Blueprints for Success Innovations in HIV Care Delivery: Nurses and the Response to the Pandemic
Originally Broadcast: November 10, 2020 | 2:00 pm – 4:30 pm ET
This 2.5-hour program will bring together nurses who work with communities impacted by HIV to discuss solutions for current issues affecting the provision of HIV/AIDS treatment, care, and prevention in the current environment. The program will be a combination of presentations and interactive discussions/workshops. The first presentation will examine telehealth as a “disruptive innovation” across HIV care, with a focus on how its implementation is impacting the care that nurses provide for people living with or at risk for HIV. The second presentation will explore the concepts of cultural humility and cultural competence and the roles that they play in the HIV care environment.
Workshops and breakouts will provide an opportunity for participants to discuss their work caring for people living with HIV via telehealth during the COVID-19 pandemic.
Discuss the potential for how telehealth may be used to support HIV care across rural and urban settings
Elucidate how telehealth can be used to address barriers for people at risk for or living with HIV in a COVID-19 world
Discuss the implications of cultural and ethnic diversity for healthcare
Consider the possibility of cultural humility as a path to equity
Offer a presentation on the importance of self-care for nurses in HIV care
Provide a platform to facilitate networking among HIV social workers, public health officials, and policy leaders
Hello and welcome. I am Christopher Chancy Watson, senior product manager, Gilead Sciences. And on behalf of Gilead, we would like to welcome you to today's program, which is entitled Blueprints for Success Training Institute, Innovations in HIV Care Delivery Nurses and the Response to the Pandemic. This program has been developed in partnership with a knack and will look at issues affecting the provision of HIV H treatment, care and prevention in the current environment. To go over briefly, today's agenda will have to 20 minute presentations, followed by a panel discussion and then a 30 minute workshop where we can put a lot of the details we've learned into practice after that workshop. We will then have a keynote presentation that is looking at supporting our patients as well as caring for ourselves, particularly in what this year has been deemed by the World Health Organization as the Year of the Nurse. Our first presentation today will be given by Dr Laurent Nelson, and it's called the Quest for cultural humility the missing link in the HIV care continuum. We will then follow that with a second presentation by the lovely Dr Carroll Dawson, Bro, which will be entitled The Role of Telehealth and Ending the HIV Epidemic. Then you'll get a chance to coordinate and work with our CSR community liaisons here Juliet in our workshop, followed by our amazing keynote presentation by Dr Susan Michael Strasser to go into our first presenter for today. Dr. Nelson is an independent foundation professor and associate professor of nursing and the associate dean of global affairs and planetary health at Yale School of Nursing and also serves on the Yell Institute for Global Health Leadership Advisory Committee. He's a very busy man. He's also an affiliate scientists at the Map Center for Urban Health Solutions at the La Cai Xin Knowledge Institute at ST Michael's Hospital in Toronto. He's the inaugural holder of the Ontario Ontario HIV Treatment Network Research Chair in Implementation Science with Black Communities in Canada. Dr. Nelson's work in research and implementation science spans multiple countries. His domestic work focuses on the use of multi level interventions to reduce HIV infection, particularly among black men who have sex with men. Dr. Nelson is a public health nurse and family practice nurse in New York, and, I must say, a dear friend and mentor. It is with further dude that I turned this over this morning to Dr Nelson. Thank you, Chancellor, for the introduction. Eyes my pleasure to talk to you today about, uh, request for cultural community. I want to start out by reviewing three concepts with you. The first concept is coaching Culture is defined as the customary beliefs, social forms and material traits of a racial, religious or social group. It includes characteristics, features of everyday existence that are shared by people in a place and often in the time. So this could include things like what you may experience as southern culture or, uh, Caribbean culture. Culture is dynamic. It is not static. Yeah, okay. It is not dynamic. Uh, it is dynamic is not static. There's no one size fits all model theory or process individuals very tremendously within cultures. So not everybody within the culture is the same. There are also other intersections, but all are shaped by their cultures. Different is simply that different. And that is a quote by Michael Wheeler. We'll hear several quotes from Michael Wheeler during this presentation. Uh, the portions we see of human beings is very small. Their forms and faces voices and words. But beyond these, like an immense dark continent, lies all that has made them, which is a quote by free of Stark. The next two concepts. I want to discuss our cultural competence and cultural humility. Cultural competence and health care is the respectful and effective response off individuals and systems to people of all cultures in ways that affirm their worth and dignity from the worth and dignity of individuals and as well as communities. Cultural humility is different from cultural, competent cultural. Cultural humility takes cultural competence a step further. It entails an ongoing commitment to self reflection and to creating beneficial and non paternalistic relationships. It is a journey of ongoing lifelong learning without a final destination. Another one of Michael Willers quote, which is Jermaine here, is that cultural competence is about the head. Whereas cultural humility is about the heart. Cultural competence is more about what we know. Intellectual exercise and skill culture. Humility is about who we are, the ways in which, uh uh it says more about our being, Uh, this next table that you see here compares different aspects of what we understand. Cultural competence and cultural humility to be So they're different goals and different values, different shortcomings, but also different advantages. You'll see here that the goals of cultural competence and cultural humility differ. The goal of cultural competence is building an understanding of different cultures again, competency based you could probably have guessed that culture humility, however, encourages personal reflection and growth. The increase culture awareness, off service providers, nurses position, social workers, even frontline staff. Yeah, the values of cultural competence, our knowledge and training. But the values of culture, humility, our introspection and co learning Colin with people that you're trying to understand the shortcomings for cultural competence is that is based on academic knowledge rather than a lived experience. It's a particular knowledge that you acquire off the times to reading. But culture humility is an exploration with no in point, uh, which can be a shortcoming. But it could also be sort of an advantage if you like that type of adventure. But some of the clear advantages of cultural competence that is that it promotes skill Building establishes minimum performance expectations and clinical practice, which are important for nurses and other health care providers who are trying to provide the highest quality care and as well an advantage to cultural humility that encourages lifelong learning with an appreciation of the journey. And it attempts to lessen destructive power dynamics. And if you'll recall from a previous slide, what I described in culture, humility is that it really de emphasizes patriarchal hierarchies. Uh, yeah, there's another way to think about cultural competence and cultural humility, and that is thinking about who is expert in the room. So cultural competence says I'm the expert. It is an M product that requires an objective set of practices. Cultural humility, however, says that you are the expert. It is a lifelong process, and it requires a subjective set of best practices. Sometimes these are learned over time, through experiences with different people in different contexts. What cultural humility is not is prejudice, exclusion, intolerance, discrimination. It is not stereotyping, labeling, judging or bullying. It is about understanding on this evolution of knowing people as you encounter them, cultural competence, actually, cultural humility. I will say, uh is a path towards health equity and equity is the fair and just and fair inclusion into a society in which all can participate and which all prosper and able to reach their full potential. Eso As I go into this, I want to remind you that there is a polling question today will have these during both our presentations. The question will remain on your screen for about two minutes. Eso please choose your response. Our first question is which of the following is the most significant barrier to end in the age of the epidemic? Please choose one response to this question. We can understand cultural humility as the bridge between cultural diversity and social justice, and this diagram is there to demonstrate this. Bridging cultural humility creates not merely an awareness and appreciation of cultural diversity, but also offers a window into understanding social justice and the need for equity. If all aspects of a person's identity are valued and the individual is made to feel empowered, this is a step towards treating that person justly. This, in turn, is a step towards the creation of equity whereby everyone is treated justly and can participate, prosper and reach their full potential in society. So cultural diversity is important in and of itself. But cultural diversity is a bridge of social justice, and as we make advances towards social justice. It does help create environments that promote equity. You see from the map. Here is a map of the world, but also darker red map of the United States we know from the Institute of Medicine's Global Migration Indicators of 2018. Uh, that, uh, that migration is a major phenomenon across the globe. Uh, 258 million international migrants were counted globally in 2017 that when we say international migrants, that is people who are living in a country other than the country in which they were born. International migrants made up 3.4% of the world's total population. Actually, 66 million of adults, off 1.3% of the world's population, had planned planned to or move permanently to another country in the next uh, in the past 12 months or the next 12 months. This was data from 2015. It is remain because I could say that I have been international migrant what made plans to live in another country and have done so. So this is a very riel president phenomenon. There are tens of millions of Latin X, African and Asian immigrants who entered the United States in the last half century. So diversity is here, our country, our communities already diverse in South United States when the communities around the world and it's important that we understand and embrace that diversity. It's also reason why cultural competence and culture community are important to make sure that as thes communities come together for these populations come together, uh, to form communities that we still strive towards equity. So I'll say a bit about ethnic and racial diversity in the United States. So the United States population maybe second to Brazil, maybe even beyond Brazil is becoming the most ethnically and racially diverse a zit has ever been. Uh, the United States has the second largest Spanish speaking population in the world. That population lives in the United States, and by 2044 it is estimated that the minority section, currently identified as a minority section of the United States, may be in the majority. Yet what that said, people of color still face structural and systematic barriers to health care. In the United States, it is quote from Melanie Ter villain and Jan Murray Garcia Eyes from 1998 but it's still important here today. The increasing cultural, racial and ethnic diversity of the United States compels medical educators to train positions who will skillfully and respectfully negotiate the implications of this diversity in my clinical practice as we do that, it is important to understand that our current clinical practices exists in a historical context. It's important to know the context now currently, but it's also important to understand how we practice in the context of history and so to acknowledge the president, we need to remember this past. The US has seen decades of unequal distribution of wealth, which is rooted and slavery. There is a historically traumatic relationship between medical institutions and black communities, including African Americans within black communities. In addition, there are impacts from stigma that emanate from some religious beliefs. There are structural barriers, including poorly funded educational systems and also a lack of comprehensive sexual health and relationship education. It is important to acknowledge these past traumas because they not only influenced by patients experience care. They also influence how providers perceived patients and how providers deliver their care. Uh, they're all of some other aspects of the past and the present that we also need to acknowledge this includes what we know now. Mass incarceration and criminalization for black men. Uh, black communities are disproportionately criminalized on exposed to criminal justice proceedings and therefore disproportionally exposed to and subject to incarceration. There are high rates of individuals who still remain uninsured, uh, health care providers shortages, uh, including in shortages in rural areas. Some of the places that we've seen in identified in the federal in the HIV epidemic plan are in these areas that experience healthcare providers shortages, including shortages of diversity of people who provide these services to populations, as well as the lack of substance use, prevention and treatment services. These things together increase disparities that we see among populations that currently we identify in some ways this minority populations who are just a portion impacted by this very health outcomes. Another thing is important to think about and it's not often said, is that his health inequities do represent structural violence, and structural violence is physical or psychological harm resulting from exploitative and unjust political, social and economic systems. Health inequities result from the synergy of these plagues among marginalized groups, which in turn drive the high rates that we see in HIV. These include stigma. You can see this from the chart on your screen. Stigma, silence and misinformation. The public perception of like of need, the reduction of service availability and support. Lack of awareness prevention, testing, treatment at preventable HIV transmission. Health health inequities are result of structural violence, the result of policies and practices that render communities more vulnerable to having disparate, inequitable negative health outcomes. We can see this if we look at various demographic categories, including race, gender and sexuality. This table that you're seeing now is an illustrative of this. So if you look at race among people living with HIV at the end of 2018, 42% of those people were African American and 28% of those people who are Latin X. So think about this. 42% of African American. Although African Americans comprised only 13% off the U. S. Population on Latin X, people comprised only 18% of the population. The rates of HIV infection among African American women in 2018 were 13 times higher than for white women and four times higher than for Latin X women look at the middle column at gender. Among people living with HIV, 78% for men, 22% were women. From 2014 through 2018, the largest percentage increase, which was about a quarter and the number of people living with HIV were among transgender women. Ah, quarter, A full quarter. The HIV prevalence and transgender women is 14% compared with less than less than half percent among US adults. Overall, he's a very serious disparities that are driven by the structural violence policies that we just described in. The previous slide on in this final column is about sexuality. A new agency diagnoses in the US and its territories. 67% of the people diagnosed with M S M men who have sex with other men and new Age retransmissions among women in 2018. Among those, 85% were women who who acquired a transmission through heterosexual contact. Uh, these are important. These are not coincidental. Thes are not random. These are the product of structural inequities and in ways that striving for equity will help to. It won't alleviate. It will help to mitigate. I'll say a bit more about racial that is right is going to be treatment. Uh, based on the 2012 survey of 544 black men who have sex with men, 29% of those who participated reported experiencing racial and sexual orientation. Stigma from health care providers for the people you go to, uh, for care, and nearly 50% reported mistrust of medical institutions among transgender people. There's information that shows that transgender people feel shut out of health care, and what this research has showed us is that 90% reported 90% of treasure, and people who are survey reported that there are not enough trained health professionals to provide care for them. 52% believe that they will be refused medical care for being transgender. 50% said they had to teach medical providers about transgender care. And 28% of transgender people postpone medical care because of their concern about being mistreated. Now there are roadblocks to cultural competent cares, not quite a simple as I may be making sound, but there are particular roadblocks to it. Uh, in their structural one is like a diversity in the health care, leadership and workforce. The lack of provided training on engaging diverse communities and care the systems of care that are not designed to meet the needs of diverse patient populations. I'm hoping you can see this thes this diagram. Uh, patients concerned about fear and distrust poor cross cultural communication between providers and patients, which is also resort of inadequate training and also culturally individual level stigma. Uh, particularly HIV is association as being a taboo on other, uh, social stigmas. So if you think health care context, it's important for the pinpoint where stigma occurs in a health care setting. And so what you see here is that it occurs everywhere. Uh, it occurs from the time people, uh, step out into the health care facility and even sometimes even before the separate to the facility. So you'll see here that the location and it's proxy in which other places can also communicate stigma. They can account for that front desk on. Also, that stigma operates on multi levels, so there could be individual level stigma that happens into personally. People can internalize the stigmatizing messages, but there can also be stigma that is communicated in the healthcare environment. What images that people see, How do we treat their privacy? How do we call their names? How do we not call their names Thes. All important on the lack of policies that offer protections for people who are diverse on marginalized are also ways that stigma manifest and health care facilities. But there are some steps that can be taken help address stigma and healthcare settings that is making sure that forms that ask questions about identity have writing options. So in case a printed option not available, someone could write in their own gender the racial identification or sexual orientation. Make sure this basis traded that is both accessible and comfortable to reflect on how power structures are perpetuated. That's my timer, uh, to reflect on how power structures are perpetuated through space design. Talk about think about how clients and providers sitting next to each other, uh, can facilitate a more even power dynamic than providers facing one another often, sometimes from a position with providers, is higher than the patient train all staff, including support staff to make sure they know about the availability of gender neutral bathrooms, for example, other ways to recognize and respect diversity that they may encounter among the clinic patient, uh, population and cultivated culture of learning so that staff feel comfortable asking for training or information if they don't know how to meet the client's needs. One thing we haven't talked about, the only mention briefly was. How does religion fit into this? And that is very important. Uh, religious and spiritual beliefs and cultures may underpinned feelings and attitudes about sexuality. HIV and healthcare approaches both the providers understanding that feels about this, but also the way that patients understand feel about themselves. Some gay and transgender people have been traumatized, discriminated against and stigmatized by some faith communities, although some also experienced faith communities as assets that they look to rely on for strength on support. Some of those attitudes may allow for racial gender, a gender identity and sexual orientation, bias, prejudice and discrimination, which might undermine treatment approaches. Many people see themselves as spiritually and not religious, and many people want to reconcile their faith and spirituality. But somebody feel shut up our religious organizations. So it is important to acknowledge that religion has played a problematic role in the lives of some uh LGBT patients, uh, some racialized patients, but that religion and spirituality is also an asset seen by some of these patients. So as I close up this section of session, I wanna just review to use some very basic terminology. Some of this we describe some we haven't. I won't go through all of them. But I'll just identify, uh, there other ISMs, right? So ageism is stereotyping of discriminating against people because of their age is often experienced by older people. But younger people, adolescents in particular also experience ageism. Uh, stigma we talked about, uh, intersectionality is the overlapping of different forms of discrimination based on different intersecting identities. And I'll just say this because I don't think I mentioned it before. It is racism is a former Racism is believing that one race social concept in and of itself is superior or inferior to another, and that an individual's character or ability is determined by the assignment to that racial category. So, uh, a question of language understanding the ways in which we can use people first language to reduce us stigmatizing people inadvertently, so H I V AIDS language can be stigmatizing. There's some language that is preferred and you'll see here from the screen language that has been known to be stigmatizing. So using the term for HIV infected person h i v AIDS patient carriers Positive preferred language Is persons living with HIV don't use infected? Uh, you don't have to think about it. I'm telling you, don't use it. Victim. Innocent victims suffer contaminated. Those are all problematic languages on dso things like personally with HIV or Survivor being adherent to treatment regimens not compliant because people have a choice of whether to take medications the way you asked him to or not. Uh, not using promiscuous, but just acknowledging factual that it might be multiple sexual partners. And then there's awesome, some stigmatizing language that we can think about for LGBT identified people and these are some do's and dont's on that as well. So language that you may have heard, uh, maybe even have used with g LGBT people that is stigmatizing. Awards like homosexual, uh, prefer language. Is gay gay men, lesbian, a gay people, some in some people before the same gender loving on. That may even be other words, but homosexual is typically not before because it's sort of reduction into a clinical term. Transgendered tranny transsexual is something that should be avoided, transgender or trans or preferred terms on. Then I'll go to the last one, which is this idea of special rights that often gets used when talking about anti LGBT extremists toe inside opposition to non discriminatory laws and recognition of same gender relationships. So it's not special rights. It is equal rights, equal rights and equal protection. And so some final points to bear in mind, uh, as we think about culture. Humility for your own work is to take the lead from the clients when talking about sex, for example. The goal is to get the necessary information that you need to write high quality care without being intrusive. Follow the clients lead by only using labels. If the client has used them, can make assumptions. Many clients today may identify their prefer pronounce. You can also, when you meet with clients, identify you prefer pronounces the way to sticking to the client off your acknowledgement that you may not know what their preferences are again. Create a learning culture in order to give clients the best care and aim to integrate. Overall health care with HIV care and mental health support. This final quote I'll leave you with is that cultural humility incorporates a lifelong commitment to self evaluation and critique, to redressing the power imbalances in the physician patient dynamic or the nurse patient dynamic, or to provide a patient dynamic and to developing mutually beneficial and non paternalistic partnerships with communities on behalf of individuals and defined populations. Thank you. It's been my pleasure toe present to you today and look forward to our when we get a chance to have a discussion. Thank you, Laurent, for that amazing presentation. Uh, one of the key points in salient pieces that is resonating for me is really creating a learning culture. And as we've worked with an act to develop this workshop, we really want to create really this learning culture for ourselves as we become better practitioners for our patients. And with that, we're excited to move into our panel discussion today a zealous audience question and answer portion. Just as a reminder, we would like to submit questions via the button at the bottom of your screen. We'll we'll be able to take some of those questions lot during this discussion piece. It is with excitement that I'm able to introduce are moderator for today's panel, Dr Sheldon Fields, who is a research professor and associate dean for equity and inclusion in the College of Nursing at Penn State University. He also serves as the founder and principal and CEO of the S. D F Group, which is a health innovation consultant company with more than 29 years of experience as a health educator, researcher and clinician. Dr. Phil's is a respected HIV AIDS prevention research scientist, a nationally board certified family nurse practitioner and an advanced HIV certified nurse. He is joining Dr Nelson as well as Dr Carroll Dawson Roles and Dr Susan Michael Strasser. And if I could just take a moment, I will go ahead and introduce you to those Panelists as well. Dr. Dawson Roles is the James P. And Marjorie A. Livingston chair in nursing excellence and chair and professor in the Department of Community Health Systems at the University of California, San Francisco School of Nursing. Dr. Dawson Roles is the current president of the Association of Nurses in AIDS Care, or a Net, and is an experienced clinician, researcher and educator. Her research focuses on the intersections of mental illness, trauma, HIV and substance use, particularly among Soc economically marginalized groups. Dr. Michael Stressor is a senior director of Human Resource is for health development at the Mailman School of Public Health at the Columbia University Medical Center. A public professional with more than 25 years of experience and nursing and public health. Dr Michael Stressor is the senior implementation director at ICAP, providing leadership for the development, implementation, monitoring and evaluation of ICAP's global portfolio of public health program. Her area of expertise includes pediatric care and support, nurse training and the use of point of care diagnosis. As you can see our Panelists today, we're gonna be dynamic and are fully equipped to carry us through the our conversation. So without further ado, I turn it to Dr Sheldon Fields. Thank you, Mr Watson. Very much. Appreciate that. And good afternoon to all of my colleagues from wherever you are. I'll go ahead and jump right into the questions and I want to start with the General one. Since 2020 was designated the Year of the nurse and Nurse midwife, I really want your opinion on the fact that the nursing profession is upwards of 90% female in 80% white, which is not reflective of our society. What is one thing you think nursing should do or should be doing to truly become a mawr diverse and inclusive profession? Dr. Dawson Roles. Can we start with you? Sure, thank you very much for the question. It's a critical question for nursing. And I would say one of the things that we could do right off the bat to change this is think about how we're gonna change his educating nurses and bringing them into educational institutions. We need to change who's educating, nursing, um, and increase the diversity there. But I think we also need to have targeted, um support and, um, working in different communities to get them into nursing. So they're aware of the profession, and they are fully supported to take up the space that we need people to take up as nurses. Mhm. Thank you, Dr Nelson. Your thoughts. You know, I agree about changing who educated them. I would say, you know, what I really understood is as a man, the power of nursing the profession is that it has maybe been one of the few in the world that has sort of been nurtured and developed and benefited from the experience of women who led it and built it. And I think, uh, finding ways to diversify. Uh, who's teaching who comes in to be very careful that we don't lose that? Because I think that is an important sort of secret ingredient that could be lost. Uh, if different. I mean, just like the presentation about paternalistic ways of thinking and not the nursing doesn't already have that. But I think there are ways, uh, that we have to be sure we hold on to what really has been. I think the seminal contribution of women to the have scientists because they've been able to be nursing a place where men didn't wanna be for very long time. So it allowed that place to be a new uh, I don't want to use stigmatizing language. Uh, but to not sort of be, they're not have to be concerned with men's ideas about what profession needs to look like and what counted and what mattered. So I think that is that is key. So I do think it's important to bring more men into nursing, for example. But to be very careful that we don't bring in some of those masculinity is and that can toxic in ways that were undermined. I think what really has been, uh no, it's powerful. Uh, professional. Okay. Thank you for your perspective, Dr Nelson. Uh, Dr Michael Strasser, Your thoughts on what can nursing due to become more diverse and inclusive. I think schools of nursing have an important role to play both for the general community but also for those that they are educating and within the educational systems within which they live and work first of all to communities to To better explain what nursing is and why nursing is important to your public's health, to your communities, health and what you, as a nurse, can play what role you can play. And we've seen that we've seen with Cove in 19 the dramatic social determinants of health. We know that for example, maternal mortality amongst black women is going up in the United States, and many women reflect on the fact that they don't feel that the warning signs those early warning signs that they felt intuitively as as pregnant women were not heard on that call comes back Thio Cultural comes back to the first speakers discussions around presence and being a coming in as a humble culture servant and and respecting that which the other person is saying. And so it is critical to public health and to women's health that we have diverse, Ah, workforce. That is not on Lee, competent in the nursing skills but competent culturally and in communities and what drives community health behavior. And so we need to see a much more colorful a much more dynamic faculty of nursing and the student body. And I think we as educators, have a role to play in actively seeking out young people who are interested in stem but also interested in that that that the bringing together of science and care through nursing and and finding people early, helping them to get the records requisites that they need and to be able to go through school successfully. This will enhance care for all of us. Yes, something else. So you have a follow up point? Yes, because I appreciate that we talked about education and I think to add on to what was just mentioned is that I think schools of nursing oh, ever. Nurses are educated sometimes in hospitals have to rethink their business model like it has to be accessible, like the same structural inequities that contribute to health disparities among diverse populations are the same things that make it harder for people to be able to go to a nursing school and pay a nursing tuition. And so we have to rethink What do we really mean when we say we want to recruit black students or transgender students or immigrant students into whose where they'll be round employment if you're not a citizen or, uh, whether that so those issues and, additionally, what it costs to go to nurses, schools and many schools and every single designed to bring in revenue through tuition. That necessarily means many people who could be in school diversifying our professional get there because the tuition cost themselves and other things that the schools are structured for. These people that would kind of recruit will still serve as a barrier, so I think it's a really fundamental rethinking of our business model. We don't have to talk business and nursing, but as we were talking about education that don't to me that this is a sort of, ah, business process issue. Yeah, our for profit higher educational system. A swell as our for profit health care system to begin with. So, you know, the reason why this is so important and that we focus on nursing is the fact that nursing is the largest health care workforce that we have and historically the most trusted. So how can we as nurses now begin to think of cultural humility as a path to equity? You know, given the points that you've got to Nelson brought up in your presentation. So talk to us about what are some of those immediate steps that we can take to start to incorporate these steps into our daily practice. Thought the Dawson roles. Sure. Thank you. Interested. Critical discussion and interesting question. I would say one of the things. That and of having this presentation that you just gave Laurent about cultural humility and cultural competence. And I think one of the big steps for nursing is a profession is for us to step back from our reliance on this idea of competence culturally, um, and shift to cultural humility and and creating this setting of learning, right? I mean, which you talked about as well. And I think that is one of the biggest things that we can do is a profession is really thio kind of let go that we are gonna understand everything. We're gonna know where everybody fits and really Thio shift the focus to ourselves and our practices. So Okay, Okay. Dr. Nelson, do you want to follow up? Sure. Thank you. I would say that, You know, we're not gonna learn our way into equity. I think in some ways we have to unlearn. I mean, that's the because the ways in which we're perpetuating and driving these inequities that because we've learned to treat people that way, already adopted these mental logic models about who needs to do be wearing what, how we approach them. And so some of it, which is difficult, but we must do it is challenging. While we automatically think some of ways that we figure how that guys are practiced and that requires riel intention, it might even be exhausting. It might even be uncomfortable as you do it and think about 10 patients before over the last three months that you're treating a particular way, but I think it's a work that has to be done. But it really is questioning, uh, our practices and why we while we approach basically the approach to understand how we contribute to the outcomes that we sometimes even point out a complaint about that were implicated in that too way. Call them nursing traditions. Dr Nelson and I believe we hide behind those traditions. Eso Dr Michael stressor your thoughts on what we can do. I think what we have to do is think about action and what would would make the best sense at this time. I think once we are through the worst of cove in 19, I think most academic institutions, and especially so schools of public health and training of health workers have to do a deep rethink of how we educate our workforce. Onda. How we have them prepared to respond effectively quickly, uh, to drive a much more robust and resilient response in the face of whatever comes our way in the future. So I think that it would be one toe, have a very significant review of of curricula and our approaches to health care systems in the development of health care services. So that's a bit larger than nursing on Lee. But within nursing, I think we need to find tangible, uh, ways to help students from go from those critical steps from high school to entry level, even into community colleges that can bridge them to university programs to hospitals that then support their advanced education. I know in some, um, cities, there are excellent community college programs that provide nurses with the R N and then entry into working within university affiliated hospitals. And that opens up further opportunity for training and education, whether they want to go more into clinical rolls or into leadership roles. And I think these have been underutilized amongst, uh so even those resource is, uh, hard for people to engage into and take full advantage of. But I think these are some of the these systems that are out there that need to be better exploited to diversify the nursing workforce. I really do like one point you just said the idea of doing a deep dive and debrief of how the covert 19 pandemic really has changed the nursing profession so So that's a That's a future webinar that I really think we need to get into. But we have a really great question from the audience. S o. The question is, why are we not focused with equal passion and commitment to bring federal funding to support men, especially minority men Thio into nursing programs in the same manner as we funded women to enter medical programs in the previous decades? Who wants to take that one on? Yeah, Don't know. E. I know a lot of feel comfortable with Laurent. You gotta thought I don't know the answer to that, but I was I don't know the answer. I know there's been some efforts, uh, private industry efforts like Johnson and Johnson to really sort of expand what it means to be a nurse to de stigmatize nursing. To a degree, I mean, when I say that, I mean, I think I think the way. So there's two things happening here. I think part of men's, uh, not being attracted to nursing. It is because of what they think nursing represents and how that does not necessarily ally with their understanding of what it means to be a man to some people. And I think that's also because I think nursing historically kind of like what shelters call this traditions has cast itself as this sort of Angelique caring soft, you know, hearing angels flowing around, you know, bringing people like the life. Some of us are flying around wrecking balls back to life, right? But it's also technically complex, complex work. It is labor intensive work. It requires intellectual sophistication. It requires critical still and thinking like, but that's not what we sort of talk about. That is hard work and laborious work on, and is most work that mostly women have been doing foods war forever in this profession. But I do think it's some degrees about how nursing is marketed to man, whoever the options. Who because because of how this professionals gender, how men understand themselves in relation to make occupational decisions, nursing doesn't seem to fit. But I don't think I think it's because people don't generally understand really the complex what we do. Mhm. That's my response. I don't know why the federal government is investing more money into it, but that's my well Well, there was a movement with the affordable care act the past sort of a general nursing education fund That's similar to how you know the general medical education is funded S O. That would have been one federal way of thinking about getting new dollars, particularly as we looked at, um, advanced practice nursing roles, which, you know, attract a few more men, you know, as they progress as well. So So So that's one way of thinking about that one, particular e. I wish I could point to it that I think, you know, men are overrepresented, for example, in DNP programs. Yeah, you know, in the leadership roles, which, in some way that I was sort of what men think that Rose should be the professional world anyway, So So anyway, I think there's probably some barriers to entry. Uh, but the example shows that when men wanna do it, they do it. Okay, do it very well. Well, absolutely, absolutely. So we're gonna have one more question here, and I want to switch to the area that's near and dear to most of our hearts here. So let's talk to the audience about your ideas about how HIV stigma continues toe impact. What we do in our health care settings. And again, what can we do as nurses? Anyone? HIV stigma? Sure, I would be happy to start that response. Um, I think I mean, stigma impacts everything right from who even is becoming Who's at risk for acquiring HIV, Um, in different settings, right? Um, in different relationships. And it's, you know, I mean it just, you know, culturally, culturally, nationally. You know, people who speak about different individuals and sort of what it means to be living with HIV. Um is there it's all that's at all can create stigma and shame. I think that's related. Thio having HIV One of the things that I think about a lot in terms of nursing and one of the things that we can dio as a profession is really to take this on, because I think, um, we continue a za nurses as nurse practitioners and as people in the health care system to really our behaviors and our judgmental behaviors of thinking. You know, this is what it means to be living with HIV, and, um, that comes out in, you know, direct ways and oblique ways. And, you know, I think this is just It's a so and it impacts everything from who accesses treatment who gets tested to who access this medication. Um, it's just I mean, it's ubiquitous in the field of HIV, and I do think there's a lot of things we can do. Is nurses, um, that have to do with our own judgment? Um, from some of the things that Laurent talked about our own background, our own religion, the way that we think about people anyway. Stop right, Sheldon, my my thought on on your your question would be, uh, based on what you said earlier about how nursing is a trusted profession but to me is one of our greatest and underutilized assets. Trust comes a voice and a voice has critical moments in times when it needs to be used. And so when we see stigma, wherever it may be, structural stigma, stigma in the interaction between the patient and the care providers or the institution stigma between, um, police and patients that we have seen in in news media and nurses intervening on to be that presence off patient advocacy on. So I think there are critical moments in time when nurses have but continue must continue and increase our voice when we see stigma calling it out in the micro aggressions and in the major aggressions that had happened and and nurses, when they go back on their their but duty bound to to advocate for the patient are protected. And that is why we are so trusted but are has to be used. And and I I would just like to finalize my comment by saying, I think there have been critical moments throughout the course of this year over the course of the last four years, but especially this year with Cove in and how unequal this this crisis has hit communities and lives and who dies. And the nurses voice needs to call that out because these communities are our patients and our patients are disproportionately affected based on their race, their color, their zip code, their education level on. Do we need to use our voice? We need to use that trust that comes from the integrity of our work. Okay, want to squander that? But I think we need to use it more so Dr Nelson, I have a follow up Well, question for you. As we began to close up here with this concept of cultural humility. How is it that we can incorporate those types of concepts into the plans that you and others are working on to really end the epidemic? Oh, goodness. You know, I really do think that. And maybe it's a similar to what Susan just described that nurses can be campaigning. This Uh huh. H i v eight nurses who work in HIV AIDS care, But nurses who don't as well. Uh, because we know, for example, we'll talk about prevention services. And, uh, prep is something that could be, uh, dealt with in primary care. You don't need to be h b A specialist, uh, Thio the four patients on that, I think really finding ways. Professional organizations, uh, to really take this on, uh, but also, from an intersection of perspective, What does it mean to be thio? Practice cultural humility around people, uh, that demonstrate racial diversity, sexual and gender diversity, economic types of differences. And how do we really embrace it as a profession and nursing? Because all across h, we can't continue when people are going to encounter nurses. And the way that nurses in these environments sort of mobilize, uh, structure around how we want to create an environment that is affirming for everybody that is responsive as much as much as possible to the individuals will come through this door, I think will help us get there. E The types of questions that get asked or don't ask will determine if somebody get assessed for whether that their behavior identifies them as eligible for something like prep whether they get offered an HIV test. I mean, this this cultural humidity has huge implications for how we can understand our patients in ways that can help provide them, or language and access to services that we won't be able to know if we don't really. We won't know to link them to these things if we don't have enough humility to really get to understand them, right? So a woman who comes in who's married for 20 years, okay, married 20 years, got to be kids, so you just get the sexual health questions. We don't ask her about her partners about what not she's heard a problem. Because you make assumptions about what this person is because of her relationship status, that is the problem that disadvantages women on that woman in this example, in my head from being able to get access to prevention treatment that is not going to serve us reaching the goal of Indonesia. The epidemic. You saw one of the slides that 85% of women, uh, who contracted HIV through heterosexual contact. Part of that is because we're skipping them like we have these mental logic that let us skip over them in the service of care. And so, even though culture humanity does not focus on HIV, I think the practice of culture humility can have very serious implications for advancing our progress towards ending the epidemic. Based on those examples of just try to offer. Thank you. Thank you very much for that. That response. So I wanna make sure we keep on track. Eso any other closing? Last minute thoughts start to Dawson. Rose? Uh, no, I'm well, yes. These kind of conversations, I think are really important for us. Toe have. And there multi dimensional. Um, and though that's where we need to go, I think as nurses, in order to, um, be better at the care that we're delivering and be more open to whoever is in front of us in any studying, whether it's HIV or not. So okay. Oh, my. Okay, well, on that note, I'm gonna move us along. I really hope everyone has enjoyed the panel discussion and upcoming. Next, I have the pleasure to turn over the podium to Dr Carroll Dawson roles. Who is going to give us a presentation on the role of telehealth in ending the HIV epidemic? Carol, take it away. Thank you very much. Uh, thank you for inviting me to participate a za presenter today, And, uh, and for these really important questions, I also want to acknowledge Gil EOD as one of our partners, um, of Anak and helping us and our work in HIV. I'm going to talk today about the role of telehealth in ending the HIV epidemic and to focus on the impact of cove it, which is one of the topics that we're talking about today and the impact of covert on HIV care. And we know it's impacted everything in our life. Um, and the same challenges have happened in HIV care. Um, redirection of resource is healthcare provider resource Is that needed to care provide care and HIV moving to respond to the covert epidemic. Some rapid changes where we're shifting to telehealth where access to services is different. Decrease virology and lab capacity. Um, and shining away from routine patient care appointments is one of the things that are one of the ways that cove it has impacted HIV care. Um also less counseling decrease frequency for monitoring and more reliance, Um, on on tele health and our need to learn how to do this with our wrap around services and multidisciplinary support, some of the impacts of co vid on HIV have been positive in terms of resource allocation. Um, the Coronavirus Aid Relief and Economic Security Act, which authorized money, um, for Ryan white programs $90 million and also for the housing for people with HIV program program has so big did we, um, the other pieces telehealth telehealth has the potential to really expand HIV care and prevention and new ways, um, offering more convenient consultation decreasing sigma. And it also might bring people that have traditionally not expressed HIV care into care who have technology capacity. Um, speaking of adolescents or young adults, some of the advantages of telehealth during the cove. It response is that it has, um, you know, help decrease overcrowding, an emergency departments and urgent and primary health clinics and still offering sports patients could bring specialized care to patients who don't have access to such care routinely. And I'm talking about specialty care can help with triage and treatment and care and coordination specifically and under resourced areas under resourced by physical clinics, um, where they're still capacity to communicate with people. It also the broadens the scope of telehealth to include no new patients. Um, one of the things where I know some of us have experiences. We have used telehealth modalities to interact with patients, but it's been people that we know people that we've already connected Thio and Kobe. It has really broaden that scope to newer individuals or people that are new to care. Um, since Cove it many health care providers are moving their services virtually as a way to triage. And this is a trend that has been going on. Um, but first, one big institution, Kaiser Permanente, who's one of the largest providers of health care in the US, is reporting now on average, 65,000 telehealth encounters a day, and that really grew during this during the pandemic from April, where the average for Kaiser was 8500 telehealth visits today to a couple months later to 45,000 visits today and now 65,000 visits today. Insurance claims ballooned for telehealth visits, and that's one of the ways we know where people are accessing care and over two thirds of U. S. Hospitals air connecting with patients remotely, As I said earlier in what's represented on this slide, is that prior to Cove it happening? We were already starting to see an increase in health in telehealth uptake, Um, and, uh, in the different ways that people interact via telehealth, whether it's provider to patient, um discharge provider to provider or physician to patient through the emergency department and specialty care. But, um, because of Cove, it you know, there's been a huge bump in this telehealth on the uptake of that to talk a little bit about expanding HIV care through telehealth. We wanted Thio focus on some lessons and insights. Mhm so there have been some studies that have shown that tele health interventions can help improve outcomes for patients. Um, this is true when it has to do with initiation of treatment and prevention and expanding access. It's also, um, demonstrated that it's a way that it can tell in health modalities can improve for attention and care for individuals as well as, um, adherents and viral suppression. There are few studies that are ongoing or who were in the field really collecting data when Cove it hit, and they're giving us important information. Um, one of these is with e Alabama E health study that really demonstrated telehealth enhanced patient care engagement across the continuum and then also in a study that's in Kenya. The well tell study where nurses were doing, you know, sm that s the mass messages to people to increase adherence. And there was a documented increase in people self reported adherence from that study and that nurse intervention in that way, using telehealth, there's also ah, study the youth to hell, health and telehealth and text to improve engagement in care or, as we call it, the white too text study, which is a study that I've been involved in, which is assessing the feasibility of using telehealth and text messaging reminders to increase linkage, thio and retention and care among youth who are already living with HIV. Some of the lessons learned about telehealth advantages further, um, is that telehealth can help reach those who may not engage in traditional methods of clinical care. Uh, help simplify the process of health care delivery. Um, by triaging each case and improving communication, really, by capturing and storing data also, telehealth can offer. It's been used for a variety of services, um, and things that I still I can't completely wrap my head around, but I But I know they're happening. There's besides chronic disease monitoring and management, there's counseling, um, dentistry, physical and occupational L um, education. There's just it's really can offer a lot of ways that we can interact with patients. It can also provide a range of modalities that allow um, patients to engage in ways that they prefer. And so, while some patients will still want to be seen in person by a clinician in terms of the telehealth modality, there's a video conferencing what we're doing today. Remote patient monitoring, phone calls and texting secure messaging. So their multitude of different ways that patients can engage and that's been some of the advantages of telehealth. This this slide really represents some of the ways that telehealth may be able to expand access to HIV care. It also shows us some of the benefits and the challenges. Um, benefits include decreased waiting times, expanded or more convenient clinic hours. Ah, stigma reduction. Um, you know, unintended disclosure where people don't have to come in to a setting that's affiliated or known to be a setting that's related to HIV, increased access to health care providers and also opportunities for education and support. So those were some of the things that are the benefits some of the challenges, um, reimbursement, polity, policies, things that are still be working being worked out. Um, as we're doing policy changes live right now, as we're doing, all these changes kind of live right now. Also access Thio video and our broadband video. Not everybody has equal access to these methods, and that is a potential challenge and a real challenge of telehealth, um, privacy regulations and policies that could be related to prescribing different kind of medications and then patient provider uptake, you know, which is some. As I said earlier some people that were providing care to may want an individual clinical appointment, as we have traditionally thought of delivering HIV care, even HIV testing and testing results, um, addition to patients. There's also our side, um, and what we like and what we think works and what we think is best. And that could be one of the potential challenges, uh, some of the other lessons and experiences that we've had about how to reach those individuals who might not engage in HIV services through traditional messages. And this slide, um, presents some a couple of studies that are ongoing. There's the Project nexus and project moxie. These studies are online. Studies that are really looking at are looking at home based HIV testing and counseling initiatives and methods. Project Nexus has enrolled or is enrolling self reported zero concordant HIV uninfected couples and self reported zero discordant couples where they can receive it. Home testing kits. Um, those participants can then report their results and take part in additional counseling and services if they are, um, randomly assigned to the treatment arm of the study. Similarly, Project Moxie, which is also on online study, focuses on uptake of HIV testing among transgender youth, Um, which is similar at home testing kits sent to study participants that have preferred a dress. And then they can report their results and possibly engaged in video chat counseling sessions. This slide talks about how Project nexus and project moxie work. As I said they are, you know it's in their online study, so people click on a banner advertisement. They complete eligibility and screening, complete in informed consent. Do a survey and then they're randomly assigned. And either group the treatment or intervention arm or the control arm are mailed HIV home testing kits. And, um, you know, are they could do the self test, can enter results online, continue to be surveyed about that experience. But where people that go into the intervention arm, they can also participate in video chat counseling sessions, thes air, really important projects because they're accessing individuals that we may not have accessed in other ways on DSA, specifically transgender and gender non conforming um, individuals who experience some of the highest rates of HIV in the country and experience also some of the greatest barriers to testing and treatment. The second lesson is, um, how can we simplify the process of what we're doing in HIV and a generalized approach for telehealth for prep services? Uptake of prep medicines remains low among those who are most at risk in different populations. Um, and this simplification of this process could really help uptake of prep, which is, um, you know, simply just there's a modality that's HIPPA compliant. UH, it's messaging platform that you either message to telephone call text messaging, email. Um, people are given laboratory tests, um, and mailed thes tests that they need to do before they started on prop. They can either do it through mail tests. Tests are mailed to them at home. Or they could go to a local facility and complete the test and then medications air delivered either by mail or picking up at a local pharmacy. So this is another lesson. If simplify, the process could result in uptake. We need more research on whether how these mechanisms really work and if they're cost effective. And what's the patient or participants experience, but their their ways for us to really simplify the rollout of some of these really critical programs that are important for ending the HIV epidemic. Tell us. Telemedicine can also be used to enhance linkage to in retention and care. Um, we have examples in Alabama's I talked about before, which is, um, patients seeking carried a clinic near their residents and accessing, uh, remotely located specialist. Where they go in, they interact with the nurse on Ben using telemedicine video resource. Is that air at this site? Um, they can interact with a specialist. Um, this operation, this network consists of two full service provider locations and there's a third in development. I think there are about 11 different sites. Um, I think I missed the polling question, so I just wanted to say that out loud. I I got so excited. I think I missed that. So, um, is this where the pole is? The polling question here? It's not okay. Sorry. I'm Here's the other thing around telemedicine or telehealth. It's like we learn. We need to learn how toe interact with all of these different mortalities that we're trying Thio, master. And sometimes we do better gun others. Um, with the slide that is up now about simplifying the process. Um, I talked about that a minute ago, but this is one of the opportunities that are lessons that we have from telehealth is really to simplify the process for prep, distribution and start up and maintenance over time. Um, looking ahead, we see that another lesson is that this offers a broad array of services. Um, the this and this refers Thio, the project that is in Alabama, that I mentioned a few slides back, um has to do with really enhancing language and care and attention in rural settings. And so there are a couple of settings where people can go, uh, to access their care and, um, interact with the nurse. A nurse, which has so in this rural or remote setting, has the video equipment that will provide, um, the access to specialists that where people can see specialists and access specially care, even if it's not in their current location. Um, this project also in addition to medical care, um, and providing prevention, Aziz. Well, as's primary care also has wraparound services, social services, educational services, hep C testing and behavioral health services. Sorry, I am I'm sending a message to my secret, um, person here who's helping me with my slides. Um, looking ahead to the next slide. And the next lesson, Um, that there are telehealth can provide a really diverse way to for people to interact, um, patients to interact potential patients to interact, um, in a way that they prefer, which is a really important part of this, um, this this this concept of storing forward, which is, um, Elektronik transmission of health care information where documents can be stored, uh, different tests, um, email communications that air secure than also remote patient monitoring, which is access thio. You know, information can be shared with the health care provider from from different, um, settings, right. Mobile health, providing health care services and health care data using a mobile device. Uh, counseling, consultation, text messaging. Um, one of the things that I referred to earlier in this way to text study or the youth to text and telehealth study is we did a ah, lot of things. Um, you know, on phones and services data on ben. Also the consultation peace with fly video consultation, which is probably what ah lot of you are most familiar with, which is really having real time interactions using audio business, audio visual technology, and then there are the the standard way, which was people going in to see a clinician. We're in the same room in the same time. In real time as we move forward. The let's talk a little bit about best practices for engaging nurses and telehealth models. Um, Nursing is supporting telehealth, and our practice can support telehealth. We've all experienced this. I think any of us who are in the healthcare field right now we've gotten quick lesson and tell health and how to do that. Um, on the run and during Kobe, nurses in all roles nurses, nurse practitioners and the whole health team. I mean, we've really shifted to being able to, um, you know, do what we do best, using telehealth for virtual visits, um, for clinical care and for non clinical care. It allows for collaboration with the team, and it also presents us with the opportunity to really increase our knowledge and skills about how to use on apply telehealth technologies. Andi, it's it's essential, um, to the way that we're educating nurses, uh, one of the you know, we think that historically or on this slide here, where it talks about how training until a health knowledge and hands on skills has not been accessible to training programs the nurse practitioner programs in the past. But it is now, you know, and this is something for myself who comes from nursing education, where we have really had to learn how to do this. And we're still learning. Um, and it's a really it's an area of growth for us and nursing as we head to the next slide. Um, the other pieces that would be important for us to translate or to think about in nursing on DNA nurse patient interfaces. Really? How do we translate patient into telehealth formats? Um, as I said earlier, you know, it's there's choice from the patient side as well as the clinician side. Um, but how do we identify who the right people are? And what's the mechanism for them to interact? Um, for their for their treatment, Um, and really also, to make sure that the systems were using our, um, tailored their tailored to the different populations that were working with whether they're vulnerable populations. I mean, vulnerable populations, of course. People who know how to use the technology and may, um, you know, they have a preference that they want. There's some other, ah, populations who are not going to be is comfortable. Um may not have access to certain methodologies. And what are the ways that we established report with patients when we're using telehealth it really Can you hear? May I did that. And I'm in both rooms. It really access to be able to establish report, report with patients and hone our communication skills, Um, the other as we move forward about how we're gonna keep going in this area of telehealth, Um, hang on as I flipped to my slides, um, and how we're adopting telehealth in HIV care and what the potential is, Um, and many of us are doing this now. Um, but broadly, adopting Tele health and HIV care has a lot of potential, um, despite some of the challenges and the discomforts and potential barriers. But it has the potential to really increase screening of HIV and adopting tele health and care. Um, timeliness of care, getting people tested, increasing access to prep delivery of prep medications, delivery of antiretroviral medications, reducing stigma, increase inherent and engagement. And we're beginning to see some research on that and also removing barriers to accessing care for people. Um, who may be, you know, getting to a clinic or traveling to a clinic could have been a barrier for them. And if they can access it on their phone, you know, this is a great opportunity for us. It also has the potential for improving patient outcomes and also increasing access to care and providers. Um, I think, um I'm not sure if people have access to the polling slide, um, or the last polling slide. But, um, the last question was to think about some of the some some of the advantages of using telehealth to deliver health care services. And for those of you who may have answered that, thank you. And I we will be talking about some of those things as we transition into our breakout groups. Thank you so much, Dr Rose, for that amazing presentation really around telehealth and how it can serve a purpose for us moving forward with our care delivery system. Now you'll have an opportunity to practice this and really begin to think about your own agency in ways that you can begin to implement. How I help into your everyday practice. Please join our breakout rooms with our Gilead community liaisons who will workshops some of this activities. And then we'll see you back here for our amazing keynote presentation. Welcome back. Hopefully you've had a great opportunity to engage without Gilead community liaisons and really putting out telehealth conversation into practice as a part of our lovely conversation and partnership with ENAC. We're really excited now to give you our keynote presentation from Dr Michael Stressor entitled The Year of the Nurse, Supporting our patients and caring for ourselves. Without further ado, we would like to turn it over to Dr Susan Michaels. Stressor. Wonderful. Thank you so much. And it's a really honored to be here, thank you to the organizer's to Gilead to enact onto the participants online. I've really appreciated hearing from my colleagues, looking at areas of work that I think are are very quintessential nursing and focus on what nursing prioritizes, patient care, patient centered care, looking at humility, cultural humility, cultural competence as well as telehealth, a very, um, not necessarily innovative but very time off of the moment strategy we can capitalize on to rapidly increase people's access to healthcare so a very interesting discussions and I have the privilege. Thio Give pep talk to all of us in this year of the nurse. Here we have a picture, as you can see Ah, Florence Nightingale with a mask on, and I'll talk a little bit more about this picture in a moment. But it was on a wall near where I work, and this year we celebrate the 2/100 birthday of Florence Nightingale, the founder of Modern Nursing. And we know nurses are working on the front lines in the cove. It crisis have worked for decades on the front lines of the HIV crisis, and the current pandemic has reminded us of the critical central importance of nursing in in responding in crises. We have seen that throughout the world and here in the United States, with the nurses traveling from near and far to assist in the response when their especially where I live in New York City, when we were really overrun earlier this year on we we want to reflect on nurses role in front line care, developing understanding and standards for infection control, for using data to drive quality improvement, caregiving as as a primary objective of our work sustaining quality care and what it takes in good times and bad. Florence Nightingale wrote a lot about that, as well as her legacy in research on patterns of disease and epidemiology. As we move forward, well, we want to talk about this year of the nurse. The W. H O has declared 2020 as the Year of the nurse. It was a time that we had many events planned, many types of opportunities for nursing advocacy. I know there were parades planned at the World Health Assembly that, unfortunately, have not been ableto happen. It definitely is not what we expected. But the Year of the nurse and midwife has been the opportunity to highlight to the world what nursing is through action through our response to Kobe 19. And I think Kennedy, the president of I. C N, says, in this year of the nurse and midwife, the eyes of the world are on our profession in a way that we could not have anticipated. Nurses are in the spotlight and all around the planet, this tragic pandemic is revealing the irreplaceable work of nurses for all to see as we move forward. We want to remember that 2020 is definitely not what we expected. We hoped it would be a year of advocacy of renewal of coming together, and it really was one that has tested us to our core in so many ways. And I think this this picture nicely shows the myriad of thoughts going around in our heads swirling really, as the diagram shows in our heads, all that we have been through frontline nurses have been pushed to the limit, working without adequate P p e. People spending long hours changing shifts or working without being able to get home to see family and friends. And as we move into the winter months, we see that we are still far from where we need to be to address this cove in 19 Pandemic. This slide shows us what I am truly passionate about. The role and work of health workers, especially nurses on the front lines, is not only critical to the public's health, but it has. It has potential severe impacts on the health workforce, and our healthcare service delivery is on Lee as strong and resilient as our health workers, and this is what I live and breathe developing systems, strategies and programs to better protect and prepare our frontline health workers. This is a diagram that has been developed to show the numbers of people that have been lost to Cove in 19, and these are documented cases that have been recognized and been vetted and confirmed as true occupational exposures. This work has been done through a joint initiative between the Kaiser Family Foundation and the Guardian. They're working together there to gather names and details of every health worker that has died from Cove in 19 due to workplace exposure. Um, of the 224 workers added to the lost on the frontline database. Thus far, 31% reported concerns of inadequate personal protective equipment. I'll say that again. 31% or a third of the health workers reported concerns of inadequate P P E. Roughly 35% were nurses, but the total also includes many others who have been made the ultimate sacrifice in their work. Physicians, pharmacists, first responders, hospital technicians, cleaners, many others and at least 90 lived in New York and New Jersey to two states hardest hit at the outset of the pandemic. It's important to note within this diagram and the work that Kaiser Family Foundation has been doing that the majority of these deaths that have been verified occurred in April after the initial surge of infections on the East Coast. And that tells us something very powerful, very straightforward, that the early days of a pandemic are risky. They are risky for everyone, including frontline health workers, but most especially the large number of nurses who are providing what I call high touch care. Who are there a. The bedside who are cleaning people who are turning people who are trying to feed people. These are the exposure moments that put nurses and nursing at risk at every loss of a nurse is a loss of significant memory in how to care for people, and it chips away at the resilience of our health system. So as we need to move forward, we need to learn to do our work better. And this is a slide that shows the cumulative Ebola virus disease, instant rates for selected health workers by type for three countries, and this goes back to a different pandemic that that has concluded it went from 2014 to 2016 in West Africa, the worst Ebola outbreak ever on We are capturing the lessons learned from from those days. And, as you can see here that the incidents compared to non health workers was much higher for all types of health workers, medical doctors, registered nurses and laboratory technicians. So all health workers are at increased risk. But again, nurses had the highest incidence rate per 1000. So this tells us that health workers are at risk and need to be protected, must be protected, especially in the early days of an epidemic. As we move forward, we need to figure out how to do this better. And we need to continue to use the trusting voice of nursing to advocate for better protection, better preparation on better preparedness systems, educational systems and response networks. Cove in 19 has highlighted the rationale behind the year of the nurse Global campaign, and why I say this is Cove in 19 has highlighted those parts of nursing, which I am most proud of, which I think put nursing out there as distinct as fundamental to protection of public health. And that's why I think I chose that combination of nursing and public health because I do believe at the center of health is our health worker. And at the center of health care provision is a nurse. And the recognition that nursing and midwifery are practical are occupations that require expert observation, patient centered innovations. They require presence being there, being with the patients 24 7 and, lastly, central to public health and Florence Nightingale gives us a lasting quote, which is relevant today, as it was 200 years ago. Never lose an opportunity off urging a practical beginning, however small for for it is wonderful how often in such matters the mustard seed germinates and roots itself. And we've seen that in Carol's presentation on telemedicine, many of the barriers to telehealth and telemedicine fell away during Cove in 19 because care provision was so restricted. And these are moments that nurses need to harness and advocate and get in front to improve patient care. As we move forward, we want to remember that nurses voices are trusted. Use your voice, use your experience when you see something wrong, speak up. Speak up both for the individual patient, but for the system, the health system as well. We have seen across the United States and the world. It has been tremendously difficult to control this virus. But we do know, even with the good news of the Pfizer vaccine that was released yesterday, we do know that there is a tough road ahead to get vaccines that are durable that can be delivered on a large scale and truly fully protect those most at risk. Those questions are still out there how we're going to do that. But what I do know is nurses will be central to making those things happen, and nurses need to voice now what is needed to do that. To do that equitably. To do that well, to do that with high quality. To do that, with care for those needing it most, and the nursing voice needs to speak up to help mount a strong response. I really wish there was a nurse on the new, newly uh identified co vid 19 task force for president elect, and hopefully that will be something coming in the future because I believe nursing as the most trusted profession brings practical results driven guidance. We have the patient's needs front and center, and that affect all of the questions that we ask all of the answers that we give and all of the ways we will work tirelessly to improve patient care. As we move forward, we need to remember that nursing is practical and we can have and will continue to do this. Our fellow brothers and sisters have perished, and we need to. We owe it to them and to ourselves to continue to push in this year of the nurse to improve health systems, protection for health workers and for healthcare writ large for communities. We have the skills we have, the knowledge, we have, the tools it's making it happen. And the simple mask reminds that us of that the best if we could move to the next slide. We know masks have always been used, and this is ah, picture off a nurse in a covert unit, speaking with the daughter of a dying woman, and the nursing is present. She is there as the woman is dying and said to the daughter, I can tell by the way your mother is breathing that her time is near. There isn't much time left, and she, as many of us have heard in the news and the media, was the connector between the patient, the dying patient and the family. And this is the power of nursing, nursing in presence. And as we move forward, we need to remember that nursing is trusted. Nursing is present, and her quote says, We got a call and it was Tatiana the nurse, she said. I could tell by the signs and the way your mom is breathing that the end is probably near. I'll say that again. I can tell by the signs and the way your mom is breathing that the end is probably near. Those were the beautiful world words of a nurse at the front line capturing a moment that will be forever remembered by that patient and the family. And it came not from just being present, but which is extremely important, but that that careful, scientific, experienced observation knowing when the end is near and nurses all over the world know that nurses will say, I get that feeling. I have this idea, and in this case it was, ah, beautiful ability to connect. In the final moments of Kobe 19. This is nursing presence. This is why nursing is trusted. And this is why nurses voices must be heard As we move forward, we need to continue to remember nurses like this. Nurses have always been on the frontlines. Nurses have always been at the bedside. Nurses have always taken up leadership positions to drive public health and pandemic response. And we known masks make a difference on. We can see here the use of simple cotton cloth masks at the turn of the last century to help people. And and we know that this simple imperative to use a mask is our best bet right now with social distancing to control this epidemic, and we must use our voice, our presence, our trust to get these messages across. Next slide nurses on the front lines This is a lovely book by a colleague who Barbara Wall and Arlene Fleming, who show historically this is nothing new. We have always been on the front lines, and we will continue to be on the front lines. This wh your year of the nurse has given us a moment to really shine and show that we didn't want Cove in 19 but it is here, and I firmly believe we must use our voice. We must use our voice to drive for for care, for primary care, for patient protection and for service delivery that is rapid and responsive and safe for the health worker. They found that nurses improvised activities at the local and national level across, uh, pandemics and disasters from the mid 18 hundreds to the present. Nurses cooperated and collaborated amongst previously established professional and social networks. And I'm sure many on this call have examples of when they have been involved and worked with their colleagues to get things done in this year. Leadership and courage, spontaneous community support. We saw that so much in New York, with people coming out to support the frontline health workers, restoration of order out of chaos again, we must use our voice to put forward the practical strategies that we know work to help fight a pandemic, the creation of healing narratives and the crossing of cultural, geographic and professional boundaries in response to crisis. And I live near Times Square in New York City, not far from where all of the Busses that would transport nurses that came from across the United States toe help us earlier this year when New York City was hit very large and that was a very moving example off nurses crossing boundaries to provide care. As we move forward, we know that our history tells us that we are innovative. We are we have been innovators and leaders in infection control in the development of quality care systems in epidemiology and data use. Florence Nightingale herself was one of the first people to look at infection control. One of the first people to look at quality of care, one of the first people to use data to drive program improvement to look at data and patterns of diseases. New patents for masks have been developed by nurses to get the PP out there. Nurses have developed systems during Cove in 19 to reduce unnecessary clinic visits. Visits. Nurses have worked together to develop PPE use and redistribution programs and online programs to care for the caregiver. Nurses have historically and throughout this year shown their innovation. Next slide Care for the caregiver. This year has been very challenging and and if you are like me, some days are good days and some days are not so good days. I feel like I have this intense brain fog on guy. No, I I at least have the tools to be able to reflect on why I'm feeling that way. And I'm grateful that I'm a nurse toe have those tools to be able to understand that. But that does not mean that we need to bear this ourselves. Nurses have been pushed to the limit, and it's very important at this time for us individually and collectively, to reach out to each other for care to provide care and to give care. The care giver in you needs to be cared for. The care giver in you needs to be nourished. The care giver in you needs to be nursed, and you need to allow yourself the time and the space for that to happen. Even if you're not actively working clinically. Just listening to the news and the numbers can be traumatic because we know what can be done. We know the riches in this country. We know what can happen when people work together and make things happen. So the challenges are many. But I just want to remind us all about stress, burnout, post traumatic stress disorder and moral injury, thes air situations and conditions, which we will see an increase up in over the next year. And the time is now to protect yourselves, to care for yourselves and to care for your colleagues. Don't be shy. Use your voice. Get the care that you need because the world needs you. The world needs you strong and healthy prevention. I would love to see a scale up for preventative programs for health workers, self care programs. And there are some online nurse led nurse driven programs Nurse wellness programs. I would encourage you to look into those, um, that can be a safe space to decompress and reduce stress there. We need to look at mitigation strategies, crisis support and counseling. Um, debriefing sessions. If you're working at a hospital, consider having debriefing sessions where you can sit down together and just talk about what went well that day. What didn't go well what you look forward to tomorrow what hit you hard. What brought you joy? Just talking like you would talk to a friend. Taking the time to do that is important. As nurses, we see the most joyous times in people's lives. The births of Children, the surgeries that are a huge success, the people who come through near fatal incidents and survive. But we also see the harshest side of life, and seeing that repeatedly is inherently stressful on. We can Onley push it down so far, and we want our health workers to be strong and vibrant, so care for you is needed. Nurse yourself first. As we move forward, I want to say thank you to Florence Nightingale for showing us the way for showing us courage amid chaos, for showing us the counting numbers is important and nursing and nurses being Dad had driven, but also that her legacy of nursing as a caring frontline Provenge profession endures. And this is the picture that I took at the front of the hospital near where I work at the Columbia Mehlman School of Public Health, and it sat down is a very small sticker. It was about this size, and it said, Year of the Nurse Flow has a posse on it. It really was heartwarming to see this, and it's moments like these during this very difficult year that give me hope that pushed me on and say our legacy through the year of the Nurse and Recognition of Florence Nightingale is so rich, is so grounded in what really matters in the world caring for others. And that should give us a voice to push for better health systems. I believe that is my last slide. Yes. I want to say thank you very much. I have a podcast called Nurses on call. If you'd like to be a part of it, please let me be happy to have you on to share your story. Thio, use your voice, uh, to to push for better health care. Better health systems. I'm better. Health service, delivery. Thank you so much. Thank you so much. Dr Michael Strasser, for an amazing year of the nurse conversation I'm just reminded in. And the point that stuck out to me is nurse yourself first. And so on behalf of Gilead Sciences, I just want to thank our speak nurse. This afternoon and this morning, Dr Laurent Nelson, our moderator, Dr Sheldon Fields and Dr Carroll Rose Dawson for lending their voices to helping us as we move forward, not just as nurses, but to understand cultural humility as a part of our health care delivery system. And in this pandemic, taking care of ourselves first allows us to be much more culturally competent for our patients. So in partnership with an AK, we're delighted you were able to join us for our pre conference institute. We will be sending out our survey. Please let us know your thoughts and information and any other topics that we can work with you to gather more information and deliver that information to you. Please enjoy your conference ahead. And thank you so much for attending this session today. Thank you.