Debra Marinari

Debra Marinari began working at Mary Washington Hospital as a nursing assistant in 1990 while she was in nursing school at Germanna Community College. After finishing her nursing education at Germanna, she began working as a registered nurse (RN) in a medical/respiratory unit. She received her BSN and MSN from George Mason University. She helped to set up Lee’s Hill Freestanding Emergency Department and the emergency department at Stafford Hospital. Marinari has served in many nurse leadership roles during her career at Mary Washington Healthcare and is currently the Director of Nursing at Stafford Hospital.

Debra Marinari was interviewed by Jess Rigelhaupt on January 8, 2015.

Discursive Table of Contents

00:00:00-0015:00
First shift as a nursing assistant at Mary Washington Hospital in 1990—Began as a nursing assistant while in nursing school at Germanna Community College—Learning about core values of nursing in the hospital and from experienced nurses—Beginning as a RN at Mary Washington Hospital—New responsibilities as a RN

00:15:00-00:30:00
Working relationship between nurses and physicians—Clinical skills—Interactions with hospital administration—Comparing night shift and day shift—Earliest memories of the discussion of a new hospital—New possibilities for patient care at the new hospital—Working the day the new hospital opened (1993)

00:30:00-00:45:00
First shift at the new hospital—Increased level of care, specialization, and surgical options at the new hospital—New clinical programs, cardiac surgery and critical care—Working with higher acuity patients

00:45:00-01:00:00
Bedside care with automation with new technology—Transition from charge nurse to nurse manager—Staffing and budgets—Earning a bachelor’s in nursing—Experience with research and evidence-based practices

01:00:00-01:15:00
Master’s in nursing from George Mason University (2006)—Lee’s Hill Freestanding Emergency Department—Stafford Hospital

01:15:00-01:30:00
Challenges with Stafford Hospital—Opening day at Stafford Hospital—First patient at Stafford Hospital—Working with EMS and planning for the emergency department at Stafford Hospital—Working as Director of Nursing at Stafford Hospital

01:30:00-01:45:00
Working as Director of Nursing at Stafford Hospital—Core values of Mary Washington Healthcare—Integrating Stafford Hospital and Mary Washington Hospital—Nurse-physician dynamics at Stafford Hospital, a smaller hospital

01:45:00-02:00:00
Hospitalists—Integrated Provider Network and looking to the future—Primary care and public health—Dynamics between the administration, board, and medical staff—Magnet status at Mary Washington Hospital

02:00:00-02:08:34
Applying best practices from Magnet experience to Stafford Hospital—Reflecting on career as a nurse—Summary description of the best days in nursing

Transcript

00:00:10
Rigelhaupt:
It is January 8, 2015. I am at Stafford Hospital, in Stafford, Virginia, doing an oral history interview with Debra Marinari, for the Mary Washington Healthcare Oral History Project. And so, as I said just a minute ago, the way I’d like to begin is if I could ask you to describe your first shift, in 1990.

00:00:32
Marinari:
I was hired as a nursing assistant. I was not a certified nursing assistant, as we do have now for the organization. I actually was in nursing school and got this position, which I was very fortunate to get. I believe it should have been a day-shift position, 7:00 to 3:00 position. I remember my preceptor very well. Her name was Nelly, and just a wonderful lady, who had been the nursing assistant for years and years—she was probably a CNA. She took me under her wing. I was going to actually be working 3:00 to 11:00, but they had me during the day, just get the graphs. I remember being nineteen and like, “Oh, my goodness. This is very interesting and I’m a little overwhelmed.” I thought, “Wow. This is going to be where I’m going to be working once I finish nursing school, or in the environment.” I didn’t know where I was going to end up, but I did end up on that floor. I knew that’s where I was going to start my learning. I just knew that I was very excited because this was going to help me become a nurse. I was scared at the same time. The first time you walk into a patient’s room, it’s like, “Wow.” I was trying to remember to hold back, thinking, “Oh, my goodness. This is somebody who is sick and I’m going to be helping them.” It was great because then I just kind of fell in love with it after that. It was exactly what I wanted to be. It kind of helped me realize that, “Man, this is good. This is good stuff.” It was neat the person that they put me with and what I’ve gained from her, knowing all the years that she had been taking care of patients and her perspective. It was good. But it was scary, definitely scary.

00:02:08
Rigelhaupt:
What were some of your main responsibilities, in those first few months you were working as a nursing assistant?

00:02:13
Marinari:
So I worked 3:00 to 11:00. Back then it was usually me. You only had like one to two CNAs, at the time—nursing assistants. We took vital signs and, of course, were responsible for all the activities. The daily living, the bathing of a patient and making sure they ate, feed them if they couldn’t feed themselves, walk them to the bathroom, ambulate them if they needed to be assisted to ambulate, if they needed to get up and walk around—just basic needs. You would make sure they had water if they needed water. Anything that they rang the bell for: a lot of the bathroom stuff, the hard stuff, but nursing is hard altogether. Anything that the patient needed was my goal. [03:00] Lots of vital signs, reporting to the nurses if we found the patient not doing well, providing skin care, and that type of thing, too.

00:03:07
Rigelhaupt:
What unit were you in, when you started?

00:03:09
Marinari:
I started on a unit called 3-South, which was a medical unit at the time. I kind of saw a little bit of everything. It was a respiratory-renal floor—and it was the same thing when we moved, respiratory-renal. Anybody that could not breathe or pee, that was our population then.

00:03:28
Rigelhaupt:
And you had already begun nursing school when you started there.

00:03:34
Marinari:
Yes. I started in ’90. I was probably in my second year of nursing school. First year, you get your prereqs. But then I was starting to get into the actually nursing, the clinical part of it. I think that’s what helped me through nursing school: I kind of had a background of what was already happening.

00:03:57
Rigelhaupt:
Well, could you talk a little bit about your education? At the same time that you’re gaining this clinical experience in the hospital, and you’re in nursing school. How do you remember those two things lining up?

00:04:09
Marinari:
It was hard. It was hard because nursing school is hard to begin with. It’s a lot of time and studying that you need to do. I had to work because I had moved out and I was going to be this superwoman and just kind of be on my own. I had moved out. I had to have work. I already had a full-time job, and was trying to go to school. This was actually a part-time job, too. Again, I wanted to get my foot in the door, to see if maybe, when I did become a nurse, they would actually hire me. It was just a lot going on. Germanna was great. That’s where I got my undergraduate degree for nursing. The program was fantastic. We did all our clinicals, at the time, at Mary Washington. When I started in the clinical rotations part and actually got to go to the hospital I worked at and that worked out well. The classes were great. They definitely kept you in the right path and they make sure you were on the right track. And if you were to go on the wrong track, they’d let you know, at the same time. You kind of form a bond with your class, at the time, too, which was nice. You had people to fall back with. I actually was fortunate enough to work with a nurse that still works here, but she actually works for Snowden at Fredericksburg. We were in the same class. We carpooled together and studied together and that was really helpful. That was nice.

00:05:27
Rigelhaupt:
Who is it you were working with?

00:05:28
Marinari:
Her name is Susie Fontenot. She worked at Mary Washington for a long time. She just went to Snowden at Fredericksburg, just a couple years ago, maybe two years.

00:05:38
Rigelhaupt:
I interviewed her.

00:05:39
Marinari:
Did you? Great. She’s fantastic. We were good friends then.

00:05:47
Rigelhaupt:
So you’re in nursing school, getting clinical experiences, a nurse assistant. Did you think you wanted to work at Mary Washington Hospital when you were done with nursing school?

00:05:57
Marinari:
I did. I really had no plans to leave or go anywhere Just my whole family was from here. [06:00] I had no intentions of going anywhere. I was not married or in a serious relationship or anything. So my hope was to finish school and work in the community that I went to school and lived in. I had every intention. I can’t remember if I’d said this. I think I said it to you on the phone. That was the advice I was given while I was in nursing school, “If you want a job, you better get a job now, because then they might hire you as a nurse.” That’s why I went down the nursing assistant route and was fortunate enough to get this job, my first job, at Mary Washington.

00:06:39
Rigelhaupt:
Thinking about when you first started, still as a nursing assistant, what did you see about the core values of how nursing was practiced? What did you observe, in those first few months?

00:06:53
Marinari:
Just what the nurses would give to the patients? I think I learned really fast that it’s not what you have to do, really, because nursing is a lot of tasks and stuff, of course, but it was beyond that. Giving medications: you definitely have to be on the ball and make sure you do the right thing and the patient gets what is needed. But it’s that last little personal touch or compassion that the patient really wants to see and get from you. It was just neat to see the level of care among the nursing staff. And they wanted to help me too. They were always constantly, “Hey, let me show you this,” or, “Let me teach you this, because you’re going to need to know this.” They were very welcoming, at the time because they knew I was going to be, eventually, a nurse. They didn’t know if I was going to work with them or not. Everybody was just very accommodating, to say, “Yeah, yeah. You’re going to be one of us. We need you.” So that was good. I did get a little more personal, maybe, little bit more one-on-one time with the nursing staff, which was nice too. It was just nice to think that they thought of me as a part of the team. I think it’s the compassion and it was more of the caring. It was true caring that you really get from nurses. Just forget all the other stuff. You could really tell when patients got better because they felt that from the nursing staff and they got more than just doctor’s orders. Even just talking to a patient about their day or what their family was like. Interaction with the families, I think, was a big part too, getting to know them on a personal level. I think that’s what stuck with me as a nurse, too. It is really get to know your patient and their family because that is part of the healing and the holistic approach. And that way, you don’t lose that. [09:00] I think when you do lose that, you kind of lose your empathy for the patient too. I think that was really helpful for me early on and that was what made me a better nurse too, at the same time.

00:09:11
Rigelhaupt:
Could you talk about how that is taught by more senior nurses, if you’re doing something, as you described—as a task. You do X. You do Y. You do Z. But something like empathy, something like compassion, something like knowing how to talk with a patient is probably less formulaic.

00:09:40
Marinari:
That’s a tough question. I think as new nurses come on, we want them to get into the role and get going. We know what we have to show a new nurse. They know what they need. Sometimes it is hard because you kind of focus more on the true, task things, how to put in NG tube in somebody’s nose, and work on that. Sometimes we don’t stop and say, “Well, think about this.” Or, “Tell the patient this.” We kind of lose some of that sometimes because we’re in such a hurry when we have to teach. When you’re precepting somebody and you have a new nurse with you it does take more time because you really want to teach and tell them so much stuff, but you still have patients to care for. I think sometimes that that new nurse learns more by just watching and listening to how that person does it. I don’t know if we always do a great of saying or telling them, “Hey, this is why I did this or this is why I said this.” We’re just kind of watching and learning when they gave that personal touch, or handholding, or sitting beside a patient. It’s just observing. You get a feel for, “Oh, wow! She seems to really know how to interact with that kind of family or that kind of situation.” Then you kind of take that and you put your own spin on it. It’s hard to teach, though. I think it maybe can be learned. You have to have something inside you to make you want to be that way. I feel that way.

00:11:25
Rigelhaupt:
Could you talk a little bit about your first shift when you came on as an RN and—

00:11:33
Marinari:
Oh, gosh.

00:11:33
Rigelhaupt:
—how you were hired? Did you have to do a formal interview?

00:11:38
Marinari:
That is a great question. Let me think. I don’t think I did a formal interview. I think I graduated and I went to Rosemarie, who was our manager at the time, and I said, “I’m done now.” I think I just asked her, “Is there a chance I can be a nurse?” Apparently, there must have been a spot. I think I probably did have to put an application in. [12:00] But I don’t remember being interviewed, now, by any means at all. I think it was just kind of like they knew me at that point in time—I don’t remember an interview. She gave me a chance and brought me in. Back then, you started off as an extern because we hadn’t taken boards yet. You stayed in what you consider an extern role until you passed your boards. Then when you came and passed your boards, then you became a full-fledged RN. So, no: I don’t remember the interview. But I remember then we did a lot of education. We had an education department. We had to go to a lot of classes and just got a lot of support that way, making sure that we had everything we need as a new nurse and that type of thing. I think I might have started off on day shift, but I eventually went to night shift. I went a couple years on night shift, 11:00 to 7:00—we only worked eight hours, back then, and spent a lot of times on rotating between day and night shift. My eventual goal was to work days. I finally got there after a couple years. Working night shift was hard, but very interesting. I can’t remember my first shift. I think because it just kind of all blended together back then with nothing standing out. I was a nursing assistant on a floor where they already knew me, into an extern position, and then into the RN. Everybody, like I said, was always very good about just making sure I had everything I needed. I had a great preceptor. Katherine, I think, was her name. It just went very well. I don’t remember any hookups or anything, about my whole orientation or process.

00:13:35
Rigelhaupt:
What were some of the new responsibilities you had as an RN?

00:13:38
Marinari:
Of course, you got to give medications, which was huge. The list of medications that some people are on is just overwhelming. Then it was trying to make sure you gave the right meds at the right time, of course. Then physician interaction and calling the physician. I do remember the first time I had to call—it was Dr. Peter Smith, in fact. I was getting an admission. It was one of his patients. And I looked at the other nurse and I said, “I’ve never taken orders from a doctor yet.” She said, “Don’t worry.” She said, “Just make sure that you repeat and tell him that you’re new and you’ve never done this before. And just tell him to bear with you while you write these down.” And I said, “Okay.” That’s exactly what I did. He started rambling off all these things about Solu-Medrol and nebulizer treatments. So I said, “Dr. Smith, this is my first time. So will you please just bear with me?” He was very nice. He was the best doctor to have my first interaction with and he was great. He spelled things, when I wasn’t quite sure. I didn’t want to screw it up. And then that was it. I got my confidence up and after that it was fine. But it was just the interactions with the physicians and recognizing if I saw a change in a patient—and just being totally in charge of five, six, seven patients and interacting with the families. [15:00] Being the one to be able to say, “Hi. I’m your nurse today.” Or talking to the family: “I’ll be taking of your loved one today” and giving updates. And then, of course, if somebody passed away, that was a whole new experience, dealing with that, and the grief and the grieving process with the family. Even with the patient who was going through that, helping them, and supporting them through their dying process. Then eventually getting to the charge nurse role, where I was actually in charge of the floor, of the nurses, and making sure everything went smoothly. That was the other new responsibility, which I wanted to do. I always knew I wanted to do that. When I finally got the chance, I took it. I think that’s the biggest thing: just know those patients were now you and you were ultimately responsible for them.

00:15:48
Rigelhaupt:
How would you describe the working relationships between physicians and nurses at the time that you became an RN?

00:15:55
Marinari:
It was neat. It’s a neat dynamic. Whatever floor you worked on, you had like your specialty group of doctors because of the patients that were on your floor. You had to really know the pulmonary doctors. You would always see the renal doctors because all their patients were usually on the floor. So you got to know a core group of the doctors. Back then, it was all the primary care physicians, where now it’s totally different and we have hospital doctors. You got to know primary care physicians, and you got to know them well. Dr. Bigoney, gosh, I remember calling her all the time, and Dr. McManus. You usually got to know them really well and it was neat because then they got to know you. If you did call them, they’re like, “Okay. There must be something wrong because I’m calling them.” They would trust you and ask, “What do you think is happening? What do you think they need?” It was just neat to kind of build that bond with them and really be able to support them and the care of these patients. That was fabulous. And there were always some physicians who do things differently, that you just kind of have to go along with and support. There was some that and we kind of had bad days and you experience some of that. But it was, overall, a very good relationship. It still is today, with the doctors that we have.

00:17:19
Rigelhaupt:
What were the hardest clinical skills to begin to get good at out of nursing school?

00:17:26
Marinari:
I think it’s doing things that you only practiced on a dummy and never had to do it on a real live person. Starting an IV: the first time I had to do that, I was like, “Oh, please, don’t mess this up.” People don’t like to be stuck. You just went in with the motto: you have done this. You might not have done it on a real person but you have done this and you never let them see you sweat type of mentality. I think doing that kind of thing, an IV or truly putting a tube down somebody’s nose or putting a tube in somebody’s bladder—those kind of things. Once you did it once it was piece of cake. [18:00] There was nothing to it. But it was just the initial, “Okay. I’ve only done this before on somebody that doesn’t talk.” Actually, it’s a little easier on a person because they can talk and tell you, “Hey, this doesn’t feel quite right. This is not going right.” I think that was the hardest.

00:18:19
Rigelhaupt:
How much did you interact with the administration as a frontline nurse?

00:18:27
Marinari:
I think, being so new, not much at all. When I started, it was Mr. Jacobs that was the CEO, at the time. I remember knowing his name and seeing him, but not very much at all. And then, of course, we know the CNO. Who was the first CNO, when I first started? Was that Schuler? I think it might have been Priscilla Schuler, at the time. Sorry. As time went on, I got more involved with the nursing side. I got to know the CNO and the different levels on the nursing side of administration, but at the top level not as much. I knew who they were. I remember it well when Mr. Jacobs left and Mr. Rankin came on. There was not a lot of interaction: I was new and the working night shift too. It’s just a different world and different involvement. I definitely knew who the administrators were.

00:19:27
Rigelhaupt:
What were some of the things that were distinctly different about the night shift versus the day shift?

00:19:33
Marinari:
You don’t have as many people around and because everybody else is sleeping. You’re awake. There were meetings or other things that seemed to all happen during the day. That’s just the way life is. Everybody can’t stay up all night and have things going on. I think it was just more working night shift, coming home, and then having to sleep and come back. You don’t always get a chance to be as involved as much as you do during the day. That’s just the nature of the beast.

00:20:06
Rigelhaupt:
What do you remember about hearing, the first time, maybe even just rumors or water cooler talk, about the possibility of a new hospital? Or was it already being discussed when you started?

00:20:20
Marinari:
Let me think. It probably was already being discussed when I was in between being a nursing assistant and a nurse. I must have been started on days because the manager at the time spent a lot of time with us preparing. I got to come over and walk through the new facility and add feedback and that type of thing. I don’t know if I knew about it when I first started, but definitely after becoming a nurse and working on the floor. There was more and more communication and we knew it was all happening, that type of thing. [21:00] I remember going up, putting the hardhat on, and walking around. It was just fabulous and exciting. Having two patients in a room was tough. Not having private rooms, as a nurse, I found it frustrating at times because we had to move people around to meet accommodations or patient needs. It caused a lot of barriers, privacy and things like that. I was excited to hear we would have a hospital with private rooms. Now the air has come up. [Pause to adjust air conditioning]

00:22:06
Rigelhaupt:
Okay. So just before pausing, I was going to ask you about, as you first started to learn about that there was going to be a new hospital, what was most exciting? What seemed like it was going to open up for possibilities?

00:22:19
Marinari:
I think it was because I knew we could offer more things for our patients. Working at that hospital, at the time, was all I knew. I thought, “This is good. We have a great place to work.” As technology progresses and equipment and just how a unit flows—we definitely had challenges. The thought of, “Wow! We can have something that’s new, start of the art, and the possibilities of what would happen once we move into this new facility.” I think that is what was exciting. We just couldn’t wait. The thought was huge. It’s a new building. It was the same system. I can remember everybody thinking, “Wow. You’re lucky to have a new building because that doesn’t happen a lot.” If it does happen, it’s quite an undertaking. We were very fortunate. The growth that we were experiencing, we need it. That building [on Fall Hill Avenue] was not going to support this community and where we were going at the time with the growth. Everybody was thinking, “Yes, this is what we need.” It was very exciting.

00:23:29
Rigelhaupt:
Do you remember anything about how senior nurse leaders or senior physicians on the medical staff or even administration talked about what this new hospital was going to mean for the organization?

00:23:44
Marinari:
I do believe I heard Mr. Rankin talk about it. I can’t remember what they called it, but I know there was a team, of course, a core team, that was working on this and rallying around and updating staff periodically about what this was going to mean. [24:00] But I’m almost sure I remember going to something in ’92, going into ’93, when we moved. I was going to things—I don’t think they called them town halls. I can’t remember now. I still have all the newspapers from when we did move. It just that this was what the community needed, what with the growth and the potential for what we can offer community, to support our mission and vision. I do remember that. I can’t remember the venue. But it was definitely there. And it was nice, because I do remember being involved, which was great, in some of the planning.

00:24:50
Rigelhaupt:
Could you talk about your involvement in the planning?

00:24:53
Marinari:
It was just being able to pick out things and giving some ideas. Of course, I think, as a nurse, we think everything can just happen the way we want: “Why can’t we put this here?” Of course, there is wall structure and things that you had to take in consideration. But we always want all these grandiose things because it would be the best. You have limitations. So it was just neat talking to folks giving us options about the nurses’ station and where we can put things for the medication rooms. I can remember doing that. Even just some of the furnishing for the rooms and ideas and things like that. We were able to go over there periodically and watch it evolve, sort of like what we did here [at Stafford Hospital]. It’s a new experience to know that we were able to give support and input.

00:25:47
Rigelhaupt:
Were there any concerns from nurses about what this new hospital would mean? Was there a consensus about excitement?

00:25:57
Marinari:
I think it was more excitement because it was so needed and just that we were just constantly growing out of what we had—space limitations and things like that. I don’t remember any concerns. I think the only concern was probably the moving. Getting the patients over there, of course—how is this going to happen? That was probably the biggest concern. But the actual going to the new space, I don’t remember a thing. We were just so happy to know this was coming together.

00:26:32
Rigelhaupt:
Do you remember any concerns that you heard about in the community, for something—it was a significant growth?

00:26:44
Marinari:
It was. I honestly don’t. I don’t remember any.

00:26:54
Rigelhaupt:
Could you talk about the last time, if you can remember anything about it, that you went to the new hospital, before there were any patients? [27:00] And you probably did a last walkthrough. What was it like to be in this brand new space that was soon going to be where you were providing patient care?

00:27:16
Marinari:
It was almost like when you’re looking for your house. You’re so excited: “Wow! This is going to be mine.” That was kind of the sense. Or like a proud new owner or something, even though it wasn’t mine. But it was like ownership and really, we’re going to make this ours and it’s going to be so much better. I can just remember going through and opening drawers and being wowed. It was the whole wow factor and it was totally different than what we had at the old Mary Washington. It was just the constant just feeling like that. Then, of course, the flurry of trying to get everything organized and just thinking about processes—how this is going to flow now? Things are so different. The location of things, even outside the unit—how does a patient get here? Equipment, where things go, supply, pharmacy, and cafeteria hours and—it was just kind of really thinking about putting it all together. Then the whole impact kind of came together. But it was just more like, “Wow, this is ours now.” I just remember feeling the pride in that and knowing that this is going to be ours. It’s like we were the first person to step into this unit. What we’re going to do there and who we’re going to take care of.

00:28:35
Rigelhaupt:
Were you working, the day that patients moved, with all the—?

00:28:39
Marinari:
Yes. I was at Mary Washington. I was at the old one and sending patients to Mary Washington. We actually had one patient who said she was going to refuse to go. I remember dealing with her very well. She was a very well known patient of ours. As we continued to prep the patients, as the day was coming closer and closer, and then, the day of the move she was bound and determined. I remember just reaching out to my manager and saying, “What are we going to do if she doesn’t go?” My manager goes, “She’ll go. She’s just being a little feisty right now.” She was our last patient to move because of that reason. Then we finally got her over to Mary Washington. It was neat. We all had our T-shirts on—and I think I still have my T-shirt somewhere. It was just so neat to see all the ambulances going back and forth, everybody pitching in, moving patients, and getting organized. It was like getting settled. It’s like, “Wow, we did it.” It was neat and it was fast! It wasn’t chaotic. It just went really smoothly. It was a good day.

00:29:57
Rigelhaupt:
So you were among the last people there, with the patient.

00:30:00
Marinari:
Yeah. Once she got loaded, then we were able to finally come up and come over. Seeing everybody getting organized and everybody getting familiarized—it was good.

00:30:17
Rigelhaupt:
What was it like to leave the space at 2300 Fall Hill, that you had worked at—

00:30:22
Marinari:
I know!

00:30:22
Rigelhaupt:
—and it’s just been filled with patients and then is an empty building?

00:30:26
Marinari:
I know! It was sad! Because it’s like, “Oh, my gosh.” It’s where we worked—not that I was there a long time, about three years. It’s like, “Wow, I can’t believe I left here.” But it’s even weird now, I think, going over there. I go over there to meetings. The third floor was the floor I was at and I think, “This used to be the floor I worked. That used to be a bathroom. It’s kind of weird.” It was sad. It was sad, but then you got over there to the spanking new building and it was like, “Okay. This is okay.” But it was sad. There was some sadness there because it was where, personally, I started.

00:31:00
Rigelhaupt:
Could you describe your first shift with—and what role you were in, at that point, as a nurse, when you started at the new hospital?

00:31:09
Marinari:
Then I was a charge nurse. I was the permanent day charge nurse. I was there usually Monday through Friday, 7:00 to 3:00. I was always in charge, at that point in time. I got to make sure the daily operations of the unit ran well and all the nurses had what they needed, and doctors. I was the point of contact for the doctors and everybody else. I would take patient assignments occasionally, but I was more of the charge nurse role then, with some other nurses.

00:31:40
Rigelhaupt:
Do you remember any challenges from—? As a charge nurse, you were probably acutely aware of where things were and how—

00:31:47
Marinari:
Yes, I was.

00:31:48
Rigelhaupt:
And flow is really going to matter. Those first few days, what were some of things the nurses confronted?

00:31:55
Marinari:
Gosh. I’m trying to think. I think just knowing where things were and how to get things, since we had different processes now, like the supply chain, materials management, where laundry would come from, and little glitches. Did we forget something? Did we forget to order pencils or spoons or something like that? It was more that kind of thing, just the fine-tuning of where things were. Helping the physicians find where the forms were and where the charts are going to be and what to do with the charts afterwards. And help, probably, computer issues. Oh, that’s right. We had to make sure all of the patients crossed over in the system. I don’t remember anything huge, by any means. It was more just a couple weeks of getting everybody acclimated. Anytime that somebody hadn’t worked, it was getting them acclimated to what was going on. I don’t remember anybody that hadn’t had a chance to be walked around and oriented to where everything was going to be. [33:00] It was just the normal stuff and nothing big. I think we were still just so glad to have what we had that it was okay. We could work through these things as they came along.

00:33:19
Rigelhaupt:
Do you remember if you or your colleagues recognized at the time or talked about that the new hospital was going to open up possibilities for growth in terms of clinical practices and the expansion into a health care system?

00:33:39
Marinari:
I don’t remember thinking as a health care system. I do know that truly that we would be able to expand what we currently did. That was for sure. I don’t remember, personally, thinking where this would lead us. At the time, I was probably very naïve too, to be honest, being such a young nurse and not in the field very long. I definitely knew this was a good thing and we could offer more. We needed to offer more. There were people in our community that we couldn’t help and they had to go elsewhere, for surgeries or specialties and things like that. That was our whole point: to do this so we could keep people in our community and really focus on our mission and what we were supposed to be doing for our patients. I do remember that really well. As the health care was expanding and growing, I knew it was there. Of course, having this great campus I knew there was more to come. But at that point in time, I didn’t know where that was going to lead us, until many years later when I got more involved in the administration side.

00:34:49
Rigelhaupt:
What new clinical practices stand out in your memory as being really important to the organization?

00:35:00
Marinari:
I think the heart program was the huge turning point for us. That didn’t start long after we moved. I think it was twenty years ago. That was huge. Just thinking that we were going to take care of and doing open-hearts and things, which is incredible. Then expanding our ICU capabilities. I remember going from what we had at the old Mary Washington to a specific medical ICU and surgical ICU, to really capture those sick patients—and then, just besides the carts, the type of surgeries that we were doing here at Mary Washington. The heart program really stands out as the most. Attracting more physicians too, with the different specialties, I think, was a big thing. It’s hard to believe it’s been so long ago. Gosh. [36:00] I think that was the biggest one for me.

00:36:06
Rigelhaupt:
Something like the open-heart program and doing the surgeries that were different, and as you alluded to, affects ICU. What did you see in some of the changes, in terms of either patients or the medical respiratory floor?

00:36:30
Marinari:
I don’t know if it was combined. You constantly see patients that used to be in the hospital. It was changing because the care that you could provide outside the hospital was changing, of course. Patients were coming much sicker than we used to treat. We thought, “Oh, well. We had some sick patients. But, boy, we were starting to see really sick patients.” It was just the way medicine was advancing and what we could offer. The things that we did to patients, even on a medical floor, was just incredible. The equipment that we had and that kind of thing allowed us to take care of these really sick patients, where before they would have gone somewhere else. They would have gone north or south. That was really neat to see. That just continues to happen all the time. The things that we used to put patients in the hospital for, you don’t come in the hospital anymore. Now it’s just incredible what nurses and the physicians manage. It was definitely change. It has always been changing. Even the things that we were able to manage on a medical floor, they used to have to go to the ICU. That whole change of allowing those nurses to provide care and giving them what they need, so a patient didn’t have to be in the ICU. There were much sicker patients that needed to go to the ICU. There’s been just a constant change, even since we moved there, and the evolution of the types of patients and where they are cared for. The heart program really started when all that was happening. That makes sense.

00:38:26
Rigelhaupt:
So thinking about those first few years—and I don’t have a specific set of time. The first few years after you move in, the cardiac program begins. What do you remember about the new equipment nurses were working with on a medical floor and some of the challenges working with patients that had a much higher acuity than probably even when you started?

00:38:53
Marinari:
It was nice. Not even just the equipment we used for our patients but what the nurses had to use for charting and things was advancing—thank goodness. [39:00] We still had paper charting for a long time, but then we finally went to the computerized system for medications and for safety. That was huge. Nurses were giving a lot of medications and some stuff that really was high-risk drugs and things like that. It was nice that we evolved to the point where we got the system that we do still use today, with the scanning and the armbands. The safety role really kind of evolved after we moved into the building, and continues to evolve now. The focus on quality and safety seems to be more prevalent now and is now where it should have been. It was just at a different level. That really started to evolve: the quality and safety. Just because we got a lot of nice things that we could use on patients, the nurse still had to have that same level to be able to take care of the patient and to do her job. I forgot what I was going to say after that. What was your question?

00:40:12
Rigelhaupt:
The new challenges of working with higher-acuity patients.

00:40:15
Marinari:
Yes. Because we wanted to make sure our nurses were safe, as well as they were taking care of the patients. That was a big thing: making sure that we brought in technology not just for the patient but for the nurse too. That was huge.

00:40:30
Rigelhaupt:
What were some of the things that you remember while still working as a charge nurse that really struck you as important for the level of clinical care the organization could offer and the hospital could offer?

00:40:54
Marinari:
Oh, wow. Nothing is coming to the front right now. I don’t know if it was anything that was brought in, but I just will have to go back to the whole quality and safety part. Knowing that our patient acuity was changing and was continuing to change. Since we were offering more services and keeping sicker patients in the building, we needed to make sure we had enough nursing staff—first of all, the ratios with patients and that type of thing. I think that was one thing I was, myself, personally, glad to be able to promote and advocate for. A lot of times it was, “Okay. You have this number of patients, you figure out how to take care of them.” But it goes beyond that when, in terms of acuity, what each patient needs is so different. [42:00] It was nice to see us come together and say, “Okay, this is a new day.” Then bringing in those things to make the care that the nurse is giving safer for everybody. More and more automation came along. I don’t know if anybody told you the stories about how we used to have to keep charges for supplies you get the patient. We would all walk around with these yellow stickies all over us. We were supposed to go back and put these stickies on a card so the patient could get charged for supplies, which we don’t do anymore. We would all just walk around with them. It was little things like that you had to try to keep up with. It was so nice when that kind of stuff went away. Let the nurse be a nurse instead of worrying about all these little things. Just recently, we went completely electronic. That kind of stuff is just huge for nursing to keep up. Patients are evolving so much. The stuff the nurse does today compared to twenty years ago is just huge—huge—because of the acuity of the patients. I’m glad that the things we do are different. I remember—oh, gosh—the pharmacy wasn’t open at night when I first was a night-shift nurse. We had to call somebody to help us if we needed something from the pharmacy. Usually, the nursing supervisor would come up. We didn’t have a secretary at night. We used to have to try to transcribe our own orders. We used to have one secretary on, for the whole building. You had to call her and she used to tell you, “Well, you’re number five. I might get to you tonight.” It was just much different than it is today. How we handle narcotics—oh, my gosh, story after story. It was just a lot different. Yes.

00:43:46
Rigelhaupt:
Well, as you described, there’s more automation, more—

00:43:53
Marinari:
More safety.

00:43:54
Rigelhaupt:
—safety, particularly around drugs. But part of what you described as we began talking was that nursing always involves working with patients, empathy, and compassion. As the staff was working with higher-acuity patients, more automation, more equipment, were there challenges, looking back, that you faced in the day-to-day compassion side of nursing?

00:44:35
Marinari:
Yeah! It was hard. As a nurse, you had to try to keep up with all this, but still do not want to lose that personalization you want to give a patient. You struggle with it, still today. But it was hard. You know you have so much to do and you need to get it done within your timeframe that you’re supposed to be here. [45:00] You get kind of overloaded: “I got to do this stuff.” Then maybe the sitting down with the patient and talking is the last thing you do—and that’s just the last thing that goes. It is hard. It’s a balance. That’s what you’re trying to figure out when you’re in the patient’s room: how can you maximize the time with the patient so they still feel like they get interaction? You would hear, “I never see anybody. Nobody ever comes in here.” Especially if you got the short straw: that patient was not as sick as maybe the patient in the other room who the nurse had. It sometimes felt like that patient got more attention because you would feel like you’re giving that person more attention, but not that one. There was some guilt. I can remember nurses feeling, “Oh, my gosh. I just don’t have time to do what I need to do.” The automation is great, but it doesn’t always save time. It was trying to let them know: “It’s the right thing to do because you want to be safe.” But it was also helping them figure out how to still feel like they are a nurse and not just a pill-pusher. Sometimes what they would say, “All I do is hand out pills.” You have got to say, “Okay. Well, you’re not. Teach them as you’re giving them out.” It was teaching them not to struggle with the fact that, as things change, you have to do things differently. For some of the nurses that had been here for a long time, I think that was a big struggle. Things change with the different paper modalities to computerization and the charting and the medication administration. That was hard for some because they were very much used to doing it one way. They had to adjust and then figure out how to still get things done. It’s a constant change. As a nurse, that’s one of your characteristics: you have to be flexible because things are going to change in nursing. If you don’t like change, this is not a great career for you because it’s going to change. Sometimes we go back to things we did a long time ago and sometimes we go to something new. A version of it always still comes around. But we, as nurses, have to be innovative and figure out what’s working best for the patients as they present today. That means change on how we do things.

00:47:12
Rigelhaupt:
Do you remember conversations that maybe you had with more senior nurse leaders, chief nursing officer, or even senior administration to articulate what nurses were facing with higher-acuity patients and if the organization did things to try and support nurses? Changing patient ratios? Were there things that changed to support nursing practices?

00:47:38
Marinari:
I get my timeframes wrong. Whoever our CNOs have been at different times throughout the years I’ve been here and the starting of shared governance where we had a forum for nursing staff to go to. There were always committee meetings or something you could go to. [48:00] I’ve always felt like I was able to go and say, “We have to do something different here. This is not working.” Or, “We need to look at this.” There has always, always been a place for us to go. I’ve always felt supported in that. Even as a charge nurse to when I originally became a nurse manager, there has always been a nursing admin level, my director or my CNO—whoever it was—who allows us to come and bring things to the table. We are always, constantly doing that. I’ve always felt we’ve been very fortunate in that—just whatever vehicle that we needed to bring things to. I think starting shared governance, going on the Magnet journey back then, and to let nursing know that they’re empowered and have the autonomy to make a difference in our practice. I think it has always been there and is still there.

00:48:51
Rigelhaupt:
And in terms of timing, is this early 2000s—

00:48:55
Marinari:
Yes, like in late ‘90s, 2000s.

00:49:04
Rigelhaupt:
Five, six years after the new hospital?

00:49:10
Marinari:
Yes.

00:49:12
Rigelhaupt:
Would you talk a little bit about your transition from being a charge nurse to a nurse manager and when that happened?

00:49:20
Marinari:
I started on 3-South at Mary Washington, the old one. We moved to 4-South, which is the same unit, respiratory-renal. I stayed there and was the charge nurse. Then we went through a rough patch. The manager at the time, who was my old boss, she was having a really hard time. Things were not going as well as it used to go. I thought, “You know what, maybe it’s time to leave? I’ve been there a long time, on the same unit; maybe I should do something different?” I went and became a case manager and ended up working on 4-South. I case-managed the patients on 4-South. It was very interesting. I told my manager at the time and she asked me what I wanted one day. And I said, “I want your job.” She was very helpful. She always encouraged me to go back to school and she taught me a lot. That’s when things started going wrong. That’s why I left to become a case manager. Then when she left and the job posted, I was there. I applied for it and was fortunate they hired me as the nurse manager for the same unit. That’s just what I wanted to do. I loved that unit. It was a hard unit because it was a medical floor. The type of patients were very demanding—just the nature of their disability or their illness. I liked that we had to see a wide variety of patients. I thought that was helpful with the skill set and it wasn’t a procedural area, where you kind of do the same thing every single day. It was different levels, lots of different family dynamics, physician interactions, and ancillary department interactions. [51:00] I just really enjoyed it. In 2002, I officially became the nurse manager of 4-South. I stayed in that role for five years, until 2007 when I left for a new opportunity. I loved it. I thought that was what I always wanted to do and it was a goal. I got it and felt proud.

00:51:31
Rigelhaupt:
What were you most excited to do as part of your job as nurse manager, when you started?

00:51:37
Marinari:
I think it was to have a high-functioning team. I know it was great people. That team was fantastic. I wanted to keep that up and keep the morale up. I think what was happening was they went through kind of a little lull. It was important to bring that team back up and to support them and advocate for them. That’s when I supported and advocated for better patient ratios. I was saying, “Hey. This is what this unit truly is. We need something different.” It was changing the staffing patterns and being able to do that. I was able to bring the service scores up for that unit. The month I left, we were at the ninety-nine percentile for customer service. That team had a morale booster. I was fortunate to do something called “Transforming Care at the Bedside.” That involved them and it was strictly the nursing team input. We met and they would tell us what they thought would make a difference in their day. What can we do to change things in their day? I still work with that team. That was the best part because they worked hard. They deserved to be recognized for what they did, have everything they need to do their job, and have a say in how they do their job. That was just fantastic. I was sad to leave, but it was time. At that point, 2007, I had been there over seventeen years. It was good.

00:53:06
Rigelhaupt:
You mentioned changing the ratios. And that involves staffing. And that involves cost.

00:53:15
Marinari:
Yes.

00:53:16
Rigelhaupt:
And actually, you had already thought about budgets some, as a charge nurse. But I imagine, as nurse manager, it’s a different level of responsibility. What did you learn about the financial part—which is a huge part of health care—as you became nurse manager? What did you learn about the organization?

00:53:37
Marinari:
I had this idea about the unit. We started taking patients from the ICU that were on ventilators. These people were very sick, but they didn’t need to be in the ICU anymore. They still needed a machine to help them breathe and that type of thing. We started taking those patients. The staff would just say, “Oh, gosh. We can’t have six patients and somebody on a ventilator. It’s just not right.” [54:00] And I totally agreed with them. At the time, I went to Eileen Dohmann, who was our vice president at that time. I had a proposal—I had written it all up—for us to be a step-down unit. With the cardiac units we had units on the second floor that were always considered step-down. I thought, “My gosh. I have a step-down unit here. I’m getting these patients from the ICU.” I went with my little plan, with everything outlined, what I had researched, and ratios. That is when she told me, “Now, you can’t be a step-down unit, but you can do this ‘Transforming Care at the Bedside’ idea.” She had just learned about it. That’s what we did and that was fantastic. That gave them power. Eventually, I was able to show the census, length of stay, and acuity. We did a bunch of studies to show acuity. I was able to increase the ratios for the nursing staff. The days when those nurses had ventilator patients, they would only have to take a four-patient assignment. Everybody else had like a one-to-five type of ratio, one nurse to five patients. That put us having eight nurses, which for a medical unit is a lot of nurses during the day. I got the support. I showed what that would mean and how much more that would cost. They listened. I had support, even though I didn’t get to change the name. We got to do other things to kind of support what that unit is. So it was good. It did teach me that definitely you had to step back and take the emotion outside of hearing your staff say, “I’m so burned out. I can’t do this anymore.” You had to take some time, collect the data, and put in some thought about return on investment and what does this do to me? A lot of times, I’ve learned over the years, you can throw a bunch of bodies into the mix, but if you’re not going to get any better outcomes or patient care is still the same, then, other than adding bodies and causing more expense, what did we truly get if the patient is no better off or the nursing staff is no better off? That has helped me immensely. That’s the first thing everybody wants: more staff. There has to be a true need for more staff. What is different? What are we doing different? What has changed? It really has helped, as a leader, to kind of evolve and think about things like that. I did, probably at the beginning say, “Yeah, I want this many nurses. And that’s because they have too many patients apiece.” Being challenged and having to go back and say, “Okay, why? Talk me through this.” Eileen was always very good about that, to turn and say, “No, you have got to tell me a little bit more.” It was good.

00:56:43
Rigelhaupt:
Correct me if I’m wrong. The questions of evidence that you brought, the research you had to do was probably not a standard part of nursing education, when you went through.

00:56:56
Marinari:
No. Especially with me being an associate degree nurse.

00:57:00
Rigelhaupt:
So you learned on the job. What were some of the ways that you remember either other colleagues or the organization broadly, supporting nurses becoming more engaged with research and evidence-based decision-making?

00:57:18
Marinari:
At the time, too, I was on my path to go back to get my bachelor’s. I was taking periodic classes. But I was having life events as well—getting married, having children—at the same time. I was on a slow path to get my bachelor’s. I think there was always somebody around to either ask or go to for questions, even people in the business side. I’ve always felt I could go to anybody and ask a question: “What do you think I should do?” I think my director at the time was Linda. If she couldn’t help me, then she would tell me, “Okay. You need to go to talk to this person and this person.” I’ve always had the best mentors. I really and truly did. And then, at the time, I had great nursing staff too. Donna Fleming—who is back at Mary Washington now—she was like my assistant nurse manager, who I got to hire during the course of my management experience. She helped immensely too. She sat down and she helped me research. Everybody was very engaged. It wasn’t like I had to do everything myself. I had great people to help me pull it all together and be the spokesperson and advocate for what I needed, or what I thought we needed. I could always go to Linda and say, “Linda, this is what I want.” Not that she would do it for me, but she would say, “Okay, these are the contacts.” I’d go back to her and say, “What about this side?” And she would point me in the right direction. That’s one nice thing: nobody ever says no or thinks that you have a dumb question or idea. I definitely remember getting hints from everybody about how to make this work. I remember talking to the folks on the second floor, but I can’t remember who it was. I was trying to get their concept of step-down. They would point me in the right direction and share more about how they got to where they were. I think I was also using the VNA, the Virginia Nursing Association, and looking up things through our certifications, through registered nurses, and researching. We have a lot of tools. So it was never a problem.

00:59:43
Rigelhaupt:
So in the few years after you became a manager—and that’s right. You went back to earn a master’s, at George Mason.

00:59:52
Marinari:
Yes.

00:59:53
Rigelhaupt:
Could you talk about the education, your decision to go back and pursue that degree?

00:59:58
Marinari:
Yes. [01:00:00] When I became a manager, I had not finished my bachelor’s. Like I was telling you, life events kind of got in the way. But I said, “You know what? I want to get my degree.” I knew I wanted to do more. I knew an associate’s degree in nursing was not going to be looked highly upon in the future. Everything is changing. This field requires you to have the right knowledge, tools, and be up to date. I said, “Okay, I’m going back to school.” George Mason was fabulous. The last year is when you have to do your clinicals for that program. The organization was great and supported me. Every Thursday I was off in order to go to school and do my clinical rotation. They supported me the whole time I’m at school. It was fabulous. When I got done, Linda, my director at the time, knew I was going to want more. We got to know each other very well and worked very well together. She was the one that actually approached me and told me about this new job and said, “I really think you should apply for the Director of the Emergency Department that is going to be posted.” I truly thought she was crazy. I’m like, “Linda, for my past seventeen years, I’ve been an inpatient nurse.” I knew nothing about the Emergency Department. I kind of blew it off when she said that to me. But then, when I got home, I’m like, “Why would she say that to me?” Then I got thinking more and more. If your boss comes to you and tells you this, it’s probably a good thing. You probably should do it. I went ahead and applied. I wasn’t sure what was going to happen. I had no idea—I didn’t know the people in the ED well at all. I’ve always been so inpatient focused. I interviewed and I was chosen for the position. It was a great move. It helped me see a different side of nursing. I was, again, so focused on just taking care of the acute inpatient side, I didn’t know what happened before the patient got there or how that all flowed or why things happened. The ED is fabulous. I wish every nurse could experience even just seeing how things work there. It makes you understand more of what happens when that patients come upstairs—the flow and the acuity and how things happen. I’m so glad that she came to me that day and said that to me because otherwise I would never have done it. I would probably still be waiting—I don’t know what I was waiting for or what the perfect activity was going to be. This definitely happened for a reason. Then I got to get involved as the Assistant Director of the ED, which was what it was supposed to have been called because we were building the freestanding ED in Massaponax. It led me here today.

01:02:34
Rigelhaupt:
So you finished your master’s before you started as assistant director of Lee’s Hill.

01:02:37
Marinari:
Yes. It hadn’t been long. In 2006 I had gotten my degree. In 2007, I took the new job. It was within a year.

01:02:47
Rigelhaupt:
Could you explain the origins of Lee’s Hill, not necessarily your work but how was this idea presented to the staff, why is the organization opening this freestanding emergency department?

01:02:59
Marinari:
Yes. [01:03:00] It was the whole concept that the community is getting bigger and bigger, we’re growing, the population is huge, and we need other avenues for access. The whole health system concept coming along. At the same time we are building the freestanding ER, we are working on Stafford. Both things were going and we are becoming a system now. We are growing. We’re getting out of just being a Fredericksburg-based facility and into the surrounding communities. The community is getting huge. We need to be able to take care of everybody. Making care accessible at different points throughout our area will be helpful for us as a system and our patients. It was just presented as we’re going open up a little freestanding ER. I hadn’t heard of such a thing. Then, of course, doing some research I learned it was being done all over: “Oh, wow! So this is the way to go.” It’s kind of like a quick point for those people that just want another place for treatment. The ED was always busy at Mary Washington—always, always. It was presented to relieve some of the pressure on the main ED. It all made perfect sense and it was great. Spotsylvania is a huge county. It was a perfect place to put one, especially to reach the Caroline population and those people way out in Spotsy. They don’t have to come all the way into Fredericksburg if they don’t want to. So it was a neat concept. I was really jazzed about it, even though I was nervous, not knowing the ED well. I kind of jumped into it with both feet. It was neat. Again, I got to be right in the planning stage. That way, I was really, really involved with cabinetry, where things were going to go, and ordering. I got to pick ceiling tiles and that one was really neat. I was even more involved than in Mary Washington. Because of the nature of how long it was taking—because it wasn’t our building—I came over here to Stafford to help Stafford open this ED. I was thinking I was going to go back to Lee’s Hill. Once I got here to Stafford, I just didn’t want to leave. When they asked me to stay, I said, “Yes!” I never got to see that building open at Lee’s Hill. That was a neat, to kind of go through the motions of opening another new place, after already being at Mary Washington and I got to experience that.

01:05:20
Rigelhaupt:
So you never worked at Lee’s Hill before it actually opened.

01:05:23
Marinari:
No. No. Stafford opened and Lee’s Hill had not quite finished yet. They didn’t have a manager here for this ED. They just asked me to come over and get it open. Once you start hiring people, getting to know people, and getting them excited about, “Hey, this is going to be your new hospital.” We used to go off-site and do all these team building and getting-to-know-you exercises. It was just phenomenal what we did with opening Stafford. It was almost like, “Oh, my gosh. I feel so bad now if I have to go back to Lee’s Hill because I got this team that is counting on me here.” [01:06:00] They were getting to know me. When they kept asking me, “Are you going to stay? Are you going to stay?” I couldn’t say no because it just felt right. It seemed like the right thing to do. So unfortunately, I never did get to open Lee’s Hill. When I walked over there not too long ago, it was kind of neat. I was like, “Oh, yeah. I picked out that ceiling tile.” It’s got this pretty design on it. It was a good foundation for me to help me open Stafford, by every means.

01:06:24
Rigelhaupt:
How many months, or years, did you work planning Stafford before it opened?

01:06:30
Marinari:
I didn’t get into Stafford until the very tail end of it because I was working on Lee’s Hill. I didn’t get involved with the planning of Stafford until late 2008, early 2009, right before we opened. I started on the activation teams. When they said, “Will you come over?” I was on the team to start that. A lot of Stafford was already done. I remember, at Mary Washington, we set up the mock rooms of what Stafford would look like. I did get to come down and look at that. But at that time, I had no interest in Stafford because I was not going to be a part of Stafford. If somebody asks me something, I always give them my input. But at that time, I didn’t have any ownership there because I wasn’t going to be a part of it. Then I got more into it and was able to be here and have some input. I didn’t have a lot of choices to make because a lot of things were already done at that point in time, but I still got to see the evolution, the moving-in day, and that type of thing.

01:07:32
Rigelhaupt:
Thinking about the few months before moving day and before opening. Again, as you talked about at the beginning part of this is thinking about culture, thinking about a nursing practice that involves compassion and not just the latest tools. You know the organization is opening a new hospital, they’re going to have the best technology—

01:07:56
Marinari:
Yes.

01:07:56
Rigelhaupt:
—they’re going to have the latest tools. And you know that’s going to be there. How do you plan to build a good culture? How do you plan to build nurses that are going to work together as a team and provide the empathic, compassion, and nursing care that is as core as any of the clinical practices that you do?

01:08:14
Marinari:
I think we were very fortunate with Cathy Yablonski coming in as our administrator for Stafford. Right off the bat we had multiple sessions together. We had all these sessions that we used to go to Jepson for and it was just really neat. She set the culture that we were going to be all “As.” That was just the best thing, I think, opening this new facility and starting fresh. They said that was going to be our culture and was going to be “always.” Regardless who that person was, a visitor, patient, each other, we were going to treat everybody the same. What we did for one, we were going to do for the next. I love how Cathy always says, “Would you want to be that patient who is taken care of by that nurse who decides not to wash her hands? You wash your hands ‘always.’ Whatever we do, we do it ‘always.’” [01:09:00] That kind of helps us stay grounded. It helps us to keep what we do and say, “Why would we not do that?” If that is what is good, then why aren’t we not doing it?” It helps us stop and think, “Okay. Well, maybe we need to figure out why we’re not doing it then.” That culture has stayed with us and it’s been really good. Now that has even gone over to Mary Washington Hospital, as part of Mary Washington Healthcare. It was neat to see we were able to start our own culture. That helped us to tell if people were a good fit or not. I hate to say that there are some people that get into nursing for the wrong reasons. You get some that are in their second or third careers. I don’t know why, but they think nurses make so much money. It’s a hard job. And they really and truly are not in it for the rights reasons. The “always” culture and supporting our mission and vision and having our values means if it’s not a good fit, it’s easy for us to say, “This is not working, because you’re not….” Whether, it’s performance or whatever. We take service very seriously, and quality. We can help people learn to do their job and be a nurse, but if you can’t show that you care, then that’s a big problem for me. That’s what I support. That’s what our “always” culture supports too. We help those people go find somewhere else to work, if they don’t think they can do it. That’s the core of what we have to do. It’s not just a nurse. Even a CNA or a transport: we all have to care, have pride, and know that is what we are here for in our job. It’s hard, but it’s nice to have a foundation of that in this building and now at Mary Washington too. We try. That’s what we do. And it makes sense.

01:10:50
Rigelhaupt:
Are there things that you remember, that you learned about opening a new hospital, from having worked on Mary Washington Hospital, that you tried to apply either to Lee’s Hill or Stafford?

01:11:03
Marinari:
Yes. Taking into account nursing—everybody on the nursing team—and what they have to do. Bringing things to the staff, so it’s not things so far away and that kind of thing; really thinking what we’ve learned in the past about what ties up the nursing staff, prevents them providing care, and having things more readily available for them. Thinking what we can do in a patient’s room, as far as keeping supplies. Or what can we do differently so that nurses doesn’t have to walk so far, back and forth between rooms, searching for things? Where can we keep things so they don’t have to search? That was neat, to know that what we struggled with in other places, and now, being new, what can we do differently here? That’s something you always have to change, too, as things change. [01:12:00] That was a big thing: what was lacking, what we were always running into trouble with, bringing it both places, and trying to fix that. Storage of things and making it more accessible were big. Having the supplies around and not down the hallway, in a closet by itself, and not out in the forefront. The placement of things was big.

01:12:31
Rigelhaupt:
You were already in a nursing leadership position, probably, as Stafford was being planned. And so my guess is you heard about it before it was made public, that the organization was thinking about opening another hospital.

01:12:47
Marinari:
Yes, right.

01:12:49
Rigelhaupt:
As you start either hearing from board members or senior administrators, what did they tell you about why they were thinking about Stafford and why the plans?

01:13:01
Marinari:
It was looking strategically about where the need was and through research looking at where the population growth was—Stafford was the next biggest growth population. A lot of people were leaving Stafford and going up north for things. Through their public relations and the strategic planning, they found that would be the best strategic location. If we were to go somewhere, that would be it. And, of course, being able to find this nice parcel to put the hospital, so close to the Courthouse. I remember that it was more of this was the next up and coming relationship for 95 and where the subdivisions were being developed and that type of thing. I can remember them being presented in that way.

01:13:56
Rigelhaupt:
Were there any concerns from nurses or other colleagues that you worked with? As you described in your unit, there was a lot of improvement, in the years you were there. What would it mean for an organization to move from a one-hospital to a two-hospital system?

01:14:14
Marinari:
There was a lot of talk about that. The ED part, people took that better. That’s my own personal opinion. That was better because the ED was always so busy. Everybody was like, “Oh, yeah. That makes perfect sense because that ED was busting at the seam. And who wants to wait four hours to be seen?” But a new hospital caused a little bit more talk. Not that the people didn’t understand why we were doing it, but I think they felt more like, “Was it just going to take business away from Mary Washington? What was Mary Washington going to lose by doing this?” Of course, now you’re talking 2007 and reimbursement is starting to change and cost things are starting to change. [01:15:00] It was a lot more, “Why are we doing this?” It came from staff and other people because this was millions and millions of dollars. It was a lot more of the whys, then. A lot of people did not agree with it. Again, at the time, I was very neutral because I was very busy, trying to learn and do the ED. But to me, being in school, it made sense. I was like, “Oh, yeah. Absolutely. It’s perfect.” I was not connected yet to Stafford. Then actually being connected to Stafford and hearing all the grumblings about, “Why are we opening? Why we did do what we did.” It was sad. I was like, “Man. I can’t believe that we’re not being supported or not everybody sees why we did this or understands.” Of course, the first couple years were hard because the volumes were low. I can remember the opening day and thinking, “Oh, gosh. Is anybody going to show up today? Are we going to get any patients?” We were kind of sitting around. Thank goodness we had a patient as soon as we opened. But you just didn’t know. This was new. Are patients going to come? Are they not going to come? They have other options. The physicians had challenges. Now they have three hospitals they had to go to now with Spotsy being open. It was competition. I think that was the other thing: Spotsylvania Regional was being built at the same time. It was like, “Why are we doing that, then? Why don’t we just stick to what we already know is working? Why do we have to do this?” I think the money thing was really on a lot of people’s minds because we were starting to feel a squeeze on things.

01:16:44
Rigelhaupt:
Was that something that was different, that nurses were concerned about the finances? Was that truly tied to Stafford or was the question about finances and health care in general becoming something that nurses were more aware of?

01:17:03
Marinari:
Exactly. I think it was just more awareness. Nurses could care less about insurance on the patient. We’re going to take care of that patient regardless if they have insurance or if they don’t have insurance. In nursing school, we don’t even talk about insurance and are they self-pay or do they have Blue Cross. That’s the farthest from your mind. All you know is you come in, that patient’s in the bed, and you’re going to do what you need to do for them. But now you have to start thinking. You have to teach the nurses, “If you discharge this patient and they have no way to get their medications, they’re going to be back in two days.” That causes a whole new readmission issue now. We didn’t have to worry about quality scores and customer service scores years ago. We just did what was right. We did what was the best thing. But now you get penalized if you don’t. Now you have to constantly show dashboards—how are we doing?—so that the staff understands that everything we do does make a difference. [01:18:00] And being that “always” is huge now. We can’t ever slip. We can’t not do something and then later regret it because something has happened to the patient and we didn’t do what we were supposed to do. I think it was because everything was changing and it was more in the news and being talked about—insurance is changing and reimbursement is changing. It was starting to be scary times, where before we never had to worry about that or even paid attention to it.

01:18:35
Rigelhaupt:
Could you tell me about the first day that Stafford was open and the first patients that came in?

01:18:45
Marinari:
We had a ribbon-cutting right out front. We cut the ribbon. It was so much fun and we’re all excited. I was a nervous wreck. I’ll be honest. I was trying to hide it, but I was a nervous wreck. I was like, “Oh, my goodness. Do I have enough people? Is anybody going to come?” The lady who was our first patient actually watched the ribbon cutting. Then she walked around and was sitting in the lobby. I remember somebody coming up to me and said, “Debra, our first patient is here.” I said, “What? What do you mean? There’s nobody here.” It was just cute: she walked right around and went through the door and came in. When I went to talk to her she said, “I’ve been waiting for you guys to open. I was so excited to hear that we’re getting a hospital in our community.” That meant the world. I thought, “Yeah, this is great. People do want this.” That made a world of difference. She was just a very nice lady. She ended up being our first admitted patient. Dr. Josovitz was telling a story just the other day. He was our outgoing president for the medical staff. He said, “I remember. We only had one floor open at the time and she was our only patient.” She just got admitted. He’s a GI doctor, he came on, and he said, “The nurses came and said, ‘Hey, Dr. Josovich. What can I help you with?’” And he’s like, “Well, I’m here to see the patient.” The nurse said, “Well, which patient?” And, of course, she was the only patient. The real lightness of the whole thing and he was really funny, how he told the story. It was neat. We were all ready. We were kind of waiting to see how many people came. It was neat to see, day after day, that you’re getting busier and busier. Then the constant, “Okay. Now we’re running. Now what do we do? They do like us. They are coming.” We were staffing up for that and changing. The way we opened was definitely not the way we were going to be able to sustain. The ED became fast and furious. The great comments about, “Glad that we were here now.” I had one lady who had several children and I was talking to her one day. I said, “I’m so glad you used us today.” She was, “Oh, yeah. I love coming here.” I said, “Well, good! Make sure you tell everybody.” She said, “Oh, no. I don’t tell anybody. Because that way your ED doesn’t get busy.” I was like, “Oh, no, no! Please tell people.” It was things like that. It was neat. It was kind of like a little hidden secret there for a while. We kind of needed it to be, at first, too. We had to work out the bugs, see what we did have and what we didn’t have, and what we needed. It was neat. [01:21:00] It was really exciting and stressful, but exciting at the same time.

01:21:04
Rigelhaupt:
So the first patient came through the ED.

01:21:06
Marinari:
Yes. She was our first. She comes in every once in a while. I had not seen her last year. But she used to come in, every once in a while, and say hi.

01:21:18
Rigelhaupt:
I think it’s very funny that she waited for the ribbon.

01:21:20
Marinari:
I know! It was the sweetest thing ever.

01:21:23
Rigelhaupt:
“I got here a little early.” Planning for the ED opening, did you have to work with EMS?

01:21:36
Marinari:
Oh, yes. Yes.

01:21:37
Rigelhaupt:
Did you have a sense of which patients you were going to take first? A more serious accident or trauma probably would have gone farther south [to Mary Washington Hospital’s Trauma Center]?

01:21:45
Marinari:
Yes.

01:21:47
Rigelhaupt:
What was the process like working with EMS to plan the ED?

01:21:50
Marinari:
That was really neat. Stafford County was just so engaged with us being here. They were so excited. They were just 100 percent on board. We just had to kind of go through what we knew we were capable of doing and providing them an outline of what we could support and what we think: “These are the guidelines. If the patient’s having this, take them right to Mary Washington because they already have that set up.” It was that type of thing. They were fabulous and they continue to be fabulous. They are great partners. We are constantly checking in with each other and we meet. They brought to the table what they could do and what they thought they needed from us. There’s a lot behind the scenes with their medication boxes. We had to make sure they had their room set up so when they came in, they had a place to chart, have a snack, and get supplies. We made sure we had all the supplies they needed to exchange out, a place for a battery, and somewhere to plug in their rig—just little things like that. They were actively involved. We did walkthroughs. We brought them in and that type of thing. Quantico was the same way. We got them involved. They were all very happy to know that we were going to be here now. Again, because they knew how busy Mary Washington was. This was like, “I can bring a patient in and out.” They don’t feel like they have to wait to get what that patient needs. That helps them to get out and back on the road, too, so they can go to their next run. It was good. It was a good relationship and continues to be a good relationship.

01:23:30
Rigelhaupt:
Do you remember the first patient that came in via ambulance?

01:23:35
Marinari:
I don’t anymore, but I know the ladies over there still do. I don’t remember the first squad now. I remember the radio going off and everybody was like, “I think we got our first squad.” I can’t remember what it was, unfortunately. I don’t remember, but I do remember the radio-com going off. They were like, “We got our first patient. And what was that?” [01:24:00] It was a new noise. We had to try to figure out how that works. It is neat, all the little bells and whistles.

01:24:09
Rigelhaupt:
Could you tell me about how long you stayed in the Emergency Department here at Stafford, and after it opened, and where you went next?

01:24:25
Marinari:
We opened on February 27, 2009. I was selfish. I said, “I’d love to stay at Stafford, but I didn’t want to be a manager.” I had already been a manager. I wanted to be something more. I had a director title when I came over here, but I was just filling in. I wasn’t sure how I was going to fit in. I did not want to be a manager. I wanted to do more. They ended up allowing me to fill the manager position. I brought in a manager. I think she started in September. I was the manager from February until September, when she started. Then she took over the ED functions. Then I got the privilege of taking over other things, such as nursing supervisors. I had case management. Now, I’m going to forget all that I had. I had little entities and things like case management and nursing supervisors. I still had the ED because this new manager was a new manager. I kind of was supporting her. From there, my role just kept evolving. Then I think I was the Assistant Administrator Director for Nursing because we had Administrative Director of Nursing—that was Cheryl, at the time. I was her right-hand person. We worked very closely together. She gave me tons of things to do. That’s when I was able to do things more nursing related, such as bringing up our shared governance committees. I was involved with anything nursing at Stafford. I didn’t have a unit because we still only had one unit open. We had an ICU and labor/delivery and that type of thing. The managers reported to the administrative director, but I helped facilitate anything nursing. I got to learn so much. That role kind of kept evolving. I kept taking on more projects. Then when the Administrative Director of Nursing left, I accepted that role. Then I got to, over time, pick up all the managers. Before we had service lines across the organization and labor and delivery reported to a director down there and so did the ED. Now I have the pleasure of having all the managers of all the nursing units report to me. It has kind of evolved. I lost things—case management. Nursing supervisors I gave to somebody else. I lost things and gained things. It’s neat. I’ve pretty much had responsibility of every area in this hospital, except for the ancillary stuff. [01:27:00] Now I just have overall responsibility and it’s fabulous. I have a great team. Everybody that works here is very engaged, has a great purpose, and they enjoy working here.

01:27:14
Rigelhaupt:
Did your title mostly stay the same, over those years? Or was it one of those things that changed rather quickly?

01:27:21
Marinari:
It was weird because my title never caught up. I’ve always been either assistant director and now I’m just the Director of Nursing. I had the ED. I was Assistant Director of ED, when I first came over here. Got that. Then it didn’t make sense because it wasn’t just the ED. Then it changed to Assistant Director of Nursing. Then, when that person left was when I became the Director of Nursing. It has been variations of it.

01:27:48
Rigelhaupt:
But you’ve been in senior administration in nursing at Stafford since it opened. What were some of the challenges and success stories you would point to, in terms of growing to multiple units? As you said, only one floor. But now is it census driven? What would you point to as things that went really well and some of the challenges that you had to work on?

01:28:14
Marinari:
It was getting the right people in the management spots. That’s huge because they’re the ones that have to make those units run. Getting the management team right in order to have the frontline people right. The people that take care of the patients, they need somebody that’s strong, that’s there for them, and can manage the daily operation. We were able to get the internal nurse management as it grew and more units opened and people came on—it was just getting that right fit. At the beginning we had some folks, but they were good and they came and have gone. It was just building our team so that we were cohesively together. With Stafford being so small, the management team can’t just be worried about your unit. We have to work together as a team. That’s kind of what we’ve built over the last five years: we’re in this together. Just because you might work in the OR as the manager, you help us make the inpatient unit or the ED successful. Patients flow all throughout. We’ve really done a nice job of not being siloed and really supporting each other. I think that’s been our biggest success. We’ve had our challenges with having to change management, but it’s “always” for the right reasons. You have to know our “always” culture and be willing to make hard decisions about staffing sometimes. Like I was telling you, we really believe, if they’re not a good fit, then we don’t need them here. There are other people that can do the job. We don’t like to hear comments from patients, “I had a really good stay, but this one nurse was not very good.” [01:30:00] That “but one nurse.” If she’s clinically sound, but she’s not very nice, then that’s not good for us. That’s not good for patient care. We need that person that can smile and be nice and make them feel better. We always say, “Just because you’re having your worst day, that patient in the bed’s having a worse day.” I always say that to new nurses who are coming in and when I talk to them. You have to leave your personal issues at home and be willing to come to the table and give them twelve hours of being nice, caring, and compassionate. If you can’t do that, this is not a right place for you. I think the biggest thing is just it takes a long time to build a team. It’s over the five years we’ve evolved with lots of changes, openings, and additions to things that we do here at Stafford. We have that now and it’s nice. Things will continue to change and we will get new players. It’s okay. We kind of know what it takes now and what we need. You really have to be flexible here. You have to be willing to do things that you normally might not do at another, bigger facility. We just don’t have a lot of people to look upon. We do work really well together, which is nice.

01:31:24
Rigelhaupt:
You described, as you started—the charge nurse, that, when nurses were bringing questions of being burned out to you, that it was a challenge and, in one of your first roles as a nurse leader, you were acutely aware of some of the challenges facing frontline nurses. Higher-level nurse leadership, as you began in Stafford, what are some of the things you tried to do to really stay aware of and make sure that the organization is really thinking about the frontline nurses?

01:31:59
Marinari:
This is probably my downfall, but I’m very nursing-centric. I do come to the table and talk about nursing, but I’m trying to do a better job of not just being nursing-centric because what affects nurses also affects everybody. I’m trying to do a better job of coming to the table with the bigger picture, of what affects Stafford and would also affect Mary Washington. It’s neat because I can still advocate. Now, at the level that I am, I can advocate even more. Listening, rounding, and having town halls and saying, “Okay, tell me what’s going on.” I have the ability to get things that they need a little faster, without having to ask permission anymore. I have more ability to now make decisions that I wasn’t able to before. Being at a different level, I wasn’t able to before or I always had to ask permission. [01:33:00] Now I get to make the decisions, which is nice. Some decisions, I have to ask others for. It’s just nice being trusted that the decisions I do make are okay. They put me in this position and they trust my abilities. I am proving myself. That’s okay. This must be needed because she’s asking for it. If I need to show you something, I will. It’s nice now, because I can get things done and advocate—even if I need to show why we need what we need. We just have so many more avenues to do that now with reports and data and all the things that we collect. It’s a little easier. But it’s harder, at the same time, because now people want to see a little bit more information when we want things. I don’t think that’s changed any. I think I’m still able to do what I need to do. I don’t always get everything, but I compromise and figure out what we can do differently or work differently. And that’s one thing here, too. We’re very resourceful. If we can’t make it work one way, we’ll make it work another way. Having another sister hospital down the road to call upon and we are becoming really good partners with them. I do spend some time down at Mary Washington. I actually have wound care nurses at both facilities. I go down there a lot and work with them on projects. I am seen as a leader and a go-to person at Mary Washington Healthcare, which is nice. It works well. I think I can make a difference and I do make a difference.

01:34:38
Rigelhaupt:
So this hospital is part of a health care system, as you just described. How do you create similar core values at a smaller hospital and a new hospital and sustain the core values that you and others value, that were done and work right now when you open a new facility? From the core values that were developed over decades at Mary Washington, how did you bring them to Stafford?

01:35:06
Marinari:
I think it was just the constant letting the team know and counting on our administrator. She was fantastic about that, as I said earlier, being that role model, starting at the top and showing it down. Then, us as leaders, all of us had to be that same way. If we say, “These are our values. These are ICARE values,” then I shouldn’t be doing something that is not one of our values or saying something that does not go along with our values. I think being a role model for the staff was huge, and constantly reinforcing what our culture was and what our intention and what our expectations are. I think, as a leader, the biggest thing that I do is being fair and consistent and keeping that along the way and holding my team to that, as well. Everybody needs to be doing the same thing among the teams. [01:36:00] Otherwise we get inconsistencies and our culture will change or we’ll see a change, if we don’t hold that true. Myself, holding my first-level team accountable and then just being a role model for everybody and not just nursing. I work closely with the ancillary, engineering, and EVS. Being a big partner and helping them, if things don’t seem to be going right, to kind of give them assistance or feedback, so they can fix it. We definitely want to right things before they get too wrong. Once things start going down a path it snowballs very easily. The collaboration among the team is huge to keep that culture and our values going.

01:36:54
Rigelhaupt:
You described Cathy Yablonski, and, as director of this hospital, playing a big role in articulating and sustaining values. But the hospital is also part of a health care system. Did you work with people, at the level of the health care system—and some of the senior administrators who are based at the Fall Hill building—or witness them really trying to make a concerted effort to have the core values of the organization, that had been developed at Mary Washington Hospital, sustained at Stafford?

01:37:41
Marinari:
Oh, yeah. It’s been interesting, now that I have, over the last couple years, been privy to some of the executive leadership council meetings where goal-setting and other things are being discussed. It was neat for me to finally see the executive level sitting around the table together from both of the hospitals. It was very insightful for me to see how things are discussed, how we get to where we are, the discussion among the team, and the good dialog that they have. It just goes to show that as a system now we have pulled it together. At first, it was animosity that we were going to be a separate entity. There were a lot of bad stories about that when we first opened and that we were going to be separate and we were going to take care of ourselves. We tried, but we were a health system and we needed to act like it. Once we finally got that in the right direction and we started acting like a health system, it’s a beautiful thing because we have each other. We should have each other. Everybody functions to look out for each other, as far as hospitals or off-site procedure areas or whatever business it is. [01:39:00] We have to look at it that way. We have gotten to that point. It hasn’t always been like that, but it’s much better than it was and it continues to grow. We are truly a health care system there now. It took some time and some coddling. Everybody is on the same page now. It’s nice.

01:39:20
Rigelhaupt:
Whatever level of administration, who do you remember advocating, to really try and break down, it sounds like, some of the walls that existed between Stafford, Mary Washington and integrate more as you described?

01:39:37
Marinari:
We don’t have a lot of tiers here at Stafford, per se, on an org chart. It’s always been Cathy. And before, the Administrative Director of Nursing was Cheryl. She was right there at the table, advocating to make this. Now I do. There are a lot of people who have worked at Mary Washington for a long time. It’s very easy to kind of just think about Mary Washington and not think about Stafford—and it’s not intent, by any means. It’s just old habit because Mary Washington has been here a lot longer than Stafford has. Sometimes it’s even myself saying, “Oh, no. Wait a minute. You got to think about what’s going to happen if we do that at Stafford now.” I don’t have to say that as much as I used to have to. I think people finally got into the habit: “Oh, yeah. We don’t just have one hospital now. Let’s do this together.” It took all of us, together, to remind each other that, “Hey, what happens at one affects the other. So we need to figure out how we’re going to do any change.” One change at one place may mean a totally different change for the other facility. It takes a while. It took all of us coming constantly and saying, “Okay, wait a minute. We’re not acting as a health system when we do things like that because we’re not thinking about each other.” That took some doing. People came from different areas. Cathy is from New York and she was used to a system. She brought her knowledge and things like that to here. This was new for us. Even though we’re only six miles apart, we were two totally different types of hospitals.

01:41:29
Rigelhaupt:
Stafford Hospital, certainly less beds than even Mary Washington was when it was on Fall Hill. But it’s a community hospital. What are some of the best things that you remember about being a smaller, community hospital, when it was on Fall Hill, that you think about having implemented—or develop here? Because it is a similar community hospital to the organization you started with.

01:41:57
Marinari:
Mary Washington has just gotten to be big. But the comparison between the old hospital and here— it’s nice that if I don’t know somebody, it’s surprising. And so it’s nice to walk down the hallway and you know who they are. You can’t do that, so much, at Mary Washington. It’s just so hard to keep up with everybody. Knowing the EVS person, to the person who is down the cafeteria, to the lab person: it’s just nice. We’ve just kind of all got to know each other. It’s a very friendly atmosphere. I think that’s the way the old Mary Washington was too, even though it was, like you said, bigger. It was still just a different feel. That’s what this building allows for. Even the arrangement of the hospital: the setting outside with the pond and the walkway that was designed. It has a different feel. We’re able to keep that up, which is nice. The welcoming-ness, the comfort that seems to be here seems to be about the same. Design-wise, like I mention, it’s very helpful to keep that up. Even at the old hospital from the nursing aspect you have to rely on other nurses on other units sometimes because you just don’t have the resources and maybe another unit does. Here we learned real fast. Even when we just had two units open—just because you were a cardiac nurse does not mean you would not go down and work in the med-surg. We’re one big, happy family and we keep promoting that. We don’t want anybody to say, “Oh, I don’t want to go work on that unit.” Well, we have to, because that’s all we have. There are a little specialties in the building, as far as nursing, but we still are willing to go out and help each other. We just talked yesterday and the ED was like, “Yeah! If you guys ever need help upstairs, even just kind of doing vital signs, we can send an ED tech upstairs to help you.” It’s just that kind of thing: we realize that when we need help, if we pull the help chain, that somebody in this building will come and help each other. That’s nice. It’s harder to do, sometimes, when you have a bigger facility because there are more patients and more things coming at you. We’ve been able to maintain that sense that we have each other. Floating and moving staff around is not that big of a deal here, which is nice. It is similar to what happened with the old hospital too.

01:44:42
Rigelhaupt:
Does the smaller facility, the sense of helping out also—is it similar with nurse-physician relationships here, compared to, say, Mary Washington Hospital?

01:44:57
Marinari:
I think so. [01:45:00] We have physicians here 24/7 and we didn’t always have that. It’s neat. We really get to know them because they’re in the building. If it’s the middle of the night, they might be sleeping, but you were able to wake them up, if you need them, and they come and help. It’s just so different. The nurses really get to know the physicians. They carry phones now. The communication is different, but I think that it is the same and I don’t see that being different at a bigger facility. I’m talking more about the hospitalists. If you go work at a teaching hospital: yes, because you’re going to have somebody new all the time. We’re lucky: we do get the same physicians over and over again. That’s nice. They don’t go. They stay.

01:45:58
Rigelhaupt:
Was that also beneficial in terms of the Emergency Department? Because my understanding is it was the same emergency physician group—

01:46:07
Marinari:
Rotating through the three [Mary Washington, Lee’s Hill, and Stafford Hospital]. That’s one thing too: the physicians are very engaged. They will come to meetings. They will participate. I have a student that I’m precepting—she is at George Mason in the master’s program. She’s with me. She works for another health system. She comments all the time that she just can’t believe the number of physicians we get to the team meetings and how engaged they are. It’s really nice. She is always floored by that after she spends the day with me. I think we were very fortunate with that. From the ED to cardiac to surgical, they definitely are there. That was nice. Even with our past presidents of this hospital it’s very Stafford-centric. They want us to succeed. They’re willing to do whatever it takes to help with growth and bring volume here and that type of thing. It’s nice.

01:47:02
Rigelhaupt:
With the rise of hospitalists, were you surprised that physicians that have private practices and are on the medical staff, but have stayed as engaged?

01:47:15
Marinari:
I think they struggle with the fact they want to be in the hospital, but things just don’t let them be as much. Some of them have just finally seceded and said, “Okay. Yeah, I’ll just see my patients on the outpatient side, if you manage my inpatient.” There are still quite a few that are engaged, even though they don’t come to the hospital on a daily basis. The care that they do in the hospital still affects that patient. They want to be engaged because they can’t help the patient if they don’t know what we did for them in the hospital or what happened. They are able to view the records and that type of thing. It’s nice. We have lots of the community, primary care physicians that come to the table because it makes their job easier if they are connected well within our system, especially since the majority of their patients come here for care. [01:48:00] They know when a test has been done so they don’t order the same test. Again, they are under the same regulations and insurance constraints, as well. It’s definitely a good relationship.

01:48:21
Rigelhaupt:
What do you think about the future, with something like the integrated provider network? It sounds like, from what you’re saying, the physicians and the health system have worked well together over your career. But this is a different, formal organization. And from the perspective of what you’ve learned—a long career as a nurse and as a senior nurse leader—what does something like the integrated provider network represent?

01:48:52
Marinari:
I really am looking forward to seeing it as it really takes off this year and over the years to come. Listening to the physician leaders and the physician that is at the meetings about the alliance, they want to do what’s right for the patient as a physician. And, of course, as nurse, we want to provide what is right. We’re all excited to find out that they can help manage these patients, without having a lot of constraints or saying no. We can help control or help manage the patient better than having an insurance company tell them how to manage the patient. It’s kind of exciting. It’s neat to hear the physicians being excited about it. Of course, there are still some unknowns and there are some that say, “I don’t know about this yet.” There are financial things involved and they have to do certain requirements and things like that. So there are some that still say, “Let me wait and see,” which is perfectly normal. But there are some that say, “Yeah, I want this. I’m ready for this. I’m tired of an insurance company telling me I can’t order this for my patient, when this patient needs this.” So it’s neat. I think, again, it goes to show that health care is always evolving. This is the next step in that direction of where health care is going, I guess, and overall.

01:50:20
Rigelhaupt:
Well, speaking of health care and where it’s going. In an acute setting and inpatient care, how have you seen Mary Washington, as a health system, now think more broadly about public health and primary care, which is obviously something that the IPN’s thinking about? But I guess this was under way before the formal organization?

01:50:56
Marinari:
Right. [01:51:00] It goes back to thinking about what we can do. Because of all the changes with insurance—and everybody’s going to have affordable care and all that kind of thing. Now the push is for outpatient workup. As myself and working with the physician partners and the physician leaders, I know, for us, in the hospital setting, we have to be looking at, if we’re doing things, should they really be here for this or is this something that could be done when they’re at home as an outpatient? Like I said earlier, what we used to do was okay. Now we have to question, “Well, really, should we do this here?” It’s like the true case management of patients, of every patient. Trying to move the patient along the continuum and get them what they need as an outpatient or get them what they need when they go home. This is such more prevalent now than it used to be. It used to be a person could come in with a hematoma of their foot or whatever and they would stay and we would do a thyroid work up. You just can’t do things like that anymore. It’s kind of taking what we used to do and modifying and helping everybody figure out what’s best for the patient and to tie into whatever regulations or laws that are out there for the patient. Definitely a lot of strategic planning and thinking has gone into this with the executive leaders and physicians and just getting everybody understanding these changes. I think that is the biggest thing: communicate what we’re finding, what we’re hearing from the government and CMS, and getting everybody on the same page, which is hard to do. That’s huge. And it means getting the patients to understand that and the community too. Communication is huge in this regard. Patients don’t understand why they can’t get these tests and ask, “Why can’t I stay another day in the hospital? Why can’t I do this? Why aren’t you doing this test?” Then I give them a list of five things to do when they go home. “And why can’t I just do them while I’m here?” Sometimes it’s hard.

01:53:33
Rigelhaupt:
In terms of hospital history, generally speaking, in the US acute-care hospitals have not put public health and primary care at the forefront of their considerations. They’re acute-care settings. Even before something like the IPN was formed, for nearly a decade as a nurse leader, did you [01:54:00] see the organization participating in primary care, thinking about public health in ways that is perhaps more formal now, with the IPN, but was being thought about even before there was that kind of organization?

01:54:17
Marinari:
I think, in my heart, I want to say yes. When I was a staff nurse and before I got into management and understood it better, I don’t think I could explain the extent or maybe even really knew the extent that we were. I think we did. We always seem to have very strong strategic thinking. Looking back now, some of the things that we have done, at the time, I think sometimes we were like, “I wonder why we’re doing that?” It makes sense now, why maybe we did what we did. But I don’t know if it has always had a strong public health focus, because, like you said, it was about the acute care experience and that type of thing. I think it was underpinnings and then it got stronger and stronger as an organization, knowing this is the way you have to go. Trying to keep people out of the hospital is just as important as them being in the hospital, which is hard because the hospital is what makes our money. It’s kind of hard to say, “No, no. We don’t want you to come back.” At the same time, that’s how we keep our doors open. It’s a struggle too. I think it’s always been there, but I don’t know if I was always either privy to the information or didn’t know that was what was happening. I have a strong sense that it was there, from the planning part and executive level.

01:55:44
Rigelhaupt:
Do you have a different view of the dynamics between the medical staff and physicians and the board and the administration, as you work with them more closely? I guess, what have you learned about those dynamics, as you have worked with them?

01:56:09
Marinari:
The biggest that I learned? This is bad to say, but sometimes you’re like, “Gosh, why did they even make that decision? Or maybe they didn’t? They must have really not thought about that.” I’ve learned that there is a lot of thought that’s put into a lot of things, a lot of dialog, a lot of back and forth, and a lot of just hard conversations and vetting through the board. I have learned what decisions are board-level versus who can make decisions. There’s a lot of behind the scenes stuff that happens that I guess myself and anybody else probably just didn’t understand until later. We just did not understand because we were not at that level or privy to it, which we don’t really need to be. [01:57:00] It was neat to see how it all came together. There is a lot of thought and, like I said, conversations that do happen. They wanted to really have a lot of dialog and making sure they had all their information before they did make a decision. It wasn’t really an answer and then regret it later. It was thoughtful and there was more to the decision than just saying no or saying yes. There was thought put into it. That was neat to see how that comes about, what needs to go where to get it approved, and who needs to approve it.

01:57:42
Rigelhaupt:
Have you talked about change differently, with either nursing supervisors, managers, that you probably meet with more regularly, and in town halls with frontline nurses? Are you able to explain changes differently because you’ve seen those conversations between the board and senior administration? Do you talk about it differently?

01:58:02
Marinari:
Yes. I think that has helped me. It’s only been the last couple years that I’ve seen the big picture of how things happen. I am able to explain first. Before you tell what is being asked of them, if it is a change or whatever, I can really explain the why thoroughly. I guess also, sometimes, as leaders, we don’t always agree with some of the decisions that are made, but we have to figure out how to accept them and follow through on whatever is being requested of you. Even though you may not agree, we still have to make it happen. That has helped me now that I understand more. I can help my team understand too. It is frustrating when you don’t know or you don’t think anybody really understood what was happening when the decision or changes were being requested. I think that has helped me. I do a much better job about the whys and really giving them information and being transparent about it.

01:59:22
Rigelhaupt:
In 2009 Mary Washington Hospital achieved Magnet status. You were here at the time. But what did that mean to the health care organization? What did that mean for nursing within the health care organization?

01:59:39
Marinari:
That was exciting. Previously we had gone for it and not getting it was hard. Oh, my gosh. In our hearts, we always knew what nursing care at Mary Washington Healthcare was: we were a Magnet. They could do it. It’s just hard when you have to fill out all these papers and “dot your i’s, cross your t’s.” Then you have somebody come in and these stories are not to their liking. Then no, you don’t get Magnet. [02:00:00] It was disheartening at the time, when we first didn’t get it. To get it this round was nice because it proved that, hey, we do have a great nursing staff. They deserved it. It was good. It didn’t mean anything for a poor little Stafford. We felt like it was something for Mary Washington because we are part of the health system. It was like, “Yay.” It was definitely well deserved and I’m glad that we were able to achieve that.

02:00:34
Rigelhaupt:
But part of Magnet status and achieving it is about best practices.

02:00:38
Marinari:
Absolutely.

02:00:40
Rigelhaupt:
Were there things that were developed either for the application that didn’t go through, earlier, and the one that was achieved in 2009 that you really saw, in terms of best practices, that were a part of Stafford Hospital from the time it opened?

02:00:55
Marinari:
Yes. Being a manager at the time we went through the first Magnet process, and knowing what they were looking for and then coming over here, I was seeing some of the similar principles—I did. I took what we did at Mary Washington and brought it over here. As I’ve said a couple times, even the shared governance concept: sitting at the meetings for the frontline nursing staff, either it be a respiratory therapist, a nurse, a CNA, pharmacy, dietary—we all get together and talk about what’s going well and what do we need to do differently. We had great dialog. Even from the kitchen would say, “Hey, you guys are leaving your—” It could just be something simple that we talk about at that forum. We could fix it because nursing staff was there. We could communicate, “Hey, really, we’re not helping our dietary partners, because we’re not clearing or whatever we’re doing to the trays.” That was a best practice because shared governance is a huge Magnet component. That was definitely something I wanted to get started as soon as we could over here at Stafford. When we do make a change, we look for outcomes and document data pre and post. That’s always the front line performance improvement and making sure we’re always doing something in regards to performance improvements. Nursing is all about innovation. What can we do to improve the care that we give? These are all Magnet things that we’ve learned over the years. Everything that I learned from over there, we definitely came over here. We just have not officially gone for Magnet here at Stafford, but we definitely are doing similar things. We do think we’re Magnet here, as well. We just don’t have the little gold seal yet.

02:02:44
Rigelhaupt:
It sounds like, in listening, you’ve had roughly a two-part career, in terms of over a decade in the med-surg unit or medical-respiratory unit and then a decade-plus in progressive nursing leadership. [02:03:00] So this question—you don’t have to break it apart—but what I want to ask you is what would you most want the public to know about being a nurse? And maybe you could answer for at the bedside and maybe you could answer as nurse leadership.

02:03:20
Marinari:
First and foremost, I’m always glad to say that, if somebody asked me what I did, I am a nurse first. Then I say I’m a nurse leader or director of nursing, or whatever my title will be. Whenever you say you’re a nurse, it always sparks something in somebody. I think it makes a difference in people’s lives. I think everybody has, at some point in time, come in contact with a nurse, either in a doctor’s office or actually been sick and had the pleasure of working with a nurse. I think it’s kind of neat to know that I can call myself a nurse, which I think is fabulous. I’m trying to think. Now I think it’s exciting that I am actually able to be a leader of a group of people that I admire. Even though I’m not at the bedside anymore, I am able to give to them or help them or advocate for them and give them what they need for nursing and so that we can continue to provide great nursing care and raise the bar, for not only Mary Washington Healthcare, but hopefully make a difference in a nurse’s life. I love to get people to where they want to be. If I hear a nurse say, “I’d really like to get into this.” Then I will definitely give them pointers, recommendations, or whatever. I love to hear a CNA saying, “I want to go back to school.” I will say, “Well, let me tell you how you do that.” I love that type of thing and to really drive the nursing profession. Anytime Germanna Community College calls me and they need help with something, even interviews or to help people that are getting ready to graduate. I’ve done this a couple times, where they say, “Won’t you come and interview some nurses that are getting ready to graduate?” They know how an interview would go with a nursing person. I love doing that. It’s fabulous to help that new nurse so that she could be prepared for an interview. Even precepting the MSN students from George Mason: I love giving back to my profession and my career from both sides, either the leadership side or the nursing side. I would like to be at the bedside sometimes, but I’m too old and too slow now. I have to leave that up to everybody else. It’s nice to still be able to go up there. I can start an IV or do a Foley catheter or something like that. But to take a patient assignment, I couldn’t do anymore. Still, knowing that I made a difference at some point, that is fabulous! I love it.

02:05:46
Rigelhaupt:
So the way I like to end is with a last question that is really two questions. One, is there anything that I should have asked and I didn’t?

02:06:08
Marinari:
Oh, my gosh.

02:06:10
Rigelhaupt:
And two, is there anything you would like to add?

02:06:13
Marinari:
Okay. Oh, my goodness. You asked a lot of good questions. I’m trying to think. I’m a slow processor, sometimes. Tonight, when I go home, I’ll be like, “Man, I should have told Jess that.” Anything that you should have asked or that you didn’t? I can’t think of anything. I really can’t. This has definitely spurred a lot of memories, but I can’t think of anything.

02:07:06
Rigelhaupt:
Then let me ask, if you had to pick, and not anything specific, because over a long career is way too hard of a question—but generally speaking, what’s the best day, in nursing?

02:07:21
Marinari:
That is hard. I think for me now the best day for me in nursing is to know—like today. Today was a much better day for our nursing staff. Yesterday was very hard, because it was very, very busy. We were running out of rooms and things like that. It was very hectic and we were trying to get enough staff in here to take care of the patients. It was one of those days that kind of put you on edge. But today, going up and rounding all the units, everybody was happy. It was calm. Not that they weren’t happy yesterday, but they were struggling. I hate to see staff struggle. Today, that’s a good thing: when I know that the nurses were able to do what they wanted to do with their patients, the patients got good care, and everybody went home and felt like they did a good job. To me, that’s a good thing. Even though I might not have got everything done I wanted to do, at least I was able to either facilitate something to help their day go smoother or followed up on something that we were working on or a process change or something like that. Currently, that’s what makes a good day for me as a nurse.

02:08:31
Rigelhaupt:
That’s a good place to end.

02:08:33
Marinari:
All right!

02:08:34
Rigelhaupt:
Thank you!

02:08:34
Marinari:
Thank you.

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