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SERIES: Inspiring Others | Driving Results - Twenty years ago, did nursing have the voice that they have today? How has nursing changed? Main Campus Chief Nursing Officer Shannon Pengel explains how the institute model--forming that triad of a physician, a nurse, and an administrator leading a clinical Institute--has had a great impact on nursing to gain a strong voice. Developing that collaboration and partnership with physician leaders and administrators gave them the ability to demonstrate how they impact change and drive results. It set the stage for people to speak up and have that dialogue and offer suggestions or solutions to problems from all perspectives. Developing trust and psychological safety creates a culture of free thinking and innovative ideas that leaders want to hear. Listen now.

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Thank You for Speaking Up with Main Campus CNO Shannon Pengel

Podcast Transcript

Introduction: Welcome to Beyond Leadership at the intersection of leadership and everything else. In this Cleveland Clinic podcast, we will commingle with extraordinary thinkers and explore the impact of their ideas and experiences on leadership and management.

Brian Bolwell, MD: I am Brian Bolwell, your host. Today, I'm very pleased to have Shannon Pengel with us, who is the Chief Nursing Officer of the Cleveland Clinic Main Campus Hospital. In this role, Shannon leads and provide strategic oversight for nursing activities and operations throughout all clinical institutes on Cleveland Clinic's 165-acre Main Campus. Cleveland Clinic main campus delivers care to some of the world's sickest patients and comprises approximately 1,400 hospital beds and more than 100 operating rooms.

All Main Campus nursing directors report directly to Shannon who leads nursing strategy, promotes innovative patient care, and advances clinical nursing practice through continuous improvement, financial stewardship, and evidence-based research.

Shannon, it is great to have you with us today to chat about driving results.

Shannon Pengel, MSN, RN, NE-BC: Thank you, Dr. Bolwell, and thank you for that very kind introduction.

Brian Bolwell, MD: Shannon, briefly tell us about how you came to be the chief of nursing at the Cleveland Clinic Main Campus.

Shannon Pengel, MSN, RN, NE-BC: It certainly has been a journey. I grew up in a really small town, just probably about an hour away from Cleveland and like most girls from a small town, I went to a school close to home. I went to Kent State University for my nursing degree. And interestingly enough, Kent State is a very competitive program for nursing. And I actually did not get into nursing school my first year going to Kent State. So I had to work really hard my first year of school and I got in my second year. So I took, what we call, the five-year plan to get my bachelors of science in nursing. And really wanted to work in critical care. I really liked that adrenaline that you got from working with trauma patients and ED patients.

My roommate was attending a job fair here at Cleveland Clinic, and she encouraged me to come and I thought, "Well, why not? I'll check it out." And at the time, it was in one of our hotel ballrooms, this open house and they had different tables and the tables were marked with different specialties. And there was one titled Cardiothoracic Surgery. And I thought, "Well, that sounds fun and kind of right up my alley." So of course I went and talked with the nurse leaders at that table and was really excited about the opportunity to get to work at Cleveland Clinic in cardiothoracic surgery.

I started as a nurse, a registered nurse, on a cardiothoracic surgery step-down unit, and really got to work with clearly some of the world's greatest cardiothoracic surgeons side by side with them. I learned so much--took care of very, very critically ill patients--and did that for a number of years. And like many nurses working at the bedside, I got married and had children and found myself struggling a little bit with working shift work, if you will. And so sometimes you have to make some sacrifices when you have a family. And so I ended up working straight night shift for many years. Although that sounds terrible, in retrospect, it probably was a pivotal moment in my career because I had the opportunity to become an informal leader. I was charge nurse every night. I became a preceptor of everyone that came on to night shift, and I had the opportunity to interact with my nurse manager every morning when she came into work and gave her a report of the floor.

That nurse manager happens to be our Chief Caregiver Officer today, Kelly Hancock. And one day after giving report, she asked me and just pulled me aside and said, "We have a leadership opportunity open on this floor. Would you consider it?" And I kind of thought to myself, "Wow, she must be really desperate or crazy to say that I could be a leader in this organization."

But she talked about how I kind of do this every night. I take care of all the patients. I take care of all the caregivers. So I gave it a shot. And, as I mentioned earlier, having kids, that makes it a little bit difficult. My husband was a police officer and so we both were within shift work. I ended up having to take really the weekend position and work straight weekends in my first leadership role. But I conquered that and got the opportunity to work with a lot of experienced caregivers on that floor and developed myself into an assistant nurse manager.

And then the rest just progressed naturally after that. I had a nurse manager opportunity present to me in a different specialty, so I did that for a number of years. And then Kelly was elevated in the organization to Nursing Director for Heart and Vascular Institute. So I followed her as an assistant director. And then again, when Kelly was elevated to our Executive Chief Nursing Officer, I moved into her director position. And here I sit today, long story short, my journey through nursing leadership here at Cleveland Clinic.

Brian Bolwell, MD: How did your views on leadership evolve and what did you learn to become more effective as a leader throughout this journey?

Shannon Pengel, MSN, RN, NE-BC: Certainly I learned the value of mutual respect for everyone that I was working with. I think one of the most challenging transitions for me was moving from an assistant nurse manager in cardiothoracic surgery to being a nurse manager in cardiovascular medicine. For those of you that work within the cardiac specialties, you know those are two very, very different specialties, and you should never compare the two when it comes to nursing practice.

But I really didn't understand or fully appreciate the specialty when I transitioned into that role. And I really had to learn to be humble and to ask questions and respect things that I didn't know and truly learn from all of the caregivers that I was working with. I can remember everything from having to sit down with the health unit coordinator and learn physicians and how patients present to this unit, to learning how to run different medications that we never had to give in cardiac surgery. So I think that was definitely one area that I learned very quickly.

And then the other area was really around collaboration with providers. When I went down to that unit, we had launched a program here at Cleveland Clinic called The Nurse Physician Partnership, and the physician partner on that unit was just incredible and probably still a partnership that I call upon today, honestly, if I need something. But I learned to work very collaboratively with providers so that we could make improvements for patient care and that it wasn't something that the provider was looking for versus something what the nurse was looking for. We did it together and we really were able to improve quality and improve relationships, improve throughput to that unit as well. So I think that's the other piece that I learned is you have to develop trusting relationships with the providers, the nurses, all of the stakeholders that you work with so that you can move things forward.

Brian Bolwell, MD: Shannon, how has nursing changed over the past 20 years in terms of responsibilities, in terms of metrics that are important? What does this evolution look like from your perspective?

Shannon Pengel, MSN, RN, NE-BC: I would say when I first started at Cleveland Clinic, nursing certainly had a role in the patient care and how it was provided, but I don't know that they had the voice that they have today. I think the professional practice of nursing has elevated tremendously over the past two decades through evidence-based research and publications and different manuscripts that we've produced. But also that collaboration and partnership with our physician leaders and administrators. And I think about the implementation here at Cleveland Clinic of what we call the institute model, but really forming that triad of a physician, a nurse, and an administrator leading a clinical Institute. And I think nursing really gains a strong voice in that. I think we were able to demonstrate our commitment to patient care, our ability to impact change and drive results, because we were the boots on the ground. We were with the patients 24/7, and we were able to implement some of that change that everybody had a vision of before. And now that we are working together, we actually can get to some of those milestones that we were hoping to achieve.

And I think patient experience is a great example of that. I think nurses, again, are at the bedside 24/7 with our patients. They understand the communication challenges. They understand how to help the physicians actually communicate better with our patients. They can explain, when you leave the room, they can interpret your message for the patient. And I think that value is definitely something we added when we came together and started working as a team. The voice of nursing at the Cleveland Clinic, having that seat at the executive level that Kelly has served in such a phenomenal way here at Cleveland Clinic, I think we really all have learned from her and really developed strong leadership within nursing.

Brian Bolwell, MD: Shannon, in your current role as Chief Nursing Officer, you're responsible for a bunch of things. Can you describe some of them?

Shannon Pengel, MSN, RN, NE-BC: Yeah, just a few. We have a very, very large footprint here at Main Campus. 1400 inpatient beds is a very large footprint. Also, all of the activities in the operating rooms that you mentioned every day, all of those patients need to be placed. So not only am I responsible for the clinical oversight of all the care that's being provided, but I'm also responsible for the throughput of all those patients, making sure they're all in the appropriate level of care. I think the other huge piece is our quality outcomes--making sure that we're driving those quality outcomes to be the best of the best, identifying barriers to those problems so that we can make improvements with those.

Patient experience, we already talked about, is a huge piece of my role. Not only making sure our patients and families have a positive experience when they're here, but also making sure our caregivers are supported and engaged and able to provide that experience. And sometimes they face challenges that that need my oversight to improve. And then also just the financial performance of the organization. There's a huge business piece to being a CNO and making sure that finances are being managed, our caregiver resources are being managed appropriately. And then, again, just the overall outcomes of the organization. Working very collaboratively with all the institutes is something that I'm learning in this new role. The Institute model is great, as I mentioned earlier, because you have that collaboration of the three leaders, but we also have to be one Cleveland Clinic, and move forward to tackle problems in the same way. So I see part of my role is being that one consistent person on the Main Campus for nursing to bring everyone together and to develop a one Cleveland Clinic team here at Main Campus.

Brian Bolwell, MD: Shannon, talk a little bit more about quality. Quality is so important, and mistakes that happen in the hospital are things that nobody wants to hear about. And certainly we need to prevent them. And yet it's hard to eliminate them totally. What is our approach to trying to really drive down safety harm events and to make this as safe a hospital as we can, knowing that we're the highest acuity hospital in the United States?

Shannon Pengel, MSN, RN, NE-BC: I think a challenge that we face is really creating that culture of safety and psychological safety for our caregivers to speak up. I'm a firm believer in the just culture model of really looking through when an error does happen, really breaking that error down and trying to identify how it happens. There's always human performance issues that we have to address. That's kind of easy, you can address that. It's the deep-rooted things within our culture that we really have to work and address. And so I think when either a mistake happens, or probably a better example is even when we have a rapid response or a clinical code on one of our units, really critically looking through and seeing what happened, not to point fingers, but we want to learn. From every event we have, we want to learn and we want to get that information to our caregivers so that we all learn. We have a large number of nursing caregivers to communicate to when things happen and we want to make sure, again, we all learn from each other.

But I think that culture really around speaking up asking questions is critically important. And I think I try to role model that in the relationships that I form with providers. I mentioned earlier that I'm a big proponent of this mutual respect collaborative relationship. We all bring something different to the table. I bring a different perspective as a nurse that you might bring as a physician. And we need to be able to have open dialogue about that without feeling attacked. It's not about who's right or wrong. It's about the best outcome for the patient. And so I think that model is what I strive for and what I try to emulate and how I try to lead other leaders to develop in their institute.

Brian Bolwell, MD: Yeah, I think psychological safety is such a big deal. I think it's applicable on many levels in this conversation, but one of the things of course is when anybody in a given care team sees something that doesn't seem to be right, it's just critically important that they feel that they're safe and they're protected to say, "Can we please pause and take a minute?" And that's something that I think everybody can try to promote.

Shannon Pengel, MSN, RN, NE-BC: Yeah, I agree. And I think it's really important to teach our young nurses, and possibly young providers, how to have those conversations. What is the right way to say that in the middle of an ICU, when 20 people are staring at you? There is a way to do it. There is a way to ask that question. And I think that's our role as leaders is really helping our providers ask questions in a way that, again, doesn't cause a defensive response. It's simply saying, "I'm concerned, or I don't understand, or did we think of this? Or why didn't we try this?" Any of those questions don't provoke a defensive response. They really promote that sense of, "I'm concerned." And I think that's what we want everyone to feel comfortable speaking up and then being able to come and work right next side of each other the next day, and saying, "Thank you. Thank you for speaking up. Thank you for letting me know. I just didn't think of that. I can't believe I overlooked that." Those are the conversations we'd like to hear.

Brian Bolwell, MD: I think that's really important. I think it's important that as leaders, I really like what you just said about thanking people who speak up. And the other thing, one of my more effective tools is to say, "I don't know." I say, "I don't know" all the time. Number one, because it's accurate. But number two, it tends to actually make it easier for other people to say, "I don't know. Or, can you please explain that?"

Shannon Pengel, MSN, RN, NE-BC: You're right. It does set the stage for people to speak up and people to start having that dialogue with you and offer suggestions or solutions to problems from their own perspective. And again, overall just creates that culture of free thinking and innovative ideas that we want to hear. Especially when we're out there rounding as leaders, a lot of times you'll get approached about something and, yeah, you got to say, "I don't know." I do try to tell that to my new leaders coming into nursing leadership too, it's okay to say that. You don't know the answer to everything and it's probably worse if you pretend to know the answer and you really don't.

Brian Bolwell, MD: One of the important things that we do as leaders, Shannon, is recruit. And so when you're recruiting people, there's a lot of qualities that you may be looking for. But one of the things that we've heard you talk about is emotional intelligence. Could you expand on why you think that's important in recruiting?

Shannon Pengel, MSN, RN, NE-BC: Specifically for leaders, I believe it's critically important for all the things we just talked about. I think being a leader is A, very difficult job. But B, I think if you don't have that relationship with others as a leader, and you don't have the ability to develop a relationship, understand where people are coming from, you're never going to be successful as a leader. There's so many crucial conversations that need to happen in leadership in order to continue to move things forward, as we've been discussing this whole time. You have to have that relationship. You have to be able to judge and understand where someone is emotionally in a situation. And I would say when I first started in leadership, when people talked about emotional intelligence, I thought it was some kind of crazy term that people in leadership use. But actually as I've been in leadership, it's an incredibly important tool.

I think I've thought about it; I was very competitive in high school. I was an athlete, played volleyball, was kind of the lead on every one of the teams that I played on. And so I kind of look at emotional intelligence the same way now. It's kind of like my defense. I have to be prepared to respond to people that are highly emotional. People don't usually call the chief nurse because they want to tell them something good. And so I have to be able to hear what people are saying, empathize with what they're saying, respond, think, all of those things without becoming defensive myself. So I think emotional intelligence has also helped me understand my own triggers so that I don't become emotional when I'm discussing situations that I may be passionate about. But I do look for that when I'm hiring a leader. Probably more so than their clinical abilities and other things, is I want to make sure I have a leader that's going to be able to emulate what I think is really important, which is again, those relationships and trust between leaders.

Brian Bolwell, MD: So what do you do when somebody presses one of your buttons? What are your tricks?

Shannon Pengel, MSN, RN, NE-BC: I pause and take a deep breath. I would say just being aware of what those triggers are is probably the biggest trick, I would say. I know when I'm in a meeting and I'm the only nurse around the table and people start talking about nursing and how nursing might be driving a problem, that's going to trigger a response in me. So I try to mentally prepare myself for that and not take it personally to just, again, "Thanks for the feedback. I don't know much about this problem. I will take it back and let you know a solution." And I think that definitely has helped me just knowing what going to trigger me.

And I think the other thing that I've learned over the years that also triggers me is I have a very emotional response when I'm talking about patient care. I'm very passionate, if you can't tell, to striving towards exceptional outcomes. So I have to be careful sometimes, especially when I'm working with managers or other leaders, that I don't get overly emotional about topics, as well. Yeah, trying to take a lot of deep breaths and not let my blood pressure show on my face.

Brian Bolwell, MD: I really like reading Bren Brown's books. And one of the things she talks about, she talks about the courage to be vulnerable. And when you do that, you kind of risk shame, and how do you combat shame? And everything you read about managing your triggers talks about the importance of pausing. But she actually has said that she'll go into a quiet space and literally say out loud, "Pain, pain, pain," when a trigger is pushed and you don't feel very good about it. I've actually tried that. It's very important to do that alone.

So I always think about leadership in a couple of ways. And one of the fundamental ways is that you can always improve. You can always get better. You can always learn more and it's important to be self-reflective. I'm sure you would say you're a better leader today than you were 10 years ago. How do you keep learning about leadership? How do you approach the whole topic of continuous improvement for yourself?

Shannon Pengel, MSN, RN, NE-BC: Well, I think especially in probably the last five years of my leadership journey, I've become very self-reflective. It's really easy to be a leader when everything's going well, but I've had some challenges. And so a lot of times, as a leader, when things don't go the way you plan them, you immediately want to go to your team and say, "What did you not understand? I had this perfect plan that I laid out for you and somehow you didn't follow it." And so I think one of the aha moments for me as a leader is really looking at being self-reflective of how I communicated that vision. Did I set clear expectations? Did I communicate exactly what I wanted to happen? Did I get feedback?

We had a recent situation where I was very self-reflective of, "I never asked my managers and directors how they were feeling about a certain situation, and that really was my fault and my bad. And why were they afraid to tell me that we were in this position?" So I think sometimes we get caught up in the fact that we made a mistake, but I think really taking that as an opportunity to learn, "Where did I not communicate well enough? Where could I have done better?" Instead of blaming others and really taking that ownership. I am the CNO. If something goes wrong here at Main Campus, I can't blame other people. I have to look at myself and say, "What did I not put in place?" And I think that's been very reflective for me in the last five to 10 years.

Brian Bolwell, MD: Yeah, I think that's really important. I think that you said several things that I think are really important. One is the whole idea about self-reflection, which I think you've got to have if you want to get better. I think it's crucial. The second thing is you've got to be willing to own things yourself. What could you have done better in a given situation, as opposed to casting some sort of negative thoughts about other people? And the third thing, when you're in a potential conflict about some issue, there's one person or another who knows more about a topic than the other person. And frequently the leader may know more about the goals, but the other person may know more about how to achieve those goals. Having the open-mindedness to be willing to, in fact, try to improve one's communication and to look at themselves in the mirror and realize that if there's a problem, it starts with you, are just so essential to leadership.

Shannon Pengel, MSN, RN, NE-BC: Yeah. And whenever there's conflict, too, I think there's usually... Of course, as we all know, we've all heard, there's always two sides of the story. And sometimes as a leader, it's hard to see that if you're the person involved in the conflict. So I think it's really important to be self-aware, and to come to every meeting between whether it's two caregivers, a nurse and a physician, that everybody has the best of agendas here, everyone is trying to achieve the best goals. And you're just trying to help them get there and not assume that people have an agenda, right? And that we're all doing this for the right thing. I think you can quickly get off course if you assume someone's trying to create a goal for themselves.

Brian Bolwell, MD: Another thing you mentioned earlier, Shannon, was how important you think trust is. One of my favorite books on leadership is The Speed of Trust. Can you expand on that?

Shannon Pengel, MSN, RN, NE-BC: Yeah, so I think you have to have, again, trusting relationships for a number of reasons. I look back at my previous role as a nursing director and I had to have a very trusting relationship with my physician chair, as well as my administrator, for a number of reasons. Sometimes you have to have those difficult conversations. And when that trusting relationship is already there, it's much easier to have that conversation. And it goes both ways. Also when things didn't go right within maybe it was a nursing unit and I had to go update our chairman about something that happened, having that trusting relationship, he knew I was going to come tell him right away. He knew I was going to communicate openly and honestly. And I think that just helps everything progress.

And then working in that triad fashion with a physician, an administrator, and a nurse, you really have to respect each other's boundaries. I had an administrator that he had certain things that he had to accomplish, and I had certain things I needed to accomplish as a nurse. And we didn't cross those boundaries. We respected what each person brought to the table. And again, I think that goes back to trust. And then finally, I would say probably the most critical thing is that my caregivers, my directors have trust in me. They need to know that I have their back, which I do 100 percent, and that I'll go to bat for them and be an advocate for them. And more importantly, be an advocate for our patients and their families that are here under our care.

Brian Bolwell, MD: You got this job right before the COVID pandemic, right?

Shannon Pengel, MSN, RN, NE-BC: Yeah, right before the third wave.

Brian Bolwell, MD: How'd you manage it?

Shannon Pengel, MSN, RN, NE-BC: It was definitely challenging. And I think I'm still trying to find my way. When you start a new job as big as this in the middle of a global pandemic and a healthcare crisis, the first 90 days of my job was really just managing crisis between very high patient census with COVID, trying to manage census of the surgical reactivation, as well as our caregivers.

Our caregivers were still getting quite sick at that time, if you remember. So it was really a daily struggle of trying to balance all this and trying to work with a new team and the nursing directors, and try to figure out what my role is. Now, I've had a minute to catch my breath and really trying to put my arms around Main Campus. And again, really focused on some of the things we talked about in the beginning of breaking down silos that might be in existence from the institute model, but really trying to make sure our processes are standardized across the Main Campus and that we're working towards the same goals.

Brian Bolwell, MD: Can you comment on women in leadership and the challenges that women, whether they have children or not, may face?

Shannon Pengel, MSN, RN, NE-BC: Yeah, I think I've had a phenomenal journey in leadership and I've had incredible mentors. I mentioned Kelly Hancock at the beginning of this, who's been a mentor to me my whole career. We've worked together my entire career here. And I think being a woman in a leadership position, again, I think the relationships I've developed over my career here have proven that clinically I bring a lot to the table. I bring a lot to the table from an operational and strategic implementation standpoint.

And I've been able to gain that mutual respect and trust as I've moved up through leadership. I am a mother of two. I think trying to manage that work-life balance is always really challenging as a leader regardless, and then is as a woman in leadership, I think it's even more challenging. You have that guilt of not being home with your kids when they get off the bus, not being able to attend that parent teacher conference.

Work-life balance is incredibly important, and identifying for you personally what is that that's most important to you. So for example, my older son played baseball all through high school and I was committed to being at his games. Then as he got further into high school, those games got earlier. When they're little, the games start at seven o'clock at night, but when they're in high school, they're at 3:30. And at the time, I had just started as the nursing director in the Heart and Vascular Institute, and really had to break it to my chairman that, "If you need me for a meeting at 3:30 on a Thursday, I will not be here. I will be here at 5:30 if you need me in the morning one day, but I cannot miss my son's game. This is what's important to me as a mother." He had a lot of respect for that and said, "Absolutely that you need to be there."

And so I think it's really setting those boundaries as a leader and saying, "This is what's important to me. I will not make any exceptions for this, but I will bend on some of these other things." And my family was incredibly supportive to me throughout my journey, and I'm so grateful for them. And I will continue to give back to them and everyone else. And it's been a journey and I'm proud of nursing here at the Cleveland Clinic. I'm proud of Kelly and all that she's accomplished. And I'm hoping that through my leadership that I'm also creating another group of nurse leaders that's going to go on for decades after I retire.

Brian Bolwell, MD: Looking forward for the next five years, do you have any goals in mind, either for the clinic or for yourself personally?

Shannon Pengel, MSN, RN, NE-BC: Well, I think for the clinic, my goal is that we're the number one hospital. Definitely. So I think.

Brian Bolwell, MD: Well, I think we already are. It's just that the rankings haven't shown it yet, Shannon.

Shannon Pengel, MSN, RN, NE-BC: The rankings, of course. So, yeah, I think we have a lot to do, and that's why I focus so heavily on some of these quality improvements because we have to move forward together as one team. We have to learn best practices from one another. We are a very large organization, but that doesn't mean that we should be doing things differently in every different clinical section. So I think for me, a five-year plan is really elevating the profession of nursing, elevating our outcomes here at Cleveland Clinic. They're fantastic and phenomenal today, but I want to make them just exceptional and really be the leaders globally in health care.

Brian Bolwell, MD: Well, I think that's a great way to finish up. Shannon, thank you so much for joining us today for this episode of Beyond Leadership. Have a great day.

Conclusion: Thank you for joining us for this episode of Beyond Leadership. We welcome any topic ideas, comments, or questions about this or any past episodes. Email us at executiveeducation@ccf.org or by clicking on the link in the show notes.

Beyond Leadership
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Beyond Leadership

Host Dr. Brian Bolwell escorts you through a network of thought leaders, sharing world-class insight on leadership and cutting-edge hospital management approaches. They will inspire and perhaps compel you to reinvent your practices – and yourself.

Developed and managed by Cleveland Clinic Global Executive Education.

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