The past two years have tested the nation’s 4 million nurses in new and complex ways. But not everything about the pandemic was bad. Hear the takeaways, how nursing will look differently in years ahead, and why leaders are taking a fresh look at their strategic plans in Part 2 of our candid discussion with Denise Mihal, Novant Health EVP and chief nursing and clinical operations officer.
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Denise Mihal 0:00
"I think healthcare for the future is changing and that's being written as we speak. I can't wait to see it. We're going to be part of that."
Gina DiPietro 0:12
That's Denise Mihal, picking up our candid conversation from the first of this two-part nursing series. I'm Gina DiPietro, your host, and you're listening to Industry Insights: A healthcare podcast presented by Novant Health. In this episode, we explore the future of nursing, what new models of care might look like, why leaders are engaging nurses differently, and how health systems are innovating to look for timesavers ... helping nurses work at the top of their license. All that and more in part two with Denise Mihal, Novant Health executive vice president and chief nursing and clinical operations officer.
Denise Mihal 0:53
Not everything that happened during the pandemic was bad. We learned lessons, valuable lessons, of how to be nimble and flexible, which wasn't what healthcare was. National American healthcare was not flexible and nimble and able to change on a dime. We learned how to do that with everything changing on a dime with what the CDC was coming out and recommending. 'How do we make this happen? And how do we keep our patients and our team members safe?' So, what is healthcare going to look like in 20 years.... I'm gonna say what is it going to look like in 2025? What other resources do we have that we can take advantage of via virtual support, AI... You're going to see more virtual everything. And not only that, I think the pandemic helped us accelerate the acceptance of virtual. How convenient it works and how well. I think that's exciting on many avenues and we wouldn't have learned that lesson without the pandemic.
Gina DiPietro 1:43
Healthcare executives have said about two years worth of digital transformation occurred within two months. Pre-pandemic, Novant Health averaged 1,000 virtual visits a year. Today, more than 5,000 virtual visits are happening daily. Another example Denise shared is the increased use of tele-sitters ... where a trained CNA can care for eight different patients - same level of care - from one location. That's done with the use of monitors, placed in patient rooms and allows for a two-way conversation.
Denise Mihal 2:15
So, our tele-sitter usage increased. And now we have tele-ICU. We have smaller community hospitals that have hospitalists on the staff. They would cover the patients in the ITCUs and they had a lower acuity of critical care patients. And if the patient hit a certain level, we would transfer them to a tertiary facility where there would be a critical care intensivist. Well during COVID, our hospitals filled up... but we utilized tele-ICU. So there's a computer on a stick ... we can call it a doc on a stick actually (laughs). And the hospitalist was able to go into the room with the intensivist from a tertiary facility, show them and talk to them about what they were doing... Talk about the ventilator settings, proning the patient and being able to care for those critical patients at satelites - with the same oversight that they would have if they were in the physical facilities. So, we were able to do tele-ICU. And then tele-neuro and tele-psych. We were seeing more psych patients in the ED. Why? Because guess what happened in the pandemic? All of your AA meetings, your drug addicts anonymous, all of those meetings stopped until they were able to figure out how to do it virtually. And did those people, those patients, have access to computers to be able to Zoom? And did they have the knowledge to be able to Zoom? So, we saw a behavioral health crisis in our emergency departments during the pandemic. Thank goodness, pre-pandemic, we had tele-psych for those community hospitals that didn't have psychiatrists on staff or even in their communities. So, we had that ability. But we had to ramp that up across our entire system, because we had needs of patients in our emergency departments and on our units.
Gina DiPietro 4:00
What else might nursing of the future look like? And how are health systems finding other ways to increase capacity to care for patients? Take COVID Care At Home -another virtual care option launched by Novant Health in 2021. It identifies patients being treated for COVID - in facilities - who can - instead - safely transition to care at home. Here's how...
Denise Mihal 4:23
We put the cameras in the patient's home. They're visited twice a day - either by a home health nurse or a paramedic. Talk about working at your top of your license. So, they have a virtual visit with their doctor once a day. They have a virtual visit with nurses twice a day. And Home Health will come in ... if you need an IV, they'll come in and hang your IV. Or can we teach you to do it at home and hook it up? Because, keep in mind, there's patients that are at home who are on ventilators. There's patients who are at home that are on dialysis. You don't have to do everything in a hospital. And guess what? Patients want to stay home. So, here are jobs for nurses that take them away from the bedside at the hospital, and puts them in front of a computer ... taking care of more than six patients or more than two patients.... Now they're taking care of many more through just the medium that we're talking through today.
Gina DiPietro 5:14
Are there any specific models of nursing practice or trends that you see as being the future of nursing? And perhaps what Novant Health is doing to innovate and lead in that area?
Denise Mihal 5:25
Gina, we used to have a model called Primary Care Nursing. 'I'm Denise, I'm your nurse. And I have six patients today.' So, another model of nursing is actually Team Nursing. It might be myself and another RN or a CNA, or an RN and an LPN, and we're going to take care of these eight patients together. It's a team. 'I'll give medications and do some assessments, somebody is going to ambulate you.' I think what we're going to see in the future is a hybrid of both. And in some areas, in critical care, Primary Care Nursing works great. Because I have two patients and I'm one nurse, and I'm keeping on top of everything. On our larger units, and our med surg units, a team approach is more conducive for that type of work. So, really looking at what our models of care are... looking at our skill mixes. We're hiring more LPNs now than we hired before. And the partnership between an RN and LPN is great. They're able to take care of a lot of patients together, and the LPN brings a different perspective to the bedside. Another great thing that we've done is studies ... by watching the nurses on some of our units. Our cardiac patients, for example, usually have more than just heart problems. They're diabetic, or they have COPD ... they have multiple conditions. So, they take a lot of medications. It was taking nurses two hours to do their 10 A.M. med pass, because of the number of medications that their patients took. So, if you look at that - at 10 A.M. and 10 P.M. - 'What if we got a pharmacy tech to pull your medications for you, so you could be doing other things?' That's what working at the top of the license is. What work can we take away? The nurse is still looking at it. And they're still going to give it to the patient, do their education, etc. But they don't have to spend time going to machines and 'Well, that's out in this machine, I have to go to a different machine. And then this is in the refrigerator and this is an IV.' So, you're going to all these different places. But again, a med tech, a pharmacy tech, can do that for you. And they can hand you sort of a tackle box, and say, 'Here's your 10:00 med pass. Go.' And you've saved so much time there. And so it's not even every med pass that we need pharmacy techs for. But what are those times of days when it's the most or the best? So that's working at the top of your license. You have busy times of the day and you have these COVID patients ... Think about this. This is another thing we learned... You have all this PPE that you're wearing and it's disposable. So, every time you go in and out of the room, you're your donning and doffing, you're taking this stuff off and throwing it in the garbage can. Well, we only have housekeeping come by once a day to pick up the trash. So, we're walking on a unit and see a nurse emptying trash from rooms because the bins are overflowing. Should they be doing that? And do we need to increase the number of times that we're picking up trash in the room? Especially on a unit that has the most COVID patients. These are little things that you don't think about, and if we could take those types of activities away ... we make sure that you're working at the top of your license. And that's what that means. That puts something in your head, 'Oh, that's what working at the top your license means.' The other thing, you know, we went to an electronic medical record in 2012. Dimensions is what it's called - Epic. Now we're looking at what we have an Epic and how much duplicate charting do we have? The same question is asked on many different pages. Well, now that it's electronic, don't you think it should populate all over? So, really looking at our documentation. Yes, assessments need to be done, but they only need to be done once. And if the physician does it, why can't it populate in the nursing notes? And if nursing does it, why can't their findings populate for the physician? So that we're saving time all around. And really, making sure that we're utilizing our AI to the best of its ability - so that it's actually working at the top of its license. That's going to be great, too. So, looking for timesavers across the board. And then, of course, there's all these different pilots that we're doing based on team members ideas of what we could do differently. And how they think we could solve some issues and problems. And that's even great because they're closest to the patient. Sometimes you have to look at their work arounds because you go 'God, that's a great idea. We need to spread that across the system.' So, like lots of things that we can do to make sure that people - one - feel heard and valued - two - that they're appreciated. And again, appreciation from a health system isn't just about money. Obviously we've said 'Yes, you have to be compensated fairly.' But it's not always about throwing money,because that doesn't give you resilience. What is it that we are seeing that we are thankful for and appreciative of? And how do we show our team members that? It might not just be a bonus here and something of monetary value, but it's just "Let me thank you. Be appreciative. Or how do I make your world easier?' You know, the executive team and other leaders are shadowing people for ... not just two hours, but four to six hours ... and learning what their jobs are like, so that we have a better understanding. 'Yes, I could see that this is hard work. And how can we work together to make it easier and to make it better for you and for our patients?' That's what it's about. Because I'll be honest with you, the strategic plans that we've had together. You know, you have an 18-month, 3-year, 5-year plan... When I sat down and looked at that earlier this year... I was like, 'We have to...' Not that we're gonna throw away the whole strategic plan. Because quality and safety and team member engagement and patient experience .. that all stays, you know .... so we're going to look at that. But the way that we approach it, because what we've been through, has to be different moving forward.
Gina DiPietro 10:40
So, it's important to find consistent ways, and different methods, to engage nurses and other healthcare workers ... especially in times of stress. Those who do leave, typically leave because of the relationship with a direct supervisor .. What Denise calls their "one up."
Denise Mihal 10:58
Looking at, you know, team members leave because of that relationship. And also, the past 20 months have not just been hard on the frontline, it's been hard on our nurse managers. And in fact, I think nurse managers have the hardest job in the system. So, what we're doing is a 2022 Nurse Manager Academy. And over the course of the year, we'll have an academic program for the nurse managers ... building and developing their leadership skills so that they can become a better leader for their team members. And also feel supported and have the resources they need. The first class that we're going to do together is actually going to be a resiliency class. Because they have been through a lot, just as all of us in the past 20 months. So, we're going to have Dr. Tom Jenike come and do a one-day session with them around resiliency... To one - thank them, acknowledge what they've been through. Let's get that out in the open, you know... And then obviously the 'how to have a crucial conversation' and do an appraisal, finance 101, what productivity looks like.... But then also those items that a nurse manager only can manage and deal with of 'How do I do reward and recognition that's fair and consistent so that everyone feels valued the way that they want to feel valued? And how do I make time for that?' There's things that we can do to help them around that. So, I'm excited because I think our investment in our nurse managers is going to, by all means, pay off and cascade to our frontline team members of creating that better place to work. Feeling more valued, feeling appreciated, and creating that family, and that relationship where, 'This is a great place to work and I don't want to go anyplace else.'
Gina DiPietro 12:40
Denise mentioned the resiliency class for nurse managers that Dr. Thomas Jenike will lead in 2022. As Novant Health senior vice president and chief wellbeing officer, Dr. Jenike and I spoke previously about the devastating cost of ignoring workforce burnout. Find his advice, and part one of my conversation within the Denise Mihal on what's accelerated and exacerbated a nationwide nursing shortage, on the Novant Health Industry Insights channel on Apple, Google, Spotify or anywhere you listen to podcasts. I'm Gina DiPietro. And thank you for listening.