Impacting Community-Based Care

Dr. Rachel Sherman Connects with Community via DNP Project and Social Justice

Dr. Rachel Sherman

It is no secret that 2020 was a very difficult and challenging year. The pandemic, social justice, and political unrest impacted everyone, including Dr. Rachel Sherman, DNP Class 36, APRN, FNP-BC.

A DNP student last spring and now a DNP clinical faculty member at FNU, Sherman was working at Prince George’s Hospital Center in Prince George’s County, Maryland. The hospital housed the highest number of COVID-positive patients in the state and, at the height of the pandemic, Dr. Sherman was losing five to six patients per day during her 10- to 12-hour shifts. The stress wasn’t left behind when the workday was over, as she has two children who were attending school from home. She also organized and attended daily social justice protests in the city. Her leadership was recognized as she was presented with the Rosa Parks Award for Excellence in Community Activism at the District 9 Prince George’s County Day of Service Awards this January. In addition to dealing with all of those things, Sherman was also trying to complete her quality improvement project as she neared completion of her DNP program. Students in FNU’s DNP program must complete a quality improvement project. This project, which is generally conducted with their patient population at their place of work, involves one term dedicated to identifying the project, collecting data, and recruiting participants. After the term break, the students then begin implementing the project, tracking the data and results which are included in a final paper. Due to the pandemic, many students like Sherman were no longer able to conduct their projects in a clinical setting. Responding quickly, FNU faculty quickly developed four quality improvement projects which could be conducted virtually. This offered a chance for the students to continue without delaying their academic progress. Sherman was one of the few who could have completed her project at her place of work, but she elected to pursue the virtual option out of concern for the safety of the project participants.

“I felt like it would be a disservice because it would take some of the attention away from the care I actually needed to provide to these COVID patients,” she said. “It was also safest for me to separate the two because I had to be in the ICU longer, exposed to COVID patients longer, I ran the risk of potentially taking COVID to another patient. It was better to do a virtual project.” Sherman’s project was “Advance Care Planning -- A Patient-Centered Approach to Community-Based Advance Care Planning.” Her social activism heightened her social media presence and when she shared that she was offering a free advance care planning project, the volunteers rolled in. In total, 85 participants signed up for the project in which Sherman intended to help educate the volunteers on what an advance directive is and walk them through the process. To assist with the management of the project, Sherman’s team included another nurse practitioner, a licensed clinical social worker, and a community advocate. “I was worried because I didn’t know how I was going to get people to volunteer to talk about advance care planning when they were already so consumed with everything else that is happening in the world,” Sherman said. “I was worried I wouldn’t have the response that I needed to have a good project. I’m watching my patients die through glass doors. I can’t hold their hands. I’m calling their family. So I’m dealing with the trauma of that and I still have to maintain a focus on my project and my kids. At one point, I thought maybe I needed to sit out for a semester, but then I got so excited to see how things were coming along and the faculty supporting me. You could tell the faculty had a plan. I felt supported. No matter what, I was always going to have somebody to go to.” While it wasn’t the quality improvement project she had planned to do prior to the pandemic, Sherman found that, in talking

“I felt like it would be a disservice because it would take some of the attention away from the care I actually needed to provide to these COVID patients.”

to community members about advance care planning, she was able to play a much-needed role that she would never have been able to do in a clinical setting. “I wasn’t serving in the role of clinician because these weren’t my patients, they were community members,” she said. “I wasn’t giving medical advice or writing prescriptions, so it was unique to step out of that role of white coat and prescription pad and be a community worker. That’s truly what community health looks like.” The project began with a screening to gauge the participants’ interest in and awareness of advance care planning. The participants were asked how they liked to learn and the program was then customtailored to their preferences. “I created a checklist so any person could go through it and essentially hit all of the required marks to inform someone about what an advance care plan is,” Sherman said. “We used this checklist to talk about what was a priority to our participants, how much they wanted their families to be involved in their medical decisions, and if there was anything that they were afraid of. A big part of advance care planning is looking at the person as a whole.” The program included spiritual assessments, discussions about healthy living in general, education about COVID, and tools with information to assist in conversations with a medical provider. Additionally, an advance care planning checklist and health care proxy checklist accompanied access to the state form to complete an advance care plan. Sherman and her team checked in with each participant two weeks after their initial telehealth visit to discuss their progress and any questions they had. “We were finding that most people were excited because they understood it and they were calling other family members to do their advance care plan,” Sherman said. “That was the beauty of it. We gave the education and now all these people who are going out to the community to spread the word as well.”

Sherman also asked her volunteers about their relationship with their medical provider and how comfortable they were having the advance care plan discussion with them.

“One of the more recurring themes was patients did not trust the local medical system,” Sherman said. “They would say, ‘I don’t trust that hospital. If I go in and I don’t have this plan or I don’t have someone to speak for me, they’re just going to kill me.’ They didn’t trust the local medical system. We found that more in our Black population -- that they did not trust the local health care system. Even in our white population, who had Black family members or friends, they made comments about how they saw their loved ones of color treated in the medical system. That was a big recurring theme that I didn’t initially set out to discover, but it became very apparent.” Of the people who enrolled in the project, 85 percent completed an advance directive. Sherman suggested that the program’s success came from getting back to the basics of patient-centered care. “Participants were very thankful because they felt like we always kept them at the center of the conversation,” Sherman said. “It painted this overall picture that we have got to get back to patient-centered care and that you don’t necessarily need a medical provider to have these advanced care planning conversations. Now we need to get our churches and other community organizations involved because this is something that can be done at a community level.” Sherman has taken those lessons to heart and is doing more community-based care, with fewer hospital shifts. “As a nurse, we get up and do this because this is our calling,” she said. “But I recognized my limits. Just seeing patients die in that capacity, I reached a point where I was either going to quit nursing altogether or I need to remove myself from situations.”

Despite the obvious and understandable stress she was under, Sherman felt fully supported by FNU and, particularly Dr. Diana Jolles, who was her faculty advisor. “Dr. Jolles was wonderful and very flexible,” Sherman said. “She was really passionate about everything I was doing from the social justice standpoint to working the actual project. I definitely feel like this program has shown me how to identify an issue and how to go about formulating ways to improve it.”

“One of the more recurring themes was patients did not trust the local medical system. They would say, ‘I don’t trust that hospital. If I go in and I don’t have this plan or I don’t have someone to speak for me, they’re just going to kill me.”