Kelly McDonough

Kelly McDonough is Administrative Director of Nursing Practice and Mary Washington Hospital Nursing Operations. She joined Mary Washington Healthcare in 2004 after serving as a nurse in the United States Army. She has served as the Nurse Operations Manager in the Emergency Department and the Administrative Director of the Emergency Department at Mary Washington Hospital. She received her Bachelor of Science in Nursing (BSN) from Radford University, her Master of Science in Nursing (MSN) from Drexel University, and her Doctor of Nursing Practice (DNP) from George Mason University. Governor Bob McDonnell appointed McDonough to the Virginia Board of Nursing in July 2013.

Kelly McDonough was interviewed by Jess Rigelhaupt on January 23, 2015.

Discursive Table of Contents

00:00:00-00:15:00
Joined Mary Washington Hospital as an Emergency Department Operations Manager in 2004—Previous experiences in the United States Army as a nurse—Memories of the first shift and beginning as an Emergency Department Operations Manager

00:15:00-00:30:00
Learning about collaboration between nurses and physicians in the emergency department—Bachelor’s in Nursing from Radford University —First duty assignment was to Fort Sam Houston—Second duty assignment was to Fort Irwin—Became a critical care nurse and served at Walter Reed Army Medical Center —Served in Iraq with the 28th Combat Support Hospital—Differences between being an Army nurse and a civilian nurse—Valuable experiences and education from serving as a nurse in the Army

00:30:00-00:45:00
Learning and developing clinical skills through experiences with 28th Combat Support Hospital in Iraq and at Walter Reed Army Medical Center—First impression of the strengths of Mary Washington Hospital—Beginning work in the emergency department—Working in operations with Dr. Jody Crane—Planning the trauma program

00:45:00-01:00:00
Planning the trauma program—Experiences with the trauma program since it began in 2008

01:00:00-01:15:00
Collaboration between nurses and physicians in the trauma program—Strengths of the trauma program—Trauma program’s work with EMS—Master’s in Nursing Leadership and Administration from Drexel University

01:15:00-01:35:39
Doctorate in Nursing Practice from George Mason University—Doctoral dissertation on staffing methodology—First person to have a Doctorate in Nursing Practice at Mary Washington Healthcare—Stafford Hospital—Summary discussion of nursing and being a nurse leader—Summary discussion of Mary Washington Healthcare

Transcript

00:00:05
Rigelhaupt:
It is January 23, 2015. I am in Fredericksburg, Virginia, at Mary Washington Hospital, doing an oral history interview with Kelly McDonough. And to begin, I would like to ask you if you can describe your first experience, first interaction with Mary Washington Hospital?

00:00:25
McDonough:
My first interaction with Mary Washington Hospital is when I got out of the military. I was in the process of transitioning from the military to civilian life and I was looking for opportunities that were out there. One of the opportunities was at Mary Washington. I had done some research. I was talking on the phone, and at that time I don’t remember who I spoke with in the recruitment, but it was a vast difference. There was a warmth on the other end of the phone. Then I did an oral interview on the phone with, actually at the time, Marianna Bedway. It was a great interview on the phone, and when I came in to do face-to-face interview, it was welcoming. I met with the whole team. It was an experience that made me want to work here for Mary Washington Healthcare.

00:01:41
Rigelhaupt:
Could you talk about the team that you met with when you came for the in-person interview?

00:01:46
McDonough:
Yes. At that time, I remember going down. It was a team interview and it was a walk down into their conference room in the ED. There were staff nurses. I believe there were two of them. Then there was a paramedic, an EMT, an educator, an EMS coordinator there, Marianna, and one of the managers that I would be working with if I was hired into the job. It was a round table and very relaxed interview, but at the same time very pointed questions about who I was and then a lot about what they did as a team. I really felt talking with that team that I saw myself there.

00:02:45
Rigelhaupt:
And the position you were interviewing for?

00:02:47
McDonough:
It was the evening operations manager position.

00:02:54
Rigelhaupt:
Focused on the emergency department?

00:02:55
McDonough:
Focused on the emergency department, correct.

00:02:58
Rigelhaupt:
What did they describe about, you said it was a team and they talked about what they did. What did they tell you about what they did? [03:00]

00:03:05
McDonough:
At the time, the emergency department was a community hospital. It was Mary Washington Hospital and it was a fifty-bed ED. It was the sole provider in the community, so there were a lot of patients and we were a busy ED. We have great physicians. The evening shift is one of those that we really need a leader that is engaged, someone that really knows and who is clinically sound, and can jump into the staff. What they described to me was they had great partnerships with their ED physicians and that they relied on one another a lot. I just remember it being they were proud to be the community hospital at that time. It just sounded intriguing to me. When I was talking to them, it was very, very warm, and you wanted to be a part of that team.

00:04:17
Rigelhaupt:
Did they give you descriptions of things that have gone well over the last couple of years, or things that they were working on?

00:04:24
McDonough:
Description of what has gone well—what I remember, this is 2004 when I had come off of active duty, or was in the process. What I remember is what was going well was their teamwork. I think the challenges they described at the time was seeing so much volume and being the only game in town at that time. I don’t remember if this was in the interview and I was told about a trauma and thinking about that—I don’t think I found out about that until later.

00:05:13
Rigelhaupt:
Did they talk to you about the way in which the emergency department fit with other units and programs within the hospital?

00:05:27
McDonough:
I think really it was about the ED. From what I remember, the team that was there was really looking for someone that was for the evening shift and able to deal with high volume and high stress. I think they really focused on their operations at that time. How I fit in, I don’t know if I got that from that interview.

00:05:53
Rigelhaupt:
Do you remember what you told them about why you’d be a good fit? I know obviously you’ve been here for a decade plus, so it’s obvious that you were. [06:00] But, what you told them about how your experience would help them with the description of the job they were telling you about?

00:06:10
McDonough:
I was very fresh from, at that time in 2004—I was part of Operation Iraqi Freedom. I had done an overseas tour of duty with OIF1 and I was with the 28th CSH. I had come back in February and then my interview was in July. I was really close to the time where it only had been a few months from being in a war zone. One of the questions was, I think, they wanted to know a little bit more about what I did. They knew I was in a burn unit. They wanted to know some of those pieces and the stress level. I was like, “Well, there was rockets. There were things. I felt safe where I was.” Evening shift for me and dealing with a high-stress ED, I sold to them, or told them, that I was fit for that job because I was able to think on-my-feet and on-my-feet make decisions and work with individuals. I was very team-oriented being with the military. That’s how I was able to talk to them about my experience. I think that was interesting to them.

00:07:43
Rigelhaupt:
Did they tell you anything about the core values of the hospital and the health care system?

00:07:49
McDonough:
I got that from Marianna when I talked to her on the phone. She went through on the phone about her expectations from an evening nurse manager, and who she was, as a director at that time in the emergency department. Further, she talked a lot about what she was trying to do in the emergency department. To her, it was someone who had compassion, who was accountable, really thrived on wanting to do better, and showing excellence in everything they do. She did explain those pieces on the phone and I think they carried over into the team interview.

00:08:47
Rigelhaupt:
So this was July of 2004?

00:08:49
McDonough:
Mm-hmm.

00:08:50
Rigelhaupt:
How soon after the interview were you offered the position?

00:08:55
McDonough:
I want to say, it was probably within a day.

00:08:50
Rigelhaupt:
It sounds like the interview went very well. [09:00]

00:09:01
McDonough
The interview went well. I remember the feeling when I walked out. [tearing up] Can you please—don’t put that in? It’s okay. It’s one of those rare times, those rare leadership moments when you meet—I didn’t expect to do that. [tearing up] That caught me off-guard, I’m sorry. When you meet an individual in the organization that—I’m sorry. I don’t know why. I’m sorry. [laughter] Boy, I hope you cut some of this out. When you meet an individual in the organization that you link with: you have the same style, maybe different, but the leadership and the values that you carry link right away. I didn’t know I was going to be here ten years. I didn’t know that I was going to leave. Sorry. [crying]

00:10:45
Rigelhaupt:
Pause, or—

00:10:46
McDonough:
No, no, no. I’m sorry, I didn’t expect to do that.

00:10:51
Rigelhaupt:
It’s a commitment to your job.

00:10:53
McDonough:
Yeah. [laughter]

00:10:54
Rigelhaupt:
Meaningful.

00:10:57
McDonough:
I’m sorry.

00:10:58
Rigelhaupt:
No need to apologize.

00:11:03
McDonough:
You meet somebody, I think, that has a belief in nursing that you link with. Since then with Marianna, I think she’s always promoted people to do the best that they could do. I think probably that has been from that time I came in 2004. From the military to here I couldn’t ask for a better boss, so.

00:11:50
Rigelhaupt:
So part of what I think I’m hearing is, the sense of working with Marianna is, over a decade-plus has been a meaningful part of your job. [12:00] So let me ask, if you could say a couple things about what’s it like working with Marianna on a day-to-day basis, not the cumulative ten years, but you know, some of things that is eliciting an emotional connection that you’re experiencing?

00:12:26
McDonough:
I would tell you that I think there are very high expectations. Number one, I think is from a patient-centered experience. The empowerment that she wants all of her leaders to feel: they are empowered to make decisions and the recognition for what you do is what she puts forward. That’s very key to a successful leader and why there is that connection. I think she’ll put her leaders in front of her to ensure that they’re successful. Then of course, again, it’s always the high standards. Once that bar is here, it never goes down. That’s what I expect of all my leaders as well and I think it’s that support system that’s there.

00:13:28
Rigelhaupt:
Could you tell me about your first shift?

00:13:31
McDonough:
Yes. When I first came on board, Marianna thought it was going to be a good idea to round with one of our clinical nurse specialists that’s still here today, Natalie Root. She was sitting in the charge spot and I was with her watching what was coming in the door and the interactions of the staff and the physicians. It was very, very busy. I remember thinking like, “Holy—. How am I ever going to understand all these little nuances?” It’s a big place and sometimes it’s overwhelming. When you walk into the doors in an emergency department it’s a fifty-bed ED. A big square, but at the time, I thought the big square seemed very, very overwhelming and large. That was probably my first experience. It was a little overwhelming, very busy, and I didn’t know how I was going to understand all the little nuances, but I did. It came quick.

00:14:50
Rigelhaupt:
What were some of the things that you learned? I imagine there was some orientation period within a shift, rounding with someone? [15:00] What were some of the things you learned about the emergency department, in that orientation period?

00:15:10
McDonough:
I would say the orientation period, to be honest, was probably over a couple of years. I don’t think you can learn it in just a couple days. I think what I did learn was how a team works very well and how the teams are broken up. The physicians and nurses—the interaction was key and of utmost importance. The interaction like I’ve never seen anywhere else in this hospital, how the physicians and nurses work together in that department. I think to any successes it’s that partnership between the two, the openness that they have, and the communication piece has been key. If I learned anything in that orientation piece, it’s where the physicians stood, where the nurses were and how they collaborated, and I think that’s half that battle to learning the emergency department, those relationships.

00:16:24
Rigelhaupt:
Did you get a sense that the successful, good working relationships between nurses and physicians have been there a long time? Is it relatively recent? I mean, did you get a sense of how entrenched that was in the ED?

00:16:41
McDonough:
Yes. It’s the way they interact and the collegiality that they had. They had what is called in the emergency department the physicians’ work area, but they call it the “fish bowl” or the “doc box.” It’s where everybody can see inside to the physicians, what they’re either doing, or vice versa. The nurses mingle with the physicians in there. They go in there, store their lunches, and they sit in there with the physicians. You can tell that there is collegiality and there are those partnerships. Otherwise it wouldn’t happen. It would be, “You’re not allowed in here. We’re not going to share our space with you. Nurses, you have your area and physicians have theirs.” They don’t do that at all. They’re very comingled. That has to be there for a really good functioning emergency department. You have to have those relationships between the physicians and the doctors, and that trust factor that’s built there.

00:17:49
Rigelhaupt:
Was that anything anyone told you about in the interview, or was it something that you had to observe in the sense of comingling in a space?

00:17:58
McDonough:
I think you have to observe it. [18:00] You have to see it and feel it. There’s truly that kind of feeling when you go and you can tell when there is a bad day or you can tell when there is a good idea. I don’t know how to explain it. But you know when a certain physician is on and the different nurses are on, and who works best together, but you have to observe it to get that and to understand what I’m saying.

00:18:31
Rigelhaupt:
And that was something that you could see very quickly when you started that there was a good working relationship?

00:18:35
McDonough:
Yes.

00:18:40
Rigelhaupt:
Well I want to talk more about your work in the emergency department in a moment. But I want to ask you a little bit about your nursing career before you started here. So you started in the Army after you finished at Radford University?

00:18:55
McDonough:
Right.

00:18:56
Rigelhaupt:
Would you tell me a little about your experience in nursing school, and the transition into serving in the Army as a nurse?

00:19:03
McDonough:
I went to Radford University. My father was in the military and I was born overseas. My whole entire life I’ve been entrenched in the military lifestyle. So was it a stretch for me to think that I was going to do something in the military? No. I was accepted into Radford University’s nursing program at the same time I was looking at the ROTC program. There were scholarships available and that was a double-win. I decided that I was going to apply for a scholarship through ROTC. I was awarded a scholarship for, it was either three or two years, and then I had a job after I would graduate. It was kind of a win-win situation as I was going through. Once I graduated, I went through ROTC with flying colors and I was commissioned as a second lieutenant in the Army. Every nurse that comes out typically is a 66-Hotel, which is just a regular med-surg nurse. From there, for my first duty assignment I went to Fort Sam Houston, which is an officer basic course. You learn how to be a real Army nurse. It’s called “All Corps.” You go with physicians, you go with pharmacists, and you go with everyone that is part of the medical corps. From there you do get assigned to your first duty station, or rather, your second duty station, which for me, was at Fort Irwin. It’s in California in the Mojave Desert and it’s a national training center. [21:00] It is really in the middle of nowhere. [laughter] And I have to tell you, it was really one of the best experiences because as a new nurse, I stayed in the med-surg area and I had PACU experience. It was a little community hospital and then I ended up moving into the emergency department there, which was only about eight beds. We did see some of what I would call emergency traumas. We also had our own ambulances and there were patients that we would have to ship out. We had to send a nurse with them. I would be able to be on the air ambulance crew and have to fly with them to either Loma Linda or somewhere else. Those are experiences you don’t normally get in the civilian workforce, I don’t think. That’s how I felt. I felt I was more good entrenched, and had little good experiences. As an Army nurse, I also had the opportunity to also go to Air Assault School. What nurse gets to jump out of helicopters and rappel down? I got to do that and that was fun. I don’t know where I’d ever use that skill. [laughter] I did that and then I applied to be a critical care nurse. That is an application process and I was accepted. That took me to Walter Reed where I gained a critical care identifier and I became a critical care nurse. I was assigned at Walter Reed subsequently, in their medical and pediatric ICU. Then from there, I was attached to the 28th CSH, which is out of Fort Bragg. That’s how I ended up going overseas to Iraq. Then I came back to the Walter Reed and then ended up coming to Mary Washington. Quick, short, long experience over a couple of years.

00:23:18
Rigelhaupt:
I think like all school probably, what you received at Radford was wonderful training, but not really enough to do the job. So what were some of the new things you learned when you were at Sam Houston, about nursing and about medical care that was different than a classroom setting, and what you got as an undergraduate?

00:23:42
McDonough:
The one thing I would say is the field experience, and you still go through Sam Houston. At that time, who would have thought I would ever do that? [24:00] It’s the portable hospital: you get to set up a whole hospital tent, it has working beds, and you work out of the hospital that can be set up anywhere, any place, any time. That was probably one item that I did that you would not have any other experience doing that.

00:24:25
Rigelhaupt:
Did you learn new clinical skills while you were there?

00:24:28
McDonough:
No, not at the Fort Sam Houston. It wasn’t new clinical skills. It was based on what you knew, but really about how to be an Army nurse, into the tenets, the leadership of the Army, and the expectations of the Army. It’s almost its own little culture and its own little world of how you need to act and be. So it’s more about being an Army Nurse Corps officer.

00:24:58
Rigelhaupt:
What were some of the things that were different about being an Army nurse than a nurse in a civilian world? I mean, some of the things that stood out to you and were important?

00:25:07
McDonough:
Highly competitive. I say that because as you go into the civilian workplace you can be an associate degree nurse or you can be a diploma nurse. Every officer in the Army Nurse Corps is four-year degree nurse and you are a BSN. The other difference is that you have to have physical height and weight standards. You have to stay within a certain range and you have to look a certain way in uniform. Your uniform has to be just so. I think there’s a little uniformity. It’s not just how you practice in nursing because that’s the expectation, but it’s how you act and represent the Army as a whole when you are on and off duty. Those things are way different than it is in the civilian workforce.

00:26:09
Rigelhaupt:
Are there things you learned in there that stand out now, over ten years later that were very important that have translated well to the civilian world?

00:26:22
McDonough:
Yes, I would say. I remember when I first walked in an emergency department—it’s funny, and I still remember to this day when I was looking for something to wear to the interview. I immediately went to Brooks Brothers stuff. Some people may find that and understand what I’m saying: Brooks Brothers is very rigid. It’s very, you have to tuck in your shirt. I had a button-up collar. [27:00] I think I even went to cuff links on my shirt because I felt like I needed to be rigid. I remember it very clearly. When I walked through the emergency department, I remember it was three physicians and they were by one of the desks. I had gone by and I was so rigid, but it was, at that time, transitioning from military life to civilian life. I wasn’t there yet. I just remember being like, “Well, you got to loosen up.” In the ED, [laughter] “It’s like, well you know, you’re going to have to loosen up.” And I was like, “What are you talking about? You need to stand fast.” I remember thinking, “You know, do you know who you’re talking to?” [laughter] I was a captain at the time transitioning. To this day, I think I still hold and that it’s just ingrained, for me it was. Not everybody is like that. For me, transitioning, I think some of that formality has always stayed. But then I’ve gotten softer as the years come by. I mean, I’ve always been compassionate, but I think some of that has come through. It’s something that I’ve had to put down, but I think those leadership pieces and the formality are still there with me. I think that’s just who I am.

00:28:25
Rigelhaupt:
What were some of the best parts about starting your job at Fort Irwin?

00:28:30
McDonough:
At Fort Irwin, I think it’s being a new nurse, being wide-eyed, and learning how to be an Army nurse, though is a little different. I was living in Bachelor Officers Quarters, BOQs they called them. It was the camaraderie of the other lieutenants at the time and physicians. I think that’s probably the best time because it is in the middle of nowhere. You have to make friends. There’s not a lot to like in there. But when you did go out, you got to go on, away from Fort Irwin: you go to San Diego or Los Angeles. It’s a nice place to be when you’re not in the dust bowl. [laughter] I think it’s the other people in all walks of life that you get in one location. And we did see a lot of different people who train there. You get a lot of different things that would come into the hospital, not that you would normally see in a little small community hospital. You would get reservists that were out of shape and that would go out in the middle of the heat in deserts. You got a lot of heat casualties. Then I’d get to go on these flights. That was me. I liked helicopters and I still do. [30:00] It’s a neat experience for a brand new nurse.

00:30:06
Rigelhaupt:
Were there clinical skills that you were most proud of getting better at, and more skilled at, that you’d obviously learned in nursing school, but that you were practicing every day as a nurse now?

00:30:20
McDonough:
I have to tell you, where I became really confident was when I was deployed with the 28th CSH. I think for any nurse, if you are put into a situation where you didn’t have any backup and it was really your expertise. That is probably what I would be most proud of because you come into your own at that time, and I felt like I did. I was probably at the top of my game from a nursing standpoint, knowing all the clinical stuff there was to know when I first came back. I was very clinically-sound at that point in time. I think that you can’t just teach that and you can’t learn that in a regular hospital. That is something you have to learn when you’re overseas and seeing the wounds that are coming back from the field.

00:31:27
Rigelhaupt:
Previously you’d worked in Walter Reed in the critical care unit. What were some of the things that you learned there that were most directly applied when you were in Baghdad?

00:31:42
McDonough:
I was seeing the end result of what happened in Baghdad to, actually not necessarily Baghdad. I was seeing at Walter Reed the end result of care that had been provided by the 28th CSH. I’d be taking care of what they actually first packaged up, and maybe second or third effect: that patient may have gone to Landstuhl, and then came to Walter Reed stateside. It was neat to be on that end first and to see the care that was provided by this team. Then I joined the team and was at the front end. You know what you do. Some of the nurses on my team, I remember, in the packaging of the patient they knew where they were going end up with. We’d write a note to the other nurses that would say, “Hey, we’re just sending a hello, our nurses to the patient.” Then we’d get notes back from Walter Reed saying, “We’ve got your stuff.” [33:00] It was just a neat connection with your nurses and your fellow soldiers. It’s one of those kind of internal things, I would say, that was probably a very good experience to see and to take over what you see in the end to the beginning.

00:33:20
Rigelhaupt:
How long did you serve overseas?

00:33:22
McDonough:
I served a total of about five months. Every nurse usually is attached to some combat unit. I didn’t go out in the first wave. For whatever reason, I was backfill: when someone had to come home, then I immediately went. I went in August, or beginning September, or end of August of 2003. It’s about five months.

00:34:04
Rigelhaupt:
And then a few months transitioning and starting here after you came back in, around February?

00:34:09
McDonough:
Yes. I came back to stateside February. I was a captain and I was married. My husband is a Marine officer. I decided to go ahead and transition to the civilian workforce.

00:34:40
Rigelhaupt:
So thinking about starting here as a nurse, and as a civilian nurse, overall, and not just in the ED, what did you see as the strengths of the nursing program at Mary Washington Hospital?

00:34:57
McDonough:
I think it was the leadership. I would say, for every nurse staff and the division of nursing in the staff, at that time there was some transitioning going on when I first came aboard to Mary Washington. But it really truly, it’s always—I think if you have good nursing leadership and they want nurses to be involved and are empowering nurses, that is what is going to make great staff. I think that’s the difference with here. At that time, the chief nursing officer was Cheryl Gibson, and then it went to Barbara Kane, and then Marianna. It’s leadership.

00:35:59
Rigelhaupt:
Did you get a sense [36:00] early on, thinking, I don’t have a specific time frame in mind, maybe the first few months, that there was a lot of support for the nursing program from senior administration?

00:36:12
McDonough:
I didn’t know otherwise. I would say yes. I would say that there was always support for nurses. I wouldn’t have known that there wasn’t anything, so I would say yes.

00:36:31
Rigelhaupt:
What were you most excited to work on in the emergency department when you started?

00:36:39
McDonough:
A necessity at the time was ensuring patients were being seen in a timely manner. That work was spearheaded by Jody Crane. It involved learning lean methodology and then going to conferences with a whole team of nurses and physicians learning how to term patients. With Jody we developed how to see patients in a timely manner, to get the care, and why that was important. I didn’t understand that in the beginning: why it wasn’t okay to have patients wait in the waiting room; why it wasn’t okay to have patients boarding in the ED and ensuring that they get to a bed; and why it was important to have a patient in front of a physician within less than thirty minutes. Those things are key. If you put it in perspective, I think now, that’s just common sense. But at the time I was coming new to a place, a new organization, and a new ED. Really understanding the metrics and those things, those were exciting to me because then I ended up learning to love it, and really enjoy that part of the job. That was exciting to me at the time.

00:38:13
Rigelhaupt:
When you left the Army, and I don’t know if it translates similarly, but more nurse management where you maybe did not have as much direct bedside care of patients? Or was this, when you started the emergency department here, with a little less direct patient care, I assume, as a manager?

00:38:35
McDonough:
As an officer in the Army, you do go through pathways of where you want to be in your Army career. At that point, I just gotten on a pathway. I am going to be a critical care nurse and that is where I was landing. [39:00] I was in the supervisory mode for being a captain. I had, as a charge nurse would in a unit here, responsibilities to oversee and delegate down to subordinates. Here was probably the first time that I was really a manager. So yes, I would say this is probably the first time I studied, even though I had responsibility in leading folks. This as a civilian, kind of translated so that I was probably more of a charge nurse, but then took a nurse manager role.

00:39:43
Rigelhaupt:
What were some of the things that were most exciting to work on in management?

00:39:48
McDonough:
One of the items, A, was the operations piece with Dr. Jody Crane. Then moving on, we ended up working on the whole trauma program. As that moved forward it was working on why we were going to be a trauma center and then attracting those patients. That was probably the first real big project. It took a lot of planning, planning teams, and then on top of that was the education needed to ensure the nurses had the ability to take care or the knowledge to take care of trauma patients if they were to come to us.

00:40:35
Rigelhaupt:
Was that something that started relatively quickly after you began, the level of training and expertise of nurses? Was something raised in preparation for the potential for a trauma program?

00:40:50
McDonough:
That was what was in place when I came in board and was what they called the TNCC [Trauma Nursing Core Course] certification. That was already in place with one of the nurses who was teaching the class and then of course ACLS [Advanced Cardiovascular Life Support] and making sure they have that certification along with CPR. What we were doing to up the certification and to get ready in preparation for trauma was to ensure that became a requirement. Now, within a year of hiring you were going to have your TNCC. You were going to be trained by us to have the TNCC certification, Trauma Nurse Core Course, and ACLS was going to be something that you had to have upon hire as well as CPR. Then we added your PAL certification, which is a pediatric ACLS version. Then also that’s what we made sure that we had upon hire to make sure that we were in preparation for those nurses. [42:00] One of the other things that wasn’t until later and after we got trauma was the support for making sure that nurses, with the physicians, would pay for some of the training course to become board certified as an emergency nurse. That was key, too.

00:42:24
Rigelhaupt:
Could you tell me, describe a little bit about the class that you were teaching to get nurses trauma nurse certified?

00:42:31
McDonough:
The course is an ANCC [American Nurses Credentialing Center] certification. It is one that, we would bring in an instructor that was certified to teach that course and with the course content. Our clinical nurse specialist for the ED worked up, made our area, and brought in computers to be a test site. Then our physicians partnered with us to aid in paying for the instructor to come and to teach. They gave us money to do that. What we ended up doing from the organization standpoint is once a nurse is certified she does get an award for that, for being certified. Then the nurse would sign an agreement that they would go take the test after going through this course and they would also get an instructional day for that. It was education that we would and the physicians aided because the importance to them: if nurses are highly qualified then it makes their job easier. Once they get certified and awarded this BCEN [Board of Certification for Emergency Nursing], the hospital would award them a monetary amount in recognition for being board certified.

00:44:14
Rigelhaupt:
I mean there’s probably dozens of important skills that come through the training, both in terms of certification, the board certification, but what were some of the new skills that nurses developed in there that were most important for this hospital’s emergency department that you observed?

00:44:33
McDonough:
I think it’s the recognition of what to do with a trauma patient and those skills. We have a clinical nurse specialist in the ED. She has partnered with the trauma program and ensured that those two individuals have agreed with the trauma physicians and our ED physicians have agreed what the care needs to look like, and even so much as designing the room together. [45:00] Having that core set of skills of knowing what’s entailed in a trauma patient, how to take care of them, you design a room around that, and then that collaboration makes a successful team.

00:45:37
Rigelhaupt:
Were you involved with the process of hiring trauma surgeons and were they part of the trauma program when it was ramping up?

00:45:53
McDonough:
I was part of the interviews and in one of the interview groups as they were coming in. I would be one of like the director scripts that would give feedback. Yes, I was.

00:46:08
Rigelhaupt:
And I think that question actually got ahead. So, what was already in place in terms of building a program like trauma before you got to the stage of interviewing surgeons that might come in to be part of a new trauma program?

00:46:27
McDonough:
I’m trying to remember what was in place before we started to interview trauma surgeons. There were a lot of steps into becoming a trauma center. One of them, I do remember is making sure that we met the standard for a Level II institution and to get the certification of a Level II trauma center. There was a lot of what we had to have available in the EDs: what level of training, what services we could provide, and did we have 24-hour availability of services? Those things were investigated along with a huge project plan. There was initially a trauma program coordinator who was aiding with that and had partnered with me, as the director at that time, to walk through and ask, are the nurses prepared? Do we have a process in place to take care of or to receive trauma patients? What do we do when they go upstairs to the ICU or the OR? They had to be brought in. Those processes were all being worked on to ensure we tidied that up before bringing in trauma surgeons.

00:47:50
Rigelhaupt:
Was there any apprehension from the nursing staff about starting trauma?

00:47:56
McDonough:
No. If you were to walk through, everybody in the ED, from a nurse and physician, felt it was the right thing to do for the community. [48:00] We are either going north or south, and to be able to provide that level of service with specialty physicians like that was the right thing to do in the community. Keep patients here as much as we can. There are only a few things that we go out for. It’s one of those right things for the community.

00:48:31
Rigelhaupt:
Part of what you mentioned about trauma, which is something that I’ve learned through these interviews is how much it’s not just about that initial treatment in the emergency department. The critical care unit, ORs, was there a sense that the ICU and ORs and all the other programs within the hospital that are going to be touched by trauma were also—or did you sense any apprehension from outside the emergency department?

00:49:01
McDonough:
You know, it’s funny that you say that because it’s not that there was not apprehension. There was, “Don’t forget me. Don’t forget me.” One of those is our pastoral care services. They were like, “We need to be part of this.” I remember when we were doing a diagram of who responds to the traumas and how that happens and they weren’t anywhere. We forgot to place pastoral care services on the diagram. I remember it was like, “You can’t forget me. We need to be on that paper and we need to be outside here.” That is such an important role that they do play in helping with families, and helping with that. It’s just we forgot. You’ll find that: we need to be part of it and people saying that. There’s no apprehension. We want to be there.

00:49:52
Rigelhaupt:
You raised pastoral care? What did trauma require in addition to what wasn’t clinical? It requires highly skilled physicians and highly skilled nurses, but it also involves pastoral care. Were there other things that were not as directly clinical that you had to think about and plan for to limit the trauma program?

00:50:25
McDonough:
I think that’s probably the most non-clinical piece. You also have the patient access, which is another one. That’s really key. How do we identify patients? If you can imagine a patient coming through the emergency department, and they had been part of, let’s say, a shooting, or something that was really intense. [51:00] You bring in a victim of any sort of violence or whatever. You have to protect them, no matter if that person is the assailant or not; you have to protect that patient. It involves how our patient access keeps their identity safe. And then security is another piece to making sure that no one comes into the emergency department like family members or other folks that could want to harm the patient. There are all those entities and we always had to think of variable entrances into the ED. Sometimes trauma brings a clientele that you may not want. Trauma means thinking about patient access and security and how they have to be involved in any kind of case that we call over or any kind of trauma comes in that we call overhead and is a certain level. What does that mean? That was thought through.

00:52:09
Rigelhaupt:
By the time trauma starting, you’ve been here a few years. Do you recall any conversations with senior administration about her meetings with them about trauma, and the importance for the community and the hospital?

00:52:30
McDonough:
It’s not something that we do because we’re trying to make the hospital make money because it’s just not. I think it’s one of the valued services. You have highly trained and highly paid individuals to take care of patients with these trauma surgeons. As well as all the resources, if you think of the resources that come into play. Those conversations had come up, but it was more internal. I think what was talked about a lot is the care—how bringing in highly-trained physicians and training the nurses was going to up the bar of care. That would be probably another springboard of for Mary Washington Healthcare and who we were as we were starting to be a health systems and getting to that point.

00:53:45
Rigelhaupt:
Can you look back on it now and point to other programs that benefitted from having higher acuity patients, and more skills necessary because of trauma?

00:54:00
McDonough:
I mean, any service you think of. Ortho. I can think of cardiac. I can think of the ICUs. I can think of all those. There’s every point in touch. I say everyone kind of benefits from having a trauma program because you never know what part of trauma patient is going to be injured, so to speak.

00:54:29
Rigelhaupt:
Could you describe, if you remember, the first trauma call after you officially started as a trauma program that you were working?

00:54:43
McDonough:
I don’t know if it was the first one, but there’s always one that you always remember. I think the one that I particularly remember was it was on I-95. There were probably a couple on I-95 we all remember. One of them was a family. I don’t know if they were jack-knifed—I can’t remember—but it ended up being families split into two locations, mom, dad, and child. I don’t know the age anymore. I just remember one of the parents had been killed in the accident. Having to have those discussions—the physician has to go and have those real crucial conversations when the patients, the other parent and the child, are stabilized. How to do those really delicate conversations of what had happened with the other loved one. Those are things that you remember and that kind of just stick.

00:56:02
Rigelhaupt:
Was there training for the nursing staff, in the sense, that’s not a clinical skill, that with having a trauma program you were more likely to be in a situation like that?

00:56:15
McDonough:
What we try to do with the nursing staff is you always want to debrief those, and you want to do it really close to the vest. Then we do do that. From the hospital system, we do bring in folks who are qualified to help to talk to nurses and ask them how they’re feeling and ensure that they have somewhere to turn, if they need further help, or discussion, or counsel. Then we can do that for them in the moment because you never know what will strike somebody, or touch a raw cord, or if they’ve experienced a loss at home, and then they experience a similar loss. [57:00] Folks go through a kind of a revival of those incidences and we do do that. That’s something, until you’ve gone through it, it’s something that you can’t anticipate, but you can have resources available for those clinicians who go through it.

00:57:22
Rigelhaupt:
And that was something that was part of planning of trauma, the likelihood that nursing staff, physicians, anyone in the emergency department, those kinds of cases in trauma would be more likely to touch people, and you would need those resources available?

00:57:41
McDonough:
I would say we probably had to enhance that. It’s something that the hospital already had, but it was more of an awareness that these tragic incidents. We have to do more if we do have these. This is what you do in the event to call those resources in.

00:58:07
Rigelhaupt:
Who did you work with the most, or who was most involved at planning the trauma program as it was being developed?

00:58:18
McDonough:
It was the trauma project directors, one, myself, the clinical nurse specialist, and we had another team member, an RN who had been involved with the training from a nurse perspective and who did some of the TNCC and making sure the nurses were prepared. Then, of course, Marianna Bedway, the trauma director, and the medical director were involved. That was probably the core team. But you also had to work with the ED physicians because when they were responding to these calls. The trauma physicians are going down into the ED, and they are working next to, or having an impact on the care that the ED physicians are providing in their area of care within the emergency department. That had to be a collaborative effort and to work alongside two physicians: the trauma physician would be working in the ED physician area.

00:59:17
Rigelhaupt:
Did that present any challenges?

00:59:19
McDonough:
How flow would be and who takes over what care. At what point do you call that? The ED physicians are right there. Do they walk in or do they know ahead of time? It took a little finesse on how we would call and understand what was coming in and to call those traumas appropriately. That’s always something that trauma programs put into place to make sure they’re reviewing from the field and that those are getting called working with EMS. They’re describing on our H.E.A.R. radio what’s going on and what they’re seeing in the field to see what’s the criteria. Are we meeting it? [01:00:00] We in ED would call what type of trauma patient it was and that alert system gets called overhead in the hospital. Then that tells you what physician responds. Is it our ED physician that responds first or is it a trauma physician? Sometimes the ED physician will be there and when the trauma surgeon comes in they do kind of a hand-off. Or there’s a place at the bedside for what physician is lead, put it that way, in that room.

01:00:37
Rigelhaupt:
What you described when you started, a very collegial working relationship between nurses and physicians. Did trauma have any effect on that, enhance it, change it?

01:00:50
McDonough:
I would say they enhanced it, the relationships between the ED physicians and the nurses. Then adding trauma to the mix and having to have that same relationship and trust: so when the nurses go in and they’re talking during a trauma resuscitation there is that same collegiality. You have to have it with both physicians—so it is, yes. They have to take feedback when we’re debriefing traumas and when we review cases together. Nurses from different areas are at the table and giving their feedback. Physicians from the ED and the trauma surgeons are at the table and they are all giving their feedback on how care is done and how we could do it better. I would say it enhanced it.

01:01:47
Rigelhaupt:
Were physicians receptive to hearing suggestions for enhancements from nurses?

01:01:56
McDonough:
As long as it is patient-centered. I think that’s what I’ve experienced. When you start doing scope creep, I don’t think that’s that collegiality that you want. I think that you say it in a manner in which you talk about processes. How could the process be done better? I mean, for me to tell a physician, as a nurse, “You needed to do it that way.” I wouldn’t want to be told about my job by someone else or to have someone tell me, “You need to do it that way.” I think we could talk about the process: the patient, how the patient was taken care, and everything else weeds itself out within each scope. If there’s something has to go review, physicians do that on the back end. Same thing with nurses. That keeps that collegiality.

01:02:48
Rigelhaupt:
If I’m not mistaken, trauma has just reaccredited?

01:02:52
McDonough:
Yes.

01:02:54
Rigelhaupt:
Five years, or maybe even longer?

01:03:00
McDonough:
Me too. I should know this. I’d have to go back and see how many years we’ve been, because sometimes, now, like it’s a blur. [laughter] I’d have to go back and double-check. It’s definitely, definitely five. Definitely.

01:03:17
Rigelhaupt:
At least.

01:03:18
McDonough:
At least. However many years. [laughter]

01:03:23
Rigelhaupt:
What are the strengths of the trauma program now that it’s been reaccredited? As you were in that process, did you have to document and write out high points?

01:03:35
McDonough:
Wow. They we have gotten really good at communicating when a code comes in. They’re able to identify from the field and it’s those field relationships I think that have gotten really good, the field relationships with the surrounding counties. Having those relationships in the field and working with those in the field have been really key to the success of this trauma program. They would have to understand from EMS standpoint what we offer with services and understand what’s significant, what’s not significant, and what criteria they’re reporting off. I would say, if anything, those relationships have really gotten really good over the years.

01:04:41
Rigelhaupt:
Did having trauma here require EMS in the area to enhance their skill level?

01:04:49
McDonough:
Yes. We have done a lot of partnering with the REMs. We could partner with training and the more you do that is the more they feel welcome into the departments.

01:05:13
Rigelhaupt:
What were some of the things you’ve trained on, you think have been most successful, or trainings that stand out in your mind in working with EMS?

01:05:29
McDonough:
I can’t think of one item. I would have to say, I think it’s been the communication. I keep going back to that because it’s not just one thing: it’s been the communication of how they come into the department, how they transfer their care over to our nurse and our team, and how they’re just part of it. [01:06:00] It used to be, yes they have always been respected, EMS, but I think you have to be more integrated with the teams to have a good trauma program. I really do.

01:06:25
Rigelhaupt:
I’m not exactly sure how to phrase this question, because this is my curiosity, but part of what you’re describing as important for the success of the trauma program, is the teamwork between physicians and nurses, communication and teamwork with EMS, and those are not necessary clinical skills. This first hour, you’re going to do this; you’re going to get this in, you know. You’re going to do certain things. What are some of the ways that the organization, and nursing, and from other people in the trauma team really try to enhance those non-clinical things that are going to contribute to high-quality clinical care?

01:07:06
McDonough:
They do try to enhance it. I talked a little bit earlier and I didn’t describe it well enough. It’s a topic and it’s a review committee. This review committee is chaired by the trauma medical director. It has the program manager for the trauma program, their clinical lead in there as well. But on that committee, it has physicians that touch the patient in different care, it has the nurses from different areas, and it also has life care and EMS representation. It also has air care. At this table they take care of different points in the community and that’s how we come together. It also has our EMS coordinator. That’s how we come together to say this is the care of patients. How could we have done it better in an overall case review? This is what you’ve brought to us. Here are the cases of this high trauma patient and one that was a lower trauma patient and these are the outcomes. Together we make a great team, but we talk about how to improve it and what needs to happen next. That brings in, if there was something that war had to do, let’s say, a better way. I’m just going to make a better collar or something that we could have put on. Or we could use that at the hospital and then we investigate that together. So they use it in the field and it’s transcended to us here. We have that good handoff of care. Does that make sense?

01:08:47
Rigelhaupt:
Have you seen that kind of emphasis on teamwork and communication that sounds like it’s essential to the trauma program, also translate to other programs and units within the hospital? [01:09:00]

01:09:03
McDonough:
Yes. I think so with anything we do or any project we do is essential. Those other projects we’ve been on take the physicians and the nurses, and different entities that besides the clinical people: it could be supply chain or it could be whoever to ensure that whatever that project, it has everybody. It just can’t always just be the clinical folks. I can’t think of an example right now. [laughter]

01:09:43
Rigelhaupt:
Do you remember anything that stands out about how other units or clinical programs, critical care, radiology, rehab have to implement to contribute to the trauma program?

01:09:57
McDonough:
Radiology has had to make significant contributions, as well as pathology has had to make significant contributions. How they’ve done that is, from a radiology standpoint is ensuring what CT scan is open. They have to clear a whole table when a trauma patient comes in. They know and they think they are going to be needed. They clear the whole table, the whole room, and they have someone on standby. Once they receive the patient there is a whole team that’s looking at it. You have a radiologist on standby to aid in reading those films. From a pathology standpoint, its blood has to be ready. If they think we’re going to need units of blood, then a runner from the pathology takes a cooler—and there had to be a process to that. Pathology takes a cooler of blood and is standing there ready to start and to hand it off and ensure that we have the right blood with the right blood type with the right patient—all those things. They had to make significant process changes.

01:11:22
Rigelhaupt:
I want to talk a little bit about your education. Could you describe your decision to pursue a master’s in nursing?

01:11:26
McDonough:
When I ended up being the director in the emergency department—and I was promoted in 2006 to the director—I knew, with our standing Army or guidance to civilian transition, I was going to pursue it. I just didn’t know at what point, but at that time, it made sense for me to obtain a master’s in nursing leadership and in administration. I did that through Drexel University and that’s kind of why I did that. [01:12:00] It was my own personal professional growth.

01:12:12
Rigelhaupt:
Are there classes or parts of the curriculum that stand out and that were most directly applicable to your job?

01:12:19
McDonough:
Yes, I would say. In my master’s program, it did focus on what you don’t learn in nursing school, which is the budget piece. I would say FTEs, how to manage a budget, how to put one together from a nursing unit, and how to staff it—that was heavy in my master’s program. I think what you’ll find around the country is that is heavy in most master’s leadership and administration standpoint, and how to lead teams. I felt like I learned that from the military, but it just kind of enhanced it. It talked a lot about cadre and talked a lot about change theories. That is what I learned and what probably stood out the most from my master’s.

01:13:11
Rigelhaupt:
Did you have to do any research projects as part of the master’s?

01:13:15
McDonough:
Yes. I did a capstone—they call them capstone projects. Actually one of mine was development and I was going through setting up the freestanding emergency department.

01:13:41
Rigelhaupt:
Was it about staffing?

01:13:44
McDonough:
That’s my doctoral.

01:13:47
Rigelhaupt:
Then I’ll get there in one moment. But you mentioned about FTEs in the emergency department, and you know you mentioned working with Dr. Jody Crane earlier. A lot of his work was about flow in the emergency department. Were there things that you saw connecting between what you worked on and learned, connecting to your curriculum?

01:14:15
McDonough:
The biggest thing that connected with my master’s was the change theory and going through the steps of how you get team buy-in. How you set up earning platform? How do you get them to be engaged? And then as you go along, how do you check that? How do you make sure that they own it when you leave and it stays sustainable? Those are things that I think connected. And more so walking through those steps and working with Jody Crane. Why we were going to do things differently in the ED than we’d always previously done. Why it is do not wait—do not let people languish in the ED and turn those rooms over. [01:15:00] There are how many hours there are? How many patients can occupy a room in an hour or less or two, three hours or whatever? How many times can you turn it over in a shift? Those are things that I learned.

01:15:24
Rigelhaupt:
And just a few years later, you made a decision to pursue a doctorate in nursing practice.

01:15:32
McDonough:
I did. When I was researching what I want to do, I decided I was going to go on to do my doctorate in nursing. I got a doctorate in nursing practice at George Mason University. A lot of that conversation happened when I was first starting to go through that practice. I had already approached Dr. Crane about being a mentor—he’s always that “forever learner,” I always think, that “forever instructor.” When I was going through it, he became my mentor through the process. We looked at how it led up to that through the end of my dissertation. We talked a lot about not just what happens in the ED, but what happens on the floor if you have floor nursing. How do you staff a floor with productivity? Can you set up a staffing methodology that is similar what we did in the ED based on volume? It’s based on tasks that a nurse has to do and how does that relate to their time with the patients. That is what I ended up doing with Jody, and he ended being one of my chairs on my dissertation.

01:17:05
Rigelhaupt:
If you could a little bit more about the specifics of your dissertation, and some of your key findings?

01:17:14
McDonough:
Some of the specifics of my dissertation were that it was a staffing methodology. We called it the “McDonough Optimal Staffing Method for Nurses.” The key findings were—what I ended up doing is researching what nurses’ daily tasks were and what was involved in their day to take care of a patient. From the time that they admitted a patient to the time discharge happened, how long did those tasks take? Then understanding how much and what type of floor it was. [01:18:00] If it was a progressive cardiac care unit, what the ratio was, understanding that ratio and the acuity of the patient, and what tasks were being done. I was able to find that nurses are overwhelmed. The input of tasks—the time that’s spent inputting data and finding equipment is more than what they do in taking care of a patient or the actual assessment and everything else, if you don’t have the right resources. How we do productivity actually is not necessarily correct. Those are kind of some of the things that I learned.

01:18:49
Rigelhaupt:
Were there changes that you tried to implement, either in the emergency department, or on floors based on your research?

01:19:12
McDonough:
I think the biggest one with my dissertation is I ended up writing it up. It was published in the Virginia Nurses Today and then it was republished again in North Dakota, I want to say. It got picked up again in another state by a nurses’ journal. It was circulated to our senior executive team. One of the things that we’ve been tackling from some of my research is the productivity. Productivity is based on a midnight census and what that means is how many patients are in a bed at midnight. That’s not an accurate picture. When you have patients that are coming throughout the day to a unit and being discharged, a lot of work effort goes into those patients. To discharge and to admit somebody is very time-intensive and so it takes away the patient care. It’s not an accurate reflection of the work that’s being done from one snapshot at midnight, when everyone is resting or sleeping. You have a lot of activity going on and taking a lot of resources. That’s well known in the organization now and can be talked about, and I’d like to think that’s from some of the work that I had done with my productivity.

01:20:48
Rigelhaupt:
If I’m not mistaken as well, you were the first person in the organization to have a doctorate in nursing practice?

01:20:54
McDonough:
Yes.

01:20:55
Rigelhaupt:
I was going to ask, what does that represent?

01:20:59
McDonough:
I think that represents the support in this organization to further your career, to gain more education, and empowers folks. [01:21:00] It empowers folks to go along in their career in nursing and I don’t think it was that way years ago from a civilian sector—let’s put it that way. I think now there’s a lot more evidence out there that supports nurses going back to school and having that bachelor’s of science. Then we do support the master’s and going on to get your doctorate is just icing on the cake. I think that says a lot. After me, there have been a few more that have gotten their doctorate or are starting the doctoral programs. It just becomes that competitive edge.

01:21:56
Rigelhaupt:
I want to switch topics just a little bit to Stafford Hospital. What do you remember about first hearing that the organization might be building a new hospital? I assume that as a manager, you heard about before the newspaper.

01:22:11
McDonough:
It was exciting. I think it was like, “Wow!” I remember some of the conversations too about some of it was to gain more volume to the health system and also offer services that Mary Washington Healthcare can offer, but up north. I remember the time that they were talking about, was it going to be Spotsylvania or Stafford? It ended up being Stafford. I know it was exciting to become no longer a single hospital. We actually are big enough that we’re expanding now and becoming a health system. That was exciting to folks. Having an opportunity to really start fresh and really start a hospital with the right ideals and get the people started off the right foot for who is going to work there. That was exciting.

01:23:04
Rigelhaupt:
Was there discussion about Stafford being a kind of, return to roots, in the sense that it’s a smaller community hospital, that does not offer trauma programs? At the same time, the organization is ramping up its clinical programs, particularly through the emergency department. It’s also building a smaller community hospital with an emergency department that won’t handle the same kind of cases that this emergency department does. Was it difficult to plan for both, and to talk about both simultaneously?

01:23:40
McDonough:
I don’t know. I think, this organization is pretty good at putting together teams to start on projects, and that was one of them. What the teams and the senior executive team would do is pull in subject matter experts that had that expertise. [01:24:00] They would help build pieces of it and then hand it off to whoever is going to end up being there. I think that’s how they dealt with trying to leverage their best talent and to aid in helping build Stafford.

01:24:24
Rigelhaupt:
Do you remember being part of any meetings, or being on committees where you said, based on our experiences building up the emergency department here, implementing some of the lean principles you talked about, where you said, this is how we want to see it go in Stafford, or these are some of the best practices that we think you should start with?

01:24:47
McDonough:
What I had feedback into are the best practices of how to set up an emergency department, the design and things that I would do differently. From how we look at the ED here and how the ED is set up there so you don’t have carts everywhere: you have high countertops, carts fit underneath, and you don’t have them out in the way of patient traffic. One of the big things at Stafford is when you walk through their front doors to their waiting area you can go into the triage room, walk into the waiting room, another internal waiting room, and walk right into their emergency department. It’s kind of like you don’t have to do these roundabouts. You walk through rooms. It was like a double doors and you didn’t have to do these in-and-out things. That was one thing that we really did that made the transition very smooth. That’s something that we don’t have at Mary Washington. You kind of have to walk around.

01:25:46
Rigelhaupt:
Do you know if there were discussions, because it was just a few years before you started that they had doubled in size, in the emergency department?

01:25:54
McDonough:
We had hit over 100,000 before opening the free-standing emergency department and Stafford. We had hit over 100,000—I can’t remember exactly. It was definitely over 100,000 and we were seeing 300-plus patients a day. We were doing it well. We were turning patients over and having a low walkout rate. Our processes were pretty sound and then we expanded. When you’re really operating at that high volume and then you open up sites that take off volume, it’s really easy to go up and to expand to get staff. But to trickle down to a volume that’s less than what you’re used to, that takes finesse. It takes a lot of redoing some processes that you didn’t have in place. As we grew things we also had to figure out how we were going to operate smaller and with less volume. [01:27:00] You know, we have seventy-plus volume a day here, or close to eighty of volume a day at Mary Washington now. It’s learning how to do those things compared to where we were and being the sole provider.

01:27:28
Rigelhaupt:
What do you think some of the best things about Stafford’s emergency department, now having looked at it, a little over five years later?

01:27:41
McDonough:
It has the same physicians and that is a very good thing. Our physician practice goes to all the different locations. That’s a very good plus: we keep consistent practices and our nurses go between the sites, and that’s a good thing. They do have a home base at Stafford. It has that home feel and freshness there at Stafford even though it opened up in 2010. You know, it has that freshness and that newer feel to it.

01:28:29
Rigelhaupt:
One of the things in researching this project that I became aware of particularly about emergency departments is that many of the cases that end up in the emergency department that are not as emergent, that are not trauma-based, but that involve issues of chronic care, access to health care. Are there things that in planning the emergency department, that your organization has tried to do to address those things at the point of the emergency department? Say trauma, dealing with a very sick patient that comes in under a trauma call, but some of other cases will end up in an emergency department?

01:29:20
McDonough:
Stroke. Our stroke care program, I think that’s another—if that’s the question. Our stroke program and how to take in someone who is having a TIA—that’s one. That’s probably the big one. I’m sorry, I just want to make sure—we’re at 4:06. I have to be up in northern Virginia at 5:30.

01:30:00
Rigelhaupt:
Let’s go to the last questions. What’s the best day in nursing?

01:30:10
McDonough:
A best day in nursing? What’s a good day in nursing?

01:30:14
Rigelhaupt:
Yes.

01:30:18
McDonough:
I think a good day in nursing, from my perspective, being the senior director of nursing right now, is when I see nurses that are walking through the front door smiling. As I’m rounding they are telling me in their day that they’ve made a significant difference with their patient or they felt that they had an impact in that day. When they’ve said that, it’s rewarding to me because then I know I’ve done my job as a leader in nursing in this organization. I have provided or ensured that there was enough staff and that they have enough education to provide care. It’s supporting nurses and if I can say that it is provided, then I feel like I’ve done my job.

01:31:12
Rigelhaupt:
What would you most want the public to know about being a nurse leader that might not be common knowledge?

01:31:24
McDonough:
I don’t know. Being a nurse leader to me is, I look at it as it is rewarding in the sense that it is a twenty-four-hour job. At least how I view it, it’s not something you say, “I’m going to go home today. Forget it.” [laughter] I think nurse leaders have the opportunity to mentor other nurses. Let me think about that real quick. It’s a twenty-four-hour job. However, it’s one that your nurse leaders may not be just the ones and they’re not always ones that are leading the unit. Sometimes your leaders emerge and are the ones providing the care at the bedside. To me, the official leaders may not be the leaders that you expect. I rely on those leaders at the bedside, providing the care, talking to the physicians, talking to the patients and the families, and to bubble that stuff up to me and say, “These are the things that are going on in my practice and how I’m interacting. This is my barrier.” [01:33:00] Those are the true leaders. I would say maybe the public sometimes doesn’t recognize that on a day-to-day basis. It’s not always just people like me. That’s probably what I’d want them to know. Those nurses are the ones that advocate for them.

01:33:24
Rigelhaupt:
What are some of the things about Mary Washington Healthcare that you would most want the public to know that might not be common knowledge?

01:33:32
McDonough:
Nurses in this building, and actually I would say at all sites, have an undying compassion for the patients that come in our door. They talk about it. They talk about the care that they provide. They’re very proud of the care they provide to the patients and with their peers. There is collaboration here that, I think, would be hard to find somewhere else. That’s a good thing.

01:34:06
Rigelhaupt:
My last question is actually two questions.

01:34:09
McDonough:
Okay. Then you got two questions. [laughter]

01:34:12
Rigelhaupt:
Is there anything that I should have asked, and I didn’t? And is there anything you’d like to add?

01:34:23
McDonough:
I think you were pretty thorough in your questions. I’m trying to think of one question that you should have asked. I can’t think of one right now. Maybe, what is Mary Washington doing right now for nursing? I think that’s maybe one. I think Mary Washington has an investment in nurses. From the leadership team here and not just nursing leadership, but all the way up to our CEO believes in the education of nurses. That has allowed us to forge relationships with the University of Mary Washington and Germanna to have a BSN program now. We’re partnering to have our nurses become bachelor prepared nurses to work at the bedside. I think that’s one thing that’s enriching about this and about the nurses that are here at Mary Washington. The leadership is probably one thing that could be out there.

01:35:36
Rigelhaupt:
I think that’s a nice place to stop. Thank you.

01:35:39
McDonough:
You’re very welcome.
[End of interview]

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