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The State of Nurse Hiring

In case you missed it, the nursing profession is going through a pretty challenging time. Whether it's COVID burnout, a severe lack of skilled workers or the Baby Boomers putting immense pressure on the health care system - just to mention a few - times are tough. It's certainly an issue Chad & Cheese aren't qualified to solve, let alone fully understand. That's why Dr. Beth A. Brooks, president of The Brooks Group, joined the boys to discuss a wide variety of topics, such as the current state of nursing, how the gig economy is impacting the profession, the power of pay transparency and if / when the robots will finally be the ones giving colonoscopies. It's a must listen for nurse recruiting professionals, healthcare networks around the country and, frankly, nurses themselves.


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Intro: Hide your kids. Lock the doors. You're listening to HR's Most Dangerous Podcast. Chad Sowash and Joel Cheesman are here to punch the recruiting industry right where it hurts. Complete with breaking news, brash opinion, and loads of snark. Buckle up, boys and girls. It's time for the Chad and Cheese Podcast.


Joel: Oh yeah. It's your proctologists' favorite podcast, AKA, [laughter] The Chad and Cheese Podcast. I'm your cohost, Joel Cheesman, joined as always, the Woody to my Buzz, Mr. Chad Sowash is in the house. And we are just giddy to welcome Dr. Beth A. Brooks, president of the Brooks Group. Beth, welcome to the podcast.


Beth Brooks: Hi, and thank you for having me on this nice cold December day.

Joel: You can't see her face on the podcast, but she was totally shocked and awed by that intro, so we'll try to bring it down a little bit for you. [laughter] Now, my intro was pretty sparse. I know you have a long resume and a lot of things that you do. So spend a few seconds on your Twitter bio to let our listeners know who you are.


Beth Brooks: So I've been a nurse executive, nurse leader for, gosh, 30 years I've been a nurse, and the last probably 20 years of my career have really focused on nurse recruitment, retention, healthy work environment. I've designed a questionnaire to measure the quality of nursing work life that's been used in 50 countries, and it's been translated into 10 languages. So I kind of have a lot of expertise and knowledge around healthy work environment, work life, recruitment and retention of nurses. And it's just been my sweet spot and my passion. And we've gone through some crazy times these last couple of years with nurse recruitment and retention.


Joel: Loco.


Chad: Yes. Well, let's talk about the state of nursing today. We're coming on the backside of a pandemic. COVID is still out there, obviously. But we're on the backside of a pandemic that was a very large load for nurses and healthcare to actually carry. So where are we at now? Do we still have a higher attrition rate? Higher turnover? What's going on?


Joel: Everything's back to normal, right?


Beth Brooks: Wah...


Chad: And what should we expect? What should we expect?


Beth Brooks: I think we should expect not knowing what's coming next. There's a lot of talk amongst my colleagues, and a lot being written about COVID will reshape the nursing workforce in a way that we've not seen in the past. We'll have a whole segment of the workforce that will prefer this gig economy type work, which is very new for someone like me who was a baby boomer nurse who eight hours a day, five days a week, staff nurse. So I think we'll have this gig economy component. We are definitely going to have, I believe and I think some colleagues would agree, a movement away from the 12-hour shifts back to an eight-hour work shift. And that's for a couple of reasons, but primarily from fatigue and burnout. We've really learned through COVID that the 12-hour shift, and there's enough data now that we know about the impact on nurse and patient outcomes, that I see a shift in the hours that nurses work. We've got the gig economy.


Beth Brooks: And then I think a whole group of nurses who have come to realize, unlike before, what their value is to the organization, and they wanna be respected, they want to be compensated fairly, and they want to be listened to. And that's sort of the message in every study that's coming out that has been. Those have been the themes. So I think it's gonna be a more demanding workforce and wanting a better work environment that we've had in the past.


Chad: So are we gonna move away from the traditional? Or do you see us slowly moving away from the traditional, not just 12 hours, but also we're seeing a lot of apps that are out there that help healthcare systems really focus on being able to manage their people better. Although those people also have the opportunity as you talk about the gig economy, not just to work in their healthcare system, but also to be able to go outside of that healthcare system. And it's almost like an Uber where it's, you're calling inert, you see what shifts are open, and you go down to, let's say for instance here in Columbus, Indiana, we go to Seymour or we go to Greenwood if there's something open and they're paying a little bit more. Do you see that happening where it's a more of a traveling kind of workforce?


Beth Brooks: I do. And I think there's a... But not for everybody, right? I think like anything, it's a big workforce and there are segments of the workforce that enjoy that kind of flexibility, autonomy, and freedom. What's interesting about what you said though, Chad, is there have been a couple of large organizations that have made employees sign almost like a pledge, "We're your first, and so you are employed by us, and your loyalty, if you will, is to us. And so we expect you to give your hours to us." And I'm kind of generalizing how I'm saying this.


Chad: Yeah.


Beth Brooks: I call it a loyalty pledge; I'm sure that's not what they call it...


Chad: Yeah.


Beth Brooks: But there have been organizations that are trying to... More stickiness, keeping those employees in their workforce, knowing that, yes, many nurses have another job and they're picking up a shift. And maybe that's okay. But then if that's the fifth shift of 12, then you start to ask yourself about fatigue and errors and other things. And that's something that we've never gotten our arms around.


Joel: Are they paying a premium for that? Is that kind of maybe a good thing for nursing, like the best of the best get sort of brought into the fold and we're paying you more money, and we'll make it worth your while to give us sort of first ride of refusal or to be your number one opportunity? Is that a good thing maybe?


Beth Brooks: I think it's a good thing when hospitals do and put in systems that allow that to work for the nurse, right? If you are going to give us your blood, sweat, and tears, we're going to offer self-scheduling so that you can have control over the schedule. We're going to try to place you on a shift that you wanna be primarily on. So I think it's that give and take about, if you're going to be loyal to our organization, we're going to sort of meet you halfway on how we offer benefits, compensation, maybe it's more continuing education dollars. So it's those kinds of other benefits besides salary that also make a difference.


Joel: Do you have a sense of what percentage breakdown right now nursing is sort of contract gig work, and what percentage is the traditional hourly one employer?


Beth Brooks: That, Joel, is a really good question, and I can answer it maybe in a slightly different way because I don't know that that's actually tracked. Part of the challenge we have in the country, across the country is there is no one way to identify a nurse. You have a license number, but that could be different in every state. You have some nurses have a DEA number where they can prescribe medication. Some nurses have what's called an identifier that you receive after you take the licensing exam. So it's really hard to know who the workforce is and where they're going, because we just don't have a great standard method to measure. But what we do know is how many nurses are in the Bureau of Labor Statistics category about travel nursing. So the travel nursing segment of nurses doubled during COVID. Now when I say "doubled," that sounds like, "Ah, it's a lot," but when it was 2%, it went to 4%. So that piece, we have better clarity around how many nurses are actually traveling than say I'm a full-time staff nurse versus I'm a full-time per diem nurse.


Chad: Can you explain that travel nurse to everybody who might not understand what a travel nurse is versus your full-time on staff?


Beth Brooks: There has always been, for as long as I've been a nurse, there's always been an opportunity to be a travel nurse. And so by that, you don't have a home institution. You work for a company that contracts with a hospital. You choose to work at that hospital on a 13-week contract. When that 13-week contract is over, sometimes the hospital will want you to renew; or sometimes the need, perhaps you were covering an LOA or an FMLA or something, and so that need is gone, so they don't renew your contract. But there are nurses who live their life as a travel nurse, and they might spend the winters in Florida working on 13-week contracts, [laughter] right? Or they spend their winters in Colorado skiing, and then they might go to California. So there's this cadre of nurses who literally move around the country going to where they're needed in 13-week increments. And they took a...


Chad: Is the pay better?


Beth Brooks: The pay is always better. But it's that old apples and oranges, right? You wanna compare your hourly rate to total comp. And then that's where those travel nurses have to think about housing, and they have to think about health insurance. And so that's... Maybe that hourly rate is not as much more than the full-time staff person.


Chad: Gotcha.


Joel: Talk about the state of recruiting for nurses. Because in this environment where it's sort of a marketplace, maybe nurses are getting reviewed by where they've worked, and you're sort of calling them on when times are, you know, need is higher than others. It's not the traditional post a job, hope to get some resumes, go hit up the schools, and try to get people in your facilities early. How is this changing the dynamics of recruiting?


Beth Brooks: So I will start... Answer your question by revealing my bias. Way back in the day, nurse recruiters, talent acquisition was done by a nurse, when RNs were in HR doing recruitment. My perception, I don't have any data, better understanding of the role, better understanding of where a candidate would fit on a department or in a specific unit, and better able to do all the pre-screening down in the HR department before that candidate got to the office. So that model has changed. Healthcare has gone to what I call this retail recruitment model. You see all kinds of other folks coming in to HR in healthcare to be talent acquisition professionals, and they have no experience in healthcare. And that's not to say they can't learn, but it's a two-year learning curve. And so that process has gotten slow. Time to fill has significantly slowed. And quite frankly, we haven't modernized our workflow in HR. And so nurses, you have to be pretty quick and nimble because those candidates have many offers. They have many options. And if you're not quick with your process and bringing someone through, you're gonna lose the top candidates, and that's what we're seeing definitely.


Chad: Can you tell us the impact that... Because the US used to have vocational high school programs, which were great feeders to our community healthcare systems, right? Can you tell us the impact that had? Was it a great impact? Did it really not impact that much because kids still had to go to college to be able to get their nursing degrees or their certificates or what have you? Can you tell us what kind of impact that had?


Beth Brooks: It had an impact. It always has had an impact only at certain times in our labor economy. Nursing has forever gone through cyclical shortages. And so whenever we go through a cyclical shortage, there's this all-hands-on deck, let's enhance our community pipeline, let's work with the community colleges, let's have opportunities for someone who's in school to do some clinical work, and then they're a part-time employee, and then they move through their education program while they're working. So as soon as we have those downturns where there's a nursing shortage, there's all kinds of activity. And it has worked. It's worked incredibly well to even take, right now, take someone from EVS, environmental services, or someone from dietary services who wants to be a nurse, help them through school and bring them back. So yes, those programs work. Unfortunately, I don't wanna say that they're not sticky, but the urgency of the value of them changes based on where the shortage is happening for registered nurses, when we go through.


Chad: Well, there's a lag time, right? I mean, because you can't just turn the spigot on and here comes nurses; you've got a lag time.


Beth Brooks: Right, right. Exactly right. And there's all kinds of reason for the lag time. But yes, you're exactly right.


Joel: And what's the shortage like now? My perception as an outsider is you have aging baby boomers, you have burnout from the pandemic. I have to imagine shortages are at a all time high maybe, right now?


Beth Brooks: I think, yes. And what's interesting about what happened during this last COVID, so enrollment went down, graduations did not keep up where we thought it would. And as that enrollment went down a little bit, then 100,000 nurses left the job market during COVID. And everyone assumed those 100,000 RNs were baby boomers nearing retirement. Well, that wasn't the case. It was young moms and dads trying to balance homeschool [laughter] with their jobs with no daycare available. And so we lost that 100,000. So right now, the latest predictions I've seen is, 500,000 nurses by 2026, at least 500,000 nurses in the next five, six years. We need to find new in addition to the retirements.


Joel: So talk to me about solutions for that gap. Chad was in the military, and we read stories about immigrants coming over. And if they are a fighting age and ability, they go to the military if they want to come to the country. Should we be thinking about immigration differently, bringing people in that want to be healthcare providers, get them in the school system, get them into the country? And also the other side of that, we talk about automation a ton. And I know that there are robotics in hospitals and in healthcare systems, but what's your take on immigrants and robots, for lack of a better term, taking some of these openings, which are gonna be a plenty?


Beth Brooks: Yes. Well, I will say, and now you're... There has always been, always, always a very active pipeline of nurses coming to America from other parts of the world, right? That is always been the case. The problem with that has been that the countries where those nurses are coming from, they decimate their own health systems. And so we create another problem in other parts of the world. The nursing immigration, again, like anything, picks up when the shortage in America becomes significant and critical, then we ramp up our foreign recruitment of nurses. I've not really heard a lot about bringing young people in as an immigrant to become a nurse. That's not something I'm as familiar with. Although I have heard about, like someone who was a physician in Poland or a physician in Russia who comes to America and then can move through the nursing curriculum quickly. But I'm not familiar with just young people coming in from an immigration perspective.


Beth Brooks: And it's unfortunate because we don't have enough bilingual healthcare providers, which impacts healthcare outcomes, which impacts health disparities. So if our nursing workforce, which is something we talk about, looked like the patients we serve, we would be in a much better place from a healthy nation perspective. But we don't have enough of those bilingual healthcare workers. And that would be a wonderful way to look at that.


Joel: And the robots?


Beth Brooks: Robots.


Joel: They can speak all the languages if you want them to.


Beth Brooks: Yeah. Well, they already have those, the translation little pods that they wheel around in hospitals or on carts. I don't know that I see robots certainly not as care providers per se, but... And I don't know if you wanna call... Have you heard about the electronic eICUs? I don't...


Joel: No, I have not.


Beth Brooks: So there's technology where a nurse, usually it's a critical care certified nurse, is sitting in a, let's call it a pod, with three or four other critical care nurses. And they are monitoring an entire ICU three towns over. It's called an eICU. So you have technology supporting remote monitoring, if you will, of hospitalized patients while there's someone in this headquarter pod. And for some reason it's totally slipping my mind what the name of the room they call it. But we do see that as a way to not replace, but...


Joel: Augment.


Beth Brooks: Enhance. If you don't have enough of the right staff on the unit, you do have your eICU staff that can come into a patient's room. And the technology is such that that camera in the patient's room can zoom right onto like an IV pump or an IV drip, and see what's working and then communicate with the patient. So that is helping. And we have a lot of young nurses coming into nursing right now who need a backup, someone more experienced, and they have that person, the remote ICU monitoring. But the robots, I think, you know what you see now is robots delivering supplies, delivering meals. You see robots in the pharmacy.


Joel: So I won't be getting a colonoscopy from a robot anytime soon?


Beth Brooks: I don't think so. [laughter]


Joel: Unfortunately.


Chad: Joel, that's like his major 2024 wish, Beth. He was really looking for a robot colonoscopy. [laughter] So it's funny because what you're talking about, we've actually seen in like hotels where you come in, there's nobody at the front desk, there's an iPad that's there, right? And you're checking in through the front desk. Now, this is how we fix a scale issue because humans don't scale well, right? We need that nurse in that room. But do we need that nurse in the room for all of the duties that the nurse has? Well, in this case, no. There's a command center and they check everything out. So it's very interesting. We're talking about hotels and then being able to scale this way. Let me flip the script on you here for a minute. Now, I understand there's a myth that pay transparency in the healthcare system would create significant cultural changes. What exactly is meant by that cultural changes, just by allowing everybody to know that they're getting paid fairly?


Beth Brooks: Just so happens that I've written a couple of... I write a career coaching column for a nursing leadership journal. And one of the articles I wrote was about pay transparency. And one of the benefits of being very forthright with what the hourly pay is, what's the pay scale, what grade, what's the range, those kinds of things, there's three things that the science has said to us. One, it engenders more trust between the employee and the organization. Two, there's this feeling of distributive justice. Everyone's being treated fairly because we know what the compensation or what the ranges are. And actually in one study, it impacted the turnover. The turnover went down. However, it has been challenging for hospitals to have that level of pay transparency. It's not something that...


Chad: Why?


Beth Brooks: They've ever done. You know what? I think it's the sacred cow, honestly, that probably should be

slain. [laughter]


Joel: We've always done it this way. Yeah.


Beth Brooks: That's what it is, honestly. And I honestly, and I don't think until me too, it really became an issue. And that there was a study that came out from UCSF like 2015. There was a $5000 difference in compensation between men and women nurses, which got everybody.


Chad: Oh, yeah.


Beth Brooks: So that has begun to change. But then there's, you know, you're not supposed to talk about salary, it's illegal to talk about salary. There's all these perceptions, like the employers say you can't talk about that with your peer. And that's not true.


Chad: Right.


Beth Brooks: So where we do have really good pay transparency is in our hospitals that have collective bargaining units.


Joel: The unions.


Chad: Unions, baby. Unions. [laughter] So, what it sounds like is literally we're trying to expand profits. Because the United States, as you know to the GDP, we spend more money than any other country that's out there, although nurses aren't seeing it. So where's that going? And to be able to grow that trust, which we've lost over the last decades, and we need, especially from our healthcare professionals, what do we have to change to make this actually work for our healthcare systems? Because again, Joel said it, boomers are out there, we're gonna have a bulging healthcare system, and we're not gonna have the staff to take care of it. So is that a piece of it? Is it pay transparency? Is it more pay? What do we have to do? What's the short term fix?

Beth Brooks: Well, nurses would tell you they want more pay. An hospital CFO will tell you there's no more money. [laughter] So there we go. Right? Now, I don't wanna bore your listeners or either of you with why nursing is on the wrong side of the ledger and on a P&L, but there is a problem with the way nursing care is invisible and is embedded into the room charge, which makes it look like nursing is a cost and not a revenue generator. So until we are shown as generating revenue, which we do, which is a whole another conversation, I could go down that little rabbit hole, but until we show revenue in the hospital, because all the tasks we do that are coded in the computer or physicians get to bill for not the nurses.


Chad: Almighty dollar, Cheesman, it's the almighty dollar.


Joel: They follow the money.


Joel: There's no customers if there's no nurses. I mean, [laughter] there's no customers without nurses, so.


Chad: I was gonna say, no, they're going to be customers. They're just not gonna get care.


Joel: Yeah.


Chad: That's the big... That's the big key there. The customers are not going away...


Joel: Yeah.


Chad: It's just whether they get care.


Beth Brooks: Yeah. So it's the money. I do think that... You said, how do we build trust back into the system? A couple of things. One, better, healthier work environments. We know that burnout is not my problem. A burnout comes from a toxic work environment. So we've got to fix our work environment. We've got to have better listening by the senior team because nurses don't feel listened to. And I think that piece of autonomy and control over your practice, that there's... You would never... One of my colleagues gives this example. If you were a CFO and you walked in and they said to you, "Oh, Joel, today you're gonna have to go work on 5 North rather than your nice office down in the... " That would never happen to a CFO. But if you're a nurse, you can show up at work and they'll say, "Oh, you're not working here today. You're going over to 3 South. See you later. Have fun." And so you have no... You feel like you're this just widget in a system. And hospitals that have worked on their work environments have leaders that listen and have nurses that have a voice in how care is provided. Those are the environments that still may have difficulty recruiting, but they have less difficulty.


Joel: And what you're outlining is the recipe for a gig economy uprising. Because if that's the environment that nurses have, I would totally wanna be a freelancer or a contract worker. Because I can tell you how much you're gonna pay me, I can just decide where I'm gonna work. And I also think, I would imagine that from a pay transparency perspective, the gig economy, assuming that you publicize what you want per hour or what you're gonna pay a nurse per hour, then that sort of levels the playing field. Because I can go and say, "Look, the nurses that do exactly the same thing that I do are on the site, they're getting more than me. So I should be getting at least that." Is that happening or should it happen?


Beth Brooks: It is. So whether it should or not, it is happening. That's exactly what's going on.


Chad: Good.


Beth Brooks: And I think it's fine. I think nurses have always been a little bit shy about talking about money, and we're all in it to take care of patients and do the right thing. And absolutely, that's true. But there's something about the work, the caring work of women that has never really been compensated appropriately. But there are nurses who bid on shifts all the time. There's shift bidding apps. We've got a shift over here at hospital A for $50 an hour, and hospital B is gonna pay 60. And you as the nurse can bid on which shift you want...


Joel: Love it.


Beth Brooks: And then go and do that. And really any nurse can do that as long as you have somewhere to hang your hat where you have benefits. Right? It's hard to not have health insurance. And it's hard to

[chuckle] hang through your...


Joel: That's a whole other podcast that we can...


[overlapping conversation]


Chad: Oh yeah. But I mean, we just talked about the country who spends the most in GDP on healthcare, and not all of our people are covered. Whew! That is another...


Joel: It's sanity.


Chad: A whole another podcast. But Dr. Beth A. Brooks, Beth, we appreciate you coming on the show. And if somebody wanted to reach out to you 'cause they want to dig a little bit deeper into this conversation, where would you send them to connect with you?


Beth Brooks: I would send to LinkedIn and just find my LinkedIn profile. Easy. It's right there.


Joel: Easy peasy, nacho cheesy. [laughter] Another one in the can, Chad, we out.


Chad: We out.


Outro: Well, thank you for listening to, what's it called? The podcast with Chad, with Cheese. Brilliant. They talk about recruiting, they talk about technology, but most of all, they talk about nothing. Just a lot of shoutouts of people you don't even know. And yet you're listening. It's incredible. And not one word about cheese. Not one cheddar, blue, nacho, pepper jack, Swiss. So many cheeses and not one word. So weird. Anyhoo, be sure to subscribe today on iTunes, Spotify, Google Play, or wherever you listen to your podcasts. That way you won't miss an episode. And while you're at it, visit www.chadcheese.com. Just don't expect to find any recipes for grilled cheese. It's so weird. We out.

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