Dan:
Marketa, welcome to the show.

Marketa:
Oh, my pleasure being here and thank you so much for inviting me.

Dan:
Of course. Tell our listeners a little bit about how you got involved with nursing policy.

Marketa:
Well, nursing and policy, it's interesting because I've always known that there has to be politics in nursing, and it just seemed that ever since I started nursing back in Czechoslovakia, and then I left after the Velvet Revolution, I went to England, and Canada, and the United States. Throughout my nursing journey, I have always been very clear on the important role politics and policy plays in nursing and in healthcare.

Marketa:
Throughout my journey, I have learned that very few of my colleagues shared my passion or my enthusiasm for the importance of politics. The longer I was inside American healthcare system and American nursing, the more it became clear that that's something that I want to be part of. Maybe growing up in Czechoslovakia and maybe having to leave my country and immigrate to the United States, and relearn the political process. Maybe that is something that gives me a little bit different angle, or maybe that gives me just a little bit different viewpoint of the role of nurses and nursing in American politics.

Marketa:
I'm just very excited to be part of ANA California, and be the advocate, and to be kind of involved at the intersection of nursing healthcare and politics, and policy, and management, and administration.

Dan:
That's interesting, I think in my career, as I went through nursing school and my colleagues we aren't really exposed to the policy aspect of things. I'm curious how, when you got to the United States, how did you start getting involved or what got you peaked in the interest of nursing politics here?

Marketa:
It was really a frustrating and really problematic journey because I knew that there has to be a place where politics played role in healthcare and in nursing. However, every time I would be asking my learned, and established, and experienced colleagues, nobody would tell me where that is.

Marketa:
I really go back to me working over 10 years at a regional hospital and realizing that not one nurse could tell me where would nurse get involved in order to be part of politics and policy? I actually flew back to Europe and I had an internship and then fellowship at the office of vice president of the European parliament. Where I really saw the importance politics play in healthcare.

Marketa:
I came back to the United States, I just did this over the summer. I went back to the United States and I kept asking the same questions. Somewhere there was the fantastic professor at, I think it's MiraCosta Community College in Oceanside, and I think that she has heard me asking the questions throughout her colleagues and she found me one day and she goes, "You know, there is this organization and they're in Sacramento and I think you need to go there." That's where I finally in 2012 learned about ANA California.

Dan:
Wow. Wow. That's amazing. I mean, what an awesome opportunity to go learn with experts in Europe and then bring that knowledge back, and then randomly find a way to get into an organization to do it here. That's so cool.

Dan:
You brought it up, nurses don't always know the ways or the impact their voice could have on policy. What makes it important for nurses to speak up?

Marketa:
Well, there is this long, very affluent political answer to it, but the really easy answer is, and if we don't do it, if we don't advocate on behalf of ourselves and our patients, who will? Because somebody will. It's not that there is a [inaudible 00:03:54] somebody will, but if it's not us, if it's not nursing, if it's not the professional organization, then who else is there?

Marketa:
If we don't bring our voices, and if we don't bring our expertise, and if we don't bring our presence, then we're not there because nobody else will do it for us. I think that's a biggest issue with nurses and nursing and I found that it's not because nurses don't want to be part of politics or policy, it's just because while we ran towards danger inside hospitals or clinics, but that's kind of controlled danger and we know what to expect there. The same danger and uncertainty in politics and policy, it's very scary.

Marketa:
It's because we don't have the fundamental knowledge, and we don't have the understanding, we don't have the knowhow, we don't have the skills, but the thing is we do. We already have all those skills. Those are transferable from nursing.

Marketa:
We have ability to communicate. We have ability to evaluate, and analyze, and plan, and put things in action. We have all of that. I mean, who else is better in conflict resolution, at bringing up difficult aspects to your colleagues, physicians, respiratory therapists, social workers, nutritionals, pharmacists, we do. So we already have them. I just think that we don't know how very usable they are inside political arena.

Dan:
You're right. Nurses are excellent at influencing patients, and physicians, and all the other care team members on getting things done to make sure that the outcome that we know needs to happen happens. I think you're right, there is a fear of, "Well, I don't know how to go lobby, or I don't even know who my representative is or how to get ahold of them other than a form email." Is that really what's holding nurses back or is there something deeper than that?

Marketa:
I think that that's part of it. I think that anytime I am... Well now under coronavirus it's a little bit different, but up to March, every time I was invited to give presentation, or speeches, or keynote addresses, the moment I start talking within 10 minutes, there are nurses sitting like, "Oh my God, why didn't anybody tell us?" Because it's really easy. You just Google find my representative. I mean, that's really easy, but that's not where the barrier is.

Marketa:
The barrier is, is that nurses don't know how to communicate with them. The reason is because they believe that politicians are a little bit different than the rest of us, but they are not. They are just like you and me. The moment I removed that barrier, they go like, "Oh my God, why don't I know this?" Just because we don't talk about it and I don't know if we teach it, or we don't teach it the right way, or if we bring it up about that we bring more barriers just the way we talk about it.

Marketa:
Maybe we don't establish clear foundational knowledge. There are all these different barriers, which I think that we kind of half create ourselves and half the political system it's not the easiest to get in and to flourish.

Dan:
That's for sure. I mean, you just turn on the news every morning and [crosstalk 00:07:05]

Marketa:
Exactly. Who wants to be part of it? I do. [Crosstalk 00:07:08]

Dan:
Yeah, no one wants to be part of the news right now. That's the worst place to be. So for a nurse who says, "I have some ideas of what we could change to make population health better, nursing better, the state better." Where is the first place they should start to kind of start that influence?

Marketa:
Well that's a very good question and I do hear it, or we do hear it quite often. I think this is where professional nursing organizations and association plays such an important and crucial role because every time I talk about my work and every time I talk about my responsibilities in Sacramento, all I hear is, "Well, that's great for you, Marketa. You live in Sacramento." Well now I do. "But do you live in Sacramento? You have access to the capitol, but I live in Los Angeles. I work 12 hour shifts. I have children, I have responsibilities. I volunteer in a community."

Marketa:
My answer is always, that's why we're here for you. That's why your professional nursing organizations are so important because our job is to provide you with the information. Our job is to provide you with the analysis. Our job is to provide you with the next steps to take. All you have to do is just belong to a professional organization and now would be a good thing to ask, "Please, belong to my organization." You don't have to.

Marketa:
As long as you belong to a professional nursing organization, we work together. We try very hard to cooperate, to communicate. I share all the information I receive. I share with my colleagues with all the other California Nursing Organization. As long as you belong to one, you will get the call to action. So just belong to a professional nursing organization where you're passionate about the practice of nursing.

Dan:
That's good advice. I think that's a point where nurses may not know where to go to get involved. I think ANA definitely has the policy lens and I think that's part of the branding of ANA, but Emergency Nurses Association, Critical Care Nurses Association, American Organization of Nurse Leaders, they all have a policy aspect to them. Just getting involved with the one that resonates with your career trajectory is a good place to start.

Marketa:
You know it the best that we all belong to so many professional organizations. I take pride in that and I take joy that I can belong to Critical Care Nurses, and I can belong to Public Health Nurses, and I can belong to Political Scientist, and I can belong to Public Health Nurses Association. I know that I'm not the only one because anytime I speak to all my colleagues, I hear about all these new information and the new organizations that I go home and I write them down so I won't forget.

Marketa:
Part of my job and part of the responsibility I feel to nursing is that I want to remove barriers. If I am adding barriers, and if I am not sharing information, and if I'm not sharing the necessary and relevant data that other organizations and other leaders can share, that I don't believe I'm doing the best for nursing and American nursing has been very good to me, gave me a fantastic life. I just want to give back.

Marketa:
All my colleagues know that they keep getting all these emails from me because I want to share, but it has not always been like that because from the culture I came from, you don't share. You don't give advantage to somebody else. You don't share the knowhow you have, but over the last 17 years, and in California, I've learned that that's not the American spirit. That that's not how you get things down, how important it is to cooperate, collaborate, being project partners, coalition partners, communication partners. How important is to share because it's not about me, it's about nursing and it's about the role of professional nursing in California and in the United States.

Dan:
That's a great point. Those ER and ICU nurses who don't like each other in the clinical setting, need to get along to make some policy for the profession at large right?

Marketa:
Oh, heck yeah.

Dan:
Put down your professional [crosstalk 00:11:09]

Marketa:
Yeah.

Dan:
I want to move on to some of the California legislation and talk about that, but before I do, I'd love for you to give an overview of how ANA California interacts and fits with the larger ANA enterprise at a national level?

Marketa:
ANA California, ANAC and I know that many of you when you've seen us lately in the media, we have the forward slash, backward slash we don't have the normal, we have the backslash and there's a reason for it because that's our legal name. The only way how we could come up with ANA California name is that we kind of included one strange kind of character, but we are the state affiliate of the national ANA.

Marketa:
National ANA was established in I think 1896 under a very different name, but in 1906 or in 1908, it changed its name to ANA. When I was writing part of my [DNB 00:12:04] report, I learned actually by doing research about ANA, that back in 19, I think it was '56, 1956, the ANA House of Delegates in 1956, voted for BSN to be the entry to profession, 1956.

Dan:
Wow.

Marketa:
I am just saying. Okay, oh my God, this is my dyslexia. [crosstalk 00:12:25].

Dan:
How long have we been fighting that stupid fight.

Marketa:
I know, but okay. My dyslexia is kicking in. It's either '56 or '65. It's one of those. [crosstalk 00:12:35].

Dan:
No big deal. It's a long time ago and we're still debating it. That's the point. [crosstalk 00:12:36]

Marketa:
It's really long time ago and we're still debating. When I found out, I was just thinking what a marvelous organization it is. No organization is perfect and nobody can please everybody, but the foresight and the professional vision that those members had back then, I think that that's something that sustains me until today. That's why I am really proud to be part of that organization and then be the leader in California.

Dan:
Thanks for clarifying that because I know that when you sign up for the larger American Nurses Association, you automatically become a member of your state organization. So wanting to make sure people understand that.

Dan:
Let's turn a little bit to what's happening in California. I know there's several bills that are going through that directly impact nursing. One, didn't make it pass committee, it sounds like there's maybe two that are actively moving through the process. Can you talk about some of the things that are top of mind for you in California impacting nursing right now?

Marketa:
I actually just received an update that three of our really important pieces of legislation made it through just over the weekend and one I think yesterday. One is really important and that's one of our priorities and it's AB, which is Assembly Bill, AB 890, eight nine zero. That's authored by Assemblyman Jim Wood.

Marketa:
He is, I think from a second assembly district and he is by training and profession he is a dentist. He authored, last year in 2019, he authored a legislation focused on nurse practitioners and how to remove physician supervision because that language and those regulations are from 70s or 80s. It's time to really remove the red tape and the bureaucracy and really let nurse practitioners do what they do best. That's AB 890 and it passed Senate committee on Saturday.

Marketa:
Then little bit later after that, there is another AB Assembly Bill 2288 and that's from Assemblyman Evan Low and he authored a bill that would allow nursing programs, nursing schools to have flexibility in terms of direct patient care versus simulation or versus virtual reality training and education during pandemics or during health state of emergency.

Marketa:
Initially my question was, "Do we need a legislation? Do we need a new law that would clearly state what we can and cannot do during emergencies? Isn't that like when the governor comes in and he will issue executive order?" [crosstalk 00:15:13] Then I actually looked and Governor Newsome while he issued several executive orders, the one from March 31, 2020 really did not give nursing schools the flexibility to allow nursing students to actually progress through their academic progression.

Marketa:
Many nursing school had issues during the spring semester. While I've heard latest data, but around a little bit more than 80% of students in nursing schools were able to bring their graduating seniors to actually graduating and being able to sit for NCLEX. There is still, I think 17% of nursing programs and or nursing students that were kind of left to deal with those remains in summer during summer 2020.

Marketa:
Evan Low authored this bill, which we were supporting, so that also passed committee on Saturday. Then I just received that Senate Bill SB 1237 from Senator Bill Dodd and coauthored by Assemblywoman [Autumn 00:16:16] Burke that is focused on a certified nurse midwives. Very similar is attempting or aiming to remove the direct physician supervision for certified nurse midwives. The same removing barriers, removing red tape, and really bringing California nursing into the 21st century. Those were really three most important priorities, and we are so happy that they passed so far.

Dan:
Those are all things that need to happen for California I think to stay relevant in healthcare and to keep the public safe. I mean, the fact that California is progressive in so many ways, except for advanced nursing practice seems kind of ridiculous.

Dan:
If you were to rate California as far as progressiveness or innovativeness within policy and nursing, where would it rank among the other 50 States? Are we bottom we're kind of way behind the times? Are we in the middle or are we kind of out ahead of others?

Marketa:
Oh my Lord what a question. Wow. Okay. If I go back based on the bill. So let's see SB 1237, I've done my research and I have spoken with a certified nurse midwives and I have learned that California is only one of either four or six states left still with direct physician supervision with very restrictive practice for certified nurse midwives. One of only four or six, again, I don't remember, but they're a very small number. That's where California is at the policy for nurse midwives.

Marketa:
Let's say nurse practitioners. Nurse practitioners, and other APRNs, it is my understanding that they've been trying to achieve legislative victory in terms of removing red tape and removing physician supervision for past 25 years and we're still not there. While 20, what 26, 27 other states already did change their legislation and we still can't seem to be able to do that.

Marketa:
The fact that AB 890 currently is just passed Senate Business and Professional, which is really a tough committee and Business and Professional and Economic Development Committee in both Senate and assembly is always first for nursing bills to go to because that committee has oversight over any license or licensees. Anything to do with nursing, it has to always go to something what we call BNP, Business and Professional Committee. The fact that it passed the Senate Business and Professional is absolutely fantastic to know.

Marketa:
The next one, AB 2288, focused on simulation and virtual reality education, especially during state of emergency. California is still offering only or allowing only 25% of simulation to a nursing program. Initially I thought, oh, 25%, you can use all 25%, but apparently they cannot because all the skills labs and all that they're doing the training and practicing while in nursing school, which is not even simulation or not even a virtual reality, that is already accounted in those 25%.

Dan:
Oh, I did not know that. Okay so that makes a big difference. [crosstalk 00:19:29]

Marketa:
Yes. Yeah. While we do hear from the Board of Registered Nursing that many schools do not even use up to the 25%, well it's not that simple. It's not that easy. There has to be certain investment from the school of nursing into some kind of simulation lab or some kind of simulation or virtual reality education.

Marketa:
You have to have faculty that is certified in order to get the full utilization of those programs. There is a little bit of investment into it. If schools know that only 25%, so let's say 20 or 19, they can use, if the question is, do they want to make the investment? Do they want to send faculty for recertification?

Marketa:
The thought is that if the California BRN, if they increased the percentage to okay maybe 50 is too much to ask, 40. We have to start somewhere. We do need to bring nursing education to 21st century. Those would be the three bills. I hope that gave you some answer [crosstalk 00:20:33]

Dan:
No, no. Yeah. That's very helpful. Yeah. Like you said, it depends on the topic we're kind of in the middle or we're somewhere in between.

Dan:
Yeah, the simulation one is near and dear to my heart. I know Katie Waxman is a close friend and colleague, and I know she's advocating for more hours within California for a long time. I actually did my PhD dissertation on simulation. I know the benefits of it. I'm a big proponent. I kind of started my innovation work in that and I hope to, like you said, allow for nursing education to upgrade to the new technologies that will train nurses and health professionals much better.

Marketa:
Dr. Waxman was my advisor for my DNP. She was advising me for a few years how to do my public policy toolkit for nurses. I am a very big fan.

Dan:
Yeah. Yeah. She's awesome. We're actually going to have her on the show in a couple of weeks. So I'm excited to chat with her more and I'll dive in with that with her.

Dan:
I know one of the bills that failed recently was the Compact Licensure Bill to include California as part of the Compact License states. I was surprised by that because there were so many supporters and only one stated opposer. Do you have insight into why that may have failed? Or what was the biggest barrier there for that one to move forward?

Marketa:
Again, not easy questions.

Dan:
I know.

Marketa:
No, so who was the biggest opposer? Who was the biggest opposition?

Dan:
California Nurses Association.

Marketa:
Well there you go. Yes, it is my understanding that there is specific language of that bill that we stayed neutral, but I had a lot of questions on that bill. While I believe that portability for a licensure is paramount and it's really important, I would understand the need for [E Compact 00:22:23] to if it was maybe few years back when obtaining California RN license took months and months and months, but based on the recent data, what we heard from BRN is that it takes about a month now to get a license from out of state.

Marketa:
I think that another completely different situation would have been had the coronavirus in California had the pandemic went opposite way, and the complete wrong way, and we were needing many registered nurses to come in and helping us. I think that that would also change the discussion, but because it didn't, there was no immediate need for nurses coming from outside of California.

Marketa:
We are the largest state. We have almost half a million licensed registered nurses in California. We are the largest state. We have the most nurses. The second is Texas with something around 300,000 nurses. We have the power.

Marketa:
I think the issue is that if the standards and if the legislative language was the same, if the standards was uniform for all states under the E Compact, I think that that would also be a little bit different discussion.

Marketa:
Our questions were, "What about continuing education?" Some states need it, some states don't, some states require it, some recommend it. Well, we require it, California requires it. Either we all require it or we don't. I think that that was just one of the issue.

Marketa:
Another issue was issue of enforcement and investigation because one of the tenets for California BRN is that it is Licensing and Enforcement Agency. If there is a complaint, or if there is a DUI, or if there is some kind of malpractice complaint, it's the BRN that starts investigation.

Marketa:
What would happen if a nurse left to go back home to his or her home state? Every time I asked, "What would happen? How would that investigation go?" Because we have to protect California patients and we have to protect our profession. I received one answer and the answer was, "Oh, but that really never happens. So I'm sure it would be fine."

Marketa:
I'm thinking, "Well, that's great that hasn't happened. That is fantastic. I'm very happy to hear that, but how would that work?" There are just these unclear questions and if there is a uniform standards for everybody under E Compact, I think that it would completely change the conversation.

Dan:
I can see that side of it too. Then there's the other side of me that says there's not a whole lot of evidence that says continuing education improves [crosstalk 00:00:25:01].

Marketa:
I hear you.

Dan:
No, but that's the process. I think those are the sorts of debates that when we get more nurses involved, we can have those debates with more evidence, and more voice, and more influence and those types of things. I appreciate that answer. I'm hopeful that we can change some of it and revisit it in the future too because I think the better we can safely allow the nursing workforce to be able to move to where the need is with patients, the better the public is. We just got to figure out the logistics. [Crosstalk 00:25:32]

Marketa:
We just have to figure out the logistics and operationalize it that it's standard and it's equal for everybody. Absolutely.

Dan:
Right. Well, this has been so fun. We could go all day I think on these. I would love to just sit down and debate some of these things with you and just kind of have fun with that, but we're coming up on time here.

Dan:
One of the things we do here is we like to hand off information to our listeners, that golden nugget about policy and your work that they can take home and maybe do some action on tomorrow. What would you like to hand off to our listeners?

Marketa:
I think number one is the importance of nursing voices and nursing expertise in politics and therefore in policy because policy is then written based on legislation and based on bills. Regulation is written based on what law governor signs or vetoes, or let it be and it becomes a law.

Marketa:
No matter what policy we have inside institutions and inside academia, that comes directly from the law. If we're not part of that discussion, and if we're not part of that debate, and if we are not at the table, then who else is doing it for us? Who else is advocating on behalf of professional nurse? Who else is there?

Marketa:
Then we are the largest health care employee group in the United States. I already mentioned half a million registered nurses in California, over 4 million registered nurses in the United States. We have this huge political power. We've been what 18 consecutive years ranked as the most ethical and trusted profession. That gives us huge position of responsibility.

Marketa:
I always quote Spider-Man, "With great power comes great responsibility," and we have it, and we own it, and we are proud about that. That could be also a great political capital that could be used to advance the profession and to make sure that our patients get the care.

Marketa:
I think if there is nothing else, your listeners will learn from this is, just be aware, belong to a [inaudible 00:27:32] belong to a professional organization, ask questions, ask to be part of policy committee, or legislative committee. Look at Google. Google it, find my representative, you will be surprised who maybe representing you.

Marketa:
I think those are just the three easy steps and then reach out to your professional organizations and ask more questions and be more involved than, hey, we're here for you. We need you.

Dan:
That's right and I know you have a lot of resources with ANA California as well, that helped nurses learn about advocacy and learn about policy. Follow ANA on social media and also go to the website there's a ton of resources there, right?

Marketa:
Yes. Thank you absolutely. We are putting together Advocacy Institute and Advocacy Excellence, and we're kind of putting together lots of resources because we have nothing to do during coronavirus so we are creating [crosstalk 00:28:22].

Dan:
I know. Well, you have a good marketer guy over there Jared. [crosstalk 00:28:26].

Marketa:
We do. We do.

Dan:
There's lots of great stuff going on. Marketa, where's the best place to get ahold of you? We know ANA California, are you active on LinkedIn, Twitter all those?

Marketa:
Absolutely. I am active also me personally and also ANA California we have thanks to Jared and Teresa at our office, we really established and increased our presence. We are on LinkedIn. We're on Facebook, on Twitter. We have Instagram and again, everything is under ANA California. Just look us up and follow us up. I can be reached at ed, which is executive director, ed, or my first name Marketa at anacalifornia, spelled out, .org.

Dan:
Awesome. I love your update videos and the different bills.

Marketa:
Oh, thank you.

Dan:
Even if you're not in California for the listeners, there's some awesome information and so you should take a listen.

Dan:
Marketa thank you so much for being on the show. We really appreciate it. I've learned a ton about policy and getting more involved. We'll make sure all of those connection points are put in the show notes so that listeners can find you and get more nurses involved.

Marketa:
Thank you so much for inviting me. I really appreciate this. This is fantastic, and also I have to say, I've listened to six of your podcasts and I knew the question about what would you like to hand off? So I was ready.

Dan:
See, we're becoming a thing. We've got it, we've got a hook.

Marketa:
Well, Marketa thank you so much.

Dan:
You're very welcome.