Dani:

Welcome back to the Handoff from Trusted Health. I'm Dr. Dani Bowie, Chief Nursing Officer of Trusted Health. This season we're covering all things healthcare innovation and the importance of fearless leadership for change. It's only fitting that we kick off this season with none other than Dr. Rose Sherman, a nationally recognized thought leader and keynote speaker on nursing and healthcare leadership. Rose works with health systems and professional organizations nationally to develop and coach current and future leaders. She also serves as editor-in-chief of Nurse Leader. She's a fellow in the American Academy of Nursing, a board member of the ANA Nursing Leadership Institute. And she also maintains an active blog and is the author of three top selling books on nursing leadership. Today we discuss universal trends from an intractable nursing shortage to the increasing span of control of nurse leaders. We cover what nursing leaders should be focusing on and what we should stop doing, and how adopting alternative mindsets from the likes of the NCAA coaches or airline crews can help leaders through this new reality. We also discussed team-based care, the focus of Dr. Sherman's recent books and some of the promising staffing innovations that need to be accelerated and more widely adopted in the industry. Here's my conversation with Dr. Rose Sherman.

Dr. Rose Sherman, welcome to the Handoff.

Rose:

Well, thank you Danny. Thank you for having me. Yeah,

Dani:

I'm really excited to talk to you today right now and how we're leading this new podcast series is around the topic of healthcare and innovation. And you just bring so much knowledge and insight in the industry. I can't wait to get started as I've been thinking about the podcast and just our listeners and how we're really focused also on the innovation, but the care delivery to our patients. You know, I would love it just to start, if you could share a story or patient experience that was really impactful in your career.

Rose:

Well, you know, Dani, there's so many I could share, but one that I think had a really profound impact on me and probably is very related to some of the topics we're gonna talk to today, talk about today, was while I was a leader in the Department of Veterans Affairs, I was selected to be part of an executive team that opened up the VA Medical Center in West Palm Beach, Florida. And we had one of the most innovative medical center directors the VA probably has ever had. Just as an example, we opened up with an electronic health record in 1995 when nobody was doing it. So we were really on the bleeding edge. And this medical center director, who was himself a Vietnam veteran something that he was really focused on was making the medical center very veteran centric. And something that aggravated him was that our VA waiting rooms always seemed to be overflowing with patients regardless of the clinic type.

 Just overflowing. And we had, prior to opening, we put all kinds of mechanisms in place really to improve the throughput with the goal of having the veterans in and out within a one hour timeframe. So that was our goal. Well, we open and our waiting rooms are overflowing and our director is very upset 'cause he thinks that we're not being very efficient, and I asked him to let me look into it. So I spent half a warning in our waiting room clinics, just talking to veterans, and one of the first questions I asked them was, what's your appointment time? And I learned that many of them had come in hours before their appointment. And I said, why are you here so early? And to a veteran, they told me that they had come in early just really to hang out with the other veterans that they really felt comfortable talking with the rest of the people in the waiting room. There was commonality of experience. And I think what we had forgotten in our planning, Dani, was really to dig deeper into human behavior before we redesigned what we thought would be an improved customer experience. I think too often, just like this medical center director, probably myself as well, framed the patient experience through our lens and not that of the patient. And that has always stuck with me, and I think it's really related to some of what we're gonna talk about today with innovation.

Dani:

Absolutely. That gave me goosebumps as I was listening to that story. And again, it wasn't a twist that I thought I was gonna take, but just hearing the perspective of the patient and also like the courage to step out and say, I'm just gonna spend some time asking questions and talking and understanding from their lens what was important to them. So that was really cool. Thank you for sharing. I'm gonna switch gears now and jump into talking about you and your career. And you know, that's been, you've had a distinguished career, broad range of experience from the nurse leader editor, role board positions, your executive healthcare positions and health systems and all this leadership development workshops that you're hosting. And based off of this diverse experience, I would love to know from your perspective, what are some universal trends that you're seeing in the healthcare industry today?

Rose:

Well, you know, Dani, as we're taping this, we're six months through 2023. And I think most leaders had really hoped at the beginning of the year that this year would be a lot less turbulent than either 2021 or 2022. But it really is not shaking out to be that way at all. I think the challenges really continue to exist perhaps even worsening like the nursing shortage right now it's looking in some senses like it might be be intractable. I think some of the other things that we're seeing is that nurse leader span of control has actually increased in hospitals today as more and more staff move to part-time. But the other trend is that because of financial issues many hospitals are really cutting down the number of leadership positions to save money. I think the other thing is that the current makeup of the workforce is different, particularly in our acute care environments.

If you really look at the data right now, 25% of our nurses have less than one year experience in acute care and not unusual to find environments where 50, 75% of the staff have two years or less. And and I think that we have a workforce that's not only demographically different, they're really seeing work in a very different way. They're focused on their wellbeing and leaders tell me, interestingly enough that one of the questions that they're being asked on interview now that never came up before is about what are the wellbeing efforts of a health system or an organization? So that's a big change.

Dani:

Yeah, I am interested and surprised to hear the approach of the nurses asking about wellbeing. You know, here at Trusted we did a survey really trying to understand the impact of health systems and the wellbeing of the frontline nurses and services that are being offered, conversations that are being had. And we're starting to see some improvement with mental health, but it's definitely top of mind for our clinicians. And one of the things that was top of mind for them was actually staffing as well. Getting staffing. Right. So that's kind of interesting to hear and a little bit of music to my ears that we're asking the right questions to the workforce is they're also asking the questions to their employers. And I'm also surprised about span of control. I mean, how much more can a nurse manager do?

Rose:

Well, they can't, Dani, that's, that's really the issue because you know, when you have a less experienced workforce and you don't have those strong core teams on the units, the onus is really on the manager. And so many managers are finding themselves at a situation where it's almost impossible to maintain work-life balance.

Dani:

And I'm so thankful that you're doing the work that you're doing and helping frontline leaders. And as you, you mentioned those trends, you know, is there anything that you would encourage our profession to focus on? Such as is there anything we should stop doing and start doing to start to overcome some of these challenges that we're seeing presently in 2023? And as we head on into the future?

Rose:

You know, there's a couple of things that, in that last question that you asked me that we didn't talk about. And one is that I think our younger workforce are really more career focused. They're seeing their work as tours of duty. You know, I'm, I'm not coming on your unit to stay for two years or even a year. And so they're very career focused. Leaders also tell me that staff are much more transactional, that there's a lot of focus on money right now, which kind of gets back to that topic of wellbeing because I, I like the Gallup model, which really not only includes physical and psychological, but also includes social wellbeing, financial wellbeing, career wellbeing. So it's much broader than that. Not surprising with everything that's going on in society, that they really are looking at the money piece of it. I think that nurse advocacy for the mandated ratios is really on the rise, and I know we're gonna talk a lot more about that and I think union activity as well.

So as I think about what healthcare and systems need to do and what nurse leaders need to do, I think some things really pop out at me. One is that I think we do have to have some frank discussions about what nurses should stop doing when medical centers really examine what nurses are doing. 50 to 80% of what they're doing right now does not need to be done by a nurse. So we don't have a workforce that's working at the top of their scope of practice. We're in a situation right now where there just isn't enough of us. There isn't enough of us and there probably will never be. And so we need to leverage both technology but also other team members so that nurses can really work at the top of their scope of their license. I think these things are really important, especially now. I

Dani:

Would agree. I I'm glad you brought that up. And it's critical, I think engaging, as you mentioned, there's not enough of us, there's a lot of work, there's not enough of us, but how can we be smarter about the work that we're doing, both in the essence of team formation and building strong teams and how we can operate together, but also engaging technology and doing that in a way that we want to elevate the top of our license and practice at this scope that we were trained to practice at. Because I know nurse managers, you know, oftentimes a nurse manager comes in and they're meant to be their master's prepared nurses. They've been trained in evidence-based practice and we bring them into these roles and expect education and you know, form them. But then the practice that they do is, as you mentioned, that transactional piece, a lot of scheduling, transaction, staffing, transaction hiring transaction, but less around research innovation models that I think could be really impactful for the teams they're leading and the patients that they're serving.

And so engaging in that technology, engaging in new models, which we're gonna talk about soon, and you have some expertise in your book, I think is so critical. Thank you for mentioning that. It's just such a passion of mine now with nursing school enrollment down for the first time in two decades and the majority of the nurses working clinically are younger with less experience than in the past. How should leaders approach leading them and managing in this new reality that you said is like tours of duty and as transactional? And so how can we help support our leaders in this new reality of workforce management? Well,

Rose:

You know, one of the things that I'm telling leaders right now is they really need to change their paradigm or mindset about nursing leadership in general. In fact, they're much more like NCAA basketball coaches right now with a roster of players who leave for the N B A after playing for just a year. So they have a whole team of one and done players. And so when you have a whole team of players that is constantly moving out and onto other things I think we've moved into a different kind of an environment. The, there's some really good work around this by Dr. Amy Edmondson at Harvard University. She talks about teaming versus core teams. And so what has to happen in that environment is that you really have to hardwire quality, safety communication in ways that you've never had to do before. And you know, in some senses I think we could look to other industries and the one that I think about is the airline industry.

When you get on a plane sometimes those crews have never flown together before. They all know their roles, but they don't necessarily know each other. So how do we become a high reliability organization in the face of all this kind of chaos and change? Because what Gallup is telling us right now is you know, they're, they're talking about a major culture shock that what happened with Covid is like an asteroid hitting the planet. But the point that they make is that there's no going back. That more and more especially of the younger workforce have more of a gig mentality or mentality that I'm gonna move around to really advance their careers. So I think that the other piece of this that we need to realize is that we still do have a lot of seasoned nurses in the workforce. And I believe fully utilizing these seasoned nurses and keeping them in the workforce as long as possible in a virtual capacity so they can watch what's going on at the bedside and really intervene if they need to with these younger inexperienced staff, is really critically important. And these younger nurses, they want their leaders to be coaches. That's really what they're looking for versus traditional leader and they want career coaching and, and that career coaching might mean leaving your unit.

Dani:

That was an aha moment. 'cause I, I did read your book and you mentioned that in your book about, you know, nurse leaders. It is like the, you know, an N B A roster. People are coming and going and embracing that mindset and being open to that and then creating the teeny approach. And I would like to talk a bit more about your book 'cause it was so great and I had so many of those aha moments as you mentioned. But your most recent book team approach to nursing care delivery tactics for Working Better Together came out in April. And what was the driver for focusing on team-based care? I know we just talked about some of it today, but why is this so important right now?

Rose:

Well, I think a couple of things really stood out to me as I was doing leadership workshops really on other topics, specifically around the topic of retention. One thing that just kept coming up, especially from these managers, were how these core teams had really fallen apart. So the question became, I did a really deep dive into the whole topic of teamwork and how do you improve teamwork? And I went ahead and designed a workshop called Rebuilding Nursing Teams coming together after Falling Apart. It was so successful, you know, I'd done 30 of them just by the fall within three months. And I knew this topic was really resonating with nurse leaders who saw, you know, if you look at the turnover during 2022, the average turnover in the United States was 27%. So this topic of rebuilding teams really resonated with this group.

Dani:

The turnover was astronomical. I mean, and every percentage point increase, you as a leader feel that, right? You feel it in your day-to-day staffing. You feel it in the composition of your team. And so I do think it's such a needed topic and something that as I'm listening to this, I'm like, oh man, I, I wanna attend one of these workshops, especially rebuilding a team after this. You know, as you mentioned, it was kind of this catastrophic event that shook everything up when there's no going back with what happened with the pandemic. And as we think about your book and the research, is there anything that surprised you as you researched for your book that would be, you know, some tantalizing pieces of information for listeners to hear as they order your book and read it?

Rose:

Well, I think one thing that really kind of struck me as I began to look at the research was that teamwork has always been really, really important in healthcare. And when leaders started telling me on these programs, listen, it's not what it was, it's fallen apart. If I were to rate my team on a Likert scale of one to 10, I'd probably give it a three and I might have given it a nine two years ago. And so we have to realize there's been a big shift in teamwork. You can't make the assumption that teamwork is really in place. But there were a couple of things as I did the homework for the book that really surprised me and that one of them was that different generations see teamwork in a very different way. And right now I think the newer nurses that are coming into our workforce are Generation Z.

So they were born after 1997, what we're beginning to learn about them, and there was a really good study that was done by the Walden Foundation, is that they are much more individualistic as a generation than other generations. So they're more individualistic rather than collectivism in their thinking about work. They also have had far less experience working on teams. So what managers were telling me on this program was that mindset was me, me and more me. And so I think part of it with teamwork is that you have to see it to be it, and they just really weren't seeing that. And you couple it with how much of their schoolwork was done remotely during the whole pandemic. It's not surprising that we've seen this steep decline in teamwork and it does need to be nurtured and team backup needs to be nurtured because that's the other piece of teamwork.

And you know, as we look at moving to team-based care models, which I can tell you across the United States right now, many, many health systems are really doing it. We have generations of nurses who have only worked with primary care, so they've never had to work in a model with other team members collectively delivering care for patients. And even virtual nursing, when you think about it, is a nurse watching a patient virtually and the nurse at the bedside, they have to work together as a team as well. So that infrastructure needs to be in place. And what I would tell you right now is I don't think that's really in place in most organizations and that that's part of the structure that needs to be there to be successful with a change in care delivery model.

Dani:

Absolutely. I really appreciate you mentioning the generational differences of, of managing and this new insight around Gen Z and you know, what they are bringing to the, to the table, which it is what it is. I I would agree, it's kind of a, a product of the nature in which they were trained, which was less teamwork, more online schooling or et cetera. And so being able to embrace that and be successful as a leader, understanding that about a segment of your workforce and then the other segments of your workforce and how you can start to bridge those gaps.

Rose:

Just one more thing on that, Dani, that I didn't bring up was that the other thing I think we need to think about is just the influence of social media on this generation. And if you really look at the social influencers you know, your nurse Ericas, your nurse Blakes out there, there's a real me first mindset among those social influencers. It's all about how many likes do I get, how much attention is being placed on me? So we're battling a little bit of that from the culture as well.

Dani:

Yeah, I would agree. And you know, I, I think this is this unique dynamic too. I've, I've heard a lot around like organizational loyalty and that's declining, you know, and, but it's also I think a somewhat refreshing that this new generation is rising up and they're saying, Hey, wellbeing's important to me. And the concept of my work in the essence of me, like that is part of who they are. And ensuring that that is tended to and cared for in the right way versus more of like, I'm just gonna have someone walk all over me and you know, and not be able to stand up for myself. So I, I'm excited to hear some of that advocacy around the importance of a nurse, but then also I think the finessing of bringing that into a team mentality because we are the delivery of care to our patients.

As you even shared with your story today, it was a team that was creating that experience, you know, and you all had a part to play. So I think that's really interesting. I'm glad that you're bringing that up. You know, staffing is always top of mind, I'm sure for the nurse leaders that you're engaging with. And as I mentioned when I did some of our research around frontline nurses and wellbeing staffing was a huge impact around the wellbeing of the workforce and their experience. And it's been a hot topic trending. We've seen it in legislation, different states trying to pass state staffing laws. I know Oregon just passed theirs. Similar to that of California. I would love to get your perspective on nursing ratios or staffing standards. What are your thoughts? And if we look at staffing just by the numbers, where does that lead us to, you know, in the next 10 to 15 years as as a profession or workforce management strategy?

Rose:

Well, I think first of all, I understand why nurses and unions are advocating for mandated staffing ratios. We're not seeing the level of change in the work environment that we need to. And I think a lot of our nurses don't feel listened to. This comes up on every single survey that they really don't feel that they're being heard. But having said that as a backdrop, here are some of my concerns. I think that right now, and I think about what happened just, you know, a couple of weeks ago in Oregon, the legislators are being told that we have enough nurses to do this. Which I have to tell you based on everything I'm seeing, all the data that I'm looking at, the health systems that I'm working with, the vacancy rates that they already have, I don't think this is the case. And they're also being told that nurses will return to acute care settings in large numbers if the ratios are in place, if you do a deep dive, which I did for a nurse leader editor of that journal.

And I wrote an editorial that comes out in October about the conundrum of mandated staffing ratios and went through all the data. You know, the numbers just aren't there, Dani. And I think the California, which has had ratios since 1999 is really the poster child for what could happen nationally. Their health systems have among the highest utilization of contingent staff in the country to really meet their ratios and yet daily they're not meeting their ratios. And so that's my big concern is the numbers. The second thing is healthcare costs, as I mentioned before, 50 to 80% of what nurses are doing right now does not need to be done by a nurse. I don't think that there's anybody out there, whether it's patients, whether it's payers, whether it's health systems, and certainly the government that wants to pay more for healthcare. And if we have nurses that are not working at the top of their scope of their license, that is what I believe is the first issue that one has to tackle before you really get involved with increasing the numbers of nurses look at whether there are other healthcare team members that you could offload at a less expensive cost some of those tasks that nurses have picked up.

So that's, that's where I'm at right now. I understand the rationale from the nurses' standpoint, but I worry because I think the legislators are gonna come back and it could undermine the credibility of nursing if they feel like they've been told something and then they find that themselves in a situation where hospitals are going in diver on diversion or they're closing beds and it's limiting access to patient care. That's really what I'm concerned about.

Dani:

I think that's a really valid concern and I appreciate your kind of setting the backdrop of like, hey, we understand why this is a topic and we understand why this is a pursued path of solution, but we also recognize the consequences of how complex staffing and scheduling is. I mean, you just mentioned it, we have a new generation in the workforce and leaders are managing multi-generational. There's expectation around gigs, transactions, payment, as well as the technology is that supporting how we're doing this work. And in some of my research that I did for my doctoral thesis, you know, the nurse staffing problem is the most complex optimization problem that exists in any industry. Matching and bringing in nurses to patients and the delivery of that care. It is not as simple as a modeling of numbers, it's deeper than that. And so I understand as well, my, my hope and passion is that we would just continue to pursue and explore how to solve this from the root, you know, the, the really understanding what's driving this and top of licensure teaming technology, multiple strategies to solve this. 'cause I know our heart is to get the right number of nurses to care for our patients. A hundred percent. Now as we think about innovation and that's what this new series and season is about, as we're talking to leaders and nurses and others across the country, you know, what are some types of innovations that you are starting to see and some efforts people are making and talking about and what are the things that aren't being talked about that maybe we do need to start thinking about for innovation and change?

Rose:

Well, I think the first thing is that nurses obviously want much more work flexibility. And I think you're all of the work that you've done around staffing and scheduling has really shown that. But if, you know, if you have 50 nurses in a room and you ask them what does work flexibility mean to you, you're gonna get 50 different answers. It really depends on your life stage. You know, if you're at home and you've got two young kids and you're trying to make sure that the daycare is open and stays open and that you get there on time your idea of work flexibility is much different than someone that maybe doesn't have any kids in the house. Maybe you're a 60 year old nurse who wants to continue working in acute care and you're at an institution that only hours offers a 12 hour shift.

And so your idea of work flexibility might be, why can't I just work six hours? Why can't I work eight hours? So I think that what's clear, what's really clear to us is that the workforce really wants more flexibility. They want much more of a say in not only the type of work that they do, but when they work. And I think this situation, Dani will become more complex because by 2030 about 72% of our nursing workforce will either be millennials or Gen Z, which means they're gonna be in their really peak childbearing years. So they're gonna want that level of flexibility. We know that they want it. I really like some of the efforts that I'm seeing around flexibility that I really like. I, I like the work that Jefferson Health has done with their Nurse Seal team. I like the work at that Allegheny Health has done with the Work Your Way program.

I like the work that Mercy is doing in terms of level different types of workforces and kind of putting them on top of each other, realizing that it's not a one size fits all. I think we're seeing more health systems now with their own travel systems. I think that people are looking at innovations around self-scheduling. I think we're also seeing some really good innovation in our academic practice environments to help nurses be more work ready. And one of the projects I particularly like is one that Emory Health is doing with Chamberlain, really preparing nurses to be able to move right into I C U and perioperative nurses nursing by giving them badges and things like that during school. So there is innovation that's happening, it's just probably not happening fast enough and it's not happening broadly enough is what I would say.

Dani:

I heard someone say this, you know, feel forward, feel fast, you know, and so it's like the mindset, which I think you and I talked about this. Healthcare is risk averse. We're trained to not fully embrace, you know, the risk and rightfully so. We have patient lives and care that we need to make sure is delivered well. But taking a little bit more of a liberty and some of this innovation to try test, you know, it's the, it's the scientific method of being able to have a hypothesis, test it, understand your outcomes and how do you need to readjust. And you know, I'm, I would encourage our listeners as much as we can, I know the scope of span of control of nurse leaders is pretty great right now, but whatever we can do as administrators and leaders in healthcare to accelerate and advance these innovations that rose, you just talked about flexibility and also the badges that you mentioned. I, I knew as I managed the workforce periop areas, I C U specialty areas which are just really tough to have a sustainable pipeline and our ORs in particular, I had a very aging workforce and I didn't know who was gonna come and replace that, that workforce that when they retired there was a big gap there. So those are some really key callouts.

You know, you have had such a decorated career and I've definitely <laugh> looked you up on Google and there's so much out there about your content, your thought leadership. But I would love it if you could share with our listeners today Rose, where to find you to contact you and learn more about this important work that you're doing. Well

Rose:

I think two of the best places that you can probably find me first of all is LinkedIn. But the second one, and for any of our nurse leaders that are out there listening that have, are either managers or maybe you have managers working with you. I have a blog emerging RN leader. I have, I write that blog twice a week. It comes out every Monday and Thursday. It's geared toward nurse managers. I've been writing it for 11 years so there's hardly any topic that I really haven't written about <laugh>. So if you're struggling with something more than likely I have written about your topic and I try to keep it really timely. So those would probably be the best ways to get in touch with me.

Dani:

Fantastic. Your blog is excellent. And we were talking before, you know, there's no topics off limit, right? Like there you get in a room with nurses and there's a lot shared and I'm so thankful for that transparency and ways we can talk about one our practice and then two different elements of practice and how to move it forward. So thank you so much for this interview. Oftentimes what we do is we ask our guests to share with our listeners, you know, what is a final handoff that you would like to give to our listeners today?

Rose:

Well I think, I think it kind of circles back to what I talked about at the very beginning. I think sometimes when we're in leadership, particularly senior leaders tend to view what's happening today through the lens of their own experiences and they're really not getting in there and really talking to frontline staff about really what's happening. Particularly these much younger frontline staff who are having a very different experience in healthcare than probably senior leaders have for a variety of reasons. Not only 'cause volumes are up and acuity is up, but also patients and families a lot more incivility worrying about physical assaults. So that would be one thing that I'd say. The other thing I'd say is that the innovation that you have talked about so much, Dani, there's so many challenges in healthcare, right? For now and in the future. And I think it can be paralyzing for a lot of leaders because they really are, as you mentioned, kind of risk adverse.

It's part of your clinical training, but you have to start someplace. And if you're waiting on people to write evidence-based articles to show you what's going to work in your environment, I think you're really losing, losing ground and losing it fast. So I would say just get started. Pick a few initiatives, just pick one or two things that you think might move the needle and don't be afraid if it doesn't move the needle to pull back and say this didn't work, so let's try this instead because many things are not gonna work. And so being willing to accept that. And then probably the most important thing is be sure no matter what you're planning, that you really include frontline staff in the planning so you don't lose the lens of what's happening through their perspective. That would be my handoff.

Dani:

Love it. That is critical. Frontline engagement, moving towards innovation, taking a step forward and not being afraid to try. And like you mentioned, talking and listening to your nurses and also your through this process. Rose, this has been wonderful. Thank you so much for joining us here on the handoff. And I can't wait to circle back around in a year or so and hear some of the other amazing work and initiatives that you're leading.

Rose:

Well, thank you Dani, and thank you to your whole audience for being leaders. This is a hard time to be a leader. Thank you for stepping up to the plate and thank you for doing it.

Dani:

Thank you.

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