Creating the workforce of the future is one of the biggest challenges for nurse leaders, says this CNO.

Dr. Jesus Cepero, PhD, RN, NEA-BC, has spent his entire career in nursing leadership roles, and is passionate about the care of babies, children, and moms. Cepero earned a doctorate in nursing from Catholic University in Washington, D.C., and a Master of Science in Nursing from Kean University. He also holds a Master of Public Administration from Seton Hall University.

Most recently, he served as chief nursing officer for the University of Michigan’s Mott Children’s Hospital and Von Voigtlander Women’s Hospital in Ann Arbor, MI. He was responsible for leading all aspects of nursing administration across the two hospitals. He developed a nursing philanthropy committee, implemented a system-wide program for senior leadership rounding, and co-led a response to the opioid crisis.

Now, Cepero serves as the CNO at Stanford Medicine Children's Health, where he provides nursing and patient care leadership across the entire enterprise, partnering with leaders in the outpatient, treatment center, and inpatient areas.

On our latest installment of The Exec, HealthLeaders sat down with Cepero to discuss his journey into nursing, and his thoughts on trends in the nursing industry. Tune in to hear his insights.

Virtual nursing will address workforce shortage issues, say these nurse leaders.

Virtual nursing will open up a whole new realm of possibilities.

From admissions and discharges to patient monitoring, mentoring, and even at-home care, virtual care technology will push healthcare into the future.

The HealthLeaders Virtual Nursing Mastermind program participants met last week in Atlanta to discuss their virtual nursing programs and outcomes. There are several key points that CNOs can take back to their health systems and integrate into their own virtual nursing programs.

Building the workforce

First and foremost, virtual nursing is going to expand the capabilities of the nursing workforce. Many of the participants agreed that virtual nursing is one of the only answers to the nursing shortage.

According to the participants, tenured nurses are able to extend their careers virtually when working at the bedside is no longer a viable option. New graduate nurses from the next generation who expect to work digitally will be able to do so, and licensed nurses from all over can work remotely and provide care to other parts of the country.

Health systems should do what they are capable of when it comes to operationalizing virtual nursing programs. Some participants use a central telemedicine hub in their health systems for the virtual nurses, while others use telemedicine stations on or near the floor. Some are also exploring work-from-home strategies.

Many of the virtual nurses in the participants' health systems are centralized and working off of a task queue, and can move freely throughout the system to complete their work. Several of the participants agreed that shift flexibility is also necessary, to give nurses who have external needs the opportunity to work when it is best for them.

Choosing the technology

Technology is obviously one of the largest pieces of the virtual care puzzle. It is critical that CNOs and other leaders invest in the right technology that will help them meet their goals, while also remaining cost effective. Leaders should not be surprised, however, to get it wrong on the first try.

According to the participants, leaders have several options for virtual care technology. Many started simply with iPads and carts, which they said aren’t long-termbut do enable them to get their programs off the ground.

When upgrading technology or starting at the beginning, several participating health systems outsourced to a third-party vendor, while others developed the technology in-house. One dilemma is whether to lease or buy the technology, since new devices are frequently updated to include the newest bells and whistles.

Most importantly, CNOs and other leaders should invest in technology that will actually be used by the care team. According to the participants, the nurses' experience with the platforms should provide them with a better, more efficient experience, because if they don't like the technology, it will not be used.

Gaining buy-in

One of the biggest challenges that CNOs and other nurse leaders will face when implementing virtual nursing programs is gaining buy-in from the rest of the C-suite.

CEOs and CFOs are largely concerned about ROI and how virtual nursing programs will save money. The participants recommended starting with concrete metrics like decreased discharge times to prove ROI. However, most metrics will depend on each health system's needs, and how they define ROI.

CNOs also need to provide their support to virtual nursing programs. According to the participants, there have been some concerns about ratio changes and nurses getting taken off the floor, and about how the technology will interfere with nurse workflows, which worries the nurses. This is why proper messaging, education, and a clear roll-out plan are critical, according to the participants.

The HealthLeaders Mastermind series is an exclusive series of calls and events with healthcare executives. This Virtual Nursing Mastermind series features ideas, solutions, and insights on excelling your virtual nursing program. Please join the community at our LinkedIn page.

To inquire about participating in an upcoming Mastermind series or attending a HealthLeaders Exchange event, email us at exchange@healthleadersmedia.com.

Health systems are brainstorming new ideas for how to build and improve virtual nursing programs.

The Virtual Nursing Mastermind program participants are meeting in Atlanta, Georgia, to discuss the ins and outs of implementing virtual nursing programs.

The program consists of CNOs and other nurse and technology leaders from 12 health systems across the country who are all at various stages in their virtual nursing journeys, and who are innovating with new technologies and solutions.

Implementation

One of the biggest hurdles for virtual nursing is program adoption and implementation. The participants discussed how to gain buy-in from the other C-suite members, particularly the CFO and CIO, and how to introduce the program to the nursing workforce.

There's also a call for defining terms, which the participants say will help with buy-in. The participants were clear that "nursing" needs to come out of "virtual nursing." The tasks being done virtually, like certain documentation functions, do not necessarily need to be completed by a nurse. Health systems should be looking at other departments or positions who can complete those types of processes. This new technology will also enable many other departments in the health systems to also use the platforms for their various needs.

The participants also shared how they have operationally set up their virtual nursing programs. Many have centralized hubs with dedicated buildings where their virtual nurses are based, and others have virtual nurses working from home. The participants noted that they believe virtual nurses need to be at least technologically proficient to take on the position and that those working from home have a private space they can use with a reliable internet connection.

Lessons learned

ROI and improved clinical outcomes are a crucial piece of the puzzle. The participants spoke about what outcomes and efficiencies they are seeing so far and the metrics they are using to track progress. Some of the top metrics include timely discharges, turnover rates, incremental overtime, HCAHPS, and other nurse sensitive quality indicators.

Every health system is going to have different needs and different ways to measure ROI, so according to the participants, it is important to start with a metric like timely discharges. Leaders should look at traditionally "soft" ROI metrics and assign dollars to them so that the rest of the C-suite will get on board with implementing virtual care programs. Additionally, if a system is going to launch a virtual care pilot, it should directly address the chosen ROI metric that will solve the problems that the health system is focusing on.

The participants said the possibilities are endless with virtual nursing technology. The programs are set to expand well beyond just documentation and more into patient monitoring, nurse mentorship, and into more forms of digital care. The ultimate goal is to leverage virtual technology to create sustainable care models of the future.

The HealthLeaders Mastermind series is an exclusive series of calls and events with healthcare executives. This Virtual Nursing Mastermind series features ideas, solutions, and insights on excelling your virtual nursing program. Please join the community at our LinkedIn page.

To inquire about participating in an upcoming Mastermind series or attending a HealthLeaders Exchange event, email us at exchange@healthleadersmedia.com.

A new report shows that lowering nurse manager span of control improves clinical and financial outcomes.

Amid high burnout and turnover rates, nurse leaders should take a closer look at a key piece of the workforce puzzle: nurse managers.

Nurse managers need time and support from leadership to complete their tasks. According to a report published by the American Organization for Nursing Leadership (AONL) and Laudio, this could be accomplished by lowering span of control.

Span of control refers to the number of employees that nurse managers are in charge of supervising. According to the report, the median span of control for nurse managers is 46 employees, but 25% of all inpatient nurse managers have spans of control higher than 78.

The problem

According to Rudy Jackson, senior vice president and CNE at UW Health and a HealthLeaders Exchange member, nurse managers often have to perform many different duties. As a result, they’re often stretched thin.

"We put so much incredible pressure on our nurse managers to manage finances, culture, patient experience, quality, [and] keep turnover rates [and] length of stay down," Jackson said. "Yet we have all of these things that we put on their shoulders before they're able to get those things done."

Jackson said UW Health is making a significant investment in reducing span of control for nurse leaders. They’re looking at metrics like total headcount per nurse manager vs. how many pilots they are working on, as well as workforce diversity.

Jackson said a recent study has helped the health system understand what “we can eliminate off their plate” to make their jobs easier.

High spans of control also impact turnover rates.

According to the report, managers with higher spans of control face more turnover costs and incremental overtime.

Nurse managers are often swamped with busy work, leaving little time for job development. Jackson said that with more time, nurse managers could develop relationships with their teams, improve quality outcomes, improve the patient experience, and ultimately reduce costs, turnover and vacancy rates.

"What I need are leaders," Jackson said, "and reducing that span of control is going to allow us to move those individuals into a leadership role where they're truly able to guide their teams." 

The solution

The ultimate goal of lowering span of control is to give time back to nurse managers while also keeping costs down.

The report says that a financial case can be made for reducing span of control, when possible, even if it means splitting larger departments into smaller ones. According to the report, leaders should consider reducing or reallocating administrative tasks to offload the nurse manager's burden, while leveraging technology.

Additionally, the report says that giving more time to nurse managers to meaningfully interact with staff lowers RN turnover rates, which in turn lowers hiring costs.  

To Jackson, the answer to this issue will vary depending on the size of a health system and its resources.

"When you look at the control data for an organization like UW Health and you compare us to others, we do have a lot of resources that support our managers," Jackson said.

"It's a matter of trying to understand what exactly are those individual things that are impacting our leaders," Jackson continued, "and how can I leverage technology to offset some of that burden?"

UW Health developed a nurse manager council so that nurse managers have a venue to voice innovative solutions, questions, problems, and concerns. Jackson said UW Health will soon be conducting time studies with managers across the health system to better understand where nurse managers are spending their time.

"One of the solutions I heard recently from a CNE was [that they] give [their] managers a day off once a week, and … in theory, that would work pretty well," Jackson said. "The reality is that the work doesn't stop."

"As CNEs, we need to start thinking about innovative solutions, leveraging technology, offering the appropriate support," Jackson said, "but [doing] so in a manner that doesn't add additional cost to organizations that already exist on razor thin margins."

What about assistant nurse managers?

According to the report, the assistant nurse manager plays a critical role in this strategy.

The study found that 56% of nurse managers are supported by at least one nurse manager. Of that number, 4% of nurse managers have all team members reporting to the assistant nurse manager and 18% share the direct reports, while 78% have all team members as their direct reports, without including the assistant nurse manager.

The report says that RN turnover is lower when assistant nurse managers are part of high span of control teams, which ultimately reduces costs. However, the data also shows that too many assistant managers can become counterproductive and lead to high turnover, possibly because roles are less clear.

Jackson has experienced working in environments with and without assistant nurse managers, and UW Health is now trying something new.

"What we've challenged our team with is start looking within," Jackson said. "What resources do we have internally that can allow us to start to decrease that administrative burden to those managers so that we can get them out of their office and elevate the roles of some of the others?"

UW Health deploys full-time charge nurses called care team leaders (CTLs). Jackson said they are looking at how CTLs can help offload the burden from nurse managers.

UW Health is also leveraging technology to help with administrative burdens.

"We're looking at technology to remove the burden of scheduling," Jackson said. "We've got to be able to put pressure on our IT departments to find those solutions that help nurses and help the organization make our leaders more efficient, [and] support our nurses even better."

In health systems where creating new roles is not possible, Jackson recommended making existing roles more supportive to the nurse managers.

"I think there's a lot of different ways to utilize the assistant manager role," Jackson said, "but I don’t think we need to be stuck with the solution that the assistant manager is the only way we're going to fix the manager span of control."