Susan Crane

Transcript

00:00:00
Rigelhaupt:
It is November 12, 2014. We are in Fredericksburg, Virginia, Mary Washington Hospital, doing an oral history interview with Susan Crane. The first voice you’ll hear, the interviewer, is Jackie Geddis. And I will be the second interviewer and my name is Jess Rigelhaupt. So, I’ll turn things over to Jackie to start.

00:00:27
Geddis:
Describe your first experience as a nurse.

00:00:31
Crane:
Wow. That’s a loaded question. I finished my four years of university up in Hamilton, Ontario, Canada. And at the time, in 1993, there was a big transition in health care in Ontario and across Canada. So, jobs were a little bit limited. I had an opportunity to move down to Syracuse, New York and start work there in a hospital. Somewhat different than what you are prepared for as a nursing student, but I ended up on a female oncology, or cancer, floor, which turned out to be my real niche. It was a big learning curve, a big, big learning curve. They give you the background. What I came from was a very problem-based critical thinking program which really helped. We didn’t have, probably, as much clinical experience as a lot of the college graduates did, but I feel like the background and education really helped with the problem solving, with the decision making, and with when to call physicians. A good experience overall. It was a great place to get started.

00:01:53
Geddis:
What other parts of the hospital did you work in since doing oncology?

00:01:58
Crane:
With oncology, that’s where I stayed. I did eight years of hospital nursing and then made a move down to South Carolina, to Charleston, where I did not have a job lined up. I went and interviewed at several hospitals that were all somewhat short-staffed. The hospitals were very much looking for nurses with experience. While that spoke to me, it felt a little bit more like a sales pitch in order to meet their staffing requirements and staffing needs. I thought, “Maybe this is time for a change.” I did the home health interview down in South Carolina, which was probably the toughest interview I had had. From there, I took the job and had a great experience down there. And then I transitioned here in Fredericksburg in the same role.

00:02:51
Geddis:
Did the education apply to home health or was it a little different? [03:00]

00:03:02
Crane:
Very much so. Even though I had had eight years of in-hospital experience, transitioning into home health I was tentative. I was a little hesitant. I thought, “Do I have those thinking skills to get through this?” You’re essentially out there on your own. People are backing you up, but once you’re in the house and it’s you, one-on-one with the patient, and you need to be able to have those critical thinking skills. Having that background, I think, along with hospital experience, really helped me on how to properly assess patients, know when trouble might be brewing, and when we needed a little more backup than just me in the house.

00:03:53
Geddis:
What was your favorite type of nursing?

00:03:56
Crane:
Oddly enough, when I look back at old high school paperwork and even before then—in seventh grade, I think—I had written a paper on cancer. Not knowing it at the time, when I went to have this job in Syracuse, I ended up on this female cancer floor. Actually, even prior to that, in my last year of nursing school, I did a rotation on a medical oncology floor. I just knew that was rewarding. It was exciting. There were so many changes taking place and a lot of treatment changes. When I did end up working on a cancer floor in the hospital, it was very gratifying. It is very, very gratifying still to this day: doing home health, having an opportunity to see a lot of that population, and continue to follow the changes and the treatment changes that are taking place right now.

00:04:51
Geddis:
So, would you say you’ve seen a great change in oncology education, which is the education?

00:04:58
Crane:
With nursing in general? I suppose it depends on what a nurse’s niche is and what they like to do. There are changes everywhere. But certainly having worked in the hospital, we used to see patients who would come in the hospital for all of their treatments. For their chemotherapy, they would come in. We’d see them for surgery. They would come in every three weeks to get their chemotherapy treatments. And now, that is all outpatient. Now they go into their doctor’s office for an hour or up to nine hours of chemo treatments in the office. Then we follow up with them at home sometimes depending on their situation. It’s been a big transition to outpatient care. I think that goes across the board with health care: the outpatient trend has been huge in the last twelve, fifteen years. [06:00]

00:06:00
Geddis:
Do you feel your education prepared you for everything on the job?

00:06:05
Geddis:
Does anyone’s education prepare them for everything on the job? No. But that’s part of learning. That’s part of getting out there into the working world and there is only so much they can teach you in a controlled setting. Even though we had our clinicals and we were on hospital wards, you’re somewhat protected in a clinical school environment. You always have your clinical instructor there. There was probably a lot more to learn once you got out there than I ever imagined. It was very frightening at times, but you could learn from the other more experienced nurses who were there. They always looked out for you. I had a chance to work with some very experienced people who I could say, “I don’t know what to do. What do I do? Is this important? Is this critical? Do I need to call someone?” They had our backs and really supported us.

00:07:11
Geddis:
What was the hardest part? What is the hardest part of the job, would you say?

00:07:15
Crane:
The hardest part of the job? I love what I do. Probably the hardest part is figuring out how to help patients or their family members or their paid caregivers navigate the health care system. Even as someone who has a lot of experience in that, it’s extremely difficult. Knowing who to contact, knowing when do you go to the hospital, or knowing when do I call the doctor. Who do I reach out to? What do I do about my insurance? What if I can’t afford my medications? It’s not always about the hands-on physical care. A lot of it has to do with continuity that happens outside of that.

00:08:11
Geddis:
Have you seen a big shift in health care in the last fifteen to twenty years?

00:08:18
Crane:
There has been. I think probably one of the bigger shifts has been towards the outpatient setting. Length of stay in the hospital, also, has been significantly decreased in the last twenty years. Where people used to stay five days for a certain surgery, now it can be done as an outpatient. They immediately go home. They don’t have somebody monitoring them, but granted the outpatient follow-up is there. I think a big trend has been towards home health. People aren’t staying in the hospital as long and it is making sure that they have some continuity once they leave the hospital. Someone who does follow-up and makes sure they have their medications and that they stay on track with the plan in order to prevent them from being re-hospitalized. [09:00]

00:09:13
Geddis:
What made you choose to go back to hospital nursing?

00:09:17
Crane:
I’m still doing home health. Not that I didn’t like hospital nursing. I loved my eight years doing in-hospital nursing. In fact, I had never thought that I would do home health. But I think it was just circumstances and where I was at the time. I had such a good first two years in home health. When I moved to Fredericksburg, the opportunity was there to continue in a home health program. There’s a lot of teaching that you can do in home health that nurses in the hospital do not have the time to do. Those patients are in and out, especially now, so quickly, you don’t have a lot of contact with their family members and people they’re going home to. The follow-up at home is what we use to our benefit to try to keep people safe at home and keep from coming back into the hospital.

00:10:12
Geddis:
So you think outpatient care helps with the relationship with the patients?

00:10:17
Crane:
Absolutely. Absolutely. I think the more outpatient care that’s available, the better it is for the patients. Firsthand experience: these patients would much rather be at home than in the hospital. Granted, there are certain times that they need to go back in, but I think the more options there are for outpatient care, in-home care, and supportive services. Transportation to get to the outpatient care is sometimes an issue, but we have supportive services to try to assist people with that and that enables them to get their care while they’re still in their home and not having to be in the hospital.

00:11:04
Geddis:
What really is your most proud moment in nursing?

00:11:10
Crane:
In nursing, in my career thus far, may have actually been in this last year. It’s been a difficult year professionally with a lot of patients who have been terminally ill. What people may or may not know is, certainly in our agency with Mary Washington, there’s a home health side and there’s a hospice side. We don’t cross-train. You’re either with home health or you’re with hospice. But I’ve had the opportunity on several occasions this year to do what I call play hospice nurse because there are patients out there who, despite knowing that they are terminally ill, have made a choice not to go with hospice care. [12:00] Being able to provide, in collaboration with their physicians, adequate symptom relief at home, to keep them at home, and honor their wishes to not go hospice, has been a real reward this year for me.

00:12:31
Geddis:
So, going back to when you first started, has the image of nurses changed? Like, from the white uniform? I know that was early, early, but—

00:12:39
Crane:
It was, but we were all still in pretty strict uniforms. No hats at the time. I think that especially as a new graduate, you had a little bit of fear of the physicians coming onto the floor. You certainly wanted to earn their respect, but in order to do so you had to build up that knowledge base for them to be able to trust you. I think that has come a long way. I think that the relationship between physicians and nurses has improved. Not knowing currently what the relationship is like with hospital nurses and hospital physicians, I can only speak to the home health side. It varies, but a lot of times they really appreciate the fact that we are their eyes and ears in the home. When we call them and we have a concern, there is a trust that is there for the most part. They will accept our assessment and recommendations and let us proceed with additional interventions to try to protect that patient and to try to keep that patient from deteriorating. I think that physicians’ and nurses’ relationship has improved.

00:13:55
Geddis:
What’s your opinion between now as opposed to before?

00:14:02
Crane:
With physicians?

00:14:03
Geddis:
Yeah, with physicians.

00:14:04
Crane:
I think it comes with experience. I mean, after twenty years of nursing, would I recommend to a physician twenty years ago what I will do now? No. Absolutely not. Because I didn’t have the background. I didn’t have the evidence-based practice to support my suggestion or my recommendation. Ultimately, they are the decision makers and that’s perfectly fine. Our job is to be out there and look at the situation. What can we do to make it better? What do we need to keep this person at home and keep them from getting into crisis? So, again, it’s physician dependent, but I think for the most part having the experience, the knowledge, and the training gives me maybe a little bit more strength and a little bit more leeway with the physicians to perform the job I’m doing now compared to twenty years ago. [15:00]

00:15:02
Geddis:
Does the role change when you’re in home health nursing? Do you feel that it’s different in a way?

00:15:09
Crane:
Absolutely. Absolutely. When I think back to working in the hospital and we would be set to send people home. I would tell people—and I tell nursing students all the time that this is the side that you always wondered about when you were in the hospital. There were many times that we would discharge people home not knowing what their home situation was, not knowing what their finances were, and not knowing what kind of caregiver they had at home. We would be thinking, “Oh my goodness. How are they going to cope with this?” Now I get to see that other side and have been doing that for twelve years. You certainly come across a lot of varied situations, some more desirable than others. You meet a lot of caregivers who are extremely willing and some patients are lucky enough to have that. Some are not so lucky. Some don’t have the support systems that others do. This is the side of nursing that is getting down to the nitty gritty. What’s keeping these people from staying in their home? What is keeping them from following what they need to do to stay healthy? You troubleshoot through all of that. You figure out what their needs are, what their caregiver’s needs are, and educate. I mean, it’s a huge teaching role in home health. For the most part, people are very, very receptive to that because they want to stay at home. It’s often a challenge at the very beginning. I think the expectations of patients and their caregivers once they leave the hospital are a lot higher now than they used to be, in part because people used to stay in the hospital for much more monitoring and treatment. Or they would go to a facility to receive their treatment, their wound care, their IV antibiotics, or whatever the case may be. But now, the expectation is if you have someone there who can help you, we’re going to send you home because we don’t want you exposed to everything else that’s in the hospital. People are much happier in their home setting. And so it is. It’s a lot of teaching and training of caregivers and patients to manage their own care at home.

00:17:31
Geddis:
Did you notice a difference in nursing from the ‘90s to the 2000s?

00:17:37
Crane:
I think focus has changed and I think for the better. A lot of it is medication safety and safety all the way around, as far as fall prevention. Infection control has been a huge trend as well. [18:00] Ultimately, if we can’t prevent the falls, if we can’t prevent the infections, and if we can’t keep people on track with taking their medications, then, ultimately, they’re going to end up back in the hospital which, of course, costs everybody and that’s not where patients want to be.

00:18:31
Geddis:
Do you believe any of the government changes have affected the system in your career?

00:18:38
Crane:
I think now probably more than ever with the Affordable Care Act is when we’re going to start seeing changes. I would love to be able to see a point where Virginia does go forward with Medicaid expansion because I think that not having that available for people only costs us in the end. A huge part of the system is finances for people. People who have no insurance will either seek emergent care for something that’s not emergent or they will stay at home until they are so deathly sick that they end up in the hospital for a whole lot longer, requiring much more care than they would have if they had had the resources to seek care from the very beginning when their symptoms started. Coming from a Canadian system where it is universal health care and having only just recently having had some firsthand experience with my immediate family with that, I think the care is equivalent. I think people aren’t afraid to go out and seek care. They don’t wait until their symptoms are so severe and get treated a lot sooner with the same quality of health care that they would here.

00:20:08
Geddis:
To switch gears, did you notice a difference in the education from Canada to here?

00:20:14
Crane:
I think it’s probably fairly similar. Moving from Canada to New York, in the particular setting that I was in, the hospital that I worked at had a hospital-based nursing program. I think they benefitted from a lot more clinical time and a lot more patient care time than I did. But it’s not that that wasn’t available in Canada. It’s just that it was a different program that I chose. I think the university and the baccalaureate programs were a little bit more focused on theory, critical thinking, problem solving, and less on, “Let’s get you all these clinical hours. Let’s give you the background; let’s give you the knowledge so that you can utilize that once you get into the nursing profession.” [21:00]

00:21:08
Geddis:
Do you think that benefitted you in any way?

00:21:15
Crane:
When I first started, no. When I first started nursing, I thought, “Boy, I would’ve liked to have been one of the nurses that had many more hours of clinical training than I did in my program.” But probably after the first five years, six years, I realized that there had been a benefit to the program that I was in. That the critical thinking skills really did actually prove to be beneficial for me.

00:21:45
Geddis:
Would you go into a different type of nursing if you could do it all over again?

00:21:51
Crane:
If I could do it all over again, no. You know why? If I had to make a choice and if I had to make a career change or an opportunity came up for me to do strictly oncology nursing, that’s what I would do. I was never meant to be in management. I like the one-on-one time. I think that’s one of the big changes, as well, that’s occurred is I feel like bedside nurses in the hospital have been taken away from the bedside. Doing home health gives me that opportunity to be back there, be one-on-one, have the time, and really get to know people and what their situation is.

00:22:32
Geddis:
What do you think caused the loss of one-on-one time?

00:22:37
Crane:
I think it’s a lot of policy changes. I think it is, again, going back to the trends of safety and medication safety and infection control. I think the environment has become a lot more controlled, and I think that’s a good thing. I think that has been a good shift. A downside? Yes. As the registered nurse and having been a patient on one occasion in 2007, I thought, “Wow. Things have really changed. I haven’t been out of bedside nursing all that long.” I think, too, you’re called to so many different directions. I don’t always think it’s a staffing issue. I think it’s a documentation issue. It is follow-up with physician issue as well, and so you just don’t have as much time at the bedside as you may have had ten, fifteen years ago. Plus, there are other people, other workers, that are available to do the job that you were doing—or that I was doing twenty years ago.

00:23:58
Rigelhaupt:
What was the change that happened, you said, in 1993, just as you were finishing nursing school? [24:00]

00:24:05
Crane:
That led to the job issues. They were, of course, a government-provided health care system. There were a lot of changes as far as combining services with hospitals, local hospitals and community hospitals, and closing down hospital beds. The need for nurses was not as great at that particular time. It had happened. It’s a cyclical event. I think it was probably in the early or mid-1970s that the same thing had happened. Within probably three years of my graduation, the trend had reversed. They were looking for nurses and trying to recruit us back. But circumstances just led me to stay in the US.

00:24:53
Rigelhaupt:
Could you talk about your first shift, if my notes are correct, at St. Joseph’s? When you started at Syracuse, and the first day you’re on as an RN.

00:25:05
Crane:
You’re hoping there’s someone there who can just watch over your shoulder. Of course, there’s orientation. You are partnered with somebody for your. Goodness—you’re asking me to remember twenty years ago. In fact, twenty years ago, November 8. You’re set up with a preceptor and you’re not thrown in there. You’re not expected to jump in and just know everything that you’re supposed to do. Having good preceptors and having nurses that enjoy being preceptors and enjoy that teaching experience makes a tremendous difference. Just as it does on the job, when you start a new job anywhere else. Guiding you, coaching you, and letting you know what physicians expect. I think that was probably one of the biggest points coming out of nursing school: you didn’t deal directly—or we didn’t, anyway—deal directly with physicians. Learning that relationship was a big plus. And having somebody else kind of lead you in there and let you know, “Okay. This is what they expect. And if you can follow along with what they expect and what they ask of you, then your relationship will be fairly smooth.”

00:26:27
Rigelhaupt:
Had this hospital made the transition to increasing hospital staffing? Or were these community physicians treating—

00:26:37
Crane:
At that time, your community physicians were still coming into the hospital. I guess my first experience with hospitalists is here, when Mary Washington hospital transitioned. Patients did have a very difficult time with that, and still are having a difficult time with the transition to hospitalists managing their care. [27:00] People always want to see their own physician. People that have not been in the hospital in many years are surprised by the fact that their physician no longer comes to the hospital to see them. They are quite disappointed. And that I can understand. Patients would like to interact with somebody that they feel knows them and somebody that they feel knows their history. I also think, and have heard from patients, that not all of the hospitalists have English as their first language. When you have an elderly person who may already be hard of hearing and then they have a physician coming in talking to them where English is their second language, it can make communication very difficult. It can make it very difficult for the patient to understand what’s going on. Why am I here? What are they doing? It’s evidenced by the fact that when we go into the house and ask these patients, “Well, what did they tell you?” They can, unfortunately, say, “You know what? I’m not really sure. I didn’t have somebody with me when the doctor came in.” I think having an advocate—I think that’s also been a big change—and making sure that you have somebody available to speak for you, speak with you, and ask questions with you. Having another set of ears to hear what’s being said is a huge advantage and a huge need at this point.

00:28:33
Rigelhaupt:
So, in Syracuse, at St. Joseph’s, you were on an oncology floor. Were those oncology physicians, or they worked closely with the hospital to manage cancer cases, or a primary care physician? Because, already, I think oncology’s more of a specialty.

00:28:54
Crane:
It is. Right. Exactly. It was more of a surgical oncology floor. We had our mix of medical patients as well, in which case their physician would come in and manage their care. If it was a surgical specialty, then it was their surgical oncologist that came and followed them specifically. If they had another medical need—if they had a cardiology need, a nephrology need—then those specialists would come in and take care of them as well.

00:29:24
Rigelhaupt:
You mentioned earlier that early on, you wished for more clinical experience. What were some of the clinical skills you honed over those first few months, or first year, that you were really proud of developing?

00:29:43
Crane:
Your general, physical assessment skills. Everything from heart sounds, to lung sounds, to bowel sounds. Although, in the first few months, I know for me, it wasn’t there. The whole novice to expert experience still goes on. [30:00] There are still things to this day that I will say, “You know what? I haven’t seen this before.” Certainly in that first year, learning what were the most common complications. What do I need to watch out for? Starting to hone in on those skills of what were the most common post-operative complications, learning how to recognize those quickly, how to maybe even predict a little bit when you might be approaching that point, and when you need to get the physician involved and have somebody come down and assess the patient. That was really probably the focus in those first twelve months or twenty-four months.

00:30:49
Rigelhaupt:
And for six years thereafter, you continued to work at St. Joseph’s, again, in oncology. What were some of the other things you learned about oncology and the disease process and how to work with patients who were confronting it?

00:31:08
Crane:
Emotionally, very taxing, of course. Learning and understanding, I think, that people cope with their disease process differently. Family dynamic played a huge, and still plays, of course—in any disease process. It plays a tremendous role. Learning to accept death. That was not something that I had experienced prior to going into this. Some people are very ready. Other patients or family members are not. Patients might be ready; family members are not. Learning to deal with that dynamic and how to not just comfort. What was important to me was, and certainly still is, is trying to make sure that what the patient wants is really what’s most important. Trying to meet their needs and keep them comfortable. What treatment they wish to pursue or not pursue? That’s not my position to judge. That’s not my decision to make. My role is to support them in whatever decision they make. That was difficult. That was difficult because you saw patients from the ages of twenty-two to ninety-five dealing with this. Patients that were married. Patients that had children, young children. And making sure that the patient was okay with whatever their decision was, and supporting that, and to help them through it.

00:32:53
Rigelhaupt:
What are some of the things that you learned from working in an oncology hospital setting that you have applied most directly to home health nursing? [33:00]

00:33:04
Crane:
In home health, you see such a variety of disease processes. But, of course, with my experience, being in the hospital and knowing that patients were going into the hospital every so many weeks for their treatment and you had in-hospital people following them routinely. With that transition to the outpatient setting, I think I wanted to try to protect them a little bit more. Having been at their bedside for whatever period of time it was that they were getting the treatment. And now knowing that, “Okay. Well, they go for their appointments. They get their bloodwork done. They get their chemo. They go home.” Carrying them through that treatment to the next one to the next one to the next one at home was really—and still is—something that I really enjoy to do. Certainly not every oncology patient needs home health. That’s for sure. A lot of people get through their treatment. They have limited side effects or their side effects are managed by their physician and they’re okay. But seeing them either improve or deteriorate with their treatments. When they’re deteriorating, that’s usually when we get called in. And, again, it is usually symptom control. Whatever their wishes are, what they want to do, and what they want to accomplish before they decide to, maybe, stop treatment is where I feel like we help to intervene and support them with whatever decisions that they or their families make.

00:34:47
Rigelhaupt:
What was your first impression of Mary Washington Healthcare?

00:34:54
Crane:
I came from maybe a larger hospital-based home health system as far as staffing and census. When I started with Mary Washington in 2004, home health was, maybe, a little bit smaller. We may not have been as productive as we could’ve been. I don’t know if that was because of our census not being as high or we couldn’t staff any more. But a lot of changes occurred, probably, within the first year or eighteen months that I was with Mary Washington Home Health in order to make us more productive, make us more efficient, and help us meet productivity. There has certainly been—and patients recognize it as well—a change in “this is health care” to “this is a health care business.” Like any other business, you have productivity requirements. You want to make sure you’re not losing money. [36:00] I think the changes that have occurred in the ten years since I’ve been here have really been focused on that—and it’s not necessarily an organizational decision. This is a Medicare decision. These are insurance decisions that we have to provide care to people with, maybe, less resources. We may not be able to make as many visits as we might like because of restrictions. I think going to more of a business model is a struggle. I try to leave that, as much as I can, outside of work and my visits because my focus is, “I’m going to get in here. It doesn’t matter what’s going on outside the house, or what’s going on inside the hospital, or the politics, or the government control, or lack of control. I’m going to treat you the same way that I did ten years ago.”

00:37:00
Rigelhaupt:
Could you walk me through, maybe, your first shift or the first shifts that you were following—had a preceptor with Mary Washington Home Healthcare, as you were learning to practice within this organization?

00:37:14
Crane:
Sure. I went with several people. Having had home health experience in the past, probably my preceptorship, one-on-one with another clinician didn’t need to be as long. I was with nurses that had been with Mary Washington Home Health for anywhere from probably five years to ten years. They knew how the system was. But, again, they, maybe, had been used to it. Maybe it was an old payment system with Medicare that you could make as many visits as you needed and the agency would be reimbursed per visit. When those changes came through to a prospective payment system where they said, “You know what? We’re going to look at your diagnoses. If you came out of a hospital or a nursing home or this was a doctor’s office referral, and where you live, and we’re going to base our payment upon that.” That impacted how nurses were doing the work. As that change was taking place, nurses, maybe, that had been there the years before in a previous system were certainly resistant. They, I think, didn’t want to see it turn into that business model. Everyone was helpful. They were gracious. They wanted somebody new on board. I was the young one when I joined Mary Washington Home Health because these nurses had been in other settings and had gone to home health afterwards. Earning their respect—I had to go through that all over again. [39:00] There are a lot of them that are still there today that I work with and all enjoy it tremendously. You learn a different system, right? Like transitioning from any other job, we did it this way. Mary Washington Hospital Home Health did it this way. It was just figuring out, “Okay. How do I make this work?” Thankfully for me, it was not a difficult transition. The computer system was the same as what I had worked with in South Carolina and that was a simple transition. Just job requirements, productivity requirements, and learning who ran the office. Who did you go to for X, Y, and Z? It was really the same as transitioning into any other job.

00:39:55
Rigelhaupt:
What was the organization you worked for in South Carolina?

00:39:58
Crane:
It was Roper St. Francis Home Health and was hospital-based as well. I think probably ten years ago as a hospital-based home health agency, you did have the corner of the market. Now, there’s a tremendous amount of competition in the Fredericksburg area for home health agencies. A lot of very small, very private home health agencies. I like to believe that our policies are probably a lot stricter, which I think they should be. I think we follow the hospital guidelines whereas in a private home health agency, maybe they don’t have access to that or don’t need to do that. I’m not sure. But I like the fact that we follow hospital policy because it leads to continuity from hospital to home. Patients know what to expect.

00:41:00
Rigelhaupt:
What did you learn about Mary Washington Healthcare’s—it was probably still MediCorp when you started, but—

00:41:07
Crane:
It was.

00:41:08
Rigelhaupt:
The organization’s mission and its values as you began working.

00:41:14
Crane:
It was wonderful to hear about a community-based organization. We want to keep this personal. We want to serve the community, give them the best health care opportunities that we can, and get involved with them. I was able to learn to know the new community that I was serving as well because anywhere you go there are different people. There’s a different lifestyle. I think that MediCorp back then and, to this day, really tries to serve its community with integrity, with respect, and making sure that their needs are met. [42:00]

00:42:03
Rigelhaupt:
In the decade before you got here, Mary Washington Healthcare, MediCorp at the time, the organization had had a tremendous amount of growth. From being in this new hospital to cardiac surgery and a lot of surgical specialties and subspecialties. High-tech medicine. Thinking about your first, say, year, early experiences with the organization, what do you think allowed it to stay focused on the community at the same time that it was becoming a higher tech medical center or regional medical center?

00:42:49
Crane:
I think being a smaller town. Fredericksburg is very close-knit. Residents here really value that. Fred Rankin, CEO, he wanted to keep it personal. He wanted to keep it small. I think being non-profit plays a huge role in keeping it very community-based and really wanting to look out for people and take care of them no matter their ability to pay. Going back to what you said: my first experiences here were small hospital, small town, and not a huge number of specialty areas. As far as they’ve come with being a stroke center, having a tremendous cardiac surgery program, and having our cancer centers open up. It has opened up a lot of opportunities for patients in the community to not have to travel outside of the area. They can receive all of their care needs right here. From experiences with patients, if they have something larger going on or if they have an issue that we know we are not the best ones to manage, we’re more than happy to send them somewhere else where we know we can get the best care for them to ensure that whatever specialty they need is available to them. The fact is that now they don’t have to go to Richmond. They don’t have to go to northern Virginia. People are very happy to have the specialties here.

00:44:30
Rigelhaupt:
Correct me if I’m wrong, but I imagine with a higher level of surgical care that can happen, and sicker patients can stay in the area, that has an effect on the patient’s acuity in the home health setting. How has the organization treating sicker patients affected home health care practices? [45:00]

00:45:02
Crane:
Our acuity is certainly higher than it was ten years ago. And you’re right. It goes back to the fact that these patients who are sicker can now receive the same level of care here means that they are coming home not necessarily “sicker.” We like to think that they’re trending to a well state by the time they’re coming home. But maybe they’ve had some complications and we’ve been able to address those here. Definitely a higher acuity. Definitely more expectations, again, on patients and family members to care for themselves at home. Really, I think, ultimately, I don’t think patients would trade that in. I think they would much rather be closer to home, have their family able to come and visit them right here, and receive the same quality health care that maybe they had to go fifty, sixty, seventy miles for ten years ago.

00:46:06
Rigelhaupt:
Was that particularly hard to confront? The higher level of acuity at the same time that there’s productivity being pushed?

00:46:22
Crane:
Yes. I mean, honestly, yes. But it comes down a lot to being able to prioritize. It comes down to knowing that, yes, we have other nurses that are working maybe on a part-time PRN basis who are willing to jump in and say, “You know what? I can see a couple of your patients today. I can help out and see someone in another area.” Knowing that we have that backup has been a tremendous help. Certainly, there are times it fluctuates. Our census fluctuates just like the hospital’s does. From day to day, from week to week, part of what’s enjoyable about home health for me is you don’t always know what to expect. You can think your day is going to be completely smooth. You may not know the background of every patient that you’re going to see and so when you get there, it is a lot longer visit than you were expecting, but patients are understanding. Again, many patients are just happy to be home. I can call them and say, “You know what? I’ve been held up somewhere with something unexpected. I’m going to be delayed an hour.” And they say, “Okay.” Because they know that I would do the same for them. And other nurses would do the same for them as well. I want to be able to give the same care to the patient now as I did ten years ago when productivity was not as high as it is now. Is it difficult at times? Yes. But that’s why we can schedule additional visits. [48:00] That’s why we can break it up to see them subsequently to continue the teaching. Maybe this visit isn’t going to be as long today, but you know what? When I come back on Wednesday, we’re going to go through a lot more. Patients can only handle so much at one time anyway. Their retention is not always great when they’re in their most acute state. In order to help them learn breaking it up sometimes into smaller segments is beneficial anyway. It’s part of keeping us on our toes: not knowing what we’re walking into, but being ready and prepared to call whoever we need to call and make arrangements. Do they need to come to the hospital? That’s what we do. Granted, we would like to keep our readmissions down. That’s also a big focus now. That is also a government and political decision as far as affecting hospital reimbursement. It is to keep patients from being readmitted to the hospital. Sometimes you can’t do it. I’m not going to sacrifice their care and their health situation because I’m thinking in the back of my head, “Gee. You know what? The hospital is going to, maybe, get less reimbursement if I send this patient back in.” If they need to be there, they need to be there. Sometimes, too, what happens is with the shorter length of stay and with the higher acuity, patients are being sent home sooner and sicker and there is a greater likelihood they may need to come back into the hospital just for a little tune-up. It is kind of balancing that. We’d like to keep patients at home and not be readmitted to the hospital. We’re still going to do what’s right for them.

00:49:56
Rigelhaupt:
Similar to the question I asked about developing clinical skills when you began hospital nursing. What are some of the clinical skills that you were proud to have developed and honed as you began working in home health? You mentioned prioritizing. You said that there are skills that you learned.

00:50:18
Crane:
A lot of it for me personally, having come from kind of a surgical specialty or a medical specialty, and then coming out into the world of home health opened up a lot more disease processes. Initially, learning a little bit about a lot of different health issues and a lot of different disease processes really started to guide me towards, “Okay. You know what? I’m going to need to learn a lot more about all of these different specialties because home health is anything.” Home health is everything. You’re going to see apples to zebras. [51:00] Does anyone expect you to know everything about all of that? No. Absolutely not. But part of the enjoyment is getting to learn that, having people who have had more experience in nursing than you, communicating with physician’s offices, and doing research on your own. For me, being able to access patient information from when they were in the hospital has been a tremendous plus, especially for those patients that didn’t understand what happened and helping them to understand, “Okay. This is what they diagnosed you with. This is what we’re going to try to do. This is what the doctor would like you to do.” It’s taken a long time and I’m still learning. Something different comes up all the time and for me it’s about not being afraid of that. You use your clinical judgement. If something is completely foreign to me, I’m going to call somebody. I’m not afraid to tell the patient, “You know what? I don’t know, but I’m going to do my best to find out for you.” Knowing that I have those resources available is really what’s helped.

00:52:13
Rigelhaupt:
What are particular treatments or practices you have developed in home health that you are proud of having gotten at in that setting? Might it be wound care? Things that you are going to confront, that you’re supposed to confront in home health care.

00:52:35
Crane:
Complications from surgery, whether it’s abdominal surgery or open-heart surgery—again, a big program and a big cardiac surgery team here. We’re seeing a lot more open heart patients come home. Looking for signs of infection. Looking for symptoms that they’re retaining fluid, that they have fluid around their lungs, or fluid around their heart. Recognizing heart sounds. Recognizing lung sounds that twenty years ago wouldn’t have really meant whole lot to me. Now, I’m much more secure and much more confident in what I’m hearing. Being able to report that to a physician’s office to say, “You know what? I think this is going on.” And they say, “You know what? Bring them him. Let’s send them for a chest x-ray.” That only comes with repeated exposure, repeated ability to assess these patients. With some of them, everything’s perfectly normal. But the more abnormals that you see, the more abnormals that you hear, I think the better you get at predicting a little bit ahead of time and before they get into crisis. Wound care, obviously, is a huge part of what we do. We did have a wound/ostomy continence nurse specialist up until she retired. I guess it’s been about two years. We have all taken on that role as well. [54:00] There are times, definitely, that I wish Ila was still with us for all of her expertise, but we also have the ability to get in touch with the wound nurses at the hospitals. We can troubleshoot. What do we do? This is what’s going on. Recognizing when I know I’ve met my limits, when I know that I’ve tried everything, and I’m not sure what to do. I’m going to reach out to somebody that I think is going to help us out.

00:54:32
Rigelhaupt:
Is that one of the benefits of having home health integrated with a hospital system, the access to, say, wound care nurses in the hospital—

00:54:43
Crane:
Absolutely. Absolutely. I really think it’s a tremendous benefit. Not only that, but I don’t know what private agencies have as far as the information about the patient prior to them coming home and what they have access to. But the fact that we are connected and we can look up and see what’s been going on is a tremendous help once they get home. To be able to see, “Okay. What have they tried? What has been done? What complications did they have?” It helps just to have that extra bit of background and, too, knowing that there are resources here. There are the case managers here. If we have a question about someone’s continuity of care at home or something didn’t arrive, we can usually follow that paper trail to see, “Okay. It’s been done. It’s not been done. We need to follow up.” Again, just the continuity of the system has been a tremendous, tremendous benefit.

00:55:47
Rigelhaupt:
Was that continuity in place when you started?

00:55:51
Crane:
Yes, but I think it really improved after the first two or three years. We just had more contact with case management. Having had the liaisons for home health here at the hospital until recently, they would know when our home health patients were readmitted to the hospital. Case managers could track them, follow them, and let us know when they were coming home and getting the new referrals. With the personal home health liaisons in the hospital, we had just that little bit of added information because they met one-on-one with the patients and could give us that one-on-one information to help us when we first went out there.

00:56:41
Rigelhaupt:
What new technology has been employed in home health nursing in the decade that you’ve been involved with it?

00:56:52
Crane:
Well, I guess I was lucky enough to start home health nursing just as they transitioned into computerized documentation. [57:00] Someone who has been there a little longer than me could probably speak to the handwritten notes without computerized documentation. Probably like anywhere else, as far as accessing information everything is right there. If someone else goes to see your patients, their notes are there. You can see everything that had been done in hospital nursing prior to home health. Being able to follow their story, see it in writing, right then and there. Being able to see what’s expected at the next visit. I think computerized documentation has definitely been a big plus. We still go in there with our manual blood pressure cuffs. There’s nothing really automated in there, which I think also helps to actually tune or hone your skills. You’re not relying on technology. Patients that want their pulse oximeter, or say, “Should I get one?” I say, “It’s not a bad idea, but I want you to remember that the numbers are only a part of that picture.” I said, “When we come in, we want you to look at this as a much bigger picture than two numbers that are getting read out to you. There’s a lot more to it than just the technology.”

00:58:22
Rigelhaupt:
And that was part of my question. Certainly, research changes in nursing over the past, say, thirty years, increased use of technology, particularly in a hospital-based setting, is a trend.

00:58:35
Crane:
Absolutely. Absolutely.

00:58:37
Rigelhaupt:
And nurses are behind a computer screen more than, probably, when you started. Certainly, the way it has been presented in reading the history of nursing, there’s a tension between technology and what it can provide in terms of information and a very high-touch practice in terms of getting blood pressures. No machine is going to listen to a lung the way you’ve described listening to lung sounds.

00:59:06
Crane:
Nope. And when you don’t have an x-ray machine or x-ray vision in the home, that’s what you have to rely on. Obviously, things have improved dramatically because of technology. In the home, are we going to see a big change in that? I don’t think so. They’ll ask us, in performance appraisals, or meetings with a manager, “Do you have all the tools that you need to do your job?” Yeah. I do. I have my eyes. I have my ears. I have my stethoscope. I don’t know what else they could give me, technology-wise, that would improve that. I think one of the trends that has already started and will likely come to us is the whole side of tele-health nursing where patients are recording their readings, their blood pressures, their heart rates, and their oxygen levels at home. [01:00:00] Being able to telephone report that to us. From that information, we make that decision. We deduce whether, “Okay. Is that normal? Is that their abnormal? Do we need to go out and make a visit?” But I don’t know what else they could give me in the home, other than x-ray vision, that would make my job any easier.

01:00:32
Rigelhaupt:
When you talk about calling physicians, are you calling the surgeon? Who are the physicians you’re calling from a home health?

01:00:43
Crane:
From a home health standpoint? It depends. Usually, it’s whomever has given us the orders to go out there. If they’ve been in the hospital for surgery, sometimes it’s the surgeon. Sometimes they’ve had complications after surgery. Their surgery went fine and so it’s their primary care physician. But we know that information, generally, up front, depending on what kind of a problem it is. Someone comes home and they’ve got a closed abdominal incision. All of a sudden, it’s draining. They have a fever. I’m going to call the surgeon’s office. Do we talk to physicians directly a lot? No. We talk to the nursing staff or their medical assistants and they relay the information. That was a bit of a change as well in home health: not having that immediate, direct contact with the physician right then and there. But, again, it is communication and developing a level of trust with the physician’s offices. It means finding out names and finding out which nurse works for which physician is a big plus. And developing—not a personal relationship by any means, but a professional communication kind of relationship that they know if someone’s calling in, there just may very well be an issue. And getting them to trust that, yes, that’s the case.

01:02:11
Rigelhaupt:
So, coming back to technology a little bit in terms of a potential upside. I think you mentioned the critical thinking that you were taught in nursing school. And, I imagine, certainly, by the early 1990s, a lot of evidence-based medicine was a part of your education. Now that you’re out in the field, say, over the last ten years, how does new evidence about treatments, for whatever kinds of cases you’re working with in terms of home health nursing, make it out to you and your colleagues?

01:02:53
Crane:
Anything from office in-services, computer based learning modules, and our annual hands-on competency modules. [01:03:00] We do have companies that will come out with a new wound product, something that is better than what they have already had before. They will come and instruct us on what it’s best used for. Or topical treatments and what they’re best used for. And, certainly information from the wound nurses at the hospital. Ongoing education from our education department making it well-known that, yes, there are other articles and there are other pieces to the puzzle that are available to help.

01:03:46
Rigelhaupt:
Are there ways in which, as you look back on your time in a hospital setting, that some of the standard practices in home health would be beneficial to in-hospital patient care?

01:04:06
Crane:
If they had the time [laughs] to spend with the patients one-on-one, but I think the education component, definitely. But, again, that’s where that transition from in-hospital to home is where we step in. I will say, though, there are—as far as education goes—the navigators that are now in health care: the cancer navigators, our heart failure navigator, and the pneumonia navigator that are here in the hospital to try to reach out to those patients while they are here. They reach out to the ones that, maybe, are the most high risk for readmission. Having those nurses be able to go in there and do the initial teaching and making sure that their plan of care for home is set up before they leave the hospital has had a huge impact. Huge impact. Making sure their doctor’s appointment are already scheduled before they leave home. We also collaborate with the eastern Virginia Medicare coaches that come out to patients’ homes. Do they have access to their medications? Do they have all their prescriptions filled? It’s a joint effort. It starts in the hospital. It starts with discharge planning. It starts with case managers and the navigators here and then into the home. You just hope that nobody is falling through the cracks.

01:05:42
Rigelhaupt:
So much of what you’ve just described in terms of access to medicine, education, long-term care, generally speaking, for most of the twentieth century, been outside the purview of acute care hospitals. [01:06:00] They’ve been treating for surgery.

01:06:03
Crane:
Right. Treat you for surgery or treat you for whatever your acute condition is, send you home, and you’re on your own.

01:06:09
Rigelhaupt:
And it sounds like in your decade of experience here, that there’s a fair amount of integration between home health care, treating chronic conditions, and this as an acute-care hospital. Were you surprised to find that when you started here or was it similar to previous experiences? Where has it been successful?

01:06:30
Crane:
I think it was similar. I think maybe in the last five years or so is really when, maybe, more of the integration occurred and more of the collaboration between in-hospital care and in-home care occurred. I think there was a—I don’t want to call it a realization—but there was evidence that kind of continuity of care is what could help prevent people from being re-hospitalized and could help people from having exacerbations of their chronic conditions. We certainly see a lot of congestive heart failure and long-term diabetics. I mean, technology has allowed us to keep people surviving acute issues a lot longer, leading to more chronic conditions in the end. It involves trying to help people manage that. In recent years, it has really started in the hospital and just continued on in the home. Without the information from in the hospital, patients do get lost in the cracks. They do fall through the cracks. The real push is, “Let’s look at every individual. Let’s look at their home situation. Let’s ask them, ‘Do you feel like you could benefit from home health? The doctor thinks you could benefit from home health. Let’s get them out there and see what we can do to keep you from coming back in over and over and over again.’” But I definitely think probably in the last five years, that that has really, really improved.

01:08:14
Rigelhaupt:
This organization and other hospitals have a long history of providing care that they may never be reimbursed for. That’s part of the mission of this and not-for-profit community hospitals nationwide. But this organization has also supported things just down the street at the Moss Free Clinic and other points of access for people who otherwise could not afford health care. Are there things that you have either seen, that have drawn on knowledge that has been developed from home health? It sounds to me like the expertise that you and your colleagues have developed in working with people with acute symptoms, but outside the hospital would be knowledge that the organization might want to draw on working with other community benefit aspects. [01:09:00] Have you seen them draw on your expertise?

01:09:17
Crane:
I like to think yes. I think they have. I don’t say that personally. I just think that as a community, when physicians and practitioners can see that, yes, there’s been a change. That teaching has occurred and that patients have been receptive and have followed up. Helping them adhere to their plan benefits everybody, whether they are insured or uninsured. We couldn’t do it without the Moss Free Clinic. We see a lot of uninsured patients. We see a lot of Moss Clinic patients. Working in collaboration with them to make sure that they follow up on everything that’s going on with them. It’s never anything isolated. They may only have diabetes, but with that comes the high risk of heart disease. It comes a risk of depression. Making sure that all of us together can cover those issues and provide some amount of education can only benefit the whole community.

01:10:30
Rigelhaupt:
Do you have a sense that the goals of integration, the goals of keeping the community healthy, is a joint effort going all the way up to the board, the administration, that really tries to make that a key part of everyday practices?

01:10:51
Crane:
I think so. I know there are changes coming in place with a new CEO and I like to believe that since Dr. McDermott is local, that he will keep us local, keep us community-based, and honor our mission and values. But I do. I think it comes from the top down. Is it sometimes affected by policy changes? Well, of course, but it is everywhere that you go. The bottom line is this is our mission. We want to take care of the community. No matter what else is going on, the bottom line is, we’re going to proceed with that. We’re going to do our best to take care of people right here in Fredericksburg and offer them as many services as we can without them having to go elsewhere and acknowledge that Mary Washington Healthcare has been here for a very long time. Yes, there is competition everywhere, but if we can continue to prove that we are the best provider, then patients will continue to come to us. [01:12:00]

01:12:04
Rigelhaupt:
Your decade here has been in home health and not as much in the hospital, a part of the organization that knows it well and has seen it grow. Are there particular surgical subspecialties or other milestones that have been developed, programs that you would point to over the decade you’ve been here that the organization should be proud of?

01:12:30
Crane:
Absolutely. If memory serves me right, probably being recognized as a stroke center was one of the earlier accomplishments in my decade here. Having a trauma program and becoming a trauma center in this area was a huge need. I think has been hugely successful. The cardiac surgery program. Yes, it had its ups and downs, but very successful, with a very low readmission and complication rate now. They’re doing far more high-risk cardiac surgeries than they were before. Certainly, having the cancer center here. I know we have worked with UVA with cardiac surgery and with cancer programs and it’s only benefitted us. We are providing services now to the cancer and cardiac population that we weren’t five years ago. It’s an exciting time, I think, for Fredericksburg. We’re growing as a community. Having those services available right here in your own backyard that are very skilled and keep you local, is just a plus for everybody.

01:13:56
Rigelhaupt:
What do you remember about hearing about the development of Stafford Hospital and a second hospital? Even the water cooler talk that this might be happening.

01:14:07
Crane:
I don’t remember much of the water cooler talk. It was just all of a sudden this was going to be happening. When you look at the growth of a community like Fredericksburg, and being close to northern Virginia, it is a very wise move. There was definitely a need. Not everybody could get down to Mary Washington Hospital. The census was high there. And trying, too, to draw those patients who were maybe borderline between North Stafford and Prince William County, the Manassas area. Knowing that we could expand specialties as well would allow us to continue to take care of that northern Fredericksburg population rather than those patients having to go up north for their care. Patient response has been very positive about Stafford Hospital. They like the fact that there’s somewhere else to go and know that whether they receive care at Stafford or at Mary Washington that information is all in one system. [01:15:00] Physicians have access to the information, which, again, just goes along with continuity and the picture is there, the information is there, and they’re not scrambling from one place to the next. The records are there. We have access to that when needed.

01:15:28
Rigelhaupt:
Have you treated patients that have come out of Stafford, then?

01:15:30
Crane:
Yes. Yes. Although not as many as some. My territory is south Stafford, so most of my patients are Mary Washington. But when I do get out of my territory or I have patients that have been at Stafford Hospital, they have nothing but positive things to say. I think it may have been slow to start as a new hospital, but that’s to be expected. Patients like the fact that maybe it’s not as busy. Definitely, patients are complimentary of the shortened emergency room visit wait time at Stafford Hospital, and they can be seen a lot quicker. I think that gives them another option and more access to health care when they need it.

01:16:13
Rigelhaupt:
I want to go back and ask about one more milestone. In 2009, Mary Washington Hospital achieved Magnet status for nursing, in-hospital nursing. But what did that mean for you looking at the organization as a nurse?

01:16:31
Crane:
Very proud. It was a very proud—it still is—a very proud time for us. It kind of grouped us with hospitals that had had that status. We worked very hard to achieve that status. It meant that, yes, we would have this recognition. We could recruit nurses who, maybe, had been in a Magnet hospital before but were looking to make that change. They would have the same opportunity here at a Magnet hospital in Fredericksburg. A milestone that we achieved and very, very proud of. Well deserved. There was a lot of effort put into that to make sure that we could attain that status and prove the quality of care that we were providing right here.

01:17:22
Rigelhaupt:
Was there integration in terms of the application and applying and all the surveying that goes along with the very rigorous process? But was home health care involved with Magnet status?

01:17:35
Crane:
Yes. Yes, we had people on the Magnet committee and so all of the information from what was going on with Magnet status here, of course, was all related to home health. We all played a real integral part in achieving Magnet status.

01:17:49
Rigelhaupt:
Were there things that you can recall that home health said, “You know, these are real markers of why we should have Magnet status.” The ways in which I imagine your unit had to share information included with the whole application? [01:18:00]

01:18:03
Crane:
I think anything from patient satisfaction surveys, to our competencies; to seeing that we are a unified group, that we work well together, and that we collaborate well together. It’s a multi-disciplinary process. Showing all of that was was a big part of the Magnet status.

01:18:30
Rigelhaupt:
What would you want the public to know about home health care nursing that might not be common knowledge?

01:18:39
Crane:
That we are there to help educate you. I think one of the misconceptions people have when they hear “home health” is that we’re going to go in and we’re going to be a nurse that’s going to sit with you or sit with your loved one. That’s another whole side to caregiving. It’s another whole side to nursing. What we like to do is help you maintain your independence and help your family keep you at home if that’s where you choose to be. Getting you set up with, maybe, services that you didn’t even know were available in the community. Equipment. Transportation. We have a wonderful social worker. Maybe you do need to be placed into a facility or need some additional rehab. We will help you with that transition. We will try to make sure that you have everything you need in your home to help take care of yourself and keep you there for as long as you want to be in your home.

01:19:46
Rigelhaupt:
What are some things about Mary Washington Healthcare that you would want the public to know that might not be common knowledge?

01:19:56
Crane:
We are now a health care corporation. Despite serving a community and being non-profit, we have a lot of new subspecialty care to offer right here in Fredericksburg where you don’t have to travel and you don’t have to leave your family. The quality of care and the quality of surgical care has advanced tremendously. Collaboration with other facilities has allowed us to gain from their experience as well, and continue to provide advanced care in the community. I think that will only continue.

01:20:38
Rigelhaupt:
My last question is actually two questions, but I’ll combo it up. Is there anything that I should’ve asked and I didn’t? Is there anything you’d like to add?

01:20:53
Crane:
Anything you should have asked? No, I don’t think so. I’m really proud of being an employee at Mary Washington Healthcare. [01:21:00] I love what I do. I like being hospital-based. There is a tremendous benefit in the community to offering home health to all patients that are in the hospital. One, to try to ease that transition to home. Two, to educate. And three, to keep them in their home with as few complications as possible, or glitches, or dealing with the unknowns. Because if we don’t know as nurses, we’re going to find somebody who does know. I am very proud of the work that we do and very happy to follow along these patients that have come out of this facility. I only see it growing in the future.

01:21:51
Rigelhaupt:
Thank you.

01:21:53
Crane:
Thank you very much.