Thank you. Yes, I started practicing when I was four years old, 1956. No, actually 1976. I probably made a typo when I sent it to you. You did. You said, and she looked up at me. She thought, you look pretty good for being 100 years old. Oh, no, I mistyped. I mistyped. It's all very good. So now for something really completely different and also to tie everybody's talk together. And I'm so grateful that you've stayed till the end, because, of course, you have many things and you've chosen this session, which means you've made a commitment to really what it is you want to hear from all of us. But I think it's really important for us to appreciate that it's not just, I'm not sure how to make your thing go. Left click. That it's not just about the next generation of nurses, it's really about the providers of care. Physicians, APPs, nurses, PharmDs. What's really going to keep us all happy at the bedside? So we've had such fantastic talks, and I'm honored to be following them. But I'm going to talk about this in a very different way. I'm really going to talk about not things that we're pulling from the evidence about resilience and moral distress and moral injury and things that we all know that people should be paid for the work that they do. We all agree that. That's not anything new to us. I really want to talk about the problems and the staff voices for a solution. So I think we already know what the problem is. We've known it. We heard about it. We've heard it from everyone. We all lived it. We were practicing during COVID. We were practicing before COVID. We're practicing after COVID. And we are learning the same lessons over and over and over and over again. They're the same lessons that we've always known. When we talk about health care and we talk about intensive care in particular, there's been a nursing shortage that we've known is going to come. It's been predicted for 2030 for over 15 years. And then COVID actually amplified that. And physicians were burning out from too much insurance, requirements on time, mandates that were not patient-related, limitation in their ability to spend time at the bedside. And APPs, as they're burgeoning and they're developing their practice, having restrictions and being placed in inappropriate positions. We've known all of these things for some time. And then COVID brought that forward. But really, what I want to talk about is the disconnect between our hospital administration, our leaders, our team members, and the bedside staff and how that's led to conflicts about working conditions and hospital staff retention. And of course, the final point of that is that the evidence is that this is not something that's transient. This is the new normal. The new normal is to be placed into these situations for all of us where the demands for our very acute patients are incredibly high, but the support that we receive is incredibly out of balance with that. OK, so one wonderful fact. Since 2020, 18% of health care workers have quit their jobs since 2020. Now, some of that was COVID-induced, but a number of surveys that have been actually published this year, and I identified these from Forbes, is that anywhere from 20% to 50% of doctors, and that will include APPs in this as well, and nurses are saying that they're ready to quit within the next year, that they're ready to leave the workforce. So one of the points is we have been here before. I would love to say that I've been practicing since 1956, but I have been in practice since 1976. I started at Mass General. I've moved to other places. I've developed my career. I'm a nurse practitioner. I'm a clinical nurse specialist. I have a master's in physiology. I've developed my career, and I've developed myself, but we have all been here before, where our issues at the bedside raise a really ugly head, and typically, we put some stopgap solutions into place. So just in case you haven't seen any statistics, just because we're here in California, I just want to remind you that in 2030, the bedside staff nurses will be at around 343,000, 400,000. The demand in 2030 will be for 387,000, 900,000, and that's a difference of negative 45,500. Now, on this list, you'll see that goes in a little bit of a descending order. This was published by the New York Nurse Association. It was very important to look at this evolution, and of course, part of that perspective and what individuals talk about is, how can we recruit new nurses? Okay, well, first of all, in 1976, there weren't as many options for a smart female as there are today. That, I will be honest with. If you thought in 1976 that you were going to go to medical school, you might have had to think about that you'd have to give up your plans for a family, that you were going to fight incredible battles, which we still fight today as women and as persons of diversity and color. We still fight those battles today, but in 1976, they were quite profound. Today, most success for bedside nurses is, how soon can I get into an APP program? How soon can I go to CRNA school? How quickly can I get away from the bedside? So, that's really important for us to remember because when we talk about recruiting new nurses, we might need to build into that, you come to my hospital for four years and you make a commitment, I'm guaranteeing you will get into CRNA school or APP school. I'm telling you, if you come to my hospital, Greater Memorial Hospital, we actually entertain Emory residents and we entertain Morehouse residents, but we are an entity all by ourselves. We are not Emory, we are not Morehouse, we are Grady. And at Grady, we're a public hospital. Right now, we're seeing 350 to 450 patients a day in our emergency department. We're boarding 90 persons. My project this last year was to open an ICU for boarded patients in the emergency department, which is 100% occupied every single day. Now, let's correlate that back to saying we're inviting new nurses to come into our environment where we are, all of us are all struggling. And it is really important to remember, and I think that is the issue. When recruiting new nurses, yes, they want a better work-life balance, but the majority of them choose nursing as a step in their pathway. So, we need to accept it and build that path for them because we have to really appreciate the only way we're going to get nurses to come to the bedside is to provide them with opportunities to advance, but to ensure that during that advancement time, they are totally committed to us. And I think that's really important. Now, if we think about, again, this is from the NYSNA, when you take a look at this, RN turnover rate 2019 was 15.9%, and in 2021 was 27%. Almost 100% increase. In 2021, hospitals that had RN vacancy greater than 10% was 35% of hospitals, and in 2022, 81% of hospitals. Now, we're all living that. If you work in critical care, it doesn't matter what your profession is. You know that we are working with the paucity of staff. Then we think about time and money spent on recruiting, and I know that was addressed earlier, but in 2015, 53 to 110 days was the amount of time that was used to recruit nurses, especially that depended on their specialty. So, if you're an ICU nurse, more time was spent on recruiting them, and in 2021, 62 to 112 days. But most important, and every one of us validates that in our practice, we all can appreciate that as nurse-patient ratio increases, patients are more likely to suffer adverse events and actually die. Now, this data, this data that you're looking at here is that for every additional patient added to a patient ratio of one to four, so that's really more a tele unit or a med-surg unit, increase of death is 7% for every patient above the one-to-four nurse ratio. Now, let me just put that simplistically in an ICU setting. In the ICU, traditionally, historically, if your patient had three vasopressors and was intubated, you were one-to-one nursing care. Today, if the patient is intubated, has three vasopressors, you're titrating aggressively, and your patient may be on CRT or have an impella or have a balloon pump, you may still have a second patient. That second patient is either considered to be relatively stable or that patient deteriorates, but the bedside nurse is not at their side. So, these are very dire issues that affect us all. And we all know, and I'm sure this was addressed quite beautifully before, poor staffing actually leads to nurse turnover rates, and nurses feel dissatisfied when they go to their car at night or in the morning, and before they can drive home, they cry because they couldn't do what needed to be done. And I'm telling you that in all of your environments, that is happening, that nurses leave their shift feeling happy if their patient didn't die, but completely dissatisfied because they couldn't do what needed to be done, and they couldn't really provide full care. And they burn out because they're exhausted, and they're overworked and strained, and they just aren't able to focus on those patient care issues in general. So, very important for us to consider that role of nurse staffing, and very important to consider the spending ratios. So, again, published from the NYSNA, that looked at after it was legally mandated for nurse patient ratios and nurse staffing methodologies, that those were implemented here in California, the place that evolved that practice, hospital income went from $12.5 billion to $20.6 billion. So, the idea sometimes that we hear, we can't afford staff, we can't not afford staff. We must actually employ staff, we must give them what they need in order to continue to move forward in our practice, and to sustain and maintain our cost centers and our ability to provide safe care. So, I think very nicely spoken about with my prior, the prior speaker is just to remember that many mental health issues like stress, anxiety, depression, and something I think if we were all honest, if any of us have been in critical care for more than two years, and it didn't have to be during COVID, but I would say that because we are continuously facing sorrow, suffering, death, horror, all of us have some level of post-traumatic stress syndrome. All of us do. If you ever have a dream where, like, because I do a lot of speaking, where you got up to speak and you didn't have your lecture, and there no one was listening, and people were doing all sorts of bizarre things in the audience, that's a stress dream. But most of us have our stress dreams about alarms going off that we can't answer. Oh, you like that? That's your stress dream, too. Okay. So, I want to share with you some of the shouts from the bedside about the problem, and I want to make sure that we can hear it and that we're actually listening, because they are really, really important. So, voices from our leadership who really believe that they're attempting to assist the bedside staff, which I think they really are trying to do, and they've done that in the development of programs such as Magnet, and this is the new Magnet 5, which is about the empirical outcomes. we're going to support exemplary professional practice, we're going to have structural empowerment, transformational leaders, new knowledge, innovations, and improvements, and this is the MAGNET program. And I think it's a fabulous development of ideology, took 14 structures, put them now into five, and our leadership talks about, okay, well, we're going to develop these programs for our staff, who we really see are hurting. We bring pets in so they can pet the dog, and that's very much appreciated and causes relaxation. We offer wellness workshops. We talk about resilience. We talk about gratitude. We have award programs. We have the DAISY award that some hospitals give, a bronze, silver, platinum, gold awards. We develop shared governance. We're developing what we call high-reliability organization strategies, which means we're going to do things in the same way. We develop rapid response, and we continue to grow it to assist nurses at the bedside when patients are decompensating. But the other thing is that the leadership's perspective is we're hiring nurses. We're hiring nurses right now, nurses who graduated from nursing school during COVID, never touched a patient, and we're putting them in the ICU, okay? Now that, we're all very grateful to have a colleague next to us when we didn't have one before, but that colleague is not at a functional level, and that colleague's being thrust into a situation where they may not get the mentorship they need because everyone is so burdened. So I want to make sure that everyone hears me here because there's many people who are not nurses. A nurse is not a nurse is not a nurse. A warm body who graduated from nursing school and passed their licensure exam is not the same as a 10-year experienced ICU nurse, and I should be counted as a full nurse. Oh, well, I appreciate that. Thank you. I'm counting myself as a nurse in a full position, but the new nurse, I don't want them counted in a full position. It's a burden for them. It's a burden for the experienced nurse, and it's unsafe for the patient. So I think we really want to be able to engage some good conversation with our leaders. We really need for them to understand what this means. Now as we all know, in New York City, we just had a nurse strike. Now I'm going to just say I ethically have some issues with being in a union. I don't feel strongly one way or the other about anybody else, just myself, except that recently I have realized how incredible it is what the union is doing, which is actually listening to what nurses are saying. They are not out there holding up signs saying we demand more pay. Every once in a while they do. Mostly what the signs you see are safe staffing, more PPE, a voice at the table. They are not asking solely for money. No one deserves to be paid what they're worth. But also if a nurse is a nurse is a nurse, why is it that I, who have three degrees and 40 years in critical care, make less than the nurse, the brand new nurse you have just recruited into this hospital? I don't understand that. And by the way, if you really want to retain nurses, you're going to need experts like me and other nurses who are at the bedside to stay there and help them. So we really have to look at that issue. But then we bring it back to safe staffing. Nurses on the picket line said their main priority was improving working conditions on short staff nursing floors. And nurses say we've been to hell and back, risking our lives to save patients throughout the COVID-19 pandemic. And by the way, in my hospital, in the very beginning of the pandemic, the only person allowed in the room, didn't allow physicians in the room, they had to be outside the room and we communicate through the window. We do your labs. We change your vent tubing. We did that by ourselves. No one else was allowed to come in the room. Everybody who took care of COVID patients put their lives at risk and we are all under stress. We're evolving from it, but we're all still under stress from that. But recognizing those staffing ratios and how that staff put themselves at risk in that time, it's really important. So staff tells me inadequate staffing is not just the numbers. So when we talk about short staffing and safe staffing, not just the numbers, but the right type of training for the area. And persons who are not trained well are basically, they're dumped into the unit and then they also are getting dumped on. And they would like to actually have time for questions and answers at the bedside, for nurturing, for supporting, for consoling. And expert nurses want to have time to do that for their colleagues and each other. They want time after a patient has died to sit, to decompress, to talk, to cry, to go forward. One of my colleagues, a very, very high level senior staff nurse, been at my hospital for 20 years says, I love precepting new nurses. I love molding their minds. I love really giving them support. They all call her mama, not because she babies them, but because she makes sure they have what they need. She loves doing it, but when she goes to the leader and says, the nurse that I am precepting really needs to spend time outside of the ICU because they have a problem with organizational skill, et cetera, I need my leaders to listen. And what she feels is her expert opinion doesn't have a voice at the table. So that nurse stays in ICU, gets promoted to go give care to patients, and she's just really tired of it. She's tired. So the big question the staff has is, what is your plan to retain staff? What's the plan to motivate staff who come in and work an extra shift? Seems like every month we're hiring six new nurses, but seven nurses quit, and we're never getting ahead of the eight ball. I feel cheated and misguided. Every single day I come to work and I fear for what's to come. Is today the day I'm going to lose my license? Tried my best to learn, grow from senior nurses, but even senior nurses don't have time to help others. They have their own patients. My first day off orientation, this is from the emergency department, first day off orientation I faced a three patient assignment. Little did I know that three to one is the normal patient ratio assignment. In the last couple of months, it's gone up to six to seven, and I've had multiple shifts where I am the most senior staff, and I'm only four months off orientation. Can you take that in for a minute? I'm a new grad nurse, four months on her own, I'm the most senior staff at one of the major urban hospitals in Atlanta. How's this safe? Feels unsustainable. Do I tough it out or do I quit? So I'm going to say, what would you say if I sang right on tune, right? You know that old song, songs for solutions. Staff says what we need and we want. First and foremost, we would have more time to care for patients if we weren't doing meaningless charting. Stop developing meaningless charting. Point click, never a story, you never really know what's been done, it's just point click, file, point click, file, and there's like 17 or 18 pages of really meaningless charting. So we have lots of technology developments that we can use to help reduce this burden on staff and improve time at the bedside, which would then allow some time for nurturing, et cetera. They want to be paid commensurate with degree experience in the community of patients that they care for. They want to have point of care education with their team, with their APPs, with their physicians, with their PharmDs. They want to have that point of care education without any judgment being placed upon them. They want to have the capability to learn through simulation and to learn in stressful simulations and simulation, to maintain their knowledge, their integrity of knowledge, and to do that again with simulation, and to utilize technology as a support, not a burden. The ownership and influence of what is happening to them and true recognition, true recognition and a real team with intentional inclusion, which means rounding isn't at the end. Do you as a nurse have anything else to add but to actually be rounding and speaking with intention, with value, with respect? We are not all the same. So lots of things that nurses can say. The work is just thrilling. It's satisfying. It's meaningful, but our environment is not. And these are all statements that nurses have brought to me and always reminding us that we do have solutions. We can hire non-nurses to do many tasks that nurses are currently doing. We can engage family members who want to participate in care. We can run training sessions for them. How do you use a Yankar? How do you turn your loved one? How do you bathe them? How can you assist at the bedside, empowering both the patient and the family and relieving the nurse? We can listen and create change. We need adequate resources. We need teamwork, and we need a better work environment and culture. So we want to build a culture of connection, and that connection is with us as a team. And with us as a team, there are some simple things that don't even require your leaders to agree to it. Out-of-time work for socials that include people from value chain analysis who have no idea what you're saying when you need an auto-affluence. They don't know what that is. Intentional rounding, every day intentional rounding that actually values, truly, not just in word, values what people say. Unit journal clubs with wine and cheese, always a good way. Listen and change, and remember that we are not all the same. And nurses want to sit at the table, and that means all tables. Just like APPs need to be on all committees that are making decisions about care and purchasing of equipment and policies and procedures, a bedside nurse should also always be at that table because they really have to be able to give their influence and their opinions. So I think it's really important to remember, and I know I'm done, so I think it's really important to remember that historically nurses were servants of the hospital. They lived in the hospital. They couldn't be married. They did what they were told. But today, choosing service does not mean choosing to be a servant. And we are really all equal in this practice of critical care. We have different levels of education. We should be paid differently for those things. We have respect for each other because of our education. But we want to remind ourselves choosing to serve is not the same as being a servant. And it's time to stop treating nurses like they're servants of the hospital. They want control over their day, their work, their nursing responsibilities. They want to be accountable. And they want their leaders to come and sit in scrubs, maybe incognito, to really observe what it is they really are doing. If their leaders sought their opinions about what should be happening taking care of patients, they would be much, much, much happier. And finally, just building effective teams. And effective teams really are about starting team training, education for how we work on a team in your undergraduate programs, all of us in our undergraduate programs. Building a team actually helps us to build daily ICU education bites. And I think those are really good. That's something I do in the ICU. We ask the nurse, the RT, the physician, the PharmD. They can present a five-minute bite about a point about some patient in the unit's aspect. And that's all-inclusive, all-involved, all the time with very little time spent. Daily rounds were all opinions included and valued. And the rounds are not in any particular order. Today, the nurse starts. Tomorrow, the APP starts. The next day, the young resident training starts. The other day, a fellow starts, and the attending, and the PharmD. No particular order because we value everyone the same. And most importantly, building transactive memory and psychological safety. Nurses feel really unsafe in their environment. They feel unsafe with their patients. They feel unsafe with their colleagues. They're always afraid if they speak up, they're going to have an RL written about them, and they're going to have problems. Creating transactive memory, which means we're all together in this, and we know each other, and we know what each other wants, and making it psychologically safe changes the culture And when we change that culture, we change everything. So of course, to be paid, commensurate with experience and significance. But the thing that's really important about the next generation of nurses, and physicians, and PharmDs, and respiratory therapists, and what will help keep them happy, is change. Thank you.

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