Dani:

Hi there, I'm Dr. Dani Bowie and welcome to The Handoff, created by the team at Trusted Health and I'm Trusted Health Chief Nursing Officer. Our guest for today's episode is Gladys Campbell, a friend and a mentor of mine who has had a long and distinguished history in the field of nursing, including as Chief Nursing Officer, as the CEO of Northwest Organization of Nurse Executive, and 20 years at the National Institute of Health. You'll hear Gladys share her thoughts on why nursing has gotten off track and why nursing now serves primarily in a symptom management role. Why she thinks more nurses need to read literature on business and management, along with some of her very favorite research on motivation in the workplace, she also shares some very out of the box ideas on how she thinks staffing agencies could evolve to meet the demands of the profession. Gladys is an old friend and an incredible storyteller. Gladys, welcome to the show.

Gladys:

Thanks Dani, and thank you for inviting me. And I also wanna see how proud I am of you with your new job and a great job you're doing for Trusted Health.

Dani:

Well, thank you. I'm so excited to talk to you today for a couple of reasons. One, I have just been so inspired by your career. You're a pioneer of the nursing profession. You have a decorated career and a very distinct one, right? You've gone to the NIH, you've been a CNO, a CEO of the professional organization of Northwest One, and you're a principal of your own company. But most importantly, what you alluded to is you've been a longtime mentor of mine from our days at Northwest One, and you have introduced me to different thought leaders such as Dr. Peter Beerhouse, Jack Neel man, Maureen Maney, and you've encouraged me to own my professional practice as a nurse and think outside the box and really challenge the status quo. You and I have had many discussions about the nursing workforce, staffing the future of nursing, and I would love to spend some time today diving into those conversations. And I'm gonna start with something, what we've talked about before. I've often heard you say that you think the nursing workforce is off track. Can you elaborate a little bit more on that?

Gladys:

Yeah, um, first lemme say that, um, a real 40% of our nurses who are licensed don't work in hospitals. And most of my comments are really good at focus on what's going on in the hospital, and I don't want any of those nurses to feel disrespected or disregarded. And I also wanna say that age humbles you. And so I don't think I am the, you know, be all, end all who's figured everything out. I wish I was, I wish I'd figured it all out. So I am always humble in my opinions and comments, and I think what's most important is that we keep the discussion cuz that will prompt innovation and creative thinking. So largely the reason I think that we're off track is I think we're doing an exquisite job of symptom management, <laugh>. And some of that comes from a story that I read years and years ago, and some of you have probably read it.

It's a story called The Parable of the Downstreamers by David Ardell. And he talks about, um, this beautiful little village that has a river running through it. And the reason the town is called Downstream is because it is downstream from this river. And one day this woman shows up in the river and she's drowning and the citizens jump to action and are able to rescue her and they feel very proud. But the next day there's a couple more in the river and they're drowning and they again jump in and rescue. And over time, more and more people are landing in this river. So then they respond by actually, um, building a hospital on the edge of the river, setting up a systematic approach to rescue, having a coordinator who coordinates all these different specialty workers who are divers and they're expert swimmers, and day after day they rescue people and no one dies.

But also nobody ever asks what's happening upstream, <laugh>, why are all these people landing in the river when they didn't before? And I think that's exactly what we've done in nursing. We have set up elaborate, beautiful, expensive systems to respond to what is a really big symptom. The problems than the nursing workforce are a symptom of something bigger. And I think what we really need to be doing while we hold our rapid response team on all of this and all of our systems and processes, cuz we need that to really be having deep detail about what's going on upstream, what is really happening upstream that has taken us to this place where our entire focus is really on symptom management. So that's why I think we're off track.

Dani:

Yeah. You know, I, I think that's a really powerful story and it makes sense and I think it has been what we've been experiencing. Now, if you could talk a little bit more about going upstream and what you think those symptoms are that have led us to this place of potential shortage, uh, workforce that's having really tough conditions that they're working in. And as you mentioned, we've created elaborate systems, we're managing to the best of our ability, but symptomatically, what is it that you see that's really pressing the nursing workforce?

Gladys:

Well, uh, first of all, you've gotta remember a pretty long in the tooth <laugh>.

And I think the reason I have some of this perspective is because I, I've been in nursing for over four decades. Um, I began my career in 1974. And so, you know, I've been around before, a lot of the people that listening were probably even born. But there was a real radical change in how all of us approached healthcare with the emergence of relative value units, which really happened way back in the eighties where people started to begin to really look at the cost of healthcare, um, where really were the costs and what was going on. And it was at that time that suddenly nursing became part of the cost center of what is the bed in the hospital. And in many ways that made nursing invisible and unimportant. So here is what is really the most expensive slash the most valuable resource a hospital has that is now looked at in a way.

Like, we have no idea really what they're doing. We just know they're really expensive. And I think most people who've spent any time in nursing management know that about 50%, 45 to 50% of a hospital's operating budget is labor. And about 50% of that is nursing. So that means nursing is about 25% of a hospital's operating budget. So if a hospital is not meeting margin, whatever, that margin might be different than frankly just meeting your bottom line. And we forget that if you've budgeted for a huge margin, that's very different than being at the point where you are insolvent. But if you're not meeting margin, the first thing a hospital's gonna do is what's a quick fix for us? Well, the quick fix is to start paring down the nursing workforce. It's the simplest and quickest way to kind of reduce your costs and move on.

And that really began what has been a decade's long struggle with nursing. So we have created a system where we manage productivity in hours and days and sometimes weeks. So that our strategic plan for finance is really at the end of our nose instead of looking at long term. Because the long term would include what does the symptom management cost us? What is the cost of full shift or incremental overtime? What is the real cost of agency supplementation? What is the cost of labor strife? All the administrative hours spent in contract negotiation and in grievance responses that is largely because of union frustration over what they view as inadequate staffing and a lack of attention to, uh, meal and rest breaks and really a healthy work environment for nurses. And then there are all the indirect costs which have to do with the erosion of teamwork, of nurses deciding, I'm gonna work my 12 hour shifts, three shifts over here, and maybe another three shifts in another hospital.

I'm gonna get in and out because I can't be these conversations where people don't understand or value nursing anymore. So I'm gonna move on. And lastly, and for me personally, just the way I'm wired, this might be the important thing is that we talk about evidence-based practice all the time. We talk about evidence-based practice as if it is the gold standard when it is not. It is actually the subbasement because if you are not practicing according to what is known, that is substandard practice, that is malpractice. And we look at evidence-based practice as if it just applies to the clinician, but it does not. There's reams and reams of data about nursing leadership, nursing management, general leadership, general management that we pay no attention to. So I just wanna cite two actually old pieces of research. The first was actually done by Warren Banon, I don't even know the year that he did this, but he came to the conclusion at the end of studying kind of retention and satisfaction in the, the workforce in general.

He said that all people, all people who are employed only want four things. They want to feel important, they wanna be useful and purposeful. They wanna feel they're making a meaningful contribution and they wanna work for a worthwhile enterprise. That means an organization that they're proud of. I think that's absolutely true. I think about those four things all the time. And I think, I don't know anybody who doesn't want that, but the next piece of research is actually I think even more interesting. And it was done by a gentleman named Herzberg and he published it in 1959 <laugh>. Okay. I always say, you know, when you do research, you're supposed to look at these most recent studies. Gosh, some of the old studies are the most powerful. But he published this article on what he called Two Theory Factor of Motivation. And he talked about what are hygiene factors and what are motivating factors?

And there's a real irony in this because hygiene factors are things like your salary, your benefits, your job security and workplace conditions that are really mostly about policies and procedures. Do you have structures in place that allow work to be consistent and to be able to conduct that work with some level of ease? They're hygiene factors. Now what's interesting is almost all of our symptom management and almost all of the union's attention is on hygiene factors. But in reality, if you meet someone's desire for these hygiene factors to be met, they aren't motivated. They might have some level of satisfaction, but they are not motivated. If you don't meet these factors, that's all they focus on. Okay, it's all they focus on. But if you want to motivate people, you first have to meet a basic need around the hygiene factors and then you have to look at other things which are job growth and advancement, a sense of achievement in the workplace, recognition for work well done, autonomy and responsibility, pride in the work. And what we've done with productivity measures is we've reduced nursing to a series of tasks. We've driven out a sense of pride, the ability for recognition. We've driven out autonomy and responsibility and we also in many places haven't met the hygiene factors. So I think that we're looking at all the wrong stuff and I think that's part of the problem.

Dani:

You know, I, I, so that's new research for me though. I know it's, it's older research, it's newer for me. And as you mentioned, hygiene factors and motivational factors. My mind goes to some of the contemporaries, which is like transactional versus transformational leadership. Similarly transactional is what did I pay you? What does your schedule look like? Kind of the, the staffing components, your benefits policies. And then the transformational that we always strive for as leaders is your career growth. What's gonna inspire you as as a nurse. And I've often spent most of my career around the transactional pieces for a variety of reasons, just because systems were not at play that needed to be, I was overwhelmed as a leader with how many nurses I was caring for patients. And my ability to spend time on the transformational piece was limited. And as a result, you know, I wasn't satisfied either. So I think those are really good call outs and ways that how do we build the right systems to, to meet the H factor and then move into the transformational space of motivation and leading the profession into more strategic thought, innovative thought and leading the profession for ourselves versus being a budget item in a hospital and viewed as a cost.

Gladys:

And I think what's interesting too is that nurses, staff, frontline staff nurses often have what I lovingly call the, I don't know what I want, but I know I'm not getting it blues. So when you ask them what do they need, they'll almost always save more money or more staff. I mean, I don't wanna denigrate them, but it really isn't what they need. What they need is a supportive, exciting, innovative growth producing environment where they feel they're really making a difference.

Dani:

Absolutely. Now, are there any hospitals or health systems who you think are getting this right? And what kind of programs or outside the box solutions are they implementing to do this?

Gladys:

Well, you know, I do have my opinions, but here's the problem. I don't have permission to call these people out and they're mostly organizations that I've done consulting work in. So I wanna frame a historical reference that'll help you get there. Yep. Uh, again, being long in the tooth, in the mid eighties, this country saw the biggest nursing shortage they had ever seen nationwide to that point. And what happened from that was the ANA and them probably early in mid eighties, um, commissioned some nurse researchers to do research to kind of look around and ask the very question you're asking me, are there some hospitals out there that in spite of this giant nursing shortage, they're doing it right and they're not having a shortage. And there were some of those hospitals, they're actually, I think we're about, uh, I might be saying this wrong, I think there were like 194 that they identified.

They didn't resear do research in all of those, but they went in and actually I was in a hospital that they came to at that time. And I was a young in my first management job, a little nurse manager in NICU, and I remember it very acutely. And the things that they found from that became the original 14 factors of magnet. It's where the magnet designation came from, was doing that kind of research about who's doing it right now. I don't think necessarily we should go to the current magnet hospitals to ask them, because I think some of them are struggling now with this issue. But I think it would be interesting for the nursing profession to redo some of that research right after Covid because Covid didn't cause this mess. It unmasked it. And for some high level researchers at a national level to go into some of these hospitals and really study why was it that they didn't see the disaster or they quickly recovered from the disaster that was covid and how are they thriving now? Because I know some of them are out there because I've seen them. And I will also say my bias, they have some of the strongest chief nurses in the business. So that strong leadership

Dani:

That would be very eye-opening to go into the health systems and do more of the research, uh, to understand how health systems are thriving or recovered quickly from covid. And I a hundred percent agree, this did not create our staffing issues. It just accelerated what was going on with the workforce, the working conditions, staffing challenges, and the management. I'm gonna talk a little bit about some controversial, you know, topics, which is contract labor. You know, I mean this can be a very divisive issue for a lot of nursing leaders. And what, what's your take on contract labor

Gladys:

Of two prongs of thank you. First of all, if you ask anybody, they would say it's a necessary evil. And I think if I was in the contract labor business, I'd be focusing on the word evil.

Dani:

<laugh> <laugh>.

Gladys:

That doesn't bode well, if people think you're evil, that means the minute they can make you unnecessary, they're gonna get rid of you. Um, there, but we all know there's a lot of problems with contract labor. They savor behinds over and over again, but they're expensive. They create a sense of antagonism between the employed staff and the contract staff. It puts additional burden on the people that aren't contract staff. Um, we have, you know, some pretty poignant stories about sometimes problematic nurses hiding in contract roles. Um, because we know that without a full compact across the nation, that we have varying approaches to licensure in different states and what those requirements are and how people are monitored. Um, there's some damage that's done to teamwork. And for those contract nurses themselves, they are at will employees, which means if you go back to the hygiene factors, they don't have job security as it pertains to their salary, which they might be making giant bucks through covid o d, but those salaries got cut the minute there was the sense that the Covid crisis was over. So those people often are not treated well either. And so you see this back and forth where nurses jump to agency to make the big bucks and then jump back out, um, when the big bucks disappear. So I would say, um, that's one half of my opinion contract labor. But if you're interested, I have a whole other set of thoughts about how contract labor could take over the whole ball of wax

Dani:

<laugh>. Well, I am a little interested, you know, because when I was leading during covid and then since joined trusted and worked with different health systems across the country, one thing that I've seen is typically contract labor was around anywhere from five 7% of their workforce composition. And it's jumped, and now I'm seeing it, 20% of their workforce composition. And you're right, it, it is a good strategy for some of those seasonal fluctuations potentially, and ways to help with demand that changes off and on. But it's one of many strategies. It's not the only strategy, but seeing a number of 20%, 25% to me is saying this looks like, um, your primary strategy of solving your workforce challenges. And so it, it's something that's top of mind for many leaders to bring down. So I, I would love to know also, you know, we see the challenges, but also what are your thoughts about the future of it and where you think it's going?

Gladys:

I've had this funny little notion and it'll probably get me into big trouble, but I'm gonna say it anyway just to, you know, kind of keep a conversation rolling. Yeah. Um, I don't often suggest that nurses follow the lead of physicians, but I think it might be time to really look at what our physicians have done way back again with those relative value units. And when hospitals began putting pressure on physicians and you know, physicians, it's like, don't touch my wallet and don't me how to practice. And nurses are really kind of the same way frankly, but physicians began pulling out of hospitals in droves and setting up their own surgical centers, their own procedure centers. And guess what? They take the patients that have good insurance, for the most part, the patients they do in the hospital, they do at the end of the day, at the end of their surgical day or at the end of their procedure day.

Now, if I'm the C E O, first of all, because they never really look at the full cost of this symptom management, I'm talking about, even though you're gonna float a big number to them, it's gonna be a lower number than what they're already doing. And it's gonna take this headache away because they hate it. Everybody hates it. In fact, sometimes in hospitals, I feel like they really don't wanna deal with nursing at all. We're just a problem for 'em. Okay. But if you did that and you did it successfully, first of all, you're, it's gonna be really hard for them to get rid of you cuz you know, on all the staff in that I see you, but then you do the ED and then you do maternity. And what if nurses, like physicians now gave service to hospitals Yes. But didn't work for them.

I think it could be really interesting. And I know you've also asked me, Danny, about what's a part a state nursing association could play in this? Well, the state nursing association, they became a federated model through the a n a, um, I can't remember when, but it was decades ago, which allowed them to create unions. That same federated model would also allowed them within their structure to be agencies. So now you've got nursing, controlling nursing as well if they did it right, and you could have very strong leaders of those areas that would attend to the motivational factors as well as the hygiene factors for the nurses. Just a thought.

Dani:

Yeah, I mean it, well those are the thoughts that we need because we've been having the conversation around workforce and staffing since I've joined the profession and it just continues on. There's a shortage. No, there's not a shortage, right? There's burnout. Uh, nurses aren't loyal. Well, there's a reason there isn't loyalty to organizations. I just read an article today that during the first wave of covid, a lot of hospital furloughed nurses. So there, there's this a symptomatic issue of the relationship between the employee and the employer. So why not look at that differently and create a better operating model? And you're right, nursing, managing nursing and moving them out of the cost piece of it and servicing it out, I think that's brilliant and I would love to see a pilot of that and how, how it work. I I think it's great.

Gladys:

Well, I, I'll tell you something, I, I actually have a plan to go to one of the state nursing associations and I'm sure they'll laugh me out of the door. And I'm used to that. I get left out of the door all the time, but I'm gonna pitch it to 'em.

Dani:

Yeah. Yep. Bring me if you do, I I would love that. Oh, <laugh>,

Gladys:

Absolutely love it. Absolutely. I will. It would be wonderful. It will be in a state that you like

Dani:

<laugh> and I don't know what states those are. I know what states those are. Sure. Um, west coast for sure. Just kidding. So let's, uh, let's talk about though, would you bring up a point which, you know, there's this conversation around flexibility and what the workforce is wanting. And part of the conversation even around contract labor or travelers is that flexibility has been a primary component of attracting the workforce into these types of, of opportunities. So from your perspective as a nurse leader, what do you think flexibility means to the leaders as well as the front line? And is there alignment or a mismatch there?

Gladys:

That's the number one issue. I think when we talk about flexibility, what the hospital administrators just saying is completely different than what the nurses are thinking. Okay. And I will also say nurses tend to first line that, you know, they're not thinking about the motivational factors. First line is they think about scheduling flexibility, but that isn't really what's gonna hold them. So what the hospital wants to be able to do, and I'm being a little sarcastic, so I don't mean to be mean, but they just wanna take nurses like cogs in a wheel and just move 'em around and put 'em wherever We need a warm body. That's what they wanna do. And in doing that, it's dangerous. Number one, it flies in the face of best practice where you're matching the skills of the nurse with the needs of the patient. And it denigrates the idea of specialty practice.

So it turns a nurse who's proud of her specialty skills into a hospital that believes she or he should be a generalist when really no one's a generalist anymore. So there's a lot of things that are wrong with that idea. But if that were possible to just move the cogs, move the pieces on the chess board, that is what hospital administrators like because it's easy and simple, linear, blah blah blah. Okay? But when nurses want is yes, they want some scheduling flexibility. And I would say most of all they want scheduling predictability because you can't plan your life if you don't have some predictability around when you're going to be available to do things in your life. The only way you get that is if you work a straight off shift. And I did that coming up, you know, back when we did eight hour shifts, I put myself on evening shift so the hospital wouldn't muck with my schedule so I could go to graduate school because otherwise I would have to renegotiate every six weeks.

So, um, I think that's what is part of the problem. But when we think about what are the things hospitals could do right now to increase flexibility, first of all, they could build large, large specialty practice groups. So the maternity wouldn't be, I'm a labor and delivery nurse, but I never do out on the floor mother baby, you know, or nursery. That you would create these large groups where you cross oriented people to everything within that large specialty division. And that large division would have its own, if you will, float or supplemental pool. So the specialty is respected and you know that you're always gonna work on your specialty, not, maybe not your your favorite unit, but you're not gonna be taken out of your specialty. So we do that. And again, you'd have these specialty practice float pools. You'd um, be able to create divisions that had specialty leaders who understood that practice.

We would reinstitute clinical ladders but do them right because we haven't done them right. And we've done them in all different kinds of ways. So that you would have four to five levels, five levels if you included clinical and their specialists and you have them in your ladder. Otherwise they would be four levels. Each level would have a separate job description and a separate evaluation tool. But all four or five levels would be focused on three domains of nursing practice. And those domains would be clinical practice education, meaning self-education as well as patient and family education and precepting others leadership, which is everything from being a charge nurse to being a preceptor to being that interim manager when needed to being a lead on project areas. And lastly, quality and research. So those four areas would be looked at in a stratified way from, if you will, novice to expert or whatever the current lingo is today, but four domains and obviously there would be different pay scales for those.

That model allows people to feel the progression and it invests the hospital and the ongoing development and achievement of its nurses and it recognizes them for that achievement, both financially and by title and by job description. I think we should go back to what we used to call the Baylor plan. I think it really helps people if they wanna work those weekends and have the rest of the week off, especially you know, new moms or again people in school or new dads to be paid a full-time rate for two 12 hour shifts and to work every single weekend. I think we should do that. I think that we should schedule nurses now. Somebody will take my head off <laugh>, I should schedule them for 10 hour days, instant eight hour patient assignment, which means nurses have two hours of indirect time every shift time when they can do charting time, when they can provide breaks for the next shift.

That's come on time when they can go to staff meetings or committee meetings or do project work that they're doing. And it also means if you have an uncovered shift, because remember your patient shifts are still eight hours, you're only gonna ask that 10 hour person to work two hours of overtime and the person that matches them on the other side to work two hours of overtime. And you've now covered that whole. So you're not asking somebody who's worked 12 hours to work more. When we know from the research that beyond 12 and a half hours, you're the equivalent of legally drunk, which means you're not fit for duty. Lastly, and this could be really, um, controversial. The federal government has this interesting model where they have in many institutions two HR plans. So I can sign on to be a hourly paid nurse and I'm treated just like the normal hourly paid nurse is treated. Or I can sign on to be a nurse for life in some places, like when I was at the NIH, you become a commissioned officer, that means you are salaried, it means they own ya. You go where you are told to work.

Dani:

I, I mean those are the things that I wanted to talk to you about today. As I mentioned, we're constantly having this conversation and the traditional models of employment haven't been solving this. So I liked your idea of you're signing on hourly or signing on for more commitment via, you know, lifetime, uh, commitment or, or something that's determined. So I think that there's a lot of opportunity there. You know, one thing that we've been looking here at Trusted in the work that we've been doing is really around technology and gig workforce and how to open up shifts and consumerize them with the right type of technology to give the autonomy back to the user to say, why is it that this is only controlled in one space, whether it's your unit or one hospital, but could we not create the right ecosystem of offering up work opportunities based off your specialty and skills where you can go to different places and you select those shifts?

Gladys:

Yes, yes. Absolutely. Absolutely. And again, with these large systems that many of them have over a hundred hospitals, you can absorb the cost because the number of your staff that choose to be in these professional salaried roles, it's going to be small. It's not gonna be the majority, it's gonna be small, but you're going to use those people in a mighty and powerful way, especially in leadership. When you have a vacancy of a chief nurse, you got a chief nurse that you can move.

Dani:

Absolutely.

Gladys:

And you and that person knows your system and your policies and procedures in your culture.

Dani:

Yeah. And it also tackles the issue of, you know, everyone's like loyalty of the workforce. It's just not there. But why not determine, let them determine the loyalty themselves. Yes, you are loyal in this way or you wanna try and work a different way. And that's okay. I really appreciate time and we're, we're coming to the end of the podcast. Um, there is a final question that I would like to ask Gladys, and that is what we ask all of our guests on the handoff is what would you like to hand off to our listeners today?

Gladys:

Well, I did think about that cause I've listened to some of your podcasts and I know you always asked that question, so I was ready for it. Um, and there's two things. One is, I, I wanna share my favorite Florence quote. Most nurses have one and then just a, a little, I don't even know if it's a quote, I'm not sure where it came from, but a little guiding principle that has helped me. So my favorite Florence quote is, she said, I attribute all, all of my success to this that I never gave or accepted an excuse. I love that. I love that. And when you think of all of her success, that's a powerful statement for her to have made. And then, um, my little guiding desire is a quote that says, perhaps the secret of living well is not in having all the answers, but in pondering unanswerable questions in good company. And that's actually what I hope you guys at Trusted Health do. That you create environments where we can ponder really tough questions in good company and with a sense of curiosity and humor.

Dani:

I love it. Yes. That is our hope and desire as well. And even the reason we're talking here today is to understand these tough questions with thought leaders around the country. And you have provided some wonderful insight and really some different models that I wanna think a little bit more about and ponder more about because there's opportunity there. So glads, thank you so much for your time and everything that you've shared here and I really, really appreciate it.

Gladys:

It's my privilege. Thank you.

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