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.