Welcome to ACNL in Action, brought to you by the Association of California Nurse Leaders. I'm your host, Charlene Platon. Our guest today is Anne Hurlith, Vice President of the Health Management Academy, which put out a recent report on the results of a survey on frontline perspectives on safe staffing. This is a must-read for anyone in a nurse management role that needs to contend with the often competing priorities of maintaining staff satisfaction while meeting budgets. Thank you so much for joining us, Anne. It's great to have you today. Yeah, thanks for having me, Charlene. So there's a lot to unpack here with this topic. And let's just start with a little bit of a background of your organization, which developed a report called Frontline Perspectives on Safe Staffing. So this report was based on a series of focus groups with frontline registered nurses and nurse managers. And it was a survey with nurses, and it talks a little bit more about safe staffing. So can you tell us a bit about the methodology behind this research and what you're hoping to learn?

Yeah, absolutely. So my organization, the Health Management Academy, we work with chief nursing officers all over the country. And really our focus within our working group is to accelerate innovation across the nursing enterprise. Together over the last few years, about three years now, we've been working together as a group called Nursing Catalyst. And, you know, we've made a lot of progress as an organization, as a profession when it comes to innovation and transforming the way care is delivered at the bedside. One of the challenges that has been coming up again and again, though, is that it feels like there's a growing divide between executive leadership and the front line when it comes to a number of things. And so that's really what we aim to unpack with this work. There are, I mean, honestly, it is a very long survey. We did a lot of focus groups. We talked to a lot of nurses via survey as well. But there are really four key things we wanted to unpack in this work. So the first is where are we at when it comes to sentiment around safe staffing? If you want to understand the perspective of the frontline, you have to know how they feel about staffing today. And so that was sort of the core foundation of everything we wanted to know. The second piece of information was how do they feel about various staffing solutions? And in particular, non-what I would call human resource solutions. So things like AI and virtual nursing, although technically virtual nursing still uses humans. Number three is okay, if we know how they feel about these various solutions, AI, for example, are we able to shift their perception of AI with information with different types of data? And if so, how do you do that well? So, really message testing and understanding changing people's minds. And then the fourth is okay, where are they getting information today? Like I said, it feels like there's a bit of a divide between executive leadership and the frontline. And so where's communication falling short, both within organizations and outside of their organizations? So, like I said, jam-packed survey, jam-packed focus groups, a lot to potentially spend time unpacking today, but was you know really insightful and really helped our members and the broader nursing community understand where is the frontline today when it comes to innovation, transformation, and staffing.

Yes, thank you for that summary. And it is a lot to unpack. And I do appreciate that this report does serve as this nice foundation in terms of nursing today when it comes to innovation and so many different things that are going on. You mentioned AI and how that might play a role into nurses' perspectives and how things are right now with uh with care delivery. And with so much to consider with these, you know, with this survey and with these survey findings, what would you say are some of the top findings that nurse managers should take away from this report when they're reading it?

Um, well, for speaking directly to nurse managers, I would say this is not in the in the report, but my number one takeaway is you have an incredibly hard job. And I do believe innovation and care transformation is gonna hopefully make some of that job easier over time because it's gonna make the job of the nurse easier over time. Nurse managers, you have an incredible amount of influence over your staff. And one of the key findings in that communication piece that I talked about was that managers are the number one source that nurses look to within their organization for information, and particularly among the most novice staff. And we all know that the workforce is, you know, younger and younger every year. Um so there's just a lot of power there. And so, what I would say to nurse managers is as we unpack this information and talk more about the opportunity of AI and virtual nursing and sort of these other solutions to help solve some of these staffing challenges, you really are going to be the champion for that. And so understanding what's coming in innovation and understanding what that can mean for the nurse is going to be incredibly important so that you're able to answer questions and really champion the future. Um, in terms of just the raw data and what we found, I think not shocking here is that nurses don't feel super confident about their organization's ability to deliver on safe staffing today. I'd say that is the same across the country. So whether you are in a mandated ratio state like California or you're not like many other states in this country, um, the sentiment around safe staffing is relatively low. And I don't think that would shock anyone who is a who is a leader today. The good news is that there is so much opportunity and that nurses, um, while not super informed on the potential of AI and virtual nursing today, are really excited and able to wrap their heads around it. And when we put the right information in front of them, are excited about the potential. And so while people might seem resistant at first, and we definitely see that in the data, with information comes a lot of power. And so I would just come back to the virtual or to the nurse manager here and say, you really do have that influence. And as we're going through some of this, just thinking about how I might translate this information to the front line is really key to the success of many of the things we want to do.

Thank you for sharing that, and I do want to acknowledge what you mentioned about the role of the nurse manager, how difficult that is, because there are a lot of key factors and things to keep on top of, including what's happening outside of your organization, what's happening out in healthcare. And then that includes what's happening with technology, and that includes AI too, right? Yeah. So I do like that shift of mindset in terms of if you are a nurse manager, thinking about how much you can really influence with your role and how much you could prepare and equip your yourself and also the nurses that you're working with and supporting to be able to learn more about what's available and what's out there and how that can really impact their environments and the healthcare organization. So I do think that that's a great uh observation and takeaway to share with the nurses, uh nurse managers who are working today in today's environment.

Yeah, absolutely.

And I did want to uh acknowledge too, with with the findings that you mentioned, you did mention that frontline uh registered nurses expressed low confidence in their organization's ability to deliver on safe staffing, which, you know, of course, as you mentioned, is not necessarily a shocking finding or sentiment that we might have heard of. And so what would you say are strategies that leadership can implement to rebuild trust and confidence in these different staffing decisions?

Yeah, well, when we broke down the data, and just to underscore what I mean by low confidence, only about 7% of nurses said they have like very positive feelings around safe staffing. Um, and then everyone else was somewhere else on the spectrum. So that's not great. I would say um, not shocking again, but not great. But when we broke down that information, both in the quantitative survey as well as in the focus groups, um, what we really found was that it came down to a lack of information. So, yes, there are times when staffing is not ideal. And certainly we don't want to say that that doesn't happen because it certainly happens. We know that happens. Um, but many times the investments that organizations are making to support staffing are not super clear to the front line. I mean, they're not sitting in the meetings, they don't hear the strategy, and they often don't even see the impact, or they don't see the steps that are being taken to fix staffing. And so my first thing would be to really anchor on regular, transparent communication about the decisions that are being made. And really that should be coming from the manager. Um, those talking points, the you know, sort of the conversation you want to have needs to be supported by executive leadership, by directors, by CNOs, but managers are really the right person to be talking about that and sharing that with the frontline. And then I'd say the second piece is to, you know, help yourself understand and also help the frontline understand why certain decisions are being made. So, for example, in some of the focus groups, um, you know, frontline nurses were talking about during the pandemic when there were, you know, absolutely insane bonuses, right, for new people to join the organization. Yet there were very few retention bonuses. And to this day, very few people do retention bonuses. And a lot of the discussion was around, you know, why are we not trying harder to retain our really experienced staff? And instead we're incentivizing brand new nurses who, you know, for better or for worse, maybe aren't quite ready to be on the unit. And so what they're seeing is not that the organization isn't trying, it's just they're not using a strategy in which the nurses on that unit or on that floor would really support. But when we came back and said, hey, you know, your organization, the reason they did this is um for XYZ reason or because, you know, recruitment and pipeline is so tough and we're really competing for scarce resources, it starts to broaden people's perspectives. And so you don't want to come in defensive about what an organization is doing, but certainly feeling like you have the information and really having that transparent regular communication and running right at the staffing discussions is important. Hard, but important.

Right. And I do like how you framed the importance of education, especially when it comes to education that the staff is aware of, the transparency of the communication and the knowledge that they get. And then also for the managers in terms of what they know and what they're sharing with the staff, because it does go both ways in terms of how everyone can feel comfortable about what the situation is in a healthcare organization. So I do believe that, you know, it is it does make sense that all those components would help with it probably help a lot with the sentiment about safe staffing and where that's at.

Right. And I'm sorry, I was just the more transparent you are about staffing communication in general, you know, the better. When you have to say, hey, yeah, we are not staffed ideally today because we had, you know, four call-outs today. Uh being frank about that is important. You know, we don't want to gaslight, we don't want toxic positivity on our units. I mean, it's not helpful. At the same time, it gives you a lot of credibility. Then when you come to your staff and you say, hey, there's this new way in which I want to deliver care. And it's going to make our jobs easier in this way, but it's going to feel harder for a short amount of time while we all learn. I mean, the power of that kind of communication is critical. But again, this is hard. This isn't stuff that comes to us naturally. And so I really, I not just managers, but urge all executive leadership to think about how we are equipping our frontline leaders who, again, are have incredible influence, who have um, you know, incredible skills and are well trusted within the organization. How are we equipping them to do all of this? Because it is really tough work.

Right, exactly. And it really speaks to just the importance of communication and really feeling that the nurses who are on the front lines or in the staff are part of the conversations, right? Or at least included in some of those conversations. So that makes a lot of sense. And one interesting thing in the report, too, was that frontline nurses uh have been sharing their skepticism about the role of AI and virtual nursing as a solution, and that less tenured nurses are more open to that idea. So, do you have any theories or any ideas on what's causing this difference? And do you think it's maybe more of a generational type of observation or more of a function of experience instead?

Yeah, I mean, I think a couple of things are going on. So I'll first say if you ask any frontline nurse on the street, do you think AI is going to be good for staffing at your organization? Most are going to be what I would consider ambivalent. They'll either be like, maybe, or like, I don't know, or like, eh, I'm a little skeptical. Very few fall into the like hard yes, hard no category. What that tells us, and what our focus groups told us, is that people just don't know what this means. Like, what I'm gonna use AI. Okay. Like lots of people are using AI, they don't even know it, first of all. Right. And second of all, like you have to be more specific in what you're talking about. And so I think this is a case where data are helpful to understand where people are today, but we also need to think about, you know, what we're actually implementing. But if we're talking in broad terms here, in terms of date, in terms of AI or virtual nursing um, you know, being implemented, I do think there are a few things going on with the way people react. I think first, let's just talk about the human response. I'm a social worker by training. I'm gonna go there every time. The human response is inertia. We love what we love even if it's not working, right? Like how many times do we keep doing things the same way, even if it's there's a better way to do it, just because it's the way we've always worked. And certainly inertia gets stronger the longer we've been doing something. Um, I think second, and to the credit of experienced nurses, they have seen technology implementation before that is quote unquote going to help them that has made their lives harder. And I'm talking, of course, about EMRs and like anyone who's gone through an epic integration or anything like that knows how hard it is, and that the promise to nursing has not always been great. Um and so I I don't blame a lot of experienced nurses for being skeptical of what technology or other types of tools will do for them because by and large, you know, the perspective of nursing has been marginalized in healthcare, and we can't overlook that. Um, I do think there's probably lightly a generational thing. I don't love when we talk in generation, like, but you know, generational differences are a very rational response to the world in which people grow up in. And certainly people who are entering nursing practice right now, who've had a couple years of nursing practice, by and large are going to be younger and by and large will be more comfortable with technology, with um computer screens, with virtual care, all of that kind of good stuff. And so I think some combination of all of those things are playing out and are showing some trends of more novice nurses being more open and more tenure nurses being less open. But my big takeaway would be overall, we're talking about more ambivalence or sort of in the middle, which tells us we have room to communicate, we have room to show them the impact and hopefully sway them to seeing real solid use cases where this can help not just the patient, but the nurse as well.

Yes, and there are a few points I want to also um bring up as you mentioned that. And in terms of the differences in of the nurses and their maybe the generation that they're born in and the experience that they have, one interesting thing is that if they are a less tenured nurse, they maybe don't have the same background as someone who is more tenured or more experienced in terms of that transition, right, from paper charting to EMR implementation and what that meant and how that impacted the nurse on the front lines. So, so definitely an experience that they probably don't have that same experience uh as other nurses do. And um, I'm not sure if there was any kind of um commentary in the report that might speak to some of that too, but uh but it also could be, just as you said, just the ability for less tenured nurses that have grown up around more technology to be more acquainted with the concept of AI and evolving technology because that's what they've been used to historically.

Absolutely. I mean, it could also be as simple as like new nurses are just trying to learn how to survive their shift. And like the idea of a tool coming in and helping them is probably a wonderful thought. Um, versus someone who's been like doing their job and might maybe is later in their career is kind of like, eh, I don't know if I need to learn something new right now. Again, this isn't like, ugh, this is the worst thing to ever happen response. This is the, you know, 70% plus who are kind of in the middle, who are like, well, I don't know, maybe good, maybe bad. We'll see.

Yes. And I do believe that there is a lot to explore, right, with that ambivalence and being kind of part of this middle ground in terms of not being a hard yes or hard no. And so when it comes to that, and when it comes to thinking about that ambivalence and maybe some of the concerns of the frontline nurses, uh, what would you say are more of those concerns that the frontline nurses are voicing about technology solutions for staffing? Yeah, absolutely.

So I'll just underscore that we asked this directly to get quantitative data, just to understand the size of how people felt about these. And then we unpacked them in focus groups, which gave us a lot of good and deep understanding of what drove it. So I'd say number one, by and large, concern about AI, about virtual nursing, is harm to patient quality and experience. I mean, it really speaks to who nurses are at their core. The first question is always going to be what is the impact here? Um and so just worried that, like, is this gonna change um the care standards or the experiences? I think, you know, early on, people were really worried about virtual nursing and like what would the patient think? Um, and and this tells us there's room for education, right? Because so many pilots again and again show the positive impact of both virtual nursing and certain types of AI pilots for the patient experience and for patient quality. So that one was like by far number one, sort of out front. And then after that, there are two things I would call out, and then one thing that I think you see in headlines that I would just note is not as big of a deal. Um, so the next two I think are really important and important as you think about bringing AI or virtual nursing into your organization. So the first one is accountability for heirs. Like, I'm a nurse, I'm providing care with a virtual nurse, and you know, horribly something happens and someone's license is on the line, whose is it? Like you have to be able to answer those questions. Um, and so that's a very just in the weeds, but incredibly important question to be able to answer when you're implementing anything that's gonna change the way in which care is delivered. So, really that accountability piece. And then the third, you can probably guess what it is, but workload. Like, what does this do to my workload? In my opinion, if the answer is this does not decrease your workload, organizations should not be doing it. Like at this point, we can't do things that are even neutral for workload. Like we need to be doing things that improve the nurse workload situation. Um, and so again, just running right at that when you're thinking about bringing something into practice and what that means. And we're not talking about short-term workload, of course. We're talking about workload over time. The one thing I do want to call out, because I think we've seen this in um on protest signs when you see certain headlines come out across last year, is that people are worried about jobs. And you saw those signs, like, you know, about replacing nursing jobs with AI. Like that, first of all, was not in the top um in terms of concerns. So by and large, the nursing workforce is not worried about being replaced. I would also say I have not seen instances at this point of virtual nursing or AI replacing nursing jobs. And so I think nurses can kind of see through some of that. And I would consider some of that a bit clickbait online, um, and that we should be waiting in that. Um, but also to just if that is a concern, to once you talk about what these pilots actually look like, it's really easy to understand how this doesn't replace the hands of a nurse, right? There's nothing that replaces hands on patients. And so um, I think a lot of nurses can see that. And that really didn't come up in the top three for us.

Yeah, and that is a bit surprising to hear just in terms of how much those headlines do make their ways around the internet and how much we see that and ingrain that rather than what you did mention as the top concerns, which are which are more focused around patient safety, quality of care, accountability for the care, and then just trying to um figure out more about how this is implemented and um how this could be a a you know a great solution for nursing that could be uh something that's worthwhile and valuable for all who are involved. And so, yeah, so so it is really surprising to hear that and and I do uh. uh agree with what you mentioned in terms of how technology um can be thought of as more of a supplement to the work that the nurses are doing rather than a replacement. And we could see that especially with the virtual nursing and different uh types of initiatives that are out there, how much that can help support rather than to replace because just as you said, nurses have a great amount of expertise that cannot be replaced with what is currently being implemented with these different technologies. Exactly. And I wanted to ask too about you know, because there is a little bit of this balance as well in terms of what we have for technology and and what we're considering for human-centered care. And how how can health systems really balance human-centered care with these with all of these potential benefits of technology and and their solutions?

I think if you start with the nurse at the center, you're going to see the impact on human-centered care on your patients and on their families, right? Like the biggest thing that gets in the way of that human-centered care at this point is the nursing workload. And a huge portion of that is going to be administrative burden, right? That is what's tearing people away from the bedside. I mean nurses want to be at the bedside. So if we enable tools, technology, other things that can take work and particularly administrative work off of the nurse's plate, it only enables more human-centered care and you know more staff centered approaches to care delivery. So it really is a win-win. I mean certainly I don't think I need to say this, but like of course vet what you invest in, make sure it's the right thing, bring nurses in, make sure it's going to impact their workload in the way that's promised. I think we are hopefully past the boom of technology in which not great things were on the market and sort of getting implemented. And I really I hope we're past that. And I think we are and I think health system executives are smart about the investments that they're making. But if you put that nurse at the center and you really think about how this is going to impact their work and their workload, I think it's pretty hard to miss on the human-centered care piece.

Right, exactly. And that's very well stated because if there is a solution or if there is a way to balance human-centered care with technology that enables some of this workload to really meaningfully be taken off of a nurse's plate, especially if they don't necessarily have to do this extra work, which over time we know nurses have collected a lot of different you know types of different um functions within their role I could, you know, we could see how that would be a huge win in our different healthcare organizations. And I do want to share too, you know, one one good piece of news in the report is that these sentiments are not in you know set in stone and you tested messaging strategies and speaking back to communication um found a fairly significant change in attitudes towards technological solutions. Can you talk a little bit about that and what kind of messages that were tested?

Yeah, absolutely. So I'll stick with AI because I've been talking about that a lot um and if you can't tell I'm a pretty big fan about the art of the possible when it comes to AI in healthcare. But like I said, you know most people, most nurses were not super enthusiastic about AI. 9% came out and said like strongly positive feelings about AI impacting the ability to safely staff with a lot of the other people in that ambivalent phase. So what we did was message testing message testing is a marketing tactic. You give some information or you ask a question, you give some information, you ask the question again, you see if it shifts their sentiment. And so we did that with our frontline nurses and we actually found that support so that positive support that excitement about AI jumped by 22% just by sharing a couple of talking points about AI solutions and pilots and what they looked like. And what that really tells us number one, we can shift minds. Number two, people are desperate for information because we put very little information in front of them and saw such a big jump. I mean 22% is quite a lot. And number three is that people really aren't entrenched in in the views. So those headlines that say you know nurses are sort of universally opposed to AI, it is not true. Like if anything this tells us that people need more information about that art of the possible about the pilots about what the impact can look like both for patients and nurses and that almost alone can shift um shift perspectives I will plug that you can be even better at shifting perspectives if you sort of get the messenger and the message right but just information alone is a is a good first step.

Yes and and in speaking about the messenger too would you say that the messenger is as important as the message because I could see how that might be a big factor in this the messenger needs to be a trusted source.

And so going back to who do nurses trust, it is their manager by and large. So I do think the messenger is incredibly important. The message does matter I will also say like there are ways to be better and worse at the messaging and you know we tested a bunch of different types of messaging and actually one of the things we're working with our membership right now is just actual real talking points based on data that will work really well with different types of personas early tenure nurses, later tenure nurses, those in unionized environments, non-unionized so you can imagine different personas, but the messenger does matter and in the organization that really is the nurse manager. There is certainly a role though for nursing organizations in all this because we also asked where people get their information outside of their organization and by and large associations above everyone else above the managers above social media by far, nursing associations holds the most influence over nurses. And so you all for example carried information is critical because nurses do look to the professional organizations that they participate in for information and really trust it, which is an important part of that equation.

Yes and it's a really interesting theme because on the one hand you have the trust between the nurse and their direct nursing manager. And then you have the piece about trust between the nursing manager and the larger organizations that are sharing these different types of communications and statements and different types of thoughts on upcoming developments. So I do see you know it is interesting to see how trust plays out kind of full circle when it comes to communication. Yeah, absolutely. And it is really interesting too to your point about how the findings state that some of what you hear just so much of is not necessarily what's happening in within your individual organization. So a really good suggestion for nurse managers or nurse leaders to uh to be able to look within their organization and not so much whatever maybe clickbait article might be saying or to really um to really uh look within more than without it at that moment.

Yeah absolutely you gotta um vet your vet your sources and just know know how the media works when before you click on certain articles.

Absolutely and in speaking of our sources and in speaking of you know professional nursing associations how can those professional nursing associations be leveraged more effectively to support these safe staffing messaging I would say the number one thing that health systems can do is to start talk about start talking about the pilots that they're running whether it's in virtual nursing, in AI, whether it's playing with new ways to deliver care, whatever it is, we tend to pilot cool things and have something great happen.

And maybe we scale it and maybe it goes to pilot purgatory and just kind of stays in a pilot forever. But that information never leaves I mean it never gets to the front line except for the people who are on that unit. And so professional organizations really are a great source to share information and to get that information out widely. I mean sometimes we think oh it was just one pilot but one pilot can really bring something to life you know um the you know I was so struck this past fall we we started tracking AI pilots at a lot of the organizations we worked at with and um one organization was was doing a pilot to help reduce falls using AI. I won't go into all the details but basically the room is equipped with um AI that watches the room without someone on the other end. So not not like a virtual sitter but literally the AI learns the pattern of the room and is able to um alert if a patient's getting out of bed when they shouldn't right and so it's like a sitter but without someone watching it. And they were able to reduce falls by something like 90%. And I was like that's incredible. Like when can that happen? Right. And and people think oh that's just like one small pilot. And it's like but that's incredible right it starts to bring to life the power of something and if you scaled that across an entire health system imagine the impact that that could have and so I would say sharing these types of stories with associations, allowing them to get pilot data out on your behalf to the broader nursing world, the broader nursing profession to the broader healthcare profession is a critical step for us all to move forward towards innovation, towards transformation and really changing the way that we deliver care in this country.

Yes, that's a great example and it reminds me too of how we use so much evidence and implementations and you know trying of different products and resources to see how effective it is before we scale it and bring it to other you know units, departments, hospitals. So a lot of this uh process speaks to how we could implement this different technology and AI in these different settings and then across other you know other organizations and more broadly. So very exciting to hear that news.

Yeah.

And you know we could talk about this for so much longer and uh I'm so sad to be wrapping up soon, but I just wanted to give you the opportunity to share any final comments that you might want to um to share with our listeners in terms of uh any of the topics for communication just or the report or safe staffing.

Yeah I'll actually I'll break your rule a little bit because that's who I am at my core. But um I would say my last takeaway is just something I've mentioned but I just want to underscore which is just the power and the influence of the nurse manager is truly the hardest job in the health system. And I think we say that again and again and people know that and yet it doesn't feel like a ton changes. And so speaking to health system executives, particularly non-nursing executives, invest in your nurse managers. Train them, develop them as leaders, get them appropriate spans of control, get their workload under control, invest in technology that's going to support them because if there is anything you want to do to try to push transformation of your health system forward, it should be investing in the nurse manager to make it happen. Because really they are the ones who are going to be communicating to be leading us through this change and they need to be equipped as leaders to do it. So that is what I would leave you with not about frontline perspectives but rather about that investment at the manager level.

Yes thank you so much and you know as many of us are members of ACNL that's such an important message and we appreciate you for being on our podcast today. Absolutely thanks so much for having me. Thank you for being here with us and our guest today was Anne Hurleth, vice president of the Health Management Academy. We'd love to hear your feedback email us at socialmedia atacnl.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 on the first Friday of every month. To learn more about the show or ACNL in general visit us at acnl.org. Thank you for listening