Dixie Bettis

Transcript

00:00:06
Rigelhaupt:
It is June 22, 2015. I am in Fredericksburg, Virginia, on the campus of the University of Mary Washington, doing and oral history interview with Dixie Bettis on the Mary Washington Healthcare Oral History Project. And to begin, I’d like to ask you if you could tell me about your first memories of Mary Washington Hospital, maybe not even when you were starting working over there, if you have memories from before the time you started working there?

00:00:31
Bettis:
Actually, my memories go back as far as being a patient there. As a child I had really severe asthma. I would be in the hospital for weeks and months at a time. That really is what led me to become a nurse: the care that I received back there in the 1950s from the nursing staff made me want to become a nurse and go back there to work.

00:00:58
Rigelhaupt:
What was it like being a patient there? Even if you could talk about as a child, walking in, where you were, what kind of rooms you were in, and the kind of care you received.

00:01:06
Bettis:
Usually, when I went into the emergency room because I was having an asthma attack. So I came in through the emergency room. I was young. I can still just remember: it was back in the days where bad asthma patients had to be put in croup tents. I was in this big old tent. The nursing staff would come by, they would roll me, and I can remember them covering me up because I would uncover myself and I would be cold. They would hand me my medicine through, like a little zipper in the croup tent. They would hand me my medicine through the tent. I used to call it my little red medicine because it was red in color. It would knock me out and I’d go back to sleep. I can remember they would wake me up to feed me. That type of thing. They were always very nice and very supportive. They were always there when I needed them. That let me say I want to give back; I wanted to come back and be a nurse.

00:02:08
Rigelhaupt:
Was it already in the Fall Hill location?

00:02:13
Bettis:
I worked in the hospital down on Fall Hill, yes.

00:02:16
Rigelhaupt:
When you were a child, did the hospital—had it already been—

00:02:18
Bettis:
Yes, it was there. As best as I can remember, it was there.

00:02:27
Rigelhaupt:
Jumping forward to the time you started being a health care provider, what do you remember about your first shift? You said you were a nurse’s aide?

00:02:36
Bettis:
I was a nurse’s aide and it was back in 1970. I was scared to death. I had taken care of patients at my nursing school and we had to work the floor then. I was used to a patient assignment, but I wasn’t quite used to how they did things at Mary Washington. It was yourself and a RN. It was an aide and an RN. [03:00] The aide was responsible for the vital signs, changing the beds, helping patients get up to the bathroom, teaching them how to do their peri care, and doing their treatments. It was quite scary, but I was paired with another aide at the time. She showed you the ropes, told you what to do, and how to do it. You had to clean your own thermometers, you had to clean your own bedpans, and you had to do all of that. There was nobody to do any of that for you. You did everything like that yourself back there then. It has come along way.

00:03:33
Rigelhaupt:
What kind of floor were you working on as a nurse’s aide?

00:03:36
Bettis:
I worked on the post-partum floor as a nurse’s aide. That’s where I really fell in love with labor and delivery. At that time, I fell in love with post-partum and the moms and the babies. Everybody likes taking care of a baby. I mean, everybody likes to see newborns, hold them, and care for them. Then you could always hold them and give them back to mom.

00:03:59
Rigelhaupt:
Could you describe where the post-partum floor was when you started in 1970 in the hospital? What it was like, how it was laid out?

00:04:06
Bettis:
It was on the third floor. You got off of the elevator and went to the right. Post-partum was a divided unit. You had rooms 300 through 305 on part of it, and then you had 361 through 367 on the opposite side, which was right across from the nursery. You had two ward beds, two ward sections. One ward had four beds in it, one ward had three beds in it, and they shared a bathroom. Three hundred was a private room, but did not have a bath and you had to use the bath in the hallway. 305 and 307 were semi-private rooms and you had to use the bathroom in the hallway. 304 was a semi-private with a bath and a shower. 351 was a semi-private with a bath and a shower, and then you had the four private rooms with bath and shower. The nursery was separate, across from the private rooms. Then labor and delivery was across the hall. If you got off the elevator and went to the left, then you went to labor and delivery. They were all private rooms back there, except there was one semi-private room and two delivery rooms. We went downstairs to the operating room to do all of our C-sections. We had to carry the patient downstairs.

00:05:33
Rigelhaupt:
Thinking about that, the first few months that you were a nurse’s aide, and providing post-partum care, what were the most common things that you were doing as a nurse’s aide in terms of treatment? What kinds of care were new mothers receiving at the hospital?

00:05:48
Bettis:
You did their vital signs and you only did them once a shift, which is a big change from today. We would help get them up to the bathroom and we would help them with their peri care. [06:00] If you had stitches—if you had an epsitomy, it meant you had stitches and you got a heat lamp. Three times a day we had to go around and give moms heat lamps to help with their stitches. Now, back there then, it said it helped dry them and it helped care for them, but today we now know that actually dried them out and caused the mother more pain and discomfort. We dried them out and didn’t let them heal normally. But back there then, ten, two, and six, everybody got a heat lamp that had stiches. That has significantly changed. But that’s why. I had to clean the thermometers and I had to clean the bedpans. We would clean the rooms, change the sheets, empty the trash, or whatever was needed.

00:06:58
Rigelhaupt:
I know there’s no typical patient, but what was a common stay like for a new mother? How long would she be in post-partum care?

00:07:08
Bettis:
Vaginal delivery stayed for three days and section stayed for five is what we normally did. Babies came out—if you were breastfeeding, you got the baby every four hours. If you were bottle-feeding, you had the babies at 10:00, 2:00, and 6:00, and 10:00 at night. And then from 10:00 at night until the morning the nursery fed the baby.

00:07:31
Rigelhaupt:
Was there a difference for nurse’s aides between working in-patient and in a nightshift, and the early time you’re working there?

00:07:39
Bettis:
Not that I recall, because I never really did a nightshift. I worked mostly days and evenings, mostly evenings, 3:00 to 11:00.

00:07:51
Rigelhaupt:
Could you talk a little bit about how your job changed when you started working there as an RN?

00:07:57
Bettis:
When I started there as an RN, you then became more responsible for the orders, the medications, and checking on patients that were having problems or difficulties. We still helped with the vital signs and we still helped with treatments because one person couldn’t do it. If a unit was full and if patients stayed three and five days, you would get quite busy sometimes with the number of deliveries. Although, we only averaged probably about anywhere from fifty to eighty deliveries a month, which is really small when we think back to what we do today. Now we’re doing, 150, 180, deliveries, sometimes 200 a month, as opposed to fifty to eighty a month. It has really changed. Your responsibility became more because you were responsible for all of the patients and for the aide’s work as well, to make sure that they did it appropriately. [09:00] Then you were responsible for interpreting all of the vital signs and for making sure you gave medications appropriately.

00:09:08
Rigelhaupt:
How did physicians make rounds in post-partum care?

00:09:11
Bettis:
They made rounds in the mornings before they went to the doctors’ offices. Then they would come back sometimes in the afternoon and make rounds as well. Circumcisions—if you wanted a circumcision, it was always done in the evenings by certain physicians. Certain physicians took the morning shift. That way they were done in a timely manner and the patients could be discharged and there would not be a hold up for the discharge: once a circumcision was done the baby had to stay a certain number of hours before it could be discharged. We had a couple of docs that did all of their circumcisions in the evening and then a few doctors that did their circumcisions in the mornings.

00:09:56
Rigelhaupt:
What are the differences in the community physicians—were they all OB/GYNs?

00:10:04
Bettis:
They were all private. There were some family practice doctors or GPs they were called when I first started. They were not family practice then, but they were GPs. There were some, actually, GPs—general practice physicians—that did deliveries as well. Dr. S.O. Payne and Dr. Bush, when I first started, still took care of their patients’ pregnancies instead of patients going to an OB/GYN.

00:10:32
Rigelhaupt:
Now, how long did you stay in post-partum care before you made the move? Could you talk about your transition to labor?

00:10:38
Bettis:
Everybody had to help. If you worked post-partum or the nursery, but especially if you worked post-partum, you needed to be able to go to labor and delivery and help. You know you can’t predict when patients are going to deliver and you can’t predict how many patients you’re going to have in any one shift. Everybody had to be able to go back and help. I went back and I helped and I learned about how to care for a labor and delivery patient. The Vietnam War came along and a lot of our nurses that worked the evening shift had husbands who were military. They ended up having to leave because their husbands were shipped out. I came to work one day and they said, “You’re going to go to labor and delivery tonight to work.” And I went, “Oh, really?” And they go, “Yeah. You got really good support back there. You’re going to go back and you’re going to work labor and delivery tonight.” And I said, “Okay.” I went back and I was there ever since. I never really left. I’ve really enjoyed it.

00:11:38
Rigelhaupt:
Do you have distinct memories of a first birth, when you first went back to labor?

00:11:44
Bettis:
I really don’t. I just know that you learn very quickly. I had some really good teachers—Betty Thomas and Sue Knight were both RNs that worked the day shift and some evenings. I had really good nurses and support from a lot of the LPNs that worked back there. [12:00] Emma Nichols, Barbara Hill, Trudy Davis were all very experienced labor and delivery LPNs back there. They would coach me, they would help me, and the docs were great because they knew I was new back there. They would be there to help support me and teach. That’s how I learned. Back then a lot of the patients went to sleep to have their babies. We learned clues by listening to them, how they breathed, and how their breathing changed. The sounds they made— you could tell by that if a patient’s labor was progressing or not. You didn’t have to do a lot of vaginal exams because you could listen to your patient and you learned to listen to your patient as to what was going on with them.

00:12:51
Rigelhaupt:
Again, I know there’s no typical delivery. But in thinking about in the first year or so, early in your career, if you had a relatively straightforward vaginal delivery, how would that process go for a soon-to-be mother?

00:13:11
Bettis:
In the very beginning, when we were back there, most of our patients would go to sleep. The fathers would bring their wife to the door of labor and delivery and they would knock on the door. We’d go to the door and they’d go, “I think my wife’s in labor.” We would bring her back and he would go sit in the waiting room, which was really not a waiting room. It was just some chairs in the hallway. We would check her to see whether she was in labor. A lot of those patients were, indeed, in fact, in labor in the very early years. They waited at home longer than typically they do today. They were more experienced. There were a lot of repeat patients having babies. If they were in labor, then we would keep them and we would go out and tell their husbands, “Yes, your wife’s in labor. You may wait here if you would like and we will keep you posted. Or you may go home and we will let you know and keep you posted. Or you can call in and check to see what’s going on.” A lot of husbands, a lot of the fathers, went home. They truly did not stay; they went home. Then, the wife would come in. Once she got to a certain point, she would get pain medicine through her IV and she would go to sleep. I mean, she wouldn’t go to sleep, sleep, but she doesn’t remember. It would have medication in it, Scopolamine, which would then keep her from remembering exactly how bad the pain was or exactly what was going on at the time. Back there then, all of our patients got enemas. And they didn’t get the little tiny Fleet enema: they got the big quart-size enema that they had. Everybody was shave-prepped. Everybody had a shave prior to their delivery. Deliveries were considered sterile and they were done in the delivery room. [15:00] The patient would be up in stirrups and they would have sterile drapes placed on their legs, over their middle, and over their abdomen. It’s changed a whole lot since then. Then, once the patient was ready to deliver, we would take them back to the delivery room and we would get them all set up. Anesthesia would come in and give them a little nitrous oxide, and a little oxygen, which then really made them not remember. But their body instinctively pushed and they instinctively pushed to have their babies and deliver their babies. After they delivered, they would begin to wake up and we would tell them that they delivered and if they had a boy or a girl. We didn’t do a lot of sonograms. There was no such thing when I first started working as sonograms. Nobody knew what they were having, as opposed to today, everybody knows just about what they’re having prior to the delivery. Then we would call their husbands, or if the patient was awake enough we would bring the phone in to the recovery room and they would call their husband and say, “We’ve had a boy. We’ve had a girl.” Then a couple hours later, they would go to their room.

00:16:16
Rigelhaupt:
And what kind of technology was common, in terms of either monitoring the mother, or you know, heart monitor, what was—

00:16:22
Bettis:
There was no fetal heart monitors back when we first started. We probably didn’t get the monitors until sometime in the, probably mid-1970s or late-1970s, I’m guessing. I could be wrong with the dates because after you’ve been there for 44 years, it just sort of all runs together when things happened. If you look in the history books, you would see what we used to listen to fetal hearts with was, like, a stethoscope. There were two kinds. One would fit over your head and the conduction would be here in the forehead and then the bell shape would come out. When you were doing fetal hearts, you would actually use your head and you would find the fetal heart on the mother’s abdomen. Or there was one that had a stethoscope with a great big round bell shape, a heavy bell shape, that would then place on the patient’s abdomen. You would have to find the fetal heart by feeling the abdomen and trying to figure out exactly how the baby was laying. Then you would place the instrument that you were using over the abdomen to listen to the baby’s heartbeat. That’s how we used to have to do that back there. We would do blood pressures the same way, manually. Pulse, respirations, temperatures—we didn’t do them as often as we do today. Today, we do them at least every thirty minutes. When I very first started we did them every hour in active labor and sometimes every two hours if they were not in active labor. That has significantly changed the process of our practice.

00:18:00
Rigelhaupt:
In the time before active labor, how many nurses would be in the room? Would it just be an RN, an LPN?

00:18:08
Bettis:
In staffing, in the very early days, it was just one RN and one LPN. There was usually LPNs on the post-partum floor as well. The LPN would be the person responsible that day with an aide, and actually, the RN in labor and delivery would then be her backup and be responsible for the maternity floor as well. This was back in the early days, back in the ‘70s. That has evolved significantly too.

00:18:39
Rigelhaupt:
Thinking about the early ‘70s, from my recollection, when active labor starts, there’s a change of activity in the delivery room.

00:18:50
Bettis:
Correct.

00:18:51
Rigelhaupt:
How would that change in the early ‘70s? Did the physician arrive or did more nurses arrive?

00:18:55
Bettis:
No. There were always just only two nurses. Your backup was always on the post-partum floor because all of the nurses back there could come and help with the delivery and caring for the labor patient. The physician usually did not come until the patient was getting close to delivery. That was depending upon where the physician lived. Now, some physicians lived far enough out that if they had a patient in active labor, they did come and stay. The ones that lived very close, within five, six, minutes of the hospital, they would stay at home until it was very close to delivery. If it was a patient having their first baby, they would probably stay at home until the patient was fully dilated. If they were having their fifth, sixth, or seventh baby, when the patient was about five or six centimeters, they would come in because they knew they would progress very quickly after that. Depending upon where they lived is when they came in.

00:19:46
Rigelhaupt:
What were some of the things the physician needed to do once they arrived?

00:19:51
Bettis:
Usually, they arrived when the patient was ready to go back or close to being when they went back. They would scrub—and again, it was a sterile technique back then and they did a three-minute scrub. They would gown, glove, cap, mask, shoe covers, and then they would do the sterile drape. If they were there waiting for the patient to be in labor, then they would come out every so often and they would check their patient to see if she was progressing. The physician would check them vaginally to see if their dilatation was progressing. Then they would go back to the doctor’s lounge or they would sit out and talk with the nurses. Sometimes, they would just sit around the nurse’s station, talk with the nurses about what was going on, or what was happening, or whatever the subject of choice may have been at the time. They could also sit and listen to their patients and tell what the patient was doing as well by the sounds that they made.

00:20:49
Rigelhaupt:
How were decisions made about C-sections at the time?

00:20:54
Bettis:
We did very few C-sections, truly. They were rarely done. [21:00] After a patient had been in labor for many, many hours and there were no change, no cervical change, then they would make the decision to section them. Rarely, did we do sections for fetal distress. Again, we’re only checking them every hour to two hours with a doptone. We didn’t have continuous tracing so we really didn’t know—we only knew what the baby was doing at that specific time, when we were listening to the heart rate. We didn’t do it very often because that was not the standard of practice at the time. So, the majority of the sections that were done, were done either for a breach—but we delivered breaches vaginally—or a patient that had not dilated completely and the patient had been at the same dilatation for hours, and hours, and hours, and had made no change. We would do the Cesarean section. Cesarean sections, at the time, were not done in our unit. We had to go downstairs to the second floor to the operating room. You had to take the patient down there plus all of the resuscitation equipment and then they had all of the supplies down there that they needed to do the section.

00:22:08
Rigelhaupt:
Would that have involved different surgeons, or I imagine—

00:22:12
Bettis:
No, the OB/GYN still did the surgery, but the nurses that helped came from the operating room themselves.

00:22:19
Rigelhaupt:
You said general practitioners would be involved with the delivery, still, in the early ‘70s. Would they have done C-sections?

00:22:27
Bettis:
No, they did not. They would then contact an OB physician. Most of the general practitioners then had an OB backup and the OB would come and do the section for them.

00:22:41
Rigelhaupt:
What were the most common medications that—you described some of the women who had received it when they delivered?

00:22:49
Bettis:
Demerol and Scopolamine, and Phenergan were sometimes given. We always put some Scopolamine in their medication because, again, it helped keep them from remembering what was going on. They also used an inhalant called Trilene, and it was done by mask. You have a leather strap with a black mask attached. There was like a little insert that would go into the bottom of the mask and it was Trilene. We put it on the woman’s wrist and then when she had a labor pain and if it got too much, she would take the mask and just put it over her face and she would breathe the Trilene. That would help her with her pain. It would also make her very, very sleepy. We graduated away from that probably very quickly after I started. Probably only used it for about a year, year and a half when I was there. We very quickly graduated from that because that was not what was best: babies came out really, really sleepy with that.

00:23:55
Rigelhaupt:
How were decisions made in terms of what medications were the standard of practice? [24:00] What were the ways that physicians and nurses learned new information about best practices?

00:24:07
Bettis:
Through their organization ACOG, American College of Obstetrics and Gynecology. Then nursing had a NACOG, which is a nurse’s obstetrical organization that put out papers and best practices. They would publish them every so often and physicians would share them with each other. Physicians shared them with nurses as well and we had our own organization that also shared with us best practices. Then whatever your local hospitals were doing too, you would partner with what Richmond was doing and what Northern Virginia was doing to keep within the best practice area.

00:24:53
Rigelhaupt:
One of the things that has been discussed in these interviews is that in this era, in the 1970s, there were some patients who weren’t treated at this hospital. Complex cases that, I think at the time, went to Richmond or to Northern Virginia. What were some of the issues in labor and delivery that might have sent a woman to Richmond or Northern Virginia?

00:25:16
Bettis:
Premature labor was one of the biggest reasons we transferred because we did not have a NICU; we were not NICU capable. It’s always better to transport mom with baby and have them delivered as a unit and have the baby delivered in a facility that could care for them immediately, as opposed to having the woman delivered here and then us having to resuscitate and bag the baby until Richmond could come and get the baby. They did have a transport—so if you came in and we could not transport you safely, then we could deliver you here, then MCV did come and get the baby, do what needed to be done, and then transport the baby back to Richmond. Severe preeclampsia, elevated blood pressure, problems with their kidneys that were more than just low-risk or in a higher-risk type population, or patients with seizures that were uncontrolled were reasons that we transported as well sometimes. We had to make sure the mom was stable though and we could not transport a mom that was not stable, that we felt that may deliver, or may have other problems on the way to Richmond. Then that would not be safe. It’s a lot. Sometimes the decision had to be made that we deliver here and then we transport. We actually have delivered here and transported mom after the delivery for a higher level of care, as well as their baby.

00:26:40
Rigelhaupt:
Could you walk me through the process of how those decisions were made? And how a physician, the nurses, would have consulted about the potential to transfer somebody.

00:26:51
Bettis:
The physician would come in and assess the patient if there was lab work that needed to be done, do the lab work. [27:00] Then they would actually call the doctor in Richmond and say, “This is the patient that I have. This is what she’s doing. Do you feel like that this is an appropriate candidate for transfer? Or I would like to transport her to your service.” The physician in Richmond would have to say, “Yes, I think it’s safe to transport. Yes, I will accept your patient.” Once that process was done, we had volunteer rescue squads. We always thought it should be with the volunteer rescue squad that was in their county or in the area in which they lived. We asked them to do a transport. The counties and city were really gracious about doing that. They would get a volunteer team, they would take one of their squads, and then they would come and pick up the patient. At that point in time, because they did not have any high-risk OB training and we would normally send a nurse. Mary Washington labor and delivery would send a labor and delivery nurse with them on the transport. We would ride with the patient down and monitored their condition.

00:28:17
Rigelhaupt:
Were there changes in labor and delivery practices that you saw? I’m trying to think about the 1970s. I know it blends together and it’s a hard question. But in thinking about that decade that you were working with—were there changes in practices?

00:28:34
Bettis:
From then until now?

00:28:35
Rigelhaupt:
Just thinking about it, you know, trying to think about that specific decade. Were there new technologies, new medicines?

00:28:40
Bettis:
In the ‘70s, everybody went to sleep. We then started with the practice of epidurals. At the time when we very first started with epidurals, they were placed with a little catheter that would be threaded into the epidural space. Then it would be taped to the mom’s shoulder. An empty syringe would be placed on the end of it and then nursing would inject the epidural medication as the medicine began to wear off. Now, that is a practice that no longer is done. Anesthesia now does all of the epidural medication. It’s a continuous rate. Whereas before the epidural would wear off, mom would begin to hurt again, and then we would re-inject the epidural. Now it’s sort of a continuous rate that goes in and mom is kept comfortable during her labor. She doesn’t feel those labor pains. Fetal monitoring was introduced at the time. We had a physician come in that actually taught fetal monitoring to us and taught us what to look for. Again, it’s trial and error. We only had one monitor. [30:00] Then you had to choose what patients would get that one monitor and which ones would just be monitored the way with the doctor that we had been doing. That was practice change. Then as we got more and more monitors, of course, our practice changed and we monitor everybody that comes through the door and place them on monitoring. The thing with monitoring and the thing that you have to remember is that we have learned more and more about babies and what babies do in utero. If we could stay with our moms at the bedside and constantly are checking, every ten to fifteen, especially with your high-risk mom, and listen to that baby more then we could do without the fetal monitoring. Fetal monitoring is an asset to us in the fact that we can watch multiple patients at any one time. If the baby rolls on its cord or if the mom’s blood pressure drops, then we’re alerted that the baby is having a problem right then and there and we can go in and help fix it. Whereas back there, in the ‘70s and ‘80s, we had no clue what these babies were doing. We didn’t know because we only listened once every hour or once every two hours. Then it went to every thirty minutes or more frequently as conditions warrant. But we did not have a continuous tracing. If you could continuously stay with your patient, that would be a wonderful thing to do. Patients would love it and we, as nurses, would love it. But that’s just not practical. We use fetal monitoring as an adjunct to our care. We use it to help us keep an eye on those babies, what’s going on in that uterus and so that we can respond quicker to an emergency. Back in the ‘70s, we may go twelve hours or twenty-four hours and never see a labor patient. We don’t do that today. We constantly have labor patients. We constantly have multiple labor patients that are coming in. We only had two nurses on any shift. I mean really, you had two nurses sitting there waiting for a patient to come in. Today you have many patients at one time and more nurses. Fetal monitoring is an adjunct to what we do today. [33:00]

00:33:03
Rigelhaupt:
Would nurses start the epidural, or was it anesthesia?

00:33:06
Bettis:
Anesthesia always had to place the epidural. Now, you had nurse anesthetists, which places the epidural as well. Physicians and nurse anesthetists place the epidural. Dr. Perseleny, actually, was the first physician at Mary Washington that learned to place epidurals. He went off and learned and then he came back and taught his peers how to place epidurals. Then as they brought on more and more anesthesia personnel from bigger institutions who already knew how to place epidurals the practice grew because at the bigger institutions they were doing epidurals at the time.

00:33:44
Rigelhaupt:
Obviously, labor and delivery is not a 9:00 to 5:00 practice. Were there anesthesiologists on-call 24/7, or were they in the hospital?

00:33:54
Bettis:
In the beginning, they were on-call, but again, they had to live within so many minutes of the hospital, and if not, then they stayed. The majority of them all bought houses so that they were close to the hospital and so that they could go home. When we needed an epidural, we just called them and said, “Patient’s ready for epidural.” They would be there within usually fifteen minutes or so to place the patient’s epidural and make them comfortable.

00:34:23
Rigelhaupt:
In terms of practices, one of the other things that I think there has been a lot of advancement on and understanding about it, is prenatal care. Were labor and delivery nurses and physicians also talking with general practitioners and OB/GYNs about prenatal care? What were some of the understandings about prenatal care, and then actually the moment when you were seeing patients in labor and delivery, and the understandings when you began your career?

00:35:01
Bettis:
I’m not really sure I have an answer for that. Prenatal care was done by the physicians. I’m not sure what the standard of their care was among themselves. I know the OB/GYNs followed the ACOG guidelines as far as testing and as far as how often the patient would come and visit the doctor’s office. Back in the ‘70s, of course, there were no ultrasounds. If there were, you know, it was very few. I delivered my child in ’76 and I never had an ultrasound the whole time I was pregnant. You knew when babies were due were based on last menstrual periods and the growth of the abdomen. From when they heard the fetal heart for the first time—there are parameters that told you that you hear the fetal heart at this many weeks gestation. When the fundus is at the umbilicus, at about 20 weeks pregnant: those are the parameters that they use. [36:00] What their parameters were with the general practitioners, I have no idea.

00:36:10
Rigelhaupt:
And my question is really just about were there some things that you might have seen in labor and delivery that became less common as prenatal care advanced? That there were some emergencies that became less likely to happen because there were advances in prenatal care? Just how those two actually go together in terms of treatment.

00:36:35
Bettis:
I think what we saw with the advancement of prenatal care was that moms were diagnosed with diabetes quicker. The practice of how you cared for a patient with preeclampsia changed. One of the bigger changes that sort of just came to my mind was that back in the ‘70s and ‘80s you were only allowed to gain twenty pounds with your pregnancy. Now, you gain fifty to sixty pounds and it’s okay. But I will tell you, back in the old days you only were allowed twenty pounds, period. That was it. And if you gained more than that, then you were put on a strict diet of tea, toast, broth, and coffee. Which now we know is not ideal and we ask patients not drink a lot of caffeine. But back then, tea, toast, broth, and coffee is what their diet was, to help them control their weight gain. But we know with the advancement, with more weight gain your baby gets bigger. If you have a problem with the baby, you have more reserve because the baby is large. But yes, twenty pound weight gain. The advancement of prenatal care is better diagnosis of diabetes and preeclampsia, and the treatment.

00:38:03
Rigelhaupt:
Thinking about the end of the 1970s, in 1979, at the hospital in Fall Hill began to expand. What do you remember about the expansion, and what did that mean for the nursing staff, and how the medical staff thought about where the hospital was headed?

00:38:28
Bettis:
My understanding is that there was physician and nursing input on the new addition that we had. We had all private rooms and we had baths in between the private rooms, which was nice. In the old labor and delivery, there was just one bathroom, period, for patients. And you had four private, one semi-private, and a three-bed recovery—or, a three-stretcher recovery area. But again, we didn’t get our patients up to the bathroom before we took them to the post-partum floor. We took them to the post-partum floor and the post-partum staff got them up and gave them the peri care for the first time. [39:00] Whereas, when we started getting more bathrooms and that availability, then we actually got our patients up to the bathrooms first, did their peri-care, and then took them out to the maternity floor. With the new advancements that was a little bit more convenient. We had two delivery rooms at the time as well. We no longer had an autoclave, which was wonderful. Before we would autoclave some of our own instruments. That was very time-consuming and had very strict guidelines that you had to follow in order to use the autoclave. So, we did away with the autoclave, which was good. It was wired for fetal monitoring. At that point in time, we had a fetal monitor in every labor room. We had one birthing room that had a birthing bed in it. You did not have to go to the delivery room to have your baby and you could actually have your baby in a birthing bed. Somewhere along the line, we actually bought what was called a birthing chair. It was a hard plastic chair. Once you were fully dilated you got up and you walked to this chair. You would sit in it and there was a place for your feet and you actually delivered. That trend did not last very long. Number one, most moms don’t want to get up and walk to their chair after they’re fully dilated. Then we found that it caused more bleeding and more stitches for the mom to have. Thank goodness that trend did not last very long. Because it was a trend and because a lot of their constituents in the area had read about it patients were asking for it and they wanted to do it. Mary Washington did indeed, in fact, purchase a birthing chair for them at the time. Probably lasted for four or five years and then the trend went away because we found that it was not the best for them.

00:41:15
Rigelhaupt:
Labor and delivery, it sounds like, was one of the units that received new space with the expansion. A couple of years of construction, early ‘80s it opened. What were some of the best parts of practicing in newer space?

00:41:41
Bettis:
It was well-equipped. The hospital, at the time, did not spare cost as far as equipping those rooms. We had new beds, new bedside tables, fetal monitors, and we had suction and oxygen in every room. [42:00] Everything was state of the art and modern for the safety of the patient and the baby. The nursery was actually connected to labor and delivery. If you had a problem with a baby, nursery personnel could be right there without delay because they were right there. I mean, there was a door that connected labor and delivery to the nursery itself. It made it really convenient and easy for them to come and help you if you had a baby that needed help to be resuscitated. You had the equipment in the room that you needed and you could pull it out in the delivery rooms. The operating rooms were, again, very state of the art and very modern for the time. It made it very much easier for us. We connected with central supply, so it was easier to get equipment from them.

00:42:57
Rigelhaupt:
At the time the expansion opens, early in the 1980s, you’re approximately a decade into your career in the delivery rooms. And certainly, you learned a lot of things in nursing school and had a lot of training. What were some of the skills, the clinical skills, patient skills, that you had developed in that first decade that you thought were really important, were most proud of, that might not have been taught in nursing school, that you learned on the job?

00:43:30
Bettis:
Probably a lot. When I think back over the career, in nursing school you’re taught the basics. You’re taught to do blood pressures, temperatures, and you’re taught how to listen to a baby’s heartbeat. You are taught about contractions. But you’re not taught to listen to your patient, necessarily. You’re not taught to—if they tell you something, you believe them. If they tell you, “My baby’s coming.” You believe them. Their baby is coming. They know. There was no such thing as fetal monitoring and we had to learn fetal monitoring from the top. There are a couple of things that really stand out. I learned to listen to the patient. I learned not only to listen to what she’s telling me verbally, but what she was telling me non-verbally. I learned to be able to assess a patient by how she acted, by her movements, by her sounds, and I learned to deliver a baby. Again, if you’ve had six or seven babies—and back in the ‘70s and early ‘80s, you know, you had large families. I learned to deliver a baby very quickly. Sometimes patients went faster than what we thought or patients came in ready to deliver. Just like today, sometimes they come in fully dilated and they’re ready to deliver. I learned they stand out. It’s listening to my patient and learning how to deliver a baby, which they don’t teach in nursing school. [45:00]

00:45:06
Rigelhaupt:
Again, thinking about that first decade, how would you talk about the working relationship between physicians and nurses in labor and delivery?

00:45:16
Bettis:
I believe the working relationship was very good. It was a small unit without a lot of staff. You didn’t have a whole lot of physicians at the time. You only had—oh, let me think—five or six OBs. And you had two general practice doctors. You got to know them because they were around with their patients and they were there. They came out and they talked to you and they interacted with you. You knew about their families and they knew about your families. There was camaraderie. It was a very supportive type of relationship with your physicians and your staff at that point in time.

00:45:58
Rigelhaupt:
Do you think there are differences in the working relationships between labor and delivery nurses, and say nurses and physicians on a med-surg floor because of the types of practices that are there? Do they spend more time than what the patients were there before?

00:46:16
Bettis:
I never worked med-surg, so I honestly can’t answer that. Being in labor and delivery, you’re in your own little world, sort of say, you’re in your own little area. Med-surg rarely came up to you for any reason and we didn’t go to med-surg. I can’t speak to the relationships between those nurses and those physicians. I’ll be frank, I never worked med-surg, and I was okay with that. [laughter]

00:46:49
Rigelhaupt:
A decade into your—you know, over that first decade, how much interaction did you have with hospital administration?

00:46:57
Bettis:
We had supervisors. We would interact quite frequently with the supervisors. At the time, I worked 3:00 to 11:00 and I can honestly say I didn’t have a lot of interaction with hospital administrators at that point in time. We knew who they were. We would recognize them if they came on the unit, but there were not a lot of interaction with hospital administrators.

00:47:23
Rigelhaupt:
Was there discussion amongst nurses and your colleagues about the role of the board, and what it did for the organization?

00:47:32
Bettis:
Not that I can remember. No.

00:47:40
Rigelhaupt:
So moving forward, thinking about, again, the early 1980s. Along with the new units that opened, a new hospital CEO administrator came on. Was that something that was significant to a staff nurse in labor and delivery or a staff nurse around the hospital? [48:00] Was that something that was memorable is what I am asking.

00:48:09
Bettis:
I just know that we got a new CEO. They were introduced to us and there was an opportunity to meet them, if you wanted to. We understood that this role was making sure that we keep the hospital afloat and that we make good decisions, as far as that goes. But not really because most of the time, the CEO—I mean, they didn’t involve labor and delivery. I mean, you had physicians that were their mentors and you had physicians that would be their liaison; you had nursing that was their liaison and that would represent us in that. If they wanted to make changes, then we would go through our representatives. If we didn’t like the changes that would be made, then we would certainly go through our representatives, and let people know and let our supervisors know that we didn’t like what was going on or what they had planned to do.

00:49:06
Rigelhaupt:
Were there any changes in the 1980s that stand out to you as—

00:49:11
Bettis:
Not that I remember.

00:49:16
Rigelhaupt:
So thinking about, again, the same era, the 1980s, were there advances in practices, or things that you began to do differently, in terms of labor delivery because of new equipment, or potentially drugs, or changes in drugs, or medicines that were given? Did the practice change?

00:49:42
Bettis:
It’s so hard to tell when changes occur because I’ve been there for about 44 years. I don’t really remember the dates, or the years, or the time, but a practice change on the whole is that we did more frequent monitoring of the mom. We did more frequent monitoring as we learned more about fetal monitoring. The hospital was very good about sending nurses to workshops and to educational opportunities. Then we were responsible to come back and teach those to peoples who did not have the opportunity to go. Education was big in providing education to your staff about the changes. Plus, when you went to the different seminars and workshops, you intermingled with other people and your colleagues and you found out what else was going on in other hospitals, as well. At some point, we started doing our own C-sections. It was better for our patients if the nurses there were able to do the sections, rather than waiting for nurses to come in from home. It was quicker and safer for mom and baby if there was an emergency and we could do our own section. We started doing our own sections in our unit instead of waiting for other crew to come in. [51:00] In the old days, we used to have to do our own packs, fold our own linen, and do our own instruments. Central supply became very important with us, in the fact that they started doing all of the instruments. They would make sure the scissors were sharpened and they would make sure the equipment was all in working order, which took that responsibility off of us. We ordered packs that were already premade. We got to say what went in the packs, but the packs were premade and they were brought in that way. There was increased staffing, as our deliveries increased. Our staffing increased to meet those demands. We adopted the guidelines of one nurse to two patients in labor. Once that patient got to be fully dilated, it was one-to-one. If you were in recovery, it was one-to-one. If you did a C-section, it was one circulator to the patient. With the increased volume, you increased your staffing. Then we had to do what we call on-call, which means you had a nurse that was available to you and the nurse had to be within thirty minutes of the hospital. If you got busy or if you got that unexpected volume that walked through the door, then you had somebody that you could call that would come in to help you. What year or what decade this all occurred? It just sort of progressed as the demands of labor and delivery progressed. As our volume progressed and as practice we progressed, then we progressed with it. I can’t tell you exactly when.

00:52:46
Rigelhaupt:
Completely understandable. And I think most of these changes didn’t really happen at one specific time, but over a period of time. My understanding, the NICU began to be developed while you were still in the Fall Hill location—

00:53:06
Bettis:
Correct.

00:53:07
Rigelhaupt:
Could you tell me about the process of the NICU, and if you were involved, and how the delivery would’ve worked with nurses, and staff that would’ve been in the NICU.

00:53:17
Bettis:
I was not involved in the NICU development at all. I know that they partnered with other hospitals with NICUs. What is good and what is bad? Where you start? How do you do it? I know that nurses were sent off for training. I know that they had and brought training into Mary Washington with instructors. I know that there were some nurses hired that had NICU training that had a background in the NICU itself. They brought in additional staff to always partner with when they did their staffing guidelines. [54:00] You always had an experienced NICU nurse on with, say, someone who has had the classes, but now needs more hands-on type of practice. You always had somebody in the hospital, in the unit, that was NICU-qualified to care for those babies should the need arise. It started off small. You only would start off with just a small amount of babies. Then as education progressed and as hiring progressed, they always hired with the NICU background.

00:54:39
Rigelhaupt:
I presume that the NICU meant that you could treat higher-risk pregnancies?

00:54:45
Bettis:
Correct.

00:54:47
Rigelhaupt:
Did that involve more education for anyone delivering?

00:54:51
Bettis:
Right. We then had to learn how to care for the pre-term labor patient. Labor is labor. We progressed to the point where we would try to stop their labor and if we could not stop their labor, then we would go ahead and deliver them now because we did have a NICU. Our bad preeclampsia: we learned to take care of those, we learned more about their conditions, what to look for, and what to watch for. Those patients would be able to be delivered there as well with the NICU. Labor and delivery had to increase their education volume in order to care for the high-risk patient.

00:55:34
Rigelhaupt:
With higher-risk patients, was there more physician involvement? Were there more nurses?

00:55:39
Bettis:
You would have more physician involvement and you would have an increase in staff. You would have to staff your unit based on the acuity of what you had in the unit. That required sometimes calling in extra staff or using your own call nurse if necessary. If you needed more than that, then you would just call around to other staff. A lot of times you would find people who would be willing to come in because they would realize that you may be that nurse there that needs help. If you needed help, you would want someone to come in and help you. A lot of times, people would drop what they’re doing. They may not be able to come in, but for four hours. But four hours may get you where you need to be with the deliveries and with what was going on. You always had to staff to your acuity. You had to staff to volume, but you also had to look at your acuity of those patients and what they needed. Sometimes we had to do one-on-ones with our very high-risk patients, which means then somebody else had to come in and do what you were doing.

00:56:43
Rigelhaupt:
So, it sounds like the health care organization and the hospital was treating higher-acuity patients who were pregnant and headed towards labor and delivery even before the new hospital opened?

00:56:58
Bettis:
Yes, we were working toward that. [57:00]

00:57:02
Rigelhaupt:
Sticking with the new hospital, what did you remember about the first discussions, maybe even water cooler talk, that the organization was thinking of building a brand new hospital?

00:57:13
Bettis:
Everybody, I think, was very excited about it. The hospital that we were in was very old. And yes, they painted, and they did maintenance, and they tried to make it look spiffy, but you know, old is old. You can only do so much with old walls without gutting the whole place. Everybody was very excited about it. We were going to get new facilities. We were excited in labor and delivery because we were going to get bigger rooms. We were doing bed deliveries in the old hospital because we had bought birthing beds and we were actually doing them, but the rooms were so small that it was very difficult to do a delivery. We would be getting bigger rooms and they would be modern and equipped. Everybody would have a shower and everybody would have a bathroom. We didn’t like the long hallways at first because we had to walk a whole lot more and the rooms would not be as close together. The tradeoff was that the patient would be much more comfortable. In the very beginning, when we opened the new hospital it was during the timeframe where vaginal deliveries just stayed twenty-four hours and sections just stayed forty-eight. That did not last very long, but the hospital was built based on that volume. The twenty-four-hour or forty-eight-hour turnaround time, which we know did not last, because that was not what was best for our patients. Then the hospital had to turnaround and build more rooms. We had started out as an LDRP, which means we labored, delivered, recovered, and kept the post-partum patient there. They never moved out of the room for the whole time that they were there. When they entered that room, they stayed there until they were discharged. That took a little bit more practice because then us labor and delivery nurses also then had to improve our skill for post-partum and nursery. At the same time, when they did the staffing for those areas they always did labor and delivery and post-partum together. You did not ever have a section that only had L&D nurses in it; you had L&D and post-partum nurses in it together. A lot of times, the post-partum nurses would help you if you had a post-partum patient. Or we labor and delivery nurses did the labor and delivery piece, then we turned them over to the post-partum nurses themselves, and then they would take care of the patient, but the patient never had to move. Now, some patients like that. Some patients were ecstatic that they didn’t have to move. Other patients wanted to move because they did not want to stay in the same room that they delivered. It was like a half a dozen of one or six of another. Some liked it and some didn’t. [01:00:00] Once the addition was complete, because of the volume and the turnover, we moved our patients to post-partum. We had the labor and delivery section and then we added an antepartum section. The antepartum patient—like, if you were having pre-term labor or if you had problems with your blood pressure and it was not time for you to be delivered, this is where we would take care of you and try to continue your pregnancy for as long as we could. Some of our patients, like, with pre-term rupture of the membranes at, say, twenty-eight weeks, or thirty weeks, or twenty-six weeks—these patients would stay with us until they needed to be delivered. Some of our patients would stay six, eight, ten, twelve weeks with us on our antepartum unit. That’s been a big change: we had an antepartum unit that we could take care of those patients on a regular basis. And they didn’t have to go anywhere. They didn’t have to go to MCV and they could stay with us, which made it better for the families and made it better for the patient. The families could come visit and they weren’t isolated at MCV. They could see their other children. They were taken care of by their physicians locally that they had confidence in.

01:01:18
Rigelhaupt:
Did the nursing staff have discussions with the administration? Or did you get input into how the new hospital, the rooms, and the space you were in beforehand was going to be designed?

01:01:30
Bettis:
There were labor and delivery nurses on that committee. What they would like to see, what they wanted in the rooms, where did they want it placed, and what would work. If you were the labor and delivery nurse in this room taking care of this patient, what would you want? How would you want it set up? So yes, there was a committee of nurses that had input into the new development.

01:01:57
Rigelhaupt:
Did you participate in any of those meetings?

01:02:02
Bettis:
I think I did. To be honest, I don’t remember. I know we were all asked for input. As part of the nurses that were representing us, they asked us to write down what we would like to see in those rooms and how we wanted those rooms done. I believe I attended some of those meetings, but not as the primary person. Sometimes I was the person that was selected to go to that meeting if the primary person couldn’t come that day. So I went.

01:02:36
Rigelhaupt:
Were there any things that ended up being in the rooms or what was decided upon to be part of the new labor and delivery space that you were most excited about, that you thought was really great, that was going to be part of the new hospital? Or pretty much everything?

01:02:52
Bettis:
The equipment was going to be in the room and you didn’t have to go some place else to get it! [laughter] What you needed to do a delivery and all your supplies were in that room and you did not have to leave that room to get anything. [01:03:00]

01:03:09
Rigelhaupt:
Did you have a chance to tour the space or see the new space before it officially opened?

01:03:16
Bettis:
I did. I actually helped set up the supplies, the ORs, and set up the supply rooms. I was actually one of the people that had been selected to figure out the how, where, and what, and when. I used one of our elite OB techs at the time that was very good at organization. We pulled her into it as well and there were several nurses. Elizabeth Bachelor is the one who actually came up with a plan. We did the ordering of the supplies and how the supplies were going to be in the rooms. We did scavenger hunts. We did different little fun game things for nursing to go over before the hospital actually opened and before the unit actually opened. We did fun little things for them to go and find where stuff was, so that when they got there on the day of the move in and there was an emergency or if they needed something, they knew where to go get it. They knew where to find it, which was important. I mean, it’s stressful moving into a new environment anyway, with new surroundings and with all new equipment. We had new IV pumps. We had new everything. It’s very stressful to learn all of the new equipment. We had games and education sessions to try to make it fun so that they learn how to use all of those new pieces of equipment. Where to find, you know, a blue pad, a delivery pack, or a pack of suture. Where would I go to even look for it? But we had a lot of nursing input into where they wanted the stuff in the rooms, how they wanted it packaged, and where they wanted to find stuff. We used nurses for that. We organized and put it together. Then we did fun little games for nursing to go over and actually practice, hands-on practice, how to do the things. Like, the new beds we were getting, how do you take the foot off the bed? How do you put the bed back together? How do you use the controls? The goal was so that when you go in that day, you’re comfortable with taking care of the patient and she doesn’t look at you and think, “Oh my goodness. Do you really know what you’re doing?” That takes a lot of stress off the nurse. It takes a lot of stress off you.

01:05:52
Rigelhaupt:
Do you remember the last time that you were in the hospital right before it opened? It’s a brand new hospital, sparkling, ready to go, but nobody’s there. [01:06:00] What is it like to walk around this space that you know, in a matter of hours, maybe a matter of days, is going to be a fully operating hospital?

01:06:15
Bettis:
It was amazing. There was staff there waiting for us to open. At some point, there was a cutoff. Rescue squads and patients were told that if it’s this hour, you go to this place. It was like, “Okay. It’s the hour. It can open now. When’s that first patient going to come through the door?” We were just walking around. We were checking things and were thinking just how very nice everything is, how everything is set up, and all the new equipment. Patients should just absolutely love their surroundings. Basically, the hospital did not spare any expense to make it look nice, to make sure that it was safe, and it gave us what we needed to support our patients.

01:07:01
Rigelhaupt:
Did you work on moving day?

01:07:02
Bettis:
I did. I did. I was in the new hospital on moving day.

01:07:09
Rigelhaupt:
Do you remember your first delivery in the new hospital?

01:07:12
Bettis:
I don’t. Too long ago, sorry! [laughter]

01:07:21
Rigelhaupt:
When you’re thinking about the first few months when you were working there—and the time period is not really critical; just early in the new hospital—what were some of the best parts about practicing there?

01:07:36
Bettis:
Everything was convenient. You had what you needed. Patients loved it. You had room for families, because by now, husbands were with patients, families were with patients, and you had room to be able to actually carry on a conversation. You had privacy; the patient had privacy. Moms got to hold babies right after they delivered. They started breastfeeding. Now we’ve trended to the fact that the majority of our population breastfeed and you were able to help mom breastfeed right after they deliver. It was just more of a homey atmosphere that was conducive to the family, for starting this new family, and putting this new family together. Whether it be just the husband or significant other with mom—whether it be her mom, sister, or whoever. Whoever she chose to be that significant part of that family, it was wonderful to be able to have the room and the space to bring everybody together to start that new family. [01:09:00]

01:09:02
Rigelhaupt:
Thinking about even when there were discussions of the new hospital, and moving in the first year or so you were working there. Was there a sense in the nursing staff that this new hospital was more than a new hospital? That it was the beginning of a transition to a regional medical center? Was that something that you were cognizant of early, or before it opened, or even after it opened?

01:09:35
Bettis:
I think it was always in the background that with the new expansion. They added new units and they added higher acuity. I don’t know if I want to say floors, equipment, or staffing, but you knew that the hospital was trending toward being able to care for that more complex patient, sicker patient. A lot of us who were there for long periods of time, and were not transitional or not the military that would be coming in and out, we were excited about it because that means our families now could be treated at Mary Washington and not have to go to Richmond to be cared for. We were excited that we were expanding our horizons and that we were going to be able to care for that more complex heart patient, that more complex kidney patient, and do those surgeries. We did not have to take our families and our patients to Richmond.

01:10:36
Rigelhaupt:
You mentioned heart care and cardiac surgery program as one of the markers of the hospital’s ability to treat high-acuity patients. What other markers would, maybe, the early 1990s, and—again, non-specific things—early after the hospital opened, mid-1990s, that you saw as significant, that was a clear indication that the hospital could provide a higher level of care?

01:11:08
Bettis:
The NICU. Our neurosurgery began to come on around the 2000 mark, or a little before. It was a big plus to have neurosurgery present there as well. It gets to more specialists, like in the kidney diseases and dialysis and that realm of medicine as well. Cardiac really stood out for me. And I guess because of my father having to have cardiac surgery. We had to go to Richmond at the time and then just a few years later we had that ability here. [01:12:00] I’m thinking, “Oh gee. Had this had happened, my dad could’ve been treated here, and we wouldn’t have had to have gone all the way to Richmond.” It was a scary time to go all the way to Richmond with him having cardiac problems at the time. That really stood out.

01:12:18
Rigelhaupt:
Thinking again of the mid-1990s—specific time is hard. Were there new advances in terms of medicines that might’ve been given, changes in surgery and potentially how C-sections that might’ve been done after the new hospital opened or in the first few years that you were practicing there?

01:12:40
Bettis:
We started treating more and more pre-term labor. We had new medications for pre-term labor. Back in the ‘70s when I first started, we used to give IV alcohol in order to transport them to Richmond. We actually got IV alcohol. People are amazed that we used to do that. But now, there was a drug that came out that was called Terbutaline, which, again, we don’t use as much. We used to give Terbutaline; it was given by shot and then it was given by mouth as well. There was magnesium sulfate, which now we used for pre-term labor as well and does a very nice job, a lot of times, of stopping labor. We learned that just plain old hydration—a lot of times moms are dehydrated, their uterus gets irritable, and it contracts. Give them fluid—a lot of times we would do that. There’s Procardia, which is a drug primarily for blood pressure, but we now know that it also works for pre-term labor as well. And then there’s sometimes it doesn’t matter what you give the patient, they are still going to deliver early. We used to put all of our patients in pre-term labor on bed rest. If you read the literature, there’s no support for bed rest. In practice, we know if we bring the patient in and get them off their feet, then it makes it better too. We’ve learned different things about how to care for our patients better than we did back there. We had an antepartum unit. We advance with our education and advance with how to care for those patients better.

01:14:25
Rigelhaupt:
One of the things that I’ve heard about the cardiac program, an early surgical sub- specialty in the hospital, is that it involves a lot of teamwork. It is not just a physician and a highly-skilled physician doing surgery. It involves a lot of training, nurses and other units, in terms of where a higher-acuity patient may move through the process of a stay at the hospital. [01:15:00] With being able to treat higher-acuity patients, involved pregnant patients, what were some of the new things that versus in terms of working with physicians to train and the kind of teamwork that you did to treat higher-risk patients?

01:15:15
Bettis:
I’m not really sure about exactly when, but the hospital developed a perinatology service, which has been instrumental, really, in us being able to keep those antepartum patients and those patients with complications here. We have a specialty physician that can lead the care of the patient. They work with the patient’s obstetrician. By doing that, then we begin to see more high-risk patients. Therefore nursing had to then become more educated on how to care for and signs and symptoms to look for in that pre-eclampctic patient and if those signs and symptoms are getting worse in the pre-termer or the diabetic. We have increased our diabetic population and patients with uncontrolled blood sugars. We now understand better about how uncontrolled blood sugars affect babies once they’re delivered in connection with a NICU. We partner with our NICU as well, to have them come out and they actually do consults with moms and their families about, “Okay, if your baby is born in this gestation, this is what it means. If this baby goes to this gestation, what does it mean?” I mentioned before, we’re keeping patients with pre-term ruptured membranes. Sometimes they’re ruptured twenty-four, twenty-five, twenty-six weeks, and we’ll keep them until thirty-four weeks before they deliver with no problem. What are the signs that we need to look for in this pregnancy—the patient may still be pregnant, but she needs to be delivered. What are those? Those are educational opportunities. Plus, the challenge then comes, not only with just the education of what to look for, but these patients are here for long periods of time. What is it that we can do to help them be a patient there? It causes stress at home. If their husbands are working and they have other children, who is going to care for those other children? Moms get bored. What is it that they can do, you know? Bring in puzzles, ring-a-word. You can only watch so much television. We had the hospital install Wi-Fi on our unit. We were one of the first units to get Wi-Fi because moms could bring in their laptops. Then they could Skype, they could talk with their friends, or they could use the computer for education. One of the moms learned to crochet. She had her family bring in crocheting yarn and she learned to crochet off the Internet. But it occupied them. [01:18:00] They have to have something to do while they’re in that bed and while they’re having to be at that hospital. We partnered with our continuing care as well. Is there something that we can do to help them at home with their struggles? Suggestions? The military has a really good program, but not all families know about it. If you’re a military and you are in the hospital, they will come and help you with your childcare; they will come and help you with what’s going on at home. There are services out there. How do you contact that? Who is available for you? There are some churches in the area that will also help you and that have programs that are available. If moms don’t know about how to go into that or to reach those contacts, then they’re sort of lost. We partner with continuing care. We partner with physical therapy to help with their muscle tone while they’re in the bed. I mean, you’re in bed for six weeks, then you deliver, and we say, “Okay. You got to get up and walk to the bathroom now.” Their muscles are not going to be strong enough to hold them. What kind of physical therapy can we do that is safe while she’s in the bed? The physical therapy is to help and help keep those muscles strong so that when she does stand up for the first time she won’t go down or she doesn’t feel like she’s going to go down because she’s too wobbly.

01:19:28
Rigelhaupt:
Do you remember, in this process of being able to treat higher-risk patients that you described and physical therapy, which is many, many different partners in the hospital? Did you work with the administration to make sure that this was coordinated?

01:19:52
Bettis:
We had our managers—they’re called managers now, they’ve had a lot of titles, and I don’t remember them all. And then you would have a director of your department. You would partner with your manager or partner with the director. This is some of the things that staff is looking into. These are some of the things that we want to do. Who are our contact people? How do we accomplish this? Then they would help you get ahold of or contact the right people. Then you would just set up committee meetings and you would involve the staff in those committee meetings as well. It would not just be one person. You would actually involve staff into how to develop the process. Like another thing that took a lot of energy and a lot of time was mothers and babies. You know, we used to have the separate post-partum unit and a separate nursery. Now, we have evolved to where we deliver the patient and the baby stays in the room. The baby never goes to the nursery unless the mom requests the nursery. The mother and baby go to the post-partum as a family and they stay together as a family for their entire stay. [01:21:00] We developed that out of and that’s what moms in the community wanted. We set up different committees that let us partner together to develop the information that we needed through taking information from the parents, what worked well, what didn’t work well, what do we need to change, and how does it work. Take that back to nursing, and then nursing developed the protocols and policies that start in the delivery room and end on discharge. That is how we did it.

01:21:45
Rigelhaupt:
Part of what you’re describing, there is a responsiveness to the community, as you mentioned.

01:21:51
Bettis:
Correct.

01:21:55
Rigelhaupt:
Thinking back, even to early in your career. Serving the community is part of the mission of the hospital. Was the mission and the values talked about early in your career in the ‘70s? Or is that something that became more clearly defined and part of the discussions later in your career?

01:22:16
Bettis:
I don’t really remember it being talked about in the ‘70s, truly. It may have been. I just don’t remember. As times changed and as progression occurred, we talked more about our mission and our values. What that meant to us as a nurse, what that meant to the patient, and what that meant to the community.

01:22:44
Rigelhaupt:
What were some of the things that you point to in the practices of labor and delivery that clearly connected to how you saw the mission and how you saw the values of the organization?

01:22:59
Bettis:
I think a lot of it, I guess, goes back to where we want to create the family unit. We don’t want to separate mom and baby, dad, and grandma because they are a family. They need to start those development and bonding skills while they’re here, where we can help them learn how to take care of that baby. For dad to learn how to give that baby a bath, change that diaper, and just to bring everybody together. Not separate them, but let them be part of what is going on. Not have dad sit out in the waiting room and not know what his wife’s going through. I’m sorry, labor hurts. They need to understand that. They need to understand and see what it takes to have a baby and what it’s like. They can’t feel it, but they can certainly experience it through their wife. Their mother needs to do the same thing. [01:24:00] The mother-in-law—if you were one of the ones that went to sleep when you had your baby, you had no clue what happened. Whereas today, you understand completely about the process and what happens. I think that’s important. It’s hard for moms to watch their daughters go through pain, and that was probably one of the things that stand out most in your mind: fathers and their mothers both have a hard time seeing their loved one hurt and you can’t do anything about it. You want to do something about it, but you can’t. They depend on us to help them through that and they depend on us to help them with their pain. But just to include them as part of the family unit, help them understand that what’s going on is normal, and help them understand that we’re going to do everything we can to help their loved one. Then to help them grow as a family, but not excluding them in anything we do. To include them in the feeding process and include them into the diaper change. A lot of dads would say to me, “Well, she’s going to breastfeed. How am I going to help?” It’s real easy. Baby wakes up, you can get up, go get the baby, change the diaper, bring baby to mom, and have her breastfeed. When mom’s finished, you can get back up, take the baby, change the diaper, and put the baby back down. You’re helping. You’re a part of the process. You can’t literally breastfeed that baby, but you can support her in her efforts of breastfeeding that baby by helping her do the things that she does. They had never really thought about that. If the baby won’t sleep, you can get up with the baby, you can cuddle the baby, and you can do the things to help the baby. Don’t be afraid to ask for help. A lot of times, parents don’t want to ask for the help because they feel like that they have to do it for themselves. No. If your community is willing to help you and bring you dinner, say, “Oh yes, please. I’ll be happy. I love to eat. Whatever time you get here is fine with me.” You know? Or if someone says, “I’m going to the grocery store, can I pick you up something?” You say, “Absolutely” If you need something at the grocery store, tell her. She’s going anyway. She can drop it by your house. A lot of families feel like they didn’t want to ask for that help. You had to encourage them. Say yes. Your community out there wants to support you. Your family wants to support you. Your neighbors want to support you. If they didn’t want to do it, they wouldn’t have asked. We help them learn and understand some of those things.

01:26:38
Rigelhaupt:
Some of what you’re describing is providing care that is not specifically medical care.

01:26:44
Bettis:
Correct.

01:26:46
Rigelhaupt:
What are some of the ways that you remember the hospital and the organization—Mary Washington Hospital, MediCorp, Mary Washington Healthcare and all of the name changes in between during your career—try and support these programs? [01:27:00] To make sure that nurses had information they could pass on to patients while they’re here. That they could provide information and care beyond the—

01:27:13
Bettis:
They were very supportive about sending us to conferences and to workshops. They were supportive in bringing workshops and conferences to us. They hired nurses that were educators as well. They brought in educators that actually focused on helping us, teaching us, and giving classes to us on new processes and new theories. They were teaching about pregnancy-induced hypertension, pre-term labor, and diabetes. We partnered with our diabetes management program. We set up classes and they actually came and taught us more about diabetes, what to look for in our patient population, and what the correct information should be. When you do your policies and procedures, we partnered with diabetes, we partnered with ACOG, and we partnered with AWHONN (Association of Women’s Health, Obstetric and Neonatal Nurses), which is the nursing organization. AWHONN has standards that we partnered with. If there were a new or changed standard, then we would update the old one. We learned to understand the process and understand what to look for. Post-partum hemorrhage is another big one. Fetal monitoring is always changing and you have to update. The hospital has always been really good about bringing in educators. They brought in computerized programs that were really good programs because they gave you the scenarios, they gave you synopsis, and they provided you education. Then you had to answer their questions, but they gave it to you in a scenario form. So, if you had a patient walk through the door with this, this, and this, what would you do? Or, if this, and this, and this appeared on the fetal monitor, what is the appropriate interpretation? If you got it wrong, then they gave you rationale and a subject to go back to. This is where you need to restudy. The hospital requires us to do that. We have to do that every two years in fetal monitoring. For post-partum hemorrhage, we did it every year because it’s high-risk and low-volume. You have to continuously update and educate on things to look for. Like, how to measure the blood loss of a patient. If I say to the physician, “The patient has lost this much blood.” As opposed to saying, “Well, she saturated two pads.” What does saturated two pads mean? But by education and through this interactive computer program, we’ve actually learned how to measure how much blood that means. We can say to the physician this is what kind of blood loss she’s had. [01:30:00] He fully understands. So it is seminars, workshops, educators brought in, and computerized programs. In order to stay there, we have to complete these things in a certain amount of time in order to continue to practice and continue to work at the hospital. They did require us to do that, which is an excellent thing. That way we don’t get behind the education curve: we know what the latest is, how to respond, and what to look for in that. We also have to have, of course, CPR and NRP (Neonatal Resuscitation Program), and those classes are actually taught at the hospital as well.

01:30:45
Rigelhaupt:
Earlier, you mentioned the perinatologist was a hospital employee, a staff physician.

01:30:52
Bettis:
Correct.

01:30:52
Rigelhaupt:
Which is different than the community physicians. Did that affect the working relationship between nurses and physicians? Part of my asking is that hospitalists are part of the staffing now, which is different than when you began your career. So, it’s also a general question about the working relationship between physicians and nurses when the physicians are staff members and employees?

01:31:26
Bettis:
I don’t think so. A physician is a physician. You have to work with them. You have to respect them. You have to be courteous. You have to approach them—I approach them no differently than I would approach any other staff physician. If I have a question, I try to ask it respectfully. If I don’t agree, we try to do it respectfully with them. They are a physician. You treat them just like you would treat any other physician on your unit, whether they’re hospital employees or private sector employees. I mean, they have a specialty, they are there for a purpose, they are there to help you care for the patient, and help direct their care with your input. You have to give your input respectfully, concisely, and accurately, and they need to do the same with you. With the other units, you know, they do consults. If there was a pregnant patient, say, with bad asthma up on one of the other units, then they would be consulted to help care for that pregnancy, not the asthma piece, but the pregnancy.

01:33:00
Rigelhaupt:
And my asking was just to get a sense of if there was any change with staff physicians versus the community physician model, which is a big change over the course of your career.

01:33:11
Bettis:
It is and it’s very nice to have staff physicians. The hospital has the hospitalist program, which is new. We’ve had it for a few years now, which is wonderful because that means we have a physician in-house 24/7. If that emergency arises and that patient’s physician happens to be not in-house or tied up with another patient, then they’re there to help us care of that patient. With perinatology, they are on-call 24/7 as well. They don’t stay in-house, but they were always available to you and they were available to come in if you called them. They would not hesitate to come if they were needed. We were very fortunate to have perinatologists, OB hospitalists, neonatologists, and anesthesia all in-house 24/7. We’re very fortunate to have the resources available to us.

01:34:16
Rigelhaupt:
Did you have more interaction with the administration and become more aware of the role they played in the hospital as your career progressed?

01:34:26
Bettis:
Administration is responsible for making sure that we have this twenty-four-hour coverage that we have and the development of the program. I was not involved with the development of the program, but I was very aware that they were being our advocates in trying to bring these programs. They realize that we are having higher-acuity patients and we were moving toward that medical center mentality, I guess, for lack of a better word. In order to do that—and we wanted the high-risk patients to come in—we had to provide for those high-risk patients. Administration did work with us to have perinatology, in-house anesthesia, OB hospitalists, and neonatologists.

01:35:17
Rigelhaupt:
Earlier, you mentioned if it was a vaginal delivery, it would be one night, C-section, two nights, and that it was rather strict. And from my understanding, there was some legislation changing and insurance companies could mandate time. And so, I think part of what you were coming to is that cost is part of medicine and part of care.

01:35:41
Bettis:
Absolutely.

01:35:44
Rigelhaupt:
Did you find yourself and your colleagues as nurses in labor and delivery becoming more aware of costs as your career progressed?

01:35:53
Bettis:
Absolutely. Administration sort of clued us in on what it took to run the hospital, where your money was going, and the cost involved. [01:36:00] They started talking more about reimbursement from insurance companies, reimbursement from Medicaid, and reimbursement from Medicare. What does that all mean to you, as a nurse here at Mary Washington Healthcare? What does that mean? With an understanding, then you sort of understand more where the administration is coming from when they let you know of these different things. There’s always a cost with everything. Whether it’s a change or whether you continue on with what you’re doing, there’s still a cost to everything we do. I will tell you, from a nursing perspective, the twenty-four-hour vaginal delivery and the forty-eight-hour C-section: nobody liked it. The patients certainly didn’t like it. We, as health care providers, including the physicians as part of that health care team, none of us liked it. That was the mandate. I mean, that’s what it was at the time and that’s what we had to live with. Until, again, you had to show and prove that this was not what was in the best interest of your patient. Then, of course, there were changes made.

01:37:13
Rigelhaupt:
Were there—and again, this is not a specific time period—were there things that you remembered learning about cost that, for lack of a better term, the light bulb went on? That were memorable for practices that you began to do in the hospital, even if it might be something as simple as using supplies differently. That was a part of the nursing practice?

01:37:38
Bettis:
When you start looking at cost, we went from doing our own linen, buying our own linen, folding that linen, wrapping the packs, and doing all of that to disposable packs. You had to look at the cost. You had to do a cost analysis: “Okay, if you use disposable packs, the disposable pack is going to cost you this. If you continued to use our time to launder, fold, and wrap, and that, you had to weigh out the costs. Is there a cost savings? And if it’s not a cost savings, then why are we changing? Or is it better? Does the improvement of the process outweigh the cost of the process?” Sometimes it did. Sometimes it didn’t. Sometimes the fact that we changed the process is good. When we went to disposable packs—thank you. Folding linen was 3:00 to 11:00’s job—you fold the linen and wrap the packs. Since I worked 3:00 to 11:00, I did a lot of that. A cost analysis was done and safety factors were looked at. Number one, it was safer for the patient having it prepackaged and all sterilized. [01:39:00] It was cost analysis wise cheaper than having the hospital having to purchase the big thick linen, having them sewed, and cut. Then sending them down to central supply, processing of the autoclave, and processing time of the people to do that. You have to take in all of that when you do the cost. When I was put on that team, I got a better understanding of what it actually cost to do what we were doing. We would always take that back to the staff. When the staff would start to grumble we could say, “Okay. No, no, no. Let me show you now and let me tell you. I know you don’t like change, but this is why we’re changing. Look at this. If you want us to continue to have to be able to buy new equipment, if you still want us to be able to get the new pumps and the new monitors, then we have to be good stewards of what we use and what we do. This is why the change is occurring.” You do your pack and then a couple years down the road, there may be something different we can do with the pack to make it cheaper or to make it better. They came out with gowns that were impermeable to blood, so we changed our packs to protect our nursing staff. Did it drive the cost of the pack up a little bit? Yeah, by a few cents, but you’re protecting your nursing staff and you’re protecting your physicians when they do the C-section, or when they do the delivery the splash is not going to go through, get on their clothes, and then endanger them. You always had to look at cost and safety as well. And what it took.

01:40:36
Rigelhaupt:
What do you remember about the first discussions of Stafford Hospital, and then Mary Washington Healthcare might become a two-hospital system?

01:40:47
Bettis:
I wanted to know why you were building Stafford. That was always the question. Why are we doing this? Can’t we just add on to what we have? Why are we going different places? Then, you know, we grew to understand that it was what was best for the community. It was dividing us up. But in all honesty, there’s still a lot of questions. We in the care of women have talked about it for a lot of years: take Stafford and make it a women’s pavilion. You do your labor and delivery, past-partum, NICU, surgeries, mammograms, cancer screening, and education all under one roof. You can go in if you have a problem and you can get it all taken care of right there. You never have to leave. Make it a women’s pavilion catered to women and their needs.

01:41:55
Rigelhaupt:
Were you involved with the setup?

01:41:58
Bettis:
No, sir. [01:42:00] The nursing staff that was going to be there at Stafford did come and work at Mary Washington and we did their skill sets. Anytime that you were hiring a new nurse, there is an educational process that they have to go through and they have to have documentation that they can do these certain things. Their nurses, in the beginning, prior to them opening came to Mary Washington and came through our labor and delivery and post-partum units.

01:42:36
Rigelhaupt:
Were there any practices or ideas that you had developed in labor and delivery at Mary Washington Hospital that you or your colleagues wanted to see become part of the culture and the practice at Stafford?

01:42:55
Bettis:
Stafford was going to be an LDRP [Labor, Delivery, Recovery and Postpartum Room], which was going to be a little bit different from us in the fact that they were going to not move any of their patients. They were going to do labor and delivery and do their post-partum stay in one room. That was just a little bit different than our practice. Again, they did epidurals, supported natural childbirth, and breastfeeding. They did prenatal classes, as well as prenatal education that we did at Mary Washington. It was just sort of like a continuing of what they did there. For their post-partum, I will tell you one thing that Stafford did that I really liked, that we did not necessarily do here: they got their C-sections up within eight hours of delivery on the side of the bed or in a chair and they got them up on their feet within twelve. That, I really think, helped their patients get up and get moving. That was a good practice. We brought that practice back to Mary Washington, to encourage them to do the same. I’m not sure, but I believe they’re doing that, trying to get their patients up and moving earlier than what we used to. That was a practice change that they learned and that they then gave us.

01:44:16
Rigelhaupt:
One of the things that I’ve learned in this project and doing some research is that hospitals are acute care centers. And for most of the twentieth century hospitals, even not-for-profit community hospitals, have not necessarily put a whole lot into a primary care or public health. And part of what I’ve learned is that there are some connections to that through, like, the Moss Free Clinic and your organization. Having seen your practice in labor and delivery, it’s much more acute. It’s a specific reason that someone’s there and not necessarily connected to chronic conditions, or public health, or primary care. But in your experience over your career, do you have recollections in the way that the organization tried to support primary care, or tried to support public health in the region? [01:45:00]

01:45:04
Bettis:
I know they were instrumental in developing the Moss Free Clinic. A lot of the physicians that volunteer at the Moss Free Clinic practice at Mary Washington. I do know that. I believe, Barbara Kane, who was an administrator [and former Chief Nursing Officer and Vice President] here at Mary Washington, also sat on their board at the Moss Free Clinic and was instrumental in helping develop some of those practices as well. Pharmacy, I believe, is also a big support there at the Moss Free Clinic. A lot of the nurses that work at Mary Washington also volunteer at the Moss. I volunteered, something like fourteen or fifteen years, in their GYN clinic on Wednesday nights. We encouraged our physicians, and they were very generous with going over there and doing that. A lot of our nurses did as well. We wanted to give back to the community for those who did not have insurance. It’s expensive to go get a pap smear or a GYN check. And you know, sometimes you just fall on hard times and you need that little bit of help for just a short period of time. They deserve health care. We would go over and help with that, as far as volunteering goes.

01:46:26
Rigelhaupt:
Does the Moss Free Clinic also provide prenatal care?

01:46:29
Bettis:
No, they do not. They don’t provide any type of prenatal care at all. If they find that you are pregnant, they will refer you to the public health departments. The hospital also works with the public health departments. There was a nurse practitioner that was for Stafford, Spotsy, Fredericksburg, and King George. We would partner with their OB patients if there was a problem, especially if they had a high risk. They would contact us or we would contact them. They were very good to work with. If there was a problem with their patient they would make appointments to come to our hospital for testing purposes. If they didn’t show up, then we would contact that health department and they would go out and visit the patient and find out why she did not come in, why she didn’t show up for her appointment, and encourage her to do so. If they missed the diabetic screen: same thing. We would try to contact that health department and they were very supportive of us going out into the community and trying to get that patient back in to our facility for care.

01:47:45
Rigelhaupt:
You just mentioned a nurse practitioner. That’s certainly, I think, one of the things that has changed throughout the course of your career, that there are more nurse practitioners, nurses with a higher level of education, nurse midwives. Did that shape the practices of labor and delivery? Are there more nurse practitioners, more nurse midwives? [01:48:00]

01:48:05
Bettis:
The nurse practitioners mainly work in the physician’s office. There is one nurse practitioner that comes over and makes post-partum rounds, but does not do labor and delivery. We do have some wonderful, and have had, some wonderful nurse midwives through the years practice at Mary Washington. That changes the focus a little bit in that they’re right there. The majority of them are there at the patient’s bedside directing their care. Sometimes they will go to the office, but once that patient gets in active labor, a lot of times, they’re there at that patient’s bedside or in the unit encouraging that patient and supporting that patient as well. They’re just very supportive. They’re supportive of staff, as well as they’re very supportive of their patient.

01:49:06
Rigelhaupt:
When we spoke, I believe you said you retired, last November.

01:49:08
Bettis:
I did. November 1, 2014.

01:49:15
Rigelhaupt:
Forty-four-year career at Mary Washington?

01:49:17
Bettis:
Forty-four.

01:49:19
Rigelhaupt:
Thinking about towards the tail end of your career, what are some of the best practices? What are some of the best parts of labor and delivery and some of the things you’re most proud of that you’re practicing?

01:49:34
Bettis:
Family care, really. From when I very first started, where you dropped your wife off at the door and you went home to where it has evolved to where the families are in the room. They’re supportive of that patient and they want to learn. We try to have dads put on their baby’s first diaper and make sure they hold that baby. Just that family unit, that family coming together over the years, and seeing how it has grown and changed is something that I really am proud of and to have seen us be that forward-thinking and moving in that area. One of the things that stick out most—because I have been there for forty-four years—is that I delivered babies of patients that I delivered. Both the husband and the wife I delivered, and then I delivered their baby as well. That was very unique. To walk into the room and have the family look at me and go, “Hello, Dixie. I didn’t know you were still working here.” Not only did they remember me, but they remembered my name when I walked in the room. I thought, “Well, gee, after forty-four years, maybe I didn’t change so much!” [laughter]

01:51:00
Rigelhaupt:
What are some of the things that you would want the public to know about being a nurse in labor and delivery that might not be common knowledge?

01:51:14
Bettis:
That’s a good question. That’s not common knowledge. I’m not sure that the public realizes just how much time and energy is spent by nursing just educating themselves and keeping themselves educated and up to date on the changes in the practice and the skillset that you have to have in order to take care of a patient in labor. You have to continually learn and things that are changing medically you have to learn in order to provide the best care for them. How much time it takes away from family, because not only are you working your shift, you have to be on-call. You have to take X number of shifts a month to be on call. Then you have the educational piece that you’re responsible for and for completing in a timely manner. That keeps you current on what is going on today. I’m not sure that the public really realizes what the background is, in order to do our best job to take care of you.

01:52:32
Rigelhaupt:
What are some things about Mary Washington Hospital, or Mary Washington Healthcare, the organization you work for, that you want the public to know about that might not be common knowledge?

01:52:46
Bettis:
I think they’ve always been an organization that approached change and was active for change. They wanted to know what the best practice is out there. They wanted to bring that best practice to the health care facility. They wanted to bring that monitoring of higher-risk pregnancies and that extra skillset to the area so that we could better serve the public and not send you out of town for something that we could develop and do a good job of here.

01:53:32
Rigelhaupt:
My last question is actually two questions. One, is there anything that I should’ve asked and I didn’t? And two, is there anything you’d like to add?

01:53:47
Bettis:
No and no! [laughter]

01:53:51
Rigelhaupt:
That’s a nice place to stop. Thank you!

01:53:54
Bettis:
You’re welcome!
[End of interview]