Nurses on the Frontline: Strengthening America’s Health Care Workforce

Kathryn Santoro (00:00:00):

Thank you, I am Kathryn Santoro, Director of Programming at the National Institute for Health Care Management Foundation. On behalf of NIHCM, thank you for joining us today to explore the critical role of nurses in our healthcare system and in the pandemic response.

Kathryn Santoro (00:00:17):

Over the past year, nurses have been among America's heroes on the front lines fighting the COVID-19 pandemic in hospitals, nursing homes, and community clinics, while putting themselves at great risk for exposure to the virus. According to an investigation by Kaiser Health news and the Guardian, 3,448 healthcare workers have died after contracting coronavirus on the job and 32% were nurses. Today, we not only honor them, we will explore how to support nurses and their work more effectively. Recognizing the stress they are enduring, as well as the critical role they play and improving patient care and health outcomes.

Kathryn Santoro (00:01:02):

The demand for nurses has accelerated existing shortages and challenges, with implications for patients, the nation's healthcare system, and nurses themselves. Staffing shortages impact patient care and contribute to nursing burnout, and a sharp increase in the number of nurses leaving the profession. Nurses continue to be at the forefront of the pandemic response, playing a key role now in vaccine access and addressing vaccine hesitancy. As the most trusted profession, according to an annual gallop poll, it is now more than ever, important to elevate their voices and local communities to combat misinformation. Today, we will explore strategies to support nurses and their wellbeing, invest in the future of the nursing workforce, and raise their voices as trusted sources for the media and the public.

Kathryn Santoro (00:01:57):

Before we hear from them, I want to thank NIHCM's president and CEO, Nancy Chockley, and the NIHCM team who helped to convene today's event. I also want to thank the Journalist's resource, a project of the Harvard Shorenstein Center for Media Politics and Public Policy for collaborating with us on this webinar and introduce Carmen Nobel, Program Director, to make brief remarks. Carmen?

Carmen Nobel (00:02:24):

Thanks, Kathryn. Hi, sorry, thanks, Kathryn. I know everyone is eager to hear from our speakers today, so I'll just briefly explain that the Journalist's Resource is a free online resource that examines public policy news topics through a research lens. Our mission is to inform the news by bridging the communications gap between academia and journalism. Our goal is to get more high-quality research into the news media stream. Our website, journalistsresource.org, features accessible summaries of high quality medical and social science research, articles about standout studies, tip sheets on how to avoid common journalist pitfalls when reporting on research, topical comics, interactive graphics, and more. Among our most popular pieces, the tip sheet explaining why journalists should interview nurses more than they do. We're really happy to be part of this webinar today, thank you.

Kathryn Santoro (00:03:13):

Thanks, Carmen. NIHCM has really enjoyed supporting and collaborating with the Journalist's Resource through our journalism grant program and collaborating on this event today. To our audience, you can find full biographies for all of our speakers along with today's agenda and copies of their slides on our website. We also invite you to live Tweet during the event using the hashtag, nurses on the frontline.

Kathryn Santoro (00:03:40):

I am now pleased to introduce our first speaker, Mary Ann Fuchs. Mary Ann is Vice President Patient Care and System Chief Nurse Executive for Duke University Health System, and the Associate Dean of Clinical Affairs for Duke University School of Nursing. Mary Ann is also President of the American Organization for Nursing Leadership board of directors. We're so honored to have her with us today to share the challenges nurse leaders have faced during the pandemic, and lessons learned to help us understand how we can best support our nursing workforce going forward. Mary Ann?

Mary Ann Fuchs (00:04:17):

Thank you, Kathryn, and thank you for having me today. I am hoping to share some great information with you. I will take the opportunity to speak specifically about insights that AONL has been able to gather along the way. Certainly, it's been a challenging year, both as a chief nurse and as organizations. So, I'll introduce you just quickly to AONL. AONL is the American Organization for Nursing Leadership, and it really convenes nurse leaders working in all aspects of healthcare. We see ourselves as the voice of nursing leadership and we are the subsidiary of the American Hospital Association with a clear vision to shape healthcare through innovative and expert nursing leadership, and doing that through one voice advancing health.

Mary Ann Fuchs (00:05:13):

We have many priorities that you can see on the slides here, but really is to advocate for nursing to help to shape the future of healthcare, really influence our workforce, sustain and evolve nursing leadership competencies that we'll talk about today. Support value-based healthcare, and then strengthen voice. That's a lot about what we're talking about today through all of the speakers here. So, we do this through education, we do it through advocacy, and we do it through community. That community really includes the vibrant network of nurse leaders that you're going to hear much more from today in the information that I present.

Mary Ann Fuchs (00:06:02):

So, the objectives that I'm focusing on today are really to explore COVID insight from frontline nurses and nurse leaders, talk about nurse executive competencies that were heightened by COVID-19, and really identify lessons learned, and some of the thought moving forward.

Mary Ann Fuchs (00:06:21):

So, the slide that you see here really comes from the American Nurses Association survey in the spring of last year, that really got the insight of 32,000 nurses from across our country as they were jumping into the COVID-19 pandemic. You can see that more than half reported being short on supplies and equipment, which really as we know is a big challenge, not just for the safety of our patients but really for the safety of our workforce. You heard earlier the number of people that we lost or healthcare workers we lost. You can see that 68% were worried about being short staffed, a big issue as it relates to being able to care for patients during this time appropriately. As we know, the nurses were the and continue to be the component of the workforce probably spending the most time with our patients. So, the ANA did this survey to help us understand some of the needs that were going on initially and continually as we sustain during the epidemic.

Mary Ann Fuchs (00:07:37):

So, AONL had this great opportunity to partner with Joslin Marketing and we did a survey in July, which we published actually in August. The results are actually more details on the AONL.org website but I'll go through these today because I think it's important as we move forward with the information. We had in this process about 1,800 respondents that responded in July over a 10-day period and we had a mix of participants. So, hospitals, largely they were either pre-surge, during their surge, or sustaining COVID-19. So, we got a broad perspective of the issues. This again was a non-incentivized [inaudible 00:08:30] survey that really looked at nurses' perceptions, their concerns, challenges, and future readiness. I will say, we are actually going to do right now are conducting a longitudinal study to remeasure where nurses are in this pandemic.

Mary Ann Fuchs (00:08:49):

So what you can see here is that 82% of the participants were chief nursing officers, chief nurse executives, vice presidents, directors, or manager, but there were other roles that were represented, but the majority, 82% nurse leaders. They were spread from across the country. This heat map shows you where the participants were located. You can see we had areas that were surging, areas that were pre-surge, and then areas that were sustaining according to the different locations in the country.

Mary Ann Fuchs (00:09:27):

So, what were nursing leader's key concerns? Well, here you can see in the chart that early we really felt nurses across the country had no playbook. We were trying and having to create new policies, new procedures, new ways that we staffed. That early on, we were really trying to learn what was happening with the virus, what was changing [inaudible 00:09:56].

Mary Ann Fuchs (00:09:57):

Secondarily as you saw before in the ANA survey, all the shortage. Shortages of PPE, the materials, whether we could test people, whether we have enough monitors or equipment to be able to care for patients. In the beginning around just even having nursing. I have one colleague I know early in the pandemic from New York where she literally called her staffing company and said, "I need 1,000 travelers tomorrow," and brought them in to help staff her organization with that process. That helped her during the surge. During the surge period of time, we didn't have the answer and we got conflicting information both locally, nationally, and the information changed, so that whole trust. The issue around trust and information really helped define that period of surge. The changing culture of being able to really understand the workforce that you were working with and being able to provide work, really became an opportunity.

Mary Ann Fuchs (00:11:10):

Then sustaining, it's really, what is the impact of change on staff? Quick frankly, what we're learning now is just the whole piece around resilience and how our staff are able to be able to continue to provide care during this time. Early on in addition, communities really came and put their arms around the healthcare workforce. Now today being able to sustain in this culture with the politicization of masks and infection prevention procedures, we have challenges to a certain extent, with families and those continuing to believe that this really isn't a problem, perhaps. It causes other challenge for our staff, for our families, and for our patients.

Mary Ann Fuchs (00:12:02):

So really, nurse leaders during this time meant that, knew that we would have to continue to build trust amongst staff and patients. It was difficult because of the constant changes that were having to experience during this time and the differences of information. Probably one of the biggest challenges for us, but let's look at some more detail in some of these challenges.

Mary Ann Fuchs (00:12:30):

When nursing leaders were really getting into this whole process, building capacity, really became an opportunity. There were so many patients that needed to be cared for, so many different things that staff had to learn. So, on average, we asked what some of those challenges were. 75% of nursing staff had to receive training to learn on average, new competencies to care for COVID-19 patients. Early on, some places could decrease other parts of their business in order to care for patients, but the staff had to be retrained in order to provide this care. Then overall on average, 62% of nursing staff in hospitals were needed to treat the COVID-19 patients. So, if you can imagine re-juggling the ship if you would, around who was providing care in what environment. These were major items that nurse leaders had to help manage through.

Mary Ann Fuchs (00:13:33):

When they were looking to really think about how they provided care, there was just a great need to increase ICU bed capacity because of the level of illness of our patients that were seeing. So, 46% of organizations increased ICU beds, and you can see on this slide here, over 73% had to increase by 20 or more beds. Some increasing hundreds of ICU beds in order to be able to provide care during this surge period of time. Made this a big challenge, not just from equipment, supplies, but people. How to care for people during this time. Remember, we had to make some major changes in how visitation occurred, how infection prevention practices were put into place. A tremendous amount of impact in the organization.

Mary Ann Fuchs (00:14:34):

So, when we took this a little bit further and we asked about some of the biggest challenges, here's how this played out. So, the biggest, 55% reported communicating implementing changing policies. 54% surge staffing, training and reallocation. 50% emotional health and wellbeing of the staff, which continues probably to be the biggest challenge because we've made impact on treatments now. We know how to care for this virus now and the patients who are experiencing it, but just the emotional health of our workforce has become a big issue. Then again, access to supplies and equipment was one of the top items here.

Mary Ann Fuchs (00:15:21):

But you can see, our nurse leaders felt... this is a question that asked how effectively did you feel you were able to address challenges? Five was really good and one wasn't so good. You can see that we managed through the surge, we tried to get up that equipment, the supplies, bringing on new technology. Nurses are innovative and as they go along the way all the time. The things that we didn't do so well though, were really to really understand health inequities and social determinants. We have a lot of work to continue to do there. Then really here for nurse leaders, sustaining academic practice partners. Remember, during this time many organizations didn't allow their students in their workplace. We didn't make that change, we kept our students to the extent that schools would allow them to come in, but being able to be able to sustain and to help people learn during this environment became very much of a challenge. As a matter of fact, the Tri Council for Nursing has spent some very... [inaudible 00:16:25] and AONL has spent some very significant time talking about how we sustain academic practice partners during this time and have put out some guidance to be able to focus as we move forward.

Mary Ann Fuchs (00:16:41):

So when we think about this, what were some of the expectations? What did nurses think during this time, were going to be things that we were going to be able to continue moving forward. I think we've done a good job trying to adapt and to adopt some of those things. You can see on this slide here, telehealth became a really big opportunity for us. How we address new staffing models, how we used everyone to their training and education became a good opportunity for us moving forward. Great interdisciplinary collaboration. I think overall, wider recognition of the nurse's contributions, which again, you're going to hear over and over, nurses are the most trusted professionals and I think during this time, we've continued to live up to that expectation for the public.

Mary Ann Fuchs (00:17:38):

So, I think some of the challenges however, we asked during this time. What was the support that they received from their communities, from their organization and team? People really felt that within their organization, within their team, those expectations were exceeded. It was everyone on deck, everyone one board doing whatever it took to care for patients. You can see on this slide here, that level of support actually decreased overall when people responded about their state government and then yes, the federal government. Felt that there was much less support from that perspective along the way.

Mary Ann Fuchs (00:18:25):

So we actually looked at, how did this impact nurse competencies? Because... oh wait, here one more slide here. So moving forward, how does... do people feel they're prepared for a surge moving forward? Yes, and again though, it depends upon having adequate supply of nurses and that, but actually knowing that we've been able to work through some of the treatments that are starting to have some effect has become really important. Now when we get into vaccines, we have hope. So great things there moving forward.

Mary Ann Fuchs (00:19:01):

As I said, AONL really does look at nurse executive competencies and how did we use these over time and what did we learn? Here's a listing of how we see leadership. Some of the core things related to communication, relationship management, and the ones that we used along the way on this list. Communication, how do we foster those academic practice partnerships and leadership during this time? We believe that as we fostered through and thought through some of these lessons, the following things really came out. That learning for us is continuous. We constantly learn that during this time we had to be up on top of the evidence, that it evolved. We had to learn how to change messages and we had to make sure that innovation was at the core. You've heard, and we can tell you a ton of stories about different things that came out of how we provided innovative care delivery during this time and use of treatments in different settings and what roles people were playing during this time.

Mary Ann Fuchs (00:20:17):

The second was really how we connected with people became totally different from how we interacted with patients and families and how we use technology. What I would share here is that AONL during this time put up on their web many different opportunities to listen and to learn. So, we had on-demand webinars around search staffing, prospective staffing models, and then had opportunities for nurse leaders to come together to talk and to be able to discuss those resources that were out there and available and to discuss really best practices moving forward. This became a great opportunity for people to share and to learn from one another in a very active way across the country.

Mary Ann Fuchs (00:21:10):

Then in addition, we provided different resources that I believe we are continuing to build upon because these are the things that kept coming up during this time. Trying to lead through crisis, dealing with the issues around moral distress within our staff, and providing those supports and resources around resilience. We also tapped in and provided those resources from the AHA and as it relates to being able to provide on-going guidance to healthcare organizations. Some of these were listed here in addition. Then again, continuing the power of connection and technology. Pretty much everything is virtual these days. Organizations totally changed how they deliver care, how they interact with their team, how they interact with patients. These are great things moving forward for us to be able to continue to build upon.

Mary Ann Fuchs (00:22:16):

Then again, fostering relationships and trust. Just the whole piece around transparency, of communication, making sure that there are multiple methods for us to be able to focus on with our teams, within our organization, external, across the country, nation. Then making sure that that expert guidance was there and available and ready for people moving forward.

Mary Ann Fuchs (00:22:46):

We also felt that nurses utilizing interprofessional teams was a real highlight here. Nurses were leading at all different types of roles from leading the command entity or the command function within their organization. Building new models, so care not just within their organization, across the continuum, became even more important. From testing, from being able to think about ways to provide hospital care at home, how you used your home care models, totally different. These were all great lessons for us moving forward.

Mary Ann Fuchs (00:23:26):

But as we move forward into the future, and I'll end here in a second, that we got a lot of future challenges because now COVID is now no longer crisis. It's a chronic disease, it's chronic illness for us. How do we continue to change the model, the delivery care models as we impact? How do we help our staff continue to manage and build resilience? This has been really a total fatigue for this. So we're now currently conducting a follow-up survey to continue to measure the response and perspective over time, and really to try to dig down deep into some of the ongoing mental health support needs of our nursing workforce.

Mary Ann Fuchs (00:24:11):

So, I think that's the end of my slides, here are my references. I'm look forward to our questions that we'll have in the question and answer period. So, thank you.

Kathryn Santoro (00:24:22):

Thank you, Mary Anne, for sharing these insights. I just wanted to quickly remind our speakers to please mute your phone when you're not speaking.

Kathryn Santoro (00:24:31):

Next, we will hear from Diana Mason, the Senior Policy Service Professor for the Center for Health Policy and Media Engagement at George Washington University School of Nursing. She is also Professor Emerita and Co-Director of the Center for Health Media and Policy at Hunter College, City University of New York. Diana is a Principal Investigator of the Woodhull Study Revisited, that examines nurses' representation and health news media. We're so grateful she is joining us today. Diana?

Diana Mason (00:25:03):

Thank you so much, it's delightful to be here today on this important topic. What I'd like to do is to first talk about why nurses' voices matter, then talk about, what do we know about whether nurses' voices are being heard. Then to talk about what does all this mean during a time of COVID? So, as you've heard already, we are the most trusted profession. I'm not going to spend more time on that. I will though, come back to that. Let me see, okay. Oh, okay.

Diana Mason (00:25:35):

So, another reason why nurses' voices matter is that we have unique perspectives on people's experiences of health, of illness, of healthcare, and we have important perspectives around what policies ought to look like that affect health. So, we are with these patients, as you've heard Mary Ann talk about. We're on the front lines of care, we understand what patients and families need and want and what communities want. I want to point out that we have a highlight educated, growing cadre of advanced practice nurses and nurses with doctoral degrees, as well as master's degrees who are nurse practitioners, they are certified nurse anesthetists, they are nurse midwives, they are nurse scientists, and they have deep expertise on issues related to self-care management, to symptom management, to infection control, to hand hygiene. I want to point out that the information we've been sharing with the public about the hand hygiene, much of that is based upon the research of a nurse. Dr. Elaine Larson who is now Professor Emerita at Columbia University School of Nursing and School of Public Health, and she had years of NIH funded research and research funded by others, looking at hand hygiene, looking at the effectiveness of the gels, et cetera. So, we have deep expertise in a variety of areas. In fact, in all areas of health and healthcare.

Diana Mason (00:27:07):

I wanted to point out, which should be obvious to you from hearing Mary Ann's presentation, that the chief nurse officer or chief nurse executive is often also the vice president for patient services and is responsible for the largest proportion of the hospital's budget. Sometimes up to 70% of the hospital budget. Who better than somebody like Mary Ann or chief nurse officer to talk about what is the impact of budget cuts, the budget strains that hospitals are feeling? What is the impact on patients, on families, on staff, and in the hospital's ability to deliver on its mission to communities as well?

Diana Mason (00:27:49):

I like to say to my journalism friends, remind them that if you're not interviewing a nurse, you may be missing the best part of a story. So, I was interested in, what do we know about nurses' voices, are they getting out? I was very much aware of this Woodhull Study Revisited, Woodhull study on nurses and the media. It's named after Nancy Woodhull, who was one of the founding managing editors of USA Today and was very concerned about women's underrepresentation in news media. Back in 1997 looking at print media, they found that nurses were used as sources in 4% of newspapers, 1% of weeklies, and 1% of industry publications like Modern Healthcare. 20 years later, we have replicated that study in 2017, we published it in 2018. Nurses were used as sources in 2% of the same newspapers, weeklies came up to 2%, and industry publications, 1%. Now the difference between 1997 and 2017 is not statistically significant. So, we're not saying things have gotten worse, but nothing has changed in 20 years.

Diana Mason (00:29:10):

So, we were interested in why. We are the largest group of health professionals in this country and globally. Why are we invisible in news media? So, I and some colleagues did a qualitative study of health journalists looking at, what were their experiences with using nurses as sources. High-level theme, the major overall theme is that there are biases about women, about nurses, and positions of authority in healthcare. Those get in the way of journalists using nurses and others. I would argue that the same probably holds with social workers for example, in health reporting.

Diana Mason (00:29:50):

There were a number of sub themes that I want to call out. The first is that there are editorial biases in the newsroom that are really embedded in their policies, procedures, and editorial practices. Repeatedly, the health reporters told us, "If I'm doing a story that's not on nursing per se, but on healthcare, and I want to use a nurse as a source, I have to justify that with my editor. I never have to justify using a physician." The idea is that physicians have a voice of authority on everything related to healthcare even though they may not know, be the best expert on a topic. Again, that includes, you're talking about ventilators, I'd want to talk to a respiratory therapist. So, there are procedures here including the style manual, the Associated Press style guide is used by most newsrooms. Up until 2018, did not permit publications to refer to anybody as doctor so and so unless they were a physician, osteopath, dentist or a veterinarian. These were largely male dominated professions when these rules were written. Now we today, they changed that in 2018 so we're able to refer to doctor Jill Biden, thank you very much. So, there are a number of other editorial biases, but those were two that I wanted to highlight.

Diana Mason (00:31:18):

The journalists don't understand the range of nurses' roles, work, and our education, that was another major theme but they're not alone. I'm constantly working on my family members and my friends, trying to explain what it is that nurses do. People think, well, nursing is caring, anybody can do it. We do pride ourselves in saying we are a caring profession but what people don't understand is that caring, true, excellence in caring requires an exquisite set of skills. It requires critical thinking, it requires emotional intelligence. Excellent assessment skills and observational skills. It requires excellent interpersonal communication skills and that we know how to manage technology and interface technology with that patient experience in a way that doesn't lose the humanity of this patient care experience. So, we've got to do as a profession, a much better job of trying to convey what it is that we do.

Diana Mason (00:32:21):

Another sub theme is that journalists don't know how to find us and they don't have time to track us down so we've got to do a better job on that. One sub theme that really surprised us was that repeatedly, the reporters said, "When we go to the communications or public relations staff of hospitals or even universities with schools of nursing and say we're doing a health story and we want a source. We're never given a nurse, and even if we ask to interview a nurse, we may not be given one." That was quite interesting. I hadn't realized this was occurring in universities, it's something we have to pay attention to.

Diana Mason (00:33:03):

Finally, this is not all on everybody else, it's on nurses and nursing. We are not being strategic about accessing and engaging media. We're working on that very diligently and we're going to be saying, we're not going to hold ourselves back anymore.

Diana Mason (00:33:18):

So, what does this mean for during the time of COVID? Well, I want us to reflect back on during the Ebola, when Ebola came to the United States and nurse Nina Pham in a hospital in Texas got infected. Journalists were calling us right and left. I was President of the American Academy of Nursing and the phone did not stop ringing. As soon as she recovered, this phone stopped and they have remained stopped by in large, until COVID hit. I expect that unless something dramatic changes, that the phones are going to stop after COVID as well. Nurses will not be as visible as they've been in the media with COVID. They're there deservedly because of what Mary Ann described in that frontline experience. They have that frontline experience, they also brought attention to inadequate PPE and that was really important. Some of them lost their jobs for talking to the media about inadequate PPE, even though they were trying to protect themselves, their patients, their families, and others.

Diana Mason (00:34:27):

What I have noticed and some colleagues including some who aren't nurses, but who are working with journalists to find sources for stories, is that journalists are mostly interested in talking with nurses when it's about the emotional aspects of care, the war-like feeling of caring for people with COVID. So, I think we have to take a look at that. Why aren't they seeking nurses as sources for expertise on other dimensions of care, other than that war, emotional experience?

Diana Mason (00:34:59):

As Mary Ann pointed out, nurses are innovating every day. There is so much that people could learn from them. Nurses have figured out how to use technology, using FaceTime or whatever to connect families with their loved ones, as well as with staff, in terms of helping with decision making about care. Nurses are leading redesign of hospital processes and procedures. I had a colleague who was sent to rescue a failing hospital during the surge in New York City last spring. It was a hot bed of COVID and she was sent out there and rescued that hospital from having to be closed down. Nurses are on the front lines of public health during this pandemic. The school health nurses, the home care nurses, the experiences of nurses and innovating during this COVID time is rich and it is deep, whether it's contact tracing, whether it's vaccine rollout, et cetera. We are innovators and have always had to be. The operational aspect of hospitals and other healthcare organizations and how to redesign it during COVID is by in large led by nurses.

Diana Mason (00:36:08):

So, we have some challenges. We have media policies that institutions have put in place that are essentially gag orders. Hospitals didn't like nurses speaking about the lack of PPE. So, there are media policies and sometimes they're selectively enforced. Not all physicians, in fact, very few physicians get fired when they speak to media without going through the PR department. Although during COVID, I saw at least two physicians who had been fired, and I think one got his job back. So that is a big challenge. Job loss, they know they can lose their job if they speak out or say too much to other people. There is this fear of speaking with journalists, even off the record. I had journalists saying, "I want to interview a nurse about [inaudible 00:36:57] topic and I'll talk to them even off the record," because they just wanted to get what the information from the frontline nurse.

Diana Mason (00:37:05):

But I have to also point out that policymakers need to start paying attention here. Here's President Biden forming his COVID Taskforce with no nurse on it. No nurse, how could you form a taskforce on COVID with no nurse? Given what Mary Ann described nurse leaders are doing in their institutions and what you are seeing on TV that nurses are dealing with, and in public health and in school health. There is a nurse on the taskforce now because the hue and cry that went up, but why did it take that? Why aren't we coming to mind right away? Certainly, relating back to the gallop poll, nurses should be used repeatedly as trusted messengers to convey messages. We are speaking out about the wear the mask, wear the damn mask. In terms of the vaccine roll out, the first vaccine was given to a nurse in hopes that it would play on that public trust, but we really should be used as spokespeople much more often than we are.

Diana Mason (00:38:05):

So, what do we do about this? I'm not going to spend a lot of time on this. Just to say that if you're in one of these first four groups on this slide, the newsrooms, healthcare administrators and executives and PR staff, policy makers, or a PR staff for universities. I highly recommend that you go back and have a deep conversation with your colleagues about, why aren't we using this resource more? In newsrooms, why aren't we using nurses as sources more? When we use them, what are we using around and are we missing opportunities for their deep expertise to inform our stories? Healthcare administrators to look at, why is this not? Why are we not using our nurses who the public trusts to speak to the public to give them as sources to journalists? Have them do speaking to town halls and public forums and helping to educate the public about some of these issues.

Diana Mason (00:39:04):

Same idea with policymakers, getting policymakers to know it's not okay anymore not to have a nurse and I'm saying it's not okay to have a token nurse. Many of these advisory groups that we form have multiple physicians on them because physicians are not a monolithic group. Well, neither are nurses. It's no longer that you get a token nurse there. You want a rich expertise that nurses can bring. I would say the same about my social work colleagues and some of the other colleagues.

Diana Mason (00:39:35):

So those are the major points that I wanted to make, I encourage us to really reflect on. How do we think about nursing? In my organization, how do we tap into the expertise of nurses and support them?

Diana Mason (00:39:49):

On this slide, I just wanted to point out the last bullet, is a webpage where you can find the original Woodhull study, the replication of the Woodhull study, and the qualitative study that I've referred to. Thank you very much.

Kathryn Santoro (00:40:08):

Thank you so much, Diana, for your leadership, elevating and advancing nurses' voices.

Kathryn Santoro (00:40:14):

Independence Blue Cross and Independence Blue Cross Foundation are committed to recognizing and supporting the contributions of nurses to keeping our communities healthy. To hear more about their leadership on this issue, we're now joined by Rev. Dr. Lorina Marshall-Blake, President of the Independence Blue Cross Foundation and Vice President of Community Affairs at Independence Blue Cross. Lorina is an Honorary Fellow of the American Academy of Nursing, and under her leadership, investing in the education and professional development of nurses has been one of the foundation's top priorities. Lorina?

Rev. Dr. Lorina Marshall-Blake (00:40:53):

Hi, thank you so much. Again, good afternoon, everyone. Hopefully you don't have Zoom fatigue by now, but this is the best way we can connect and learn from each other right now. Again, I want to thank Dr. Fuchs and Dr. Mason for their outstanding presentation. Again, thank you to NIHCM, I've been here before but it's always a privilege to work with your great organization. I'm really, really excited and honored to be a part of today's session, the first in the new series, healthcare workforce 2021.

Rev. Dr. Lorina Marshall-Blake (00:41:25):

Again, by launching this series at this time, I think NIHCM shows that you really have your finger on the pulse of the times. When I hear Dr. Fuchs and Dr. Mason talking how all the different challenges and what nurses are going through, it's just imperative that we have this discussion.

Rev. Dr. Lorina Marshall-Blake (00:41:45):

But for the past year, our frontline, when you look at... and it's been mentioned again, our frontline healthcare workers have fought the fight against COVID-19. They put themselves and their families at risk for us and our families. So many of them, too many I believe, have sacrificed their health or even their lives. Again, looking back in the slides talking about not enough PPEs, nobody really caring or hearing the voice of what nurses have to say.

Rev. Dr. Lorina Marshall-Blake (00:42:14):

Again, I think we need to talk about how to rebuild our healthcare workforce after such a challenge. Again, with nurses leaving, not only are they on the frontline, but they're leading the conversation, they lead the discussions. As I was listening to the presentation that was just before us. It shouldn't be just nurse just for a day. It should be a nurse every day and hearing their voice.

Rev. Dr. Lorina Marshall-Blake (00:42:39):

So NIHCM has stepped in, I believe to help lead the conversation. Their first topic is dear to me and my heart and everyone at the Independence Blue Cross Foundation, nurses. The reason I'm here is because Independence Blue Cross and its foundation, we're celebrating our 10th anniversary, have committed to supporting the nursing workforce. Again, it didn't just start. Independence has been supporting the nurse workforce since 2004, but the foundation came in 2011. We believe that nurses are the foundation of a responsive, compassionate, and sustainable healthcare system. That there's no way to do anything without nurses.

Rev. Dr. Lorina Marshall-Blake (00:43:26):

So, Independence to date has invested more than $24 million over 16 years in education and professional development for nurses. Today I'm going to talk a little about what we think should be the priorities in supporting the nursing profession. Then later if we have the opportunity, we'll do the Q&A.

Rev. Dr. Lorina Marshall-Blake (00:43:46):

Our first priority that we're looking at and it's come to the fore and has been around for a while but really is front and center, is to ensure there is a pipeline of qualified and culturally competent nurses. Okay, recently I just finished a two... no, I guess three-year participation with NACNEP, the National Advisory Council on Nurse Education and Practice, where we just came out if you get a chance, the 20th report... 17th report, excuse, preparing nurse faculty and addressing the shortage of nurse faculty and clinical preceptors.

Rev. Dr. Lorina Marshall-Blake (00:44:26):

Again, the conversation about shortage of [inaudible 00:44:32] and it's real. Again, it may depend on where you are but if you look at what has happened with COVID and the pressures, the stress it has placed on the whole nursing force. Again, we have 10 years ago, NACNEP later reported, talked about the shortage. It is now 10 years hence and there's still a shortage because folks are retiring, again, they're stepping back from stress. Again, academia is not paying as much as the clinical. So again, you've got all those pressures that are surrounding that. So, we need to promote nursing and open up opportunities to as many people as possible.

Rev. Dr. Lorina Marshall-Blake (00:45:15):

At the foundation, we award funding to nursing programs in our greater Philadelphia... and you go to the next slide, to our greater Philadelphia region for undergraduate, graduate, and doctoral scholarships. Our funding has provided more than 3,000 scholarships across more than 20 nursing programs. We have a footprint [inaudible 00:45:39] in Philadelphia but we are Montgomery, Buck, Delaware, Chester, and Philadelphia County, and we support all 20 nursing schools within our footprint.

Rev. Dr. Lorina Marshall-Blake (00:45:49):

We also developed an innovative model to help prepare future nurses to deliver care in our community. Over the past 16 years, our nursing internship program has given hundreds of aspiring nurses a chance to work at community health centers or in health center administrations studies while they were still in school. The beauty of that, I got excited, I'm audacious enough to believe by the opportunity for our students to then be in the health center, and there are 50 of them. That they get the opportunity, they then come back and say, "I want to be a public health nurse, had not considered it." Really boots on the ground and making a difference. Again, as nurses come to the forward with their, again, compassion and caring, but they have the skillsets to do the work. Not just bedside community health center, but even in the board room. Because again we know the value of real-world experience, and that's why I love these internships for people entering the healthcare workforce.

Rev. Dr. Lorina Marshall-Blake (00:46:53):

This past summer, I had 30 undergraduate nurses that did it virtually and we still were able to add the clinical in too. It was a challenge, but we were able to do it. But our internship program also emphasizes innovation and leadership in nursing. Four of our former nurse interns received the President's Engagement Prize from the University of Pennsylvania, which is a $100,000 prize to develop and implement programs to improve the health and wellbeing of the community.

Rev. Dr. Lorina Marshall-Blake (00:47:28):

Another former nurse, and this is just within the last week or two, intern recently launched, it's called Lumify Care, an innovative solution to provide light to nurses without disturbing sleeping patients. He was just recently featured in The New York Times. So of course, he was one of our interns so we've claimed him, we've talked to him. So, it's like we're like I'm like a proud mother.

Rev. Dr. Lorina Marshall-Blake (00:47:53):

Another priority especially now, is to support the health and wellbeing of nurses so they can continue delivering care to their patients. Again, we look at burnout, we look at the fact that there's stress, again, you don't have enough equipment. You have more patients than you ever could have because even before COVID, now I'm going to say... and it's born outside both presentations. Even before COVID-19, it wasn't easy being a nurse. So, our focus on nurse wellbeing started with a study and partnership, and this was recently with Villanova University to learn how the opioid epidemic was affecting ER nurses. What they found was that those nurses experienced high levels of burnout and secondary traumatic stress that leads to compassion fatigue and influences the delivery of care to the patients with substance use disorder.

Rev. Dr. Lorina Marshall-Blake (00:48:56):

But moving forward, we hope to stand on this to learn more about the effects of COVID-19 on nurses. Again, you saw the studies that have been done, and that's why I said I was excited when I saw Dr. Mason's information. I said that there's some opportunities. I think [inaudible 00:49:13] opportunity with major organizations that we can partner and do some different things. Again, to provide engaging solutions to address their mental health and wellbeing. Everyone is stressed and it goes back to again, mental health and wellbeing and showing up ready to do the work that you need to do but if you're burned out, that makes it very hard. This research that we did with Villanova helps us support nurses now and develop effective models to educate the next generation. So again, we didn't know but we went to those who were right on the forefront. Again, when I look at the health centers, we support 50 health centers. All of them are nurse led. So, I often joke, my joke is not is there a doctor in the house, but is there a nurse in the house?

Rev. Dr. Lorina Marshall-Blake (00:50:07):

Another priority is to help good nurses to become great healthcare leaders and scholars. Nurses do amazing work in the hospital room and the operating room but we also need them in the board room and the classroom. I think again, the voice of the nurse on every level. It can be hard to prepare for leadership when there is such a demanding day to day job.

Rev. Dr. Lorina Marshall-Blake (00:50:35):

At Independence, what we did, we launched a campaign called Nurses Can, that features nurse leaders who are role models in research and innovation and public service. So again, Dr. Fuchs as you were talking I was thinking of that, that brochure that we created that highlighted those different areas but not nurses can't, but nurses can. Nurses can be anywhere. We also developed a national partnership with nurse.com to develop continuing education content. We support community-based research projects by graduate students that have the potential to transform healthcare delivery. As a matter of fact, we were one of the inaugural founders of the Robert Wood Johnson Foundation's Future of Nursing Scholars Program. We had eight PhD scholars which support students pursuing a PhD in nursing.

Rev. Dr. Lorina Marshall-Blake (00:51:33):

The final part I want to discuss probably is one of the most important. How can we help nurses lead the way in delivering culturally competent care to today's diverse patient population? Again, we've heard some stats and another one according to the CDC, cultural competence is the integration and transformation of knowledge about individuals and groups of people. In some specific standards into policy, excuse me, and to practices, and attitudes used in appropriate cultural settings to increase the quality of service. Again, I think it comes back to again that word, attitude. When you look at attitude, attitude has three things that are part of it. One, it's crucial to everything we do, whether you're in healthcare, when you're in engineering. Your attitude or attitude is crucial. Secondly, it's a choice. So, people make the choice on how they're going to respond. Then hopefully if it is the right attitude, that it would be contagious and it would catch on like wildfire.

Rev. Dr. Lorina Marshall-Blake (00:52:41):

Now, when I said culturally competent, why is that important? Because we know the healthcare system doesn't work the same for everyone right now. I don't think I have to go into that, but we already see what the inequities are, we look at health equity, whether it's preterm babies, maternal healthcare, whether it's diabetes, whether it's high blood pressure. We know that exists. We know there are racial and cultural disparities in care and outcomes.

Rev. Dr. Lorina Marshall-Blake (00:53:09):

For example, African Americans are 60% more likely to be diagnosed with diabetes and 40% more likely to have high blood pressure. COVID-19, and I think again, we probably join each other on this, has made these disparities even more stark. Healthcare has been part of the discussion of inequality since the George Floyd protests. Nurses can be leaders in advancing health equity. Again, as Dr. Mason talked about, messengers. I have a saying, trusted messengers with trusted messages. I believe that's what nurses are because they're on the forefront, they're on the frontline and they as already been said, they are trusted. They are a known commodity, there's no question when it comes to nurses.

Rev. Dr. Lorina Marshall-Blake (00:54:02):

Now the first person, I don't know if you saw it or not, in America to receive the COVID-19 vaccine was Sandra Lindsay, a nurse at the Long Island Jewish Medical Center. As a nurse and black woman, she wanted to inspire people who looked like her, who might be skeptical of the vaccine. Again, nurses on the frontline leading, it's okay, I've been able to do it. Especially in communities of color and the African American community, there's that tendency which regard to, is the vaccine safe? Should I do it, shouldn't I do it? There has been such a history of how vaccines have been used or tests that have been done. So again, I believe again, nurses. When we talk about nurses on the frontline, it is about leadership, it is about stepping forward, it is about having a voice, it is about going back to where Dr. Mason was talking about. In other words, it shouldn't be an afterthought that you have a nurse speaking out or interviewing. You should automatically have a nurse. Again, I got excited as she did, when they finally got a nurse on the COVID taskforce.

Rev. Dr. Lorina Marshall-Blake (00:55:15):

Now, our foundation is supporting also grass roots organizations for addressing inequitable assets to COVID-19 testing and vaccines. Matter of fact, I don't know, you probably saw it on the news, we were one of the first funders and be continue to fund the black COVID doctors who did over 4,000 vaccinations this past weekend from Friday at 12:00 until Saturday morning at 12:00. Again, making sure the funding is there in addition there's another group for the Latino community called CAPE Community Access Test and Experience, and I was with them yesterday in a Latino neighborhood doing COVID testing and education. Again, it's getting the education about COVID and getting rid of the myths that are out there and also about the vaccine at the same time. But again, for the black and Hispanic community, we are right there on the forefront.

Rev. Dr. Lorina Marshall-Blake (00:56:20):

Then I would be remiss if I didn't talk about as we get future nurses into the pipeline, our nursing internship program, which is committed to ensuring young nurses are prepared to care for diverse communities, because I mentioned they go out into these 50 health clinics. The clinics are in the community. We lead professional development sessions for the students that focus on issues related to diversity and cultural competency. Again, we do our session but again, it needs to be in curriculum, it needs to be something that is practiced often. Our internship sites like I said, include community health centers in medically underserved areas. Again, they often serve diverse communities, include Hispanic, Latin X, African American, LGBTQ. So again, making sure that we touch those populations who right now have no voice really, and are underserved. But early exposure like I said, to these environments can help increase the number of nurses in communities that need them. They can also reduce the risk of burnout that is often experienced in underserved settings.

Rev. Dr. Lorina Marshall-Blake (00:57:33):

We are proud of this program and the bridge it provides and I think that's what it is. We have to provide the bridge for our future nurses to get across. We have to expose them to those settings that are out there. The other opportunities that are there from academics, which is great but also to the community. In this issue like in so many others, nurses can show us the way. As long as we make sure they have the right preparation. I think it's all about the prep time, it's all about being prepared. So, I hope again, I made the case, that the stakes are really, really, really high for us to get nursing workforce development right. We need to get it right and the time to get it right is right now, especially I believe, after a year that was so difficult on the healthcare system. Is it going to be easy? No, it's not going to be easy, but I know that the best minds and they are nurses, are working on the problem. Beginning with this group today.

Rev. Dr. Lorina Marshall-Blake (00:58:34):

Again, it's been a pleasure to speak to you and I look forward to the questions. Again, thank you for the opportunity on presenting.

Kathryn Santoro (00:58:42):

Thank you so much for Lorina, and Independence Blue Cross Foundation, for your leadership preparing the next generation of nurses to care for diverse communities.

Kathryn Santoro (00:58:52):

I'll also let our panelists to come off mute, I know we're running very short for Q&A but we know there's no end in sight for the demand for nurses. Mary Ann eluded to COVID-19 as a chronic illness. We've heard about the importance in vaccine delivery. A lot of questions have come in about the concerns about recruitment and retention of nurses, both now and after the pandemic, as well as students that might be thinking about entering the nursing profession. How do we bridge these gaps and what is the key strategy or solution that each of you might want to leave us with today about how we can really support the workforce going forward?

Diana Mason (00:59:40):

So, this is Diana, I'll start but I think Mary Ann will have a good bit to say about this, as well as Lorina. There actually is internationally, the International Council of Nurses is calling for countries to see this as an opportunity to invest in healthcare and invest in nursing, that this is the time to do it. So, you're investing in nursing education programs, making it more affordable to go to school. You're looking at other ways to support nurses in practice. I for one believe that just as professors have sabbaticals, nurses who have been working for 10 or 15 years should have some kind of a sabbatical to refresh and regroup. Particularly those who are in front line clinical positions. So, I think it's an opportunity to look at how to improve healthcare by investing in nursing.

Mary Ann Fuchs (01:00:31):

I would agree with Diana and her comments. As it relates to ways to continue to support. I think at both, especially at a federal level, just the continual investment in nursing education resources to not just support the frontline staff, but also to support ongoing education and the educators because that continues to be a challenge. Making sure we have adequate education, educators, becomes really important.

Mary Ann Fuchs (01:01:10):

I think funding, especially in addition for just mental health support and the ongoing needs of our workforce will be very important moving forward. I would say there is evidence though, that applications are up at schools of nursing. That's really good, and that's why we do need the funding for educators. We need I think our students to be extremely flexible to have the attitude of dedication and loyalty, making sure that we're able to continue that innovative learning experiences for people.

Mary Ann Fuchs (01:01:51):

The other thing I would say is that we have to continue to focus on the ability for nurses at all levels to practice to their scope of training and experience. So that becomes continually an underlying opportunity for us that we have to continue to break down barriers. What we've learned during this pandemic is just to be able to use all of our trained individuals to the level of their scope and training.

Kathryn Santoro (01:02:22):

Great.

Rev. Dr. Lorina Marshall-Blake (01:02:23):

Okay, and I'm going to... I think the word for all three of this is the word invest. When I think of invest, and especially with regard to nursing is looking whether it's [inaudible 01:02:33], whether it's Robert Wood Johnson, whether it's the Independence Blue Cross, there needs to be more philanthropic dollars to help fund it because nursing school is not cheap. Again, if you're looking to fill the pipeline and especially to bring in more culturally diverse communities into nursing, the cost oftentimes are prohibitive.

Rev. Dr. Lorina Marshall-Blake (01:02:53):

I think also, in building the pipeline... I was just recently in a conversation the other day where looking at someone who was a CNA and now they're going into community college and going from community college into an RN program. So again, showing the... what is it? The path on how to get there but also providing I believe, the resources and the dollars to help get them there too. But again, it is a... I think we just have to make sure that that pipeline is continually fed due to retirement, due to nurse burnout, and really due to COVID. I'm sure it will go away some day, but in the meantime, making sure that we also have programs of self-care and back to the sabbatical. Making sure that nurses have the opportunity to regroup and to be resilient, so.

Diana Mason (01:03:49):

And that we're preparing a pipeline that looks like the communities we're serving.

Rev. Dr. Lorina Marshall-Blake (01:03:54):

Thank you, thank you.

Diana Mason (01:03:54):

So back to your diversity issue, Lorina, yeah.

Rev. Dr. Lorina Marshall-Blake (01:03:56):

Exactly.

Kathryn Santoro (01:04:00):

Well, thank you to our really excellent panel of speakers today. You gave us a lot of great information, that your slides are available on our website. We'll be making a recording available and sharing all your great resources.

Kathryn Santoro (01:04:14):

I also want to thank Carmen and Journalist's Resource for collaborating with us on this event. I'd like to just quickly ask our audience to provide some feedback. There's a brief survey on the bottom of your screen. Thank you for joining us for the discussion. We also have some other NIHCM resources available on our website. Just want to thank you all again for joining us today and ask everyone to please continue to stay safe.