Rae Woods (00:02):
From Advisory Board, we are bringing you a Radio Advisory, your weekly download on how to untangle healthcare's most pressing challenges. My name is Rachel Woods. You can call me Rae.

(00:14):
We are entering our fifth year of Radio Advisory, which means that this is our fifth Nurses Week episode. If I think back on the episodes that we've created to honor nurses and name their needs, it is obvious that things have gotten better since May of 2020. But I think that's actually less of a reflection of widespread industry progress and more about how our very circumstances have changed. For one, we're obviously not smack dab in a pandemic anymore. Labor costs have come down, but are we really out of the woods? I'm not so sure. In fact, I'm afraid we've become a bit numb to the ongoing workforce crisis because the reality is that nursing turnover, burnout, shortages, these are all still very real problems today.

(01:01):
If provider organizations want to truly do better for their nurses, quick fixes won't work anymore. And no, celebrating them one week out of the year won't work either. Leaders need to invest in sustainable solutions, ones that will require them to fundamentally reimagine the nursing care team and maybe even think beyond the nurse.

(01:23):
To talk about all of that, I brought on Advisory Board nursing experts, Monica Westhead, Allyson Paiewonsky, and Ali Knight. Welcome to Radio Advisory.

Monica Westhead (01:33):
Good morning.

Allyson Paiewonsky (01:34):
Hey, Rae. Thanks for having us.

Ali Knight (01:35):
Good morning. Happy to be here.

Rae Woods (01:38):
First thing I should say to all of you is Happy Nurses Week.

Monica Westhead (01:41):
Happy Nurses Week.

Ali Knight (01:41):
Happy Nurses Week.

Allyson Paiewonsky (01:43):
Happy Nurses Week.

Rae Woods (01:44):
I'm excited to be with some of you again, some of you for the first time to celebrate this day, this week, this important part of the healthcare workforce. I'm going to do something dangerous right away because this really is supposed to be a celebration, and I want it to be a celebration. But can I admit to the three of you that I'm frustrated? It feels like we've been talking about the same problems and sharing the same message for a while now. I have a feeling that you're going to tell me that despite my frustration, despite our listener's frustration, we are absolutely still dealing with a workforce in crisis even if things aren't quite as urgent or as bad as they once were. Is that correct? Allyson, let's start with you.

Allyson Paiewonsky (02:30):
Yeah, I think that that is safe to say. I think unfortunately that is exactly right, Rae. But we have seen some positives since we last spoke. There has actually been an increase in the number of RNs who are entering the workforce again. We have seen a rebound since COVID, which is great news.

Rae Woods (02:48):
Great news.

Allyson Paiewonsky (02:49):
But we're still seeing elevated turnover and vacancy rates as well as a real big shift in where RNs want to practice. Where we need the most is not necessarily where they want to practice. So certain settings like post-acute or acute care settings are still really struggling with those turnover rates and feeling that brunt of a nursing shortage still.

Rae Woods (03:11):
Ali, I know you get on the phone with and talk with nurses and nurse leaders every day. Is the sentiment in the data that Allyson is talking about showing up in your conversations?

Ali Knight (03:21):
Absolutely, yes. Nurse leaders are working hard, but making only incremental headway so far in addressing some of these challenges.

Rae Woods (03:32):
I did just say that we've been doing podcast episodes on this topic for the last several years, but the truth is this actually extends long before Radio Advisory existed. There are decades of Advisory Board research on nursing. It is something that the three of you and your research teams are certainly not slowing down on in terms of your focus area. My question is, and I don't mean to be negative, but is the message we and you have been giving to the market sinking in? And if it's not, what barriers are getting in the way of us making progress on this? What do you think, Monica?

Monica Westhead (04:13):
I think the message very much is sinking in. I think everyone across the executive team, across the leadership team in healthcare knows the importance of making improvements for the workforce. I think the challenges here are many. Health systems are still struggling financially coming out of the pandemic. I think there's a bit of a disconnect in terms of how provider organizations understand the needs of the people that they're employing and the demands and what people want as the new generation of the nursing workforce.

Rae Woods (04:47):
Yes.

Monica Westhead (04:48):
I also think that it's not just about numbers. It's not just about how many nurses you have. At this point, it's also just about a lack of expertise and a lack of clinical experience.

Rae Woods (05:02):
Among the nursing workforce, you're saying.

Monica Westhead (05:03):
Among the nursing workforce. There are a lot of challenges that we're facing even though we have seen significant improvement in investment.

Rae Woods (05:12):
There are all these barriers, but I agree with you that leaders, even non-nursing leaders understand that this is a problem that we need to get ahead of and we have to move to sustainable, scaled solutions. I will tell you my goal for this conversation is that everyone who's listening to this episode can walk away and know exactly what to do, so that 12 months from now we're not having this same conversation again. In order to help them do that, I do think we need to name what is different about what they need to do to support their nurses in a sustainable way that we haven't actually said before.

Monica Westhead (05:49):
I think a lot of it is about the work that nurses do and really putting some focus now on what is the work that actually needs to get done in the clinical setting, who is doing that work, how the work gets done. I think there's been so much focus on the HR issues and making sure that you have enough people, but as I said, this isn't a numbers game anymore. This is really focused on what is the work that needs to get done and how is it going to get done, whether that's through members of the care team or through technology.

Rae Woods (06:26):
You're also talking about a shift that's a lot bigger. Dare I say, it's a little bit more philosophical or it's more uprooting of what we're asking of nurses than things we've said in the past. Like be more flexible, allow folks to work in different locations, change the hours that they work, things like that. It sounds like you're talking about something much bigger than that.

Monica Westhead (06:46):
Yes.

Rae Woods (06:47):
Let's talk about the first one you mentioned, Monica, which is who does the work? Are you saying that the future of nursing is maybe not just about nurses?

Allyson Paiewonsky (06:58):
Yeah, I think that's exactly right, Rae. I think the way we're thinking about solving the problem right now is solving the nursing problem with more nurses, but there aren't more nurses to solve that problem.

Rae Woods (07:08):
Despite the fact that you said graduates are up, right? There's still not enough.

Allyson Paiewonsky (07:12):
There's still not enough, and there's still not enough in the settings where we need them the most. Finding ways that we can think about how we're supporting the nurses that we do have to do the work that needs to be done. That could be thinking about different support roles or even completely new roles that we haven't thought of or even considered in healthcare before, and bringing those into the care team so that they can support nurses could also look like technology and using technology to support nurses as well. I think there's lots of options there, but work doesn't just need to be done by nurses, and it can't just be done by nurses because there's not enough of them and they don't have the experience to do it either, as Monica mentioned.

Rae Woods (07:50):
Ali, are nurses receptive to that being the answer? We want to make sure that we're still celebrating RNs this week and beyond. Are they welcoming, and perhaps not just RNs, but LPNs, CNAs, do they understand that this is what's going to ultimately help them, that this is the right answer for them?

Ali Knight (08:09):
I think they're on a varied spectrum of how they feel about this. As we're talking with other leaders, the change management aspect of it seems to be really critical. The organizations that have found a lot of success with these expanded care models have included the front line in the development of the model, and they've seen higher engagement. Whereas those that have added to the care model without some of that inclusion of the front line, they're struggling a little bit more with the division of work that comes with the expanded care team.

Rae Woods (08:42):
Listeners, you just heard a big lesson. It is not about just saying, "This is what we're going to do," it's about bringing the workforce and the nurses in as you are implementing solutions like this that we know can be helpful.

(08:55):
I do want to channel the pushback that I hear, and it's actually something that Monica already said, which is that the who isn't just about the person, it's not about the title, it's not about the license, it's about the experience. This gets really tricky when we have, as Allyson mentioned, lots of new grads, but those new grads don't necessarily have the same practical experience, obviously, as somebody who's at the end of their career or who's recently retired. I imagine that comes with its own set of challenges when we're talking about sustainability and changing who does the work? How do we get around that?

Allyson Paiewonsky (09:32):
I think a lot of the issue is that the way that nursing schools are educating nurses right now is not preparing them for the reality of practice. So you have a lot of new grads who are entering practice and they don't have the right expectations or understanding of what it looks like day to day. They don't know how to take care of the patient load that they're expected to take care of once they enter practice. Finding ways to make sure that they have the right expectations and the right support when they're actually entering your hospital and beginning their practice, I think is really crucial so that they have the right expectations and those expectations align with the work that needs to be done at your organization.

Rae Woods (10:06):
Because that's what our listeners have control over. We might want to or need to eventually change the way we're thinking about nursing school curriculum, but let's not wait for that is what I'm hearing.

Allyson Paiewonsky (10:16):
Yeah, exactly. I think that that is something that our listeners have less control over and would take a lot more movement and effort to change. What you do have control over, like you said, Rae, is who you have in front of you and how you're preparing them for practice.

Rae Woods (10:30):
Where does that bleed into not just expectation setting, but training and supporting those new grads in a way that's sustainable for the organization, but also for the rest of the care team? We are trying to avoid more turnover, more burnout, more frustration.

Allyson Paiewonsky (10:46):
I think that that is one of the issues is I hear a lot of hesitancy to invest in training the staff if we know that first years have some of the highest turnover rates of the nursing workforce. Why am I putting work into investing in the staff and preparing them for practice if I'm not getting that return on investment if they're not going to be loyal and stay at my organization? But I think there's potential to have really negative impacts on patient care.

(11:10):
I think there's also almost this moral obligation of it's on us to prepare the next generation of nurses. I know that's not always the argument that wins healthcare executives over, but we do need to prepare this new generation of nurses to take on the really complex patients that we know are coming down the line and are in our healthcare systems today.

Rae Woods (11:30):
And figuring out how to make it a win for the existing nurses and members of that care team that are going to be doing that training. We can't just ask them to do more. How do we make it an engagement lever for them or a retention lever specifically?

Ali Knight (11:48):
In order to make progress here, we'll need to think differently about onboarding new nurses than what we did even five or 10 years ago because the experience we have left to precept these nurses and support them looks very different. What may have been successful in the past is going to need to be shifted or rebuilt in the future, which might mean different types of orientation or a little bit longer onboarding or increased support after that onboarding happens.

Monica Westhead (12:19):
It's worth noting that residency programs are not new. Organizations have been doing nurse residency programs for decades, but I think there is a new, there's more ROI to do them today if you can truly get people invested in continuing their careers and preparing them in a way that's going to promote longevity in their nursing role.

Allyson Paiewonsky (12:42):
Yeah. I think when we're thinking about onboarding, it's also important that when we're thinking about the nursing care team, we're not just thinking about nursing centric support staff and really expanding our vision of who belongs on the nursing care team or who can help support our nurses. Thinking about how do we bring in roles like transport or phlebotomy and really integrate them into what we traditionally think of as the nursing care team, and then even expand our vision and create new roles for the future and think about who else we could bring in to offload some of that work for nurses and support them with care delivery.

Rae Woods (13:14):
When we're talking about the who, first of all, we are literally talking about a larger group of people, not just RNs, not just CNAs, not just LPNs, a lot of this extra support staff. We are talking about the different expertise, and I guess tenure level of who these folks are and making sure that we are guiding them, training them along the way.

(15:12):
Now, let's get to how the work gets done. We already mentioned technology, and this is where I hear folks really seeing tech as the answer to sustainability. They're talking about it as being the thing that's going to get nurses themselves out of being burned out and are going to be the miracle for our business. Is that the way that we should be thinking about virtual nursing and tech enabled nursing workforce?

Monica Westhead (15:40):
I think that's a really interesting question because I think those actually need to be separated. From my perspective, virtual nursing is very different from a technology enabled workforce. I think they both have a role in improving future care delivery, but I don't think that virtual nursing is going to be the savior that a lot of organizations think it is. Virtual nursing in itself is not a technological solution. It is having a nurse that is not physically at the same location. It's basically telehealth, right?

Rae Woods (16:13):
You've changed where they've worked, but you haven't changed, to your point at the very beginning, Monica, what that work is or any of those other parts.

Monica Westhead (16:18):
Exactly. It has really important purposes. You can use it in rural environments where maybe you don't have as much clinical expertise, situations where you're trying to offload tasks like admissions and discharges that just take a lot of time, but don't necessarily need someone there in-person.

Rae Woods (16:35):
I'm guessing you're not going to tell me that we shouldn't do virtual nursing. It's merely that it is not the singular answer to workforce sustainability.

Monica Westhead (16:44):
Yes. I think many nurse leaders when we talk to them and we ask about technology, they say, "Well, we're doing virtual nursing." That's great, but it's not going to solve all of their problems. I think technology for nurses needs to be thought about in a much broader context, including things like AI, ambient listening, all of these other types of technologies that I don't think are being thought about as much specifically for nursing.

Rae Woods (17:10):
Yes, yes. You said that virtual nursing is not the same thing as a tech-enabled workforce. What would a tech-enabled nursing workforce look like that actually gets to the sustainability that we're trying to achieve, both for the individual humans and for our business?

Allyson Paiewonsky (17:25):
I think that it would be a tech-enabled workforce would allow nurses to do the work that they want to do and be able to provide that hands-on patient care that they should be providing. Thinking about what are all of the tasks and things that nurses were really never intended to do or went to school to do. They didn't go to nursing school to do documentation in the EMR. That is not something that they want to do. That's not something that brings them joy or is an engaging task for them. Thinking about how do we take away that work and bring back that, maybe, joy in nursing or bring back that ability to provide hands-on care without all of these other tasks that are weighing them down.

Rae Woods (18:06):
Which is the same way that we talk about it for physicians, for APPs. I think what you're just saying is, hey, let's not forget the nurses.

Allyson Paiewonsky (18:16):
I think we often forget the nurses because the financial incentive isn't there the way that it is APPs or physicians. I think we really need to reframe how we're thinking about this and why we are making these investments in technology.

Rae Woods (18:30):
Let's be really specific about one investment in technology that everybody wants to make, which is AI. That's the big buzzword. Generative AI is the big buzzword of the moment, and we need to make sure that we're actually using it to improve the clinician workflow, the nursing workflow, rather than making it harder. Do a little bit of predicting for me when it comes to AI and nursing, is there a world where the future of AI and nursing would actually do some replacement here? I'm thinking about that virtual nurse example that Monica gave. Could AI actually replace virtual nurses or even what a bedside nurse can do, or am I thinking about this the wrong way?

Allyson Paiewonsky (19:09):
I think we're already seeing people try to do this already, Rae. We're seeing examples of tech vendors who are offering these AI-enabled virtual nurses who can provide patient education, these sorts of tasks.

Rae Woods (19:21):
Is that a good thing or a bad thing?

Allyson Paiewonsky (19:23):
I think it's a bad thing. I think that AI could never comprehensively fulfill a nurse's full scope of practice. I think there is opportunity, for sure, to help with admissions and discharge and certain tasks like that.

Rae Woods (19:35):
Administrative tasks, right?

Allyson Paiewonsky (19:37):
Yes. But nursing is so much more than tasks, and I think when we are using technology, it's taking those tasks and making things very task-based, which is what we want to remove or transition away from nursing from this task-based focus that we have right now into a more holistic way of providing care to patients.

Rae Woods (19:58):
Which actually brings me back to one of the very first things that you said, Monica, which is if we're going to be able to have a different conversation this time next year, we have to think about what work gets done. Let's talk about what that means. I assume it means in part saying what tasks don't need to be done at all and what tasks can be taken on by technology, by the shiny new GenAI something. What else needs to change when it comes to what kind of work we even ask of the nursing workforce?

Monica Westhead (20:31):
I think some of this actually comes down to collaboration in the leadership ranks and making sure that all of the leaders are aligned on the same goals of not only efficiency, but also creating a collaborative work environment. We've heard of situations, for example, where processes were changed during COVID, for example, where environmental services staff no longer went into patient rooms to empty trash, and that never changed when we came out of the crisis. Now, it's now just part of the nurse's workflow to empty trash. In the example that I'm talking about, the CNO was able to work collaboratively with operations leaders to remedy that situation. But I think, that's a really small example, but I think it illustrates the importance of everyone on the executive team being on the same page in terms of really making a true team-based care delivery model.

Rae Woods (21:29):
It also illustrates, in my mind, a big frustration that nurses themselves have literally on this week every year, which is, I am underappreciated because I keep being asked to do tasks like empty the trash or remove food or things like this that are not top of license for me. It's hard, let's just be clear, it's hard for nurses to feel celebrated when they're being asked to do work that is not appropriate for their license or for what they can bring to the patient experience and the clinical outcomes that we're trying to achieve.

Monica Westhead (22:05):
I actually want to push back on that a little bit, Rae, because I think there is an interesting distinction between asking nurses to do things that are not necessarily top of license and asking them to do things that don't facilitate their ability to take good care of the patient.

Rae Woods (22:23):
Interesting. Tell me more.

Monica Westhead (22:26):
Many nurses, actually, if you ask them what they enjoy about nursing, what brings them joy, a lot of the things that they would talk about would not necessarily be considered top of license. The historical idea behind top of license care was actually to create a more efficient and cost-effective way to use your staff. You're paying nurses more, you should have them doing things that only they can do, and lower paid staff should be doing tasks that don't require a nurse to do.

(22:57):
But if you take top of license practice to its natural end, that means that nurses are not able to sit with the patient, they're not able to have a conversation with that patient and help provide them emotional support or prepare them for a procedure or get to know them and talk to their families. For many nurses, that is a really critically important part of why they went into nursing to begin with, and actually does enable them to provide better clinical care as well.

Rae Woods (23:26):
Is about what work we ask nurses to do.

Monica Westhead (23:31):
Yes.

Allyson Paiewonsky (23:32):
When we're so task-focused, we are creating an assembly line of clinicians and not building a care team. We're not thinking about what is the actual work that needs to get done to benefit the patient. Instead, we're so busy consumed with who is licensed to do what, who can take on what task? At the end of the day, sometimes you have a unit or there's a shift where you don't have enough CNAs, so someone is going to have to take out the trash who probably isn't licensed to take out the trash. I think we want to avoid creating these hierarchies among care team members and creating more of a teamwork environment where it's about the patient and thinking about what is the work that needs to get done and how can we provide the best possible care to that patient in today's environment?

Rae Woods (24:16):
I really, really this pushback. This week I'm aware of the fact that a lot of folks tend to talk about the phrase bringing joy back to the practice of medicine, which I think has become a bit of a throwaway, but what you all are actually describing is about that kind of meaningful work, not just task-based work.

(24:37):
All of the strategies we've talked about thus far in terms of who does the work, how that work gets done, what that work even is, these all sound great in paper. But again, my goal for this conversation is that we're not going to repeat it again in Nurses Week 2025. Let's think back to some of those barriers we initially talked about in the start of this conversation. What needs to change today so that we can actually make progress in the next 12 months?

Ali Knight (25:05):
I think what needs to change today is really interdisciplinary collaboration that starts at the C-suite. To Monica's earlier point, C-suite leaders really coming together to understand what are the needs of the patient and how can we align or realign our organizational resources to make that happen? From there, once you have your C-suite alignment, it's then in involving the frontline staff, again, in that process to ensure and even ask the question of them, what gives you joy in your day? Because that becomes part of the building block as you look at the work that needs to be done to ensure that those joyful moments are able to happen.

Monica Westhead (25:48):
Ali, you're a nurse and you've also been a manager, so how has that played out?

Rae Woods (25:55):
Wait, how did we miss that? Ali, Happy Nurses Week.

Ali Knight (25:57):
That's why I said thank you at the beginning of the podcast. Oh, thank you. It's Happy Nurses Week. Then I'm like, wait, that was directed at the audience.

(26:09):
I think, for me, I got joy when I was able to work directly with my team to solve those goals and [inaudible 00:25:46] or the pain points that detracted from the joy of their job or took away from the time that they were ultimately able to spend with their patients having those meaningful connections.

(26:28):
For the frontline, the bedside nurses, the CNAs, often it's the time to sit with the patient and have a conversation to understand them on a deeper level, to really get to know what they're feeling, what they're experiencing. Those don't have to be lengthy conversations. Sometimes, it's just five minutes of that uninterrupted dedicated time.

Rae Woods (26:50):
Last question from me is any parting advice that you might have for our listeners as they celebrate nurses this week and they look to define a more sustainable workforce in the long term?

Monica Westhead (27:05):
I think this is an exciting time for nurse leaders. I think we've come out of a few years of survival mode, and now instead of trying to figure out how do I staff today, I think many nurse leaders are ready to start thinking differently about what the nursing role will look like in the future, and I think it's an exciting time for innovation.

Allyson Paiewonsky (27:28):
I think also we have such a new generation and a new workforce of nurses that we really have the power to shape and recreate what we think the nursing profession should be, so not letting that opportunity go to waste and I think really diving in and helping those nurses transition to practice and practice in the way that care needs to be delivered today.

Rae Woods (27:49):
Well, thank you all for coming on Radio Advisory. If I don't talk to you before that, I'm sure I'll talk to you Nurses Week next year.

Monica Westhead (27:56):
Thanks for having us.

Allyson Paiewonsky (27:58):
Thanks.

Ali Knight (27:58):
Thanks, Rae.

Rae Woods (28:03):
The most important thing that I learned from this episode was actually the moment when Monica, Allyson, and Ali pushed back on me, we do tend to get too focused on tasks. We have the right goal in mind, we want to make work and life easier for our workforce and our nurses, in particular. But we have to take a more holistic view both to nurses, the care team, and the kind of work that needs to be done not only to create a more sustainable workforce, but to make experience and outcomes better for patients. Remember, this week and every week, we are here to help.

(29:03):
If you like Radio Advisory, please share it with your networks. Subscribe wherever you get your podcasts and leave a rating and a review. Radio Advisory is a production of Advisory Board. This episode was produced by me, Rae Woods, as well as Abby Burns, Kristin Myers, and Atticus Raasch. This episode was edited by Katy Anderson with technical support provided by Joe Shrum, Dan Tayag, and Chris Phelps. Additional support was provided by Carson Sisk, Leanne Elston, and Erin Collins. We'll see you next week.