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Beyond Nightingale

thank you note," says Reeves.

Afew days before the final graduation ceremony, Prouty and other SON administrators talked about the closing on a local radio show, Breakfast at the Hanover Inn. "We're the only profession on the health-care team which does not require a baccalaureate degree to start," Prouty explained. "We are feeling that this is really essential. The nurses have to make so many decisions now. . . . They're not any more following orders blindly as they maybe did in the past. . . . They make many very, very important decisions."

While Hospital and SON officials were preparing for the closure of the school, they were also engaged in discussions with the University of New Hampshire (UNH) and Colby-Sawyer College in New London, N.H., regarding the establishment of baccalaureate and graduate nursing programs. In 1981, Colby-Sawyer began a bachelor of nursing program—with the college offering the classroom instruction and DHMC a site for clinical rotations. Many of the program's students were starting their training from scratch, while others were already registered nurses, including MHMH graduates, who wanted to add the bachelor's degree to their credentials.

"I remember in particular Sue [Reeves] and Marilyn [Bedell], who were my classmates, who brought a very different perspective to learning about nursing than the other students in the class," says DHMC nurse Polly Campion, M.S., R.N., who was in the first nursing class at Colby-Sawyer. The diploma graduates "were very grounded in what it meant to take care of a group of patients on a daily basis. The rest of the students were naive when it came to what it meant to be working moment by moment with very ill people. [The diploma students] informed the learning and the conversation with a richness that came from knowing what it was like to be up in the middle of the night with a patient reaching the end of life, while you're trying to manage five other patients who are also ill." Campion is now the director of Clinical Improvement and of the Office of Patient Safety at DHMC.

Reeves agrees that diploma-school nurses, because they had so much more clinical experience than college-educated nurses, could "hit the ground running" when they got hired. But the college-educated nurses acquired skills quickly. "Not only did they meet the level of practice of the diploma graduates, but they were able to be good conceptual

"We've had nursing research going on here for longer than most organizations," says senior nurse executive Nancy Formella. "We have more advancedpractice nurses—ARNPs, nurse practitioners—here than at most academic medical centers. Our relationship with the Medical School is excellent." The nursing environment at DHMC, she adds, is "a gem."

thinkers [and] see health-care problems in different ways because of their background and experience and training as nurses," says Reeves, who got a B.S. in nursing from Colby-Sawyer in 1988 and an M.S. in nursing administration from UNH in 1991. "I'm a strong believer that nursing education is sophisticated enough now that it belongs in the collegiate environment."

As nursing education was becoming more sophisticated, so too were the interactions between doctors and nurses as they began to think of themselves as part of the same health-care team. "I always felt as if my input and my opinion were considered as much as possible," says Campion, who was a staff nurse in the hematology-oncology inpatient unit in the 1980s. "We'd round with the physicians, whenever they were rounding. They looked for input from the nurses about how patients were doing in order to make decisions about what the next step was for them."

DHMC's involvement in nursing education has remained strong even since the SON closed in 1980. "Just because we were closing the school, we were not compromising our commitment to nursing education," says James Varnum, president of MHMH since 1978. If anything, the commitment was strengthened. Today, DHMC has affiliations with a number of colleges and schools that train nurses and other health-care professionals. "An academic medical center is not just a place that trains doctors," Reeves points out. "We train physical therapists, occupational therapists, respiratory therapists, radiology technologists," as well as nurses. "If it's a profession or a discipline within health care, we have all of those students here all the time."

DHMC recently instituted its own nurse residency program for newly minted nurses. It used to be that new nursing graduates went through an orientation period after they were hired. They were matched with preceptors and spent several weeks

gaining experience before they were considered "a stand-alone, boots-on- the-ground nurse," says Reeves.

But under the old system, explains Suzanne Beyea, Ph.D., R.N., director of nursing research at DHMC, "it could take months to get the experiences." So Beyea and others launched a residency program in 2004, with funding from the U.S. Department of Health and Human Services. Now, new graduates come into a structured residency program and fine-tune their skills by practicing on human-patient simulators, sophisticated mannequins that respond physiologically like real patients. "We like to think we're one of the few hospitals in the country using simulators for nurse orientation," says Beyea.

DHMC's nursing programs can boast of a number of other firsts, too. "We were one of the first organizations in the country to adopt the concept of the clinical nurse specialist and then foster that role," says Nancy Formella, M.S.N., R.N., senior nurse executive at DHMC. "We as an organization built a system of shared decision-making on our units called shared governance. We've had nursing research going on here for longer than most organizations. We have more advanced- practice nurses—ARNPs, nurse practitioners—here than at most academic medical centers. Our relationship with the Medical School is excellent and there are opportunities within there as well." For example, DMS offers a nurse-shadowing elective aimed at helping medical students better understand nurses' role to foster collaboration with each other.

"The richness of this environment and the ability to grow and develop and move into different areas as a nurse in this setting is really unique," says Formella. In 2003, the American Nurses Credentialing Center awarded DHMC its "Magnet" designation in recognition of nursing excellence. "When you really dig into what's going on in nursing here, and what has gone on over the past few years, it's a gem."

Medicine has come a long way from the days when nurses stoked the fires and changed the beds. Today, nurses can consider careers as nurse practitioners, nurse researchers, nurse administrators, nurse educators, nurse entrepreneurs, and more.

There probably won't ever be another MHMH School of Nursing, nor will there ever need to be. Peter Nolette is doing a pretty good job of keeping the old one alive in the hearts of all its alumni.

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Laura Carter is the associate editor of Dartmouth Medicine.

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