August 19, 2020

Episode 21: Understanding health equity starts locally

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Podcast

Description

Why does the U.S. have such disparities in health outcomes across different patient populations? It’s a question that has come up with increasing frequency in the wake of COVID-19 and larger conversations around racial equality in the U.S. 

On this episode of The Handoff, Dan and a special co-host speak with Shawna Butler, a Nurse Economist and the host of Johnson & Johnson’s See You Now podcast about what health equity means to her and her advice for nurses who want to ensure more equitable outcomes for their patients.  

Shawna believes that health is inherently local and that by focusing so much on global comparisons, we’re missing an important part of the story. She encourages us to look at our cities and towns to understand the root of the problem and start to find solutions. 

Dan also speaks with Shawna about everything from how the U.S. healthcare system stacks up against other countries and the number one thing she would change (hint: it’s probably not what you think!) to school re-openings and even her takeaways from multiple encounters with late Congressman John Lewis. 

Links to recommended reading: 

https://nursing.jnj.com/see-you-now-podcast 

https://exponential.singularityu.org/medicine/

https://www.trustedhealth.com/blog/how-nurses-can-help-dismantle-racial-healthcare-disparity 


Podcast

Transcript

Dan:
Shawna and Sarah, welcome to the show.

Shawna:
Thanks Dan.

Sarah:
Thank you. Good to be here Dan.

Dan:
Sarah going to let Sarah to lead the conversation here because she's so good at it and has co-hosted several podcasts in the past. But before we jump into that, Shawna, can you give us a quick background of what you're up to and just a quick background of your experience.

Shawna:
Sure. So as you mentioned currently the thing that's taking up a lot of time and energy and investment is my role as the host of The See You Now Podcast, which is really looking at the really challenging healthcare problems and the innovative solutions that we're coming up with to address them and specifically looking at them through the nursing innovation lens.

Shawna:
So that puts me in all sorts of conversations. And I come to that role from two roles that have really helped define and shape my career over the last I'd say five, seven years. So recently I have been living in the Netherlands and serving in the role of the EntrepreNURSE-in-Residence. And my focus there has been how do I help at a government and a national level really bring nurses formally into the innovation agenda. And in addition, it's a role that continues, I'm the managing director for a healthcare conference called Exponential Medicine.

Shawna:
And I like to describe that as Disneyland or clever optimists. It is a group of people who care deeply about the problems in healthcare. The optimist part about that is that they really have a sense of, 'we can solve this'. And the clever part is that they're playing with new tools and new toys, things that frequently have not been part of healthcare.

Shawna:
So whether it's voice recognition or AI, robotics, synthetic biology, we have had point-of-care testing. But this is a group of people who see the problem, see another tool and have the confidence and the competence and the craziness to say, "How do we actually help solve these problems and in the process maybe reimagine the health experience." So and at this moment in time, as we're all living a pandemic life, we are in the process of rethinking what does that conference experience look like?

Shawna:
So we've always had the community and we continue to be a community and never has there been a greater time where we've had to drive health innovation and we have to drive it fast. So this community is hungry and eager to be the leaders in solving these problems. Getting to all those roles just clinical background in adult critical care medicine at university settings, also small regional areas, and I think the other really formative part of how I think about work and care, was I spent several years doing international medical repatriations.

Shawna:
So I got to see health delivered in practice in so many different settings around the globe. And it really opened up my mind and my ideas about health is incredibly local and there are no easy solutions, there are just a lot of really hard questions. And we need to be looking at this in so many different ways and we need to be looking in a lot of different places to see how people are managing care and how they're getting really good outcomes.

Shawna:
So much of what nursing does is that we are helping to have healthy pregnancies. We're looking at how we raise children to be ready to learn and to move into their adult years. And then as their adult years, we're thinking about preventing infections and diseases and then end of life care. How do we do that with dignity and grace and safely? So it's just been interesting and I think that that was the thing that really opened up my aperture, is seeing care delivered and practiced all around the world in so many different settings.

Dan:
There's so much to dive in there.

Shawna:
Are you sorry you asked?

Dan:
I want to talk about all of it, but I want to just have Sarah, because she hasn't been on the show yet, I want to have Sarah do a quick intro and then I think Sarah take it away with where you want to take this.

Sarah:
Yeah, thanks Dan. That's a tough intro to follow. But I'm Sarah, I am the founding clinician here at Trusted Health where I work with an incredible team of innovators, of engineers, designers, some of the smartest business people I've ever met. And what I'm the most proud of is a whole team of clinicians here at Trusted to change the way nurses work and manage their careers.

Sarah:
And my background is in pediatric nursing. But Shawna has been a huge inspiration and motivation for me as I've taken on nursing in a new way. So I'm personally super excited to be here talking to Shawna and a huge fan of the work that she does globally. I think one thing I'd love to dive into a little bit is the health equity piece, because your experience and insights into how care is delivered and health outcomes globally is incredibly unique and is more relevant I think today than ever.

Sarah:
So I think many people are familiar with the term health equity, but would love for you to speak a bit more about what that means and where it really shows up the most.

Shawna:
It's a big topic and we use it a lot when we think about what's happening right now in healthcare. How is it that we have such disparities and by disparities the big difference between how it is in one area, we'll say one zip code, how it is that we have such a difference in our longevity, our health outcomes, who has asthma, who doesn't, who has access to care, who doesn't, how much it costs somebody, how affordable it is or isn't.

Shawna:
And oftentimes we want to do this comparison between, say the US in Canada or the US and Britain. And we want to parse that out into the different business models, or the different training or the infrastructure that we have in place. And we're doing comparisons that, while global comparisons are important if we're not looking within our own cities, within our own villages, within our own towns, that's where I think that the beginnings of the disparity comes forward. And equity means to me that every person has the same chance to have really good health and opportunity and experiences.

Shawna:
And I break those out very distinctly because the health outcome is who lives longer? Who has the lower rates of cancer? Who's likely to have mental health depression? The access board is, who gets to have it?. But then the other part we really need to think about it is how do we value? And this is one of those really big differences that I've noticed in my global experience is that, when you go to places where their society, their organizing governmental body has said, health is a right and available to everybody.

Shawna:
Those are the groups where equity is greatest, where the outcomes, the access and the experience and I actually should have spoken to the experience part, the experience is when I walk into a healthcare setting is my experience, my reception, my people believing and trusting that I'm describing my symptoms. Is it treated the same across the board? Whether I am a black woman, a brown woman, whether I speak English, whether I'm in a wheelchair, there are so many different ways that we would discriminate in how we deliver care. And I don't mean discriminate as an unfair treatment. I mean how we put distinctions around the care that we give. There is the whole other discrimination of inequitable treatment, unfair in that legal sense of discrimination. But I think we also need to think about the treatment plans and the ways that we've thought about certain cultures.

Shawna:
Well, this culture is more stoic or this age group is more hypochondriacal. And so sometimes within the way we have thought about the science of care, hasn't always been equitable either. In addition to all of these other things that we're having this huge moment of reckoning about the inequities that exist within everybody is like I said, their experience first of all. What does it look like when you come in to get care? The access to it, the outcomes around it.

Shawna:
So health equity is a huge conversation. And I think where it really needs to start is in our own local practice areas. Our own institutions, and we have to start there to examine is what we're doing equitable? Is it fair? Is it right? Is it decent? Is it human? And I think in order to address it on the global level, the global level is, or on the state level, those are really good benchmarks. But I think change really happens at the most local level we can get at. And that might be more than what you wanted for a discussion about equity, but I feel really strongly about this.

Sarah:
No, that's great, and I love the passion. For all of the nurses listening and nurses everywhere, how should nurses think about the role they play in addressing these disparities and how can they practice this at their individual level?

Shawna:
I think for each one of us it starts with an internal assessment to really check our own biases. We know those biases that we have to begin with, but then there's also the unconscious biases and we all have them. And the more we are open to asking ourselves to be able to say, what is my bias? Maybe I don't like working with the elderly. Maybe I don't like working with children. And oftentimes we identify it's not that they don't necessarily like it, it's that I don't feel comfortable. I don't feel secure in my knowledge. I'm not able to really connect with them. So I think it starts at that very personal level within your own practice to figure out what things you feel really confident about, what things you feel not so secure in because you just don't feel like this is in your ... I'll give you my bias.

Shawna:
I can not do eyes. You want to give me any trauma that comes through, any difficult situation, I'm good with it. But the moment you say, "Oh, we've got somebody who's got an eye injury." I can't do it. I just like-

Sarah:
Eyes, eyes that's your problem?

Shawna:
I can't. My eyes start watering, I start getting faint, I also have a tough time with burns. There's just something about that, that it's really, really, really tough for me. The people I love that I have this huge affinity with people who don't have homes. People who are in refugee situations. I just have an affinity for that. So, looking at your own practice biases I feel, even though I've got three children, taking care of children, feels really scary to me. I am much more secure in taking care of our eldest and our wisest part of our community members.

Shawna:
So I think that that really starts there. And then there's this whole other piece around, did I grow up in an area where I was exposed to a lot of different cultures, a lot of different foods, a lot of different religions. Or did I grow up in an area where I really just didn't know much in the way of diversity? I think that those are the really good starting conversations, and then seeking out people who look nothing and sound nothing like you.

Shawna:
And that has been the practice that I've used is when I am in a room with a lot of people that are my same age, look the same way, come from the same place, I think to myself, I don't have enough points of view here. What are the voices and the ideas and the problems that I'm not aware of because those aren't the lived experiences. And I think that's a very practical guide. And I invite people all the time. Whenever you're doing anything, invite somebody in who doesn't look anything or sound anything like you and half your age. Or maybe at this point if you're in the younger part where you are Sarah, you need somebody twice your age.

Sarah:
Yeah, I love that. I think that self-reflection, awareness and mindfulness and really thinking about looking inward and starting with yourself as something that's more relevant today than ever. Well it sounds like health equity really starts on a local level, I'm curious with all of the experience you've had in seeing how care is delivered globally. What has surprised you the most about how we deliver care here in the US and where do we have the most room to grow?

Shawna:
That's a loaded question Sarah. Oh my gosh, like-

Dan:
Everywhere.

Shawna:
One of the interviews that I did with the gentleman by the name of Guy Vandenberg, he's in San Francisco is still actively practicing. He actually is from the Netherlands. I was living in Nijmegen which is where he was from. So it was interesting to have that cultural piece. But he was on the front lines of AIDS activism. And the point that he shared with me, he said, "AIDS pointed his finger at everything that is wrong with our healthcare system." And I heard him say that prior to COVID-19.

Shawna:
And those words and that insight that he has, and he has traveled all around the world working on the AIDS epidemic and helping us to get testing in place, to get treatments in place, to address the stigma. And I feel like those words are just ringing in my ear that this pandemic has pointed to every single gap and shortcoming that we have within healthcare.

Shawna:
If I'm looking at it through that economic and that strategic structural lens at the core of this, we have not in this country taken health as a right, or something that we want to make sure that everybody has. We have a very cobbled together system of how we finance it, how we insure it, how we deliver it. So at that structural level, when we don't have the sense that everybody is deserving of care and really good high quality care, it's hard to build a system when we don't have that.

Shawna:
The second thing is we don't have incentives that are aligned to actually achieve health. We have a financial model that is focused on doing things, having activity, having reimbursable events. We haven't transitioned over into a financial model that actually measures values and incentivize and compensates for creating health and to working in teams.

Shawna:
I think that the next level as we're building up what needs to happen, we have let deteriorate and we have underinvested in public health. And the vast majority of countries that do well is that they have really strong public health backgrounds. Because these are things that you and I can be in a situation of, we want to quit a bad habit, we want to quit smoking, we want to get more sleep, any of those things. You and I have a lot of control over that. What we don't have individual control over is clean air. We don't have individual control over clean water, safe schools, a food system that helps you to stay healthy. That's where public health comes in and that's the baseline of health. And when we don't address our public health foundation, it's going to make it really hard for people to in their daily choices they have a choice that creates good health.

Shawna:
You hear those phrases, you are what you eat. You are what you practice to do. And that assumes that you only have good choices that are available to you. You're only as healthy as the good health choices that are available to you. If we don't have good mobility and good public health transportation for people who live in maternity care deserts or live in food deserts, it's really hard to get started off into healthy habits.

Shawna:
So I think at our core, we're trying to innovate and solve problems into and I'm putting air quotes around a system that's not really designed to deliver health. We definitely deliver good care, we definitely develop great drug development and drug discovery and new therapies and fine, fine, fine institutions and brilliant dedicated practitioners. We haven't put all of those wonderful ingredients in a paradigm that is incentivized and designed to actually deliver health for all. And so it's a big question, and that might be a really big answer that it feels overwhelming. I know that it's achievable. I think what we need and oftentimes what we're missing, is we don't necessarily have political will, decent, moral, courageous leadership to make tough decisions.

Dan:
So Shawna on that same point, do you think other countries leverage non-physician care? And I won't highlight nursing because nursing it's different across every country, but is non-physician care a staple of countries that are doing better? Or what's that special sauce?

Shawna:
What other countries have done that we haven't done and I think it's mostly around the financial incentives, we are the only country that does not promote and work to have every single licensure work to the top of their skill and their license. That is the major difference. We have a financial model, a care model, a licensure model, and a financial model, that is focused on, it's physician driven, it's that physician license, which is the most timely, most expensive for any country to invest in.

Shawna:
And so I'll use pediatrics as an example, in most other countries, well child visits would not be something that the pediatricians would be doing. Pediatricians are focused on the illnesses and the diseases of children where that specialty training, that in depth really understanding the complexities of a childhood illness where that skill is needed. When you're looking at normal signs of development, is a child walking? Are they talking? Are they forming their words correctly? What is their nutrition look like?

Shawna:
That requires not that same level of training. So what other countries have done is that every single person works at the top of their license. The way you can understand this is that we've all seen the graphs, the US spends more money on healthcare, and we don't get nearly the health value and the health outcomes that other countries who spend a fraction on their healthcare. And if we were to make one shift, if somebody would have given me three wishes to make in our healthcare system to really fundamentally change outcomes, access, experience, it would be we need to have everybody who's trained to be working at the top of their training and their license and their skills.

Dan:
Yeah. And we saw examples of that when I was at my previous organization in states where licensure, at least for nursing was you could practice at the top of your scope. And we saw some great outcomes related to that. Both patient satisfaction, provider satisfaction, the physicians were doing the things that they were trained to do surgeries, complex care, really hard diagnoses. The nurse practitioners were taking care of the routine and the other care side of things. And it was all triaged by an RN. And so this is great model of using everyone to the top of their scope and everyone was happy and the patients were getting the care they wanted and it was cost effective.

Shawna:
And they loved it. From the standpoint of there's so much around chronic care management, but the vast majority of what people need is lifestyle. They need education, they need support, they need accountability, they need education on their medications. And I often think that in a healthcare system, if we get to a point where in diabetic care or mental health, you have to be resorting to the physician level training, we've really failed. That's not a success. I remember my very first insight about this was a patient that I was taking care of in an ICU and she had uncontrolled diabetes and we've been taking care of her for a ... this was somebody that we had known well. And she had a lot of comorbidities, a lot of things that we were taking care of and it ended up that her diabetes we weren't managing it very well and she ended up with an amputation.

Shawna:
Well, scheduling that surgery and planning that surgery and getting her home, it was very complex. And we felt like as a team, wow, we were able to get her through that surgery successfully. We were proud and we did, we did really good care. I was the nurse who was sending her home. And it just really struck me in this moment of, oh my gosh, we were successful in getting you through this very complex thing. I'm sending this woman home without a leg. That is not success.

Dan:
Yeah.

Sarah:
No.

Shawna:
That is ... yes she didn't have a postoperative infection. Yes we had her in rehab. Yes we've got a new device that we're putting on her leg and we figured out all of these different things. But wouldn't it have been so much better if we had just figured out how to manage her diabetes.

Shawna:
If we had just put together a lifestyle where she didn't have diabetes. To your point Dan going back, we've seen healthcare systems where when we invest in the earliest stages, the early detection, the prevention, the lifestyle, the things that sometimes don't feel all that sexy. It feels repetitive, it's the same message over and over and over and over again, get more sleep, walk, be active, eat more vegetables and green things than you do things that have processed sugar. Sometimes we love the crisis, we love the hero worship, and we don't get as excited about the things that require being maintaining. When there's a crisis, man, everybody's on board, we're all jumping in. And then when we need to start managing it, it kind of loses its energy.

Sarah:
Yep. And it's placing the focus and the resources to prevent the need to even have the heroes and the crisis really focusing. Speaking of crisis and all of the heaviness in the world, I'm sure there's a lot these days that keeps you up at night. What do you feel particularly optimistic about?

Shawna:
The pace of innovation right now, and also being forced to let go of older ideas. Sometimes grasping new ideas isn't the hardest part. Sometimes it's letting go of things that we have always done. Simple things. When I think about just how we're going to access care right now. We've had this model of you go somewhere, they have a waiting room, they didn't call a reception room, you have a waiting room, this congregant type of setting. And we don't value people's time. And we say, you need to come and be in this geographic location. We have been forced to do things that I think are actually in some ways more convenient to say, let's schedule when you're going to be here. Notify us when you get here. We're going to have this room set up and be ready for you. We're going to try to individualize this.

Shawna:
You know what do you really even need to come in? Is this something that we can handle through a text message, through a phone call, through a video chat? And I get excited about the fact that we're using technologies that can really help us democratize care. Is there a way for us for people that have been hard to reach and hardly reached? Are we in a position now where we're able to say, stay where you are, let us come to you, the technology allows that.

Shawna:
So I think that that's one of the things that because we have been forced to think about these things in different ways, it allows us to let go because we just can't do it completely in the bricks and mortar fashion that we've been able to do it. So I think that that's one of the things that I get excited about. And I think the other thing is because every person across the globe is facing the exact same problem at the same time and we're all on the same side of we need to figure this out, seeing the types of cooperation, not so much collaboration, but cooperation and idea sharing, and seeing that sense of that a stride forward is a stride forward for everyone. That lifts my spirits and I need a lot of that right now, because there's a lot that I'm worrying about.

Sarah:
The aspect of, not that we would have ever wished for this but the global aspect of the pandemic has been, it's been really interesting to see how that has brought innovators and healthcare together across the entire world, and it's something we can all collectively rally behind. To switch topics a little bit and I know I keep throwing big questions at you, but as a pediatric-

Shawna:
Bring them girl, bring them.

Sarah:
... I'm particularly interested. I've seen a lot of conversation around and going back to the public health and the basics is opening schools so that parents can return to work, and so we can move forward there. What are your thoughts on the playbook for doing this and who's writing it?

Shawna:
I'm not sure that people really are appreciating the linchpin of moving our economy and our way of life. And let's face it, this pandemic is really inconvenient. I don't know about you, but going to the grocery store to pick up eggs, it's never been more inconvenient.

Dan:
Yeah.

Shawna:
But in order for us to have things returned to something that has a lot less friction, a lot more joy, we have got to get our children taken care of. As much as the content and the instruction and the teachers, is that social and emotional learning. It's the play, it's the creativity. It's very hard to do that independently. And we've got to, we really need to get them back into school and we need to do it safely.

Shawna:
One of the pieces that I've been thinking about a lot with the economy is how tied our running of the economy is to the ability our children to be taken care of and done so safely. Just looking at our healthcare system within healthcare, about 80% of the healthcare workforce at all levels in all roles are women.

Shawna:
Women are the primary manager of children in the home. When we don't take care of getting kids back into school, we're going to have a really hard time getting our economy and our health system back. And what we'll see is that women rightfully so, parents they're going to prioritize, I got to take care of my kid. If their kids aren't in those places and childcare centers and in schools, they're not going to be able to return back to their work. And so I'm not sure that people are really tying together the return to school playbook with the return to work and return to the economy. And when you think about it, when a child is ill or sick and needs to be at home, one of those parents is going to have to be back there with them. And so not only getting them back to school, but getting them back to school safely so that they can stay in school.

Shawna:
So we need to be thinking about the priority of this. And part of that priority means we got to be putting a lot of planning in it. We got to be putting budget in it. We need to be putting our best thinkers inside of this. And this goes back to service design. And part of that, who needs to be writing that playbook, are all of the touch points. So particularly nurses and school nurses, are essential to this because they're the healthcare arm within our school systems, particularly the K-12, so they need to be in there. But we also need to have, who's managing transportation? Who's doing food services? Who's doing our afterschool activities? So all of those facility managers, we need designers in there.

Shawna:
Brittany Merkel, I just had a wonderful conversation with her. She's a nurse and a leader in design thinking. And she's at University Health Ventures, and she's actually in Ohio and part of doing the walkthrough in schools and figuring out every single step of the way. She's a service line designer. So when we think about when kids are on buses and they're dropped off at school and when they come into school, what entrances are they going through? What are those rituals and routines to make sure the kids feel welcomed and safe and secure and confident. Which groups are we testing? What testing are we going to use? Is it something that was done at home with a parent? Is it something that we do together as a group so that everybody feels like we're in this together? So there's a lot of psychology and a lot of ritual that helps to build collective understanding. Is it something that's teacher led? Is it student led? There are so many different facets to this.

Shawna:
I think what we need to have is scientists, child life specialists, teachers, our people who are involved with transportation. Anybody who is a part of that journey of bringing us back into schools, I think we need to have them there. And in addition to the science, we need to have the artists. Because what I have found is that whenever we need to figure out something that requires a lot of creativity, tapping into poets, musicians, playwrights, people who have had to figure things out to share a story and get a point across, our creatives have a set of skills that our scientists don't necessarily have.

Dan:
Yeah.

Sarah:
Yeah.

Shawna:
So I think about all of those people who are the child life therapist, the play therapist, the musicians, the film producers, people who are in dance. They are the ones who bring joy and connection and community to our science. So I think understanding the importance of writing that playbook and then who it is we're bringing in to write that playbook. This is not just a function of a mandate we got to get our schools open, we know that. Nobody is in question of that. But how we do it and who's a part of that and I think that the most untapped resource in this back to school, we're not asking students. And I promise you, you asked six through 10 year olds how to solve any problem. Oh my gosh, they come up with brilliant solutions that only the creative, sometimes reckless thinking that a six to 14 year old can come up with. We need some reckless thinking in this moment. We need to harness that.

Sarah:
Yeah. I love that and I love that you brought up child life specialists. Thinking about the psychological aspect of this for children reminds me so much of the psychological aspect of being hospitalized as a child. And we as pediatric nurses heavily relied on what you said artists. So the musicians and child life specialists to make any of that delivery of care really happened. So I love that and how complex it is, is certainly something that we can't take lightly to make that happen successfully.

Shawna:
Well and the other thing too that I want to point out is that as we're putting together that playbook, I think we need to structure it in a way that says, here are the core ideas and the core things that you need to address. And then we talk about it needs to be tailored to each one of the different regions or different parts of the country. I think we need to get more specific. It actually needs to be tailored to the facility, because what we're doing with just kindergarten and our childcare centers, we have different security concerns than we do with our high schoolers.

Shawna:
And each one of those buildings and those physical infrastructure settings, they're designed within different climates, within different cultures, within different building materials, with different security needs. And so that playbook needs to have fundamentals and then some ideas. But I think it's an interactive playbook. It's not something that's carved in stone. It's something that's on a highly editable Google document that's very shareable and like a Wiki page. And we're going to learn from so many other people's ideas of how they're going to do signage and how you go into one entrance. Because what's going to work in one, it's not even just one area, it's one building or one part of a classroom, we're going to be doing a lot of microlearning I think.

Sarah:
Yep. And we have to be open to iterating as we go.

Shawna:
Yeah.

Sarah:
Gosh, well, with so much discussed here and I think I could continue asking you a million questions, but what would you really love to hand off to our listeners? What do you want them to take away?

Shawna:
I think at this moment in time, I had the good fortune to meet Congressman John Lewis at a very early age multiple times. I first met him when I was six. I met him again as a teenager. I met him again as a young mother, I had the good fortune to be in the district that he represented. I am very proud to have voted for him. And I think about those words and the times when I had been around him, that calming presence and his invitation and his encouragement and his almost requirement to be in good trouble. And I encourage and that hand off piece is at this moment in time, we need people who are courageous. I'm not a fan of the fearless concept because I have a lot of fears. But I can overcome those fears and have courage. I'm looking for and I see around me so many people who speak up. Who get into that good trouble.

Shawna:
People used to ask me, one of the times when people would ask me, what is it that you do? And I would tell them that I'm a strategic troublemaker. And I think that that trouble theme came a lot, I've been thinking about that the very first time I heard John Lewis say, "Get into good trouble." And I have taken that as a strategic troublemaker. Nobody likes trouble, and being a troublemaker just for the sake of troublemaking is just trouble.

Shawna:
But when you have a very clear end point that there are people who don't have a voice and don't have a choice. And when you have a place of privilege and opportunity that we do, we have a responsibility and an obligation to do the things that maybe somebody else in their role can't. And I feel very fortunate at this stage in my career, and some of the things that I've been able to do and the network of people that we've developed over years.

Shawna:
That there is an opportunity that we have an obligation and a responsibility and an opportunity to make things better. So I am just thinking very much about Congressman John Lewis and his lifelong encouragement and invitation to get into good trouble. And so I invite people to join me, to be that strategic troublemaker and ask the questions, when everything is going right, are you willing to be the person who's willing to stand up and say, and how can we do it better? How can we do it for more people? How can we do it in a way that is more beautiful?

Sarah:
I love that. That's super inspirational and I know Dan has used the word rebel before, but meaning the same. Well Shawna where can our listeners follow along your good trouble?

Shawna:
I love that. Yeah. Follow along my good trouble. So good places to find me, I'm on Twitter at my Twitter handle is Shawna Butler R N. And you can find me on LinkedIn. Please reach out to me. I'd love to hear the problems that you're seeing and solving. The things that frustrate you. I'm a person who taps into frustration because it doesn't wane. And then of course, on The CNL Podcast where we get to really take a look at some big problems that are worth our time in solving and the remarkable people who are thinking about caring and taking action to solve them.

Dan:
That's great. And I want to thank both of you for taking the time to be on the show and talk about getting into good trouble. I love that. I've always called myself a chief provocation officer and I think it's all in the same vein, and that's why I think all three of us are here today is that we share that same mindset. So Shawna thank you so much for being on the show. Sarah, thanks for coming in and doing an awesome job with the questions and co-hosting today.

Shawna:
I have a question for you guys.

Dan:
Yeah.

Shawna:
Are you registered to vote?

Sarah:
Of course.

Dan:
That's another good hand off. All the listeners should be ready to vote.

Shawna:
If you're not registered, get registered and make sure you take three other people with you and make sure that you have on your calendars that we are voting on November 3rd. Regardless of who it is and we want to focus up at the top of those. But it is on our local level. Know who's running for your school council. Know who's in your health department. Know who your DA is. Make sure that you're paying attention. Our vote, this is again, John Lewis, he just pounded that into me and it's a sacred right.

Dan:
And that's another great handoff. Thank you Sarah and Shawna. Listeners registered to vote, check out Shawna on Twitter and let's get some good trouble going. Thank you so much.

Sarah:
Bye guys.

Thank you and welcome to the Trusted Community!
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