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 Dr. Nancy Blake, Chair of ACNL's Healthy Work Environment Committee. Dr. Blake is also the Chief Nursing Officer at the Los Angeles General Medical Center, formerly known as the Los Angeles County USC Medical Center. Dr. Blake was recently a panelist at the Healthcare in the Age of Personalization Summit, discussing what nursing can teach physicians and CEOs about leadership. Dr. Blake is also associate adjunct professor at UCLA School of Nursing. Welcome, Dr. Blake. Thank you so much for joining us today.

Thank you for having me.

It's an honor to have you here on the podcast, especially as an active member of ACNL. And we're really excited to talk with you.

I'm excited to share what I can share with our leaders.

Absolutely. And we want to learn more about the summit that you had attended and tell us a little bit about it. How did it go?

It went well. I was asked to participate as a panelist and didn't realize what a big deal it was. There were CEOs and business people who were talking about the age of personalization and how we have to pivot to where we were before with our patients and our staff because things have changed. And where healthcare was just one of those things that happened, and people went to their doctors, people are actually looking for the right match and people who really focus on their needs. I was able to speak about what I've learned. I've been a nurse for 44 years, and I've been a nurse leader for 40 years. And I've been a member of this organization that had numerous names over the years since 1989. But what I've learned is in order to retain our nursing staff to work with our patients, and you know, we take care of the most vulnerable populations in the LA area. We need to take care of our staff. The pandemic has definitely turned our profession upside down. A lot of people left in 2022. And we had 22% turnover that year. And we've been trying to play catch up to hire staff and retain staff. Good news is we implemented professional shared governance a little over two years ago at LA General. We implemented a residency program two years ago. There's been a lot of exciting things that have happened, but our turnover rate went from 22% in 2022 to 13.6% in 2023. And we're under 7% for 2024. And we've had 500 new graduates. The last cohort just started last week, 100 people. And we have a 93% retention rate. So allowing the staff to make decisions, allowing them to take ownership of their units, um, their um, you know, professional work, offering them um the mentorship that they need to move their profession along and really focusing on them as professionals has really helped the culture of the organization as well as um having those metrics. I mean, I'm so excited. We also obtained as a county hospital for the first time a leapfrog A. So our patient. And we submitted our magnet document on June 3rd, and we're waiting to hear. Um, but I think we'll successfully have um a magnet survey, hopefully before the end of 2024. Um, and 10 of our units became uh beacon with AACN, three gold and seven silver. So um just by changing the culture and by focusing on the employees and their needs, um, improving staffing at the same time. And I always say it's like a chicken in the egg phenomenon. You can't have a healthy work environment without staffing, and you can't have staffing without a healthy work environment. So um a lot of good work. I've hired some great directors over the last three years that I've been there that are really focused on servant leadership and um really listening to the staff. Um I always say if you want to know what's wrong with an organization, um, you talk to the staff. And if you want to fix it for very little money, you can talk to the staff and they'll let you know. Um perfect, absolutely not. Um, and do we have all the problems solved? We don't because our patient populations have changed. Um, there's a lot more patients that are showing up that have mental health issues. Um, so we're dealing with workplace violence and protecting our staff and de-escalation and all of those things. But um, you know, that's what I talked about in the podcast was you really need to focus on your employees. Um, because if you if you keep your eye off your employees um and you focus on something else, you're gonna lose their trust.

Right. And first I just want to say congratulations for being a panelist on the Age of Personalization Summit, because that is a huge audience to present to. It's wonderful to have your representation as a nurse and as a nurse leader. And I think it speaks volumes to the importance of having nurses at the table, right? And being able to be a voice for nurses. And you had a lot of great oh, and and go ahead, sorry about that.

Well, and the exciting thing is they did a Forbes article about our talk. Um, that was just published in the last couple of weeks. So, you know, they told me when I got involved in this, oh, there'll there'll be a Forbes article about this too. And you know, you think, yeah, sure, right. But it actually um it's online, but it was pretty exciting um to actually see it in print and to have them quote me on ways to really focus on the staff.

That's amazing. Congratulations on that too, because Forbes is a huge platform as well. And a lot of people might immediately think of Forbes as solely a business type of publication or a business platform. But Forbes is also an opportunity to represent healthcare and in a really big way as well. So very huge congratulations on that. And again, really lending to the power of the nursing voice and how important it is right now, especially after the all of the peaks that we've experienced in the pandemic and all of the hardships that have come to nursing during that time. So well done and congratulations on that front.

Thank you.

And I do want to speak to some of what you mentioned before because there were a lot of great nuggets there in what you just mentioned about the talk from and your participation in the panel. And a lot of that was focused on making sure that we take care of our staff. And, you know, one of those key takeaways uh that were mentioned in the panel was really about what you said about how leaders should listen to and act on those staff ideas instead of really trying to go it alone, which I think could be a big tendency for leaders to do. And why is it that you think that new leaders might often feel this need to be the one with all these solutions when they're taking on a leadership role?

You know, I spoke to um, we do a nursing leadership development workshop. It's it's six months or 12 weeks actually, with our um new nurse managers. And I'm I spoke to them yesterday and we talked about shared governance. And I said, you know, it's really easy. Um, it's really hard because as a new nurse manager, you want to show that you have it all together. Um and sometimes we think we have to have all the answers. Um, and we think we know what the staff need. Um, and I said, it's it's okay to say I don't know. Um, or I'll find the answer for you. It's really important to circle back. Um and and what I found was very helpful, especially during the pandemic, is to be completely transparent. If you can't do something, tell them you can't do it and tell them why. Because if you don't answer that, they'll fill in the blank and they'll fill it in with something that's not true. Um if you can do something, let them know you try. And I have tried a few things. And you know, coming from the private sector, you know, working for 35 years in the private sector, and then coming into the public sector in a county facility that has all sorts of county rules and regulations and civil service, there are things I can't do that I could easily do when I was at in the private sector. Um, but staff know I try, and I think they appreciate um the advocacy because they want to know that first of all, we understand what they do, and second of all, that we do our best to advocate for them. Um, and that's the kind of thing that I think helps build trust. Um and over the years, I've learned psychological safety, that you don't shut someone down. You listen to them and you allow them to speak. Um, but as a new manager, I wanted to have all the answers. I wanted to show I had my act together. Um, and I fell on my face a few times by by behaving that way. And I think tracking her, like I said, I've been a leader for 40 years. So I've fallen on my face a few times and gotten backup. Um but you know, this is a new generation that's coming in, they have different needs. Um and if I assume I know what they need, I'm gonna make a mistake. So what I tell them is feedback is not a bad word. And um, to me, I'd rather have them tell me to my face if they have an issue than talk behind my back. And if I'm working on something that doesn't meet their needs, I want to focus all the time and energy I have on things that do. So tell me to stop doing that and start doing something else. My direct reports, I try and ask them at least once a year, what do you want me to continue doing? What do you want me to stop doing, or what do you want me to do more? Um, and you know, you have to build trust with people. And I went to a leadership class years ago, and I remember the one nugget that I took away from that was you have to put money in the bank before you can withdraw. So you have to build currency with staff in order to get them to trust you.

Right. And there are so many important points that you emphasize there. And I first want to acknowledge that it is really difficult to be a new leader and to to not kind of take on all that role of being the one who has all the answers and the one who has all the solutions. It's not that different than when we start a clinical role in nursing and we want to not appear that we don't know everything or that we appear to not have all the answers. Because of course, as new, as new healthcare workers and in probably most fields, we want to feel competent and we want to feel that we can find all those answers often individually. But healthcare is a team sport, and there's a lot of great feedback and a lot of great suggestions that team members can have. And it's very interesting because I think we often hear about, you know, in our nursing careers about how nurses have great ideas, but they might not always feel that they could share those ideas with their manager because of that lack of openness and transparency and that safe space, right? To share those ideas. And and I would say to that, how how do you encourage staff then to share their ideas if they've experienced this? And and what strategies do you uh do you use to ensure that those ideas are implemented?

Well, I think, you know, first is to listen to what their ideas are. Um, and second, to sit down with them and figure out how to operationalize it and give them feedback and maybe send them back. I just did an article that was published, and it actually was published um in the AACN um staffing standards, uh, where I sat down with the staff when I was at Harbor UCLA for two years before I came over to LA General. Um so I've been with the county for a total of five years, but um, they came to me and said, you know, we have patients that are one-to-one in the ICU. So I said, okay, give me a list. Um and they gave me a list, and some of the things were subjective. So I said, let's develop a policy. Um, but here's the feedback. This is too subjective. I need to send you back like a CRRT patient, if you're familiar with, you know, chronic renal replacement therapy. Um, you know, that in and of itself doesn't make somebody a one-to-one, doesn't drive 24 hours of care. So um, you know, I gave them examples and was very specific about if I'm gonna go to the system CNOs, and then I'm gonna have to go to the CEO's and DHS leadership to buy off on this. I need to have something very specific. So we went back and forth for several months. Um, we finally came up with a product that I thought that we could live with. I brought it to the chief nursing officers because there's four hospitals, and um, they gave me some feedback and I went back to the group. Um, we made those changes and then I brought it to DHS leadership, which included the CEOs. Um, and we ended up adopting it. And I speak on the topic of staffing across the country, and everyone always asks for our policy. Um, and so AACN said, can you publish this so we can put it in the staffing standards? So we published it in um AECN Advanced, and it's open, it's open source, so you don't have to have the journal in order to get it. Um, but it actually goes through step by step what we did. But the title of it was Collaborating with Frontline Staff Leadership Collaborating with Frontline Staff. Um, and they were very proud of the finished product. And when I asked them to publish it, you know, some of these were frontline staff nurses. Um, but it goes through step by step what we did with them. But that's an example of taking an idea and going back and forth and back and forth to come up with something that was good. I mean, it's not 100% of our patients are one-to-one, but those, you know, 20%, which we find across the country is 15 to 20%, you know, have some criteria to say, yes, this patient truly does drive more than 12 hours of care in a 24-hour day. Um, and like I said, you know, very the staff was very excited to also see it published in staffing standards that are being accessed by, you know, ACNL members, AONL members, members across the country, because everyone's struggling with the same thing. So to take an idea and come down and bring it to tangible resources. But you know, we've done a lot of that in the last um three years at LA General. And the staff feel like their voice was heard and they see an end product. And when you do that, they take ownership. Um, and I don't know if yeah, if you've heard Joe Ty speak, but he gave me a big poster from my office, and it says from a culture of accountability to a culture of ownership. When somebody owns it, it's sustainable.

Right. And I love that you shared that. And and there's so many things I want to discuss too, because first is the idea of really having this nice collaboration between the leaders and the staff members, because I think we often might think about leaders and staff and more being kind of against each other rather than working together. And the example that you shared with the policy that you created is a really nice example of a collaborative approach to listening to ideas, being able to share that with the appropriate stakeholders, and then going, you know, making iterations and making it work for all the people involved to best serve the team, best serve the patients. Uh, so that is a really wonderful example. And I think that that's something that that education is something that needs to be done more broadly. I I think that uh oftentimes some of the barriers for nurses and sharing these ideas could be just not knowing what's all entail, well, what's all involved when it comes to making these changes in the workplace because it does involve a lot of those specifics, right? A lot kind of like a business plan to really hash out what's needed, right, for for these conversations. So I think that that's a very important piece. And I also like what you shared in terms of you know, continuing continuing to have this collaboration and and can you share a little bit more about fostering collaboration uh collaboration across disciplines? So, for example, fostering collaboration with physicians or with administrators? Sure.

So when I was looking, I took a couple of years off. Um, my husband had retired um years ago. So I thought, you know, I'll take a few years off. So I left my job in 2017 and I thought I would potentially retire at that point in time. Um, but I hated it. My adult children think I'm crazy. I wanted to go back to work. I felt like I still had a lot to offer our profession. So I went on a journey and went through 40 interviews for a CNO job. Wow. Um, all over the country, I was offered numerous jobs, um, was the final candidate and withdrew myself after speaking to some CEOs because I heard everything from I need you to be loyal to me, not the nurses. There's no opportunity for professional development in nursing. Um, and what I said in my interview is I want to be at a place where the leadership team is truly collaborative, where they support each other. And when you walk out of a room and make a decision, nobody knows who was the dissenting vote. Um, that you don't say, I really didn't want to do that. That we all go back to our own professions and say, we're doing this because it's better for the patients, or we're doing this because it's better for our organization and our staff. Um and people always question why I went to the county because they were like a county hospital. And I said, because I, you know, I felt like I walked in, I wanted a place that cared about their employees and cared about the patients that they served and cared about quality care for the patients that they served, as well as I was looking for the administrative team and paying close attention to my interviews. Um and so I found it, you know, at the county, but I I've really found it at um LA General because we support each other. We have a triad model of leadership on our floors. So we have a physician leader, a nurse leader, and an administrator that supports those people as well. Um it was started, I think, at Cleveland Clinic. Um, but and it was mentioned in the podcast, the Forbes article about triads, and they come together. So we have the triad group that does safety rounds with the nurses once a week. They talk about what's going on, if there's a problem between the physicians, and those leaders take ownership and they have joint accountability. So they have joint accountability for the happy's, the falls, um, but they also work together as a team. Um, and I tell people we win together, we lose together as a team. So if we're against each other and we antagonize each other, we're gonna lose. Um, and like I said, we have as an organization have gotten a leapfrog A. We're moving our CMS scores higher. Um, we're looking everything, the patient outcomes um have gone down. Um, the the bad outcomes have gone down significantly. And our numbers look really good, no matter what metric you're looking at. And that truly comes from a collaborative team working together. Um that's the expectation of our CEO that the CMOI and I are on the same page. We always make sure that when we make a decision, we run it by each other before we publicize our decision. So, you know, I think that's where you see collaborative practice.

Right. And that's such a thoughtful approach, too, because I don't think it's uncommon for people to see the other situation where there are a lot of silos and there are a lot of, you know, teams who think individually rather than together in terms, especially with leadership, right? We see different disciplines. Disciplines of leadership. And there might be some of that environment that's not as collaborative. So I think it's a very thoughtful approach that you found you found in an environment that actually embraces the collaboration among these different disciplines. And the outcomes say it all, right? I mean, I think it really shows just uh from the willingness of the team to be able to collaborate and listen to all the people who are at the table, rather than maybe only hearing one person or one group's ideas and implementing only that. And the idea that you mentioned about ownership and accountability is so important. And I think that it's it's something that leaders might not often think about as much in terms of having their staff be accountable for different things and seeing how impactful that can be. And you know, at the summit, there was this idea mentioned in terms of having champions and units that can drive change. And I think that really speaks to that accountability. But can you talk a little bit more about that?

Sure. Um so we had a problem with HEPIs a few years ago. So we um along with Kaiser, Kaiser leadership actually shared their curriculum for skin champions. We had something apparently very similar to that at LA General prior to the pandemic. Um, but we actually did training and we have champions on both days and night shifts to make sure patients are turned, to look at the wound, to do that four-eye check. Um and when we actually rolled out the skin champions, our numbers improved 100% because the manager's not there 24-7. Um, but our ICU in the last 12 months has their hap ice have decreased 57%. And we rolled out the skin champions a year ago. So um, you know, when people say, What are you doing? We're just getting people on the unit that are focused on this because the managers are busy. I mean, we understand the management role, you're balancing staffing, you're balancing schedules, you're balancing, you know, uh making sure that you're meeting your metrics. Um, but they're not out on the unit 24-7. So now we're trying to add fall champions on all the floors. Um, but we find that when you get champions, that it's it's their um passion. Um, and then they start reading articles and they start, you know, coming to me. And how about if we try this and how about if we try that? Or we have this team that's not coming and doing what they need to do. But um, you know, there's everyone has their eyes on the prize. Um, and so we have magnet ambassadors, which are we call practice excellence champions now because they're getting the word out about all things magnet, shared governance, professional practice model. When we did our nurse engagement survey, um, you know, we never got more than 35, 40%. We got 80%. We did it in February because we said this is really important for our magnet document. Um and so, you know, we got a lot of very good information and then we circled back with the team. And here's your score on each and every question. What do we need to do to change this? What do we need to do to improve this area? And then we got a whole lot of information from them. And I just had a strategic planning receipt, uh retreat off-site, and a third of the people in that room were frontline staff, so they were shared governance council members. Um, and it was a whole different um, we all walked away from leadership to staff, and we invited all the advanced practice, somebody from each one of the advanced practice groups as well, which they hadn't been invited to these. But we all walked away with a really good feeling about the organization. Um, and it was really a nice day. And some of the things that I've been wanting to do, I brought up to the staff and they were like, do it. And I thought I was, I thought it was something I would get a lot of resistance. Um, but you know, you just present the information and they'll take it back and they'll sell it. Um and and the passion in their faces and the excitement to actually see it come to fruition um is really exciting for me to see because that's what I like. I mean, I've done everything I wanted to achieve in my career, and now watching other people grow because they're gonna be my replacement. Um they're gonna take care of us when we're sick.

Right. It's so true. And and I, you know, I do want to say congratulations on all of those outcomes as well. They're it's really interesting and very um empowering to see what outcomes can happen when nurses are able to take ownership of these different initiatives and when you can utilize champions to really be the point person for some of these different, um, very important initiatives on the unit or in different practice settings. And speaking to that, I want to ask about how do you identify those specific champions within units to take on these new initiatives? Because I also know that there might be some hesitancy for people to be a champion, or, you know, how do you know if someone's ready or is willing to be that person?

You know, I think some people come naturally come out and volunteer. And what I've encouraged the managers is tap that person on the shoulder that you think has um, you know, the ability to do it and show them that you'll support them. And I think that makes people feel really good because the fact that someone tapped them on the shoulder and said, Hey, you know what? You might want to do this. And I think you'd be really good at this. Um and then they in turn, you know, bring another one and another one and another one. But I think some people are hesitant to come forward. And there's been a lot of people that I've walked up to and said, you need to go back to school and get your bachelor's degree because I see you as a nurse manager someday. And um, you know, they just never thought that they could get there. Um there's a few people that I said that to when I first came to LA General and there they just graduated. So um it's exciting to see that.

Right, absolutely. And I think that for a lot of these different leadership opportunities, nurses may not necessarily see that potential in themselves that other leaders might see so clearly or so easily. And so, and I think part of that too is the recognition of these different individuals as they do this work. And I just want to ask about how do you how do you ensure that there is that level of recognition for these champions um throughout the organization?

Well, I try and do whatever I can. Like I said, I'm not Stanford, so I don't have a lot of money or cedars. Um, I actually put out a uh request to the UniHealth Foundation last year at this time. I just sent a cold letter and said, I need, I need some funding to do well-being initiatives, you know, explained the um pandemic and meaningful recognition um for staff and some other things. And I I put out a letter, they asked me to do a letter of intent, then they asked me to do the application. I got $300,000 in May. Wow. And it's things like you know, a coffee card that the director can go out and say, Hey, I heard you came in four hours yesterday to relieve for breaks. And the fact is what staff is telling me is they've been noticed. So that's how we determine who's going to the magnet conference. I bought 40 tickets to the Dodger game uh last week and brought them as my guest based on people who've done different things. And they were like, seriously, me? You don't want to bring my manager. It's like, no, you did this. So the reason we're taking you, so we we offered it to all the Daisy uh awardees from last year.

That's great.

Um but um, you know, we brought people, we've been trying to do things for meaningful recognition. Um, we are doing uh 10 cohorts, 10 groups of um people in the AACN CSI Academy. Um, and it's all about healthy work environments and um and most of them have done the healthy work environment assessment tool. And in all the areas, everywhere in the house, I think we've done it now. The lowest score is meaningful recognition. And I always tell people, I was on the board of directors for American Association of Critical Care Nurses when they rolled out the healthy work environment standards. And meaningful recognition is what meaningful recognition is to them. So we have a group from our jail ward, we have a group from the OR, we have a group from primary care, um, we have two med surge units, two ICUs, um, a specialty care emergency department. All of them, meaningful recognition is different. Um and so they're doing rolling things out. A lot of them have to do with acknowledgement uh from the manager or from their peers. Um, like the 5B ICU, it's the B's, and they have B of the month. So, you know, they have this little, you know, um uh board that people can nominate, you know, the B of the month. Um it's you know, it's and then the B of the month gets something. Um, and the the rewards are different for each unit, but you know, I really think it's not thank you very much. Here's your pizza. It's thank you for doing this. It's the fact that someone noticed what they were doing. Um people always get embarrassed and they look down and they they say, oh no, no, no. But you know, they always tell me it's amazing that somebody nominated because I didn't think anybody saw this. Or, you know, so it's not all about um, you know, just throwing things at people. It's about being very intentional and specific when you're acknowledging them.

Right. The having the specific recognition to share with someone makes a very big difference in terms of how the person will interpret that recognition and how how specific and relevant it is for that person, just because you can call out those specifics. And that makes a huge difference. And uh, you know, we could talk about so much more, uh, but we do have to wrap up the conversation. I just wanted to give you the opportunity to share any final comments that you'd like to share with our listeners when it comes to when it comes to being a nurse leader and being able to listen to staff members.

Well, I do have to say, um, you know, if you're new to the area, go on a what I call a listening tour. Before you go in and make major changes in an organization, listen to the staff. Um, you'll be able to filter out what's working, what's not working. Um, you don't want to touch those things that aren't working unless they're destructive for the organization. Um but uh, you know, it's really important when you listen that you give them the answers if you have them. If you say you're going to do something and you can't do it, you circle back with them. Or that you give them an update if something takes a long time. Um staff want to know that you're listening. Um, I have an app that uh Jocelyn Insights has, and staff can tell me anything. They can tell me anything confidentially, um, or they can tell me it's a healthy workplace app. Um and um over the last three years that I've been on this app, which I was it was originally a research study with Hunter Jocelyn and I, um, to really see what frontline feedback meant. And I can actually text back answers to the whole group. But I find now when staff send me information, they actually put their name on it. So I can circle back because I always tell them sometimes I have clarifying questions. But I think listening, knowing that you don't always have all the answers, you know, even after the amount of experience I have, I still have to say I'll get back to you. But get back, circle back with them. Don't ignore them because if you ignore them, they're not you're gonna lose their trust.

Absolutely. The follow-through is very important and you know, just as important as being able to keep note of those different um pieces of information that they share. But thank you so much, Dr. Blake, for being part of our podcast today. It was wonderful to have you here, and we really appreciate your expertise.

Thank you for having me.

Thank you. And our guest today was Dr. Nancy Blake, chair of ACNL's Healthy Work Environment Committee and Chief Nursing Officer at the Los Angeles General Medical Center. We'd 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 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.