Strategic planning for the nursing shortage with Kathleen Sanford (Pt. 1)


MODERN HEALTHCARE: Hello, Kathy. How are you doing?

KATHLEEN SANFORD: I’m really well today, Kadesha. How are you?

MODERN HEALTHCARE: I am good. Thank you so much for making time.

So, we started this conversation during the Modern Healthcare Women Leaders Conference. You mentioned that you were in the middle of strategic planning. I wanted to have you on this podcast to hear how you’re approaching strategic planning, specifically for the nursing shortage that has been looming for a long time. I want to start with three data points and then we’ll get into the questions.

The first is that more than 500,000 seasoned RNs are expected to retire in 2022. That means at least 1.1 million new RNs are predicted to be needed to expand the workforce, replace the retirees, and avoid a nursing shortage. The next data point is that by 2030, the number of US residents aged 65 and over is projected to rise to 82 million — leading to an increased need for geriatric care and care for people with chronic conditions and comorbidities. And then the last point is that a study of COVID-19’s impact on nurses shows that over half of nurses felt exhausted during the pandemic — and that’s probably an understatement. And nearly 30% have expressed a desire to quit.

I don’t think any of that data surprises you; I do want to know how you plan for it. So, let’s start with just your personal nursing experience. How did you transition from direct patient care to the strategy side of nursing?

KATHLEEN SANFORD: I began my nursing career in a different place than many of my colleagues. I was what was called a Walter Reed Army Institute of Nursing Scholarship recipient. And so, learned all of my nursing education on taking care of patients at the same time as I was learning how to be an officer. That’s something that the Army does. And I wouldn’t say that I was particularly strategic as an army officer. I was a head nurse, but I was taking care of patients. It was when I left active duty that I discovered that when you go into a management position, you need to not only think tactically — you need to think strategically about how you’re going to get things done.

And one of the things that I discovered early on was that I had difficulty talking to my finance colleagues and some of my NHA colleagues because they talked in numbers. Finance colleagues had difficulty understanding what I was talking about: patients and quality and experience. There seemed to be a language barrier. I realized that it would probably not happen that my finance colleagues would go back to school to learn the clinical world. So, I decided I needed to go back to school to learn the management world. Now, I already had a Bachelor’s and a Master’s that the Army paid for when I was on active duty. So, what I did was go back and get an MBA. Now, that’s not a real big deal these days. But back when I did it, there were very few nurses in business school. So, I learned there and some of the classes that you have are about, of course, strategy as well as finance.

So, I learned that and was able to understand that I truly do enjoy leadership and management positions. And the only way that you are going to make changes that are needed for the good of patients and society, is if you have a little position power. And you get that by becoming a manager or a leader and then helping other people become managers and leaders — even if they do want to stay at the bedside. So, that’s how I decided to get into learning about strategy. I went about it in a very organized way: Get the education, get the understanding of the words, so that you can communicate with those people who are planning strategy for the organization.

MODERN HEALTHCARE: Your direct patient care experience and your nursing experience just adds an additional layer that is probably not present at those tables very often. What would you say has changed the most about strategic planning for nursing over the course of the pandemic? What do healthcare leaders have to think about now that maybe they didn’t have to think about so much before?

KATHLEEN SANFORD: I think one of the biggest things that came out of this pandemic was a bigger understanding from people about the value of nurses. Now, I don’t think we didn’t value nurses, but I don’t think that we understood how very valuable they are in all parts of healthcare. And one of the big “ahas” for me is when we started having shortages due to the fact that we had so many COVID patients. And we were trying to figure out how we were going to take care of them in critical care. If we didn’t have enough critical care nurses, could we send in surg nurses there? Could we send office nurses there, etc.? It was astonishing to me how many people who I had worked with for years across the entire country, didn’t understand that a nurse is not a nurse is not a nurse. They truly didn’t understand that you couldn’t just take a nurse who had been in an office for 20 years and have them really be able to function completely, either on a med surg unit or in critical care.

Yes, nurses have a basic education and have the basic understanding of nursing care. But nursing over the years, just like medicine, has become more and more specialized. And so one of the things that we have to think about now that I don’t think we thought about quite as much before is the fact that nurses are specialists. And as we look at nursing shortages, we can’t just be talking about nursing shortages in general. We need to be talking about where are we going to need these people in the future? What kind of skills are they going to need? What specialties do we need to prepare them for? Because we understand that healthcare is going to be changing, too.

The second thing that came out of the pandemic is, we are doing a better job thinking about the health and wellbeing of our staff than we’ve done before. It’s not like burnout is new. I have been in nursing since the 1970s. I also collect literature from years before I had been in nursing, and burnout was something nurses were talking about decades ago. And I remember the early research in it. It wasn’t about working hard, it wasn’t about a job where you ran all the time — which we did and we still do — nurses still do. It was about lack of power, lack of control over your life, your work life, and what was happening. And that was what was leading to burnout. In fact, that’s how it was described in the ‘70s. It’s a lack of control. And they said that’s why the nurse execs are less burned out than the front staff nurses because we had more control — over our time and what’s happening.

Watching others talking about burnout — I looked at that and had some conversations with them and what came out loud and clear was I no longer have control over my time. There’s productivity, how many patients I have to see, how quickly I have to see them. I no longer can control things like I used to be able to control things. There are people trying to tell me how to practice medicine. Wow! This is just like what nursing has gone through for years and years, and so now we’re having burnout with other people. So, when we talk about burnout, it is not about working hard — it’s about lack of control.

And one of the things that the pandemic has caused is more lack of control because of the number of patients coming in, and you had to deal with so many things you hadn’t had to deal with. So, we need to look at it differently. We should have always been thinking about it. It’s not only the physical health of the people who take care of our patients and our clients and our families, but their mental health, wellbeing. And we’re going to have to think about that forever into the future. And right now due to COVID, we’re going to have to think about it a little bit differently.

And having been a military nurse — by the time I did my active duty and then my Reserves and National Guard, I’d put in 34 years with the military. So, I have a lot of understanding of PTSD. What we’re going to see in the next few years is going to be similar to that PTSD, and we are going to have to think about that in new and different ways — and how we as leaders are going to help all of our staff. I know we are talking nursing right now, but it’s all of our staff — particularly those at the front lines — deal with the emotions that are going to be hanging on for quite a while.

MODERN HEALTHCARE: Absolutely. How do you even start the process of strategic planning, then? So, you’re thinking about the need for nursing specialists, you’re thinking about the need for giving nurses more control, you’re thinking about the shortage. So, if you had to come up with a step-by-step process for how to strategically plan around nurses — especially with this shortage — what would you aim for and what steps would you include?

KATHLEEN SANFORD: Well that’s a perfect question because I did have to and we are! We started before COVID.

MODERN HEALTHCARE: Right.

KATHLEEN SANFORD: We started our strategic planning before COVID, just looking at the research about why nurses stay in nursing. What’s going to happen with the population going forward, etc.? So, COVID has exacerbated it, but we started before COVID. In fact, the last large meeting we had of our staff was our Chief Nursing Officers from across the system coming together to begin our strategic plan. And that was in November before we had heard about COVID in January.

It doesn’t matter whether you are starting it now or you started it before COVID — this is the way that we look at it. First of all, we believe, and I believe, that you look at research first. Make sure that you have looked at the research of what the issue is right now as we are looking at the future — there’s research about what we think is going to happen in the future, but what does the research say about why people stay with you? Or why people leave you knowing that this shortage has come and gone over many years? And it was foretold for a long time, that we wouldn’t have enough nurses in this era.

So, you look at your research, and your research includes your staff satisfaction scores, how your hygiene vs. your motivational factors are. In management 101, we studied a psychologist named Frederick Herzberg. And he talked about the Two Factor Theory about what it is that actually motivates people, what makes people stay with you, and what makes people leave you. And I’m always amused when I go somewhere and people are talking about, “This is what makes nurses leave, this is what makes doctors leave.” It’s all the same — it’s all the same theory. There are things that you have to have in any job that will keep people from being unsatisfied. But you have to have other things that make them satisfied! So, just a reminder, because when you look at the research, it talks about relationships with the staff — the rest of the staff, relationships with their bosses, their workload. And it talks about value of the work they are doing — whether they feel valued, and whether they think the work they are doing is valued. And it talks about having a voice, and that goes back to the burnout part. If you don’t have a voice, you get burned out because you don’t have any control.

Back to nurses again. In this research, you’d be looking at working conditions, salary benefits, policies, and how to get along with co-workers. If you don’t have those, you’re unsatisfied. But if we want them to stay and to be happy, and to be fulfilled in their jobs — which we do — then you have to look at motivators which are, they need to feel like they have achievement, that they love the job itself, that they get recognition, and they have a chance to grow. So, that’s the research part that number one, you’ve got to do your research first. You don’t just start doing strategy without some research.

I’m pretty simplistic about strategy. I took a little break from being a chief nurse for a while — spent two years working in a strategy department for a system and learned about it. And I’m pretty simplistic and that is, you have a vision of what you want to be, what you want your organization to be. And with that vision, you come up with goals that will get you to that vision. And then you figure out where you are right now, and then you figure out a plan how to get from where you are right now to where you’re going to go. I don’t think strategy is a big mystery. It’s where do you want to go? Where are you now? And how you are going to get there over a certain amount of time?

We started out making sure that we were going to involve everybody — because remember, I said the motivator is to have a voice. Well, we have 45,000 nurses. How do 45,000 nurses have a voice? So, we started out — figuring out how we were going to give people a voice in strategic planning. It can’t be something that Kathy Sanford, or Kathy Sanford and the other chief nurses sit around and decide. A lot of people have to be involved. So, we came up with a vision, and we spent almost a year — during COVID — coming up with a vision and still got 16% of our nurses involved in putting that vision together. 

And in the end, gave every nurse the opportunity to vote on what would be, of what we would be 5 years from now. And with that vision — based on the research we’d done and based on what the staff had told us — we came up, then, with a specific goal. And I’m going to tell you what ours is because there is no secret about it: Become the employer of choice for nurses and the entire care team in a system that’s widely recognized for outstanding care and service. That’s ours. Other people have different goals.

I actually spoke to another system recently who had asked me to come and talk about strategic planning and I came on to their call — it was a Zoom call — and a little earlier than they knew I was there. And they were saying, “We are gonna be number one. Everybody’s gonna want to work for us.” When they introduced me, I said OK, I heard what you all said and you know what? I love it that you want that, because if we all did that, we’d be able to make a better healthcare system for the entire country. And we would be able to take better care of the people we take care of and the communities we take care of. But just remember, we at CommonSpirit are going to give you a run for your money. And I hope that everybody else does, too.

When we were looking at the gap after we had come up with the goal and the vision, we set up groups to address different tactics that we thought could get us there. We’re still in the middle of that because as I said, we have been pretty busy with COVID and staff nurses are difficult to free up. If this is going to involve people, things shouldn’t be done to people. They should have a part and a voice, and they best know what would work or what wouldn’t work.

MODERN HEALTHCARE: That’s right.

KATHLEEN SANFORD: So, that’s number one. We’re putting together different groups — even if some of them are committees to come up with solutions — and then other larger focused groups to say, did what we come up with make sense? Is this going to help you? And then you have to prioritize all of the different goals, all of the different tactics that you’re going to use to get to the strategy because you can’t do it all. It would be too much change at one time, and they have to be funded and they have to be critiqued. So, you can’t do it all. You have to prioritize it, and then you have to say right up front — what are we going to do to correct our strategy if the world changes remarkably and if we find out that we were wrong? So, right up front in our plan, come up with what are we going to do to change if the goals aren’t really the right goals for the future? Almost a formula of what you need to do if you’re really going to make meaningful change.

MODERN HEALTHCARE: That was like an MBA in five minutes. So, let’s say you’re at the point where you have your wish list of what your goals are, you have your mission clarified, and you’re at that point where you are prioritizing and you’re deciding how you’re going to course correct. Who should be at the table during those discussions? Who should be involved in these strategic conversations? You’ve already said nurses should absolutely have a voice, but who else in the health system should have a voice?

KATHLEEN SANFORD: I also mean the front line managers, the middle managers, the chief nursing execs, the system execs — I think all types of nurses should be involved. And one group that gets missed a lot is your night supervisor. Whoever thinks to ask the night supervisor anything? I have been a night supervisor and let me tell you — they come to work with impossible odds. Not enough staff, emergency rooms full, staff calling in sick, etc., and somehow they get us through to the morning with everything turning out all right. So, you need to think about all of those people including the nurses that you don’t remember.

But you also need to talk about other team members because you need multiple tables, multiple focus groups — because nursing is not a single-person sport, it’s a team sport. Pharmacists, your respiratory therapists, and your OTs, and your dieticians, and, of course, your physician partners. And I can go through the whole list. So, even though it’s nursing, I’m not a nurse chauvinist, and I believe that this is all done together. And be sure that you have not forgotten the one group that we often do and that’s the people we take care of themselves!

MODERN HEALTHCARE: Absolutely.

KATHLEEN SANFORD: What we have at CommonSpirit Health are called P facts, patient and family groups that advise us about how things are working for them, how they are not working, how they could work. And so you must involve them as well. What do you see as a pain point as a patient who comes to us or someone who is getting a service from us? What do you see as a pain point and even if you don’t know, what do you think might be the thing that would solve it? So, you have to involve them, too.

It’s not a very simple thing to do a nursing strategy because so many people are invested in what nursing does. And nursing is so invested in what all the rest of those people do as well. So, during that almost two years that I took out and worked for strategy, I was the person on the strategy team that was sent out to talk to the Lions Club, the Rotary Club, all the different clubs, and ask people what they wanted and it was very interesting because it wasn’t always what we thought.

MODERN HEALTHCARE: That’s right.

KATHLEEN SANFORD: It’s a big table but what it really is, is multiple small tables being coordinated.

MODERN HEALTHCARE: I’m so glad you said that because the nursing experience actually kind of makes or breaks the patient experience.

KATHLEEN SANFORD: I always say that one of the issues that we have in management: We avoid, sometimes, things that give us acute pain at the risk of chronic pain. “Oh, we have to make this change, it’s just going to cause all this trouble. It’s going to be a problem, maybe we shouldn’t do it.” And so we stay with chronic pain for years and years and years — and don’t fix it.

OUTRO COMMENTS: Thank you, Kathy Sanford, for that insight on strategic planning for the nursing shortage. Before the pandemic and now, strategic planning for nursing is a critical aspect of keeping our healthcare system afloat, and we’ll continue with part 2 of this conversation in the next episode.

Again, I’m your host, Kadesha Smith, CEO of CareContent. We help health systems reach their target audiences through digital marketing that focuses on the right content.

Look for more episodes of Next Up at modernhealthcare.com/podcasts, or subscribe at Apple Podcasts, Google Podcasts, or your preferred podcatcher. If you’ve been enjoying Next Up, please go ahead and leave us a review on your preferred podcatcher as well. Thank you again for listening.



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