily basis. There are also situations, ingularly or collectively, nurses experience with considerable personal impact. Having spent 10 years in acute and critical care pediatrics over 20 years ago, there are a few experiences that stay with me; experiences that served as the impetus in my decision to move from cute and critical care to community health.

Admitted to the toddler unit one evening, a child, less than 2 years old with hydrocephalus (abnormal accumulation of cerebrospinal fluid in the brain, increasing the pressure inside the skull, resulting in enlargement of the head), was experiencing difficulties with his ventro-peritoneal shunt (a shunt to drain excess fluid and relieve pressure in the brain). He had just completed a CT (computed tomography) scan (x-rays that make detailed pictures of the body area being scanned) a few days ago with no significant changes according to his mother. After talking with his parents and saying goodnight, they departed for home, and my shift started at 11:00pm. He had an uneventful night, as classical music played in his room, with a strong, regular heart rate and respirations.

At 6:00am, his cardio-respiratory monitor alarmed, his heart rate was decreasing quickly, a code 500 was called, and a team of medical professionals descended upon his room instantly. He was transferred to the intensive care unit. It was the next night that I learned he had passed. I don’t quite remember the reason for his passing, but I do remember going through this experience and thinking about what his home life was like prior to this day and what it would be like moving forward. Did he and his family have enough support, did they live near resources or was it a long drive to the nearest healthcare facility? How would his siblings respond?

Similar questions were raised when a 7 year old child was admitted with a third degree burn to his leg. It is never easy admitting a young child, any child, at night with a third degree burn and having to place that child in a tub to clean and debride their burn. Despite medicating the child prior to this procedure, it is a frightful and painful experience for the child and their parents. Preparation of the child, parents, and nurse themselves is critical before initiating this procedure. Most often, the parents were asked to wait outside, get some coffee, have a meal, or take a break during the child’s procedure. After performing a number of these procedures, and the successive care that follows after skin grafting has been done to heal the wound, I wondered what happened at home and in the community that could have prevented the burn and what happened after a child was discharged from the hospital.

Again, I thought about the supports and resources available to the family at home and in the community. At the time, I worked in a tertiary children’s hospital that served four northwestern states, so I knew that we had families who lived in remote areas. Getting to the hospital may have been by air (plane or helicopter) and therefore, commuting was not an option for families whose child had a extended length of stay. Since we saw families for such a short period of time and within a specific context (ex: hospital), questions related to prevention, environmental influences, family support and coping were at the top of my mind. Working permanent nights provided little opportunity to interact with families to plan the discharge of their child or to do follow-up to see how families coped or adjusted back to their everyday lives.

Prompted by this inquiry and additional education, my career moved me to pursue work in the community, specifically, in Native Hawaiian communities. The community experiences have, at times, been far more complex and acute than what I experienced in the hospital setting. While delivering preventative care is most appropriate in the community, working with patients to manage and/or recover from uncontrolled chronic diseases, violence, substance use, homelessness, and many more restricting factors presents with far more complexity than I experienced in an acute care setting many years ago. These experiences have helped to shape my nursing practice and continue my process of inquiry through community based research.

Hawaiian Cowboy

By R. Oneha

I had the honor of meeting Mr. P. over 40 years ago. I did not see him at the beginning of my tour of duty with this program, but knew of him. He lived on Moloka`i and many years later, he moved to O`ahu and we interacted with each other daily. He was very interesting and independent. He had his own daily rituals that he adhered to faithfully.

He moved to O`ahu because his wife, who was also a resident of this program, had a stroke and required total care. He would awaken very early, say his prayers, put on his bilateral prostheses with assistance (one leg was a below the knee amputation and the other leg an ankle amputation). He never let the loss of his limbs stop him from doing anything and he wore his prostheses every day. He would then proceed to the dining room for breakfast, walk along the guardrails with his cane, have the nurse fasten his spoon to his hand, and proceed to eat everything on his tray. He did this with all his meals and never ate between meals. After breakfast, he exercised outside of his room along the guardrails, back and forth many times, then he would proceed to his wife’s room to say “good morning” to her. Although she could not speak, he talked to her about all kinds of things and would pat her on the shoulders. Sometimes he would pray in her room.

Patients in this program were scheduled on specific days to shower, his day to shower was his greatest delight. He did not want any help. With both prostheses off, he would sit on his shower bench and soap himself with the soap in a cloth bag with much gusto until he was quite sudsy. This always concerned me because the soap made the shower bench slippery and I feared he would slip off of it; however, he would not accept any assistance. He would stand on his ankle stump to rinse off and he made quite a production of it. He washed his head alone too. He then proceeded to dry himself quite thoroughly with a bath towel and plunked himself in his wheelchair that was at the shower entrance. He had to use the wheelchair when his prostheses were off. The nurses helped him dress.

Sometimes he would kneel on his bed to pray which almost gave me a heart attack the first time I saw him, because of the potential for him to fall off his bed. The man was fearless.

He usually napped in the afternoon after lunch and repeated the same rituals before supper. He would then listen to the news on his TV until he got tired and usually retired early. He attended Mass every Friday a priest was visiting or he would receive communion whenever a Eucharistic minister visited the hospital. If there was patient entertainment, he always attended and loved to sing and dance with all the nurses. He had excellent rhythm and his favorite song to dance was Hawaiian Cowboy. He would use his cane as a horse and pretend he was riding it! And he continued this into his 80’s! Such a special person.

I was also told that when he was younger, on Moloka`i, he and his wife owned a piggery and supplied the settlement residents and staff with pork during World War II. He also carried the mail and supplies from the peninsula where they lived to the top of the island on a mule that followed a treacherous switchback trail. They were definitely heroes of the war effort. He planned for his and his wife’s funeral and paid for it in advance with his own money, although the State of Hawaii would have paid for it. His kindness, generosity, independence, and fearlessness, despite his challenges was a great inspiration. He was extraordinary in my eyes and in the eyes of the other residents with the same diagnosis. He never let his disability keep him from living. He was blind, a bilateral amputee, stumps for fingers that lacked sensation and a heart of gold! Despite these challenges and the stigma associated with Hansen’s Disease, he persevered.

My nursing career was embedded in a specialty program caring for those once only known to have been sent to the isolated peninsula of Kalaupapa on the island of Moloka`i. Located on the island of O`ahu, Hale Mohalu cared for those diagnosed with Hansen’s Disease. The profound physical, emotional, and spiritual challenges faced by individuals with this disease also teaches tolerance, patience, compassion, and empathy. Influenced by my experiences, my daughter also pursued a nursing career, beginning at the other end of the age spectrum caring for children in an acute and critical care setting. It wasn’t until many years later, that her experiences led her to work in the community.

Transforming Policy

By M. Bellhouse-King, L. McCollum, and E. Teeter-Balin

Mathew Bellhouse-King, Lia McCollum, and Eve Teeter-Balin are three Family Nurse Practitioner (FNP) graduate students at the University of Hawai‘i at Mānoa who had the transforming opportunity this past Spring to work and intern at the Hawai‘i State Legislature.  Mathew worked as a Legislative Assistant for Puna & Kaʻu Senator Russell Ruderman, while Eve and Lia interned with Kihei Senator Rosalyn Baker, the Chair of the Commerce, Consumer Protection, and Health Committee.  This experience helped to demystify the legislative process, while emphasizing the importance of nursing advocates who are engaged in the legislative process.

Legislators rely on constituents to inform their decision making. As a staff member, Mathew had the opportunity to serve as a liaison for constituents. Individuals and organizations communicate their support, opposition or comments concerning legislation, and this information is synthesized by staff and presented to the Senator when decisions are made on bills. Legislative topics this session included telehealth, prescriptive authority, vaccinations and long-term care. Witnessed first hand, constituent input had a significant influence on the Senator’s decision making. The reality is legislators are not experts on every subject and rely on their constituents to inform them of their needs and how potential legislation might affect them. The personal touch is often most effective. Requesting a brief meeting with the office or submitting a handwritten letter certainly stands out. With a clear and concise message your voice has power to influence legislation.

Legislation is most effectively influenced by well-organized people with a cohesive, articulate message.  Lia had the unique perspective of interning at the Hawai‘i State Legislature while employed as a Graduate Assistant (GA) at the Hawai‘i State Center for Nursing (HSCN). Health policy advocacy is one critical vehicle through which the HSCN strengthens Hawai‘i’s nursing workforce. The HSCN supports policies that promote leadership development and diversity in the nursing workforce, and that address scope of practice issues so that nurses are well-trained to meet the evolving complex healthcare needs of Hawai‘i’s people. By virtue of its many partners, statewide reach, and prominent reputation, Lia saw that the HSCN has access to several resources which can be used to garner support for nursing-related policy initiatives, and appeal to legislators.

As such, the HSCN provides a strong voice for the nursing workforce, and plays a critical role in developing a clear articulate message for health policy affecting nurses. When communicated through testimony, the Senator may be more likely to consider such a message when advocating for a particular piece of legislation in Committee or on the Senate floor to her Senate colleagues. This is particularly important given that there are literally hundreds of people and organizations who submit testimony to Senator Baker’s committee. Ultimately, rallying behind an organization such as the HSCN, or other professional nursing organizations that already have multiple resources at their disposal to push clearly articulated messages for nursing-related legislation, is one way that nurses can engage in and gain a stronger grasp of policy affecting the profession and delivery of healthcare.

Policy dictates EVERY aspect of our practice.  Eve had the privilege of witnessing the telehealth bill (SB 2395) go through the entire legislative process to the actual signing of the bill into law by Governor Ige.  The legislative process is grueling and at times frustrating.  Only about 5-10% of bills pass the Hawai‘i State Legislature to become laws each session and a bill can be amended every time a bill is heard in a committee.  SB 2395 was referred to 7 committees and was amended 7 times! Through the diligent submission and coordination of testimony by HSCN and other healthcare professionals, SB 2395 gained language that included APRNs in the definition of “Health Care Provider” in this very consequential healthcare bill.  This wording allows APRNs to be reimbursed for patient interactions via telehealth, thus substantially increasing the healthcare workforce available for those in rural areas of Hawai‘i.  Being present for the signing of SB 2395 into law on July 7, 2016, in the presence of legislators, and hospital and insurance company representatives, highlighted the necessity of having a voice for nurses present, especially when a bill has so many stakeholders.

We each gained a significant understanding of the importance, as well as the complexity, of engaging in the legislative process and encourage nurses to participate however they can.  We have been very fortunate to have had this opportunity and will continue to take these lessons through our careers as APRNs.

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