The Community As Classroom

The men’s catcalls were jarring. Their comments about her clothes and looks, crude. Several of them had histories of violent behavior. They could be aggressive, or unreachable. And when they arrived drunk or high for their medical appointments at the clinic, Ashley Knutson, MS, BSN, RN, wondered whether she had what it took to care for them, or whether they would even let her. “I’d look at these men and think,‘What kind of authority do I have to teach you about your health?’”

Yet, it was Knutson’s desire to work among marginalized populations—so different from those she knew growing up in Fargo, North Dakota—that brought her to Washington Heights as a student at Columbia Nursing. By requiring five weeks of community health rotations, Columbia Nursing would challenge her to see beyond stereotypes. It would teach her to relate to patients as individuals whose backgrounds and hardships drove their health and health care needs. It would put a human face on every health issue that she encountered—from diabetes to HIV/AIDS to homelessness to addiction—and help her to address them not in an academic vacuum but within the context of people’s lives.

The program curriculum is designed to prepare students—particularly those moving into nursing from another career—to practice at the highest level of the profession clinically or in research. In addition to scientific rigor, the program emphasizes the role and responsibility of the nursing profession to address population health needs within a broad framework, including culture, socioeconomic status, or spiritual wishes, says Karen Desjardins, DNP, MPH, assistant dean for academic affairs and director, Entry to Practice program. In addition to rotating through clinical assignments in Columbia University Medical Center’s adult medical-surgical, psychiatric, pediatric, and obstetric-gynecology acute settings, the first year nursing students spend time in a community setting, such as a homeless shelter, elder care center, Head Start program, harm reduction/needle exchange center, or primary care clinic. The population health class supplements their on-site experience. Says Desjardins, “We’re all individuals but we live within a population, and everything, like our family and what restaurants or grocery stores are in our neighborhood, affects our health.”

Emphasis on community service will continue as part of the school’s new curriculum and degree programs anticipated to begin in 2016.

Debunking Stereotypes

For her community rotation, Knutson chose Project Renewal, an agency that provides primary care, addiction treatment, mental health services, and employment assistance for New York City’s homeless. It operates licensed, federally qualified health centers in the Fort Washington Armory men’s homeless shelter, where she worked, and in a women’s shelter on East 45th Street. It also operates a mobile medical van.

Knutson had heard about the men at the Armory. She knew they had hard lives. “I was wary,” she recalls. “I’d heard warnings about interactions I might have there.” Indeed, several of her patients had mental illness or were struggling with addiction. Some had gang affiliations. Many had chronic infections. At some point, most were in crisis. “People would leave the clinic and come back high or drunk, or would not manage their psychotropic medications,” she says.

Roslynn Glicksman, MD, MPH, medical director for primary care at Project Renewal, notes that there are many stereotypes about people with mental illness or addiction, as well as people who are poor, uneducated, or homeless. “In many situations, life just happened,” Glicksman says. Someone lost a job, suffered a trauma, or got sick. They could not work or pay their rent. “Everyone has a story. The challenge is learning to talk and listen to people with these backgrounds.”

Knutson braced herself for the challenge. She tried to ignore the catcalls. Being fluent in Spanish, however, she couldn’t help but decode the men’s comments. This helped her. Men would lob a remark at her, and she’d lob it back. They’d snicker over a joke they thought she couldn’t understand, and she’d chuckle. “Once they see you can speak the way they speak, they trust you,” says Knutson, who is studying to become a Family Nurse Practitioner and plans to pursue her DNP degree at Columbia Nursing. “If you give them sass as fast as they give it to you, it’s points in your direction. They find a bond in that.” Still, the bonding took time, especially when it came to accepting Knutson’s help. “They were very closed off,” she says.

One patient, who had hypertension, denied having the condition or needing treatment. Moreover, the clinical nursing skills that Knutson had mastered by the time she started working with the man were not what she needed to counter his resistance to treatment. She needed to follow her gut. Fortunately, she had become familiar enough with his moods to spot his distress after she took his blood pressure. “He said very little and looked down at the floor when I spoke to him,” she recalls. She sensed that speaking with him in Spanish might ease his anxiety. “I suggested we talk a bit more, but in Spanish.” After a few minutes of small talk, the man acknowledged his condition. “By the end of the visit we were communicating about high blood pressure and medication to control it. He even agreed to receive a flu shot from me, after weeks of refusing it.”

The nursing program gave Knutson an opportunity she wouldn’t have had in a controlled hospital environment: to get to know the individual behind the patient, and to tap into her own sensitivity and compassion, inner talents that had drawn her to nursing in the first place. Indeed, the more she got to know the man, the more empathy she felt for him, and the more she understood that dispatching clinical knowledge was only part of what it would take to care for him; the rest would be seeing how his background and life experiences informed his health care needs.

Getting Something Back

Working with people who were homeless, or had drug addiction or mental illness wasn’t new to Benjamin Raudabaugh, an Adult-Gerontology Acute Care Nurse Practitioner student. Before arriving at Columbia Nursing, he worked at The School of Medicine at the University of California, San Francisco, conducting research on people with dementia and psychiatric disorders. He also worked in a needle-exchange program for intravenous drug users. At Project Renewal, he expected to meet men with broken lives. He anticipated giving them the best care he could. What he didn’t anticipate was getting something in return.

“Certain people came in and left. They were there to get things done,” Raudabaugh says. “Then there were others who shared a little more about their lives.” Some talked about their job or housing problems; others talked about their families. One of the best parts of the rotation, he says, was when the men opened up to him about their lives and inquired about his. “They’d ask how I was doing and where I was in my education,” he says. “When that happens, the whole interaction feels a lot less like a business transaction and a lot more like a shared experience. It feels personal.”

One man, however, had a troubling story to share. He had been in prison, where he acquired an infection in his leg. The infection led to his having his leg amputated below the knee. The prosthesis he received never fit right. It chafed and created a wound. Now, the wound was infected, and the man was in pain. Furthermore, he had lost all trust in the health care system.

Raudabaugh told the man that a specialist would evaluate him for a new prosthesis. The man was grateful but leery. Raudabaugh assured him that seeing the specialist was his choice. “When you’re a clinician, it’s really important to give patients the power to make decisions, and to be in control of their health and well-being,” he says. The man accepted the new prosthesis and returned to the clinic several times. “We cleared up his infection,” Raudabaugh says. “To have him open up and trust that we were giving him the best care possible and not cutting corners was really nice.”

Raudabaugh knew that he couldn’t solve the man’s problems. He could, however, give him the support that he hadn’t gotten in prison or elsewhere. “Caring for these guys is not just about giving them a prescription,” he says. “It is about taking a step back and trying to ignore prejudgments, and realizing they are just as smart as you, and just as deserving of respect.”

Identifying Disparities

People in the Manhattan and Bronx communities where Columbia Nursing students perform their community rotations are typically medically underserved. Often, English is not their first language. Some are undocumented and afraid to seek care. Ethnic or cultural biases cause others to resist or reject care that is available.

These types of scenarios sensitize students to the ways in which people’s backgrounds affect not only their health but also their access to care, and their experience of the health care system, says Jennifer Dohrn, DNP, CNM, director, Office of Global Initiatives. Dohrn teaches a required course on addressing population health needs on a global scale taught in conjunction with the community health rotations. For example, the program sheds light on why a pregnant woman from Senegal, where women help each other during childbirth, might shy away from an “interventionalized” and “medicalized” hospital delivery, and it trains students to recognize gaps in service, like the lack of linguistically appropriate nutrition information in communities where diabetes is prevalent. “We’re educating nurses who will understand health disparities in the context of how people live in the communities that nurses are serving,” explains Dohrn. “You want someone to be able to look at a community and ask, ‘What are the priorities?’”

Putting Patients First

In the waiting room of a Washington Heights urgent-care clinic hangs a poster written in Arabic, Bengali, Greek, Haitian Creole, Hebrew, Hindi, Korean, Mandarin, Cantonese, Russian, and Spanish. It reads, “We speak your language.” It is a hot summer Saturday afternoon, and the clinic is hushed. Two patients watch widescreen televisions that are mounted on opposite walls as they wait for prescriptions. A young man emerges from a back room. His eyes scan the empty chairs. Discreetly, he calls a name. A woman stands and joins him at the front desk, where a receptionist translates their conversation from English to Spanish, and back. The woman’s case is not urgent. She is a regular patient at Columbia Student Medical Outreach (CoSMO), a free clinic that uses this space on Saturdays and occasional Thursday evenings to provide primary care largely to undocumented immigrants.

Columbia University medical, public health, and advanced nursing students run CoSMO. They see patients who come in for scheduled, routine treatment and management of conditions such as diabetes, hypertension, hyperlipidemia, joint pain, or arthritis. They also help to mentor first-year nursing students. Angela DiLaura, BSN, RN, who is studying to become a women’s health nurse practitioner is one of four nurse preceptors who teach the students basic skills: triaging patients, taking vital signs and recognizing abnormal ones, drawing blood, giving intramuscular injections, documenting medication distribution and other forms of treatment, and learning how to present patient data to senior clinicians. “By week five, they’re nurses without the license,” DiLaura says. “They don’t need help doing injections. They’re very skilled at drawing blood, triaging, and speaking with the nurses and doctors.”

Besides clinical training, working at CoSMO gives students the chance to develop relationships with patients whose chronic conditions require ongoing care. Although a language barrier prevented Kyleen Swords, RN, from fully communicating with the patients she came to know at CoSMO, she understood they appreciated her learning enough Spanish to ask, how they were feeling or what medicines they were taking. “They were extremely grateful to me and all of the staff, and very patient with us, since we were all mostly students,” says Swords, who divided her community rotation between CoSMO and Jewish Home Lifecare in Manhattan. “What I liked best about CoSMO was that the situations were not acute; instead, the patients were seen for checkups. Working there solidified my desire to work in
an outpatient setting where I can build relationships with patients.”

Over time, a sense of familiarity evolved between Swords and her patients. She didn’t focus on their being undocumented immigrants; she focused on their need to feel comfort and care. “It is my responsibility as a nurse, and as a future nurse practitioner, to accommodate patients in every way possible,” says Swords, who is pursuing a doctorate in the family nurse practitioner program. “Regardless of where someone is from, what language she speaks, or what her beliefs are, every person’s health needs to be a priority.”

Discarding Assumptions

As students build relationships with patients, many find that their negative stereotypes fall away, their empathy deepens, their awareness of health disparities sharpens, and their assumptions change about what patients need most.

When Rebecca Wilkof ’14, began teaching nutrition education to the seniors at the YM & YWHA of Washington Heights and Inwood, she assumed they would know certain nutritional truths, like all sugar is bad. After all, many of the members who attended the Y’s health and wellness program had diabetes. “I assumed they knew that eating a whole watermelon was not much better than eating a piece of cake for a person with diabetes,” says Wilkof, a Northern California native who grew up eating organic foods and belonging to a gym. But her patients didn’t know why they needed to moderate their sugar intake, or why eating saturated fat was unhealthy. “It’s one thing to explain the difference between saturated and unsaturated fat to someone in their 20s or 30s, but another to someone who’s 80 and has been eating saturated fats her whole life,” she says. Moreover, most of her patients, who were Dominican or Jewish, had food traditions that revolved around meat and cheese, or cooking with schmaltz (chicken fat). “‘Low-fat’ wasn’t in their vocabulary.”

Wilkof’s patients faced other challenges as well, like living far from stores that sold fresh produce. “Even if they knew what to buy, it was still hard to get,” she notes. Moreover, a broken-down wheelchair or elevator, or a blizzard, could strand someone at home for days. “I didn’t understand how important mobility was to what kind of food my patients were eating,” Wilkof says. “For me, not being able to get around means not getting to the gym. It doesn’t mean having to buy a can of soup with a lot of sodium in it.”

Wilkof helped her patients make dietary changes that accommodated the challenges in their lives. In a cooking class called “Light Bites,” she made “bodega chili,” using beans instead of meat, and other healthy ingredients that local convenience stores sold. In her class on the cancer-fighting properties of antioxidants, she baked blueberry bread. She made brownies with yogurt when she taught a class on probiotics. “You have to learn what resources are available to patients,” she says. “The point of nursing is to give care to people according to their needs and not according to your prescribed version of what they need.”

Meeting Patients Where They Are

As communities grow more diverse, and as individuals—especially the medically underserved—live longer with chronic illness, nurses are becoming the main providers of primary care. To meet the challenges of an increasingly complex health care environment, nurses need more knowledge, not about science but about their patients, whose difficult backgrounds play a pivotal role in shaping their health care needs.

Ashley Knutson never came to terms with catcalls. But by the time she finished her community health rotation, she was no longer wary of the men who made them. They were, after all, in need of care, and her job was to provide it, based in part on how well she had come to know them. “It became a process of me building confidence in my ability to relate to them, wherever they were.”