Episode 6: Nursing Through the Ages

Cara Lunsford (01:03.647)
She'll make it sound great. She always does. She always does. Well, America, I'm so happy to have you here. We've talked several times. And in fact, the last time we talked, I was like, well, that could have been the podcast. Because we just it was so organic. It was so easy. And and we have actually you and I have been on a previous podcast through

America Farrell (01:05.89)
Okay.

America Farrell (01:21.762)
I remember.

Cara Lunsford (01:34.111)
Cost of Care, where we were accompanied by Sarah Warren. And that was such a wonderful experience because your son was the host of that one. Such a great podcast, by the way. Anyone who's listening has to go check out Cost of Care. It's wherever you get your podcasts.

America Farrell (01:35.48)
Yes.

America Farrell (01:58.786)
I endorse that, but I'm a little biased, so.

Cara Lunsford (02:02.181)
You know, you you are because you're his mother, but I am not. I was on it, but I I requested to be on it. I basically went back to our company and I said. We should absolutely sponsor an episode on cost of care. This is an amazing podcast, and I think we have the ability to really reach some people. And talk about things that matter to us.

And I had already listened to a few different episodes, one of them being the Million Dollar Baby, which

America Farrell (02:38.412)
I heard that as well, yes.

Cara Lunsford (02:40.617)
That one was just, really blew me away. So yes, if anyone has an opportunity, go listen to America's Sons podcast, Cost of Care. And today we get the opportunity to talk to you. And I would just love for you to just introduce yourself to the audience, tell them who you are and how long you've been a nurse.

and because we're gonna be talking about nursing through the ages.

America Farrell (03:13.538)
Right. Well, thank you so much, Kara, and I appreciate the invitation to be talking with you again today. And I did enjoy our last conversation. You're easy to talk to, and I'm very much looking forward. Finally, to this day, has arrived after a couple of little setbacks. So I'll start with my name is America Farrell, and my first name really is America. A lot of people ask me how I got my name. My father was very patriotic. He was an advisor to President Eisenhower.

I was born in an election year. I was his last child and I was born out of the country. So I think he got a little carried away with all that and just went a little crazy. He was a little eccentric anyway, in a good way, but he actually wanted to name me Miss America with Miss being my first name and America being my middle name. And luckily my mother stepped in and drew a line, set a boundary and said, we're not doing that to this child.

Cara Lunsford (04:09.897)
That's hilarious.

America Farrell (04:13.726)
Anyway, my name is America, but everybody's called me Missy. That's my family name is Missy. So we got the Miss in the America in there finally. anyway, I was born in 1955. So I am a product of the last century. So I'm glad you invited me on to do nursing through the ages because I do feel qualified at this point to do that.

Cara Lunsford (04:41.075)
I hope it doesn't come across as I think you're old. That is not the case at all. You're just well qualified.

America Farrell (04:44.602)
No, no, no. You just well qualified and I've got deep perspective on this. I graduated from high school in 1973, graduated from LPN school in 1975 and went straight to work. I wasn't sure at the time that I wanted to be a nurse. I was not one of those girls that grew up in my life playing nurse or anything like that.

Cara Lunsford (04:53.866)
Yes.

America Farrell (05:12.494)
It was more of a practical decision. And in the culture I was raised, it was not uncommon for women to get a college education, but predominantly the education was either in liberal arts or in fine arts. And somewhere in the back of my head, you my plan was to grow up Mary Richmond and live in a cottage with a white picket fence and have babies and, you know, be part of the bridge club and junior league and things like that. But I just had a

Cara Lunsford (05:41.279)
Sounds lovely, sounds lovely.

America Farrell (05:42.57)
Yeah, right, but I just always had this little nagging thought in the back of my head that what if that doesn't work out? Maybe I ought to get something vocationally that I can support myself. So the three options that I saw that would were reasonable for me to attain at that point in my life was either being a teacher, being a secretary, or being a nurse.

And I thought being a secretary sounded boring. Sorry to any secretaries out there. I've since learned that I was very wrong about that. I knew I did not have the patience to be a school teacher. So I thought by process of elimination, that just leaves nursing. So I went ahead and joined a VOTEC school and I thought, well, I'll go get my LPN. Back then it was 18 months. And I thought, well, at least, you know, I have something to make a living.

while I figure out what I really want to do. But within two weeks into the program, I had already been down to the RN school in my community and talked to them about signing up because I instantly fell in love with nursing. And they were already full for that year, so I couldn't get in here. But long story short, I was able to clap out what I had done in LPN school and go in as a

in the second year and I went to a diploma program which for any nurses listening, some of you may remember what a diploma program is and it's a, thank you, it's a three year program. For those of you who don't know, it's a three year program. Back then we didn't have associate's degree and we didn't have a bachelor's degree either. I mean it was diploma or nothing.

Cara Lunsford (07:16.457)
I do, I do.

America Farrell (07:27.674)
And basically you lived in a dorm on the campus of a hospital and you were the slave labor of the hospital. And in return you got a great education and I will say a great education. And we had to be on the floor at seven every morning with a smile on our face and our white uniform starched and our cap and our white hose and our white shoes. And we worked all day every day. Like I said we were basically the slave laborer but you really learned a lot.

that way. I graduated from nursing school in 1978 and I had worked as an LVN in the intensive care unit putting myself through RN school. And when I got out of RN school I stayed in ICU because that was my love, that was my first love, it's been my only really love.

Cara Lunsford (08:20.243)
Isn't that amazing that I just want to make a note that you were an LVN in the intensive care unit, which is not something you hear about anymore. You don't hear about LVNs actually in the acute care space that often. But I think that maybe that's coming back a little bit more. But I just wanted to note that really quickly because I thought that that's a really interesting call out that that's where you worked.

America Farrell (08:30.148)
you can't do it anymore.

America Farrell (08:37.41)
No, not anymore.

America Farrell (08:47.33)
Yeah, and we could do everything that an RN could do except hang blood.

Cara Lunsford (08:54.803)
Wow.

America Farrell (08:55.018)
so we could do everything an RN could do. So it was in the ICU. Now, I don't want to get, yes, yes, yes, we did full assessments. No, we did everything in the ICU. Now, not to make this too complicated, but out on the floor back then, they had team nursing.

Cara Lunsford (09:03.231)
Could you do assessments? Could you do assessments too? wow. Not just data collection.

America Farrell (09:19.662)
So you had the RN doing the assessments, hanging of the blood, the complicated things, checking off orders. Your LVN, your LPN, whatever you call it, was the medication nurse. And then you also had a CNA. So every day you were a team of three and you might have eight patients. And we'll talk about that again in just a little bit. I hope, bring me back to that because nowadays,

Cara Lunsford (09:33.279)
Mm-hmm.

Cara Lunsford (09:43.539)
Yes. Yes.

America Farrell (09:48.63)
out on the floor, it's not uncommon for one nurse to have eight patients. And I do want to touch on that a little bit.

Cara Lunsford (09:53.77)
Yes.

I'm sorry I interrupted you, but I was like, don't want to skip past that, because I think that that's such an interesting thing that you were, you know, that you called out that you used to work as an LVN in an intensive care unit.

America Farrell (10:00.545)
No!

America Farrell (10:09.924)
Yeah, and that's how I pretty much put myself through RN school. Anyway, I worked as an ICU nurse for 27-ish years. And when I was in my early 50s, and this anybody listening, I want to tell you it's never too late. When I was 44, so I completed a master's degree, but I did an MBA, not an MSN. Got a little bit of heat from that.

but I persisted anyway and ended up going into hospital administration. And so you can be a nurse manager, director with a bachelor's degree. And I had had to go back also and get my bachelor's degree, which I completed at age 40. And then at 42, I was back in school pursuing a master's degree at MBA.

finished with that around age 44 ish, something like that, worked as a nursing director at various hospitals in an ICU progressive care units. Often I had ICU progressive care unit and ER all under me. I also, you know, kind of did some other things which aren't relevant really to this conversation, but just know my pretty much my whole

background was ICU, some emergency room. And then I went to work for a company when I was about 50-ish to be an internal consultant with them. I traveled a lot, saw a lot of different hospitals, and I was their ICU consultant. And I'd go out to their hospitals and help identify where some problem areas were, you know, that kind of thing.

And I came back and I kept going, you know.

America Farrell (12:08.056)
hospital's really good, the nurses are really fantastic, but I don't know about the leadership. Anyway, long story short, I decided I wanted to be a hospital CEO. So at age 53, I hop out and get thrown into the pool, you know, found my company. I'm always will be grateful that they gave me that opportunity. And I was a CEO for about a year and a half, and then I got my own shop.

So I've been a hospital CEO nonstop since 2009 and was CEO of probably four or five different hospitals. I would get moved around within my company. And then I wrapped up my career in, I retired about a year and a half ago, about two years ago.

Cara Lunsford (12:52.532)
Ahem.

America Farrell (13:02.538)
So I got about 50 years in of my career and it's been a great journey. Started as an LPN, ended up as a hospital CEO. a big shout out for me to any RN CEOs that are out there because it's a long journey and a completely different skill set. But I will always say that nurses make the best CEOs because we are all about the patients and we can keep our hospitals focused on patient-centric care.

Cara Lunsford (13:33.595)
I could not agree. I could not agree more. this everything that you just said is exactly why I wanted you to come and speak, you know, with us and with the audience. So because you have a very unique perspective because you have worked bedside for many, many years. You've worked management for.

America Farrell (13:33.786)
So that's my journey.

Cara Lunsford (14:02.981)
many years and many, years. And you've also now you're over on the administrative side as a CEO.

America Farrell (14:03.46)
many, many years.

Cara Lunsford (14:14.225)
And I think a lot of times what happens is that some of the people, some of the nurses that are at the bedside, there's this kind of that we kind of demonize the the administrative like they don't understand us. So there's this huge disconnect between.

America Farrell (14:29.486)
Right.

Cara Lunsford (14:34.889)
feeling like the CEO or the upper administration understands or truly understands the pain points of what the frontline staff is facing. And yeah.

America Farrell (14:48.106)
And doctors very much are like that as well. Again, it's not just the nurses that demonize administration, it's the physicians. And as a CEO, I was on the receiving end of that a lot. But it also taught me a lot. one of the main things that I learned when I very first started, my very first shop,

Cara Lunsford (14:53.5)
No.

America Farrell (15:14.446)
first day I put up an 8 by 10 framed picture of my nursing graduation picture. So I'm like you know 55 years old at this point and this is my picture of me when I was 22 and I got it right on my credenza like you can't miss it and I thought well this is either gonna make me or break me I'm gonna see how this goes you know and also in a few minutes I know we'll talk about a little bit of gender bias and

Cara Lunsford (15:43.252)
Yeah.

America Farrell (15:44.11)
nurse doctor dynamics and I thought okay this is either gonna make me or break me but without exception every physician that walked in my office went you're a nurse thank goodness I can talk to you I can talk to you now and you'll get it and

Cara Lunsford (15:46.249)
dynamics.

Cara Lunsford (16:07.593)
That's wonderful. That's wonderful.

America Farrell (16:09.218)
Yeah, it was really, really good. And so if they wanted to come in and yell at me about the nurses are not getting eyes and nose on the chart fast enough or radiology is having a problem. And I had been a C.O.O. So I had also been well versed in imaging, lab, pharmacy, all the other ancillaries, the therapies. I'd managed all of those as well.

knew nothing about them when I started. And, you know, literally my first day as a COO, I walked down to imaging and the director had been there for like 25 years. And I just said, hey, Carlos, I'm your new boss, need to let you know I know absolutely nothing about imaging and your department, how you run it, what's important to you. And you're gonna need to teach me. And I think that's the attitude that made me successful.

was not going in like I knew everything. It was the same thing in pharmacy. It was the same thing in lab. I mean, I didn't know anything about the nuts and bolts of how any of those departments worked. But anyway, that was good training for me. And then so when I got to be a CEO, I did have that broad knowledge of pretty much every department in the hospital. And I could say to anyone that came in my office, just tell me what your problem is.

I think we could fix this. So it was good training for me.

Cara Lunsford (17:38.623)
Yeah. So. So I think that that's like that's that's also a nice shout out to say, hey, if you're thinking about going back to school, you don't have to go for your MSN, you don't have to go for your DNP. You know, you can go for an MBA and you can effectively move up into positions where you can feel like you can move the needle and be effective in changing health care systems. So.

America Farrell (18:07.514)
Right. And even when I did that, that was back in 2000, 2001. And even then, when I was applying to a university where I did my MBA, and I won't call it out because I don't want to, you know, embarrass them. But when I was applying and interviewing, the question just kept coming up. Why do you want an MBA? You're a nurse.

Cara Lunsford (18:37.769)
You're just a nurse, America. You're just a nurse. We hate that just a nurse.

America Farrell (18:40.746)
Yeah, you're a nurse. It's like you're a nurse. What could you possibly understand about business? You're a nurse. You're just a nurse. And I just said, listen, I'm accountable every day for what goes on on my floor. And nobody teaches you business in nursing school. Nobody teaches you really what an FTE is or how to stay within a budget. I mean, I didn't hear any of that. I grew up in the day, which was I'm here to take care of patients.

And you're here to worry about the money. Don't bother me with such nonsense. I'm just going to take care of patients. And I've lived through years and years of change, I'll just put it. And you kind of have to adapt with the times. so that's why I wanted to do an MBA, just because I could get a little bit more business knowledge.

That was just for me because I knew I wanted to go into administration and you can do three things as a nurse. You can either go the education pathway, be educator, you can go the clinical pathway, be like nurse practitioner or you know clinical, yeah, clinical nurse specialist, any of that or you can go the administrative pathway and I already knew I wanted to go to the administrative pathway. So that's more why I did that and we didn't even have

Cara Lunsford (19:52.117)
clinical nurse specialist or something.

America Farrell (20:06.136)
We may have had one or two MHA programs, but they were very rare when I did my MBA. And so that was the closest thing. If I had to do it again, I'd probably do an MHA.

Cara Lunsford (20:19.613)
Yeah, that makes sense. Like that, think that's another good alternative that if you don't want to do an MBA, like the MHA is probably a good that's a good pathway.

America Farrell (20:28.684)
Right. And I even have friends though now that have an MHA and have gone back to get a MBA on top of that just because they wanted that little bit more depth of knowledge. And I was blessed to go to a really good MBA program. And I'm glad for that. The director of the program had actually been the dean of Harvard MBA program and had left to come

kind of found this one and so brought a wealth of knowledge and experience with her. And yeah, she wasn't really sure about me, told me she was kind of there. She's going to watch me, you know, and see how see how I did. And.

Cara Lunsford (21:17.769)
That's so interesting. I I think that that brings up a really good point of you were talking about gender bias. I think if we go way back, if we go back 50 years or even further, I had interviewed Dr. Anne Burgess. Are you familiar? Yes. Yes.

America Farrell (21:38.85)
Yes, yes, you turned me on to her and I've done a lot of study and research and watching and she's amazing.

Cara Lunsford (21:46.917)
She's so cool. Yeah, was totally fangirling over that. So so, you know, so she talks about a little bit of what it was like and. But very briefly. So for you, when you when you first went into I know we talked a little bit about how.

America Farrell (21:50.585)
Yes.

Cara Lunsford (22:12.845)
Women had a couple of like typical options for them, like you said, secretary, teacher, nurse, and that tended and if they were going back to school, it was something in the arts, liberal arts or fine arts, something to that homemaking, stuff like that. But even though you did. So you did choose nursing, but it was still I mean, I would say it's still it was still very oppressive.

America Farrell (22:26.052)
Fine arts, homemaking, yeah.

America Farrell (22:43.13)
Okay, so it was now I'm gonna if you'll indulge me for a moment, this may take maybe three minutes. I'm gonna take you. I'm gonna take you back to 1887 for just a moment. And I'm gonna give you a perspective. And I did the math this morning before I got on the podcast. And if I go 2024.

Cara Lunsford (22:49.14)
Yeah.

You can take as much as you want.

America Farrell (23:11.598)
minus 1887, that's 137 years. If you divide that by two, that's 68 years. So I'm 68 years old right now. So that's my lifetime and just one other lifetime. So I went not that far back, to be honest, that's like two lifetimes ago. But let me tell you what life looked like.

for a nurse in 1887. And you may have seen this, but for your listeners out there that haven't, this is called an 1887 nursing job description. Okay? Okay. In addition to caring for your 50, five, zero patients, each bedside nurse will follow these regulations. And there's nine of them. Number one.

Cara Lunsford (23:48.425)
Can't wait, I can't wait. I'm so excited.

America Farrell (24:05.966)
Daily, sweep and mop the floors of your ward, dust the patient's furniture and window sills. Two, maintain an even temperature in your ward by bringing in a scuttle of coal for the day's business. Three, light is important to observe the patient's condition. Therefore, each day fill the kerosene lamps, clean chimneys, and trim wicks.

Number four, the nurse's notes are important in aiding your physician's work. Make your pens carefully. Make your pens carefully. And you may whittle the nibs to your individual taste. So I'm not sure if they meant pens or pencils, but either way, you had to make them. But you could whittle the knobs to your individual taste. That's important.

Cara Lunsford (24:48.159)
Gosh, make them.

Cara Lunsford (25:05.833)
Were they actually using ink like back then? I think it was like where you dipped, you dipped in ink, right?

America Farrell (25:07.731)
Yeah. Yeah. Yes. Five. Each nurse on day duty will report every day at 7 a.m. That hasn't changed and leave at 8 p.m. We're kind of back to that now. Except on the Sabbath on which day she will be off from noon to 2 p.m.

Six, graduate nurses in good standing with the director of nurses will be given an evening off, one, one evening off each week for courting purposes. Or two evenings a week if she regularly attends church. Seven, I know isn't this hard to imagine nowadays. I see you cringing.

Cara Lunsford (25:55.387)
I can't, I know, I know. So I guess, this is gonna inform a lot of our conversation.

America Farrell (26:02.682)
Okay, seven, each nurse should lay aside from each payday a goodly sum of her earnings for her benefits during her declining years so that she will not become a burden to others. For example, if you earn $30 a month, you should set aside $15. Now that's not a goodly sum, that's half of your paycheck.

Cara Lunsford (26:29.034)
Yes.

America Farrell (26:29.806)
Yeah, okay. Number eight, any nurse who smokes, uses liquor in any form, gets her hair done at a beauty shop, or frequents dance halls will give the director of nurses good reason to suspect her worth, intentions, and integrity.

America Farrell (26:54.73)
Nine, the nurse who performs her labors and serves her patients and doctors faithfully and without fault for a period of five years will be given an increase by the hospital administration of five cents a day. Now I did look up in preparation for this how much five cents a day is, you know, in our modern day money and it would be a dollar sixty six.

So every nurse now, if they perform faithfully for five years, can get $1.60 a day, or if you do the math, $49.80, almost $50 a month. But that's after five years, and then you get $50 a month. So now let's fast forward a little bit to 1970 or so. And yes.

Cara Lunsford (27:48.041)
I'm so curious, by the way, and I'm gonna look this up, and I encourage our listeners to look this up. I wanna know what the job description is for a doctor back in 18, like just to see how much more well respected they are in that. It would be so interesting to see the difference.

America Farrell (28:05.497)
Yes.

America Farrell (28:12.0)
Absolutely, absolutely. We should all do that. So I was going to, I'm gonna come on up to 1970. I lost my train of thought here for just a second. I'll hold on a minute.

Cara Lunsford (28:14.227)
We should all do that.

Cara Lunsford (28:35.189)
Don't worry, we have editing.

America Farrell (28:36.762)
Okay, don't worry, we have editing. I know what I was gonna tell you. In 1970, went to boarding school. I was in boarding school. I went to boarding school for high school and I was in an all girls boarding school in the deep south. And just to let you know that urban legend, I don't know if any of your listeners out there will remember a TV show called Gunsmoke.

Cara Lunsford (28:38.645)
You

America Farrell (29:05.304)
And there used to be a character on there named Miss Kitty. And she was the brothel owner, but beloved by everyone. She was the mainstay of the whole town. And you had, you know, the sheriff and it was a great show, Gunsmoke. But Miss Kitty was actually went to my same boarding school when she was a teenager, but she was expelled for filing her fingernails in public.

So, yes, we've come a long way from 1887, but even fast forward almost hundred years, there still was a lot of preconceptions about how a lady should conduct herself. And nurses were held to an even higher standard than regular ladies because we were angels of mercy and we were the doctor's handmaidens.

we were all this and all that. so, you know, 1973 comes around, I graduated from high school by 1975, and you know, from 73 to 75, I'm a student in my LPN program, from 75 to 78, I'm a student in my RN program.

And, you know, when we were the nurses, when the doctor arrived on the floor, the nurses had to get up out of our seat at the nurse's station, give him our chair and bring him his coffee, cigarette and ashtray. And then when he went to go rounding on the patients, we followed behind with our chart, with all the patient charts, we carried them. We were his caddy. We carried them and we...

had to hand them to him and then he would write in them and then give them back to us. So we had this great big, you know, stack of charts we're carrying down the hall. I just don't know why then, you know, they didn't have little carts, but I guess that was another story. And at that time around 1973 to 1975, the world was just starting to let nurses take.

America Farrell (31:17.582)
blood pressures, or at least where I was, because they felt like that was too highly technical a task for nurses. You know, to put the cuff on, get it right, use the stethoscope, listen to the blood pressure, that was a doctor's job.

Cara Lunsford (31:32.767)
For those of you who can't see me, I'm just sitting in horror. The whole time, my face is just contorted in disbelief. And it's just so hard to believe that we were thought so little of.

America Farrell (31:36.172)
I'm

America Farrell (31:55.822)
will and you know God forbid that you would ever question a doctor writing an order. This is part of the reason I wanted to go into the ICU was because they let you do a little more in the ICU. The doctors had a little bit more respect for you in the ICU and it was just life was a little better in the ICU or specialty areas ER operating room cath lab.

Not that cath labs were all that popular yet back then, but specialty areas, you got more leeway and you got to do cooler stuff. And that's what it...

Cara Lunsford (32:36.735)
Did you feel like a lot of nurses? I'm just so curious. Did you feel like a lot of nurses? Sometimes I read things about the past or I hear things about the past and I wonder if the nurses felt as oppressed as when we look back on it. If in the moment they were like, this is wrong.

America Farrell (33:03.002)
I'll give you my opinion and not all of your listeners would agree with me, but I don't think so. I think we were programmed to believe what we believe. I think we were conditioned and we were...

I don't want to be cynical, so cynical and say we were sold the fairy tale, but I'm just for this purposes of this, you know, we were sold the fairy tale that we were angels of mercy. You know, come on, we're all dressed in white every day. We're sitting at the patient's bedside. you know, part of our evening care that we did every night included a back rub and

We sit and we listen to them and it was very holistic and we really were like angels to the sick and the dying. And I think part of what just came along with it was that, yeah, we were often disrespected by physicians. But that was just, you know, that was just part of it and you dealt with it.

Cara Lunsford (34:12.351)
That was part of it. That was just kind of part of it. But did you feel like you actually had more like you were more satisfied with the work that you were doing? Because I do think that some of what's missing today is actually some of what you just said, like sitting at the bedside, the holding space, the listening, the showing up, being able to be an ear to them. We miss that now. Like some of that's actually missing.

America Farrell (34:37.167)
right.

that's a lot of that is missing. And, you know, to my point, when we did team nurses, we may have 12 patients or maybe even 14, maybe 12, 13, 14, depending on where you work, but you're a team, you know, you're team nursing and there's an old Indian proverb that says one man cannot build a house alone.

but two men working together can build a village. And so because of synergy, so every day you go in, you've got your team and you know, it would be fun to have competitions with the other teams and you know, we just, loved it. It was, you have a friend. And then when we went to primary nursing, it became you yourself and you, and they started with,

Cara Lunsford (35:15.285)
That's cool.

America Farrell (35:39.906)
Okay, you've got four patients, but at the time they also took the unit clerks away. So you're putting in your own orders. You were doing everything, including often cleaning the rooms and emptying the trash for the patients. And yeah, housekeeping comes around once a day, but if you're in an ICU, you fill up that trash can three or four times during your shift. mean, so you're doing...

everything. Now if you're in an ICU though to my point you've usually got back then we had two patients. So I always felt like I could just take really really good care of the two patients but I'm talking about the floor nurses that originally were told that they would take four patients a day then it creeped up to five then it and and they kind of started to do away with the CNAs. So maybe you'd have one CNA for your whole unit for the day.

Well, good luck trying to get somebody to help you change a bed, get a patient up, do a bath, walk somebody after surgery. It's like, no, it's you. We didn't have that in team nursing and I'm just a huge proponent of team nursing. And I know some places are easing back into that and I say congratulations to them.

Cara Lunsford (36:58.527)
What about where you work? Is that been kind of, are you bringing that back a little bit more or trying to?

America Farrell (37:02.778)
well, I've been retired. I've been retired for a couple of years, so can't really speak to what they're doing currently, but there was talk of that, you know, because how do we, how do we bring some synergy? Because to me, the problem is you have all these nurses doing primary nursing, but each man is an island. It's, like every man for himself. And it's very, very, very difficult. And those, nurses.

are heroes. They're just heroes. I don't know how they do what they do. Especially during COVID, I could cry just even talking about the sacrifices that nurses have made. But anyway, we'll get back on topic. But that's just sort of how things, how I've seen the evolution. Yeah. Yeah.

Cara Lunsford (37:53.045)
Slow boiled. It's like people got slow boiled. know, you just kind of, the heat just kind of slowly creeps up and you know they say, I don't think this is actually true at all, but they're like, if you, you know, put a frog in water and you just kind of slow boil them, they won't jump out. But if you throw them right into a boiling pot, they'll like jump right out of the water.

America Farrell (38:09.604)
frog.

Cara Lunsford (38:18.994)
I think it's good visual because I think that happens a lot is that you... Yeah.

America Farrell (38:22.34)
Yeah, and there is a lot of truth to that. You know, and I remember when, I still remember when nurses petitioned in most places and went from wearing whites to wearing scrubs. And at first,

Cara Lunsford (38:41.05)
yeah, when was that?

America Farrell (38:43.798)
In my lifetime, I mean, I was still working in the ICU and I went in every day in my white dress and my white hose and my white shoes and my white cap. And I did that for years and years and years. And then we transitioned to scrubs and I was alternately horrified. But at the same time I went, well, this makes perfect sense. And it's really about time.

Because, you know, I'm trying to get blood out of my white dresses and things worse than blood. You know, and it was a huge laundry challenge. I thought, well, this makes sense. I wonder why we haven't done it. But culturally, socially, psychologically, moving from whites into scrubs was... Yeah.

Cara Lunsford (39:15.434)
Yeah.

Cara Lunsford (39:36.627)
and dresses into pants. I mean, because you went from a dress to pants. And that was also something that for a while was not acceptable. you could.

America Farrell (39:45.486)
Well, we could wear white pantsuits. We could wear white pantsuits. So in all fairness, I did have white pantsuits, but you know, I was about half and half. I still wore my dresses a good bit. But yeah, but going into scrubs just made me feel like we had become a technician or something. I don't know, only people in the operating room wore scrubs. It just seemed wrong, you know? But it took me about five seconds to adapt.

Cara Lunsford (39:51.777)
interesting.

America Farrell (40:15.244)
And I was, you know, happy.

Cara Lunsford (40:17.909)
I had two teachers, by the way, I had two teachers during my because I went to county. We talked about this. I went to county nursing school and they started as a diploma program. And I'll joke and say that the block sisters who were twins, Carol and her middle name was Lynn and then Carolyn Block. Yes. And they both wore the white dresses and they would even wear the hats.

America Farrell (40:38.017)
no!

Cara Lunsford (40:48.545)
Yes.

America Farrell (40:48.812)
Yeah, I wore my hat a while, even with my scrubs until, you know, they said we didn't have to anymore. And like nobody was doing that anymore. So a lot of changes, you know, that we've gone through. remember when DRG's came out. And that was when we first had to start being a little bit accountable for the money we spent. And I remember being so offended.

When I became a nurse manager, this was after my MBA, but we used to go in every month, and they still do this, nurse managers need to go in, you have to meet with the CFO or his designee, his or her designee, and you have what's called an MOR, and it's your monthly operational review, and they sit down and they look at your productivity and your labor cost and your supply cost and all of these things, and I had never been trained in any of that. we used to call it our monthly hemorrhoidectomy.

between us and all the managers, you know, and I remember being so offended when somebody told me to open a package. If I open a package of four by fours and I only used half of them, I had to seal it back up and use the other half later. But the problem was that

The CFOs, they don't know, like these are sterile. You can't just reuse them. And I remember one of my biggest fights was over four by fours. Once you open that package, it's not sterile. You cannot pack wounds with a leftover four by fours that had been opened yesterday. know, things like that, that just took years of... And you're not, yeah, just years, yeah.

Cara Lunsford (42:38.197)
Fighting. It's fighting. It's tiring, isn't it? It's tiring to fight to to Yeah.

America Farrell (42:43.704)
And that's what nurses go through. And you've got a manager that'll come back from the MOR and they have their next staff meeting and they go, okay, everybody, you've got to reuse your four by fours. And then all the nurses get mad. But to my credit, I was never that nurse manager. I said, that's what they told me in my MOR. But I'm coming back now to tell you, do not do that. You do not have to do that.

Cara Lunsford (43:05.682)
M-O-R.

America Farrell (43:12.418)
You do what's best for your patient. Now, where you can save money, please save money.

Cara Lunsford (43:20.927)
Yeah, and that's fair. I think that that's fair. Yeah, mean, let me just be honest. hopefully if anyone from Children's Hospital is listening, they're going to be like, that's where all the money went. But it was me. It was me. But because we had a lot of families that would come through there and they didn't have a lot of money. And we knew they didn't have a lot of money.

America Farrell (43:23.236)
but nothing that will compromise patient safety.

America Farrell (43:35.866)
It was you.

Cara Lunsford (43:49.243)
And I'd be like, here, take this extra thing of diapers, just like here, take these diapers home with you. And I'd like throw them in a bag like when they were being discharged or something like that. And I'm sure that. Well, they. Yeah.

America Farrell (44:01.208)
And that's what good nurses do. this day, to this day, that is what good nurses do.

Cara Lunsford (44:09.095)
Yeah, mean, you you but you don't necessarily understand the downstream effects or.

whether or not there's other avenues you could take. Maybe you get a social worker involved or you make sure that they're getting access to certain things that they didn't have access to if they don't have enough money, making sure that they have WIC or that they have WIC or they have social programs or things like that. And that's important for nurses to understand is that it's easy for us to just kind of throw some supplies in a bag. But sometimes it comes back to bite us in different ways.

America Farrell (44:32.065)
Exactly.

America Farrell (44:49.742)
Well, and you have to, yeah, you have to do both. You've got to throw the diapers in the bag to get them through the next two or three or four days. Till then you have got to also help them access social services. And that's why we have beloved case managers to do that. Cause that's a whole universe unto itself. But back in my day, we didn't have case managers. So we did all that. But back in that day, we didn't have a whole lot of social services either. So.

Cara Lunsford (44:50.354)
sometimes.

Cara Lunsford (44:55.007)
Yep.

Cara Lunsford (44:58.698)
Yep.

Cara Lunsford (45:09.779)
Yes.

America Farrell (45:17.806)
You pretty much just kind of sent people home and threw some stuff in a bag and said, you know, here and figure it out. And so we're much more sophisticated now with all that, but I'm glad you did that. And nurses today still do that kind of thing.

Cara Lunsford (45:24.159)
Here you go. Yeah.

Cara Lunsford (45:35.879)
Yeah, I agree with you. I think it's important. And I think that that's why I was kind of curious when you were talking about the times of being able to be more at the bedside. Because it's really tough, right? It's like, you can look back.

And not everything is sunshine and roses, right? For sure. But then you can tease out and pick out small things that you're like, but what would we bring back? Like, what would we make sure that we had today? If you know, because it's not all bad, right? It's there's elements of it that we're working things that we're working for the nurse, that they had more time with the patients, that there was team nursing.

America Farrell (45:58.072)
Right.

America Farrell (46:19.267)
Right.

Cara Lunsford (46:23.932)
and that team nursing was valuable. And so I think that's the value of history, right? And why we're here today, why we're talking.

America Farrell (46:32.002)
Right and and you had back to the team nursing too and you had time not just with the patients but you had time with each other. And so if you're a brand new nurse and you're just out of school and you've never changed a wound before or you've never.

empty to drain or put a Foley catheter in or any of those kind of things. There was always somebody on your floor that knew more than you did. You always had a veteran nurse. You've always had a preceptor. You go on a floor now and there's statistics right now that say like any given unit about 80 % of the nurses are within two years of graduation. So you've lost a lot of that senior nurse

I'm your proctor, I'm your mentor, I'll show you how to do this. Or to even talk through things, you know, about questions. And there's...

Cara Lunsford (47:24.82)
Yep.

America Farrell (47:32.728)
I think that in academic medical centers, university settings, you do have more access to education as a new nurse. But if you're at a community hospital or, you know, God forbid, a rural hospital, you're kind of on your own unless you're very, very fortunate. Because the resources aren't there.

Cara Lunsford (47:39.487)
Yeah.

Cara Lunsford (47:49.214)
Yeah.

Cara Lunsford (47:52.755)
Yeah, I mean, that's actually.

Right. Exactly. I mean, that's actually one of the reasons and a spoiler alert because, you know, we're talking about this and we haven't actually released it or created it yet fully. But one of the things that we're working on is a bridging the gap new to nursing eight part webinar series where we're helping these new nurses that are in the first six months, year of graduating who need some of that support and especially

America Farrell (48:15.677)
good.

Cara Lunsford (48:25.583)
to what you're saying, these rural hospitals or these areas where they just don't have the resources, they don't have some of the educational stuff, or they don't have the residency programs that maybe some of these larger health systems have. And.

residency programs are such, they're such an important, I had a residency program. I also had wonderful, wonderful nursing school. Like I learned so much, but it's because I went to county and it was a little bit like, here, here's all the charts and we're leaving for eight hours. Good luck to you. And that was it, you know, a little sink or swim.

America Farrell (49:05.048)
Right.

Cara Lunsford (49:09.577)
but I learned so much. And then I went into a nice hospital that had a residency program and really got that extra level of support and care and then had wonderful mentors and wonderful preceptors within my hospital.

And that was 17 years ago. That is so not the case today. It's just that there's so much burnout from the older nurses, I don't want say older, the more seasoned nurses. Yeah.

America Farrell (49:38.382)
Right. Well, and there are still residency programs. There are still preceptors. People can still, depending on where you work, when you get out. You know, when I was a new nurse, I mean, I went into the ICU, but the only reason was because I'd worked already in the ICU for two years and they just kept me. But you couldn't go as a new grad. You were not allowed to go into specialty area. You had to work at least a year out on the floor.

and get thoroughly beat up out there. And then if you did a good job and they felt like you were smart enough, hard enough worker, they'd accept you into a specialty area. That's not like that right now. There are, you know, there are parameters. They still do. The specialty areas are very clinically detail oriented. And so you do have to

to have a good grasp of clinical knowledge to be successful. And sometimes that really does take a year and that's okay. And there's nothing wrong with that. But sometimes it doesn't. So my point to all this is that so many things have evolved, but I can't right now imagine going in

America Farrell (51:07.512)
I think going onto the floor and doing floor nursing, if I was a brand new grad and I just got out of school and they said, here, here's eight to 10 patients or eight or nine patients here, yours, who do you talk to? Who do you talk to? Who do you say, who do you talk to and say, I'm scared to like, I have no idea. Like you're like deer, you're like deer in the headlights and

Cara Lunsford (51:23.807)
Well, and I don't know, I don't know. Yeah, who do you talk to? Exactly.

Right, I don't know what to do.

Yeah.

America Farrell (51:36.834)
The programs now, if you go to an associate degree, they get you through very fast. You get the minimum amount of knowledge required to do your job and then you go out into the work field and then that's when your real education starts, is day one in the workplace, not in school. Yeah.

Cara Lunsford (51:53.365)
But it's the blind leading the blind. It's almost like the blind leading the blind because it's like you get out there and like you said, there's like 80 % of your colleagues.

I have almost the same level of experience that you have, or just maybe slightly more. But, but there's not that decades of experience. mean, I worked alongside people who were 20 year veterans, 25 year veterans, 30 year veterans. And I can't tell you how valuable that was because you just, you don't have at that early stage, you don't, you don't have the, well,

America Farrell (52:08.067)
Right.

America Farrell (52:17.474)
Yes. Yes.

Cara Lunsford (52:31.367)
you might have a gut instinct on things, but you don't have the history. You don't have the experience. Yeah, you don't have all of this stuff that you have to pull in and you put together to create a picture that helps you make a decision. And it's all based off of stuff you've done in the past that helps lend it lends to that, ability to make good critical thinking and, and, and everything. So you have to have that.

America Farrell (52:35.652)
confidence.

America Farrell (52:59.222)
I remember, and I can remember the first two things I remember very distinctly, the first time I had to question a doctor on his orders. And it was a real existential crisis for me. It really was. It really was. Because I knew that what he had written was wrong.

Cara Lunsford (53:19.699)
And what did he say?

America Farrell (53:20.856)
But I was like, had been out in field for probably less than a year. He was nice, but nevertheless, it was a crisis for me. You know, he was nice. He thanked me.

Cara Lunsford (53:31.594)
Yeah.

Cara Lunsford (53:35.529)
How did you do it? Do you remember? Do you remember what you said or how you said it?

America Farrell (53:37.78)
I just sucked it up and I just did it. It was probably something along the lines of, hey, I know you're a doctor and I'm nothing, but that's an exaggeration, you know, but it was probably something along the lines of very humble, but I.

Cara Lunsford (53:50.557)
Yeah. Yeah.

Cara Lunsford (53:57.14)
Yeah.

America Farrell (53:58.594)
was just transcribing your order and I noticed that it said this, is that really what you meant to write? I didn't say I think it was wrong. I said, is that really what you meant to write? And it's like, no, there should have been a decimal point in there. Thank you for catching it. Well, that could have killed a patient. But I knew it was wrong. Like I knew the order was wrong. And I don't know how pharmacology was for you when you were in nursing school, but it was the dreaded course for us. And we had everything on index cards.

Cara Lunsford (54:25.865)
Yeah. Yep.

America Farrell (54:27.704)
and our teachers would roam around and they'd take the index cards away and you had to know everything about a drug and I just knew that that was wrong. My other crisis moment was like the first time I had to call a doctor at two in the morning and wake him up.

But I knew I had to because the patient was like crashing. you know, it's like you have to, I don't care how.

Cara Lunsford (54:48.605)
Isn't it crazy though that that's the dynamic that that's

America Farrell (54:51.842)
And we were scared to death to do things like that.

Cara Lunsford (54:55.421)
It's really horrible. I mean, it's horrible that that's the experience, right? Like you're just there. You're just trying to like, you're all part of a team. You're all supposed to be the eyes and ears and you're supposed to, you're supposed to be doing that. That is the role.

America Farrell (55:12.058)
Well, I am happy to report that in my journey of nursing through the ages, I have seen physicians change. And I have seen their trust in the nurses go up. I've seen nurses credibility go up. And I say, any doctor that has a half a brain cell in his head needs to go have a relationship with the nurses that are taking care of your patients.

and you need to get to know your nurses and they do. And if they don't like their nurses, they'll be verbal about it. But the nurses that they have respect for, they will listen to them. Like those nurses will always have their say. And I'm glad to see that.

Cara Lunsford (55:58.269)
It concerns me. It concerns me a little bit about the potential for that, for the old dynamic to kind of come back because we have these much younger nurses. They don't have someone that they can trust that they can go to. They're inevitably going to call a doctor with a question that that the doctor is going to think is ridiculous.

America Farrell (56:23.116)
absolutely happens all the time.

Cara Lunsford (56:25.473)
And I'm concerned that we will start to recreate a lack of respect for the profession because we don't have the clinical experience in nursing school that we should be having or the mentorship and the preceptorship that we should be having because that's the buffer between.

America Farrell (56:44.174)
right.

Cara Lunsford (56:52.169)
going to physicians with a question that maybe you would have answered by someone on a more senior level.

America Farrell (56:59.482)
Well, the only thing I think, I think there's one speed bump that will prevent a lot of the past behaviors is that most hospitals and medical staff bylaws now have a zero tolerance policy for abuse. And so if that nurse does call the doctor at two in the morning, he doesn't get to just cuss her out and slam down the phone.

Cara Lunsford (57:24.051)
Yeah, yeah, that's true.

America Farrell (57:25.998)
because she will then be required to go report that to her manager and then it goes on up the chain until it gets back to that physician and they will be disciplined. That's how it's supposed to work in most cases. I'm not saying that infractions don't happen. I'm not saying that people don't report it. Right. But there is at least now a zero tolerance policy in medical staff bylaws that prevent

Cara Lunsford (57:31.349)
Yeah.

Cara Lunsford (57:40.585)
Yeah, or that people don't report it because they don't want retaliation or yeah.

America Farrell (57:54.746)
a lot of those bad behaviors because as you know, medical errors, a vast majority of those happen because nobody wants to confront the doctor. There may be a wrong order or something that a nurse will see, but they're too scared to report it or say anything about it because of what you just mentioned, fear of retaliation, that kind of thing.

you know, and that is into a whole other conversation about medical errors and missteps and safety events, near misses, you know, those kind of things. A lot of that has been because nurses don't want to challenge a doctor. And I'll tell you, it's still happening even in the OR, you know, when you even though we have timeouts and we've had them for 100 years, you go, how could there possibly be a wrong site surgery nowadays? Like, how could that happen? How can you leave a sponge in a patient?

Cara Lunsford (58:32.789)
Yeah.

Cara Lunsford (58:49.236)
Right.

America Farrell (58:53.166)
because you have to go through all these protocols, right? Because you still...

Cara Lunsford (58:56.777)
Yep. You have to count everything. Everything's counted and.

America Farrell (59:00.972)
Right, but I saw a case not too long ago where the doctor, the surgeon lost his marbles, said, we're not doing timeout. I'm not doing it. You start the patient. You this, you that, you this, you that. And to the nurse's fault, they let the doctor get away with it. And there was a mistake made. And it was a same site surgery mistake.

And you go, how does this even happen? Because every nurse needs to say, no, like just say no, no, we're not starting the surgery until I, the nurse, am satisfied that we have ticked through. Like you wouldn't fly an airplane until you'd gone through your checklist. I don't care if the pilot was in a hurry because he had a date that night and he had to get out of there.

Cara Lunsford (59:54.557)
Right, of course.

Cara Lunsford (59:58.986)
Right.

But that's also like another female, if you think about it, that's another female male dynamic, right? Like if you think like flight attendants and captains for the longest time was women and men. yes, yes. there's and and there's always been a bit been, I think, that that concern or that silencing and.

America Farrell (01:00:01.966)
But we still

Yes.

Yes.

America Farrell (01:00:12.674)
Yes.

and secretaries and bosses. Yes.

America Farrell (01:00:31.066)
Just go along to get along and don't make waves and don't push back and just be a good little nurse and just do what the doctor tells you.

Cara Lunsford (01:00:31.091)
One of the things, yeah.

Cara Lunsford (01:00:37.865)
And I think the way, yeah, and I think the way you push back at a, you know, or how you feel confident about pushing back, it really does stem from feeling competent in your job.

America Farrell (01:00:54.702)
Yeah, and back to your point, we've now looped around to your point that you were making a few minutes ago. When you are a new grad, you don't really start to feel competent to probably three to five years in.

Cara Lunsford (01:00:57.834)
Yep.

Cara Lunsford (01:01:07.399)
Absolutely. So if you've got eight, let's do the math there, right? If you've got 80%, if around 80 % of your staff on the floor at any given time has two years or less, think about the chances that those nurses will speak up.

America Farrell (01:01:11.35)
haha

Cara Lunsford (01:01:30.857)
What are the chances that the medical errors will increase? How is that going to ripple across and affect the operations of that hospital in the bottom line? And you have to take those things into consideration. What that's doing to your organization.

America Farrell (01:01:59.599)
Right?

Cara Lunsford (01:02:00.499)
You know, maybe I'm a little rose colored lenses, but I always feel like, aren't we just thinking about what's safe for the patients? Like, but at the end of the day, that does it does affect your bottom line if you're having all these medical errors and you don't have people feeling competent or comfortable to speak. So.

These hospitals, they have to do something about this because this is going to have grave consequences to the public.

America Farrell (01:02:31.706)
Right, and as a hospital administrator myself, that was on my mind 24-7. And, you know, I had two, like two best relationships. One of those two was with my chief nursing officer. The other one is with my chief financial officer. And my job is to get all three of us in alignment rather than working at.

purposes and I felt like I was really really blessed I had very good CFOs to work with that got it and and you know you often have your chief quality officer as well you know in there going we can't do this it's not safe now so many things are regulated that weren't back then that we do have more safety parameters in play for example computerized charting

computerized physician order entry, barcode scanning before you give a medication. Because of technology, there's a lot more safety mechanisms in play.

Cara Lunsford (01:03:49.831)
Yeah, before you give a medication, if there's an allergy to it, it's gonna alert you when you go to scan it, you know, as long as you didn't give it first or something and then scan it. I don't know how that works.

America Farrell (01:03:49.902)
but still.

America Farrell (01:03:54.894)
Flag it.

America Farrell (01:04:00.954)
Yeah, mean, you got a PIXIS machine that is interfaced with the medication administration record electronically. So if you go to get 20 milligrams of Lasix out, that's a drawer that it's going to pop you open to. So it's not like you can just grab 100 by accident.

There are a lot of safety measures in, but again, it's really, really important because the CFO has a job to do and that is to make the hospital financially viable. And Cara, as you know, there are hospitals closing across the country every day. And a lot of them are rural hospitals. They just cannot keep the doors open.

And the job of a CFO is extremely difficult and you're always doing that balancing act between it's just like you in your own household, you know, how much money's coming in, what are my expenses going out and how do you balance that?

Cara Lunsford (01:05:14.367)
Do you think it's a reimbursement? you think like a, I mean, from your perspective, all of these like rural hospitals that are closing, what do you feel as someone who's worked as a hospital administrator for so many years? What do you feel is like the major contributor to that?

America Farrell (01:05:36.77)
I well, I think it's twofold. I think part of it is definitely reimbursement and you've got CMA driving that Medicare Medicaid what they drive is pretty much what commercial insurance is going to follow with in the not too distant future. So and you also have managed care that is determining what hospitals will get reimbursed and what they want and and that's a huge

We can do another podcast on that another day, but that's just a huge factor in what hospitals are getting paid for their services that they're providing. And often, and people don't realize this, people think, hospitals, they've got deep pockets, whatever. But people don't realize what a thin line, a thin margin hospitals are running on because in hospitals, we are being told what we will get reimbursed. It's not like the olden days where you just

Cara Lunsford (01:06:10.474)
Yeah.

America Farrell (01:06:37.7)
filled out an invoice, you send it off and the insurance company pays you and says, okay, now that's another reason we have case managers. You have to justify every penny you've spent on that patient for that diagnostic code. And what if somebody comes in with a diagnostic code and their average length of stay is say three to five days, but they have a complication, they end up staying two weeks in the ICU. We still just get paid that bundle.

We eat the cost of that. Now, later on down the road, we can submit paperwork for our losses for a year. And again, even pre-COVID, most hospitals did a pretty good job of getting a good portion of that reimbursed by the government, if you could justify it. And your CFO would do all that paperwork and you could get a lot of that back. Since COVID,

Cara Lunsford (01:07:32.115)
Yeah.

America Farrell (01:07:38.774)
Not so much, not so much. Every day is a struggle. Every day is a struggle financially for hospitals to keep the light bill paid. And people don't believe that, but it is true. Unless you have lots of patrons or donors or endowments or things like that. know, like children's hospitals are usually in a pretty good place. But.

Cara Lunsford (01:07:52.937)
What would you say? Yeah.

Cara Lunsford (01:08:03.113)
Yeah, well, if you're a not-for-profit or you're...

America Farrell (01:08:08.762)
If you're a faith-based or your children's hospital, you probably have some income sources other than flat reimbursement. But I worked in the for-profit sector for most of my career and we have none of that. you know, it's kind of like you're at the mercy of what you're getting reimbursed. And just briefly, the other thing I want to say about this is that we've also seen a sharp increase in self-pay patients.

people that just can't pay. So say you're living in a rural community, you've got a community hospital there and just, I'm just going to make this up, Cargill is your industry in your town and it employs 20,000 people out of the 45,000 people that live there. And then Cargill corporate for some reason decides to shut that particular plant down, maybe because it's not

Cara Lunsford (01:08:59.156)
Yeah.

America Farrell (01:09:06.906)
profitable or whatever reason. I don't know. I'm just using that as an example. Okay, now what are you going to do? You're still the community hospital. You're still going to have to treat all these people, but now everyone's lost their insurance. And you see that happening a lot across the country as we lose businesses and as businesses get sent abroad, those kinds of things because the cost of doing business is too high in our country. So we shut down the plant. We open a plant in China.

But now you've got a bunch of people that are under underinsured, uninsured, or even if they're insured, as you know, it just doesn't it doesn't cover it because you still got to pay your 20 % or whatever it is, which could be exorbitant to it back to my son's podcast, The Cost of Care. Listen to that because it's.

Cara Lunsford (01:09:56.339)
Yeah. It's a chicken. It's very eye opening. mean, yeah, that's a it's a hugely eye opening one. And and I I want to ask you one more question because obviously I could talk to you for hours and hours and hours. And I'm sure I'll have you back on because we'll need to talk about other things, But I'm curious, just speaking to that financial aspect and.

America Farrell (01:10:13.87)
Ha ha ha.

Cara Lunsford (01:10:20.437)
how things were reimbursed and how, because this is, it is nursing through the ages, but it's also just healthcare through the ages, right? Is that this is how things are done now, right? And it's not really working, right? Like we can see it's not working because it's upside down and hospitals are closing and so there's all kinds of evidence to support that. Where do you feel...

America Farrell (01:10:27.352)
Exactly.

America Farrell (01:10:37.323)
no. Right.

Cara Lunsford (01:10:47.743)
Kind of like what you were saying before, you felt like team nursing was a much better way. We should be kind of going back to doing more of that team nursing. I couldn't agree more. What are the things that you could possibly pick out from the past that you thought maybe were working better in terms of just the health of a hospital system or how things were reimbursed or how things were, you know, what are your thoughts?

America Farrell (01:11:14.564)
Well, my first thought comes back to patient acuity.

Cara Lunsford (01:11:22.505)
Yeah.

America Farrell (01:11:24.25)
The acuity of the patients now is nowhere like what it was when I was a younger nurse. The patients in the hospital now, even a routine patient on a medical surgical floor.

would have been an ICU patient back then. I mean, the acuity has gone up so much because the object of the game is to keep everybody out of the hospital, right? So if they're going in the hospital and you know this, patients that go in the hospital nowadays, you gotta be pretty sick to get admitted to a hospital. And you gotta meet a whole lot of criteria or cause insurance won't pay for it. Well,

Cara Lunsford (01:12:00.861)
Yeah, yeah, otherwise they want to send you home.

America Farrell (01:12:08.536)
Back then, you know, we didn't have the insurance like we do now. Some people did. people, people used to pay with chickens and harvest. No, I'm not kidding. I'm...

Cara Lunsford (01:12:14.783)
How are people paying? People are just out of pocket?

You

No, I know. I know. I have four chickens. I'm thinking about maybe bringing a chicken to my next doctor's appointment.

America Farrell (01:12:29.762)
You know, and or they'd have to or they would have to figure out like, how do we go on a payment plan? Can I pay $25 a month or can we barter? And there was a lot of that that happened back when I was a young nurse that I've seen disappear. But back to what I would change, I'm not advocating bringing that back or anything, but I'm just thinking.

Cara Lunsford (01:12:37.737)
Yeah, barters and.

Cara Lunsford (01:12:44.405)
Yeah.

Cara Lunsford (01:12:53.471)
chickens. Yeah.

America Farrell (01:12:55.162)
Well, it wasn't always chickens. It could be corn or you know, whatever your whatever it is you raised but I Guess the thing for me is the nurses now are expected to do so much more with so much less Less time less resources in the in the in the way of having

Cara Lunsford (01:12:58.769)
Yeah.

America Farrell (01:13:23.2)
someone to talk to someone to say hey I'm thinking about this I don't know if that's right or not like what would you do I need to call this doctor but I'm really scared all right you know that just always having somebody

Cara Lunsford (01:13:41.331)
Like always having a resource nurse or something like that. Like always having a resource nurse like on every floor.

America Farrell (01:13:47.662)
You know, and having somebody to help you do a bath or turn a patient, you know, they have lifts now. So you go down the hall in the supply closet, you bring back, you get a lift.

America Farrell (01:14:02.382)
The teamwork, definitely I would bring back. I don't know what we can do about the patient acuity and, but you know, I would say the staffing ratios are pretty tight right now. They're all mathematically calculated, but you don't build in for crisis. I mean, we just saw this going through COVID, staffing ratios went right out the window. And I say staffing ratios as a generalized term.

Usually you see those in unionized hospitals. But well, where you have unionized hospitals and I've managed, I've been a nurse manager in a unionized hospital, but even a staffing matrix, let's just call it a staffing matrix, which is supposed to be a guideline, but often it becomes written in stone. And then, you know, you've got

Cara Lunsford (01:14:35.357)
or California where we have actually like, yeah.

America Farrell (01:14:59.29)
people in the financial end of the hospital that are like, you didn't stay on your matrix, why didn't you? And they don't understand it when you tell them, why didn't you? So it's a real balancing act between.

And good nurses can do this. Good managers can do this. Good directors can do it. Good chief nursing officers can do it. Good CEOs can do it. Good corporations can do it. Realize that you set a guideline, but it's just that it's a guideline. But to remember that the patient comes first. And if I guess as we wrap up this podcast, I guess that would be my tagline.

because medicine has moved into corporate medicine. I don't care if you're for profit or not for profit. Everybody's trying to make a profit. we have become, healthcare has become extremely corporatized. that's everything that goes along with that is what I've seen in my 50 years of practice. We have gone from being patient centric to being financial centric.

Cara Lunsford (01:15:54.377)
Yeah.

America Farrell (01:16:14.49)
And there's a lot that's been lost. And again, this isn't just for nurses. This is for physicians. It's for rad techs. It's for anybody that therapist, anybody that interacts with a patient has seen this, this evolution or do you call it devolution, deevolution?

Cara Lunsford (01:16:29.609)
Yes.

Cara Lunsford (01:16:36.071)
Yeah, yeah, yeah, you're right. Like, yeah, it's where something's devolved. Yeah. Yeah.

America Farrell (01:16:43.335)
Yeah, and I'm still and I'm still not exactly sure myself how we got there, you know how we got here.

Cara Lunsford (01:16:51.913)
I mean, greed is a problem. mean, greed tends, like if you track things to where like something's gone wrong, and it doesn't matter what area you're looking at, there tends to be some element of greed, whether it's in politics or it's in healthcare or...

America Farrell (01:16:55.14)
Yeah.

America Farrell (01:17:13.838)
Well, and there's also an attitude of entitlement. You see that among physicians, you see that among CEOs a lot. It's like, well, this is my job and I deserve this. And it's the opposite of a service mindset. And I've been a CEO and I know what a lot of CEOs outside of my, because you read modern healthcare, you see all this and you go, these.

Cara Lunsford (01:17:31.54)
Yes.

Cara Lunsford (01:17:41.684)
Yeah.

America Farrell (01:17:43.726)
Hospiceos are making what? Like. What?

Cara Lunsford (01:17:46.387)
Yes, yeah, I know. And I think that that's what ends up like really pissing some people off, right? Is that they go, well, you know, the president of the United States is only supposed to make $400,000 a year. And I'm not sure what that number is today, but it's because it's a service, right? Like you are a public servant. And I'm not sure that it should be any different for healthcare.

America Farrell (01:18:02.595)
Right.

America Farrell (01:18:06.563)
Right.

Cara Lunsford (01:18:16.341)
You're a public servant to some extent.

America Farrell (01:18:16.954)
No, well, and I'll take it even a step further. I think it should be a ministry. And when you're a nurse and you're at the bedside, that needs to be a ministry. That's a calling. It's not a job. It's a calling. And if you can't look at it like that, you're in the wrong profession. You should get out of nursing. And I would say the same thing all the way up to the CEO because leadership starts at the top. And it's not.

Cara Lunsford (01:18:36.639)
What would you say to the, yeah. Yes. Yes.

America Farrell (01:18:45.24)
It shouldn't be about the money. You have to be fiscally responsible. But that's not what drives your success. What drives your success is have you helped people? Have you saved lives? Have you been there for people in times of crisis? This work is not like anything else. It's not like Home Depot or banking or real estate.

No offense to any of these people, but this is different. You've got people at the worst times in their life. They're sickest. They're many times on death's doorstep. They're afraid. Their families are afraid. You tell me any profession that has people at a more vulnerable state than health care.

Cara Lunsford (01:19:15.178)
Yeah.

Cara Lunsford (01:19:32.725)
Yeah, and I think that like what I think you're right. think that that. I like I totally agree. I feel like it is a calling, right? Like I feel like nurses go into this oftentimes. Well, some people go into it. They feel like it's recession proof or it's a good job that will last, you know, for a long time, despite technology changes and stuff like that. But.

America Farrell (01:19:54.148)
Right.

Cara Lunsford (01:19:57.757)
I think if we change the focus and if everyone from the very, very tippy top is a public servant all the way to the people that are direct patient care, that's where if you set the tone and you say all of us are public servants.

America Farrell (01:20:00.216)
Uh-huh.

Cara Lunsford (01:20:20.123)
all of us go into this knowing that we're getting kind of public servant, you know, pay, we're getting the salaries of public servants. Well, a, it attracts a certain type of person, whether it's to that place at the CEO, or whether it's the person who is providing direct patient care, nurses, techs, doctors, and then it just changes the whole landscape and the whole culture.

America Farrell (01:20:26.04)
Right.

Cara Lunsford (01:20:48.385)
It's where I think nurses end up having a problem is when you say, well, for you it's a calling, but for that CEO it's a business. Yeah, that's where you lose nurses, because nurses are like, well, wait a minute. So I'm the indentured servant, and they're making millions and millions of dollars a year, and I'm kind of, yeah.

America Farrell (01:20:58.422)
Right, it's a business.

America Farrell (01:21:09.273)
Well...

America Farrell (01:21:13.54)
But I can't, but I have to recycle a package of four by fours.

Cara Lunsford (01:21:16.981)
Yeah. And then they're like, well, wait a minute, that doesn't work for me. Right. So it either has to be across the board. Everybody is a public servant and knows that that that there's pay that's associated with that. And, you know, obviously, like people need to be able to make a living, a house, take their send their kids through school, you know, take a vacation. That still needs to be part of like what you should be able to afford if you are a nurse.

America Farrell (01:21:46.542)
Well, yeah, yeah, absolutely, absolutely.

Cara Lunsford (01:21:50.121)
Yeah, I mean, they're not doing it for free, you know, but yeah.

America Farrell (01:21:55.194)
Well, and I'm also happy to say that in this day and time, nurses can support a family. I mean, the pay has come a long way from what it was back in the early days of my career. And I'm glad to see that. And I think that part is getting better. back to your question of what would I pick out, it's hard to just say, OK, what would I pick out in nursing? Because it's whole part of a, nursing is a part of a system.

Cara Lunsford (01:22:01.033)
Yes.

America Farrell (01:22:26.542)
that's broken. And if I could just wrap with one thing I would say as nurses.

America Farrell (01:22:39.556)
Take care of each other. It's not every man for himself. Don't turn into that. Don't be like that. Help. Help each other. Strengthen each other because the stronger you are, the better you can take care of the patients. The better nurse you can be. Take care of each other. Go back to the old ways.

Cara Lunsford (01:22:49.577)
Yeah.

Cara Lunsford (01:23:03.627)
my God. Go back to the yeah, I think that that is such a beautiful thing to end with is that, you know, what's that takeaway for you after having gone through everything that you've experienced over many, many decades of nursing is that the thing you're left with is that we have to take care of each other. I could not agree more.

America Farrell (01:23:28.388)
Because it's a battleground out there. It is. And everyday nurses walk in. You never know what you're getting. You never know what you're gonna walk into. never... Exactly, exactly, we have to help each other or the whole thing falls apart.

Cara Lunsford (01:23:39.251)
We can't turn on each other.

Cara Lunsford (01:23:50.279)
America, thank you so much for spending so much time with me and you know, it's I know this was kind of a long podcast, but when you're talking about nursing through the ages, come on, it's a lot to do. It's kind of a lot.

America Farrell (01:24:06.122)
I know, it kind of is.

Cara Lunsford (01:24:08.339)
Yeah. And then, you know, of course, you say something, it's like, well, we have to kind of dig into that a little bit or we have to talk about this a little bit. you know, but I think that at the end of the day, the listeners will get so much value and so many wonderful takeaways and and all the other people that listen to the podcast, because I know it's not just nurses. There are administrators, there are people that can listen to this and take some things away

from a management level and from an administrative level to say, you know what, she's right. We should be instituting that here in our hospital or we should be doing this. So I'm just so deeply grateful.

America Farrell (01:24:51.566)
Or at least have the conversation, you know, at least be open. If what you're doing isn't accomplishing the goals that you want, try something different. Even if it is from the 1970s, maybe we had something going on right back then too, you know?

Cara Lunsford (01:25:03.667)
Yeah.

Cara Lunsford (01:25:08.937)
Yeah, that's such a great point. I feel like that, for me, that was such a good, what I really enjoyed taking away from all of this was just like, nothing is ever all bad, right, in the past. Well, I mean, I guess there are situations where there's things that were all bad. But in this situation, there's usually something that you can take away. And you can say, that was working. And we shouldn't have gotten rid of that.

America Farrell (01:25:22.307)
No.

America Farrell (01:25:37.934)
Right. Right.

Cara Lunsford (01:25:38.502)
and let's bring that back but with also these other things that we have that we didn't have back then like technology and all the stuff that you were talking about. Yeah, it's a refresh. Yeah.

America Farrell (01:25:45.69)
You know, call it a refresh, call it an update. Yeah, just maybe you don't do it exactly the same way, but you kind of bring back the concept and adapt it to modern day parameters.

Cara Lunsford (01:25:58.409)
Yeah, like there's virtual, you know, the team that we're talking about, somebody could be a virtual nurse, right? Like you could have virtual nurse that's there that's part of the team who you can call on at any time. That's not there on the floor, but you can ping them and talk to them and get a mentor. know, so there's, I think that's exactly right, is that you reinvent it a little bit. But with the same type of model.

America Farrell (01:26:06.041)
Right.

America Farrell (01:26:11.609)
Right.

America Farrell (01:26:24.844)
Exactly.

Cara Lunsford (01:26:28.644)
And that's what I was really hoping we would get out of this podcast today. And I think that's exactly what we did get.

America Farrell (01:26:35.094)
good, I'm glad to hear that. Thank you so much for having me and I always look forward to hearing from you. don't be a stranger.

Cara Lunsford (01:26:42.834)
Thank you, America. This is I absolutely want you have a wonderful rest of your week and weekend and please give your son a big hug from me the next time you see him.

America Farrell (01:26:57.026)
I will, he just had a birthday yesterday. So.

Cara Lunsford (01:27:02.101)
My gosh, was it the 23rd? Mine's the 22nd.

America Farrell (01:27:08.268)
Okay, you guys have something in common now.

Cara Lunsford (01:27:09.459)
Yes, we do. We're also both cusp. We're kind of cusp baby cusp babies like so we're like Libra on the cusp of Scorpio. So that's cool. Well, I'll definitely reach out to him and I will send him I'll send him a nice little happy birthday.

America Farrell (01:27:20.918)
what?

Hahaha

Perfect. Well, thank you, Kara. It's great to see you.

Cara Lunsford (01:27:30.207)
Thank you so much, America. Have a great one. Bye.

America Farrell (01:27:32.792)
You too. Bye.