Robert Wingo, BSN, RN, RN-BC: Empowering Nurse Leaders with Financial Intelligence for Better Budget Allocation, Resource Utilization & C-Suite Buy-in!

Thank you for joining me for another episode of the Nursing Strategies for Success podcast with this week's guest, Robert Wingo. Robert is a board-certified nursing informatics professional with 23 years of experience specializing in nursing full-time employee budgets, implementing and supporting nurse staffing and scheduling systems, productivity reporting, data analysis, the creation of custom data analysis tools, and custom reports. His care-centric modeling approach to nurse scheduling empowers all stakeholders in the budgeting, staffing, and scheduling process through a deeper understanding of how resource variances impact staffing capacity and the ability of nursing leaders to provide patient care time off, and education. So let's welcome Robert to the show. Welcome to the Nursing Strategies for Success podcast, brought to you by The Nurse Speak, a show where we rally some of our nation's greatest nurse leaders, educators, experts, and advocates to tackle some of our greatest challenges that the nursing profession faces. My name is Damion Jenkins, and I'm your host for this show. So sit back, relax, and get ready to learn that nurses can do anything. Okay, Robert, thank you so much for joining me on the Nursing Strategies for Success podcast. Why don't you just take a moment and introduce yourself for the listeners? Let them know a little bit about who you are, where you started in nursing, and where you are today.

All right. Yes. Thanks so much for having me on, Damion Jenkins. As you mentioned, my name is Robert Wingo, and I was a, a nerd long before I was a nurse. I started out in the early '90s in oncology nursing. That was also during the big managed care revolution where there were a lot of changes. Uh, you know, initially I, I really enjoyed it because my oncology patients would come back every 4 to 6 weeks for their next cycle of chemo. So I got to know them, I got to know their patients, their family, um, and they would come and find me when they would come back, say, hey, we're down in room whatever, please stop by and visit. I really enjoyed that interaction, that level of interacting with the patients and their families. But then with the managed care revolution that came along and they pushed all of the chemo admin to the outpatient clinics. And so then my patients were only coming back to the unit, uh, when they were febrile or neutropenic, or they were actively dying. And that wasn't quite as enjoyable. And there were also some staffing cuts around that time as well. Um, so I made the transition to a clinical informatics team that we had there at the hospital at the time and became an administrator for the clinical documentation system we were using in our ICUs. Uh, I did that for a couple of years and, uh, got a nursing informatics position at a small hospital down in Miami, Florida. Uh, and that was, uh, 1999. And that was when I started working with my first nurse staffing and scheduling system. And so, uh, since then that has been my focus, nurse staffing and scheduling and everything around that. And that seems to be a hot topic these days. Wow. Yeah. So I spent a couple of years in Miami, but then came to Houston. There was a hospital here in Houston that had installed the same software that I was working with there in Miami, and they were looking for someone to come in and be the tech lead and the project manager for that in their IT department. So I came and did that. Ultimately, nursing decided that they wanted somebody in their shop that was responsible for the staffing and scheduling system, which was only being used by nursing at the time. So nursing actually stole me away from IT. Then I was dedicated 100% to staffing and scheduling. I became the manager for a small team of analysts that was responsible for supporting that system, everything from upgrades to education to configuration changes. And even though I was the manager, I worked as a high-level analyst and was responsible for most of the custom data analysis that we did. I built a number of custom data tools to help us to analyze things. I developed a custom productivity report and a handful of different dashboards to show us some data out of our system because what was delivered from the vendor was so terrible. And I also worked with our director of finance to completely redesign the budget tool that we used. That was where I really got into the budget stuff and really started sort of connecting the dots and figuring out how, you know, changes in the budget variances in available resources ultimately impact our staffing capacity and what we're able to do at the bedside.

Right. Well, it sounds like you had an idea that these things needed to come about way back in the '90s, right? So, you know, later end of '90s, you said 1999, and you've been doing this since. Have you seen much change as far as, you know, organizations adapting these tools to improve I mean, I know being a nurse for 12 years now, I've seen a lot of implementation of these dashboards and these different types of systems to try to track better and give us more real-time data so faster decisions can be made. Um, but we're still having the same problems with staffing. We're still having the same problems with not having enough resources to support, you know, educational initiatives, replacing equipment on time. You know, making sure we can hire that extra nurse so it's less strain on a, you know, patient-to-nurse ratio on a daily basis. So have you seen much change with the implementation of these, um, kind of systems?

Um, no, actually, no, I haven't. And I, I think I've identified actually where our problem is, and it's not necessarily with our, um, with our technology. Yeah. Uh, in this process, uh, a handful of years ago, I actually discovered that there's a a nursing budget process that's out there in circulation that has a calculation error in it. You know, when we're new nurses, we're, you know, they kind of put the fear of God in us with these medication calculation exams, right?

Right, right.

Well, it turns out that, you know, with these budget calculations, you can cause some problems for your patients as well due to understaffing and so forth. And so this error that I found initially, I thought, you know, I found it at an institution. I thought it was just a simple math error. I actually found it in a book that I'd bought to help educate myself about, you know, finance a little more in depth. And this author, Professor William Ward, he's a professor at the Johns Hopkins Bloomberg School of Public Health, where he's taught graduate finance classes for many years. Yeah. And he explicitly describes this error in his book. Oh, that's interesting. That seems to be what I'm running into as well. Well, when I started looking, long story short, I've identified this error in over 30 sources so far spanning 40 years.

Wow.

The very first author that I identified this error in one of their articles in one of the journals, I reached out to this author and said, hey, I think there's a an issue here and provided her with the information from Professor Ward's book, as well as a mathematical proof showing, you know, hey, you're shortchanging yourself here on your FTEs. And the reply I got back was, well, basically, thank you for your email, but I've always done it this way.

Right, right. That's the way it's always been done. Those wicked words, right?

Yeah. Yeah. I've worked with 3 large consulting firms and they do it that way too.

So it must be right, right?

Yeah, it must be right. And so I had another conversation with Professor Ward and he was like, wow, this is just nuts. And as I've been digging around, I keep finding it. It keeps popping up everywhere. It's in journal articles, it's in textbooks, consulting materials. Conference presentations. It's everywhere. And what this— what happens with this error— so when you go and you do your budget, you go and you figure out, okay, how much, how much staff do I need to take care of patients on my unit if I'm expecting, you know, an average daily census of 30 patients and I want to staff to a 1:3 ratio, right? That's real easy to calculate out how many nursing hours you need. Well, you have to add in extra so that if somebody is out on vacation, you've got somebody to step in and cover. And so that's the non-productive time. You basically got two types of time. You got your patient care time, which a lot of people will call productive time, and then you've got everything else that's not patient care time that a lot of people will call non-productive time. Although that, that term has become more, uh, controversial.

Yes, I would agree.

Some people don't like it.

I'm one of those people. I don't like it.

Typically the things that you find in sort of the quote-unquote non-productive category are things like time off, orientation, and education. And so what happens is, is with this calculation error, you end up with a shortfall about 2.5 to 6% of the hours that you need to fulfill your budget assumptions. So if you decided that you wanted your total budget to have, you know, 15% non-productive resources built in. But with this calculation error, you don't calculate 15%, you get like 13.25% instead. And so you start off a little short, uh, you know, before, before you do anything, right? And so it's— and in looking at the nursing literature for the past 40 years, the other thing is, is there's a lot— there's a ton of information out there on how to create a nursing budget pretty much like I described. You figure out how much you need to take, you need to schedule for patient care, and you figure out how much extra you need to hire so you can cover for time off and education and so forth, right? Um, and that's pretty much where it stops. There's, there's little to nothing out there that informs or educates nurse managers or, and other nursing leaders on how to take that budget and, and create safe and effective schedules. Yeah, there's just nothing out there that talks about that transformation from the budget, uh, to patient care. And I think that's where the huge gap is at this point. For the, over the past year and a half, uh, I've attended a handful of these nurse manager workshops that some of these big professional organizations put on out there where they talk about the financial aspects. And one of the problems is, is some of these workshops are actually teaching this incorrect formula, right? So you've got, you know, these high-profile professional organizations promoting this formula, but then again, they're in the workshops, they pretty much stop with the creation. There was nothing that talks about You know, this is how many resources I have. How do I effectively, uh, you know, divide them up so that I'm providing adequate patient care, time off so my people don't get burned out, and education time so I maintain the competency of my workforce, right?

So it sounds like, you know, they help to teach how to create the budget, right? But then there's no implementation of the budget, that ongoing problem solving when we have these unexpected variables that pull us in 1,000 directions, which we all know. Any nurse who's been a nurse for more than 5 minutes knows that nothing goes as planned.

Absolutely.

No matter how much we try to prepare and anticipate, nothing goes as planned. So, you know, it's wonderful to create a system that has all the bells and whistles and the spots where you could plug numbers in, but if we don't have a practical application where we can run simulations and see the different, you know, outcomes based on resources provided or lack thereof, then we really don't have a good insight to how can we staff safely, how can we provide the time off that our staff definitely need so they can rest and recover and have a life outside of work. And then the education, which is huge for me. I'm education. A big advocate for education and there's such a lack. That's why I became an educator in the first place is because I saw such a huge gap in what the expectations of practice are versus what we're actually being prepared with. Right. And the amount of resources that organizations are putting into education, it's, it's really abysmal, um, in the grand scheme of things. But so, yeah. So let's talk about, that's a big problem, right? We were teaching to the wrong thing. There's lots of evidence that shows we've been teaching it the wrong way. I still find errors in practice when it comes to certain skills that I teach, whether I teach home health aides or I teach registered nurses or even teach master's prepared nurse educators who are getting ready to finish their MSN and get their degree. I'm finding a lot of practice errors in how things should be done. You're right, when you reach out to the authors or the publication companies that produce this material, They say, well, we don't have any proof otherwise, except, except I do give them the proof, and then they still are resistant because it costs them money to reprint, to edit, to send out notices to say, hey guys, just so you know, in Chapter 13, these textbooks, there's been a correction to the statement, right? They just don't want to be bothered. So a lot of, a lot of people in places are just saying, ah, Well, no one's died from it yet, but that's actually not true, right? So speaking to mishandle— mishandling budgets, we do have poor outcomes, right? We do have patients suffering. We do have nurses losing licenses because of errors, because of unsafe working conditions. And certainly we have nurses leaving the profession because they just can't take it anymore. Management, especially like middle level management in nursing, I don't know a single nurse manager who has been in their position for more than a couple years.

Yeah, and it's, you know, it's really hard. So, uh, during the course of my work, I actually was working with a nurse manager for one of the largest health systems here in the U.S., and in working with her, we actually determined that they were using this flawed budget process, and she was really struggling with staffing and overtime. She was getting chewed out by her superiors.

Right.

Um, and so I crunched the numbers for her and basically because it's just this one math error, this health system needs, uh, probably close to 2,000 more nurses than they realize. Wow. In order to be able to meet their budget assumptions. Uh, and that's just one health system. So basically with this math error, uh, any facility or health system that's using it, you're looking at, uh, at them needing, uh, anywhere from dozens for an individual facility to hundreds. For these health systems, more staff than they originally budgeted for. And that's just, just phenomenal. Um, you know, you, you mentioned, you know, that the education piece, and going forward, education is going to be extremely important. And as I'm sure you know, it's one of the first things to get the axe, because in the hierarchy of patient care, time off, and education, unfortunately, uh, you guys are a low man on the totem pole.

And always have been.

Yes. But, but, you know, going forward, you know, there's, there's been a lot of stuff that's come out that really highlights how important education is going to be. Uh, there was one study that came out that showed that the average tenure of the, of the nurse had dropped by almost a third.

Yep.

Uh, and then, uh, Dr. Peter Bearhouse, who's one of the gurus for workforce issues, uh, has estimated that, uh, between now and 2030, every single year due to the baby boomers retiring, we're going to be losing over 2 million years of nursing experience each and every year.

Yep.

Um, and so that's just a phenomenal, phenomenal brain drain there and just loss of, of expertise. And so that's why I've been trying to, with, with my message, you know, everybody hear all these staffing discussions and everybody's so focused on patient care, of course. And, uh, we're not going to solve it by focusing on patient care. We need a more holistic approach. To workforce management because we, yes, we need to do patient care. That's, that's, you know, what we're there for. But we also, but we also have to provide enough resources so that our staff can have time off so they don't get burned out.

Right.

And then we also have to have resources to provide education so that we can, you know, train, you know, train and orient, you know, new employees or even experienced employees as they come over so that we can maintain the competency of our workforce.

Right.

And so that's part of the message I'm trying to get out there, that we need to take a wider view of these workforce issues. And it's not just patient care, it's a package.

Absolutely.

Have all three.

Absolutely. And, you know, I just want to piggyback on what you said about the, again, the education piece, making sure that the onboarding is done, you know, well, right? It has to be done well, and it has to be beyond the standard of checking the regulatory requirement. Like, seriously, we have to stop being a checklist checklist type culture and say, yeah, we taught about infection control. Yes, we did fire safety. Yes, we did vaccine compliance. No, it needs to be above and beyond. Everyone leaving these organizations, you know, after the orientation or after in-services or after ongoing professional development, they should be able to really speak to their knowledge and then demonstrate their knowledge on a daily basis. Too many times resources are mishandled, right? We are— we're already shortchanging ourselves with budget and staffing, but now we have again middle-level management or even upper-level management oftentimes being pulled to the clinical settings because the clinicians don't know basic skills like how to take an out— take out an IV, right? Or— and so these organizations are also spending tremendous amounts of money on third-party companies to manage their patients' or residents' IVs. And I'm like, why is that the case when we have registered nurses on the floor? There is no reason why we need a third-party company that we spend, I don't know, $200,000, $300,000 on in a year to come and pull out peripheral midlines or central lines when those things can be taught to nurses and we can have ongoing competencies and evaluations to make sure everyone's staying competent. It makes no sense to me. Um, but you know, unless we get more buy-in from leadership to allow educators to be empowered so we can create these systems, then it, you know, they'll just keep wasting money, bleeding money, and always thinking that educators are bottom of the totem pole and not essential. So, so how is the work that you are doing, right, focusing on this specialized budgeting for nurse leadership to make sure they're staffing appropriately, making sure people have time off, and spending the money on education so that they can have high-quality, competent staff. How is your work making difference? What are you doing right now with that?

Um, well, it's, it's been a bit of an uphill slog. I've actually spent the last couple of years talking to a variety of nursing and healthcare leaders, and, uh, they actually haven't been very receptive. Part of the problem is When you sit down and do the math, they kind of go, oh my goodness, um, we're more short-staffed than we thought. That's— and they see the dollar signs, of course.

Everything's bottom line, right?

Yeah. And so that's part of the reason why I started the blog. The blog, my blog, the Nursing Informatics Blog, has been up for about a, about a year. And after talking to all these leaders and not really making any headway, I decided to take it, uh, take it to the streets.

Good.

And put this information out there for bedside nurses and professionals such as yourself and people in middle management to try to get the information to them. Because I'm sure— and so it's large and it's not like I have this huge software package or anything.

Sure.

It's actually education, training and education and understanding the interrelated mathematical models of these nursing information, their staffing information structures. I'm sure, I'm sure you and many of your listeners have had the experience of the nurse manager putting out a schedule with an overtime sign-up sheet. Of course, that was, that was a thing 30 years ago when I was a nurse.

Yeah.

And, uh, if you, if you, if you look at it mathematically, there's actually a very, very simple explanation for what has happened. Well, that nurse manager sits down to work on their schedule and they go and they approve all the time off and education. They're spending more on that than they have the resources to cover.

Right.

Bottom line. And there's actually a very, very simple formula that a nurse manager can use where they take some of their position control information that they get from finance on their, you know, how many positions they've got filled. They can actually crunch the numbers and figure out when they sit down how much they can schedule for non-patient care shifts while reserving the resources needed for patient care. And, uh, you know, the thing is, is I've yet to run into any, uh, nurse managers that have that level of awareness.

Right.

But you'll hear a lot of places, they'll have some sort of, you know, loose guideline to say, oh, you can allow, you know, 10% of your staff off, or you can allow, you know, 3 nurses off per day or something like that. And those, those are kind of sort of, you know, broken clock methodologies. They might be right twice a day, but the majority of the time they're going to be wrong. Right. And as your resources fluctuate, you have to sit down and do that calculation. One other thing that I would like to mention that's a huge factor in the problems we're having now is the vacancy rate. Yeah. So if we think back to the example I was using earlier where I budgeted my unit for 15% nonproductive resources, I've got 15%, you know, in my budget for nonproductive FTEs. Um, if you had a fairly modest 7.5% vacancy rate, you effectively wiped out half of the resources you budgeted to cover for time off and education. So, uh, last year, uh, NSI Nursing Solutions Incorporated, they do a big annual survey of turnover and retention and so forth, and they determined that the last— the— for 2021 the average vacancy rate out of survey respondents was 17%.

Wow.

So what does that mean? So if my unit, if I budgeted 15% nonproductive, but I have a 17% RN vacancy rate, that means that I have absolutely zero resources available.

You have negative.

Exactly. You're in a negative situation, right? You've got no resources available for time off and patient care, and you don't even have enough resources to do your schedule for your budgeted level, level of patient care that you planned for, right? And so what happened— and this is before you approve your first, first time off request.

Yeah, anything, right?

Right. And so what happens in that scenario is every single time, every single non-patient care shift that you schedule, every time off request, every education day, it creates— it pulls the shift away from the bedside and creates an unfilled shift.

Right.

And with, with— we've got so many facilities that have such a high vacancy rate right now, um, that, that's where, that's where so many of us are living. Um, in, in the state of Maryland, they've got a 25% RN vacancy rate. That is just horrific.

Yep.

Um, and so, I mean, they're so far in the hole. I mean, what do you do? It's, you know, it's virtually impossible to give people enough time off because you've got to provide, you know, provide resources for patient care. Education is going out the window in a lot of these places.

Yes, I know. Just because there's—

yeah, I know. Yeah, because there's no time.

Yeah, we've shrunk orientations from 7 days or 5 days to 1. We've taken in-person hands-on demonstrations for in-services, which require hands-on because it, it involves highly technical skills, and we've recorded videos and put them online, and it's all because we were told we had no choice, right?

And that's because, and that's because nursing leadership, you know, from the unit managers on up, they are under such pressure. Yeah, uh, to get people, to get people to the bedside. Um, NSI was also reporting that it's taking almost 3 months to get a nurse hired, so you're looking at probably at least 6 months to get somebody hired and productive. By the time you onboard them and get them through, uh, through orientation. And so that's making it very rough for the managers and directors, right, for managing their unit. That's where all of this— that's where all this pressure is, uh, coming from, to kind of hurry people through the process and cut the corners, which is not something we really need to be doing. But right, it's kind of, kind of a catch-22 situation at this point, right?

You know, but one of the frustrations that I've had for a long time, um, especially with being kind of the right-hand man of nursing leadership for many years now as one of the educators is a lot of the delays has nothing to do with any of the nurses, not the nurse managers, not the CNO or CFO or COO. If they're all nurses, it's not— it's usually HR. It's usually the application process, whoever's reading them or approving them, requesting documentation. A lot— and I've worked in many facilities over the years, and each HR process has been wildly different. From facility to facility. It's another one of those things that they really need to invest in streamlining the process. Um, the technology that they use to weed out applications, it's not really great. It— we're losing a lot of great candidates. They don't even make it to the inbox of HR reps. It's just, there's so many inconsistencies there alone where I've had people who were approved by managers Everything was approved by leadership, and it took the person 4 weeks to get noticed that they, they're scheduled for this day to come in. I'm just like, what? Why did it take 4 weeks for them to get an orientation date when we hold orientations every week? So, you know, there's a lot of inconsistencies there as well. So if anyone has any control in the HR departments, um, we need to try to fix that as well. Um, and I think Another big thing is a lot of these departments and healthcare facilities are still too siloed. I mean, they're just very siloed and they don't, they don't work together. Everyone has their own— that's my job, not— that's not my job. And then it winds up being, um, a bunch of people not knowing what other people are doing. So that's a big problem too.

Yeah, I agree.

Awesome. So Robert, it sounds like for any nurse leader who needs to have a better understanding of how to manage the budget, maybe in a smarter, more proficient way beyond the old-fashioned, you know, tables that we get passed down from the C-suite that says this many patients, this many nurses, go, and you have to figure it out. And you're right, they have those loose-fitting kind of rules where you can only have 3 nurses off in a day or in a week, but that changes from case to case. Like, they make exceptions on a case-by-case basis. And sure, we should able to make accommodations as needed. But if they can have a, a much more concise way of making sure they're allocating their resources appropriately, I think anyone would love to be able to have access to that information. So how could they reach out to you? Um, give us a few resources that people can immediately start looking at now so they can start implementing that into practice. And if they want to work with you and have your education, how can they get in touch with Um, sure.

So my blog is out there. It's called the Nursing Informatics Blog.

Awesome.

And it's at, it's at informaticsnurse.com. Uh, you can also find me on LinkedIn. I'm very active on LinkedIn. Uh, Robert Wingo, that's W-I-N-G-O. You can find me there. Those are probably the two easiest, uh, easiest ways to do it. Uh, and on my blog, I talk about what I'm calling my, uh, my care-centric approach to nurse scheduling. Uh, and the premise there is, is that we look at the, the resources that you have on hand right now. And the care-centric piece means that however, whatever you have now, we're going to go ahead and before we do anything, set aside the nursing hours that we need to provide patient care.

Right.

Uh, and so then we can look at what's left over and say, okay, this is what we have for all, all of the non-patient care stuff. Uh, and then you have to consider things like, you know, leave and orientation and You know, a few other things, but it's a very simple formula where the nurse manager can sit down and plug in a few numbers and say, okay, this is how much I can spend, this much for time off while I'm making my schedule and not impact patient care. You know, one of the other things is I know that many nurse managers, they struggle with, they don't get good training and education on the finance side of running their unit.

Absolutely.

Um, and you know, a lot of these managers were, you know, started at the bedside and have kind of, you know, worked up from the bedside, from the clinical side, right? And they don't have a lot of exposure to the business side of things, right? Um, and so that, that's what I'm, I'm trying to change. Uh, back in 2000, uh, AONL, ANA, and HFMA, the Healthcare Financial Management Association, put out this, uh, report where basically they were calling for increased communication and collaboration between nursing and finance, which is, which is great. But unfortunately, nursing is sort of at a disadvantage here because we've largely abdicated the bulk of our financial knowledge and expertise to the finance guys over these, these many decades. And so I'm trying to provide, you know, through, through my methodology of looking at the budget and staffing and scheduling, a greater sort of more holistic understanding of You know, what is it that you're, you're working with? And I think we have to get to the point to where, um, so where, uh, fiscal management in nursing is considered an integral part of nursing care delivery, right? Because we have to, we have to take the resources we have and effectively manage those to provide the 3 things we need: patient care, time off, and education.

Right.

Um, and you know, the few nurse managers that I've worked with, they didn't really have this, this, you know, awareness of, uh, you know, when they would sit down and work on their schedule, understaffing would become a more conscious decision because you can say, well, I can spend 100, you know, 150 hours this month. I've got, you know, 250 hours of requests. Then what am I going to do? Am I going to deny? Am I going to deny some of those? Uh, am I going to approve some of those knowing that it's going to leave me short-staffed with some unfilled shifts? So then understaffing becomes a more conscious decision. But the other thing that it, that my approach does is it provides the nurse managers with very valuable knowledge and data so that they can push back.

Thank you.

And, you know, if they're getting chewed up by their directors in finance about their level of overtime, or, you know, they're not getting all of their competencies checked off, the nurse manager can come back at them with some data. They can, she can crunch the numbers, they can crunch the numbers. And I go back to their directors in finance and say, okay, you're yelling at me about overtime. But I've done the math and this is what I can do with the resources I have on hand right now.

Right.

You know, never mind that I'm budgeted for all these positions, but I've got a lot of them that are unfilled. And because of that, I'm not able to give my staff enough time off to stave off burnout.

Right.

So then you can put it back on them and say, what am I supposed to do here?

Right. Give me more money. I need more money. Right. So Thank you so much for that. That was exactly what I was going to ask next. How are you empowering nurses to be able to speak the language of the C-suite and say, no, you're not going to get the outcomes you want with what you're giving me. It's impossible, right? And nurses are amazing at that. We have such the skill and talent to look people in the eye and say, that's not going to work because we've done our assessment, we've done our evaluation, we've picked up all the pieces, we figured it out, we looked at it long and hard, and it's not going to work, right? We do it to physicians oftentimes when they're asking for things that just aren't reasonable or practical for some patients. And it might be on a case-by-case basis, but some orders or some treatments or some interventions are just not going to work based on what we're being provided with. And so, right. Thank you for making sure that part of your education empowers nurse leaders to be able to push back and say, hey, I just don't have what I need in order to meet these outcomes. So you're placing unrealistic expectations onto me and setting me up for failure. And that's a direct reflection of you as a leader. Right.

And that's exactly what's been happening. So many of our nurse managers have been set up for failure with these impossible, uh, Scenarios. And, but you know, it's, it's not just the nurse manager. I believe my approach can actually empower all stakeholders in the staffing and scheduling process.

Sure.

Uh, for example, for, for the staff, you know, the nurse manager can, uh, you know, crunch the numbers and share and say, look, I know you guys have some vacation requests put in, uh, but I've got too many requests out there. I can't approve all of them.

Right.

And so as a nurse manager, I can go to the staff and when my staff meeting and say, okay, here's what we're working with. Would anybody be willing to move their vacation request? It sort of becomes a negotiation, and it's transparent with the staff to let them know this is what our staffing situation looks like. And maybe I can say, well, you know, we've got 3 people in orientation, but it's going to be another couple of months before they're productive. And then, you know, once they're up and running, then we can probably approve more time off. Again, for the nurse managers, it's very empowering because it gives them more, more knowledge and control over their unit. It also allows them to engage on a, on a more knowledgeable level with, you know, their directors, their CNOs, and the people from finance because they have data.

Yeah.

And for, and for the CNOs, it also provides them with, you know, ammunition when you, when you aggregate this sort of data for all of the units, it becomes a very powerful picture, right? A very powerful piece of information that CNOs can take back to finance and say, look, this is, this is just unacceptable. Here's what we're working with in nursing. This is why we're using so much overtime. This is why we're having to bring on so many agency personnel. This is, this is part of the reason why, uh, you know, our safety and quality metrics are are taking a dive, and it's another, another data point that they can use. And at the same time, I think, I think it can help finance to better understand what it takes to, to really run nursing operations when you look at having the right way, right?

The right way.

The right way. Yes. Thank you. And so, so yeah, so that's, that's kind of what I'm trying to do with my approach and to get people to get, uh, you know, everybody in nursing to be more savvy about, uh, things around budgeting and staffing and scheduling.

Yeah, I think that—

and it's, yeah, and it's gonna, it's gonna take data, of course. You know, Florence Nightingale, she was, uh, she was actually a data scientist, and it was her work, uh, in the Crimean War with her data collection and analysis about the morbidity and mortality on the troops and these amazing graphs that she prepared for, uh, for her reports. Uh, and so we can, we kind of need to get back to our roots. I think we've got all the tools we need in nursing to actually, uh, begin solving these problems, but it's going to take data and it's going to take, uh, the nursing process.

Absolutely.

We've got to do our, our assessment. We've got to make a plan. We've got to do an intervention and see how it worked.

Yeah.

Uh, and, um, so that's what I'm trying to do. I'm trying to get people to, to look at the data, to think about this in terms of like I said, the nursing process and the way that we approach it. Uh, let's, uh, work smarter and, uh, and not harder on this.

I thank you so much for all of that. So just piggybacking off of the, the nurse manager bringing that data to the staff and allowing the staff to, one, be in the know of why certain decisions are being made, because that's something that I always craved when I was a staff nurse. When these big decisions, these big policies, protocols— no one's getting a raise, no one can take vacation, we're not hiring anyone. We were never informed of the why, right? So of course we're left to our own devices and our imagination, just thinking that it's big corporation capitalism against the little nurse. And we don't feel valued, we don't feel appreciated. And that just adds to the workplace trauma that we're experiencing. When we are having a moral crisis because we signed up to care for people and make people feel better and be a contributing part of society. And yet we don't feel like we're accomplishing that because we're so stretched, right? And then that right, that right there alone can change the difference between if someone is disgruntled and burned out versus someone who feels empowered and deciding to be a team player, right? So that makes the whole difference. And I think that's so important. If there's one singular message the work that you're doing can do, it can actually improve the way we think about the work we do, despite how stressful it might be. When we have a seat at the table to make decisions about how operations are going on a day-to-day basis, Well, then there's no one to blame except us at that point. If we decide we're not going to negotiate well and be a team player, then that's on us, right? So if the manager says, hey, this is why I can't approve all of your time off, and people fold their arms and say, oh well, well, I put my request in, so I'm gonna get it. Well, you're, you're being part of the problem at that point.

Yeah.

But oftentimes we're not. Privy to that information and we're just told this is the way it is, right? Because it's easier sometimes for leadership just to say that because it's too much of a long-winded explanation, or honestly, they might not even know, like you said.

Yeah, and I think a lot— I think a lot— yeah, I think a lot of them just, they don't know. The conversations that I've had with, uh, nurse managers, they, they had no idea until I kind of sat down and explained it And I've actually had a couple of them say, wow, this could be revolutionary if we could get it out there. And I think with the way I'm approaching the data and encouraging it to be used, I think it can create a lot of transparency and accountability.

Right.

But I think that maybe— I think there may be some people that might not like that much.

Of course there's going to be people who don't like that. We know who those people are. Yeah, I can guarantee you they're not nurses.

Well, they, they may, they may be, but they may not be at the bedside. We may not talk about some people in, uh, management here.

Look, any nurse who practices by their license, who took the oath to do all the amazing things that we said we're going to do, if they're practicing at the highest standard of their license, they would not be against this change. Yeah, nurses should not be focused purely on financial incentive, no matter what level you are. I don't care if you're the chief president of the Johns Hopkins system, like, I don't care who you are. Money should not be a motivator for you. Patient outcomes, improving the process, beefing up education, elevating the profession— that's my call and my challenge for any nurse out there. Be the nurse you signed up to be. It's not easy, no matter where you are on the spectrum of nursing. It's never easy. But we have such power when we hold true to our license, to what we signed up to do, to always practice ethically, morally, responsibly. You know, again, you saw celebrations on LinkedIn. We're all celebrating, you know, 21 years consecutively, the most trusted profession. But if we keep having nurse leaders in the C-suite making the same shady decisions that guys in finance make, you're just exacerbating the problem. We have to push back and we have to hold strong to the values of the nurse, because if we don't, we might as well just do whatever we want and hope for the best.

Yeah, right. And, and you know, that, that's actually been part of my frustration because I actually have several CNOs that I've approached about these, these issues. And their response was, well, but we've always done it this way.

Of course.

Yeah. So, so the, we've always done it this way is actually shaping up to be a pretty significant factor in the nursing shortage at this point.

Yeah, of course. I mean, it's been 20, 20 years in the making of business as usual, right? A lot— at least 20 years of a lot of the same situations, you know. Uh, that brings me to the strikes that just happened here in New York, you know. The, the, the same policies and procedures for maintaining staffing and, and benefits and pay increases and ratio and all of this stuff has been the same, the exact same for 20 years. It hasn't evolved at all. And while it's And while patient outcomes continue to decline, patient satisfaction with the service that they're receiving continues to decline, nurses are leaving the workforce, nurses are getting more and more dissatisfied with the role that they play, nothing changed. And it takes people to walk out before administration or the people who make the decisions will say, okay, fine, you get what you want now because we're completely crippled by you leaving. Things have got to change. And it sounds like you, I, and everyone listening to this podcast are all like-minded individuals, and we all have a piece of trying to make that change. And I think what you're doing is excellent. I'm actually very interested in learning, um, how I can bring what you have figured out to all of the leadership positions that I work with. I work with nurse leadership in a variety of organizations, and budget always seems to be a big complication for them. Um, so my last question for you before we wrap up is, so you said you empower the nurse managers or leadership to be able to push back, push back to the CNO or push back to the C-suite or higher, the maybe even the board of directors, right? And do you find that your process helps even when the provided resources are like super substandard, can it still help to improve how the nurse manager has better control over their budget?

Uh, yes. So, you know, the, the big, the big issue is, is understanding what's possible with what you have on hand today, right?

Perfect.

Um, and, you know, we've, we've got, we've got, you know, some of these big think tanks that have put out these plans, uh, the Partners for Nurse Staffing plan that was the big, you know, 5 professional organizations got together and came up with their recommendations for addressing the nursing shortage. Uh, the Maryland Hospital Association, they have their own plan, and they all, they all have fantastic ideas in them. The problem is, is that many of the ideas, practically all the ideas, it's going to take months to years before we see results, right? We don't have, we don't have months to years, right? And so what we have to do now is we have to figure out how can, how can we effectively allocate the resources we have on hand right now? What can, what can we do with the staff that I have today? And my approach will help nurse managers figure that out. And sometimes that, sometimes, sometimes it, it helps them make a little more sense of it. But unfortunately, other times they just sit down and crunch the numbers and go, oh wow, I'm in worse shape than I thought. But at that But at that point, they have data, right? And in these situations, data is powerful. And I think that's where a lot of nurse managers just haven't really known where to start, right, to begin to have that conversation with finance. So if I can get nurse managers and other nursing leaders to understand some very simple mathematical concepts around these budgets and how they relate to staffing,, and how that they can run a few calculations and get some data that they can take back to their superiors or to, to find us to say, hey, let's, let's sit down and talk about this and let's see if we can figure out, you know, how, how do we, you know, how do we navigate this? What is there an alternative solution? Maybe my unit was budgeted for, uh, you know, 1 to 3 nurse to patient ratio. I've been running 1 to 5. And that's just not working for me. 1 to 3 is just not going to happen. The market's not going to support it. Maybe we can get to 1 to 4.

Mm-hmm.

And then what would it take to do that? Uh, and then looking at, you know, realistically, what are the resources that I have as a manager available to provide my staff time off and, and, uh, education? Um, what I'm hoping is, is that eventually if we can get enough people looking at, uh, our budgets and staffing in this way and looking at the data. I believe we can get to evidence-based management where we're looking at the decisions made by leaders regarding the resources available. And I think it would be very interesting to look at what happens with different levels of resources available for time off and how that impacts employee and patient satisfaction, how that impacts burnout. And those are all things that, you know, the resources, they're controlled at the management level. Right. And then ultimately, you know, we could— I believe we can be able to look at, um, how those decisions— because one of the other things that I've developed is what I call my nurse staffing information structures. I was submitting a manuscript on this. And so the structures are the budget, which feeds our position control. The position control has the filled positions. Which then become the employees on our schedule. The employees on our schedule then become the employees that get assigned to either a patient care shift for staffing or a non-patient care shift. And by implementing that staffing, we then provide patient care, which ultimately gets us our outcomes. All of those layers are mathematically linked, and there are, there are key components in there that you can track all the way through to staffing. And, and we know that there's a a lot of good literature out there on a variety of, uh, you know, quality and safety metrics that are sensitive to staffing. So if we can trace that back all the way to management decisions, uh, then I think we're kind of knocking on the door of evidence-based management and looking at developing, um, potentially guidelines for, um, you know, minimum levels of resources needed for things like education and time off, uh, you know, in order to maintain workforce competency or to avoid burnout.

Absolutely. And I think, you know, with that evidence-based management will come a more standardized process. Just like, you know, in order to be a registered nurse, you have to go through a standardized process, pass a standardized exam. And most facilities have some sort of standardized onboarding orientation, shadow shifts or buddy shifts, preceptorship, that kind of thing, right? Validation of your skills, so on and so forth. There, there's very little standardization of someone being promoted from bedside nurse to manager. Right. Um, and this financial intelligence is something that I've always craved as a nurse to under— to better understand how my organization is functioning and why so many cuts are happening and why we keep getting denied, um, resources that we desperately need. Um, why, why no one's getting raises despite we're working harder and harder day by day. Had I had that insight, maybe I could have pushed back. Maybe I could have received the resources for the unit that we needed when I was in interim positions or when I was in charge of figuring out scheduling and budgeting, which is no one taught me. Have to figure it out. Honestly, I was winging it most of the time. I think most people do. We're given some very loose guidelines by leadership and we're told, "Go." Right. Yeah, mentorship's also very important.

Oh yeah, yeah. If I could, I'd like to squeeze in one little—

sure, absolutely.

So one of the big barriers that we have with, uh, with getting a lot of these positions filled is the way that nursing is paid for in an organization. I don't know if there are a lot of people out there that don't realize that nursing is actually seen as a cost, to the institutions. Correct. Um, yeah. And, uh, you know, nursing is often paid for, um, out of a portion of the daily room rate charge that each patient— correct— each pa— each patient is charged. And so I think part of the challenge there, and there's, there's a movement growing, um, calling for us to look at changing, you know, nursing reimbursement, uh, to— from a cost to a revenue-generating model. For, for value-based nursing would be the term you would want to look for. Because obviously if you've got, you know, a walkie-talkie patient that's pushing their IV around the pole just waiting to be discharged, you know, versus the, you know, unresponsive or confused patient that's on a lot of IVs and has antibiotics and a Foley and needs turning and so forth, those are two, two very different levels of care, right? And so there may be some opportunities there to look at, you know, just like when you would go to your physician and your physician can bill for a simple office visit versus a complex office visit. I think, I think in order to fund the positions and salaries that are going to be needed to put nurses back at the bedside, nursing is going to have to find a way to fund its own operations, right? But of course, that opens up a whole can of worms from, you know, the policy and Of course, insurance companies are fighting that, right? Yeah. But you know what? We've got the money in the system to fix this. A lot of the insurance companies are posting record profits in the billions of dollars.

Of course.

I think last year the top 5 or 6 reported in aggregate about $40 billion in profits.

Amazing.

Yeah.

But yet our premiums keep going up, prescriptions keep costing more. And, you know, that ultimately comes down to the good old capitalist kind of mindset. Where, you know, again, I'm challenging nurses to kind of make sure you're very separate from them. We all need money, right? We all need money. But does this— does the president need $15 million a year? I'm not quite sure that that's a fair salary for anyone. That's exorbitant. I'm sorry. Right? And yes, these big corporations are making tons of money and very little is being put back into public resources. Like, running healthcare organizations. Um, so yes, so I am very familiar with a lot of the different movements happening to kind of restructure the way nurses are being paid. There's lots of different organizations. Some are trying to kind of advocate for more of like a public utility where a portion of the salary is covered, so it's less of a burden to healthcare. Some people are trying to get legislation passed so that way we can bill for our services, or at least the hospitals can bill for those hours, you know, just having another means of the healthcare organizations not bearing the burden of the salaries of the nurses. But I want everyone to be very, um, open to the idea of the word burden. To us is a lot different to them. They're still making tons of money. These organizations are swimming in money. So when they tell you they don't have it, it's baloney. They have it, they just don't want to be below a certain profit margin. They've set a ridiculously high profit margin and they're doing well. So we do have to try to get people at the top, the— all of the boards of directors, the people who handle all the decisions, they need to just be more generous with the resource allocation. Come out your profit just a little bit for a few years and you'll see tremendous You don't need $57 billion before you die. I'm sorry, I don't care who you are. It's just, you don't need it.

Yeah.

Awesome. Well, Robert, thank you so much for all of the work that you're doing. I think, you know, really empowering nurses and nurse leaders with financial intelligence on how to better budget is going to be so helpful for the new grad nurse all the way through someone in my position. You know, 12 years in, going on 13 in the leadership space myself and still trying to figure it out. So it's going to be a tremendous help. I'm definitely going to start reading up on your blogs and, and see how I can learn more information and bring it to the teams that I work with. And, um, I hope we get to, you know, hang out soon and talk shop and figure out how we can continue to improve the nursing profession. It was so wonderful having you on the show., and I look forward to talking to you soon. Take care.

Yes, thanks so much for having me on, David. My pleasure.

And that concludes episode 2 of season 3 of the Nursing Strategies for Success podcast with this week's guest, Robert Wingo. All the ways to connect with Robert will be in the show notes of this episode. We hope that everything that we shared will help to empower you to lead the charge, make the change, and continue to elevate the nursing profession. If you have any questions about anything we shared in this episode, please feel free to visit thenursespeak.com/contact and get in touch with me. I would love to have a conversation with you. So until next episode, take care, be well, and remember that nurses can do anything.