Dan:
Jana, welcome to the show.

Jana:
Thank you. I'm happy to be here.

Dan:
Yeah. I'm happy you're here too. I know we have co-conspired on multiple conversations in the past, so this is another one, we'll just formally record this one.

Jana:
I like that. I like the co-conspirital role. I was going to say, I'm going to add a bunch of things to my business card after that introduction, like thought leader and co-conspirator, how about that?

Dan:
I love it. So, tell me what you're up to. I mean, Oregon is, right now, currently, at a peak of COVID, it's starting to light on fire, just like California is, as far as actual wildfires. So, what's the, kind of, current state of the nursing workforce in Oregon?

Jana:
Meh.

Dan:
My favorite word.

Jana:
That's your favorite word? And, I mean, that's basically what's going on. So, one of the things that we do is, we have this weekly call where we check in with nurses across the state and just ask, okay, what are you worried about right now? What's happening in your neck of the woods? As Willard Scott used to say. And basically, it's exactly what you're describing. The state of Oregon's on fire, the COVID fire is mostly happening in Southern Oregon, where vaccination rates are low and hospitals are small but it's got that ripple effect that you're hearing about all the time where, you've got people that are getting really desperately ill. There's not room for them in these small critical access hospitals out in the rural area, then they have to be shipped up to the urban areas and there's, kind of, not any more room in those places.

Jana:
The forecasts were really dire and they were saying, around labor day, we would need 4 to 500 more beds than we had staff to be able to support. I don't see that happening, not quite as bad as that and I think that some of the things that have been done about bringing the national guard in has been really helpful. But boy, is that taking a toll on nurses, right? I was describing this to somebody else, it's like, we've got this game of Jenga that has been the nursing pipeline and the nursing profession, that we've just been building over the last 30 years and boy, somebody grabbed a piece from the bottom because we're getting really, really hit hard with that. I mean, the forecasts were saying that things were going to start going down but as the case rates go down, there's still the collateral damage that you have to clean up.

Dan:
I was seeing that too, that case rates were supposed to start going down yesterday or the day before, right after labor day, I'm like, did they not think about labor day? The one catalyst that last year catalyzed us through, well, a bunch more cases, everyone's getting together and barbecuing and doing what they do on labor day and- [crosstalk 00:03:50]

Jana:
Oh, yeah.

Dan:
I'm like, man. And then, I was watching something, a post on LinkedIn recently, we were chatting about it earlier, this whole idea of complex systems. We're living in this complex system of a pandemic, which is completely unpredictable and we keep trying to predict it and we're not good at it. We can't predict what's going to happen tomorrow, let alone, six months from now. And it's like, we're making these plans based on some certainty that does not exist, it's just nuts.

Jana:
Oh, exactly. And I think that that's true with nursing and nursing workforce too. I can't tell you how many times... We're running into this situation, this isn't necessarily that happens in every area, in every state, but we're running into this situation where we have major hospital systems that, they don't have enough preceptors, they don't have enough bandwidth, actually. So, nursing students that are in their final year of school, can't get that final practicum, they can't get their clinical place because the hospitals are just completely booked. And so, they're getting creative with where they're getting that clinical experience, which is amazing, because we've been begging them to do this for years and years and yet, it's just still not enough. There's still a lot of transformation that needs to happen within these systems, in order to be able to take on that group of people that have been trained in such a different way.

Dan:
Yeah. I think that's a really good point. And I think the reason markets innovate, one of the reasons markets innovate, is because they run out of road, which means whatever they're doing no longer works, there's no more room for it to go. And that forces change and I think, so there's an opportunity for, especially nursing education, to rethink how it does things, especially clinicals and health systems to rethink what they're doing. But I'm also curious, what are you hearing from the front lines? What are the nurses who are battling COVID... It's more predictable for them, they know every day they're going to show up, they're going to put on a bunch of PPE and [inaudible 00:05:36] and masks and spend 12 hours dealing with the pandemic firsthand. What's the sentiment from them? What are they asking for? What are they saying to you?

Jana:
Yeah. It's weird. I think, for them, the phrase that I keep hearing over and over again is, I have never in my entire career seen anything like this, never. I really want people to understand that. Right now, there are a bunch of news stories and there's even, hospitals are making these videos that are showing what it's looking like for frontline workers that are working in the hospital because it's like, for some reason that message isn't getting out, which is really strange. What I'm hearing from the frontline workers and well, frontline workers but mostly nurses that are working at the frontline, they're tired of this. Sometimes they're angry. A lot of times they're angry that this is still going on. They are just exhausted of coming in and having to deal with the trauma of patient that are so, so sick and dying.

Jana:
And then, on top of that, families, the families that they have to mitigate and try to navigate that relationship of helping someone pass when they can't necessarily be seen or in some... well, I don't know that this is happening too much in Oregon, but I've heard of in other places in the nation of where nurses have to manage family members because they're being allowed to come back in. I think it's hard. I think that this is just the hardest that anybody has ever seen it. I think they're really tired. I think that they feel angry about the way that their administration is handling things. The other thing that I see is that, despite being tired and sad and angry and frustrated, they're still freaking doing their jobs. They're still going in and they're still taking care of people. They are still so committed to doing that. Who wouldn't admire that? Seriously, who wouldn't admire that commitment and that passion to be like, I am so angry and sometimes I hate you people, but I'm still going to take care of you and still give you my best because that's what I do.

Dan:
Yeah. I mean, nursing definitely has that core ethical direction that drives them beyond many of the external factors. Although, we're seeing that starting to crack, like you mentioned. And you described the entire pipeline of talent in all clinical areas, physicians, nurses, therapies, allied services, all of it is, sort of, broken at the moment and I know that's a focus of you and your organization. What does that pipeline look like? Because from a national view, we're still graduating lots of nurses, 150,000 a year, whatever the number is.

Jana:
Yeah.

Dan:
And they're still not getting jobs and yet, everybody is screaming for talent, clinical talent, that side of the equation doesn't make sense. And then on the other side, you have this idea of this, kind of, tension between staff nurse, travel nurse, what do I do? Maybe I do both or maybe I leave the profession completely for a little while and come back later. I'm interested on what you're seeing in the nursing pipeline across the systems.

Jana:
Oh, yeah. Talk about a complex system, right? So, what we're seeing in Oregon especially, and this is more in the metropolitan areas than it is in the rural areas, but the rural areas are being affected by this as well. We're seeing nursing students who are being kicked out of clinicals, that's still happening, especially in Oregon, when there are these big flare ups of COVID and other... I mean, let's not forget the wildfires that California's experiencing, Oregon's experiencing those too. And there's just so many things that are needed to maintain a health of a community, right? So, you've got these nursing students who are not being able to get those clinicals. I think that the nursing educators that I have seen have done a phenomenal job at pivoting to other education modalities, like simulation and mostly simulation, but the different kinds of simulation that you can do to really make sure that you've got really good qualified professional nurses when they graduate.

Jana:
And those nurses can pass the NCLEX. Absolutely, they can pass the NCLEX. The NCLEX is a test of what's your basic knowledge of nursing and if you can pass school, you can pass the NCLEX. But what happens is, when they get out into the workplace, they may have really amazing critical thinking skills but they haven't touched anybody or their exposure to an actual person, who is actually sick, has been limited. So, they're going to need a lot more orientation, a lot more transition. I would say, there are some hospital systems that are already thinking about that but whenever you're in an emergency, when you're in an emergent situation where you just need people now, you're not necessarily going to be looking for somebody that you can spend a lot of time with to do that orientation. So, my big fear is that, you've got new grads that, in a lot of times, they're really going to be just, kind of, thrown to the wolves. And there is a need for compassion and empathy in nursing right now to really, really mentor and be protective of those new grads.

Jana:
Conversely, I'm very concerned about the students that are in nursing school because, like you said, we're having these workforce shortages and it makes zero sense. We have about 3,500 nursing students in the state of Oregon. When we talk about engaging those nursing students into the work of the cause, all of a sudden you start hearing a lot of different people that are trying really hard to, kind of, keep things at the status quo. You've got educators that are trying to make sure, well, if your student is going to actually be in practice, then they need to get clinical hours for it. If they get clinical hours, there's certain affiliation agreements that need to be signed, regulations that need to be done.

Jana:
At the same time, you've got your board of nursing, that their goal is to make sure that patients are safe and absolutely we want that to happen. So, they're trying to rewrite rules about, let's just try to keep these students safe and let's try to keep these patients safe and work with their educators, make sure that they've got supervision. And then you get to the employer side and they're like, you know what? It would be easier for us to pay a traveler $150 an hour than it would be for us to try to onboard the student with all of these different requirements that we're going to have, in order to get them credit for this. It's like, some of these regulations have got to give, otherwise we've got a linear pathway into nursing and it's so highly structured that that tension is going to break, at some point, if it hasn't already broken- [crosstalk 00:12:12]

Dan:
Yeah. We may be at that point. I don't know.

Jana:
I know, exactly.

Dan:
Going back to the meh, I'm like, your regulations are meh, at this point- [crosstalk 00:12:20].

Jana:
Oh yeah. No, they totally are. What I love is when I hear people on the news and they're like, oh, nurses are at a breaking point. I'm like, honey nurses are broken, it's done, okay? We're done. We're done. The broken has happened.

Dan:
The broken has happened.

Jana:
The broken has happened. So, can we start talking about what the new stuff is going to look like? Because I'm so much more interested in that.

Dan:
Yeah. No, I think you bring up really good points and I don't know, I keep going back to the complex system stuff. But linear solutions don't solve complex problems. And I feel like we're still in these linear solutions and regulations should be creating guardrails but not prescribing, because we're in a moment of unpredictability, you can't prescribe a solution. And it's something that frustrates me in the profession just in general is like, every five years, it feels like, we go through the same conversations, the same stuff, the same problem, the same solution, we try it again a different way. And there's not a lot of innovation. I think if we learn nothing from the brokenness of our profession, at the moment, of nursing profession, it's that we got to stop solving tomorrow's problems with yesterday's solutions or we will literally lose an entire workforce to something else because people will not put up with a shortage of clinicians anymore. There's got to be a solution somewhere and slowly pumping it back with nursing students is not the answer, completely. That's part of it but it's not the answer.

Jana:
No, exactly. I mean, it's a multi-layered problem with multi-layered solutions. And if we keep just trying to apply the same solutions that we thought of before, not only is that extremely boring and not creative at all, it's not going to work because if it would've worked, we wouldn't have the problem in the first place, right? If those solutions would have worked and I adore the comparison to Blockbuster, because like you said in the beginning, I'm not a registered nurse. My background is in public administration and my undergraduate degree is in journalism. And what was so interesting to me is, when the journalism industry was going through this fundamental change in the early 2000s because of the internet, just watching my friends and my colleagues that were working at newspapers and working at TV stations and working at radio stations and just suddenly finding themselves out of a job because there was a complete shift in how that industry was being consumed.

Jana:
And what I see is, the same, kind of, thing is happening with healthcare and it's happening with nursing too. So, my friends that were journalists that are like, people aren't going to want to get content from just anybody, they're going to want somebody who has rigorous journalistic standards and has gone to Northwestern. Yeah, guess what? That's not what people wanted, they wanted access. They wanted access to the internet, they wanted access to YouTube. Tik Tok is huge for a reason because they want to be able to watch people's videos and they don't care if they've got this high level of journalistic quality. Now, when I compare that to the nursing industry, does that mean that I'm saying that nurses don't need to have some kind of standard? No. Because Tik Tok is different than treating human beings and human bodies, right?

Jana:
So, there does need to be a standard and there does need to be a level of quality. But if nursing doesn't take this opportunity, it doesn't look at this opportunity right now for the opportunity that it is, then we are going to get things that are going to be really dumbed down and we're going to get people that may not have the same high standards of care that a registered nurse has right now. And it's going to look very, very different. How do we want that change to look like in the future?

Dan:
Yeah. I think that's a good analogy too. And healthcare is at that same point. So, it's not the internet necessarily. Well, it sort of is the internet but it's technology, in general. We continue to think that care happens within the four walls of a physical place and so, we train nurses to do that instead of thinking about the holistic care everywhere, kind of, concept that's happening now. And how do we create the workforce of the future, that delivers care everywhere and not delivers care at XYZ hospital and XYZ town all the time? Now, that still has to occur and there needs to be people that can do that but there's such opportunity to get ahead of this stuff in different ways. And I think it, kind of, goes back to one of the points I want to chat about is, the lack of distribution or the maldistribution of nurses across Oregon, specifically in your case, but in the country, the supply and demand signals are completely broken.

Dan:
States don't know how many nurses are in their state working in any specialty at any given time, except that every two years, when you renew your license, you've got to fill out... 30% of them fill out that survey and then you, kind of, guess from there. And so, you don't even know how many ICU nurses are potentially available to fill the roles, unless you send out ads for jobs and hope and pray. And it just seems like there's a big opportunity there. I know that's something you've been focused on. I would love to hear your thoughts on, how we might better distribute or even know what's happening within the clinical workforce, so that we can tap into it more efficiently?

Jana:
Yeah. It's such an important thing. So, first of all, just as background, because you've read the report and I'm certain that other people haven't read the report. We did a report, we've done actually a series of reports, that are looking at, if you're looking at the concept of shortage, right? If we go back to the 80s or we go back to the early 2000s and we talk about the concept of shortage. That just, kind of, implies that, if there's a statewide shortage, then we don't have enough nurses in the state, so we just need to make more, right? But that doesn't make any sense. Again, when you're treating human beings that are in different kinds of communities and different kinds of environments, you really need to take all of that into consideration. So, in the state of Oregon, what we've seen with this maldistribution is a really high concentration of nurses that are in the urban area and it's really hard to recruit and retain nurses in the rural areas.

Jana:
That isn't going to change after the pandemic. There's nothing. And the reason why that's not going to change is because the drivers of that maldistribution, of the geographic maldistribution, has nothing to do with healthcare per se and everything to do with community economic development, whether or not the spouse of the nurse has a job in that community. What do the schools look like? So, it's a much, much holistic picture. And also, when you look at the maldistribution of nurses, people will be talking about the nurses retiring in this silver tsunami or these number of nurses that are going to be leaving the workforce and that is absolutely true in the Northeastern part of the country. There is a concentration of older nurses there, they don't have younger nurses that are replacing them. But on the West Coast and particularly in Oregon, the number of nurses that we are graduating and also importing into our state, that are under the age of 45 or under the age of 35 actually, is equal to the number of nurses that are retiring.

Jana:
So, when we talk about those maldistributions, we really need to understand what that looks like in our certain areas, because what will happen is, in the Northeast, they're looking at, how do we make sure that we can increase the number of people that are willing to be nurses in the Northeast to replace the number of people that are retiring? In the West, what we're looking at is, how do we retain that knowledge gap of these nurses that have been working and have 20, 30 years of experience? How do we make sure that we continue to educate and really bring up the professionalism of nurses as a transition into the career, as we can retain them and just create this amazing group of nurses going forward? It's not a matter of bodies that we need, it's a matter of knowledge gaps that we need to fill.

Dan:
That's a really interesting perspective. And I was in South Carolina, it was the same thing. So, they have these, sort of, urban centers or these urban academic medical centers that have most of the nursing talent but then, they have rural ambulatory clinics or FQHCs or whatever. The younger nurses don't want to go live there, they want to live in the center of the college town or the urban center. And so, how do we rethink that, just from a workforce standpoint? Maybe the solution isn't that you hire people to live and work in that town necessarily, but maybe you figure out some way that you have a flexible workforce that takes assignment there for a couple weeks at a time or something. Kind of, a hybrid travel model without the crazy travel stuff that goes on. And I don't know. I mean, I think there's just such an opportunity to rethink all of that.

Dan:
Because the generations before, in my opinion, were, you graduate, you get a job, you stay there as long as you possibly can, maybe you switch one or two times and then you retire. The workforce of today is not that, they want flexibility, they want to align with their values, they want to work here for a little while and go somewhere else and they want to settle down and maybe have a family or just chill for a little bit and then, they want to go back out. And we don't have systems set up to support that type of thinking because it's all been built on that industrial model of, work here forever and maybe get a pension or some retirement and go home. I don't know if you're seeing that, that's partly an assumption, that's partly some of the data we got from our own survey but is that in the conversations, as you're talking with your stakeholders about what the future generations of nursing? Or it's not even the future, it's the now generation, the people graduating nursing school now want in their professional career.

Jana:
Yeah. I think it's interesting because since, especially in Oregon, wherever there's a COVID search, that's going on right now, I think that when it comes to nursing students, it's really hard for them to think too far in the future. And let's be honest, I think it's hard for all of us to think very far in the future because we're just not good at predicting what's going to happen next, right? What I have seen is... And it's interesting that you bring up that model because another place that I am working with is, I'm the president of the National Forum of State Nursing Workforce Center, so it's, kind of, like, the Oregon Center for Nursing but for 34 other states, so there's 35 of us. We were having a big conversation about, well, what is it going to look like in the future? And it was interesting because that really came up, what happens if we have a more flexible workforce?

Jana:
We've been able to see with the states that are part of the nursing license compact, we've been able to see that they've had so much more flexibility, that nurses basically become almost a free agent, if you will, where they can leave their state and go to another state, make a ton of money as a traveler and then come back to their state. It's great for the nurse, it's not great for their community. It's really hard for their community when you have that kind of a workforce that is just, kind of, a come and go and what you said before, we have no idea where they are. It's really hard to be able to navigate that. So, if we start moving into that direction, does that mean, if we put everybody into some kind of a regulatory agreement, like the national compact, does that mean that nurses are basically free agents and they can go wherever they want to and, kind of, live the life that you want? Absolutely. But that's not going to work if they don't bill for are their services.

Jana:
If they can't get reimbursed for their services, that's not a model that's going to work. There's so many different elements that need to happen. My fear, this is honestly the thing that keeps me up at night, my fear is that, there are going to be so many people that just want to get us back to the status quo, that we're going to come up with some monstrosity of a system, of a complex system, that we haven't even imagined yet. What we need right now is some serious, serious, concentrated, passionate thought about, what does our future, not in healthcare, look like? And how does nursing inform that future? Because if it's going to be something where, okay, we're going to start trying to work with people who are workers that are not registered nurses but they can do some things, under this kind of regulatory control, we'll have them do this thing. Then that's going to move the emphasis of having registered nurses in one setting into another.

Jana:
And before anybody says, oh, yeah, we had that conversation in the 80. Yeah, you had that conversation in the 80 but look at where we are. Let's not keep spinning our wheels here, let's break the wheel completely and think about what we want healthcare to look like going forward.

Dan:
Yeah. I love it. I love every sentence you just said. And there's just so much opportunity for innovation, regulatory innovation, rethinking the workforce, leadership innovation, school innovation. Like Ken Robinson, Sir Ken Robinson, who has an amazing Ted Talk, two amazing Ted Talks, some of the most watched Ted Talks on the planet, said, of education, we don't need evolution, we need revolution. He goes on to describe it and he quotes Abraham Lincoln in this video, the dogmas of the quiet past are inadequate to the stormy present. And I'm like, man, where's Abraham Lincoln? That quote, let's just put that quote on every door, on every coffee mug, at every Starbucks, at every Stumptown coffee in Oregon.

Dan:
We got to just break ourselves out of this thing and we don't know and I think that's the leadership piece, we don't know what we're doing right now. And so, taking comfort in what was done is not relevant. We have to push ourselves into discomfort. The frontline nurses that listen to this too, it's the same thing, we got to push against what we think we know and try and develop something in the future. I know we're all tired, we're all tired and frustrated but if we give up and we stop putting energy into changing the system, then we'll go the way of the Blockbuster.

Jana:
Exactly. And let's not forget, there are 4 million nurses in the United States. There are 4 million people who have just an enormous amount of knowledge, personal experience. They know what needs to be done, this is the opportunity. I think that if there's ever been a time that nurses could actually be influential, now is the time that nurses can be influential on what that change can look like. We can't just sit back and be like, well, what am I supposed to do about it? I just come, I show up for my shift and I go home. Yeah, you do. And right now you're really tired and we want to support you in your exhaustion and make sure that you're taken care of.

Jana:
And there's a bunch of other people, like me, who are not nurses, who are fighting on the backend, to be like, tell us what you need because we're going to try to shape some things and influence things now, in any way that we possibly can, because we know that we can take care of the health of our entire country, our state, our communities, our entire country. We know we can do it, we just need some leadership to make that happen and nurses are the leaders that can do that. I am a big believer of that.

Dan:
That's awesome. And that's the positive side of it. I think the opportunity is there and we need to seize it. We, as a profession, and the supporters of the profession, need to stop waiting for someone else to fix it, I think, because it's not going to happen. We got to take the reins here.

Dan:
All right, well, we've had such an amazing conversation. I want to keep talking about all of this stuff but I think you provide a lot of great insights, number one, what's broken. And we, kind of, went down the dark negative path, which is fine because I think we need to call it out for what it is but it is the opportunity to move forward, that's awesome. There's so many great resources, like the studies you've done, that give insight into what the problem is and what the patterns of movement of the nursing workforce are and to help leaders help make decisions.

Dan:
What you've described in Oregon is a microcosm of what's happening in every single state across the country and I think we can get a lot of learnings from that. And the call to action is, leaders, you don't know what's going on. You don't know what the answer is and be okay in that discomfort and let's build this together. There are people and resources out there that we can pull together and create our co-conspirator network to build the future of the profession and of the health system, which I think is the exciting part.

Jana:
I love all of that, yes. And if any of your listeners are not in Oregon and they're like, well, I'm not in Oregon. Check out and see if you've got a nursing workforce center in your state, you probably do. And if you don't have a nursing workforce center, call me and I'll figure out how to help you get one because there are a lot of people that are looking at these workforce issues from a really, really high level and can provide some great information on what would work in your state.

Dan:
Love it. We'll post the website to the nursing workforce center. Where can they find you though? Where do you like to hang out online?

Jana:
Oh, well, I like to hang out on LinkedIn. I try to stay away from Facebook because it scares me. So, I'm most on LinkedIn, you can find me on LinkedIn. The Oregon Center for Nursing is on Twitter, the Oregon Center for Nursing is on Facebook, so check that out. But if you want to find me I'm on LinkedIn, just come connect with me. I would love, love, love to connect with a lot more people, happy to help.

Dan:
And even if you're not in Oregon, nurse leaders who are listening, the data that Oregon has is a microcosm of what you have in your own state. So, it can provide you insights, even if it's not exactly what's going on in your area. So, check it out, check out LinkedIn, check out the Oregon Center for Nursing and let's change the world.

Jana:
That's my plan, man.

Dan:
Well, thanks so much for being on Jana and let's go out and do something about it.

Jana:
I love it. Thanks Dan.

Dan:
Thank you so much for tuning into The Handoff. If you liked what you heard today, please consider leaving us a review and subscribing on Apple podcasts or wherever you listen to podcasts. And for more information about Trusted, please visit trustedhealth.com. This is Dr. Nurse Dan, see you next time.