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Bill Klaproth (Host): So in these trying times, how do you maximize nursing's impact through professional governance? One to provide better patient care and then to also provide for the nurse, his or her personal development and to help avoid burnout and to keep our nurses engaged. So, let's talk with Tim Porter-O'Grady, Senior Partner Health Systems at TPOG Associates.

This is Today in Nursing Leadership, a podcast from the American Organization for Nursing Leadership. I'm Bill Klaproth. Tim, thank you so much for your time. It is great to talk with you. So when we say maximizing nursing's impact through professional governance, what does that exactly mean? What is the issue or what are we trying to solve here?

Tim Porter-O'Grady, DM, EdD, APRN, FAAN (Guest): As you can imagine Bill, time for nursing during the past two years has been rough. The experience has been overwhelming for most nurses and in nursing organizations, there's an organizational model that increases their opportunity to own practice and to participate in decisions and facilitate change and all of the things that relate to the work of the profession.

And that's identified as professional governance. It's how the staff participate in making decisions that affect patient care. As you can imagine, during the crisis, there's an intense kind of pulling in the wagons, if you will, and making more vertical decision-making and narrowing the range of those decisions in order to make them more quickly to address crisis and all the issues associated with that.

And sometimes what happens is that the engagement that was present in the professional governance framework, disappears or gets diminished. Those who normally participated in making decisions about patient care and about issues of importance related to that, are not at the table or are not engaged in their councils and the places where they make those decisions.

And many times those decisions are made by people other than those who do that work. With the introduction of what's called the incident command during crises, often decisions decend up the hierarchy and those who are at the point of service, most familiar and in touch with how those decisions may impact patients or how they may even be better informed, are no longer involved. And that loss creates a huge amount of backlash, if you will, organizational, relational, personal health, engagement and those kinds of things. So that's what we mean by that.

Host: Okay, well, thank you for explaining that. That makes sense. So, just so I have a better understanding, so when we're talking about maximizing nursing's impact, one it's for better patient care, right. And two, it also is for personal development. Is that correct?

Tim: The whole issue of professional nursing practice is to be able to have a significant and meaningful impact on patient care and the patient relationship. So the goal of the organization ultimately should be to reduce any of the variables or noise if you will, that would impede that relationship.

A part of being able to handle that, is making sure that there's nothing in the way of nurses making decisions and joining in terms of their collective contribution to patient care and utilizing them to the fullest extent possible, because that's how they're used to doing their work. And that's how they believe their relationship to the patient should unfold. When that gets short-circuited or when decisions are pulled away or they end up at the hands of people who are not essentially accountable for the delivery of that service or that care; then it begins to affect both the quality of that care, the relationship the nurse has with the patient and the kinds of outcomes that might result, from in some way, impeding that set of variables.

Host: Okay. So when you mentioned making sure there's nothing in the way, is that where incident command comes in to remove those barriers and make sure there's nothing in the way, is that correct?

Tim: Incident command can do that, but a lot of the problems that have occurred in crisis is that incident command, instead of doing that, often subsumes those decisions, or places those decisions within the purview of administrative leaders or management leaders, in the interest of consolidation, of compatibility between decisions, better use of resources, higher paced decision-making and dealing with intense kinds of impacts that come out of decision-making.

Now none of this has been shown to make better decisions. But it's a natural normative thing to do in crisis to kind of narrow the range of decision-making, batten down the hatches, pull the wagons in closer together in order to have more control over the circumstances that might emerge out of a crisis; when in truth, the opposite is really better.

Host: I was going to say, does this then help address staff crisis and burnout as well?

Tim: The professional governance structure is really designed to continue to engage and to empower and to provide a mechanism for nurses to support each other and for a stronger partnership between the organization, its leadership and the professional nursing staff. And so in a crisis, what we want to be able to do is maintain those relationships because during times of high intensity, where that impact on the nurses can create all kinds of negative forces; we want to be able to make sure that there's opportunities for those relationships to stay intact, for nurses to stay involved and engaged, for them to have an option and opportunity to access support, and encouragement and all the kinds of things that help with their mental and emotional health and stability, and to actually experience the renewal that comes from those things being in place.

And so what we were talking about is saying when you, lose touch with your professional governance, and that is an integral part of your incident command network, then these negative impacts accelerate. What we want leaders to be aware of is to re-engage that empowerment that comes from the professional governance structure that's in place and not let go of those in the crisis so that these negative impacts of crisis don't accelerate as they have. Because when they do Bill, what happens is that what we've seen, nurses burn out. They leave the organization in droves. They go to for-profit staffing organizations that pay them huge amounts of money, that their institutions can't afford to pay them. And they tend to lose faith in their leadership, in the organization, and sometimes even in their profession. And we have, increased number of nurses that just leave the profession altogether.

Host: So, you mentioned negative forces and negative impact, and you also mentioned taking care of the mental and emotional wellbeing of nurses. How do you do that then? How do you re-engage with them? How do you care for their mental and emotional wellbeing?

Tim: Well, you know, surprisingly enough, it's the simple things, as you could imagine, or guess that sometimes slip through the edges of all of these changes. It's kind of re-engaging yourself with those kinds of things, for example, simply recognizing, both formally and informally, the contribution that nurses have made in a crisis, such as the pandemic. Let's use the pandemic since it's clearly the force at issue here. Engaging nurses means recognizing the contribution that they've made, recognizing the value that they have in the organization, by enumerating their contribution, by celebrating that contribution, also by supporting them through other kinds of support systems; time and counseling, opportunities to get away from the patient's bedside for 10, 15 minutes, just to recalibrate, to rest, to engage, to have opportunities to gather nurses together for short periods of time, five to 10 minutes where they can communicate and relate to each other, a particular stressor or, or, constraints that they're experiencing or, or challenges that they are going through, that they can share with each other in support of each other. Those simple kinds of things are normative, not suspending your councils, where nurses get together to make decisions about what is the best strategy to choose.

For example, some organizations that have trouble with the amount of personal equipment that is necessary when you're trying to isolate and protect the patient. How do we manage that? How do we distribute it more evenly? How do we address ways of extending that equipment or, or making better use of? By engaging the people who were there using that equipment and making decisions about how that might be better utilized. Issues in terms of decisions about even outpatient placement or schedules or shared workloads, all of those things that relate to giving clear examples that you have invested in the nurses at the bedside and that their work, their advice, their counsel, their deliberations, their decisions, are vital and valuable to the organization in a way that's meaningful. That offsets a whole sense of not being engaged or trusted or included or, referenced in a way that has meaning and value for those that own that process.

Secondly, giving them an opportunity to be able to heal or to spend time in regathering their strengths, re-enabling themselves, if you will. And were counseling that become necessarily, having that available one-to-one short term. And in dealing with those issues immediately so that you essentially build a culture of engagement and investment and ownership, that is fundamentally a part of what we call the professional governance infrastructure or the clinical environment of excellence.

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Host: Yeah. That's a very well put. So recognizing the contributions of the staff and individual employees that they've made, not suspending councils, making counseling available, some of the key takeaways there. Those are so good. So Tim, can you talk about any measurable successes that you can share with us? And has there been any unanticipated or surprise benefits, or outcomes that you discovered that you can share with us as well?

Tim: We could spend a lot of time on places that really, really did this well, and didn't suspend their professional governance and engagement systems in the organization and actually used them to maximize their work. I think of Sharon Pappas, the CNE at Emory University Medical Center, for example, and in some of the tactics that they used. They have 11 hospitals in their system. And when there was a critical decision that needs to be made about patient care or about PPE or about distribution of resources and problem solving day to day; they would have their council leadership, their unit council leaders get together, using a video and telecommunications over two to 10 minutes opportunity to address a problem across the 11 hospital system so that they could make decisions about patient care or about resources or about struggles or conflicts or issues, quickly in a short term, but engaging the people that have ownership for those and utilizing their system in a critical way, to make decisions and to demonstrate their trust and their commitment to their nurses. Lurie Children's Hospital presented their case at the recent Magnet Conference in Atlanta about their experiences with holding true to their professional governance structures and making sure at the unit level, especially, that staff were engaged in problem solving, that those problems were not shifted off to other places. But that the resources necessary to solve those problems were brought to where the problems were rather than the problem sent somewhere else, so that they could demonstrate the problem solving occurred at the point of service in the patient's environment, with the people who established that relationship and would live with those decisions which is a foundational principle of the profession. Those are a couple of examples of how that gets played out even in a crisis, you don't cease to stay connected to both the systems of engagement, as well as the personal relationships that are essential to involve and embrace staff's participation in the crisis.

Host: Right. Well, thank you for sharing those examples. And I guess the bottom line for me is when we're talking about maximizing nursing's impact through professional governance; what that means is you get happier, more well adjusted, more engaged employees, right? And you also get better patient care.

Tim: Well, ultimately, that's the impact of hopefully what we are doing you know, in the places where we deliver care and healthcare. If our goal as nurses or as healthcare professionals, regardless of what role we play, is to actually create the conditions, out of which health results; it seems that we would want to pick those strategies, which best demonstrate that that's going to happen. And that if we're not healthy with each other, if we're not healthy in our relationships or in our structures or in our interactions and our trust with each other; then how in the world can that translate to creating health for those that we serve?

So that a healthy organization, a healthy workplace is clearly the beginning point, but for nurses, a profession like any other professional, like the medical profession or the law profession or engineering profession, they have a very strong commitment to the work that they do, to the value that they have, to the difference that they make, to the role they play in society.

And it seems wiser to build on that inherent commitment and energy and social contract, if you will, inside of the organization with all of the structures and processes that you have there and out of that connection and that trust and that engagement; you can't help but expect that the patient will be the beneficiary.

Host: Absolutely. So, Tim, this has really been a fascinating discussion. Thank you so much for your time. Anything you want to add before we wrap up at all in talking about maximizing nursing's impact through professional governance?

Tim: It's an exciting time. We're hopefully getting near the end of the COVID crisis period and hopefully getting to a little bit more normative where we can sit together and assess and review and re-examine, and then begin to try and see if we can validate and reconstruct some of those values that we believe are essential and are inherent and in the assessment, not only reconstruct, but, perhaps make some new decisions and turn some corners and maybe even deepen our commitment to each other because that's certainly going to be what is going to be needed for us to be able to thrive going forward.

Host: So true. So well put. Well, Tim, thank you so much. This is really been fascinating. Thank you for your time. We appreciate it.

Tim: I enjoyed being here. Thank you very much.

Host: And once again, that's Tim Porter-O'Grady. And for more information, please visit aonl.org. And if you found this podcast helpful, please share it on your social channels and check out the full podcast library for topics of interest to you. This is Today in Nursing Leadership. Thanks for listening.