In this episode, Griffin spoke with Monica Moore, a former nurse practitioner who currently consults with fertility practices around the globe from her home base in Florida. They discussed the topic of nursing staff retention, how to prevent burnout, and the importance of emphasizing employee engagement. You can reach Monica on Twitter @monicamoore422, on Facebook at Fertile Health Expert, or through her website, https://www.fertilehealthexpert.com.

Griffin Jones: Today on the show with me is Monica Moore. Monica attended the University of Pennsylvania, where she became a Nurse Practitioner. She also was a clinical instructor at Penn, and then was a clinical instructor at Yale for a number of years. She worked at RMA of Connecticut, and now consults fertility practices around the world from her offices in Florida. Monica, you are the person that so many people think of when they think of nursing in our field. Welcome to Inside Reproductive Health!

Monica Moore: Thank you for having me, Griffin! I’m excited!

GJ: So how did you get to be that person? There’s a lot of nurses and nurse practitioners, but how did you get to be the person that consults with practices about their nursing team and find yourself in this role where you’re dealing with so many clinics? Why is this important?

MM: I guess I wanted to have that person. I wanted a person to do that for me, when I was orienting and later when I was a nurse manager who was so busy that I don’t feel like I really gave the new nurses everything they needed in terms of succeeding and the information they needed just to be confident at their jobs. So I created that position for myself at the places I worked, and then I moved around a little bit. Once I moved to Florida, I figured this is my opportunity to try to make this consulting aspect of the business work, instead of just doing it on the fly. A lot of my previous clinics where I worked in-house became my clients— and still are— and so I’m able to train their nurses remotely from a quiet place, without patient phone calls and all the other distractions, like being pulled into meetings. I find that being able to do that really gives them what they need in terms of succeeding. I feel that it takes a lot of pressure off the nurses who are well-meaning, but either don’t have the good materials or the time to properly educate somebody, which to me is the first step in many steps in really improving nurse engagement, which is my passion.

GJ: Let’s talk a little bit about the importance of nurse engagement. Maybe it’s just me, and the tracks that i attend when I’m at a conference— I’m going to patient relations programming or practice management programming— it seems to me from afar that nursing just seems so siloed, even when we overlap a little bit. I think that nursing is the central point of patient relations, if we’re looking at it like in access. It’s the bullseye. Would you agree with that or disagree with that? Let’s talk a little bit about what that’s like.

MM: For sure. So you know how you have that expression, “You only have one chance to make a first impression?” A lot of offices feel like it’s their website, or maybe the front desk, but truly the person you’re gonna be in constant contact with, who’s your liason between you and other parts of your care team, who’s your person, so to speak, is the nurse, in most practices. As it should be. They’re your organizer, they’re the director, they’re the liason, they’re your educator, and so in keeping with that, for sure, to me, they are the person that it’s very important in every reproductive endocrinology office— which is what I do— or every office so to speak. But they are very autonomous in this field, which is great and not so great when you don’t really know what you’re doing, which is where people like me come in. The patients when they go to reach out to talk to somebody, usually often reach out and talk to their nurse. Then the nurse will have to delegate and sometimes doesn’t delegate, which we can talk about later in terms of overdoing the non-nursing essentials but the patient’s person is the nurse, in my opinion.

GJ: So we get people to appreciate that, and I think most practice managers and physicians can appreciate that at an intellectual level, and that’s our audience— practice managers and practice owners. One of the things that they often mention that they face challenges with is really high burnout rate with IVF nurses and feeling like they just can’t retain them. So, before we go into all of the reasons why that might be happening, can you set the stage for us of what burnout is for an IVF nurse, and what is happening?

MM: Yes. So I feel like we should talk about a couple of terms. One term we talk about a lot is retention. That’s somebody staying at their jobs— and that’s just the bare bones, if you want somebody to stay at their job. What I like to talk about, and what I’m interested in, is engagement. That’s somebody having an emotional connection to that job, to their manager. They’re the person that, on a snow day, stays late at the office because they need to make the calls and other people live two hours away. They do it because they are emotionally connected, they have an attachment to this office. They want to see it do well. When we talk about burnout, that’s the opposite of engagement. Nurse burnout is when somebody is taking care of somebody, and we can talk about this in terms of compassion fatigue, which is another term for it, but they become cynical. They start to complain. They feel like there are ceilings where they’re working. They feel underappreciated. And it starts to effect their role, which starts to affect patient care. It also affects the other nurses and every discipline in the office. When you have a complaining, cynical, crabby-pants nurse because they feel underappreciated, there is a trickle-down effect which becomes a waterfall in terms of the lunch room and in terms of how the patients are treated. They just do the bare bones stuff, as opposed to being engaged. An engaged nurse is a completely different person when they’re talking to patients. And that’s what you want in your practice.

GJ: And that’s interesting, because on a spreadsheet, burnout might be the opposite of retention. You’re saying it’s the opposite of engagement. That’s to say that someone might be burnt out, totally not engaged, but they’ll still stay on the staff and take a paycheck for, what, six months, a year, two years, FOREVER?

MM: As a nurse manager, those are the people that we struggle with. That particular subset of nurses- those who are staying but are unhappy. We can’t really write them up, saying, “You haven’t done this, you haven’t done that, you really need to go,” and they’re not going because, whatever, they get benefits through their particular practice, or it’s an easy job for them in terms of hours or childcare. But those are not ideal. So just having nurses stay, which is already a feat in and of itself, just having nurses stay is not good enough as far as what you’re going to get distilled down into patient care.

GJ: So before I talk about the reason why they stay or why practices don’t fire them, and you hinted to it, let’s talk a little bit more about engagement. How the heck do you measure that?

MM: It’s difficult to measure in ambulatory care settings, which is what a lot of fertility offices are. A lot of the research is done in hospital settings. So, one of the sentinel articles which is old now, it’s from 2004, there’s been a couple of updates, but these researchers found that more than a third of the nurses they’d surveyed intended to leave their positions in the next year. As we know, orienting new employees, especially new nurses, can be incredibly expensive. A lot of nurses will leave before the one year mark or after the ten year mark, so there’s an overstimulation/understimulation ends of the continuum that need to be addressed. Another statistic that I found interesting is that the manager of the nurses, or the team leader, is responsible for 70% of the variability in terms of whether the nurses are engaged— not retained, but engaged. And it’s not buying somebody a pen or giving somebody a lunch. It’s making them feel appreciated according to certain- you can study the metrics, which is difficult in ambulatory care settings to study the rate of retention, etc.

GJ: Do you have any indices— I think a good manager knows when their employees are really about taking ownership of their seeds vs. those that aren’t. But it’s tough to measure, ok, we had a snow storm three weeks ago and Janet stayed an hour and 45 minutes extra so everyone else could go home that lives further away. What else are you looking for?

MM: Well, there’s a couple of metrics out there for nursing, not necessarily specific to certain kinds of nursing. One is called— the American Nurse Association put out this Magnet Recognition Program. It’s 14 defining qualities in organizations that help with enrichment and retention. I didn’t write all 14 down, but basically the gist is they want to be recognized, they want intellectual stimulation, they want to know that there’s no ceiling to what they can be doing, they want supervisor support, they want their leaders to inspire, engage, and motivate them, and motivate them to inspire others. The opposite of the burnout, crabby lunchroom nurse. They want to know what the expectations are, so they can meet them. One of my least favorite things to do as a nurse manager was to write an annual performance review, because I had 30 of them to write. At the beginning, I’m using good words, being thoughtful— by 15 or 15, I’m, like, “What’s another word for do? What’s another word for dress?” And I really was doing them a disservice in my mind by trying to group them together. These need to be done thoughtfully and regularly, and they need to have the expectations set, because then you can’t feel bad if somebody doesn’t meet an expectation that they don’t know or that they haven’t been told about before.

GJ: So it’s nurse manager’s job to be measuring these, evaluating these, and then sharing that feed back with the nurses.

MM: In my opinion, or team leader, depending on who does the evaluations of a larger office potentially would have a couple of nursing leaders who report to the nurse manager or nurse specialist, whoever that falls under.

GJ: What happens when it’s the leaders and the managers who are burnt out?

MM: Well, that happens often. (laughs) It happens often, and then those are the people that end up staying. So then the next person up— the nurses and leaders need to feel that their next person up recognizes them, supports them in terms of having a competitive salary, understanding that they can’t do everything, even if they do do everything, they potentially can’t do it well. I feel that, for nurse leaders and nurse managers, they need to be valued. I think that a lot of times, they’re undervalued. What do they really do? What do you see? You’re in these meetings.. In order to attract qualified nurses, you need to make the job attractive. That attractiveness is a role that will continue to evolve into different iterations, depending on what that person wants and what that practice needs. And it’s keeping up with that. The only way you can do that is having a relatively regular review or process or discussion or conversation.

GJ: In smaller practice, would that be a practice administrator? Or does the physician-owner need to be involved in that feedback?

MM: I think the practice administrator for most practices. I feel like they’re the next person to talk about the non-clinical part of the practice. But then, whoever the physician is, whether it’s the medical director or if there’s a different physician who ends up becoming the nurse liaison, it would be that person. And having that open line of communication. On the nurse manager’s part, or nurse leader’s part, they need to be prepared for these meetings and discussions with, “Here’s what we think is going on,” concrete details, and importantly, what they suggest, if they have any suggestions, about what to do if there’s a challenging outcome or situation. There’s nothing that people dislike more than somebody complaining to them without having any ideas, strategy,clue about what to do next and just leaving the room. For everybody to be prepared, and for there to be an open line of communication and approachability by the next person, whether it’s the physician or the clinical practice manager is important.

GJ: Can you give some more examples of what the details would be if there’s any sort of issue going on in the practice that the practice admin or medical director is bringing to the conversation with the nurse manager?

MM: A lot of times there’s a specific person that’s staying, but nobody wants them to stay, including the person themself. There needs to be concrete examples of what is happening and what was done, according to what was happening. Has the patient been— we have people come from other practices that have ten years of infertility experience, so we get them into our practice and assume that they know infertility. Either they do, and they do it in a different way, or they were in a practice where they were not autonomous, so they’re afraid to take risks. In that situation, what drawbacks need to be addressed? What strengths need to be addressed? Maybe that person is great for your center, but not for their current role. Maybe you’ve got to find a creative spot for them in your practice. If it’s a NP that’s being late on all of her scheduled appointments throughout the day, maybe she needs to be taken out of the clinician role or put into a partial clinician role, so maybe part she would end up doing some direct patient care, because that’s what she likes better. It’s writing down what the issue is and having a policy and procedure. I also think having regular quality control or quality improvement meetings are essential. All of the practices I work with either have them or we’ve implemented them. Whenever there’s a mistake, there needs to be no judgement about who made the mistake, a written account of what happened, and, more importantly, what you’re going to do to keep it from happening in the future.

GJ: In really small practices, there’s one doctor and one nurse. In really large practices, does it have to be every doctor with every nursing team? A doctor has a few nurses on their team in larger practices, or is it really the doctor of that one physician who’s the nursing liaison to show the appreciation, gather the feedback, conduct the evaluations? I wouldn’t see every physician doing that, but I guess if you have an amazing nursing liaison as a physician, does that compensate if a lot of nurses have poor relationships, or just don’t feel like they’re getting encouraging feedback from the doctors they’re working with?

MM: I think if they don’t feel supported, you have to find out where the stopgap was. Maybe it’s the nurse leader. Maybe the physician has no idea the strides this person is making in what they’re doing because the nurse leader isn’t fully acting as the advocate for that person. But let’s assume the nurse leader or manager is, and she’s doing regular reviews. Some practices have a physician sit in on the review with the nurse manager. That physician could be the one that’s there that day, or it could be the physician who knows that particular nurse because that nurse has that physician’s patients the most. Not everybody has primary nursing in their practice, so a physician can have a couple of nurses, but that nurse can have all the physicians’ patients. It depends on what kind of model the practice uses. I always recommend that two people are sitting in on whether it’s the regular physician or the practice manager, along with the person that wrote the evaluation, the nurse leader or manager.

GJ: What do you do as a consultant when you start to see that there might be a really deep-seated cultural issue of feedback, of the way staff gets along? We work with clinics both really small and really big that have amazing cultures. We can physically feel it when we go to their office, when we go out to dinner with them, the way they treat each other. It’s not something that they’re just checking off on a quarterly spreadsheet. It really is in their DNA. Working with those clinics is night and day different from different people who… it’s just broken. It seems like trying to help them implement one system over here becomes so much more difficult because it’s just broken from the top and it’s been that way for awhile, and it’s systemic to the practice. When you feel like there’s a bigger cultural issue than can be solved in a couple of sessions, or workshops, or a training system over several months, how do you address that?

MM:I’m lucky, I think you and I have talked about this in the past, in terms of how we pick our clients. We’re at a point where in order to do the best job, we have to pick people who are receptive to our ideas. When I have somebody approach me to be a client, I”m able to assess that pretty quickly. I go to the center, where I stay with them for a couple of business days, often there’s been phone calls before. I can say that there’s very often where one of the nurse managers who’s there is not happy about me being there in the beginning, feels threatened, feels that I’m going to be judging what she— most of the time it’s a she— has done in the past or continues to do. That ends up being ok 99% of the time. In terms of the entire practice,I have had practices that I have turned down as clients because I can tell that they are not-- that there’s-- it’s going to be very difficult to make any kind of positive change. I’ve had practices where I’ve asked them to invest in their nurses— not just financially, but emotionally— and I can see it’s not happening. They’re not interested in making robust patient education systems on their website or in other ways which can decrease the work that nurses have to do. That’s stuff you can tell early on. Other practices I’ve gone into and I love everyone there, but they just don’t have the paperwork that’s necessary, they don’t have the manuals necessary, they’re not sure about FDA guidelines, those practices I’ll take in a heartbeat. They have the glue— or they’ve recently converted to electronic medical records and they need help with it— those practices I take on in a heartbeat because the staff I can help and fix because the culture, the cohesiveness of the practice is already there. I cannot do anything in terms of making a practice cohesive if there are a lot of hard feelings and antagonism that precedes me.

GJ: To me, that’s one of the best parts about being a consultant. The better you get, the more selective you can be in the clients you take. The more selective you can be in the clients you take, the better you get.

MM: For sure.

GJ: It’s a virtuous cycle. If we feel this way as consultants, that should be a red flag. If consultants don’t want to work with you on a basis where they’re not with you all of the time, what does that mean with attracting talent?

MM: Well, it’s interesting. A lot of them will want me to be basically their headhunter. So like, ‘If you can’t work with us, will you help us find nurses who will?” I’m reluctant to do that. Because I’m not going to have somebody, especially if they’re going to move to a different state, much less a different practice and give up their benefits or retirement that they’ve invested in so far, to be in a place where I don’t feel comfortable working there. I’ve had to have uncomfortable conversations with physicians about why I wouldn’t necessarily recommend their practice for nurses to move there because of X, Y, or Z. But I usually have already written down in my practice assessment what the issue is. If they’re willing to work on the issue— and a couple have been— I’m willing to recommend nurses. If they’re not, then I’m uncomfortable recommending nurses to a place where I wouldn’t even work for a short time.

GJ: Maybe we should elucidate a bit more what core culture is. I don’t necessarily mean bad people— sometimes I know really good people who own and run practices that just don’t have the time, ability, knowledge… for whatever reason, they cannot or will not invest deeply into these areas of the practice. I think that’s ultimately what it comes down to. If you’re unable or unwilling to, that results in the inferior culture, or the cultural problems that manifest themself person at the top. That’s often not the case. It’s often good people who had a good practice for a long time, but they just don’t want to or can’t get into it enough to let you do your job or let other people do their job. At least that’s my take on it. What do you see?

MM: Everybody I’ve talked to is because of the latter that you’ve described- not the abusive, boss. Everyone falls into well-meaning people that can’t get their act together. Part of it-- I think it has to be broken down into parts. One is that there are a lot of good people there, but there’s not a collective good. Not a collective cohesion. There’s not a need for the nurses to work with each other and work well interdepartmentally. I see that there’s a lot of resentment between departments; people don’t know what the other department does. And I”ve seen a lot of practices where it starts with the physicians who can be incredibly unapproachable. I’ve seen that less and less- I’ve done this over 20 years- it’s becoming less and less the physicians are unapproachable. It used to be that you had to go through 50 people to get to the physicians. That’s becoming a little bit better. But even if they’re approachable, that doesn’t mean that anything you’re saying is resonating with them in terms of making a change based on your suggestions. I think that everyone wants to be heard and even if they’re not going to listen to what you have to say, you can tell when someone is heard or when someone is shutting you down. There’s also within individuals… what I find, is that I would rather, in terms of hiring, hire somebody who is an ER nurse or a critical care nurse to work in an infertility practice and teach them reproductive endocrine theory than teach someone who knows women’s health how to multitask. A lot of times what I find in cultures with well-meaning people are individuals who are unable to multitask. What happens to those who ARE able to multitask overdo everything because they feel like they can’t delegate, the ones who can’t multitask spin around in a circle and just do things that they can do quickly, but they don’t really do anything well because they can’t figure out where to start. The practice of reproductive endocrinology is very quick, the patients are very savvy, they’re very well read, and you really need to be on your game. You need to be able to do a couple of things at once, and you need to be incredibly organized. Those are things that cannot be taught. Really, the culture of the practice starts with who you hire and the qualities that you look for in someone that you hire, which don’t need to be women’s health. Women’s health is so easy to teach to a bright, savvy, motivated person. I cannot teach a women’s health person to be bright, savvy or motivated. And that, to me, is the issue. That’s the start. In terms of the collective cohesiveness, it’s how they’re treated once they get there and how they continue to be treated.

GJ: So, based on what you just said, the caveat being how they’re treated once they get there, I’ll see your assertion of the culture starts with the people that you hire and raise it with it starts with the people doing the hiring.

MM: Agreed.

GJ: That starts from whoever’s name is on that business. There’s one thing I’ve been writing more about, asking people about, interviewing more deeply, is the structures that practices are built on, because multi-physician practices can work, and independently owned practices can work, but I don’t think they can work the same way they did 25 years ago. That has to do with how the structure is set up from the very beginning. Not necessarily as a legal entity, but operationally. One of the things I enjoy most about owning Fertility Bridge is that it’s a dictatorship. I don’t have to ask another co-owner what direction we should take, should we hire someone. I solicit the advice of mentors when I need counsel, and I get the advice of my team, I get their feedback to help inform my decision. But the fact that one person makes the decision makes it a lot easier to chart the direction. I think a lot of practices are set up to where that was just the way it worked in the last century. You had a doc that completed medical school and there weren’t all these large practice groups. You either joined a health system or university or they owned their own practice and opened that. However many physicians there were is typically how the partnership was divided. Now, when you have companies coming in with a very specific direction and motive and goal set, competing against practices that don’t have a mission statement, don’t have defined annual goals, mainly because they don’t have one person in the visionary role steering that ship. That’s where I think it starts. Would you agree or disagree?

MM: Agree. I think that every practice needs a visionary- or a couple. But they also need the people that carry out the visionary’s stuff. I consider myself a visionary in some ways, and I like to start stuff and I’m terrible at finishing stuff, which is why I’m good as a consultant, because I get everyone going and I hope to train people to do that. You need somebody that sees the bigger picture. I was reading about the difference between a leader and a manager. A manager looks inside to figure what the can do in order to tighten up the inside part. A leader looks outside to determine where they are in terms of where the other centers are and what people need. Going back to what you said, these companies that are buying these practices, for example of lot of them are promoting egg freezing. Egg freezing, or oocyte freezing, we just became not experimental in 2012-2013. Now there’s a huge need for it. There’s a lot of data on it that it works now when it didn’t work so well before because of the tech that we used. A lot of these large companies want centers to really focus on egg freezing for “social reasons” in terms of people that are aging or don’t have partners so they can protect their reproductive potential in addition to patients who used it before, such as patients who were undergoing cancer treatments or toxic treatments that might negatively impact the ovaries. The business might be getting very, very busy with egg freezing because that’s what the company that bought them thinks that they should be doing. They might be saturated with patients who might want to do it, who require a lot of counseling, as they should. This is a big ethical issue. There’s a lot of financial repercussions, we’re still not sure how many eggs to freeze, etc. There’s a lot of studies this is ongoing and evolving. And the nurses still have other patients who are still getting embryos back and are still making pregnancy test calls. Where do they find their role? After the person who freezes their eggs freezes them, the eggs go in the freezer and that person is gone for at least a couple of years or maybe a year. But you still have your patients that are ongoing. You feel like you have to have your attention, or maybe your caring, divided between what’s expected of you and taking care of the people who are already there.

GJ: So when we lose some of the nurses because maybe we’re not set up to support them as well as we want to be, or because we’re not in line with how we need to be operationally, do you find that people keep the nurses that shouldn’t stay on the team for one of these— which one of these two reasons do you find people keep nurses that shouldn’t be on the team more than they should be. I typically find there are two reasons for keeping anyone on the team longer than they should be, no matter what the team is. The first is that the person in charge of hiring and firing doesn’t want to have that conversation and let them go or feels bad about it or makes excuses for them. I typically do not make that mistake. I have been guilty of the second mistake, which is can’t or won’t take the time to find the right person to replace them. What do you find is more common when there’s somebody on the team that is causing a toxic problem?

MM: I think what you said… the latter. I think we’re all in managerial positions somewhat getting better at uncomfortable conversations, so we’re going to have those conversations where the lack of a conversation is going to keep the person there. But, in my opinion, we don’t want to make another hole in the staff by firing somebody. Sometimes, oftentimes, there’s one nurse that’s there that you’re like, “Oh my gosh, we can’t give the patients who need extra support to Joan, and we can’t give this person to Joan,” but Joan is really good at following up with insurance companies and making sure the person gets their medication. Which, in my opinion isn’t a nursing role. We end up keeping Joan- we keep a body there that does these tasks and then we don’t open up the hole because we don’t want to have to orient somebody, and we keep thinking Joan is gonna get better and more appreciated and it keeps getting worse. What we don’t realize is that the other people that are taking on the stuff that Joan can’t are getting more and more burdened, and more resentful of Joan and the people who are unable or unwilling to just let Joan go. I’ve talked to a lot of people over the years about this. One thing that makes nurses good is intuition. A good nurse has good intuition. If you know in the first three months that this nurse isn’t gonna work out, you still have to do all the writing stuff, but you’re right. You know you’re right. And it’s best for everybody— including that nurse who probably isn’t happy calling insurance companies all day– to then let that person go. But it is very difficult, because then you have a hole you created. You’re down a person, so the remaining people are taking care of her work, and then, they’re like, “Who’s going to be the one to talk to the new orientee? Who’s going to be the one to train the orientee?” The day is so burdened and so heavy when you’re going over every word you’re saying with someone that you’re orienting, and you’ve still got your own work to do, which most of the practices don’t have a separate nurse educator. Getting rid of that person opens up a whole new can of worms.

GJ: In my business, I keep two positions open evergreen at a part-time level, just to get people in. If they’re good at those in different ways, if they can spin out as a project manager or a social media manager,they can evolve to different things and I just want those people in my ecosystem so that I’m not having this problem if and when it’s time to replace people or as we grow. Can practices do something similar?

MM: There are– for nurses, there are roles that are more or less complicated or involved. In the infertility setting, a lot of people have asked me of that track. If we would be willing to hire a new graduate. New graduates have a hard time finding their first job, like anyone that’s new in the workforce. People have asked me if I’d be willing to hire a new graduate. I used to say no, or I’d say only in the OR. Because you’re teaching them prostop stuff that’s pretty easy to teach and then they’re getting a little bit of reproductive endocrinology, you get a feel for the person, you’re getting to know if they can problem solve. I still feel that’s good. Now? I’m willing to have a new graduate start work in a reproductive endocrine center. First of all, a lot of these grads that go through and get their masters have never worked as a nurse before. They go to nursing school and then immediately get their masters, so I don’t know that a new graduate who’s hungry to work and is interested in something is necessarily a worse hire than someone who’s been on the floor for fifteen years and are sick of it and want to get into an ambulatory care setting because they want to work Monday through Friday. I really think it comes down to the particular person. For nursing roles, there’s varying levels of complexity. You can start someone in a not complex role and gradually move them into that. We’ve had people that we really liked that say, “this is too much for me. I like what I’m doing, but it’s too much,” so we job shared. Two of them cover Monday through Friday. They like it because they have days off in between. Other people who need more of a challenge, we put them in the third party program, where you donate eggs or embryos or carry another person’s pregnancy, because there’s complexity there, there’s different people that you have to deal with. We have people who say, “I just want to be in the operating room. I need to know what I need to know for the operating room.” If they’re a good employee we find them a role like that. We probably always have a nursing position open because we have a position open, and who are we going to find to fill it. We need to lessen the weight of experience and be more critical of the person themselves and find what their positive attributes are.

GJ: I wanna wrap this up by talking how we can support nurses throughout compassion fatigue. I’m very open about this with my clients, my employees, my team are more important to me than my clients. I tell my clients that. My employees are the most important to me because if my employees are happy, then everything is right. They like working with each other, they like doing new stuff, they like doing extra things for the client. They take ownership. They don’t throw blame at each other. Speed is so much more prevalent. I tell people all the time, I will not take on a new client if I feel like they’re going to be abusive to my team. That’s a lot different in a REI practice when you’ve got so many patients, and so much more emotion and the gravity of everything they have to deal with. How do you balance that with the patients that are struggling with all that that can get projected onto the nurses, versus the nurses having to do their job and also provide compassion for them so that they are taken care of, happy with their care, more compliant in treatment so they get better outcomes, versus the nurses being taken advantage of and then having compassion fatigue. How do you balance all that?

MM: First of all, what you described with your employees is how I would define engagement. All those things you said that is important for your employees to do and for you to support them in doing is an engaged employee. The opposite of that is… what makes nurses good is their caring, their compassionate, and intuitive. Compassion fatigue is almost being that to your own detriment. Let’s put it in a… when I first started working, I was in the neonatal ICU. I loved the babies, I loved taking care of them. Unfortunately, you lose babies in the neonatal ICU. You get very close to the parents. And for me, being twenty-something years old, it was just emotionally too much and I knew, and I left that. Once I got into reproductive endocrinology, you don’t have that critical care aspect with the loss of a person, but you have the loss of a dream, which is someone’s pregnancy. You make many, many, many, “You’re not pregnant” phone calls. You get very close with some of these patients– many of us do. I’ve been in the same place for fifteen years and people are still sending me pictures of their kids that are now 15 years old. They find me wherever I am. They feel- there’s a very strong bond there. But that bond keeps me up at night, wondering if I could’ve had a bit of an easier or better conversation, did I talk to the person in the right way. In terms of compassion fatigue, you really need to be good about boundaries. You need to have self care. For me, who’s always willing to take that extra weekend or do mandatory overtime, I had to stop doing that because I realized I was doing it to my detriment. I wanted to be there for the practice, but I wasn’t there for myself. It’s setting a boundary in terms of self care, setting boundaries with patients. I’ve had patients send me 15 emails a day. I say, “I understand you’re nervous. I’d be nervous, too. You can send me one email with 15 bullet points.” And they do. Otherwise, I don’t say anything, I don’t set a boundary, and I’m like “Oh, there’s this person again!” and I start talking about the person to the other nurses. It just perpetuates, and it feels unprofessional. Which it is. So, for me, it’s really… the other thing is you want to have the systems work. You need to have an IT person or an IT system that’s good and available. The not having IT support or nurses not knowing how to do computer stuff is a big issue-- the nurse is not doing nursing stuff, which to me is calling for a pre-authorization of medication and being on hold for 15 minutes. A lot of practices have nurses doing that because there’s no one else to do it. Having a non-clinical person to be that support and let nurses act as nurses, so they can take care of the patients they have and set the defined boundaries and stay in them for their own personal care and to take care of the patients. I’m still going to be up at night, wondering if I said something the right way or I should’ve said something different, and thinking about that patient who’s been through eight cycles and are still getting a negative pregnancy test and what I can do for them-- that’s part of me. That’s not going to be something I wish I’d done differently. I’ve done this for so long now that I feel like I know what to do and what not to do.

GJ: Do nurses set their own individual boundaries, or is that set by the team leader, the nurse manager, the practice leadership..

MM: I think large boundaries are set by them, but when it comes to how many emails a day or how many phone calls a day or that is something different. That’s an individual nursing thing.

GJ: I guess there has to be some agreement from the top of, “We’re going to support you in these boundaries,” having an idea of what they are because I could easily see a nurse setting some of these boundaries that if that is not in agreement with leadership, you’re not doing your job…

MM: Yes. It has to be a conversation. I’ve had to have that conversation, because there have been patients who really have pushed limits. I’ll go to the physician I work with and say, “Hey, Jane Doe is really pushing limits. I’m going to challenge her. I’m going to push back, here’s what I’m gonna do and say and I need your support.” 99% of the time they say, “Absolutely.” Very rarely, but just giving a heads up-- if the patient reframes the conversation and calls the doctor and says, “Monica called me and told me not to email her anymore,” they were already given the heads up that this was a pushing back and what happened to precede that.

GJ: Monica, I’m not just saying this because we’ve been friends for awhile and we’re on interviews together, but I think anyone having issues with their nurse management, issues with retention, issues with burnout among their nurses should contact you. We’ll have your contact info in the show notes. Everyone I’ve talked to that’s worked with you has nothing but great things to say about you. What would you conclude, knowing that our audience is practice managers, practice owners, physicians, that they should know about their nurses and their nursing teams?

MM: I really feel that I can’t say enough about making people feel supported. Making people feel valued. I think that one of the main reasons people leave is because they perceive they’re undervalued in some way. Whether that’s a “Hey, how’s it going today,” whether it’s starting a meeting off with,”I want to thank this person for this,” whether it’s sending an email out about a new baby or congratulating someone for something, I really feel that in order to attract qualified nurses, you need to have a really good job setting. It needs to start off that way with the hiring, and then they need to be valued once they get there. You need to incentivize someone to be there, but the incentive doesn’t need to be monetary.

GJ: Monica Moore, thank you so much for coming on Inside Reproductive Health!

MM: My pleasure! Thanks so much for asking me!