Speaker 1 (00:05):

Welcome to Hospitals In Focus from the Federation of American Hospitals. Here’s your host, Chip Kahn.

Chip Kahn (00:15):

Hello and welcome to Hospitals In Focus. We so appreciate your listening. Today we’re going to be talking about one of the critical issues facing healthcare in America, the growing workforce shortage, which is especially acute for hospital nursing. Joining me is someone well positioned to examine the problem, Dr. Sammie Mosie, the chief nurse executive at HCA Healthcare. Thanks so much for joining me today, Sammie.

Dr. Sammie Mosie (00:42):

Thanks for having me, Chip.

Chip Kahn (00:44):

Sammie, to get things started, let’s talk a bit about why you became a nurse in the first place and what are the highlights of that journey from the bedside to leading almost a hundred thousand nurses across the country?

Dr. Sammie Mosie (00:58):

Yeah, well, I think like a lot of nurses, I became a nurse because my mom was a nurse and that inspired me. She would come home from work and talk about her patients and the impact that she had, and I just really had a lot of pride in her and I wanted to follow in her footsteps. So I began my nursing journey like many in the med-surg environment, so working to provide care to the patients in that space. And then I continued on my journey, scaling outside of med-surg, going into different areas such as ICU and ER, and then that tap on the shoulder that happens to many about thinking about a leadership position. So I took on a manager, a director role, ACNO, and then in the end I was a chief nursing officer, and that happened in seven years. So I was pretty aggressive when it came to accomplishing goals and just wanting to have a bigger impact on nursing in general.

(02:05):

I was there and my nurses wanted to go after ANCC magnet status designation, and so we went on that journey and obtained that. And that was just a great opportunity. Especially as a young leader, it gave me some guidance and a vision on how to lead my team and it was really good principles to lead by. And so I adopted that model.

(02:30):

And then being part of HCA Healthcare, which I have been for 26 years, and just growing up in the company, they’ve allowed me a lot of opportunities to grow. So I went from being a CNO at the hospital to coming on staff at the corporate office and taking on different initiatives. And part of that was establishing our nursing agenda. We didn’t have an agenda prior to that, so it was about 10 years ago. We started looking at how we continue to elevate nursing excellence in our hospitals. So going back and working on our nursing agenda, establishing that, utilizing the voice of our nurses to help drive that, and also thinking about structure.

(03:16):

Structure was a big piece of the organization when it come to nursing that we had opportunity in. HCA Healthcare being so large, we have 180-plus hospitals, and we wanted to make sure that in our model, which is a group model, currently we have three different groups, and then we have divisions that live under those models and hospitals that live within those divisions. So each division can have anywhere from eight to 20 different hospitals. And the divisions had a president, but they didn’t have a nurse executive at the table. And so we implemented a structure and a career path for nurse leaders as well so that we could have a nurse leader at every level of the organization and HCA Healthcare. And I think that that was probably one of the wisest decisions because that was hardwired. We had leaders in place, we’re moving our agenda forward. And then when COVID hit, we had a way to ensure that we were able to move quickly and have conversations with our nurses just based on having that beautiful model.

(04:22):

So about 18 months ago, I moved from being the assistant chief nursing officer, assuming the chief executive officer here at HCA, and it’s been an incredible journey.

Chip Kahn (04:36):

That’s terrific. Sammie, you mentioned COVID a moment ago and in a sense the readiness of your structure for that kind of challenge, but in terms of all of us now, and particularly the public in general, everybody’s moved on, but the trouble is that those at the front line who had to live through that, had to work through that, had to frankly save so many lives that made an imprint on them. Everything I read, everybody I talk to in the industry is still I think living with that. How has that affected nursing in general and what kind of challenges has that experience that was like no other left for you? What kind of challenges are you facing?

Dr. Sammie Mosie (05:24):

Well, the entire healthcare industry and community hospitals in particular have gone through some really extreme difficult periods over the past few years. We went into the pandemic thinking about two priorities. One was to protect our people and the other our organization so that we could continue to keep our doors open to our community and provide that high quality care. But just like it was for the population, but maybe a little more intensive, this was a traumatic experience for nurses. I classified as it really shook the nursing industry and one estimate is that we lost a hundred thousand nurses within the US from 2021 to 2022. So pretty significant workforce shortage that was happening, and nurses were really focused on taking care of their family and taking care of their patients. And just the imbalance of that created some tension where some of the nurses took early retirement, others moved home to take care of their child as they were homeschooled or being able to be closer to their families. But also there was this competitive opportunity for nurses too to go out and work in different healthcare systems for elevated incentives.

(06:48):

So it really was a time where the past loyalty of having experienced nurses stay for a while got disrupted by COVID and the impact of that. So the workforce shortage I think has really impacted all of us, but I would say the most traumatic part of this is that trauma that our nurses went through and that’s hard to erase just like any trauma. So ensuring that we continue to focus on that and be reminded of that. Those nurses came in every day to take care of very sick patients, seeing mortality events more than ever. And that trauma is something that we continue to grieve through, mourn through and just a reality that exists in the nursing industry.

Chip Kahn (07:38):

You talked about the fact that a hundred thousand nurses possibly nationally left the field during the COVID. We were prior to COVID and into COVID in a sense, hitting a period in which we were seeing a down cycle in terms of the total number of available nurses and just in terms of retirements and aging. So in a sense for nursing, my impression is it was a perfect storm, this overlay of this new issue and the fact that frankly there were many nurses headed to retirement anyway. Can you talk about in terms of a lasting effect the pandemic may have had to this problem and where you see it going in terms of having sufficient nurses available at the bedside in the hospital? Because as you said, two things happened. One, you lost nurses generally to the profession, but in some cases you lost it to other settings that didn’t have the same pressures as COVID filled hospitals.

Dr. Sammie Mosie (08:40):

Well, Chip, I think that description of the perfect storm is accurate when it comes to the nursing workforce. There were studies that were indicating that there would be a 2030 shortage, but COVID did just accelerate that and we had that a hundred thousand nurses lost within the US. There are a couple other things that I think contribute to this and I think there are people out there that say maybe there isn’t a shortage. But I’d like to talk about just a couple facts that help at least drive my thinking and where we’re thinking about it at HCA Healthcare. We do have this explosion of opportunities within nursing and that can be within the walls of the hospital, but it is also within the communities that we serve.

(09:30):

Additionally, there are studies out there that are saying that we’re going to need a 6% increase of nursing supply until 2031. And so that is what? 200,000 nurses if you look at that. Also, we have the retirements, we have nurses that the average age is 52 and we know that there’s opportunities for retirement there. So that is about from the estimates we’re looking at, there’s one study that says 200,000 nurses will retire annually until 2031. So we keep thinking about the deficit that exists there, but there’s a couple other variables that I don’t think people realize, and that is the number of students that take the NCLEX every year. So the students will translate to the nurse if they pass that NCLEX exam. Well, that number has remained flat for the past four years.

(10:27):

So for the past four years, I’ll be generous, there’ll be 150,000 students taking the NCLEX exam. So we still have that 200,000 nurses are retiring, 150,000 are taking the NCLEX exam. One variable for that as well is that there are 96,000 qualified students that are turned away every year. So I don’t think it’s a lack of interest in nursing, but it’s a lack of the ability for us to grow that student population as we think about this opportunity to continue to improve those numbers. So there’s some variables there that I think need to be considered when we’re talking about is there a shortage or isn’t there a shortage? I think it’s well documented that there is a shortage and our ability to think about care differently is upon us now as we work through that.

Chip Kahn (11:23):

Boy, the numbers just tell a cold truth and it’s sort of disconcerting when some from the union community, labor community or others try to act like there’s not a shortage when it’s right in front of you and so clear. And your responsibilities are for HCA Healthcare. Let’s talk about your issue from two angles. First, in terms of the nurses you do have in retaining those nurses and keeping them at the bedside for patients, how are hospitals and particularly your hospitals using technology to tackle those challenges that burden the nurse? And how are you getting the nurse in a sense from the desk and the computer to the bedside so that they can do what they trained to do and frankly what’s fulfilling for them?

Dr. Sammie Mosie (12:14):

Yeah, I think it’s upon us to evaluate innovative care models and what that looks like for the future. One thing we’re using technology for is just a lot of hospitals are doing it, virtual nursing. We do have several facilities that are piloting that concept for us, and I think it’s very promising taking that workload burden off of the nurse by leveraging a different type of model in admission and discharge. A lot of the literature is talking about this now, but I do think that this is something that’s going to stick. I think there’s other opportunities though regarding inefficiencies that exist when it comes to technology, and I look at it even broader than just technology. So I think about it with people, process and technology.

(13:07):

The people, part of that is really looking at the care team and how we can support that nurse. There is a shortage, so how do we think about really ensuring that that nurse is working at the top of their license? By supporting them through having patient care techs, additional transporters. What type of people can help take some of that workload burden off of them?

(13:31):

And then I think about processes. When I think about processes, and it goes into technology as well, but when I think about processes, I think about any inefficiencies that take that nurse off of the floor or away from that patient. And whether that means having medications at their fingertips, having supplies on the unit, being able to locate supplies efficiently. Those are the kind of things that are just burdens that should not be there. It’s impacting that nurse and taking them away from the patient.

(14:05):

And then leveraging those technologies. I think we should continue to challenge anything that we’re doing manually and explore is there opportunity for us to automate? Is there opportunity to remove that and have that completed by someone else? So our focus should be keeping that nurse at the bedside and being able to practice at the top of their license.

Chip Kahn (14:27):

You touched on it a moment ago too, in terms of the space in nursing schools and the interest in it. HCA also there, HCA Healthcare is taken it upon itself to make sure that you have enough training going on and they’ve done that through the Galen College of Nursing. Can you talk about the partnership that you have with the Galen College of Nursing and what your concept is there in terms of developing your own workforce?

Dr. Sammie Mosie (14:58):

Yeah. And this is such a great successful story and I think a differentiator for HCA. We acquired Galen College of Nursing in 2019, so right before the pandemic. And that college system had several campuses, but we have grown that to 19 campuses now. We’ve looked at our markets to understand which markets have nurses that will be retiring, which ones have a gap of nurses right now, and how we can think about any growth opportunities as well. So we place those campuses in our markets to help with that supply. But I think what is really exciting about this is the future of being able to integrate Galen into the HCA Healthcare facilities for the future. So we have a pretty robust educational structure. We actually have our educators service, a shared service. We have over 800 educators in our system and they go out and help support our new nurses as well as our experienced nurses with any educational opportunities or onboarding or planning for complex procedures.

(16:12):

So we’ve got a great model there, but we also have simulation space that helps facilitate that onboarding of students. So a real learning environment exists in our markets and it allows that student to transition from the student space to a practicing clinician using simulation. Well, what’s beautiful is also Galen uses simulation, so how can we continue to just modify that?

(16:40):

I think we have a lot of opportunities to study as well with Galen on how we can help facilitate that student. I think we’ll be a leader in this space in the future as we work together to bring both of those agendas, but it’s exciting. We have 12,000 Galen students enrolled currently in those campuses, and 3,000 of those are HCA nurses that are going back to school to either get their bachelor’s degree or their master’s degree, and we help support those through tuition reimbursement and grants.

(17:15):

I think what is really interesting is that Galen will help us with our supply, but if you go back to that number I told you before, the 150,000 students that are testing every year, we’re going to grow that. We’re going to grow that year over year. So we won’t be just changing the statistics at HCA Healthcare, we’re going to be changing national statistics as we add more students to take those NCLEX exams. I think it’s something that our other hospitals could help support as well as our government resources to think about how we can continue to invest in instructors to continue to grow that number of nurses and students available.

Chip Kahn (18:00):

It’s terrific what you all are doing with technology, in a sense, growing your own nurses with Galen, but what happened in COVID and whether it was a traveling nurse situation and just the turnover and churn of those at the front line or just the pressures in a sense was a breakdown. And the question is for me, with those other components, how are you rebuilding culture? Because that’s so important, both in terms of nurse productivity with patients and good service with patients, and frankly, retaining those nurses because those with experience we know in healthcare are better at healthcare than those who are coming in and out. And to maintain safety and the quality of service, you really need continuity of care and continuity of those nurses at the front line.

Dr. Sammie Mosie (18:53):

Yeah, this is actually another good story for us. We talk a lot about turnover, but we are getting back to our pre-pandemic baselines when it comes to retention. So significant improvements in retention, and that means an increase in net gain for headcount for nurses at the bedside. So very positive story there. And I do think that that is the result of our nursing strategy. So when we think about what tactics we utilize to help drive that culture that you’re asking about, we have four components of that. We have one pillar that’s our advocacy and leadership agenda, and that’s focused on ensuring that every level of the organization has a strong nurse leader. We know that employees are there because of their leaders and the relationship they have with them.

(19:45):

We have an advantage here. We have a very strong nursing pipeline when it comes to leader talent. About 90% of my ACNOs and my CNOs are promoted internally. And why that is is because we actually start with our charge nurses and start training them very early when it comes to leadership principles. So we put a big focus that charge nurse is on every unit, every day, every facility. And so our ability to really invest in them and ensure that they’re able to lead their team is very important for that pipeline and that helps build the culture. We also have a staffing and care team support focus. So again, talking about how we use different models of care or different teammates to help facilitate care because this has been a big part of our agenda over the past two years, but also the wellbeing of our staff is part of that too. So what programs do we have to continue to support them through this?

(20:49):

I think we have moved on in certain spaces, but nursing is just a tough profession. So we just always want to have resources to help facilitate any of that emotional need that they have. So we’ve leveraged vendors and others to help facilitate that, but we have some really good programs internally where our nurses are giving voice to what we need and we’re able to respond to that.

(21:14):

I think voice is one of the most important things. We require shared governance councils in every one of our hospitals, and that is an opportunity to allow that nurse to talk about their working environment, to talk about any of the challenges that they’re facing, and then our leadership teams can work together to help solve that. I think that that’s a differentiator for us as well.

(21:36):

Third part of that strategy is education and academic partnerships. Again, we talked about Galen, but Galen doesn’t answer all of our needs. So we work with our academic partners in our communities to ensure that they have the clinical rotations. That’s been a great experience for us. We have built nurse extern programs and that nurse extern is able to come in and work with our nurses side by side. It helps with their onboarding, but it also helps that nurse extern realize that they want to be part of our healthcare system because they’re talking to a nurse every day and they’re telling them they want to be part of that. So that’s a great opportunity is really embedding and continuing to facilitate our nurse extern program, which is a big success. We have about 6,000 nurse externs in our hospitals. We have 41,000 clinical rotations. So there’s so many opportunities to continue to build culture, but also to include others in that as well.

Chip Kahn (22:32):

Wow. It just sounds like you’re doing so many different things. How do you see this playing out over the next five or 10 years? And maybe in a sense, how optimistic are you for the future considering all the broader pressures on healthcare provision and on the nursing profession and the numbers that we’ve been talking about in terms of nursing in general?

Dr. Sammie Mosie (22:52):

I’m very optimistic. I think if we stay on track with using that voice of our nurses to drive that great culture, then we’ll continue to retain our nursing staff. And we’re already seeing that. We are seeing more experienced nurses come back too. So that’s positive. As we think about that care complexity and how we want to onboard new nurses, it’s really important to have those leaders in place and clinical experts. I’m optimistic for nursing in general, just signs through our Galen enrollment. At each one of our markets, we are seeing an acceleration of students coming into that space. So we’re not seeing campuses where we can’t feel, we’re seeing the opportunity to continue to grow in that space. So I’m very optimistic that we’ll have a workforce that will have a great culture for them to thrive in, and then those nurses will also have a great opportunity to continue to grow through all of our education offerings and experiences that they can take advantage of.

Chip Kahn (23:54):

Sammie, this has just been great, and I just want to express my appreciation for your service and to all the patients across your system that every day benefit from your leadership. So with that, just want to thank you so much.

Dr. Sammie Mosie (24:08):

Thank you.

Speaker 1 (24:14):

Thanks for listening to Hospitals In Focus from the Federation of American Hospitals. Learn more at fah.org. Follow the federation on social media @FAHhospitals, and follow Chip @chipkhan. Please rate, review, and subscribe to Hospitals In Focus. Join us next time for more in-depth conversations with healthcare leaders.

Sammie S. Mosier is senior vice president and chief nurse executive for Nashville, Tennessee-based HCA Healthcare, one of the nation’s leading providers of healthcare services. Dr. Mosier leads a team of nurse executives at the regional and facility level, and approximately 93,000 registered nurses working in HCA Healthcare hospitals, ambulatory surgery centers and other sites of care.

Mosier joined HCA Healthcare in 1996 as a medical-surgical nurse at Frankfort Regional Medical Center in Frankfort, Kentucky. Throughout her career, Mosier has demonstrated a strong focus on advocating for nurses, driving clinical excellence and colleague engagement, and supporting the professional development of leaders at every level of the organization. She spearheaded HCA Healthcare’s Nursing Advocacy Agenda, Unit of Distinction Awards and the HCA Inspire mobile app, which recognizes and connects nurses across the enterprise.

Most recently, Mosier served as the chief nurse executive officer for the HCA Healthcare National Group and vice president of Group Clinical Operations in the Clinical Operations Group. Prior to this role, she served as the vice president and assistant chief nurse executive with the legacy Clinical Service Group since 2016.

Mosier earned a doctorate in healthcare administration, a master’s degree in management and leadership from Webster University, and a bachelor’s in nursing degree from McKendree University. She is a board-certified nurse executive through the American Nurse Credentialing Center.