Rae Woods: From Advisory Board, we are bringing you a Radio Advisory. My name is Rachel Woods. You can call me Rae. On this podcast, it is always my goal to share bold ideas, new insights, fresh tactics. But today, I'm going to dig back into some of the recommendations that I've already told you. Because when it comes to protecting the nursing workforce, I'm not seeing nearly enough action. That's why I brought two nursing experts to today's episode, Monica Westhead and Carol Boston-Fleischhauer. Welcome to Radio Advisory, Monica. Welcome back, Carol. Monica Westhead: Thank you. Nice to be here. Carol Boston-Fleischhauer: Nice to see you. Rae Woods: Monica, this is your first time on Radio Advisory. No pressure. Are you a loyal fan? Are you a loyal listener at this point? Monica Westhead: I can confidently say this is the only podcast I listen to. Rae Woods: Wow. I don't know if that is really good for me or really bad for podcasts in general. Monica Westhead: I'm not a big podcast fan in general, but I feel like Radio Advisory always has some interesting bits of wisdom. So I love this one. Rae Woods: And now you get to be one of the people that's offering that wisdom. Rae Woods: Well, we've officially been fighting covid-19 for more than two years, which of course means that nurses have spent more than two years on the front lines of that battle. Do some level setting for me. How would you describe the state of the nursing workforce right now? Carol Boston-Fleischhauer: The nursing workforce across the country is just starting to recover. The aftermath of the worst public health crisis that most have ever witnessed. Those that remain employed are incredibly proud of their accomplishments, but they are also very, very tired. And they are questioning, not so much a career in nursing, but the commit to inpatient care delivery, of all of the RN jobs out there, is absolutely the hardest. Rae Woods: What about you, Monica? How would you describe the nursing workforce right now? Monica Westhead: I agree with Carol. I think they are tired. They're burned out. They are frustrated with the environment in which they have been working for the last several years. I think it goes beyond just the COVID-19 pandemic. The pandemic has surfaced some of the things that have always been problematic for the nursing workforce. I think we've just reached a breaking point for the nursing industry. Rae Woods: That's left a lot of nurses themselves leaving the industry. Maybe they're leaving bedside nursing, like Carol mentioned, or maybe they're saying, "Hey, I don't even want to be in this healthcare business at all," which has left us with some very serious staffing shortages. That's something that many leaders felt during the latest Omicron surge. Now, Carol, I know that you've been on this podcast before, frankly, even before Omicron, to talk about the fact that these shortages were challenges, not just for chief nursing executives, but for every single member of the C-suite, right? CFOs were willing to pay just about anything to make sure that we had enough bodies available to staff units. But my question is, did paying for more nurses actually fix the problem? Carol Boston-Fleischhauer: Well, I think what you're referring to is C-suites paying a lot of money for traveling nurses. During the height of the various surges, there was not necessarily a significant uptick in compensation for permanent staff. Rae Woods: That's right. Carol Boston-Fleischhauer: It was the need to bring in all sorts of agency staff to supplement the tremendous shortages and vacancies that hospitals and healthcare systems experienced and still experience even today. We have not fixed the permanent nurse compensation problem yet. And we've got to go there. We've got to go there because there's just too many registered nurses that have said, "I don't feel valued for what it is that I've committed to, what it is that I'm willing to continue to commit to." Especially in today's environment where inflation is so high. We cannot continue to support these folks with the 50 cents an hour increase and call it a day. Rae Woods: By the way, I think you bring up something really important there, Carol, which is that even those CFOs threw a bunch of money at the problem in the form of travel nurses, which of course drove up costs for the system, it not only didn't fix the structural problems, but it also maybe created a new one. Where those legacy nurses who aren't being valued, whose compensation isn't changing, are saying, "Hey, what am I doing here?" Maybe actually left the workforce because they felt even less valued, right? We almost created a virtuous cycle for ourselves. Carol Boston-Fleischhauer: Well, yeah, I think there's both the significant percentage of permanent registered nurses that left permanent employment to go into travel nursing. Because they said, "Why should I do the same job when they paid half as much as what a travel nurse pays?" So there's that issue. In addition to the continued, I think, disillusionment of many registered nurses who just don't feel that the organization has responded enough with some of the structural changes related to the practice environment, such that they're leaving the inpatient practice environment altogether. Right now, only about 54, 55% of registered nurses in this country work in hospitals. They've got so many other job opportunities outside of hospitals, and that's going to get even more competitive if we don't get at some of these structural compensation issues very quickly. Rae Woods: So, we're seeing this churn, right? I think that churn is adding to another challenge, that frankly we have talked about before on this podcast, which is the experience complexity gap. Where do we stand with that challenge? Monica Westhead: The experience complexity gap is something that we've been talking about for a long time. Essentially what it is, is when you have nurses that are coming out of school or who may not have as much clinical experience because they haven't been in the workforce for as long, we're seeing an increase in those nurses with less bedside experience, at the same time as we're seeing an increase in patient acuity. So we've got patients that really need the expertise of an experienced nurse, but we're seeing fewer experienced nurses at the bedside. So all of the things that Carol was just talking about, especially thinking about nurses that are leaving the bedside at the hospital to potentially go work in other settings, it is increasing that gap in the hospital. Monica Westhead: Now, I will say that's not just limited to the hospital setting by any means. We also see it very much in post-acute care, for example. It's pretty common to go work in a skilled nursing facility either right when you first graduate from nursing school, because you want to get some experience to get hired at a hospital, or toward the end of your nursing career. So we don't necessarily see a lot of longevity for nurses working in post-acute care. I think that was true before the pandemic, but it's certainly exacerbated now. And when you have higher acuity in acute settings, all of that gets pushed downstream as well. Rae Woods: So the situation is bad. We don't have enough bedside nurses, or we don't have enough nursing expertise. This is where people start to use the word crisis. I'm not sure if crisis even begins to cut it when we think about what nurses have been going through. But if I'm honest, we've been having a conversation like this before. We've about how to help nurses, how to support nurses. And yet, we are still here using words like crisis. The question that I'm getting from health leaders is, "What the heck am I supposed to do now? How am I supposed to support these people?" Carol Boston-Fleischhauer: The foundational recruitment of retention practices that I think the entire industry is keenly aware of, we got to keep going with those. I mean, we have to keep going with what we know can solidly recruit and retain staff in our organizations. However, we've got to get at root cause as to why people are disillusioned with providing care in an inpatient environment. When we take a look at the disillusionment, it really comes down to employees saying, "I want much more flexibility in my work environment because I need it. If I can't get it from you, I'll go elsewhere." Secondarily, "I want an organization that really cares about my personal well-being." And third, I want an organization that will help me rekindle my sense of feeling valued and feeling as if I'm contributing to the purpose that I committed to in the first place when I became a nurse. These are tough issues to get at, but they're deeper than the standard recruitment and retention practices that we've talked about historically. Monica Westhead: Carol, I would agree with everything you just said. I would also add, nurses want professional development opportunities. And I think a lot of nurses leave the bedside because they want to pursue advanced practice. For many of them that is their career goal. But in other cases, it's because they're looking for some kind of professional development or professional growth that they don't necessarily see us able to provide to them within the current structure at the bedside. Monica Westhead: The other piece of the puzzle, I think, is support staff. If you are in a situation where you've got so much turnover and can't fill roles in the CNA ranks, that work has to go somewhere. In many cases, that work is going onto the RNs. So it's important to remember, as we think about RN turnover, RN staffing, that RNs are one piece of a very complicated, interdependent staffing puzzle. Rae Woods: All right, let me admit to both of you, I'm having a little bit of déjà vu here because I'm feeling like we've talked about this before. We talked about the challenge that nurses are cleaning up rooms, and they shouldn't be doing that because there is no support staff, like you said, Monica. We've talked about the fact that we need to truly show nurses that they are valued and not just throw them a pizza party. And we've said over and over again, that nurses need the kinds of flexibilities that fit into their world. And frankly, fit outside of 12 hour shifts that have existed since the dawn of nursing. Why am I having déjà vu? Why are we still out here telling leaders that they need to make these changes? Monica Westhead: I think these are very difficult changes to make. It's not that anyone doesn't know that we need to provide nurses more flexibility, that we need to rethink what those roles look like, but it is just a lot more challenging to actually do those things than it is to rely on the smaller pieces that I think leaders have been trying to use for the last few years, hoping that eventually this would go away. I'm not optimistic that the shortage is going to go away without some significant changes in the way that we structure nursing roles. Rae Woods: Hmm. Carol Boston-Fleischhauer: I guess I'd go one step further. I would say this is more than just C-suites feeling challenged by this. I think executive teams are now just coming to terms with what we're talking about in terms of a dollars and cents investment. When I'm talking dollars and cents investment to support the workforce moving forward, it's beyond compensation. It's taking the time that you need to put in place a significant process and working through any changes to make certain that the registered nurses, and other care providers who are being asked to staff work differently, are supported with change management, to be successful in working in different models and in a different roles. Rae Woods: Wow, you are exactly right. Because if I think back to the last two years, there were certainly moments where leaders pushed for flexibility, because they basically had no choice. But thinking about embedding flexibility into the career of a nurse, as just one example of something we need to do, that's a huge operational undertaking. How do leaders actually go about doing that? Carol Boston-Fleischhauer: Well, think about this for a minute. When we think about staffing an inpatient unit, we have relied on predictable 12-hour work schedules and predictable stable roles for one unit, for a registered nurse to work in. So if we're talking about flexibility in, for example, shifts, where we have four hour shifts or six hour shifts, we are totally disrupting the workflow of the standard 12-hour shift. Working as a registered nurse over the years, I had a schedule in my mind as to what I was supposed to do at 9:00, at 10:00, at 11:00, at 12:00. If you're interjecting different shifts into the 12-hour model, then you've got to have different handoff processes. You've got to have different relationships and operational supports between the staff that are coming and going in between that 12-hour model. This is hard to do. We've talked about it a lot, but this is really hard to do. Monica Westhead: I also think shift flexibility is certainly one of the most important angles of flexibility, but another piece that a lot of health system leaders don't necessarily think about is where people are working. Flexibility in terms of care setting, in terms of actual job role, I think a lot of leaders are still thinking about staffing based on individual units. So, "Do I have enough staff to run this med surg unit on this day?" Versus more system oriented thinking. Monica Westhead: Because when you think about what nurses want, you may have some nurses that have not thought, for example, about working in home health, but that's actually a really good fit for them because of the schedule flexibility, or because of the difference in commute. Or working in a skilled nursing facility might be good for people who are looking for a specific amount of autonomy or leadership that they might not find in an inpatient unit. So I think we talk about flexibility, we don't want to lose sight of what that means in a broader sense. It certainly means shift length, but it also means, what type of work are they doing and where are they doing it? Carol Boston-Fleischhauer: Yeah. I mean, I guess, Monica, from my perspective, where I'm hearing most of the concern right now is not so much the allowance of registered nurses to work in other sites or settings within the care system, or broadly defined, as much as, "How do I keep registered nurses in the inpatient setting as long as is possible?" Because that's the biggest pain point that I think hospitals and healthcare systems are collectively saying is at a crisis level that shows no signs of reversal. Rae Woods: By the way, Carol, that might be true. That might be true. That because the biggest problem is in bedside nursing, the kind of flexibility we need to prioritize first is kind of the basic shift type. But I think Monica has a really important point here. Because the shortage is so dire, I think the only way that we can actually address this problem is to think about the career of nursing in general and allow these kinds of flexibilities. Because the opposite is probably also true. Just like some bedside nurses want to move to a post-acute setting or home health setting, there are probably also folks that want to, for a period of time, not for eternity, practice bedside nursing. That kind of flexibility, I think, could allow us to kind of share our resources more broadly. Monica, what do you think about that? Monica Westhead: I think we have to think about nursing as an industry on the whole. Because certainly, there is a huge staffing crisis when it comes to inpatient acute care nursing. I would argue the same is true for skilled nursing facilities. They are having a really significant problem with staffing nurses, RNs and LPNs, in those facilities. At the same time, I heard from a nurse leader recently that they were just trying to keep nurses working in their system. Their goal was, "I have a nurse that doesn't want to work full time anymore. Wants to work only a certain amount of hours per day." This CNO was thinking, "Well, can I have that person ... can I propose to that person that they do home health and they only take three visits a day?" By doing that, it would allow that nurse leader to keep that nurse in the system and to retain that nurse, who may at some point decide they want to come back to the bedside in the hospital, but it would keep that person from having to leave the system to get that type of flexibility that they were looking for. Rae Woods: Or potentially to go to a competitor. Monica Westhead: Yeah, exactly. Carol Boston-Fleischhauer: Right. I think organizations and systems that have, that they own post-acute care, they own home health, they own ambulatory practices. I'm seeing more and more executives say, "We've got to allow these folks to move around, so long as they stay an employee of our system versus leave the system altogether." Rae Woods: Which by the way, is a completely different way than we've thought about nurses before. There is not a single executive that I talked to that isn't focused on the nurse turnover problem. But this conversation is making me think that they're thinking way too narrowly about nurse turnover. They are thinking about turnover at the inpatient level or at the unit level. What you're describing is something that's a lot bigger than that. Carol Boston-Fleischhauer: I think what more and more systems are saying is we've got to measure turnover from our system, not turnover from a unit or from a site within the system. That type of turnover is actually internal churn. It's not turnover from the system. I do think more and more executive teams are coming to grips with that change and what the metric actually should reflect. Monica Westhead: I think turnover is a difficult metric because it is just looking at people in the door versus people out the door, as opposed to where they're going, what they're doing. I think we know that increasingly people that enter the nursing career are not looking to spend the entirety of their career at the bedside. They might want to do different things within that realm of nursing. So just looking at pure turnover is not necessarily giving us the whole picture of where these nurses are going and whether they are leaving the industry entirely, whether they're going to other sites of care, or whether, as Carol mentioned, they are pursuing some of these new opportunities that we're seeing pop up for nurses across the healthcare industry. Carol Boston-Fleischhauer: I disagree with what you just said, Monica. So I would be curious as to what you think should be the metric moving forward. Monica Westhead: I don't think that turnover is a bad metric. I think it's just that executives need to realize that we're probably not going back to a world where people are going to spend 20 years at the bedside anymore. So high turnover is probably just the norm. Rae Woods: I agree with that, because, honestly, no other industry anymore measures loyalty by their employees in decades, right? That's just not the economy that we live in today. The idea of a lifelong employee feels very, very antiquated outside of healthcare. So I'm not sure why we're trying to get back to that inside of healthcare. What I love that you're describing is the idea of enabling nurses to become system citizens, folks that are not loyal to a unit, but are loyal to the entire enterprise. Which by definition means they could move around. They could adopt different shift lengths. They could move into the post-acute world. They could move back into the bedside. And that loyalty is to the enterprise, not necessarily to something as small as a unit. Which does make it much more difficult to measure, but perhaps that's the goal that we're moving towards. Rae Woods: We've focused a lot on flexibility here. We've talked about flexibility that nurses want. And frankly, we've talked about some of the flexibility that hospitals still need today. These are big changes that we're suggesting, that involve a lot of operational firepower. But my question is, is that enough? Is that going to be enough to address understaffed units that truly have of a shortage of bedside nurses? Carol Boston-Fleischhauer: Well, we've agreed that to achieve true workforce flexibility is hard. And we, I think, are also agreeing that that in and of itself is not enough. We have a demand supply imbalance of registered nurses in this country. And we can't continue to staff our inpatient units with the type of legacy staffing models that we had when we had enough registered nurses in this country. So the second structural challenge here is really getting aggressive about alternative staffing models above and beyond what we've historically done in the past. That's hard philosophically. It's hard operationally. It's also hard from a dollars and cents perspective. Because when you're changing the work of what a registered nurse does, including who she or he might be working with to support the work, you need time, you need coaching, you need change management support in order to transition these folks into a new way of working. That's another example of the investment that I'm talking about here. You can't change a staffing model on a dime. It takes time to do this right. And time is money. Rae Woods: I'm curious that we're this far into our session and neither of you have brought up a word that is used a lot when we talk about nurses. Neither of you have brought up the term resiliency. Why is that? Is that missing from this conversation? Monica Westhead: I think resiliency is really important. We all know that we have to support our nurses. We have to provide them the mental health support that they need, the rest that they need, but none of that is enough. I think a lot of leaders will sometimes focus on resiliency to the exclusion of putting in the additional work to actually make these structural changes. They will say, "Well, I'm providing time off. I'm providing aromatherapy. I'm providing mental health support." But they're overlooking the root cause of some of the issues that are causing this burnout in the first place, which are a lot of these structural issues that Carol was just talking about. Rae Woods: That's why we're basically describing changing the career of what it means to be a nurse, and what it means to practice at the bedside. Carol Boston-Fleischhauer: I don't know that we're suggesting that we need to change what the career of a nurse is, but I think what we are suggesting is, a work environment for a registered nurse that doesn't work is not going to help to support resiliency of the worker. You've got to get at the work environment and change the work in order for the individual to feel relatively stress free, confident that the types of things she or he will need on a daily basis to provide care are always there, and the processes are functional versus dysfunctional. Resiliency, of course, is important, but resiliency is more than just emotional support. Monica Westhead: That's right. Carol Boston-Fleischhauer: Resiliency also requires structural change to the work environment within which these workers are trying to be successful. Rae Woods: So if we need to be willing to change the structural aspects of nursing, what is the one thing that you want our listeners to focus on right now? Carol Boston-Fleischhauer: To change the structural environment within which registered nurses work does not compromise nursing practice. It does not compromise what it means to be a nursing professional. In fact, it's just a reflection of the organization, responding to what today's professional needs in order to remain effective. Carol Boston-Fleischhauer: To my colleagues who remain concerned that some of the massive structural changes we're suggesting could denigrate what the historical role of the registered nurse has been, I would say, "Gosh, don't view this from a glass half empty perspective, view this from a glass half full perspective. We're trying to help the registered nurse be a professional in today's environment versus continue to cultivate an environment within which the professional nurse cannot function at the top of license." Monica Westhead: Carol, I love everything that you just said. I've been hearing a lot about people saying that nurses finally know their worth. I think nurses have always known their worth. We're at a point now where executives beyond just the CNO are starting to realize the critical importance of the RN, and the environment that the RN is practicing in, to the success of the overall health system. And I think if I were to think about the one thing that I would want people to take away, it would be that system thinking element. You can't fix the nursing problem without fixing the support staff problem. You can't fix the nursing problem in one setting without thinking about other settings. So as much as I agree with Carol about making sure that we are providing opportunities for nurses to really enjoy being nurses again, I think we also need to think strategically about the role in which we are putting nurses, and how we are supporting them structurally across the healthcare delivery system. Rae Woods: Wow. Well, there are definitely no easy answers here anymore, but I'm glad that the two of you are working with executives and trying to push us to really think differently about nursing. Thanks for coming on radio advisory. Monica Westhead: Thank you, Rae. Carol Boston-Fleischhauer: Thank you, Rae. Rae Woods: I keep hearing organizations and leaders ask themselves, "How can we show nurses that we value them?" Monica and Carol are right, there are no easy answers anymore. The best way that we can can show nurses that we value their work is to actually address some of the structural root cause problems in nursing. It is not going to be easy, but remember, we're here to help.