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Original Articles

Always a Nurse

The Community Nurse

Allard, Billie Lynn MS, RN, FAAN

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Nursing Administration Quarterly: January/March 2020 - Volume 44 - Issue 1 - p 66-70
doi: 10.1097/NAQ.0000000000000400
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ALTHOUGH I recognize it is a cliché ... I always wanted to be a nurse. From my first interaction with the school nurse, she was my hero. That escalated as I met hospital nurses ministering to my dying grandmother, and ER nurses caring for me when I broke my clavicle. I read every Cherry Ames nurse book multiple times, and imagined my exciting life experiencing each one of those roles.

As I near the final chapter of my career, I look back with pride, appreciation, and the certainty that I was meant to be a nurse. I believe I was a nurse from the moment I was born.

I was the eldest of 4 children. My mother was a stay-at-home Mom who got anxious and nervous with anything remotely medical. She panicked when my 2-year-old brother hit his head on the coffee table resulting in profuse bleeding from his ear. I was 4 years old, and got the dish towel, and held it to his head until my father got home. I also recall being very sick at age 5 with measles, complicated by nausea, vomiting, and high fever. My mother was sobbing at the toilet as I vomited repeatedly, but I reassured her I was going to be alright and not to worry!

With my sights set so clearly on nursing as a career, I was certain that the path leading me there would be simple. Boy, was I wrong! As we discussed college, I was clear with my parents that I wanted to be a nurse. Although they supported my decision, my father stated that I most likely would get married, have children, and not have a career at all. He limited my choice of colleges to state schools, as he did not want to “waste” money. I loved my parents dearly, but they were both partial to boys, as was evidenced by my name. I was supposed to be William. Thank God the next child was a boy. His name was Bruce, and he went to Middlebury College. I chose the University of Massachusetts and loved attending the school. My major could only be listed as prenursing. Prenursing majors were all assured that if we got good grades and worked hard, we would be accepted into the BSN nursing program at the end of our sophomore year. I am a worrier, so I studied nonstop. Every elective I chose was somehow related to nursing and I looked forward to starting clinical classes the next year.

In spring of 1974, colleges and universities were focused on equal opportunity, trying to assure that all students, regardless of race or ethnicity, would have a fair chance. That fact, combined with the pre-med students who failed organic chemistry switching their major to pre-nursing, became a roadblock to my pathway to be a nurse. In April of 1974, I received a letter telling me I was not accepted into the nursing program. After an investigation from my mother, who attempted to undo the university's decision all the way to the governor's office, we were told despite my excellent grades, I would not be admitted. They used a random process because they had 4 times more prenursing majors than slots for students. I was assured that next year, I could be given a position in the program.

I was devastated beyond belief. I almost quit college and enrolled in an LPN program in my hometown. I wanted to be a nurse and I was supposed to have a BSN degree in May of 1976. The notification came too late for me to apply to other programs, so I chose to change my major to Growth and Development (Education Department), take 18-21 credits per semester, and then attend an Associate Degree in nursing program. That's how I ended up with an associate degree in Nursing and bachelor's degree in something else. Not exactly how I had planned it.

Despite my circuitous route in nursing education, my career has been everything I dreamed of. I loved being a nurse from the moment I began my education. I loved the white uniform and insisted on wearing a cap although few others shared my enthusiasm for this custom. I was so proud to have the opportunity to care for people and their families. In the first few years, I experienced every specialty in my community hospital setting. It was a wonderful “smorgasbord” of opportunities. Each one was delightful, and helped to “round out” my experience, knowledge, and expertise. I was a childbirth educator, helped women in labor and witnessed the miracle of birth. I supported loved ones at the bedside of their dying family members, encouraging them to say the things that they needed them to know and to not be afraid to be close, holding their hands and hugging them. Other memories: realizing a patient had a leaking aneurysm and that we have minutes to get him to the OR to attempt to save his life and watching a sobbing mother sing, “You are My Sunshine” to her 1-year-old toddler who died of crib death and refusing to let us take her baby to the morgue.

All of those experiences have made me who I am today. They have helped me to live each day to the fullest and not take it for granted. They have made me appreciate health, time with the people I love, nature, the ocean, the beautiful sunset, the smell of lilacs, and the sunshine on my shoulder.

Fast forward to the next 20 years. Despite multiple competing demands, I earned a master's degree in Nursing as a Clinical Nurse Specialist over a 7-year period, traveling 90 minutes over the Taconic Trail 3 nights a week. At the time I was the Director of the Emergency Department and had 3 children playing 3 sports. Looking back now, I wonder how my husband and I made it all work, but we did. My parents were very proud of their daughter (the one who was not going to have a career). I cannot help but think that their expectations actually impacted my drive to be all that I was meant to be as a nurse.

As happens to so many enthusiastic, clinically expert nurses, I was lured into a leadership position by a visionary CNO who recognized my potential, or so he said. In my quest to make a difference I took the leap with promises that he would be my mentor. Thirty days later, he was escorted out of the building with his belongings. Somehow, I did ok without him, spending 3 years as the Director of a Cardio-Pulmonary Unit, then 15 years as Director of the Emergency Department with various assignments to lead Maternity and Oncology along the way.

My children had all graduated from high school and my husband was open to me spreading my wings beyond my one hospital setting. As I began to interview for positions elsewhere, the CNO role became available at my hospital. What was this, a conspiracy to keep me here? “If it is to be ... it will be!” I applied through a search firm, keeping it confidential. After a nationwide search, I became the CNO. “Now,” I thought, “I will have the authority to make the changes that need to be made in my hospital.”

The first 4 years were wonderful working with the CEO that hired me. But, with mounting fiscal pressure from a poor payer mix, negotiations with 3 labor unions and increasing debt load for the health system, he was let go. The next CEO hired did not share my values. This was my hospital, and I felt the need to “save it.” After 3 years of turmoil, emotional unrest, and abuse I was told to “retire.” I refused! So, I was fired, with a severance package in jeopardy due to possible bankruptcy. My spirit was broken; my career was over; and I was devastated. I, like so many other nurse executives, had given my “ALL” and was empty, with nothing left to give.

As I frantically searched for a new job to pay my mortgage, extenuating circumstances made it challenging. My father was suffering from severe dementia, and I was the sole caretaker and his only child in town. My youngest daughter, who lived nearby, was pregnant and about to deliver a high-risk baby with multiple health issues. Despite a few CNO job offers, I needed to choose being a daughter, mother, grandmother, rather than the high-pressure job as a nurse executive.

I decided to take a job as director of education at a Magnet community hospital 13 miles away from my home. I felt relieved to have a place to heal. A fellow CNO and colleague from the Organization of Nurse Leaders surrounded me with love and care and compassion. I was determined to be a great educator and make lemonade out of lemons. Little did I know that I was on the brink of the most exciting role of my nursing career.

For 9 years I have been on a journey of exploration and discovery. My entire nursing career has prepared me for an important new role. Although my pathway has not always been easy, it has afforded me the development of true grit, endurance, strength, and courage. Having worked under the constraints of a nursing union contract, years of pent up innovation and creativity were dying to be unleashed. When my CNO assigned me to find a way to use the clinical nurse specialist in a creative role for the future, I was on it!

The magic and mystery and potential that I uncovered at Southwestern Vermont Medical Center (SVMC) was invigorating. My victim mentality evaporated. This was a nimble space and place where innovation could happen. SVMC had a visionary leadership team, minimal debt, responsible fiscal management, and was a Magnet nursing organization. Who could ask for anything more?

Suddenly, opportunities were in front of me I never would have imagined. Reconnecting with the Organization of Nurse Executives of Massachusetts, I was offered an opportunity to join the faculty for the Leadership Academy. Giving back to the nursing profession by sharing the pearls of wisdom I had learned as a leader was invigorating and fulfilling. I suddenly felt buoyant, hopeful, and ready to start a new chapter of my career. The opening slide of my first PowerPoint presentation in this position was a bulleted list of my life with hopes and dreams for the future. I was about to make them all come true... (see the Figure).

Figure.
Figure.:
Introductory slide at Allard's presentation to the Organization of Nurse Executives of Massachusetts, May 3, 2019.

TRANSITIONAL CARE PROGRAM

For the past 9 years I have become a pioneer in the territory of “value-based care delivery.” As an expert nurse, I am seeking a way to redesign care delivery that is founded on the premise that all decisions reside in each individual person's hands. Transitioning from the term patient to person, our focus is on improving health. As a nurse, I was able to deliver care in a medical model founded on the principles of science, research, and effective treatment for chronic disease. My nursing role was to assess, report back, and assist with the implementation of physician orders. I did it with caring, compassion, and personalized care designed to meet the needs of my patients and their families. I felt so blessed to be invited into the inner most sacred moments of people's lives. I was a hospital-based nurse, often in critical care settings. We saved lives, were very skilled and knowledgeable and were well-respected. The care we provided was what saved lives every single day. In the back of my mind was always this nagging doubt, especially when discharging patients to their homes who seemed to be unprepared. Why were so many people readmitted, “noncompliant” and coming to the emergency department (ED) and hospital so often? I witnessed people with substance use disorders and challenges with mental health coming to the ED 3 times per day, 5 days a week, complaining of chest pain, and getting expensive work-ups that we knew were not needed. I felt powerless to help them and make a positive difference in their lives. I thought that there must be a better way ... a secret sauce ... a light at the end of the tunnel. At my organization, I was given an opportunity to explore the possibilities ...

On our journey of transforming care delivery, we redeployed clinical nurse specialists to partner with primary care providers. As care shifts from inpatient to outpatient settings, this seemed logical. Expert hospital-based nurses with “fresh eyes” navigated with high-risk patients across the care continuum. The Community/Transitional Care Nurse (TCN) team met weekly to download the “aha” moments, serving as a support group to share the many lessons we were uncovering that we wished we had known years ago. As the weeks and months went by, and we moved out into uncharted territory, we were finding a pathway for value-based payment founded on the tenets of the triple aim: improve the “person” experience, improve the health of the community, and decrease the costs.

We now embrace the value of community partnerships, as the community is where people spend most of their lives. Embracing the role of agencies who do important work outside the walls of traditional health care delivery has been critical to our success. Together, we can create hope for psychiatric patients who currently frequent the ED. We are learning to appreciate the value of Maslow's Hierarchy of Needs. Many of the “patients” we see in the hospital are at the bottom of that hierarchy because they need “food, water, shelter.” If we do not recognize and assist with their basic needs, they will not be successful in managing congestive heart disease or pulmonary fibrosis. As a hospital nurse, I had never asked if those needs were being met. Now, with expert nursing eyes, we are witnessing the reality of the root causes of poor health when we are visiting people at home. Could it be that the only accurate medication list comes from establishing a trusting relationship with a person in their “comfort zone” where they feel safe to tell you the truth? We never realized that so many people cannot afford the medications prescribed for them and may have to choose between medication, food, or heating their houses. We have discovered that complex discharge instructions are not helpful and most people we visited were confused and not taking medications correctly. Stock piles of partially used medications were in every home, representing wasted health care dollars.

People with end-stage chronic disease are sharing with the TCNs that they do not want to keep going to the hospital. “Help me to stay home,” they ask. We can help that by earlier referrals to palliative care and hospice happen. We can partner with their doctors and with community partners and make a plan that is based on the individual's wants, needs, and desires for the future.

Somehow, I ended up in a place and space where meaningful, sustaining change can happen. That was a perfect storm of circumstances. Vermont was on a mission to lead the country in the shift to value-based payment. The State's Green Mountain Care Board must approve all hospital budgets and set cost-containment parameters. Grant funds became available for new program development to test out hypotheses. We have a mature medical home program, which has strengthened the foundation of primary care to be ready for change. As an almost 5-time Magnet hospital is the little engine that could ... and we did.

In the past 6 years we have partnered with all primary care providers and many specialists. We have community care teams established with community partners to provide integrated plans of care for highest risk families and children, and people with substance abuse disorders and mental health issues. Diabetes educators meet people wherever they are, beginning at primary care practices, express care, and EDs. We are trialing clinical pharmacists who assist providers in office practices focused on decreasing polypharmacy; we have a physical therapists available in the ED to streamline value-added care being at the right location at the right time. We are partnering with the city and state government, schools, and day care centers to tackle vaping, smoking in public places, childhood obesity, food insecurity, sex education, health, and wellness.

This has become my life's work as a nurse. I do not need to be a CNO to do this. I am leading a community in a positive direction of health and wellness. That includes informed choices by individuals being embraced by the health care team. We have achieved success with most of our programs. As the shift to value-based payment occurs, time will tell what happens. Initial results have been positive. What we have uncovered cannot be denied and must be taken into consideration as health care reform evolves.

Decision-making lies with each individual. A TCN must build relationships to leverage influencing better decisions. We need to remember that people cannot recover and manage chronic diseases when they are hungry, homeless, unsafe, and unable to afford their medications. Addressing these issues is part of the recipe for the “secret sauce” of how best to redesign care delivery. Health care reform is upon us and nurses have a unique opportunity to take the lead and demonstrate what person-centered, coordinated care looks like.

For 35 years, I was a nurse doing everything I could to meet the needs of my patients and their families. Despite my best efforts, it seemed the health care model was moving in the wrong direction, losing sight of what worked best for people. In the past 7 years, I see that changing. Using motivational interviewing, encouraging all clinical disciplines to function at their highest level of licensure and embracing community partnerships is getting results.

I have loved being a nurse my entire career. Value-based care embraces nurses doing their best work and reengineering health care delivery across our country. Let's do it!

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