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Jim Jordan:
Welcome to the Chalk Talk Jim podcast, where we explore insights into healthcare that help uncover new opportunities for growth and success. I'm your host, Jim Jordan.

Jim Jordan:
Hello everybody, and welcome back to the show. Today we have an exciting interview with Keith Carlson. He's an experienced nurse, an author, a coach, a podcaster with over 27 years of experience in nursing. Keith has a unique perspective on the nursing profession gained through his diverse background working in community health, home health, and hospice care. He's also a board-certified nurse coach, and he's focused on helping nurses advance their careers. In our conversation today, Keith shares insightful commentary on the state of nursing and healthcare based upon his experience, and we discuss the corporatization of healthcare, the nursing shortage, staffing challenges, physician burnout, and suicide, and much, much more. Keith offers a thoughtful critique while also recognizing that there's positive changemakers out there trying to improve our healthcare system. Overall, I'd say it's a highly informative and engaging discussion. I think both healthcare professionals and the general public will truly appreciate. I hope you enjoy this interview as much as I do. And why don't we start by Keith telling us a little bit more about yourself?

Keith Carlson:
Thanks, Jim. Yeah, I've been a nurse for 27 years at this point, coming up on 28, and I've really I cut my teeth in community health, federally qualified health centers, working in the Latino community, in economically depressed cities in western Massachusetts, and did home health, hospice, very intensive HIV case management. Eventually became the director of nursing of a home health agency here in New Mexico. And so I've really worked in the outpatient space, the ambulatory space. I've honestly avoided the hospital my entire career, which I was told would be career suicide, but it's worked out pretty well, and the hospital space just was not my happy place. So I was like, well, I'm just not even going to go there. And during over these years, especially in since around 2010 or so, I discovered podcasting, I discovered that I could do freelance writing, I discovered coaching, so I became a board-certified nurse coach, which was a pretty new designation at the time. And I focus on nurses' careers. I help nurses with their careers, and so everything revolves around that. And I have seen that things have devolved in the healthcare space on many levels since I started out in the late 90s, actually the mid-90s. And there's a lot of issues going on out there and a lot of strife, and people have a lot to say about what's going on in healthcare right now. So I'm in the mix working a little bit clinically and also talking to nurses and healthcare leaders all the time. And there's just it's quite a time we're in right now in this sort of post-pandemic world, wouldn't you say?

Jim Jordan:
I would. I want to step back a little bit. What's the board-certified nurse coach? What organization does that certification? And in case anyone else in the audience is interested in pursuing something like that.

Keith Carlson:
Yeah, it's INCA, the International Nurse Coach Association, founded by Barbie Darcy, who's been around for many years. She lives here in Santa Fe, New Mexico. Susan Luck. There's other people who were involved, and they did a lot of work to codify coaching in from a nursing perspective and create a curriculum, textbooks, evidence-based information, and also a certification exam for people to become board-certified. So before that, nurses would do certifications with a lot of wellness organizations out there to become health coaches, which was great, and life coaches, but to actually codify nurse coaching and create a whole curriculum and a conceptual framework around what nurses can do when they have the skills of a coach and healthcare organizations are actually seeing the benefit of that, and they're actually hiring nurses as coaches, health coaches to work with their patients. And I've delved more into the career coaching because I felt like nurses needed my help, and I thought I could have a greater impact myself by helping nurses create careers that worked for them, whether it's entrepreneurship, the clinical space, leadership. So board-certified nurse coaches can actually do anything they want. But the basis of it are these the core of the nurse coaching concept and the framework, which I think is really cool. And I think it's great that part of nursing has been officially recognized as a specialty.

Jim Jordan:
Now, have you seen in any larger healthcare institutions where they've had that nurse coach helping other nurses as opposed to being patient-facing? Are there any institutions that are starting to do that?

Keith Carlson:
I hope so. I haven't heard of any specifically, but I hope there's organizations that have nurses who are working as coaches or mentors for their staff. And I think nursing is missing from my perspective, this philosophy of mentorship. I just feel like we need that. We're desperate, we're hungry for it. And I feel like a lot of newer nurses just get thrown to the lions and it's sink or swim. I'm mixing metaphors here. There's something about the nursing space and the healthcare ecosystem that chews up a lot of nurses, and it's sad because they're the backbone and the lifeblood of the system.

Jim Jordan:
So we were starting to talk about 2000 as a pivot point, in your opinion, and we certainly knew there were there was a nursing shortage coming. But I think it's something else. When I look at how they're managed, the efficiency before for the audience, we were talking before of a daughter who's a nurse, the scheduling of people and allowing them to have personal lives. There's something that leadership of these healthcare institutions do not understand in terms of managing their talent. What is it that you think is needs improvement, or why is this being ignored?

Keith Carlson:
It's multifaceted. One thing I think is the corporatization of healthcare has dehumanized the space, basically. You have a lot of larger organizations gobbling up smaller organizations, big health systems. Some of them are doing it well, and some of them are not doing it well. And I feel like the drive for profits and the shareholder mentality from my perspective has it's changed healthcare. Everything is so profit-driven and productivity-driven. We have I know we're not talking about physicians, but just to say physicians have been pushed into this 15-minute visit model. And nurse practitioners who work in primary care and specialties are being pushed into this 15-minute model. What can you accomplish in 15 minutes? Everything is being driven in these directions that are dehumanizing, that decrease the quality of care that we can provide. And for nurses, talk to many nurses and you're going to hear about staffing. And your daughter will probably talk about staffing. And during the pandemic, all hell broke loose, right? The feces hit the fan, right? And we had to figure out how to care for people in this absolute historic moment, which my hope at the time was that we would learn from that experience and realize, oh my gosh, look at these hard-working healthcare professionals and nurses, and look at our staffing models and look at how we're forcing people into these roles that are unsustainable. I don't feel like the lessons of the pandemic have been learned by most organizations, and we're back to business as usual. And all the thing about banging pots and pans at change of shift and heroes work here and all that thing. I feel like that whole paradigm of heroes and angels and saints and the way that we're painted is dehumanizing as well. Because, like your daughter, nurses are human beings and they need to have lives. They need to have mental, physical, emotional, and spiritual health. And like I said, they're thrown out into this world where they're getting chewed up. And that's a long answer. I'm sorry, but I feel like there's it's just so multifaceted right now.

Jim Jordan:
Yeah. There's a common theme. I think you were referencing nurses and doctors as really the front line. Right? Obviously. And that when you think of just-in-time manufacturing and they talk about non-value added, anyone who's not touching the product is considered non-value added. And your goal is to make sure that the person that's doing the touching is completely optimized and happy. And somehow you talked about this phase of scaling and cost-cutting we seem to be in and we call it corporatization. Yet if you go to big companies like Boston Scientific and Medtronic, they actually know down to the half penny what it takes to do things and the importance of people and productivity and rest in their factories. And we just aren't there yet in healthcare. And I'm not sure if it's just because we're starting in the past 20 years to computerize this business. But if you're developing systems, why are doctors still spending so much time in the electronic health record? You certainly need the guidance when you're developing a system. But once the system is burned in, there should be a low-level person doing that to save their time. And I don't think we have time for people to have conversations to hold hands anymore to, you know, I remember when my mother was passing that she had a nurse or two that would spend an extra five minutes and have a conversation, and that is part of nursing. That is actually probably why most people went into it.

Keith Carlson:
Yeah, it's like gold that time with the patient. And the other day I posted something on LinkedIn. I said that I had taken my father-in-law to the emergency room. He was evaluated, but the doctor never touched him, even though he had abdominal pain. Even though he was short of breath. The doctor didn't even put a stethoscope on his body. They drew labs. They did an x-ray never came within five feet of his body. Right? And then I saw a neurologist for a condition I have for a virtual visit. When I went into my chart and saw the neurologist's notes, the neurologist charted all these things that were done during the visit. Like he said, he had me touch the different parts of my body to show that they were equal neurologically. And he said that my gait was normal, even though I walked with a cane. And what I realized was he just imported a visit from someone else, and then just all the buttons were already clicked. So I took him to task and made him change the note because I didn't want my insurance company to see, oh, is gaits normal? He's neurologically intact so that I feel, and you should see the string of comments and reposts for that. What I said everyone is saying the same thing. So if doctors don't feel like they have time to even touch a patient, to do a physical exam, to listen to their heart for a murmur, or listen to their lungs or touch their shoulder, and they're importing pre-programmed visit notes that aren't even accurate, which is actually insurance fraud. If you come down to it, what's going on there? And if a nurse like your daughter has five patients or six patients when she's supposed to have three, and she can't give the quality of care that she was trained to do in nursing school, how is she going to feel when she goes home at night? So there's a disconnect there that makes me. It's maddening, I would say, and it's extremely frustrating.

Jim Jordan:
Where do you think the cycle goes? What challenges when you're working with nurses is, are you seeing that is unique, or problems that have been solved in a unique way that maybe the rest of the audience wouldn't think about?

Keith Carlson:
Some nurses turned to entrepreneurship more and more. They're inventing products. They're becoming freelance health writers, coaches, podcasters, starting all sorts of consulting businesses. They're creating new paradigms because they feel like they need to take control. Take my good friend, Dr. Renee Thompson. She's a doctor of nursing practice. She is the CEO and founder of the Healthy Workforce Institute. She'd be a great person to have on your show. Her mission is to be put out of business because she's trying to help organizations eradicate bullying and incivility, and she works with very big health systems here all over the United States. She doesn't want to even have a job. But bullying and incivility are so rampant in so many organizations that she goes in and she helps rework their culture from the top to bottom and the bottom to the top.

Jim Jordan:
So when you're saying this bullying, you're not talking about the children, you're talking about corporate cultures.

Keith Carlson:
I'm talking about nurse to nurse. First of all, that's a big one. And from my experience and my observations, that's internalized oppression. The nurses, when you feel oppressed from the top, your oppression goes to the goes laterally and you oppress the people around you. So there's a lot of dynamics there. So people like Dr. Thompson are creating companies where they're trying to change the face of healthcare. And then there's people like me who work with individuals. Some nurses are finding organizations where leadership is actually good, where there's solid, positive, humble, powerful leadership. And there are healthcare organizations in the United States that are doing it well. And I do talk to some nurses who are actually quite happy. So that's also lovely to hear. And what I want to see, and I think we're seeing is nurses are voting with their feet. And the organizations that don't know how to lead, that are toxic, that have toxic leadership and cultures. Those organizations, I'm sorry, but they deserve to go down. And the good organizations need to continue to rise and be supported. So I just think people need to vote with their feet, and patients need to know what's going on so they can vote with their wallets. And I think that's one way we can force change within the system. That's maybe that's naive, I don't know, but.

Jim Jordan:
Yeah, if you're interested in working in a hospital scenario, we're now in a lot of places in the country where you have 1 to 4 providers covering the whole region, and if you go back 30 years, 40 years ago, you had a lot more independent facilities. And I think that's probably one of the challenges. For those that are happier, what is it that their leadership is doing that you see differently from the toxic environment?

Keith Carlson:
They work in organizations. Let's say it's a hospital where staffing is actually paid the attention that it deserves, and the staffing is sane and humane, and the nurses feel like they can actually care well for their patients because they have the number of patients that makes it functional and also possible to provide the best possible care they can, the way that they were trained to do and give the holistic care that nurses are in the business to provide. So there are organizations like that. I think there are outpatient facilities and organizations where nurses feel they can also provide the care they want, whether it's home health or hospice or independent physician practices. Here in Santa Fe, a number of physicians in different specialties have abandoned our main hospital here and created their own physician run group, and they're contracting with a different hospital and working as an independent organization, but within a hospital. And so they voted with their feet. They left that particular hospital and we're like, see ya. We're going to create our own physician controlled practice where we call the shots. And I think maybe that kind of model will continue to create the environment where everybody can thrive. And what I perceive so far is that new entity here is so far pretty successful, and people seem like they're happy and it's heading in the right direction because the physicians have control. They're not being controlled from some big corporate entity out of state. So I think people are figuring out workarounds, and I think that's what we need to do. And people need to take the bull by the horns and figure out what's going to work for them and their region, or their city or their town.

Jim Jordan:
So as we see the people that are doing some good things and we hear more about the bad stories, how do you keep current on these rapid changes? Is it through these stories? Is it through the coaching association? Where do you get your sort of mega trends and things that are going on?

Keith Carlson:
Good question. One is doing my podcast. I've just recorded episode 49, so I talk to a lot of people and I'd like to have you on my show as well. So I talk to people who are in positions of leadership and power and thought leaders and people who are looking at this in all sorts of creative ways. So that's one way. The other way is I hang out on LinkedIn because I think LinkedIn is a great ecosystem for keeping your finger on the pulse of what's happening. There's of course, there's talk on the site formerly known as Twitter. There's conversations on Facebook, but feel like LinkedIn is the it's a great clearinghouse of conversation. And I think there's a lot of good people there posting sincerely and authentically. And I get a lot of my information from there. I also just talk to a lot of my friends and colleagues and people who are knowledgeable, and also as a career coach. Nurses contact me every day, so I hear a lot of stories and that gives me insight. And then as a writer, I interview people. I pull together stuff that I'm hearing out there in the ethers and put it into my own words, and I write for different organizations, so that also helps me distill what I'm hearing and feeling and seeing and put it into my own contextual framework for the organizations I write for. Of all these different streams of information coming in, and I try to continue to distill them. And then I speak at conferences and I get to talk to people in groups like that, too.

Jim Jordan:
Is there a new emerging issue that you're starting to get concerned about that hasn't really made it out to the public knowledge yet?

Keith Carlson:
No, there's nothing I'm hearing that is not in the public sphere. There's the staffing, there's burnout. There's honestly, there's suicidality in this country. We lose a physician to suicide on an average one a day. So about 400 physicians a year take their lives in the United States. And that is shocking to me. We don't have stats on nurses, but we know what's out there. So that might not be something the public thinks about. Really, one doctor a day takes their lives. What is that about? So I think that would be shocking to your average healthcare consumer on the street if you went up to them and said, do you know, I feel like there's just the ongoing conversations about what the heck is going on with healthcare in the United States, why do we spend more per capita than so many other countries put together? And we have these outcomes that just don't make sense in relation to the amount of money we spend. Something's up and.

Jim Jordan:
We're number one in spending and 9 to 12 in any given year in quality.

Keith Carlson:
Pretty much. Yeah. And that's I think it's shameful. And we we're supposed to be the leaders in all these different industries and there's just something amiss. And I like I said, I thought the pandemic was going to be the thing that shook it all up. And I feel like it shook it all up. But then it was like a snow globe and everything just fell to the bottom and went back to the way it was before. And it's a strange metaphor, but there are good people out there like you, like Dr. Thompson. There's so many people out there trying to flip it, and I just feel like we have to keep up the pressure and have more and more people out there who are willing to take the risk and put forth these new ways of looking at it. I hold on to my glimmers of hope that things will continue to shift.

Jim Jordan:
So I think also that I've never met a bad healthcare executive in terms of their ability to see the big picture, who intended to be a bad healthcare executive. I think what we're missing is information and understanding what is it we're trying to achieve and how to achieve it. And I think we're missing a structure. I look at the United States and I think it was the 80s or '90s formed the Baldrige Award to try to improve manufacturing to compete with Japan if most of our audience is probably too young to remember this, but we were very uncompetitive, our quality wasn't there, and the governor made an initiative to put in systems for that. It seems to me that as we're trying to do that with healthcare, if you really think about it, it's been 2008 to 2010 where we started really thinking about this. And one of the things that as I talk to people about artificial intelligence is the ability to get longitudinal data and make some sense out of it in a rapid way. And so I think part of the challenge we have is we don't understand cause and effect, whereas the nurse and the doctors do understand cause and effect. And there's so many layers between them and trying to understand how to financially keep an organization going. I think that's one of our challenges. And so I wonder when I look at physicians in rural settings and urban settings, you can see a dearth of support in number of people. Is that the same with nurses? Is there a shortage, more of a shortage of nurses in rural settings than there are in urban settings? Or is that not the same problem as we have with doctors?

Keith Carlson:
I'm not 100% certain, but I know, like I live in a very rural state, New Mexico, where I think we're the third least populated per square mile, something like that. And I do know that in some of these rural areas of New Mexico, there's a lack for sure, of physicians and nurses, and school-based clinics are one way that we reach some of the communities. We have a nurse or a doctor who round through a school-based clinic because there's not much else to work with. And the main hospitals are so far away. So I think the shortages happen in urban and rural settings, unfortunately. And there's a lot of different. There's a lot of different threads of the explanations for why the nursing shortage is what it is. There's a lot of different reasons for it, and some of them are being addressed and some of them are not being addressed. And we have so many nurses retiring. We do have a lot of people coming into the profession, but we have a lack of educators at the university and college level. So tens of thousands of qualified candidates are turned away from nursing schools every year. So that's a big piece of it. That funnel that feeds the profession has a bottleneck, and that bottleneck isn't really being addressed. And that's a big problem.

Jim Jordan:
So you're saying so I know when you think of physicians, there's associations in the US government at how many people are trained. I don't think that's the case for nurses. It's more of a supply and demand, am I correct?

Keith Carlson:
I believe so, yeah, to the best of my knowledge.

Jim Jordan:
Yeah. So in this case you're saying that there's not there may be more people willing to be a nurse. They just can't get trained.

Keith Carlson:
Tens of thousands. And part of the reason is because you can work clinically and make a heck of a lot more money than you can being an educator in academia. So there's not a lot of draw to the academic setting for that reason. And if we're turning away that many candidates in the face of a growing shortage, hundreds of thousands of nurses that were going to be short over the next decade or two, then that's something that should be addressed at a systemic level. And if that bottleneck doesn't get addressed by, I don't know, is it the government? I don't know who is supposed to deal with this, but something needs to be done because we need that funnel to continue to be fed. And there's a lot of talented people out there who would like to come into nursing. And nursing is a very progressive, holistic, growing world. There's a lot of options for nurses now. There's so many things we can do, but we need to keep that funnel healthy and keep people coming in and mentor them so that they can grow into leaders and just be the future of the profession.

Jim Jordan:
So it's not dissimilar to our public schools, where we're not attracting these folks due to salaries. And it strikes me as I'm listening to you, I'm here in Pittsburgh, and obviously, University of Pittsburgh and UPMC Medical Center are very tightly aligned. And as you were saying that I was thinking, most of my daughter's instructors also had a clinical appointment, and that's probably where they made most of their money. And they're giving back was probably not costing them something. If you were a rural setting, just only instructor sounds like to me interesting. I wasn't aware of that. So in your journey so far, what's the biggest lesson you've learned?

Keith Carlson:
I've learned so many lessons over the years. One is that, like I was mentioning, nursing is an extremely varied profession that if you ask the average person on the street what a nurse does, they'll say they care for them in a hospital. And that's about maybe 55% of nurses, maybe 60% of nurses, work in acute care hospitals of some kind. So that other 40 to 45% of nurses do other things. The breadth and depth of the profession has really grown over the decades, and I feel like nurses have so many choices now, and it's very exciting on many levels. And I think technology, artificial intelligence, there's just so many, there's so many options and opportunities for nurses who want to delve into new spaces. So there's lots of room and people are doing pretty cool things. So that's one thing I've learned. The other thing I've learned is that the American healthcare system, like I've been saying, has some toxicity in it. There's some dysfunction that needs to be addressed. And I've learned through my podcast, for instance, that there's a lot of really smart people who have some pretty amazing ideas and are doing good work in the world, and it's those people who keep me buoyed and help me feel that, that there's a way forward because we can become pretty despairing if we look at all the problems. But there are a lot of potential solutions, and there are a lot of amazing, brilliant people, and talented people who are working really hard and are very dedicated and earnest. So it's those people I like to highlight and those people I like to support because I feel like the solutions are there. I just feel like we need them to come to the fore. So that's another lesson I've learned is that the potential is there, it's all there, and we just have to knit it all together and figure out how to make it work.

Jim Jordan:
So my last question would be if you could, and I'm going to focus it on hospital because it seems to be the biggest challenge we have. What do you see as the biggest threat that needs to be overcome to advance nursing in the hospital setting?

Keith Carlson:
I think one of the biggest threats is culture. I just feel like we have toxic cultures. Like I was mentioning Dr. Renee Thompson and her work with the Healthy Workforce Institute. I feel like we need to address that. We need to make sure nurses support each other and that there's a greater sense of mentoring and nurturing. And there's this whole trope of nurses eating their young. And it's true to a large extent, and I feel like that has to be flipped on its head. And we need to take these younger, newer nurses, like your daughter, for instance, perhaps, and take them under our wings and nurture them and teach them and put them on our shoulders more or less, and show them, like all the possibilities that are there, and open the world to them because the world is their oyster. But we need to give them the tools and the strength and the support to get there. And I think having a culture of mentoring and support and humble leadership is central to helping our profession realize its potential in the 21st century.

Jim Jordan:
So I guess that also goes back to how we teach our healthcare executives in universities. What would?

Keith Carlson:
I believe? That's true. And I think there are leadership models that are dysfunctional and toxic and unhelpful, and there are humble, forward-thinking, progressive ways of looking at leadership. I think that can really make organizations and the people who work for them shine. Really elevate them. So I don't understand exactly what's being taught in those graduate and programs out there in terms of healthcare administration. Hopefully, these conversations are going on and people are will be turning out leaders who are going to change the paradigm. And I do feel hopeful with what I see in the younger generations and the earnestness and the desire for change. So I hold out hope that these newer generations are going to flip the script a little bit.

Jim Jordan:
I do think we had my wife and I had a recent experience where one of our doctors retired, and we had a meeting with the younger doctor; and perhaps the older person would be upset when you came in with your doctor, Google notes, and the younger person is ready to sit there and answer all your questions in a very patient way. And so hopefully that's a sign of things to come. One of the things that I love about being associated with Carnegie Mellon University's Heinz College is the Heinz College itself was founded by this gentleman named Bill Cooper. And he always had this men and women of intelligent action. And there's an aspect to the school, as intelligent and conscious as a person would be. In Heinz College, they talk about people and empathy, and leadership. And I think that there's been times as we've been planning our curriculum where you struggle with the balance of the quant and the people, and I think that's one of the challenges we have in our universities now is given how many courses we have to make a student, how do we balance all that? And I think it's the same thing as I talk to training young physicians. At some point when we look at the nursing shortage and the physician shortage, but we're actually going to see by 2030 more and more nurse practitioners that they're going to start working in teams. They have to start working in teams, right? So physicians need to let nurse practitioners and PAs do and if you talk to them, they'll say, we're trained to do so much more than we're doing today. And that aspect of working with people, I think is got to be involved in their in our future.

Keith Carlson:
It does, it does.

Jim Jordan:
Let's end with where's your podcast? How can people find you? And if someone wanted to work with you as a coach, how would they get in contact with you?

Keith Carlson:
Sure. My podcast is The Nurse Keith Show. It's on every app you could think of Spotify, Google, Amazon, Apple, and then all the other apps overcast, etcetera, so you can find it anywhere. It's the Nurse Keith show. And like I said, I just recorded episode 449, and there's lots of bonus episodes too that don't have a number. So it's somewhere in 480 or 490 episodes, so it won't take long to catch up just a little bit. 500 hours of listening. I'm also at NurseKeith.com. That's where people can learn about my career coaching, and that's pretty much the clearinghouse for everything related to me. And I'm very active on LinkedIn. People can always find me there.

Jim Jordan:
Perfect. Anything else you'd like to share with the audience?

Keith Carlson:
I'd just like to share that nursing is, like I said, the lifeblood of the healthcare system. We're the largest workforce within the entire workforce in healthcare and nurses. I don't believe nurses are heroes. They're not angels. They're not saints. They're human beings. And if we see them as vulnerable human beings who are just like you and me, who work really hard, who have so much to give, and I feel like the profession has so much potential, and it's really growing and I think. In the 21st century. I have hoped that it's really going to realise its full potential. Like with nurse practitioners and advanced practice nurses, I feel like there's so much there. So I just, I hope people will take that to heart and just support the nurses in their lives and encourage them to realize their dreams within their careers and find the way forward that works for them. And I feel like there's a lot of good happening out there, and I want people to realize how many good people are out there working really hard.

Jim Jordan:
Perfect. Well, thank you so much for being a guest. I really appreciate it.

Keith Carlson:
Thank you so much, Jim. Look forward to having you on my show too.

Jim Jordan:
All right. That was fun. Thank you.

Jim Jordan:
Thanks for tuning in to the Chalk Talk Jim podcast. For resources, show notes, and ways to get in touch, visit us at ChalkTalkJim.com.

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