Sarah: This is At the Core of Care, a podcast where people share their stories about nurses and their creative efforts to better meet the health and healthcare needs of patients, families and communities. I'm Sarah Hexem Hubbard, Executive Director of the Pennsylvania Action Coalition and the National Nurse-Led Care Consortium. As part of our special COVID-19 vaccine confidence efforts, we're creating a series of podcast episodes that can be helpful to nurses at this time and the communities they serve.
Nurses nationwide have shared their perspectives and for this episode, we'll discuss vaccine hesitancy with nurse Deborah Washington, who joins us from Boston where she's been director of diversity for nursing and patient care services at Mass General since 1995. Dr. Washington also serves on diversity advisory committees for multiple nursing schools, and led diversity committees for the National Black Nurses Association and the future of nursing campaign for action.
At the end of the episode, a nurse practitioner from Kansas will share her experience with vaccine hesitancy in the community where she works. But first, let's turn to Dr. Washington.
Dr. Washington, thank you so much for making the time to join us.
Dr. Washington: Absolutely.
Sarah: So before we dive into talking about vaccines, can you share a bit about your current role as the director of Mass General's nursing and patient care services? How does the program look now compared to when you took the position in 95.
Dr. Washington: I came here as a student nurse. Nursing as a second career for me. Through volunteer work, I became interested in nursing through working with the elderly. I spent about seven years at the bedside. And through committee work became interested in how hospitals operated, and then leadership.
And I led the Diversity Committee initiative, the first one we had, and that was a huge program. And out of that program, they decided that the diversity program needed a point person, I volunteered to apply for the job. And it was fortunate enough to be selected out of the pool of applicants and became director of diversity in 95. And the world has changed tremendously, primarily because now people can tolerate the conversation and all of the things that make up that conversation much, much, much better today than they were back then.
Sarah: So, moving to vaccine hesitancy, vaccine confidence, what's the venue or setting where you're most frequently having conversations about COVID-19? Or about the vaccines? Is it something standard that you're hearing? One of the forums where that question comes up?
Dr. Washington: Well, because of COVID, I started focusing in on community engagement work, as opposed to being focused internally, the conversations virtually happened with community leaders, community organizers, community activists, and because of COVID, what really began to happen is that Black communities in particular, started forming Coalitions and partnerships. And that's where those conversations have been happening primarily for over a year now.
Sarah: And so, I'm assuming in the beginning, it was more about understanding the virus, mask-wearing, testing. What are the conversations about vaccines in that community right now?
Dr. Washington: Well, there was the hesitancy, the topic that we're talking about, based in the whole notion of: it's not safe, it's not going to be good for us (people of color). And people worked their way through those issues over time. And they’re now talking about, “We don't have avenues for easy access to the vaccine compared to some other population groups. They do have access. We need to improve our ability to get that vaccine now.
Sarah: How do you see access issues? I know we've heard about unreliable transportation being an issue, access to Internet. How is that playing out?
Dr. Washington: Well, it's interesting. People have been able to live through this process, the demands from the CDC in terms of how to remain safe and whether or not that fits my ability to follow those guidelines and the conversations that came out of that: “Are they crazy, you know, that's not how I live my life. It's impossible.
Having those conversations and then moving towards: “Okay. They say they have a vaccine, but now we're going to talk about all the conspiracy theories and the rumors and the misinformation.” And we worked our way through that and Then it became: “Okay, there's the vaccine, but I'm not gonna get it until Dr. Faucci gets it.” And he got it.
And now it's: “Alright. It's available, but it's only available in certain locations. And can I get to that location? And why isn't it in the middle of where I live as opposed to downtown?”
Sarah: And have you gotten any feedback about the signup portals? I'm not as familiar with the systems that are rolled out in Boston. But has there been feedback about that? Or has there been an opportunity to inform any of those systems?
Dr. Washington: Well, I don't know if other states and cities have had some of the glitches that we've had. But the governor had to go on television to apologize for a significant glitch with the registration process, when we first started really being able to roll out access to the vaccine. So, it was complicated in terms of language accessibility in terms of the technology, am I familiar with it in terms of if the information is written, it's so detailed, I get lost in the details, what phone number or should I call? Who can help me to navigate the system? So, access in terms of directions, simply stated directions, common sense ways of access is what BIPOC people are asking for?
Sarah: I don't know that that's across the country, that folks have really been able to meaningfully engage in those conversations and move beyond them. So, I'm wondering, you know, if you have thoughts, suggestions. Looking at the persisting inequities, looking at the history with Tuskegee syphilis study -- and unfortunately, other examples of this troubling history -- what do you recommend when nurses are talking to their clients? Or when you're talking with community leaders? How do you start that conversation?
Dr. Washington: It’s important to bring more diversity to nursing and to the workforce. And we need to think about the whole concept of racialized medicine, and how we need to be careful and mindful of how we use our science when race is part of the demographic of the people who are participating in our studies.
It makes a difference if Black people are talking to Black people, compared to a mixed-race conversation. When you have a mixed-race conversation, other dynamics enter into that conversation. And those other dynamics, sort of, limits transparency. And if there is one thing that has made a huge difference, in coming up with strategies and coping mechanisms, is to pull ourselves together. I think if I had to share with you the biggest difference I've seen over this past year because of COVID, it is Black people, communities of color, the vulnerable are actively gathering themselves together. They're not accessing the system to say, “KNOCK KNOCK KNOCK, let us in, let us join you in this problem-solving conversation.” They're doing the polar opposite. They're gathering themselves together to hold the conversation, to come up with strategies. And then it's: “KNOCK KNOCK KNOCK, this is what we need. And this is how you're going to get it to us.”
It's a change in the power dynamics of the community's voice in healthcare decision-making and healthcare strategizing. And what I like about today's environment is that the system is listening.
Sarah: Where have you seen nurses in those conversations? How are nurses of color? How are black nurses stepping up to lead that?
Dr. Washington: That's a very interesting question, because when I think about how the community is responding to COVID, nursing is not convening those conversations. Community leaders, long-established community leaders are convening those tables, and they are inviting nurses to participate. Nurses -- because of time, family commitments, all of the things that we're familiar with -- don't necessarily show up in droves at that community table where strategizing and planning is taking place. What nurses are doing, minority nurses, Black nurses are doing is to respond to the outreach of: “This is what I need. Can you help us? Your voice carries weight. Can you help us to think about whether or not what we're asking for is feasible? How does the system operate?”
Sarah: I love the way that it's being flipped because we often talk about the nurse as the communicator, sort of, of the system. That nurses understand the health care system, and they're able to make – you know, share that understanding with patients and clients. And here we're saying the community is understanding what they need, bringing in nurses to help translate that to the system. Could you talk just a little bit about examples of what a community strategy would look like?
Dr. Washington: At the tables that I'm participating in as director of diversity from an academic medical center, wearing that hat as well as wearing the hat of a Black nurse who is concerned about the Black community, what I've noticed is that the system, as represented by my organization, was working in parallel to what the community was trying to design as an ask. So, my organization was creating things like the care van. Which back in the old days, just reminded me of, like, the bookmobile that carried the books that brought those books to the vulnerable communities that didn't have a library.
This whole notion of bringing care to the community, as an idea from my organization, in parallel to the community saying: “Not everybody can get to a vaccine site that's designated by the state or the city governments. How do we get a service that is brought to the community itself?” Once the community convened its table and started inviting and having its reputation built up in papers and social media about what it's been doing, we were able to then share information. So, the caravan became part of an event that the community organized, and they were then mutually of service to each other.
Sarah: I would love to hear what you think about misperceptions, misinformation, and how to address that. Any examples or strategies -- really, tactics -- when a nurse is talking to a client who maybe has some misperceptions? What are some tools that nurses might have to start that conversation?
Dr. Washington: During this time of COVID, when everybody is scrambling around trying to figure out how can we make a difference, the question comes up around our reputation as nurses of being the most trusted profession. When you think about that accolade that we've owned for many, many years, what exactly does that mean in times of COVID? When the other part of the COVID narrative is, “we need trusted messengers, we need trusted messengers”, where do we stand in that narrative in that scenario, with that accolade that we've always held? And we have work to do, in terms of seeing nursing, as a driver of things, as a voice that can sit at a legislative table, or an organizational strategy table and have impact is a conversation that needs to be included in this current awakening around inequities around what's inadequate and insufficient. Around what is a stack deck. The community is looking at nursing and saying, “Okay, what part do you play in this? What part are you owning, what part are you driving?”
The whole notion of nursing as a partner and a co-creator of change is very much on the mind of community activists and community organizers. Should we constantly pursue you to be with us at all costs and at all times? And I don't know that nursing as a discipline, as a profession has answers to all of that for the community moving forward. And I am trying to make that impression on communities of color here in Boston, that nursing as a discipline and nursing as a power broker absolutely has place in influence in terms of helping you to reach your goals of access and care planning and disrupting things that need to change. We do have a voice and you can trust us to do that work with you.
Sarah: I so appreciate this direction of nurses as power brokers and nurses as trusted advocates, not simply for that patient-nurse relationship, but in that larger system as an advocate. And that is truly the role of nursing, right, that is the nurse. The nurse as an advocate at all levels. In what ways has COVID-19 either created pressure on nurses to step into these roles or raised attention to the need for nurses to step into these roles?
Dr. Washington: COVID has exposed what we've been talking about for a long time. Social determinants of health. How long have we been talking about that? Health Disparities. How long have we been talking about that? We study it, we research it, we make recommendations and suggestions. But if you talk to a community leader, and they say, “Show me the action you've taken, show me the risk you've taken in terms of promoting an action”, the list is short, when it comes to nurse-led action.
Over this last year, as a nurse who represents my organization, when we think about health literacy, that's the most powerful action we've taken in terms of how to message to a community within its cultural values. I can address vaccine hesitancy as a nurse, as a Black nurse, by tapping into the cultural values of Black people around the need to protect family and family relationships. And family is a very big definition. It's not just blood relation, and all of that. So, if I'm going to do a public service announcement about, please consider taking the vaccine, I'm going to couch that message in ideas of protection and family and brother and sister. And using the language of the community.
Nursing as a communicator, as a relational discipline, there's nothing better. That is the work where we can actually make a difference tomorrow, and a few years from now. We need to expand our ability to take hold of that and claim that and intrude upon the medical narrative of who's running that show.
When you think about what was once valued and medical care as the clinical piece, the treatment piece, the data piece, and all we're hearing these days around trying to get people to adhere to safety protocols and to take the vaccine as the community says, “I don't care about the science. Who can I trust to tell me what is the right thing to do? I need to know the person I'm speaking to; I need to trust the person I'm speaking to.” And that's all about messaging.
Sarah: How do we support nurses who are stepping into those power broker roles into those communicator roles that maybe hadn't been called upon in that way before? Or maybe even that might be feeling new to them? Like, how do we support nurses in that capacity?
Dr. Washington: When you are a nurse in an organization, you need to feel that you are backed by that organization. If I'm a nurse who's talking to a physician, if I'm a nurse who is female, who is talking to a male. If I am a male nurse who's talking to someone who misjudges me in some way, shape, or form. In any of those scenarios, and any of those aspects of being a demographic part of the picture of nursing, if I stand up for myself, if I speak up for myself, as someone who has expert knowledge, as someone who knows a patient, as someone who has a great idea, that I will be able to have that idea heard and carried forward. Not necessarily always agreed upon and accepted. But that I opened my mouth, I moved my lips, words came out and somebody paid attention. Once a nurse has the experience of an idea moving forward, that in itself is empowerment that makes us take that next step in consistently doing that.
Sarah: I'm going to change tact for a minute and get personal for a second. We have been really hearing that people want to know, are you vaccinated? You know, and what is your vaccination story? And so, I want to ask, if you're willing to share, are you vaccinated?
Dr. Washington: I am. And I went through a process with my family to reach my decision around getting vaccinated. The process was answering all their questions and concerns. Because a year ago, COVID was a stigmatizing diagnosis. And people were not readily sharing with one another. And certainly, were not going to the doctor in a rush to be able to get that diagnosis. We had zoom meetings about it. Not only with the family, but also with friends. And we told our jokes, and we questioned what was going to come out of the research, and who was doing the research and all of that. And then paying attention to the larger environment, the increasing infection rates. Back in the early conversations about the possibility that they would have to ration ventilators. And we heard stories about people who had children with disabilities, and what that meant in terms of them being able to access treatment. And all of that all became very concerning. So we decided that because of elders in our family, because of babies that have been born over the past year in our family, that those of us who wanted to be shields is the word that I use, we were going to get that vaccine to be those shields. So, I stepped up and got my vaccine. And the side effects lasted for about a day. And the only side effect I had really was a bad case of the chills. But that was over and done with within 24 hours. And that was it.
Sarah: Thank you for sharing that and for being a champion for us in this setting. But for also being that for your family. They're very lucky to have you. And this is on families, too. I mean, I think the pandemic has been incredibly stressful and exponentially so for nurses, for health care workers, for anyone in this field. This has been hard; it continues to be hard. So how do you manage that? And how do you manage that for others for the nurses that you work with? Or for your family as well?
Dr. Washington: You just have to acknowledge what people are sharing with you. That, yes, it is scary. That, yes, all of the information, yes, it is concerning, yes, it can be confusing, because there's so much of it. To acknowledge all of that. And to be able to listen closely to what a person is really trying to say. I might be talking about whether or not I should get the vaccine. That may be what I'm saying out loud. But what I'm really asking is: “Did you get it and what did you go through? And do you recommend that because if you got it, and depending upon what comes out of this conversation, gee, I might get it too.” So how we share honesty and truth with people is the way to get buy-in as a trusted messenger. Just to get them to take it step by step. Without a sense of coercion or blaming or shaming involved.
Sarah: This approach to health care, this approach to person care, hopefully will stay with us beyond a pandemic. And I wonder if you've thought about that at all, you know, what the future might look like and how you see healthcare looking going forward.
Dr. Washington: The most practical thing we can do these days is number one, to stop treating health disparities and inequities as sort of a crisis intervention, address this issue for the moment and then let's all go back and do what we were doing. But to take the interventions that we're applying now, find ways to measure them for outcomes and effectiveness, and then package them for incorporation into the system as it exists now. To take the tried and the true, to take what is actually happening, and then passionate as a permanent part of the healthcare system. That's the way we need to go now, I think.
How do we expand the idea then? You know, right now, the care vans deliver education, testing. It's all COVID-focused. But how do you expand it to other functions in terms of, you know, put a social worker on that van besides a nurse, an advanced practice nurse. And my dream right now is to use the concept of a remote worker, to fashion that into a nurse who takes care of several blocks of her community. And she doesn't have to come into the hospitals, she stays in her community and delivers care and establishes those relationships that are proving to be so important now and up the ante on in terms of having a known healthcare provider who is a nurse.
Sarah: People think about telehealth as important for access to care in a rural area. And it certainly is, but it's important for access to care in an urban area. And it's a different kind of access. This was just such a wonderful conversation. And you've been so active in community events that are often in evenings and weekends and really meeting people where they are, which is you know, that's nurses, right. So, just want to really appreciate you making the time.
Dr Washington: Sure
Sarah: And now we're going to hear from a nurse practitioner in rural Kansas who talked with us recently about her own experience with vaccine hesitancy in her community.
Ashley: I'm Ashley Beying. I'm a nurse practitioner in rural Kansas. I work primarily at Waverly Medical clinic. It is a clinic that is associated with the Coffey Health System. We are located in east-central Kansas. So, I primarily care for patients across the lifespan ranging from the ages of infancy to elderly.
On a quarterly basis, I work at the Coffey County Health Department, which is an entity unto itself. And I provide well-woman care and do well-woman clinic in that setting.
I have a lot of passion behind getting individuals vaccinated. Not just with the COVID vaccination, but vaccinations that people are to receive across the lifespan. With vaccinations, we're giving children MMR vaccines and we're giving them Tdap vaccines. And we're giving people HPV vaccinations. You know, we're giving all of these different vaccines that have been well-studied, and tried and true, to help to prevent these diseases. It’s a public health measure. And that's what public health nurses are created to do: to provide vaccinations and that level of education on public health crises to your community.
At the beginning of the vaccination period back in January, when we started to have the ability to get the widespread vaccinations, they were being distributed to county health departments. Our county health nurses who work at the health department had made the statement that they were not going to administer any vaccinations. And that they would have them provided through the county, but they would not be giving them because they do not think that they have been safe or well researched.
After a period of time, they were able to get nurses that they could contract with and provide those vaccinations. But the statement that was put across our news and the newspaper and on Facebook and social media, I think that created a little bit of fear in patients and maybe questioned whether this is something that they should get, is it going to be safe?
Several patients actually were angry. But I have had some patients that have said, you know, “I'm hearing this, what do you think? Do you think that this is a vaccine that’s safe?” And I think that's where, as a provider, you get to have that open dialogue and conversation where you can share in their concerns, but also educate them with the research that shows the efficacy and shows now millions of people have gotten this vaccine. If it was something that would be a long-term complication, it would have been taken off of the market.
As people were spreading more information on the news and on social media, we were able to put out those infographics and information as far as telling people they can feel safe, they can get this vaccine, that we have gotten it. I, myself, was in the newspaper when we first received the employee vaccines back in December. So, trying to create that, you know, level of communication that people can understand that people that you can trust are receiving this vaccine. Maybe not without side effects. Because we know that the side effects come from your body's immune response. But are getting that safely without any long-term complications.
For the county that I serve, Coffey County, right now 232 individuals out of 1000 have been vaccinated, which really is right in line with our Kansas state average as 23.2% of adults receiving vaccinations. So, I do think that, despite that initial setback, people are getting vaccinated.
It's important to be very empathetic. Show that you can see where they're coming from, but at the same sense, hopefully, guiding them to making those choices that are not only good for them, but good for all of the people around them.
The biggest thing is just keeping open-ended questions with these patients. Asking them, why do you feel this way? Or what guided you to feel this way? What are your reasons for and what are your reasons not to? And can we kind of come to a[n] agreement on why would the reasons for outweigh the reasons not to? Is it because you have had misinformation? Is it because you are afraid of the side effects? Is it because your friend on Facebook shared a post and said their person in Florida died? What's the barrier here and how can we cross that barrier?
CREDITS
Sarah: Funding for our special vaccine confidence series comes from the Centers for Disease Control and Prevention. Stay tuned for more episodes coming up. We'll be exploring vaccine confidence, best practices, misinformation, hesitancy, partnering with community-based organizations, and how nurses can share their vaccine experiences. For more information about related upcoming webinars and where to find COVID-19 resources, log on to nurseledcare.org. You could also stay up to date with us on social media @NurseLedCare.
At the Core Care is produced by Stephanie Marudas and Emily Previti of Kouvenda Media and mixed by Brad Linder.
I'm Sarah Hexem Hubbard of the Pennsylvania Action Coalition. Thanks for joining us.
This project was funded in part by a cooperative agreement with the Centers for Disease Control and Prevention (grant number NU50CK000580). The Centers for Disease Control and Prevention is an agency within the Department of Health and Human Services (HHS). The contents of this resource center do not necessarily represent the policy of CDC or HHS, and should not be considered an endorsement by the Federal Government.
