Welcome to ACNL in Action, brought to you by the Association of California Nurse Leaders. I'm your host, Charlene Platon. Nurse turnover is one of the most persistent challenges in healthcare leadership, and it's also one of the most telling signals of organizational culture. My guest today has spent nearly four decades at a single organization building exactly the kind of culture that nurses don't want to leave. Cheryl ranking DNP, RN, NEABC, and DIP ACLM is the Chief Nursing Officer at El Camino Health, which recently earned its fifth magnet designation from the American Nurses Credentialing Center, placing it among fewer than 2% of hospitals nationwide to achieve that distinction. Cheryl, welcome to the show. Thank you for being here.

Thank you for having me, Charlene.

For those who are on the magnet journey, I'm curious if you can share what it takes to keep earning magnet designation, not just once, but consecutively and five times in a row at that.

Well, I actually want to start even earlier than those five times, uh, the first one being in 2005. But actually, it goes back much further than that at El Camino Health. And that is when we first opened our doors. I think in 1961, nursing excellence started from the very beginning. I think our uh founding nurse uh leaders here at El Camino set the standard of excellence long before I started here, um, 38 years ago, there was a culture of excellence here. And in fact, when the original magnet research occurred in the early 80s, El Camino was part of that nursing research study and named as one of the original magnets in the original research in 1989. Yes. So then when the magnet program changed and developed in what we know it today as the very rigorous uh program that we apply to and must submit our data to indicate that we have superior outcomes, certainly El Camino had laid the foundation long before that. But it is a challenge to keep that excellence up. And I think that, you know, those uh nurses before me certainly laid the foundation, but always looking to continuously improve and listening to the frontline nurse's voice and how we can continue to improve uh in nursing excellence, patient outcomes, patient experience is certainly key throughout all of these years of being magnet and continuing to get designation after designation.

Well, it's really great to hear about the history that El Camino Health has with Magnet. And for those who may still be early in the journey or maybe are not yet magnet designated, what does that look like in practice from what you've seen for the people who are implementing this work, you know, managers, frontline staff, what might Magnet look like from that practice level?

Right. And so I think again, structures and processes need to be put into place. And that's the one message I would give to nurse leaders and other nurses and other organizations attempting to become Magnet is it all starts with your structure and your process and ensuring you have uh ways in which nurses from the front line can be involved through shared decision making and other kinds of committee structures where the nurses' voices are heard. We all know that's foundational to ensure the nurse's full voice is lifted up because nurses at the front line know and understand what it uh what it takes to achieve those clinical outcomes.

Yes, absolutely. And the structure is such an integral piece in magnet, and you're mentioning about involvement from nursing, and one of the ways that nurses can be involved in the structure is particularly an opportunity for them to provide direct feedback. And so part of the magnet evaluation involves that direct feedback from nurses about the workplace. And so, what did you your nurses tell evaluators this time around, most recently, about the culture, about um El Camino Health, and what does that feedback tell you about the culture that you've built?

Well, first of all, we couldn't even have gotten a site survey if our uh our far Indian QI, which is the nurse uh evaluation survey that we do annually, wasn't top-notch. And so we knew that we had um a work environment where nurses wished to work because of the outcomes of our nurse engagement survey, and through across all seven domains that have to do with RN to RN communication and collaboration and management visibility and autonomy and staff development, we had very high scores. Higher, our nurse scores were higher than the rest of the organization in our most recent engagement study. So we we've really been developing that over time. But when the the appraisers for the magnet um site visit came on site last November, this is exactly what they heard. When they visited with our nurses, I didn't get to be a part of those meetings, but when they visited with our nurses during breakfasts and lunch and shared governance meetings, uh, what I heard were very positive feedback from our nurses who told us in the survey and then told us with the appraisers that they believe working here is where they want to be and they don't want to go anywhere else because of the work environment that has been created here at El Camino Health.

I'm curious about any feedback that has been shared from leadership at El Camino, whether that's charge nurses, nurse management, uh, nurse managers or directors.

Well, uh, that's really huge that those leaders at the bedside at the unit level uh have structures and processes in place as well, too. And uh we uh really urge our and have taught our managers and other leaders across the organization some of the really key elements uh to bring back to the units to ensure that we're creating an environment where our nurses at the front line feel they belong. And meaningful recognition is right up there, along with um uh ensuring the managers visible on the unit and really championing shared governance, encouraging attendance at shared governance meetings, and ensuring that it all areas that the nurse of the voice, the voice of the nurse is heard.

Yes, and it sounds like managers are really well integrated into this structure as well. They provide, it sounds like they're the conduits to provide a lot of connection between the nurses and the uh components of Magnet and these avenues for nurses to be involved and be part of committees and part of shared leadership. And I'm curious if you can share for a leader, a manager director who is at El Camino Health, what might it actually look like for one of the managers, let's say on like a Tuesday morning that has a unit of, you know, multiple nurses there, what might it look like on the ground level about a culture of nursing that's been built with all of this in mind?

Yeah. Well, um, from a workflow perspective, nurse managers are um expected to be with their nurses um at different uh intervals throughout the day. I can tell you that as part of their standard work, uh nurse leaders are there uh as the shift starts during uh we call them tiered huddles, other organizations call them the same, uh, where they're meeting with the frontline staff at the very beginning of the shift to share important key information, to get feedback, to set the standard and set the tone for the day. Um, and then uh they participate in uh other huddles with their leaders uh throughout the morning on day shift in particular, and then gather feedback and bring it back to their staff, you know, around midday. So we're communicating consistently uh throughout the shifts so that staff have the information they need to take care of patients. And there in a healthcare environment, things change rapidly, and we need to have those structures in place so managers can communicate effectively with those at the front line.

Yes, that's great to hear. It sounds like the managers have multiple um touch points for communication with the staff and that there's really structured check-ins, um, different tools that can be used at the unit level. And I'm wondering if you can walk us through what those tools are because other organizations might not have, you know, the software recognition tools or the nurse retention specialist specifically.

Yeah, so we're very fortunate to have uh a software tool that is a management tool. And this is one thing we put into place where we want to be able to support the managers with a tool that helps them with just a few clicks be able to do what they might otherwise take a lot more time to do. And so that's why we implemented this platform a number of years. It's been three years now, where we've implemented uh a software that helps bring all the disparate systems that managers have to go into throughout their shift, brings all that information together, actually. And then uh the the manager can actually uh act and take those nudges. It's kind of AI informed, I guess you'd call it, where uh there's a nudge sent to the manager. It almost looks like a social media feed, like a Facebook feed where, hey, uh this nurse, Charlene, has been here for 10 years. Send her a congratulatory note. Um, and then it's one click to send Charlene a congratulatory note that looks uh very authentic. Of course, the manager reviews it and makes sure it's authentic, can add some of her own customization, like a picture, emoji, but then it goes off to uh Charlene to, and Charlene feels very special that her manager recognized her, and that comes directly out of our HR system. But maybe Charlene is having some overtime day after day after day, and so in that case, you know, maybe Charlene's having something going on, you know, that we don't know about. And so it gives us insights into that too. So then a nudge is sent to the manager. Hey, you might want to check in with Charlene. Something might be going on. She's been here late three days in a row, and so then the manager can send a note and say, Hey, Charlene, I noticed this. You want to check in? I just want to make sure you're okay. And so it's it's showing concern because there might be something on in it going on, and it kind of continues to develop that relationship between the manager and the employee that's so critical to the employees feeling they belong, and that we're promoting their success uh in our organization. So that's how the software platform works. Now, we also around the same time uh hired a nurse retention specialist. Her name's Amanda. Um, and this was a unique role that I had seen that other organizations, a few others across the country had developed. And that's at the time that we had a higher turnover right coming out of COVID, as most other hospitals did across the country. And I really wanted to try to understand what was it that was happening and what can we do to prevent that. And so we were able to get a grant to hire a nurse retention specialist. And what we were able to put into place is having this one nurse meet with our new hires, meet with our new graduate nurses, and create career plans so that we could promote our nurses getting involved with our committees and other structures we have in place and see how they can get sticky to our organization and feel really loyal to our organization because we've invested in their career and promoting their growth within our organization.

Yes, and I have a few follow-up questions for that actually, and that's really exciting work. The recognition tool that you shared sounds really innovative. And, you know, we have interviewed several leaders on this podcast that have different types of resources and tools. Um, and one of the people that we interviewed was Tim Darling from Laudio. And I'm curious, is this recognition software similar to something like Laudio or is it a different? Oh, it's Laudio. Oh, it is. Oh, that's a little bit. I was like, I knew it sounded familiar, and this is really great to see because it really sounds like it's a layered, like a tiered kind of thought, like intentional with um multiple levels there.

Yes, yes, it is Laudio.

Yeah, that's great. Yeah, we interviewed Tim uh a while back and he told us a little bit too about insights from leadership, which was great to see. And the second question that I had was um going back to what you mentioned about turnover, because I know that El Camino's turnover rate uh peaked at 12.7 around the pandemic, um, which I understand was the highest in the 37 years um that you've been over there. But but then after that, it went back down to below 5% for the turnover rate. And so that is a dramatic shift and uh really quite impressive. And what did that change reveal about you know what holds a team together when things get hard? Or can you tell us a little bit more about that?

Yeah, that was um a challenging time as we came out of COVID, as we know. And at that time, I was just looking at how we can ensure that we hold on to those nurses we have now. Um, we did lose some staff, and honestly, we tried to understand why they left. Um, they do tell us some of the time in exit interviews, some left the region. They wanted to go back home, but others left because they had promotional opportunities at other organizations. So we wanted to ensure we had all those promotional opportunities available at El Camino Health. So we went about making sure we have enough transition to different specialties uh programs within our organization, and we we added some more and more frequently. We also wanted to ensure that our end to RN communication and collaboration uh was the best it can be because the last thing we want to have happen is have team members leave because of any kind of um uh incivility or other kinds of um communication issues we may have within our organization. Our Central Partnership Council, which is our main coordinating council, took this on as a goal and they said, you know what, we have to support each other through this as we're coming out of COVID. And they found some different opportunities in which we can support each other and uh be kind to each other as uh as we um out of the pandemic and as we grow uh as a nursing workforce and bring in new members of our nursing workforce because that was really happening during that time. I think all over the country in our industry, we saw a lot of new graduate nurses coming into our organization and we wanted to keep them, we invest in them. So we wanted to create structures to ensure that we do. And I have to say, our uh new grad retention rate is 92%. So we've really worked on that over the years to ensure our new graduate nurses feel really safe here, really well taken care of, and that they can be successful and stay at El Camino Health.

Yes, it sounds like it was a combination of a lot of, you know, intentional, thoughtful conversations, and then also follow-through with different resources that were available to help make the shift and then to um, you know, help to keep the turnover rate low and then also keep other scores like retention for new hires high. And, you know, we talked a lot about managers too and the programs that they have access to at the unit level. And I do want to zoom out a little bit too because people listening to this podcast might be in the situation where they would like access to some of these resources, but maybe don't know where to start in terms of making a business case for that. And so, you know, El Camino Health is invested in different programs, but they these types of programs might on might not always get budgeted easily at other organizations. And so, you know, just like what you talked about with the with the specialist and the nurse retention specialist and then the program, the software recognition tools. I also know that El Camino Health has a comm team for patient de-escalation. And how would you say that managers or others from different organizations can help make the case for investments like these so that they're supported by organizational leadership? And how does the organization decide, you know, which resources to include in the budget?

Well, I'm so fortunate here at El Camino Health because we have a very generous foundation. Our El Camino Health Foundation, almost every new program I've started, like the ones I've talked about today, I've been given seed money by our El Camino Health Foundation. Now I have to write a grant and I have to show that it's worth funding, but what it's been able to do is take a concept and provide proof of concept. So I've often taken those grants to the foundation and said, would you fund this for a year? And here's what I'm I'm expecting to see at the end of the year. What are my KPIs? What is the return on investment I plan to uh have happen after a year of this pilot project? So I've taken all of these, in fact, the nurse retention specialist and also the uh employee support specialist, uh, as well as the the Lodio platform to our foundation first. And then after a year, I've been able to calculate an ROI. How have we improved our turnover? How have we improved our employee engagement? And how have we improved our um also our um manager satisfaction with the LADIO tool? So um that's been really, really helpful for us to get the original money to get the thing started and then and then prove that it works and then continue with the program under the operational budget.

Yes, and it sounds like it's a combination of different moving parts and having the data to help support some of these business cases, and then also having the ROI plan um created, and then having all this information, whether it's you know, nursing satisfaction, patient satisfaction, all these different types of data available to help uh make the case even stronger. Um would you say that of all these components, there was one in particular that was a really big component more than others? You know, was it financial that really moved the needle? Was it more outcomes or other uh something else maybe?

Um You know, I think that um I was able to make the case on engagement and turnover actually does have a financial outcome to our organization. So um I was able to attach, you know, what it costs to have a nurse turnover in your organization, especially here in the Bay Area. It's very expensive. So if we can save nurses from leaving our organization, that can add up to thousands and really millions if you're able to keep nurses uh within your organization. So that's the kind of dollars and cents I was able to prove in my ROI.

Yes, and I want to double-click on that because one of the things we talked about earlier was recognition. And we know that recognition can come up constantly in these different conversations about retention, right, for nursing retention. And I'm curious with all of the data that you've seen so far and with your experience about recognition, what would you say is the difference between recognition that really moves the needle on some of these outcomes versus recognition that maybe doesn't really result in any meaningful change?

Yeah, here at El Camino, we have, as I said before, many ways in which we recognize. We have the Daisy program, we have um uh what we call Our wow cards where we can give each other uh recognition through a portal here at El Camino. Um, and of course, we have employee of the month, we have other unit specific recognitions, we have a big employee awards banquet every year. So all of these things in my mind really add up and uh let the employees know um that they really matter, they really contribute to our success and the outcomes of our patients. Now, one thing we do for nurses that I think is unique is our clinical ladder program. So all of that recognition actually gets recognized in our clinical ladder program. So when nurses have opportunities to participate, lead projects, get recognition, work out in the community, they earn points on the clinical ladder, which then leads to, you know, some changes in salary, some adjustments up in salary. So that's meaningful to nurses uh at our organization. It does move the needle.

Yes. And, you know, it's been great to hear what you've been sharing about the different programs, you know, the clinical ladder, recognition software, uh, different tools and resources and support that El Camino Health has had. And with your journey at El Camino Health for nearly 40 years and being the CNO for over a decade now, I'm curious what do you know now about building a nursing team that people want to stay on that you wish that someone had told you earlier in your career?

Well, I think uh having a really solid group of nurse leaders is so essential. And uh we really work on succession planning here at El Camino Health in ensuring that nurses who want to work up, work through the leadership ranks, who feel loyal uh and who want to stay at El Camino, that they have those opportunities to grow and develop and become a leader here. And we have many examples of that. In fact, our magnet program director was once uh she and I uh came up through El Camino around the same time. And Jackie Keene, she's been here for uh 37, 38 years too. And she is another example of someone who was at the bedside and decided to take on different roles throughout her career. And we're really promoting that here at El Camino Health and ensuring our managers are uh feeling supported and uh creating that team where people want to stay. Because when the managers are working together well and they feel like uh they're supported, then of course they can support their teams at the front line and create those structures, those processes and that um work environment where nurses at the bedside want to stay and can do their best in providing care to our patients.

Yes. And I, you know, I want to say we we've talked um about so many different things in our time together. And as we wrap up our conversation today, I do want to give you the opportunity to share any final wisdom or insight to our listeners about anything that we might not have mentioned yet today.

Oh well, uh, I just appreciate this opportunity to speak to uh nurse leaders across California, maybe across the country, and what a pleasure it is and what a privilege it is to lead nurses. It's a challenging time in healthcare right now, and unfortunately, I don't think it's gonna get better anytime soon. So we need to continue to raise up our profession within this country. And I would just appeal to all of us to continue to do that, um, whether that's um in the state capital, in the national capital, writing a letter to ensure that the leaders in our country understand the importance of our profession and how what we do matters and what we do leads to healthier patients, which lead to healthier communities, which leads to a stronger country. So that's my last parting words.

Yes, and this has been a wonderful conversation, Cheryl. Thank you so much for your expertise and for sharing your insights with us today. How can people learn more about El Camino Health?

Well, they can go to our website, elcaminohealth.com. And uh we'd just love to hear from you through the website. And uh I'm also on LinkedIn.

Wonderful, and thank you so much for being here today. It was wonderful to talk to talk with you today.

Thank you, Charlene. Great to be here. Thank you for the opportunity.

Our guest today was Cheryl Ranking, Chief Nursing Officer at El Camino Health. We would love to hear your feedback. Email us at socialmedia at acnl.org and connect with us on LinkedIn and Facebook at ACNLNurse. And as always, if you like the show, please remember to rate, review, and share. ACNL in Action is presented by the Association of California Nurse Leaders with new episodes every month. To learn more about the show or ACNL in general, visit us at acnl.org. Thank you for listening.