Dan:

Garrett, welcome to the show.

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Garrett:

Thanks so much, Dan. It's a pleasure to be here.

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Dan:

All right, Garrett. So you have tons of stuff going on, right? So you have workforce. You work with the board of nursing. You work with nursing schools, you have supply and demand studies that you're doing. You're running a side vaccination, sort of standup vaccination clinic all together, one in a very small team, doing amazing things in the state of California. So out of all that, what's your latest focus?

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Garrett:

Yeah. Dan, it's just been an amazing time. I mean, the pandemic, as terrible as it has been and as chaotic as it has created the environment, there have always been opportunities that have come forward. And I think one of the things that we've done at HealthImpact is take this opportunity to refocus on priorities and needs of the nursing community as well as the people living in California.

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Garrett:

And so at HealthImpact, we really look at the concept of workforce, thinking about six focus areas specifically. So if we think about the workforce, we have to think about pipeline, right? How do we get people into nursing? So we have a burgeoning area on K through 12 education. How do we sensitize students in primary schools about the health professions? And so we put together a roadmap or actually a document that describes many of the health professions that people can get into. And so that's been really helpful to disseminate to different schools.

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Garrett:

The second focus area that we think about in terms of pipeline and workforces, the prerequisite education. HealthImpact was formally known as the California Institute for Nursing and Healthcare led by Deloras Jones, who was our first CEO and president. Deloras came from Kaiser, your former stomping grounds. And she was very instrumental in trying to get different colleges and universities to agree on a core set of prerequisites.

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Garrett:

Like some schools and colleges would say, "Oh, it's okay to take anatomy and physiology together without a lab." Other colleges and university would say, "No, you need to take them separately with labs." And it actually created this major problem because students who were interested in nursing didn't know exactly what to take. And so she did an amazing job in streamlining prerequisite education so that people can apply to multiple schools.

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Garrett:

Now, what we're looking at is we've been doing some preliminary conversations with one particular community college thinking about, "Well, how do we make sure that the education that they receive is translatable to human health?" I don't know if you ever were in anatomy class and you dissected a frog leg, right? Most of us do.

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Garrett:

So then the concept is action potential of cells. But that's all you learned was action potential of cells. And we know that that has huge implications for cardiac disease, especially the dysrhythmias, and so early repolarization, problems of the heart. So now what we're trying to do is make that contextual so that people can actually understand why I'm dissecting a frog leg. But this actually has something to do with human health and make that connection.

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Dan:

Yeah, that's awesome. That was something that we looked at when we were building the Kaiser med school too, was how do you take these sort of foundational science or sometimes it's termed basic science, so foundational science concepts and make it relevant clinically right out of the gate. And so, like you said, you're not focused on just the anatomy or the frog in front of you, but you have a case study or a connection back to when you see that leg twitch, when you do X, Y, Z, that's what your heart's doing automatically.

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Dan:

And so when you add sodium to that, how does that change it? And when you add X, Y, Z to that, how does it move it? And to make those explicit connections, rather than just hoping that you teach action potential. And then somehow the student makes some magical leap and connects it to the clinical piece down the road. And so I think that's an awesome approach.

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Garrett:

Yeah. We're trying to do this as a pilot and then try to figure out how to expand that across California so that it makes it easier for learning, to your point, what you're doing with the medical school at Kaiser.

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Garrett:

The third focus area is the pre-licensure education. So the nursing programs, both at the RN and the APRN levels. And one of the things that we know is that just like direct care nurses, we talk about the nursing shortage, but really it's not that there's a deficit of nurses with licenses. There's a deficit of nurses in positions where we need to provide direct care.

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Garrett:

We still need to fill the pipeline. People are retiring at accelerated rates right now. So there is a pipeline improvement that we need to attend to. And we're also seeing early retirements of people leaving the teaching profession. And that's a grave concern. And I'm happy to talk about that in a minute because three states, Hawaii, Connecticut, and California are all putting this as a high priority area. We're all addressing the issue from different perspectives, but the faculty workforce is as important as the direct care nursing workforce.

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Garrett:

Then after you go to school, you graduate, you get licensed. You now enter the workforce. And the three focus areas that we have there is, one, upskilling the workforce through either academic programs or through mentoring or transition of practice programs. As you know, we educate people and this is appropriate to be generalists, right? But when they graduate from school, they're immediately thrown into a specialty. It could be public health, it could be critical care, it could be emergency, it could be labor and delivery.

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Garrett:

And so that transition of practice also known as apprenticeship programs is something that we're really paying a lot of attention to, because we know that people leave the profession within the first two years out of school. And so we need to support people definitely through the beginning parts of their education. And it's exciting time. There's a lot right now of money and attention, focus on apprenticeships programs kind of in general, because we're not the only profession or vocation that is struggling with the mass resignation.

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Garrett:

However, we're focusing transition of practice on specialties. And our first one that we got funded and were going to be heading up under Eddie Burns, who is my Director of Strategic Initiatives at HealthImpact is in ambulatory care. And just like we have seen in the public health crisis, we need more nurses in the ambulatory care space.

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Garrett:

So ambulatory care for us includes public health, school nursing, clinic based nursing, home care, hospice, those types of specialties, because we know that there's a lot of care that's needed out in the community. And most nursing schools across the country are focused on educating nurses to become acute care.

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Dan:

That's something I saw, Garrett, when I was at Trusted Health. We were trying to staff in during the pandemic and I talked to a few hospital leaders at the time and they're like, "Look, we're good on sort of the generalist roles and med surg tele, we're okay there. We need people to staff our level for NICU and we need [inaudible 00:07:33], OR nurses that can do the surgeries that only the Stanfords and UCSFs, et cetera, do."

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Dan:

And we can't find those people. And there's a ton of nurses out there all trying to find jobs, but these super specialties, these sort of really highly credentialed and certified roles just aren't there. And the students coming out of school aren't even exposed to those things, let alone given a chance to become new grad transition programs in it.

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Dan:

And ambulatories as well, right. We're expanding into home and remote patient monitoring and possible at home and all these things that are going to require nursing skill set. But again, we're basically graduating the generalist nurses. And it's like, I give this analogy all the time, like if you bought an iPhone and it took you a year to turn it on, you'd stop buying iPhones. Now, you're inside the head of the CEOs and CFOs of health systems saying like, "Look, yeah, there's a bunch of nurses graduating, but they don't meet what I actually need. And so how do we change that talent pool to actually match the demand in this health system side?"

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Garrett:

Absolutely. And our second program that we got approved through the Division of Apprenticeship Standards in California is perioperative nursing, specifically intraoperative nursing too. And let's face it, when we look at the data around perioperative nurses, their average age is in the 50s. It's not a specialty that a lot of nursing students get a ton of exposure to. So they don't really think about perioperative nursing.

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Garrett:

There's always behind the red line, being sterile. And it's hard to get past the red line to get into the intraoperative suite for a lot of good reasons, for safety and for asepsis. And yet it still is a barrier to having people enter into the specialty because it becomes mysterious. And so we're working on now creating our second apprenticeship program in perioperative nursing. And the other thing that we're really focused on is we want to support facilities and agencies that don't have a lot of resources.

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Garrett:

If you're at Kaiser, Kaiser has plenty of resources. They have a lot of people, they can mount their own transition to practice program in these specialty areas. And we fully support that and applaud that. There are lots of other community hospitals, critical access hospitals, surgicenters, public health departments that don't have the resources. They don't have the person power to actually create a curriculum. They don't have people who can teach in the curriculum. They are so bare bone staffed. So it becomes this kind of death spiral, if you will.

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Garrett:

And so what we want to do is we want to provide this opportunity not to be in competition too, but to support anybody who doesn't have access to those resources. And so that's our mission really is to help support and fill in the cracks.

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Dan:

Yeah, that's great. We had Laura Reichhardt from Hawaii as well recently on the show too. And she was talking about the statewide residency collaborative, and they're sort of standardizing that across the state of Hawaii, which I think is a great opportunity to learn from and potentially model as well as we look at other states. And Hawaii is very rural, so they have to sort of band together, because they're very isolated out there, but there's also parts of California that are the same way.

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Dan:

They're isolated, they don't have talent pools. People don't think about living there when they think about California, but they have hospitals and people in populations that need that care and may not have the resources. So I think it's important that we kind of innovate beyond ourselves and really sort of figure out how do we create these collaboratives to provide training into the spaces where there isn't nursing talent adequately living or moving there.

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Garrett:

Absolutely. Hawaii, California and Colorado are three states among other states, because I don't want to minimize my other colleagues' work, but we do have a lot of rural parts of our states. And so Colorado, Hawaii and California really have taken on this concept of statewide transition of practice and how do we centralize things.

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Garrett:

And again, one of the silver linings for the pandemic, although I do recognize that we all have Zoom fatigue, but it does allow us to reach places where we never really thought we could reach before and connect with different people. And so the three states are really taking up this whole transition of practice across the state, especially in rural areas very seriously. So it's an exciting time. As I mentioned, that's the fourth focus area.

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Garrett:

The fifth focus area is looking at nurse wellbeing, health and wellness. And really we're looking beyond just the "resiliency programs". Those are foundational. We need to have them. I am not at all minimizing the importance of those, but it only attends to part of what we're struggling with. And I've been working with Doctors Alyson Zalta, Candace Burton and Danisha Jenkins at the University of California Irvine.

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Garrett:

And we just finished a study looking at moral injury of nurses during the COVID pandemic in California. And we did a survey. It was over 200 nurses as well as did focus groups. And our data are quite compelling that nurses are experiencing a lot of moral injury. As we all know that there is depression, anxiety, other mental health concerns. And we're also looking at suicidality. As you know, being from former Kaiser, the nurse who killed himself at work in the emergency department, Kaiser Santa Clara, just a couple weeks ago.

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Garrett:

I still work at Stanford as a nurse practitioner. And we had that one nurse who in the middle of a shift in the ICU, he said I needed to go to his car. He went, he drove across the Dumbarton Bridge at the Bay Area and allegedly, or presumably jumped off the bridge and committed suicide. So we need to look at this in a very intentional way. And we're doing that through research and also figuring out what kind of intervention is the right intervention. Because I think that's the thing that nursing doesn't quite understand just yet is resiliency programs.

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Garrett:

Again, I know that there's a backlash to the word resilience or resiliency, and I totally get it. So if not that, then what? And so we're starting to explore the different interventions and Dr. Zalta is a clinical psychologist, and we're excited to have her as part of the team and getting her leadership as well.

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Dan:

Both of those suicides hit close to home, literally within miles of my own house and with organizations I know well. And every time that happens, it makes me so sad. But also like you said, what is the right intervention? Because during the pandemic, we also offered free crisis counseling hotline staffed by mental health nurse practitioners, four nurses. We sent it out to over a hundred thousand nurses and we got five calls in a month in three months, five calls.

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Dan:

On the other side, we have nurses calling us in the middle of a shift, breaking down crying because of the situation they were in. And then so it's like, how do you break through this clinical armor that nurses have? And I don't know. I mean, I don't know if you found some answers there. I know Dr. Ber Melnyk also is focused on this at Ohio State and this kind of code of armor of this persona that nurses need to be the hero that's sort of reinforced by society as well. It's hard to break through that to say like, "I need help," when you're so focused on helping others.

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Garrett:

First of all, we have an outstanding nurse scientist in California. Her name is Dr. Judy Davidson, out of the University of California at San Diego, who's done a lot in nurse suicide, even prior to the pandemic. And so some initial thinking that we're having as a team is putting together the concept of virtual peer groups with nurses trained to lead these types of groups.

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Garrett:

And these group sessions would be a mix of two things. One is psychoeducation topics and then group processing. So Thomas Joiner is a psychologist, who's done a lot on suicidality and he has a suicide risk model. And in his model, it talks about the concept of being connected. And I think having a shared experience, not necessarily suicidal thoughts, but the shared experience, I think that might be one of the things that might be helpful to overcome this concept of just a hotline. Because there isn't a shared experience and connectedness to a group where other people have been struggling.

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Garrett:

And so he talks a lot about that in terms of the concepts of loneliness and how we can think about decreasing loneliness by sharing that we've all had this experience and that connectedness is a buffer to suicidality. So it'll be interesting to see.

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Dan:

Yeah, for sure. No, that's great. And that was sort of the thinking we had preliminarily without the evidence kind of working in the moment was having nurses talk to nurses. And that was sort of the rationale behind having mental health nurse practitioner because then you have at least a shared understanding of what is happening. And what we've found with talking with many of our nurses at the time was we were like, "Well, you have access to EAP programs and this stuff."

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Dan:

And they're like, "But I have to explain what nurses do. They don't understand what I'm going through. It's more work for me to even get help then because I'm trying to explain all these stuff and reliving it that I just don't want to deal with where when I talk to another clinician who's in the trenches with me, instantly we have a connection and we get it and then we can move on. We don't have to spend time kind of rehashing things."

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Dan:

And I think that there's an important aspect to that, especially for the cohort of nursing, which has that shared experience. We never facilitated to talk about it. It's like you have these bad shifts and then you're like go home and deal with it, however you deal with it. The 7:00 AM beer after a night shift or compartmentalizing and not talking about it, or the TikTok and kind of tongue and cheek stuff.

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Dan:

But to actually hash through these real emotions, I mean, it's battle. It's battle. It's war zone. It's not fighting and killing, but it's that trauma that we're never facilitated to talk about. It's always figured out on your own time.

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Garrett:

Absolutely. And that's one of the things I'm very thankful to have Dr. Candace Burton on the team, because her work has been in trauma informed care. And now what we're doing is we're looking at trauma informed care of each other and how do we work together. And it sounds like to your point and the work that you've done previously, we're really on the cusp of breaking this wide open.

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Garrett:

And I think the other thing is helping nurse leaders understand how to actually move beyond individual intervention and how do you help groups of people. And even across particular units, it would be great to have a director or a chief nurse say, "I just want to open this up." And they're not getting involved to setting up the structure, but saying ... Oftentimes we do this in nursing and it just kind of baffles me a bit is we'll want to do something for our unit. And oh, look at all the great things that we're doing for our unit.

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Garrett:

And that's fantastic. How do we spread that? How do we cross boundaries? How do we connect with people across an organization or across maybe multiple organizations to pull things together? Because I think sometimes when I see things on LinkedIn or Facebook, it's showcasing the individual as opposed to showcasing the collective. And that showcasing the collective is I think an important aspect as we continue to move forward.

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Dan:

Yeah. And nursing in general, it needs to focus on it itself as a profession, as an entire body. There's a lot of factions, and that's just a microcosm of it, our unit versus our hospital, versus Kaiser versus Stanford, versus ANA versus AONL. I mean there's all these kind of factions, and I think there is this need to break it open and say how do we support the whole profession in some way and not make it sort of this proprietary thing that lives in an organization or in an association and that kind of stuff.

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Dan:

So that's really exciting work. And it informs the workforce piece. So that's the burnout, the loss of nurses from the profession. And then the other side of that that you're working on is licensure, training. So what are some of the innovations that are going on or what do you think some of the needs are from a licensing perspective to actually get nurses into ... We'll use California as an example, but all states are sort of struggling with this ... into the state in a more reliable way so that when we have these ebbs and flows of patient care needs that we can do it seamlessly and safely?

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Garrett:

That's absolutely the right question to ask. And that leads us to the six focus area HealthImpact about our workforce strategy, which is understanding the concept of workforce migration. And we do that through statistics. And I work so closely with Dr. Joanne Spetz who is phenomenal at UCSF. She does a lot of data workforce analyses and understanding the concept of where are people, where do we need people is essential in other states like Oregon, Utah, and Texas but also doing amazing work in terms of workforce analysis statistically.

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Garrett:

I think the other thing is just being clear about for us, at least in California, is how long does it actually take to get a license? California is not part of the compact, the National Council of State Board of Nursing compact. And I don't think that we will ever be that. There's a strong history of being proud of having high standards to get a nursing license in California. And I don't say that that will change in the foreseeable future. For those states that part of the compact, that's really, really helpful so that people have mobility across state borders.

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Garrett:

I think clarity and transparency, especially in this day and age is incredibly essential for us to move forward with the workforce. And so thinking about how long does it take, what's the minimum, what's the maximum amount of time in a given let's say fiscal year? What is the mean and the standard deviation so we understand what the bell curve looks like can also help us understand how do we actually meet the needs of people living in California?

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Garrett:

And do we have enough nurses? And if we don't have enough nurses and it takes a long time, well then that opens up possibilities for process improvement projects to see how we can reduce the weight because it is Boards of Nursing across the country. Their primary responsibility is to protect the public. And part of protecting the public is actually providing that there's enough qualified, licensed nurses to provide care. And the exacerbation of the great resignation along with early retirements and the natural retirement cadence is really putting Californians at risk for not getting the best care that they can because of just shortages.

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Garrett:

So it's an exciting time. And I think that we need to pay more attention to that. And at least in California, the Board of Registered Nursing is very sensitive. They have heard the concerns and they are actively thinking about ways to address those issues and I'm very thankful for that. And just adding more transparency around, well actually, how long does it take will help us make even greater strides.

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Dan:

Yeah. And transparency back to the applicants to know where their piece is in the process, making that easily accessible so that they can be proactive in some of those requests and take the burden off the people. And I think in my experience, working across 50 states, California's the slowest, in my opinion, upwards of 13 weeks that we noticed for nurses who were licensed in other states to get licensed in California. And at the beginning of the pandemic, Washington who's also not part of the compact was able to get nurses licensed quickly in 24 hours, where when we were emailing the Board of Nursing, we saw standard email return that just said, we are trying to figure out how to work from home.

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Dan:

And I don't want to knock the board anymore. I've been very public about how much frustration I have with it. And I know there's people there that are really working. I know you're working with them and I think that that's important, and it's voting season. So the primaries are here. There's different leadership. There's different philosophies. And so I think nurses and the public need to have transparency into that piece so they can also help with legislation and leadership at the state level in order to help push that forward too.

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Garrett:

Absolutely. It's a team effort, right?

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Dan:

For sure. Yeah. And there's not one person to blame. It's a broken system. I know there's lots of pieces to that. And I agree we do need to keep California safe. And I know there are some pieces in there that we can quickly act if we need to with EMSA and those type of things. But I think we do need a better process because honestly, California is a great place to practice and a lot of nurses want to work here. And so let's make it easy to get the best nurses into California. That just makes sense in so many ways.

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Dan:

So, one of the things I wanted to ask you was we talked about kind of education, retaining workforce, licensure, and I love innovation. So what are some of the cool innovations you're working on? I mean, you set up VaxForce really quickly, which was amazing during the pandemic. What are some of the other kind of cool edge running pieces that you are really excited about?

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Garrett:

Yeah. So just a little bit of background for the VaxForce initiative is VaxForce was a kind of a brainchild of many of us at HealthImpact to try to figure out how to increase the number of vaccination events that we can do in under resource communities and communities of color. It happened really quickly. We were able to get it up and running within six weeks. And so we started doing vaccinations in remote parts of California and in underserved areas of California, inner city, et cetera, really quickly and partnered with a lot of different organizations.

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Garrett:

One of my favorite ones among many because we've had quite a few events, was going out to a farm in Sacramento County, which is kind of in the upper middle part of the state in Sacramento. And we went to a farm. And on Cesar Chavez Day, we vaccinated about 200 farm workers and their families. And that was incredibly rewarding for me because in my opinion, it harkened back to the days of the frontier nursing effort, getting care where it was needed where people lived and worked.

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Garrett:

As of today, we've given over 8,200 vaccines across 71 volunteer opportunities and have had enrolled 315 volunteers across the state. And it's an interprofessional initiative, so we have students from the health professions. We have dentists. We have physicians, nurses, physician assistants, all coming together to actually give these vaccines. And it's been incredibly rewarding.

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Garrett:

Approximately 48% of the vaccines that we've been giving are in the Latinx community, 25% black, 4% Asian Pacific Islander, 20% white and 3% have reported mixed race. And so it really is, in my opinion, a success story of how we can collectively pull together and go out into communities of color and help give them access to the things that they need to stay safe and healthy.

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Garrett:

We're starting to think about wrapping up VaxForce. So VaxForce is a program for both matching volunteers to events, but it's also a volunteer management system. So we've recruited volunteers to come. We've done credentialing very quick and meets all the criteria for credentialing to make sure people have their license, et cetera, et cetera, background checks, and then did a competency validation process.

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Garrett:

So VaxForce is a program and now we're starting to think, "Okay, well maybe we should expand to beyond vaccine. So how do we actually think about the next step?" And I'm excited to say that we're in preliminary. I want to be very clear. It's preliminary conversations with public libraries across California and thinking health education, health literacy, and screening for diseases is essential.

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Garrett:

So, public libraries are seen as trusted resources in their communities. And nursing is the most trusted profession. So how can we get nurses into libraries either through a telenursing program because we also have a telenursing program called Trust a Nurse, Ask a Nurse, and we got that up and running. It took a little bit longer. It probably took us six months, but we have a telenursing program where we can connect a nurse on one side to somebody on the other side.

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Garrett:

And maybe what we could do is create these privacy pods, if you will, in libraries so that if people have any questions, they can just show up on the scheduled times when we would have a nurse at the other end. And because it's telenursing, we can have a nurse staff, multiple libraries throughout California in these privacy pods, and have people ask questions and try to understand what was going on.

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Garrett:

Now, we will have to be very careful that we're not crossing a line and not creating a nurse-patient relationship, but more of like education. And this is what we've done through Trust a Nurse, Ask a Nurse is really help people understand and develop a relationship with a nurse so that they can ask questions and figure out what are the resources that are available to them.

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Garrett:

So, it's a really exciting opportunity. And we're talking again with a few library systems throughout California, especially in the rural settings to get a nurse out there as part of the fixture of the library.

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Dan:

That's how we met was with that idea. We chatted, I don't know how many years ago, probably four or five now where you presented that idea. I know we had some calls with different organizations about it and it didn't take off then, but look at that. That's amazing to see that come to life and that you can execute on it. And I think it's an awesome opportunity to provide care in the communities, which is where it needs to be. And so kudos to making that dream come alive, no matter how long it takes.

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Garrett:

Some things have to percolate for a while, right?

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Dan:

That's right. Well, that's what I tell people. I'm like, "Look, in crisis, those barriers, those crazy ideas that kind of got caught up in the bureaucracy, they go away." And so you can kind of execute those ideas because the bureaucracy is kind of stopped. So, I love it. I think it's great. And that patience, that entrepreneurial spirit is amazing.

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Dan:

So we're coming to the end of our time here, Garrett. I know we talked about a lot of stuff and it's just so impressive, the work. I think we have listeners from across the world, we have listeners across the country and California provides an example for ways that other states, nursing leaders, nursing educators can kind of think about how we can transform this workforce because it's going to take the entire country to do this and beyond.

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Dan:

We'd like to end the show on kind of sharing that handoff, that one nugget that you want to kind of leave the audience with. So, what would you like to hand off to our listeners, Garrett?

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Garrett:

There's a couple different nuggets, if I may, Dan. One is the nurse leaders. I think we need to really create psychologically safe spaces for those people that work for us and with us to understand what are the issues and what are the solutions that they think are going to be meaningful to help them in their work and help advance nursing where they are, because my philosophy is one size fits none. And so being able to create these psychologically safe spaces is essential.

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Garrett:

And I think for nurses everywhere, it's be bold. Find your tribe who will support you, who will help defend you in a very difficult environment that we all are living in. The world is on fire figuratively and literally, and we need to find people who are like-minded to help move things forward because it's only through that connected team-based perspective will we actually make any progress.

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Garrett:

These are difficult times and I don't want to minimize that at all. I want to acknowledge. And I want to thank all nurses who have lived through these really difficult years for your service, your dedication, and also your struggles for mental health and physical health that have been making this pandemic even harder than it perhaps needed to be.

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Garrett:

So, thank you to everyone. It's really a heartfelt feeling of gratitude to all your listeners, Dan.

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Dan:

No, I appreciate that, Garrett. And I think the other piece is nurses that are listening, get involved with your state workforce centers. They're everywhere. They're in many states and they're amazing people. I mean, I've worked with you, Garrett. We talked to Laura in Hawaii and John and Oregon and Christina in Missouri. And there's just a great group of thought leaders that can support the workforce.

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Dan:

So with those nurses with ideas, call Garrett up. Connect with the HealthImpact on that because there's opportunities to really support the profession, and you're doing some meaningful work on it. So, appreciate that too, Garrett. And thank you for your dedication to the profession and supporting California specifically as well.

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Dan:

Garrett, where could people find you if they want to connect with you? Where do you live online?

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Garrett:

You can connect with me on LinkedIn. So, I'm on LinkedIn. We also have a Twitter handle, @HealthImpactCA is our Twitter handle. We also are on Facebook and our website is healthimpact.org, and my email address is there. Our phone number is there and we would love to hear from you.

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Dan:

Awesome. That's so great. And we'll put all that in the show notes as well. Garrett, thank you so much for being on the show. This was an awesome conversation and hopefully it inspires some of our listeners to push the workforce forward in many ways. And I just want to thank you for your time.

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Garrett:

Thank you, Dan. I appreciate all the hard work that you're doing too.

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