Bill Klaproth (Host): This is today in Nursing Leadership, a podcast from the American Organization for Nursing Leadership. I'm Bill Klaproth. With me is Ashley Marston, ACNO, Ambulatory Care at Emory Healthcare, and Karla Schroeder, VP CNO, Ambulatory and Virtual Care at Emory Healthcare as we discuss Eagle in Flight, Advancing Leadership, Engagement, and Culture in Ambulatory. Ashley and Karla, welcome.

Ashley Marston, PhD, MSN, BS, RN, NE-BC: Awesome. Thank you, Bill. Thank you for having us.

Host: Absolutely.

Karla Schroeder, DNP, RN, ANP-BC, MHA, NE-BC: Yes. Thanks, Bill. Thank you so much for having us today to talk about our work.

Host: I love it. Well, thank you both for being here. This is going to be fun. So, Ashley, let me start with you. What problem were you trying to solve when you created Eagle? And why was it urgent in ambulatory care?

Ashley Marston, PhD, MSN, BS, RN, NE-BC: That's a great question. So as a nursing leader, we knew we had strong leaders. We just didn't have that consistent structure for them so that they could really have that foundational element. And as we know, care is continuing to be more and more complex. It's seen more in the ambulatory space versus inpatient and inpatient leadership has really been around for a lot longer, right?

So, ambulatory has had physician offices that partner with administrative partners. And really, that's changing. So, how do we help our nursing leaders? And the reason why that's urgent is from a safety lens, you've got a lot of variation in our leadership. And so, we knew that that could translate to variation in care. And so, that would translate into patient outcome. So, that's really what made it urgent for us in ambulatory care.

Karla Schroeder, DNP, RN, ANP-BC, MHA, NE-BC: Yeah. Great. Thank you, Ashley, so much. And as care does continue to really shift into that ambulatory space, that acuity level continues to rise. So, we're really looking at that factor as we train our leaders out.

Host: Absolutely. And then, Karla, how is ambulatory nursing leadership fundamentally different from inpatient leadership, and why does that difference matter?

Karla Schroeder, DNP, RN, ANP-BC, MHA, NE-BC: Yeah. So as we look at our leadership structure and how that's different, I want you to go back to what Ashley said, and think about how long leaders have been in place and nursing has been in place in an inpatient setting. That's not actually true in the ambulatory setting. They are physician practices and traditionally have relied on administrative leaders to help in that practice. And nursing is relatively new in that space.

And so, as we integrate nursing leaders and nursing practice into that ambulatory space, we recognized we needed to build up those leaders as that care continues to shift in complexity. So, you think about the fact that those nursing leaders are now having to learn things like complex scheduling, OR scheduling, infusion scheduling, billing practices that are very different than a fixed location.

So, my geographical footprint covers the entirety of the state of Georgia. That's 300 different practice sites, infusion centers, ambulatory surgical centers. So, the difference in the way that we function is just very astute. And so, we needed to shift the way that we looked at the way that we were practicing. And not to mention the fact that the compliance is very different. So, we have a robust infrastructure that is fundamentally different than an inpatient single site setting. Our joint commission is different. And we cover things like sectors, billing, you know, compliance issues, all different spaces, all different leadership structures. And we have an interdisciplinary triadic model where we work with physicians, advanced practice providers and administrators, not just single nursing leaders. So, fundamentally different.

Host: So, would you say we're leveling up ambulatory? Would that be a good way to put it?

Karla Schroeder, DNP, RN, ANP-BC, MHA, NE-BC: That is absolutely the right way to say it, and that's exactly how we say it.  We say leveling up.

Ashley Marston, PhD, MSN, BS, RN, NE-BC: He knows us.

Karla Schroeder, DNP, RN, ANP-BC, MHA, NE-BC: That's right. He knows us, doesn't he, Ashley?

Host: You know, every good host does. What can I say?

Karla Schroeder, DNP, RN, ANP-BC, MHA, NE-BC: That's right. So Ashley, if you had to describe Eagle in one sentence, what is it and what makes it compelling?

Ashley Marston, PhD, MSN, BS, RN, NE-BC: Oh, wow. One sentence. Okay. So, I would say Eagle is a competency-based leadership system that can translate expectations maybe into accountability and into real behaviors and real work. So, that's my sentence.

Host: Okay. Good job.

Ashley Marston, PhD, MSN, BS, RN, NE-BC: And I'll say, I think that is what's key, right, is moving it from theory and we're just talking about things or you know, about what to do for a leader, but how can we give them something hands-on, practical applicability that they can take and use on their unit and make real behavior change.

Host: absolutely So, Karla, what are the core competence components of Eagle? What does it actually give leaders that they didn't have before?

Karla Schroeder, DNP, RN, ANP-BC, MHA, NE-BC: Right. And I think, you know, even though it is fundamentally different than an inpatient setting, when you look at AONL competencies, they actually cross all of the settings of a healthcare system. So, what it gives us is structure. So, we actually took our nursing leader roles and then mapped them to those competencies. So, it gives us structure. It also gives us function and process. So, structure, function, process should sound very familiar to most people. And we mapped those out to our job descriptions, and we mapped those then to our competencies, and then aligned them with our outcomes.

So across the board, we start them and ground them in a self-assessment. So, starting from the basics, where am I landing? Like, where am I at? Because you really can't move forward until you know where you're starting. And so, as you talked about, leveling up, well, to level up, I need to know where I'm at. So, that's where we started. And then, we created an educational program, but we also recognize that it needs to go beyond that. So, interactive workshops that then move into ongoing work. So, it's coaching one-on-one interactions. And then, that's standard work. So, we built in standard work. So setting those expectations, I know what I need to do within my role. And I know how to continue to do that. So, we also built in succession planning. It's built into our evaluations.

So, there's no question whatsoever what I need to do, what it is that I need to continuously do, and what I need to do to get to the next step. So, it's very thoughtful and integrated. I think Ashley mentioned this. Like, what do I need to do next? What are my expectations and how am I going to get there?

Ashley Marston, PhD, MSN, BS, RN, NE-BC: Exactly.

Host: Yeah. So, structure, function, process, it almost kind of sounds like moving from movement to momentum and then to maturity as you finalize these plans and get it to where you need it to be.

Ashley Marston, PhD, MSN, BS, RN, NE-BC: That's right.

Host: So, Ashley, how does Eagle balance operational excellence and outcomes while still protecting human-centered caring and culture?

Ashley Marston, PhD, MSN, BS, RN, NE-BC: So, I think it's key there. That's one of my favorite questions, is those things can't be separate. So, they've got to be woven in together. Because if you take operational excellence and saying, okay, here's some standards that can lead to burnout and people feeling like they're inadequate, and that's that quiet quitting that we've heard about. And then, if you take human caring, that can lead to really emotional behaviors or risk even. So, putting those two things together though, you can lead with expectations, accountability. But also, always have that connection and leading with purpose and being able to connect to your team. So, I think that's kind of key, is just Eagle really anchored both of those things together so that we don't forget that human piece of everything we do.

Host: Yep. Absolutely. All right. So, let's talk about results, Karla.

So, what outcomes or early wins have you seen? And what impact are you measuring to show that Eagle is working?

Karla Schroeder, DNP, RN, ANP-BC, MHA, NE-BC: Yeah. So, I actually got a little treat when we came here just right before we actually walked into this podcast. So, we are actually at a conference right now. And from my past life, a leader came in and said, "Hey, I want to know the impact that you had on my life." so, this work actually started before we moved into the work that we're doing. And she said, "You hired me as a leader and look at what I'm doing now."

So when you talk about impact of the work that you're doing, that's what you want to see, that you're a mentor and a guide in people's life. And so, when you talk about the impact of this leader work, we want people to be able to say that right there.

So, the early wins that we're seeing within our institution are things like we're adding value into our day-to-day practice. And we're seeing that in some of our scores, because we are doing multiple different measures. So, we're seeing increases in our sense of belonging. Not only with our frontline team members, but with our leaders. We're seeing a decrease in our turnover and a really significant decrease in our turnover.

Ashley Marston, PhD, MSN, BS, RN, NE-BC: Yes. It was 15% relative reduction in our leader turnover from the beginning of Eagle until the end of Eagle.

Host: Well, that's huge. That is a win in and of itself. That's a win.

Karla Schroeder, DNP, RN, ANP-BC, MHA, NE-BC: It is, yep. And we look at our leader index scores, which actually shows things around like do our frontline team members trust our leaders to which our relative score is around 4.3 right now. And in our director team specifically, it's 4.75. So, we have incredibly high leader index scores. We're showing lower turnover scores. So, we have some pretty high like metrics from a metrics standpoint, from a raw metrics standpoint. But the things that we're seeing that are really anecdotal are, I feel better prepared to take care of my team.

Ashley Marston, PhD, MSN, BS, RN, NE-BC: Role clarity.

Karla Schroeder, DNP, RN, ANP-BC, MHA, NE-BC: So, Ashley mentioned role clarity, the human part of it because we are human beings taking care of human beings and those trust scores are really important. I feel more prepared. I feel more engaged, I feel more relational. This is really value add and time well spent. So, we're also seeing that anecdotal information that we feel is really important as well. I don't know, Ashley, if you want to add to that?

Ashley Marston, PhD, MSN, BS, RN, NE-BC: I'll just echo some of that. They really talk about role clarity and feeling like they can lead their teams better. And what was great is at the end of the day of each session, we'd have multiple people come up to us like, "This was so great. Thank you so much for taking the time to do this." They do get that one-on-one time with us as leaders too. But then, it's weeks, it's months later. You see it in these scores. You see them come back to you the next time we have any type of get together where it's a Daisy Ceremony or whatever it is, and they're like, "Thank you so much. I was able to take what you taught me and I'm teaching someone else." And so, that's kind of what it's about, right? It's passing along . And they were talking earlier about sharing the journeys and bringing one another up. So, I think that's just such a great reward at the end of this.

Karla Schroeder, DNP, RN, ANP-BC, MHA, NE-BC: Yeah. And they're asking for more.

Right. It's, "Please give us more. Please show us more. Yes. Can we do more? Can we give this to our frontline team and bring them up into it? And so, I think that's the big win for us.

Host: Yeah. That's interesting. So in real-time, you might be thinking, I hope this is making a difference. But to hear that feedback afterwards saying, "Yes, it absolutely did make a difference." That's got to be a real good feeling. And like you said at the conference here, someone coming up to you and saying thank you. that really made a difference. So, that's really important. And I think, as you were mentioning earlier, the nurse retention as well is so important. We've done so many podcasts on nurse retention and how important that is. So, this all filters into that then.

Ashley Marston, PhD, MSN, BS, RN, NE-BC: Yes.

Host: Hey, great job, you two.

Ashley Marston, PhD, MSN, BS, RN, NE-BC: Thank you.

Karla Schroeder, DNP, RN, ANP-BC, MHA, NE-BC: Thank you.

Host: You're getting a high five. All right. As we wrap up, let me ask you each this question. So Ashley, let me start with you. What is the one key takeaway you want a nurse leader listening to this podcast today to apply immediately when they go back to the shop, what do they start doing right away?

Ashley Marston, PhD, MSN, BS, RN, NE-BC: So immediately, if you aren't already, lead with purpose. So, don't wait for any structure to be given to you, go ahead and take the reins. I was reading a book years ago, and I was talking to Karla about this the other day. It's a book called The Florence Prescription. It's by Joe Tye. I know he's kind of a big name in the nursing world too, but it talks about the invisible architecture that makes up an institution, and that's the culture.

And I thought that was so wonderful because it is, as you round, as we do different things, it's not that we don't have data structure, process or anything like that. But it's something that's not tangible. You can't put your finger on it, but you always know, okay, the culture here, there's something different. And that's what we're wanting to do here. And so, Eagle really helps people anchor themselves and, "Hey, where am I? Where do I need to go? What do I need to do for my team so that I can help others?" Because in the end, the greater our teams can excel in that. And then, we can keep humans at the center. Then, our patient's are going to feel that. Everyone's going to feel that our culture here in the hospital is different. So, I guess that's kind of what I would say is lead with purpose. Make sure you're keeping humans at the center of what you're doing and realizing, hey, any conversation we're having, even if it's around data, and I love data, I'm a data girl, but the patient's at the end of that data, right? And so, making sure we're always remembering that.

Host: That's always a good mission.

Ashley Marston, PhD, MSN, BS, RN, NE-BC: Yes.

Host: Remember, the humans lead with purpose. I love that. The invisible architecture, that's really cool too.

Ashley Marston, PhD, MSN, BS, RN, NE-BC: Yes. That stuck with me through the years.

Host: Yeah, absolutely. Karla, how about you? What should someone do when they get back to the shop tomorrow?

Karla Schroeder, DNP, RN, ANP-BC, MHA, NE-BC: Yep. And I think Ashley nailed this one. So, we do solely ground ourselves in purpose and take the reins. So, what we talk a lot about is we are human beings, taking care of human beings and go to your teams and remind them of that. And we do a lot of work in purpose and relationship building. You'll probably notice that I have cowboy boots on. If you haven't noticed, I totally have my cowboy boots on.

Ashley Marston, PhD, MSN, BS, RN, NE-BC: Literally boots on the ground.

Karla Schroeder, DNP, RN, ANP-BC, MHA, NE-BC: And we are boots on the ground leaders. And we are very intentional. So, I would say focus on the word intentional. And so, what we say is, you know, lead with your boots on the ground. And take the time to do that and be very intentional because quite frankly, we have an opportunity in particular in ambulatory care to write the book.

Ashley Marston, PhD, MSN, BS, RN, NE-BC: That's right.

Karla Schroeder, DNP, RN, ANP-BC, MHA, NE-BC: And we are writing the book.

Ashley Marston, PhD, MSN, BS, RN, NE-BC: Yeah.

Karla Schroeder, DNP, RN, ANP-BC, MHA, NE-BC: We do not intend whatsoever to have somebody hand us the book. We quite intend to be the author of the book.

Host: We are going to write that book.

We're writing that book.

Karla Schroeder, DNP, RN, ANP-BC, MHA, NE-BC: And we're writing the book with authority, but being very intentional about it, being very purposeful about that. And we are writing it with the focus of human grounding. And again, with that intention of we are human beings taking care of human beings. And we are deeply grounded in rooting in the why are we doing it? What is our purpose and how do we stay anchored to our mission, vision, and values? But also, lifting up those leaders and helping them to understand that, and then grounding them, or like we talked about, really lifting them up into those national competencies and giving them that guidebook so they then accelerate and they are grabbing on and taking hold of that. And so, that's what I would say do next, like just take hold and write your book.

Ashley Marston, PhD, MSN, BS, RN, NE-BC: Yes.

Host: I love it. Write that book. It's going to be a good book.

Ashley Marston, PhD, MSN, BS, RN, NE-BC: It's a great book.

Host: I love it. Well, when you talk about human beings taking care of human beings, you can't lose with that message.

Karla Schroeder, DNP, RN, ANP-BC, MHA, NE-BC: That's right.

Host: For sure. Ashley and Karla, thank you so much.

Ashley Marston, PhD, MSN, BS, RN, NE-BC: Yeah, thank you.

Karla Schroeder, DNP, RN, ANP-BC, MHA, NE-BC: Thanks for having us, Bill. We appreciate it.

Host: Yes. Yeah, great to have you here. And once again, that is Ashley Marston and Karla Schroeder. 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. You can see all our podcasts at aonl.org/nursing-leadership-podcast. This is Today in Nursing leadership. Thanks for listening.