Chapter 07: The Organization of Nursing Under Joyce Alt and John Crosley: Giving Nurses Autonomy
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Description
In this chapter, Mr. Brewer gives an overview of how nursing was organized and strengthened under two Division heads, Joyce Alt [oral history interview] and John Crosley, stressing the responsibility and autonomy afforded nurses. He talks about his work on committees responsible for planning the design of new facilities, noting that he could bring detailed knowledge of the processes of care and patient flow essential to plan good design.
He then explains that the autonomy nurses enjoyed under Joyce Alt was unique to MD Anderson. He explain that nurse training was continuous to keep up with treatment advances, and this expectation made oncology nursing different from other specialties. He gives examples of research and technological advances that changed nursing practice.
Next, Mr. Brewer talks about John Crosley, who became Division head in 1995/’96, at the same time that the VP of Clinics, Donna Sollenberger [oral history interview], implemented the multi-disciplinary care model in the Ambulatory Care Clinic. He defines the model and discusses how the reorganization was received. He then talks about the subtle differences in vision that Ms. Alt and Mr. Crosley brought to nursing.
Mr. Brewer then describes what teamwork looks like in the care of ambulatory patients in a complex ambulatory center that brings together twenty specialties.
Identifier
BrewerCC_02_20190606_C07
Publication Date
6-6-2019
City
Houston, Texas
Interview Session
Cecil C. Brewer, RN, BSN, MS, Oral History Interview, June 06, 2019
Topics Covered
The University of Texas MD Anderson Cancer Center - Building the Institution; Overview; Professional Practice; The Professional at Work; Leadership; On Leadership; MD Anderson Culture; Working Environment; Multi-disciplinary Approaches; Mentoring; On Mentoring; Technology and R&D; Research; Definitions, Explanations, Translations
Creative Commons 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
Tacey Ann Rosolowski, Ph.D. Now, let me ask you, in what way were the leaders of nursing at that time because there’s—I mean I know Renilda Hilkemeyer was kind of ending her career when you arrived, but then we had Joyce Alt and then we had a succession of other leaders. How were they transforming nursing practice along with this transformation of the actual possibility for treatment? What were their philosophies about how to create nursing and create and recreate nursing as these advances in treatment were happening?
Cecil C. Brewer, RN, BSN, MS:
Well, I was very fortunate to have worked with Ms. Hilkemeyer in my early career at MD Anderson. I believe she probably left Anderson, retired in the late—probably around mid-’70s. And Joyce Alt who was a nurse at that time in POCU unit became the director of nursing by title at MD Anderson. And her vision for nursing and nursing practice was that she believed that nursing was an independent discipline where nurses were highly educated and had the appropriate training, if you will, to provide sophisticated care to our patients. So she designed a program called a career program, which offered nurses a career path to match their capabilities. Tacey Ann Rosolowski, Ph.D. And you’re talking about Renilda Hilkemeyer?
Cecil C. Brewer, RN, BSN, MS:
No, I’m talking about Joyce Alt. Tacey Ann Rosolowski, Ph.D. Joyce Alt, right. You talked about that career path plan in your last interview, so I want to make sure we use our time well here.
Cecil C. Brewer, RN, BSN, MS:
So the directors at that time—so Joyce Alt, I would say that the philosophy matched the advances that were being made in medicine. Everyone was adapt—adept to what was happening in the research arena, in the scientific arena, and the evolution of nursing, and the division of nursing adapted. Now, how did we adapt? We adapted by creating a model almost like the physicians in the ’80s. The organization of nursing created research paths. So the physicians are doing medical research, nurses are now beginning to do nursing research to map and complement what was going on in the area of medicine, chemotherapy or surgical oncology. The nurses were trained. We hired on what we called clinical nurse specialists, and they specialized in programs, and they were program writers, and they were procedural writers, they were algorithm developers to match and to mimic the science that was going on in oncology care. Tacey Ann Rosolowski, Ph.D. How were you personally involved with some of those? Did you do some of the research or creating this new—?
Cecil C. Brewer, RN, BSN, MS:
As a leader, my role was more of a leadership role. I did have a few publications. I did quite a few speeches in oncology. I focused more on how leadership integrated with the clinical aspect of care and what was required of the practitioners to carry out the sophisticated oncology care and discipline such as reporting in my line of authority were clinical nurse specialists, these were all highly educated clinicians, master’s prepared, a few with PhDs. We had clinical, what we called, clinical instructors who were master’s prepared. So with that level of sophistication, they were able to execute with certain amount of parameters, and I just provided the resources to make things happen if you will. Tacey Ann Rosolowski, Ph.D. Can you think of a particularly cool project that was undertaken under your—that you saw that that there was a great project, you gave the resources, and there was a really great outcome for patients?
Cecil C. Brewer, RN, BSN, MS:
Okay. In my career, there’s been just a tremendous number of those things. Tacey Ann Rosolowski, Ph.D. I have no doubt.
Cecil C. Brewer, RN, BSN, MS:
Some are management, some are clinical, some are collaborative. Let’s see in the early ’80s, I think I’m known as the cost containment person in the ’80s for MD Anderson managing—providing the stewardship for how MD Anderson’s monies are spent. One of my projects called the Price is Right Program. There was a film that we produced in collaboration with medical photography and the medical writers here where we demonstrated to staff the cost of things at MD Anderson in a fun way. And this was done during hospital week, twenty-hours a day, around-the-clock presentation. And these programs were filmed and were available on TV for staff to look at. That’s a major project because the impact was to get the staff—make them more aware of what things cost, so one would be a better steward of how you use supplies, what was disposed of, what was tampered with or pampered. That’s a management project. Another management project would be working to help design new facilities. I probably worked on every facility that’s been built by MD Anderson up until 2000 and at least 2010 as the primary nurse go-to person, the build out the Lutheran Pavilion, which is now the purple zone, the build—the design and organization of the Alkek Tower, how the nursing units were laid out. All the intricacies that go into how a unit works, looking at all the disciplines who will be interacting on that unit— Tacey Ann Rosolowski, Ph.D. I mean I can imagine—
Cecil C. Brewer, RN, BSN, MS:
—another floor. Tacey Ann Rosolowski, Ph.D. —that would be absolutely key to have a nursing voice in those design phases. What were some things that people were not aware of? When you sat in on those planning meetings, what was the kind of essential information that you realized you had to give, I mean, that people in research or people in administration, they had no clue?
Cecil C. Brewer, RN, BSN, MS:
One of the things that happens when you specialize—specialization is both good and bad, now all the plus—not good and bad but pluses and minuses. You get kind of like in your tunnel vision. On a nursing unit, you’ve got to look at the patient flow and understand the patient flow and that—and you have to be a patient care provider to best understand how things flow. You work with your architects, your engineers, they can design based on the information you give them, but they’re—they don’t have the details of how a patient entered the system and do a process flow. So what I learned is that as we process flow—do a bit process analysis from A to B, that’s how we would be able to—better to—able to design the units based on the process analysis at that time. Integrating how nurses interact with nutrition services, how nurses interact with pharmacist and physical therapist and occupational therapist, respiratory therapist, so forth, and so on, and then blend all those disciplines together and then this is how it impacts the patient. I think those are some of the things that I see that we were able to bring to the table that brought perspective, well, this is a nurse’s—this is a day in the life of a registered nurse at MD Anderson. Tacey Ann Rosolowski, Ph.D. It seems to be that you’re really a 20,000-foot thinker. You seem to see big pictures, see a lot of things interacting. Am I getting that right?
Cecil C. Brewer, RN, BSN, MS:
I love that because that’s kind of been my MO, if you will, over the years, having been expo—given the authority and the permission by Joyce Alt and by (inaudible) Hilkemeyer to explore and given autonomy to make things happen. I was given the project and executed the project not only with hospital designs, which I’m known for and working with... I actually had the opportunity to work with Kirk Hamilton, the big architect firm here in Houston to help design. We had—it was a session, a plenary session that set out to design hospitals of 2000s. This was in 1993. We’re trying to project how hospitals would look in 2000, so you really had to get out of your box and open up your mind and say, "How do we design hospitals in year 2000?" Because you know once you put that brick and mortar in place, it’s going to be there for years, and you’re trying to do your best planning, so... Tacey Ann Rosolowski, Ph.D. Well, and not to mention just the resources spent, and if you blow it, (laughs) not good.
Cecil C. Brewer, RN, BSN, MS:
And so that was a project that I sat—I participated in and then for, I don’t know, it’s probably about six weeks of just brainstorming and taking Post-it notes and ideas and blending those all together to come up with multiple designs, and the outcome of that session with them was the Alkek Tower. Tacey Ann Rosolowski, Ph.D. Oh, wow.
Cecil C. Brewer, RN, BSN, MS:
And he published those. Kirk Hamilton published a book, the hospital design in 2000, of which I’ve given a copy of it to Javier. And so that was a major project. Tacey Ann Rosolowski, Ph.D. Now, was it usual or unusual for this level of—for nurses to enjoy this level of autonomy at that time? Was that something unique to MD Anderson, give me a clue about that?
Cecil C. Brewer, RN, BSN, MS:
The question is, was the autonomy unique to nursing at that time? Yes and no. All hospitals—or my peer group, I’ll put it, my peer group at other hospitals did not necessarily enjoy the autonomy that we were enjoying at MD Anderson. I think the director at that time, Joyce Alt created the environment of trust, sophistication, intelligence, and ability to execute. We had a degree, a high degree of acceptance with the leadership of MD Anderson and with the physician group. Now, how did that happen? This is how it happened. When you’re working at a specialization, you’re working as a team, and the team is headed by a medical director, so you’ve got these relationships that are being developed—that are forming because we’re all on the same page. We’re all here to say—we’re all here to care for, say, head-and-neck patients, so everybody is—we got the common goal and had a common trust. If you carry that over to all of your various disciplines, we would expect—the expectation was there, and we were given the tool to manage this autonomy not only the resource, the financial resources because they’re required but also the training necessary to carry out. So training was a continuous process all throughout the ’80s and the ’90s to the... This is something I’ve always said about nursing at MD Anderson, so what makes MD Anderson nurses so different from another oncology nurse at another institution? So we have Memorial Sloan Kettering, Fox Chase, there are all of these other comprehensive cancer centers, but we say we are the best. Why? What separates MD Anderson nurses from other? And I’ve always said the difference that I saw was that the level of staff development, the number of programs and educational programs and continuous education separated us out. What do we do? We design specific programs that nurses—were mandatory for nurses to complete certifications in their particular chosen specialization. So if you were a bone marrow transplant nurse or you’re a leukemia nurse, there were courses designed by nurses, by our staff development that—curriculums, and it was continuous, and it was documented, and it was expected, and it was part of your performance evaluation. Tacey Ann Rosolowski, Ph.D. And I assume this was all tied to the innovations that were going on in research on the—
Cecil C. Brewer, RN, BSN, MS:
It was all relevant to the time, and it was dynamic. The information changed according to the development of technology. Another project that comes to mind was, and probably it happened in early ’90s. There was a huge research project that was going on to determine the effect of various chemotherapies on the cardiac tissue of the patient. And at that time, MD Anderson did not have, what we call, a telemetry unit. In other words, we were not able to monitor our patients’ cardiac rhythms on a regular inpatient unit. But the research required that we have that type of unit, and my unit was chosen to develop the first medical telemetry unit with the sole purpose of supporting the research that was going on to deter—with Bristol-Myers to determine the impact of certain drugs on cardiac tissues of the patient. Tacey Ann Rosolowski, Ph.D. What was the unit you were working on that at that time?
Cecil C. Brewer, RN, BSN, MS:
The initial telemetry unit was called Five West. In today’s world, it’d be called Five Blue, which is not an inpatient unit anymore. I think it serves as an office space now, but it was in the original Anderson wing. It’s called Five West, and I think this—that the equipment were supplied by the pharmaceutical company. And there was this collaborative research grant, and we were able then—there are lots of intricate, lots of details that go on within that provision of care not only from how you prepare your nurses to care for patients on telemetry but also on the legal and the critical care aspects of care that go on with that. And that was a huge project. Tacey Ann Rosolowski, Ph.D. Now, what role were you serving in at that time?
Cecil C. Brewer, RN, BSN, MS:
I was the director of medical oncology. That was early ’90s, and I moved from my role as assistant director. We changed the titles to directors, giving us more scope, more responsibility, more autonomy, and expectations of executing our level of accountability. And so that was a major project of early the ’90s, the medical telemetry unit. Tacey Ann Rosolowski, Ph.D. Tell me about when Joyce Alt left, who took over after she left the institution?
Cecil C. Brewer, RN, BSN, MS:
Okay, Joyce— Tacey Ann Rosolowski, Ph.D. Was that Donna Sollenberger?
Cecil C. Brewer, RN, BSN, MS:
No. No, John Crossley. Tacey Ann Rosolowski, Ph.D. Oh, okay, right.
Cecil C. Brewer, RN, BSN, MS:
Joyce Alt tenure at Anderson was through 1995 I think—I might be off a year so—but ’95 or ’96 and then John Crossley came aboard. Nineteen ninety-five, ’96 was a tremendous evolution of how care was delivered at MD Anderson. Tacey Ann Rosolowski, Ph.D. Why so?
Cecil C. Brewer, RN, BSN, MS:
This was the time not only did John Cro—Joyce Alt retire, John Crossley comes in, and also Donna Sollenberger, Charles Balch, David Hohn, David Callender— Tacey Ann Rosolowski, Ph.D. Actually, Charles Balch came in ’85.
Cecil C. Brewer, RN, BSN, MS:
Well, but he—Charles— Tacey Ann Rosolowski, Ph.D. But he reorganized.
Cecil C. Brewer, RN, BSN, MS:
Yes. Charles Balch was the precursor to—well, you’re correct. In 1995, we had I think Dr. Callender, David Callender because Dr. Hohn and Dr. Balch were leading up to this point. But when Donna Sollenberger came as the vice pre—I don’t know the appropriate title, but vice president— Tacey Ann Rosolowski, Ph.D. Of clinics.
Cecil C. Brewer, RN, BSN, MS:
—for clinic and hospital, she also brought in a different philosophy of care. It was called multidisciplinary care across all disciplines. Now, multidisciplinary care had been practiced in pockets throughout the history that I’ve been in MD Anderson. Head and Neck Surgery has always said they provided multidisciplinary care. In 1995, ’96 Donna Sollenberger actually put a model in place across the entire ambulatory area that integrated surgery, medicine, radiation oncology all under one umbrella. And I believe [that is?]—or I know that process is what is in place today in the ambulatory area of the MD Anderson where in one center, you get a—you receive multidisciplinary care truly. You have a surgery, surgeons—you have a surgeon working in the center not down the street or around the corner, you have medical doctors working in the center, you have your radiation oncologist working in the center. It’s like a one-stop shop for the patients. That started under Donna Sollenberger, David Callender. And that time when John Crossley came, for me, I was working on inpatient side of the hospital. As a nurse, you either work as an inpatient nurse or nursing director or you work as an ambulatory nurse or director. When John Crossley came, I transitioned to—from inpatient focused to ambulatory focused in the ambulatory treatment centers. Tacey Ann Rosolowski, Ph.D. Why was that? Why did you choose to?
Cecil C. Brewer, RN, BSN, MS:
I chose to transition for a number of reasons: One, opportunity, a vision of being able to look at and do something different in oncology, and the challenge that this role was presenting to me with. It had a wide scope of responsibility, and it had a leadership that was visionary, and it was multidisciplinary. Tacey Ann Rosolowski, Ph.D. Now, let me ask you because I want to talk about some of the initiatives that you undertook in that role, but before we do that, how was this new vision that John Crossley and Donna Sollenberger brought—how was it received?
Cecil C. Brewer, RN, BSN, MS:
Well, John Crossley’s inpatient vision—now, let me go back to his vision. I did not work under Dr. Crossley’s leadership for—just a few months before I transitioned to ambulatory. The division, John Crossley revamped the philosophy of nursing to a professional development model. That meant revamping all evaluation processes and the advancement processes and how nurses were to approach their job in a professional—more professional way. On the other hand, Donna—in the ambulatory area where Donna Sollenberger had the control, her focus was multidisciplinary care not only for nurses but for everybody, for all the disciplines—pharmacy, for physical therapist, social workers, patient advocacy, all. Those are the disciplines that mostly—interacted mostly, I would say eighty percent of the time in the ambulatory area. So the am—I’m sorry. Tacey Ann Rosolowski, Ph.D. No. I just wanted to ask because I wasn’t clear from your description how John Crossley’s view of professional development was different from Joyce Alt’s.
Cecil C. Brewer, RN, BSN, MS:
Joyce Alt’s philosophy was more of a career progression for nurses, that nurses are embodied with a certain amount of skill set and knowledge and training and the opportunity for nurses to grow, career growth. I believe John’s philosophy was that he’s going to take that career growth and add to a level of more... He wanted to add more autonomy to it and more advanced—advancement I would say. It was not that much different, but the model was different. In other words, how do you get to that point? And he called it a PDM approach, professional development model. That’s what it was. And that’s what he brought into the nursing department at that time. Like I was saying, I only stayed in nursing under his umbrella for a few months, but all nurses report directly or indirectly to the chief nursing officer. And even though I was working in the Ambulatory Treatment Center, I had a relationship to nursing because I was supervising nurses. I was the leader of nursing and we had a duty to inform, to comply with certain policies that were within our nursing practice, the scope of nursing practice, which is expected by our license to abide by and to cooperate to make nursing a unified group throughout the institution and so— Tacey Ann Rosolowski, Ph.D. Was that becoming difficult as the institution got so large and as so many specialties started to proliferate?
Cecil C. Brewer, RN, BSN, MS:
I think the organization of MD Anderson is unique, and it provides us a very complex matrix of how nursing interacts with medicine and with the administration because each area is so specialized and has so much ownership. An ambulatory nurse works with ambulatory patients and spends most of her time working directly with physicians doing clinic visits and clinic examinations and protocol management, etc.; whereas, an inpatient nurse spends her time at the bedside. Eighty percent—no, ninety percent of the time, the physician is not there so that collaborate—that level of, excuse me (coughs), collaboration is not as constant. So now, you got some ownership issue, this is my nurse, this is my pharmacist, this is my dietitian, this is my whomever, and it’s very complex to manage, very complex. It required a lot of give and take, a lot of understanding of other points of views, and it’s a challenge. I think it’s probably still a challenge today, and I don’t think that challenge is going to go away because this is a very complex organization. It’s not silo-ish, but it’s also a very integrated, and actually, it’s very complex. That’s what it is, very complex. Everyone can’t do it, everyone can’t manage the day-to-day interactions and planning and organizing and reorganizing, and you’ve got all these different things going on with research and treatment and acuity of care and— Tacey Ann Rosolowski, Ph.D. So it really takes a special personality and skill set to operate in this environment. It isn’t just learning about delivering patient care; it’s sort of learning an entire context in which care is delivered.
Cecil C. Brewer, RN, BSN, MS:
From my perspective, I think you’re correct. Working within the oncology community is not for everyone, not for every nurse. Working within the oncology nursing community at MD Anderson is even more complex because MD Anderson is like no other hospital. This is a very highly resource-driven institution not only from personnel but from all of the delivery systems that are here. And a good description—we have described that if you look at the emergency center—no, let’s go back to the Ambulatory Treatment Center. The Ambulatory Treatment Center is the hub of MD Anderson’s treatments. All disciplines send patients to the treatment center to receive outpatient treatment. Think about that, how complex that is. Say if you have 20, at least 20 different specializations, highly complex, highly specialized treatment plans going to an area, you can’t expect each nurse to understand all of those different protocols and algorithms and personalities that come with that from the service, but that’s the essence of this complexity I’m talking about, this complex environment. It takes a tremendous amount of organization, education, directing, and constant process improvement in order to manage this complexity. Early on in the evolution of the Ambulatory Treatment Center, which is another... When it was first organized, yeah, we called a bed unit, a shared unit, and the A unit, A, B, and C. Everything was named after a piece of furniture we called it. If you’re in station 19A, 19A was called urgent care center, urgent care, emergency care, that’s where you go. That’s where MD Anderson’s ambulatory patients or MD Anderson patients who became ill would go for their urgent care, emergency care.
Recommended Citation
Brewer, Cecil C. RN, BSN, MS and Rosolowksi, Tacey A. PhD, "Chapter 07: The Organization of Nursing Under Joyce Alt and John Crosley: Giving Nurses Autonomy" (2019). Interview Chapters. 909.
https://openworks.mdanderson.org/mchv_interviewchapters/909
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