Rebecca:                                Welcome to this Tech Crunch webinar, Can Technology Solve the Nursing Staffing Crisis? I’m Rebecca Love, the Chief Clinical Officer at IntelyCare. As a nurse, my life’s passion is centered around empowering nurses and identifying the ways we can sustain, build, scale, and strengthen nursing’s impact on the future of healthcare. 

The nursing profession in America is in crisis. 2020 and ’21 was the largest exodus from the nursing profession in U.S. history and the demand for the largest occupation in the healthcare sector is rising across the country as 500,000 nurses are expected to retire by 2022 and 900,000 nurses are expected to leave the profession over the next five years. While COVID-19 is certainly a primary contributor to this shortage, a multitude of issues has been driving nurses out of the profession since long before the pandemic started. At the core of the exodus is a broken staffing model for nurses. The rigid scheduling of eight-to-twelve hour shifts to fill a 24/7 demand is robbing nurses of a work-life balance and driving a burnout rate seen in few other professions.

While providing technology is certainly not a cure-all for nurses who have been a victim of the shortcomings of the U.S. healthcare system, tools to reimagine and redefine how nurses work can go a long way in keeping more by the bedside and preserving the future of the health of our nation.

Joining me today are four leaders who are at the forefront intersection of some of the issues burdening America’s nursing professionals and technologies that can help alleviate them. Let me introduce to you David Coppins. David is the Co-Founder and CEO of IntelyCare. As IntelyCare CEO, David is dedicated to empowering nurses to redefine how they work through and access the right technologies. Next, Aashima Gupta. Aashima is the Director of Global Healthcare Strategy and Solutions at Global Cloud. She spearheads healthcare strategy and solutions for Global Cloud and in this role, she sets the direction for transformative healthcare solutions and leads engagements with key healthcare executives to help transform their business strategies to define new models for care, revenue generation, and improved care experiences. Next, Dr. Rhonda Collins. Dr. Rhonda Collins is the Chief Nursing Officer at Vocera, where she works closely with nurses, physicians, IT professionals, and other healthcare leaders around the world to improve the lives of patients, families, and care teams. Next, Dr. John Pirolo. Dr. John Pirolo is a healthcare leader who has been involved in the evolution, deployment, and optimization of clinical technology, data, and analytics solutions across the continuum of care delivery used for the last 20 years. He is a clinical thought leader and the former Chief Medical and Informatics Officer at Ascension Health. Thank you all for being here.

Dr. Collins:                           Thank you Rebecca.

Dr. Pirolo:                             Thank you.

Aashima:                               Thank you Rebecca.

Rebecca:                                Thank you. We know that this year has been an incredible year in healthcare across the entire spectrum. And a question that I would like to pose to you, and we’ll start with Rhonda, how can technology be leveraged to decrease the strain on nurses and reduce burnout?

Dr. Collins:                           It’s a great question. You know, the goal with nurses is to keep them mobile, right? To untether them from the traditional work environment. And to do that, you have to provide them with the right technology. If you think about in your own personal life how much of your technology follows you from your home to your car to your office to pick up your children, to whatever you’re doing in your life, it keeps you connected and it keeps you effective in your life, and we can’t take that away from nurses. Frequently when they enter their work environment, they’re putting away what makes their personal lives convenient and having to use what is very dated, such as landlines and fax machines and all of those things we’ve seen them having to use. We’ve seen them using multiple disparate devices, with this instrument, you can talk to this little group of people, and with this one, this device, you can talk to that other group of people, and with this one, you have to page and wait and hope that somebody calls you back. So all of the research I’ve done on how to manage nurses in their work environment and how to get them to adopt technologies, the number one issue they say that really congests their day is just finding people. It’s not a huge clinical issues. It’s nothing that has anything to do with making somebody better. It’s just trying to find the right people and it’s those little things that just wear people down over time until they’re like, this is just so difficult, I’m frustrated with this, and we start to see the attrition that we’re seeing.

Rebecca:                                And John, you’ve been in healthcare your entire life, working by the bedside as well. What is resonating with you in what Rhonda is saying?

Dr. Pirolo:                             Yeah, I think Rhonda hits on the practicality of making a nurse’s job easier, more intuitive, more streamlined. I mean, physicians have a unique view to nursing. We work with them closely. We see all that they do and it is – I mean, it’s kind of not short of miraculous, really. They are the hub of care that goes on for a patient. They manage logistics, they manage communication, they conduct clinical surveillance, they carry out the maintenance – the health maintenance of a patient when they’re being cared for. And, you know, technology, I think, to be frank, has poorly served them to date. It’s been fragmented. It’s not taking into account all that they have to do. And so as we talk about technology elevating that experience, and really elevating the experience is what will short-circuit burnout to some degree, I think we have to be very intentional about the technology accounting for really the vast array of work that they do.

Rebecca:                                Absolutely. And you know, Aashima, you’re sitting at the head of Google Health Cloud right now. What is your perspective from that level with regards to the conversation we’re having at hand?

Aashima:                               Yeah, absolutely, Rebecca. I will double down on what Dr. Pirolo just said. If you look into – as someone who is now in a technology company, but I also spent years at Kaiser Permanent. For a long time, technology has been kind of handed over or poorly rolled out, but the opportunity for technology is tremendous. I’ll give you four practical examples that I’ve seen now. Number one that came into light was a virtual nursing station. This was at the peak of the pandemic, we were at Mount Sinai, and the rapidly moving situation with COVID-19 was made even more dire because of a lack of PPE. There was a government mandate to wrap up capacity for the ICU bed availability, there was a shortage of nursing. So the Mount Sinai Integration Team worked with Google and we deployed these Nest cameras. There were two cameras, hundreds of rooms, where one camera was doing the microphone, the other camera was doing audio/video communication. And the live video stream was then transferred over to this newly constructed workstation for the nurses, which, by the way, was in the hospital, but it prevented them from making frequent trips inside the rooms, but being able to monitor and step in when they needed to. And that was rolled out in a matter of weeks. 

So what I’m seeing is when there’s a necessity, the solution was found out. But this solution has applicability beyond COVID as well, so this was the worst case example. 

The second example I will say is, you’re very familiar with what Dr. Pirolo just mentioned, the click fatigue. Today, we see 96% of hospitals have adopted EHRs. It’s up from 9% in 2008, but these systems, as we all talk about, were optimized for billing, they were not very succinct for patient care, or they were complicated to use for nurses and physicians. So the opportunity here with the data interoperability is there are many systems making them easy by logging in and logging out by the card, but can the data flow easily from within the systems? And the new interoperability tools speak to that. Can it help reduce the click fatigue by creating seamless data exchange and be good for patients as well? When you go as a patient and you need your patient records, today you get a CD-ROM. So can we make it more digital, more API-enabled? I think that’s the opportunity.

The third opportunity I see, which has risen to the top is the next frontier of innovation in AI is going to be the productivity segment, or AI-powered assistants. Applications that assist nursing care and providers by using AI and machine learning trained medical models for notetaking, for capturing the Roys and the interface as a note and then creating and adding that to the EHR. So these are new medical NLPs, Roy is a new interface, this is emerging because can we reduce the burden? Again, this is not just the bright and shining object, but the premise here is there are a lot of manual, repetitive and redundant tasks that can be automated. So imagine a chat bot that a patient can ask questions – a conversational chat bot, they can ask multiple questions freeing up nurses’ time. They cannot answer all of the questions; the trick is to find out the applicability.

And the final point is around scheduling and this is the work of IntelyCare, David, you and Rebecca are doing. A growing number of patients receive care in multiple care settings, hospitals, home care, and then can we bring the level of production and scheduling, can we make it easy and give nurses the agency to manager their time and give them the flexibility? 

So these are the four areas that I see will be key, but as Dr. Pirolo said, I will caution that we need to take technology there so that they are easy to use, they are built with nurses as stakeholders and co-creators of these solutions because otherwise these will be very clunky as we roll them out. So we need to be cautious about how things move in healthcare, who are the users, and somebody who comes from tech and also from Kaiser, I think that’s the bridge we need to build in bringing nurses to the table as Rhonda said. So that’s a long-winded answer, but there’s many aspects of technology here.

Well, thank you, Aashima, that was very helpful to understand. And David, just hearing what Aashima was explaining of all of these impacts that can happen in healthcare around technology, specifically mentioning scheduling, what are you seeing and hearing from the frontline as we’re dealing with this burnout and scheduling and work-life balance in the nursing arena?

David:                                    Yeah, so I think one of the biggest issues that nurses have felt, and certainly that’s the feedback we’ve been given, again, cautioning, I’m not a nurse, but the feedback that we do talk to thousands of nurses is that the scheduling – and that’s a broad topic, but the inflexible scheduling is one of those elements that makes it extremely difficult, that their schedules are laid out far in advance, they have no flexibility around that. We had one nurse come to us who was working in one of the major health systems and she – her husband was coming home from Afghanistan and it was a very exciting time, 30 days in advance she asked for a day off, but the request was actually denied as the date came up. And so she had no choice but to leave. Now she’s, of course, working in a float pool, PRN, PRD type capacity. But I think there’s scheduling inflexibility and then there’s that feeling of always being on call. Even if you’re not technically on call, you’re feeling like you’re constantly on call because you’re constantly getting texts and phone calls to say we need help, can you come in? Can you come in? And nurses are hard to generalize, but nurses respond often to a call of need. Somebody is in need, somebody needs help, right? So they feel this kind of compulsion, I need to go help. I need to go help my colleagues. I need to go help these patients. I need to be there. And the feedback we get is that just leads to that burnout. So COVID has absolutely accelerated this, but it is something that all types of healthcare institutions, health systems or post-acute, they’re not quite understanding the damage that that is causing and actually contributing to the exodus, in this case. 

So solution, back to that – and you probably couldn’t have done this without technology previously, but there has to be a way to be more schedule-forward, so meaning more progressive in that way. Being flexible, being able to reduce certain shifts. We have a lot of nurses that are feeling like they’re being forced to retire because they can’t handle these long shifts, either. And especially with the pressure that they’re feeling currently. So there’s kind of an acceleration in that retirement element. Anyway, can we reduce the number of hours required for some people, instead of a 12-hour or even an eight-hour, can they do a four or six-hour? If it’s that or somebody leaving, let’s try to keep somebody around. If the scheduling system is so inflexible, then hire a person, a manual effort to move things around to make sure that we can accommodate the nurses that are feeling close to burnout. 

Rebecca:                                It’s interesting, you know, Rhonda, you and I are nurses by training and there’s a number of issues that come out at us with regards to burnout and staffing and shortages along these lines. The inflexible nature of our work-life balance absolutely exists. The question that I have is we’re hearing so much about burnout and there seems to be I think a fundamental disconnect of the understanding of burnout in nursing and burnout in the general idea of the word, and I was hoping you could give us a little bit of insight from your experiences as well on what is defining burnout in nursing and how is it different from what we might be seeing elsewhere?

Dr. Collins:                           Right, thanks. You know, I’ve listened to this word “burnout” for years and it has started to become ineffective because we just used it to describe everything that was wrong. “Oh, they’re just burned out,” or “I would move them to here because they’re burned out on this particular topic.” And then I started to think, you know, we’re blaming the individual for being burned out when it’s the environment delivering the issue that’s burning them out. And so really, I’ve just come to the conclusion that burnout is a work-related injury and we have to treat it as such. So instead of focusing on the individual and blaming the individual, we’re constantly putting together resilience packages or bringing in consultants to talk about self-care or consultants to talk about how do you cope – coping skills are very popular, when in reality, the work is the issue and we have to deal with the work. So how do you do that? Well, there’s multiple things. I look at nurses who have been given pizzas and healthcare hero signs in their yards and cookies and all of these kinds of things, which I’m sure they’re very grateful for it. But what they really want is for the environment to be better, to feel like they have more control over that environment, and to have the tools or the skills that they need to do their job. So then when you go back and ask, what do you need to do your job? I need to be able to come to work and utilize the conveniences of my personal life in my work life, or when you send me into a COVID room and I’m still having to put things up to my face to find somebody with more experience, you know. 

I spoke to a young nurse who had just been working less than a year and she was put to work on nights in the ICU and her biggest issue was that she couldn’t find the more experienced nurses to guide her when she felt insecure. And when she was telling me this story, her eyes welled up with tears and she said, “I just couldn’t do it,” and then she looked me straight in the eye and said, “I will never go back.” The statistics tell us that the number one attrition right now are nurses with less than one year of experience. That is the highest number of nurses in the statistic leaving the profession. Whether they’re leaving the profession for travel work or they’re leaving entirely, I don’t have that statistic, but less than one-year experience are our most fragile and they’re out of here. For the first time ever in the history of nursing, retirement is in the top three reasons that nurses are leaving the profession. Part of that is because of the baby boomer generation and part of that is because they said, I’m not sticking around for round two, three, four, five, six of COVID, I’m exhausted with this. 

We have technologies. I mean, we’re here to talk about technology. We have technology that can carry the burden of memory, push information to the nurse on the go, consolidate teams, allow them to move in the environment they move in and in the context they work in. When I’ve done my research on nurse acceptance of technology, the number one thing that guarantees acceptance is: does it work within the context of my care? I don’t really care if it’s four clicks or five clicks or whatever the magic number of clicks are, if it really works, that’s what I care about. When I did my latest research on that, the issue was if it was convenient, was almost statistically irrelevant. The most overwhelming statistically relevant was it has to fit within the context of my work. And what we found during COVID was nurses wanted to be able to be hands-free. They wanted to be able to communicate while wearing full PPE. They needed certain particular things that allowed them to function in the context of their work. And so that’s what I say to people who are engineers and tech-related, when you look at how people work, you have to understand their workflow before you can design the technology. Because if you start designing technology and then you’re trying to pound the nurse into the workflow of the technology is where you get this extreme fatigue and lack of adoption, nurses saying, this is too hard, you’ve overwhelmed me, and I’m done. 

I don’t want to sound like nurses are delicate flowers because we’re not, we’re really some of the most resilient and focused people that you’ll ever meet. But I do think particularly for my profession, we have to intentionally dismantle what got us here. And that means we have to look at, how do we schedule? How do we provide them the tools that they need? We have to question regulatory guidance. We have to question education. We have to question everything. This is our opportunity. We have to stand up and as leaders say, you know, what we really need is this or that, rather than saying we’re going to solve this new problem with our old tools, because it’s not working. 

And one issue just on that is the issue of travel nurses, which is an overwhelming topic right now, that they’re spending millions of dollars on travel nurses, paying them three times the salary of the nurses who are staying. We have the issue of recruitment and we have the issue of retention. So I think what we have to acknowledge is in the past, we’ve used travel nurses because we could spend six million dollars for three or four months rather than raising all of the salaries forever; that seemed to make better business sense to us. But this is not the same problem; this is not a three-month issue, it is a decade issue and it has to be addressed.

Rebecca:                                Thank you, Rhonda. And you know, Aashima, how are you feeling when you’re hearing what Rhonda is saying? I mean, obviously, you know, intentionally dismantling what we have built here to redo is definitely at the forefront of what a lot of technology companies are looking at in healthcare.

Aashima:                               I think Rhonda hit it on several points. First, we need to address the burnout, but we also need to ensure that there are times – when Rhonda talks about the cognitive overload and you already have something on your mind and something needs to get done, and that cognitive overload is where I believe we can add and it will create more value, give them more time so that they can then take care of patients. At the end, technology is a means to an end. Today, as Dr. Pirolo was mentioning, it’s clunky. We need to get to a point where technology is an invisible enabler, it’s in the background. There’s a point solution fatigue. There’s a solution for everything that then we roll out to the nurses. So one of the takeaways that we have all learned in the PPE example I gave from Mount Sinai, it was readily received and accepted because it solved a problem for the nurses. We co-created with them, they were part of designing the solution with us. So it’s not just about bringing a camera to a patient’s room. We need to bring nurses into this dialogue. We need to listen, we need to listen and test, and like we do with software in general and technology, you don’t solve it with the first product that’s a success, you reiterate, you learn, you do IB testing. I think we need to get that engineering approach in how we roll out the systems, but there’s a very, very high bar. And the high bar is the solution needs to work, we’re talking about a medical setting, but the methodology of introducing new technology, of listening to the nurses, it is important and I believe that’s where, Rebecca, you and I have talked about the education opportunities. Can we bring nurses into this conversation? We need to invite nurses into this dialogue because yes, Aashima, maybe other start-ups and other folks are thinking about the solution, but co-creation is the key. Many well-intended solutions in the past have caused this cognitive overload that we’re now talking about. We can call it click fatigue, we can call it many different words, but at the end, the trick is to achieve the transformation and help them without overwhelming them with systems with new technologies, new point solutions and I think that’s where it needs to go.

Rebecca:                                So smart, Aashima, and you know, this methodology and what you’re talking about is absolutely critical. John, you’ve been around healthcare as we said, at those frontlines, working with nurses, and when Rhonda mentioned, and you just heard, the largest exodus is actually nurses with less than one-year experience. This is a turn from anything we’ve ever seen historically in the United States. It’s always been older populations that tend to retire in certain segments. But what is your opinion on what you’re seeing in this burnout? And how is it different today than what we’ve experienced over the history of the past, you know, ten, twenty years in healthcare?

Dr. Pirolo:                             Yeah, so, just to kind of double-down on a little bit of Rhonda’s comment, I think that it’s really important in delivering technology that the technology understands the actual clinical process that’s in place and that the clinical process itself has been reimagined before the technology lands. Technology develops really fast. Changing administrative models to run clinical workflow structure, team compositions, differential shift configurations, different staffing models, those are – I think Rhonda can comment, those are very challenging to get implemented in the field with speed. And when those clinical models, when the fundamental clinical care model is not redesigned, I would suggest to you, you can throw a ton of new technology at it and it’s not going to work very well. So I think in driving a solution to this, co-creation may be the term you want to use, but there’s got to be a symbiosis between the clinical care model itself and the new technology. And that care model shouldn’t be driven by the technology but informed by the capability the technology can bring, right? I think relative to how burnout differs today than it did before, I think it gets more press today. I think people are more aware of it and so it gets attention, but 15 years ago when I was practicing adult cardiac surgery, we had brand new nurses get dunked into the ICU taking care of fresh hearts and they were totally overwhelmed. And it actually wasn’t technology, it was the care model they were expected to suddenly adapt to.

Rebecca:                                Yeah. And David, you’re on the frontline of a very large nursing workforce. This idea of technology and being able to work better for the nurse, as you’ve just been hearing, it’s not something – in healthcare, it has not been done well. What are you seeing from your experiences and direction into this area?

David:                                    You know, I think, as we mentioned – actually, after Rhonda was speaking, I wanted to say amen, amen. That’s everything I’ve been hearing – again, I’m not a nurse, but we do get a chance to talk to hundreds, thousands of nurses giving us feedback all along of why they’re kind of leaving full-time work and health systems to go to these other models. And I’ll just rehash, I think the fact that we should be blowing up and looking at scheduling from a completely fresh perspective. I love the way, also, Rhonda talks about let tech carry the burden of memory. I had this nurse tell me the other – she was telling me all of the things that she had to remember before she checked out, or before she was done with her shift, and oof, I don’t know, maybe it’s because I’m in my 50s or something, but there’s no way I would have remembered all of that. I’m feeling – because if you do have that kind of mental list going, that also is a burden. I think it’s also smart to keep questioning kind of what’s the regulatory environment. I’m just echoing what y’all said. So I think it’s time – maybe John and Aashima said this, now is the time. Now is the time to effect change. When any society is hit with a massive detrimental effect or event, it’s when people are most open to change. I’d say the staffing crisis we have currently is certainly of monumental proportions in healthcare and now is the time to really pull it apart and re-examine.

Rebecca:                                You know; I think you’re absolutely right. And there’s something fundamental to this conversation I want to bring forward, which is the reason individuals are in hospitals or nursing homes is to receive nursing care. Because the truth is, surgery or occupational therapy or PT, all of that could be done in outpatient settings, right? But the truth is, you’re in a hospital and a nursing home because it is required to have 24-hour coverage, seven days a week to keep you alive if you are not in that setting. The question I want to ask to you is because we know this shortage exists. We’re having a 20% shortage of nurses in hospitals, we have a 130% turnover within nursing homes at this point in time. There are not enough nurses to go around. So how can technology, and why should technology be co-created with nurses to help them actually practice to the top of their license? Because I think we’ve heard Aashima say this before, it’s really important to have nurses engaged. Aashima, let’s start with you on this, and why this perspective is going to be absolutely critical to the future of healthcare in a really meaningful way.

Aashima:                               Thank you, Rebecca. This is a very important subject and topic and to be honest, I think the skills nurses truly need, it’s back to basics: how to engage, communicate, and empathize with patients, give them compassionate care. The things that get in the way of delivering that compassionate care are the things that we can help. I will be the first to say that technology is not the panacea, but there is the cognitive overload that we talked about, right? So AI-driven digital health technologies have a promise and can promote that compassionate care by taking stuff off of the plate of the nurses. Can we make it easier for documentation when you’re talking about EHR, note taking, can we interface and when a patient is being discharged or being moved from a department to a different department, can we gain insights in the clinical notes and provide them some context around the patient without them having to go through the pages and pages of clinical notes and figure out what’s going on with the patient? So I believe to do that, we need to understand the clinical workflows. They’re underappreciated, said Dr. Pirolo, and I totally agree. We need to understand the workflow, but in terms of cognitive overload, technology has created the cognitive overload, and that can lead to exhaustion, it has led to exhaustion. So I believe the way to move forward or to heal the burnout is really inviting the nurses to engage in this dialogue and being conscious of that, that our way of rolling things out in the past, we need to test, we need to listen, we need to learn, and we need to be iterative in that approach. And nurses are key stakeholders. So it’s not a technology that we create and hand it to them, and I can’t stress it enough. This was one of the challenges that Dr. Pirolo said on the nurses’ side, this whole user research, being on the site, seeing what is important to them, you cannot understate the benefit of doing that. But, we also need to know there are models like DPT that can create this note taking, the NLP, the voice, that’s a process that exists, and it also goes back to that data interoperability. Today, the data lives in siloes, it’s fragmented, and yet you’re keeping a human calendar and cognitive workload of connecting the dots in these different siloed systems. We need to fix that. We need to provide a simpler answer to that.

Rebecca:                                Absolutely. And you know, Rhonda, you’re the chief nursing officer for a medical device company and putting nurses front and center on those executive committees. But what are you seeing from the value when you co-create alongside technologies, alongside nursing?

Dr. Collins:                           Yeah, I’ll give you a story. Years ago, I was working for a medical device company and I was in the room with a bunch of engineers who were showing me a workflow on the device and I said, I mean, what can happen if they do this or that? And they said, well, you would have an unintentional over-infusion of a medication. And I said, oh, well, that has to be fixed. So we went around and around and around over it, and eventually one of the engineers said to me, it’s not even logical that someone would do this. And I said, I didn’t say it was logical, I said someone was going to do it. And it was less than a year until it happened. I’m not throwing shade at anybody or at any situation, but those are conversations that happen all of the time. You have to look at really understanding, again, how nurses work. You have to understand how technology works because technology works in a certain way too and sometimes that limits us. I think it’s a matter of educating and getting the feedback and the workflow driven. In my business, we’re always trying to understand how do we – communication is the foundation of everything. And so when communication works, it’s a solid environment. When it doesn’t work, it’s a fractured environment. And so that’s what we focus on. And so I frequently say – and John can testify to this – as a nurse, nobody ever asked me how I wanted to be communicated with. They never asked me if I wanted to be paged on my personal phone or anything, I mean, I just had to take whatever came at me in whatever direction it came from at whatever time of day it came and I had to deal with that. And not only that, I had to know specialists and sub-specialists and I had to know all of their preferences. So I might have ten different preferences just on how to be contacted on one patient. But that’s all information that clogs up everything. And when we talk about cognitive overload, which is something I’ve been writing and speaking on for probably three years now, those are the things that I’m talking about. It’s very rarely this huge clinical concept or notion or practice guidance. It’s always just trying to take care of the patients and make sure that information is not left out that can cause harm. That clinicians don’t get fatigued from everything they have to do and cause harm. We want everyone to be safe: the clinicians, the patients. These are all of the things. And so I look at technology is an assistant. It’s not the thing, it’s the assistant to the thing. And that’s where we have to go with it. And so I think that we can get wrapped around the axel, if you will, talking about features and functions and where we need to go and all of this when in reality, we have to look at the state of the individual trying to do the job and then we surround him with the capabilities of technology, whether that’s information, the ability to talk to whoever you need to talk to at the right time, consolidating platforms, the EHR has done a good job of that but it’s also been quite challenging to expand beyond that. And my personal feeling is we’ve talked EHRs to death. We need to talk about now how do we integrate what needs to be integrated with those to really enable and make more capable the people who are doing the work.

Rebecca:                                Yeah, I love that. Go ahead, Aashima.

Aashima:                               I was going to say, I think to build on your point, I’d also say during the pandemic, we saw the world running around with new solutions, new re-imaginations, and that’s a time now we invited – there was a sense of urgency, there was a common enemy called the virus and the stakeholders came to the room and I’ve never seen a business model re-imagined so fast. So we can do it. We have done it. But at the peak of the pandemic, I can tell you, we were responsible for creating this speed to scheduling, the ICU capacity, where are the oxygen bags. And I’ve seen the health system uploading the Excel spreadsheets to find out what the capacity of the ICU beds are. We have got to do better. We have automated that. Daily health solutions were created, spun up, almost overnight. So to me, this is a similar sense of urgency now, to bring the stakeholders and technology is one stakeholder, but we really need to challenge the status quo and reimagine within the context of workflow and leverage technology where it can be beneficial. Can we take stuff off of the nurses’ plate? Can we reduce the cognitive burden? And even small efficiencies can have a big impact cumulatively. But I think that’s where I would leave it, that this is the moment. As we have all learned from the pandemic, we are, as a community, all very capable of working together, understanding the workflow, bringing the impact. This is the moment now for the nurses, we need to come together.

Rebecca:                                Absolutely. Well said, Aashima. I heard you both in speaking, David, you obviously have been working a long time in technology and there was something Rhonda said about how nobody ever asked the nurse how they wanted to be engaged with. I think you’ve had a lot of experience and understanding what has been the drivers of nursing behavior. So can you give us a little bit of insight into there is a problem in the market and how you’ve been looking at that problem differently?

David:                                    We’ve been studying that for quite a long time, and it’s not just the communication, it’s how do they want to work with their employer? And you know, I’m not sure that this could apply to everyone, but one of the things that we care about is making sure that they feel like they’re in control of their own lives, right? They still want to work and they want to work plenty of hours because they need to pay for their bills and so on, but they need far more flexibility. So the first thing we did was we said we’re not going to put any restrictions on you. Let’s just make sure that you have all of the opportunities in front of you to work. We use a lot of machine learning, too, to make sure that we’re matching really based on past behavior as well as their stated preferences. Stated preferences unfortunately change all of the time, so you can never rely on stated preferences. You actually also have to look at the data. What did they do? And what was it that ultimately – in fact, I think it’s kind of funny how something like 70% of applicants at our company say they want to work weekends, and then at the end of the day, a very small percentage of them actually work weekends. Anyway, but the notion is let’s make sure that we know what they care about so we can get a good head start but then use their behavior as really the more predominant indicator of their preferences. 

The second thing here that we care about is being able to allow nurses to work in different facilities. And so for us to make that work, we also have to be sure that we have the right capacity in order to fulfill the needs in a particular facility. So we actually define the world in these little micro-markets, and guess what? The micro-markets are actually defined by how far is a nurse willing to drive and how far is a CNA willing to drive? And by the way, it’s not miles. It’d be really nice if they could just draw a circle, a radius, around all of the different facilities in the world, but instead, it’s time. So a nurse is typically willing to drive about 45 minutes. A CNA, nurse assistant, is willing to drive about 30 minutes. If you keep that in mind and also match them with the right thing, then you see their work blossoms. And then the feedback just becomes so positive, that they feel like this has been an amazingly great experience. So that’s one of the ways that we’re applying technology in this space.

Rebecca:                                I love it. And John, what are your thoughts in hearing all of this?

Dr. Pirolo:                             Yeah, so I think that the key ingredient here, again, across burnout, across top of license, across experience, often boils down to time and how the technology we apply provides and gives time back to a person. I think nurses or any clinicians will naturally work at top of license if they have the time to do it. And giving them the time back does involve reducing non-value add kinds of activities, right? But interestingly enough, in reducing those, I want to not lose sight of what we’ve talked about, cognitive overload. Even transactional activities a nurse does, like scheduling a test at the request of a physician or based on protocol, whatever, those are not just transactional. There’s cognitive work going on on the part of the nurse about when that should be done, potentially who should do it, how does it interact with other activities the patient has. And so as we’re asking clinical staff and general nurses, in particular, to do more of all of these things in a complex environment, I want to be really cautious that we don’t kind of trivialize this idea of what cognitive means. It means understanding these activities in the context of the clinical circumstance of the patient. This is where next gen technology is going to have to use AI. It’s going to have to use advanced data processing in order to actually make the assistance cognitive because you’re reducing a cognitive burden, right? So it’s not just a menial kind of a thing you’re doing. I think there’s a ton of value there. David mentioned a lot of examples where in clinical activity or in his own shop, they are doing this. That kind of capability, both advanced analytics and AI need to be core to the next level of technology they’re going to be brought to bear.

Dr. Collins:                           You know, Rebecca, if I could just say something about cognitive burden – cognitive burden or cognitive load only works with the short-term memory. Short-term memory lasts anywhere from eight-to-sixty seconds. That thing that can disappear from your memory bank very, very quickly, but can also create really critical situations if it’s forgotten. Our long-term memory is what I call muscle memory, it’s a thing that stays with us. Also involved in cognitive load are three aspects: external, internal, and germane. The internal cognitive load is what I call the backpack you can’t take off. That’s what you and I show up to work with every day. Who has the kids? I have an elderly mother who has issues. Or financial issues. It’s a thing that goes with you and sometimes it takes up more space in your cognitive world than it needs to because that’s the situation of the day. You can’t unload it. And then the environment is what delivers the extrinsic, and that is what’s going on. I may show up and I’m overwhelmed with patient care or it’s a very difficult environment. And so if you combine the intrinsic with the extrinsic, you can see how this load just starts to ratchet up. And then there’s the germane, which is how I respond to my environment. And when I respond to my environment, if I’m so overloaded on intrinsic and extrinsic, my response might not be exactly what it would be at any other time. This is what clinicians – both nurse and physicians – run from. Because they don’t know what to call it, they don’t know the name, they just know how they feel and how frustrated they are in the environment. So when we talk about technologies and AIs and all of these things, what we’re looking at is trying to ease this overwhelming burden of information that they have to make sense out of. It’s like getting a list of names and numbers and now all of the sudden I’m responsible to make that make sense and I have to do it very, very quickly. And I don’t have a calendar that I can control by. 

If you think about when you show up at work, you may have a vague idea that you’re going to have X number of patients, but you have, quite literally, no idea what’s going to happen or what’s going to happen with the family. And all of those just continue to ratchet up and ratchet up until you reach what we have been discussing, which is burnout. So I’d say get in front of it. Look at how you can use technology or how you can use the interpersonal dynamics of scheduling or people working with people to prevent that burnout. Because once you get to burnout, you’ve let it go on too long. And you’ve got to do something about the work environment, because as I said, it’s a work related injury. So let’s focus on the environment. And sometimes it seems really overwhelming to folks, but that’s the one thing that’s going to make a difference. Whatever the solution is to that work environment, that’s the solution.

Rebecca:                                Well, you guys, this has been a really incredible conversation and we’re coming up to the end of our time together. I want to give everyone a chance to share any last thoughts or feedback and regarding even your lives or how your company is responding to the issues we’ve discussed today. So Aashima, we’ll start with you.

Aashima:                               Thank you, Rebecca. I think it’s been a really enriching discussion, I learned a lot.

Rebecca:                                So Aashima, I’m so sorry, your whole thing froze until the end so I’m going to ask you to redo that and I’m just going to reframe the question again. I apologize and we’ll get everyone to do that. We’re coming up to the end of our time together. Are there any last thoughts that you have either about how your viewpoint or how your company is addressing the issues that we discussed today, Aashima?

Aashima:                               Thank you Rebecca. I would like us to find ways as stakeholders with nurses as one key component to inspire them with the art of the possible and that we are here for them. So the question that I would pose to all of us as a healthcare ecosystem and community is, what will the nurses of 2030 look like, ten years from now? And my sense is that he or she is somebody who is really good and enjoying what they do best, which is taking care of patients, but they also have enabled the co-creation of the technologies which they use who are apt in working across care settings: home health, skilled nursing facilities. And there’s a seamless exchange of data to help them do their job, or as we talked about, operating them at the top of their license. To me, that’s what the nursing of 2030 would look like. And at the end, we all have a time-sensitive opportunity to make it easy for them to deliver the key tenant of their profession, which is to deliver compassionate care.

Rebecca:                                John, final thoughts?

Dr. Pirolo:                             Again, great conversation today and I really appreciate the chance to participate. In the last two decades, I’ve been lucky enough to be involved both in kind of reimagining things and thinking about the art of what’s possible and sometimes, a little painfully, in the translation practically of those things into something that works. And I would maybe leave the group with a tangential thought just to take away. Seamlessness of data is kind of the cine qua non of actually being able to make what we were talking about today real, and as folks go up and think about how they’re going to apply some of these thoughts, at the very beginning it is really, really important to understand in detail your data substrate and the data domains you want to actually leverage because that’s where the wheels come off in going from something that looks beautiful in blue sky to something that actually works for a person at the sharp end of the stick. So I’ll leave it at that and say thanks very much again for the time.

Rebecca:                                Thank you John. Rhonda?

Dr. Collins:                           Thank you. You know, obviously I’m passionate about the work experience of a nurse specifically because I am one and I have that lived experience. But also for all clinicians, because ultimately, it impacts the health and well-being of our country. That’s ultimately the health-seeking public is the benefit of whatever we do here. I think that we are on a collision course with nurses leaving the profession and trying to bring nurses back in. I hear lots of really exciting ideas about how do we bring back the one million nurses in the United States who are not working in nursing? How do we leverage their expertise wherever it is or whatever little part of what they can contribute, you know, how do we think more intelligently about this and more collaboratively about it? In my work and what I do is really focused on the lived experience of physicians and nurses working as an effective team, both inside and outside the hospital as we look at hospital-at-home, and how do we take care of sicker patients outside the four walls of the acute care hospital? We’ve been talking about this for decades, but truly COVID has driven us to accelerate that and so we have a lot of work there. The other thing I spend a great deal of time talking about is the safety of the workforce and workplace violence, which is just – it’s really exacerbated right now. And how do we combine culture and protocols with technology to make a safer environment for these people coming to work? I had a nurse say to me recently, “Every night that I kiss my children goodnight, I wonder if it’s the last time that I’ll ever get to do that,” just because she’s going to work in the emergency room. And so we have to be able to provide safe environments, technology can certainly support that. There’s lots of conversations that have to happen. So I would think in my work and with my company, this is what we focus on. How do we activate and how do we keep functional teams with information, pushing information and allowing them to then have the conversations they need with the right people at the right time in the right way?

Rebecca:                                Thank you Rhonda. David, last thoughts?

David:                                    Sure, and thank you all for participating in this, I’ve learned a ton. This is amazing. I guess when I think about why for the last five-and-a-half years I’ve really tried to understand what nurses – what drives nurses and what they care about. We are a nurse-centric company. I think we’ve got a long ways to go, but I think we’ve done some pretty good things so far. I think back to my experience when my mother was in the nursing home the last several months of her life and I’d come visit her often and there was Rosie. Rosie was the nurse that came around and would see her quite often. And Rosie was just unflappable, the happiest person I had ever met. And it was just a tremendous comfort knowing that she was taking care of mom – until Rosie stopped being so happy. She would come in and out quickly, she wouldn’t be there as often, and then the care started to falter and we realized, me and my sisters, we had to help feed mom at lunch time and make sure she was well-taken care of. So I finally stopped Rosie and she said, well, we lost two other nurses in the facility and they haven’t been able to be replaced yet and this is my new life; I’m now doing the work of three people. And it’s interesting, while you can take the point of view of we need to care about all of the moms and dads in these nursing homes, but at the same time, if we don’t provide an opportunity for the nurses to have a better experience, the Rosies of the world are going to leave and they’re going to find alternatives. What we’re trying to do, and I come at it from a very technology-driven perspective, is to try to find and make a situation where nurses can flourish, can actually succeed and be happy about how they’re working, where they’re working, as often as they’re working and the stress level and the opportunities that are in front of them. I think one of the things we’re very passionate about is also how do we offer them upskilling opportunities and expanding their ability to work in many different places. So anyway, this is my passion and we’re using technology to try to provide.

Rebecca:                                Thank you John, Rhonda, Aashima and David, and thank you to everyone who tuned into this Tech Crunch webinar, Can Technology Save the Nursing Crisis? Because as you heard today, it’s going to take a lot of us doing a lot of different things and focusing on the nursing staffing shortage to make a difference in the future to the healthcare future of the United States. Thank you so much for being here.

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