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Bill Klaproth: This is a special AONL podcast as we speak with session presenters from the AONL 2022 Conference. With me is Dr. Claire Zangerle, she is the Chief Nurse Executive at Allegheny Health Network, and Dr. Dan Shapiro, Vice Dean at the Penn State College of Medicine and Principal at DES Health Consulting.

This is Today In Nursing leadership, a podcast from the American Organization for Nursing Leadership. I'm Bill Klaproth. Dan and Claire, welcome. Great to talk with you. So we're going to talk about 12 recommendations from studying burnout, violence and turnover in nurses. So, Dan, let me start with you. When we talk about burnout, violence and turnover in nurses, why is this such a problem? What got us here?

Daniel Shapiro: Well, it was a problem before the pandemic, but it's particularly worsened and that we're seeing massive flight from nursing and nurses are leaving nursing for some pretty good reasons. Nursing has become fairly violent. The environments they're working in are really stressful and sometimes scary. And so making the practice environment better helps all of us. It's good for the society and it's good for the systems we're working in.

Bill Klaproth: Yeah. So this definitely is an issue. And we're seeing this not just regionally or at individual healthcare organizations, it is happening all over the country. So knowing that there is a problem in burnout, violence and turnover, how are you addressing this? What initiatives or tactics are using, Clare, to try to combat this, if you will?

Claire Zengerle: Even before the pandemic, we started looking at the data and we asked our employees, we asked our nurses, we also included physicians and other practices at Allegheny Health Network. But when we did the survey, we found out that they had some top issues that were really bothering them, that related to their wellness. And of course, burnout is part of the whole wellness journey and how to address that. What we found are some pretty simple things that we could do to address that.

First of all, they want to be kept safe. They want to be able to come to work and feel that they're in a safe environment. And one of the things that we did is we asked them what would make them feel safe. Well, a lot of that just had to do with putting better lighting in the parking garages, better lighting when they're coming on and off shift where they're parking their cars, that was very simple. The harder thing to do was what happens when a patient is combative because of their diagnosis or when a patient is combative just because they're downright mean. So those are the differences that we see in the type of violence that we have. So we brought in a police force, a real police force. They're cops that work in the police force and they work for health system. That in and of itself was almost a huge sigh of relief, having that presence to deescalate some of the violence that happens. We also told them, "Nothing is unreportable. Report everything," because we want to make sure that they understand that no violence is acceptable, whether it is a combative patient that is because of the diagnosis or the other type of violence.

The other thing we looked at was they weren't getting enough to eat or drink during their shift. It was very traditional that they would come to their shift when they'd swipe in and automatically swipe no meal. And that in and of itself was a cultural issue. So we put processes in place to make sure that everybody got a meal break, got a just a general break during those long twelve-hour shifts that they have, even an eight-hour shift or four-hour shift. Everybody needs a break for that type of work. So we did intentional work on, I mean, literally down to, "Here's a piece of paper. This nurses going to lunch at this time, this time, this time." We also installed water stations, so they could refill water bottles and we made it okay to drink water on the nursing units. And a lot of the regulatory rules that we'd had in the past saying, "Oh, you can't have any kind of liquid on the unit," just all went away because we actually read the rules and what they said. So, hydration improved. So that was an initial survey that we did. And then subsequently when we surveyed, we saw vast improvements in all of the areas that they asked for help in.

Bill Klaproth: Yeah. So you had to actually go out, and I'm sure you were seeing this on your own, but you actually went out and asked. It sounds like you did surveys to uncover these things like you talked about, safety, report everything, meal breaks, water stations, but the safety thing, the lights in the parking lot, you might not have ever known that unless you asked.

Daniel Shapiro: So, we've developed a system that basically uses Maslow's hierarchy to organize nurse responses, because it starts with physiologic basics. Are you eating, sleeping, drinking, having time to use the restroom? How often are you having to hold your pee for more than an hour? And mental health, that's part of the basics. You know, depressed, anxious, using substances. Up from there is physical and emotional safety, and then respect. Do you feel respected by the things in people you interact with every day? Then do you feel connected and that you work in an accountable environment? So all of these measures, and it's our contention that if we clean up things lower in the hierarchy, you get to a place where you actually get to enjoy having an impact on patients. But those things along the way, being dehydrated, for example, like we know that people's cognition and their mood is much worse if they're dehydrated or hungry. Maybe you've had a fight with your spouse when you've been hungry. We don't need a full confession.

Bill Klaproth: Hangry.

Daniel Shapiro: Right, exactly. Or the physical violence. I mean, I think Claire and I were both startled by the amount of physical violence we found in the surveys. So what this model does when we turned it into dashboards is it gives a leader like Claire who's highly motivated, sophisticated, and experienced the radar she needs to make decisions about where to invest her limited resources, right? So she knows where the hotspots are, she knows what the big issues are, and that's how she identified the dehydration for example, the violence for example, issues with accountability in some units, right? Claire is overseeing, what, 11 hospitals at this point. You know, at Allegheny Health, if you go into one of the hospitals and go into the bathroom at the hospital, they're opening another hospital. You know, they're growing really fast, so it's a lot for her to track. So that's where our partnership works.

Bill Klaproth: so it's interesting, and you mentioned Claire earlier. I love the term you used, intentional work. So all of this uncovering really allows you to be intentional in trying to improve this stuff.

Claire Zengerle: Absolutely, because resources are limited and we have to be good stewards of our resources and you can't fix everything immediately. And as they say, you can't boil the ocean. But if we can put a drop in the ocean and have a huge impact, and that is what this work has helped us do. This model is something that has helped us organize our work. And nurses like to be organized at the bedside, no matter where nurses practice. So it really resonated with nurses that if we've focused on approaching the problem through this model, then we would have some results and we were thrilled to have them. Are we done? No, we still have a long way to go. And we'll use the model to keep going.

Bill Klaproth: I'm feeling heard, right? They probably went, "Oh my God, they're listening to me. I'm feeling like I'm being seen here. They're addressing the problems to make my job better," which in turn makes their life better, which in turn makes patient care better. It's all a big circle. Am I right, Dr. Dan? Am I heading in the right direction?

Daniel Shapiro: Nurses can't stand surveys until you ask them questions that actually really matter and then you make changes in response to what they say, and then you get much more receptivity and higher response rates.

Bill Klaproth: So Dan, how do we scale this for someone listening that says, "Gosh, you know what, I need to do this too"? How do we send this out across to the country, to everybody? How do we do that?

Daniel Shapiro: You can work with a group like ours, or I think it's equally possible to do this work using the model, informally or formally assessing where their own people stand relative to the hierarchy. You know, we use focus groups first to inform our surveys, because we know that every system is different. By harvesting wisdom from those groups, we read every single word, we thematically analyze them, and that can be done at a local system level by folks who are motivated.

Bill Klaproth: You can identify the themes for that specific healthcare organization, right? Well, you said you were shocked when you saw the amount of violence that was being unreported. And that's why you came up with report everything. You were like, "Oh, my God, we didn't know this was happening," right? So now that you know this, you can address the issue.

What are some of the other key takeaways for someone listening to this podcast and what they can do? We talked about surveys, learning from your own staff. Anything in general, other tips or suggestions for someone listening that you learned along the way, Claire?

Claire Zengerle: I think inherently what we learned and you read about this all the time, the patient experience is truly very, very important. And nurses put that high on their list. However, changing the culture where we say the employee experience is just as important, if not more, because it actually informs the experience the patient is going to have. So it's very much like put your oxygen mask on first if you're on an airplane and then give it to somebody who needs the help. So we learned that we had to live that every single day and by pulling all of this information and then reacting to it and doing something with it, our employees felt like we were listening to them and more engaged, and that got us a lot of credit and it was the right thing to do.

Bill Klaproth: What about measuring success of this or understanding, "Okay, we did change this and the result is this"? Any examples you can share with us of measuring the results of this?

Daniel Shapiro: Claire has seen improvements in violence, improvements in dehydration, improvements in perceptions of accountability across the board. These are powerful measures that predict long-term longevity in an organization. They're absolutely important. The other thing I think that Claire and Allegheny Health executives have done that I think is profoundly important is that they have spread the model to every single employee. So this May, we're going to do all 22,000 Allegheny Health employees. Now, that's important because you can actually burn out a nurse without touching him or her. If I burn out transport, if I burn out housekeeping, if I burn out food services, guess who's going to have to do all of those jobs? Frontline nurses. So by also recognizing that we work in a milieu, that we are tied much more together than we think we are, I think Allegheny Health is moving the needle forward.

Bill Klaproth: So when you say rolling this out to 22,000 employees, how do you do that? What does that look like?

Daniel Shapiro: Carefully.

Claire Zengerle: We do it systematically. You know, we started with a couple of groups and then, over the last couple of years, we've rolled it out to them. Of course, every department has their own leaders, so their leaders are going to be responsible for the results of those surveys. And then I see this globally as coming together with all of us saying, "These are our results across the network," and it literally will improve the culture. And I think that's where we're going to see the results.

Bill Klaproth: Absolutely. Well, this has really been fascinating. Thank you both for your time. Same question to both of you as we wrap up. When we talk about burnout, violence and turnover in nurses, anything you want to add, Claire? Anything else we should know about this?

Claire Zengerle: This is something that every healthcare leader must pay attention to. Because of the current challenges we have with staffing and bringing people into the profession and retaining people in our profession of healthcare in general, specifically with nursing, if we don't take care of ourselves and each other, then we are not going to be successful. So that's why this work is so important.

Bill Klaproth: Right. Not only for their wellbeing, but for retention as well, which is really important. And it seems to be a theme of a lot of the interviews we've been doing today. Nurse retention is really, really important. Dan, how about you from your perspective? What else should we know about this? Any final thoughts from you?

Daniel Shapiro: I think a lot of healthcare leaders feel overwhelmed by this. And the reality is it is absolutely possible to make huge progress.

Bill Klaproth: A note of optimism. There it is. Dr. Dan ends with optimism. I love it. Yeah, there is hope. And we can get this done, but it just takes some digging and learning, right? And putting strategies in place. Good stuff. Well, Dan and Claire, thank you so much for your time. I really appreciate this.

Daniel Shapiro: Delighted.

Claire Zengerle: Thank you.

Bill Klaproth: And once again, that's Claire Zangerle and Dan Shapiro. 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.