Chapter 09: Successes in Strengthening Nursing Community and Practice

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Chapter 09: Successes in Strengthening Nursing Community and Practice

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Ms. Alt begins this chapter by commenting on the reputation of MD Anderson and how this bolstered the successful evolution of the Division of Nursing. She notes that other departments/divisions were jealous of the fact that she was able to secure so much support for nursing staff. She also notes that the turnover rate went down to fifteen percent, where it stayed. Next, Ms. Alt explains the Medical Technician Program and the context in which the need evolved for special staff to provide drugs safely and comments on the sharp divide between in-patient and out-patient services. Next, she talks about the “build your own package” program. She notes that all nursing were “graded” according to a transparent system. She talks about vising a fire department to see how they addressed staffing issues and explains why human resources didn’t grasp the specifics of nursing’s work scenarios. Next she discussed the IV Team, also covered in session one. She notes that Millie Lawson, a key figure on the team, published several articles on the system devised and the lower infection rates achieved.

Identifier

Alt,J_02_20180618_S09

Publication Date

6-18-2018

Publisher

The University of Texas MD Anderson Cancer Center

City

Houston, Texas

Topics Covered

The University of Texas MD Anderson Cancer Center - Building the Institution Building/Transforming the Institution; Leadership; On Leadership; MD Anderson Culture; Working Environment; Growth and/or Change; Obstacles, Challenges

Creative Commons License

Creative Commons Attribution-Noncommercial-No Derivative Works 3.0 License
This work is licensed under a Creative Commons Attribution-Noncommercial-No Derivative Works 3.0 License.

Disciplines

History of Science, Technology, and Medicine | Oncology | Oral History

Transcript

Chapter 09: Successes in Strengthening Nursing Community and PracticeB: Building the Institution;CodesB: Building/Transforming the Institution;C: Leadership; D: On Leadership;B: MD Anderson Culture;B: Working Environment;B: Growth and/or Change;B: Obstacles, Challenges;

Tacey A. Rosolowski, Ph.D:

How was this also—because I’m thinking here are all these changes that are taking place within an institution, but then also nationally, there are advancements in thinking about nursing as an entire practice. What does it mean to be a nurse? What is nursing as a clinical practice, as a research practice? Now, did you see… How did you see MD Anderson keeping pace with those thoughts in the field at large?J

Joyce Alt, RN, MS:

Well, this sounds egotistical but I don’t mean it that way. There aren’t that many [great] cancer hospitals in the United States. So, I think we rode on the coattails of the reputation of the institution and that allowed us to build more naturally. Competition from other hospitals just really wasn’t there. Some though, were ahead in research, because they did have research programs, but Pat got the schools of nursing to also come and do their research. It was just growth, a period of growth, but the jealousy and all this, it was hard. I’d get a few black eyes once in a while. I wasn’t doing enough for anybody else, I was only concerned about nursing, and I would be criticized for that.

Tacey A. Rosolowski, Ph.D:

Now these were African American nurses?J

Joyce Alt, RN, MS:

No, the other management in the institution.

Tacey A. Rosolowski, Ph.D:

Oh, I see.J

Joyce Alt, RN, MS:

They didn’t have to worry about getting people there, to staff the hospital around the clock, you know ward clerks weren’t that hard to find, nurses were. So I’m sure we were seen as the privileged in getting—and I was criticized and I don’t really care. We had time and a half for nurses, unheard of, but that became part of… With the Career Ladder, we graded every person that came in and we put them on the rung that they belonged with their points, but the next rung and the next rung, always was an increase in salary, but in addition to that, for the first time, we could pay them for overtime and others said well, that’s not very professional.

Tacey A. Rosolowski, Ph.D:

Why is that not professional?J

Joyce Alt, RN, MS:

You shouldn’t be paying professionals overtime. And when things got better, it got worse for me, on the overtime bit, but that’s what it was.

Tacey A. Rosolowski, Ph.D:

Now what did you see accomplished, because you’re talking about how a lot of changes started to be visible after only 4 or 5 months. Now how about after five years, how about after ten years? How did all of this new culture of self-governance and support for nurses change?J

Joyce Alt, RN, MS:

I’m trying to think of when. Anyway, when I left, which was not on good circumstances, but somewhere in there, our turnover went down to [17] percent and has stayed there.

Tacey A. Rosolowski, Ph.D:

Wow. Okay.J

Joyce Alt, RN, MS:

And it wasn’t any one factor. I also got highly criticized [in the professional nurse community] because I started the Medication Technician Program.

Tacey A. Rosolowski, Ph.D:

What’s that?J

Joyce Alt, RN, MS:

I did it with a physician who I knew would support me and contribute highly. I felt that if we can teach patients’ families to give their medicine, why can’t we teach others to do the same? The medication load in that hospital is enough to crush, you know crush you.

Tacey A. Rosolowski, Ph.D:

Tell me about that. I’m sorry if I’m digressing here, but you know, I really don’t know what you’re talking about in terms of the medication being a nightmarish situation.J

Joyce Alt, RN, MS:

Pain, nausea, chemotherapy, blood, and then whatever health situations go on with that. Medication load was terrible. Thank goodness we had a pharmacy who mixed our drugs. That took off, well, we got these people from U of H [University of Houston], we got quite a few from U of H. You had to have two years of college, preferably science, math, and we educated you on how to give drugs safely, never independently, and that was the key. So if the patient needed for pain unit, you’d go to the Kardex and say give them Dilaudid, and I looked in my chart, well hasn’t had it since one o’clock, I could do that. No you can’t. You say to the nurse, ‘can I give this?’ ‘Yes.’ I mean it really took off the burdens, particularly on weekends.

Tacey A. Rosolowski, Ph.D:

So this was a group of individuals that you hired. What was the education level you required?J

Joyce Alt, RN, MS:

Two years of college.

Tacey A. Rosolowski, Ph.D:

Two years of college, and then they could—was this a full-time position?J

Joyce Alt, RN, MS:

Yes.

Tacey A. Rosolowski, Ph.D:

Wow. Now how many of these individuals did you hire?J

Joyce Alt, RN, MS:

I bet you about 40.

Tacey A. Rosolowski, Ph.D:

Oh wow, okay.J

Joyce Alt, RN, MS:

And the Board of Nurses called me up [ ] to testify and everything, but that’s okay, we came out fine.

Tacey A. Rosolowski, Ph.D:

Now, did these individuals serve inpatients and outpatients?J

Joyce Alt, RN, MS:

Well, the outpatients aren’t, at that time, really weren’t giving that many drugs, so the nursing staff could manage that. Two things. This self-governance model, the other thing it helped with, we always had you work in the outpatient and you work in the inpatient. We never crossed the Mason-Dixon line and what we were trying to do is pass that philosophy on. It was very hard and I’m not real sure why, but I think when you’ve got, in the outpatient units, the physician/nurse relationship was much stronger, I mean they were working together eight and ten hours a day. If we could start training to go back and forth you know, it made sense.

Tacey A. Rosolowski, Ph.D:

What would you see as the advantages if people could move back and forth?J

Joyce Alt, RN, MS:

Oh, the patients, they know… The patients treated on the inpatients, they go to the outpatient, and they know these nurses here, the nurses know the nurses here, they send them back when they’re needed. It was more like everything wasn’t new.

Tacey A. Rosolowski, Ph.D:

Right.J

Joyce Alt, RN, MS:

The other component we plugged in which helped us to manage is the Build Your Own Package time management.

Tacey A. Rosolowski, Ph.D:

Oh, right. Yeah, you mentioned that last time and that was selecting shifts.J

Joyce Alt, RN, MS:

Yeah. We had nurses driving in from Louisiana.

Tacey A. Rosolowski, Ph.D:

Really?J

Joyce Alt, RN, MS:

Yeah. Because they could work two 16-hour shifts in a week and they were through. We brought people out of semi-retirement, it was good pay.

Tacey A. Rosolowski, Ph.D:

And these would be experienced people too.J

Joyce Alt, RN, MS:

Oh yeah, because we would be grading them, putting them on the ladder too. Nobody could come into the Division of Nursing without being graded.

Tacey A. Rosolowski, Ph.D:

And what was the grading, how did that process take place?J

Joyce Alt, RN, MS:

The Director of Nursing was the final person to okay hires and she would interview. We had the criteria, you know if you had six years of oncology nursing somewhere, that brought you a lot of points on the ladder. Anyway, the person was interviewed and it was shared with them, what rung they would be placed at.

Tacey A. Rosolowski, Ph.D:

And I’m sure that sometimes, that kind of grading is done almost in an environment of secrecy, you know there’s not a lot of clarity about how people are being assessed.J

Joyce Alt, RN, MS:

Yeah, and this was all published.

Tacey A. Rosolowski, Ph.D:

Yeah, yeah. So that must have been really helpful.J

Joyce Alt, RN, MS:

It was, and I thought it was fair. Like you said, no surprises, and you’re right, because let’s say a real strong nurse came in. Well, you had to prove yourself, we all know that, as a new employee, but then the jealousy can set in, because she wasn’t sure how she got there. So, yeah, that helped. I went to it --actually, we’re not the only people on earth that have trouble with staffing 24 hours a day, seven days a week and holidays. I went to a fire department and I said how do manage your—tell me about your staffing. I’m concerned, you’ve got some of the similar problems, and they showed me some patterns, and that’s what they were doing, but on a much smaller scale. But I sure learned a lot from them and then we adjusted.

Tacey A. Rosolowski, Ph.D:

I mean it’s interesting because I think a lot of employees run into challenges in communicating to operations people that flexibility in their scheduling might be really helpful and very advantageous to the work they have to do. It sounds like you were really, really open to lots of different scenarios for scheduling.[Redacted]

Tacey A. Rosolowski, Ph.D:

Oh, is this—you talked about the Patient Manifold the last time.J

Joyce Alt, RN, MS:

Well yeah, but we established an IV Team.

Tacey A. Rosolowski, Ph.D:

Okay, yeah, tell me about that.J

Joyce Alt, RN, MS:

It was headed by Millie Lawson, she’s just a phenomenal person and so smart, and she worked with a physician, and I’m sorry, I can’t remember [his name]. Anyhow, he was the medical director for the team and knew his stuff, and they started IVs around the clock, seven days a week [ ].

Tacey A. Rosolowski, Ph.D:

Now, why is that important? I don’t know why starting them around the clock is significant.J

Joyce Alt, RN, MS:

IVs infiltrate a lot. [ ] [As a member of the team,] they didn’t go up there and probe and probe like the one who is not as skilled, and then they did the long-dwell catheters and that was only a physician’s responsibility. So the physicians said to them, I’m going to teach you, it’s going to be your responsibility, because you’re going to be better than my residents, and they were, I mean because they were doing it all the time.

Tacey A. Rosolowski, Ph.D:

All the time, yeah, yeah.J

Joyce Alt, RN, MS:

[Millie] traveled a lot, through the United States, explaining all the things they did and how it reduced infection. You know, it got to be a point where the patients would want to know where the IV nurse was, just call them the IV nurse, you know, that’s confidence.

Tacey A. Rosolowski, Ph.D:

Right. Sure, sure. That’s amazing.J

Joyce Alt, RN, MS:

Yeah.

Tacey A. Rosolowski, Ph.D:

Yeah. So, who came up with the idea for the IV Team?J

Joyce Alt, RN, MS:

This physician and Millie, I think they just thought if we could control this, it would be better for the patient, and I think it was simple as that, and they just…

Tacey A. Rosolowski, Ph.D:

That’s a great example of one of those, somebody has a good idea and okay, run with it, and it makes a real change.J

Joyce Alt, RN, MS:

Then the residents got a little irritated with it, ‘Well when are we going to learn?’ He says not here, I mean he was real clear. (laughs)

Tacey A. Rosolowski, Ph.D:

Wow. So he didn’t bring the residents into that group at all.[Redacted]J

Joyce Alt, RN, MS:

Yeah. But[ ] [they were a team of experts and] so good.

Tacey A. Rosolowski, Ph.D:

Yeah. Well, I mean that whole… I’ve heard this over and over, you know the people who just see the issue over and over and over again, they become so familiar with every single challenge.J

Joyce Alt, RN, MS:

Yeah, and the beauty, other than the—I mean other than the thing not being so painful, plus the infection rate went down. Millie had written quite a bit, a few articles that got published.

Tacey A. Rosolowski, Ph.D:

Okay. I was wondering if you had published on that because it seems huge.J

Joyce Alt, RN, MS:

[ ] [It was great but Millie did the publishing. She and her team were the successes and I only supported their efforts.]

Chapter 09: Successes in Strengthening Nursing Community and Practice

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