Becker's Healthcare (00:00:00):

Welcome everyone to today's webinar, A Call to Action Moving from Symptom-based to Evidence-Based Management to Solve the Nursing Workforce Crisis. On behalf of Becker's Healthcare, thank you so much for joining us. Before we begin, I'm going to walk through a few quick housekeeping instructions. We will begin today's webinar with a presentation and we'll have time at the end of the hour for a question and answering session. You can submit any questions you have throughout the webinar by typing them into the q and a box to see on your screen. Today's session is being recorded and will be available after the event. You can use the same link you used to walk into today's webinar to access the recording. If at any time you do not see your slides moving or have trouble with the audio, try refreshing your browser. You can also submit any technical questions into the q and a box. We are always here to help with that. I am very excited to introduce our amazing speaker today. We are thrilled to be joined by Gladys Campbell, principal of Campbell Coaching and Consulting, and also we have Dr. Dani Bowie, CNO of Trusted Health. Thank you both for being here today on I'll pass the floor over to you, Gladys, to get us started.

Gladys (00:01:05):

Mariah, thank you so much for that lovely introduction and also thank you to all of you who are attending this presentation for the gift of your time. The objectives are up in front of you, but I want you to know that for Dani and I, one of our primary objectives is to begin a conversation for those of us who have been in nursing and in the staffing business for a long time. We know that this is a huge issue and we're not going to be able to hit every single possible definition of the problem or suggested solution in the 60 minutes that we have. So we're going to do our best to give you a little bit of historical perspective and a little bit of how we got where we are here today to convince you that maybe we should quit banging our heads against the same wall that we've been banging on for literally decades and move to a different kind of thinking through looking at the research.

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So that's where I'm going to hope to start. And then Dani and I are going to be offering you two possible suggestions for interventions that you might try individually or as a bundle because I don't believe there's just one solution to this problem. So starting historically, of course as nurses, we have to start with Florence, and I just want to give you a brief synopsis of what happened with Florence Nightingale when she went to the front of the Crimean War. Many of you know that she's credited by the British of literally winning that war for the British, and she was called by the head of the British Army and asked to come and work at this hospital that was on the front of the war, to which she said, no thank you. And there's a lesson to be learned in that. But she then went on to say that if you'll let me come and run that hospital, well then I'll come.

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And so she came to a hospital and there are varying reports about what the situation looked like, but that hospital had between 2000 and 4,000 beds. Its main corridor was four and a half long, and there were beds placed along that corridor that were only one foot apart. There was a 20% mortality rate in that hospital. And as you might imagine, that meant the acuity of the patients were very high. And Florence brought with her some nurses. She brought her nursing workforce with her and that workforce, and there are varying accounts of this consisted of 24 nurses, some say 26 nurses, and one report said 38 nurses. So I think it's then fair to say that our nursing staffing issue began more than 60 years ago. But also it's important to understand that during that time, most nurses did not work for hospitals. So one of the reasons Florence might have brought such a small workforce with her is that they had no idea how to organize hospital-based work.

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Most nurses worked in the community and public health and community health in home health and in midwifery, and they worked as individual sole providers who were often paid for by family members directly or they worked in small private practice groups. And I want you to hold onto that because I think that's an important part of our history. In my memory, the first time I kind of had bells and whistles going off as a nurse and as a nurse leader at the bedside was in 1992. You can tell I'm a little long in the tooth here, and that's when C M S adopted RVU or relative value units and made those the policy and the way of doing business for reimbursing physician services and reimbursing hospitals for physician services. And of course when that happened, all the insurance companies immediately jumped on board, which they always do.

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They will follow what the federal government is requiring as a payer and then jumped on board to that. And what happened because of that, and it was very subtle in the beginning and it was hard to realize how this tiny little movement, if you will, was going to radically change the culture of hospital clinical care for both physicians, nurses, and others because it meant that care was deconstructed, if you will, and disintegrated from viewing the patient as a holistic body mind and spirit being into a series of body parts broken or healthy and a series of interventions that needed to be done to fix broken body parts. It also disintegrated the patient's medical record, which originally told the story of the patient, the patient's goals, who the patient was, how the patient lived, as well as what was going on with that patient in terms of their health and wellness.

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And all of a sudden the focus of the patient medical record became documenting with very specific language to maximize the ability to get reimbursement for tasks, procedures, et cetera, that were performed on the patient. That's a very different model and it began to subtly change, if you will, the culture of healthcare and how we had always viewed it as clinicians. This became a source of subtle distress for people. And I remember very specifically with physicians, they were radically upset by this because they felt it was cookbook medicine that they no longer controlled what they were going to do for patients, that it was controlled more by reimbursement and that they didn't have the freedom to make decisions about what was best for that patient. And many of you who are as older, maybe even older than I am, probably remember that. And it also began the noise making for physicians about moving out of working directly for hospitals, working in hospitals and contracting and being credentialed by hospitals but not necessarily working for hospitals.

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So during that time as all of this was bubbling up, I think many people, clinicians of all stripes had this kind of epiphany about something is really changing. And I'm not sure we put a name to it because really the name to it was there was becoming this cultural shift where there was a lack of alignment between the culture of most clinicians in their vocational calling and what was going on with hospitals because hospitals were beginning to turn into businesses and even that language was being used, you would hear from CEOs, get with the program here, this is a business. And not realizing that that kind of language in many ways felt offensive to those people who went into healthcare, again, physicians, nurses and others to literally do what we framed as god's good work. And there was even a time when hospitals were viewed as the place, the beacon on the hill that had taken the place of churches in their communities.

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It was the place where God's good work was done and all of a sudden subtly, and we didn't put language to it that was really being challenged and just as the patient was, if you will, disintegrated from being a holistic being and the medical record was disintegrated from telling the patient's story. The other thing that happened was hospitals began to really look in a much more clear and dissecting way at their budgets. They began to split budgets into an operating budget, a capital budget, a contingency budget, and even others. And when they looked at operating costs in that budget, they realized this is what it costs to keep the lights on and run the place. And the thing that jumped off, and it should be jumping off the screen for you, is that the number one biggest area in operational costs is the cost of labor. Labor even today is between 40 and 50% of a hospital's operating budget. And within that nursing is about 50% of the labor costs. So I hope you're connecting the dots there.

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What this means is that frequently, if a hospital is, if you will, getting off margin, getting worried about bringing in the amount of money that they need, the quickest and easiest way for them to get back on track is to reduce the size of their nursing workforce. It's the quickest way to do it. And that has created for nursing this really interesting, I call it the I love you, I hate you, gaslighting scenario, which is when you really need nurses like we did during covid, nurses are paid whatever amount of money that can be scraped out of the barrel to get them to come and not only work, but to do overtime, extra shifts so that we can take care of patients. When those crises end as happened with covid, all of a sudden nurses are being laid off and it creates this interesting dynamic, this kind of whip sign dynamic for nursing as a profession that has led nurses in a large way to feel a lack of loyalty to their employers because they also feel that that loyalty isn't returned to them.

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At the same time, the control for the volume of nurses that are available to literally be deployed in different areas was largely removed from the hands of chief nursing officers, division directors and nursing managers and put into the hands of the CFO. And when that happened, further disintegration occurred because suddenly we were looking at budgeted hours per unit of service and for nurses, the unit of service was the patient day. So now we get down to literally looking at nursing based on hours of service. Now, this is an example from a real life consultation that I did, and I want you to look at it because in general you can tell right away by the budgeted hours of unit for service on this unit that this was an extremely acute trauma and trauma surgery intensive care unit that was in a large inner city medical center.

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And when you look at this, their budgeted hours per unit of service are over 24 hours a day. Now, if you're a nurse, you immediately think, wow, that's great staffing. They have more than one-to-one care in this unit and their actual hours were 27.2, which means they're over budget. The most important thing to realize is that for our CFOs, and I would say this is appropriate, that's really all they look at, are you over or under your budgeted hours per unit of service? But what's important for us as nurses is to be able to, if you will, dissect that down a little further to figure out why is there this disconnect between what looks like a very generous budget and nurses saying they don't have enough staff. So what happens when you pull the data string? And for most nurses in hospitals today, it's almost impossible to really get this level of data.

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You can see that there are fixed and variable hours fixed people are on salary, variable hours are people that are paid by the hour and within variable hours there are direct hours non-productive or benefit time hours and indirect hours. And what's important in that is most hospital CFOs combine non-productive and indirect hours as if indirect time is non-productive, which it is not. And often indirect time is in fact required time. And when you do this on this real life example in the yellow box, you see where the problem is, it's the allocation of those hours. So their actual hours per unit of service, which is the patient's experience and the staff nurse's experience is 16, which is not enough for what was this very acute unit. Now there's a bigger backstory around this, around how all this could be fixed and it was fixed. But I think it's important for you to see the impact of how these hours are distributed and what happens specifically when indirect hours aren't looked at in a way that can be captured.

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So some of the examples of indirect time are listed here, and I'm not going to read this to you, but you can see many of these are things that really need to happen if you're going to give exquisite care and if your teams are going to work cooperatively with each other. So it's important for us to be able to look at that. But what's happened in all this in looking at productivity measures and nurses being really managed by the hour to literally meet productivity standards is what's happening with these two little dogs who are walking along saying, why is it always sit, stay healed, never think innovate, be yourself, okay? And that's what's become missing in our work. It isn't that the work is too hard. I would say that I think nurses are bred to work hard. In fact, we get upset when we feel bored because all of a sudden an eight, a 10 or a 12 hour shift feels like for forever if you're not moving quickly and feel like you're really working during all of that time, what's happened isn't the volume of work, it's that the work has been dummied down to the point where it's just a series of tasks that must be documented so that the hospitals can achieve maximal reimbursement and so that others outside of nursing can micromanage the productivity of the nursing workforce.

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And it's problematic. I think it's been a lot of this kind of stuff that has led nursing to believe that if we just legislate nursing hours per patient day, if we just legislate what the metric needs to be for nursing ratios, that our problems will be solved. And most of you know that I think it was over 20 years ago that California embraced legislated staffing ratios. So actually they became the learning lab for this theory. And I'll start by saying my little friend Einstein here who was a mathematician, you may not know that. He actually said the most important things in life can't be weighed, measured, or counted. And I completely agree with him. We're looking in nursing to believe that you can have a linear solution to a systematic problem. And I'll tell you that linear solutions cannot solve systematic problems. And if we want to look to California as the learning lab, we have to ask ourselves the question, if legislative nursing ratios were the be all end all solution for this issue, then why aren't nurses flocking in mass to California to go work there?

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Why hasn't that happened over the past few decades? And why is it that so far in 2023, there have been five major system nursing strikes over staffing. And the previous year there were eight major strikes in California in systems related to staffing. And in 2020 and 2021, there were another eight major system strikes in California. Why are there labor strikes overstaffing if legislated ratios work? So you can see where I stand on this issue. And to be honest, it breaks my heart that nurses have put so much energy in believing that this is the solution to our problem because I don't think that it is. So that's what really brought Dani and I to this point of trying to rethink why aren't we looking at the evidence? And here's an interesting little dilemma for us, and that is that we expect our clinicians to practice to the evidence.

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In fact, anything short of that is really considered malpractice and yet our leaders and administrators rarely even know the research of leadership and administration. And I include myself in that because I spent from age 24 on in leadership positions in hospitals primarily. And I am willing to say that I wasn't always deep into the literature, but we should expect that same evidence-based approach from our leaders that we expect of our clinicians. And if leaders looked at the research, they would see there's a lot of information there that we should be leaning into. Also, I will just say off the record, and Dani probably experienced this in her doctoral program that we're often told as nurses, and I think others say, you really should only look at the last five years of research. And I'll tell you, I completely disagree with that because most research is replicative.

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And you want to dig down to look at what was the foundational, original research that was done in an area that everyone else has built on. What is that and how do you then build on that again to make that original research even stronger? And when Dani and I first talked about this webinar, we talked about the research that was done by Hertzberg, and some of you may know him, but his research was published, I believe it was in 1959. So it is very old research, but it's fascinating and it actually ties to Maslow's research on human hierarchy of needs and also to other research that has been done by other management leaders around motivation, satisfaction, and retention in the workplace. But Hertzberg is not a healthcare person, and his research was not with healthcare workers, but he developed what he called a two factor theory of motivation that argued that job satisfaction and dissatisfaction actually exists on different continuums.

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So if you address a dissatisfaction, you don't necessarily get satisfaction, if that makes sense. It sounds like it is hard to kind of wrap your head around this. And he studied 14 different factors and classified them as motivational factors, those that increased job satisfaction and motivation and hygiene factors kind of a funny term. But hygiene factors were those factors that pertain to the work environment and if attended to could prevent dissatisfaction. So hygiene factors in summary are those kind of linear things. They're about the numbers of staff, the volume of staff. Do you have enough people to do the work? Do you have an adequate salary? Do you have adequate benefits? It includes interpersonal relationships, which really means are you working in a safe environment, an environment where you feel psychologically and physically safe? That doesn't include disruptive behavior. It does include do you respect your boss?

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And we all know who your boss is and how that boss presents themselves as a significant impact on staff satisfaction and basic working conditions. The physical surroundings, the amount of work again, and safety where the motivational factors are things like advancement, the work itself, the possibility for personal growth, responsibility, authority, and independence. These are the places where those little dogs on that walk want to be that place where they can be creative and innovative and feel like they're making a real difference. Now, what this says to us is if you don't handle the hygiene factors, it's really hard to get to the motivational factors, but if you handle the hygiene factors and don't attend to the motivational factors, you will not have staff satisfaction and you will not have strong retention and you will not have staff that are motivated to make their optimal contribution in your workplace. You need to attend to the hygiene factors first and then the motivational factors, but you have to address both. What Dani and I are going to do is give you three short exemplars, and she's going to start with an example that does address hygiene factors and all the exemplars we're going to give you are based on data and some on research. So they're not just our thought of the day. So I'm going to pass the baton to Dani and let her talk about this issue.

Dani (00:21:27):

Thanks, Gladys. And I think it's really important how you teed up the history and the delineation of factors that contribute to our working condition and the call to evidence-based leadership. I think what's important here is I've only lived in the environment that's been described both as a nurse, as a manager, leading systems for workforce transformation and understanding the friction that's happening with managing the workforce and looking primarily at cost, which is what most nurse leaders are held to. And so that really created passion in me to solve what is happening with this hygiene factor of staffing. And as Gladys said, there isn't just a one size fits all solution. There's multiple approaches that should be taken. And in fact, as Gladys referenced, I did do my doctoral thesis around predictive scheduling. So I actually went deep into the literature and found probably in the 1950s some seminal work around predictive schedules, did they exist and then built onward into about 2018.

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So what existed and realized there actually wasn't a lot of literature out there around predictive scheduling tools and technology to support frontline managers in what is oftentimes consuming their life, and rightfully so because they need to get staffing right to care for patients. But in that constant churn of attending to the hygiene factor, we realize that the motivational factors are often left unattended to. So I'm going to talk about some of the hygiene factors of working conditions and staffing and staffing models that may be applicable to those of you on the call to think about, to help change the game and get you time back as leaders to attend to the motivational factors of your workforce. So recently here at Trusted Health, we did a survey of around 1900 nurses really trying to understand mental health and wellbeing. And in the research what we discovered was the most impactful on nurses' mental health and wellbeing was actually one nurse staffing shortages. So as Gladys highlighted that direct patient care time not meeting that is extreme pressure on the frontline workforce and then also the staffing levels. And so these have huge implications for health systems and most notably the wellbeing of our workforce and how they experience the work that they're doing.

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So then I went to the frontline because I was like, I think it's extremely important, I've managed this in different capacities, but I wanted to know from the frontline's perspective, what are they wanting, what is important to them? We know the literature shows autonomy, choice, control, but flexibility has also been a pretty catchy phrase over the last three to four years. But what does it really mean to the frontline? So I asked some questions. I have new research coming out, but this is some research that I did in the past. And what I discovered is that the frontline said that self-scheduling was by far one of the most flexible options for 'em. Now, I'll caveat that I believe that we need to do some research around what does self-scheduling really mean, and that's what I'm doing, but this is an important piece that we can take away.

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How can we give choice and control around building schedules to truly meet the needs of the staffing unit? Additionally, I wanted to know from the frontline, okay, you told me what you believe is the most flexible option, but tell me what you think is the most important to you. And again, what I discovered self-scheduling, so takeaway for leaders here is I really think we need to think about how we can build models around self-scheduling, engage technology, and really start to give choice and control back to our frontline. Secondly, in this you'll see that combination of shift lengths, so the type of work that they're able to select and schedule is important, but also less hours. Part-time gig work is something that was favorable to the workforce.

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So with that being said, flexibility is top of mind. I know a lot of health systems are incorporating flexible programs, so this is something that many are going after. I've seen per diem programs come to life, part-time roles expanding beyond usually an 80 20 rule. Float pools definitely over the last three to four years, internal agencies became a very big program for health systems to consider as they were experiencing just such staffing crisis with the pandemic. What I've discovered in this and through my doctoral work and thesis is that these programs are great, but the ability to scale to really impact staffing to support the frontline manager is limited because you do not have the right technology at play or you're not optimizing the technology that you have at play. So it's really important to look at your programs, your policies, and also the technology that you use to do this work.

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I wanted to give you a couple different ways to think about this. So I've built some different programs over the last 10 years for health systems. One was an internal travel agency for a health system spanning multiple states, large multiple hospitals. And here's a profile that you can consider. You can do this as a local program. So this could be something that's more at the market level within a region, a 50 mile radius for driving, and you can set up different ways to engage the workforce in the work that they're doing. So you can do contracted work such as four, four to eight weeks in a specific assignment you could assign on day of staffing needs. So you could create more flexibility to the demand. And then you look at how are you attending to these hygiene factors of pay stipend and reimbursement for travel?

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What does mid-shift floating look like? What are your benefits? Do you get paid time off in between assignments? What's your retirement? Are you eligible for incentive pay? These are all important components that need to be addressed in these programs as nurses are considering joining them. And it's also important to consider the fact that with flexibility and moving around, we should be compensating our nurses for that flexibility and desire to be nimble and move to help meet staffing needs. I think there's another program that you can consider here that's important, and that's so if you build an internal travel agency, fantastic, that was a local program that I think can be relevant to health systems. But I also think there's the opportunity, as I mentioned, gig programs per DMM is kind of what I call them. This is coming to life in a new reality because there is technology to finally scale these programs in a way that allow for ease of management, knowing who's working and how they're working, credentialing and competency and the clinician to be able to drive the way that they're working through seeing shifts and claiming shifts in a mobile app.

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So for the sake of the listeners on this call and presentation, I wanted to provide a profile. So as you saw the internal travel program and things to consider, here's some other things to consider if you want to build a per diem gig workforce, make it really flexible, right? Look at your qualifications, but also our requirements and how flexible can you be with this workforce pay structure. Are they eligible for incentive? Is it a flat rate? Should it be higher? Some of those important considerations that need to be built into your programs and then scale with technology. And we'll talk about that in a second.

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This is another program. So as you heard Gladys said, we're offering you different options to consider, and this is really where my emphasis in work has been over the last 10 to 15 years is trying to solve the challenges we're facing that has been set up from our history. So thinking about a system internal agency, I showed you a local one. Here's system something to think about. You can set it up as a separate entity. This allows you to move between union and non-union facilities. You have one system job description reports to a system leader. You can put in this program your full-time, part-time and gig workforce. So there's a way to really differentiate and build out some opportunity for work within that program. This is ultimate flexibility. They can work across all entities, but we would look at specialties. So you'd really design this based off of specialty critical care.

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It could be med-surg, pediatrics, women's, you name it. There's ways that you can build that, ensure competency, skillset, and then support your specialty areas. I just put some considerations to think about which I know organizations like to consider. And then here's another program for you to think about, which is a secondary gig program. So if you build out these system per dm, gig programs, internal travel agencies, those are awesome, but that may not be for everybody. So here's some other options to really gain access to the workforce in a new way and allow for that flexibility. The choice new opportunity, A secondary gig position is something that I've seen particularly with those that are in part-time status. I think this is a really great option to consider. You keep their primary job at the unit they're hired to and then you create a second job profile and you're usually scheduling solution.

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Oftentimes I exclude union hospitals because you don't want to send a non-union employee to a union facility and vice versa. And then they maintain their primary place of employment through the unit that they're hired. But the secondary job profile will open up shifts for them to be able to claim and work additional shifts where they're qualified to work. So it's giving you access or expanding your workforce and allowing you to really give them the opportunity to drive this without having to rely on external agency. And then lastly, here's just one more program to think about and then I'll talk about the tech and hand it back over to Gladys so we can continue to talk about some more models and the importance of motivational factors. But you can also look at traditional internal gig programs. So that could just be within one hospital, existing float pool manager, one job code.

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You can build it at the hospital level and you can read in here the defined work and roles and considerations. I would encourage us to also think about innovative internal gig programs. And what I mean by that is, again, if you're hiring someone, whether it's a full-time capacity or part-time, let's think about opportunity to work preceptors, break nurses, are we providing mentors to our workforce? Again, these are more of the motivational factors of attending to the workforce needs with mentorship, preceptorship and support. And so are there nurses who are skills and have ability and can provide support in that way and grow, but also have the opportunity to claim extra or open shifts in a clinical capacity. So creating that flexibility within the workforce I think is critical in the days ahead, specifically as we look at the continued nursing crisis, the retirements that we are continuing to see and expect, accelerate, and ensuring that we can keep the knowledge that's been built through years of practice at the bedside, helping support the nurses that are growing and newer to the profession.

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And then also think about a seasonal gig. Do you have a lot of seasonality? Are you in Florida? Are you in Arizona? Oftentimes in those places you do have seasonality. So building in jobs where you hire at a 0.6 and then you fluxx with your demands up to a 0.9 and down to a 0.3 based off of the trends that you're seeing. And this is a possibility and a reality that I think we should consider as we look at managing our workforce and providing options of flexibility and control, passionate about technology. I believe it is critical to making these programs a reality and scaled effectively. And most importantly, supporting your frontline managers and the work that they are doing. We can't do this manually anymore. We can't send emails, text messages, phone calls. So our product here is called works, and we have some great applications that can be used for onboarding, credentialing and automating a process of creating a workforce, but we also have a really powerful tool that will automate the distribution of those shifts.

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So as you think about that gig workforce and how challenging in the past it's been to manage such as I'd have to call people, it's an emails, did they pick up a shift? It was a lot of work. This is now taking care of and automates with integration into your scheduling solution. So this is just a view for your frontline as you think about solving immediate staffing needs. I do believe that this technology will help delight your frontline nurses, give them choice and ability to work when they work, choosing when they work, how they work, and also supporting your managers of not having to do all of this manual work. So I'll hand it back over to Gladys to talk more about beyond the hygiene factors. And I believe that this is, we can solve these issues. I believe that there are ways to address both factors and in fact, we must in the days ahead to sustain the workforce and continue to deliver the excellent patient care that we're called to and really meet the calling that we have as nurses. So Gladys, I'll hand it back over to you.

Gladys (00:35:26):

Thanks Dani. That was really good and helpful. So Dani talked about her passion being figuring out these structures that ultimately are addressing, if you will, if you're thinking of Maslow, the bread, water, and air of what needs to happen before you can move into, if you will, self-actualization. My passion has always lived on the self-actualization side, I'll admit. And it gets fuzzier. It began because it's not linear. So along with Maslow's work really complimenting what Hertzberg was saying. There's another gentleman who did a lot of research in the area of management. His name is Warren Bennis. You may know him. He's written prolifically. And one of the things that I always go back to is something that Warren Benni said after doing some of his research. And he said, and I believe this, we all want the same things and what we want are to feel important, to feel useful, to make a meaningful contribution and to feel that we work for a worthwhile enterprise to be proud of the place that we work.

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I return to this quote from him over and over again to just retest my commitment to as a leader, this is what the people who work for me really want. And again, you're never going to get here if they don't have the bread and water, which is salary benefits, scheduling, good people to work with and a boss they respect. So I just want to throw that out as another point of research for you to feel that you can relate to. The other thing I want to share with you, for those of you who don't know, this is the vision statement of the American Association of Critical Care Nurses. I will say somewhat cynically, most hospitals have their vision statements somewhere on a plaque on the wall, and for most of us it would be pretty hard for us to recite that vision. But this vision that A C N created more than 20 years ago, and I was president, national president of the organization for a period of time, is the only time I've worked for an organization that had a living breathing useful mission statement.

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And that statement says they exist to create an environment focused on the needs of patients and their families or nurses. And I say clinicians or clinicians can make their optimal contribution. And in that organization, every single proposal that came before the board for action was weighed against this vision statement. Does this proposal either improve the environment in its focus on the needs of patients and families or improve the ability for nurses and other clinicians to make their optimal contribution? And if it doesn't do one of those two things, we ain't doing it. And I think it would be interesting if you have a vision that doesn't create life in your organization isn't useful. Maybe you just want to steal this one because I'm telling you I think it's useful. So let's talk about two models that I've used in my consulting practice and I want to say with all humility to great success.

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So first off, I began to look at practice and process improvement and we know that there are zillions of those out there, some that we're required to participate in and how those can be used as a vehicle for staff development. And this is a little cynical. The focus is not really on what is the outcome of this practice or process project it's on. Can we use it as a vehicle for staff development, for individual leadership development from team leadership development, from project management leadership development? And in that way can we allow staff nurses to own their own success in these projects instead of just feeling like a tool to move the project along? So I'm going to give you two quick examples because we have limited time. One was in a unit where I was hired to help a particular unit. It was a procedural unit.

(00:39:32):

So they had physicians from all different specialties. They needed to have extensive experience in all these different specialties. They did the intake admission, got the patients to the procedural area and did post procedural recovery and discharge of these patients. The nurses and all the various physician groups that they worked with, frankly didn't even know each other's names. They were very dissatisfied because it's the kind of unit that doesn't get a lot of attention. A lot of people think, oh, all you do is change the paper on the table. There's this kind of feeling that you're not intensive enough to be or acute enough to really be important. And the nurses felt that they felt their unit wasn't respected. So we came together to do a project. And I'll tell you the goal of this project, and I was dumb struck by it, was the nurses wanted to see their c e O more.

(00:40:29):

I knew their C E o. And I told them he's a lovely guy, but God did not grace him with a lot of charisma and I couldn't understand what it was they wanted to see him for. In fact, I was sarcastic and said, I know him. I can get an eight by 10 glossy of him. I can have him autograph it for you. I'll buy the frame and put in a little frame in the nurse's station. Are you happy now? And of course they were very unhappy with me when I said that, but I finally said, if you want to see him, you tell me because we've done an exercise dissecting their work. You tell me of all the patients you've described, which is the largest group of patients you see in your procedural area who also bring in money, they're moneymakers. You tell me who those patients are.

(00:41:12):

And at that time what they said were liver cancer patients. And of course there were multiple different protocols that people followed for treatment when they had liver cancer. And we picked those patients and these nurses worked with me originally working just with nursing and then bringing in other disciplines, every discipline under the sun from registrars to outpatient nurses to admitting people to the physicians to the techs in the procedure area, you name it. They were in there. And literally within the scope of this project, we increased the throughput and flow of patients, all patients in the unit by 103% without any increase in staffing or without any sense of the staff now being grossly overworked, they didn't even realize they had increased their throughput by 103%. And some of the other outcomes were that unbeknownst to me, there were three nurses in this work group who were on performance improvement plans and were on the road to be terminated.

(00:42:18):

I didn't know that and I was glad I didn't know it because all of them were saved and they turned into massively productive people and they'd been problem people because they were so distressed with the cultural environment in their unit. And next, when these nurses presented, because these are staff, this is a staff nurse led project, when they presented, which I required of them their project to the senior leadership of the health system, this chief medical officer of the health system has said, stood up in this meeting and said, we have heard report after report after report of what has been going on in improvement projects and quality projects in our organization and not a single one has been as impactful as this. And on top of that, physicians were going down to talk to the C E O in droves asking why other units in the hospital weren't run in a similar way.

(00:43:13):

So of course then the C E O did come up to the unit, which I then remembered was our goal, I confess. So that's one example. Another example was a unit that I went into that had over a hundred percent turnover a year, and they only had three, what I will call real nurses, meaning three employed nurses. Those three, two of them were very nice, but not all that competent. One of them was extremely competent, and this was a high acuity intensive care unit, but she could be a little rough around the edges. Okay? So we created a series of projects based on research, we call it systematic clinical inquiry, where nurses who had questions back to the A C N vision about how they could improve the care of patients and make their optimal contribution whenever they had a question, we turned that into a unit-based research project, which I'll tell you was no easy feat given the fact that the majority of these nurses did not have bachelor's degrees and the opinion of who gets to do research by the end of five years, this was a long project, 35 published studies came out of this unit.

(00:44:26):

The unit had a waiting list, remember it had a hundred percent turnover. The unit now had a waiting list of who wanted to work in this unit, and almost a third of the nurses in this unit who had been very adverse to going back to school because they viewed it as elitist, almost a third of them not only went back to school but went on for terminal degrees. And I will tell you two this day, that group of nurses gather together because of how supported they felt. When I go to the east coast, if I get work or a conference and get to go to the east coast, I meet with them still to this day. And this project happened years ago. So it's two examples of how you can have radical turnarounds in staff satisfaction and the contribution of nurses to the satisfaction of patients and families and positive outcomes if you engage them in projects that are something other than disintegrated tasks.

(00:45:25):

Lastly, I want to suggest another option which you might not like, but this really comes from Buck, Mr. Fuller's advisement to us who says, you never change things by fighting existing reality. That's the head banging we've been doing on this of staffing numbers. You need to build a whole new model that makes the existing model obsolete. So what he's saying is, quit trying to fix the model you're in. You're not going to fix it. Create the competing model which will make that existing model obsolete and let it rot on its own. So one of the things I began thinking about back to Florence was when she was originally working how nurses didn't work in hospitals. And so maybe what needs to happen is we need to follow to some degree the lead of physicians. And I really say that, but maybe nurses need to separate out their practice from employment with a hospital.

(00:46:28):

I'm not talking about all nurses becoming agency nurses. I'm not talking about that. I want to be very clear. I'm talking about nurses creating external specialty practice groups where that practice group in its entirety contracts with a hospital to cover completely some of the work. So for example, the manager of the practice group, the nurse manager and a business manager can go to a hospital and talk to them about what it has cost them in external labor, in incidental and actual full-time overtime in labor strife and labor strikes to run their intensive care units. And I can tell you it's a pile of money. And most hospitals hate their ER and their I C U nurses because we're troublemakers and I'm one of them. Okay, I understand. I don't take the hate personally. Okay, we are troublemakers. What if somebody went in and said, I'm willing to completely cover everything you hiring, firing, education, staffing, everything, and even the labor strife.

(00:47:35):

I'm willing to handle all that for you, and I will run your I C U and fully staff it and you can check that box and you no longer need to spend your time calling people endlessly to work overtime. Guess what? They've got two phones and they're not going to answer your call, okay? And we'll take care of it for you. I am convinced the hospitals will jump at that opportunity and we already have a model because physicians have already done this and nurses can then sit apart from the hospital. Again, they work in the hospital, but they are not employed by the hospital and they have a practice group and their manager also lives in that practice group and they now can create a culture that works for them because the culture is separate. Because I ultimately believe the real problem for nursing and hospitals is we have an absolute separation in values and culture between the business model of the hospital industrial complex and what clinicians want to do, which I still believe I'm an altruist.

(00:48:37):

I still believe is God's good work. So with that, I will just say, and hopefully we have time for some questions. So what path do you want to take to resolve this issue that has plagued us for decades? Do you want to keep buttoning your head against the wall? Do you want to spend years trying to get legislative staffing ratios because you think that's going to fix it and it's not? Or do you want to be creative and innovative and try something different? So with that, I'm going to turn over a little bit of our q and a time. We've just got a smidge to Dani and see what you guys think. And again, before I do that, I also want to say here is our context information. And like I said, we want to start a conversation. And so any of you who are interested in continuing the conversation or if you have questions that don't get answered, here's how you can contact us. So feel free to use our contact information.

Becker's Healthcare (00:49:34):

Wonderful. Thank you. Bet. Thank you both for an excellent presentation today. Ask that we will now begin today's question and answer question. Again, you can submit any questions you have by typing them into the q and a chat box on their webinar console. So let's get started with the first question we have, ladies, someone asked, how do you define the distinction between nursing shortages and staffing? They seem interdependent to me.

Dani (00:50:04):

Yeah, I'll take a stab at it. And then Gladys, if you want to also add some perspective here, the way I really view a nursing shortage, so we know that there's a nursing shortage coming, but it can be defined by geographical regions. So just essentially in the economic framework of not enough nurses to meet demand. And then I look at staffing as your day of. So really how many nurses do you have daily to care for your patients based off of the census fluctuation? Oftentimes what I've discovered, and I believe shortages exist, they're coming specific to certain regions for sure. So we need to build that pipeline. But as you think about your staffing, what I've found in health systems is oftentimes we were not matching the right number of nurses to the number of patients. So there was a mismatch between supply and demand.

(00:50:58):

So there could have been potentially a shortage. You have high vacancy, not enough nurses, but ultimately the day of staffing is to find the right number of nurses to meet those patients. And so that's what I define as staffing is you look at your staffing and you're like, some days I'm understaffed, or other days I'm overstaffed. And that is a mismatch of that supply and demand economic in the day of versus just how many nurses do we need to care for the American patient population in the days ahead. But Gladys, I'd love it if you had any perspective on that as well.

Gladys (00:51:32):

I think your comments are spot on, Dani. And I think normally when we talk about shortages, we do talk about regional shortages and usually it's the state centers for nursing that are monitoring overall. Do we have a shortage or is it just that you and your hospital aren't able to attract the nurses? So when you have a staffing problem, it could be a hospital-based problem, not that there literally is a state or a regional shortage. So you have to really be able to look at both because your interventions are going to be different based on what it is.

Becker's Healthcare (00:52:04):

Wonderful. Thank you both for answering that question. The next one we have for each of you is can you describe the resources that were needed to support the unit with the research projects, whether positions FTEs utilize the guide them through E P D process?

Gladys (00:52:23):

I can address that. The most valuable resource we had was a clinical nurse specialist who was very boots on the ground practical person, also doctorly prepared, had an enormous amount of experience in research and also had her own clinical lab. She had enormous credibility as a researcher and she also knew how to make things simple. We did not add any resources. Once she came to work in the unit, and I guess she would call her a research, but she wasn't hired specifically to do this project, she did it as part of her job as a clinical nurse specialist when she saw what a mess this unit was in. And I'll tell you as a manager, and again, you get back to the bread and water stuff about staffing. So now I've got a clinical nurse specialist who was just hired. I didn't have a part in hiring her, and she's telling me the first thing she wants to do is start a research project. I thought she was out of her ever loving mind, but let me tell you the way she strategized that around beginning by just asking questions every day when we would do rounds at the bedside. So we did this with no extra resources and part of it was because every single project was based on the needs of patients. So it could take place as part of routine care of that patient.

Becker's Healthcare (00:53:51):

Wonderful. Thank you for answering that question. The next one we have for you is what are your thoughts on virtual nurses in the inpatient setting?

Gladys (00:54:02):

Can I grab that, Dani?

Dani (00:54:04):

Yeah, chime. Yeah, I'll chime in after you go.

Gladys (00:54:08):

I had a huge epiphany around this years ago. I was on the original board for VIS aq, if some of you remember VIS aq, which was one of the first forays into virtual I C U care. And when I went to the virtual center for an I C U, I saw a doctor, a nurse, and a technician working side by side in a completely quiet environment with screens where they're able to look at all of these patients and confer with each other where the nurse would lean over to the physician and say, what do you think about this? Look at this. And they'd be talking, we hardly ever have time to do that. And I realized how quiet it was. It's never quiet for nurses. We never have time to really think it's so darn noisy in the work. And then I went into the unit and I was in the room of an extremely ill young man who'd been run over by a truck, literally had tire trucks on his chest, and I pretended I was a new grad and I was kind of like, he's bucking the ventilator camera.

(00:55:10):

And immediately I had resources there telling me what to do. I suddenly realized you could have one clinical nurse specialist with physician assistance in a remote capacity supporting every single nurse who's caregiving. So they never feel alone and they always feel they have a reference. And you could also take nurses who frankly were physically disabled who normally would not be considered fit for duty and have them be in those centers, especially nurses who had years of experience and really knew what they were doing to advise nurses. And it would be a wonderful way to utilize nurses better and to provide newer nurses with the support that they want. Dani,

Dani (00:55:55):

Yeah, sorry, I was just unmuting myself. I would agree. So I actually, I know a lot of health systems that are spinning up these programs, rolling 'em out, and as Gladys mentioned, I'm a big proponent of it. I think it's a great way to extend knowledge of the workforce, particularly those that aren't looking to work for 36 to 40 hours at the bedside per se, but have opportunity to create that flexibility. So think about it in the framework again, as of a gig layer or a per diem opportunity, you could have virtual nursing, then you could have a couple shift here and there to pick up extra shifts. So there's some creative ways to build these programs in that I think extends the life of your workforce in a new way and engages them. I think there is though a caveat to call out, and so far in the models that I've seen, the virtual nursing units do not change your staffing numbers. So by no means does it actually reduce the number of nurses that you need to care for a patient. Maybe in later stages it will become more efficient. So I don't want people to operate under the assumption like in virtual settings, I can then also reduce the number of nurses. It's an augmentation in a new way that helps provide that support, particularly to nurses who are newer to practice or help with some of that administrative task and component it.

Becker's Healthcare (00:57:21):

Got it. Got it. Thank you both for answering that question. The next question I have for both of you, it's a bit long to follow me. Someone said, love this approach. Who manages the competency if in our end works in one hospital and has a big in another? Is there a way to keep their competencies in annual education on file so they don't need to do to fire safety and all the other related general competencies? I'm not referring to unit specific, but standard processes that do not change.

Dani (00:57:56):

So that's part of the technology that we have works. There's ways to house and centralize all that competencies that's set across your enterprise. In regards to management, there's a couple ways to think about this. If you have a gig role, that's a secondary job. So their primary job is hire two unit. Oftentimes what I find with the expansion into this gig to go to another hospital, if they have a float pool leader, I actually open it up into the float pool leader so they have that secondary job and then any additional competencies would be managed through the secondary job for the float pool component is a way to look at it and happy to have more discussion around some of the ways that you can create structure for management around competencies and skill sets at your enterprise level than down to your unit level as well.

Becker's Healthcare (00:58:51):

Wonderful. Thank you so much. This might be our last question of today, but someone asked, I suggested a seasonal gig type position at the last place. I managed and was told that HR would need to be involved because it doesn't work with benefits. Have you seen these challenges, and if so, how did you overcome

Dani (00:59:12):

Your HR partner is a critical component as I was describing these different jobs and how to set them up. So absolutely across collaboration with those is going to be necessary to forming and bringing these programs to life. As you think about a seasonal gig, one way that you can overcome that is if you hire at a 0.6 and then fluxx able to provide benefits so that is a way that we were able to move around. It was with looking at a 0.6 FTE was eligible for benefits. We would offer that, and then of course, fluxx with the seasonal trends that we were experiencing based off of patient demand.

Becker's Healthcare (00:59:55):

Wonderful. Wonderful. Well, unfortunately that is the time we have for today, so I do want to thank you Gladys and Dr. Bowie for an excellent presentation in Trusted Health for sponsoring today's webinar. To learn more about the content presented today, please check out the resources section on a webinar console and fill out the post webinar survey. Thank you again for joining us, and we hope you have a wonderful afternoon.

Dani (01:00:19):

Yes, thank you. Take care.

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