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 Sill Turpanier, System Chief Nursing Officer at Providence, where he oversees a team of 36,000 nurses across a 52 hospital system. Sill is in an ideal position to talk about all the things that go into nurse staffing and recruitment. But before we get started, we have some quick housekeeping. Registration is now open for ACNL's 2025 annual program to be held this February at the Disneyland Hotel and Resort in Anaheim. Registration is available on our website at acnl.org slash annual hyphen program. That's acnl.org slash annual hyphen program. We will leave a link in our show notes as well. And remember, if you like the show, don't forget to leave a review in your favorite podcast player and tell a friend or a colleague about us. It really helps us out. And now back to our podcast. Welcome, Cell. Thank you so much for joining us today.

Oh, thank you. It's great to be with you here, Charlene.

Yes, and there's so much to talk about here with the topic of nurse staffing. And I just want to dive right into it. But you know, when we think about nurse staffing in general, it's really no secret that staffing levels impact patient outcomes, but then hospitals also have to work with certain budgets, right? And how do you strike that balance?

Yeah, no kidding. We are diving right in. Yes. Yes, you know, staffing level impacts outcomes. And let's not forget that the model of care influences the staffing needs. So you and I have data suggesting that when you reach a certain level, you know, negative outcomes can happen to patient. And also, let's also remind ourselves that the data that we have is primarily based on one very important premise, which is that we practice in a certain model. Traditionally, the studies that have been done that you and I are aware of offers us uh guidance around certain practices, and it's primarily with either primary care or total patient care. So we also have to keep that in mind. And to your and to go back to your question, though, I believe that the best way to address this, that balance that you're just describing, is by first identifying the needs of the patients, then you identify the team that's required to meet those needs, you develop a staffing plan, and that plan needs to be costed out. It shouldn't be the reverse.

Right. And I know that it's, you know, this could be such a challenge too. And, you know, I just I wonder too, because when we think about those challenges, um, and maybe some of the challenges that you faced when it comes to this all, what are what are some of those biggest challenges um that you have faced when it comes to achieving these optimal nurse staffing levels?

You know, I want to start with I what I would call the bit, you know, the elephant in the room. It doesn't matter how good you and I are at recruiting nurses and retaining nurses, we will never have enough if we keep on working the same way that we work right now. So I believe that the current model, primary care model, total patient care is probably the biggest barrier that we have in front of us today. It just doesn't work anymore. And we've kind of sort of known this for a while, and uh and now we have to do something about it. I have been a nurse a little bit longer than you have, uh, 35 years this year to be exact. And it's just fascinating to me when I think about when I, you know, when I go back to my initial years and even when I was a nursing student, you would show up on a department and how the work was assigned to me is the same way the work is assigned today. And yet the entire world has changed around us. So we have to ensure safe staffing via new models of care. The other thing that I want to call out is that their current the current laws is um I don't know if the barrier is the right word. Uh if I would go as far as calling it a barrier, but it certainly does not offer enough flexibility to innovate.

Right. And, you know, it's an interesting point that you made about how there hasn't been much change with staffing and how we've done things um, you know, several decades ago. And I wonder, do you do you know what might be the biggest reason for that, for why it's been so hard to change things for this, for these processes, or why it's been so hard to change things in healthcare in general?

I think there's I think it's multifactorial. I think part of the part of the reason is sometimes um sometimes we can be our own worst enemy. Uh it's very hard for us to let go of our uh of our practicing of our practices. I I sometimes I uh I jokingly say, I just love our profession because it is steeped in tradition. At the same time, I could talk about because it's steeped in tradition, we can be, we can find ourselves in our own way and and our inability to innovate. So I think we own some of that. Uh it's also very complex because we, you know, we're not the only players uh in healthcare. So we work, we're surrounded, and we're part of a team, and uh, and that adds a certain layer of complexity. And the third thing that I would say that um that is is likely part of the reason why it's uh it's hard for us to change or to see whether we need it to change is to a certain extent, you know, the model worked out economically uh to the industry, so why change? And and I think that this is why today it's the perfect environment. It doesn't work out economically anymore. Nurses do not like practicing the way they're practicing today, and we don't have enough and we'll never have enough. What a perfect opportunity right now to strike and change that and deconstructing the role as we know it today.

Right. That was beautifully said, and uh there is a lot of opportunity. And it's it's interesting because this is all um a lot of the focus on nurse staffing now comes at a time when there's also been more focus on nursing innovation, you know, more focus on leveraging nurses or actually elevating nurses to come up with more of these solutions. And, you know, I'm curious about your work too, because in your career you've been responsible for dozens of hospitals and tens of thousands of nurses working in different teams, settings, and specialties. And when you're building or restructuring a team, what is your strategy for determining, you know, this perfect or at least this um right skill mix?

Yeah, I'm gonna go back. I'm gonna start by going back to a statement I made at the beginning of our call. Uh, I believe that the the best way to address this is by first identifying the needs of the patient, then you identify the uh, you know, the team that's required to meet those needs, you develop the staffing plan, and then you assess the cost. The reason why I started with look at the needs of the patient is that I find that it's oftentimes lost in translation. There's an assumption that we must have the same players and we have to figure out okay, so now we have we have this group of people, and let's ask ourselves, what should these people do for the patients? And with the assumption that we have the right people to begin with. And I think that that's the that's the space we find ourselves in right now. We just went through a very interesting exercise as we are redefining and and and helping nurses deconstruct the their role as they know it. And then I remember when we started this journey, we were having a conversation with uh nurses, and we were asking them to list uh all of the things that uh the activities, the task that they do in order to meet those needs of uh of the patients. And uh I would challenge anyone that is listening today to go back to your team, if you're a practicing nurse, to ask yourself that question. If you're a leader of a group of nurses, engage in this conversation with the nurses, you are going to be shocked on how much stuff nurses are doing that, quite frankly, let's be honest with each other. You don't need to be a licensed nurse to do that. Now, I get why we got there. Where they're 24-7, it's very convenient to ask a nurse to do all of this. But what you and I have to address as we are identifying the skill mix is we can no longer talk, what I would say talk out, talk out of both sides of our mouth. I can't say in one sentence, nurses need to practice through the top of their license and in another breath say they are accountable for all needs of the patients. That does not make sense anymore. That's why the skill mix, I love your question, the skill mix is very important because we need to make sure that that means that patients have different needs. Nurses don't have to meet all of those needs. In fact, they shouldn't, if we allow them to practice to the top of their license. That means that we have to let go of certain things, and we also have to make sure that we elevate uh the role of the entire healthcare team.

Right. And I really love how you shared the exercise that you had your teams work on with really writing down, really um being familiar with the work that they were doing and what they were owning, because I I actually would say that most teams probably don't know all that information. Um, you know, I I'm not too sure if if um nurses have really done that exercise themselves. But um from my own experience as a nurse and from what I know about my colleagues and my friends who are nursing, many nurses self-identify as the person who does it all, right? I mean, they are the telemonitor tech, they are the CNA, they are the nurse, they are the secretary at some time. So it gets really confusing, right, to understand who should own what. So I really um I really like like that strategy that you have because it would be a good exercise, not just for the nurse, but the whole team.

Yes, yes.

And it's it's also interesting just because you, you know, the nurse kind of captures all the work, right? If there's something that's additional to be done, the nurse ends up capturing that. But that's that's kind of part of this older model, right? Um, of the nurse kind of being the catch-all. So so very interesting to kind of lay it all in front of you and just kind of see what's what's being done. And then from there being able to distribute the work appropriately among your teams.

Yes, and it's and it and it's scary work, to tell you the truth. And uh, depending on who we might have, you know, if we had others in on this conversation, we might have people who would call out to our attention, now wait a second. Uh uh do we have any evidence uh that would support us changing the model? And to that I would answer, we're starting to get some information about that because many people are dabbling in this space right now and and testing models as we go. And we cannot afford to wait 17 more years to have studies, because you and I know it takes 17 years for an actual study to translate into practice and to become like common practice. We can't afford that. We we just cannot. So we have to test stuff in the moment everywhere, and uh we just have to learn to let go.

Right. That's such an important call out, and and that can actually be much more challenging than than might be expected in a team because if you're a nurse who's had a lot of this ownership before, it could be really hard to let that go. It's kind of a natural feeling, you know, to kind of let some of these tasks be delegated to others. Um, so so definitely can understand the challenges there. And, you know, um, yeah, and when building those teams too, how do the skills that you're looking for really change as nurses transition into different positions, you know, that are away from the bedside and maybe even closer to more decision-making um types of roles in the boardroom or in leadership? Um, what are your thoughts on that?

That's its own podcast in it by itself. You know, I'll uh I would say so, yeah. I mean, yes, definitely, you know, different roles uh requires different competencies. Uh and so you have to be very uh very mindful of that. And uh and and I would say that the the further away you are from the patient, uh the more uh the more you need to be skilled at uh I would say uh getting stuff done, leading uh by inspiration, influence, so you get stuff done through others. Uh and uh and that's uh that's an important competency uh to learn. Uh it doesn't come naturally, not everyone is wired uh to be able to uh to inspire others. And and note that I'm very I'm actually very deliberate about using the word inspiration versus influence. Uh I find that all generations that find themselves in the workforce today, that you know, from from the newest generation to the oldest generation, whomever's practicing today, everyone responds well to being inspired. Not everyone responds well to being influenced.

Right.

And uh so I so I would say that uh you know the further you you you know you go to the bedside, it's very important to be to be cognizant of that and then to be aware of that. And the other thing I would say is you know there there's leadership as a uh as its as its own specialty. And it takes it takes leadership skills at all level. Uh in fact, there's a growing body of uh of literature talking about the bedside leader, uh, for instance. Uh I mean, not to be confused with leadership as as a specialty, but nonetheless, uh it that's where it starts.

Uh right. And I appreciate your um your the intentionality but but you know behind those different words, inspiration, influence, and being mindful about who you place into those positions, because those are competencies, right? To be able to inspire and to be able to influence and to do so in a way that's actually very effective for your team, being able to understand their needs, being able to support them and and then inspire them, right? To to make changes, to make actions that might be different from what they've done in the past. Um, for example, going through an exercise like what your teams have gone through to understand the right skill mix. So very important um uh pieces to keep in mind there. So I appreciate you sharing that. And, you know, I want to, you know, switch it a little bit to talk more about the nursing shortage and kind of the crisis behind that, because there has been so much talk about the nursing shortage. And even for me in my career, I've heard this throughout my entire career, much uh, you know, before the pandemic started, this was a conversation for decades, right? Um, I'm sure that you've heard this as a conversation throughout your whole nursing career as well. And and so uh we actually had uh an episode on our ACNL in action podcast a few years ago with uh featuring Garrett Chan from Health Impact. And, you know, he talked a bit about the nursing nursing shortage and how it was a big challenge back then, and it's still a challenge now. Uh, but what do you see as really a major contributing factor or what major contributing factors are present to the nursing shortage in today's age, in the current state?

Yeah, I appreciate that. And uh the alarm bell that uh Garrett was uh uh was talking about, or was at least banging on, you know, back then uh is uh is we're still we're still sounding the same alarm today. You know, nothing has changed. In fact, we know that uh worldwide uh we're gonna be short 13 million nurses by 2030. Now, Charlene, 2030, we might as well look at our watch. This is like it's like tomorrow morning, really, when you think about it. 13 million, that is more, that's like the size of a country. Some countries have less than 13 million people. So uh so it's very important that we get grounded on that. Uh and anyone listening to this right now thinking that this too shall pass, it will not pass. And in fact, if we don't do anything about it, if we think we're hurting right now, we have seen nothing, uh nothing yet. And I would also say that if it's 2030, and we are indeed looking for 13 million nurses, because we haven't changed the way we work and we continue to rely heavily on an all RN model. I would say to all of us that we only have one person to blame, and look at yourself in the mirror. Because that's what I'm gonna do. Because we know it, you and I know it right now. So let's make sure that that doesn't happen to any of us. There are there's so many contributing factors uh to the nursing shortage. There's macro level uh factors, there's micro-level factors on the macro level. If you look at any uh any data and statistics and you look at the trend over time, uh the math just don't work, forget the nursing population, just the population itself. Birth rate is low, the population is aging, immigration is is low. We have counted on immigration in this country to support the workforce for decades. So unless everybody uh is starts to every family starts to have five children tomorrow morning, uh uh you know, for every single family unit, we're it's never it's never going to catch up. And you and I know that that's not going to happen. I just can't imagine that uh you know that happening. That so those are those are factors that you and I on the short term, even long term, I mean, this takes decades to change that. Now you layer on top of that those who are willing to go to nursing school, can pay to go to nursing school, can finish nursing school, and then are willing to stick around. That I mean, you can just see the funnel is you know smaller and smaller and smaller. But there are things that you and I have control over that we should be very, very, very mindful of. And that has to do, I want to call out two things. The work itself, this goes back to my comment around models of care and how we approach the work. We must do something there. I I'll just leave it at that. I think I've I've made my point uh enough earlier, but the other part. That I want to talk about that I want to call out as a contributing factors to the nursing shortage is the bullying that we're seeing in our practice. It is so sad that we are still talking about that. And I would argue that uh it's actually worse now than it's ever been. And there's bullying at all sorts of level. Um, you know, a few years ago, when you and I would be talking about bullying, we'd be talking about uh, you know, managers bullying their employees, uh maybe position to nurse, you know, bullying, and and a little bit of lateral bullying as well, particularly with new nurses. I mean, we've been talking about for a long time. You know what I'm seeing a lot of right now? Nurses bullying their managers. I mean, it's just all over the place. There is something that is happening. Uh there's something in the water everywhere that just makes it uh that it's almost like an acceptable, uh, an acceptable behavior. So if you want to keep, if we want to keep our nurses, we must make sure that we we step up and we break the silence and uh um and call each other out when we're seeing it so that we can uh eliminate it that needs to be eradicated from our profession.

Right. And there is a lot to unpack with what you just shared because, you know, just going back to um the episode with Garrett and his call to action, uh, what he saw then for the nursing shortage is still the same problems that we see today, just like you mentioned. And in fact, I think a lot of this was compounded over time, right? It just kind of builds and builds, and now it's at this point where it's almost snowballing. I mean, it's at that point now where it kind of seems, I don't want to say irreversible, but it seems very significant. Um, but I think part of the reason is because of um these other contributing factors that you were speaking to. And our culture is a really big one, you know, what makes up our culture, how we interact with each other, and that includes the bullying, and that includes what we allow in our work environment and what we allow for communication with each other, with you know, with the um different positions that we have in the healthcare field, and then even with patients, because I would say it's been more challenging now communicating with patients and in our world today.

Mm-hmm. Yep, yep.

And so just like you alluded to earlier, with the funnel, the funnel of nurses who want to stay and who are retained in the profession and who still maintain the same passion, it's really hard with all these different contributing factors that are that are uh that we're seeing in the and and then on top of the things that we haven't been able to solve from decades before. So um a lot of that really is from uh what we've been enabling to perpetuate, but it's it's really hard because uh of all these other kind of unseen things that we don't always openly talk about. But um I'm curious, can you talk about how organizations have implemented different strategies or some solutions to make more efficient use of the staff that they have um currently in the workforce, you know, and maybe other strategies like flexible staffing, um, just to meet demand fluctuations or to have more efficient use of the different nursing roles that we have available. Um, just or just any thoughts for what you have seen that has worked really well.

Yeah, there's there is definitely a lot of work that's being done in that uh in that space and um not documented enough. So anyone that's listening to this that is also trying uh something new would invite uh people to disseminate their work so that we can learn uh from each other. Uh I alluded to some of the work that we're doing uh within Providence uh uh around uh around deconstructing uh the work as I just described earlier. And if I go a little bit deeper into that uh and kind of fast forward after I described the exercise I just described uh earlier for you, that that that end the the end product of the this deconstruction is the creation of what we affectionately called internally the co-caring model. And in the co-caring model is where uh people approach the work uh uh in a in a team-based uh perspective. And imagine that that team is there both physically and virtually. So caring for patient both physically and virtually at the same time. Uh imagine that uh you have a uh three individuals that at any g at any given time are caring for a group of patients together. So in this world, which is not a primary care model, um where uh so the the traditional concept of the one nurse to patient ratio uh does not exist because it's really about a group of folks, a group of professionals, uh a group of caretakers working together uh to care for uh for a given uh a given group of patients. And so in this co-caring model, you have uh a diet partnership that's at the bedside. You know, sometimes it's an RN and a CNA or a technician of sorts, sometimes it's an RN with an LDN or an LPN, uh, for instance. And and you also have an RN that's uh that's part of that team that is uh caring for patients virtually, and where they were able to reconstruct the the various roles where people are approaching the patients uh you know that way together. And it's uh it's actually beautiful to see the magic that happens uh as they care for patients, uh, for patients that way. Now, I also shared at the beginning of the uh the call, we were talking about certain barriers, and I called out that I I would you know hesitating to call it a barrier, but certainly want to highlight the fact that when you find yourself in states that have laws that have already predetermined what your model of care is going to be as part of the law, it's uh it's troublesome because it's very hard to innovate uh in those uh in those spaces. So we have to be uh we have to figure all that out uh you know together. And there's many other, there are many other organizations who are embracing uh virtual nursing, virtual caring for patients virtually in uh in the acute care setting. And that's great. We need to leverage technology because you know we approach this with people, but there's also technology that can assist. Uh, you know, there's robots that can assist, uh can assist us. There's a technology that we are uh exploring right now around wearables, where uh you would put a wearable on a patient and uh there's no vital signs anymore. I mean, think about that. Like when I say like blood pressure, respiratory rate, O2 set, uh heart rate, and uh EKG on one patch and takes care of all that, and everything goes into the medical record. Now, isn't that insane that you and I are asking all of our teams to take vital signs manually on all patients every four hours or so? And the time that we spend doing that, capturing the information, transcribing it to the medical record. That's silliness. You and I can be walking around with a watch and have all of that as part of our as part of our right, it's insane. And yep, here we are doing this. So I think let's not underestimate how we can leverage technology in a way that we can then leverage our team to do more meaningful work as opposed to tasks. It really drives me bananas to think that when you when you start asking nurses what they do, uh many of them very quickly will list uh uh will give you a laundry list of tasks that they do. It's like we've become like the taskmasters. And you know, I quite frankly, I'm I'm part of the generation that created that. And uh so I take oh I take ownership of this. We need to change that. We need to we need to create models where nurses it's not all of it's not about doing stuff and checking the box, but rather it's about the knowledge base that you bring to the bedside and leveraging the entire uh the rest of the healthcare team. I mean, nurses have completely forgotten how to delegate.

Right.

They don't feel comfortable delegating, they don't want to delegate, they don't really understand what that means and how they can best leverage it's almost like they feel guilty if they don't do everything for the patient. That that's we need to get out of that mentality.

Right, and and what you've emphasized before with this, with the co-caring model and being together and working with your team to build together, that actually helps with the delegation issue, right? Because I could see a nurse who has spent their entire career controlling and owning so many different facets of their job, really struggling with delegation because it was never written anywhere else that someone else would support the nurse in doing XYZ. I could definitely understand that. Um, but I really like how you frame the co-caring model because it gives the opportunity for more of this type of interdisciplinary approach using other members of the team or just, you know, other members of the uh immediate team that you're working with to come up with, you know, almost come up with the delegation together so you could decide who does what in the appropriate model, in a sense.

Yes. Yes.

And then maybe even leveraging technology on top of that, because, you know, uh, like you're mentioning with wearables and different things, we also have things like continuous glucose monitoring, which is really cool to see, uh, and innovations that you could use to complement so many of these models that will be innovative, right? That are that are different than one person does the task mass master situation. You know what I mean?

Yeah, yes. And you know, and and sometimes we'll hear by uh and and I I get I get the I get the worry and I get why people are, you know, might be thinking this way. Uh but uh some folks may may say, well, you know, we don't want, we don't want the technology to replace, uh, you know, to replace our jobs. Like we don't want to find ourselves out of our jobs. You know, to that I say, well, first of all, uh, wouldn't that be a great day if you and I felt that we had enough nurses and too many nurses? I mean, I can't even imagine that that is gonna happen. In fact, the data tells us that it will never happen. So let's chill out. That's that's the first thing I have to say to that. And two, uh, so there's never going to be enough people. Most of us have jobs that we have had that we've had posted forever in a day. What makes us think that people are gonna come out of the woodwork and you know, tomorrow morning? It's just not going to happen. This is not about removing jobs for people. This is about ensuring that we have enough people to do the meaningful, hands-on, caring activities that we need for them to do by allowing the technology to do the non-human centered stuff. Like, you know, like like the wearable example that I used earlier, or like robots that can go from one end to the other to deliver something. Very reliably, by the way, I might add, that they don't get lost for 13 minutes if you get my hint. Uh, and um, and uh, and and and can make sure that you you then can also leverage your entire you know workforce and and again I I'll use that word to really allow them to do meaningful work.

Right, to allow them to do what they do best, you know, in their in their nursing role and not have to be distracted or concerned about anything outside of that.

Yep, yep.

And you know, as we wrap up our conversation today, I really feel like there's so much more to talk about, but I just want to give you the final comments if there's any um other types of insights that you'd like to share with our listeners today.

I would probably start by reminding us that safety is our number one priority for our caregivers, our nurses, uh, the entire healthcare team, for our patients. It doesn't matter who you are uh and and what role you play in the organization, uh your safety, our safety is the number one priority. And and to that end, that also means that we must ensure safe staffing. And I believe that safe staffing must be done for tomorrow via new models of care.

Great, thank you so much, Sill. We really appreciate your insights and for being with us on the podcast today.

Well, thanks for inviting me, and thank you for all you do, Charlene.

Thank you. And our guest today was Sill Trapanier, System Chief Nursing Officer at Providence. We would love to hear your feedback. Email us at socialmedia atacn.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.