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Nursing As a Profession: Changes Through the Years
Reflections from Rosalee Sites, RN, BSN, MA
Memories of Early Days
Cleaning our own bedpans in the soiled utility room...steaming needles and syringes after checking the needles for burrs...no IV meds...1 nurse and 3 aids on a 52-bed unit...no critical care units...no recovery room after daytime hours...smoking on the wards...doctors smoking!...
Growing up in Elkins, West Virginia in the 1940s, Sites remembers wanting to be a doctor. Interested in all things medical, she knew from an early age that medicine was her destiny; but because of financial considerations in her family and some of the limitations of the time, she instead applied for, and received, a nursing scholarship to the Davis Memorial Hospital Program. After 3 years of rigorous studies in the classroom and on the job training which involved staffing the floor, she was awarded the coveted black stripe on her nursing cap along with her pin and headed to work in 1965. Graduating from a degree program during that time, meant that she had to work hard, repeating a good deal of her initial training, to finally get her BSN 8 years later from East Tennessee State University.
"Nursing has been a wonderful profession for me, and I would do it all over again if I could." Working the night shifts on the wards meant that she was responsible for as many as 52 patients a night. She remembers making her rounds early in the shift and taking special note of those that might need something right away. One particular night stands out in her mind because it highlighted the importance of her role as a nurse and how the patient perceived her as being someone they could count on. While rounding, she came into one lady's room and the patient said, "You are here. I've been waiting for you." She asked, "Is something wrong?" The woman went on to say that in the daytime she had family around and there were lots of employees working but at night "It is you and me. That is the reason I wanted to meet you." Her statement stamped itself in Sites' mind, helping her clearly understand how important she was to her patients-they trusted her and counted on her honesty and care; she felt a sense of responsibility for their successful treatment and recovery and her role in it.
"Nursing assessment skills are the most important tools we have even now. But back in the early days, they were some of the only tools we could employ: skin color, temperature, respiratory rate, nail bed color, clamminess, pupillary response-all of this nursing observation had to take the place of non-existent monitors." Sites says she can remember rolling a patient's bed into the nursing station with her, so that she could watch them while she charted. "There was just so much less that we could do for people during those times. Medications were limited as were tests. We had to do the best with could with limited resources."
"Me, God, and the Telephone"
Early on, Sites recognized her special skills in administration and after a few years of general nursing began to specialize in administration as house supervisor with coverage of the emergency room, a small 4 bed unit at the time. As house super she had to do bed placement, deliver antibiotics to the floors on her rounds, and cover the ER. "It was me, God, and the telephone," she remembers. Making necessary calls to physicians at home and running the ER which would be considered primitive by our standards today, was all in a days work.
"As a nurse, I have been privileged to share very special moments in patients' and families' lives: being with them as their loved one takes their last breath, bringing a smile to a critically ill child, listening to an elderly lady talk about her family, helping a family member get their father who had dementia on his knees as was his nightly custom for prayer..."
After getting her Master's in Organizational Management, Sites continued to make important pioneering differences at Holston Valley Hospital in Kingsport, Tennessee where she continues to practice today. She started the first state-of-the-art Emergency Department, beginning with 23 beds. To really understand what was needed and what was available in terms of design and functional capability, she and a team of other employees visited EDs around the country to borrow the best ideas from the all, eventually making the ED at HVH one of the premiers in East Tennessee. She also headed up a group needed to obtain a Trauma Level 1 designation and worked hard to make that hallmark of advanced technology and ultimate care in trauma part of her local hospital.
"The Changes Kept Coming"
As the years rolled by, intravenous antibiotics became commonplace; roller clamps and marked bottles morphed into bags of fluid which gave way to machines that counted the drops and delivered the necessary medications in the right quantities to patients. Scans, CTs, MRIs, EKGs, ultrasounds, robotic surgery, all become part of the daily routine for a changing profession. "Even though the changes kept coming, I always realized that the role of the nurse remained central in all of the care we provided. Our patients continued to count on us."
Sites went on to clarify, "Your patients will remember you giving them medication for pain, for starting their IV, for inserting their NG tube but more importantly, they will remember you for listening to them; we used to have a physician on staff who said, 'If you listen to your patients they will tell you what is wrong with them.'"
The advent of CPR and Life Support provided new ways to intervene at the end of life. "The first person I did CPR on was my own dad in 1965. Because he didn't survive, I worried that I had done something wrong, but later I realized that he had a long cardiac history and there was nothing that I could have done." With CPR came ventilation, ICU care and increasingly interventional medical care.
"Continued Education is Critical"
A lifelong learner, Sites revels in tackling new topics and continues to be a focused student. As a nursing leader at her institution, she took to heart the major importance of encouraging her staff and others to continue learning. She pushed LPNs to get their RNs, made ACLS mandatory for ED nurses (to loud outcries of protest!), prodded along the process of obtaining certifications in ED nursing. Along with all of this, she was visionary in understanding the critical importance of working with and training the EMS staff so that the pre-hospital care maximized the patient's chance of survival.
"As professionals, we owe it to our patients to learn all we can and to push ourselves to reach out for more." She objects to ever hearing the phrase, "I'm just a nurse," and emphasizes the unique and special role that we enjoy as nurses who often are the ones seeing the bigger picture, the ones who are able to bring different disciplines together, the ones who translate what is in the EMR to both the physicians and the family. Our role has always been important but never more than now.
Nurses as Leaders
"Being a nurse has responsibilities and requires leadership." Throughout her career, Sites has taken seriously the role of mentor to other nurses, and finds it deeply disturbing to hear nurses complain about the profession she loves. "Maybe you have not thought o yourself as a leader but that is exactly what you are. You are a professional nurse and you will be a leader in whatever area you may find yourself."
As her career progressed, Sites sought out ways to not only improve conditions within her hospital but also in her area. Helping to start a local medical clinic for the working uninsured and serving on a number of boards and committees, Rosalee continues to see part of her role in nursing as someone who takes on community issues as well. She has been known to quote Sir Winston Churchill, "We make a living by what we get, but we make a life by what we give."
Evolving Uniforms and Lack of Uniformity
In the early days of nursing, compliance with uniform standards was strict and adhered to stringently. Sites remembers, "We polished our shoes, ironed pleats in our aprons and looked forward to the day when we could earn the right to wear the black stripe on our caps." She laughs to think that they were also required to wear girdles so that there would not be any distracting "jiggles!" Sites states, "What we wear can help inspire confidence in our patients, because if we dress well for our role, it can help us and it can help them. Appearances do matter."
Nurses in most areas were not allowed to wear pantsuit uniforms until the mid-'70s. Scrubs came out in the mid-'80s and a general loosening of uniform standards continued until recent times when many hospitals have adopted new, more consistent uniforms, including the requirements that all RNs (and other professionals) wear a certain color scrubs so that patients and families can have an easier time distinguishing between providers.
Career Changes and New Challenges
Most nurses would readily agree that being able to change positions within the nursing profession is one of the great benefits of our training. Sites is no exception. After spending many years in the ED, Sites wrote a grant to the Robert Wood Johnson Foundation and was approved to start a Parish Nurse (also known as Faith Community Nurse) Program in her community. Now, 20+ years later, she continues on as the director of the program, faithfully administering the growth from a start of a handful of nurses and churches to two different programs with almost 50 nurses total.
"Our hospital system wanted to find a way to engage with older adults and I saw Parish Nursing as a great way to do this." After receiving the grant and getting the program started, Sites pursued innovations, continuing education for the group, and diligently encouraged all the FCNs under her leadership to meet and exceed expectations.
"One of the primary roles of Parish Nurses is advocacy. They need to be informed, knowledgeable and caring. Sometimes, the nurse if the only person who really cares; is there anything more important than that?" she asks.
"We have come from a time when we could do very little for our patients to a technology-heavy environment that threatens to distance us from those we care for." Sites goes on to say that the very technology that improves patient care can also cause us to lose perspective in our personal lives, over-focus us on screen time and diminish the necessary personal interaction. "You must work on being healthy in mind, body and spirit, modeling a healthy lifestyle for others, refueling and renewing your strength so that you can continue to give."
When asked about the future of nursing and the ways that we may need to improve, Sites goes back to the basics: education. There she sees systems that are producing new nurses with good textbook knowledge but less practical training; nurses who are equipped to pass the NCLEX but who are less equipped to do basic bedside procedures. "What happens, when we have graduate nurses that are not fully prepared is that they end up leaving the profession. They feel dissatisfied with their jobs and they change jobs, experiencing less support from their peers. "As mentors and nursing educators, we must pursue avenues to do a better job with training so that when nurses hit the floor they are at least able to have some level of proficiency so that they are assets and feel reasonably comfortable in their roles."
Parting Words of Wisdom
Through a long career in nursing, Sites has seen a lot: evolving from when we could do very little to extend or improve life to an almost hyper-interventional care time, she sees the need for balance, gratitude and grace. She continues to see nursing as one of the most relevant professions in existence, but one that cries out for its nurses to get back to their roots of truly caring for one another, both our patients and our fellow employees.