Rae Woods:
From Advisory Board, we are bringing you a Radio Advisory. My name is Rachel Woods. You can call me Rae. Since we've launched this podcast, I spend a lot of time talking about the COVID 19 crisis, but I would argue that the biggest crisis we're facing in 2021, isn't actually COVID, it's the nursing crisis. Today we don't have enough nurses or nursing expertise to meet the demands of the Delta surge plus everything else that hospitals need to get done. And if we're going to get ahead of this, we have to start addressing some of the bigger problems bedside nurses face today, including those that they faced prior to the pandemic. So to do that, I've brought my colleague and advisory board, chief nursing officer Carol Boston-Fleischauer. Hey Carol, welcome back to radio advisory.

Carol Boston-Fleischhauer:
Great to see you, Rae, great to chat with you this afternoon.

Rae Woods:
It's been a while since we've had you on the podcast, you were one of our first guests talking about, gosh, back in 2020, the first nurses week at the very, very beginning of the crisis. And I'm guessing you're going to tell me that the situation for nurses hasn't exactly gotten better since then.

Carol Boston-Fleischhauer:
I guess that's an understatement. In fact, a question that I get asked about every day and that is, how do we stop the Exodus of registered nurses from our inpatient healthcare environments, period, hard stop. That's it, that is the number one question.

Rae Woods:
I completely agree. And I don't want to use this word lightly, a lot of people talk about crises, the COVID-19 crisis. I've talked about various health equity crises before but maybe this is a better use of that word because we really are dealing with a crisis amongst our workforce. And for today, I want to focus specifically on the nursing workforce. We're going to get into the specifics but I just want you to start to level set with me at a high level. What is actually happening in the nursing space? Why is it crisis level?

Carol Boston-Fleischhauer:
Yeah, for all sorts of reasons, for all sorts of reasons, registered nurses are leaving hospital employment at rates far greater than we've ever seen as long as I've been in health care. So, and we now have an increasingly severe supply demand imbalance. Every workforce metric that executive teams track is going in the wrong direction. Turnover, they can see rates time to fill, all trending the wrong way, no signs of reversal.

Rae Woods:
What does that mean for the individuals who are responsible for responding to that supply demand mismatch?

Carol Boston-Fleischhauer:
Well, in the immediate, what chief nurse executives challenged to do in partnership with human resource executives is figure out how to staff units in order to keep not only beds open but also services at the level that the community needs. That's the immediate pressure point that every chief nurse executive that I talk to almost on a daily basis is contending they are having increasingly more and more trouble with.

Rae Woods:
And this is why the word crisis is so important. It's not just that the individual people, the nurses themselves are feeling pushed out of the workforce, it is also a problem for the administrators, the hospital executives, the people who are responsible for making sure that we can provide patient care. Let me ask you this. Are we seeing this across the whole country or is this really just a problem in areas where the Delta variant is creating surges?

Carol Boston-Fleischhauer:
Gosh, I wish it was just regional. While some regions are obviously more hard hit than others, I would absolutely suggest that 99% of your listeners to our conversation are dealing with extreme staffing issues right now, not just in one or two units but quite frankly, across the house.

Rae Woods:
How much of this is a problem of boots on the ground? We talk about not having enough people, enough actual bodies to be able to staff inpatient units, ICUs, et cetera or is this something more than that? I'm thinking a shortage of skills and expertise that are necessary at the bedside.

Carol Boston-Fleischhauer:
Many organizations are unfortunately seen increased numbers of mid-career as well as more experienced registered nurses, either taking time off or leaving the organization altogether, if not retiring from the profession. And so, one of the phenomenon that organizations are dealing with is an increased number of brand new or novice nurses that are available to work that are being hired to work with less than a threshold experience in order to handle the complexities of the care environment that they are facing. Be it COVID related care or non COVID care that as we all know, was delayed for such a long period of time during the height of the surge last year. So there is an increasing imbalance between the level of experience and therefore the skill level of registered nurses that are practicing and willing to be employed in the inpatient environment at a time when the care in the inpatient environment is more complex than ever before.

Rae Woods:
And this is exactly why executives are making what I might call, desperate moves. You mentioned this already but in a world where this supply demand mismatch is so severe, we see executives saying we'll do anything to get people and hopefully some expertise at the bedside. And I'm seeing executives pay, I'm talking huge signing or retention bonuses just in order to keep the lights, on how much money are we really throwing at this problem?

Carol Boston-Fleischhauer:
The sign on bonus war that's going on, not only locally but quite frankly across regions, can go anywhere between, I don't know, one or $2,000 to up to 40, if not $50,000, just to get one clinician into the organization. These are extraordinarily high incentives for registered nurses who quite frankly, have lost a fair amount of their organizational loyalty and so therefore are willing to go within reason, wherever they can get the biggest compensation boost for the employment that they're willing to commit to. But the problem with sign on bonuses is, they don't incent a registered nurse to stick with an organization. There's typically a finite period of time that the registered nurse has to stay with an organization in order to get the complete sign on bonus. But the majority of organizations report that overwhelmingly, as soon as the sign on bonus time requirement is satisfied. These registered nurses leave and they go somewhere else to get another sign on bonus. And so, it is a BAND-AID solution. It does nothing to change the downward spiral that so many provider organizations are currently experiencing.

Rae Woods:
And this has to be why this is getting the attention of one key member, at least of the C-suite, which is the chief financial officer who is writing these checks. And from what you're telling me, it doesn't actually seem to be working. We're paying 40, $50,000 to get one person in. And it sounds to me like these nurses are still leaving the institutions.

Carol Boston-Fleischhauer:
A couple of additional issues here that executives in particular, chief financial officers and chief executive officers have to balance, for every registered nurse that you incent to come into your organization and you pay a huge sign on bonus in order to get them in, on the one hand, what you're doing is you were supporting your organization's ability to staff the organization perhaps over the next month but you're doing nothing to stabilize your workforce over the longterm. Nothing because these folks have no organizational loyalty to you. Furthermore, evidence has clearly shown that sign on bonuses generate incredible resentment amongst incumbent registered nurses, got stuck with organizations during the height of the surge.

Carol Boston-Fleischhauer:
Maybe with a little bit of bonus pay provided, but nothing in the level that the sign on bonuses. And so, put yourself in an incumbents shoes, why should I stay with an organization who maybe gave me a couple of pizzas and gave me maybe a $500 bonus check? When in fact people that are coming in from our competitors are now getting paid upwards of $40,000 just to accept employment. There's a disincentive to your incumbents at the same time.

Rae Woods:
But let me push back a little bit from what I'm hearing from the CFOs. I grounded this move in desperation, which I think is an accurate way of describing how these folks are asking. I think they know that it is a BAND-AID at best. And they might say, "Yes, I want to fix the structural problems of nursing but I need to fix this shortage problem that I have right now." And so they're almost willing to throw money at the problem. What do you have to say to that move? Is that the right thing to do, knowing that it's temporary, knowing the downstream impact that it's going to have on incumbent staff or do we need to think about different kinds of solutions here?

Carol Boston-Fleischhauer:
That's the only thing an organization does, is invest in sign on bonuses, as well as augment rotating staff with extended contracts, with agency labor. It's going to do nothing to stabilize your workforce over the longterm. So the expenses associated with chronic sign on bonuses and chronic use or over-reliance of travelers never goes away. It's a cost that frankly, from a financial standpoint, an organization just can't sustain. So if an organization has to resort to sign on bonuses and I get it, don't over rely on sign on bonuses and agency labor to the detriment of doing anything else to invest in what you've got to do to stabilize your incumbent workforce at the same time. It's not an either or it's a both and.

Rae Woods:
So then let's talk about what it would really take to stabilize the workforce. Now, I'm not sure the right way to think about this is as purely a COVID-19 problem. Obviously the pandemic has made this a lot worse but are there underlying reasons that existed before the COVID-19 crisis that showcase the fragility in the nursing workforce, especially in the inpatient space?

Carol Boston-Fleischhauer:
Yeah. It's interesting, a lot of folks may have forgotten but we were already facing a growing nursing shortage, pre pandemic, many organizations were starting to grapple with that issue on how to retain their nurses, especially their novice nursing staff from leaving within the first one or two years of employment, unfortunately and understandably organizations had to prioritize COVID readiness and COVID care over just about everything else. So things like focusing on vulnerable engagement drivers and professional development and all the things that we normally do to retain employees were suspended. The problems are still there.

Carol Boston-Fleischhauer:
It is to say that in addition, however, to the preexisting conditions of a very complex care environment that we were trying to retain nurses in pre COVID. The damage that staff incurred during COVID has left indelible marks on them. Everyone has seen the data, we've got more mid-career nurses, either taking extended furloughs to regroup if not leaving their jobs, if not the professional together because of what's happened to them. We've got a battered workforce here. That's been through a lot and we haven't addressed the pre-existing COVID conditions that we were dealing with prior to COVID hitting our organizations as well.

Rae Woods:
And by the way, this is a great teaser for the episode that we are going to have next week, which is continuing this topic of the crisis of the workforce but focusing on how we can address some of the moral injury that people on the front lines of this war are facing every day. So what you're telling me is that this is not a problem that is going to go away if and when the pandemic wanes. Now let me force myself to take a positive take for a moment. The one glimmer of hope that I have is that people are talking about this crisis who are not just nurses or who are not just nurse leaders. I have never before in my career had so many executives, CEOs, CFOs COOs, these core members of the executive team come to me and you and our colleagues at Advisory Board and say, "Help me combat this workforce issue." We talked a little bit about the CFO concern. What are you hearing specifically from the CEOs?

Carol Boston-Fleischhauer:
Well, from CEOs, I'm understandably hearing all sorts of concern regarding the continued commitment to making certain that the organization or the system safely provides high quality care at the same time, making certain that beds stay open and services are offered in order to support the healthcare needs of the community. And so CEOs clearly have got a vested interest in safe, efficient staffing as an alternative to closing beds, closing services and obviously impacting revenue. We've got chief medical officer's expressing the same concern. If they can't get a case on because you've got a shortage of perioperative staff or you can't admit a patient into an organization because beds are closed. Physicians are frustrated because of the care that their patients can't have at the same time, as a consequence of the staffing shortage. This has got a ripple effect across everybody. This is not a nursing labor issue. This is a strategic challenge.

Rae Woods:
And I agree with you completely, especially on some of these ripple effects. When we start to think about safety, when we start to think about never incidents happening, I actually had one physician leader say to me, pretty bluntly, "Nobody is working at top of license at my hospital." I don't know if that's a sentiment you've heard but I hate to say that (beep) really it's rolling downhill. And I've heard from nurses that they are cleaning rooms, delivering food. This is not something that is just impacting one aspect of the workforce it's impacting everyone.

Rae Woods:
So this is a strategic issue and it's an issue that you're hearing from CMOs, from CEOs. I want to come back to the CFO for a moment. We talked about the cost side of the equation. Needing to write these massive checks but I'm guessing they're also very, very concerned about the revenue side of the equation.

Carol Boston-Fleischhauer:
I know that many organizations are being forced to use some sign of sign on bonus incentive. As well as augment their permanent staff with increased use of traveler nurses, why? To keep beds open, to keep revenue flowing, to keep services available for members of their community. But it is only to say that if the only thing an organization invests in is incentives for new hires and acquisition of traveler contracts over an extended period of time. As I mentioned before, that expense is going to continue to be hitting your organization's bottom line, which is why as it relates to sign on bonuses for example.

Carol Boston-Fleischhauer:
We're seeing an increased number of organizations say, "You know what, I'm going to use a little bit of a sign on bonus but I'm also going to use a retention bonus. I'm going to incent employees that stick with us versus use that precious pool of money only to attract new people in or I'm going to use some of that money for employee referrals so that we can, once again, reward our employees who are talking to their friends or their colleagues throughout the community to see if in fact employees can bring new candidates into the organization without these outrageous sign on bonuses." So, there's a limited amount of money. The question is where do you invest it to get the best return on investment that you possibly can?

Rae Woods:
And if you're forced to make one of these BAND-AID moves, it sounds like you're starting to at least hear from some folks that they're connecting that desperate move to something else. It's the sign on bonus and because we know that this has to be temporary, otherwise we're just going to be making the problem worse.

Carol Boston-Fleischhauer:
Well, you're raising an interesting assumption there. And that is that people would presume that this is not the only set of things that we need to do. I'm just saying BAND-AID solutions are just that, they have a place, they have a purpose but to only use investment money to support BAND-AID solutions will do nothing to turn the situation around within your organization. So the question is, if you've got a finite amount of money, how do you use some of it to support the immediate staffing needs of your organization in order to ensure that beds stay open and services are available within the next month but at the same time, invest in what it is that registered nurses are saying is pushing them out the door in the first place?

Rae Woods:
And what is it that frontline nurses are saying they want from their employer?

Carol Boston-Fleischhauer:
Well, number one, registered nurses are saying, I am leaving this inpatient environment because of the excessive workload and not enough support. You mentioned earlier Rae, this notion of registered nurses being forced to do all sorts of things that are not at top of license. Absolutely that's the case. So, how is it that an organization says, "We want to protect our registered nurses. We want to make certain that they can practice at the top of their license and their capability but we shouldn't have to rely on our registered nurses to pass trays and to empty garbage and to change beds and things of that nature, unlicensed sets of activities." So enter the entry level worker strategy. We're seeing smart healthcare organizations say, "Boy, we've got to develop a pipeline here for support staff to support our registered nurses so that they don't feel as if they're not getting the support that they need."

Carol Boston-Fleischhauer:
This is tough for provider organizations because entry-level workers in every industry are a hot commodity right now. And hospitals unfortunately, are now competing with the likes of McDonald's and Walmart and Costco and so not only does entry level, salary levels have to be looked at but also what else are you providing for these folks so they'll stick with you as well? 401ks and PTO and professional development. That's what an entry level worker is looking for. No different than what a professional worker is looking for as well.

Rae Woods:
But perhaps that's a good example of your point about using the limited dollars that you have and spreading them around appropriately. And instead of putting $50,000 in hiring a single person, how could I spread that around to make sure that we're supporting the support staff that are going to help far more than one single registered nurse?

Carol Boston-Fleischhauer:
That's right. That's right. I'm working with a large system at the moment who since January has spent $140 million on agency labor, 140 million. Now it's a large system mind you but $140 million. And so what the leadership team is saying is, "All right, we can't eliminate agency labor immediately, we can't." But if we took a look at the sum of $140 million and we said, "We're going to try it, we're going to figure out how we're going to titrate the reliance of our organization on contract labor over the next 18 months to two years." So how can we use one of that $140 million on things that we know registered nurses need in order to stay employed with us, support staff, professional development, meaningful recognition. And by the way, we haven't talked about this yet but also support for the first line nurse manager. We've talked about the role of the nurse manager, being the chief retention officer for years.

Carol Boston-Fleischhauer:
These first line nurse managers have been as battered as frontline employees over the past few years. And yet we know that an effective frontline nurse manager can impact staff engagement five times the national norm, as well as decrease registered nurse turnover at the operating unit level, by almost 40%. If in fact the registered nurse has the time to focus on the human resource needs of his or her employees. And so how do we invest in nurse managers? How do we use that limited money rather than using all of it for travelers, all of it for sign on bonuses, how do we redirect some of that money over to what we know will make a difference?

Rae Woods:
And I think what you're getting at here, Carol are some of the solutions that are at the finger tips of executives that go beyond these BAND-AIDs that we know are going to have negative ripple effects for everyone. And for perhaps years to come. What are some other shorter term moves that you want to make sure executive teams know about so that they're not forced into these completely unsustainable financial moves.

Carol Boston-Fleischhauer:
As I work with executive teams, I try to encourage them to not get ahead of their skis. In other words, let's start by what we know can be impactful in the short term to stabilize the Exodus of your clinical workforce. And so I've mentioned before tried and true evidence-based HR retention practices, attention to vulnerable engagement drivers, making certain that you've got a relevant professional development program because it was suspended during COVID, making certain that you've got meaningful recognition are examples of tried and true HR retention and best practices. We are seeing organizations continue to struggle with the basic process of getting a willing candidate in the door for an interview, an offer made, an offer extended, the offer accepted and the employee's first day of employment.

Carol Boston-Fleischhauer:
You got to presume that every registered nurse who's looking for a job is getting lots of offers. And so the question is, how do you expedite the process of identifying a candidate, interviewing that candidate, making an offer, in getting that individual in the door as rapidly as you possibly can so you don't lose that candidate to your competitor. If Amazon prime can deliver anywhere in the country within 24 hours, why can't we deliver an offer at least as close to that timeline is as possible? So we've got to think about that from a very different vantage point.

Rae Woods:
We started off this conversation in a really sobering place but what you're actually giving me now, Carol is quite a bit of, of hope because what you're telling me is that there's actually a lot that can be done to support the nursing workforce. And there's a lot of stuff that folks aren't necessarily trying, or maybe they're doing it in pockets because they're defaulting to these desperate decisions. The most important thing that I've heard you say in this conversation is that we need executive teams to solve some of the root challenges in the nursing workforce in order to make a long term difference.

Carol Boston-Fleischhauer:
Actually, I'd push on that. It's not problems within the nursing workforce, it's problems within the healthcare environment, within which nurses are being asked to work.

Rae Woods:
Ah, this is important, the system in which nurses are asked to work.

Carol Boston-Fleischhauer:
The system itself. Yeah, yeah, yeah, yeah. I mean, we have got so many complex variables here that once again, I mentioned we're rising to sea level pre pandemic that never were solved.

Rae Woods:
These are the things that are ultimately going to improve the value proposition for the folks who are leaving the workforce in droves. So my final question to you is, if you had one message for C-suite leaders to take away or act on so that they can create a system that nurses want to work for, that they see value in, what is that thing?

Carol Boston-Fleischhauer:
There are here and now things that every C-suite needs to make certain that they address. There are also some more complex changes to the environment within which nurses practice that need to be simultaneously attended to, as evidenced by what nurses are saying themselves, that's pushing them out the door. So organizing work differently by putting in place team based care versus primary or total patient care. Taking a look at how we can use virtual care technology, not just to expand physician practice and access but also to support staffing strategies. We also mentioned, of course, the importance of the role of the nurse manager. And finally, don't underestimate what registered nurses are looking for in terms of employment flexibility. Here and now tactics let's get retention under control but don't underestimate what registered nurses themselves are saying is pushing them out the door. We've got to confront those structural issues as well.

Rae Woods:
So if we need executives to understand exactly what nurses need and want and invest in the long-term solutions that are going to get them there. I'm curious, do you have a final message for the nurses themselves that are on the front lines?

Carol Boston-Fleischhauer:
Be part of the solution. Take advantage of the opportunities that I believe your leaders are affording to you to think creatively, think out of the box about the structural barriers that are pushing you away from inpatient care, be part of the solution versus sitting on the sidelines because we have to solve this together, we can't solve it without you but you need leadership to partner with you at the same time.

Rae Woods:
Well, thanks for coming back on Radio Advisory, Carol.

Carol Boston-Fleischhauer:
Thank you.

Rae Woods:
Carol talked about so many different tactics to support the workforce in the short term and in the longterm. But if there's one piece of advice that I want to make sure that you remember, it's the idea that this is not just the workforce issue and we need executives of all kinds to make sure they're creating the system and the environment for which nurses want to work. And for which nurses see value, that's the way that we're going to support, not just our frontline staff but ultimately patients. So remember as always, we're here to help.