Nurse On the Move: JoAnne Phillips

“Nursing is the toughest job you will ever love.” JoAnne Phillips MSN, RN, CCRN, CCNS, CPPS, recognizes that hard work can produce gratifying results. As a manager of quality and patient safety at Penn Home Care & Hospice Services, a clinical informatics professional development specialist at the University of Pennsylvania Health System, and a doctoral student working towards her DNP at Vanderbilt University, Phillips doesn’t take her role as a nurse lightly. She is constantly looking to improve the quality of life of those around her, which is why she is our next Nurse On the Move

Phillips preiously served as a clinical nurse specialist in the transition, surgical critical care, and patient safety departments of the University of Pennsylvania. She earned her master’s degree in science in critical care nursing from Widener University, and prior to that, she served as a clinical instructor and staff nurse at Hahnemann University Hospital. 

Through our interview, I learned why Phillips chose to go back to school, as well as why she sees nursing as the best job to make a difference in a person’s life. 

Q: What made you choose nursing as a career?
A: When I was hospitalized as a child, I watched what the nurses were doing and I thought that is what I wanted to do. When I was older, I worked as a volunteer in the neonatal intensive care nursery. Then I knew that was what I wanted to do. I can’t exactly say it was a calling, but pretty close. 

Q: What is your favorite aspect of being a critical care nurse?
A: I had the opportunity to work at the Shock Trauma Center in Baltimore, where I truly learned the impactful role that a primary nurse could play in the patient’s outcome.  Patients could be incredibly sick, and I knew that the best medical care partnered with the best nursing care could lead to the best patient outcomes. As a lifelong learner, I thrived on the constant opportunity to learn more in critical care. 

Q: You specialize in patient safety. What is the biggest concern you have regarding the well-being of patients and how are you combatting it?
A: I don’t think patient safety is one issue, but a virtual kaleidoscope of issues. We need to better understand how systems work together and the role human factors (how we interact with processes and technology). Since humans will always be part of the equation, we need to know that there will be mistakes. Our role as safety leaders is to make it less likely that humans will make a mistake. Something I tell my colleagues, “If we make it easy for people to do the right thing, they will do the right thing.  If we make it too complex, they will do workarounds.” That is often where we see negative outcomes. 

Q: In your role as a clinical informatics educator, why do you feel informatics is important to nursing?
A: I would encourage nurses to work toward letting the computer work for you, instead of you working for the computer. We hear from staff that documenting in the computer is too hard. My response is that we have not designed the system correctly. One of the staff told me it takes eight clicks to chart a dirty diaper – a great example that we have made it too hard. Bottom line is [computers] are here to stay; [they are] an unbelievable resource of information.  Once we have better interoperability (computer systems talking to each other), it will be awesome. 

Q: You are working towards earning your DNP. What made you decide to go back to school?
A: The more I learn about patient safety, the more I realize to work toward a solution, I needed to understand even more about systems. My DNP program is focused on health systems management, and I believe it will position me to take a leadership role in patient safety, to mentor and develop many others to understand how we can create a safe environment for our staff and patients. 

Q: What is the most vital thing a nurse can do to improve their career?
A: To be a nurse today, I think you need to be a lifelong learner. Not just in an academic setting, but through ongoing personal and professional development. There are endless opportunities for nurses to learn and develop – conferences, memberships in professional organizations, online learning.  If finances are a struggle, many of these opportunities are free.   

Q: What do you see for the future of nursing?  
A: Nurses are the solution to the future of healthcare. We spend 75% of our healthcare dollars on chronic care. There is no one better positioned to manage patients with chronic, complex medical issues than a nurse. We need to create an environment that will draw and keep the best people in nursing. What better job is there than to know that you made a difference in someone’s life? Even if that difference is helping them to a peaceful death. As many have said before, nursing is the toughest job you will ever love. 

Do you work with a nurse that inspires you? Nominate them to be our next Nurse On the Move by emailing submissions to ClinicalEd

Posted: 11/4/2014 7:43:41 PM by Cara Gavin | with 0 comments
Tags: informatics, joanne, move, nurse, nursing, on, patient, phillips, safety, the
Categories: Leadership


Ebola: Keeping Perspective

Our NursingCenter team has been following the Ebola outbreak closely over the past months, but with recent developments of disease transmission here in the United States, media coverage has increased and protocols and recommendations are being closely examined. As nurses, we play an important role in patient and public education, and it is important that we continue to act with compassion and skill while gathering our knowledge from reputable sources and keeping recent developments in perspective.

Nina and Amber
My thanks and best wishes for a quick recovery go out to Nina Pham and Amber Vinson, two nurses who contracted the Ebola virus while caring for Thomas Eric Duncan, the infected patient who died on Oct. 8, 2014.  I commend your dedication and compassion. I am proud of you.

Nurses and other healthcare providers
To those of you caring for Nina and Amber, those already in or heading to West Africa to help with the outbreak there, and those studying current guidelines and possible systems issues, thank you. I am confident that your hard work will make a difference here and abroad, and that best practices for the safety of patients, healthcare providers, and the public is the priority. 

Stay informed
As a nurse, I will continue to look to professional organizations for the latest information and guidance. The Centers for Disease Control and Prevention has a long list of guidelines and checklists for U.S. health professionals. The Global Alert and Response of the World Health Organization includes up-to-date news and facts, frequently asked questions, and preparedness guidance. The National Institutes of Health also lists facts about the virus as well as the latest developments of research on prevention, treatment, and detection. 

I encourage you all to stay up-to-date and share your knowledge with your patients and the public. Refer to the sites above or to our Ebola page on NursingCenter (which we update daily with information from the above sites). Our colleagues at the American Journal of Nursing have also shared valuable insights from a nurse epidemiologist, who addresses the concerns surrounding personal protective equipment, and a nurse informaticist, who looks at the role of electronic health records in handling the Ebola outbreak.

Moving forward
I had the pleasure of spending the past week at Nursing Management Congress and was in the company of over 800 nurse leaders from around the country as the news of Ebola virus transmission in the U.S. unfolded. Themes from the general sessions included a focus on restoring pride in nursing, believing in team members, and dealing with root causes instead of putting out fires. I think these themes are appropriate as we face this new challenge in healthcare. 



NursingCenter Named Top Blog for Nurses

Last week, NursingCenter’s In the Round was named one of the Top 100 Nursing Blogs by BestMedicalAssistantPrograms.org, and we couldn’t be more excited! Listed among a variety of blogs dedicated to nursing students, RN’s, NP’s, educators, travel nurses, and more, our blog is described as a site “dedicated to helping nurses be the best workers they can be.” Three of our recent posts are also cited as favorites, including:

Directing Nurses Back to Patient Care
Technology and Global Health: A Nurse Presents for the U.N.
Nurses Who Led the Way: Florence Nightingale

We are honored to be a part of this list and to be featured among some of the best blogs for nurses out there. We want to ensure the nursing community stays connected, so here is a list of our favorite blogs for nurses (these are listed in alphabetical order): 

AJN Off the Charts
ANS: Advances in Nursing Science Blog
CorrectionalNurse.net
JParadisi RN's Blog
Not Nurse Ratched 
Nurse Code
The Adventures of Nurse Niki
What Should We Call Nursing 

Thank you to all of the sites that have included us as a top resource for nurses in the past, including OnlineLPNtoRN.org, OnlineColleges.com, CorrectionalNurse.net, LVNtoRN.net, and Jacksonville University’s School of Nursing. We are grateful for the recognition and aim to continue to provide excellent content for nurses. 

What are some of your favorite nursing blogs? Leave them in the comments below! 



Join our nursing community!

Since starting at Lippincott’s NursingCenter.com this past January as their Digital Editor, my favorite part about my job is talking with our nurses and members. I really enjoy the sense of community I get from speaking with nurses, whether it is in person at one of our conferences, over the phone at my desk, or on this blog. 

Another great resource for our community is our social media sites. Both our Clinical Editor, Lisa Morris Bonsall, MSN, RN, CRNP, and myself regularly update our accounts and use them as important tools to reach out to our nurses. I love seeing what people are talking about, how they are responding to current issues, and getting feedback from our followers. 

Social media is one of the best ways to reach us, so I invite you to join our nursing community by following us on Twitter @NursingCenter or @CaraGavin, Google+, Facebook, and LinkedIn. We want to hear from you! 

Posted: 9/30/2014 7:53:33 PM by Cara Gavin | with 0 comments
Tags: community, facebook, google+, linkedin, nurses, nursing, nursingcenter, social media, twitter
Categories: Technology


Nurses On the Move: Paula Roe

As fall gets underway and nurses head back to school, it’s important to look at how academic and professional education can shape a nurse in different ways.

September’s Nurse On the Move,Paula Roe BSN, MBA/HCM, FACHE, has a unique experience with nursing. She currently serves Simpler Consulting as a senior advisor - where she helps clients achieve sustainable breakthrough improvements in care quality, productivity, and cost reduction by applying process improvement techniques to daily operations – and operational excellence practice leader, responsible for Simpler’s internal process improvement.

She previously spent six years as the vice president of operations for St. Elizabeth Healthcare, a regional hospital system located in northern Kentucky. Before that, Roe spent 13 years with the Toyota Motor Engineering and Manufacturing American, where she learned the tools of the Lean management trade.Roe’s experiences have shaped her perspective as a nurse and operations leader. Through our interview, I discovered how these different settings impacted her thoughts on nursing and patient care. 

 

Q: Why did you choose to receive your BSN and start your nursing career?
A: A career in nursing was not my original plan. When I enrolled at Ohio State University, I was on course for a degree in engineering. By my sophomore year…I was forced to take the pre-medical school-level anatomy class to fulfill an undergraduate requirement. As soon as the class was underway, I knew I was hooked. I soon met with my advisor and found that nursing was the best match for me.

Q: You went on to manage a CTU/SICU department of a hospital. How did this shape your decision to earn your MBA in health care management?
A: Early in my nursing career, I was involved in staff nurse counsel and had the opportunity to present to hospital administration on a regular basis. I really enjoyed this interaction and pursued hospital administration as department manager of the CTU/SICU. When I went to work for Toyota as a safety, health and environmental administrator, I never lost that dream of working in healthcare administration. Lucky for me, Toyota offered MBA programs on campus, and I was able to earn my master’s degree specifically for healthcare management. 

Q: Please describe what Lean management means to you and why you believe it’s an important tool for nurses to use?
A: Lean is all about delivering value to the customer. From a nursing perspective, the customer is the patient and the patient’s family. When you think about nursing and the tenants of Lean – striving for zero defects, the relentless pursuit of value, and the delivery of service in the least wasteful way – the two are necessarily harmonious…The delivery of care is spending time with the patient and delivering care value. We need to relentlessly pursue the elimination of wasteful steps, challenging our day-to-day activities to spend more time with patients and deliver the best care in the least wasteful way. 

Q: In your role at Toyota, how did Lean management practices and role process improvement techniques shape your perspective as a nurse and operations leader?
A: When you start a career with Toyota, you start a lifelong journey of hands-on learning. The training advances as you practice and apply these Lean skills. Lean is also a team-based model; it allows teams to bring their ideas and thoughts together so the whole group is focused on what matters most. But with Lean, the team makes decisions together on execution and output as well. And action is immediate, meaning you are able to achieve breakthrough results within a very short time. I very quickly saw how Lean’s team-based approach could be applied to the nursing world.

Q: How do you define a nurse leader?
A: I came across not long ago a quote from renowned leadership expert Dr. Stephen Covey: “Leaders do what’s right and managers do the right thing.” To me, a nursing leader is one who does what’s right for his or her staff, the patient, the organization, and the population served.. 

Q: What do you see for the future of nursing?
A: I believe that nursing will continue to be developed from within the profession and innovative ways to deliver care and patient treatment models will emerge. But, nurses will have to also look outside of nursing for solution approaches. I foresee Lean and other management techniques more widely accessed. I believe the pace of change in the industry is going to require new and breakthrough ways of looking at things, and traditional improvement approaches are going to be challenged. As Einstein said, “Insanity is doing the same thing over and over again and expecting different results.” In nursing, we’ll need to think outside of the traditional nursing box to eliminate waste and to ultimately spend more by the patient bedside.

Do you know a great candidate to be featured for Nurses On the Move? We want to know about the nurses who are advancing the profession and inspiring others to do the same. We will feature a new nurse every month. Email your submissions to ClinicalEditor@NursingCenter.com.



Enterovirus D68

In the Midwest,  an enterovirus, known as EV-D68, is causing concern. While not a new virus, EV-D68 has recently caused severe respiratory symptoms in affected children in Missouri, and several other states have contacted the CDC for assistance with a possible regional outbreak as well. These are Colorado, North Carolina, Georgia, Ohio, Iowa, Illinois, Missouri, Kansas, Oklahoma, and Kentucky. Symptoms of a common cold are typical at the onset of EV-D68, however the development of fever, rash, or dyspnea – particularly in children with asthma – is occurring and necessitating hospitalization, and in some instances, ICU admission. 

While details continue to be released, please remember your role in patient education and infection control. Tell parents and caregivers about these symptoms of EV-D68 and advise them to seek care for their child if fever, rash, or breathing difficulties develop. Also, share these basics of infection control:

  • avoiding close contact with people who have respiratory symptoms, such as coughing or sneezing
  • staying home when sick
  • washing hands often with soap and water for 15 to 20 seconds or using alcohol-based hand cleansers 
  • not touching eyes, nose, or mouth 
  • keeping surfaces and objects (especially tables, counters, doorknobs, and toys) that can be exposed to a virus clean
  • practicing other good health habits, including getting plenty of sleep, staying active, drinking plenty of fluids, and eating healthy foods

As more details are released, we’ll be sure to keep you informed! 

Update 9/16/14 - More states have reported EV-D68 infections. Please visit our page on this topic for more information and resources!

Reference:

Bonsall, L. (2009). Be prepared for H1N1 flu. Nursing Made Incredibly Easy!, 7(6).

 



Are you ready to go back to school?

Deciding whether to go back to school for your advanced degree can be a difficult decision. Whether you are a registered nurse with an associate’s degree looking at bachelor’s degree programs, or an advanced practice nurse thinking about a doctorate, there’s so many factors that go into making the decision, including timing, money, availability, and program options, it can be hard figuring out if you are really ready for that next step.

For further insight into this issue, I spoke with Wolters Kluwer Medical Research Division and NursingCenter’s chief nurse, Anne Dabrow Woods DNP, MSN, RN, CRNP, ANP-BC, who received her doctorate in nursing practice this May from Texas Christian University. Dr. Woods has been a nurse for more than 30 years and a nurse practitioner for 16 years. Currently, she serves as our chief nurse, as well as the publisher of the American Journal of Nursing and the Joanna Briggs Resources. She also works as a critical care nurse practitioner every weekend, while also serving as adjunct faculty for Drexel University.

Although Dr. Woods certainly has enough on her plate, she still chose to go back and get her doctorate. “The way healthcare is evolving,” says Dr.Woods, “I needed to go back for my doctorate to learn the skills, resources, and tools I need to really be effective in the market.” She sees the pursuit of higher education as a major trend across the profession. “Transitioning nurses who have their associate’s degree or diploma to a bachelor’s degree is really important. There are skillsets they haven’t learned before, and a bachelor’s degree will really help them in their practice. The other big push I see is advanced practice nurses going back for their DNP. It’s really only been in the last 10 years that we’ve had the ability to have a practice doctorate. The Future of Nursing initiative and the LACE model of nursing is that by 2015, all of these advance practice programs should be DNP.”

Once she decided to pursue a doctorate, Dr. Woods knew it was going to be costly, which is a major concern for most nurses contemplating higher learning. She explains, “It’s really expensive to go to school. Nurses need to do their homework and find out where they can obtain funding – scholarships, grant money, student loans.” Earning an advance degree is pricey, but Dr. Woods knows the value of an education. She says, “Even though it’s really expensive, and I probably won’t make any more money from having it, I feel that I am a better nurse and nurse practitioner by having it. [Nursing] is about being able to provide better care for the patients, the community, and people on a global perspective…It’s never about the money. It’s about practicing to the fullest potential that you can practice and providing the best care to our patients.”

Money isn’t the only issue for nurses looking for more education. Many nurses continue to work fulltime, while balancing families, friends, and other responsibilities. This was no different for Dr. Woods, who says, “The biggest challenge for me was time management. I work fulltime, and, I practice every weekend as a critical care nurse practitioner. Trying to fit in school work, even though it was a part-time online program, was challenging. The course work wasn’t hard; it’s the amount of work and the time it takes to do that work that is hard.” Being prepared for the commitment in cost and time is crucial to earning an advanced degree.

After the sacrifices she made to earn her doctorate, Dr. Woods already sees the benefit of her choice, only three months after graduation. She says, “As a DNP now working every weekend with nurses, they have really embraced my new degree and will ask me how they can think differently about this situation or what they are missing. I find myself doing a lot more teaching about things related to patient care or ethics of care. Now, I can help the nurse look differently at these issues.” And she doesn’t plan to stop learning any time soon. Dr. Woods explains, “I’m going forward to get some additional certifications to be the best healthcare professional, the best nurse practitioner, the best nurse I can be.”

Choosing the path of higher learning isn’t for everyone. Those who do take on this challenge, however, understand the immense benefit to not only themselves, but to the nursing community as a whole. Now, are you ready to go back to school?



Suicide assessment – an important nursing responsibility

As we continue to mourn the loss of Robin Williams, an iconic entertainer and comedian, it’s important for us to take a step toward learning from his death. As nurses, our responsibilities to our patients are numerous, but we know that safety is a number one priority. Even if we don’t routinely care for patients with mental illness, patients that we encounter may have a mental illness of which we are unaware. Some patients may have an undiagnosed or newly diagnosed disorder that may increase their suicide risk, whether due to its pathophysiology or its impact on quality of life. In nursing school, we learned about suicidal ideation and how to do a suicide assessment. I’d like to share some resources from our journals with you to revisit this important topic.

 

Assessing patients for suicide risk
Nursing2010 

Suicide Prevention in Neurology Patients: Evidence to Guide Practice
Journal of Neuroscience Nursing

All along the watchtower: Suicide risk screening, a pilot study 
Nursing Management

As If the Cancer Wasn't Enough... A Case Study of Depression in Terminal Illness
Journal of Hospice and Palliative Nursing

Additional Resources
American Foundation for Suicide Prevention
National Alliance on Mental Illness
U.S. Department of Health and Human Services – Directory of support groups



Nurses On the Move: Lorry Schoenly

Nurses work in all types of environments. Whether it is an ER, university, military, consulting firm, or even a prison, the role of the nurse goes far beyond the typical hospital setting.

July’s Nurse On the Move, Lorry Schoenly PhD, RN, CCHP-RN, is a correctional healthcare risk consultant for jail and prison clients. She also currently serves as part of the faculty at the Chamberlain College of Nursing and writes a monthly column on correctional healthcare issues, along with podcasts.

Schoenly previously served as the director of education of the National Association of Orthopaedic Nurses and assistant vice president of Rancocas Hospital, among other titles. She started her career as a staff nurse. She received her bachelor’s of nursing from Excelsior College and earned both her master’s in burns, emergency, and trauma, and doctorate in nursing from Widener University.

Through our interview, I learned why Schoenly went into correctional nursing and what daily reminder she has for nurses.

Q: Why did you decide to become a nurse?
A:  I never imagined being a nurse while growing up. I come from a family of educators. While in critical care after the difficult delivery of our son, I looked around at the nurses scurrying about and thought, "These folks are doing meaningful work.” I was hooked.

Q: You started as a staff nurse and remained in that role for a little over three years. What motivated you to continue your education and become a staff instructor and, eventually, a director of education?
A:  I guess I have always been an educator at heart. As a staff nurse…I was like a sponge soaking up information from any inservice or continuing education course I could find. I was thrilled to apply and be accepted [to a staff development position]…where I was able to continue in patient care, while managing the orientation of new staff and creating inservices for new treatment and equipment. For me, it was an ideal combination.

Q: As a nurse educator, what advice do you have to inspire others to further their education?
A:  You can almost never go wrong with education. One of the joys of nursing is the wide array of opportunities. If you are unhappy in your current position, research other options and determine what is needed for an entry-level position. Enjoy the journey and seek to apply everything you learn in the classroom into your current work experiences.

Q: How did you become interested in correctional nursing?
A:  Like many in our specialty, I am an accidental correctional nurse. I don't know anyone who announced as a child that they wanted to be a jail nurse when they grew up. In fact, it had never occurred to me that nurses worked in jails and prisons until I answered an advertisement for a nurse educator position in the NJ prison system. However, once I saw the great need for nursing care and nursing caring behind bars, I saw an opportunity to bring my skills and abilities to bear both locally and nationally. Correctional nurses care for a vulnerable, marginalized, and very needy patient population. And, it takes grit and determination to work in that environment day after day. I see firsthand the struggles correctional nurses have in the low resourced and ethically challenging criminal justice system. I do what I can to support their efforts.

Q: As a correctional healthcare consultant, what is your biggest challenge related to patient care?
A: The greatest challenge I face when helping improve patient care is organizational culture. Pervasive attitudes among team members are hard to eradicate. We want quick fixes, whether it be losing weight, getting dinner on the table, or improving a relationship. It is the same in healthcare. Leaders want to write a policy, inservice staff, and then move on to the next thing on the list. It doesn't work like that in organizations, even though we wish it would!

Q: If you could give nurses a daily reminder, what would it be?
A: The encouragement I use at the end of each of my Correctional Nursing Today podcasts is to "Make today count for good.”  As nurses, we always have an opportunity to make a difference in someone's life, and I try to remind myself of that regularly. A quotation on the whiteboard of my office that encourages me is from Goethe, "Knowing is not enough; we must apply. Willing is not enough; we must do,” As an educator, I try to continually encourage others to apply what they are learning, otherwise it is for naught.

Q: What do you see for the future of nursing?
A:  The future of nursing is bright as we move forward. There are many opportunities for nurses to make a difference, no matter the position or location. Correctional nursing, in particular, is advancing as a specialty, and I am delighted to be a part of it!

Posted: 7/31/2014 8:39:12 PM by Cara Gavin | with 0 comments
Tags: correctional nursing, correctional nursing today, lorry schoenly
Categories: Leadership


Directing nurses back to patient care

What made you decide to become a nurse? Was it the thrill of directly impacting a patient’s life? Or, was it because you really love tracking down medications and filling out paperwork? I’m going to guess it wasn’t the latter, and the people at the Institute for Healthcare Improvement agree.

In a recent article this week in the Wall Street Journal, Laura Landro explored the institute’s new partnership with the Robert Wood Johnson Foundation to develop Transforming Care at the Bedside, a program “to help hospitals increase to 70% the amount of time nurses spend in direct patient care while improving the work environment for nurses.”

This initiative attempts to answer the increasing need to streamline the work nurses are doing, while improving nurses’ delegation practices, “shifting more routine tasks to certified nurse assistants and other less high skilled staffers.” In an interview between Landro and Patricia Rutherford, a nurse and vice president at the institute, Rutherford explained, “We shouldn’t be using expensive professional nursing time doing unnecessary and inefficient things when that time could be reinvested in direct patient care.”

The institute isn’t the first to notice the lack of time nurses are spending with patients. In 2008, the American Journal of Nursing published a series of studies that found direct patient care “accounts for less than 50% of working hours.”

NursingCenter’s own clinical editor, Lisa Bonsall, MSN, RN, CRNP, remembers her frustrations at the bedside. “Patient care is what nursing is all about. I can remember clearly being pulled away from the bedside searching for supplies or medications, or even fixing or calibrating equipment. One time, I was caring for a patient admitted with DKA (diabetic ketoacidosis), who needed finger stick blood glucose checks every hour for titration of his insulin drip. We had two machines on our unit and one was broken. At about my third hour of the shift, the machine that was working needed to be calibrated…[which] took quite some time. This event not only took me away from the bedside, but put him at risk as I was unable to check his blood sugar for about two hours. Fortunately, no untoward events occurred, but I remember thinking at the time, ‘There’s got to be a better way!’”

Studies show the more time a nurse is at the bedside, the better the outcomes. Bonsall explains, “The relationship between patient safety and nursing care is documented in the research, including direct impacts on healthcare-associated infection, readmission rates, and mortality. We are the ones noticing the subtle changes in a patient’s status. If we are repeatedly pulled away from the bedside, those changes can go unnoticed.”

In a 2010 internal audit conducted by Presbyterian Medical Center, it was discovered that “nurses were involved in direct patient care at the bedside for only 2.5 hours every 12-hour shift.” Nurses were spending too much time searching for missing test results and supplies and not enough time monitoring their patients. After implementing the Transforming Care at the Bedside program, the center was hitting “6.5 hours per shift at the end of 2013 with a goal to hit 8.5 hours by the end of 2015.”

Time will tell if the center is able to hit their goal. But, as more hospitals begin to take a robust approach at managing their nurses’ time and delegation strategies, the hope is to return nurses back to why they began their work in the first place – to care for the patients.



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