Dani:

Welcome back to the Handoff from Trusted Health. I'm Dr. Dani Bowie, Chief Nursing Officer of Trusted Health. Today I have the pleasure of speaking with Dr. Jeff Doucette, SVP and Chief Nursing Officer. At Press Ganey, we discuss relevant data trends of the nursing workforce and how health systems are recovering post pandemic. We also explore the impact of an engaged nurse leader and how key subsets of resilience can be used by leaders to support frontline retention development and career longevity. Here's my conversation with Dr. Jeff Doucette.

Welcome to the Handoff. I have the pleasure of speaking with Dr. Jeff Doucette, SVP and Chief Nursing Officer at Press Ganey. Welcome, Jeff.

Jeff:

Hi, welcome. Thank you for having me.

Dani:

Oh, my pleasure. Hey, I want to get started with centering us back to our purpose as clinicians, nurses, healthcare providers, and we want to keep the patient the forefront and the center of the work that we're doing. Is there a patient experience or story that has had a profound impact on you as a leader or a clinician at the bedside that you could share with our listeners today?

Jeff:

So about three years ago, I had the privilege of leading the nursing team at Thomas Jefferson University Hospital in Philadelphia as their C N O during all of the pandemic. So for the first 18 months. And I received a call from a colleague who I was connected to on LinkedIn who lived and worked in New Jersey, but I had not actually met in person to let me know that her mother who was in an assisted living facility had had a major medical event and was being transferred from a community hospital to Jefferson. It was at the time that we weren't allowing visitors, which I think looking back we can all agree was a big mistake for everybody. And so she reached out to me and asked that we do whatever we can obviously to take care of her mother, which the team did an incredible job and to try to connect her with her mother however we could. So using technology and vending the rules as only nurses can, we ensured that they had time together and were able to see each other. And she sent me a friend request on Facebook, which I usually don't accept from work people because I just, that's my private space. But I accepted it and I'm so glad that I did. So her mother ended up being discharged and lived for another three years

That the family was able to spend with her. And yesterday was her birthday, her first birthday since she had passed away. So her daughter posted this beautiful tribute to her mother on Facebook that I saw before I went to bed last night, and she thanked the team at Jefferson for giving the family three more years with their mother. And so even as a nurse leader, we sometimes don't think that we're making an impact. And really all I did is what any nurse leader would do when a colleague calls and just give people a heads up and let the teams do what they do every day providing incredible care. And it's so meaningful to her that I went back and saw a memory every year for the last three years that on her mom's birthday she's posted some kind of thank you to the team at Jefferson and to me. So those are the things that I try to stay really grounded in my role as the C n O of press skating.

Dani:

Wow. Listening to that story, we can't quantify the impact of some of those interactions that you have, as you mentioned, gave her three years of more experience with her family. And I just think that those interactions and the ways that you allowed for best patient care and the experience through what I would agree, as you said looking back, probably shouldn't have removed the connection of family with patients. I mean, we know that that's so critical to recovery. And so being able to help her through that critical crisis moment, well, you in fact are leading a crisis recovery at a massive scale. So being able to move from macro to micro and still keep grounded in the roots of providing best patient care and remembering those moments, I think is a good call out for all of us healthcare leaders and how those moments of listening and acting in a small way probably created such a massive ripple effect in a positive way. So thank you for sharing.

Jeff:

No, of course. I think the other point I would make in that list that you were making is being present, right? It's really hard for clinicians right now and it's really hard for leaders to be present because there's so much going on around us, but that presence can make such a huge difference at just the right time.

Dani:

You're absolutely right. I think being able to kind of silence all of the things that we're dealing with to focus on some immediate, Hey, this is what I'm going to take care of in the moment, and remembering that's our purpose and why we do the work that we do. So again, thank you for sharing. Now, Jeff, you've had a really fantastic career. Can you share with our listeners a couple of highlights that have helped shaped your career and pivotal moments as they think about their career journey as well?

Jeff:

Yeah, I mean there's just so many. The very first one, you know what? I was a 14 year old candy striper in an emergency department in Virginia way back when we still had to wear those ugly pink outfits and they didn't have any men volunteering or any young men. So one of the volunteer ladies hand sewed me a pink zip up smock that I could wear so I could be a hand striper. And that is so pivotal for me because I really into that role thinking that I wanted to be a physician. And when I started, I got randomly assigned to the emergency department and just immediately fell in love with it. And what I saw was that physicians were leading teams, however, it was really the nurses that were creating meaningful impacts with their patients and really doing the technical work that I really was excited about.

So because of that experience, I decided I didn't even think of nursing as a career choice until then. So I completely changed paths. I became an EMT while I was in high school and then a paramedic while I was in college and worked as an orderly in an emergency department and then started as a new grad. And I think back to, I never wanted to be in nursing leadership. I wanted to be a neonatal nurse practitioner of all things. I had been a flight nurse and I loved doing neonatal flights and just by chance they kept canceling all of my classes for being a cleanse spec and a NNP. And I was like, well, I can only do grad school now. So I transferred to the school business and someone tapped me on the shoulder and said, we want you to be in leadership.

So I think the commonality is to expect the unexpected for sure, and that at every moment that there was a door in front of me, there was a hand reaching through to kind of pull me through. And I try to think about that in every interaction that I have with someone along their career journey. So whether it's someone who's thinking about nursing as a profession or even colleagues that I have that are nearing the end of their career who are thinking about what can I contribute in my performance or post-retirement phase? So I just always try to think of the people who put their hand through the door to pull me through and how I try to do that for as many people as I can. I think the last bit of career advice that I always, always give is that nursing is in a very small circle and everyone knows everyone. And especially as you get into the levels of leadership, the circles get even smaller. So never burn a bridge. Always treat people as if they will be your boss or your employee someday in the future because the likelihood that that will happen is very high

Dani:

Valid point. I have received that advice as well as to never burn bridges because it is a small circle and you run into everyone at the same conferences, different health systems, and ultimately, I think what you're pointing out is we are of a profession that works for a greater good, we have a common purpose and to help each other only advances our profession. Just as you mentioned, the doors open and hands help pull you through. That speaks to the power of community and believing in each other and supporting each other and the fact that nursing career possibilities are endless. And so hearing your story too of you had exposure at so many different levels, not even just as a nurse, but as you moved your career through to nursing, and I'm sure that's extremely valuable to you as a leader, as you led multifaceted teams for health systems and had the frontline experience in that way.

Jeff:

I love what you said about believing in one another because for 30 years now as a nurse, all I keep hearing is, oh, nurses eat. They're young. And I just keep reminding people that nurses are not that tasty, so we need to stop doing that, right? It really is the power of belief in another human being is an incredibly powerful gift that you can give them. And sometimes we just have to tell people and remind them that we believe in them and that when we do that, it can be so empowering to help people through things that we don't even see on the surface of what we experience as colleagues. So I love that sentiment.

Dani:

Absolutely. I mean, nurses could probably, we'd probably taste a little gritty if I'm going to be honest. So let's transition and talk more macro level workforce trends. This has been top of mind for many health systems, particularly post covid and even leading into the pre covid conditions. What are some pertinent trends about the nursing workforce that have arisen over the last three to four years that you could share with our listeners?

Jeff:

So we're very fortunate that at Press Ganey I have access to some of the most robust data sets that exist in healthcare, particularly in the workforce space. So we conduct about 2 million healthcare employee engagement surveys every single year looking at the state of the workforce in healthcare, and then we pulse on top of that in many of these organizations so that we can get snippets of moments in time about how things are going throughout the year. So overall employee engagement in all job sectors in healthcare has been declining since 2019. What has been very encouraging though is in the last 12 months we have seen that employee engagement has stabilized across all job categories in healthcare. So while clinical nursing continues to be on the lower end of the scale, it is good to see that number has stabilized. Now, keeping in mind that 2019, which seems like so far ago, long ago was before any of us had heard of covid. So we were already in decline, and then obviously the pandemic just put a huge strain on the system and really took what were cracks and made canyons

Of what was happening in the work cultures of healthcare organizations. So the organizations that are outperforming all of their peers right now are really taking an employee first approach. So again, as long as I've been a nurse, we've always talked about patients first, but the only way to get out of this hole that we find ourselves in terms of employee work cultures and professional practice environments is really having an employee first approach. So once we're fixing the culture or improving the culture, I should say, I don't know, maybe fix is too strong the word, but that's where we're seeing that the rest of the performance is helping all ships rise across the board.

Dani:

We started our podcast with the patient story, which is it is important, but that is an extremely important call out of supporting your workers or your frontline clinicians. First, do you by chance know particularly what health systems are doing with that employee first approach that is making the impact as you're seeing it stabilize and then start to improve?

Jeff:

Yeah, I think so. There's a couple of things that we talk about in terms of our best practice recommendations, and it really is primarily around selection and the first couple years of employment. So we certainly need to focus on retention of long-term employees, but where most health systems are struggling right now is in that one to two year turnover mark, and it really starts that selection by making sure that you have selected the right people to be on your team. During the pandemic, we got very used to doing 10, 15 minute zoom interviews that were more like, do you have a criminal record? Do you have a license, do you have a pulse? And if the answers were no, yes, yes, then you got to start on Monday. And it was all about how quickly can we get people hired, not necessarily that we were doing the work of selecting the right people.

We actually recommend about a three hour best practice interview right now. So that about 45 minutes is spent with the hiring manager, where the hiring manager is doing the least amount of talking. So the applicant should be talking about 90% of the time, and you should be using a behaviorally based interview guide to really help the hiring manager understand who the person is. We think every clinician especially should have a peer interview, a structured peer interview. So people need to be trained on this by human resources. There needs to be an evaluation process, but we also find that having a peer interview significantly improves the quality of the candidates that you select. And then finally, the last piece of that kind of roughly three hour process is an immersive experience. So we have the applicant show up in whatever they would wear to work. So if it's a nurse unit, they show up in scrubs for the interview, and then we have them do an observation on the unit or units or teams that they're thinking about being a part of.

Because when you're immersed in the team, there's two really critical things that happen. So one, you kind of get to see the person in their natural elements, so it gives you a different take then how they are prepared to answer interview questions. The second is they get to see the work and how it's done, and that interaction with the existing team starts to build sense of belonging. So we understand now that sense of belonging is kind of that key ingredient that drives down turnover at the first and second year mark. So once we've selected the right people, giving them a really good onboarding process and having a continuous listening strategy through the first two years of employment is the critical linchpin that is helping organizations drive down turnover at the one and two year mark. So continuous listening strategies can look a lot of ways.

It can be stay interviews with leaders, it can be constant communication with preceptors and educators who are helping with the onboarding process. It can be pulse surveys that we send to new hires through a course of time. I used to have Java with Jeff, so like coffee with the C N O, because coffee with Jeff just doesn't sound as good. Those kind of things where we're having constant interactions and feedback from new employees, our data suggests that most employees have developed a sense of belonging at the end of their second week of employment, and that sense of belonging is almost fully baked by the end of 90 days. So you basically have about three months to anchor this person in the mission, vision, and values of your organization. And if you haven't done a good job of that early in their employment, they're far less likely to stay.

Dani:

I actually haven't heard of such a comprehensive approach to selecting candidates, and bear in mind I was a nurse manager and then led at different health systems and it was pretty transactional. It was like, all right, we'll give it an hour interview. Does this make sense? If you're putting that energy into the forefront of bringing them in, I suspect you're also putting the energy into creating the experience throughout. And I know first year turnover, pre pandemic was a concern for a lot of health systems and we would constantly monitor that and it's expensive and we worry about longevity of nurses in the workforce as a whole, right? We don't want to lose them from the profession. So what you're describing to me is transformational and something that I wish I would've been doing as a nurse manager to help with that onboarding and that experience from the very beginning because it also is like a partnership.

We're interviewing you, but the candidate has a chance to also experience an interview and determine is this the right fit for me? And I just think that that's so key. Let's talk a little bit more about resilience. So we're talking about the onboarding, selecting the right people, but resilience is a concept that we hear throughout healthcare both in terms of how an employer is responding there own individual resilience, but also there's resilience organizationally and the systems that we create. What are the key subsets of resilience that can be used by a leader to help support the frontline as through their journey and career at the bedside?

Jeff:

So this is my absolutely favorite topic of my least favorite word. So I don't like using the word resilience, and the reason that I don't is that it is, I think overutilized and people really don't understand what it means. Or if you ask 10 people Tell me what you think about resilience, you'll get 10 different answers. I equated to the late nineties, early two thousands in my early nursing leadership career where we were always talking about empowerment. Everyone needed to be empowered, but then you'd ask somebody, well, what does that look like? And they really couldn't tell you. So what I like to do is talk about resilience and the two subscales that make up what we call resilience and how we measure it at Press Ganey and overall employee engagement has stabilized across all job categories in healthcare. And the main driver of that is that we've this year seen a slight improvement in resilience scores across the board in all job categories with nursing actually moving up pretty significantly and nursing support staff being at the top of the scale right now.

So it's really encouraging to see that. So the way that we measure resilience and we define resilience as our ability to respond to change, and we know that that change in nursing is on a scale. So you change the coffee in the break room and that is ruining my day is one end of the spectrum to here's a global pandemic, see what you can do with it other end of the spectrum, and everybody responds differently on that scale. So that's how we think about resilience. So the two subscales that make up resilience are called activation and decompression. Think of activation as your why. So part of your activation is intrinsic, right? Why you and I became nurses, why we chose the organization that we do work for, those types of things. Then there's an extrinsic component of activation, which is really related to your connection to the mission, vision and values of the organization in which you work.

And there are some key drivers of activation and things that leaders can do to drive up activation really around how we keep people connected to the core work and mission of what we do. So that's one side of the equation. The other half of resilience is what we call decompression, and that's how we get away from the work and recharge our batteries. What we are seeing right now is that probably the single most critical issue that nurse leaders need to be at paying attention to, not only for themselves but also for frontline clinicians, is this concept of decompression where clinicians and leaders are not able to fully disconnect from the work to recharge their batteries. They are not doing well if there's nothing else that people focus on. This ability for people to be completely disconnected from the work is critically important in addition to being disconnected from the work, thinking about how we make a decent or good shift great while people are at work also contributes to decompression.

So as an example, the current data in press ganeys National Database of Nursing Quality Indicators or N D N Q I shows that less than 30% of clinical nurses have taken one uninterrupted 30 minute break. In the last seven shifts, they worked less than 30% have had one 30 minute uninterrupted break in the last seven shifts they worked. So as leaders, we can ensure that people are getting breaks that are uninterrupted, that they are having time to get away from the work while they're at work. We're actually getting ready to launch a pilot study on November 1st with a couple organizations where we're going to be test piloting a concept of a decompression huddle an hour before the shift ends because we know that if we can change people's thinking from negative to positive at the end of the shift, we can alter the body's chemical response to stress. And in a small little test of change that we did, we saw that nurses were leaving the shift feeling better by participating in a decompression huddle. We're doing a pilot research study now to prove this out. So those are the two big components that make up resilience, and there's lots to unpack of course, in the best practices around that, but people getting away from the work and recharging is more important now than it's ever been before.

Dani:

I haven't heard it described that way in terms of activation and then decompression. And I do think a lot of focus is around the activation piece. Are you connected to the mission, vision and values of our organization? How can we inspire you to do the work? But then it lends itself to the decompression of getting your breaks and time away, and particularly over the last three years with the staffing crunch and the crisis of such huge patient volumes and then lack of supply of nurses, I think that exacerbated that. So I'm excited to hear about this pilot that you're leading, what the outcomes are and how that can be translated to tangible strategies for frontline managers to lead that. Those are micro shifts that could probably make a really great impact versus sometimes we think about wow decompression. It could be so macro and do I have to give them two weeks off? Or what does this mean? How can I help this? And how can we get that for our frontline managers who run 24 7 too?

Jeff:

Well, I'll say about, and the nurse manager role is something that I've talked a lot about. I think I wrote my first editorial about we've got to change the role of the nurse manager like seven or eight years ago, and Jonah 24 7 accountability I hope is becoming a thing of the past because it is single-handedly killing our nurse managers from the inside out. Really literally and figuratively, like rethinking ways to reform the nurse manager role is I think also going to be critical to how we move the entire workforce forward because such a key linchpin.

Dani:

I would agree. Which brings me to my next question, the nurse manager role, and it is a nice dovetail. They're crucial to the success of a health system. They truly are. And what's the impact of an engaged nurse leader and the outcomes that they have when they are engaged for a health system?

Jeff:

So we are very fortunate to have a full-time nurse scientist on our team, Dr. Nora Walorski and Dr. Wakowski has spent the majority of her career researching nursing leadership, and now she's at Ganey using all of our data to help us make connections for non-nursing leaders about the intersection of quality, safety, reliability, and service, and how the nurse manager is really the linchpin of where everything comes together in execution, especially for hospitalized patients. So we just published some data where we took all of our nursing engagement data, so we were able to look at a cut of nurse managers and their level of engagement. Then we took the units that those nurse managers lead and we took their data from N D N Q I at the unit level, and we were able to do an analysis of the level of engagement of the nurse manager and compare that to the outcomes data for nurse sensitive indicators.

And it will be of no surprise to anyone listening to this podcast that the higher the level of engagement of the nurse manager, the better the performance was on nurse sensitive indicators across the board and the higher levels of engagement there was for all employees that reported to that nurse manager. So having a highly engaged nurse manager is critically important to the overall success of the outcomes, and it translates across the board even in terms of financial outcomes. So what we saw in our analysis was that when the nurse manager is highly engaged, all ships rise in terms of performance. They tend to have lower turnover, higher retention, better cost of care, lower complications, and again, our data clearly showed that the nurse sensitive indicators that we measure in N D N Q I were significantly better when the nurse manager was highly engaged.

Dani:

Wow. I love what I'm hearing too is the access to data that you have to help bring insights to our profession is just paramount. It's so critical. I would agree with you. I think the nurse manager role is so pivotal to transformation in health systems and part of my passion after I became a nurse manager, I was like, whoa, this is insane. The 24 7, the scope and then the demand on staffing and scheduling. And so I became passionate around how can we create automated systems, do predictive scheduling, really augment the work of a nurse manager who spends so much time around staffing and scheduling, and it's kind of a lose situation because it's tough to make these manual decisions when you're leading such large teams in very complex situations with what patients need and the skillset of a nurse and matching those. So as we're listening, I'm sure many are like, what is the best practices around supporting frontline managers to create that engagement? What should we be thinking about to help transform that role?

Jeff:

Much like we were talking about frontline clinical nurses, decompression among leaders is critically important. So what we're seeing in the data sets are that leaders are about a year behind where clinical nurses are. So about a year ago, clinical nurses in terms of all of our data sets around engagement, were at their lowest point and now are on the upswing for nurse leaders. They're now kind of at their lowest point starting to come out just a little bit, but so they're about a year behind where clinical nurses are. So this decompression component, particularly for nurse leaders is very, very, very critical. So we're working with a lot of organizations who are doing things like having their nurse managers work a four day work week and not four days in the hospital and then a day at home on Zoom calls all day. It's literally a day off during the week so that you can decompress and do life, right?

I'll never forget when I first became a nurse manager, I was really concerned about going from hourly to salary. I could work as much as I wanted to make as much money. And at the time, particularly nurse managers were not well paid as they are not well paid now. So one of the selling points was always like, well, you're salaried now so you can go to the doctor and the dentist and the dry cleaner whenever you want. What they don't tell you is you can never get away from the hospital Monday through Friday. And even a lot of nurse managers are expected to be the on-call staffing person on the weekends. So that kind of stuff has to stop. So organizations that are moving to a four day workweek have seen anywhere between 20 and 30% increase in productivity from their managers and increased performance.

So I think that the concern is, well, they're not going to be here a day of the week, so how's the work going to get done? Well, a lot of the work that nurse managers are doing is not value added. They're in meetings that they don't need to be in. They're spending all this time doing paperwork and clerical things that they don't need to be doing. Staffing is a perfect example. Your company, other companies have developed technology to try to help automate some of that work. So when we can give nurse managers the time to lead, they do really, really well. I think just kind of thinking about the workload, that 24 7 accountability and I think span of control is a huge issue for nurse managers. So you look in most healthcare organizations outside of nursing and you find department directors that have spans the control of 30 to 50 FTEs at the director level, you look at a nurse manager, the average nurse manager has about 75 FTEs and upwards. I had an operating room one time when I started as the C N O that the nurse manager with just two clinical supervisors had 220 FTEs. It's just not manageable. And so we have to think about the role differently and really redefine the work, but I think decompression, again, continues to be a really important aspect of this work.

Dani:

I'm glad you mentioned the four day workweek. I've heard of health systems doing that, and even as we just started this podcast off about how to bring the workforce in, how to help train them and give them the experience that is so foundational to how we should be leading, but oftentimes we prioritize what makes the most sense and what's going to make things run staffing or pay or whatever it is. So being able to kind of flip the script and think differently around the nurse leader role is crucial, and I am just so thankful, Jeff, that you and your team are bringing that to light and pushing forward in that transformational space. Jeff, this has been a wonderful conversation. I would love to know where our listeners could find you and have a conversation or reach out to you or your team.

Jeff:

Yeah, so thank you again for having me. This has been a great conversation and I hope your listeners find it helpful. So the easiest place to find me is on LinkedIn because we post a lot of great information there through my site on LinkedIn. Folks can also email me and my email's really easy. It's jeff.doucette@pressganey.com. So would love to hear from folks.

Dani:

Wonderful. Well, Jeff, what would you like to hand off to our listeners today? As a final piece of advice or wisdom?

Jeff:

We as nurses understand that our impact goes well beyond what is happening right in front of us in the moment. And we cannot forget that. We cannot forget that the opening story that I told that years later, what is a simple phone call to us? Or just making sure that what our people do every day is going off without a hitch can have lasting impacts to people. I always think about that famous quote that says, people may not remember your name, but they'll always remember how you made them feel. That is the impact that we have. And regardless of how things may look and feel today in this kind of still coming out of this pandemic reality, every single nurse at every single level has the ability as the most trusted profession in the world to make that difference. So don't ever forget that when you're mired down in the day-to-day activities that could really have you rethinking whether you did the right thing or not, we're making an impact, and the more that we can have a collective voice moving forward, the bigger the impact will be.

Dani:

Thank you, Jeff. I couldn't agree more, and I love your passion for our profession. The way that you and Press Ganey and others, you're paving the way for transformation and that the call is deeper than transactional. It's a transformational change for healthcare leaders in general and the frontline clinicians and our patients. So great impact. Thank you so much for what you shared today, and I look forward to some of these pilot studies that you're doing and more data to come.

Jeff:

Again, thank you so much for having me. I've really enjoyed the conversation.

Dani:

My pleasure.