Dan:

Natalia, welcome to the show.

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Natalia:

Thank you so much.

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Dan:

So New York has obviously been in the center of everything, from the very first spike to multiple spikes after, and now sort of coming out of the pandemic. As we look to the next 12 months, what's top of mind for you?

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Natalia:

Top of mind for me right now is really to ensure that we are bolstering the nursing workforce. As you know, there's a national shortage of nurses so we're really looking at our workforce in terms of recruitment and retention. Looking at our specialty areas, particularly the operating rooms, the emergency department rooms, where it's typically harder to recruit new graduate nurses and what that means in terms of supporting these areas right now. And training programs so that we may possibly put in new graduates into these spaces, but still providing them with the support they need to be successful. So I think right now we're just really pursuing numerous initiatives to really reinforce and to support our nursing workforce, to ensure that these recruitment programs are encouraging new people to pursue nursing as a career. Thinking about junior high schools and high schools and working with the Department of Education to really inspire young people to become nurses, really starting earlier than usual. So again, not thinking about high school, but thinking about junior high school and how can we inspire individuals to become nurses? We're really tackling this from many different angles, and partnering with educational programs to create pipelines so that these younger generations can really afford to go to school.

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Natalia:

To afford to go to academic programs, whether it's associate degrees or baccalaureate programs here in New York city to become nurses and hopefully work for New York city Health + Hospitals. So I think top of mind is just recruitment and how do we strengthen the nursing workforce long-term?

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Dan:

No, I love that. I mean, I'm a product of new grad in the ER and I never left that specialty. When I started at UCLA, I got into the ER. I think if I would have worked anywhere else, I may have not stayed in the profession as long. Just, the ER was my calling. I hear that from so many other new grads now, "I just want to go work in the NICU" or "I just want to go be an OR nurse." There's not as many as you would think pipelines into those as direct entry from school. I love that you're focused on that because I think the next generation doesn't want to wait and necessarily pay the dues that are arbitrarily set for them. They want to jump into the things they're passionate about and when they do, they give you their full selves. They're so excited to be part of something that they didn't think was possible.

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Natalia:

I agree 100%.

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Dan:

So how are you seeing the pipeline of candidates and nursing schools? I've talked to a lot of educators recently about, what's the enrollment like and how are graduation rates? That kind of stuff. It varied depending on where you are in the country. So how is New York as far as enrollment in nursing school and the pipeline of great candidates coming out of the different schools?

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Natalia:

I'm very impressed. Most recently I visited Queens Plaza College, which is a site that we often recruit nurses from, or just ensure that we have strong partnerships for clinical placement. The new graduates there are really excited and scared at the same time. They've had to do a lot more simulation than most classes because of the pandemic, so they're scared in that regard. But I'm really impressed with the academic settings in terms of the simulation programs that they've put together, to really ensure that the nurses are getting the best clinical experience they possibly can despite the fact that the options were so limited during the academic program. So I think that we're seeing a lot more interest in nursing programs. The graduates are doing well, but there are some schools that are also struggling with passing the boards because of that limitation in terms of clinical placement, unfortunately.

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Dan:

Yeah. That's definitely a variable that I've heard across the country, where clinical placement sort of shut down. They had to move to almost full simulation, virtual standardized patients. And then the culture shock of mannequin-based training, which I'm a huge fan of and started my nursing career with building the Arizona State Simulation Center. But it's not everything. You need to be able to get in and be in the environment to understand what's going on. And they're still into this almost post-pandemic state, where there's still a lot of chaos, staffing issues. There's still really sick patients, there's high acuity and that kind of stuff. If you haven't been in a hospital for a year and a half, it's hard to get up to speed really quickly.

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Natalia:

Exactly.

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Dan:

So what are some of the lessons that you're not going back to? That's something that I'm really passionate about. I was just speaking at the Nursing Workforce Center's conference a couple of days ago. I kept hearing people say, "Well, we just need to get back. We need to get back to pre-pandemic." The question for you is, what are you not going back to?

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Natalia:

I think we're not going back to everything in person. For a system as large as ours, the largest municipal system in the United States, hybrid works really well for us, in terms of the utilization of WebEx or Microsoft Teams and in person. So I think that's one aspect that we will hold onto, because our ability to have nurses participate in large numbers is just astronomical. It's just amazing how many nurses were able to engage with our programs across our 11 acute care hospitals, our five nursing homes, the nurses in all New York city jails, the nurses in the community. So we definitely want to ensure that we keep a hybrid model. The other thing that we're not going to let go of is just the fact that we now really think of technology when we're hiring nurse educators or corporate officers in terms of nursing leaders, making sure that they have the ability to really navigate technology. We're rolling out so many amazing things. We most recently rolled out a new EMR system across our system. Right now we're rolling out a new scheduling system. We're rolling out a new payroll system. We're rolling out a new medication administration system. All of this is technology. I think the one lesson from the pandemic was that in person or paper is really just not the way to go anymore.

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Natalia:

So when we had to onboard 5,000 nurses during wave one ... actually 5,100, when we had to onboard over 1,000 nurses for the following wave, when we had to work with the Department of Defense, we had to really pivot to online. And ensuring that nurse educators have that as a skill, I think was something that we didn't think about. So one thing that I'm really challenging all of the universities we work with, is ensuring that technology is really a competency that leaders and educators are graduating with. When the pandemic hit, we had to create COVID-19 training online and over 10,000 nurses have completed that training. We had to onboard and train the Department of Defense, right? Because of the social distancing aspect of COVID, we cannot have 30 people in a room. So despite the pandemic, even though social distancing is not as tight as it was before, I think the fact that we're able to send, whether it's competencies electronically or ensure that things are completed in an electronic manner, we're not going to let go of that. I was really blown away by our physician partners during the pandemic because they had electronic forms ready to go for the physicians that came in to volunteer. We had to really create that for nursing because we were so accustomed to orientation in person.

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Natalia:

I think what this pandemic has done is really challenged us to work closely with nursing informatics teams. So nurse informaticists right now, to me, I just see them in an entirely different light in terms of their importance. One thing I want to do is really break the silos of advanced practice nurses, not just from a clinical perspective but also from an administrative perspective. So having the educators, the informaticists, all really thinking about, how do we educate our nurses in different ways to really be innovative? I think we use the word innovation but we don't really think about innovating futuristically. So that's what we're really working on right now at Health + Hospitals, is thinking about the future and thinking about automation and thinking about AI from a nursing perspective.

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Dan:

Yeah. I think those, you're right on track with all of that. It's something I've been trying to push the industry forward on as well. Which is, we've done things this certain way for such a long time with poster boards for annual education days and in person orientation. I mean, I remember when I was the director of nursing education at Ohio State University Medical Center. Orientation before I got there was 14 days long of in-person, eight-hour day lecture. Now it's like, you can't do this. You're costing the system ... Every class that came through, you're costing the system up to two to $3 million in just orientation time. There's an opportunity for us to learn better, meet people where they're at, look at competencies, not throw everyone through the same thing. I think using tech to do that is great. Then on the workforce side, like you mentioned, augmenting nursing practice with technology, with virtual care, with online trainings that help them skill up quickly and faster than they had to. Allow the night shift to go to sleep and do an online program. Don't make them stay for another 12 hours after their shift kind of thing. There's just all these awesome opportunities for us to just make life better for our clinicians using technology.

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Dan:

I think the hospital systems and the schools that double down and build that as a core competency, are going to be the ones that really thrive post-pandemic.

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Natalia:

I agree.

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Dan:

What are some of the things you're going to keep? Lessons learned that came out of the pandemic, that you really want to keep that practice that wasn't so disruptive from the chaos of COVID 19.

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Natalia:

So looking back, we have the Nurse Residency Program, which many health systems have. I made the decision during the pandemic to not stop the Nurse Residency Program, which is where one day out of the month, of the 13 shifts of every nurse ... a new nurse, that is, a new graduate nurse or new to the specialty, they have protected time to really learn the skills they need to become great nurses on the floors. So within that program we decided to create a reflective part of practice. I think we're not going to take away the ability for nurses to really provide feedback on what they're going through and reflecting on their days. So within the Clinical Ladder Program, we embedded a reflective essay and reflection as part of the program, that also stems from the Nurse Residency Program. I think having the nurses express what they're feeling, what they're going through, needs to become the norm. Most recently I had the honor of listening to Patricia Benner talk about novice to expert, as many nurses have heard. But what was poignant during this talk was the fact that she talked about the power of the narrative essay and just the narration of a nurse's story.

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Natalia:

I think we're doing more of that post-pandemic, just having the nurses really tell us what they're going through, what their fears are, and building upon that, to really create the infrastructure around mental health support of our new nurses. Of all nurses, actually. So I think reflection is really important at all times for nurses, because we deal with death and dying. We deal with the good and the bad of individual's lives, so we have to really create mechanisms for nurses to always have that opportunity to share what they're feeling so that they can really bring their most present selves to work. That's something we're definitely not going to let go of.

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Dan:

Yeah. I think that's a great thing not to let go of, that reflection piece. I was just speaking with another colleague around the mental health of nurses and some data that came out recently. One of the things that we were chatting about was that as a whole, we don't do a great enough job of embedding some of these practices into the workday. We allow people to come do their shift and then they go home and then they have to deal with the trauma or the bad day or the death, or whatever. We don't have stuff embedded in the shift necessarily to help support it. So I think practices like reflection, group discussion, trauma-informed care, those type of things allow for those emotions and those feelings to be processed, and not just leave it on the nurse to go figure out how they're going to cope in ways when they get home and are off shift. So I love that practice. What kind of feedback are you getting from that? I mean, sometimes I think your nurses are like, oh, I got to do a reflection. This is the worst thing. What am I doing here?

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Dan:

But other times I think people really resonated with it, so what's some of the feedback you're getting from it?

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Natalia:

Some of the feedback we're getting is really around training and how we really needed to ... I read some of them and it allowed us to really do a SWOT analysis on our onboarding of new nurses. There was a lot of feedback in terms of their onboarding process and what was rushed, what they needed more of. So that allowed us to bring that feedback back to our nurse educators to create a SWOT analysis, to look at the strengths, weaknesses, opportunities and threats of our orientation program because of the pivoting during the pandemic and also just what new nurses really need. They were really honest in terms of what we are doing well, but really what we're not doing well. And also the need for PPE during the pandemic, which, we were able to create a PPE hotline to ensure that the nurses were able to have PPE readily accessible particularly for the night shift. I think that was the gap. To the point that you made earlier, most hospitals are 24/7 so we have to ensure that all the resources are available for the night shift.

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Natalia:

I think that's something else that really stood out from the essays that we read.

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Dan:

Yeah, that's great. It's a realtime feedback so you as a leader can make realtime decisions and help fix some of the things so they don't fester and lead to worse things down the line.

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Natalia:

Exactly.

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Dan:

So how are you thinking about the workforce? I know at the beginning you mentioned there's a shortage. You're focused on the new grads and the transition to practice programs and allowing a specialty piece. There's some online education as well. One of the things I've been thinking about is, we may never, ever be fully staffed the way we were again. You may not have enough full-time employees at your system to staff like we did. So this idea of a flexible labor, flexible nursing workforce is emerging and in demand by some of the new professionals as well. How are you thinking about the future of the nursing workforce?

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Natalia:

I was lucky enough to be part of a nurse staffing taskforce, which was put together by the American Nurses Association, The American Organization of Nurse Leaders, The Critical Care Society of Nursing, so The American Association of Critical Care Nurses, and also the Healthcare Financial Management Association and IHI. So all of these organizations came together. They were able to put together an amazing team of nurse leaders across the country, to talk about the staffing challenges across the country. We came up with recommendations and we have a white paper that we recently released. I'm also currently part of another ANA staffing think tank, where we're really putting together recommendations as well for staffing. With that being said, being part of these amazing initiatives has really given me insight in terms of the way that we staff hospitals, the way that we give benefits to staff. If you think about nursing, there's so many different generations of nurses within one building. The question is, are we really customizing benefits that are tailored to new employees? Are we really giving the flexibility around staffing? Oftentimes we would say, nurses work three days or four days a week. That's amazing. Well, it may not be based off of what they need. So we're really thinking about their shifts, the availability of per diem roles, again, the customization of benefits.

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Natalia:

If someone is not ready to retire, they may not be thinking about a pension. So how are organizations really thinking about the benefits of new nurses that may want a higher base salary versus using dollars for something else? So really giving a comprehensive perspective in terms of what do nurses really need or want, is what we released in this white paper, which I'm really proud of. So I think the future for staffing and the workforce of nursing is really thinking outside of the box in terms of care hours, in terms of staffing, the 24/7 makeup of hospitals, in all different ways. I think we have been doing things such as self-scheduling and we think that's enough. I don't think that's enough at this point. So right now we're thinking about the rural settings, the urban settings, and what does that mean around staffing? We know that a significant amount of nurses decided to travel during the peak of the pandemic. We're seeing that come down a little bit. But what does that really say in terms of what we need to do from a compensation perspective? So I think it's going to take a lot of stakeholders, including frontline staff to really come together, as we're doing within this ANA staffing think tank where frontline staff and nurse leaders and CEOs and CFOs are all at the table, really thinking collaboratively in terms of, what do we do?

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Natalia:

There's not one solution. This is a major problem that's been exacerbated by the pandemic, that I think is going to take a lot of dialogue and a lot of comparison with other professions as well to see, how do we really tackle this? It's a really difficult time.

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Dan:

Yeah. No, I totally get it. I love the flexibility, the way you're thinking about it, as far as flexible benefits. What I've seen with some of the next generation nurses is, working for Health + Hospitals or Kaiser or whatever for 30 years is not in the cards initially. It's not in their mindset so they don't resonate as much, as you mentioned, with some of those pension retirements or vesting after 10 years of work or five years of work and those type of things. They want more of that flexibility and maybe a little bit higher pay to do other things with it. I love the way you're thinking about it. I'm curious, how are your HR colleagues taking that? Because sometimes the barrier is, we can't do that.

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Natalia:

Well, we just released this. We just released the paper. This is outside of Health + Hospitals, right, because we are a city organization. But I love the recommendations we came up with. And what I have brought to my organization is the need to really have HR partners for nursing, the largest workforce in any healthcare system, where we need individuals who really are experts in terms of benefits, explain them to nurses. So not just pick an insurance coverage plan, but really someone to really explain, what does a pension mean and what are the benefits? We even have nurse leaders who really are not prepared to retire at many organizations. So I think nursing in general, we need more support around benefits. The conversation I've had internally at our organization is just creating that position to really explain our current benefit package. Although it's amazing, to your point and my point, a new graduate may not be looking for those benefits as those who are thinking of retirement. That's a conversation we'll have in the future and will take a very long time.

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Natalia:

But I think this white paper is really cutting edge for organizations that are really ready to think outside of the box, in terms of what do our employees may want or need?

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Dan:

Sure. No, that makes sense. I think it's starting the conversation and having some of the data behind it, those recommendations are great as well. Hopefully it starts that dialogue because we have to rethink it. Health + Hospitals is a large public health system and has done a lot of innovative things, which you've described. What can other public systems learn from what New York Health + Hospitals is doing?

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Natalia:

I've been in New York City Health + Hospitals for three and a half years and it's been an amazing journey thus far. I love our system. I love our mission. A couple of things I would really share with other public health systems is, this is an important time for public health nursing. I love to use a phrase, bringing pride back to public health. COVID-19 was a public health crisis and there's no better time in my opinion to be a public health nurse. I really would love public health systems to really lean on that, and really foster a culture where individuals want to join your organizations because of what you do for individuals and for patients. With that being said, I think there's an amazing opportunity for public health systems to really think about the fact that we are just as good as private systems in terms of nursing excellence. I think that's been a huge transformative process that I've been leading at Health + Hospitals, which is to really instill within our nurses that they are amazing and the work they do is so important.

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Natalia:

So right now we are really going on a Pathway to Excellence journey and ultimate Magnet because we are just as amazing. I think it's really empowering all health systems, regardless of your payer mix, that the nursing care you provide should be just as good if not better than any other institution. I really believe that.

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Dan:

Yeah. I think the first thing you said is such a key, is the mission and living the mission. If you can live the mission, then all the other things fall in place, which I think organizations sometimes take for granted. They wordsmith these missions and they sound right. But if you actually live the words on the page, it leads to amazing things. Your organization obviously is a great example of that.

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Natalia:

Thank you.

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Dan:

The last topic I'd like to dig into is, we have a lot of nurse leaders that listen to the show. I constantly get asked, what's my pathway to the next thing? What's the future of nursing leadership? What should I be thinking about and learning about? So I would love to hear your advice to other nurse leaders on how they can excel and help us transform the profession?

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Natalia:

I think nurse leaders need to keep learning and to really challenge themselves to also be innovative. I was honored to be part of the inaugural class at Case Western University, within the Marian K. Shaughnessy Nurse Leadership Academy at the Frances Payne Bolton School of Nursing, where we had nurse leaders across the world come together and really think about the future of nursing and what that means for nurse leaders. I've also most recently finished a post-doctoral fellowship program, the Coldiron Senior Nurse Executive Fellowship Program at Case Western University. I just continue to learn. I continue to publish. I continue to present. I continue to ask questions. I continue to apply programs. I have five degrees and I'm still going back to school, because I believe in learning. Because I think that's the way that we keep our finger on the pulse, to make not only ourselves better but our workforce better and our institutions better. So I think continuing to learn and that's the only way, because I think times are constantly changing so we have to evolve as well.

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Natalia:

And the more we can contribute to ourselves from a personal perspective I think, the more we can really contribute to our profession. So keep learning, keep engaging, keep networking, and keep disseminating your amazing work.

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Dan:

Yeah, it's a great advice. Keep learning and I think using the practice and the science of leadership to lead, is also something that's huge. One last question and then we'll start to wrap up is, what's one or two of the key competencies you look for in a new nurse leader for your organization?

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Natalia:

I look for someone who is connected to the mission and that is caring for underserved, regardless of their ability to pay, regardless of religion, and really connecting to the work we do. So within my role as senior vice president, chief nurse executive, I also am coaching of the Equity and Access Council. I listen for keywords during an interview. Their interest in diversity and inclusion, their interest in creating an inclusive environment. Their passion for really thinking about LGBTQ+ programs or women in leadership. Just someone who is inclusive in their thinking is one of the number one things I look for, because that is who we are. Secondly, someone who has led with outcomes. Someone who is not just talking about the work they've done, but someone who's really shown improvement in really building teams and executing their vision with fruitful outcomes. I would say those are the top two things I look for.

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Dan:

Outcomes and mission. I love it. I love it. That's great. Thanks for sharing that. I know a lot of people are interested in furthering their career and I think those are two great things to focus on. One of the last things we like to do on the show is hand off something to the audience. That's one nugget of information that you want them to walk away with. What would you like to hand off to our listeners?

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Natalia:

I would like to hand off, take care of yourself so that you can take care of others.

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Dan:

That's a perfect end. That's exactly right. And that's probably the third competency, is how the nurse leaders take care of themselves so they can take care of others. I think it's a great message. We were just recording a podcast around some mental health nursing statistics too. It's definitely something nurses don't do enough of, and that we as leaders need to support. So I think it's a great message to end on. Natalia, where can we find you if people want to get in touch with you or learn more about your work? Where do you live online?

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Natalia:

Sure. So I am @NCineas on Twitter. That is where you can find me.

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Dan:

Love it. Twitter's great. We'll put that in the show notes. Thank you so much for being on the show. We really appreciate it. Your insights around leadership and systems and the future of the workforce are going to help hundreds and thousands of people out there, so just really appreciate your time today.

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Natalia:

Thank you so much for having me. It was a pleasure.

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