Dan:
Mike, welcome to the program.

Mike:
Yeah, thanks Dan. Thanks for having me.

Dan:
So Mike, you've done a lot in nursing. Everything from candy striper all the way up to nurse exec, and now leading an academic program. Tell us a little bit about your journey.

Mike:
It started off as a candy striper. I was always interested in helping people, kind of the fast-paced emergency medicine and I started as a member of the first aid simulation team in high school and I really got intrigued by it. Then my family doctor actually got me an appointment with the chief nurse at our local hospital. I shadowed for a little bit and then became a candy striper. Then from there, just went on and after my bachelor's degree, debated, "Now what?" And thought about med school and it just wasn't what I wanted to do. It wasn't a life I wanted to lead, so I went directly from my bachelor's program to my master's program to my DNS, which I would not advise going straight through with no breaks, but my wife was quite supportive.

Mike:
I did that and was lucky to land in several good places. I spent 20 years at the University of Rochester where I learned a ton and that's really what launched my career. Prior to that, I was in Buffalo. I spent 10 years at the University of Buffalo and also practicing at VA. So just I've had a ton of different opportunities. At one point, I thought I wanted to be a chief nursing officer and that kind of changed when the healthcare system started to change about five to six years ago. So now I'm in academia and loving it at The Ohio state University.

Dan:
Awesome. So you've had a lot of different perspectives of the healthcare system. How have you seen burnout evolve over those experiences?

Mike:
I think back and in my career, I started in the ICU and we didn't talk about burnout. We didn't talk about burnout in school. I didn't talk about burnout in grad school. I Didn't talk about burnout in my doctorate program. It hasn't been until this really, this most recent decade that burnout's become a topic, if you will. In fact, I went to the literature and I did a search of pub med and I looked at the decade from 1980 to 1990 and there were approximately 900 citations. I just use one search term, burnout. I did that for 2010 to 2019 and I got something like 6,000 or 6,500 hits of citations. So it's become more prevalent and I can't help but think that this whole burnout thing has evolved because the health system has become less friendly to work in from a provider perspective.

Mike:
I think what's happened and there's this concept of emotional labor and this emotional labor says that when you enter a profession, whatever it is, you have a certain value system that you think you want to uphold and the organization that you work for does not have that same value system. So there's a dissonance between value systems. I think with the advent of the EMR, with the advent of the patient experience where the patient is always right, actually the original emotional labor literature was done, flight attendants. If you think about flight attendants from 20 years ago, they always smiled.

Mike:
They always gave that guy in the second row his fifth drink, even though they knew he was hammered and it was okay and they just smiled and that disconnect between what their value system was and what the organization expected and I see the same thing happening in our healthcare system today. I don't think the acuity's necessarily higher, we could argue about that, but case mix index hasn't really gone up that much. So I think it's got nothing to do with the people. It's got everything to do with the system and the system has just become extremely complex and not user friendly for the end user, whether it be a nurse, a physician, a tech, whoever.

Dan:
I think Marilyn Chow from Kaiser Permanente did a study a number of years ago looking at the work of nurses and 36% of their work was finding equipment, finding people, finding stuff, coordinating different aspects that were just like non-value-added care. I think that's gotten worse. So nurses are running around trying to find stuff rather than interacting with their patients. They're either dealing with the electronic medical record or all the complexities of care and like you said, it's not what they signed up to do. They didn't want to be data entry clerks and a lot of their work and physician's work has been a lot around data entry.

Mike:
That really has come out in the literature. Dr Shanafelt who was at Mayo and now I believe he's at ... I think he's at Stanford now. He's published a ton on this and the effect of the EMR on physicians and the same is true for nurses. When I practice at the bedside and I watch what those, well I watch what I do and then I watch what those nurses do and they just ... their focus is not on the patient. They're focus is on the electronics and like you said, trying to find stuff. The system just doesn't work for them.

Dan:
From your position in academia now, what have you seen in the discussion from academics around this, not necessarily the research side, but is there burnout discussions for students in undergraduate, graduate nursing students or even in our master's in healthcare innovation students? How is that discussion starting to change over time?

Mike:
I think that we do see it in students, and I'm not sure about our MHI students. I think, very proud of our MHA students. It's a different breed. But what's interesting is I teach a design course with one of the faculty from design in our design department. He had his student group do a project on stress, burnout, resiliency on campus. The feedback they got from students was, it's not the amount of work, but it's that the faculty don't seem to coordinate the work. So we've got midterm exam week and oh by the way, that's the highest rate of students taking their own life. We've got exam week.

Mike:
So there's these busy weeks throughout the semester that the students' feedback to us was, "Why don't you guys get together and distribute the work over the semester and make it a little more student-centric? Why does there he need to be a midterm exam for every class?" So what the students were looking for is a little more deliberate approach to reduce their stress. I don't think the students are coming in any less resilient. Again, we shouldn't be at the individuals. We should be looking at the systems that they come into. I don't want to minimize ... there certainly are significant behavioral health issues in this country and in college students. I don't want to minimize that, but I do think we could do a better job of reducing that stress with some pretty simple fixes.

Dan:
There's definitely a better way to do academia for sure and we're seeing it. I just led a webinar today for AACN about how do you take your in-person class online quickly and kind of hack that together. I think we're going to be challenging some of those traditions and we need to, because learning science has changed and it's similar to like what we do in the hospital with annual evaluations. A midterm doesn't really tell you anything other than they know the content for that week.

Mike:
That's a whole other podcast about disruption in academia. Interesting story, I was watching CNN and John Berman and they were talking about how colleges are going to online learning and he made a comment about, "Boy, what would you think if you were somebody's paying $70,000 and you had to take your ... everything online now." So right away he tweeted that or he said that online. So I got online, I tweeted back to him and I said, "John, just so you know, there are a lot of people in this country that do a very good job of online teaching and I work for one place that's the best." He actually got back to me and he said, "I know you guys do amazing work. I apologize if this offended anybody. I was just commenting on if you go into a program expecting a brick and mortar face-to-face with faculty and then you don't have it, what does that mean?" So anyways, it's a interesting time.

Dan:
The Ohio State has a lot of initiative around both healthy nursing but healthy college in general. Can you talk a little bit about what Ohio State's doing as far as being the healthiest university on the planet and how that is trickling down to the healthcare professions?

Mike:
Our boss here and my boss, Dan, when you work at Ohio State, Dr. Bern Melnyk was the first chief wellness officer for an academic institution in the country. She brought to that position a lot of energy and innovation around health and wellness. She's been able to really infuse and change the DNA on campus around health and wellness and it's actually starting to show. She shared some data that they collected around claims, insurance claims, disability, days out of work and stuff like that. She's starting to move the needle. Well, it's not just her, she's got a big team dedicated to this, but it starts at the top and she's got organizational commitment to this wellness initiative. It trickles all the way down to the point where at our meetings we practice act of applause. So when a speaker comes up, we stand up and give them a standing ovation.

Mike:
When they're done that, we give them a standing ovation. So we're always moving. She sent emails out to us Friday afternoon that says, "Let's take a break off of email. No emails between five o'clock on Friday and eight o'clock Monday morning," and it works. It absolutely works. So I think we are starting to see the needle move, but it's been a team effort. Like I said, she's got a lot of great people around her helping her with that and we have a program in the college called Live Well. It's an acronym for a bunch of things, but the bottom line is every faculty member is to integrate Live Well into each of our courses so that students understand that it's important to take care of themselves as well as do a good job in their courses.

Dan:
That's great. She had another program called Health Athlete, which turned into Nurse Athlete, which I was a trainer for, for a little while. I know she was doing some research on nurses at OSU Wexner Medical Center and measuring cortisol levels and things. I have to get the results for that, but definitely embedding wellness into the front lines as well.

Mike:
Yeah, it's definitely part of Ohio State's DNA.

Dan:
Yeah, I love that. Switching gears a little bit, Ohio has a bill moving through the state legislature that's aimed at curbing nurse burnout by ending mandatory overtime. You were a chief nurse for a while. What's your take on this?

Mike:
That's a loaded question, a very, very loaded question. If you want me to answer it from the chief nurse perspective, staffing is really complicated. Depending on your culture around leave use, sick time and how you manage performance around time and attendance, it can be really challenging. One of the institutions I worked at, it was an organized hospital and I think the view there was that sick days were considered benefit days. If it's Friday night and you're supposed to have four nurses on a 32-bed unit and three of them call in sick and your float pool is basically down to nothing, what are you supposed to do?

Mike:
Is it healthy? No, it's not healthy. But from the organization's perspective, you got to take care of the patients. So it's really complicated, Dan, because I can hear the nurses listening to this saying, "Well, you're just full of crap because blah, blah blah," and I get that. I get that. We know from the literature that after a certain number of hours nurses aren't on their game and we know that, so it's really complicated. I can say that the way to fix that is to fix the culture. When I was in Rochester, we had a different mindset around staffing and it was kind of like each unit self staffed.

Mike:
So if one of your staff called in sick, you had to staff it from your own pool of people. We didn't have a float pool because we felt that the float pool kind of enables time and attendance issues and we didn't have the ... I mean, we had issues. Of course, we did, but not the way I've seen it elsewhere. Mandatory overtime, it's a tough thing and you got to staff, but we know that it's that good. It will, with too many hours, lead to fatigue and that leads to burnout and depression. So we know that that happens. I will say that we've done some work with hospitals in the Netherlands and overtime for nurses is illegal. Nurses can't work overtime. Could we do that? I don't know, but this, I think, gets at your gig labor force, man. That's right up your alley.

Dan:
Right. Well that's, yeah. I think mandatory overtime is a symptom of the system problem, right?

Mike:
Yeah.

Dan:
So it's less about just ending mandatory overtime and really doing overhauls of how we think about staffing and flexible versus permanent labor and do hospitals need to hire 150 nurses onto a med surge unit so they have a pool to call from or is it better to have a more flexible on demand? I think those are all the debates that are still out there, but I'm hoping that there's opportunities to innovate there because it's not a simple solution. For managers and leaders out there listening, what advice would you have to them to first think about burnout and take a different thought process around it and how would they start addressing it in your mind?

Mike:
So they have to have gas, and gas is, they got to give a shit. All right. You have to establish relationships with your staff. You have to spend time getting to know your staff. I think the best managers that I've ever worked with knew their staff, their staff would go the extra mile for them. They would die on the sword for them because they knew they cared. I think new managers, I've hired numerous managers. I've been a new manager. No one says to you, when you get a new manager job, "You should spend the first 30 to 60 days just developing relationships." What we do is we say, "Okay, here's your ledgers. All right. Here's your power levels. Here's your staffing plan. Here's your man hours per patient day. Here's your this, here's your that." we give them all the things to manage, but we don't give them any tools to lead.

Mike:
Anybody can learn a ledger. Anybody figure out power levels, but it takes a very special person to lead. The key to leadership is relationships. So I think from what I've seen and what the literature shows, is those managers that have gas, they're the ones that see less turnover in their staff, which means there's less burnout. They're the ones that see greater engagement of their staff. They're the ones that put out a call for somebody to come in and work an extra shift and you got five volunteers because they want to work for you.

Mike:
So I think it starts with relationships. Then there's this concept called managerial courage and your staff need to know that you have the courage to speak up for them. I've seen so often that there's a filter between the manager and the director because you don't want to send anything up that's going to make you potentially look bad. Those managers that have courage to bring those things forward are the ones that the staff say, "That's somebody I want to work for." By creating this culture, this healthy work environment, I think it just leads to a lot less burnout and the need for resiliency because it's a good place to work.

Dan:
In my PhD program, I published a paper on transactional versus transformational leadership and its effect on burnout and you're exactly right. It's the people that build relationships that can speak up, that do all those transformational leadership things. They have better patient outcomes, they have better staff retention, they have people that will show up, they have less staffing issues. But if you go into it as these are numbers and these are just check boxes that I got to do and budgets I've got to fill out, you lose people really quickly, especially with millennials coming in, wanting to align their work with a mission, a bigger purpose. If you don't create a bigger purpose, they're out the door in the first year, so-

Mike:
Absolutely.

Dan:
There's definitely opportunity there.

Mike:
Millennials will talk with their feet.

Dan:
Yep.

Mike:
When I was teaching undergrads, I was doing a leadership class with the seniors and they were like, "Dr. Ackerman, is it bad to have three jobs on your resume in the first five years?" And I'm like, "That's what they called us when I was a boy. Not today. You want to work in a place that is a good fit for you." So I use my daughter as an example. She's not a nurse, but after just graduated from college, she went to Europe to live. She's had three jobs in the first five years since she's been there because she's just looking for the right fit and now she found it. So that leader is so critical to this whole thing.

Dan:
For me, even new grads that are listening too, vote with your feet too. Don't be forced into going into a specialty that you're not passionate about. Wait and be patient and find that role. I started in the ER. If I had started any other specialty in the whole hospital, I would have burned out really quickly. So it's really about finding what you want out of your role and going and getting it and ask forgiveness instead of ask permission for a lot of cases. So, we're in the midst of the coronavirus outbreak and crisis. What effect do you think that's going to have on burnout?

Dan:
I think we're seeing two different things. One, people are really rallying nurses, working extra, putting up with poor conditions. We see the craziness that happened in China and Italy, but it seems like healthcare professionals while burning out, are still feeling like they're doing something. then on the other hand, there's lack of PPE. There's all kinds of crazy working conditions that could also potentially accelerate some of the burnout issues. What are your thoughts on what's going to come out of this?

Mike:
I think a lot of it is going to depend on how long this goes on. So I think if there's a light at the end of the tunnel, I think nurses, physicians, we do rally. I've seen this firsthand, I spent four years in senior roles working in Buffalo. The last snow storm we had in Buffalo, we got eight feet of snow in two days, eight feet in two days and you try to stay off a hospital when you get eight feet of snow in two days. I can tell you, I wish I could have bottled the teamwork and commitment of the staff that were working for those seven days that ... because we had a hotel that was connected to the hospital.

Mike:
We lived in the hotel for five days. I was the administrator on call when this whole thing started. I basically lived there for five days and the spirit of cooperation and, "Hey, we can get through this," was amazing. A week later it was like, "What happened?" Because he got back to the same old, same old. So I think, I have no idea, but I think that's just what we do. We'll rally, but there's a limit of what you can ask people to do. So I think the longer this goes, you're going to see people just get their wits end, especially if they don't get the support that they need. I can deal with the hand gel thing and I actually posted this-

Dan:
Soap and water, people.

Mike:
What happened to soap and water? Just cause you don't have hand gel it doesn't mean it's the end of the world. Now PPE and masks and stuff, that's another story. But if you don't have a mask, you don't have PPE and then, God forbid, you go home and you get sick and you pass it on to somebody else, it's ... and your family. So I think, Dan, it's going to really be how long this goes on and the response that we get from the federal government and then the state agencies. I think we're good if it's short-lived and by all accounts, China was able to close all their temporary hospitals.

Mike:
They've leveled off after three months, four months. So hopefully, we see the same thing. I think we will get through that because that's just what we do. We band together and we get through it. But I think the longer it goes, I think you're going to see people really just ... it's hard. It's hard work. You don't know. You don't have what you need. The trash doesn't get picked up. The deliveries don't come in. It's difficult. So I'm hopeful that we'll get through this and people will number one, be better off for it because they feel like they contributed to something that was really a huge big deal for our country. But I just hope it's over quick.

Dan:
Definitely agree with that. I think the other thing is we need to learn from what's going on now and not just go back to the same old, same old and actually use this push, this kick in the pants to adapt practices across the health system from academia and teaching to staffing to how we treat our clinicians and patients. so I think the worst thing we could do is just go back to pre-COVID same old, same old and actually learn and iterate and actually build on this.

Mike:
What's interesting is for all the doubters of remote working, the remote workforce, I think this is going to demonstrate, for the most part, that yeah, you can do it and you can still be productive and if you trust your employees, they'll come through for you. So, and the same with online learning. I think there's some things that shouldn't be online, but I think for the most part, I agree with you. I think we should learn from that and say, "Okay, this did work and how could we make it better?" Interesting times.

Dan:
So we like to end the show with one question, like with that pearl that you can leave the audience with. So what do you want to hand off to our listeners about burnout?

Mike:
This is not popular amongst many people, but I think it's very true. When we use the word burnout, I think it basically blames the victim. When we use the word resilience, we say, "Just suck it up and deal with it." I think we need to stop focusing on the individual and really start focusing on the system. For instance, with asbestos. Asbestos was an industrial hazard, right? People that worked in this asbestos and it wasn't known and the same is true for some of our working conditions that we have now in healthcare, whether it be the EMR, lack of support, supplies, non-tasks that we have to do. So when asbestos was discovered and we know what healthy workplace looks like, so with this best is we didn't say to the workers, "Here. Wear these masks so you can be more resilient to asbestos."

Mike:
We got rid of this asbestos. So let's get rid of the stress, what is causing the burnout in our healthcare systems and I think we'll be at a better place. So let's stop focusing on the individual and I'll all about self-help and meditation and essential oils and all that stuff. We have to be healthy. We got to diet, exercise, we have to be healthy. But with this problem, it's a systems issue. It's like you line up 10 people in a row, you hit them all over the head with a hammer, one person falls down. Our first question is, "What's wrong with that person?" Instead of, "Why are we swinging a hammer?" I think we have to start asking, Why are we swinging a hammer?"

Dan:
That's a great point to end on. Mike, really appreciate all the insight on burnout, COVID-19, leadership and just thanks for being on the show today. Where can we find more information about MHI and where can people connect with you if they have more questions?

Mike:
Well, I'm on LinkedIn. That's probably the best place. Connect with me on LinkedIn. I'm on Twitter @MHAckerman and MHI, you can just go to The Ohio State College of Nursing website and just Google OSU MHI and you'll find us. It's a wonderful program.

Dan:
Yeah, it definitely is, and I say that being faculty and working with you, Mike, it's been a pleasure. Thanks for being on the show and we'll get all those links to the listeners in the show notes. We'll see you next time on The Handoff.

Mike:
Thanks, Dan. It was great. Good luck to you.

Dan:
Thank you so much for tuning in to The Handoff. If you like what you heard today, please consider writing us a review on iTunes or wherever you listen to podcasts. This is Dr. Nurse Dan. See you next time.