August 19, 2020

Episode 20: Nursing leadership in the era of COVID-19

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Description

Being a nurse leader is never easy, but during a once-in-a-generation public health crisis like COVID-19, it’s particularly difficult. On this episode of The Handoff, Dan speaks with Marion Broome, Dean of Duke University’s School of Nursing, about how she and her team are coping with the COVID-19 pandemic, and how she thinks about leading through difficult times. 


Marion is a big believer in two things: relationships and communication. She encourages all leaders to build a strong foundation with their colleagues before a crisis hits. When you’re in the thick of it, Marion says it’s all about communication and that it has to come from the top. She shares with Dan how she’s put this into practice at Duke with weekly town halls to keep everyone informed. She and Dan also discuss the art of decision making in a crisis, and why non-decisions effectively become decisions.

Podcast

Transcript

Dan:
Marion, welcome to the show.

Marion:
Thank you. It's my pleasure to be here.

Dan:
I know you're doing a lot of amazing things at Duke. I loved the innovation space that you'd recently built and all of the initiatives around just getting leadership embedded into nursing curriculum. It seems like a lot of that's being put to the test with the COVID crisis. So I would love this to start out with, what are you doing now, how have you evolved the school and what's the latest at Duke?

Marion:
Well, one thing that's become really clear to me during this crisis, this COVID is still, relationships are the most important thing, that you have got to not only have trust from your team, trust from those you serve, in our case students, but also trust with your partners like the health system. If you walked into this crisis without those, it's going to be really, really tough. So some of the things I did, I think intuitively as a leader before have paid off, but none of us expected this crisis. I don't know that I would have put the strong value that I've realized on relationships as I've seen coming through this. We have been able to pivot because we had a fact into online learning because we were very fortunate to have, as you know, we're number two graduate school and master's program number four in the DNP.

Marion:
Those were have been online for years. So we have a whole cadre of faculty who are absolutely outstanding educators using distance technologies and distance pedagogies. They just reached out to help the ABS and the CRN and the PhD faculty who had to just literally in a matter of few days, make that switch. They're continuing to do that. That just says a lot about teams and people helping each other, and a community that can work together so quickly and do it, not because it's actually their problem, their class that has to go online, but because it's the community's problem. So that was one thing that really kept coming home to me time after time is how leaders must make the time to invest in relationships.

Dan:
Are you seeing that change with the virtual methods? Are people still able to build those relationships as effectively through the tele-connection?

Marion:
Yeah, actually, if I've been involved in any initiatives that involve new people, new to our system, and I just spent yesterday on a call with 860 national clinician scholars program participants who just joined and it's hard, it's much harder. Without question, you're constantly looking for verbal clues and you're scanning and you're clicking so that you can get to everybody.

Dan:
Right.

Marion:
When you're in a physical presence state, you're picking up cues from the people in the room with you, but now you're having to scan and constantly try to interpret, what are people thinking? How can I connect with them? If I connect with one, can I not connect to the other? It's been, I think, much more difficult to do that with this video.

Dan:
It's kind of overwhelming to the senses. You have to take a lot more focus to figure out what's going on in the room and the kind of feeling and the emotions and things. Yeah, I agree. Yeah, I've done some virtual presentations recently and it's been hard to kind of keep the same level of energy and engagement even when you're speaking without that kind of looking at people in the room and seeing head nods or frowns or crossed arms or whatever else is going in the room.

Marion:
You cannot just say something to people once. You have to say it over and over. You have to constantly, especially in a crisis situation, people are seeking information. They don't know where to go. They don't know what the truth is. This was a perfect example of it, especially in ambiguous situations, which this whole crisis still remains. If the leader doesn't reach out, email just doesn't get it when you have an organization of 200 people. That is one of the beauties of Zoom is you do get a lot more participation, I believe, when you hold these town halls now. If people value so much information, and I think you have to use more than just town halls, I think you do have to use every personal opportunity you have via an email or a telephone call. But I also think...

Marion:
I kept getting this daily early in March and then all the way through July. It was daily and then when it went to three times a week. So it was just a synopsis from Duke about the cases and what's going on globally, what's going on nationally, what's going on in the other private schools, what of course is going on in the North Carolina schools, what's going on at Duke? And I would send that out to our faculty and staff. It's a quick read. I can't tell you how many people appreciated that because they were getting so much information from the news and they don't trust the different sources anymore. So they felt like this was something that they could read when they had some time and they could digest and there were links in it and that kind of thing. So it became crystal clear to me that... Somebody said, "Well, when do you want to schedule the next town hall?" I said, "I think we have to have one a week." What do you do without those?

Marion:
What do you do when you're trying to create new initiatives, like we are trying to do to respond, well, we are responding, all the schools to our presidents mandates around our racial justice action plans? Within a period of two months, we've had task forces working on things and getting a say, but task forces are small. They're 20 people. Now, we have to go back out and communicate again and get input from people. You can't, especially during this time, that's critical because people are hypersensitive to be feeling isolated, not included, not knowing what's going on. So I think communication is... And it has to come from the top. It can also come throughout the organization in different departments or unit managers or whatever, but it does have to come from whoever is over that area of responsibility. So that was sort of my, again, it was something I knew I did intuitively to start and then I realized, this is something you got to keep up without question.

Dan:
Yeah. I think that's a great point, the communication piece because in crisis, the lack of communication and information leads to rumors or it leads to assumptions. So if you're not communicating, people are making up the gaps in information. Many times, that's toxic to the organization. They're acting on faulty assumptions and they're not clear on roles and responsibilities and outcomes and things. So I think that's a huge piece is sometimes even oversharing just so that people have access to the information, so they can make the decisions they need to.

Marion:
Absolutely.

Dan:
So I'm curious because you're in a unique role where you have the university and the health system hand in hand. I'm interested, what is the role of a nursing school in a crisis when you're attached to a health system? What has your school stepped up to do? What role have you played? What's going on there?

Marion:
The first thing is the week of March 16th. I remember I flew back from Atlanta and the next afternoon, was in a nurse leaders meeting, and Marianne Pinks who's the health system CNO was holding her meeting. I think they were meeting like every other day at that point or every day. So several of the academic leaders, program leaders went with me and we just said, "Look, guys. Tell us what can we do to help? What do you need? We are probably going to shut down. We're going to have to go online. We do know that we'll have to have some conversations about finishing out some of our students' clinical, but it looks like our seniors anyway have gotten what they need to this point to be able to graduate after they finish their courses, but how can we help? What can we do for you?"

Marion:
I think that just meant so much to them that we were even willing and able and wanting the help and come over and do whatever we could. So then when the issue of... This was when the first shields were being... Nobody had any equipment. People were looking for PPE everywhere and have five or six different lines, and half of them were stuck in China and half were just not making it to the... It was just amazing times. We were having daily calls. So we decided at Duke that perhaps we could make some of these shields. We have a school of engineering, Ryan Shaw, who I believe you met-

Dan:
Yeah.

Marion:
... with his colleagues and engineering to come over and, "What do we need to do here?" And then they needed to be said that we needed to make sure these would work. So some of our PhD students and some of the nurses and physicians from the hospital came in and actually, everything was able to be fitted for different sized people, for different tall, wide, etc, and we knew how much materials was going to be needed or going to be needed per person. It was like a beta lab. It was just wonderful. Then we can turn that over to the department... It wasn't an academic department. It's engineering department and the university, and they could put it together. So that just meant a lot, I think, to the health system. In fact, I know it did, to the house system that we were willing to use a space and bring people together while they were trying to respond purely to the amazing number of patients that were being admitted and that kind of thing.

Marion:
The other thing we did is when we, at that first meeting I was talking about, we knew we had seniors who were going to be spending four to five weeks without any... They'd already finished enough clinical to graduate for that semester because we have them do a lot of intensive clinical in that fourth semester, but they also had it... The health system said, "We could really use some patient service assistance. And what do you think?" And we said, "Let us see whether they'll be willing and able to do that." Well, they were. I think 45 were hired and they were paid. They weren't taking direct care of COVID patients, but they were freeing up nurses to take care of COVID patients. So that was another example of just building on our academic practice partnership, and really being able to be asked, that they would feel comfortable to ask us and we would come up with some options for them to consider and then tell us, "Yes, this would be helpful."

Dan:
Yeah. Those are great examples with the ability to step up with additional resources to rally people and ideas together and build something that's useful. It's great. Health systems that don't have an academic partner have to kind of beg, borrow and steal those things. So those are great examples there. The COVID thing has kind of spun everybody into weird places, both physically, mentally and in the innovation space. As a leader, do you think there's a way to prepare for this or is it just you need to always be prepared to kind of step up in a time where it's kind of unprecedented and unknown?

Marion:
I think that's a great question. I hope we don't have too many more opportunities.

Dan:
Right? This might be a little special.

Marion:
This is a little... I do think this is going to be the defining moment in anybody who's alive right now to think about. But I do think that I have called on some of the, even to get through this crisis, some of the lessons that I learned early on and throughout my career as a leader; letting your team do their job, not micromanaging things, and yet being aware of what's going on. so that when, in my job, I have to communicate across campus because we've got all kinds of task forces. So my job is to represent my school and bring my experience to those discussions. But I have to know when there's needs, what's going on enough in our school and I have a phenomenal leadership team who in fact, can do a stellar job of running the research area, running the academic area and I have to trust them and just keep me informed, I'll give my opinion, et cetera.

Marion:
Those are, I think for leaders who struggle with control, these kinds of times are very, very difficult. I've been coaching a couple of leaders outside my organization in this respect because people become very anxious when they're in a crisis and you cannot control anything. You really have to work on yourself pretty quickly as a leader, especially a formal leader and decide what is it you can control? What can I do in this particular situation? What is it left up to other people to do? One also has to know that any non-decision is a decision.

Dan:
Yeah.

Marion:
So you can hold off until you have enough information in a situation like this, and you will still be sitting here a month from now. The evidence changes constantly, so you can't get frustrated with that and you just have to say to people, "This is where I think we are right now. The intel I have tells me this. We may have to change it, and I'm going to need you all to tell me what's happening on the ground," because the university may need to know that. So if we have to change and pivot, we will. But right now, I think we have to make a decision like when are we going to bring our students back?

Marion:
Health systems decided that we can come back. Let's think about when we're going to come back. Is it entirely safe? What is entirely safe? Are they doing everything humanly possible and everything based on evidence? Absolutely. Will some of that evidence change over the next two months? Probably. But you know what? You're just going to have to go with what we have right now. We can't wait two months. We will not graduate the students in August if we do that.

Dan:
You brought up a good point there, which is pivot and change. That's something I learned that through the crisis as well. We have a small company. We're about three years old and I think one of our biggest competencies is pivoting and changing being okay with that. We literally moved people out of roles into new roles, rearrange things, overhauled processes and all that kind of stuff to respond in days where some other organizations we were looking at, they went straight to cutting staff and employees and that kind of stuff. We were able to think of it as a more fluid process and move things around fluidly rather than being stuck in kind of a command and control or aligned to the thing that you can cling on to and control almost like a budget and that kind of stuff, but really working with the people to figure out where their skills and talents could be used to maximize outcomes for what we needed to do at the time. So I think that pivot and change is a huge leadership skill.

Marion:
It's sometimes difficult in an organization because not everybody has that skill set. So then you find yourself saying, "Well, here's your options." If you're willing to flex part of your job to do this, we had to do the same thing because some people's jobs change totally. But if you want to stay, which we want you to stay, then you're going to have to think about what part of the organization can you contribute to. The bottom line is it's really your decision. You have to decide if you're going to be comfortable contributing to another area. The beauty of some of the COVID, the impact on organizations to me, especially you can imagine universities and health systems, which tend to take their time making decisions, we tend to talk a lot about what we're going to do and policies and getting permission from... Boy, we have started moving faster.

Dan:
It feels good, doesn't it?

Marion:
It feels good because That's great because like, "Oh, gee. At the end, everything was fine." I hope some of that stays that you can look at processes and say, "Do we really need to take six months to do this? Or can we do this on two? What do we need to do here?" I'm hoping that stays.

Dan:
Yeah, that's a great point. The speed of decision making and consensus building when you're rallied around kind of a common issue is so much faster. I resonate so much with, "Yeah, we'll talk about it. Well, we know in six months we'll build out that strategy deck and then we'll have the board meeting and then we'll come back and we'll revise it. Then we'll..." Now, it's like we need to get, in our case, it was like we need to get 200 nurses to New York by Monday and we don't have time to lolly gag about this. We got to figure it out over the weekend and at night and we're going to make it happen. It just changed the whole speed of decision, which is amazing. I do hope some of that sticks because it was focused and it was evidence-based, and we used the information we had at the time and we can do it to so much faster when you're under pressure. So I hope some of that stays for sure.

Marion:
I do too.

Dan:
So I know one of the other passions you have is developing nurses and helping them become better clinicians and better leaders. So tell me about that. How have you approached building a skill building nurse's leadership capacity in your coaching roles?

Marion:
I've been so fortunate to have, early in my Deanship, an individual that's an alum who gave me a fair, just a good amount of money and it was unrestricted and that doesn't happen all the time. So I decided, again intuitively, that I would like to use that to make some money available to faculty to choose these, any one of these variety of leadership [inaudible 00:18:17] these nationally. We have so many of those. We have the Johnson and Johnson for nurse practitioners. We have [inaudible 00:18:24]. There's just so many different year long leadership opportunities. A thing I like about that, rather than bringing something just in house is it gets people out of the organization, especially for people who've always been in the organization.

Marion:
So you get to hear from other people at your same level in their career, and you get to hear how they're thinking and take a look at your own organization and choose a project that really would make a difference to you as an individual because it's only through these projects, these life projects, these experiences that we really learn about ourself as leaders. We can sit there all day long and take all the tests you want to take, and they'll tell you all about your personality and your leadership style, but the fact is until you have to interact with other people and lead them somewhere, you're going to know a little bit, but not as much as you're going to know after you tried to lead people.

Dan:
Yeah, that's for sure. So how do you help leaders find their niche? I think in nursing specifically, there's kind of a unspoken tradition of, "Well, if you want to be a leader in healthcare, you got to be a charge nurse and then a nurse manager, then a director," or, "If you're in the academia, you got to go up through the tenure track faculty and then become a associate Dean, assistant Dean," all that. But there's a lot of nontraditional roles. My whole career has been around that kind of pathway. So I just wonder how do you help people find their passion and their niche, even when it's outside of that traditional pathway?

Marion:
Well, first of all, what I say to people is if we're only counting on the leaders at the top, we're not doing half the work.

Dan:
Yeah.

Marion:
When I say work, I mean the work of leading people at every level of being able to come up with innovative solutions to very difficult challenges that we all see throughout our organization. There are leaders at every one of our organizations. It depends on whether you're talking about management and you have to be a charge nurse, and you have to be a unit manager, you have to be an associate Dean. Every single administrative job has a component of being a manager to it. But when you're talking about leaders where who's the leader on the unit, the person that everybody goes to, "Hey, what do you know about this? What'd you hear about that? What do you think about that? And should I think about that?" Those are your leaders on the ground.

Marion:
People go to them because they listen, because they care, because they are an expert in their area. Whatever their particular patient care setting or their courses that they teach, they are stellar at those. That's why people go to them because they trust them. They know they're credible. They know they're a hard worker, but they also really gravitate to them because they know they'll listen. So I say to people, "You don't have to be an extrovert to be a leader." There are actually, I always talk about the good to great organization buck that all the leaders of these top companies were actually very humble individuals. If you do want to be a leader and you do gradually want to assume more administration, that's wonderful, but you got to start with what do you know?

Marion:
What are you an expert at? Because here's what I think, you have to be confident. Nurses, any health professionals, not just nurses, but any health professionals gain confidence because they're good at what they do. When you gain confidence and people come to you, you'll begin to feel like a leader because you'll be asked to take on something that's a very difficult challenge. You'll actually say, "Oh, I don't think I'm really good at that." Well, it turns out the person you'll think... I used to think, "Oh, they must know something about me I don't know because I don't think I can do that." Well, but I didn't want to disappoint them, so I did it. And guess what? I did a pretty good job because about killed myself doing it. That's true of the young leaders I work with. They kill themselves doing it.

Marion:
You'll come out on the other side and you can just see this new confidence. So when you're coaching people, what you're doing is asking them to reflect what they're going through. What do they want to do? What do they want to be in terms of a leader? Do they want to be one of the quiet influencers? Do they want to be a manager leader? Both of those are part of some jobs. Or do they, in 20 years, want to be the CNO or want to be a Dean? That's a good conversation. How is that fitting with their personal life? Because we can't just think about our work life without thinking about our personal lives and how that's going to match because every leader is going to have to spend, emerging leaders, established leaders when times like this happen, you're going to be working really hard.

Dan:
I'm interested in your thoughts here too, because one of the things that I'm seeing is the difference in generations with nurses and how they approach leadership in their careers. What are you seeing in that aspect as you coach and see the emerging, the new nurses coming into the profession? What are the differences between what they want and maybe what past generations saw as their opportunity in the profession?

Marion:
Well, I think what past generations saw for the most part, including mine of course, is that there were boxes to check. There were roles to play. There were things you had to do. We built our networks as part of our service to our profession, to those in the school or in our hospital. This generation builds networks like it's just part of their DNA. They have so many different layers of networks to get information from and colleagues that they trust and they believe are credible. So they think a lot more about their careers. The literature is very clear on the fact that most women, for instance, who are my age, who came up in the seventies professionally, we didn't plan our careers. Even as Deans of medicine who are female, and they'll tell you, "No. I just kind of fell into it."

Marion:
That's exactly what I will tell you is I chose academe... I loved practice, but I chose academe because it was more flexible, and I just felt like I had to have that because I wanted a family. Well, it turns out I was pretty good at it because I'm organized and especially research. That was the real thing for me. Researchers were sort of rewarded in academe. So it wasn't that I sat down one day and said, "I'm going to do this in two years and this in two." We did tend to fall into positions and into areas of influence for ourselves. But now, I see so many young, well, a lot of new nurses are coming from other fields. They've been leaders in other fields. So they're kind of much more deliberate and strategic about getting a lot of advice from people and then kind of charting their own way.

Marion:
They're very clear, which I tell them is not new, but work life balance. I was very clear. Like I said, when I took an academic job, I didn't realize people in academia work so hard. But I've learned that. By then it was too late because I loved it, but it's a whole different world. So 40% of nurses are now millennials and they are going to bring to leadership, a whole different set of skills. One of those skills is going to be these networks and these relationships and how to get input very quickly. I don't think there's much difference in the generations in terms of this building of confidence, especially for female leaders. Female leaders have taken a lot more time and energy to build their personal confidence in their own leadership. I still see that in the younger nurses, but they'll get there.

Dan:
Something that I see with the newer generation is they're not afraid to leave if they're unhappy. So they'll go find the place where they feel valued and they can make an impact. I think in the past, people were afraid to do that, that you kind of pick your organization and you stay there. We're seeing the newer nurses get a year or two of experience, and then a lot of them, I was just talking to a colleague at Ohio State, they hire about 150 new grads every year. She said 90% of them want to be travelers after the first two years. So it's this whole different idea of workforce and life balance that is going to drive a lot of changes, I hope, in the system.

Marion:
It is, and I hope the system changes so that they will, and I think some are listening because of course every academic health center has figured that out now, and I've always said why don't we find something challenging for them to do? You get bored pretty quickly. And they're smart. The last five years, we've brought in smarter nurses in ever [inaudible 00:27:23] 10 years, let's say. Well, you can't expect them to stay in the same job for 15 years for heavens sakes, but you don't want them to leave the system. So you want to have more of an internal career development plan. So maybe they want to travel to another part of the health system that's going to challenge them. I've also gone through it a lot why when people start to get restless, and they'll tell you they're restless, "Why don't you say maybe we take you off staffing 20% of your time? You've mentioned all these quality areas we could improve. What if we put you on 20% time to really work in an interdisciplinary team improving that quality for our patients?" They might jump at that-

Dan:
Yeah.

Marion:
A different sort of work and keep them engaged because the reality is for organizations, it takes an awful lot to... It takes like $60000, $70000 to orient a new nurse. So they're going to have to come up. Now, the chemistry's changed or the algorithm or whatever. The planning's changed. They're going to have to come up with ways to keep their employees. But that's, I think, going to require that they allow employees and not only allow it, but see it as an advantage, see it as an asset that you have somebody who has been somewhere for two years and now wants to gain new skills or go to another part of the organization where they can be challenged.

Dan:
Yeah. The flexibility internally will keep them entertained and engaged. I think that's awesome. That's exactly what health systems and leaders should be thinking about, or they risk losing people to other organizations that are willing to do that. So now, I think it's going to be interesting to watch how systems adapt. The tech industry had to do that. They had so much great talent. People were so heavily recruited that they were able to move. If they didn't like somewhere, they'd just go next door to the next place. I think nursing is there as well. There's a shortage and nurses are needed everywhere. So you can kind of choose the place you want to be, which is kind of a good problem to have if you're a nurse coming into the professions.

Marion:
It is. It's a wonderful problem.

Dan:
So one of the things we like to do here is hand off information to our listeners, that one golden nugget that we hope they take away from our chat today. So what would you like to hand off to our listeners?

Marion:
I think I'd like to say that know thyself is the most characteristic or maybe even behavior of a leader. Leaders constantly evolve. They constantly have to grow. They have hard knocks. We learned hard lesson. If you're not willing to grow, or get outside your comfort zone, or listen and grow, then leadership is not for you, I'd say. If you are willing to grow and know yourself, self-reflect, take advantage of opportunities and then get some input on how well you did with those, I think you'd be a phenomenal leader and we need you. We need you.

Dan:
We definitely need phenomenal leaders. That's for sure. Well, thank you Dean Broome. I really appreciate the conversation today. This was awesome. We covered so many different topics and I'm excited to see where this information goes and who can take some of these nuggets and change their practice. Stay safe and thank you again-

Marion:
Thank you.

Dan:
... for all the great insights.

Marion:
You're welcome. I enjoyed it.

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