Changes in Nursing: An Interview with Dr. Beverly Malone

We had to fight more to get into the boardroom. I think we still have to fight, but there was just a little bit more of an edge to making it to the boardroom. When I was coming through, I remember I was on a board at a university hospital center and I was probably one of the few nurses in the entire state of North Carolina that sat on a hospital board. I was a vice-chair, and everyone thought that was amazing.

And, now it’s just that nurses need to be there to give that perspective of patient care – the 24-hour watch. So, as decisions are made, they are made with the backdrop of really what’s happening to the patient. No one knows the patient in the way that we do on a 24-hour basis and so we should have opportunities to share that as these healthcare decisions are made.

And, it’s much more of a team [at the bedside]. There is no captain of the ship – as my physician colleagues used to think of themselves. It’s much more what the patient needs – it’s circumstantial, situational leadership. It’s circled around the patient and what the patient needs, and not just because ‘this is the way we do it, this is the way we’ve always done it, and therefore that’s how it’s going to be done’.

Of course, technology is a huge one! Just using my phone and staying in touch with all my colleagues simultaneously…None of that was available. We thought, “Perhaps it’ll happen in the future,” but it was much more a fantasy than it was reality. And, then it just seemed to happen and burst out all at once. So, all of that is being integrated into the healthcare that is being delivered.

The technology for the patients makes a big difference, too. People are living longer and instead of suffering from an illness and passing away, they tend to live with the illness instead. There are all types of chronic illnesses that we did not see extend when I was [entering the nursing field]. That’s very important, but it also creates a huge difference in the problem areas.

The other piece is that education for nurses is different. When I was coming through [as a new nurse], there was no simulation and we gave each other injections with salt water, which was a little bit painful and I still feel like there are colleagues who are holding me accountable for giving them their first injections!

So, all these changes have been occurring and some are just incredibly wonderful and some raise questions like, “How are we going to make sure that nurses remain the bridge between technology and the patient? Are we actually moving the patients through the system too quickly? Where are we moving them to once we discharge them? Are we sure that they have a zip code and that they have a place to go?” Those are the kinds of questions and issues that must be faced as things move quickly.

Also, the hospital is becoming a critical care hub. When I was coming through, it was just the place to be and the community was sort of like a sideshow. But now, the community is becoming the core and people want to stay in their homes. And, there’s so much more to healthcare than just giving the care itself. Now, we have to ask, “How do you adjust to being at home with whatever illness you have or whatever situation you’re in?” and, “How does your family adjust to that with you?” So, all of these important things that were on the edge, tipping around the corner when I was coming through are now central to caregiving.

With all the technology, I think the greatest fear is that those skills are going to be lost.

I used to run a neonatal intensive care unit – I called the neonates 2-pound bags of sugar because they’re so tiny. Moms would come in after going through the birthing experience and be told that they can’t hold their baby because something is not quite right. It would be like a jungle of technology and wires, and those wires would be attached to their baby. So, having a nurse [to guide a mother through] that and who can say, “Your baby needs you to hold them more than ever – you’re not going to crush your baby by holding your baby,” is so important. I think it is just wonderful how nurses are making that difference and we must keep making that difference.

We are navigators through the healthcare system – we know what works and what doesn’t work. We can even tell you which physicians are best to work with in terms of a situation, because we know the entire system. For me, that’s always been a very proud piece of nursing.

You can have everything else – the skills and the ability to suture – but if you don’t have that compassion, it doesn’t matter.

I have to say that I am a fighter for simulation and making sure that nurses have the opportunity to practice. I think we’re like pilots in planes in that we need that practice to decrease the number of errors.

The first invasive procedure that I made on a patient, I should write a letter of apology because they were my first – the first time I had ever done anything like that. And it shouldn’t be like that.

When I was an undergraduate nursing student, I remember I thought I would have to go home. I went to my faculty member and I said, “I just cannot make a four-corner bed.” And she said, “Well come with me…I’m going to put you in this room and I’m going to lock this door. When you can make that bed, you can come out.” I made that bed and made that bed. Now, I can make a four-corner bed. I can do it – I can toss a dime on it and it will bounce!

That’s the practice. That’s what simulation brings the opportunity for you to do – to gain the confidence that you’ve got the skills down. It really gives you room in your mind and in your heart to think, “What else do I need to bring? I can do the skills, but how do I bring the compassion? How do I make sure that I’m collaborating with my colleagues – that I’m not ignoring them – and hear what the patient and the family need to tell me all while making sure that I’ve got these other things happening?”

Well, our job – which I love to say – is to accompany the patient and family and community on the journey. That’s who we are – we are with you from cradle to grave. We’re right there. Every step of the way, there’s a nurse. I don’t think there’s any higher honor than being able to accompany people – children, adults, seniors – on their journey. It touches my heart to think of it.

And as faculty, we accompany the students on that journey to help them understand how important it is to be there with the family - to be there making that difference. What I’ve learned is that, because I’m a psychiatric mental health nurse, I don’t always have to be physically touching patients. As faculty, I can prepare students so that they can touch patients and I touch my patients through those students. I think that’s a very powerful thing.

It’s the same effect for administrators who are nurses, who run nursing units and hospitals. While they’re not touching patients personally, they’re touching thousands and thousands of patients through the staff that they’re working with. And when you understand that – oh, my goodness – you get such a high. It’s such a warm, good feeling to know that you’re in this role that seems removed from the patient, yet you are still as close as you ever were.

I think it’s when the National Council of State Boards of Nursing actually did research that said it’s okay for schools of nursing to substitute clinical time with simulation – that you can teach students through simulation. I think that nursing schools were holding back thinking that the National Council of State Boards of Nursing wouldn’t allow it. By them doing that research study, I see it happening more and more. My colleague, David Benton, who is the CEO of the National Council of State Boards of Nursing, is such a strong proponent of seeing all the ways we can use technology to make our students better prepared. That’s a big one.

I think that hospitals are finally starting to understand that you can’t just throw a nurse from graduation directly into practice. I think that’s what we were trying to do before.

We have residency programs and there’s frequently a mentor or preceptor, who is there because he or she wants to be, and they’re going to help that new nurse understand how to work with the nurses that are already on the unit. They’re going to help them understand how to work with their colleagues who are physicians – and I did say colleagues. And, I think that those things must be taught. They don’t come naturally when you step out of your program and into a setting – whether it’s in the community or a hospital. You must really have someone you’re watching do that.

And, when the hospitals have their simulation labs up to snuff, and they give new nurses the opportunity to practice their skills again, the reinforcement happens over time. That’s really the way to go about doing it.

I think that’s what we’ve been talking about. Kramer wrote a book, Reality Shock: Why Nurses Leave Nursing, and that was the idea that you come from the safety and security of a school of nursing and then you’re thrown into the realities of working with patients. You go from having two patients to having ten and you’re saying, “What happened here? I can do my two patients – I did my two very well – but ten patients?” All the variables about being in the real world of providing care start to happen at once. I don’t know where we made the assumption that we should just know that.

Our job is to make sure that it’s not that abrupt. About 1/3 of nurses who are in their first-year leave, so it’s so important for them to feel cared for and to slowly start to understand how to navigate the system.

The students. I am blown away by their abilities. I think about where I started and, oh, my goodness, they’re so far ahead of me and they’re going to do incredible things! I get really excited about what they bring to the work and what their ideas are for the future. They’re ideas that I can’t even start to think about in terms of technology.

I understand the pure joy of seeing these changes and making sure that a nurse is ready to move to the next stage. And, I think that simulation is one of those propellers to move to the next stage.

I’d like to say, “Don’t forget Florence. She was born this week – it’s to celebrate her.” She deserves so much applause for what she was able to do because she said, “First, do no harm.”

This is still such a huge issue, because – I’m sorry – the hospital wasn’t built for nurses or for docs. It was built for patients and patients come first. And, the ‘do no harm’ is about our relationship with patients, whether we’re in the hospital or the community.

First of all, do no harm. I want every nurse to have that at his or her core. Because that’s the error message – that’s about reducing the errors. And, that’s where simulation comes in and makes such a huge difference in making sure that those errors don’t necessarily have to occur.

The other thing that just touches my heart and that I’d like you to think about is that while Florence was in Crimea, there was another nurse named Mary. Mary wanted to practice with Florence, but she was of color. And at that time, it was not permissible, so Florence sent her away. But, Mary practiced on the other side of the water and is loved and beloved person in the British community to this day. They have a statue of her. So, while we celebrate our dearly beloved Florence, don’t forget about Mary Seacole.

To me, that’s a message of diversity that needs to go all the way from the times of Florence to our times now. And as we look ahead, we are going to have to really think about this whole thing around diversity and inclusion. The world is changing, and the demographics are too, so we need to educate a diverse nursing workforce to make sure that we provide better care to a diverse nation and community.