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 pandemic coverage. We're spending this episode with Dr. Garrett Chan, a nurse leader from California.
Garrett is the president and CEO of HealthImpact, an organization that has driven workforce development innovations within nursing. And throughout the pandemic, as we're going to hear from Garrett, HealthImpact has been behind two major initiatives to help promote vaccine confidence.
The organization initially launched VaxForce to recruit skilled volunteers who could perform vaccinations; and then Trust a Nurse, Ask a Nurse, a telehealth platform staffed by volunteer nurses to field COVID-19 vaccination questions from community members.
Besides running HealthImpact, Garrett is also an associate adjunct professor at the University of California San Francisco. Previously, he served as Director for the Center for Education and Professional Development, and Director of Advanced Practice at Stanford Healthcare.
Welcome to At the Core of Care, Garrett.
GARRETT: Thanks so much, Sarah. It's a pleasure to be here.
SARAH: So the first question we always ask our guests is the story of how they got into nursing. How did you choose this field?
GARRETT: Well, it's interesting. As I talk with many, many nurses, everybody comes to the field of nursing in different ways. And I, actually, accidentally fell into the profession. So after I graduated from high school, I didn't quite know what I wanted to do. So I went to a local community college. And I started taking classes and art and art history and advanced Spanish because I had taken Spanish in high school, and I really wanted to learn French. So I took beginning college French as well. And as I was taking all of these humanity courses, I thought, hmm, I think I want to become a curator of a big museum. And so, I continued on my humanities path. And at the end of my second year, as it was getting closer, one of the things that I had to do in this particular community college is that if we weren't ready to graduate or transfer at the end of the second year, we had to see a career counselor. So I wasn't quite done yet. And so I decided to go and make a visit with her.
So I sat down on the other side of the desk, and she asks me in this voice, what do you want to do? I was shocked and it took me a moment. And I said, ‘Well, I want to be a curator of a big museum.’ And she looks at me, and I'm not going to continue the voice. And she says, ‘There are no jobs. And you have to get a PhD in order for you to get into any of the big museums.’ And so I thought, hmm, I don't know what I want to do. So she looked at me and she asks, ‘Do you like people?’ And I thought, yeah, I like people. People are fine. She asks, ‘Do you like science?’ And I remember so clearly thinking, did you look at my transcript? I do not have one science class on my transcript. But I remembered my high school biology and chemistry teachers, and they were amazing people. And so I thought, yeah, I like science. And so she asks me, ‘Well, how about a nurse?’ And I thought, ‘huh.’
SARAH: And for those listening, you may not know that Garrett certainly went on and continued his studies. So laughing off the PhD. You certainly didn't stop after that.
What led you to specialize in workforce development?
GARRETT: I think there are just these times in our lives where things just happen and coalesce around a particular issue. One of the things that led me to workforce was that I decided to go on, as you mentioned, for my PhD. And I did my PhD at the University of California, San Francisco. So my PhD is actually in palliative care and emergency nursing. At the time, Dr. Patricia Benner, who is a quite famous nurse around specifically skill acquisition in nursing education, she happened to be doing some work in palliative care. And so I had the opportunity to study under Dr. Benner for my PhD. Now, while she was doing some palliative care work, you can't really leave her sphere of influence without getting involved in skill acquisition and nursing education. And at the time, as I was getting ready to graduate, she was doing a research study, funded by the Carnegie Foundation, looking at nursing education. And so I was very peripherally involved in that project. And what she was looking at was, how we were educating nurses and getting them prepared to be practice-ready.
So I'm both a clinical nurse specialist and a nurse practitioner. But as a clinical nurse specialist in the emergency department in a Level Two trauma center, I was responsible for new grad entry, transition to practice programs. And I found that back in 2000, that there were a lot of new grads who were leaving their academic programs, really, at the advanced beginner stage.
Fast forward about 17 years. I'm now at Stanford Healthcare as the director for the Center for Education and Professional Development, and I was overseeing the new grad residency program. And I realized that the new grads were actually coming out as novices and not advanced beginners. And so because I had a lot of history and experience with skill acquisition and preparing nurses, especially new grads to pick up the practice of nursing, it led me to really focus on preparing and in some cases, remediating new graduates to pick up the practice of nursing. And so that was a very rewarding experience. We were able to implement programs that helped new grads feel successful and confident in their care.
And then at a certain point, I applied to become the president and CEO of HealthImpact, which is the California nursing workforce and policy center. And so I was fortunate to be hired. And now at HealthImpact, we're doing workforce programs and workforce strategy at a statewide level. And so I really feel like a lot of the things that I had done in my past, led me to this point in time where I'm looking at workforce issues in nursing, and especially in the COVID pandemic, the challenges of educating nursing students, and upskilling the incumbent workforce is really some of the things that I'm passionate about.
SARAH: So bearing all of that in mind and HealthImpact’s comprehensive workforce development approach, let's turn our attention now to the pandemic. Can you take us back to when the pandemic hit? At what point did the idea for VaxForce come up?
GARRETT: My background is as an emergency nurse. That's my area of specialty. I've been in emergency nursing since 1997. And disasters are really part and parcel of emergency nursing. Now, none of us have ever lived through a pandemic. So it was going to be different. But I started thinking, okay, what are the phases of a disaster? And so, there's the immediate response and how do we respond immediately? And so the lockdowns, the social distancing, physical distancing really came into play. That, of course, created wrinkles for the workforce in terms of how do we educate these nursing students so that they can actually graduate.
So I knew that we were going to end up with a vaccine at some point in time. And when I thought about the concept of vaccine, now we didn't know when we will be able to get the vaccine. But as I was planning for the vaccine rollout, I thought that there were going to be three, if you will, roadblocks or barriers, major issues that we had to overcome.
The first one was going to be availability. There's some something like 400 million people in the United States, not everybody's going to be able to get the vaccine immediately. So the availability of vaccine was going to be one of the major issues.
But over time, there would be more vaccine that would be manufactured. And we were going to enter into a place of not having enough personnel to administer the vaccine. So we have enough vaccine, but we wouldn't have enough people out in the communities to actually administer the vaccine.
And then the third big barrier, I thought, were going to be the people who resisted the vaccine. We have known for a very long time, especially in California there has been a vocal anti-vax community. And so there was going to be a time when there was going to be for whatever reason people were not in favor of the vaccine.
And not in favor of the vaccine is really a continuum. There are some people who are just questioning it. They're not quite sure they want more information. And then we have people who are spreading misinformation and disinformation, which is very much on the other end of the spectrum.
And so, to start thinking about the vaccine effort, I thought, Okay, well, let's start getting VaxForce up and running, so that we could onboard volunteer health professionals. It's interdisciplinary. We have nurses, physicians, pharmacists, physician assistants, anybody who is licensed, who could have their license verified by our system was invited to participate. In addition, we did make it available to students of all the health professions, so that they would come with a clinical faculty member who would oversee a group of different students. And as a way to actually open up a possible clinical rotation for any of these schools that were looking for clinical rotations.
And so as a result, we created VaxForce to help administer vaccines with a particular focus on underserved communities and communities of color. So we have had 305 volunteers that have signed up since March of 2021. We've administered over 8,000 vaccines to community members across 66 volunteer opportunities. And the vaccines have been received by the following races and ethnicities. So 48% Latinx, 25% Black, 4% Asian Pacific Islander, 20% White and 3% reporting mixed race.
SARAH: And so we're talking an entirely volunteer workforce.
SARAH: And how active is VaxForce at this point in the pandemic?
GARRETT: So we are still doing about three or four vaccination events per week, with a focus on doing outreach. Some of our vaccination events have been in the farm worker community of Sacramento County. Part of the county is very rural. And there's not a lot of access to care. So we have had many different outreach events there. We've also done school-based events. We've also done skilled nursing facility events. So it's really exciting to see all of the different opportunities and getting the vaccine out into the community.
SARAH: That's great to hear that you're continuing to do that many events. You know, I think that there was a lot of attention to these, you know, mass vaccine events, early when the vaccine was more widely available. And then it sort of died down and there wasn't as much attention. But to know that there's still people out there getting creative, meeting people where they are is really exciting to see.
So once VaxForce was set up, is that around the time that HealthImpact also rolled out Trust a Nurse, Ask a Nurse?
GARRETT: Again, the third major hurdle was about people who are questioning or anti-vax. And so that was the impetus to create Trust a Nurse, Ask a Nurse. If you happen to be in a health plan that is very well organized, all you have to do is pick up the phone and you can talk with a nurse. But for state-based plans like Medicaid, and in California we call it Medi-Cal, it's hard to find somebody who you can trust to pick up the phone and just ask a question. And even for those people who have other types of insurance, it might be hard to get into talk with your provider if you're in a community clinic, for example.
And so Trust a Nurse, Ask a Nurse was really created to help make available to anyone within California an opportunity to talk with a nurse to get more information. And so, it was really to overcome the third kind of hurdle that we were going to see. We started the development of Trust a Nurse, Ask a Nurse in February of 2021. And we were able to get it up and launched by September of 2021.
SARAH: And for listeners who want to learn more about Trust a Nurse, Ask a Nurse, check out our previous episode with nurse practitioner Lizett Leandro. She helped to get this telehealth platform up and running. And so was there a lot of vaccine hesitancy going on at that point? I know you had sort of laid out that third area you were anticipating seeing some of that distrust, maybe misinformation, even. What was happening at that moment in time when you were rolling this out?
GARRETT: When you look at our state overall, because the urban and the suburban areas were highly vaccinated, you know, 60- 70%, we did have large swaths of California that were not in favor of the vaccine. And so in those areas, kind of in general, if you will, were areas that didn't have a lot of access to health resources. And so that's another reason why we wanted to bring healthcare to these people, so that they could ask questions and seek information. And again, for the people who are truly anti-vax, who really subscribe to the misinformation or disinformation, that was not the population that we were trying to reach. We were trying to reach the people who just had questions and were unsure and needed reassurance.
SARAH: Such an interesting model to recruit volunteer nurses for these shifts. Was this the first time HealthImpact had done a volunteer-based model like this?
GARRETT: Yes, it is the first time that we've done something like this. And with VaxForce, we got a lot of response. For Trust a Nurse, Ask a Nurse, we did have some difficulty. And I think part of the reason is because we rolled it out in September of 2021. And by then, there was so much fatigue in health professionals. That it was hard to mobilize people and people just didn't want to talk about vaccines and COVID anymore. So it was a bit difficult. And the other thing is in some ways, I think it was easier to recruit people for VaxForce because it was in-person. And people wanted to connect with, they weren't patients, right? Because we didn't really have a formal relationship other than giving them the vaccine. But there was human contact. And so that was really rewarding for our volunteers. And so there is something to be said about, you know, telehealth fatigue, Zoom fatigue. And so it did present a little bit more challenge to recruit volunteers for Trust a Nurse, Ask a Nurse.
SARAH: So when you say it was difficult to get volunteers for Trust a Nurse, Ask a Nurse and the fatigue, can you go a little bit deeper there and it kind of gets into this next section. At this point in the pandemic, especially, nurses are still navigating COVID. They might be getting sick themselves or their families are. It's directly impacting their lives, everyone around them. And now we also are asking nurses to support folks through vaccine hesitancy or questioning. Frankly, at this point, they're choosing to remain unvaccinated. So you spoke about that vaccine fatigue at the start when you were recruiting volunteers, what does that look like now?
GARRETT: It's still an issue. I mean, we're, in some ways, in the middle of it. And you know, I think it’s what we're trying to appeal to our potential nurse volunteers is there are still a lot of people who have questions. California is a very interesting state because geographically and from a population perspective, we have these really big centers of population density. And so what we're trying to have nurses understand is that, well, there might be a lot of nurses in the urban areas, Los Angeles, San Diego, the Bay Area, there are lots of places that still need nursing services and nursing help. And so, trying to appeal to nurses and say, you know, it's a safe place for you to be in telehealth. You're not in contact with any person from whom you can potentially contract COVID. And we still are helping people out in the field.
So, you know, I think the other thing is for Trust a Nurse, Ask a Nurse is that vaccines were really the first pilot. This was what we wanted to try to establish Trust a Nurse, Ask a Nurse in because it was something very topical and timely. The intent of Trust a Nurse, Ask a Nurse is to continue and add additional topics to telehealth. So specifically in the areas of patient education, and perhaps even screening, or even pre-screening tests, so that we can screen for health needs. And so as we start expanding Trust a Nurse, Ask Nurse and determining what the next steps are, we still haven't come up with a final decision around where we'll go with Trust a Nurse, Ask a Nurse beyond vaccines, that might also engage nurses because it will be an opportunity for them to talk about things other than COVID.
SARAH: So I know you're saying those decisions haven't been made yet. Using your imagination, seeing what you've seen so far, what do you envision? What could the potential be for something like Trust a Nurse, Ask a Nurse or for the VaxForce?
GARRETT: It's fascinating. The literature actually is quite mixed. When I've done lit reviews around things like telehealth or even like health fairs, the need is so great, that you could really do anything, and it would help. Cardiovascular disease, cancer, mental health, like screening for depression and anxiety. I'm not sure if this is going to be the area that we'll go into. But suicidality, we are in a crisis of suicidality. Also something that I would love to do, we still haven't decided on this is screening for cognitive decline. We're having an aging population. And there's so many things that people are wondering and want to know about in terms of general aging. But also, things like, well, my parent is getting older, and they're not being able to take care of themselves in their own home. What are the options? You know, people don't really understand the concepts of board and care. What's the difference between that and assisted living versus a skilled nursing facility, custodial care, skilled nursing facility skilled care? I mean, there's just so much confusion, and our health system is not easy to navigate. And so thinking about some of those topics are things that I believe people would really want to know about. Addiction. What about addiction? How do I help my loved one, dealing with their addiction disorder. So there's a lot that we can do.
SARAH: Yeah, definitely. And you know building on that, that trusted relationship with a nurse that we often are going back to. And I also love the way that you've also tied this to workforce development as well. And really kind of meeting that need for how do we pair these emerging needs that we're seeing with the need to continue to cultivate a workforce that's prepared, that is ready to meet those needs. So before we come to an end, are there any final thoughts or reflections that you want to make sure we share with our listeners?
GARRETT: I think we're in a really tough time. I mean, we understand this, and especially around the nursing workforce. There are a few things that I would like to share.
First is that the workforce, while they're migrating perhaps away from direct patient care, they may still be in the profession. And we have to be okay with that. We have to recognize that that is part of what the current phenomenon is looking at, or what we're experiencing. So how do we help people who have perhaps been in acute care, move, transition well into doing maybe more community-based care, or public health or school nursing? There are a lot of transferable skills from acute care into ambulatory care. And that's one of the projects that we're doing is we're upskilling the workforce by offering a transition to practice or transition in practice into ambulatory care. So for new grads or for people who are experienced nurses, if they want to move into ambulatory care nursing, we've created a transition to practice program for that.
The second is the concept of retention and well-being of the of the workforce. It's on everybody's mind. And it's really important. I would say that they're the concept of retention and well-being is so multifactorial.
And I would say perhaps a bit too much attention is focused on resilience. We're trying to say, be more resilient. And here, do yoga, do more exercise, eat healthier. Meditate. And that's important. I don't want to minimize that. That's the foundation though, we can't stop there. We need to think about healthy work environments. We need to think about flexible staffing. We need to think about the concept of mentoring, and we need to think about how institutions can really change their cultures to be cultures of health and well-being and not place it on the shoulders of the individual nurse who may be challenged with burnout or perhaps who is suffering from moral injury. These are such complex issues that we can't stop at just resilience interventions.
SARAH: Absolutely. And as you mentioned, this is on the top of everyone's minds, including ours.
Several of our recent episodes really dig into these issues. So definitely check out those episodes if you haven't heard them already.
Garrett, thank you so much for joining us on the podcast.
GARRETT: It's a pleasure, Sarah. Thank you so much for pulling this podcast together. It's so important.
SARAH: And for more about HealthImpact’s Trust a Nurse, Ask a Nurse volunteer-staffed telehealth program, check out our episode with Lizett Leandro. She shares what her experience has been like doing this type of public health outreach.
LIZETT: Most people trust nurses and you’re calling somewhere where you know you're going to have a professional answer your questions. And this is why we offer it to all community members. You can have a community member from a breastfeeding clinic call. You can have a community member from like a local library that is not sure if their child should have the vaccine. So it's from all levels of care and in the whole spectrum of from pediatric to breastfeeding to adult to you know I have X, Y and Z conditions, can I get the vaccine?
SARAH: Support for our special COVID-19 pandemic coverage comes from the Centers for Disease Control and Prevention.
You can find our most current and past episodes of At the Core of Care wherever you get your podcasts or at paactioncoalition.org.
At the Core of Care is produced by Stephanie Marudas of Kouvenda Media and mixed by Brad Linder.
I'm Sarah Hexem Hubbard of the Pennsylvania Action Coalition. Thanks for joining us.