Ruth Landry-Stone is a registered nurse (RN) and began working as a home health nurse with Mary Washington Healthcare in 2001. She received her bachelor’s of science in nursing (BSN) from Virginia Commonwealth University (Medical College of Virginia). Earlier in her career, she worked at Sinai Hospital in Baltimore, Maryland. She started working as a nurse in home health with Bay Area Health Care, part of the University of Maryland Medical System. She has over thirty years of experience as a nurse.
Ruth Landry-Stone was interviewed by Jess Rigelhaupt and John Holwick on November 12, 2014.
Discursive Table of Contents
Decision to become a nurse and connection to being in a family of nurses—Nursing education at Medical College of Virginia (now VCU)—Working at Sinai Hospital in Baltimore—Working with Bay Area Health Care, part of the Maryland Shock Trauma Center at the University of Maryland
Returning to Virginia—Working with At Home Care, a home health company—Starting with home health in Mary Washington Healthcare (MediCorp at the time) in 2001
Changes in home health practices—New technology—Early career experiences in home health in Mary Washington Healthcare
Combined home health and hospice in Mary Washington Healthcare—First impressions of Mary Washington Hospital in 1995—Mission and values of Mary Washington Healthcare
Nursing care at Mary Washington Hospital—Work-family balance—Organizational support for nurses—Prominence of role educating patients and families in home health nursing—Comparison of experiences working in Baltimore and Fredericksburg
Home health’s role in the continuum of care—Providing care as a home health nurse—Developing clinical skills and bedside manner—Developing meaningful relationships with patients—Enjoying work as a home health nurse
Importance of the mission at Mary Washington Healthcare—Enrichment from being a home health nurse
It’s November 12, 2014. We are in Fredericksburg, Virginia doing an oral history interview with Ruth Landry-Stone for the Mary Washington Healthcare Oral History project. The first interviewer, which you’ll hear a male voice, will be John Holwick. I will come in later. My name is Jess Rigelhaupt. So John, you can start please.
Just to start us off, what made you want to become a nurse?
I came from a family of nurses. My grandmother, who I’m named after, was a nurse as well as six of her seven sisters. They all went into nursing decades ago when their mother became ill and they decided to open a group home to care for their mother. They all went to nursing school and cared for their mother along with other folks. Hearing their stories of nursing over the years and the variety of types of nursing, it was an inspiration. Also, on my father’s side of the family there were nurses. I came from a family of nurses. As a matter of fact, my grandmother was Ruth Elizabeth— I’m a Ruth Elizabeth also—and she worked at Fauquier Hospital, which is in Fauquier County. She worked there for fourteen years and in the later part of her career she worked in the emergency room. I remember one day going in there to go say hi to my grandmother and she said, “Do you want to see a procedure?” I said, “Okay.” She took me over to the door and there was a kid who had broken his thumb and a doctor was putting a screw in it. There were large screens so he could see very closely the screw going into the thumb and I had never seen anything quite like that. Then the next thing I know I woke up on a gurney with my grandmother giving me smelling salts under my nose. [laughs] But that didn’t deter me and that was the only time I really had that extreme experience with a nursing procedure. When my grandmother died—how many years ago? [03:00] About twenty-six years. Fauquier Hospital named the nursing excellence award that they give annually at Fauquier Hospital after my grandmother for her dedication to her patients and to the profession of nursing. I’ll try to say that and not cry. [laughs] Remarkable woman.
That’s quite the family tradition. An incredible first experience.
[laughs] Yes. Absolutely.
So I understand you went to Medical College of Virginia (MCV). What was it like training to be a nurse there?
It was an incredible experience. It was quite involved. It’s an enormous inner city hospital in a big regional medical center. After my first semester of nursing school, I could then work as a nursing assistant in the hospital itself. I did that to put myself through school. I saw medicine, patients, and surgeries like I never knew existed. It really was an expansion of me as a person. It was also part of a community of health-oriented people because there is a medical school, a dental school, and a PT school. It was an enormous medical institution and research hospital. It was a vibrant community that was there. After my first semester, I was able to work as a nursing assistant, which I needed to do. I would go to school Monday through Friday then work every weekend in their medical-surgical pool and I got incredible experience managing patients. I was taking care of their basic needs: cleaning skin, turning and positioning them, feeding people who couldn’t feed themselves, cleaning up after people who defecated on themselves, and making beds. It’s such an important part of caring for a patient. I did that and then I went to the pediatric float pool and that was really challenging, seeing children with enormous medical issues. I took care of young babies who had been birthed. I got to be very good at bottle-feeding lots of babies at once. [06:00] I was taking care of kids whose parents just left them there in the hospital. Some parents would give birth and leave their babies and the babies weren’t getting that connection, rocking, and tenderness. A wide variety of experiences at that institution.
Where did you first work after graduating from the Medical College of Virginia?
I worked in Baltimore. I met my husband when he was in medical school and I was in nursing school. There were a lot of those connections being made. [laughs] There were even nurse to nurse connections. We had two male nursing students in our class. There was a lot of that with the medical community. My husband got a job, an internship in Baltimore at the Sinai Hospital in Baltimore. Then he worked there and I gave birth to our son, our first son, and then I didn’t work. I was in the hospital giving birth to our first son and I was supposed to take my nursing boards that I worked so hard for. In those days, they only offered them twice a year. I had to wait six months again to be able to take them. I gave birth to our son, moved in, and then went to work there in their medical-surgical float pool and worked part time. I could balance the job of being a new parent, a homemaker, and a nurse. I again got a large variety of experiences and became familiar with the community in Baltimore. That was my first job. I did that for two years.
Could you tell me about your first shifts specifically as well?
My first shift as a nurse? When I went onto the nursing floor, for me it was always a challenge to punch in on time. Punch in. Boy! That was the first challenge of my shift: getting there within the five minutes. Fortunately, in my present career I don’t have to clock in like that. But nevertheless, clocking in on time. Then it was going to the floor and getting an assignment. I followed a nurse for a number of months to get a sense of what the policies and procedures were on that floor. [09:00] I saw how much experience those nurses had. They could look at pills, know what they were, and they could easily put in and run IVs. They were so skilled at what they were doing. I wondered how I was ever going to get there. Fortunately, I had the experiences as a nursing assistant at MCV, which helped me manage my caseload. I was really good at being able to manage and organize. But seeing the skill level of the nurses who had been there, it was pretty enormous.
So you mentioned you worked for two years at Sinai. Where did you go after?
You know, it was between two and three years. But yes, sorry to interrupt. Go ahead.
Where did you go after Sinai?
After Sinai Hospital we lived in Baltimore. When I was in nursing school at MCV. I went out with a home health care nurse because we had different rotations, through pediatrics, psych, community health, home health, and medical-surgical. When I went out with the home health nurse I had an immediate affinity for that job and I thought what an amazing nursing job that is. I felt that immediate connection and it was something I always wanted to do. But to qualify to be a home health nurse you had to have a couple of years, at least two years of medical-surgical nursing background, because you had to have really sound skills of assessment and interventions to be able to be out on your own, autonomous in the community. Once I got the two years at Sinai Hospital, I did overlap for a year doing some work at Sinai and then working in home health. Then it was too much and I went and worked with Bay Area Health Care, which was part of the Maryland Shock Trauma Center at the University of Maryland. I was a case manager in the inner city Baltimore. I worked a variety of different hours, from part time to almost full time depending on what the home life needs were and whether I was having another baby. [12:00] I hit the streets of Baltimore when it was the murder capital of America. Richmond was also the murder capital of America when I was at nursing school there—it’s that I-95 corridor. I was able to do what I wanted to do which was home health nursing.
How is home health nursing different than your previous experiences?
I had experience in working in institutions such as hospitals and it didn’t really appeal to me or my nature. Home health allows you to work autonomously. It enables you to have a connection with the patients in a very personal space of their home, where they spend the majority of their life and they live with whatever acute or chronic disease process that they have. When they’re in a hospital situation, if they’re having some acute issue or there for surgery or some flare up of some chronic issue, it’s a whole different type of nursing you get in the hospital. You get a Band-Aid on and kind of get fixed up and you go back to your home. Being in the home, interacting with people there, and being able to do a lot of education with folks about their disease processes, their medications, skincare, their exercise, and all of the parts of what it takes to be a healthy individual. It takes time. We have a variety of interests and education levels in patients, as they do in hospitals, but you often have a greater length of time in the home to be able to make a difference through education. It’s determining what are the patients’ needs. What do they want? What do they need? What do they expect from home health care services? It’s having that interaction with patients where they live as they deal with their illnesses. [15:00] It is really pretty powerful. After being in a patient’s home doing everything I can to help them I also enjoy going out to my car, opening my sunroof, and turning some music on as I drive to the next place. It’s a little reprieve and a little downtime before you go in and you really have to be attentive, so attentive to what someone’s needs are. In the hospital, it’s a much greater challenge to give nurses that down time. Even when you’re present with someone in the hospital, there are buzzers going off and you’re getting called to go and do something else. The time is so much shorter that you can have with somebody when you do hospital nursing. All of that really changes when you’re invited into someone’s home. Sitting at a kitchen table, or their living room sofa, or in their bedroom with them and having a dialogue with them: it’s the type of nursing that suits who I am.
When did you start working in Virginia?
We moved back to Virginia. We had lived in Baltimore for ten years. It was great living in that big, vibrant city. We had three children, my husband finished his residency, and then he got cancer when he was thirty-two years old. So young. He had Hodgkin’s disease. We had three young children and we were in the city school systems of Baltimore, which we didn’t feel were safe. It was getting more violent in the city. We were having to send our children to private school and we were paying more for that than college tuition. The violence and the kids couldn’t ride their bikes to the park because their bikes would get stolen. It didn’t feel like a good place to be for a prolonged period. My husband got treatment for his cancer and it wasn’t going to be curable. [18:00]. He was a physician and obviously he got the best care he could get and we realized that. I remember being in line at a grocery store once and seeing an article on a magazine saying that Baltimore was the number one city in the nation for getting cancer and my husband was diagnosed with cancer a few years previously. I thought, “What the hell are we doing here?” But also because he was ill and he wasn’t going to survive. How long he was going to live? We didn’t know. We came back to Virginia. I had family in Warrenton and my husband had family in Northern Virginia. We chose to live in Stafford County because of the school district. We could send our kids to public schools, and we believe in public schools. Then we got a nice set up here in Fredericksburg. He got a job. We were here for a while. I mean we’re still here, but before he died of cancer in 2001. We have been established and that’s how we ended up here.
Where did you first work when you came to Virginia?
I worked with a company called At Home Care and I worked with them starting in ‘98. I took couple of years off after we moved to Fredericksburg because I had young children. I just wanted to get us settled and so I took a few years off. I had always enjoyed nursing. To me, my nursing career wasn’t a job. It was a hobby. It was a wonderful experience that helped balance out my life. I felt like I was doing a good service for the people in the community where I lived. I was missing doing that. It was good I had that pull because I had years of experience and I was easily able to get a job. Women these days are so pulled between staying at home with the kids. Do you have a full time career? Or do you have someone raise your kids? [21:00] For me the balance was working a variety of hours of a part time employee as well as being there for my children, for my husband, and for our community. I worked at At Home Care and enjoyed that. I had a wonderful branch manager, who is still a good friend of mine. I remember with my son Lucas that I would drop him off at the Montessori school and then go see a few patients. Then I would come back and I still had some patients to see. She would say, “Bring him in, his lunch, his blanket, his favorite video, and we’ll put him in the conference room. He could watch a video while you go see another patient.” It was extraordinary to have that. I worked there for a couple of years, but I had my eye on Mary Washington Healthcare for a while. The At Home Care was a branch of an organization that was started by a couple of brothers who probably wanted to do good, but also wanted to tap into the medical side of being able to make money. They were based in Richmond and this was a satellite office and I really wanted to be in our community-based facility, which was Mary Washington Healthcare. I believed in their mission which was, is to serve the people of our community and to optimize their health. I came here in 2001.
So you mentioned that At Home Care was a private organization. Were there any differences in how nursing worked in a private organization versus Sinai or Mary Washington Healthcare?
I think all facilities and all organizations whether they’re for-profit or non-profit still have to be aware of the bottom line. They have to stay in business to be able to serve. I know that At Home Care was a place that they were not as generous with benefits or with the salary because they were trying to maximize their profit and they were also trying to grow their organization. [24:00] Sinai Hospital was a part of a large Jewish community in Baltimore and it was a Jewish facility. They had enormous resources from the Jewish community, which was an amazing community in how they support one another. It was extraordinary to see that and be part of that. Mary Washington Healthcare is a non-profit and it’s a much larger organization than At Home Care. They had better benefits and better salary. That appealed to me to because I knew that soon I was going to be supporting my family and my three kids by myself because my husband was going to die. We didn’t know how long. He was on what they called in the National Institute of Health in Bethesda, “salvage therapy.” It was just therapy that they did—what an awful term—because people weren’t going to be cured. They could salvage what they could get of their life and their health and keep them alive and that is what they did. He died at this hospital, at Mary Washington Hospital, in 2001, on the first day I started my job here. I’ve told this story a lot, so I’m going to try not to cry. I went in and I was so excited on my first day here. Our office was on Princess Anne Street across from Carl’s Ice Cream. I go in to meet them and see who is going to be orienting me. I get a phone call that he was taken into the ICU. He had been at the hospital. He’d been in and out so many times that you really don’t know even if you’re a nurse or a doctor, you really don’t know when the last time is going to be. I needed to move forward with my job and I just remember going in and seeing one of the ladies who was going to orient me. I started crying on my first day of my job that I really wanted. [27:00] Then I got on the phone and I called there—what was it called then? I forget the word. It’s not called risk or it’s not called stress. Fortunately, Mary Washington Healthcare is a big organization and they have a place that employees can call if they’re really stressed out. I called them and immediately tapped into the great resources and benefits they have here at this organization. It was very helpful. The people and the ladies at my office were very understanding. They really needed a full time nurse, but they allowed me to have three weeks because he died a short time after he went to the ICU. They allowed me a few weeks to be at home and start reading the material, which I don’t think sunk in very well. They gave me time. That is quite an auspicious beginning.
There was a strong support system when you entered Mary Washington Healthcare?
Yes. You’re working with a group of women and mothers. It’s not that men aren’t compassionate or understanding; they certainly are. It’s the triple combination of being a woman, being a mother, and being a nurse: where you get lots of compassion, empathy, nurturing, warmth, understanding, and the problem solving. It’s extraordinary to be working with a group of people like that and then for the organization itself to have some of the resources that are available. It’s not to say that just because they’re women, or nurses, or mothers that they’re perfect, angelic beings. They certainly are and we all are humans too. [30:00] So we have the darker side and attributes that go along with being human. The people that run this organization are business people also and there are those constraints. It’s a good place to work.
I notice the time frames you have worked covers a wide range. Have you noticed any changes in home health nursing over the years?
Yes. When I started as a home health nurse it was all done with pen and paper. We were brought along seven or eight years ago and we had to start doing everything on computers, on laptops. You take a bunch of middle-aged or early middle-age women who aren’t really computer savvy and had lived most of their life without one and are pretty content and had to drag us into the twenty-first century. We were a little resistant and it took a lot of education. It took time being with the computer to be comfortable with it and having some mechanical object in between us and our patients. We want to be there with our patients. That and other changes—I’ve seen a lot of changes. We used to have probably more staffing than we have now. They used to just give us assignments and tell us to go at it. Now there are productivity parameters that you’re supposed to work in and that’s a big challenge and a big change. [33:00] We used to collect data and set up plans of care for our patients based on what they wanted and what we thought was good for them to learn. Now those are all measured, all that data. Another reason that we had computers is because we had to fill out—eighty percent of our patients were Medicare patients. We are reimbursed by Medicare. So you can imagine a government program and there are all sorts of rules and regulations. They want to measure the outcomes. They want to measure to see what are the patients are like when they were first seen and had they improved with the services that home health gives them. The measuring of it is very new also, well within the last five years. Another one is the technology. There’s so much more technology now that patients have in their homes and they need to be instructed about. They need to become fairly independent. We’re talking about lay people who don’t have any medical knowledge other than they are a patient and they see some of these things and the nurse going in and instructing them and being there as a safety net and a resource. There are patients who have these machines called VACS that are hooked on if they have big wounds that take a long time to heal. They cover it up with a sponge and drape and they attach it to a mechanical object that’s battery powered or plugged into a wall that they have to carry around with them. It facilitates healing. I have a patient now with a small IV pump that they carry around with big central lines that go into their body. You never used to see people in the community, in their homes, with IVs like that. You’re talking about people who don’t have much of an education and who are fearful. I have a patient now on medication that keeps his heart beating. Go ahead and tell people, “You are going to be living with this full time. You have to take care of that pump because if the pump stops and he stops getting that medicine, he may die.” Taking the time and being able to increase their comfort and increase their knowledge until people are really able to mange that at home. [36:00] We still see them on a weekly basis and more frequently if there are complications. We’re still there, but the acuity of the patients have increased and the amount that the family has to do for their patients, for these increasingly sick patients, has increased also. There are just more rules and regulations—there’s just so much more. I would say that I probably spend a third of my time with the patients, a third of my time driving from one patient to the other, and a third of my time documenting. I don’t think the ratio was like that before. I used to be able to spend more time with the patients and less documenting. I think that gets the gist of it.
What are you most proud of in your nursing career?
Wow. Probably that I can continue on the nursing legacy that my grandmother and her sisters started and to care for the patients, to give them excellent care, and to care for the people in my community. I’ve lived here since 1995 in Fredericksburg. I can go through the city of Fredericksburg and I’ve probably been in one house in one every one of those blocks and in the countryside, but not as many. Doing the best for the people in community and sharing the knowledge that I have with them.
So if you go back in time a little bit to 2001. [39:00] I understand it was a very hard first day. Starting with your first day back three weeks later, what do you remember about your first shift? If you could describe those early shifts working at Mary Washington?
I did orientation with a nurse, obviously, and she was a case manager. We would go see her patients. I’ll tell you, it was good that I had a decade of experience as a home health nurse because I had a lot to draw on. I remember being tired. Even though it had been three weeks, I remember being tired. Starting off the day with energy and enthusiasm, but I think I just didn’t have the stamina. But also, I remember her kindness and understanding of where I was. When you go out with a nurse they’re also assessing your ability to be able to perform your job in someone’s home. I was able to do that. That’s what I remember: the kindness of the nurses. I remember, too, how the nurses that I went out with really enjoyed their jobs. They enjoyed their jobs. It’s interesting—the core group of nurses, the field nurses that I was with at the time, a lot of them are still with the organization. If home health nursing is for you, then people really stand by it and they have a belief in it. To be around a community of people who enjoy their jobs, how great is that.
Did you have a sense of how established home health was within the organization? Was it still a new program? Was it long established when you started?
When I came on with Mary Washington home health there was a director who had been there for probably twenty-some years. She was the director of both home health and hospice. There were two different buildings that were close to each other and it had been done a certain way for a long period of time. I think there was a time as again we were looking at budgets and viability of certain programs for the organization. They brought in an outside, independent individual who came with her team and did an assessment of home health and hospice to see if there were changes that could be made. Evidently home health and hospice was losing a lot of money. MediCorp, it was called MediCorp then. My sense was they were really trying to determine if they were going to keep the program going. There were a lot of places and a lot of hospitals based, or even independent, home health and hospice agencies that weren’t viable. The organization was trying to make a determination. They bring in an independent auditor who was an expert and could say these things could change, you could streamline the program, and you can stop gushing out money cut some of your losses. There was an enormous change and that director left. I think it was after twenty-five years of being with the organization and I think probably doing a wonderful job. Then Eileen Dohmann came in: what a dynamo. She made changes for the better because it revitalized the organization. It was a tough transition time. We had a loss of a lot of nurses. There were changes to a lot of procedures and protocols. There was a lot of contempt. Some people didn’t want to go along with the change and some people did. They moved us from Princess Anne Street down to Massaponax where the company had bought a lot of property and we established down there. We weren’t across from Carl’s Ice Cream anymore. [laughs] [45:00] They combined home health and hospice and had one director for both of them. They also got rid of a lot of the middle management over with home health and hospice when they made the change of director. There were nurses who had been there for a long time who weren’t supportive of what the changes were going to be and a lot of middle management left. They didn’t really bring in new middle managers; they moved up some of the managers. That was a little challenging too because some of them weren’t really ever managers before, or didn’t have a lot of experience, or needed to grow into the job. It made for some tough transition times. But I would say that for me one of the nice things—I don’t mean this in a negative way at all—is that we’re really autonomous. I might go into the office my office twice a month. It’s not that I don’t enjoy the people. They’re wonderful people. You also don’t have to get all involved in office politics and all that business. You can really keep your focus on taking care of the people that you’re there to serve. That’s what you want to do and that’s what I did. I still believed in home health nursing. I tried not to let whatever was happening with these management issues negatively impact the performance of a job.
So you moved to the area in 1995 and it sounds like you were aware of the organization before you started working there. So what were your impressions when you first moved here in 1995 of Mary Washington hospital was and at the time MediCorp?
My impression was that it was a community-based hospital and was a non-profit that tried to care for the people in their community. [48:00] They didn’t have a part-time job here initially when I came to town, so I didn’t apply for a job here because I wanted to work part time, and that’s why I went with At Home Care. But then as I settled in and realized I was going to need a full time job then I wanted to be with this organization. My impression was that with any hospital and with any organization, some people like it and some people don’t. There are good things about it; there are negatives about it. I thought that it was really wonderful that our community here in Fredericksburg had a hospital here and I heard there was a lot of room for improvement. I had seen them work on that. I think I had a pretty realistic view of what it was: a good community organization, with good and bad.
You mentioned the mission and the values earlier and that’s certainly something that has been discussed in these interviews. Did what you know about it in terms of your impression of its mission and values before you started working here match up with the orientation and what you heard about it?
Yes. The mission is to improve the health status of all the people in the community. They just added the words that we serve within the last couple of years. Did it measure up? I think it does. I think that people who work here want to do the best for their community. They are continually striving to do that and they try that in a variety of formats. They saw the value of home health and hospice and they streamlined it and they saw that we are a valuable part of the community and almost an extension. We are an extension. We are in people’s homes. We are an extension of this hospital and a central part of it. [51:00] They have been and are supportive of the Moss Free Clinic. We serve, in our organization, through home health and I know the hospital does too. There are so many folks that don’t have insurance or are homeless. They are supporters of the Thurman Brisben Homeless Shelter and Micah Ministries, which is an organization for the homeless folks and underserved populations here in Fredericksburg. Those are enormous programs. They really, I believe, to try to not let people fall through the cracks in our community. There is a safety net and a certain level of quality of life that you can have. The organization does that as much as it can, as much as a medical organization can. I know that they are supportive of doctor offices and laboratories. And when people are living with wounds more than ever, you know, they opened up a wound center. When people have congestive heart failure, they have congestive heart failure clinics. I think they’re constantly changing across those lines. They’re constantly seeing what is pertinent and what the needs of our community are. Yes, I think that they do try to follow through on their mission and their values. I don’t think they’re perfect. Do you want me to expand upon that?
It’s up to you.
Okay. The organization is run by humans and humans have flaws, frailties, and egos. All of those things right there make an organization. They’re human, a human construction, and they’ve got their faults and foibles. [54:00] I can give a couple examples and it makes me a little unnerved to say this because I love what I do. I really enjoy working for this organization and I believe in it, but there are some downsides. What I can say is that a few years ago, maybe three-four years ago, the organization used to have a pension plan and all employees were eligible for that. Then they decided like many corporations to do away with the pension plan—because that’s the way America is going. Some people got who were here for a long time were able to take advantage and got their pension, but others were not. The leadership educated us about that. They came around and I remember asking, “How much money does it save the organization?” Well, it saved them $2.5 million annually. At the same time in the local newspaper, or about the same time, there was a list of salaries for all of the top leadership positions at the organization. A lot of them easily doubled their salaries. Their salaries came with increases and bonuses. Their increases, not bonuses, came to $1.5 million. To save $2.5 million for the 4,990 people that worked here, they gave $1.5 million of it to the top ten people who work in this organization. That was disheartening. It was disturbing to a lot of people that I spoke with. We were told, “Well, that’s the way of the world.” That’s a bit of a cop out. It doesn’t have to be the way of the world. This is a non-profit organization and there were plenty of people making a big profit for themselves, and their lifestyles at the expense of the organization and not only that, their fellow 4,990 employees. That really bothered me. [57:00] I thought it was and I still think it’s immoral. Skimming off the cream of the crop of whatever resources come into this organization is not okay. I have that same belief not just for this organization, but for other corporations in America. The divide between the rich and the poor is just getting greater. That was very, very disturbing. I will also say that another downside that was disturbing for me is that I understand in America we’re the most productive nation on the planet. People work hard and more than many places in the world. Not that people don’t work hard in other places aren’t—I’ve traveled a lot and I enjoy seeing what life is like in other places in the world. We work really hard and we have a different set of values: we’re probably pretty material and materialistic in this country. When they decided to institute productivity, whereas before we would be sent out to and go do your job: “Just do a good job.” How great is that? Then they instituted productivity where they measure how many people you have seen, not the quality of your job as much. Even though, it did matter because we had to get improvement of scores. But also what mattered was if you meet the productivity because more of the rules and regulations and reimbursements were being measured. So our productivity was really driving our organization with home health and it put a great burden on the nurses. It switched from really just giving good care to people in the community to, “Boy. Did you give good care in an allotted amount of time?” Probably three quarters of the nurses who work in my office are the sole or head of households so their jobs are very important to them and to their families. At the yearend review you get reviewed on what your productivity is. [01:00:00] There’s also an enormous pressure from the supervisors to make sure you meet productivity. What was happening was nurses, to meet the productivity and to keep their jobs were working off the clock, which is illegal. “It’s against the rules. Don’t do that.” We were told. But it almost felt like it was a wink and a nod: “Don’t do it, but you better meet your productivity. We don’t care how you do it.” Essentially that is how nurses were meeting the productivity. It wasn’t really an accurate measurement of what nurses were doing because nurses aren’t doing their jobs within the eight-and-a-half hours that’s allotted to them. That type of thing is the darker side of where health care has gone and where organizations have gone. Those are two of my most disturbing parts of being in this organization.
Since you’ve worked here you have not spent nearly as much time in the hospital as a floor nurse. What’s your impression, thinking back to when you started, what was the strength of the overall nursing program at Mary Washington? What were places it had room for improvement?
You mean as far as home health nursing? My husband was here, my first husband. I experienced it that way, as a family member. I remarried and I remarried a fellow who has two sons. We’ve been together over a decade. Now we have five sons and they’re wonderful. [laughs] I was going say, and I kid my second husband, and I say, “ I know you married me because you want a private duty nurse.” He always is having something, an ailment or another thing. He’s active very physically and he’s had a non-healing wound. Just a few months ago he got hit by a car while riding his bike and he ends up here as a patient here. [01:03:00] I’ve been a patient’s family member at the hospital and I would say that I was always pleased. Also, I’ve had kids in the emergency room here with broken arms, broken legs, and those types of things. I’ve always been pleased with the nursing care at the hospital. I’m a nurse, so I don’t know if I’m better able to advocate. I know people who get the best care in the hospital because I believe that hospital nurses are really stretched thin. They are given more to do than probably even possible to do and they do it in an excellent way within the parameters that they have to work. Being here and being an advocate for my husband while he was unconscious or on medication, I think that is sometimes important to getting good care. I think it’s not that people don’t want to give it—they’re only human and there’s only so much you can do within a certain period of time. Within my organization, within home health, we’re also running into the same issue as the productivity, budget cuts, and staffing freezing has happened. They have been really good to me there. I worked full time and then I worked part time—when I needed to make that transition from full time to part time because I had five teenage males living at home and life was a little insane. One of us needed to be at home more and I did it. But nevertheless, I said to the leadership, “Hey, I need to go part time.” They were so good they said go find someone else to go part time and you can do a job share—how great is that? So we did that. Then there were times when our census was low and they would cross train me to do chart review. They were really thoughtful in that way. What I can say is that the nurses who have came into home health are skilled and you have to be to be out there on your own. [01:06:00] They do annual reviews of things that we use on the patients, like the glucometer, blood pressure, VAC machines. They make sure we get regular education. They educate us regularly on patients that we take care of like coronary artery bypass patients and congestive heart failure patients, or the COPD patients. We have people in charge of those programs here at the hospital come down and in-service us so we know what to expect and what they want form a home health nurse. We work to educate people, to live within their disease, and try to keep them out the hospital and promote their independence. There’s a lot of education that takes place. Some of the nurses do it better than other nurses. Some have better interpersonal skills and some have better management skills. There are a variety of nurses that are there, but I think they’re all capable and educated. If we feel like we don’t know something, which happens, there is education. We have patients with chest tubes and they live with chest tubes in at their homes. We just had an incident and there was education on that. We’re always trying to keep up with the latest gadgets and techniques. Now unfortunately due to budget cuts, our nursing educator in our office is going to be going back to being a field nurse. It will be interesting to see what they’re going to do as far as nursing education. They also have to educate us all the time on new rules and regulations the government comes up, such as Medicare. So we’ll see. Hopefully, we won’t be negatively impacted too much by that.
Part of the history of the organization over the last twenty-ish years is a transformation from community hospital to a regional health care center. This question is, really, how does that impact, shape the experiences of home health nursing? [01:09:00] And part of what you could speak to is you have done this through a large teaching hospital, the University of Maryland, and you have work experience at a community hospital. I’m wondering if you could talk about the change you’ve seen here, but also speak to how you’ve seen it parallel other medical organizations you’ve been a part of?
Okay. You want to know—because Mary Washington Healthcare was a small community hospital and now has become a regional hospital and what have I seen as far as the differences in that, in home health care? They started the heart program here and they started that years ago. We see a lot of patients who have coronary artery bypass grafts and that’s an enormous surgery, but people are in and out of the hospital in five days. That’s incredible! They used to stay in the hospital two weeks. What a scary thing to have that surgery and go home and be in the hands of your family and only have a nurse come for thirty or sixty minutes twice a week for a couple of weeks and then once a week for a few weeks. We’re always there as a safety net, but the education is so important. We’ve seen, I would say, an increase of acuity of some patients. I don’t know that I’ve noticed a specific change as we’ve gone from a smaller community hospital to a regional one. We just kind of take the patients as they come. Whatever needs they have we try to meet them as best as we can. If we don’t have information then we go and we get information on how we can best care for that and for folks and their needs. [01:12:00] I know that there’s a difference from some of the population that I saw in Baltimore. I used to see so many patients there who were young African-American men who had gunshot wounds and had to live their lives as consequences of that. Almost all that was related to drug wars and so many of those young men’s lives were so deeply affected. When I lived there was a mayor, Kurt Schmoke. He was an African American fellow and he was fifty-ish. He said that he thought that the drug issue should not be a legal issue, but it should be a health care issue. So many people shouldn’t have these legal records because fifty to sixty percent of African American men in Baltimore had records. What kind of future can they have? And that it should be addressed as a health care issue. I think the change is so slow and it is coming about, but it is so slow. When I got to Fredericksburg, I have only had one gunshot wound patient. The population is different certainly, being in a big urban hospital and then being here. As part of the shock trauma rehab center I saw so many people who had big trauma injuries. [01:15:00] I don’t have the sense that I’m seeing as many of those types of folks here. I think some of the challenging cases still get sent to UVA or Inova Fairfax or MCV—probably Washington Healthcare doesn’t want to hear that. It’s not the head trauma center and it’s a different type of regional trauma status. We do what we can.
Part of the history of hospitals is that they are acute care centers, versus the kind of work home health nursing involves, a lot of education or primary care. What are some of things you have felt that the organization has supported in terms of educating the community, serving the primary health mission, which is different than acute care, and some of the ways you have seen that and some of the things that you have been most proud of developing in your own practice in home health nursing?
Hospitals are more acute care. I feel like a lot of times that home health nursing is a bridge. It’s a bridge between an acute situation that a patient is having to the wellness continuum. We’re the bridge between wellness and an acute situation. We do that through assessing patients, assessing what their needs are, and finding out from them what they want home health to be doing for them. I don’t know if you want specifics about specific things nurses do? Our goal is the continuum in health care, as the bridge to get people to wellness. When patients are certified for home health care services, you’re certified for sixty days. A plan of care is set up and to receive home care health services you have to be homebound. [01:18:00] Homebound means it’s a great or taxing effort to leave the home. That used to be pretty specific, but now it’s a grey area as people live with these chronic illnesses more and more. You have to be homebound. We’re a short term, intermittent service. Short term, meaning that we will come, for like the coronary artery bypass patients or congestive heart failure, and we will typically see them a couple of times a week. We will stay with the patient for thirty to sixty minutes a couple times a week for a couple of weeks and then maybe once a week for five weeks or to the end of certification period, depending on what their needs are. Some patients who have bad wounds and we have to pinpoint at our first visit that we don’t do daily wound care. Home health used to be paid per visit and used to be able to make money—the organization made money—every time a nurse went out, but now that has changed. When you admit a patient for home health care services, the organization is paid a lump sum of money and they have to allocate that to all the different disciplines: the nurse, the physical therapist, or the home health aid. That has changed and we no longer go out and see patients daily. We have to pinpoint someone in the family to change this big gruesome dressing. Then we go in there to do support. You are certainly well within your right to refuse. Patients or the family members can refuse to do that and then we can go in there more regularly. These days you really don’t have to do a dressing on a daily basis because there have been so many changes in wound care products. You can put special powders or salves around or specific dressing types into wounds. It’s best to leave them in there for days at a time so that the nurse doesn’t have to go out as much. They also help the wounds heal faster. They’ve done a lot more research on healing wounds. It’s interesting, when a lot of people hear the nurse is coming out, they think we are going to come sit with them for eight hours every day. Some people are disappointed to hear that we are a short term, intermittent service where we come for thirty or sixty minutes a couple of times a week. [01:21:00] Then it’s our job to educate them and say, “Well, this is what we can help you with.” A lot of the big things we do are assessments of all their body systems, check their vital signs, and check their pain level—all of the body systems. Patients these days are on so many medications. I had a patient once: twenty-eight different medications. That’s the all time record. Patients are on so many medications. Patients are also living longer than ever. We are going in and checking how all these medicines are working and how are you even able to manage taking that many medications at a time. We are teaching people about their blood sugars, diet, activity, and health. You are dealing with people who have had lifelong health issues. I’ve had patients who go and have part of their lung taken out for lung cancer and then you go into their house and they’re smoking. People with diabetes who just had a horrible diabetic hospitalization because their sugars are so high and you go in and they’re drinking regular soda. It takes a lot and it’s a team effort. It really takes the patient to be motivated. I remember when I was a fresh nurse coming out of school and I thought I had all this great information and knowledge. It just blew my mind that I had all this that I could share and people and a number of them were not so interested. Or they were, but could only make a certain amount of movement. It is over the years with nursing I’ve decided, you know, and I’ve really tried to inspire people and show them the benefits of maintaining good health habits. I myself try to have integrity with what I teach. [01:24:00] I’m not a big woman, but I have high cholesterol because I eat too many baked goods. I go to Eileen’s Bakery and Cafe too many times and I eat the beautiful desserts. My doctor had to tell me only once a month. I understand and I can empathize with the challenges that it takes to modify your behaviors. It’s enormous what medical care can do these days to keep people alive. Then you get to the point of the quality of life versus the quantity of life—that’s a big one also. We set up our plan of care and we work towards it and some people get wellness and they really on board, some people get part of the way, and some people will probably be back and forth. Some patients we see all the time, revolving doors. Some we’ll probably never see again because they’re in a good space. Was there another part of that question?
So it’s clear listening to you through the way you described working as a nursing assistant and in terms of bedside care, compassion, and empathy, and increasingly case management skills and educational skills in home health care. But I want to ask you about some of your clinical skills because I think it’s an important part of nursing too. If you could think back to your first couple years on the job at Sinai, what were some of the clinical skills you were most proud of having gotten good at and being able to practice well as a nurse in a hospital?
That was a really long time ago. [laughs] I got really good at running those IV lines and managing antibiotics and timing everything. We were doing that before we had pumps for IVs. Managing and setting them up so if you had four or five people on IVs, you have to taper them so they don’t stop at the same time. [01:27:00] That was a big one. I tried to give as much time as I could to the people and tried to hear what they had to say and hear their stories—so interesting. Making sure they were comfortable and making sure they smiled now and then. If I could get a patient to smile during a shift—wow—that was a great thing. I was good at handing out the pills and cleaning people up. The other clinical skills of the empathy, the listening, and the education—they were there, but in the hospital I didn’t feel like they were there. Not that I didn’t have empathy, care, and concern for my patients, but I didn’t have the time to do that like I have the luxury of in home health. I don’t know. I think I probably did a good job.
What would you most want the public to know about being a home health nurse that might not be common?
That’s an interesting question. We really enjoy our jobs. Although I think patients know that because I’ve had so many patients say, “Boy, it seems that you all like what you’re doing.” I remember one patient. He was an African American man and about eighty-five years old. I saw him for five or six months. He had congestive heart failure. And who would have thought that a middle-aged woman nurse and an eighty-five year old country African American guy could really hit if off and have fun and have an exchange of ideas? [01:30:00]. He’s so feisty and opinionated. The incredible stories he tells me: he was in World War II. He was in the Philippines, over in the Pacific, where he fought and he told me about how he fought along side Caucasians and they were all brothers. Then he came back to America and he went with one of his G.I. buddies to go have a drink in a bar and he was told he couldn’t go in, back in America. It really hurt him and this was the country that he was fighting for and then when he’s back on its soil it turns its back on him. He gives me food from his garden and I give him food from my garden and we tell garden stories. He’s a spiritual guy so we’ve had a lot of those conversations. I’ve gone out of that house laughing so hard and just having the best time. I say, “Oh my gosh. People shouldn’t know how much fun I’m having or else they won’t pay me.” [laughs]. I think we’re all like that, or the ones that have stayed in it for a long time. We really care about the people and we like to make human connections. I feel like I want to hear what they have to say because I want to honor people’s stories. I’ve heard some amazing stories and met some amazing folks in my travels.
Similar question about Mary Washington Healthcare: what are some of the medical practices, maybe nursing practices in particular, in this organization that you would want the public to know that might not be common knowledge?
Can you repeat that please?
What are some of the things about nursing and medical practices at Mary Washington Healthcare that you want the public to know that might not be common knowledge? [01:33:00]
That’s a good question. I think we believe in our mission. Sometimes I think that you can get so caught up in a system, in an illness, and the stress of all of it. Folks can depersonalize and dehumanize the people who are trying to give the care. I think that a reminder that people go into this profession because they want to help. They want to serve. Yes, I think that’s it.
The way I would like to end this is by asking a question that is actually two questions so. Is there anything I should have asked that I didn’t? Is there anything you’d like to add?
Let me see. I think you were thorough. I think have talked a really long time and I’m getting a little tired. And I’m a little tired of hearing my own voice. [laughs]
That question does not have to be answered.
What I can say is I’m going to refer to my notes. I think that I’ve pretty much said what I want to. I would say about home health nursing too and I would say that people will ask: we take out nursing students from several of the colleges around here and they wonder about how nurses feel going into strangers’ homes and people that they never met. Are we afraid? I would say that Baltimore was certainly edgier than it is here in this little town. [01:36:00] I feel that home health has really enriched my life and my ties to the community. I’ve seen the full spectrum of how people in our community live: people who don’t have running water, or people who have holes in the bottom of their trailers, and people who live in luxury mansions. The whole gamut of humans and humans’ existence. In some ways you feel blessed and it feels a little selfish sometimes. I’m fortunate. I also feel like humans are complex animals and we have some dark sides and some light sides. I feel like I am a vigilant about being on the side of bringing forth some of the great qualities of human nature. I’m not saying that I’m a saint or a good person. For me, it’s not my ego. For me, I feel like empathy and compassion and kindness just comes through me and I’m just a vessel for that. What a wonderful gift that is.
Thank you. That’s a great place to stop.
[End of interview]