The baby girl was rushed through the emergency room, strapped to a gurney. Matilda thrashed around, frightened and irritable, a lightweight blanket covering the wires attached to her small body. She was breathing fast — unnaturally fast — and her tummy pulled back hard with every inhalation. Her fine black hair was matted with sweat. Someone had painted her little fingernails and toenails candy pink.

Matilda was on her way to Santa Barbara’s Pediatric Intensive Care Unit (PICU) where, through its double doors, a small, tightly-knit team of pediatric specialists stood ready. As soon as Matilda arrived, Nurse Joanne Ronaldson began talking to her in soothing, encouraging tones. “Hello sweetie,” she said. “Everything’s going to be fine, what a good brave girl you are.” Meanwhile, the attending intensive care physician and a respiratory therapist moved about in measured, purposeful activity. Ronaldson and the therapist removed wires attached to a heart monitor and settled Matilda onto the hospital bed where she lay, all 22 pounds of her, alone on the big mattress. The doctor, focusing intensely, listened to the child’s chest through a stethoscope, then studied her X-rays, which Ronaldson had snapped to the light box. Matilda’s lungs were being attacked by respiratory syncytial virus (RSV), a virus particularly harmful to babies and small children, one that, left unchecked, would make breathing too strenuous for Matilda to maintain.

To save Matilda’s life, the medical team would have to connect her lungs directly to a respirator — sparing her nine-month-old body the energy it needed to fight off the virus. This was a difficult though common practice that would require running a thin tube down the baby’s throat to her trachea through which the oxygen would flow, and another down her nose to her stomach, which at first would eliminate gases and later feed her.

The baby’s mother had arrived separately — only patients are allowed to travel in ambulances — and she was stressed almost to the breaking point. Nurse Ronaldson, a calm, self-assured woman with warm blue eyes, moved forward and took her by the arm; she explained quietly and simply what was happening to Matilda. The mother — who had been observing the activity in the room carefully — seemed to trust her. A hospital volunteer escorted her to a nearby waiting area.

The nurse then returned to the corner room — what Cottage calls the isolation room — and began preparing the sedatives and other medications the baby would need. At this point, Joanne Ronaldson had been on duty for 30 minutes. Dressed strictly for comfort in loose red pants, a short-sleeve shirt layered over a long-sleeve jersey and red clogs, a beeper hanging from her hip, Ronaldson is the nurse every American hospital is looking for. Trained at a prestigious three-year nursing institution 30 years ago, she has had experience at every level, from pediatric floor duty to administrative head nurse. She personifies Cottage’s chief nursing officer Alicia Kelley’s belief about the nursing profession — that it’s a gift that comes from within. “To be close to a fellow human being and help them at their weakest point . . . it’s what life is about.”

Heal the Healers
And yet nursing is currently undergoing a crisis unlike any it has faced since Florence Nightingale first took her lamp to check on wounded British soldiers on the battlefields of the Crimea. The nursing workforce is aging more rapidly than is any other in the United States. The Journal of the American Medical Association estimates that by 2020, the country will have 400,000 fewer nurses than needed.

In worse shape is California, 49th out of the 50 states in the ratio of nurses per capita. And even to maintain this sorry status we will need to attract 30,000 new nurses in just two years, according to the California Economic Development Department. Here in Santa Barbara, the three Cottage hospitals combined are short some 100 nurses. A $35,000 bonus in addition to relocation fees and rental assistance awaits all new nurses willing to sign on. But until they do, their positions are filled by highly paid traveling nurses who are typically contracted to work for 13 weeks before moving to another facility.

How did this happen? It’s not for lack of caring, giving people eager to join a compassionate profession. Rather, these hard times in nursing are the result of long-term problems left unaddressed in our healthcare system, women’s changing roles, and the shortage of nursing faculty.

In the 1980s, managed care companies began allowing fewer patients to be admitted and cutting what they paid to hospitals for care. Nurses were laid off. Many went into other lines of work. “It’s amazing how many RNs there are out there who aren’t nursing anymore,” Kelley said. At the same time, funds for nursing education have, until recently, been stagnant. And there are fewer nursing faculty available to teach because a nurse with a master’s degree can now make a lot more money working in a hospital. So there are in fact too few spaces in classrooms for students who want to learn. According to the American Association of Colleges of Nursing, 16,000 aspiring nursing students were turned away from baccalaureate programs in 2003.

Santa Barbara City College’s School of Nursing graduates between 50 and 60 male and female nurses a year, 70 to 80 percent of whom go to work at Cottage. It has a waiting list of 270 students, according to the program’s director Jan Anderson, who noted that despite the discouraging situation the quality of today’s average nursing student is as high as ever. “My students are the kind of people who pick up stray animals and care for them,” said Anderson.

Happily, programs are in the works to revitalize the nursing profession. Congresswoman Lois Capps, herself a nurse, authored and shepherded through legislation the Nurse Reinvestment Act in 2002, which has so far funneled $29 million into nursing scholarships, loans, and retention programs. Cottage Health System donated money to hire more faculty at SBCC’s nursing program. And former Governor Gray Davis’ controversial staff ratios law — which took effect in January and, for the first time in America, limits the number of patients a nurse can care for at one time — will improve working conditions for nurses across the state. Whether any of these will attract new faces to the profession, or help retain those already practicing, it’s too soon to tell.

Before there were nurses, of course, women had always nursed. It was the women who tended the fevers of the family. But it wasn’t until the 17th century, when an order of nuns founded by St. Vincent de Paul began a program of training for their nursing novitiates, that nursing began to get on a professional footing. By 1846, the first nursing school opened in Germany, where the young Florence Nightingale, in 1851, learned her skills. It was she who shined a light on poor sanitary conditions in healthcare institutions of that era (particularly within the British military) and spearheaded the reform of healthcare practices within the British Empire. She introduced statistics into public health administration so that medical practices could be scientifically evaluated, and ultimately, Nightingale’s reforms galvanized women throughout the world to join the ranks of professional nurses.

Life Lessons
Joanne Ronaldson had once dreamed of being an actress. But her father, a New York City Fire Captain, discouraged it and his opinion carried a lot of weight. Both of her parents, Joe and Ann Ronaldson, had tremendous influence on her life. Married 57 years, the Ronaldsons raised 14 children together — five of whom had been orphaned by the death of Ann’s sister and brother-in-law. Joe and Ann raised their family in an environment that was not only loving but encouraged service and duty; their charges grew up to be nurturers and heroes, numbering two nurses, a cardiologist, a psychologist, a Special Ed teacher, a volunteer high school basketball coach and three firemen. Joanne’s brother Alfred was killed on a fire call in 1991. Twelve thousand people attended his funeral in New York, including Mayor Koch and Governor Cuomo. Every Father’s day in New York City, a 5-mile charity marathon is held in Alfred’s honor. But it was her mother who set Joanne on the path to nursing. Growing up, it was the young Joanne who always rushed to take care of her brothers’ and sisters’ cuts and bruises, and her mother encouraged her to follow that instinct. Without making a commitment, Joanne promised her mom she would give nursing a try. The summer after her high school graduation, she volunteered as a nurse’s aide in the nursery of St. Vincent’s Hospital in Manhattan. There, her obvious affinity for the work won her an invitation from a doctor to observe a birth. “I just said ‘Whoa! This is so exciting . . . I’m going to go to college and yes I’m gonna be a nurse.’”

That her second taste of the profession took place at King’s County Nursing School, part of the enormous county hospital in Brooklyn, made all the difference. “There was such a diversity of problems and such enthusiasm. I loved the stories I could tell my family when I came home.” And right from the start, Ronaldson knew she wanted to work with kids. So in addition to the rigorous nursing program, she took two years of child psychology classes to better understand how children react in traumatic situations, completing two years of a psychology degree. And, she said, she’s used it every day of her life since.

Ronaldson’s first official nursing job was in the Neonatal Intensive Care Unit (NICU) at King’s County Hospital. She discovered how right her mother had been. This was her field. Still, she was only 20 and, as she put it, “every New Yorker was curious about California.” While on a two-week vacation to visit a friend in west L.A., she decided to move here. A few days before flying home, she went on three job interviews and received three offers. One was in the PICU at Children’s Hospital Los Angeles, which boasts a reputation for having some of the best pediatric doctors in the country. She jumped at the chance to gain the experience. “My father encouraged me. My mother absolutely did not encourage me. But my father wanted me to spread my wings, so he convinced my mother.” Two weeks later, her parents drove her across country in a car stuffed with her belongings.

A lot of wonderful things happened for Ronaldson in the year and a half she was at Children’s Hospital L.A., but one that taught her a lesson that has stayed with her was the life and death experience of a seven-year-old boy. The child, who had been accidentally shot in the chest, was in cardiac arrest. Three doctors and several nurses were working to revive him when suddenly his aorta burst, causing internal bleeding. His blood pressure rapidly fell to nothing. The heart monitor flat-lined. No heart beat.

“Here was a beautiful, healthy, normal child and he was arresting,” recalled Ronaldson. “The fact that we could prevent him from dying was uppermost in my mind. We did not have to lose this child.”

For thirty minutes, the doctors and Ronaldson worked feverishly to save him, everyone doing everything possible. Ronaldson began to yell into his ear “Michael, Michael you’re going to make it. Stay with us. Fight harder.” But nothing changed. Still no heart beat. Almost everyone conceded the boy was gone. Everyone but a single doctor who steadily continued to apply every resuscitation technique in the book, pouring blood products, fluids and medicine into the boy’s body. Ronaldson kept on, too, calling to Michael, begging him to come back. Then, miraculously, the boy’s pupils began to move, and his heart to beat.

Later, when he was in the recovery room after surgery, the boy remembered hearing someone yelling at him to come back, and recalled watching the doctors and nurses work on his body from a perspective high above the room. For a child to come back after a flatline is very unusual. “For all of us,” Ronaldson said, “We knew we might never be part of something like this again. But sometimes when you least expect it, a child who has really used up all he’s got comes back to life. As a nurse, I must never forget that second chance.”

Hope Floats
Ronaldson also met her future husband at Children’s Hospital L.A. They became engaged and moved to the Bay Area where her fiancé began a surgical residency at Kaiser Permanente. Ronaldson was hired as head nurse at Marin General’s NICU. At only 24, she was responsible for all nurses on that unit, as well as evaluating babies. She got tremendous experience at Marin General. She attended C-sections and even had to intubate babies who, like Matilda, were in respiratory distress.

A year later, the couple moved to Pittsburgh, where Ronaldson had no trouble getting a job at Pittsburgh Children’s Hospital in the PICU. Pittsburgh Children’s was a seminal experience for Ronaldson because it was a Level One ICU, equipped to handle the most difficult, complex cases, including pediatric organ transplants. It was also a teaching hospital, and every June the overworked attending physicians tasked with instructing a new group of inexperienced interns advised their charges to seek the guidance of the facility’s highly skilled intensive care nurses. Ronaldson was often invited to join morning rounds. “It was fascinating,” she said.

Given her love for children, it was no surprise that Ronaldson was eager to have a few of her own. By the time she and her husband moved to Santa Barbara in 1981, where he had accepted a job at the Santa Barbara Medical Foundation, Ronaldson was six months pregnant. The next 15 years were devoted to a more personal kind of nursing — the raising of children. Ronaldson and her husband had two boys and two girls. Having had such wonderful role models for parents, she wanted to show her own kids how to be part of a community, and so she threw herself into fundraising for their school. “Because we had so much,” she said. “I wanted to give something back and I wanted my kids to be grateful for all we had been given.”

It wasn’t until after she and her husband divorced that a return to nursing became a serious consideration. Ronaldson realized that, not only did her children need to feel whole again, they also needed to see their mother react calmly and with resilience. And, boy, did she.

At first, she wasn’t sure she would like working at Cottage, with its Level 2 PICU. She was used to big, metropolitan medical teaching centers. Cottage, for its part, wasn’t sure Ronaldson, after 15 years away from the profession, would still have what it took to be a topnotch nurse. Medicine had changed. She was assigned first to the pediatrics ward, where supervisors kept a close eye on her. She only had to work there six weeks before she proved her mettle and was transferred to PICU, the only one between Los Angeles and San Francisco.

In PICU, Ronaldson came alive. She found a setting and community that had all the things she loved, the capacity to work together as the type of unit she knew best — as a family, where everyone worked together. “If you’re not a team, it doesn’t work,” said Ronaldson. “If you don’t have respect, it doesn’t work, and we do. It makes me want to come to work.”

Last October, Ronaldson received a commendation from the Board of Supervisors at the Emergency Medical Services Agency’s Conference for Bravery. The award acknowledged the care and advocacy she provided a little girl who had fallen off a horse and was bleeding from her ear and in her brain. On three occasions, Ronaldson stepped forward and asked for additional care and service, and the girl recovered completely.

Ronaldson has worked at Cottage since 2001. She officially works three 12-hour shifts a week, earning $32 an hour. In reality, she ends up working four to five shifts each week, as well as being on-call for transport duty, traveling in an ambulance to bring a sick child back to the PICU. But with Ronaldson, there’s no grumbling about overtime or midnight wake-up calls; for her, nursing is work that can change the world.

On the day Matilda was brought into the unit, her mother returned to the room, six hours into Ronaldson’s shift. A young, single, working mother with four children, she stood in the doorway, dressed in the protective plastic robe everyone must wear in the isolation room. She looked particularly forlorn, her eyes red with exhaustion and worry. She turned to Ronaldson, who explained carefully every step that had been taken in treating her child. “We see so many of these cases,” Ronaldson reassured her. “Don’t worry. She will get better. She will.”

And she did. A week later Matilda left Cottage in her mother’s arms. Sometimes it’s the small things that change the world.