Bill Klaproth (Host): So today, we're going to talk about foundations of professional governance, where it's going, why it's important in the future and what is the difference between nursing professional governance and shared governance?

Host: Well, we're going to find out with Rachel Start, Associate Vice President, Patient Care Services, Hospital Operations, Medicine, Behavioral, and Emergency Services at Rush University Medical Center; and Dr. Tim Porter-O'Grady, Senior Partner Health Systems, TPOG Associates. He is also a professor at Emory University School of Nursing.

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

Dr. Tim Porter-O'Grady: Happy to be here.

Rachel Start: Great to be here, Bill.

Host: You bet. So, let's jump into this. Rachel, let's start with you. So, can you explain to us what is professional governance and how is it different from shared governance?

Rachel Start: Bill, so professions exist at the behest of society, right? We've been given power by society as a profession that has validated our own body of knowledge over 40, 50, 60 years. We have a deep body of scientific information that we have found is our own. And as a profession, we're responsible to use the power we've been given by society to mobilize that knowledge into real health returned back to the populations we serve.

So, governance as a profession means we are working continuously to grow our body of knowledge, to evaluate ourselves, to take full ownership for those gaps in the care of our patients and populations; to recognize and develop each other, so that our practice, our science continues to deepen and results in a demonstrateable service back to patients and populations. Professional governance means every single nurse is doing this regardless of role or setting. I would love for Tim to do a little bit of the description of that difference then between that and shared, because he has really written a lot. As we've evolved as a profession, we have moved from a notion of shared to professional.

But what really I feel is important going forward as a nursing community is that we really fully own that patients are relying on us for health and livelihood, autonomy, independence, wholeness within their communities. Taking that knowledge upon us that they have a trust in us means that we take our practice serious enough to govern it, to own it, to be highly accountable for it, and to seek to see serious demonstrable outcomes that show the value of what we're bringing in our governance back to society.

Host: Right.

Dr. Tim Porter-O'Grady: You know, Bill, one of the real challenges for nurses as a profession different from other professions is that we have always been employees. We've generally mostly been associated with hospitals and institutions and, therefore, been seen as a part of that infrastructure. So, it's been really challenging to be able to identify us consistent with the identifiers that other professions use, like lawyers and physicians and engineers and architects and in the larger, more historically male-dominated professions that don't have this kind of attribution. So, a part of our journey has been to really deal with our identity and to be able to significantly focus on that identity. And then, through that process, begin to ask ourselves how do we govern ourselves in the places and the ways we find ourselves, and what are the elements of the journey that informed that.

And so, shared governance was how do we participate with the organizations in order to know what our contribution is and what their support is of that contribution. Where the next step, professional governance, is how do we really clearly identify that unique contribution that we make as a discipline to society that we own that is a part of our contribution, and how do we value that and then the infrastructures that we build around that to make that our way of doing business. And that's probably the simplest contextual way of describing the difference.

Host: So Tim, moving out of post-COVID, I'm sure that has realigned and recalculated a lot of things. How can we rebuild and recalibrate nursing post-COVID and why should nursing professional governance matter?

Dr. Tim Porter-O'Grady: Well, you know, we could really spend a lot of time on that conversation. But in the interests of just being incisive, COVID was really, really devastating for nursing. Nurses are the largest profession closest to the patient. We are the largest single professional group in healthcare. And so much of the burden of care falls to nurses and, during the pandemic, of course, that was accelerated by the increasing demands in the clinical environment. So, what happened as we tried to adapt to the crisis, what often happens is that we narrow decision-making. We build infrastructures that make decision-making clearer and more precise. It's called incident command, which means that all the decisions move up to the top of the ladder. And the people who have the biggest stake in those decisions are in many ways affected negatively.

And there were four losses that nurses felt that came out of the pandemic that most of the research reveals: a loss of engagement, a loss of investment, a loss of support and a loss of leadership. And nurses actually said in reporting on the studies of nurses post-pandemic, that they expected to increase the intensity of their care delivery because of the demands, the clinical demands. But what they didn't expect were those four losses, and those are what drove them away from hospitals in droves into the arms of high-paying external agencies or out of the profession completely. And so, here we are now recalibrating, reconceiving and restructuring, trying to struggle with not repeating those things that were causative agents and not really clear about what that looks like and how that approach should unfold. So, a part of the struggles now are related to re-looking at environment, re-looking at the workplace, re-looking at relationships and, as a result, re-looking at professional governance, which is the framework for all of this and asking some serious questions about how to rebuild. Rachel, does that complete the picture?

Rachel Start: Yeah. I think there is a much lower patience level or threshold for anything that's not authentic. I would just share that about our nursing staff and especially younger generations entering into our profession. And that's why I think professional governance at this moment has such an important and really valid argument. I think our nurses don't want, and you'll see throughout social media, you know, the proverbial pizza party, the proverbial lunchbox for Nurses' Week. I think they honestly came into a pandemic taking on serious issues, and they want to continue taking on serious issues. And unless that's going to be the agenda of the day and the practice that they're able to take on and fully understanding of how to move through systems and structures to make those practice changes, I think they opt out of our profession. They opt out. They just really do go back into that employee mindset.

I really do think that it is post-pandemic, those of us that can reinspire reengage our colleagues into a notion of what truly is at stake with patients and populations as well as reengage folks in the authentic power that they really have been given as a professional, whether it is in an individual role or in the community, that there are serious ideas around how to turn down surgical site infections, how to improve hemoglobin A1c in the diabetic population, how to get fresh foods to large communities that are in food deserts. That is the work that nurses still want to do. They are very engaged in that, and I think they engaged in serious, serious problem-solving in the pandemic. And there are great exemplars across the country of organizations that continue professional governance, leveraged it and really had great trackable outcomes for care as well as for their staff. If we water any of this down for our generations now or younger, they're going to opt out. And so, authenticity to me is top of mind. Explanation of the big picture, the high stakes, that is how I believe we engage going forward. And honestly, any lesser than that is not going to fix all of the chaos happening in healthcare anyway.

Dr. Tim Porter-O'Grady: I'm so excited by what Rachel's saying, but think about the generation that is now coming on board. Because we had a shortage of faculty, we actually controlled the number of people who came into nursing schools. And so, we raised the standards for entry. So now, we have these 3.5 to 4.0 people that are our children that we drove to everything on the face of the earth to do that are high energy, high intellect. We now have the same requirements for entry into nursing school that you have into medical school, into law school, into engineering school, into architecture school, exactly the same standards of entry. And the same kinds of people coming in with this high level of energy, this high capacity for thinking and reflecting and doing and acting and they just didn't go to nursing school. They were president of their football team. They went on a mission to Africa. They played sports and all of that kind of stuff. I mean, they were far more energetic than I can even possibly think of having been when I went to school. And now, they come into the workplace and they bring those expectations in. And when the workplace doesn't gel with what Rachel was saying, and doesn't bring that, it doesn't work, and now they're expecting

Host: Yeah. As you were saying, they had a loss of engagement, investment support and leadership. That's what they need. They need all of those things as they enter the profession. So, Rachel, then, what difference does professional governance make in the life of the individual nurse then? Speaking of what Tim was just talking about, when they enter, they need all of this investment support, leadership engagement. How important is professional governance then to them?

Rachel Start: Myself included, many colleagues have benefited positively from authentic engagement and professional governance and a true understanding of what we have to do in terms of managing our own practice. I believe that a journey with that cognizance leads to the development of a leader. It's leadership type behavior. I think it opens up doors and connections for nurses to understand what colleagues are doing, how to create collaborative work with other disciplines. Certainly, we know in the communities of nurses that have truly engaged in high levels of professional governance, they are very trusted as valid partners within the interprofessional team as well. And so, I've experienced in growing from a newer organization to professional governance on a journey that level of interprofessional trust and collaboration and reliance from physicians, pharmacists, therapists that grows. And so, you walk away into your daily job or your daily work with a greater degree of collegial that's with other teams as well.

I do like to focus not solely on the benefits though to nursing. But I like to focus nurses on the benefits that we're supposed to be supplying back to patients, right? I think ultimately nurses got into this role and into this profession to make a positive difference. And that is the most way to feel gratified as a nurse, is to make a positive difference, right? If there is a limitation to what can happen because the mindset is employee and even the organization in which that employee works is very limiting, then that nurse may not fully realize the full positive benefits as an individual with our profession. Would you add to that, Tim?

Dr. Tim Porter-O'Grady: Yeah. You Know, nurses want to own their contributions.

Rachel Start: They do.

Dr. Tim Porter-O'Grady: And this new generation is clear about ownership. And so, they don't see themselves in a very subordinating way. They see themselves as colleagues. Just what you were saying, Rachel, they see themselves as colleagues. They see themselves of people of value. They have something to contribute. They have a difference to make and want to make that difference. And they really don't want to put up with a lot of, I don't know if BS is a legitimate word to say on these podcasts, but, essentially that's what they don't want to put up with. And so, they're clear about that. If you take what Rachel was saying about that ownership, one of the struggles is the leadership capacity to actually lead that kind of a person in the health work setting. And so, one of the challenge that we have that is different now is that the skillsets of subordinate leadership, leading your employees, leading your subordinates, doesn't fit that model and doesn't fit this player. And so, a part of what leaders have to learn is that you're leading your colleagues instead of your subordinates. And that's a whole different set of leadership skills. And so, a part of the demand now is really focusing on what those are, developing those, so that there is a match between the leadership and the people in the practice arena that want to fully express that ownership of practice and make a difference and the organization that you represent as a leader.

Host: Instead of that top-down leadership, you want a more collaborative environment. You want to elicit feedback from them. "How can we do this better?" instead of me telling you, "Here's what you're going to do," "Tell me how you can do your job better, and let me try to help you achieve that," right?

Dr. Tim Porter-O'Grady: Well, even more than feedback, because feedback and input is advice you get from people that don't matter. Because the person who makes the choice about whether that input is valuable is the person who receives it, not the person who gives it. And how many times have you given input and it's been completely ignored? How much value do you get from that when you've given input? Eventually, input ultimately leads to disengagement. So, what you want instead of input is say, "What decisions do you own? What are the decisions that are essential and necessary to your work?" In a profession, they're pretty clear. And let's make sure that they don't transfer, let's make sure that leadership doesn't make them, and let's make sure that you're at the table when it involves what you do, so that you're making the decisions that you own, and the organization is supporting those in the best interests of those we both serve.

Rachel Start: I would just say that, honestly, this conversation is a little bit circling around where we started and that difference in the notion between shared and professional. I think it's really important to make clear that professional governance is a flat structure. It's non-hierarchical. It assumes that every nurse in the profession accountable for his or her practice. And that includes the administrative nurse who has a body of expertise and specialty to them. We have certifications for administrative nurses. At the professional governance table, that person has a contribution to make from their body of expertise, just like the critical care nurse, the ambulatory care nurse, the educator nurse, right?

In professional governance, we strongly adhere to deference of expertise. If we don't have all of the requisite voices or brains at the table, we're not going to come up with the best decision. And in the past, we've thought that that manager or administrator needed to stay silent, which all that did from my perspective is reimplemented hierarchy. It said to the staff, "No, you go ahead and do your work. We'll go back in our office. We'll stay silent here just to give you time to do this work," which promoted an environment in which it was this input, like what Tim is saying, where you have your time to do this work, and I'll go back and consider if we're going to actually implement, right, which doesn't give that true level of power to the expertise that it should be deferred to.

And so in that same way, there are proposals that from a clinical practice perspective need to happen. But they need to understand resources, regulatory implications, legal implications, human resource implications. And unless that manager is acting from his or her specialty, these other practitioners within our profession will not have the full body of knowledge to make an effective decision. And so, I've been learning a lot. Actually, I'd love to volley it back to Tim, in professional governance, really the difference between positional and role leaders and how that is going to help us move forward with a flat hierarchy within practice management. But do you want to add to that, Tim?

Dr. Tim Porter-O'Grady: Yeah. We have a whole new understanding of leadership that comes out of what are called complex adaptive systems, where we look at complex systems and figure out how they work. And in it, there's leadership that's positional, that's the manager role. And there's five accountabilities there: human, physical, material, support and systems. And that's what you expect from that person. That's what you want them to bring to the table. That's the skillset you want there, to Rachel's point, in order to inform decisions to make sure that they can be successfully resourced. But you know, there's also role decisions that people have by virtue of who they are and what they're doing and what is expected in terms of the outcomes of activities there.

So, there's clinical leaders, there's council leaders, there's committee leaders, you know, there's board leaders. And that's leadership too, but it's defined by role. When you leave, that leadership stays there. And then, there's that emergent leadership, you know, that comes out of a situation, a scenario, a problem, a concern, an issue where somebody has expertise, understanding, knowledge, and brings that to the problem-defining, problem-solving process and actually exhibits leadership in moving towards that problem resolution. But that leadership extinguishes at the end of that moment and goes with the person to whatever other opportunities for its expression. And now, our obligation as human systems is to be able to incorporate that into our way of doing business with each other, to our relationship, our processes, our deciding and our acting, and honor and respect each of those leaderships in making things happen and getting positive outcomes without destroying relationships along the way.

Rachel Start: Right.

Host: Absolutely. So in professional governance, how do nurse leaders then need to change to play their part in empowering patient care nurses to fully engage their role in nursing professional governance? Tim, let me ask you that.

Dr. Tim Porter-O'Grady: Well, a part of the leadership role is understanding both its contributions and the specifics that belong to the role and those things that don't belong to the role. So, clarity around what the role elements are and what the role elements are not, and then educating and developing leadership in order to be able to live and to express within that model of understanding. Competency development, as Rachel was suggesting, being competent inside the role and truly understanding that. And the leader recognizing that they're the bridge between the organization and the individual and making that linkage and creating the opportunities for that connection to produce real value and outcomes.

And lastly, I think, in a profession, relationships drive everything. The relationships inside the profession, between the professionals, between the profession and the organization and between the other disciplines. Because patient outcomes, clinical outcomes, making a difference is the convergence or results from the convergence of the efforts of all of those who make that difference. So, convergence becomes really critical here. How did all of our skill sets-- the doctor, you know, the orthopedic surgeon, we want him to really do good surgery when we're having a hip replacement. But you know, we want him or her to get out of the way when it's time to take care of that and to see that the person can get up and walk and live and thrive and go home. That involves nurses coordinating that whole journey, physical therapists, all of the players coming together, so that at the end of that experience, there's a convergence of a whole lot of effort that nurses manage, coordinate, integrate and facilitate, if you will, to make that happen. And that's got to be a part of the relationship, honoring, respecting, understanding, articulating and managing well. So, those are just some of the key elements.

Rachel Start: I think I really like to focus folks back and I work with 12 different departments, many staff nurses in my role. And I think as a nurse administrator, my key role is to get information into the hands of our nurses that would equip them with problem-solving opportunities, to understand the big picture of where healthcare's at. Whenever I speak on the topic of professional governance, I always like to start at a frame of what's happening to our patients and populations, since that is why we exist.

I like to diminish that professional governance exists just for nurses. In fact, that's totally untrue. Professional governance is the act of us structuring our impact back onto society. And if we focus just on what we do as nurses or on growing our own satisfaction with our role or our employment, it's never going to be up to the high stakes we have right now in healthcare. Thinking truly about that 40% or more of patients right now cannot afford healthcare, that we have vast inequities, that in the pandemic we saw 3.2 times or more inequities when it came to hospitalizations and deaths in vulnerable populations. Those are the truths I like to get back to nurses that I'm working with, because those are the problems they want to solve and they should be solving.

So equipping nurses, and as an administrator involved in a lot of different professional organizations, I have access to a lot of that information. Those system truths or the things about populations that are gaps aren't always getting into the hands of actual practitioners. And I'm not practicing. I'm not touching any patients, right? And so, I need to get that information into the hands of people that can do something with it, right? I can make the resources happen. I can make the connections happen. But I don't have the real time information about touching patients anymore. I don't. And so, I think that plus what I have found to be very effective my role currently is to set up scenarios in which piloting and creativity are totally possible at all times. So if there's an idea, trial it out, there's no wrong answer. If you aren't successful and you're tracking your metrics, then you just go a different way. What else can we try? And I'm finding that there is a lot of engagement in creativity, in innovation. Our younger generations have a lot of comfort with technology. They want to be creative, and I think that's engaging them.

And I'll just point out one other thing is that the preparation that these younger generations of nurses really had throughout their life on the topic of equity and justice is significantly more than myself or other generations above me had. And they come with a knowledge of mission of justice, of respect for all voices. That's already ahead of potentially where we were in the past. And so, leveraging both creativity, you know, their engagement acknowledge in authentic work as well as this understanding of really healthcare for all, I think really can help propel our staff to achieve more than we've ever achieved.

Dr. Tim Porter-O'Grady: They know something's wrong.

Rachel Start: Yeah.

Dr. Tim Porter-O'Grady: I get this all the time. From this next generation, they know something's wrong with the healthcare system. And this is my 50th year as a nurse. And when I look back, we nurses have supported many things in healthcare that are illegitimate, inappropriate, and sometimes held a healthcare system together that we really should have teased out and broken apart and looked at. I mean, think about this World's Health Organization data. We are number one by double the next nation in terms of what it costs to get healthcare. Number one double the next nation. But when it comes to health outcomes and health impact and the health of our citizens, the health of our society, the net aggregate indicators of health out of the 23 large economy nations that we are a part of, out of the 23 of those nations that we are members, the large trading nations, we are number 30 in terms of impact.

Host: Not good.

Dr. Tim Porter-O'Grady: Now, they may not be able to put that language to that scenario, but these people know that something isn't clicking and are hungry to find out and are drilling down. And in Rachel's role, and we've talked about this a number of times, in Rachel's role, they're telling her they may not be able to say specifically, but they're telling her what they know isn't jellying.

Host: Right.

Dr. Tim Porter-O'Grady: And so, that's the landscape of the next two decades of leadership.

Bill Klaproth (Host): Yeah. All right. So, let's talk about the landscape coming up the future. So, what do nurse executive leaders need to do to enable nursing professional governance to thrive and make a difference in their clinical organizations moving forward? Rachel, let me ask you that.

Rachel Start: I'm loving the conversation that's happening in the country around value-informed nursing practice, and I think my colleagues and the staff that I work with really love that conversation. And what I'm talking about, and I know that Tim can elaborate on, is really being firm on what we demonstrate, what we contribute back to patient care, having that as a ready argument that we can speak to, and also understanding the financial impact that that brings, that will contribute positively to that economic burden to patients and populations, that will contribute positively to change in healthcare, right? So I, think that really because the stakes are so high, we have to translate some of those things to our colleagues to push that impetus further. Would you add to that, Tim?

Dr. Tim Porter-O'Grady: Yeah, I would just resonate with it essentially. One of the issues that we've had for the full life of the profession since Florence Nightingale to today is that we've been on what we call the left side of the ledger, which is the cost side of the ledger. Nursing is embedded with the laundry and the landscaping and the furnace and all of the other cost items. And so, you can imagine the mental model that leaders have with nursing when we are collectively in that arena of costs. And so, the whole approach to leadership when you're dealing with cost is effectively margin leadership, watching the margin, watching the cost, tightly managing what it takes to do the work. And so, you're always seen within that framework and that mental model creates a set of behaviors that results in many of the outcomes that we're struggling with now.

And so, one of the real efforts that Rachel was really drilling down on, is being clear about the contribution value that we make as a discipline that has value that can be translated in three different ways. Number one, in terms of resource use and how equitably and appropriately that's used. Number two, in terms of impact, clinical impact, the impact on outcomes, what Rachel was talking about in terms of the difference that we make with regard to these outcomes and the health of those we serve. So, that we enumerate that, we give it a language, we use an algorithm to be able to get at that as a way of doing business. And finally, what are the numbers? You know, If there aren't numbers, there isn't sustainable value. How do we translate that into the numeric financial and economic numbers that indicate to us this is what it's taking and this is what it's getting. And we know that we do all of these things, but because we sit on the left side, the focus is only on one element of what it is, and that's how much resource we use. And so, that's the work of, again, at least the next decade. And that work has begun already. And I'm looking forward to where that will take us.

Rachel Start: Bill, I would add a little bit to that. A lot of this in this conversation has been reflecting back and we had a conversation in another meeting a couple weeks ago really about what changed about 20 years ago. We had a huge influx of information into our healthcare system in which we needed to be very checklist-driven, very protocolized, and it was all tied out of good intention to patient safety, reduction of error. There was literature that came out at the national level about errors and whatnot. And some of what I'm reading and I've been thinking about in terms of setting up creative spaces for innovation and growth of our practice, I think in conjunction to this value-informed nursing practice, there has to be a willingness for us to think possibly somewhat deviant from those protocolized, very strict structures that we have put in place for ourselves for practice. And of course, I never want errors to decrease safety for patients. But I just do wonder about if some of those strict and stringent checklists that we've been following in our practice, if we need to be able to have some ability to create new, to think outside of those, if those have somewhat limited our ability to grow our science, because they are very rote, they're very structured and often they are built outside, I'll say even in my own organization, they are often built outside of nursing professional governance and tied to doctor orders. So, I'm talking a little bit on a tangent here, but I'm wanting to emphasize the importance of creativity in this era of value informed nursing practice, that we know what we demonstrate now, but I think we're going to have to continue to empower an environment of creativity and innovation, to recognize that creativity and innovation and to be willing to take some risks on what we think we know and allow folks, especially with technology and creativity, to do some out of the box work.

Dr. Tim Porter-O'Grady: And, you know, that creates equity. Here's a small example. I don't know if you remember, during the Ebola crisis when we had a few Americans that were over there and got sick and they were brought back to the United States, let me tell an Emory story. One of them was an Emory physician and they brought him back to Emory because we had a big Ebola clinic there that was run. And he was in really bad shape. And they pulled him through and got him through, and one of the few people that actually lived from this horrible experience of having Ebola.

And they were having an interview with him on CNN and I was watching. And he had insisted that the nurses in the unit be with him while he was in front of the microphones. Because he said, "I had good medications, I had a good diagnosis. I had good doctors doing the doctoring." He said, "What made me live, however, were these people that surrounded me here. I would not be living if these people here weren't driving what was going on." And I thought, building on what Rachel was saying, that's the stuff we're talking about. That really results in the message that he was delivering.

I sometimes think when you see on television these tragic circumstances where people are involved in these shootings and are brought to the hospital in critical care and that kind of thing, out comes the critical care doctor to report on how the patients are doing. And my immediate thought is, "How does he know?" He went in, he pulled out the bullets, he sewed them up, he got the organs reorganized, sent them to the ICU. And what do you suppose his work is now? Waiting while the patient heals with the people that are helping him heal. But the person who's coming out to give the report on how the patient's doing, which would be how is a patient doing in terms of their illness, their recovery, their strength, their family supports, their consciousness, their contribution to their own care, their communication with the caregivers, you don't hear anything about that. And you know why you don't? Because a physician who's reporting doesn't know anything about that. So, you got the wrong person reporting on the progress of the patient other than the physiologic condition that are the signpost of how good the care was that he was getting. And in the interest of equity, that's a part of what should be the normal expectation of the conversations and contributions of those that makes them and nurses are those people.

Host: Absolutely. Well, I want to thank you both for your time today. This has really been interesting. If I could just very quickly just get a wrap up from each of you, Tim, any final thoughts you want to add?

Dr. Tim Porter-O'Grady: Yeah. Just very briefly, as I said, this is my 50th year and I'm as excited as I ever was challenged differently many different elements on our agenda that are critical. But I think that the generation and the opportunities and the challenges that we have at this time are about as significant as they've ever been since the time of Florence Nightingale. And so, I'm thinking that we are on the way to some really important work

Host: I love the optimism.

Dr. Tim Porter-O'Grady: Yeah, professional governance is at the top of the list.

Host: Fantastic. And Rachel, how about you? I want to thank you for your time, and final thoughts from you.

Rachel Start: I would just say to any nurses, colleagues, students, listening that the stakes are too high for us to do any lesser than full in on professional ownership and accountability, that the patients we care about, the populations we care about really do rely on us fixing the gaps that they're experiencing and won't be able to live as full of lives or have as autonomous of ability to make their own decisions or guide their own livelihood unless we are all in on professional governance. That is the work we have to do today. We need everybody's creativity. We need everybody's ability to collaborate, to think big about what we can do, and to take this serious as a professional mission, as well as one that's one within our community.

Host: I got to be all in. I love it.

Rachel Start: Yes.

Host: That's great. Well, Rachel Start and Dr. Tim Porter-O'Grady, thank you so much for your time today. I appreciate it.

Dr. Tim Porter-O'Grady: Thank you. It's been a joy

Rachel Start: Thank you.

Host: And once again, that's Dr. Tim Porter-O'Grady and Rachel Start. 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.