Louise Fletcher

Louise Fletcher is a registered nurse (RN) and began working in the emergency department at Mary Washington Hospital in 1990. She is currently an education coordinator. Fletcher has worked in numerous roles as a nurse in the emergency department and helped to develop the trauma program at Mary Washington Hospital. She received a Master’s of Science in Nursing (MSN) in 2014.

Louise Fletcher was interviewed by Jess Rigelhaupt and Ellen Peiser on November 5, 2014.

Discursive Table of Contents

00:00:00-00:15:00
Began as a nurse at Mary Washington Hospital in 1990—Experience as a nurse in New York City—New technology—Learning on the job—Physician-nurse dynamics—Earning a MSN—Duties as Education Coordinator for Mary Washington Healthcare

00:15:00-00:30:00
Communicating information to nurses and staff—Growth of Mary Washington Hospital—First shift in 1990—Core values and mission of Mary Washington Healthcare—Transition from oncology back to the emergency department—Trauma team

00:30:00-00:45:00
Design of the emergency department in the new hospital—First day in the new hospital—New clinical programs—Public health

00:45:00-01:00:00
Business of health care—Development of the trauma program—Emergency department doubles in size in 2000—Strengths of the emergency department—Use of evidence-based medicine

01:00:00-01:15:00
Use of computers and new technology—Importance of bedside manner for patient care—First impressions of Mary Washington Hospital’s emergency department and comparisons to experiences in New York City—Hospitalists—Patient care in the emergency department—Lee’s Hill Freestanding Emergency Department

01:15:00-01:27:50
Strengths of the trauma program—Trauma program’s work with EMS in the region—People influential in advocating for the trauma program—Working as a nurse in the emergency department—Interview concludes

Transcript

00:00:05
Rigelhaupt:
It is November 5, 2014. We are in Fredericksburg, Virginia doing an oral history interview with Louise Fletcher. The first voice that you will hear asking questions is Ellen Peiser and the second voice which you are hearing right now is Jess Rigelhaupt. We will be doing the interview. So, Ellen, I will turn things over to you.

00:30
Peiser:
Okay, could you please describe your first day at Mary Washington Hospital?

00:00:35
Fletcher:
My first day at Mary Washington Hospital was in 1990 and I was extremely nervous being a city girl—New York City, born, raised, bred, and worked there. I was coming into a more Southern area and a different type of setting in a community hospital. It was a little nerve racking for me.

00:01:10
Peiser:
How did you get into nursing?

00:01:11
Fletcher:
At a very early age I had asthma. In fact, I still do and that’s why they call me Wheezy. I always felt that the nurses were so good to me and that’s what I wanted to do, to emulate them.

00:01:30
Peiser:
What was your work history before you came to Mary Washington Hospital?

00:01:35
Fletcher:
I graduated in 1978 from an LPN program. I then went to a community college to get a two-year degree. While I was going through school I worked med-surg and the float pool. I was always drawn to the emergency department. I worked in the city hospital.

00:02:08
Peiser:
What is a float pool?

00:02:08
Fletcher:
A float pool would be when you would come in the day you were assigned and you could work anywhere in the hospital. It seemed that they were either always putting me in pediatrics or the ER. Pediatrics was not my forte, but the ER was. So I stayed there. That was my calling and was my good fit.

00:02:35
Peiser:
How was nursing different in Fredericksburg than it was in New York?

00:02:41
Fletcher:
That’s a good question. You are comparing, I guess, apples and oranges. This is more of a community type setting—more warm and fuzzy. Whereas in New York City, its very busy, rushed, and it’s a different type of clientele and definitely a different type of nursing there. [03:00] There is no room for fluff and puff.

00:03:13
Peiser:
How did you avoid burnout when you were working in high stress environments like the ER in New York and in Fredericksburg?

00:03:20
Fletcher:
You have to have an outlet and at different stages of my life I had different outlets. When I was younger you would be going out with your friends after work and you would have that companionship. You can chat about things. Then as you grow personally, your life changes personally. Then you get married, you have a spouse, and then you are involved with your children. You just have to learn: when walk out of that door of work, you are done. There is no mixing. The door is shut and you just have to say, “Work is work. It’s done. Here’s my family, that’s who I’m going to focus on right now.”

00:04:08
Peiser:
Do you see other nurses have a more difficult time with that? Especially younger nurses today?

00:04:13
Fletcher:
They do. They do. I don’t know if it’s the sign of the times, the pressure of society, the instant gratification of society, or the shortening of nursing programs from hands-on to online. There are so many different factors. A lot of times I hear that they are in nursing just for the paycheck and not for the patient. That is to me, after thirty-six years, very disheartening.

00:04:54
Peiser:
I’m going to ask you some questions about the trauma unit here at Mary Washington Hospital. I was wondering what do think was the most important aspect that prompted the necessity of a trauma unit here at Mary Washington Hospital?

00:05:09
Fletcher:
I think that location had a lot to do with it. We are in the I-95 corridor. We are kind of triangled in between Richmond and Washington. I think as the cities on both ends, north of us and south of us, encroach and people travel more there was a definitely a need for a trauma center in this area.

00:05:40
Peiser:
Today technology seems to affect every aspect of our life. I was wondering how technology is or was used by nurses in the trauma unit?

00:05:52
Fletcher:
The specialty equipment that we use—charting, computers—those were a big learning curve for myself and a couple of other nurses that are in the same type of generation. [06:00] Whereas younger nurses could adapt quickly. For us it took a little bit longer. Then again technology is great, but it does have its pros and cons. I feel that some of the younger nurses rely too heavily on the technology aspect and not on their good clinical judgment or, for lack of a better term, that gut feeling. They’re treating the machines and not the patients. It’s a skill. You have look at patients.

00:06:53
Peiser:
How do rapid advancements or changes in technology affect nursing and nursing practice?

00:07:02
Fletcher:
There are pros and cons and it’s just the technology is available. With the proper education and the proper rollout, people have the buy in and the understanding what it’s for and how it’s going to work hopefully for the better. I think those are the key points. People have to be accepting and willing to also change.

00:07:39
Peiser:
What was one of the first things that you learned on the job that you weren’t taught in your education?

00:07:48
Fletcher:
This may sound terrible, but you can’t always believe what the patient tells you. If I go in the room and I asked them a question or a set of questions, somebody else will go in there and ask them the same set, and then the physician will go in. It’s kind of sifting through that information—it’s like looking at a data sheet and nurses have to pick out really what the patient is telling you. I don’t think that even as nurses we are being prepared for a lot of the interpersonal dynamics between family and colleagues. That’s a learning curve. How to handle yourself how to react with the family and how to react with the patient? Don’t take it so personally when the physician screams, yells, rants, and raves. At the end of the day, it really doesn’t mean anything. You’re there for the patient. It’s just the personal skills that needed tweaking. [09:00]

00:09:04
Peiser:
During our research we have noticed that doctors and nurses, especially in the last twenty years have had some friction in the workplace. What kind of interpersonal relationships existed between doctors and nurses when you first started at Mary Washington Hospital?

00:09:23
Fletcher:
I going to even take it back a notch to the late ‘70s, if you don’t mind. In the hospital that I was working in, if a doctor came into the nurse’s station you were expected one, to give him your chair, and, two, to make him a cup of coffee. Since then, the practice has changed. I have got to say and to be honest, and maybe my view is very one-sided, but since being at Mary Washington and being with the group of ER physicians that I have worked with for the past twenty-five years I honestly have nothing but good things to say. They were always very interactive with the staff. It was more of the same level: we are here as a team. You know, we played hard at work. Socially, people became friends. It wasn’t uncommon. I can’t speak for the rest of the hospital, but you work so closely in life and death situations that you really have to function well together. There can’t be any line to separate us.

00:10:45
Peiser:
Do you think that that evolution was a product of place or a product of changing aspects of nursing?

00:10:55
Fletcher:
I think it was a product based on the environment. You have to be able to react quickly. You have to be able to depend on each other. Your communication with the physician, back and forth, has to be precise. You have to really trust each other and that’s what we do. You know, there are bumps in the road, with very critical patients or trauma that we look at. But we debrief at the end: “What did we really do well? What could we have done better?” Communication and trust are key. You just have to be on point, you have to be on your game, and you have to rely on that person.

00:11:54
Peiser:
What prompted you to pursue your MS degree?

00:12:00
Fletcher:
Well, to be honest with you, my Dad wanted me to at least get my bachelors. He wanted to see that and before he passed away he did. He did get to see that. For my MSN, that was me. That was the icing on the cake.

00:12:31
Peiser:
Congratulations.

00:12:32
Fletcher:
Thank you.

00:12:34
Peiser:
What did earning you MSN degree in 2014 change your view on education in nursing?

00:12:41
Fletcher:
I think my education in nursing was always ranking as number one. You can’t go through life kind of buried or stalled. You have to grow professionally and personally. Through education I found things out about myself. Things I had done five or six or eight years ago in a different role and if I look back and do some self-reflection I can say, “Wow, what was I thinking?” But, you know, I didn’t have the education to back it up. The experience and education kind of puts all of the pieces together with that.

00:13:30
Peiser:
What are your duties as an education coordinator at Mary Washington Hospital?

00:13:37
Fletcher:
Well, I’m in my fifth week. It’s been kind of, as my director told me the other day, “You kind of hit the ground running.” It was a lot of education the last couple weeks with all of the things that are going on with the CDC and different things. Its hands-on, taking that knowledge, being able to apply it, and show people the correct way to do something, like a task. Always reinforcing them. If someone is having a problem, then going back and trying to approach it another way. It’s getting the education out there to the nurses. What they need to be successful, but also what they need to practice safely.

00:14:38
Peiser:
This education that you are giving out to the nurses, are you working directly with the nurses or through larger staff meetings? How are you disseminating this information?

00:14:50
Fletcher:
Currently, it’s been one-to-one. [15:00] Just for example, our recent completion of the garb [for Ebola] that the CDC recommends was over one hundred nurses that I either had as a group, four or five in a group, or sometimes just one depending on when the training session was and how they flowed in and out. I was actually hands-on with all those nurses. Personally, I think that’s a good way to do it. You got to practice it, you got to feel it, you got to touch it, and you got to do it to totally understand it. Because I could sit up there and “blah-blah-blah” like that teacher on Snoopy or Peanuts and all you hear is “blah-blah-blah.” You know? I wouldn’t want to listen to me after a while either.

00:15:44
Peiser:
What nurses do you work with? Do you work with all of the nurses at Mary Washington Hospital or specific groups?

00:15:52
Fletcher:
I am currently assigned to the emergency department here at Mary Washington Hospital and Lee’s Hill. I have both facilities that I take care of.

00:16:06
Peiser:
So far, what has been the most fulfilling part of your job as an education coordinator?

00:16:14
Fletcher:
Honestly, whether you are at the bedside or the education coordinator, it’s the people. That you have fulfilled their expectation of you and just that warm fuzzy hands-on. We’re working this as team, not me here is the educator siloed and she’s handing out papers. We’re working together. Whether it’s downstairs in the conference room or it’s upstairs, it’s that hands on with people—it’s that closeness and it’s that contact.

00:17:02
Peiser:
Mary Washington Hospital grew in size in the 2000s, what was the most challenging thing about the hospital’s growth?

00:17: 12
Fletcher:
I think the most challenging thing was that we came from Fall Hill—it was so funny but it was stressful. We had to move all those people from Fall Hill over to here. That was kind of once in a lifetime experience: where you got to move a hospital to a hospital. I think it was getting the buy in that your little tiny community hospital is growing and will eventually offer all there services like trauma and many different things. It was getting the people here to realize that growth is coming and you have to move forward with it. [18:00] You don’t want to stay back on the bench and miss it.

00:18:08
Peiser:
There have been some health care changes in coverage in both in the Clinton Administration in the ‘90s and today the Obama Administration. How did you see or how do you see these changes in health care effect nursing or Mary Washington Hospital?

00:18:27
Fletcher:
Let me choose my words here. I think as a bedside nurse we are still going to deliver the expectation of the best care that we can give and that we are able to give within our practice. As the organization, there are going to be some financial challenges. But I truly believe that they will work those challenges out and not at the cost of the patient care that is being delivered.

00:19:14
Peiser:
All right. The last I have for you is, what kind of advice would you give to somebody that is considering nursing as a profession?

00:19:24
Fletcher:
Go into nursing with your heart and because you actually want to make a difference and help people. But don’t go into nursing if you see it as a paycheck because the satisfaction is not going to be there. Those other folks, they gave nurses a bad name because there is no warm and fuzzy there. Nursing is caring. That’s what it’s all about. You are there for the people. So if you want to be there, then jump in. My daughter is a nurse. My bonus daughter is a nurse. They’ve done it because they want to, they have good hearts, and they want to take care of people. That’s why you go into nursing.

00:20:12
Peiser:
Thank you.

00:20:13
Fletcher:
You’re welcome.

00:20:15
Rigelhaupt:
So, I wanted to start off by jumping backward in time a little bit.

00:20:19
Fletcher:
Okay.

00:20:20
Rigelhaupt:
Your first shift in 1990, if my notes are correct you said you started in oncology.

00:20:26
Fletcher:
I did. I did.

00:20:29
Rigelhaupt:
Describe walking into the hospital for the first shift. Where you went, what the oncology unit looked like. I don’t know if it was an eight-hour shift or a twelve-hour shift at that time, but what that first shift was like.

00:20:42
Fletcher:
That first shift I can remember the manager, Janet, met me and she was always so bubbly. I think she just retired after all these years. I walked into there and I said, “Oh my God. What have I done?” [21:00] I felt that this was this old little hospital. I felt like I was in a little apartment in the city. I had no idea what oncology was really about. I was an ER nurse. I didn’t do long term care. It was like, “I’ll take care of you. I’ll do whatever I can while you’re here, but you’re going to be leaving.” This was scary. It was scary. I had what, ten or twelve years under my belt as a nurse and it was scary. I’m sorry. I have no other way to describe it.

00:21:45
Rigelhaupt:
So what were some of the things you learned over those first few months that you were working that made it less scary and a part of your nursing practice?

00:21:54
Fletcher:
I guess the people I worked with made the transition easier. The manager at the time made it very easy. She used to be an ER nurse a long time ago. The people that were on the unit appreciated the care as a patient and their families. You kind of grew together. It was at times very heartwarming and at times extremely sad. I think that’s why my stint up on the floor was not as long as it could have been. God bless those oncology nurses. It takes really a special type of person to do that because you really have to wear your heart on your sleeve. It was very hard, very hard.

00:23:06
Rigelhaupt:
In this interview project, I’ve heard a lot of people talk about the core values and the mission of the organization. When you first began was that something that was talked about? How did you learn about the mission of the organization and the values?

00:23:27
Fletcher:
As the organization grew things like that—the mission, the values—were covered in your HR orientation. You know, “This is it. Blah.” But then as the hospital grew and the organization grew, these things were more verbally expressed in many types of forms of communication. What was expressed, you also saw it happening. [24:00] When we’re here to serve the community, they truly are. They are here to serve the community. I think that’s why we grew so well together.

00:24:15
Rigelhaupt:
Could you talk about your transition from oncology back to the ER?

00:24:21
Fletcher:
I felt like it was the biggest weight off my shoulders. I came running down full speed. Not that I wasn’t grateful for the people that were up there. They were so nice, but I needed to be in my comfort zone. I needed to be where I knew how to be the best nurse I could be. I think everybody has their little niche and it’s just finding that niche and listening to yourself about it. There was no just jump right back in with two feet and went on my merry way.

00:25:07
Rigelhaupt:
But as you described this emergency room and the hospital was smaller or different—

00:25:14
Fletcher:
It was.

00:25:15
—than what you worked with in New York. So what were some of the things that you learned about the practice of emergency medicine in the community and this hospital in the first few months you were back in the ER?

00:25:27
Fletcher:
Very, very varied. I could not believe—and this is terrible to say—but I could not believe that people would come to the emergency department for an earache or a stubbed toe or to get a prescription refilled. In New York that is unheard of. I mean, you have to have an appendage off before you would get even to triage. You know what I mean? It was just very, very different, the way they were thinking. It was just very low key, very relaxed. Triage was a little school desk, a chair, and a manual blood pressure cuff. I was like, “Wow.” But this is still okay because I was still in an emergency room. It really was an eye opener for me, but I also found that the people in the community were a lot more receptive and nicer than in the city type of setting.

00:26:42
Rigelhaupt:
So thinking about this, I’m guessing this was around 1991, that first year you’re back, there are still car accidents in this area. There are still traumas. I know a lot of things were flown out at the time, potentially—

00:26:57
Fletcher:
They were.

00:27:00
Rigelhaupt:
But, things probably still came by ambulance to your emergency department. What was it like to ramp up? For the emergency room physicians and nurses to go to those types of patients from the ones also getting their prescription refilled?

00:27:22
Fletcher:
It’s like turning a light switch on and off. You just have to gear up and then you have to gear down. I was like, “Why aren’t we keeping these patients? We can do so much more.” There was this whole procedure of landing the helicopter over at the high school, on the field and getting the fire department. I was like, “We really should be keeping these patients. You can do this.” I guess it was gradual. I don’t think at the time they were ready to take that leap. A lot of physicians and a lot of nurses who had been there for years were not ready to take that trauma leap yet and grow. It’s really not difficult ramping up or down even today. You have a trauma alert, you get ready, you do your thing, you get done, and you go see another patient. You are doing your best job and you know what to do. Trauma is a very recipe kind of thing. You do what you need to do, you get it done, and you get the patient to where they need to be, and then you go on to your next patient.

00:28:37
Rigelhaupt:
Thinking about trauma practices in the early ‘90s, and the skills involved for the nurses, what were some of things that you were the most proud of that you experienced in New York and brought to the team, or that the nurses did that was about being skilled medical practitioners? Try to think about that tension between skilled medical practitioners and nursing with your heart. The bedside manner and caring is really important, but you are highly skilled.

00:29:23
Fletcher:
We are. It’s that autonomy that during those stressful times where you can do and you can practice what you know how to do, no questions asked. The more experience you have the more it’s just doing it. You don’t have to sit back and you don’t have to think about it. You do it. You do it. It’s great. You don’t have to be that nurse that the doctor has to tell you, “You have to do this. You have to do this and you have to do that.” [30:00] You can do it because you have been trained to do it and you know what to do. You run as this efficient kind of team: the doctor has his role, the nurses have their role, and you do it. You do it together and it’s done. It just works really, really nice. It’s like having that dance partner that doesn’t step on your toes. You know what I mean? You can just waltz together so nicely and that’s what it’s about. It’s that team.

00:30:34
Rigelhaupt:
Were you involved in thinking about the new emergency hospital department would look like in the new hospital? It’s now 20 years old, but it’s still the new hospital.

00:30:43
Fletcher:
[laughter] It’s still the new hospital. Yes. At the time they asked a lot of the staff their input about the rooms, the equipment, and the layout, which was really nice because it made it a user-friendly department. I remember going to lots of invites about the rooms and how they would be setup and about the doors and about the flow. Even the physicians were involved. They went right down to where the soap dispenser was. It just made it easy and made it workable for us. It wasn’t somebody that was over here designing what they do—an engineer—and then having us try to conform to his design to make things work. It was more of a joint effort.

00:31:44
Rigelhaupt:
What were some of the things that you really wanted to see in terms of flow or layout that you remember talking about and making recommendations for?

00:31:53
Fletcher:
Definitely those trauma rooms and the size. Whether they are trauma or critical care patients, you need the room, you needed the equipment, and you needed easy access to things. The nurse’s station needed to be centrally located, as it was at the time. It still is, with a little bit of a different design, but we outgrew that too with all the people.

00:32:29
Rigelhaupt:
Could you describe the day, if you were working, that the patients moved across the street?

00:32:37
Fletcher:
I did work that day! I started my shift at Fall Hill. Four hours there and then I came over here for four hours. It was just exciting, a lot of hustle and bustle. You worked with the EMS and the fire department. Everything was well coordinated and orchestrated. [33:00] It was just the excitement in the air. People were very proud of the new department and they wanted to show it off. Even the patients were involved. They asked, “What number am I? Am I you’re first patient? Am I you tenth patient?” I don’t know. It just kind of a nice community thing.

00:33:25
Rigelhaupt:
And that’s what I was going to follow up on, because I imagine that accidents don’t happen on a schedule.

00:33:33
Fletcher:
No, they don’t! [laughter]

00:33:35
Rigelhaupt:
That even on that first four hours, in the emergency department in the new hospital, I imagine that ambulances pulled up. What do you remember about treating your first patients in the new emergency department?

00:33:48
Fletcher:
You know, there’s always that moment of, “Oh, hey. Here’s my patient. Now where’s the med room? Where are the supplies?” [laughter] You’re trying to go through this checklist that’s in your head because at Fall Hill you knew where everything was. You could find it in your sleep if you had to. Then it was giving people directions to the lab or x-ray or something like that. But everybody was very good natured and easy about it. It was fun. I’m sorry. It was fun! [laughter]

00:34:21
Rigelhaupt:
Part of what happened after 1993 was that it seems like the medical and clinical practices began to expand within the organization. What do you remember about the first new clinical practices that were memorable or struck you as important that the organization had begun?

00:35:00
Fletcher:
I need to think about that for a minute. Clinical practices. They really wanted the nurses to be in the forefront to make these important changes to have the clinical evidence base support to make these changes and put them into practice and to see that they were successful. I feel like I should have studied. [laughter]

00:35:46
Rigelhaupt:
Oh, no! Certainly one of the things that have been talked about within the organization and yesterday there was a small celebration for it, was the twentieth anniversary of the cardiac surgery program. [36:00] As one of the things that changes the direction of the organization.

00:36:04
Fletcher:
Yes. Whatever that did, trauma did. They had neurosurgeons here that did. It was like the organization was a bud when I first got here, like a rose bud. And as time grew, it grew, and it kind of just expanded and opened up. You had all these little petals, but all these petals were successful to make it what it is today. That’s the way I can describe it.

00:36:55
Rigelhaupt:
So, you mentioned keeping patients in the emergency department rather than flying them out. What do you remember about that transition where the emergency department was keeping patients that were more critical, had a higher acuity and what that meant for the organization?

00:37:21
Fletcher:
It was not siloed into the emergency department. It was hospital wide, from the ICUs to the surgeons. There had to be that big buy in: that we had to take care of these patients. We are a community hospital, but we have to broaden our way of thinking. We need to supply our community with greater resources. Why should the community leave to go north or south when we are right in their backyard? It was a system wide buy-in: keeping that trauma patient, keeping that neuro patient, and even the STEMIs. But you have to have the people on the forefront willing to take those steps and make that change. It’s a drive. It’s a drive for that patient and you want to give them the best care that is available.

00:38:30
Rigelhaupt:
Change isn’t always easy.

00:38:32
Fletcher:
No. [laughter]

00:38:33
Rigelhaupt:
Were there any concerns from either physicians or nurses as the organization began treating sicker and sicker patients and keeping them in the ICU with long term care?

00:38:48
Rigelhaupt:
Right. There is always a group of people, no matter young or old, that change bothers them. But I think that realistically if the change is happening and you can see the results then that is part of the buy-in. [39:00] Those people will eventually come on board. If not, I’m sure there were other options available to them. But you can’t stay siloed and you can’t stay stagnant. The world grows, the community grows, and people grow. Change is good. Change is a good thing. You got to keep moving and keep moving forward.

00:39:53
Rigelhaupt:
Even during this era of change, as you described earlier in terms of the core values, they became talked about more—

00:40:03
Fletcher:
Yes.

00:40:04
Rigelhaupt:
Did that go hand in hand? If you could describe the way that the mission was talked about or the core values were talked about during this era of expansion?

00:40:16
Fletcher:
Do you mean when we grew a freestanding emergency department or when we grew another hospital? I’m not following you.

00:40:25
Rigelhaupt:
I was thinking about the first few years after moving to the new hospital, the first few years after 1993 and cardiac surgery. The organization is growing along with size and clinical practices. Did that shape how the mission was talked about, how the core values were talked about, and how front line nurses heard about it and remember it?

00:40:57
Fletcher:
That communication grew as the organization did because you had to have A to complete B and to go on to C. Everything was kind of interchangeable. If this is what we are doing for the community and this is our goal and this is where we need to be, then it is a hand-in-hand process. It is not single by themselves. This is really what our mission is and out goal, but we are doing something over here. That doesn’t really work because they don’t tie in. The community, as well as the associates, has to see the full circle.

00:41:48
Rigelhaupt:
So one of the things I’ve learned in researching, hospitals such as this, acute care hospitals, are very good at acute care cases, but questions of primary care and public health are not always at the forefront. [42:00] But the emergency department is one of those places that they intersect. Are there ways that you have seen the organization try to serve the community and also to advocate for better access to primary care, to concerns about public health?

00:42:31
Fletcher:
Most definitely. Folks, they come into the emergency department whether it’s in need of medicine or if it’s in need of further treatment. I mean you have the Moss Clinic, you have many different types of medication programs, and you have case managers that are in the emergency department. There are resources right there and we have this information that we can share. We have a working relationship down with Richmond with the dental school. People come in with dental problems and they don’t have the financial resources and we can refer them there. Yes, there are avenues that people can take, whether it is our senior citizens or pediatrics. There is always some information and some way we advocate for the patient and give them the resources they need.

00:43:43
Rigelhaupt:
Have you seen a close relationship between the hospital and the Moss Free Clinic?

00:43:50
Fletcher:
I have a lot of the emergency room nurses who have volunteered their time at the Moss Free Clinic and, I guess can say this, on the discharge instructions it will say to follow up with them. They are there.

00:44:16
Rigelhaupt:
Another thing in terms of learning about health care is that cost is something that has been front and center in the last decade and was probably talked about in the last decade and was probably talked about for decades before that that. But certainly it has made a lot of news in the last ten years. So this question is really about the business of health care, and I don’t mean that in a critical way, but all health care providers have to be concerned about cost and revenue. I think I’ve had one person in an interview say, “If there is no margin there is no mission.” [45:00] Are there ways in which nurses within in the emergency department have been urged to think about cost and think about the business of health care. And how has the organization advocated for nurses to learn about that and be informed of that?

00:45:13
Fletcher:
I think as nurses do our part, that you don’t want to be wasteful with any of our resources. If you are in this trauma and you are getting a patient, you are not going to open every piece of equipment and every item that you have. I think you are more conscious the materials you are using. In that vein, we are giving them all the care they need and if they need it we are going to open it. But not to be so wasteful with supplies and things like that is the only thing I can think of. I’m sorry. I’m not on the business end.

00:46:03
Rigelhaupt:
One thing I’ve learned about hospitals, in terms of running them, is that it’s a dynamic between the board, physicians and the administration. In your twenty-four years of experience here, I was wondering if you have impressions of how that relationship has worked within the organization?

00:46:28
Fletcher:
I mean, I’m a bedside nurse. You hear in staff meetings about treat and release times, treat and admit times, patient revenue, and in the red or in the black. All this information goes to administration and goes to the board. I have got to believe that they made the best decisions that they can. I am not intimately involved in that. I have to believe that they make the best decisions.

00:47:17
Rigelhaupt:
Have you seen an increased voice in nursing in terms of having a vice president and a chief nursing officer at the senior administration levels speaking for nurses or bringing that perspective to senor administration?

00:47:38
Fletcher:
Repeat that question?

00:47:43
Rigelhaupt:
Nothing very specific—just if you had an impression about the role that a chief nursing officer speaking to senior administrators and the board about nurse’s concerns. If that’s been consistent over the years that you’ve been here? [48:00]

00:48:02
Fletcher:
I think it has. I really do. We’re on the front line. We’re your eyes and your ears. I think it has. I really do.

00:48:19
Rigelhaupt:
So going to the origins of the trauma program, were you involved in planning it?

00:47:28
Fletcher:
Yes, I sat on a couple committees. I sat on the interview for the trauma surgeon. I was involved with the supplies and the processes of what we have today. Again, we were not siloed. I was in a different role at that time. It was a group of us from the ER. It was just very, very exciting. It was exciting to do the education and the ramping up for trauma. It was exciting to think that trauma was here, we were getting ready, and we were going to do this and make it successful. The last sixteen years I have been involved in the TNCC, which is a trauma nursing class that ties into when we get the recertification for trauma. It was just a very exciting time. If I could do that work wise again, I would love to do it. But since we made it, we’re good.

00:49:48
Rigelhaupt:
What do you remember about the earliest discussions, maybe even the water cooler talk, about this might be coming down? How did that circulate among the ER nurses?

00:50:06
Fletcher:
I think the nurses and the ER physicians were excited. I think that maybe the physicians in the rest of the house were not as excited. There was a small group that really pushed it forward. I had to do this presentation once and I thought I was going to turn into a pool of liquid because it was in front of a lot of different levels of administration about trauma. I was talking about the JLARC study and the needs for this. [51:00] Again it was getting away from that small kind of community thinking and having to take the next step in expanding to meet the needs of the community.

00:51:18
Rigelhaupt:
What about the change within the ER to really launch the trauma program?

00:51:23
Fletcher:
The ER physicians were already doing the traumas as well as the nurses and it was just kind of getting a different set of players in. Now you had trauma surgeons. The ER physicians had to take a different role during the trauma, but we just expanded the team, that’s all. We changed our processes a bit, but it’s still that dance. It’s still that waltz.

00:52:03
Rigelhaupt:
Do you have any memories of the first trauma case after the trauma program was officially underway?

00:52:11
Fletcher:
Oh, yes. [laughter] There was definitely that kind of little bit of pucker factor. It was definitely working with a different group of physicians that you had that trust. Then you are expanding your trust to the trauma doc and you really didn’t know them. With both sides the dance was a little stiff then, but it lightened up quickly. It’s like going out on the first couple of dates. You’re like, “Errr.” [laughter] Then after a while you’re like “Oh. Okay.” You know, he’s not a serial killer or anything. [laughter]

00:53:09
Rigelhaupt:
Do you remember the first trauma case after that where you had that feeling that this dance, we’ve got the steps together. Where this went really well and we just worked really well together. If you can describe what that’s like, what ever you can talk about the case, markers that you can point to that were clear indicators that this went really well?

00:53:43
Fletcher:
The markers would be the room being calm. Everybody knowing their role with really minimal conversation. [54:00] You do what you’re supposed to do and nobody’s yelling and nobody’s screaming. Nobody is like, “You didn’t do this.” The markers are the calmness. People are doing, performing their role, and having the best outcome for the patient with no screaming, yelling, choppiness, running around, or nothing. Just calm.

00:54:36
Rigelhaupt:
Earlier before the trauma program started the emergency department doubled in size, in 2000.

00:54:45
Fletcher:
Yes.

00:54:46
Rigelhaupt:
What do remember about why that was needed?

00:54:52
Fletcher:
I think it was just the influx of people to the area. Limited resources at the time—we were the only hospital. There might have been a couple of little clinics here and there, but we were it. We were seeing over 400 patients a day. It’s a lot of people to see in an ER. The area just grew. It was this massive boom.

00:55:31
Rigelhaupt:
Were you seeing potentially 400 patients a day that were also coming in and needing more than needing a prescription refilled. I mean, that you were seeing people that were coming in sicker?

00:55:46
Fletcher:
They were. Gradually as the years went by, we have a lot more critically ill, critically injured people. Part of it may be as a whole the community is aging. Some of it may be because now we are starting with the guns and knives club whereas before we didn’t have that type of clientele. Even now with the different type of financial stresses on the outside—whether they have insurance or don’t have insurance and whether they have money or don’t have money—they still come. We are the community hospital. We are here to serve them. That’s what we do.

00:56:48
Rigelhaupt:
Jumping backward in time, thinking about those first few years that you were in the emergency department, what did you see as the real strengths of the nursing staff in the emergency department? [57:00]

00:57:02
Fletcher:
As a group we worked really hard together, we worked really well, and we were like a family. Every once in a while you would get into a tiff, but you always had each other’s back no matter what. That was always a good feeling. If you were tied up with a critical patient you know that somebody has your back with the rest of your team. Or you can call out for help down the hall and they would be coming running. The strength is, in itself, the people that work there.

00:57:50
Rigelhaupt:
Soon after the first few years there was a rapid expansion with the organization and as you describe it, within the emergency department. In what ways was the sense of family or the good working relationship you described continued during an era of expansion?

00:58:13
Fletcher:
It did continue. Nursing has a bad rep of eating their young, you know. You are hard on them, but we grew a lot of our own nurses—nurses that were secretaries and nurses that were techs. We grew them and when they got out of nursing school they were ours. They knew the expectations. They fit in. If anybody came aboard they were immediately welcomed. Even if you were there three days and so-and-so was having a Tupperware party, you were invited. Nobody was ever left out of anything. If people felt isolated, it was their own choosing, not the group as a whole.

00:59:08
Rigelhaupt:
You know I imagine during this era with the rise of technology and computers in the 1990s, what you describe as clinical evidence and evidence-based medicine is becoming more and more practiced. Was that something you experienced in the emergency department? Was that a part of the change that you saw?

00:59:38
Fletcher:
I mean it was a part of the change. The ER physicians group got larger. There were young guys and gals coming out of medical school or the service that were very in tune with this and wanted to see these changes. [01:00:00] As they expanded, the younger doctors took key positions and wanted to do the best for the patient. They were just on the forefront of that. Nursing had the clinical nurse specialist that was doing all this research for what would work well in our department. Expanding it into maybe pediatrics and different formats like that where you would feel comfortable. So what is the best that we are going to do for this patient? Let’s apply what we know works.

01:00:48
Rigelhaupt:
I’m wondering if there’s a tension in terms of nursing practices with push towards computers and evidence-based medicine. You said earlier that there are some nurses that are nursing to the machines instead of the gut, the feel, or the experience. How did you experience that transition with decades of experience before the type of computers and evidence-based that is there now and the tension that it might have created?

01:01:23
Fletcher:
I think it does, even to this day. You know, when you walk in to see a patient, you should walk in and see the patient. You should know the color of their eyes and talk to them and assess them. Do not look at the computer. Look at a patient as a whole for who they are. Get your good baseline. Not to be offensive, but a lot of the young nurses they just want to get the information down, figure out what is in the computer, plug it in, and you’re done. I don’t know if that goes back to the nursing schools. I know that everything now is computer-based even in the nursing schools. How do you get that good feel of taking care of a patient? I’ve gone into several schools and just looked at their simulation labs and said, “Well this is all well and good, but it’s still not a real patient.” It is just we are getting away from that hands on thing where we are too relied on the technology. You got to use your senses. That’s why you’re there.

01:02:54
Rigelhaupt:
Are there ways that you can see in your role as education coordinator [01:03:00] or in the recent past that the organization and nursing leaders have tried to make sure that the touch, the art of nursing is really part of what the nursing staff learns and is part of the culture of nursing particularly in the ER?

01:03:21
Fletcher:
Right. Culturally it is not an option. It can’t be. Even when I sit down with the new hires: it’s get to know your patient and talk to them. I had two transporters that came in the other day. I said, “Don’t rush in the room and just pick up their stuff and say, ‘Hey we are taking you to your room now.’ Have that kind of contact. Think how you would feel if you were in the bed or stretcher and heard, “Oh. We got to do this. Bye!” And out the door they go. You know, take a minute.” Everything is time crunched and you realize that. Even when I am practicing on the floor I realize that. But those thirty seconds can sometimes make a big difference in how the patient and the family perceive you, how they perceive your unit, and how they perceive the organization as a whole. We are not a factory. We are people. We just do not put patients on a conveyer belt and you’re done. Keep the human in the patient.

01:04:50
Rigelhaupt:
So going backward in time again, and I know I’m jumping around.

01:04:52
Fletcher:
It’s okay. I can relate. [laughter]

01:04:53
Rigelhaupt:
But, what was your first impression of the emergency room physicians. Part of me asking is that I don’t know if this was the case in the hospitals you worked in New York, but here they were a private group contracted to work in the emergency room, not hospital employees.

01:05:18
Fletcher:
Correct.

01:05:19
Rigelhaupt:
Was that different from the hospitals you worked previously? What was your impression of the physicians?

01:05:32
Fletcher:
The ER no matter where you work, whatever state, it’s a beast unto its own. Here it was kind of a warmer type of camaraderie than in the New York City hospital or when you have a lot of residents and a lot of different types of personalities. [01:06:00] Just culturally it was just very different. It was more laid back here. They want you to learn. They want you to ask questions. They don’t get offended. They know that you are not attacking their practice, you are just trying to find out. It was quite refreshing. It was more on the same playing level than having that big deviation.

01:06:36
Rigelhaupt:
Correct me if I’m wrong, but it sound like from what you just described that your initial impression from working in the ER it was a much more team oriented base—

01:06:45
Fletcher:
Yes.

01:06:46
Rigelhaupt:
—between the nurses and the physicians. One of the things that has happened in the organization in the time that you’ve been here is that there are more hospitalists

01:06:57
Fletcher:
Yes.

01:06:57
Rigelhaupt:
More physicians that work all the time and don’t have offices that come back and forth. They are here. Are there ways in which you’ve seen the team based culture that came out of the emergency department try to be emulated by other units, be it the hospitalists or be it the ICU, or other places there are other places where there are regular practicing physicians?

01:07:25
Fletcher:
The only place that I honestly see it, and that’s part of an extension of us, is trauma. Dealing with the hospitalists as a whole is very, very difficult and frustrating. It’s how they make you feel. It doesn’t bother me. I’ve been doing this for thirty-six years. When they make nurses feel like they are not worth what they are saying, I think it’s wrong. Communication is lacking too: “You get this.” It’s rude. It’s like, “Don’t bother talking to me. I’ve been with the patient for three hours and you have been here two minutes.” I don’t know whether it’s just cultural, or they’re so busy, or what. But it makes it very hard and I think the people that suffer are really the patients. When you are trying to communicate something to them and they don’t want to hear it. It’s sad. It’s really sad.

01:08:51
Rigelhaupt:
But that sounds different from the experience you’ve had with twenty-plus years in the emergency department.

01:08:57
Fletcher:
You couldn’t pay me enough to be up on the floor. [01:09:00] I wouldn’t do it. I wouldn’t stand for that treatment. I wouldn’t tolerate it, not having worked in the environment that I’m working in. It’s not acceptable.

01:09:20
Rigelhaupt:
Is it something special about the ER or about this ER that physicians and nurses work well together that you see not be emulated in other places?

01:09:42
Fletcher:
Just a mutual respect. It’s a hard job, whether you’re coding a baby that’s been sick, or you’re coding a middle-aged person, or a senior citizen. It goes back to that trust, that communication, and that teamwork. You want to be successful at end. If you are not, this is the same person where you are walking into the family who has just lost somebody. It’s all those human factors. It’s there. It’s there.

01:10:28
Rigelhaupt:
What are some of the most rewarding patients to work with in the emergency department?

01:10:36
Fletcher:
I have to say the senior citizens. I don’t know. There is just something sweet about them. They’re gracious. I love my children and my grandchildren to death, but I’m not a pediatric nurse and don’t ever intend to be. I like the geriatric patients. I think they have a lot to offer us too in terms of who they are, where they’ve been, and just the conversations. They are the ones that always want to give you a hug. They’re just nice, just nice.

01:11:24
Rigelhaupt:
Have you also been involved of the planning and the opening of Lee’s Hill and what you remember about the emergency literally expanding to a different site?

01:11:40
Fletcher:
I think I was on the fringes of that. I think it was part of my last year before I stepped down as manager so I don’t really recall too much about that. [01:12:00] A lot of staff were willing to take that plunge and that risk by going down there and trying something different. They were kind of ready for a little bit of a more low-key environment then what we have here.

01:12:20
Rigelhaupt:
So, you wouldn’t see the same level of patient at Lee’s Hill, obviously not the trauma patients. The ambulances don’t kind of drive there but is it a different patient population?

01:12:33
Fletcher:
Just by me being down there the last couple weeks, I would say yes. Not that they don’t get their acute patients—I mean they do and they take very good care of them. They then wind up being transferred here. They have that more walk in clinical type of patient: “I need stiches.” “I have an earache.” “I ran out of my Percocet.” Those kind of patients. I’m not saying that they have their share of bad ones—they do. I’m just saying that it is a smaller, more controlled environment. I think the people that are really sick automatically come here, whether they drive or whatever means they get here.

01:13:34
Rigelhaupt:
As the emergency department expanded and you could take a higher level, a sicker level of patient. What were some of the other the departments that you were working with, particularly with trauma that would be the ICU? I don’t know if cascading is the right word, but there are more and more departments involved.

01:13:59
Fletcher:
There was. I mean you had to get CAT scan on board and you had to get lab on board. There’s a different order set for trauma patients, for CTs. The OR had to stand ready. They need whatever specialty equipment they use in the OR. ICU nurses had to be trained on taking care of trauma patients. They are all excellent nurses. It’s just that trauma is a little different recipe of taking care of them. It works. It works.

01:14:39
Rigelhaupt:
Was that an exciting opportunity, to work with radiology in terms of CTs, bringing them on board?

01:14:45
Fletcher:
It was. We sat on lots of meetings and we worked on different order sets. [01:15:00] It was like you worked on all these little pieces and then all of the sudden it just came together and it was like, “Here we are. We did it. We did it. We’re doing it, and we are doing it well.”

01:15:10
Rigelhaupt:
So trauma is about six years old?

01:15:12
Fletcher:
I think six years, seven. We just had another review so it’s probably about six years.

01:15:17
Rigelhaupt:
What would you point to as the strengths of the program over the first six years?

01:15:22
Fletcher:
The buy in of the staff wanting to have it here. It kept rolling like a snowball, getting bigger and bigger. People were getting excited when they saw things happening, changing, and doing—the snowball got bigger and bigger. It played out very nicely. It was a lot of hard work on all different levels, from housekeeping all the way up to the board. You needed all these players to make it work. You truly needed the whole village, as they would say.

01:16:11
Rigelhaupt:
What nurses in the emergency department would be called in on a trauma case? You talked about trauma nurse certification. What’s the process of who’s involved in a trauma case?

01:16:26
Fletcher:
Everyone that works in the emergency department nurse wise has to have TNCC within the first year. Then there was a screening process of who were really going to be your trauma nurses. There was a whole process with letters, interviews, and things like that. We do have a core group of trauma nurses that are assigned, depending on their shift, to that particular room as their responsibility. They have the knowledge of all the ins and outs of the equipment, the different format of charting, the different processes, and things like that. There is a core group. Some people really like trauma and some people are like, “You can have it.”

01:17:21
Rigelhaupt:
What are some of the things that you would say attracted nurses to trauma or brought them into that core group that would be in the leadership or a trauma role on that shift?

01:17:38
Fletcher:
I think it has to do with the nurse wanting to grow professionally. It’s also the nurse that has a lot to offer experience wise and that they just want to make a difference caring for that type of patient. [01:18:00] You really have to enjoy that type of role. It’s down, it’s dirty. It’s quick and you are done before you move on to the next one. No bells on the toes—it’s just you like it or you don’t.

1:18:29
Rigelhaupt:
You know one of the things about trauma from my understanding is that it also involves a lot of education—

1:18:34
Fletcher:
It does.

1:18:35
Rigelhaupt:
—with both the nurses and also EMS in the community. Have you been involved with any training with the EMS to talk about trauma protocols?

01:18:49
Fletcher:
Initially, when we started laying the groundwork to move forward on this program, but then trauma services took over all that. They do have whatever training they have in conjunction with EMS. EMS knows what our specific criteria are for traumas and just like us they get the huddle after the fact too. You know, “What went really well or how can we improve on this?” EMS had gotten so good right now they’ll say, “Oh yeah, we are bringing you a code orange.” They even know our level of code and they even go ahead and give reports. Everything is a work in progress. Nothing happened overnight, but it’s good. It’s good. People worked hard.

01:19:51
Rigelhaupt:
Who were the nurses and physicians you remember making important contributions really pushing from an emergency department to a trauma program?

01:20:01
Fletcher:
You mean name wise?

1:20:05
Rigelhaupt:
Yes. I mean, who do you remember working with?

01:20:06
Fletcher:
I didn’t know if I could say that. Let’s see. We worked with at the time, Dr. Garvie and Dr. Crane. Marianna was always the lead in administration. She was kind of the driving force behind that. The ICU nurses—I’m bad with names. Natalie was involved with that a lot—she is our clinical nurse specialist. At the time the trauma surgeon that was involved at the ground level was Dr. Earnhardt. [01:21:00] I remember that was all the preliminary group that got this thing rolling.

01:21:12
Rigelhaupt:
In your new position role as an education coordinator, you described that you are dealing with things that are coming up around the CDC. I assume you are referring to Ebola.

01:24:24
Fletcher:
Right.

01:21:27
Rigelhaupt:
It’s the things that you have to do that come up, there’s a protocol. But I’m sure that you are thinking about some of the cultural things. Some of the things about talking with patients—for lack of a better term and not to be too touchy feely, but the art of nursing. Are there ways you can see yourself trying to emphasize that in the education program that you are working on?

01:21:58
Fletcher:
Definitely. All this technology and all this education is wonderful and you need it, but you have to apply it to a person. It’s a whole package. Your patient is in the center. We are doing all this on the outside to take care of the center. It’s not that we are doing all this and the patient is over here. We can’t lose sight of the human aspect of it. No matter how nice or how not nice they can be, they are still our patients. They are still apart of the community and that is who makes us successful as practitioners.

01:22:53
Rigelhaupt:
Decades of experience as an emergency department nurse.

01:23:00
Fletcher:
Wouldn’t trade it.

01:23:02
Rigelhaupt:
What would you most want the public to know about being an emergency department nurse?

01:23:12
Fletcher:
One, we are people in your community. We are delivering the best care to you and your family and kind of be nice to us. A lot of times people aren’t nice anymore. It’s kind of sad. You come in for help and yet you are going to be really mean and curse me out? I’m here for you. I’m trying to make you better. You know we are people in the community. We have families and we have kids. We have a stake in here and we just want to make your world a little bit better. [1:24:00]

1:24:02
Rigelhaupt:
It’s clear to listening that being compassionate and patient-centered is pretty core to you as a nurse.

01:24:10
Fletcher:
It is, very much so.

01:24:12
Rigelhaupt:
But I also want to ask you about the clinical skills that you have as a nurse. What are some of the things that you have been proud to get really good through practice? In terms of maybe a really hard IV stick or the things that you do that you are very skilled at that you are most proud of, having mastered or gotten really good at over the course of your career?

01:24:37
Fletcher:
I guess my reading the patient, my patient assessment. If there are hard IVs—yes, they always call on me—or the pediatric ones. God bless those little kids, but you get it and you do it. I just feel like after all these years that I am on the top on my game. Yet, I do know that I learn every day something new. You don’t become stagnant. It makes me feel really good when people come in that are part of our staff, our extended family, and bring their family members in and they want you as a nurse. One day I had three people over twelve hours that were all part of either the organization or worked in the ER and they asked for me as their nurse. To me, that says a lot. It really does.

01:25:56
Rigelhaupt:
I asked you about what would you want the public to know about being an emergency department nurse. What would be some of the things that you would want the public to know about Mary Washington Hospital and Mary Washington Healthcare as a health system that might not be commonly known?

01:26:12
Fletcher:
We do provide excellent care. We do have cutting edge resources, whether it is CT scanners or something up in the OR. We have an array of specialties in our organization and our resources are available outside of these walls too. Sometimes it’s a question of asking. Don’t be afraid to ask. We are here to help you.

01:27:00
Rigelhaupt:
So my last question is actually two questions. One, is there anything that should have asked that I didn’t? And two, is there anything you would like to add?

1:27:14
Fletcher:
I think you covered everything quite well. You even made me think of things I haven’t thought about in a long time. Nursing has been good for me. It was my right career choice from being a little kid. After thirty-six years, I just want to give back to nursing. It has as given a lot to me in my life.

01:27:48
Rigelhaupt:
I think that’s a nice place to end. Thank you.

01:27:50
Fletcher:
You’re welcome.

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