Coronavirus, Public Health Watch Now: Nursing and COVID-19: Perspectives from the U.S. and Latin America

2020 has become the year of COVID-19 - but long before that, it was the World Health Organization’s “International Year of the Nurse and Midwife.” Experts at the WHO are urging for massive global investments in nursing education and jobs, including in Latin America, which has become the epicenter of the global coronavirus pandemic in recent months.

In late May, Latin America surpassed both Europe and the United States in number of cases and number of deaths, and it is now home to some of the largest outbreaks in the world. What is the state of nursing globally, and specifically in the U.S. and Latin America? How will investments in nursing assist in dealing with the COVID-19 pandemic in the region? What are lessons for policymakers in ensuring nurses are full participants in addressing the health of communities in this pandemic and beyond?

To find out, Perry World House, Penn Nursing, and two renowned global experts on nursing policy - Penn’s Dean of Nursing Antonia M. Villarruel and PAHO’s Regional Advisor on Nursing and Allied Health Personnel Silvia Cassiani - came together for this virtual event on nursing, COVID-19, and Latin America.

Transcript

Michael Weisberg [00:00:00] Welcome to The World Today, a program of Perry World House, the University of Pennsylvania's global affairs think tank. I hope everyone's safe and healthy during these unprecedented times. My name is Michael Weisberg. I'm a Professor and Chair of Philosophy and Senior Faculty Fellow and Director of Postgraduate Programs here at Perry World House. Today's guests are Dr. Silvia Cassiani and Dean Antonia Villarruel.

[00:00:24] Dr. Silvia Cassiani is the Regional Advisor on Nursing and Allied Health Personnel for the Pan American Health Organization, often pronounced PAHO or OPS in Spanish, La Organización Panamericana de la Salud, an international organization that works with countries throughout the Americas to improve and protect people's health and is the regional office for the Americas of the World Health Organization. Dr. Cassiani began her career after graduating from the College of Nursing at the University of Sao Paulo, Brazil. And she completed her master's degree and a doctorate in nursing from the same institution where she later in her career served as the position of Dean of Nursing, and then came to work at PAHO and the WHO. Dr. Cassiani has served as Regional Adviser on Nursing and Allied Health Personnel since 2013 and is responsible for technical cooperation with the PAHO member states to promote equity and health, and improve the quality of life for the people in the Americas. Through  the development of nursing, practice, education, leadership and research.

[00:01:32] Antonia or Toni Villarruel is the Margaret Bond Simon Dean of Nursing at the University of Pennsylvania School of Nursing and the co-director of the school's WHO Collaborating Center for Nursing and Midwifery Leadership. Toni holds an appointment as Senior Fellow at the Leonard Davis Institute for Health Economics here at Penn. And as a bilingual and bicultural nurse researcher, she has extensive research and practice experience with diverse Latino and Mexican populations and health and research in the topics of health promotion and health disparities. She currently chairs the National Academy of Medicine's Roundtable on the Promotion of Health Equity and co-chairs the Strategic Advisory Council of the AARP/RWJ Center for Health Policy, Future of Nursing Campaign for Action. Dr. Villarruel is a trustee of the American Board of Internal Medicine Foundation and an invited member of the Aspen Health Strategy Group. She is a member of the National Academy of Medicine, as well as a fellow of the American Academy of Nursing and the College of Physicians of Philadelphia. She's the recipient of many awards and honors. She earned her B.S.N. from Nazareth College, her M.S.N. from Penn and her Ph.D. in nursing from Wayne State University.

[00:02:45] Thank you both so much for joining us today at Perry World House, and the floor is yours to give us some introductory thoughts about the global state of nursing, perspectives across the Americas and the impact of COVID-19 on all of us. So we're gonna start with Dr. Cassiani.

Silvia Cassiani [00:03:01] Good afternoon. We are in a difficult time right now. Many countries are experiencing shortage of health workers, but we know that without the nurses and other key workers, the outcomes of this pandemic will be worsened. Not just the health of the population, but its impact in economics, politics, and other sectors of the society. However, long working hours, a shift to work high workloads, and other psychological hazards led some of the nurses and midwives to partake occupational burnout, psychological distress or declining mental health. The entire population are applauding the courage and dedication of the nurses and midwives and call them heroes.

[00:04:04] In the Americas, we have 30 per cent of the nurses, of the global nurses, or 8.4 million nurses. And in many parts of this region, nurses and midwives often are the first and sometimes the only resource in direct contact with patients, meaning remote areas or even with the indigenous population. But the crisis of the global public health provoked by this pandemic in the year that we should celebrate the Year of the Nurse and Midwives can be an opportunity for more and investments in nurses' roles, to recognize their contributions and the vital role, and accelerate investments. The Pan American Health Organization works with the countries to invest, to value, to respect and to trust in the nursing workforce.

Michael Weisberg [00:05:13] Thank you so much. Toni? You were muted.

Antonia Villarruel [00:05:28] Sorry about that. So good afternoon, everybody, and thank you, Michael, for inviting us to be here as part of this COVID series and again for highlighting both the role of nursing and the importance of the Latin American region in some of these efforts. Dr. Cassiani, it's always good to see you. You were a colleague first and again, as director of the of our collaborating center, we've enjoyed your leadership here as we work to improve the work force, the human resources capacity of nurses in Latin America to improve health.

[00:06:07] The first thing I want to mention again, is the importance of the Latin American region. That's, again, highlighted in this pandemic here. So when I came to Penn, certainly the emphasis on China and some of our other neighbors was important. But I felt because I'm Mexican by background and because of the work that I've done in Latin America, Mexico and the Caribbean, I really wanted to see who my "playmates" were here on campus. And I was struck to see the depth and breadth of work in all areas of Latin America. Michael, I look forward to hearing more about your work in Ecuador. In our school of nursing, we've had longstanding relationships to prevent Chagas disease in Peru, part of a huge collaborating center in Guatemala focused on violence as well as midwifery education. My own work in Mexico. I've really been struck since I've been here. And we formed a group called PAN in Latin America and the Caribbean to see the depth and the breadth of Penn's presence in Latin America.

[00:07:21] And again, how important that scholarship and interaction is important for our students, for attracting the diversity that we want here on campus and importantly, for contributing to the region. And when we think about why is Latin America so important? You know, first of all, we think of proximity. We share water, we share air, we share people. I forget who it was who said, when the U.S. catches a cold, Latin America catches pneumonia. And so we see, you know, the economic impact of what happens in the US profoundly in Latin America. We are affected by the political and civil unrest in Latin America and how that affects immigration policy. So we all have a large stake in what happens in our own neighborhood, in our own backyard. So, again, the resources at Plath, the support of the Perry World House. And again, our opportunities to work as a collaborating center in the region is of just utmost importance in the whole global health arena. And I'm pleased that it's a priority of our school. And again, rising prominence here within Penn's campus.

 [00:08:37] I think as Dr. Cassiani said, when we think about COVID and nurses, we've been here. We've been here before. Nurses have been very present in epidemics and pandemics before. When you take a look at what happened in 1918, for example, in one of the worst flu, the Spanish flu epidemics, nurses were out there front and center. Not just in caring for patients, but also in public health, in applying good public health principles that, of course, we learned from Florence Nightingale, who was a staunch supporter of good handwashing, proper sanitation and sound preventative measures like face masks.  As Dr. Cassiani, nurses are leading here in this country. Response teams that demonstrate their skill and their expertise, such as disaster preparedness, predictive modeling, hospital and field operations and human resource management. You've also seen nurses as strong advocates as we're talking now about opening schools and the importance of school nurses, and making sure that students and teachers are well taken care of. We're important in terms of the testing. It's many of the nurses that are out there in the parking lots, in their hazmat suits, doing the particular testing. It's also in the testing of vaccine trials. There's going to be a huge vaccine trial that's taking place here at Penn. And it's, again, nurses that are going to be moving on this. And importantly, using whatever microphone we have, using social media as well as the media to educate the public.

Antonia Villarruel [00:10:18] Now, this comes at a huge consequence for not only nurses, but all health care providers. We've seen the consequences and the impact that accidental, or because of lack of adequate protection, exposure to the virus has had on both physical and psychological fatigue. I think, Dr. Cassiani might address this later, but [00:10:44]in some Latin American countries, health care providers and nurses in particular are being assaulted in their communities. They're seen as being dirty. They're not allowed to come into their communities. And again, this has caused specifically in Mexico, an international uproar.  So, again, even when doing good, we take on the issue of of victims. So, you know, again, the existing working conditions both in Latin America and the US, a short staffing, et cetera, are exacerbated by this pandemic. But I don't think that deters nurses from doing the work that they need to do to keep populations healthy, both in the hospital and in communities.

Michael Weisberg [00:11:32] Thanks so much. You've covered a lot of ground, at least some initial questions I wanted to ask, but before we go any further, I wanted to ask you both about 2020. Before we started thinking of this as the year of the Corona virus, it was the Year of the Nurse and Midwife. And this was a declaration of the WHO to honor these professions. We'll probably spend the rest of the hour talking about COVID-19 so before we do that, I wondered if you could each say something about that, the Year of the Nurse and the Midwife.

Antonia Villarruel [00:12:05] Sure, I'll start Silvia, and then maybe you can talk about specifics in Latin America. So, yes, 2020 was going to be a year of great celebration, the Year of the Nurse and Midwife. And it was a designation by the World Health Assembly. And this is important because it's the first time that the World Health Assembly has created a "Year of" for a particular profession. And so why was that so important, or why recognized nurses? Well, one practical recognition is that it's the 200th anniversary of the birth of Florence Nightingale, who is the founder of modern nursing, a pioneer in public health and the use of data visualization, and an advocate for social reforms. But importantly, the recognition of nurses and midwives during this health assembly was done in recognition of the importance of nurses in the workforce and to try and elevate the key role that nurses and midwives play in contributing to the United Nations Sustainable Development Goals. And so why is this opportunity so urgent?

[00:13:12] So think about an industry in which a key group, which constitutes over half the workforce, is facing an enormous workforce shortage within the decade. Imagine an industry of key end users who possess critical evidence, expertise and experience, but who were excluded from planning and strategy decisions by policymakers at the institutional, regional, national and international level. Imagine an industry in which half the workforce has the education and skills to address the most perplexing programs in a way that benefits both the economy and the population. But imagine that this well-educated and trusted workforce is prevented from working to the full scope of their education and license in a way that restricts and diminishes practice and innovation. This is the situation of nursing and midwifery in most countries around the world, whether those countries are research rich or poor. So currently cast below the globe. Nurses and midwives account for nearly 50 percent of the health care workforce globally, yet the world is experiencing a shortage of health care workers. [7.8s] And nurses and midwives collectively comprise 50 percent of that shortage.

Antonia Villarruel [00:14:30] So this is a global phenomenon. We're experiencing it here in the US and Latin America because of the added component of the age of the workforce. So people are aging out of nursing and midwifery. In addition, in the United States in particular, there's been a high reliance on international nursing. And because other countries are experiencing that shortage, that's a supply area that we're not going to have much resources. [00:15:02]So despite our numbers, the highest percentage of the health care workforce. The expertise of nurses and midwives is consistently underrepresented in middle and high level policy discussions and decision makings at the institutional level and at the governmental levels. [17.0s] Nurses and midwives have these requisite skills, it's what we're educated for. It's important both in terms of economic production and in terms of gender equality. But because of our lack of representation here, we are prevented from practicing to the full scope of our license. Not just in the United States, but all across. So, again, this has a significant impact on the health of the public. So the idea of this report was to, again, systematically document what is the state of nursing across, taking a look at population, taking a look at policy recommendations that were in place in countries to serve as a benchmark and as a call to action to governments and policymakers to elevate nursing in these policy areas. And Silvia, I mean, I know you will speak specifically to Latin America, but everything that I am saying is absolutely true. So I know we would be interested in hearing specifically about the findings in the Latin American region.

Silvia Cassiani [00:16:35] In terms of the region and looking at Latin America and the Caribbean. As I said, we have about 8.4 million nurses in this region. It is about 30 percent of the nurses in all over the world. So we can see that one-third of the nurses in the world are in these regions. The issue is that a few countries has more than half of these nurses. For example, United States has about half of these 8.4 million nurses.

[00:17:14] So imagine, as Toni said, one country with half of the nurses, and the other countries are splitting the other half. Budget, as Toni said, is a very important aspect. We need to invest more. So talking about Latin America. We see that it's a call, as she said, for investment. We say that to human resource for health, they are not cost, they are investing it in. And looking at what we are facing this year, with this pandemic. What would it be without the nurses? Nurses are the pillars of the health system. But the full potential of nursing and midwifery has not been used in Latin America. We need to discuss more to the governments, ministries of health, education and labor that they can trust in the education that the nurses in this region, especially in Latin America, they had. We needed to work to expand their roles in public, in health or in primary health care.

[00:18:32] PAHO talks a lot with expansion of the services of the primary health care. We know that primary health care services, they can deliver and they can be resulted in almost the 80 percent of the cases. So imagine if we had been nurses with autonomy, with full recognition, with a good working conditions, a quality education and motivated, working in those places. So the solution of the problems of the clients in the population, the nurses with their education, they can deliver. We needed to improve it in modernizing nursing regulations in Latin America. We needed to give them a better working conditions. We have to discuss about the migration of nurses, especially in the Caribbean. And we are facing that with the pandemic, the migration will be increased a lot in the next years. So  the migration is not just in the Caribbean, but also we face in Latin America.

Silvia Cassiani [00:19:46] But we have to say that, and Tony said very well, this year is this celebration of the Year of the Nurse and Midwife. If the pandemic do not to allow us to celebrate as we should do, but can be an opportunity for the discussion, for leading the positions of the nurses and midwives in the country. Next month, we are starting to have a policy dialog. We are giving tools for the countries to use this is part of the report to create opportunities, to create a discussion and to transform and to influence health policies in terms of the health workforce and also nursing workforce. So we hope that with these we can lead this position to leverage the nursing much more in the countries.

Michael Weisberg [00:20:48] So you both started to touch on my next question, but I'll ask it anyway and maybe try to ask you to elaborate on the specific parts. So in preparing for this, Dean Villarruel, I was looking at Penn Today and saw you quoted saying that, "when it comes to pandemics, it's nurses who are on the front line who spend the majority of time with patients who put themselves at risk." And so I guess one of the things that I was wondering is, it seems from as an outsider that that we collectively across the Americas are failing nurses in this pandemic, as they are on the front line. I'm just wondering, what kinds of. You both mentioned the need for more nurses and education, but what other kinds of policy changes need to happen? And it sounds like there's currently a forum for this discussion to happen at the highest international levels. And if you want to start, Dr. Cassani, what specific kinds of policy changes are required?

Silvia Cassiani [00:21:45] It's not a change of the policy, but the influence of policy. We as nurses, we call for help for all in all policies. But we also wanted to contribute more. To seat in the decision tables, to discuss about the health of the communities, the health of the population, and to work in there professionally. So we are looking for interprofessional education. We are looking for working in collaboration with other health team. But we also, to recognize the contribution in all the education that we have as nurses. We reported a lot of issues related to the working condition and this is not news to us. This is not the pandemic. As you said, we have several nurses died from the virus, and many of them related to the working condition.

[00:22:51] We also needed from the health policy, good data, to understand the country's health workforce. The perspectives as we could see, many of the countries in Latin America especially did not have good data. So how many nurses you have on demand? How much nurses is your supply? So sometimes, these kind of data is not well practiced in the country, you know, even though they reported and informed about the data in Latin America, and Toni mentioned that we are almost 50, 90 percent of the workforce. We also need investments in retention schemes. Like I said, in the Caribbean, in other countries, we need the gender sensitive policies and also an acceleration of nursing education. The region needs more nurses. And to do this, we need to accelerate and use the experience of the United States to produce, to increase the supply of nurses as the United States have been in the past years.

Antonia Villarruel [00:24:13] So I do think that there are some changes that are are needed to protect not only nurses, but other frontline workers. The first one is access to PPE. I think we're seeing shortages in the Sun Belt, for example. Again, the same supply chain issues that people don't have, what it is any of the frontline workers have, what they need to be protected. So that has to happen. The second thing is that there has to be in place, adequate psychological and social support for these frontline workers. And this is like a PTSD. I think the stress of frontline workers in the hospital is huge. And then you go to this. Oh, my gosh, I have to go home and I have a kid. I have a sick parent. How am I going to be able to protect them?

[00:25:07] So some systems have been very helpful in providing housing, for example, or providing meals to again decrease the risk that hospital workers may or may bring home, and that should happen. [00:25:21]I was pleased to see that the governor here in Pennsylvania just implemented some hazard pay for frontline workers. I don't think nurses will qualify just because of the of the income level. But again, that's a step in the right direction. [14.0s]

[00:25:37] I also think there's been some good changes, good policy changes that have happened as a result of COVID that have allowed nurses and other healthcare providers to practice, to decrease regulatory barriers and to increase the scope of their license, practice to the scope of their license. So one example is in the area of telehealth. So regulations that had to do with, you know, again state licensing and borders and payment have all been eliminated so that if you're licensed to practice as a physician or as a nurse and in one location, you can provide telehealth to somebody else in another area. Nurses and PAs, as a result of the loosening up of some of the restrictions, are able to build for and provide these telehealth services, which again, is important. People are still in need of care and telehealth seems to be the only way to do that.

[00:26:32] There's also been a number of, you know, again, crazy restrictions that have been placed on nurses and other folks so that in the home healthcare area, for example, only a physician could prescribe palliative care. And when really it's just the nurse calling up the physician to say, hey, you need to do this. And so some of those barriers have been removed to allow, again, nurses and others to practice to their full scope. So, you know, in a crisis, we tend to be a little bit more innovative than try what we need to do and our hope is, is that these regulations and because they are important, they're necessary and are not dangerous, can be implemented once the epidemic is out as well. So those are examples of some policy changes.

Michael Weisberg [00:27:19] Those are great. And just a brief follow up to that. Has it also changed how. You're leading a school, has it changed how you're thinking about the future of nursing education?

Antonia Villarruel [00:27:29] Well, I like to say that we've moved, you know, 20 years and two months. And so the idea of using a virtual remote education is something that we had never met. So we never have done. But I think they were like many bricks and mortar college, Ivy League colleges had been slow to adopt. And now that's pretty much the norm. And so I think we're looking at everything that we're doing and saying, you know, not only does it make sense in this pandemic, but is it going to make sense moving forward? So, you know, our faculty and our students have had jumped in, have been innovative, have been willing to try different things. I mean, we have we have to give in our environment. So those changes will continue. I think certainly preparing nurses for telehealth is something that was, you know, very little. But it's something that I know is is going to be routine because people are not going to go back. I mean, the telehealth component, that's the genie is not going back in the bottle. So we have to prepare our workforce to be able to do that.

Michael Weisberg [00:28:37] So I get one more question before we turn it over to the many questions pouring in from the audience. But since the three of us are all interested, especially in Latin America as well as the United States, I just wonder if you could comment on what seems to be. It seems like this disease has been really devastating in the United States and in Latin America. And what have we done wrong or where we just unlucky? That's the brutal questions, so guys can choose who goes first.

Antonia Villarruel [00:29:09] I'll start, I think we have different perspectives and I unfortunately. Maybe Silvia, you can point to some good countries that are doing well in the Latin American region and moving in controlling the epidemic. And the US, sorry to say, is not a leader in that initiative. And when I look at what's the issue here is with our country, I'll say it's a lack of national leadership and consistent evidence based regulations that move forward. I see similar situations happening, for example, in Brazil and in Mexico, where the leaders mock the science and just aren't taking this seriously. And I think choosing to present false narratives between the economy and health and restrictive and integrating this issue of, you know, of "freedom" and freedom of choice and not recognizing the collective responsibility in terms of community health. So that's where I see it. And would be interested in your perspectives as well.

Silvia Cassiani [00:30:23] Until last week, United States and I feel that this week is the same as I did my research. And the Brazil, combined it, they had these 76% all cases of COVID in 71.3% of all deaths. So just did these two countries. But they issue with COVID that is concerning PAHOis not just about the patient itself, is the continuity of the essential services of the first level of care was affected. You know, so we have, especially [00:31:07]Goudeau [0.0s] population, indigenous population, several Primary Health Care Services were closed because the health professionals were transferred to the hospital. So we had the disruption of services relate to NCD, cancer patients, of also the cancelation of elective services, immunization of children, prenatal care. So all other types of help were discontinued. And the countries have been using the mobile stadium hospitals and also alternative health care sites. The training of health care professionals, especially nurses, because several nurses didn't have the experience to work with these control of disease or patients in these situations. So PAHO had worked with the countries, providing training to several nurses and also to provide an estimate of the necessary human resources.

[00:32:30] Toni said that in terms of the school, they have to accelerate 20 years to just two months. And the countries, they had to do the same in terms was the health services. They were not prepared to have the intensive care units in also personnel training. So the pandemic was like an accelerator of change. But the issue is the issue of weak health systems that we have in several countries in Latin American also. But the other countries as well. So they have the systems, they were not prepared. They were weak. They had a lack of resources, lack of human resources. They were not investing in education and training of the personnel. And also in terms of the labor itself, the contracts. So we had the good experiences of countries that have declared the COVID as the occupational disease for nurses. otherwise they will stay at home because they had quarantine, and they were not paid. Or sometimes their contract was finished. So we had good experiences, but we have others that show that the health systems, they needed to be strengthened in every country.

Michael Weisberg [00:34:10] OK. Thank you so much. So now we have many interesting.

Antonia Villarruel [00:34:13] Michael, Michael, what are your thoughts? I mean, you've done a lot of work in Ecuador, and I think Ecuador was good and then not so good for a period of time.

Michael Weisberg [00:34:24] I think, I guess I agree with Silvia. I just think that it was. Even in a country like Ecuador that had a reasonable health system, it was just overwhelmed very quickly. I mean, it's happening in the United States. It clearly is going to happen in a country that's not as developed. But I wish I knew. I mean, there's some speculation that there were particular contingent facts, like a lot of Ecuadorians had been in Madrid for vacation at just the wrong time. But that I don't know. But I think it's very interesting that this is a case of a disease that good old fashioned public health would have helped a lot. And that was not really the emphasis in health systems that we know about. And I think we see it really does reinforce the importance of nursing and public health, how to manage a crisis like this. But that's the amateur speaking.

[00:35:21] So here's the first question I'm going to ask from the Q&A. We'll never get to all of the wonderful questions, but someone asks, indigenous communities seem to be disproportionately affected by this disease. What are the biggest challenges in a pandemic or in this pandemic, or in any pandemic and working in these communities? And is there anything that we can do from abroad?

Silvia Cassiani [00:35:47] I can start. It was something I hard to hear that the indigenous population in Latin America, they were infected by the health workers that were there to help them. And also because of the mobility of these indigenous population to the city. So the health workers that went to these tribes to help them. Suddenly, they were responsible for infecting them. And we know that the many indigenous populations, they do not have access to health services. They do not have easy access because sometimes they are far from the cities. And when they go to these cities, this transportation is hard. They need helicopters, they need boats. Even in Brazil, we have an issue. So we need to think, as we are discussing about COVID as the facilitator of change. These populations, they are in remote areas. So out of these cities. How they can have a better access to health services? It's a human right. The help is a human right. So the access to the health services and also access to professionals, health professionals. We know that many health professionals, they do not want to stay in these remote communities, far from the cities. So who is the person who is able to stay with the community? It's a time to think that maybe we need to invest in the community, community health workers. To invest also in the training of the community as nurses, as medical doctors, where they can stay there and they can treat the population. So it's very difficult. We heard in Brazil several cases. So it's very difficult to hear about these indigenous populations.

[00:38:18] But we also have COVID in the green zones, with the persons that were in prison. So as we are discussing about the health and health care systems. These are people that are out of the services because they cannot have access, we need to improve the access to everybody. If one is sick, everybody is sick.

Michael Weisberg [00:38:55] Did you add anything to that, Toni?

Antonia Villarruel [00:38:58] You know, I'll just say that, you know, our our Native American communities are absolutely devastated. And Silvia, it's not only the lack of health care, its lack of water. They don't have access to water to do handwashing. So, you know, again, when we talk about what's needed to change, it's, you know, again, the conditions where people can exercise good public health measures. So.

Michael Weisberg [00:39:22] This is one more way that the poverty and lack of access to resources kills people, we might say. So several people picked up on the comment I think, you made Toni, about PTSD. I'll just read one to one of them as an example. I've lost many family members to this virus. And as a result, I have concerns about how minorities have been overwhelmingly affected by COVID, and it causes hesitation working in a clinical setting. In addition, I think the PTSD is true and raises some challenges when considering the future for nurses like myself who've been personally affected. So what resources or support could be provided, should be provided?

Antonia Villarruel [00:40:06] So one of the things that we're doing, that we're working in partnership with Penn Medicine, who, first of all, recognizing that there is real trauma in what people are facing both in and outside. So number one. And the second thing is mobilizing resources that exists. Within Penn Medicine they have a great support system for frontline workers, and I'm pleased that our Penn nursing students are advanced mental health practitioners are providing services to those frontline workers as a hotline to again, To listen, to help debrief and then also to refer as needed. So, again, I think we're going to see a lot of innovative strategies to be able to help. I know a lot of professional organizations are moving forward. I think, you know, even pre-COVID, there had been a big movement about clinician well-being from the National Academy of Medicine, recognizing, again, the stress that health care workers are in increasingly, because of the situations that they deal with. And I think COVID has elevated and certainly shined a light on this particular issue for everyone. So those are some steps.

Michael Weisberg [00:41:22] Mm hmm. Another related question is, one of the people on the call mentioned that Israeli nurse has just finished a strike themselves, calling for 2000 more nurses. And this was, I think, in reference to when you were discussing what concrete policy steps could be taken. So I guess the question is should nurses take job actions or what can nurses do as a collective to really amplify their voice and to have more attention paid to their issues? You guys being two of the representatives of the leadership of nursing through the Americas.

Silvia Cassiani [00:42:01] I can start. First of all, we need two to work together. It's not the nurses talking to nurses about the nursing. So we needed to have it together, the government, to have the parliament, to have the ministries of health for Labor, Education, Treasury and Finance and all these stakeholders. We needed to have the other professionals in discussing about the contributions of nursing to the health of population and what else nurses can do to improve the condition of health of the country. It's important in the countries to have the leadership, the right leadership. Sometimes it's a group of the Senior Chief of Nurses Officers with the colleges of nursing, the universities and also the nursing associations. So both of them will discuss the situation of the health of the country. And how nursing and midwifery can improve this situation. So we are looking not just ourselves as a profession, but what can be done to improve the situation of the country in terms of health. So this plan, together, with these other key stakeholders and with the support of the of the government and also the universities can influence the policies. We need to lobby more about what nurses can do to improve the situation of the country in terms of the health.

Antonia Villarruel [00:44:16] So I'd like to say that, you know, at Penn we have a Center for Health Outcomes and Policy Research, CHOPR, run by Linda Aiken. And again her group and her colleagues, and not just in the US, but in Latin America, in Chile in particular and around the world, have demonstrated that an educated workforce at the baccalaureate level, improves patient care outcomes, decreases mortality, morbidity, etc.. We have the evidence that we need. What we need to do, as Silvia said, is change the political will. And I think there've been a number of, again, thinking about work in Chile. It's again, talking to the Ministry of Health, providing the evidence and saying this isn't something that you're doing for nurses. I mean, when we advocate for nurses, we're not advocating for us as a profession. We're advocating for the health of our communities and the population. And that's what we're framing. We're saying by investing in this type of workforce, you're going to have better outcomes. And so the legislation is one, getting the allies to be able to do that is another one. I think here in the in the United States, we have a designation called magnet hospitals. Which, again, part of the criteria for this designation is it's like a good housekeeping seal of approval. You know you're going to be getting good care there, and people know that that's a market driver. So people want that magnet designation. In order to get that, they have to have a more educated workforce. So, again, that wasn't a governmental policy. it was a market policy that, you know, again, based on evidence. A lot of it created here at hand nursing that this type of evidence and background will create those patient care outcomes. So if you're wanting to attract physicians and patients to your place, you're going to make sure you have world class nursing. I mean, I do tell my colleagues that Penn medicine is great. As great as Penn medicine is, you can not have a great facility unless you have great nurses. And they have great nurses.

Michael Weisberg [00:46:23] You give an example of what would be one policy that, you know, maybe a conventional hospital wouldn't have, that a magnet hospital designation would have that's nursing related.

Antonia Villarruel [00:46:34] So part a couple of the big indicators are, you know, number one, a high proportion of baccalaureate prepared nurses. Number one, because we have evidence that says baccalaureate prepared nurses are important. The second one is that nurses are involved throughout the health care system and making the needed policy changes that need to happen. So, again, they're you know, they're involved in decision making from buildings to rooms to to staffing to patient flow. So they're involved in the operation of the organization.

[00:47:12] I will just have to, again, shout out here, because we are so fortunate in our region that we have three nurses, three of them who are Penn grads, two Penn nursing grads who are the CEO's of the hospitals. So CHOP, the Children's Hospital of Philadelphia, the Hospital of the University of Pennsylvania and our BA system are all run by nurses. So again, CHOP, and all of them are magnet associated because, again, it's this hospital that recognized the investment that's needed in the workforce to produce the patient care outcomes.

Michael Weisberg [00:47:51] While we're. I'm sorry. Go ahead Silvia.

Silvia Cassiani [00:47:53] No, Mike, I want to add to that we also had been nurses in completing that high level positions. In Costa Rica, the Vice Minister of Health is a nurse. We also have a nurse who was a minister in Peru, and we had several nurses in the parliament. So looking at nurses in this political tables, in these positions. They are very helpful to to look at the health of the population and also give some recommendations to nurses who are in the position of the chief nurses officers and others.

Michael Weisberg [00:48:40] So, while we're on this topic, if you could give a characterization of how. You're saying these really remarkable hospitals have nursing leadership. What's a sort of nursing perspective on health that might be a little bit different than the perspective of a physician, let alone an accountant running a hospital? What is having a CEO as a nurse maybe bring to a hospital?

Antonia Villarruel [00:49:11] So if you were to ask me, I think it's a holistic perspective. It's not just on disease management or procedures. But it's, again, taking holistically of the whole patient and the family. It's making sure that they are integrated into all decision making, all the operations of the hospital. So, again, it's keeping the patient and the family central. It's, again, not only when they're in the hospital, but when they go home, when they heal and it's paying attention to quality and safety. It's the ability to lead interdisciplinary teams. So I think those are perspectives that, again, aren't unique to nursing, but I think our strength of what we do and what we bring. Again, thinking that we are the largest health care workforce in hospital systems and to have a leader there and to raise voice so that our voices are heard at every level, at the unit level. And again, building interdisciplinary teams where nurses both participate and lead, and practice is collaborative. I think that's what nurses bring to the table.

Silvia Cassiani [00:50:27] And we are the majority of all the health system, not just that the hospital level. We are 50, 90 percent of the health workforce. In several countries, it's about 70 percent, seven zero percent  of the health workforce. They are nurses. So why not they are in these positions?

Michael Weisberg [00:50:53] Excellent. So as the hour's coming to a close. One thing we like to ask guests are thinking about the kind of next generation. And obviously both of you are deeply involved in education. But, you know, Perry World House is about global affairs, you both are involved in global health. If a student was interested in beginning her career in and thinking about global health, what do you think is a good course of study and what kinds of experiences? I mean, right now, of course, we can't go anywhere because of COVID-19. But how might someone organize their their studies, whether it's in nursing or one of the other health professions? Silvia, did you want to start with that one?

Silvia Cassiani [00:51:36] Say to these younger students, in this region the nursing work force is aging. We have around 30 per cent of the nursing workforce with 55 years or older. So they are expected to retire in the next 10 years. So we need younger people in this profession. And even though we have the places to replace it, we do not have enough nurses. So we need more nurses. But we also need male nurses. We need males in in nursing field to achieve a gender balance. It's not just to young people, but we also need to to achieve a gender balance. 

[00:52:32] I would say that the nursing services, they are an essential component of the Sustainable Development Goals in universal health coverage. They are the core of the primary health care teams. In many parts of the region, nurses are the first and sometimes the only, as I said, human resource in contact with the patients. And in all cities, they are essential to improve access in coverage by health systems. And in the United States, 80 percent, 85 percent of the Americans said that nurses are honesty and they have the ethical standards. The Gallup interviews that showed these, in other countries as well. And finally, I would say you never have difficulty to find the jobs. Sometimes it is not to well-paid, sometimes it is not well recognized. But there are jobs for nurses in all over the world.

Michael Weisberg [00:53:48] It's very interesting that, you know, in the course that you mentioned about the Gallup, the high opinion I mean, that suggests a role, I was talking about health care in general. But a role for nurses in particular maybe, as frontline health communicators. And especially in this time of so much misinformation about COVID-19. I mean, we have a great center at Penn, Kathleen Hall Jamieson thinks about these kinds of issues. So this is worth a program in itself to discuss that. But, Toni, I wonder if you could answer in particular, like if a student of yours was interested in a global perspective on health, if there's a path that you could take them on.

Antonia Villarruel [00:54:29] Of course, of course, there is. So, you know, a school of nursing that has a worldwide perspective. Our faculty are involved globally, not only in Latin America, but in Africa, in Europe, I think just about every place in the world. So our faculty bring that. Our students bring that. They bring that particular interest. We do offer a global health minor. And so we have, I see my colleague Nancy Biller here is on. She takes a good time with students to help them identify what their particular interests and then direct them to faculty in the school. But importantly, to direct them to areas across campus. This is why, I see Richard Perry is here, we're so grateful for the Perry World House. Because that is a place where students can congregate, and learn and can have great dialogs with the Vice President of Ecuador, for example, or from the ex-President of Mexico. Where else can that happen? We also bring a lot of global visitors to campus. And so, again, to hear about what's going on in Rwanda or in Botswana, I think it is important to do. I think as our colleagues like to say, as you can go international just by looking at the community enclaves in Philadelphia. So you can go to Puentes de Salud and hear about the stories of the recent immigrants that are coming from Latin American countries. And you can go to Chinatown and or South Philly and talk to Vietnamese refugees. So, again, we believe in bringing the world to Penn and having our students go outside. And there's just plenty of opportunities across campus that our students are really, really have the privilege of taking advantage of. So, you know, again, minor. But again, there's just so many things to take advantage of.

Michael Weisberg [00:56:32] So in closing, we always ask our guests about things that make them optimistic, and I mean, this was a very heavy conversation, thinking about PTSD experienced by health care workers and devastation in indigenous communities and Native American communities in the US and that even in the richest country in the world, there's not enough PPE available for nurses. But all of that said, I mean, does anything that you've seen during this time give you hope? Local, national, regional, international? And in particular, do nurses bring you hope?

Antonia Villarruel [00:57:10] Well, I'll just say for me, yeah, I'm very hopeful. I think the pandemic has shaken up things as to how they used to be. And I think we have a real opportunity to seize this and to make it the opportunity that we want to be. So even though in this year, 2020, we weren't able to have all the celebrations and parties that we had planned for, I think people recognize. I'm hoping they recognize not only people as as heroes, but recognize the centrality and the importance of nurses in achieving health for the public. And so that's what makes me optimistic. And Michael, I want to thank you and Perry World House for giving this opportunity to elevate nursing in this pandemic. And again, as always, great to be with my colleague, Silvia. But, Silvia, what makes you hopeful?

Silvia Cassiani [00:58:04] You know, I am sure that the pandemic has created these opportunities to expand their discussion of the working conditions, as we said, the deaths of nurses and to highlight the human resource for health as essential workers to keep society moving. Without them, our situation will be much, much more hard. And to conclude, I want to say thank you so much for this opportunity. Thank you for our PAHO WHO Collaborating Center in the University of Penn where Toni is the dean. They are helping and they are supporting a lot, PAHO and the work with nurses. We had a wonderful meeting last year. So maybe next time Toni can talk much more about what they have done. And it is a historical event that we had for the Latin America to discuss the future of nursing, the future of nursing education. So our PAHO WHO collaborating centers, they are arms that we have in WHO and in PAHO to expand the ideas the principles of health for all. So we count on them and the university and the college of nursing. They are so supportive in these missions, in these principles of PAHO and WHO. Thank you so much, Toni and your colleagues.

Michael Weisberg [00:59:54] Thank you to both of you so much. And I'll just say, I hope it's not always COVID-19 that brings us together, that there's many, many people on campus interested in global health and Latin America in particular and nursing. So hopefully in the coming years, we'll have many more events together, hopefully in person. But for you and for everybody on the call, thank you for spending your afternoon with us. This is the last of our summer series of The World Today, but we will be, one way or the other starting back up come fall. Everybody look out for our e-mails. Thanks again to Dean Villarruel and to Dr. Cassiani. It's been a real pleasure speaking with you this afternoon. Thanks, everybody.

Antonia Villarruel [01:00:35] Thank you.

Michael Weisberg [01:00:36] Bye.