Dan:

Welcome to the show, Rayne.

Rayne:

Hey, aloha, and thanks so much, Dan, for having me. It's always great to connect and talk about nursing, nursing leadership, and where we need to go, man.

Dan:

Yeah, love it. So Rayne and I have a long history at Kaiser together. He was on the informatics team, I was on the innovation team. We worked really closely on a lot of different technology stuff and became friends and co-conspirators as we navigated the complex system of a large healthcare organization. We've authored a book chapter together, a couple book chapters together, and so we definitely have two sides of a great coin related to the technology in nursing. But before we dig into all that, Rayne, I'd love to have you just talk about your career path because like me, you started in the ED and you sort of worked your way up and then you kind of shifted, went over to informatics and then ended up doing your PhD in that. So I'd love to hear your story.

Rayne:

That's one of the beauties about nursing is that you could practically go anywhere and do a lot of things with the nursing background. And like you said, having started in the emergency department, I think, which truly matched my personality anyway, my mind, it just races all over the place. I like to multitask. I love managing crises and just being in the center of chaos to try and organize and put some sense into things. And so I think a lot of my career path and my adventures kind of follows that team in working in the emergency department. But while in the ED, I also fell in love with education, and I think that's where my path academically went towards research, getting a PhD. And truly the informatics thing, just like many people who fall into informatics, came spontaneously as I was doing a, I think it was an ACLS or a PALS class. Somebody said, Wow, obviously you like teaching, you want to implement this EHR in a few hospitals, a few meaning 21.

Dan:

Yeah. You mean an entire region.

Rayne:

Right? You mind joining us and co-leading this effort, and again, being from the ED, it's sort of like, yeah, let's do it. Let's knock this out. Let's see what happens. And as we were going from hospital to hospital, Dan, as it became more clear to me that this was beyond going from paper to the computer, because the initial thought when going live, especially, we were one of the first installations of this major EHR vendor in the hospital space. And so for us, the thought was, oh yeah, we're just going from putting things on paper and faxing stuff to putting it in a word processor or Microsoft Word. And then soon it became sort of like, wait a minute, this actually enables us to connect with other people, look at this same chart at the same time, not have to run this really huge folder folders up and down floors to make sure people have the right information.

And it became eye-opening in a sense of the impact to what information can do when you make it portable, accessible, actionable, et cetera. And I think that really fascinated me from initially that informatics lens. And so after deploying 21 hospitals and seeing early on the initial impact, I really wanted to study, well, if we have all of this information similar to our consumer lives, how are we really managing and leveraging it to actually improve patient care and actually give people the right information at the right time versus throwing the kitchen sink of information at people and hope they know what to do with it? And so it just became a huge area of opportunity in terms of research and because of my passion for education and of course leadership, it's huge.

That was another thing that really struck me is, gosh, we're now expecting our nurses, especially, to document a lot. In fact, we document the most, I think in terms of these EHRs, and we're asking our nurse leaders to audit, congratulate, coach, mentor folks using this data, being data driven, yet how many managers, directors, CNEs actually get in this chart and get in the system and are proficient enough to point those things out whether you're doing a great job or here are areas you need to improve on, or here's our data and how we're doing. And that was rare, if not homemade in most organizations because there were no classes for leaders to navigate the EHR and leverage it in their roles. It was mostly how to document how to find stuff, how to bill the right way, et cetera. So that became my journey. And then eventually my path made it back to the emergency department through informatics in that we started to look at things like social determinants of health.

So I went back into the ED environment to really study things like homelessness and social determinants of health and using our data to really look at what were the barriers to health and why were people coming back into the ED or into the hospital and what can we do about that from a community and resource perspective? And then eventually made my way back to education. One of my initial passions now with this nursing shortage and with the great resignation that we call it, the turnover, how do we get back in and promote between new grad programs and really, man, just building a succession plan because you and I, at some point, Dan, need to retire and open up that cabana in the Caribbean.

Dan:

Yeah. Or Maui. Either one's good.

Rayne:

Yeah.

Dan:

Yeah, no, I love it. We have to create the future of the profession, so you can leave it in good hands and go relax for a little bit.

Rayne:

That's it.

Dan:

Yeah, and I love that path. I mean, you've jumped around and you have really sort of personified that nursing opens a lot of doors and you don't have to have this linear path. And you've done management, you've done informatics, you've done education, you've done resource, you've done social determinants, now you're back to education and operational leadership, and I think that's just a cool way to think about it. And I think a lot of nurses think that the only way out of the staff job is to either go the management route or go to the nurse practitioner route. And I think both you and I have taken that non-traditional sort of route of all kinds of different things and kind of piece together this custom made career.

Rayne:

That's it, man. And it's like operationally, we always talk about a speak up culture when it comes to speaking up about errors and safety concerns. But I think in a leadership perspective, we have to speak up as leaders when we see things. That's why I love following you and reading your posts, Dan, because when you see things that are directionally like, Wow, are we really going back and is this Groundhogs Day again? Or are we moving forward and really speaking up about what we need? Especially when you look at the generations of nurses today, the types of educational resources, the way people learn and take in information, and the traditional succession paths in nursing that we need to let go of in many aspects in order to promote development and diversity and just really promoting leadership, I think, and making people feel confident that they can do this job and that they can lead because of their ideas and where they want to go with nursing and not get so stuck in traditions so much. Although tradition's important in some senses, based on what we're seeing between technology, innovation, the use of AI, it's just amazing the speed at which people learn, and that includes nurses and our patients as well.

Dan:

Yeah, no, agreed. I think there's just so many more tools at your disposal and you can't know enough about care anymore. You can't memorize everything that happens in the ED or the ICU or the med surg unit even. You have to access this stuff and being proficient in that. I posted something recently, yesterday, I think, around this new competency that nurses need to incorporate machine generated insights into their clinical decision making, that's one of the companies we need to be pushing on in nursing school and beyond. And it got a lot of pushback.

I mean, there's definitely nurses who have been around a while who posted on there saying, Well, you're going to remove critical thinking from nurses and machines are only trained with blah, blah, blah data, and nurses don't enter data. So anyway, we could go all day into that, but I think at the end of the day, we have to start thinking about technology as super powering our decision making, not replacing it, but to augment it. And I feel like there's still two camps of I don't believe technology. We have to touch patients, we got to write it down, blah, blah, blah. Then there's the other camp of technology can save everything and then there's no frameworks of connecting them in the middle. I don't know. What have you seen in, because you're much more deep into this than I am. I mean, what sort of trends are you seeing with our nurses in adopting technology to augment their decision making?

Rayne:

Well, I think one of the things that always fascinates me from both sides is to your point from the nursing and nursing leadership perspective, it's tough to adopt change. It's sort of like that philosophy of why fix what's not broken? When people have been working in a broken system. You get used to working with broken stuff, and that's why we tape pens together.

Dan:

Yeah, right.

Rayne:

You know what I mean?

Dan:

Carry around to highlight [inaudible 00:09:15].

Rayne:

Right? Why do I need a stylus? I love my taped together pen. It's sort of like that's the way we work. We work in a world of workarounds. And so no matter how good a technology or solution is, it's tough to break through what we've been doing for so long is still working. For me, as we look at technologies introduced to nurses and in our environments, it's got to meet a lot of important criteria for it to break through.

And as you know, hey, it's got to be easy. I can't type in more passwords and go into overtime just because now I have to chart more stuff. It's got to be easy and it's got to be meaningful when it comes to what are you taking away from my plate, knowing that we already have full plates in terms of our day to day care and routines. It's like, what is this new tool or technology going to take away and maintain or improve the quality of care and actually make it easy for me to spend more time with my patients or to actually go to lunch or use the bathroom.

Dan:

Take a break, use the restroom. Yeah.

Rayne:

And so it's the same for leaders. It's like, why am I still working with 10 different systems to get one thing done when we tout interoperability and the ease of use of a lot of these technologies, when you look at the consumer market or even the payment, you can touch to pay, tap to pay, use your retina, I mean, some of those things, wow, can we apply some of those tools into our world to make it a lot easier?

As simple as dictation, the fact that we're still typing and clicking when dictation tools are out there to be able to write notes, transcribe notes in a lot of those things. It's just one of those things where wow, and I think that's where the value of having nurses, such as in your field, Dan, with innovation technology and having nurses at the front lines of development and design are important because they can relate to the world of the bedside nurse or the manager or the educator and really be able to translate why this new thing is not only better, but will free up time for you to be able to do self care or actually take a break or whatever. And that's what we need versus, oh, here's this thing. It doesn't really make your job easier or improve quality, but you just have to type in 10 more passwords, but isn't it so cool once you finally get through the [inaudible 00:11:47]?

Dan:

Here, click the button. Yeah.

Rayne:

Right. And you know, you can't help but when you go to these conferences, that's what you see, right? It's like, wow, here's a free pen. And by the way, here's this new thing we've invented. Have you talked to nurses? No. Have you seen what we do? No. But we have someone on the team who used to be a nurse, but they were in home health and were selling something to the hospital. So there's a mismatch with the solution to what problems they think we're trying to solve. And that's what we're seeing still today, Dan.

Dan:

Yeah, no, I agree. I think there is a mismatch. I think that the companies building the systems don't understand nursing workflow and there needs to be some shifts there. What are you seeing with the new grads? I mean, are they demanding like, Hey, I'm going to use my phone at the nurses station no matter what your policy says, and I have all these apps and I'm looking it up. Or are they being, indoctrinated is probably the wrong word, into the old world thinking?

Rayne:

Yeah, no, that's a great question, Dan. And since being in Hawaii, there's a different flavor versus the mainland in that we don't have as many choices in terms of programs and development. That's a big part of my job, is trying to connect and really partner with not just the Hawaii State Center for Nursing and our friend Laura over there and the community-

Dan:

Who was also on the podcast.

Rayne:

That's right. And our labor partners. I mean, it truly takes a village to get any of these developmental programs done. And so when we look at new grads today, as we study the needs of different generations, today's generations, they want to know that they're part of something meaningful. They want to know that we're innovative in the sense of really taking into account that you don't need to read a 300 page book. Oftentimes it's a YouTube video that they're learning from or something really quick. So that's why it's, what I was actually glad to see is more and more use of the QR code. Remember the project you did with the QR code and I think [inaudible 00:13:41] supply.

Dan:

Yep.

Rayne:

That's becoming more standard today. We finally caught up with the times in terms of making it easy. Again, make it easy for me to find information. And I think coming out of the last two years, man, and just having an environment where preceptors are burnt out, managers are burnt out, charge nurses are burnt out, educators are burnt out because all we've been doing is education on PPE, what to reuse, what not to reuse, who needs the oxygen, who needs the ventilator?

I mean, it's just been two years of just this purgatory of COVID because that's all that we could teach about or talk about. And so there was controversy around do we pause clinical rotations, which a lot of programs did. And so a lot of the new grads that we're seeing now, you know, Dan, they haven't spent a lot of time at the bedside with real people. It's been mannequins. It's been simulations. And as great as those technologies and tools are, nursing is still about building that relationship and rapport with your patient. And I think in a sense we're playing catch up. And so the new grad programs that we're running sometimes feels like finishing the fourth year or the last year of nursing school for the new grads today. In that we're going back to what we call back to basics.

Here's how you establish that rapport, here's that assessment, and while the patient's screaming and writing in pain, here's how you get your assessments done. Here's how to deal with family members who are stressed out and anxious, because there's only so many things you can simulate and replicate in a fake environment. So now that they're coming into this overly stressed environment where patients are sicker from an acuity perspective, you have families and patients who haven't been to the doctor or the hospital in a while because of the fear of COVID. So they're a lot sicker. And so it's almost like things are coming together where you know almost have to take a step back and just absorb what's going on before customizing our new grad programs to do that though, going back to basics, you don't have to focus necessarily on these hundred things. Let's go back to basics and focus on things. I mean, we've talked about hand washing so much that my fear is that as things open up, it's like, yeah, the mask thing might be going away in certain aspects, but we still have to wash our hands everyone.

Dan:

Right.

Rayne:

You know what I mean? It's sort of like, again, let's not throw the baby out with a bath water. If we've learned anything, it's let's prioritize because oftentimes we get asked, has healthcare or nursing or operations really changed? It really hasn't. I think what the last two years has done, Dan, is it's made us refocus on the important things. And oftentimes those are the basic things that we've forgotten. And so people have forgotten that we have to document certain things or here's the protocol for this or whatever. Just because again, we've been so focused on maps, on vaccinations, on testing, that it's reconverting our minds back to again the basics.

Now we're seeing beyond COVID, in Hawaii, RSV is blowing up in terms of the pediatric population. There's a huge emphasis now on behavioral health because of the last two years and what remote work and just the depression of the economy and that's done to people. So behavioral health is huge as far as what we're dealing with right now. So with the new grads that we're seeing today, it's how to skill them up in order to meet the demands of the patients that we're seeing. So high acuity, behavioral health, home health, a lot of those things that the pandemic has really highlighted.

Dan:

Yeah, no, I agree. And I think it is, there's this back to basics and like you said, some of the new grads entering the workforce now didn't touch very many patients because of COVID. And so you have to relearn things and I think there's a big evolution there. And again, tech can support them in different ways. So I think those basic skills are key there.

You mentioned self care a lot and that's been top of mind for multiple conversations that have gone on recently. I was just on an ANA California panel about it again and it continues to kind of spin around. I was just texting with a colleague from previous organization and she's like, We're in this meeting, we're brainstorming all of the ways that we can retain nurses and they're back rubs during this shift and pizza and all this stuff. I'm like haven't we tried all this stuff before and it just like doesn't land? The pizza parties, the ice cream carts, I think the healthcare workers are over that and want real system changes, which you talked about a little bit as well. What are you seeing as far as self care and how are you approaching it over in Hawaii, both personally as well as for your teams to of renew and shake off the pandemic and start building some of those skills so that they can stay fresh and engaged with their patients?

Rayne:

Yeah, no, great question Dan. I think personally, as I shared with you, for me, living in Hawaii and not going to the beach or the ocean at a regular clip is almost like ironic. It's like, well why did I move here if I wasn't going to enjoy nature or the beach or be out and really enjoy being in Hawaii? So for me, I think between just getting outside and then being in the water, which I love anyway, I joined a canoe club and just between being out in the ocean and just appreciating life and just living that mindset of gratefulness that I'm still alive, my loved ones, my friends, they're still healthy and alive and a lot of them have made it through COVID and the pandemic and just being thankful and just reflecting on how small things really are when it comes to challenges and problems compared to the world out there.

And it's taught me a lot about leadership as well as I posted recently on LinkedIn in terms of the different roles leaders have to play is similar to being in the canoe. You're either navigating, you're leading, you're the engine and really reinforcing something. And so it's being able to work as a team, I think, to play different roles. And I think in terms of at work and really solving for the resilience and the attrition problem, there's a lot of back to basics there as well because it's checking in with individuals as to where they are. Because one of the things, as you know, the pandemic did is it not only rocked us from a profession of nursing, but our own personal lives. People had to go home and become teachers and it's like, yeah, your kids were now home while you were trying to provide telehealth or virtual care or try to change your schedule and try to figure out how am I going to work night shifts and then be a teacher in the morning to my kids?

And it just burnt a lot of people out because they were burning the candle on both ends. I think it's understanding where people are now that hopefully we're coming out from underneath this and then customizing sort of what they need. So is it a scheduling issue? Is it, gosh, you have all this time off saved up that you couldn't take because we needed you working. Right now we're holding on to some of our travelers just to be able to give people a break and get them that vacation that they've wanted, even if it's a staycation, just to get away from here and unplug. And then for our managers and leaders it's making sure and really being hard on folks responding to emails when they're supposed to be off. Why are you answering text messages and emails, I thought we had coverage for you? Because it's a slippery slope when there's a perception of that presenteeism where I have to always look like I'm on or people don't think I'm doing my job. And it's like, no, that's not the case at all. You're on vacation or PTO so you can unplug and get away from here.

One of my old managers used to tell me, Rayne, the only way you can tell that you had a good vacation is when you forget your password. And she was so right because if you could be so unplugged and off that you forget your password or passwords and you're not quite sure what the thing is to do and to approve expenses or do your compliance training, it's like, wow, I was gone for pretty good time and unplugged. And I think you have to plant seeds in front of you to look forward to. And so for my team as well, Dan, I'm very purposeful about asking them, when's your next time off? When's your next vacation? And not proceeding with the conversation until they can come up with a plan or some type of schedule to where they have some time off and what are you going to do? And being purposeful that when I'm rounding or checking in with them to ask them, how was your vacation? Not even talking about business or what we're doing in terms of the next initiative, but how are you? How is your vacation? What'd you do and when's your next one? Because look, we're here right before the holidays again, and time's just going to keep flying. So unless we take care of ourselves, man, no one's going to do it for us. And the work's only going to grow now that we're opening back up again.

Dan:

Yeah, well yeah, we're seeing volume return and continued short staffing and things. Have you guys played around with different shift types and things as well? And sort of trying to meet that, I don't know, break in the 12 hour kind of nostalgia that we have in the profession, but trying to find different shift lengths or shift types that allow people to not be so in the fire all the time. I don't know, have you played around with any of that?

Rayne:

Working closely with our labor partners and really looking at being creative as far as what we can do for folks, especially if they've been working full time plus the last couple years is like, wow, how can we provide them respite? But I think the approach that we're also taking is with our friend Julia and looking at things like can we expand our float pool so we're not really having as much per diem staff, but a float pool that can really be dedicated to giving people coverage, whether that's maternity leave, FMLA, PTO and expanding that float pool to cover not just the hospital, but eventually our nurses in the ambulatory spaces as well so that they have more options for coverage. Because right now it's like the person you're asking to cover you for vacation is probably also in need of vacation.

Dan:

Right, right. Yeah.

Rayne:

It's like rub it in, man.

Dan:

You cover me, but this is like your eighth shift in a row.

Rayne:

So that's kind of what we're dealing with. And so we're trying to not only work on customizing schedules, but looking at people in terms of, gosh, how many nurses would help to give people a break in med surg, telemetry, ICU, ER, et cetera, and then let's grow that because then that helps us from decreasing our need for travelers, helping with sick time because people can take care of themselves and not feel like they have to use sick time to get time off. And so it decreases pressure from a lot of fronts for us.

So that's a huge investment and a huge focus for our CNE and our operations and for those who've been working for so long that we hear a lot about the great resignation and whenever you hear buzz about retirement, it's having conversations with your most senior staff to say, Hey, what if we get creative and instead of working 40 hours a week, can you work X number of hours but then have the rest be preceptor time or be a mentorship so that we don't lose you all together, we leverage your knowledge and expertise to teach the next generation and these new grads who really haven't had real clinicals. And it's really refreshed a lot of folks who were feeling like, gosh, I'm just so burned out from the shift work, can I do something? So it's reigniting their passion for education, for precepting, and it gives them hope because it's like, wow, I'm training the person that's going to be covering my vacation and the future succession here. And so those are some of the, I think, biggest things we've been focusing on, Dan.

Dan:

That's awesome. And one thing, there's definitely a different way of life in Hawaii and definitely different culture, the family and the island sort of coming together as one big community. Have there been things that you've learned since moving there that you've incorporated into that self care and employee onboarding and building that team around you that you've learned from the island culture?

Rayne:

Yeah, it's interesting. It's such, I mean literally a geographically small area compared to coming from northern California. And so the chances of seeing a coworker or your patient or patient's family at Target or at the grocery store is pretty high. And so that service, that patient engagement, the care you give in the hospital is very important as far as our reputation and just making sure we don't burn those bridges because the likelihood that you're related to or you went to high school with or you know their relative or they were your teacher is really high. And so that feeling of community is so huge here that I think that bleeds into the care that we provide and the quality. And so people take that really seriously when we're trying to improve something. And the feedback loop especially, as far as, gosh, I was in the hospital and here's what I experienced, and so that spreads like wildfire because it's such a small place.And so I think that's one of the things. And I think culturally, there's so many multi-generational households that we talk a lot about acute care at home, a lot of these initiatives now where they're trying to really get the most bang for your buck in terms of what can we do at home to prevent hospitalizations or ED visits? And so here what we're seeing in our workforce is a lot of them actually are caring for parents, grandparents at home as well who are Kaiser members. And so it's sort of like, wow, it's a ripe environment to actually test a lot of these technologies, innovations models out with our own staff who are caring for their own family, their own parents or grandparents at home because that's a reflection of the communities we serve. And there's this thing about the Hawaiian culture and really learning that as well in terms of, ironically here in Moanalua Valley where our hospital is, Dan, it was a valley of healing and the water is a huge symbol of that healing.

And so having a hospital where you're in a valley of healing is so symbolic that any changes to our structure and our architecture, we consult with the native Hawaiians and the community in terms of is this okay? Is this aligned with the culture? And so that's been such a wonderful learning for me in terms of the meaning of the culture and the community as it stands with what we do here in the hospital and in our operations. And so it's just been wonderful. And so with many organizations, in fact, most organizations now focused on diversity, inclusivity, equity, a lot of the things that we're talking about in terms of healthcare today, this is such an awesome place to learn that, not just from learning the Hawaiian culture, but because we're in such a melting pot when it comes to the workforce, the communities we serve. And of course the tourists that come through Hawaii, I mean they come from everywhere. And so it's like you have to be prepared to meet the needs for many cultures, many backgrounds, generations, et cetera. So it's been a huge learning for me as a leader and for us. Yep.

Dan:

No, I love that. That's great. And that whole aspect of Ohana, and it is small, I mean, one bad experience at the Kaiser hospital can spread across multiple families, like you got to be on your game.

Rayne:

That's right.

Dan:

It's different because there's only a few choices, and I think we talked about this with Laura too, it's rural, there's a lot of rural aspects and it's hard to get. I mean, we drove up to the North Shore when we were out there a couple weeks ago and you know, drive through little tiny towns that are an hour away or more from the nearest facility and the access. And it's not like you can just jump on the 405 and drive on the freeway. You got to go through all these tiny one-lane roads and backwoods and stuff.

Rayne:

That's it, Dan.

Dan:

It's a whole different challenge and you sort have to be ready for all that.

Rayne:

And then like we talked about before, in those rural areas or communities, how do we work with their high schools and their schools to really promote healthcare jobs early on? Because the only chance you're going to get someone to stay long term in those areas as we see today, is if they're from those areas and from those communities. If they become the doctor or they become the nurse or the healthcare leader, or they're the entrepreneur who wants to open a clinic from that community, it's because it's like they have this burning platform to give back to their community.

That's been the challenge for places like the big island and in many rural parts of Hawaii today is trying to attract, especially in our specialty areas, whether it's physicians or nurse practitioners or therapists, behavioral health is how do you get them to stay in such a rural community in Big Island or in Kauai or you know what I mean? Especially if they're just starting out in their careers. And so it's like, wow, well the only chance sometimes we have is to make sure that they're from those communities and that they're growing from those and they see the plight and the need in those communities, and now we've given them a chance to go back to make a difference. And so how do we invest in those opportunities? So that's huge as well.

Dan:

Yeah, no, agreed. Well, Rayne, we're at the close of our time together and we like to end each handoff episode with, what would you like to hand off to our listeners? What's that one nugget that you want them to walk away with from our conversation?

Rayne:

Wow. Yeah, I think the biggest thing when you look at the great resignation and a lot of people ask what keeps you in it? What keeps you in nursing? What keeps you coming back every day? What gives leaders, nurse leaders hope for the future, especially with the last couple years we've been through? And I think just again, getting back to basics. We're a profession of caring, you know that saying, no one cares how much you know until they know you care. That's it, man. And it's like that's got to translate to each conversation, each relationship, each initiative, anything you go into. If you don't care about what you're doing or who you're doing it for, then we're in the wrong profession. And I think that's the fire that can overcome burnout and exhaustion and because sometimes caring too much is also tiring and that's why self-care comes in. You know what I mean? So I think caring is a huge thing that we need to get back to and caring for ourselves, caring for each other, caring for our communities, and of course our colleagues and our nurses and staff. So I think just keeping it simple, man and having fun because you never know, today might be the day that we start our cabana in Maui.

Dan:

One day, Rayne, we will do a cabana, even if it's a pop up cabana, we're going to do it.

Rayne:

That's right. With those floating bars.

Dan:

Yeah, that's right. Oh my gosh. Well, Rayne, it's so great to have you on the show and thanks so much for sharing your knowledge. You epitomize an awesome career path, really staying grounded and preparing the future of our profession, which is awesome. I know you're on LinkedIn and other places, so find Rayne out on social media, check out his book chapters, he's authored a lot of articles. He's got a great message out there around the use of informatics to enhance leadership in nursing practice. And just really appreciate your time today, Rayne.

Rayne:

Thanks so much, Dan. And then we'll see soon, okay? Let me know if you need anything.

Dan:

Aloha.

Rayne:

Aloha.

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