Mary Jane Bowles

Transcript

00:00:08
Rigelhaupt:
It is November 7, 2014. I am in Fredericksburg, Virginia at Mary Washington Hospital. I am doing an oral history interview with Mary Jane Bowles. The first interviewer who you will hear is Austin Clay. I will be the second interviewer and my name is Jesse Rigelhaupt. So I am going to turn things over to Austin to begin.

00:00:28
Clay:
Just quickly, can you state your name and position here at Mary Washington Hospital?

00:00:34
Bowles:
My name is Mary Jane Bowles. I am the clinical nurse specialist for critical care services at Mary Washington Hospital.

00:00:42
Clay:
Can you tell me about your first shift as a nurse here?

00:00:48
Bowles:
Wow! My first shift as a nurse here was in the surgical ICU. It was October of 1997 when I started here. I came into the surgical ICU with cardiac surgery experience and that’s why I was recruited to Mary Washington Hospital. My first shift I was caring for a very sick cardiac surgery patient. That was my first introduction to the team. It was my first introduction to the surgeon, but I decided after that day that it was a pretty awesome place. I was glad that I made the transition.

00:01:43
Clay:
You talked about making a transition. Can you tell me a little about your educational background and places you worked prior to coming here to Mary Washington?

00:01:52
Bowles:
I graduated from Eastern Mennonite University in December 1981. I started at George Washington Medical Center in a combination floor of a medical neurology and overflow surgery; it was really a combination floor, forty-eight beds. I started there as a new graduate. They didn’t have anything like a new graduate program back then. You just did a certain amount of shadowing orientation with an experienced nurse and then started out on your own. I started there in January of ’82 and if you remember historically that was right after Reagan was shot. George Washington was the big hospital. [03:00] Consequently, I moved from that unit into the ICU there and what I learned from George Washington was many, many things. One of the largest takeaways that I took from that medical center was that I could have a patient that was homeless. Someone who was not so famous in one bed and in the next bed I could be taking care of the Secretary of State, which I did at one of my shifts. They were given equal treatment. That always to me was such an amazing, amazing thing that it just didn’t matter. Everybody was given equal opportunity, equal treatment, and that has become part of my mission. It doesn’t matter who you are. We should all be afforded the same level of care. That is one of the beautiful lessons I learned from that hospital.

00:04:24
Clay:
After you worked there, how did you end up transferring to Mary Washington Hospital?

00:04:30
Bowles:
From George Washington, I moved away from the area for a couple of years for personal reasons. I worked at the University of Virginia-Health Science Center. There I worked in their heart transplant and lung transplant unit. It was their open-heart unit, but my specialty within that unit became taking care of the heart transplant and the lung transplant patients. I had kidney transplant and heart transplant experience from George Washington but this allowed me to get into the world of lung transplant. I learned so much and it was such a good experience. I was at University of Virginia for a couple years and then moved back up into my old house again. At that point George Washington was in the process of downsizing, building a new hospital, merging, and being sold so I ended up going to The Washington Hospital Center. I decided I needed something different, other than my usual ICU, so I worked in their trauma PACU. [06:00] From that I was able to add—and really that’s the beauty of nursing is you have the basic skills but you can really move around and take care of multiple different patients. I had ICU background. I got the ICU patients so it was just a different place. Once again, you learn each place has their strong suit and one of MEDSTAR’s is trauma patients. I was able to really hone my trauma skills. Then, once again not because of the hospital itself but because of personal reasons, I moved. My kids were in high school. My son particularly was real heavy into playing sports. The commute from where I was living in Woodbridge and going into the city, you would be “white knuckling” it on the way home. I was trying to get home in time to see my son play basketball, which was very important to me. I started looking and they had just begun the open-heart program here at Mary Washington. They were looking to add a second surgeon. They wanted more experienced ICU nurses to help build the program. I came down here and ended up being recruited by the nurse recruiter. I ended up coming here to Mary Washington Hospital for that open-heart program.

00:07:50
Clay:
So can you tell me, because you have the ICU experience, what are the connections between the ICU and the cardiac care surgery program?

00:08:00
Bowles:
Here, the open-heart patients go into the surgical ICU. Some places have their own individual recovery room for open-heart patients, which really is an ICU. It is just focused on open-heart. Here, the open-heart patients go right into the surgical ICU. This is part of what I perceive as the beauty of the ICU. Other people beg to differ, but I like the diversity. One day you can have an open-heart patient and the next day a trauma patient. The next day you can have a neurosurgery patient and the next day you can have a thoracic surgery patient. I’ve always enjoyed the variety. That was part of my draw in coming to this ICU. The open-heart population has been my expertise for many years is part of the surgical ICU here. [09:00]

00:09:05
Clay:
Can you tell me some of your responsibilities working here at Mary Washington Hospital?

00:09:11
Bowles:
At that time when I came I was staff. Then in 2000 or 2001 they did some reorganization and they eliminated the centralized department of education. They opened up decentralized educators, meaning that the educators were departmentally based. I applied for the nurse educator position. I was accepted. I moved into nurse educator and that was for all of cardiac, not just the ICU. Then I was responsible for not just the ICU, but for the medical ICU, the step down unit, and for the medical progressive care units. I had all of those units. Then, I went back to school for my masters and I graduated in May of 2003 from Marymount University in Arlington with my advanced practice degree. Then I moved into my current role as clinical nurse specialist for critical care services. Now under my purview, I have surgical ICU, medical ICU, and cardiac/trauma step down, the surgical intermediate care unit, observation unit, and medical cardiac.

00:11:08
Clay:
I know you talked about education and I know you’ve done some continuing education but can you tell me a little bit about how education and nursing go together and about continuing education as well?

00:11:25
Bowles:
You want history, right? ANA in probably 1965, 1966, already mandated through white paper that nurses at the bedside, if they wanted to be called a profession, needed to have a degree. Their recommendation at that time was that it should be a Bachelor of Science in Nursing. [12:00] Larger hospitals, at that time, had their own school of nursing and the hospitals then started transitioning those diploma programs to associate degree programs. With the concept from the American Nurses Association, the ANA, that these associate degree nurses would go back and get their bachelor’s. That it would be eventually a bachelor’s of science at the bedside. Now 2014, right? That was ’65, ’66. Finally, we are coming to the point of it being mandated. By the year 2020, within hospitals, eighty percent of bedside nurses must be bachelor’s prepared. It was really interesting because way back when I was going into college, which was in the ‘70s, you went to your advisor in high school. I was told that for nursing you had to have a bachelor’s of science, so that is the road I took. I thought that was what you were supposed to do. To my surprise, when I came into the working world, I find associate degree, diploma, and bachelor’s degree nurses. There were multiple levels of entry. There were even licensed and practical nurses. Everyone really kind of did the same job. I think coming out of college my biggest “aha” was what I was taught is not congruent with what the educational requirements of nursing are. My expectations of what nursing would look like evolved and as I went into the intensive care unit. That was much more congruent with what I was taught because the larger component of nurses in the ICU were bachelor’s prepared. You just have a little different intensity of education requirements. [15:00] That is really interesting now that we are still having that struggle. To me, it just totally boggles my mind. As I walk around, and now with our new graduates we are hiring, we are having them sign an agreement that they will go back to school. They will get their bachelor’s if they come in with an associate’s degree—we don’t give them that option anymore. We will probably evolve at some point. I would venture to guess. It is evolving within other organizations where they are sending their staff back to get a bachelor’s degree. I’m assuming that we will evolve here, as we do on a national level. On a personal note, education has always been important to me—educating and knowing the “whys.” If you know the “whys,” you have a little bit of a greater passion of doing it correctly. That’s my philosophy. In teaching other nurses, I find that to be accurate. It has always been in my personal evolution to want to do that education process. I want to help the nurses give better care. Ultimately, that leads to better patient outcomes. What has changed in the last couple of years, the newer impetus, in education is nursing research. In nursing research there is a clinician out of the University of Pennsylvania, Dr. Aiken. She has worked very closely with a couple other physician colleagues. She is a Ph.D. prepared nursing scientist. She has worked very closely with a couple other colleagues, Dr. Buerhaus and Dr. Needleman. They have done large, multiple hospital studies where they have looked at patient outcomes with correlation to degrees. They have found that there is a direct correlation between outcomes from nurses who are bachelor’s prepared and better patient outcomes. They have also done studies where they have looked at just having your specialty certification and outcomes. [18:00] This doesn’t show better outcomes necessarily with certifications and outcomes unless there is a degree with it. So if you have a Bachelor’s Degree and a certification then there is a huge change in patient outcomes and now that we have data—data drives care. Now that we have that data we can no longer ignore those discrepancies between the education level and the nurses. This happened in the last ten years, five years really, since the publication of the future of nursing by the Institute of Medicine. They published that in 2010, 2011. Since that book came out and the completion of all the studies are driving change at the bedside so much so that my level of clinical nurse specialist has changed. Starting in 2015, there will now be a doctorate program requirement. I knew that it was coming down, given the literature. In 2010, I went back to school. I just finished with my doctorate in nursing practice. Starting in 2015, the goal is to have all advanced practice role nurses—whether it is nurse practitioner, midwife, CRNA, which is a Certified Nurse Anesthetist, or clinical nurse specialist like myself—be a doctorate prepared nurse. There are big changes. You probably did not want that long of answer about the evolution of nursing, but huge changes.

00:20:06
Clay:
What are some things that you had to learn by actually working as a nurse that you wish you would have learned through your education programs?

00:20:23
Bowles:
I think probably a greater focus in nursing school on psychology and maybe even a component of sociology, of looking at diversity. We are at the bedside. We have over the years gained a greater understanding of disease processes and we can change practices. [21:00] Technology has advanced, so you can’t really teach that in nursing school. As you come out you have to learn technology as it advances, but human nature by and large doesn’t change. You have to be able to handle the diversity of personalities and the mental health issues. If you become sick with a disease process you don’t leave the mental health at the door; you bring it in with you. I know I started out on neurology, so maybe I was faced with that more initially then some nurses. I had a minor in psychology. Some of that stuff I used more than what I learned in nursing depending on my population. I think there is going to be a shift—there has to be and there needs to be more—to equip nurses at the bedside with more interdisciplinary education. I’m hoping that will come with the changes of requiring bachelor degree nurses at the bedside.

00:22:38
Clay:
What is the hardest thing about being a nurse?

00:22:48
Bowles:
You are taught in nursing school not to get attached to patients. You have to learn to be professional: you go in, do your profession, and then walk out of the door at night. Humanistically, I don’t know how you do that. I’ve been a nurse over thirty years. I still remember some of my key patients way back when I started. Throughout the years I just don’t know how you do that. I teach my new nurses that you will carry it with you, particularly your very difficult ethical cases and trauma cases. You just have to have some outlet to deal with that or else it will eat you up. That is something I learned over the years. [24:00] If I had a very difficult case I would go home and my house would be spotless because man I could scrub. It was my way of releasing all that built up emotion of the day. I garden now. I can weed some flowerbeds after a bad day. As humorous as it sounds, it is so therapeutic. That’s what I teach the nurses. You have to have something that you enjoy. Doing that is therapy that can help you work out those emotions. I think of the old adage, “Yes, we are a profession and you walk out at the end of the day. Yes, we are a profession, but we are a human profession, taking care of humans.” There has got to be some way that you help the staff handle those emotions because if you don’t they burn out and then we lose them. I think in the future we have to do a much better job of that.

00:25:28
Clay:
When you were in school do you remember them teaching any different things to handle burn out, different strategies?

00:25:40
Bowles:
It was not a huge topic of discussion but remember this was late ‘70s and ‘80s. I’m sure it is now. I don’t know because I’m not in the curriculum world. I hope it is now, let me put it that way.

00:26:04
Clay:
Just before I finish and let Dr. Rigelhaupt ask you some questions I just want to ask you one last question. What are you most proud of from your job here at Mary Washington Hospital?

00:26:26
Bowles:
I had a physician tell me one day after we were having a quite heated disagreement—not that I would ever disagree with anyone. He said that the day I walked into the door at the ICU at Mary Washington Hospital, the level of professionalism changed. [27:00] I have not ever forgotten it. If I can keep it at that level, then that is what I’m most proud of.

00:27:10
Clay:
Very good. Thank you.

00:27:15
Rigelhaupt:
So looking back to that first interview as you are learning about the potential of working in the ICU here, what do you remember hearing about the ICU. How it was described to you and some of the things you might work on if you accepted the position?

00:27:32
Bowles:
Back then the big focus was on growing the cardiac surgery program. At the time, I brought knowledge of the cardiac surgery population. I had already participated in critical care courses, teaching as an instructor in critical care courses both at George Washington hospital center and at UVA. So it was coming for the expertise at the bedside but also coming to help teach and grow the staff. I remember taking a tour. You have to remember, I worked at a very old GW that was built in the 1800s, probably. Then I worked at the Washington Hospital Center, which was a maze. You had the old part of the hospital and then it grew new wings but the core of the hospital was very old. I remember them telling me it’s a new hospital. They had just moved from the old site at 2300 Fall Hill. It was new and it was all private rooms. That was, “Wow! All private rooms. Really?” So I came up and took a tour. I remember after leaving from the interview that I thought, “I don’t even remember what we talked about.” I just remember being in awe of how new the hospital was, how clean it was, and how all the rooms were private. I just thought that was fabulous.

00:29:30
Rigelhaupt:
What were some of the surgical cases that were emphasized in the interview as you were beginning, whether it was the nurse you interviewed with or you interviewed with Dr. Armitage, who was heading the department?

00:29:50
Bowles:
I did not interview with Dr. Armitage. I interviewed with a nurse manager at the time. The patient population we talked about of course was cardiac surgery. [30:00] Then they were also recruiting a neurosurgeon. They were hoping to grow the neurosurgery population with the pipedream that in the future of possibly keeping trauma. One of the first committees I was on in the cardiac surgery committees. One of the first hospital committees that I remember participating in was in trauma planning. We are twenty years now with our open-heart surgery program. We just celebrated the twentieth anniversary. That was already up and running when I got here. Now it has changed and evolved. We’ve done a lot of stuff with that. Equally important has been the growth of our neurosurgery population. It has evolved into trauma services, which start in ‘94 to now being a Level II trauma center. Way back when I interviewed in ‘97, what is in fruition now was we need to get a neurosurgeon in. We need to develop the competencies in the nurses to care for the neurosurgical population. That was a huge discussion when I was hired given my prior trauma background at the Washington Hospital Center. Those were the two highlights of the interview. I did meet a couple of the staff that day. I don’t remember meeting any of the surgeons that day, but I did meet a lot of the staff.

00:32:00
Rigelhaupt:
So right around the time that you started there was a second cardiac surgeon that had begun.

00:32:07
Bowles:
Dr. Mcmanus.

00:32:13
Rigelhaupt:
What were some of the changes that happened in the cardiac surgery program in the first year or two that you were there?

00:32:23
Bowles:
Volume and standardization. Once you bring a second cardiac surgeon on board, now they come with their own protocols. You have the protocols that are established by the first cardiac surgeon. Then a second cardiac surgeon comes along. Now you have to synchronize those two protocols and standardize it so that it works for your population. Then, with growth and with the second cardiac surgeon on board, you could run two OR rooms simultaneously. [33:00] So you don’t have one patient coming in, you have two. Now you have to work with staffing changes. You could have two critically ill patients coming out at potentially the same time. It was more during that time. Not so much change in what we did, but growth of volume in those first couple of years. That was a change from having a single cardiac surgeon here. He had to have days off. If he had days off then there wasn’t anyone covering for him. At that time there was one interventional cardiology team and it was a team. There was one group. They took off and then the preload to the cardiac surgeon usually went down. That’s when the cardiac surgeon usually took off. Then our staffing totaling went down. Now that you had two cardiac surgeons, that all changed. If someone took off there was still someone there—there were always cases being done. Then we started recruiting on the backside of that and we started recruiting interventional cardiologist. We started getting a second group. Now, after that we had even more patients. I think in those years what we focused on more than anything else was growth. Then in 2000, 2001, 2002, all of our data from cardiac surgery was put in the thoracic surgery database, STS, as it is shortened. We started coming out with stricter guidelines as to how things should be done. Staying on top of that then became the changes in the 2000s. There were stricter guidelines of glucose management and fluid management in that population. Side effects and care of renal failure and arrhythmias and all of that was standardized. Bringing all that in then became the next focus.

00:35:53
Rigelhaupt:
It sounds like adding a second cardiac surgeon doesn’t so much change what the cardiac surgeon does in the operating room.
.
00:36:00
Bowles:
No.

00:36:05
Rigelhaupt:
There may be two, but they are doing what they are trained to do. But it does sound like two patients coming out at the same time and headed to surgical ICU, that would have a dramatic change in nursing and nursing care. So how did nursing have to change in the ICU particularly with cardiac patients with a second surgeon and the potential for simultaneous surgeries?

00:36:30
Bowles:
We changed our staffing model. Historically, you work from 7:00 a.m. to 7:00 p.m. These patients usually come out between 10:30 and 12:30. The second nurse started coming in and working from 11:00 a.m. to either 7:00 p.m. or 11:00 a.m. to 11:00 p.m. The nurse that was going to get the one cardiac surgery patient had to transfer their patient out to the step down unit. They would take the first cardiac surgery patient that came out. The other nurse that came in at 11:00 took the other one. So how it impacted staffing was just that we had to change a little bit and bring that second nurse in at eleven o’clock. The standardization was probably easier on the nurses because historically it was you would treat your patients one way. You would treat your patients another way. That was no longer an option with the standardization. It is very recipe driven. You individualized it based on how your patient is reacting. Everyone gets the same thing. From that standpoint, the standardization that occurred in the 2000s was not just for cardiac surgery. It was cross the board. All societies of brain surgeons, societies of thoracic surgeons, societies of general surgeons were all standardizing their care. It has even gotten more prescriptive in 2010 and beyond with antibiotic therapy and surgical guidelines. From a nursing standpoint we like that. From a physician standpoint, not so much because their methodology is the best. It’s the age we live in.

00:39:00
Rigelhaupt:
So one of the things that I have heard about the cardiac surgery programs was that it was one of the first programs here that took a more team orientated approach between nurses and physicians because of the complexity of the patients versus being at a community hospital where the physicians would come in. The complexity of cardiac patients meant that there had to be a greater sense of teamwork among the nurses and physicians. What did you sense as you started to be the sense of teamwork among the physicians and nurses in the cardiac program?

00:39:50
Bowles:
I think coming from a university setting where I worked on the floor you had that camaraderie with the team because part of what was on your team were residents and interns. Coming to Mary Washington I found the cardiac surgery program was what I expected. It wasn’t as different to me as it was to nurses who were first initially trained here. The team and the majority of the team came from Pittsburgh with Dr. Armitage. Both the perfusionists came from the Pittsburgh area. The PA that they brought down with them came from the Pittsburgh area. A couple of the respiratory therapists came from the Pittsburgh area. So that whole team came down and relocated here. It was real change in paradigm for the nurses who were here. It was a very team approach. When I came and I was like, “Who teaches the classes?” The initial classes were taught by the team who came: it was Dr. Armitage and the physician’s assistant. They taught the initial classes. It was very collaborative in how they took care of these patients. As they set up the program—probably years ahead of themselves—part of what they set up was not only do we want to take care of patients here in the hospital, but also we want to ensure that when they go home they are taken care of. We no longer have these rooms, but initially we had transitional care rooms. It was where we had the open-heart patient in this room and we had an open door that was going in between where the cardiac surgery patient was in the step down unit and the room next to it. [42:00] We had the family stay in that room. We taught the family how to take care of the patient when they go home. Once they got home we set up, which we still do, home health visits. A home health nurse would come see them in their home and make sure they were doing okay. That concept, I mean wow, that is part of affordable health care. That’s really the continuum of health care that is really what affordable health care is about. It’s not just about care at the hospital. We need to ascertain that. When we send these patients out, the next provider knows what we’ve done. They are taken care of in their homes. They don’t turn around and come right back in the hospital. Kudos to Dr. Armitage and his team to have that vision as they set up the program—that that is how they set it up. It was totally visionary. Now once we get into the bed crunch of current years we had to take away those transitional care rooms, which broke my heart. I think they had such value. We have put in place an individual that we call a cardiac surgery navigator. Her sole responsibility is to see these patients pre-op and talk to the family while they are in surgery. There is a flow of communication from the surgery to the family in the waiting area. They meet with the family immediately after surgery. They make sure that the family has all the information they need for taking the patient home. We’ve gone out in the community and done education with our rehab centers where we send patients to make sure that they know how to properly care for these patients. That vision and that team is just what we need in health care.

00:44:30
Rigelhaupt:
When you started here in 1997 most of the programs that define Mary Washington now as a regional medical center were not in place. Were you surprised to practice at what was a new facility, but still a community hospital, and that mirrored what you had experienced at UVA, GW, [45:00] and Washington Hospital Center, that were all teaching hospitals?

00:45:10
Bowles:
I was more surprised at how other services were lagging behind. We had a dynamic new cardiac surgeon that was changing the face of Mary Washington. He was the hot ticket. To me, the teamwork of the cardiac surgery population was the standard. It is what we have worked so hard in the last couple of years to make the standard, the expectation, and it is now. Bringing the hospitalists on board so that we have 24/7 coverage of the patients in the hospital that was huge, huge, huge and it changed the way we do business.

00:47:36
Rigelhaupt:
Do you remember a practice or a clinical area that first began to emulate the kind of teamwork that you were working with and experienced as you began in the cardiac surgery program?

00:48:00
Bowles:
I’m just trying to figure out which group probably stepped up to the plate. I think one of the groups that we started working with very closely was the pulmonologists. The pulmonologists were our caregivers for the medical ICU population: your pneumonias, your COPD, or anything that came in from a medical condition. They covered it in the medical ICU. They came in and they wrote their recommendations down. Then it was still based on the physician that had that patient on the outside to carry out what the recommendations were. It was a very disjointed process. With Dr. Ryan, vice-president of medical affairs and who is now retired, and Dr. Fuller, chair of medical ICU, who is now out in the sleep medicine study, we began to have physicians partner with nursing to improve ICU standard care. Back in the ‘90s, we began looking at how we could make this process better and make it more of a team. We looked at Fortune 500 companies and what were the Leap Frog criteria for care within the ICU. For that population and from a hospital administrative component, they looked at how financially we could bring a team in to give care for this population. That team probably was the first to emulate that whole cardiac surgery team: from in the hospital ICU, to following a patient out to the floor, to how do we make sure that they don’t turn around and come back in. Now it is the standard of care. When we set up the trauma services it was. Dr. Roberts who was recruited. He wasn’t here to see the cardiac surgery because he came in from West Virginia. It was that same team approach: “I have my team. I have my nurse practitioners. We make rounds and we make sure that everyone knows what is the expectation of care for the patient that day.” [51:00] They put in the same quality performance initiative that we had in the cardiac surgery. Although cardiac surgery was the forefront, it has become the standard, “which is a beautiful thing,” as Martha Stewart would say.

00:51:28
Rigelhaupt:
To develop these new programs and to focus on a collaborative approach probably takes a relationship between the physicians, the nurses, and the administration. What do you remember about how those groups worked together in the cardiac surgery program as you began working here?

00:51:56
Bowles:
When I first started working here it was Kevin Van Renan; he was the director of cardiac services. Fred Rankin was CEO and Shirley Gibson was CNO. The collaboration between surgeon and administration was very close. They worked very well together. I think as the hospital has grown it has probably had growing pains. When you are running a program like an open-heart program, but only have 200 beds you have to worry about from an administrative perspective, you can give a lot more resources to an open-heart program. When you are an administrative team and you have 437 beds at one hospital and the potential for 100 beds at another hospital—somewhere around fifty patients, but you still have the potential for 100 beds. The resources you can give any one program are not as great. Then you have other programs. You have trauma. You have center of neuroscience. You have Virginia vascular and heart institute. I think the perception from the different groups is that maybe they don’t have as much support. I don’t know that it’s really not support. It’s just that administration doesn’t have enough time. [54:00] It’s like two parents. If you have one child they get a lot more attention. If you have nineteen or whatever that show is, there is just not as much time and more limited resources. From the perspective of a nurse negotiating between the two in my role, I think there is. From an administrative standpoint, they just can’t hand over the Gold American Express card all the time. From a structural standpoint, they are trying to make it work and trying to do what is the right thing for the patient, in this organization, Mary Washington. What makes it stand out in my mind from some other organization is they really do work hard to, at the end of the day, make sure we can give adequate patient care at the bedside. I think it comes a little bit with education and community focus. It’s not just a patient within the organization: it’s a patient within a community. It’s a little bit of a different feel being within Mary Washington than being in a larger urban organization.

00:55:45
Rigelhaupt:
So the questions of resources and questions of how an organization will develop are connected to the values of the mission of an organization and that is certainly something that I have heard about in these interviews. What do you remember hearing about how the mission was articulated and the values of the organization as you started working here?

00:56:07
Bowles:
It was the first day of orientation. I mean it was a core part of the hospital’s orientation. I don’t remember which executive it was that did the opening in the orientation, it was too many years ago, but I remember hearing that articulated upfront. We are part of the community. We value you being part of the community. Our job is to improve the health care of the community and that was stated over and over again. It truly is the core of Mary Washington Hospital. When you are talking about whether it is starting trauma or open heart, it doesn’t matter what it is. [57:00] It is the groundswell from the community that is asking for these services. We have the facility here, why don’t we do it here? Oncology is another program, although I’m not so involved with them. It is more outpatient. And yes we have an acute unit in the hospital that is also very much community driven if I am getting chemotherapy. If I have to come in every week for a two to three hour period, then please let it be at my own facility and don’t make me travel to Richmond. I think one of the things that I appreciate about Mary Washington, what keeps me here, is how strongly they feel about addressing the needs about what the community wants. I think it’s what makes the organization special.

00:58:11
Rigelhaupt:
Hypothetically, a transition from what was a community hospital, with the name community connected to it and it had that focus. Hypothetically, this transition to a regional medical center with surgical subspecialties and higher levels of care, there was the potential to lose that focus on the community. Why didn’t that happened?

00:58:49
Bowles:
I think it is probably two fold. You have administrators that kept that on the forefront. They live in the community. It is unlike an urban area where you have four or five different hospitals. Nurses job hop to where the next sign-on bonus is. You don’t have that in this area. You have two hospitals. They live in the community. They are more invested in the care with the hospital being in their community. That’s the one side, the organization side. Then the physicians also live in the community. In metropolitan areas again physicians will be listed at multiple different hospitals. [01:00:00] They will operate at multiple different hospitals. They are starting to do that now where you see particularly our Stafford groups also up in Northern Virginia. Our physicians here have HCA in Spotsylvania. They are still within the community. They still want to make sure that it maintains that community focus even as we are growing—and how we’ve grown and changed. I mean, we just have. There are very few patients that we fly out to MCV or Inova anymore. When I came here part of what we went through in training is how do you transfer. Who you do call? Probably open heart was the first one that was the impetus to change. Now, it’s why are we flying them out? Should we be? It has changed that paradigm.

01:01:22
Rigelhaupt:
So you’ve been here roughly seventeen years. I want to ask you about what milestones, signs of growth, and things you think the organization should be proud of. Try to break it into five-year chunks so maybe in those first five years, 1997 through the early 2000s. What are some of the things that as you look either clinical practices or changes in nursing that you would point to as important signs of progress in the organization?

01:02:01
Bowles:
Shared governance. Within nursing we implemented a robust shared governance model. All of the units had a unit council. The expectation was that if you wanted to improve the care of the patient, who better to do that then the clinicians who were caring for that patient? In that vein of changing the practice and caring for the patient it had to be based on vigorous literature. You had to bring in your collaborative partners into making that change and then from the unit base. [01:03:00] We developed hospital-based councils so that what was happening on one unit could be discussed with what was happening on another unit. Care was not so siloed. You had that communication across specialty lines. From a nursing perspective, I think that shared governance was probably the biggest impact in the first five years.

01:03:40
Rigelhaupt:
Can you think of any specific things that came through that? Where nurses brought ideas to physicians or to the administration that were implemented?

01:03:54
Bowles:
I think the first big change through shared governance was not necessarily constructed with physicians. There were a lot of unit-based things we did with the care of the patient at the unit level. We still were under the mindset here when I first came here that a nurse is a nurse is a nurse. With the shared governance model and the growth of the organization, the cardiac nurse doesn’t always know how to care for an orthopedic patient or vice versa. The nurses were becoming more and more specialized. It was very hard for me to come in even though I was an ICU nurse. For them to say, “Okay, we don’t need you in the ICU today. You go out and work in, I don’t know, Timbuktu.” Staff was dissatisfied with that model. They went to search what was the best practice model. They came out with a model of, “Yes we know that we have to have some ability to flex, but let’s make it within our care centers instead of the larger organization.” Within our medical care centers there are some commonalities and within surgical care centers. There is commonality within the critical care center. There is commonality, so let’s make it floating within the care center and not critical care to surgical. That was very successful: it met the needs of the organization, but also highlighted the benefits of nurses’ specialty. [01:06:00] We still have that model in place. It has expanded. It has a little bit different meaning. We have ICUs at Mary Washington and we have ICUs at Stafford. It’s not just Mary Washington that we are looking at. It’s also Stafford Hospital. That opens up taking that same blue print that was established, expand it, and still make it work. From nurse collaboration with physicians, I think it was the beginning of a lot of our standardized order sets. That was very much collaboration between physicians and nursing. When we are doing an appendectomy, we might have twenty different orders from twenty different physicians. It is still an appendectomy so let’s take those twenty and make it so that appendectomies are all treated the same way. In that first five years when we started it, it probably didn’t take hold until the later 2000s when all the guidelines started to come out. It was that initial discussion. We used to joke that there was a protocol for everything, even when you eat and go to the bathroom. We have a protocol for everything. What we really did during that time was standardize care, which was so incredibly important.

01:08:14
Rigelhaupt:
So thinking about the second time period, from 2002 even maybe to 2010—my question isn’t really year specific. I’m just trying to break it up into smaller chunks of time. What are some of the milestones you would point to as far as standardized order sets or are there other things that really contributed to the expansion and growth of Mary Washington Healthcare during those years?

01:08:39
Bowles:
Huge. Those were really exciting times. We built the freestanding ambulatory surgery center. It opened up, probably 2003, 2004. [01:09:00] We opened up the west wing of the hospital in 2004. We opened the freestanding surgery to what I would call a lot of easier patients. I don’t think the patients would like that term. Those surgeries that used to be outpatient were no longer here at the hospital. They were in the surgery center. Now what were on the docket for surgery here were cases that were more acute. Which now totally changes your nursing care because those simple appendectomies, you didn’t have them. All of your patients were sicker. So with that we looked at and brought in hospitalists. We realized that the expectation of those sicker patients is that you had to have a physician here on sight to meet the needs of the patients. Now that changes your relationship with the community physicians. You have to develop a different relationship with them. We have very few community physicians that come into the hospital to see the patients anymore. It is almost all hospital care driven. We have more specialists now. With trauma you have to have subspecialties to maintain your trauma. Subspecialties don’t like to hang around just to wait on the trauma patients. Now you are bringing in another group of patients that normally would have gone to other organizations. Now they are in your system. The volume of what we have to teach from when I first started educating the staff to educating the staff now is totally different. When a nurse comes out of nursing school they have the basic tools of how to care for a patient. What they have to learn when they come into the hospital is how to apply that with this population, this population, or this population. Those populations are growing so that really changed that paradigm of care. [01:12:00] Then toward the late 2009, 2010 we were so full we didn’t know where to put patients. It was everyday this time of the year. Coming in we had so many patients in the ER. We didn’t know where to put our patients. Of course that has been getting that certificate of need for building Stafford Hospital and then opening Stafford Hospital, which I think opened in 2009. It was the success of bringing patients to the hospital, and then it was an, “OMG what do we do with them?” That was huge and to then go to having to build another hospital. It was every day of, what is changing today?

01:13:20
Rigelhaupt:
So what you describe, with the higher acuity patients in the patient setting sounds like it also fits with national trends in terms of hospital based care. But I want to ask you about that in terms of your role as an educator and in thinking about the nursing program in general terms and change, in the sense of what are some of the things that you are really proud of that the nursing staff is really good at? And that reflects the changes to treat sicker patients that is different than when you started here? In general, what are the nurses really good at here?

01:14:09
Bowles:
There was a large focus starting in 2002, 2003 with our initial beginnings of trying to make Mary Washington Hospital a Magnet organization and we focused heavily on our shared governance, which was up and running. We also focused on making sure that nurses understood what it meant to give evidence based care. That was a huge component of every class that I give, still is. It is not good enough to say this is the way we do it just because this is the way we do it. Rather, this is the way we do it because of the outcomes that we know will occur if we do it this way. [01:15:00] This is what research shows us if we implement this. These will be our outcomes. The first real taste of that I think the staff realized was when we implemented a ventilator associated pneumonia protocol in the ICU. It was a collaboration in 2003 between our own unit based shared governance, led by myself and Dr. Brown. We changed that every patient on a ventilator needs to have these elements. Part of it from a nursing standpoint is every patient had to have their head up in the bed up thirty to forty-five degrees. They had to have intensive oral care. From the physician standpoint, these patients had to be on the right antibiotics and had to have DVT prophylaxis and GI (peptic ulcer) prophylaxis, which we’ve now found is not really true. At that time yes and it was implementing that bundle care. I remember implementing that and not just the nurses. The nurses’ assistants were to be my checkers in making sure that the nurses did the intense oral care. They would come and get me and they’d say, “Mary Jane, it is all stuffed in the bottom drawer there. They’re not doing the care they should.” I started showing the correlation between how many patients and ventilator days we had and how many supplies we had to order. The incongruence between those two numbers meant I knew they weren’t doing it like they should. It came to the point of then showing the nurses, “Okay, this is how many occurrences we had of ventilator associated pneumonias. This is how it is coming down. To the point where in 2005 we had none.” Showing that data to the nurses all of sudden it caught on. They realized that fruition of what they were doing and how amazing it was. [01:18:00] What a change they were making and it was now like, “Whoa. I’m pretty good. I give good care.” They were so incredibly proud of the care that they’ve given that when we’ve carried out other processes very similar to that with other change practices in the ICU it has been the expectation. Instead of the exception, now we are being able to show them national numbers and this is where hospitals are. Then this is where Mary Washington is. Then you think we are a committed hospital. Now we have a case mix that tells you the acuity of our patients and are our patients are just as sick. It is helping them realize that and helping them understand how awesome they are. The good care they are giving has now caught on to where we have Eleanor Redmond doing that with the stroke population. We have Cheri Basso doing that same kind of thing with the heart failure population. It has changed the paradigm of care at Mary Washington. It has been amazing.

01:19:52
Rigelhaupt:
Could you talk about—were you involved with the process of achieving Magnet status?

01:19:55
Bowles:
Yes.

01:19:56
Rigelhaupt:
Could you talk about the history of achieving Magnet status?

01:20:02
Bowles:
When we submitted our documents in 2003 for the first time the documents were accepted, but we did not achieve Magnet status at that time. When they came on-site there was still disconnect between the populations of nurses and understanding the breadth of what Magnet status is. Instead of hanging our heads, we collectively said, “We have got to charge ahead and we are good. We have to build on the foundation we have started. We have to build on it.” That was part of, one, standardized care; two, it was evidence based; and, three, the nurses knowing it was evidence based. [01:21:00] Having them involved in that aspect of what I tell the staff is, “This is what we have to do. This is where we have to get to, but how we get from here to here, you have to decide.” So it’s having them in that decision making process. By 2009, when we submitted our documents, the second time, I was involved in that also with Sara Phillips. By the time they came on site to do the 2009 visit there wasn’t a nurse in the organization that didn’t—well some might have had a few. For the majority of the nurses, they were very confident that we were that good. We deserved to have that Magnet recognition. Through that whole process we had physicians involved. They were involved in our collaborative practice groups and still are. They’ve been involved in those collaborative groups. When we sat down with interdisciplinary groups and talked to the Magnet surveyors, they were like “Wow!” They walked out of the meetings and even said, “You have a really strong interdisciplinary team.” Into the last step, where you have the public hearing—the surveyors are in there and you can have members of the team come in and speak. We had multiple physicians that came and spoke. They talked about how great the collaboration is between physicians and nurses. Patients also came in. What was also neat during that whole collaboration was that the nursing schools in the area came in. The nursing schools talked about how great the collaboration was between Mary Washington Hospital and the nursing schools. It was a wonderful time. We have submitted our documents again. We are up for accreditation renewal again. We have gone through a lot of changes in the past year, a lot of cuts. I think it’s going to be very hard on the staff. [01:24:00] It’s going to be a more somber visit this time. The nurses still are being recognized for giving quality care, by our excellence in our stroke, our disease certification, and our open-heart status. I mean we were just re-designated as Level II trauma. They are still doing the quality of care. It is just harder to do it. But that’s health care 2014.

01:24:41
Rigelhaupt:
What do you remember about the moment that you found out the hospital had achieved Magnet status in 2009?

01:24:53
Bowles:
There was a call. They called and let you know. You don’t get a sense when they are here on site as surveyors, unlike the Joint Commission. At the end the Joint Commission will tell you, “We found x, y, z, deficiencies or we didn’t find any.” They really give you a sense of how the visit went. With Magnet it’s different. They really don’t give you a sense. You do not get the feeling it went pretty well or not. They are pretty poker face. They don’t let you know one way or another. They submit their findings to the Magnet Commission and the Magnet Commission has your documents. They have the findings from the site visit. It’s the commission that makes the final determination. Then they will call you. They give you a time when they will call you. If you even get a designated call then you know it’s pretty good. We made our call out in the atrium. We invited all the nurses down. The atrium was full. It was packed with nurses and we put the phone call on speaker—not just the regular speaker, but on speakers so that everyone heard the designation. It was a mad cheer. It was good. Whether we got it or not, the nurses got to a point where were felt we were Magnet, although the award is very good. [01:27:00] It’s very nice. It was a very palpable feeling through the organization and not just on that day. During that time, the dynamics were changing and we were changing the expectation of nursing care within the organization. One of the things that the Magnet surveyors said was what had happened around 2006, 2007 is we sent out a survey to the staff through shared governance. The CNO wanted all the nurses to wear the same color and all the support associates to wear the same color. There was a survey sent out at that time through shared governance asking, if we do go to a standardized color what should it be? And how should we roll that out? That recommendation from that survey went up to the nurse executive group. The nurse executive group made the final determination of navy blue and how it should be rolled out. They didn’t bring it back down to shared governance. They just made the final determination. The nurses were up in arms. They were like, “No that is not the shared governance process. They should have brought it back down. It should have been the staff that had that final determination. You didn’t follow the process that we had in place.” The Magnet surveyor told the whole shared governance, but also the nurse executive team. Once you get to that level, it changes how you do business. You will never make that mistake again. You want to have that nursing voice. They have it.

01:29:27
Rigelhaupt:
You talked a little bit about the opening of Stafford, the second hospital within the health care system. What has been your involvement with Stafford Hospital?

01:29:51
Bowles:
Little. Not much other than I go up there to do education at times. [01:30:00] As we were going through the process of setting it up, there were meetings that I attended looking at what is needed in the small ICU. The Stafford ICU is a smaller version of what we are. They don’t need what is at Mary Washington Hospital. They were kind of taking the same blue print of supplies of what we were doing at Mary Washington. It is like, “No, they don’t need all this stuff.” I was in some of those meetings. The first people that were put in place were the executive team. Even though it is part of Mary Washington they really wanted Stafford to have their own identity. They worked very hard on establishing a group from Stafford to build their own team. Did I have some advisory capacity every once in a while as far as ICU? Yes. But that was really it, they did a very good job at having Stafford independently grow and have their own identity.

01:31:40
Rigelhaupt:
You mentioned that early on even during the time of your interview that there was talk about starting a trauma program. Could you talk a little bit more about the history of starting a trauma program? I mean did it start from small discussions, to maybe a little more serious water cooler talk, and then really the process of planning that program?

01:32:009
Bowles:
Yes. Early 2000s one of the general surgeons, Dr. Earnhardt, was chair of our then trauma committee. At that point, our discussion focused on with our capability of what we have at Mary Washington Hospital current day. What is the patient population we should be keeping? What is the patient population that is not safe here too? Then it was evolving to, “Okay if we hire a designated trauma surgeon what would that look like? If we are going to have a trauma surgeon, is there enough volume for them?” Let’s get the volume of how many patients we transfer out and what does that volume look like. [01:33:00] What is the primary diagnosis of those patients who transfer out? We started having those conversations. Then, “Okay, we need to start putting some trauma protocols in place. Wait, we probably shouldn’t be putting trauma protocols in place. We should bring a trauma team in cause they are going to want to put their own protocols in place.” It evolved over the years from what can we safely keep, to what is our volume, to let’s look at is there a need in the community, and finally to yes there is a need in the community. Then it was on to a Certificate of Public Need. Then there was talk of establishing protocols to wait: we probably shouldn’t do protocols until we have at least a director and a trauma nursing director in place. We also need a trauma surgeon in place. Once we had the director and surgeon in place, that evolved to, “Okay, now do we have the proper equipment do we have the proper protocols?” The director and surgeon were both here on site. The surgeon would just do regular general surgery and emergency general surgery. They were here on site for several months with us building protocols and doing drills before we actually turned on the light. Part of that, I subsequently was involved in. I was involved in the building upfront within the hospital and the transfer of patients from ED to ICUs. Then I was on to the step down. At the same time we were building that trauma team. The team was out in the community building support, educating, and of saying, “Hey this is what is happening and you can now bring our patients here instead of flying them to Inova, VCU, or UVA.” The team was working on that from the EMS perspective. By the time that the light went on and we were open for business there a lot of leg work has been done and protocols in place. By the time we actually went live we had the clinical guidelines team. [1:36:00] I was on the team, but then there was a whole other clinical performance improvement team and the administrative team. I was just on one component of it, but still to this day we still continue to do drills to make sure that we keep up our skills. There is still a close relationship between the ED team and the ICU team. The ICU nurse still responds to the trauma codes for that continuum of care, from bringing that patient up from the ED to the ICU. A lot of those things that the clinical guidelines team had set up initially are still in place. Part of what Dr. Roberts did in that initial trauma build is what we actually had in the trauma bay. He put footprints of where in the bay everybody stood so that when that first patient came in it wouldn’t be like a panic. Everyone knew exactly where they were supposed to stand and what they were supposed to do. He and the director really set the stage for that and to make that successful. It was probably a good ten years in the making, if that makes any sense. Those initial meetings were very changed from talking about who we need to transfer out to who we need to keep and how we evolve the programs. To go through that whole process was very interesting.

01:38:03
Rigelhaupt:
So part of what you had developed some expertise in before coming here was trauma and PACU. I think myself and the general public probably has a at least a misguided opinion trauma, probably from television shows of the frontend of trauma and ER, but this is a long term process and it is not that first golden hour in terms of treatment. What are some of the things that are really important in building a trauma program that follow, that first traumatic entrance into the emergency department that make a trauma program successful and should be emphasized here?

01:38:45
Bowles:
Trauma is acute care, but that is a very small component of it. Most of trauma is rehab. [01:39:00] Yes, we want to be successful so we can send them to rehab. That is important. But it’s rehab. I mean, if you are talking a spinal cord injury comes in, they are in the hospital five, seven days tops, but they are in rehab for two sometimes three months. What changed community wise with the advent of trauma was HealthSouth. Just as we were talking about building a trauma program, we had to have rehab beds. It was during that time, and I don’t remember exactly when HealthSouth opened, but it was right around the time that we went live with trauma. Part of what was negotiated with HealthSouth was some of those beds would be acute rehab beds for our trauma patients. I guess what is important are our clinical guidelines that we set up for acute care. The thing that is more important is that long-term rehab center that they can be transferred to prior to HealthSouth. We had to transfer all of our patients to Richmond or National Rehab in DC. Trauma changed the dynamics for the community and with the advent of Health South.

01:40:54
Rigelhaupt:
Do you remember teaching the nurses in ICU perhaps even in the emergency department as trauma was being developed to think about questions of rehab? I mean the long term care involved with trauma, were there some things that you were excited to teach about?

01:41:15
Bowles:
The initial trauma course was taught by me, the trauma director, Dr. Roberts himself, and I think it was just the three of us. Dr. Robert’s first presentation went through the dynamics of the process. It was very weighted on what this means for the community and what is the age of a typical trauma patient and their rehabilitation needs. [01:42:00] That was part of the component. Because of that the team itself need its own dedicated case manager/social worker to ensure that we had the capability of transferring these patients to where they need to go. That was part of the whole build.

01:42:35
Rigelhaupt:
I can’t help but be struck from early on in the interview the discussion and focus on the community. That was also there with trauma, which to me is so associated with high-tech, specialty surgery. And it sounds like very early on much of the training was about the community as much as it was about acute care that was going to be given.

1:43:11
Bowles:
Always.

1:43:12
Rigelhaupt:
Was that something that was talked about when the trauma program was being developed?

1:43:20
Bowles:
When you take care of someone before the trauma program and when you took care of them in the ICU, you’re like, “Okay now I’ve got them stabilized, but I’ve got to transfer them to Washington Hospital Medical Center.” So the families are the ones distraught because family member had been in a traumatic accident and now they have to ask, “I have to go where?” I cannot tell you how many times I have had to draw them a map and tell them, “Okay this is how you get there.” They are not thinking Google or GPS. Your focus is, “Okay. They are going. How do I get there? Okay, so they are going to be there. It takes about an hour and a half to get there from here. And I’m going to have to do that every day.” So yes, that was a huge focus very early on in the whole program. One was identified by the state: there was a need for something in this area. Two, the stresses we were putting on our community families by then having to drive every day or then make the decision of not seeing their family member that day because they just physically couldn’t get there that day. That was part of the initial planning. [01:45:00]

01:45:04
Rigelhaupt:
Moving toward the end of the interview, I want to ask you, what would you most want the public to know about what do you do as a critical care nurse and as an educator?

01:45:27
Bowles:
We take very seriously the impact that we have on patients’ lives. It is not a show on television. It is an honor. It is a responsibility that we hold very dear to our hearts. We want the ultimate best for their loved one. Even though I’m not at the bedside giving that one-on-one care like I used to, I live that everyday making sure that I give and equip the nurses to be the best that they can possibly be. It’s the last thing you want to do is to have to walk out to someone and say, “We made a mistake.” You don’t want to do that. Every day is different. As we age—the US—there are more and more chronic illnesses that we can’t solve. We can’t fix everything. The expectation sometimes is that we can, and we can’t. It is very hard to help families realize that sometimes. We try to the best of our ability, but we can’t fix everybody’s heart even though we want to. [01:48:00]

01:48:03
Rigelhaupt:
What are some things that you would want the public to know about Mary Washington Healthcare that might not be commonly known?

01:48:14
Bowles:
I know that probably what is in the paper sometimes and what is in the media sometimes is pretty one-sided. My perception is that the community doesn’t realize what a diamond in the rough this is. Although the larger universities give very good care and if you have some sort of a strange illness you want to be there, I would put the care here and my nurses here and the care that they give up against Johns Hopkins any day. I don’t think that people in the community realize this. I think if they have been here and they have seen it, they would realize it. I don’t think they always appreciate the quality of care that is given in this organization and the surgical expertise that our physicians have. It is phenomenal.

01:49:50
Rigelhaupt:
My last question is actually two questions. Is there anything that I should have asked that I didn’t or is there anything that you would like that add?

01:50:03
Bowles:
Should have asked, but you didn’t? I always use the question when I’m doing staff interviews and now you’ve turned it on me. [laughs] I don’t know if there is anything that you should have asked that you didn’t. I’ve been here longer than I’ve been anywhere. There is a reason why. [01:51:00] I appreciate the quality of care that is given. It makes me proud to come to work to know that there is such the quality of care and know that patient outcomes are so high, wonderful, and they are excellent. By in large, when you are rolling out something new staff is energized. You are rolling something out that is going to improve patient care. They want to do the best they can. It’s not, “I’m here because I have to be.” It’s “I’m here because I’m excited. I want to learn. I want to do the right thing.” That is why I’m still here seventeen years later.

01:51:54
Rigelhaupt:
That is a nice place to end. Thank you

01:51:56
Bowles:
You are welcome.
[End of interview]