- This is Laura Dero with the Becker's Healthcare Podcast.
I'm thrilled today to be joined by Trish Solano,
who's a Chief Nurse Executive
and associate Chief Clinical Officer at Advent Health.
Trish, it's a pleasure to have you on the podcast today.
- Thanks so much, Laura. I'm happy to be here.
- Now we're gonna talk a lot about, um, a strategy
that you have at Advent Health,
and one that we have included in an article
with Becker's talking about use less, lose less,
and hire more inside the strategy that Advent Health used
to cut nurse turnover.
Um, and so I'm excited to dig deeper into that,
um, specifics there.
But before we do, can you tell us a little bit more
about yourself and your background?
- Sure. Um, well, I'm just coming into my 30th year
as a nurse and, um, started in critical care
and in my, in my background, I was a CNO
for our Children's hospital
and a CNO for our flagship Orlando campus, as well
as a Chief Clinical Officer for one of our markets,
and have been in the chief nurse exec role
for about four years here.
Uh, you know, we're located here in central Florida, uh,
but have, uh, 51 hospitals across the US in nine states.
- Absolutely. And that's, you know, a huge undertaking
to be able to oversee the nursing workforce
for such a large system crossing, as you mentioned,
multiple states in several different facilities.
So, you know, I, I'm excited to dive in
and see how you're able to manage all those things.
Um, and in particular, you talked about, um, with us
for our article, how the useless strategy, um,
has played into reducing their turnover at Advent Health.
Could you expand upon that a little bit, a bit?
Um, what does that really mean to you
and how do you see that playing out on a regular basis?
- Sure. You know, I think, uh, for us, um,
what the use less element of useless, lose less, hire more,
it was not about, uh, decreasing staffing, which is
what people automatically kind of think.
It's really about using less RNs where, uh,
where you don't necessarily need to have an rn.
So, you know, there's a certain amount of the work
that nurses do that can be managed
by other licensed personnel keeping
RNs at the top of their license.
So, you know, some of the feeding, walking clothing, um,
bathing and other elements don't necessarily need
to be done by an rn.
So our useless strategy was really around appropriately
elevating the RN to the top of their license
and making sure that we had enough of the other, uh,
providers to care for patients, whether that's drawing blood
or transporting them off of the unit.
There's a variety of different things.
I think over the course of, um, the last two
or three decades, many organizations have pulled those
resources away from nursing, which ended up, um,
just leading the RN to provide a whole bunch of things that,
you know, perhaps, uh, were not necessary, uh, for them
with their licensure.
So the lu the useless element, uh,
involved us bringing on additional patient care techs
as well as in some markets launching LPN models,
but bringing on patient care techs
and others to provide care according to their license
helps keep their RN focused at the top of their license
and just improves the care that's delivered.
- That makes a lot of sense.
You know, it really seems like it would be beneficial
overall for the RN to have the opportunity
and ability to focus more on patient care
and as you said, the things
that they're trained most highly to do.
Um, and, and does that mean, you know, then some
of the other, uh, work is, is either, um, done by people
with other experience levels
or in some ways, I'm sure automated?
Um, how does that really show up for you?
- Yeah, well, you know, for us it's really about bringing
back those individuals who have that skillset who we,
you know, perhaps over the course of the last two decades,
health systems said we actually don't need to have those,
um, those individuals working in the hospital.
You know, labor is the largest, um, one
of the largest costs for any hospital.
So over, over the course of, um, over the last few decades,
many health systems have removed, uh,
or at least decreased the support from transportation,
from phlebotomy, from nutritional services,
and then from patient care techs.
So, you know, for us here at Advent Health,
our market's looking across where they currently were
and how they could better right size the, the people
that they needed to help support the rn.
So the RN who is obviously, you know,
the most highly paid out of
that whole group can focus on the work
that they need to focus on.
So not only, uh, you know, are we using less RNs,
which are a really, um, uh, a difficult commodity to get,
but we're using them appropriately at the top
of their license, and we're making sure that that also, um,
helps to address any workforce burnout.
If they have to do everything well, how are they going
to do the one thing that they need to do well, really well.
- Absolutely. That's really an extra excellent point.
And, you know, I'm wondering too if you could share some
specific examples of changes that you've made
that have positively impacted nurse retention.
- Sure, sure. Yeah, we've had, um, just some great,
great wins in retention of our, um,
bedside nurses over the last 24 months,
and we're really, really excited about where that has gone
for us as a company and,
and what it means to our communities across the country.
Our, um, nursing leaders, um,
our nursing leaders had an opportunity
to really have additional support
and education preparing them to lead.
Now here you have, uh, an assistant nurse manager
and a nurse manager who are running operations 24 for 24 7,
and we realized that we had an opportunity
to better prepare them for that role.
So, uh, 24 months ago we developed
and launched nursing leadership development content
that was very tactical
and very practical, uh, for our nurse leaders so
that they understood what it meant to
actually develop staffing
and manage staffing throughout the day.
Um, things like unit huddles, uh, a variety of different,
um, educational topics that a and s
and nurse managers now would learn in a,
in a pretty tactical clear,
but prescriptive format as they transition to their roles.
We also launched a professional excellence program kind
of commonly known across the country
as the clinical ladder for nursing.
Big, big, uh, win for us.
And, you know, nurses are looking for a standard way to, um,
to develop in their career.
And that doesn't have to mean, you know,
if you're a bedside nurse
and you wanna continue to
develop, you have to leave the bedside.
You know, we wanted to kind of flip the script on that,
that we really value our nurses
who have 10, 15, 20 years experience.
So how do, how can we recognize that
and how can they be
recognized for what they bring to the bedside?
The third one was our competitive market pay.
You know, we, um, post pandemic market pay changed
so quickly across the country.
So, you know, we went from evaluating market pay to,
to every other year, a few years back to every year,
to every six months.
And over the course of the last three years,
we evaluated it, uh, quarterly to really make sure
that we had a pulse on what was, um,
happening in our local markets.
'cause it's easy to get out of, um, out of line with
where compensation is going, when there is a pandemic
and a national nursing shortage.
So our focus on making sure that we maintained compensation
that was competitive for our nurses.
Also, another, another strategy.
The third of really four strategies that we use.
Fourth one being, um, career pathways
and, you know, tuition reimbursement,
student loan repayment, all of these things, um, nursing
and Advent Health, a really competitive that nurses
recognize that we were here to provide for them a pathway
to develop, and that we were also able
and willing to resource that.
- Certainly. And, you know, I I think that's such a strong
and powerful message, as you mentioned, um,
to really put the resources behind those efforts and,
and making sure that no matter what the nurse chooses and,
and feels like is their best path forward for them, um,
that they're valued and supported.
I, I love that. I think that's such a remarkable way to,
you know, develop a culture within the organization.
- Yep, absolutely. You know, they'll, the whole idea behind,
um, magnet hospitals, if you,
if you recall when they first launched was, was how,
what are the elements that will make a
hospital a magnet for nurses?
It will draw nurses to that facility.
Those things haven't changed in, in, in 20 years.
Um, not, not really, not much .
- Yeah, absolutely. Absolutely.
, that's so, you know, such a great point.
And you know, the other thing I was wondering is
that the article mentions strategic overlaps
between the use less and lose less.
Can you explain how these improvements contribute
to the overall success of the nurse staffing strategy?
- Sure, absolutely. So, you know, in order to, uh,
the use less, which is using, um, other, other providers
outside of just RNs to provide a real, um, kind of model
for care, um, in order to do that,
we had a couple things we had to do right, uh,
namely leadership development so that our nurses,
our assistant nurse managers who run operations 24 7 as well
as our nurse managers had that they were prepared to,
to effectively staff.
They needed to understand what that meant
and all of the variables involved in that.
Um, when, when assignments are being made for nurses,
it's not just a, a ratio of a number of patients as it seems
to be kind of, uh, dumbed down in, um, in the press.
It, it's much more than a ratio.
It's actually the nursing, um, not only the complexity
of the patient, but the experience level of the nurse
and the intensity of the work.
So it's the acuity, the intensity, as well as
that nurse's experience.
Those three things work together in conjunction to determine
what an appropriate, um, assignment is for a nurse.
So we needed to go back
and just do some level settings, nursing staffing principles
and practices that that class for our nurse leaders,
you know, really helped to get everybody on the same page.
And then, uh, things like leading effective unit huddles,
if, um, there's a good way to do it, a way
that is actually useful, that is, is helpful
to both the staff as well as the leaders
communicating effectively with physicians and providers.
Um, you know, we, um, brought on
as many hospitals did across the country, uh,
a significant number of graduate nurses, uh,
over the last 24 months.
And we needed to make sure that they were transitioned
to practice in a way that they felt good about,
that they weren't just thrown in to these units.
Um, and having to suddenly communicate and,
and develop, you know, really working relationships
with physicians, uh, that they didn't know
and weren't comfortable with.
And there is a, there are nuances to those relationships,
um, and then, you know, principals of onboarding,
staff nurses, it, it can be challenging
for a 26-year-old assistant nurse manager to be managing 22
and 21-year-old nurses.
So, you know, do they understand how
to appropriately onboard those new nurses and what they need
and, and how a GN can make a smooth transition
to practice practice.
So the fundamentals about that, we outlined that
and then made sure that, uh, everybody participated
and really raise a bar for our nursing leadership relative
to, um, their ability to lead.
- You know, that's so interesting to hear,
and especially, um, that last point you made, you know,
with, um, new leaders emerging and coming in
and then all of a sudden having to manage large teams,
you know, it, it, it's a, a skill
and especially as, um, you know, the, the workforce changes
and kind of the dynamics, um, within, you know, the,
the whole, um, department I can imagine
or the whole hospital are changing as well.
And, you know, is there anything that you've noticed,
I guess, compared to whether it's pre pandemic
or just how things used to be that, you know,
you really see it as being, um, super helpful
and beneficial within some of these trainings so that, um,
going forward, you know, the, the hospitals
and the nursing departments in particular, um, are,
are really becoming those places, as you mentioned
before, that people are, are really wanting to work at
and wanting to be at in strong teams
and not engendering some of the, um, challenging aspects
of culture that we've seen previously.
- Yeah, you know, I think probably one
of the most important things is that the, um,
the leader who's leading operations on that unit for
that shift, there's always someone 24 7 for us,
it's an assistant nurse manager or a charge nurse.
Um, they really have to, uh, number one,
be in the position to be able
to evaluate what's happening on the unit at any given time.
That means, you know, we need those, those unit leaders
to not have an assignment to actually be free so
that they are, they are continually evaluating the workload
of the bedside nurses.
Sometimes a graduate nurse
or a nurse, you know, a novice nurse who's got less than two
years experience, that nurse might not, um,
realize when they are starting to get into trouble,
when perhaps they're not able to keep up with, um, and,
and appropriately assess and evaluate their patients.
They feel stressed,
but they, they need help sometimes to identify, you know,
what, the workload of this assignment is actually
not appropriate, you know,
and a way that, you know, we have focused on doing that is
to have, uh, nursing leaders who actually are assessing
that along with the bedside nurses.
Um, you know, high intensity leads to burnout,
and burnout leads to turnover
and leads to bad patient outcomes when you don't have enough
nurses to provide care.
So, you know, preparing our leaders
to manage operations 24 7
and um, to more effectively make
and manage staffing assignments has really been fundamental
in supporting the improvements in our nurses' perception
of staffing adequacy.
Um, you know, I say perception of staffing adequacy,
because every nurse, regardless of
what the staffing level looks like,
they have their own perception of
how they feel on that given shift.
You know, we measure staffing adequacy in our annual
nursing engagement survey.
So the N-D-N-Q-I survey asks tho, you know,
those really important questions,
do we have enough registered nurses to provide quality care?
How do nurses, do nurses have enough time
to discuss patient care problems with other nurses?
Do we have enough staff to get the work done?
Are there adequate support services to allow me
to spend time with my patients?
Those four questions really give you a great pulse of, of
how those nurses on that unit feel.
You know, we had a just significant increase in staffing,
adequacy perception from our nurses last year,
a 14% increase.
And, um, and I, uh, all
of our nursing leaders in our markets
and divisions all, all accredit that
to an increased awareness, not only the education of how
to step, but awareness of the frontline nurse leaders that
that is their responsibility, you know, to,
to be making sure that those bedside nurses have
what they need, and if not, that assignments are changed
and redistributed more appropriately.
I think that was probably one of the biggest.
And you, you hear about that a lot in the, um,
in the news when you,
when you hear about nursing dissatisfaction, uh,
very frequently, it's around that, that we don't have,
you'll hear them call it a charge nurse
or our charge nurse has an assignment, you know,
and when that happens, who is, um,
who's got their eye on what's happening on that unit?
- And it's such an excellent point
and certainly a situation that is less than ideal
and hospitals don't wanna get into that situation.
For sure. Um,
before we wrap up here,
I was wondering if you could tell me more about some
of the results that you've seen from the recruitment
and retention strategies you mentioned,
including your partnership with the schools
and your Clinical Leader Ladders program.
- Sure. Um, well, yeah, our results, you know,
we've been very, very pleased.
We, we exceeded our hiring targets.
You know, we had a, um, hiring target of about 5,000 nurses.
We hired 7,000.
So we beat that goal by, by, um, 2000
or turnover, significant increase in 24 months from,
from over 31% to, uh, just under 19
nursing agencies, uh, post pandemic,
many health systems brought on agency nursing.
You know, we, at the height of the pandemic, uh,
we're at about a 13% of our, uh, work hours agency.
We're down to 1% now. So, uh, nursing engagement improved.
The N-D-N-Q-I, uh, annual nursing engagement survey, which,
you know, probably the survey most hospitals take across the
country, we saw improvement in all eight domains.
Really, really pleased with that. Um, and the turnover.
So we launched a clinical ladder across the company, um,
about 18 months ago across the entire company.
And the nurses who participate in that clinical ladder,
their turnover was less than 5%.
So, you know, that's really a,
that was a game changer for us.
The latter turnover we're engaging nurses and, um,
and they're staying, you know,
and relative to academic partnerships,
you asked about that as well.
You know, that was a, a big, uh, big deal for us,
really connecting with all of our feeder nursing schools,
uh, making sure that we're there.
We're connecting with faculty
and students opening up positions on our
end for nursing students.
So our nurse tech positions, allowing them to work,
you know, a, a one, perhaps it's one shift every other week
so they can kind of get to know us and we get to know them
and, and they can figure out
where at Advent Health they wanna land
where they wanna make their home after graduation.
We also launched a number of dedicated education units, uh,
with local colleges of nursing,
really strengthening those academic partnerships.
We expanded our practicums, our clinical rotations.
We have our, um, team members working as adjunct faculty to,
to help support those colleges of nursing so that they have
the, um, academic leaders that they need while they continue
to also, uh, develop and expand their pool.
Our graduate nurse residencies we're all, um,
standardized across the company, really making sure
that they were evidence-based and that they
provided a, a solid education with a,
with evaluation throughout the graduate nurse residency so
that those residents were prepared
and transitioned well practice.
We also did the same thing for our preceptor.
So, you know, every graduate nurse residency is led
by preceptors bedside nurses.
Uh, we realized that we had an opportunity there
to help standardize their approach to the preceptor role.
Did they understand, you know, what it meant to be
and adult learning, um, strategies so
that our preceptors were functioning at a very high level
and able to really transition those GNS in a way
that was, uh, good for everyone, the gn as well
as the organization, and then a number
of nursing mentor programs as well.
I think our relationship with our colleges of nursing
and then our own Advent Health University College of Nursing
as well, um, has really strengthened in the last 24 months.
We've become very, very good partners.
- Well, that's great to hear,
and certainly inspiring just everything you've put together,
um, or, and resources that you put towards the nursing
and and development program.
Um, this really great to hear, Trish, thank you so much
for joining us on the podcast today to really expand
and dig deeper into what you're doing at Advent Health.
Um, I really appreciate it,
and I look forward to connecting with you again soon.
- Hey, thanks so much, Laura. Uh, I enjoyed it.
Have a great day.
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