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Bill Klaproth (Host): So, how has the pandemic negatively impacted nurse leadership and the work environment? Well, it certainly has taken its toll, but there is good news. So, let's talk with Rosanne Raso, Vice President and Chief Nursing Officer at New York Presbyterian Weill Cornell Medical Center and Joyce Fitzpatrick, Professor at Frances Payne Bolton School of Nursing at Case Western Reserve University in Cleveland, Ohio.

This is Today in Nursing Leadership, a podcast from the American Organization for Nursing Leadership. I'm Bill Klaproth.

Rosanne and Joyce, thank you so much for your time. It is great to talk with you. Rosanne, let me start with you. So, how has the pandemic negatively impacted nurse leadership and the work environment? Fill us in.

Rosanne Raso, DNP, RN, NEA-BC, FAAN, FAONL (Guest): Based on the research that Dr. Fitzpatrick and I did, and this was in the summer of 2020, so this was early in the pandemic, the pandemic impact was very high at that point. It was I think 8.4 out of 10 for leaders and seven point something out of 10, overall. So, pandemic impact was high. And we used authentic nurse leadership as the instrument for perceived leadership and that was present.

So that was good news, despite high pandemic. Healthy work environment, using the American Association of Critical Care Nurses Instrument was not present for clinical nurses. In fact, four out of six of the domains were not present. So, that was a very worrisome finding. Joyce, anything you'd like to add to that?

Joyce Fitzpatrick, PhD, MBA, RN, FAAN (Guest): Well, I think you're absolutely right Rosanne, that, last finding that you mentioned, regarding clinical nurses perception of the work environment is important and there is a lot we can do to improve the work environment of clinical nurses. Some of the things we knew about before the pandemic, where we needed to engage clinical nurses more in the planning of the work environment, get their ideas of what could be done to enhance patient care, to engage them in what is referred to as shared governance structures or professional governance structures. Some of what we learned in our research was new in that the pandemic might've had a negative impact on the perception of the healthy work environment. But we do know things that can be done to improve nurses' lives in the work place.

Host: Yeah, that's very important. So, let me ask you this Joyce, how did you research this? How did you go about finding out this information?

Joyce: Well, it was important for us to do a national sample of nurses and nurse leaders. So in fact, we partnered with our colleagues from the Daisy Foundation in order to get the word out to nurses across the US. And so our colleagues at the Daisy Foundation, sent out our survey and asked nurses in their network, which is a wide national network, about their willingness to participate in our study. So, we were able to gather thousands of opinions from nurses and nurse leaders about not only the status of the work environment, but also as Rosanne mentioned, their perceptions of nurse leadership.

Host: Right. And Joyce, let me ask you this. What is then the current status of the nursing workforce and nurse leaders? Where are we at now?

Joyce: So we did this study in summer of 2020, which of course a lot has changed since summer of 2020. And in fact, we're in the process currently of finalizing our replication study. So, roughly one year later, what is the situation? And while we don't have the results of that followup study to share, we do know that there are some changes that are needed for all of us to do a better job of caring for patients.

Rosanne: Yeah, I agree. And I mean, outside of the framework of research, we all know from just reading the newspaper, nevermind the professional literature, that the status of the workforce is decimated. And, but I do believe that leaders are still leading and they're exhausted. And they're tired and some of them are even angry and may feel helpless, but they are still leading and staff are still respecting leadership. I believe that.

Joyce: Well, that's the good news. You know, then our study among nurse leaders in particular, indicated that there still are strong nurse leaders. As Rosanne said, some of them are exhausted, but they're there every day leading nurses to provide better patient care.

Host: Yeah, that is so important. So, Joyce, you said earlier, there's a lot we can do to improve the lives of nurses. And Rosanne, you just said the status of the workforce is decimated. So, when it comes to talking about a healthy work environment, when it comes to staffing and collaboration and those types of things, what can be done? Roseanne, let me ask you that question.

Rosanne: Well, I think that Dr. Fitzpatrick mentioned some interventions for collaboration, which are really important, such as implementing or reinvigorating shared governance models, so that nurses have a voice in what we're doing, which, in terms of what we're doing, the domain of staffing right now is so critical and everybody wants to fix it.

It's just finding nurses. They're not there. So, then the question is, well, how do we still provide patient care if we're not going to be able to get more nurses? What do we need to do to change models of care so that we can meet patient needs and nurses aren't morally distressed and frustrated?

So we have to decrease the work burden of nurses. What can be done by others? What is non-value-added that we should not be doing anymore? How can we leverage technology and have virtual nurses doing some of the things that are just kind of paperwork oriented, but can be done virtually? How do we leverage advanced practice nursing, to improve patient care in this environment? And how do we just allow innovation, which then ties together with collaboration. How do we let nurses drive what we're doing and innovate, and cause those are the best solutions.

Joyce: I think to add to what Rosanne said, we need to thank the nurses for the work they're doing. I mean, every nurse who comes today to work should be thanked for the work that they're doing, and we need to listen to them. One of the projects that I'm involved in now as a follow-up to our interest in this topic is capturing the stories of nurses who are delivering care during the pandemic. And listening to those stories is important for us to learn what it's like for the nurses and for us to learn what we can do as nurse leaders to make their lives better.

Host: Right. Yeah. That is really interesting. Joyce, let me ask you this. Rosanne just said, you know, when it comes to staffing domains, the nurses just aren't there. So, you're trying to come up with other methods of patient care, like automation and things like that. What are the overall implications of all of this? What does all of this mean?

Joyce: Well, I honestly think the future is going to be better. We will have learned how we can do things better, how we can innovate. And as Rosanne said, how we can better use technology to support nursing care and we're never going to replace nurses with technology. We can support them with better use of technology, better use of our understandings of documentation.

We can shorten the time that it takes for documenting care. That would free up nurses' time. So, I think if we can capture some of the innovations that are happening every day in every hospital, and make those part of the mainstream of care delivery we'll be in better shape in the future.

Rosanne: In terms of, cause I think your question was like, what does this all mean? What are the implications? And definitely everything that we just talked about and in addition to that, to focus on leaders for a minute. The leadership was present and it correlated highly with work environment and it was one of the six domains that was still present. So, focusing on leadership, which contributes to a healthy work environment, which everybody is desperate for right now, is another one of the domains besides staffing, besides collaboration and communication and recognition is leadership. So, the implications for developing and supporting leaders, particularly with relational competencies, I think is really important moving forward.

Host: And let me ask you this then Rosanne, and Joyce kind of presented some ideas of what to do moving forward and that the future outlook is bright. What can someone do today or now to start this journey of some of the things you just talked about? What can they do at their own hospital or organizations to start this trend if you will, to working towards a healthier work environment?

Rosanne: First of all, it starts from the top. So, I think that the senior leadership has to be committed to it. That is one thing. I don't think you'd find somebody that isn't, but you have to be a little structured about it. It can be a belief in a value that drives you forward, but there has to be some structure behind it, is that shared governance structure. What communication structures you have, what recognition structures you have. What leadership development structures you have, and they may all look different in different organizations. But they have to be there. So, I think having structures around every one of these domains for work environment is where we need to go.

Joyce: And of course, we need to make our goals and priorities explicit to the nurses who are delivering the care. As nurse leaders, as Rosanne said, it starts at the top. The nurse leaders need to make their leadership ideas, their plans, their vision, explicit to all nurses, and there needs to be meaningful recognition. We don't need tokenism in recognizing nurses. We need to be able to reward them in a very direct way for the excellent care they're providing.

Host: Yeah, meaningful recognition. Everybody's looking for that. So, I think you both brought up some, just some really excellent points. So Rosanne, let me start with you, knowing what you know now with all of this research, what's your overall takeaway from all of this?

Rosanne: My overall takeaway is that nurse leaders are just awesome, and have not abandoned their staff, their patients, or each other. So that's one. And the second is that healthy work environment, the work environment is suffering now, and it's kind of heartbreaking and we really need to focus on improvements there. We must, we absolutely must moving forward.

Host: Yeah, Joyce, let me ask you the same question. Knowing now, looking at all this research, what is your main takeaway from this?

Joyce: My first takeaway is that nurses are the ones leading care at the bedside. And we've always known that, but now the public knows the value of nursing. Nurses matter and they matter every day for every patient. And as Dr. Raso said, nursing leadership matters, it really matters to the nurses to see their leaders as strong individuals in the care environment. And it matters to the group of nurse leaders that they together are planning the course of the future. So, I think we've learned a lot and much of it has been reinforcing of our values that have always been part of the nursing profession and values that have been strongly invested in nurse leaders.

And our research indicated as Dr. Raso said, as Rosanne said, our research indicated that even in the height of the pandemic last year at that height, nursing leadership was still present. And what we did in that research is we asked nurses to evaluate the leadership of their supervisors. So, if you were a clinical nurse, you evaluated your nurse manager, for example. If you were a nurse manager, you evaluated your nursing director. So, it was always someone above you in the organizational structure. And no matter across all of those groups, nursing leadership was present. And that's a very strong statement that even in the height of the pandemic, that we had strong nursing leadership. And so we want to strengthen that and that's in it not only did we learn that it was strong, but we learned ways in which we can strengthen the skills and knowledge of nurse leaders.

Host: So, let me ask you this. So, one last question, and thank you both for your time. Rosanne, let me start with you. If you could look into your crystal ball, as we hopefully finally get the pandemic under control this year, and maybe get some normalcy back, how will the work environment change? Obviously, I think it will get better. Do you think the staffing levels will improve? If you could, what's your vision for the future and where we're going?

Rosanne: I do think it will get better. Nursing school enrollments have not suffered, so there is a pipeline. Will it be enough for the need? We still have to answer that question, but there is a pipeline and I have to say that the new graduate nurses that we are getting here are just fabulous. They're engaged, they're energetic. They want to make a difference. They want to be involved. So, I have a lot of what I'm seeing for the new graduates and even what I'm seeing for the folks who haven't left, and are sticking it out, is a total commitment to patients in the profession. So, my crystal ball is positive. We have to get through this next year or so.

Joyce: The status of enrollment in US nursing schools has surged in 2020. I'm a nurse educator and we're all seeing record levels of enrollment in nursing across the country. So, that's very positive because of course, we have an aging population, we have individuals living with chronic diseases. So, the pandemic is not the only healthcare issue that we're dealing with. But we are in fact, seeing an increase nationally in nursing enrollment.

I believe it's because young people in particular want to engage in meaningful work. So, nursing is viewed very positively by the public. We know that that's what's attracting nurses to our educational programs.

Host: Oh, I love hearing that. Young people like to engage with meaningful work. That is awesome. So Joyce, same question to you. If you could look in your crystal ball, looking ahead, where are we going? What do you see happening in the future?

Joyce: You know, we have a great deal of research from the past that indicates that a lot of the work that nurses do in acute care facilities is non-professional nursing. So, I think we've learned how to restructure the work environment to not only enhance professional nursing practice, but rather to introduce new care models.

So, we've learned a lot about how to work smarter during this difficult time. And I think that leads us to better care in the future. I also think it's a very positive learning environment for us to try out new ways of delivering care and to try out new techniques for delivering care, new staffing models certainly will be part of the change.

Host: Well, I love ending on a positive note. So, according to both of you, I think the future looks pretty good. And obviously from your research, as you said, we can look back and historically we can see some things and learn from that, that is really important to know, and to apply that to the vision moving forward.

Well, Rosanne and Joyce, thank you both for your time today. This has really been informative. Thank you again.

Joyce: Well, thank you.

Rosanne: Thank you.

Host: And once again, that's Rosanne Raso and Joyce Fitzpatrick. And for more information, please visit aonl.org. And if you've 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.