And I'm going to go ahead and start the webinar. All right. Good afternoon to those of you who have already joined us. We're going to give folks just about a minute or so to make sure everyone's had the ability to log on without difficulty, and then we'll go ahead and get started with today's presentation. So we'll be starting that, like I said, in about 30 seconds or so. All right. I see it as I've got one minute after one. So I'm going to kick us off. I'm Denise Bushman, the Vice President of Care Transformation at MedAxium, and I am joined today by Missy Dorsey and Fred Scott Comer. Missy brings us an extensive background in adult critical care. She's got about 10 years or so of experience in critical care nursing leadership positions and is presently the Director of Adult Critical Care, Cardiothoracic and Cardiovascular Nursing at Spectrum Health, which I would be remiss if I didn't say is actually newly rebranded as Corwell Health, that's following a merger with Beaumont Health in Eastern Michigan. So Missy is located in Grand Rapids, Michigan. Fred is an Assistant Professor of Nursing at Grand Rapids Community College, also in Grand Rapids, Michigan, and Fred came to nursing as a second career, so brings that broad perspective of preparing nurses to enter the workforce from a personal perspective as well as a professional perspective. So his background is also in cardiovascular nursing and prior to a move to academia, worked as an educator for the Heart and Vascular Institute at Spectrum Health, and there he focused on education for the CAP and EP labs and non-invasive imaging. So we're delighted to welcome both of you to the webinar today. We will plan to leave some time for questions at the end of Missy and Fred's presentations, so please feel free to enter your questions or comments by clicking on the Q&A icon at the bottom screen of your page or at the bottom part of your screen. You'll also find a link to the slides from today's presentation, and you can access those by opening the chat box. So slides will be in the chat box, enter questions or comments in the Q&A box. Today's session is also being recorded, so if any of your colleagues that were unable to join today are interested in listening, they can go to the MedAxiom webpage in a day or so under events and education, and then click on the MedAxiom Academy link where they'll also find earlier sessions from the staffing webinar series, and there are also other recorded presentations that they can access there as well. So this is the fourth webinar in our cardiovascular staffing series, cardiovascular staffing in a COVID and post-COVID world. Today's session is going to focus on nurse staffing issues, that is understanding a novel strategy for attracting and retaining staff nurses, as well as a look at the challenges of nursing education, preparing nurses to enter in the workplace, and the implications for hiring managers, in particular, knowing what to expect of new graduates who have completed degrees in this whole COVID, post-COVID world. Just as kind of a framing element here, the recently published 2022 NSI National Healthcare Retention and RN Staffing Report indicated that more than 60% of respondents indicated their RN vacancy rate topped 15%. I'm sure many of you are dealing with traveling staff and have vacant positions posted, and you're wondering, like, how are we going to possibly fill all of these positions? In addition to that, knowing that 30% of registered nurses are over the age of 60, there is that impending potential retirement looming out there for many of them, as well as understanding that in this same report, only 8% of registered nurses indicated they wanted to work at the bedside as a nurse. So the crisis is real, and without spilling too many more numbers that will only maybe make you feel a bit disheartened, I'm going to hand it off first to Missy, who will give us a reason to be more optimistic with a strategy that may improve staffing. So with that, I am going to advance my slides. I forgot to show you that screen that showed where you can find the chat box and the Q&A box. So, Missy, I'll hand it over to you. Thanks so much for joining us. Great. Thanks, Denise. Yes, I am in nursing leadership, which sounds like many of you are, and I'm going to review something that we did a few years ago. Really, it was pre-pandemic, and it really showed that it worked well from a strategic staffing plan during the pandemic, but then also kind of outside of the pandemic. So we're going to introduce what this is. We're going to talk a little bit about current state, which Denise gave you a little taste of that, and I'm sure many of you already have those unfortunate numbers. And then I'm really going to go through the logistics of what this looks like. So I have standard work document that I will review, pros and cons, because there's definitely both of those, and then our outcome summary. Next slide, please. So introduction to the dual role. So throughout history, the nursing profession has experienced fluctuations in turnover and retention and has experienced cycles of significant nurse shortages. And this, even before the pandemic, nursing turnover was a concern due to burnout and moral distress, compassion fatigue, and the desire to continue for those darn advanced degrees that everybody wants to get, and then obviously travel opportunities. The COVID-19 pandemic has intensified many of these factors, and Denise had mentioned, you know, obviously the travelers is one of those big things. So next slide, please. Great. So this is according, this data is a little bit different than what Denise discussed, but it is definitely still as sobering, I would say. And this is from the 2022 NSI National Healthcare Retention and RN Staffing Report. And it really just identifies that turnover has increased by 8.5% in this last year, which is a lot, and I think anyone who works in nursing leadership can definitely attest to this. Sometimes it feels a little bit higher. The national turnover, according to this source, is 27.1%. And then hospitals that have turned over 95.7% of their RNs in the last years, or last five years. And to me, when I look at that statistic, it's, it feels very high, but I think when, like I said before, when you're working in these environments, it does feel like that day-to-day when you have people coming in and telling you that they're going on to pursue different opportunities. It can definitely feel that you've turned over probably almost 96% of your staff. The same Healthcare Retention and RN Staffing Report outlines that the average cost of a nurse turning over is $46,100, and that can range anywhere from $33,900 to $58,300. And then over that, over a per year in turnover cost, an average hospital can spend $7.1 million. So this is, this number to me is staggering. And I think, you know, when you report it, the, when you break the report out a little bit further, it describes that each percentage point lost in nursing turnover equals about $262,000 from the organization each year. Next slide, please. So the, the work that we started with the dual role at that point in time, I was the nurse manager of a 22-bed cardiothoracic ICU, heart and lung transplants. We have an ECMO program, a very busy ECMO program, many different types of advanced heart failure devices. So we were, we are, and were a very busy 22-bed ICU. We had many different reasons why people left, a few of those high physical and psychological demands, constantly working with these very sick, acute patients, some that would not do well, and having those, that moral distress and that compassion fatigue, increased workload. So obviously many of you that work in staffing know that throughout the pandemic and after, we have had to increase the workload on the bedside staff and increase their hours worked doing different types of mandatory overtime, just so we can provide care to the patients. Difficult working environments, relationships, you know, things got testy over the pandemic and continue to be. People are reacting and it's typically a symptom of the stress that they're under. Undesirable team dynamics, restricted growth opportunities, when people feel like they don't have that opportunity to grow within their role, keep learning, that's difficult for people sometimes and they will leave that position. Obviously the inability to cope with emotional and psychological and physical demands. I think we all probably have felt the inability to cope in the last couple of years and having to deal with that sometimes is not worth working in these environments. Depersonalization, if you work in a large organization, which I do, sometimes it can feel so big that you, you know, you feel depersonalized. So the statistics of this specific cardiothoracic ICU, at the point in time, we had a 25.7% RN turnover, very high and definitely felt it on the unit. And then the 2018 data source that we're using is the orientation cost, which at that point was $800,000 that we spent in 2018 just to orient new staff. Next slide. Perfect. Okay. So what is a dual role? A dual role is an employee who works a portion of their FTE, which I'm sure many of you know is a full-time equivalent 1.0, you know, person in two different spaces. So what it really does is it allows that team member to practice nursing in a multitude of ways. It utilizes different nursing skills and it really provides a more in-depth wide range of skills to those patients that we're serving. The intent really when we started this was to reduce the burnout in the nurse, but what the initial implementation found was it not only increased nursing retention, but it improved nurses' clinical skills, it improved relationships amongst departments, and it created a strategic staffing plan that was a key factor in successful staffing throughout the pandemic. So that was a nice surprise when we got into the pandemic. And you might be thinking, you know, that's not very innovative, a dual role, that's just somebody who's splitting their FTE. I have people that do that. When people tell me that or they ask me that question, what's the difference, I think the difference is that this was promoted and it was a method of retention and reducing burnout and fatigue. So it was intentional conversation about what would a dual role look like for this employee. It was very purposeful. So as you go through this presentation, think about that in your mind, that it's not waiting for somebody to come and ask you about it or having somebody else present the idea. It's really utilizing it as one of those retention strategies. All right, next slide, please. So I'm just going to walk through the standard work and kind of go through some of the key points that I think are important with, you know, working through each step. So step one, employee and leader discuss a dual role opportunities and determine the secondary unit. So for instance, I have a nurse that comes to me and they say, you know what, I'm feeling like I'm getting burned out. There's, you know, I'm working 36 hours in the CTICU. Some days that could be six days in a row and I'm, you know, I'm getting burnt out. Is there something else I can be doing? So asking the questions about what else interests you? Is there anything else out there that you have found like maybe you'd want to do? So I've had people say, you know, the emergency department, or I've had people say labor and delivery. So having those conversations about exactly what does that secondary department look like? And then once they come to you already identifying that secondary department. So what is the total FTE the employee would like to maintain? Are you a 0.9 FTE? Do you want to do a 0.6, 0.3? Are you a 0.6 FTE and you want to do a 0.3, 0.3? So what split of FTE is the employee interested in? And then is the leader in agreement with the split? So if somebody is coming to me or I'm the one, you know, obviously if I'm the one who's talking about it, I probably am going to be okay with it. But am I at a point in time that I can say, okay, let's go through this process because there does have to be some stability or some benefit to the risk of having somebody split that. And then, like I said, does the current unit have the ability? So employees interested in broadening their skill sets to decrease the burnout and continue the growth. And leaders are encouraged to use this as a tool when employees are feeling these, the feelings of burnout and fatigue in the same environment. And sometimes it's just that repetition of the same environment. So current leaders should assess if the team member is experienced enough. If I have somebody who comes to me who's off orientation for only three months and they're wanting to do a dual role, my conversation would be much different if I have somebody who comes to me with three years of CTIC experience. This also could be looking at what kind of specialty training they have. Are they fully trained in the environment that they're stepping away from for a little bit? So those are key points to make on this step one. Next slide, please. Step two, employee reaches out to the second leader. So I really put that on the employee to do, trying to find out, do they even have an opening position? So somebody comes to me and they say, you know, I currently work in the CTIC. I've been here three years. I'm getting burnt out. I really want to do L&D, but I don't want to leave CTIC. Okay, well, does L&D have the opportunity for you to do a dual role there? Do they have an FTE open? Sometimes they don't. And then it's just really putting that on the next leader's radar to say, hey, there's this opportunity out there. And I think the big thing here is, is that leaders should support this, support as needed in this process. I do like the employee reaching out, but it is, what I found is me sharing information with the other leaders and really kind of supporting them and having them buy into this was really important for that leader to make an informed decision. It often feels like, well, this is much more work for me as a leader that I have to, you know, work with another leader on their schedule and all of these different things. And that is true. I have done this and I've done this with over 27 employees and it, the benefits most definitely outweigh the risks and the work that is being done. So it's sometimes just having that empowering conversation with another leader to say like, I've done this before. This is what it looks like, those types of things. It's important for that work to be done. Next slide, please. So step three, once determined, employee applies for a position within the secondary department. So the way that we did this and the way that I would advise is that you keep it clean and you have them apply through your human resources platform or whatever that is. There may need to be a specific requisition place. So for instance, if L&D says, you know, I don't have a 0.3 FTE open, but I'll put one in because I have the ability to split up a 0.6 and I want this person to work a 0.3 in my space. And again, keeping the strategy the same when it comes to hiring through your HR platform is key to the organization of multiple dual roles. It really keeps things clean. Interview is conducted by the secondary leader and employee. So it's very important that that secondary leader has the opportunity to provide their own formal interview, allow for questions, discuss expectations, and have it kind of be their own thing, because it's important that the team member knows what's to be expected. And then also that the leader can say, you know what, yes, I think this is a good fit for you, or no, it's not, because not everybody that wants to be a dual role is going to be appropriate for that position. Next slide. So if there is a plan to offer, a secondary leader will reach out to the current leader to discuss a transition, orientation, and other expectations. This is really, this looks like any type of churn or any type of internal transfer. You know, usually it's a leader-to-leader conversation to talk about transition. The way that this is different is that you're still going to be staying in that first unit. So what does the orientation time look like? What is, is it full time? So I have to give up my nurse for a full, you know, three months to the emergency department so they can have full orientation down there, is my expectation that they pick up a shift every couple of weeks in my space. And that's typically how we worked it, depending on the environment, depending on their experience. That is one of those, I would say, risks that you're, you're taking when you, you do have to make sure that your unit is stable enough that you can have them step away for a period of time to do that full-time orientation. Discussing what scheduling practices and expectations look like for both departments. So for instance, if I'm on a self-schedule and they're on a core schedule, what does that look like? Who is going to own the holidays? Who's going to own the weekends? And from our experience, whoever has the higher of the FTE, like if I had a 0.6 and L&D had a 0.3, I would own the holidays and the weekends and those types of rotations. It kept it very clean that way. Overtime, what do we do with overtime? What do we do with required extra shifts? Some of our dual roles did on-call requirements. So trying to identify how to support the team member, but make sure that each of the departments are being able to be, you know, taken care of. What are the team meetings and services educational expectations? That was huge because it really is identifying these things to the team member saying, if you take on this dual role, you will have to do two of everything normally. So if I have an in-service and cardiothoracic ICU on a new device or a new practice, but then so does L&D, they have to go to both of them because they are signed up to work in both of those shifts or both of those areas. And then we've had in the past some differing pay scales. Through this work, we've been able to identify those and actually make them a little bit more aligned so we didn't have this issue. Next slide, please. So once key points of transition plan are determined, this information should be presented to the employee during the offer. So as these are the expectations, you're going to work your holidays and your weekends in CTICU. You are, you know, required to do your annual competencies and, you know, your skills reviews in these types of environments. Team meetings are every other month, whatever that looks like. Making sure that it's in writing and the employee knows what they're signing up for. So if the employee accepts the offer, a collaborative meeting should be held with both leaders and the employee to review the plan and ensure all questions are out there. If it's a new leader who's, this is their first time of doing a dual role, I've often found that that initial meeting together really just gets some of those questions answered once, you know, kind of the dust settles. And it really allows the employee to kind of have a very clear understanding of expectations. Transfer date is determined and then they move through whatever your HR platform is. Next slide, please. So clinical departments that we have had in the dual role in the past, so obviously the cardiothoracic critical care, we've had the emergency department, the cardiovascular recovery unit, endoscopy, bronchoscopy, ECMO, labor and delivery, anesthesia, the cath lab, pediatric ICU, which is a dual role between peds ICU and cardiothoracic ICU is very interesting. We've had the PACU, surgical services, which included outpatient, care management, quality and safety, and our unit champion role. Next slide. I do wanna point out in that last slide, you know, one thing that we recognized was that during the pandemic, when we were starting to shut down some of our elective surgery places, our endoscopy, outpatient endoscopy procedures, our outpatient surgeries, those staff members that were dual role in those were able to shift that other part-time FTE into the inpatient space, which is where we needed them. So they were not losing out on hours and we were getting the help that we needed during the pandemic. So definitely a pandemic win for that. So there are definitely pros that we've seen in this, decreased burnout, increased job satisfaction. It is appealing to new graduate RNs, which working through that is, you need to work through that pretty carefully because obviously a new graduate RN comes with no experience besides what they get in academia and making sure that you're supporting them and they're not biting off too much that they can chew right off the bat. Strategic staffing plan, as I mentioned during the pandemic and even before the pandemic and after it has been super successful, increased clinical skillset that transcends areas of specialties. For instance, our LND and ICU trained staff, you know, when we had these pregnant moms that were in the ICU, that level of care that they could provide those moms was much different than just a regular ICU nurse and vice versa. When they had sicker patients in the LND area and those nurses were on, they could provide a different level of care. Interdepartmental collaboration and relationship building. I have different relationships with people in all of the areas that I worked with the leaders far beyond before I did any of this because it's really that personal relationship and that professional relationship that you're working through as leaders to support a team member. And you get close and you have more conversation. And it's been actually a really great benefit out of it that I didn't really foresee that being. So financial benefits due to increased flexibility with staffing. So we call them LVTOs, but low volume times off. Not that we have seen that in the last couple of years, but as I mentioned, you know, when we were canceling outpatient surgeries, some of those staff were not getting their hours completely where when we had them able to come into the inpatient space they were able to get those hours. Also prevents less overtime for the people that are working in the inpatient space. Professional growth and development. It really gives people the ability to kind of, I would say itch that scratch where they want to continue to grow. It has even prevented people from, not that I want to prevent people from going on and going to school, but sometimes they have that feeling of, oh, I feel like I need to do something. My peers are doing something more. What is that? I don't necessarily want to go to school. It's really giving them that ability to continue to grow and stay at the bedside. Some barriers for sure that I think are needed, or need to be just aware of when you move through this is the mid shift pulls. So it's 3 p.m. on a Wednesday. CTICU is, you know, we have a new admit. We need a staff member. LND, they don't need, you know, they're canceling staff. You call over, hey, can I take Melissa from you? Sure. Well, now she's giving up her patients in LND and she's coming into CTICU for a four hour shift. And you can think probably how often that would occur. That can be very, it can make them feel very shuffled around when you're kind of going with where the need is, because that can change obviously hour to hour. So just being aware of that, respecting those people and kind of having that conversation up front. Differing pay rates became a huge dissatisfier, which you can imagine. If I'm working in an environment that I'm making more money right now, and then at 11 o'clock, the other environment needs me, and I'm not having the choice, I'm getting pulled back to that environment and I've dropped my rate by a dollar or two, that can be very frustrating. So again, we learned from that, aligning pay scales has been really successful. And then just identifying the inability to keep up on specialty competencies. So for instance, in CTICU, we have a lot of different specialties, impellas and ECMO and different things like that. And if they're unable to keep up with that, if they're maybe working a 0.3 in a space and they're only working one 12-hour shift a week, making sure that you have a methodology of making sure that staff are being competent and staying competent with taking care of those patients. Next slide, please. So our outcomes, in 2019, we had a total of 22 nurses, and we had just one RN out of those 22 nurses leave, which on the average rate at that time was 17%. In 2021, we had 24 total staff members and two of those nurses left. And both, all three of those nurses were relocated nurses to another state, out of state with spouses. Decreased intent to leave by 76.5% of the respondents, our decreased burnout by 100% of the respondents, increased overall satisfaction of 100%. Increased, as I mentioned, collaboration between RNs and multiple departments. If you think about an ICU nurse and an ED nurse, that relationship building and the ability to see out of your own silo was huge. And it really allowed those nurses to kind of spread that collaboration as they're working in those departments. Because it's very easy to point fingers and having these people kind of spread out through the different units was really helpful. And again, strategic staffing during surges, whether it's a pandemic, it's flu, RSV, trauma season, any of those types of surges that we see within the healthcare field, it was very helpful. Next slide, please. Perfect. So in summary, dual role offers staff retention. We've seen decreased burnout in it, decreased turnover. It has improved collaboration amongst leaders and amongst staff members themselves, flexible staffing needs, obviously a huge expansion of skills, relief from high acuity demands. And then overall improved job satisfaction. Excellent. Thanks so much, Missy. A really terrific example of ways in which you can solve both issues of staff retention and maybe even to some extent staff recruitment by having a space in which they can grow and expand skills. So we'll have a chance for responding to some questions at the conclusion of the next presentation. So I am going to hand it over to Fred Scott Comer and we'll hear this next section and then we'll take it away for some questions. So welcome, Fred. Interested to hear what you've learned in academia. Thanks, Denise. Thanks everybody for being here today. So yeah, so title of this is COVID-19 and academia, and they'll get the PowerPoint up. I'll just do a brief introduction and talk a little bit about what I'm going to talk about. Oh, there it is there. So today I'm just going to spend some time in one of the questions I'd ask as we cover this agenda is we're going to look at, I asked about 12 questions of staff of different people. And I looked at people in academia. I also talked to people who work in industry or in the hospital you would know it as in acute care setting, and then even clinical educators as well as other faculty at different universities. And one thing I will say also in terms of the perspective that I'm going to share is most of these people I communicated with were in actually in West Michigan. And so just know that these are numbers I'm sharing with the relationships with individuals I have in our local area. And the questions were just basically have them give me their perspective. Has COVID-19 changed academia at all or the students we're sending into industry or into the healthcare systems that our students end up in once they get their license. And some student comments, I'll share those. Some of the things I also, and that was the other population I also reached out to the students as well to get their opinions. I figured, and we want to hear from them. And if there are problems that we've identified just some potential solutions and things that we want to talk about and then just a brief summary at the end and question and answer session. We can go to the next slide. So are there deficits? I've talked about this a little bit. And again, those 12 questions that I asked too as we tried to identify, are there deficits due to the heart of allowing students into the clinical setting, it was some varying comments and it was interesting. I got responses from several different individuals and from different schools. Again, like I said, and even in the clinical setting and there was always a little something different that I would get. But for the most part, things were similar. None of this would be rocket science that I'll share today. 12 questions that I'm gonna deal with is, have them look back and where they were when the pandemic started and when everything was asked to be shut down by our governors, by our president, by everybody at that time in leadership. And then we're gonna talk about, did they feel was it impossible to do? How do they think, another question would be, how do they think COVID-19 affected nursing students enrollment? Did it go down? Did it go up? What about our ADN versus our LPN programs versus our BSN program? And then I'll look at how long did it take colleges and our healthcare partners or clinical institutions to realize that we gotta get students back face-to-face when everything was halted or put on pause, so to speak. And then how well did students adjust to the changes in the learning style and the learning presentation? What role did simulation play with trying to make sure students were properly educated or prepared? And then how has the adjustment back to what we are now experiencing a new normal, how has it been going? What are some of the challenges we're seeing? And I asked them to give me a few examples. And do you think there were a higher number of successful students directly influenced or caused by the pandemic? Do you think students that entered the nursing educational workforce, are they better, stronger, weaker nurses? And I'll give you some of the perspectives and feedback I've received. And then what are five or 10 things or five or 10 words that would describe students in the pandemic? And then five or 10 words that would be used to describe faculty during this pandemic. And then as of today, what do you feel is in the current state for the nursing academic world or school specifically in terms of COVID-19? Next slide. I will say I did ask one person I know who works on the East Coast about how their hospital and local colleges at that particular area navigated COVID. And a lot of the similar things I wanna share here. So that would be the only one out lying thing that would be different from the people I said, mostly I've talked about in West Michigan. And I think what I noticed the difference between them and us is that they struggled a little bit getting students back into the clinical setting into the hospital. It took a little longer for faculty to be ready for that as well as for those institutions to be ready. So that would be one difference. Looking at the first question that I just listed here you can read it there on the screen. Most people shut down March, 2020 and everybody is familiar with that. Our world stopped everywhere, no matter where you lived especially in America and even throughout the world. The instructors didn't think it was impossible. Most of them had already started planning. They had already started looking into, they kind of knew the handwriting was on the wall. It wasn't their first rodeo. They like, this is a major change, a major thing going on. And we know we're gonna have to make some adjustments. They didn't know exactly what but many of them had started meeting with their teams had started dialoguing about what do we do? Started talking about simulation. If we have to use it as a component on online work they looked at recorded lectures, looking at those things and deciding at that time that they were already thinking ahead of the game. Some instructors had already started recording their lectures previously in other semesters, not related to COVID, just in general. So they were thinking, well, maybe I could use those recorded lectures to use online for students during the time of the heart where we couldn't be face-to-face. And then they got the call and obviously they pulled together teamwork and started pulling together the education and working together. So for some programs, they had the summer. So some of our schools in our area, they don't, our BSN schools especially, all of them, they don't go year round, particularly they stop in the summer and take a break, give the students opportunity to work and do different things like that. And then for our community college that I teach at, we go year round. We admit students every semester, fall, winter and summer. And we do two seven-week sessions in each of those semesters. So ultimately we're in front of the students two seven-week semesters, or at least six times throughout the year for those seven-week periods. So for us, we didn't really get along hot. And it was kind of nice for us because we got the word. We had students that were headed to leadership in March and April. So we had to come up with a plan right away. And I'll talk about that in a few minutes of kind of some of the things we did and how we adjusted in those moments and to make things work. But the staff was proactive. They responded well. Obviously there's a lot of stress. We had instructors that didn't teach online. We had to have colleagues help them. You go to the next slide, Denise. Colleagues helped them to try to figure that out and navigate that. I'll talk about that a little more in a second. How do you think COVID-19 affected nursing student enrollment? For most schools, it didn't affect them greatly. So let me give you an example. One thing we saw was there was a decline of students who didn't want to enter at that time because they were nervous about going into the clinical setting or fearful. But then we had the future for frontliners and it brought us people who had not considered healthcare as a viable option in terms of a career. So we kind of balanced itself out. We didn't see like where we had gaps of 20, 30 seats available for students. So we didn't really see a drastic change. And that was kind of the consistence as I looked through my notes and as I talked, communicating with different faculty and we didn't have a big gap with that. But we did find that maybe some students didn't come because now nursing isn't as thrilling in the past years as it had been as a traditional role or job where I can go into healthcare and help somebody. Many of the reasons many of us went into healthcare. So we thought that that was some of the dynamic too but that future for frontliners, those students came in and they're on a set amount of time they have to use that money. They're given out a block of money, that bag of money and they have to use it within a certain timeframe. So they were more engaged, more focused and whether they performed well whether nursing was the best job for them. I think time will tell. I think for some of them, we've already figured that out but I think time will tell for those individuals who reacted to that benefit being there and coming into nursing as an option. So that was something that we saw as well. That was a good thing. As we lost some students, we gained others and some of them brought different perspectives different walks of life because they had considered nurses. And we know sometimes those individuals can make good nurses as well even though they don't have all the clinical knowledge and experience that others may have. So we saw a little bit of both of those things. Go to the next slide, Denise, please. So some of the things that you see here how long did it take colleges and our healthcare partners to realize? They realized right away. I mean, Poor Health, Poor Well or Spectrum Health was a leader in helping our college. I know Rams Community College really jumped and get right going right away. I mean, they were all over it. I mean, they also realized that they needed those bodies in the healthcare setting. So we had opportunities where they were able to use what we call graduate student nurses. So that would be students who had finished the program but had not got their license yet. They can come alongside and work with a licensed prepared nurse almost like a extra leadership for them. But there are also with things that they can do on the clinical side, like a nurse tech or support staff that they can do independently or along with other staff. So it was a win-win that they saw as an organization. So that was definitely a benefit there. So that was definitely a win-win and a benefit for them. So that was a great thing. So, you know, for us, we immediately, we got our leadership students, our director worked with the organization, different hospitals and got our leadership students who was affected the most by that timeframe between March and April, who could not enter into, you know, their leadership because the halt had been placed on having students in person. And so, and we were still trying to figure out how to do their lecture components and the online classes. And so a lot of that came together in a short span of time over a few weeks. But our director in particular, you know, Michelle Richter, she worked with our local partners and they got students right back in the clinical setting right away. They were able to finish their leadership. I think most of those students that we had in leadership that time finished it. Maybe a few didn't continue because of fear through the pandemic for good reasons. Obviously, because before we knew a lot about this, it was a really scary experience for everybody. And I think we know more now than we've ever had, but, and through experience, unfortunately, but it has helped us grow. So our colleagues, I think they helped us considerably. And those were some of the things that they did to prepare these students to enter. We also had alternative sites. So the alternative clinical sites from represent there is, we had students in our, especially our LPN programs, as well as a lot of BSN programs, the students I've taught in both programs. BSN programs, usually the students first semester, whether they're going to be an RN or LPN, they haven't in a long-term care setting, but we know at the height of the pandemic, they were not allowing anybody in. And for good reason, those were our most vulnerable populations of individuals who were there. So we didn't, though that we had to really, really be really creative around simulation and around a virtual classwork, around virtual assessments with our LPN programs. And then some of the alternative clinical sites we did use, we took actually LPNs into the acute care setting and they were allowed to do certain things. And what our BSN students do is the same thing. We use some of our acute care sites because remember their first semester, a lot of the programs, they don't pass medications and things of that nature. So we were able to let them get in for that basic skill and learn those things at that time. And some of those, those would be some examples of what I mean by alternative clinical sites from what they would traditionally go to, again, because of the lack of access to those long-term care facilities for their first semesters. Next slide, Denise. So how did the faculty respond to COVID-19? I've already alluded to this a little bit. I mean, faculty were great. They came together, they teamed up. Again, we had some instructors that already had the blessing of the gift for teaching online. They had done it before. And so they were able to help other colleagues and other individuals work through that gap that existed. Our IT support team was phenomenal. I mean, I can speak specifically about my experience. I came into full-time academia in August of 2020. Denise probably, I used to work for Denise. I was her educator at Spectrum, but why would I change jobs during a pandemic? But I mean, I had great support. I think my IT team, I didn't know how to use TechSmith normally. I didn't know how to record lectures on video. Now I had done Microsoft Teams. I had done some work with Zoom, but I hadn't taught students over Zoom. I mean, like we're doing today. I really hadn't done that. But a lot of us just kind of really knee-jerk reaction. We knew how to teach. We knew how to present. We just had to, in the moment, say, hey, look, we gotta get these students what they need and where the vehicles are gonna get it. And so we made the adjustments. Staff was really great at doing that. I mean, I remember sitting down with an IT person for hours. I mean, just trying to make sure I'm knowing how to do Zoom right and how to do classrooms and how to do polls and do quizzes and different things. I'm working with our Blackboard, our IT team at the campus, learning how to do different things in Blackboard. Our staff, we had to take an online hybrid certification class to better prepare us. And so there was a lot of work on the front side to help us do that. And again, like I talked about the peer support. Next slide, Denise. So how well did students adjust? Now this was tricky. So online, as you can see, we haven't had it today. Thankfully, we're two, going in three years into the pandemic and nobody has unmuted. Nobody has a dog barking. Nobody has a little child coming up, talking to them saying, help me blow my nose. So now we know that we can do this thing virtually. But for students, it was a chore. Many of them, especially at the community college are coming fresh out of high school. They've done a few prerequisites. So in terms of professionalism, what they haven't learned at home, what they didn't learn in high school is what we get. It's what we got when they came, when they entered the door. So we had to help them. So professionalism was lacking a little bit. Students wouldn't turn their camera on. And there was a lot of grace. There was this whole accountability was decreased during COVID. And some of you all may remember this as managers or leaders in healthcare. We just kind of said, we gotta get people through it. And understandably so. Not judging the decisions we made, but ideally we had to pull back a little bit and we had to say, okay, we gotta give people a little grace. They're facing this disease that's killing their family, that's hurting and harming people all over. We don't know anything about it. So to some degree, the accountability was decreased. And so we didn't make students turn their camera. We couldn't require them, which for me was very frustrating because I want to see people and being in person and feed off their body energy or see if they have a question, if they look inquisitive. You lost that aspect by having to... So the learning style, I think the students were challenged with that. During a certain time, we would ask them to turn their cameras on to one-on-ones, office hours, if we were doing test reviews, because we had to do those virtually because we couldn't do anything in person. Everything at the beginning of the pandemic, we shut it down. So it was really a huge learning curve. And I think we're seeing some of the effects of that now as students are coming back. They're struggling a little bit more with that accountability or placing the blame on the staff, whether it's in the hospital as well or as in the academia world. I think you're seeing it in both places. And I think that if that came through in several of the comments I received from the faculty and instructors and the different people that I researched this information from. So a lot of it is group size challenges. It was different in terms of just really trying to get through those things. Test scores, I think they dipped a little bit. We had some of our instructors tell us they dipped a little bit initially because it was hard for students to test online. It was hard for them to get ingest to the different learning mode and how to study on their own and not being able to get questions answered in the moment. It was tough because that's what we lost, that aspect of a student being able to raise their hand and say, hey, I have a question in the moment. So that was tough. Next slide, Denise. So what role did simulation play? I talked a little bit about this already. You had virtual clinical visits. There was, if there wasn't already created, it got created real fast by different organizations. Lippincott had things. Shadow Health, Elsevier had what we would call virtual clinical visits where students could mock and walk through virtual clinical visits online. Unfolding case studies, which some of you may all know as evolving case studies, and I'll bring that back up later, which is a huge asset to help with that clinical judgment and a critical thinking piece that is needed. Just having students unfolding, depending on what decisions they make with those unfolding cases will direct which way that case study would go to make it realistic. If you make a bad decision in a clinical situation where the patient died, would it get worse? You make a better clinical decision, would it get better? So a lot of that was involved. Health assessment labs, we did a lot of that, but we had to do more of it because they weren't seeing patients face-to-face. And then there were a ton of virtual simulations that students had to attend. Next slide, Denise. So how has the adjustment back to the normal been going? What are the challenges, if any, with the adjustments? Please give me an example. So I had this sort of question I asked them. So one of the biggest things is the proverbial sneeze. I have that up there. Even today, if somebody was to sneeze and we were all on mute, we'd be like, oh, do they have COVID, right? We get all nervous and we get worried about it. Same thing in the classroom. And you got 20 or 30 bodies stuffed in the classroom. And that was hard, not only for me as an instructor, but it was hard for the students. They're trying to learn, the stress level. Well, I catch COVID from that person. You know, it was amazing. I never seen so many people who had allergies during COVID. Everybody has allergies, right? They were just nervous about getting COVID or having COVID. So that's a whole atmosphere that hasn't really won away. I think it has gotten better. I was in class, there was a student who sneezed and everybody didn't look at that student and think they had COVID. So that was a hard atmosphere. Coming back to this new normal, some places, they still require masks. I was at a long-term care site last week with students. They're still in an N95 mask. They have not gotten out of them with the exception of maybe like six or seven weeks during this whole pandemic. They've been in N95 masks. They haven't stopped. Some long-term care sites are not wearing masks at all. So there's this disparity and this difference between what every organization is doing. So COVID restriction changes as part of the problem. And again, I talked about a decreased level of accountability and all that already. So those were some of the examples they gave me of things we see. And then some students are hesitant to come to class because they're nervous about getting other people sick or getting sick and taking it back to their families. Next slide, Denise. So as we look at questions, and do you think there were a higher number of success? I talked about this a little bit earlier. I think students struggled early on, but I think when I show you some of the NCLEX scores in a little bit, we'll see that that hasn't been as much of an issue as we thought it would be. There was a little bit of a decline with some students, but overall, we haven't seen a great deal of high percentage decline over time. Just for a second. Go ahead, next slide, Denise. I thought, yeah. So, yes. So this slide, I don't have a lot to say. We've talked about the leniency, lower standards. It was kind of a continual question. I think we came to, we talked about already, people concerned about taking care of their family. So we can skip this slide. Next slide, Denise. These are some words that we use to talk about some of the things that students felt during the pandemic. These comments came from instructors, faculty, people in the industry, as well as students themselves that responded to me directly. People seem to be a little more scrappy, a little more on the edge now. Missy talked about that during hers and part of it. So a lot of that's still in students just as well. Next slide, Denise. And this was faculty. Things you would expect to see or hear in terms of their level of understanding of the situation. So these are just some general words that you can see. Go ahead, next slide, Denise. We had people retired during the COVID. Specifically, they said they retired. It was hard to juggle seasoned instructors. Just on this slide, I'll spend a little time talking about some of the other things I've kind of already talked about. Retirement, what we're seeing is with new faculty, which is a good thing we have it, but what we're seeing is there's deficits in our training models. Instead of this one-on-one mentorship that used to happen in academia, which in SCC, we have continued that, but some instructors have told me they know of and have heard of people who are now, who are having to mentor multiple nursing students because there were several seasoned faculty at a lot of schools that retired. They tried to make it through it. It was just a lot for them to continue. And they have done, they served their time. It's no judgment against them, but they did what was best for them. But they did tell me, and this is the point I wanna make, they would have probably worked longer if COVID not hit. Go ahead, next slide, Denise. These are some more comments the students have made, specifically gave to me about some, I even had students that they liked the fact that they didn't have to drive and park on campus. So they liked that part about online learning. They struggled with some of the Zoom etiquette and things like that, that students didn't exercise. You can go to the next slide, Denise. Common terms we already went through it. You can stay right there, Denise. So BSN, interplex pass rates. You can see across the board, 2019, we were at 91.22%. 2020, when the pandemic hit, 90.29%. These are national numbers, by the way. And then if you look in 2021, we were 86.06%. And then for BSN for 2022 so far, and I believe NCLEX has been administered, it's 86.06%. So there has been a slight decline in our BSN and our ADN and our PAN programs nationally. And locally in the state of Michigan in 2020, it was 83.57. And for a lot of our schools, but we have schooled it really well. GRCC in 2020 and 2019 had 100% in both their PN and RN interplex pass rates. So you saw also some schools that did not decline. These are national numbers. So we have seen a little bit decline. Next slide, Denise. So what do we do? We got to increase clinical judgment. Some instructors and staff and nurses and managers are seeing a lack of clinical judgment, critical thinking. Now NCLEX had already identified this pre-COVID and that's what the next gen NCLEX testing style is about. It's about boosting that clinical critical thinking and clinical judgment. And so they had already realized that before COVID hit. And so what some of you are seeing, we're not sure it's because of the pandemic more so or less is it because of the reality of we needed to change how we approach things in education as well as in our orientation with our new nurses using some of these types of things that I have on the slide, like simulated clinical experiences, critical thinking, case studies, things in that example. Next slide, Denise. Just to give you a quick glimpse, what NCLEX is doing is they're going to a clinical judgment measurement model and they're looking at all of these different areas. And you can find this on the NCSBN website. I'm not going to spend a lot of time talking about it. We don't even have time today, but take some time to go to ncsbn.org and go through this process but it can show you the different things to try to boost the clinical judgment of nurses across the country is what we're starting to see. And these are some of the things I've heard, the managers I've talked to, they're saying as part of their concern with students new grass is coming to them. Next slide, please. This is just an example of some different type of NCLEX item types. If you go to NCSBN website.org, they will, you can go through these and see the different types of things. And some of these we're already using on nursing schools and we're adding more. Next slide, Denise. And this is a type of question. This is a bow tie style of a question. You give a case scenario. There's a little H and P there the students can read or the person in this way NCLEX is going to and what we're doing in nursing schools. And then you can see there where they would have to go in and say what actions to take, what is the potential condition and then what parameters to monitor ongoing with the client's progress. Helping those students make those more complex clinical judgments. Next slide, Denise. I put, be my last one. Whatever we do, let's keep our students in the clinical setting. We'll mask up, but we can't operate in fear. That's all I have. Thank you for your time. Good, terrific. Thanks so much, Fred. Really a fascinating discussion here today, both in a couple of things. And what strikes me that I've seen from both of you today is there's really an emphasis on the loss of expertise that we've seen both in staff nurses at the bedside, the ability both to care directly for patients and then mentor new nurses. And then the loss of expertise even in academia and educate those new staff or new nurses throughout their programs. And I think it also struck me as the importance of the need for innovation and innovative thinking. Missy, I heard from you that innovative thinking in terms of what can we do to expand the opportunities for staff nurses to keep them engaged, to expand their expertise, as well as to give people a little mental break from the stress of the ICU. And then the innovation in nursing education to give the nursing students the ability to understand information and to apply it maybe in unique ways when they're not able to do some of that hands-on stuff. I'm looking to see to make sure, I don't see any questions in the Q&A. We've got just a couple of minutes. So those of you who know me know, I'm never remiss for wanting to ask a question. Missy, I'm interested in knowing when you had the idea for this dual role staffing that sounds like it's really been quite successful. Did you immediately have support from leadership or how much of a sell job did you need to provide in order to have this approved and have the support to pursue something like this? Yeah, I think my leadership specifically, I didn't really need any, I don't wanna say I didn't ask for permission, but it really was nothing that needed that approval. And I think where I needed support was from my peers and the leadership roles to say, to really get them to buy into the benefit of it and really explaining and empowering them to kind of embrace this because as a leader, you look at it and you're like, that is too much work. I've already got too much going on. So that really was where the biggest lift was, but it was, that's where like, I feel like some of the best benefit was because I was able to collaborate with other leaders, identify different spots within the hospital that I wasn't that familiar with. And then my leadership, as they realized what we were doing, and then I kind of explained the process, we're in full support of it. We still talk about this as a strategic staffing plan and as a way of retaining and recruiting staff. So it's been very supportive. Yeah, it sounds like one of those things that if you're willing to take the leap, you find the benefits. And there's like, why didn't we do this before? Yeah. So it sounds like, do you know our other leaders in other areas? Obviously this happened for the CTICU. Has this happened then and progressed through other departments where they may not have a dual role in ICU, but maybe a dual role elsewhere? Yeah, there have. I've talked to a few of my peers that actually have talked to us. I don't think there's anybody that has really grabbed onto it as much as I have. And I think obviously I found a lot of purpose in doing this work because of my turnover rates in CTICU. But I think there's definitely more buy-in to it. From a national perspective, I presented on this at the Magnet Conference and that was last year. And I've talked to probably 20 different hospitals and organizations throughout the nation that want to do this. So I think now that the pandemic itself is getting to a stable point, we're now in a different type of staffing crisis. I really think it gives us time to pause and think about implementing more of these ideas instead of just surviving through an influx of patients because of a pandemic. So I'm hopeful that there'll be more of this to kind of continue to spread. Yeah, yeah, great. Really good for, just again, I love the innovation that's there and the opportunity that it provides staff. And then Fred, I'm just curious too, in terms of the students you see, it strikes me as though resilience could be a real positive outcome. And that's something that they could take that into the clinical setting. Do you think that resilience, did you see, have you seen a change even just in the students that you may have had back in 2020 versus the students you see in 2022? Or I know you've taught for a long time. So do you see a shift in terms of students either willingness to take the steps needed in order to get work done or to be successful clinically? Is there a difference in what you see for resilience in these staff or staff students now that you saw in previous students? Yeah, so I think the resilience for nursing and you guys have been in nursing, you gotta have that to survive nursing in general, nursing school, I should say for sure. But I've seen with those different types of students we're getting that are coming who may come from a different work background or work aspect, they may, I don't know that they're a group, they're more resilient. I can't say for certain that I've seen that. And I think one of the responses I got, just wanted to ask that, was from another person. They said, they were like, we don't know yet. We don't really know if they're more resilient in terms of what will they be like as nurses and when they get out. But as students, it seems to be typically pretty good. I just think it's really trying to get students back on track to say, hey, this is personal responsibility. Because as I said, during the pandemic, I think there was a little more lenience, a little more grace and just really trying to get students back. Okay, we gotta do this. We gotta take care of sick people. We gotta be able to staffing these or our partners. So I think to some degree that's. Great. Well, very good. Well, thanks again so much. I see we're at the top of the hour. So thank you for joining us today. As I said, the slides are available in the chat. If you'd like to click on that link, you can access those and then feel free to share the opportunity to listen to this webinar. So Fred and Missy, thanks again for great presentations for helping us have a little additional insight. And thanks to those of you who've joined us online. Have a good day. Thanks Denise. Denise.

dual role staffing strategy

nursing education

COVID-19 impact

Missy Dorsey

Fred Scott Comer

burnout reduction

online learning

simulation

virtual clinical experiences

clinical judgment