In this 8-part series from the National Academy of Medicine, we explore practical strategies for the nursing profession to advance health equity. We’ll hear stories and experiences of frontline nurses and other health experts from a wide range of settings. These strategies reflect the recommendations from the report The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity.
If you’re a nurse, involved in any health sector, or want to know how to create a better future for all Americans through improved health outcomes, this podcast is for you.
Episode 8: The Goal for 2030
There is no time to waste to begin implementing strategies that empower nurses to address health inequities. For too long, health inequities have negatively impacted far too many people in the United States. In this final episode of the Future of Nursing, we explore the goals that can be achieved by 2030, the practical steps that must be taken to move forward on the lessons we’ve learned, and how nurses around the world are stepping up to improve the health and well-being of the nation.
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Episode 8: The Goal for 2030
Dr. Scharmaine Lawson (00:15): For too long, health inequities have negatively impacted way too many people in the United States, and the number one thing we’ve learned throughout The Future of Nursing Podcast is that nurses have a major role in addressing health disparities and in turn improving the health and wellbeing of the nation. And we’ve also learned that they cannot accomplish this on their own. In this episode, we’re going to be hearing from some familiar voices from the entire series.
But before that, we wanted to share another story with you, a story that once again shows why it’s urgent to implement practices that empower nurses to address inequities they encounter with the individuals they care for. Dr. Emily Jones is an associate professor at the University of Oklahoma College of Nursing. She started her career as a labor and delivery nurse before going on to earn her PhD. Dr. Jones remembered a significant moment early on in her career. She witnessed the current health system, prevent an individual from receiving the care they truly needed.
Dr. Emily Jones (01:25): When I was practicing as a nurse in inpatient obstetrics a little over a decade ago, I could see that the postpartum care that we routinely provided, created a huge gap for women to fall through. I helped care for a pregnant adolescent. She was probably about 17 or 18 years old, and she was diagnosed with gestational diabetes. She also met the criteria for metabolic syndrome and was at really high risk for developing diabetes.
Although in that obstetrical setting, we didn’t focus on her future risk as much as the present risk and especially the condition, the risk that was conferred for her growing baby. This young woman stayed on our antepartum unit for several weeks related to her gestational diabetes diagnosis and the need for nursing support to help her maintain safe blood glucose levels. Close to term, this patient gave birth to her baby. And after a few more days of monitoring her blood glucose in the hospital, she was discharged home.
Dr. Scharmaine Lawson (02:23): This particular individual had a much higher risk of developing a more serious illness down the road. And what happened next really concerned Dr. Jones.
Dr. Emily Jones (02:33): Here’s the surprising part, her discharge instructions sounded nearly identical to every other postpartum or new mom’s discharge instructions. As her nurses, we didn’t counsel her about her significant risk for developing type 2 diabetes or refer her to a diabetes prevention program or postpartum support group for other moms with similar high risk conditions, most likely because no systems were in place to provide or pay for such care.
What I witnessed time and time again was that we commonly swept the realities of a gestational diabetes diagnosis or other pregnancy related condition under the rug, so to speak, and failed to act in a way that could have prevented disease down the road.
Dr. Scharmaine Lawson (03:18): It left Dr. Jones wondering why didn’t they provide this person with preventative care?
Dr. Emily Jones (03:26): It wasn’t that we weren’t allowed to recommend those things. It was that recommending that sort of preventative or prevention focused care postpartum was not really even on our radar as obstetrical nurses. And that in part was a result of the fragmented, siloed care that we offer women, which really is more focused on body systems than on the whole person.
What I wish we could have offered to this young woman would have been those resources in way of relationships with community care providers or health advocates that would have provided her with a network of support to optimize her health after pregnancy. And after her insurance provided postpartum care coverage ended, I wish we could have health oriented systems in place with the goal to prevent chronic conditions like diabetes and help new moms optimize their health before subsequent pregnancies.
Or better yet, I wish we could have systems in place that actually account for and seek to address the root causes of poor health in the first place and can pave the way to healthier pregnancies for everyone.
Dr. Scharmaine Lawson (04:39): For Dr. Jones, the clinicians tend to focus only on patient symptoms and illnesses rather than causes and long term consequences that will impact the health and well-being. Clinicians felt like they only had the time and capacity to view the individual through the body system they were treating. The problem is that this kind of can leave health inequities unaddressed.
Dr. Emily Jones 1 (05:04): I think it’s important for nurses to have a human centered approach that examines the need of the end user, and the end user of nursing is the community we serve. We can’t address the inequalities unless we address the inequalities every day. I think we need to know that our communities are made up of systems.
Dr. Scharmaine Lawson (05:31): This is why the Future of Nursing Report was created. People need better care, the systems in place and the people who work in healthcare like nurses have the skills to provide it. We must address the root causes of poor health outcomes by preparing and supporting the nursing workforce to advance health equity. And to do this, clinicians and health systems must acknowledge the entire being of the person who is seeking care.
Speaker 2 (05:59): Why are nurses so important? Number one, it’s the perspective we bring. Nurses are educated to look at people and communities holistically. We’re not just looking at one aspect of a person. The socioeconomic factors, the social determinants of health contribute more to people’s health outcomes. We’ve got to be assessing them. We’ve got to be able to intervene with them, and we’ve got to be able to evaluate the efforts. We’re really partners with the people. We’re partners with the community in addressing all these things.
Dr. Scharmaine Lawson (06:32): As health systems allow nurses to provide holistic approaches to care, nurses are then empowered to use their voice and address the inequities in front of them inside of the clinic, out in the community, and in leadership. When this happens, nurses can influence the health of the nation.
Speaker 3 (06:52): In the Future of Nursing Report, we talk about the importance of engaging in public policy from local to national levels, serving on boards, serving on advisory committees that advice state agencies and federal agencies, for example, volunteering to do that work, to become appointed to those positions. We talk about the importance of nurses engaging with government officials at all different levels.
This is really about using the voice and the expertise of nursing, lifting it up to impact the health, not just of seven patients on a shift, but in addition to that influencing the health of seven million patients or 70 million patients or people, families, thousands of communities by engaging and ensuring that health policies are supportive of achieving equity in health and equity in healthcare in our country.
Dr. Scharmaine Lawson (07:50): This is the final episode of The Future of Nursing. In this episode, we want to look forward to 2030 by remembering what we’ve learned throughout the series and explore how we are going to move forward. If we’re going to move forward, we must collaborate and work together to put these strategies into place.
Speaker 4 (08:24): I think what’s important to share is that in the United States compared to other developed countries, we have the highest poverty rate, the greatest income inequality, and some of the most poorest health outcomes. And as you know, all this was highlighted more with the COVID-19 pandemic, where the deaths that were occurring in our communities are occurring to black, Hispanic, and really communities of color. I believe that now is the time.
I’m very hopeful that we are going to advance and address the social determinants of health, because I can’t see how we remain this way. I understand that we spend the most amount of money in healthcare, but we have the poorest outcomes. It just doesn’t make any sense to me. I’m hoping to see that we actually develop this shared agenda with all of the organizations in nursing, out of nursing, and that we all begin to work together.
And once the shared agendas identifies our priorities, the directions and that the health systems, our leaders really look to nursing because I believe that nursing has the education, the leadership, the skill to move us forward. I really do believe that
Dr. Scharmaine Lawson (09:50): Throughout the series we’ve covered each of these topics in depth. These are the things means we need to do if we want to advance health equity. We need to permanently remove the barriers that hold back nurses from fully practicing to the scope of their education and training. We must diversify the nursing workforce to reflect the population we serve. We need to value nurses’ contribute through reformed payment systems. We must better prepare nurses to tackle and understand health equity.
We need to fully support our nurses’ health and well-being as they work to support the nation. We need to strengthen, protect, and prepare our nursing workforce for the next public health emergency. And lastly, we need to create a shared agenda across nursing organizations that prioritizes addressing social determinants of health. It starts with knowing the state of the science and a vision to move forward. With the Future of Nursing 2020-2030 Report, we now have a resource that explains the evidence behind these recommendations.
And this resource also lays out how individual nurses, educators, organizations, policymakers, and health systems can begin acting on the strategies.
Sue Hassmiller (11:19): I want to invite all nurses to read the report, first of all. It is a long report. But if you look at the recommendations in chapter 11, look at those recommendations and see what resonates with you, see who you can bring to the table, wherever you work or maybe you do do your volunteer work, and see what some of you can work on. Look up the state action coalitions in your state by going to the Future of Nursing: Campaign for Action.
And if you really want to work on these recommendations, see if you can help your state action coalition. I think the other thing I would say is this is a really hard subject matter for all of us. A lot of people in this country have been working on health equity for a very long time. It has been their issue.
Dr. Scharmaine Lawson (12:17): How do we move forward? Well, first, all key players must know what their role is in advancing health equity. Roles will look different between nursing leaders, educators, frontline nurses, and policymakers. When everyone is certain of their role, they can have a better understanding of what strategies they need to implement to move forward. Nurses can then begin planning how they will personally work to advance health equity.
Many of the nursing experts we’ve heard from in this series have seen some amazing ways that nurses across the new, even across the world, have worked to deliver the best quality care to people from all backgrounds and experiences. For Maureen Bisognano, President Emerita and Senior Fellow of the Institute of Healthcare Improvement, there was one nurse who did this that she’ll never forget.
Maureen Bisognano (13:11): I also read an article in The New England Journal of Medicine. And in the body of the article, there was a sentence that changed me. Susan Edgman-Levitan and Michael Barry, the authors of the article, said, “We can’t only ask patients what’s the matter. We also have to ask what matters to you.” I ripped up my plenary, rewrote it on the plane. And when I got to Paris, I said to everybody in the audience, “When you go back, don’t only ask the patient what’s the matter. Ask what matters to you.”
And Jen Rodgers, a pediatric nurse from Scotland, did just that. She went back to her hospital and she went in to ask the first patient that she was seeing, a young girl named Kendra, “What matters to you?” Kendra has autism and has never spoken. Kendra and her father made a poster for her door and she wrote what matters to me. And she said, “I’m seven years old. I have autism. I don’t speak. I say hello by pulling your hair. I don’t like medications by my mouth. I will make a run for it. I like fuzzy toys. I can dance.” They put the poster up on the wall.
That night, Kendra’s father, who was her only caregiver, had a cardiac event and he was taken to the adult hospital in Glasgow. Kendra was by herself. But the doctors and nurses said because that poster was on her wall, they knew that she would pull their hair. They knew that they needed some extra attention to give medications by mouth. They said, “We know her and we know how to take care of her.” They changed the way they cared for her.
Jen Rodgers then spread this idea of what matters to you across the entire pediatric hospital, and then across Scotland. Last year, Jen Rodgers was named as Scotland’s Woman of the Year for changing the culture of healthcare in the country, not just in healthcare, but woman of the year, because she changed the way people looked at patients.
And instead of looking them as a disease or a process or a vital sign, she looked at them as a whole person with their family and brought together all of the assets that every patient and family bring and as well, the science of medicine to provide the best care.
Dr. Scharmaine Lawson (15:30): Ms. Bisognano has seen how nurses around the nation are recognizing the health inequities in the communities they work in, and they’re stepping up to address them in unique and creative ways.
Maureen Bisognano (15:43): I’ve seen impact, big impact, on all different parts of the population. I’ve seen nurses working in communities with mothers, starting mothers support groups, so that children are born healthier and they’re fed more appropriate food in the beginning so that they end up with a healthy beginning. I’ve seen nurses work with elderly populations who are at home, working with new models of care to keep them healthy at home.
I’ve seen nurses in schools really thinking about how do I understand, especially in this COVID time, the impact of COVID on the mental health of young kids and teenagers. We are in such dire straits in the United States in some parts of our country with mental health and resilience.
Dr. Scharmaine Lawson (16:29): The nursing profession is critical to reducing health disparities and improving the health and well-being of the population. There’s a lot of work to be done by 2030. It’s going to take the work of individual nurses, educators, policymakers, and health systems to accomplish this. And it’s hard work, but it can be done. Many of the clinicians we spoke with have a lot of hope for what the next decade holds for the nursing workforce.
Speaker 5 (17:00): We are not going to be prepared as a nation unless we can see and feel comfortable with the notion and the fact that our frontline healthcare professional is comfortable with their role.
In a world in which we are increasingly aware of the fact that the line between what happens within the clinic doors and what happens outside the clinic doors to affect the health status of our population, there is a critical need to reassess the ways in which we educate our health professionals and the way in which we deploy them as team members to be able to work with each other and to have a comfort level in working in multiple venues and circumstances.
This report has helped set the stage for accelerated progress of not just the nursing profession, but the whole health system as it moves to meet the challenges and the opportunities of the 21st century.
Speaker 6 (18:09): When 2030 comes around, we need to see a shift in our educational systems, not just the healthcare system. We need to see that we are supporting well-being, that we’re not dismissing the needs of our nursing students, that we are providing nursing students with the training, the skills, and the capacity to recognize their biases and to mitigate them, to have frank conversations about racism and how it gets in between and disrupts outcomes.
I’d like to see us partnering more, partnering more with healthcare systems in a way that only look at how we deliver care for patients, but also to bridge that gap between what it looks like to be a nursing student and practicing and what it looks slight when the nurse goes to practice.
Speaker 7 (19:17): We can begin to make some inroads in terms of health disparities. I really feel that that’s where we can be. And in terms of health equity, we need more nurses in government, whether it be local, state, federal, we need more nurses on boards who are diverse, who understand the patients that they’re working with, who can bring those voices, be at the table when policies are being made. Being able to say, “Hey, this sounds like a good idea, but let’s think through. How might this affect X group of people or Y group of people?”
Dr. Scharmaine Lawson (19:55): The recommendations in the Future of Nursing 2020-2030 Report have a specific goal, the aim to ensure that nurses are inspired, supported, valued, and empowered to chart a path forward so that all people have what they need to live their healthiest lives. The nursing profession must focus on educating and developing nurses, including advanced practice nurses, to work competently in home, community based, and acute care settings.
These efforts can then build a culture of health and health equity in America. And there’s no time to waste.
Speaker 8 (20:33): Nurses can’t solve all of the problems by themselves, but nurses can play a role in reaching out to others within the healthcare sector, other professionals, so that we can comprehensively deal with the challenges our patients face.
Sue Hassmiller (20:50): I would encourage nurses no matter where you work, no matter where you are in the spectrum of understanding health equity and what you’ve been working on to really have crucial conversations at work and do so with kindness and respect and patience.
Dr. Scharmaine Lawson (21:09): Like Sue Hassmiller just mentioned, we encourage everyone to read the Future of Nursing 2020 to 2030 Report and consider starting conversations and discussions in your organization, workplace, or school about the recommendations and stories you heard on this podcast. We all have a role to play and should now take this opportunity to work together for the health and well-being of the nation. I’m Dr. Scharmaine Lawson.
We hope that with these stories and recommendations, you feel more empowered to influence the future of nursing. You can find the report, The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity, at the report homepage at nap.edu/nursing2030. As always, thank you for listening to the Future of Nursing Podcast.
Episode 7: Strengthen and Protect Nurses
Nurses are on the frontline of public health emergencies, including pandemics, environmental disasters, and mass casualty events. The nursing workforce must be prepared to respond to these events, and be protected as they respond. In this episode, frontline nurses share their experiences responding to the COVID-19 pandemic and other public health emergencies and explore how nurses should be strengthened, prepared, and protected for the next emergency.
The Future of Nursing Podcast — Download the PDF
Episode 7: Strengthen and Protect Nurses
Dr. Sharmaine Lawson (00:15): West Virginia has a history of poor health outcomes. Many people experience food insecurity and financial instability. West Virginia is rural, and this makes it difficult for people to find transportation that allows them to access care. The COVID-19 pandemic only magnified these problems. Angela Gray is a public health nurse who’s worked in West Virginia for over 15 years. She’s now the Nursing Director for the Berkeley and Morgan County Health Departments. Angela grew up in Morgan County, West Virginia, and she’s seen these poor health outcomes unfold, but she had never seen an emergency quite like the global pandemic.
Angela Gray (00:58): I felt that we had done all these drills. I’ve been through H1N1, through mass vaccination in the past, but nothing compared to this. There were several key points that I know where I thought they didn’t prepare us for this. When New York got hit so hard and you saw the refrigerator trucks come out for the bodies, I knew that would happen. That was in our training to expect that. It was very surreal to see it happen, believe me.
Dr. Sharmaine Lawson (01:30): From the start of 2020 up through 2021, nurses underwent some of the most intense moments in nursing history with the COVID-19 pandemic. They worked hours upon hours to protect the public, and often at risk of their own physical and mental health. In this episode, we are going to hear from frontline nurses about their experiences and together, we are going to explore how nurses can be strengthened, prepared, and protected for when the next emergency strikes.
This is the Future of Nursing, a series from the National Academy of Medicine, based on the recently published report, The Future of Nursing 2020 to 2030, charting a path to achieve health equity.
I’m Dr. Sharmaine Lawson. At first, when the pandemic began, Angela Gray saw glimpses of hope.
Angela Gray (02:33): In the beginning, it was … really restored your faith in humanity as you saw the country come together. People were so grateful, and we were calling people who were positive for COVID and helping them and their families through it. Then at one point after a couple months, it was like somebody turned a switch and then people became very angry. We got cussed more in a day just for trying to do our jobs and collect the data points that was required for us to report.
Dr. Sharmaine Lawson (03:02): When Angela saw this shift in the public, she knew it would take a big toll on the nursing workforce.
Angela Gray (03:09): It was very tough in that transition of, oh my gosh, we’re the people here that are trying to help you, and they’re blaming us because we’re the ones that are out there trying to make sure the guidelines are being met and the recommendations are being met. So yeah, it was very difficult and it really hit our mental health. By October of 2020, I had four staff members that disclosed that they had to go to their physician to get on anti-anxiety medication or medications to help them sleep. That was just the staff members that disclosed to me. So I try to advocate for us here.
Dr. Sharmaine Lawson (03:48): Backlash from the public was one reason why nurses’ mental health suffered. It wasn’t just their mental health that suffered, but their physical health as well.
Angela Gray (03:58): By that time in September, they had mandated that our National Guard be off two days a week because they had already seen the stress under them, but nobody was advocating for us. I’m like, “Look, we’re working seven days a week for months on end, 12 and 16 plus hour shifts. We’re taking on so much.” I said we can’t continue these long stretches like this. You’re not going to have any of us left. So then they, our administrator, stuck up for us and said, okay, I’m going to mandate everybody have off two days. So some people got that. Some of us didn’t because even if you were supposed to be off, your phone never stopped. You just could not get away from it. It was literally consumed every aspect of your life.
Dr. Sharmaine Lawson (04:44): Nurses across the country were fatigued. They couldn’t always just rest from their duties. They put their own health and wellbeing at risk to protect the public. Dr. Michael McGinnis is the Leonard D. Schaeffer Executive Officer of the National Academy of Medicine. We heard from him in an earlier episode. Dr. McGinnis watched as nurses, Physical and mental health went under extreme pressure, and he discovered something that was concerning. Most nurses did not feel prepared for this.
Dr. Michael McGinnis (05:16): Nurses were thrown quite abruptly during the COVID-19 pandemic onto very front lines in very hazardous conditions. The effective function of the system was fundamentally anchored to their effectiveness. Yet four out of five nurses, when asked whether they felt equipped and trained adequately to be able to contend with emergency circumstances, whether related to the COVID-19 pandemic, or related to other external threats to the nation, or emergent situations, felt that they didn’t have the training.
Dr. Sharmaine Lawson (05:56): Public health emergencies can be caused by transmissible diseases, but can also be caused by environmental disasters and mass casualty events. In the past decade, 2.6 billion people around the world have been affected by earthquakes, floods, hurricanes, and other natural disasters. The COVID-19 pandemic is just one example of a public health emergency. When disasters strike, nurses can engage the community and build trust with them. They can educate and protect them. They can also help people prepare and respond. When it’s time for the community to recover, nurses can help people to foster resilience. Nurses may go through training that prepares them to respond to these emergencies, but often it isn’t enough, and many are left unprepared. Dr. Roberta Lavin is a nurse practitioner who spent much of her career on disaster preparedness and response. She’s recognized that there are some areas in nurses’ training that demonstrate a lack of preparedness among nurses when it comes to public health emergencies.
Dr. Roberta Lavin (07:05): In my discussions with many nurses, I’ve been told that they’ve had little to no training after graduation from nursing school, and much of the training is provided to those in the emergency department and to administrators, and not to the average nurse on a unit. The second area is lack of serious disaster preparedness planning that involves nurses. The quote that struck me was one that said, “We train people to put out a fire, but not how to evacuate the patients during the fire.” The same can be said for how we handle infectious diseases. We train people what they should do to handle infectious diseases, but we never have them practice donning and doffing of the PPE that they need to use.
Dr. Sharmaine Lawson (08:00): According to Dr. Lavin, we have to act now to really prepare the nursing workforce for disaster response.
Dr. Roberta Lavin (08:07): We know that we’ve always said that this is the time we have learned the lessons from the pandemic. We do after actions and we put the things together and then we say we’re going to fix them. We said after 9/11 and the anthrax attacks, never again. Then Katrina and Rita came, and we weren’t prepared. Again, we said never again, and Puerto Rico came, and we weren’t prepared. We said, never again, and then this pandemic came. Maybe this will be the time that we take the lessons we learn.
Dr. Sharmaine Lawson (08:44): It’s imperative that we do learn from these lessons because natural and environmental disasters are happening more frequently. Public health emergencies, like the COVID-19 pandemic are inevitable, and our nursing workforce must be prepared, along with our health system, to protect our nurses as they work to protect us.
Public health emergencies can take many forms. They can be global, national, or contained in a local community. Prior to the COVID-19 pandemic, Angela Gray had her own experience with other public health emergencies in West Virginia. While these cases happen in West Virginia, they also frequently happen all across the nation.
Angela Gray (09:33): Sure, I think the opioid epidemic is a perfect example of a public health crisis in this country, versus something communicable like COVID virus and pandemic. So we’re always looking at these emergencies, and depending on the research and the data of where the numbers are and the stats are and what’s happening, chronic disease in West Virginia is huge rates higher than other parts of the country. Even in the same country, you may be working on different needs based upon your community and what the threats are in your individual communities. It might be the same all the way through the nation. It’s just, it can be very different in different areas of the nation. Here in West Virginia, teen pregnancy, chronic disease and illness, diabetes, substance use disorder.
We had a huge hepatitis A outbreak that the country usually sees less than 1500 cases in a year. West Virginia usually sees less than 15 cases, and we ended up with 2,500 cases in West Virginia in one year. So that triggers our response of getting out and trying to vaccinate, getting ahead of it, trying to contain it. So lots of emergencies, and then also down to we would respond and support our other community entities if it would be a water spill or a contamination of water on the environmental side of public health. There’s multiple things that we’re doing behind the scenes every day, protecting our communities so everybody can go about their way and feel safe.
Dr. Sharmaine Lawson (10:59): When nurses are equipped to respond to disasters and other public health emergencies, communities can become safer and care can be delivered even in the midst of a crisis. But as of right now, many nurses admit they do not feel equipped to respond to these kinds of events. Because they are not prepared for disaster and public health emergency response, rapid action is needed. So what can be done? First nurses and nursing leaders must understand what their roles are in public health emergencies and natural disasters, training programs should consistently address what these roles are, so that when a public emergency occurs, nurses can be confident of how they are expected to respond. We also need reform in nursing education, practice, policy, and research to address the gaps in nursing disaster preparedness. We need experts from nurses to researchers to develop a national strategic plan that then addresses these gaps, figures out how they can be solved, and whose responsibility it is to implement new strategies.
This action is especially important as nurses are often addressing health inequities while responding to public emergencies. With preparation, nurses may feel more confident in their ability to respond to crises. We can never fully mitigate the stress that public health emergencies can cause for nurses, but we can work to lessen the trauma they may experience due to the disaster. Derek DeSilva is a young intensive care unit nurse who practices at a hospital in Austin. Derek had begun working on the ICU floor just a few months before the COVID-19 pandemic began. He felt like he had a good grasp on how the floor worked. He had even gone through some emergency preparedness curriculum in nursing school. But then everything changed and he realized he wasn’t prepared for this at all.
Derek DeSilva (13:05): Whether that be in nursing school, hospital staff, people, disaster management organizers, the idea of a widespread pandemic wasn’t something that we were prepared for, really coached about, or given any extra resources.
Dr. Sharmaine Lawson (13:20): Positive cases of COVID began increasing. As the ICU began to fill with COVID patients, Derek watched as existing health inequities were magnified.
Derek DeSilva (13:31): I definitely noticed quite a few of these health disparities. Typically, they surround around having health insurance. Some patients would massively benefit from being able to transfer to more specific facilities, or being able to be eligible for certain medical treatments that they simply did not get access to because they didn’t have health insurance. Where we had them, as as much of their health that we could rebuild in in our unit, that’s as good as they were going to get, because without insurance, they weren’t going to be able to transfer to that facility. So these patients were basically stuck in our ICU. They couldn’t progress to the level of care that they absolutely could and would need simply because they did not have health insurance, and it would not approve for these life bettering, life saving procedures.
Before maybe not having insurance would be missing out on an opportunity to maybe gain more mobility, or have some specialized training to maybe learn how to eat again after a stroke. But during the COVID-19 pandemic, not having insurance for some people meant that they were going to die.
Dr. Sharmaine Lawson (14:49): Derek and nurses across the world witnessed devastating outcomes due to this pandemic. Many nurses were often the ones who held the hand of a dying individual. They’d call family members of patients so they could say their last goodbyes. Some nurses even sang a last song for the patients who would not be leaving the hospital. These were often just short, significant moments, and nurses often had to quickly move on to assist another individual. Nurses were not prepared for the trauma that came from witnessing these terrible outcomes. Health systems quickly realized that their nurses were under incredible pressure. They worked to provide resources to support their nurses through these intense and very sad moments.
Derek DeSilva (15:37): Our hospital system was actually really good about providing some mental health services, about providing some outlets. We got free basically telehealth counseling sessions to be able to talk about it. A lot of people, a lot of nurses, a lot of medical professionals were able to just get together after some shifts and talk about some things, but it was nice to know that there was at least some support and it was totally free. You got to use those, and I’ve got quite a few colleagues who were able to use these telehealth counseling sessions or mental health sessions, or so to be able to just decompress and talk about some of the things, talk about everything that happened.
Dr. Sharmaine Lawson (16:27): This support was helpful and helped to ease some of the burden nurses experienced. But it didn’t take this burden completely away, and not all health systems and employers were prepared or equipped to guide nurses through this time long term.
Derek DeSilva (16:43): It was good to get some support from management, but at the same time, it wasn’t like management could give you a break. It wasn’t like the hospital suddenly stopped when you got burnt out. They were still asking for extra shifts. They were still asking for people to come in and pick up extra, like I said, all the way to even January of 2021. So it was good that there was some support. There was some ways to talk about things, but getting burned out was a very real thing for a lot of nurses. It almost seems like that’s the kind of support that we needed more. But things changed early on, early March to July, March to August. Having someone to talk to that was the biggest thing after that second wave. Like I said, at least in Austin area, a second wave happened around July.
Having more resources and more personnel would’ve been the next kind of support, I think, that a lot of people were looking for, just because of how burned out everyone was getting from picking up so much extra. Maybe during these situations, people are going to be dying every day. That’s the reality, and I feel like we are so desensitized to that now. We’re ready for a situation like that. But talking about it, I mean, we in nursing school, in hospital orientation, I think we get some information about make sure you do self-care, make sure you’re checking in with yourself, but even going to the ICU, it doesn’t seem like there’s a lot of real preparation. I think the same could be said for the emergency department as well. There’s some stuff you’re going to see there, and people are going to die in those places. Is there really a way to prepare you for that?
Dr. Sharmaine Lawson (18:38): Providing resources for counseling and support is beneficial, but hospitals and health systems must also have a systematic approach to support their nurses when a public health emergency begins. In an earlier episode, we talked with Frank Boz. Frank is a nurse in the cardiothoracic intensive care unit. In our episode on supporting nurses, Frank shared how the leadership at his hospital supported him in an unexpected way. This kind of support may have cost the hospital resources, or required them to change policies, but it gave nurses a voice. It gave them a chance to better understand what to expect as procedures shifted. In our supporting nurses episode, we also talk with Marcus Henderson, who is a practicing psychiatric mental health nurse and member of The Future of Nursing 2020-2030 consensus study committee. During the pandemic, Marcus saw that it was critical for hospitals to invest resources in finding creative solutions to protect and support nurses during public health emergencies.
Marcus Henderson (19:42): There’s a lot of work to be done if less than 10% of hospitals have bit the bullet to say, “We’re going to show that we invest in nursing.” So I think there is still a lot of work to be done. It comes in pockets, and I think COVID has shown us that these workforce issues related to staffing shortages, burnout, resourcing have not gone away, and in some places have exacerbated greatly because of the challenges that COVID has imposed. But I think it has shown us the creative solutions that can be developed. But I do think there is much work to be done.
I mean, it’s crazy to think that when a nurse reaches out for help and support, for example, reaching out for mental health support, that they’re penalized and their ability to function at as a nurse is called into question. Rather than providing that nurse with the support that they reached out for to do their job better and to progress. So we have to change the whole framework and the whole culture around support and wellbeing, because people see nurses that reach out for support as a deficiency and not an area for growth.
Dr. Sharmaine Lawson (20:57): Derek DeSilva found that there was yet another specific kind of support nurses really needed, especially since for many nurses, a public health emergency is only one example of a situation that might cause trauma for nurses. Outside of emergencies, nurses still encounter emotional and difficult situations, whether in the ICU or another floor in the hospital or in a public health setting.
Derek DeSilva (21:21): I think the biggest thing that would help nurses is other nurses. I think the biggest way that I learned, and for a lot of other nurses as well, is getting to talk with some nurses who have experience, who have lived through some of these situations. Saying, “Yeah, I was working, like I said, 50, 60 hour weeks for an entire month, and I got … I started getting burned out,” and talking about burnout. This is something that happens with new nurses all the time. Being able to talk with someone who had the same experience, who was a young nurse at one point as well, and have seen many other nurses make similar mistakes or go down a similar path, and I found that to be valuable. Having other nurses, having experienced nurses who have gone through similar situations talk to you, or talk to newer nurses and say, “Hey, these are the things to look out for. Watch out when you feel yourself starting to feel more upset or not excited to come into work. Be mindful that it’s more about the patients.”
I think in one sense, maybe in nursing school, having nursing students talk with individuals who have gone some of those situations, some of those public health emergencies, I think it would be extremely valuable.
Dr. Sharmaine Lawson (22:35): Or Derek, this was one way he knew nurses could be protected through public health emergencies specifically by supporting each other. But there was something else nurses needed, especially during the pandemic, as policies and guidelines frequently shifted.
Derek DeSilva (22:51): A lot of what we do, pretty much everything we do has 10, 20 years, quite a few decades of best practices that have only been improved upon as the years, as the decades have gone on. To have something that we don’t have best practices for, that it seems like we’re making and things up as we’re going along, I think that scared people. I think what could be done in the future to mitigate the fear that nurses had with all of these changing procedures is to use what we’ve learned from this last pandemic. To be honest that when something new comes up, when something outside of our scope of expectation and preparation comes up, that they need to expect some of the procedures to change as the science evolves.
Dr. Sharmaine Lawson (23:38): Nurses around the nation, even around the world now understand that when an emergency like a pandemic is occurring, procedures are guaranteed to change. Education and training should prepare nurses for these changes so they can know to expect them and move forward with confidence. This is just one example of the many lessons learned from the COVID-19 pandemic. Like Dr. Lavin mentioned earlier, this time, we must take these lessons into consideration and act on them.
Derek DeSilva (24:09): Hey, if this happens, we’re going to try to call and retain these nurses, or something to that extent, giving a little bit more importance on the fact that something like this could be possible. We do CPR training every two year years. We re-up that CPR training every two years, and we stay keen. We know exactly what we’re looking for, and we get a refresher. We do fire drills now almost monthly. So I think incorporating this, and talking to newer nurses, and incorporating this in hospital orientation could have the chance to just make it seem a little less scary and give people a little bit more understanding as far as the expectations. You’re not going to have 100% premonition of what’s going to happen, but at least having some idea of expectations going in, I think might do wonders for the new generation of nurses who are just coming to the field.
Dr. Sharmaine Lawson (25:07): We have to understand that by strengthening and preparing nurses to respond to the next emergency, we are also protecting them. The physical risk can’t always be taken away, but they can be mitigated when we equip our nurses to be confident in their knowledge, skills, and resilience.
We want to take this moment to honor the nurses around the world who paid the ultimate price of caring for people during the COVID-19 crisis. To the nurses who are still working on the front lines to protect the public, your dedication and persistence in the face of adversity has saved countless lives. We look to you for the future of nursing to help ensure that what happened to the nursing profession this year and those in their care, especially the disadvantaged and people of color, that this all becomes an event of the past.
The COVID-19 pandemic is just one example of how disasters and public health emergencies can cause a significant burden on the health of populations, healthcare professionals, and nurses in particular. The pandemic made it very difficult to manage its effects on diverse and highly vulnerable populations. Existing health inequities were exacerbated. Like we mentioned before, future natural disasters and infectious disease outbreaks are inevitable, and they will present similar, maybe even greater challenges for the nursing profession. Therefore, bold action is needed to help our nurses be ready and prepared for these events.
If you want to learn more about what your organization can do to strengthen, prepare, and protect nurses during public health emergencies, check out The Future of Nursing 2020-2030 report. You can visit the homepage at nap.edu/nursing2030. As always, thanks for listening.
Episode 6: Creating a Shared Agenda
The Future of Nursing Podcast — Download the PDF
Episode 6: Creating a Shared Agenda
Dr. Scharmaine Lawson (00:15): Throughout The Future of Nursing podcast, we’ve heard a lot about social determinants of health. In case you needed a reminder on what social determinants are and how they impact health equity, we talk with Dr. Victoria Tiase.
Dr. Victoria Tiase (00:28): So social determinants of health are factors that are typically not collected during a healthcare encounter.
Dr. Scharmaine Lawson (00:38): Dr. Tiase is an Informatics Nurse, the Director of Research and Science at New York Presbyterian Hospital, and is also on the Future of Nursing 2020-2030 committee.
She’s noticed that when people are seeking medical care, there are often other factors influencing their health, factors that may not be acknowledged during an assessment.
Dr. Victoria Tiase (01:01): So there are social and behavioral aspects in which a person lives, works, and plays, that might impact their access to healthcare, and, as we have noted from evidence, can also impact their health outcomes. So things like their financial status, their housing situation, and even the physical environment in which they live and reside. So these factors can certainly augment the way we provide care and also help us support the best access to healthcare for individuals.
Dr. Scharmaine Lawson (01:50): Knowing the social determinants of health that influence an individual’s health outcomes is critical to giving them high quality, patient-centered care. In New York City, there are some unique factors that influence the health outcomes of many people in the city’s population.
Dr. Victoria Tiase (02:06): So an example of where a social determinant of health might impact someone’s ability to access care, is certainly seen, from my perspective, here in New York City, with the homeless population. So the homeless population might not want to access care or might not be in a place where they can access care. And I think very connected to that, is also access to transportation.
So one of the examples that we use quite frequently in New York City is individuals that might not have the financial ability to take a subway for regular appointments. And how can we help subsidize that through different programs or initiatives to support that, ensure the patients have a Metro Card, and can get to care when they need it?
Dr. Scharmaine Lawson (03:02): It’s not just New York City where things like financial instability or lack of transportation contribute to much of the population not receiving high quality care. People in urban and rural areas all across the country also experience this. Helping people access public transportation so they can get to healthcare appointments is a great way to address one specific social determinant in one specific location.
Throughout The Future of Nursing podcast, we’ve been exploring specific ways that nurses can address social determinants of health and work to advance health equity. But to do this, it will take a broader, more coordinated, and more collaborative approach to really address these challenges on a national and global level.
Dr. Martha Dawson (03:49): We have to focus on not only from the patient and engage in the community.
Dr. Scharmaine Lawson (03:56): That’s Dr. Martha Dawson. Dr. Dawson is the president of the National Black Nurses Association. And she’s seen why it’s so important to develop a broad strategy for nurses to address social determinants of health.
Dr. Martha Dawson (04:09): But we also have to focus on it in terms of: how are we going to educate future nurses to be comfortable in that space and to really understand what the social determinants of health are? And then to understand how that really ties back and connect to our political system, the political determinants of health, and those social justice issues that we have to address. Whether we are talking about housing, the environment, jobs. Whether we are talking about, again, how people live, work, and play, how the communities are affected by certain policies and procedures and statutes that are out there.
And how do we get those nurses, or the frontline caregivers, in public health, or in practice, or in a long-term care facility, how do we help to educate them within the academic setting so they’re ready to advocate once they leave the educational setting?
Dr. Scharmaine Lawson (05:11): There are many moving parts in equipping nurses to address these things, therefore it’s important that all organizations and nursing leaders are on the same page. So we must focus on creating a shared agenda to address this unique challenge in health equity.
This is The Future of Nursing, a series from the National Academy of Medicine, based on the recently published report, The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity.
I’m Dr. Scharmaine Lawson. I’m a nurse practitioner. And I’ll be taking you through the stories of nurses confronting health inequities. And together, we’ll learn how nurses can use their unique skills, knowledge, and dedication, to address health inequities and overall improve the health and wellbeing of the nation.
In this episode, we’ll be hearing from the experts about a really important recommendation in The Future of Nursing 2020-2030 report, which is to develop a shared agenda for addressing social determinants of health, and overall achieving health equity.
There needs to be an agenda that includes explicit priorities across nursing practice, education, leadership, and health policy engagement. And the process for creating this agenda should be led by the Tri-Council for Nursing and the Council of Public Health Nursing Organizations.
The Tri-Council for Nursing is an alliance between several nursing associations and organizations. And the Council of Public Health Nursing Organizations is a coalition of the nation’s leading public health nursing organizations.
Of course, there are dozens of national organizations and hundreds, if not thousands, of local groups involved in healthcare across the country. With all these different groups attempting to address social determinants of health, it can be challenging to envision what a shared agenda might look like and how it might come together.
Dr. Victoria Tiase (07:23): A shared agenda is something that outlines common interests and goals. So it can also include work plans, or a framework, in order to do the work. But I think the key point, and really a key message from the report, is that it’s shared. And what that means, it’s not a separate agenda for each nursing organization; which is sometimes what we’ve seen in the past.
So this is the idea that it is a cohesive agenda across academia, practice, industry. And specifically, in the report’s recommendation, we call out all nursing organizations nationally, should initiate this work to develop explicit priorities. And we also mention nursing organizations such as the Tri-Council for Nursing, which is AACN, ANA, AONL, and the National League for Nursing, as well as the state boards of nursing. So a whole bunch there, aligning with the Council for Public Health Nursing Organizations.
So it’s really about working collaboratively and leveraging the respective expertise of all of these organizations in this agenda setting process.
Dr. Scharmaine Lawson (08:46): As this shared agenda is created, it’s incredibly important to draw from the expertise of nurses.
Dr. Victoria Tiase (08:53): I think the new piece and the new message in this report, is that we are looking at a shared agenda across nursing organizations. So not each individual organization. So the hope is that, when one is created, it will not only leverage the expertise of nurses, but draw in knowledge on community needs and even partnership with patients in underserved communities. So I think that the difference here, it’s a real opportunity to use the collective voice of nursing to advance this work in health equity.
Dr. Scharmaine Lawson (09:34): Dr. Dawson, who we heard from earlier, has established some clear ideas for how nurses and nursing organizations can establish this agenda.
Dr. Martha Dawson (09:44): I think, first of all, we need to look at: so what is going to be the agenda for nursing going forward? We have to look at this from the large perspective first and focus on what is best for the profession. And then how do we create those strategies, goals, and objectives, so that we are working together and not necessarily in parallel with each other?
So, for example, when we start talking about the social determinants of health, I think we first all need to agree that the social determinants of health are really the downstream issues that we are trying to address and resolve. And maybe we need to take a step back and begin to address those upstream things that actually causes the social determinants of health.
Dr. Scharmaine Lawson (10:35): Like Dr. Dawson mentioned, a shared agenda must address the root of the problems that cause health inequities. To address these problems as effectively as possible, nurses must be unified.
Dr. Martha Dawson (10:47): So if I begin to address that within the National Black Nursing Association, it would be great to know that all other nursing associations are doing the same thing. Whether their practice is membership focus, from professional colleagues, or if we’re in that practice area … because there are many association that focus on practice … or if we are in that leadership sphere, or even if we are talking about researching advocacy and policy influencing, I think we need to have the same message.
Dr. Scharmaine Lawson (11:19): Nurses can lead the effort to address social determinants of health and achieve health equity, but they can’t do it alone.
Dr. Angie Millan is a nurse practitioner who has served as a president of the National Association of Hispanic Nurses, and is also a member of the Future of Nursing 2020-2030 committee. Dr. Millan has recognized that there are several entities within the healthcare industry that have to work together to achieve these goals.
Dr. Angie Millan (11:45): In order for nursing to play a critical role and make an impact, those who employ nurses need to straighten the nursing profession, they will need to provide the education and supportive work environments, and make sure that nurses have all the resources that are needed. Because for nurses to advance the shared agenda, they will need to be well prepared to bridge medical and social, advocating for policies, addressing poverty, racism, and other conditions that stand in the way of health and wellbeing.
So the country’s challenges include not only public access to high quality affordable care, but also the lack of access many communities have to fresh food, clean air, even public transportation and good schools. These are all factors of health and wellbeing.
So the shared agenda will focus on addressing the social determinants and the barriers, specifically for the underserved communities. We need the government, the payers, the health organizations and foundations. So we need to leverage all groups, all expertise, and we need to work as one and not in our own silos.
So the agenda also needs to include clear priorities across nursing practice, education, leadership, and health policy. So cross-sector collaboration is key, and we need to prioritize and align resources so that the limited resources can be leveraged and maximized.
Dr. Scharmaine Lawson (13:23): And while it will take the efforts of healthcare professionals, academics, and public health experts, The Future of Nursing report is clear about who is responsible for implementing these strategies.
Dr. Angie Millan (13:35): Nursing will implement the shared agenda. The committee’s calling out on all nurses, at all levels and all work settings, to help implement this shared agenda. Because nurses are uniquely woven into the fabric of the community, they’re in schools, different workplaces, they go to people’s homes, they’re at prisons, they’re at hospitals, they’re at assisted living facilities and other community spaces. So they’re positioned to be a more powerful part of improving health and health equity.
And, again, we will need nurses with their various expertise, from all levels, to be able to address complex social, economic, and environmental problems in a more effective manner to better coordinate and integrate in order to have a greater impact on health outcomes.
Dr. Scharmaine Lawson (14:29): While it may be a challenge to establish a shared agenda across so many different organizations and professions, the results will undoubtedly change healthcare.
Maureen Bisognano (14:40): I believe that a shared agenda is going to be critical to improving health and healthcare globally, especially here in the United States.
Dr. Scharmaine Lawson (14:50): That’s Maureen Bisognano, the President Emerita and Senior Fellow at the Institute for Healthcare Improvement, who we heard from in our last episode. For Maureen, there’s a reason why nurses are in the best position to improve healthcare.
Maureen Bisognano (15:05): We’ve got a tremendous opportunity for nurses, because nurses work in so many settings, in schools, in nursing homes, in all different settings. So nurses are out there in the field seeing the burden of social determinants. And they’re in the best position, in a community, to bring together the resources to think upstream about: how do we prevent healthcare problems?
Dr. Scharmaine Lawson (15:29): In order to create and implement a shared agenda that allows nurses to address healthcare problems at their root, there are certain steps that must be taken.
Dr. Tiase laid out exactly what those steps are.
Dr. Victoria Tiase (15:43): I think the first piece is to perform an assessment and look at the gaps, in terms of where there are states that might not have similar policies, or where there are gaps within states or organizations that are perpetuating health inequities.
A next step would be to identify the relevant expertise in each of the nursing organizations, and taking a look at what each of those organizations bring to the table. So this also includes bringing in the National Coalition of Ethnic Minority Nurses, also connecting with our public health organizations, connecting with payers and foundations and other groups that have a vested interest in supporting nurses as well.
Dr. Scharmaine Lawson (16:46): Multiple players in healthcare will collaborate to create this agenda. And according to Ms. Bisognano, nurses must take the lead in these developments.
Maureen Bisognano (16:55): Nurses really step up to develop these innovations. They’re out in the field, they’re looking at food, they’re looking at housing, they’re looking at parental and family problems. And they’re working out there to try and surface those, and then bringing people together to begin to solve them.
I think the problem we’ve got in the United States is an ineffective or an accelerated way of sharing. We need to make these models visible so that nurses working across the country can learn from each other.
At IHI, we run these collaboratives, these joined learning sessions, where people come together and they share their current experiences and they learn together how to build new ones. I think if nurses can see the innovations that are happening around the country and they can share together, not only the problems they see, but the solutions that they’re finding, I think we could accelerate the pace of change across the country.
Dr. Scharmaine Lawson (17:55): Nurses will have to step up and use their voices. And they may need to do this in some non-traditional ways. And Dr. Tiase believes the voice of nurses is especially important to address this challenge.
Dr. Victoria Tiase (18:08): I think one of the untraditional ways that nurses can step up, that I am quite passionate about and which we have seen over the past year, is the use of communication strategies. We have seen that the nursing voice is being heard. And now it’s about using these shared agendas to leverage that collective nursing voice to enable change. So this includes the use of social media to amplify messages to the public, to policy makers, and also to connecting with the media, because I think we can also influence and promote the expertise of nurses in health equity related issues.
One other idea, which perhaps might be more traditional to some, but I think most might find this untraditional, is working to increase the number and also the diversity of nurses on boards and in other leadership positions, not just within healthcare, but outside of healthcare. So I think we have made some great strides in getting nurses on boards within healthcare, but it’s really that outside of healthcare where I think there is great opportunity.
So what I mean by outside of healthcare, I’m talking about community boards, housing authorities, even school boards; from a technology perspective, nurses working at large technology companies. So I think there’s a lot of opportunity there for nurses to influence the work that goes on in other sectors, which will then very much connect to this work on a shared agenda to dismantle inequities.
Dr. Scharmaine Lawson (20:12): It’s important to recognize that these innovations are already happening.
Maureen Bisognano recently visited one program that really showed her the kind of impact nurses can make when they use their voices and choose to act, after observing problems in a community that were disrupting people’s health outcomes.
Maureen Bisognano (20:33): There are examples from around the country, around the world. One of them that I think is very powerful, is during the course of our work for the report, I went to visit the Rhode Island Institute
Nursing Middle College. And this is a group of nurses in Rhode Island who used to work in public health.
They were used to seeing the burden of social disease and impact, the burden of poverty, the burden of drug use in communities where people had no resources. And that was their job, in the old days, was taking care of people once they got sick.
But one day they stopped and asked themselves: why don’t we move upstream and prevent these problems from happening? So these nurses, public health nurses, opened up a high school, a charter high school, grades 9 to 12, they have several hundred kids in the school. And it’s the first school in the country that’s a high school crossing over into a college. That’s why they call it Middle College. And the students are almost all focused on healthcare as their professions.
They begin as nursing assistants in the summer breaks. They’re learning not only science and anatomy and physiology and math, but they’re learning empathy and caring. They actually do experiential learning, like they put on glasses that make it look like they have glaucoma so they get to see what it’s like when a patient has glaucoma or any kind of disease.
Dr. Scharmaine Lawson (22:07): Addressing social determinants of health requires a shared agenda across nursing. And nurses are just the healthcare professionals to put this strategy into practice.
Dr. Angie Millan (22:17): We’re 4.2 million nurses. The call is for all nurses at all levels. So this includes your LVNs, the RN, your public health nurses, your advanced practice nurses, faculty, nursing leaders, researchers. And also at all settings, whether they’re in acute care, community, public health. They need to all be involved to be able to address the social determinants of health. And nurses will need to work as individuals, in teams and across sectors, to meet these challenges, because we have many challenges.
Dr. Scharmaine Lawson (22:54): Through creating a shared agenda, organizations can work toward the same goals. And this can propel nurses and healthcare leaders into action.
Dr. Martha Dawson (23:04): Until we become a serious nation about addressing these type of things, then we just going to continue to have conversations, but we’re not going to have action and we are not going to be able to address the social determinants of health. We need to be speaking with a united voice. Because we all know that that’s power, in numbers.
So I think this is an opportunity for the nursing profession to come together and say, “This is the big piece of the pie, and all of us need to collaborate so that we are not conflicting with each other, that we’re supporting it and aligning with each other.”
Dr. Scharmaine Lawson (23:41): This collaboration is necessary. The COVID-19 pandemic underscored the health inequities that so many people across the nation have been experiencing for decades. The COVID-19 pandemic is just one example of a public health emergency. And it’s taught us a lot.
In our next episode, we’re going to hear stories from frontline nurses who have served the nation through public health emergencies. And we’re going to explore how we can strengthen the nursing workforce to be more prepared when disasters strike.
Until then, if you want to know how your organization can coordinate with others to create a shared agenda to address social determinants of health, check out The Future of Nursing 2020-2030 report. You can visit the report homepage at nap.edu/nursing2030.
And, as always, thanks for listening.
Episode 5: Lifting Nurse Practice Barriers
Removing barriers to the nursing scope of practice is critical to advancing health equity. In this episode, we hear stories from advanced practice nurses who were sometimes not allowed to practice at the top of their education and training. They, along with other health experts, share how they responded, how these barriers impact health outcomes, and how they can be removed. We also explore how valuing nurses’ contributions through reformed payment systems allows nurses to further address health inequities.
Episode 5: Lifting Nurse Practice Barriers
Dr. Scharmaine Lawson (00:16): To obtain their licenses, nurses go through years of training, education and clinical experience. Advanced practice nurses go through even more extensive training. And with this education and training, they have the authority to prescribe medications, diagnose and treat illnesses and manage chronic diseases. Nurses have substantial expertise and this expertise can help more people access high quality care.
But there’s a problem in many places in the United States. Even though advanced practice nurses have the training and education to do things like assessing people, diagnosing, prescribing medications and conducting telehealth visits, they often aren’t allowed or aren’t paid enough to do so.
Dr. Mary Joy Garcia-Dia is the President of the Philippine Nurses Association of America and has specialized in nursing informatics. Throughout her career, she’s received a lot of feedback from fellow advanced practice nurses who weren’t allowed to practice to the fullest extent of their education and training even though they were equipped to do so. One story stuck out to her from a nurse practitioner named Dr. Danilo Bernal.
Dr. Mary Joy Garcia-Dia (01:31): Dr. Bernal, he decided to work in a emergency room after experiencing burn out from working full time in another facility. He was surprised that doctors in this new hospital refused to let him work in the main emergency department area. But instead, he was assigned to work mostly in rapid care or urgent care area.
When he asked the reason why he cannot work in the main ER despite his previous training and experience, he was told that he is not a physician and that his training, education and background is not enough.
Dr. Scharmaine Lawson (02:13): It didn’t matter that Dr. Bernal had the proper qualifications to work in the emergency department. The hospital saw him as unqualified simply because he wasn’t a physician. Unfortunately, this is the reality for many advanced practice nurses. And when nurses aren’t allowed to practice to the full extent of their training, a lot of people miss out on access to high quality care.
This is The Future of Nursing, a series from the National Academy of Medicine based on the recently published report, The Future of Nursing 2020 to 2030: Charting A Path to Achieve Health Equity. I’m Dr. Scharmaine Lawson. I’m a nurse practitioner and I’ll be taking you through the stories of nurses confronting health inequities. And together, we’ll learn how nurses can use their unique skills, knowledge and dedication to address health inequities and overall improve the health and well being of the nation.
Right now in America, there are barriers that keep nurses from practicing to the top of their education and training. In this episode, we’re going to learn how these barriers impact health outcomes, how they can be removed and why it’s critical to remove them if we want to advance health equity.
A nurse’s scope of practice varies from nurse to nurse. It all depends on what kind of licenses they’ve earned. And what kind of training and education they’ve received. Dr. Ashley Darcy-Mahoney is a nurse practitioner and she gave us an example of what her scope of practice allows her to do.
Dr. Ashley Darcy-Mahoney (03:59): I am a neonatal nurse practitioner. And so one of the things about scope of practice for me that’s important is that as a nurse practitioner, my scope of practice is for children, aged zero to two years old. Beyond two years old, I would not practice under my own license or education and training because I was not educated and trained to be a nurse practitioner for people beyond the age of two.
I am also a registered nurse. As a registered nurse, I can provide care across the life span under the scope of practice as a registered nurse. Which means I could provide nursing care as an RN to somebody that’s an adult or a teenager, but I could not do that under advanced practice license.
So I would prescribe medicine, for example, to a 20 year old. But I could prescribe and do prescribe medicine to infants in a hospital.
Dr. Scharmaine Lawson (04:51): Dr. Darcy-Mahoney is allowed to prescribe medicine to infants under her advanced practice license. This is one example of what a nurse’s scope of practice can entail. What’s important to acknowledge is that there are certain health systems and certain regions in the country that still would not allow Dr. Darcy-Mahoney to practice in this way.
There are a few reasons why advanced practice nurses are restricted from practicing within their full scope of practice. One reason is that some public and private health systems refuse to recognize the qualifications of an advanced practice nurse.
This is what Dr. Bernal experienced. However, Dr. Bernal had a very different experience at another health system, even though he had the same training and qualifications.
Dr. Mary Joy Garcia-Dia (05:35): He also experienced and had the chance to work and be trained as a family nurse practitioner for over four years in another emergency room department. And it is a training and teaching hospital. And this is why after he completed his family nurse practitioner program, he was able to practice in the main emergency to eval with patients, diagnose, order and interpret diagnostic tests. He was able to initiate and manage treatment, including prescribing medications and controlled substances, doing admissions, transferring and referring patients under the supervision of his attending physician.
Dr. Scharmaine Lawson (06:17): In this particular setting, the physicians and health system had a much more inclusive perspective and team based approach that supported the role of advanced practice nurses.
Dr. Mary Joy Garcia-Dia (06:28): He was very lucky that the physicians that they had worked with incredible group of doctors who were not only working as clinicians, but educators as well. They treated him as one of their colleagues and he was afforded the respect of a medical provider and being part of the care team. He said that he would love to work in an environment where doctors respect nurses and treat nurse practitioners as a team member, allowing them to practice at the top of their profession and education.
Dr. Scharmaine Lawson (07:00): Dr. Garcia-Dia remembered another story where another health entity attempted to restrict a nurse practitioner.
Dr. Mary Joy Garcia-Dia (07:07): One other example that Dr. Eliza Green, another nurse practitioner that we have had experienced is while she was trying to order a cat scan of the abdomen and pelvis with contrast to her patients. The facility refused to do it and demanded that the script be written by a doctor instead of a nurse practitioner as they do not recognize nurse practitioner in their diagnostic facilities.
Fortunately, the doctors that she worked with are very supportive and told the manager of the facility that they do not nurse practitioners, they will send their patients somewhere else. From there, they have changed their practice since then. And now included nurse practitioners as recognized providers in their facility.
This example, Eliza have always learned from it and teach her student that if they’re going to work for a practice, to make sure to investigate if the doctors are supportive of nurse practitioners.
Dr. Scharmaine Lawson (08:09): Public and private health systems often have the power to recognize the qualifications of advanced practice nurses. When they do this, they can then allow these nurses to fully practice in what they have been trained to do. But this is only part of the problem, because while health systems can lift their own restrictions, this can only be done if there are no state or federal laws that put those restrictions there in the first place. And unfortunately, there are many states in America that have these barriers.
Dr. Ashley Darcy-Mahoney (08:41): We have, across the United States, a group of states, 20 plus states and the District of Columbia that have scope of practice laws that don’t require nurse practitioners to practice in collaboration with or under a physician colleague.
We have another subset of states who have other collaborative agreements. And finally, a third set of states who have what we would call the most restrictive laws that require nurse practitioners to practice under, I would say, the authority of a physician. And those can be challenging in some ways for patient care, depending on what laws entail.
Dr. Scharmaine Lawson (09:17): When laws restrict nurses scope of practice, patient care is heavily impacted.
Dr. Mary Wakefield (09:23): More than 80 million people live in areas of the United States that have been designated shortage areas of health professionals.
Dr. Scharmaine Lawson (09:30): That’s Dr. Mary Wakefield. Dr. Wakefield has spent much of her nursing career working in public health policy at the federal level. And she’s witnessed the impact scope of practice laws have on communities.
Dr. Mary Wakefield (09:42): The research is so crystal clear about the quality and the accessibility that advanced practice registered nurses provide to the communities that they serve. It is so crystal clear that in those places where these advanced practice registered nurses do not have the ability to practice fully to the top of their education is a lost resource to individuals and families and communities.
These restrictions are really an artificial artifact of regulation and law that stands in the way of individuals and communities having full access to clinicians. In this case advanced practice registered nurses who can provide a wide array of health care.
And in the process, providing some of the very best care that can be available. So removal of those restrictions critically important to expand access for the millions of Americans that currently don’t have it to the extent that they should.
Dr. Scharmaine Lawson (10:49): To make these restrictions even more complex, the scope of practice laws vary across states. This can really create challenges, especially during a public health emergency.
Dr. Mary Wakefield (11:01): So this business of having an artificial difference applied from one state to another is just that. It’s an artificial restriction, a difference that really can create challenges, especially in areas that need nurses and need them quickly, like traveling nurses.
That was the case with COVID last year where some of the governors of some states recognizing that they were totally overwhelmed in their hospitals with inadequate numbers of nurses given the patient loads that were coming in and setting up tent structures, et cetera, had to build out more beds for patients.
The rate limiting factor often wasn’t whether or not they could create more space with a bed in it. The rate limiting factor to provide care was did they have registered nurses licensed in that state to provide care? Did they have sufficient numbers?
Dr. Scharmaine Lawson (11:51): The COVID pandemic forced many states to examine their policies that restricted nurses from being able to practice.
Dr. Mary Wakefield (11:59): I think that it really took the pandemic to lift up the challenges of state by state licensure and the inefficiencies of getting a license rapidly to be able to practice in another state. I think it took the pandemic. And the reason why, perhaps, it took this pandemic was because a lot of disasters that we’ve seen in the United States play out historically have been local or regional.
So for example, flooding or a tornado or a hurricane where a city or a state or, perhaps, a couple of states are impacted. But in this case, we had the need for nurses all across the United States in state after state where traveling nurses were moving quickly.
And there was a real challenge as states were competing for those nurses to get them to the locations where they were needed to practice most expeditiously. So I think the pandemic put a very sharp focus on this challenge.
Dr. Scharmaine Lawson (13:01): The lifting of restrictions because of the pandemic revealed this: the barriers that restrict nurses from fully practicing, they can be removed.
Dr. Mary Wakefield (13:09): So some governors stepped forward and lifted those restrictions and basically said, “We’ll accept nurses who are licensed in another state.” And they applied much more efficient processes of then going through the process of getting a license from the state needed that nurse. They really removed barriers state by state when they were being overwhelmed by patients diagnosed with COVID-19.
So there are ways around this. The governors have moved restriction in emergency situations. But it should not take an emergency to help facilitate nurses getting to patients and populations and locations where they are needed.
Dr. Scharmaine Lawson (13:50): Like Dr. Wakefield mentioned, these barriers to nursing scope of practice mean that communities, especially underserved communities, do not have equal access to high quality care simply because there aren’t enough clinicians.
And while some states lifted these restrictions because of the pandemic, these barriers need to be permanently removed.
Maureen Bisognano (14:16): We saw eight states expand the scope of practice for nurse practitioners.
Dr. Scharmaine Lawson (14:21): That’s Maureen Bisognano. Ms. Bisognano is the President of the Institute for Health Care Improvement. Throughout her nursing career, Ms. Bisognano saw more and more why it was so important for these restrictive barriers to be removed.
Maureen Bisognano (14:34): But we still have 27 states that have restrictive practices for nurse practitioners and midwives. We need to take that barrier away for two major reasons. The first is right now we’ve got dire shortages of staff, particularly in rural settings. And particularly midwives.
So if we want to produce the kind of health equity across the country, we’ve got to take away those barriers of scope of practice.
What we are finding is that nurse and midwives are producing excellent results in expanded scope of practices where they have it and we need to take away those limitations.
The second is the power of relaxing these scope of practice restrictions. A recent Milbank study showed that increasing the scope of practice for nurse practitioners generally decreases the number of opioid prescriptions. There was a fear that if nurses were able to prescribe opiates that the numbers would go up and it’s already a devastating problem in our country.
But the study found that nurse practitioners prescribed less opioids and decreased the amount of opioids that patients in their population were taking. That’s a demonstration of the way that nurses think. We look at other ways to treat patients and families, not just a prescription. And I think that’s one very powerful way for us to begin to lobby at a state and then a federal level to take away these restrictions. It will improve health and health care across our country.
Dr. Scharmaine Lawson (16:11): Expanded scope of practice made a big impact on the opioid crisis and a lot can change with just one piece of legislation. What this showed is that removing restrictions on nurses can actually help to advance health equity forward.
Dr. Ashley Darcy-Mahoney (16:29): One thing that many of us has heard about is to address the opioid crisis as one, perhaps, example as we think about health equity. In 2017, a federal waiver allowed nurse practitioners to prescribe buprenorphine to patients. And this significantly increased access to care in some rural communities and kept many people who were experiencing addiction safe.
Dr. Scharmaine Lawson (16:51): The Comprehensive Addiction and Recovery Act of 2017 increased the number of nurse practitioner and physicians assistants who could safely prescribe buprenorphine. From 2016 to 2019, the amount of clinicians per 100,000 people in rural areas increased by 111%.
Dr. Ashley Darcy-Mahoney (17:10): And so that’s an example of a health equity issue right? Maybe those families and those patients, those people couldn’t access a particular prescribed medication that they needed to be able to treat their substance use disorder and, therefore, didn’t have the same kind of equitable access to care that other people may have, perhaps, in an urban environment.
Dr. Scharmaine Lawson (17:33): The country’s needs are evolving. There’s an urgent need to address substance use disorder, but there are also many other needs. By 2030, over 20% of the population, which is 73 million people, will be over the age of 65. And older people have a higher prevalence of chronic illnesses like diabetes, heart disease and Alzheimer’s disease.
There are increasing rates of maternal morbidity and mortality, especially among black and American Indian and American native women. In all of these areas, nurses can help provide treatment and help alleviate provider shortages.
These are just a few, but urgent, reasons why it’s absolutely critical to remove nursing scope of practice barriers.
Maureen Bisognano (18:22): When nursing scope of practice barriers are removed, we certainly see nurses practicing in rural underserved areas and in urban underserved areas. Nurse practitioners are there already. But this really encourages and makes possible nurse practitioners to engage that entire array of services that they provide, whether that is diagnosing and treating an illness, prescribing medications, practicing with autonomy.
Certainly held accountable as all health professionals are. But practicing often in places that are remote and underserved. Remote in terms of rural, frontier areas, and remote in the sense of working in underserved urban areas where that ready access to health care services doesn’t always exist.
So this is really about a world where nurse practitioners and certified nurse midwives, nurse anesthetists and so on have barriers removed that allow them practice, especially in communities that have historically been marginalized with regard to access to health care.
Dr. Scharmaine Lawson (19:33): Policy makers need to permanently lift the barriers that restrict nurses scope of practice and, consequently, limits people’s access to high quality care. When organizations and state and federal entities remove these barriers, they enable nurses to better address factors that negatively affect the health of the individuals they care for.
And overall, this enables nurses to improve the value and quality of health care. As we advocate for these restrictions to be lifted and engage in discussions on removing barriers, we need to center our conversations around one thing.
Dr. Ashley Darcy-Mahoney (20:09): I hope that when we think about the barriers that exist that we begin to keep the patient at the center of that conversation, rather than thinking about it like a turf war which I think is often how it’s thought of.
Dr. Scharmaine Lawson (20:21): Removing barriers to nursing scope of practice should not be about just who holds the most power and authority, rather we should remove barriers to develop a system that relies on team based care where all kinds of clinicians work together to deliver the best quality of care to people.
Dr. Ashley Darcy-Mahoney (20:39): For the most part, my physicians colleagues and I practice in a way that’s extraordinary collaborative. We all know what our strengths and our weaknesses are and how we can work together as a team to bring those strengths to our patients. I think all clinicians: nurse practitioners, physicians, pharmacists. All of us want what is best for patients.
And in most cases, team based care is what is best for patients. Operating as a team. Operating within the confines of our health system means that we all provide sometimes similar and overlapping jobs, but we also provide different roles for a patient.
And so when you talk about what needs to be implemented to address the scope of practice issues, I think in some ways, taking a step back to see what it is that everyone is capable of doing. What it is that nurses and nurse practitioners are capable of doing in terms of education and practice and where we complement our physician.
Dr. Scharmaine Lawson (21:40): When we remove barriers to nursing scope of practice, we’re also showing that we value nurses’ contributions in health care. Often nurses’ contributions are not seen as valuable as, say, a physician’s contributions or even a surgeon’s contributions.
Maureen Bisognano (21:58): I think there is a tremendous amount of improvement potential in recognizing nurses’ contributions. I think the hierarchy in health care has been detrimental. Doctors speaking one language and nurses another. Having calling doctors doctor and nurses by their first name.
Every time you walk onto a unit, in my experience, you can tell whether the culture is open to closing that gap or not. And I am seeing some promising changes, but we still have a long way to go.
Dr. Scharmaine Lawson (22:31): Ms. Bisognano had a moment in her career where she clearly saw that even though she was a nurse leader, some of her colleagues viewed her a bit differently in comparison to other health leaders.
Maureen Bisognano (22:41): When I was first a CEO, my first national meeting of CEOs was me flying to the south part of the United States and walking into a room where I was the one woman and the only nurse. All the other CEOs were men. They were all over 60. And when I walked into that room, I got a very strong feeling of my difference. When I walked into the room, one of the men turned around to me and he said, “Honey, get me coffee.”
And I thought this moment is going to have an impact on my career. And so I thought for a moment and I said, “I’m happy to get you coffee. How do you take it? And this afternoon, you can get me coffee and I take mine black.” And then everybody started laughing.
And I think that said to him, I’m not trying to better than you, but I am equal to you. And I think those kind of moments we have as women and as nurses really begin to change the culture and open people to seeing women and nurses in a different way.
Dr. Scharmaine Lawson (23:48): When it comes to valuing nurses’ contributions, it is important for health systems to recognize that what nurses contribute is just as important as what physicians contribute.
But there’s another major component that has the power to truly value nurses’ contributions, and that is payment models.
Dr. Marshall Chen (24:08): We have a problem with the way the current billing system is set up.
Dr. Scharmaine Lawson (24:11): This is Dr. Marshall Chen, the health equity researcher who we heard from in our last episode. Dr. Chen has spent a lot of time looking at how current payment models in health care affect the quality of care delivered to patients.
Dr. Marshall Chen (24:26): The current predominant system is fee for service. So this is the system where basically you do a service, you get reimbursed for it. Everyone agrees this is an inefficient system. It basically incentivizes volume, not necessarily quality care or the experience of patients.
Dr. Scharmaine Lawson (24:41): Not only does the fee for service model encourage quantity over quality of care, but it doesn’t reimburse equally.
Dr. Marshall Chen (24:50): It tends to basically overweigh and be overgenerous regarding things like procedures and surgeries, high tech things and then to under reimburse a lot of these key core nursing functions so things like the time that nurses spend educating patients, coaching patients, working on self management, doing monitoring in between clinic business, working with the patients when they’re at home. These are all things which either aren’t reimbursed or terribly reimbursed.
So there’s a gross inequity that because it’s not being reimbursed then there’s no incentive for health care systems to do this.
Dr. Scharmaine Lawson (25:27): The current health system does not value addressing social determinants of health or value advancing health equity. But this can be changed.
Dr. Marshall Chen (25:36): If we value something, we should then back it up in terms of putting our money where our mouth is. If we truly value the patient experience, patient outcomes, we should reward that. If we truly value improving care for marginalized populations, reducing health disparities.
Dr. Scharmaine Lawson (25:52): Sustainable and flexible payment models must be established to support nurses to do things like address social determinants of health and health inequities. There area few different ways that this can be done.
Dr. Marshall Chen (26:04): There are ways that we can tweak fee for service to help and support nurses. So one is to make sure that there are billing codes for some of these essential nurse functions that can address medical and social needs. So that there are billing codes to support team based care, care management, care coordination, conditional care.
Dr. Scharmaine Lawson (26:25): Current procedural terminology are billing codes that report the kind of medical, surgical and diagnostic procedures and services provided to a patient. These codes are assigned a value and that value determines how much a provider gets paid. In this system, an hour long specialty procedure can be worth three to five times higher than an hour long counseling session where a patient receives health education.
This gives more weight, value and importance to complex procedures. But not for things that nurses do, like providing care management, helping to schedule appointments and providing follow up care, like explaining medications once a patient has returned home.
There are, however, other ways the payment system can recognize the value of nurses’ work and how it impacts people, especially for those who experience the negative impact of social determinants on their health, like working an hourly job that doesn’t give them enough time to seek preventative treatment.
Dr. Chen describes how these models are different from fee for service, which is currently how most of the U.S. health care system operates.
Dr. Marshall Chen (27:31): These alternative payment models, there is an opportunity then to think about, if you’re giving us up front money, there are these terms like global payments, capitated payments or per member per month payments, as examples.
Dr. Scharmaine Lawson (27:43): Alternative payment models and value based payments are complicated. But essentially, these models are focused on investing in quality where payment is given up front with the expectation of better outcomes and results. This shifts the incentives for the health care team and system to provide high quality care that achieves better results, rather than incentivizing providing the most expensive care.
Dr. Marshall Chen (28:07): If you give us the money up front, that potentially enables you to direct that money towards some of this nurse infrastructure that can address the patient’s medical and social needs. Something like team based care, again, it’s just generally not well reimbursed, if it all, under fee for service.
But if you can imagine though if you have up front money that you can invest in things like these nurse led care teams or care management programs or other associate personnel like community health workers, that provides you an opportunity to then create more logically designed systems of care that proactively address patient’s medical and social needs, of which nurses have a key, if not leading, role.
Dr. Scharmaine Lawson (28:46): As Dr. Chen mentioned, if we truly care about the health of the nation, we have to invest our resources into advancing health equity. Dr. Chen mentioned new payment models that can give health care organizations the flexibility to support key nursing roles, including care management and team based care, expanded scope of practice, community nursing and telehealth.
If you want to learn more about payment systems that promote health equity, check out chapter six of The Future of Nursing report where we go into further detail on how to incentivize these changes. These are such important changes to make because when payment models are reformed, nurses in all settings can then address the medical and social needs of the individuals they care for.
Dr. Ashley Darcy-Mahoney (29:34): It’s about how we value health and how we value health and wellness. And much of our health equity conversation centers around how do we keep people healthy. And we have to be able to provide high quality access to care for people.
What I hope the public feels and what our patients and the community want is that we want to make sure that we can give everyone access to high quality care and there have been and continue to be institutional and structural barriers that don’t enable us to provide that care. And if remove them, we’re hopeful that the nursing workforce can begin to move our country towards better health equity.
Dr. Scharmaine Lawson (30:18): Removing barriers to nursing scope of practice and valuing nurses’ contributions, these are both part of the larger strategy to advance health equity. And when these things are done, more people across the nation will have better access to high quality care.
There are a lot of key players in this mission to improve the health of the nation. In our next episode, we’re going to explore some nontraditional ways that nurses, nurse leaders and nursing organizations can collaborate together to address health inequities. Until then, if you want to learn more about this topic and what your organization can do to remove nursing barriers, check out The Future of Nursing 2020 to 2030 report. You can visit the report home page at nap.edu/nursing2030. And as always, thanks for listening.
Episode 4: Fully Support Nurses
Nurses’ work is often demanding and exhausting. Nurses face physical, mental, emotional, moral, and ethical challenges every day. These challenges can poorly affect nurses’ health and well-being, resulting in a burnt-out workforce and decreased quality of care. Nurses’ health and well-being must be supported so they can effectively care for patients, advance health equity, and improve the health of the nation. In this episode, we hear from frontline nurses and other health experts on how nurses are impacted when they experience challenges like burnout, racism, or are reluctant to report bad situations; and focus on what strategies should be taken to better support nurses and whose responsibility it is to do so.
The Future of Nursing Podcast — Download the PDF Episode 4: Fully Support Nurses Dr. Sharmaine Lawson (00:16): Nurses are committed to meeting the diverse and often complex needs of people every day. For many nurses, their careers include caring for the needs of people and communities with knowledge, care, and compassion. While nurses may be motivated by a deep sense of service and purpose, the work can be, and often is, demanding and exhausting. Nurses encounter physical, mental, and emotional, moral, and ethical challenges every day. These challenges shift depending on the nurse’s role and work setting. They can include managing and supporting the complex needs of multiple people, risk of infection, physical or verbal assault, having emotional conversations with families, confronting social and ethical issues or encountering health inequities such as food insecurity. As nurses have encountered these challenges, it’s very clear that nurse’s health and wellbeing are affected by both the demands of their work and the inadequate systems in which they care for people. Marcus Henderson (01:21): I think in cases where I have have not felt supported or a colleague of mine has felt supported, I mean, it really does damage to you as a person, as an individual and as a nurse, because it makes you feel as though that, well, what is my role here? What is my purpose in being here? Dr. Sharmaine Lawson (01:38): If the stresses and demands of nursing poorly impact a nurse’s wellbeing, well this in turn affects the quality and safety of care they’re delivering to patients. Dr. Marshall Chen (01:48): The more fundamental problem is that many nurses are not feeling well because of systems issues like understaffing, taking care of too many patients at the same time or feeling that they don’t have power, that they don’t have a voice in how the systems are organized and how cures delivered or nurses and other providers feeling that they can’t deliver the best possible care because what they’re supported for doing isn’t the best possible system for caring for patients. Dr. Sharmaine Lawson (02:19): If the health and wellbeing of nurses suffer, the health of the nation and suffers. This is the Future of Nursing, a series from the National Academy of Medicine, based on the recently published report, The Future of Nursing 2020-2030, Sharmaineting a Path to Achieve Health Equity. I’m Dr. Sharmaine Lawson and I’m a nurse practitioner, and I’ll be taking you through the stories of nurses confronting health disparities, and together we’ll learn how nurses can use their unique skills, knowledge, and dedication to address health inequities and overall improve the health and wellbeing of the nation. There are many stressors that can impact nurses health and wellbeing. In this episode, we are going to focus on three: burnout, racism and the reluctance to report when things go wrong. We’re going to learn what it’s like for nurses to encounter these issues and what should be done to better support them. Burnout for nurses is not new, but the COVID 19 pandemic especially exacerbated the severity of existing burnout, compassion fatigue, and mental health stressors experienced by nurses. Burnout is characterized by one or all three of the following characteristics: emotional exhaustion, apathy, and/or a low sense of accomplishment at work. Marcus Henderson (04:09): Burnout can take many different forms. Dr. Sharmaine Lawson (04:12): That’s Marcus Henderson. Marcus is a practicing psychiatric mental health nurse and was a member of the Future of Nursing 2020-2030 Consensus Study Committee. Unfortunately, Marcus has been all too acquainted with burnout. Marcus Henderson (04:27): One example of how burnout has surfaced in my clinical practice experience has been when I work from seven to seven and there oftentimes not being a nurse coming to relieve me. Now I’m tired, I’m exhausted. And I have to come back in here the next day, and I’m tired and exhausted and I might make an error. I might have poor judgment. But you’re relying on me to fix your problems when you’re not thinking about how all of this is impacting me. And there’s a lot of evidence out there about how long work hours and shift work impacts nurses’ health and wellbeing negatively. Dr. Sharmaine Lawson (05:06): Marcus’s burnout was attributed to many things. The main factor being that his health system was understaffed. As a result Marcus was overworked. Not only did Marcus feel exhausted from being overworked, but he began questioning whether the health system, he worked under truly prioritized his wellbeing. Marcus Henderson (05:27): I know many nurses that that’s how burnout has festered in their careers, is that the system use you as expendable. Well, if you can’t do it, then I’ll just replace you. But while you’re here, I’m going to suck out as much as I can. Dr. Sharmaine Lawson (05:41): As nurses experience the consequences of working with little support in an understaffed system, it can lead them to question their value. Marcus Henderson (05:51): When we talk about the lack of support, do I feel valued by the system? Do I feel as though my contributions are recognized? Do I feel as though that I have the resources to provide patient care? Dr. Sharmaine Lawson (06:04): There are several factors that can create an environment in which nurses feel the strain that leads to burnout. These factors can include high workloads, staff shortages, extended shifts, and the burden of clinical documentation. Dr. Kenya beard, who we heard from in previous episodes has witnessed how these factors have placed an unrealistic and unsustainable expectation on nurses. Dr. Kenya Beard (06:30): When we talk about nurses who are under-supported, first with COVID, we’ve seen some pretty unrealistic demands placed on nurses across the board, which has impacted patient outcomes. But high workloads, the high workload demands, they are not new to nursing. Dr. Sharmaine Lawson (06:49): Burnout creates a big risk, and that is, it puts the nurses’ mental health in danger. And this must be acknowledged in the workplace. Dr. Kenya Beard (07:00): When I get evaluated as a nurse, I should be asked, first of all, do you feel supported? We have seen that nurses are at a higher risk for suicide than the general population. Dr. Sharmaine Lawson (07:11): Even before the pandemic began, suicide risk was twice as high among female nurses compared with American women as a whole. Dr. Kenya Beard (07:25): How are you protecting your mental health and your wellbeing and what is it that I can do to help support your wellbeing? I think institutions need to recognize that when we talk about wellbeing, it has to be operationalized in a way that wellbeing becomes a core value. And when we talk about core values, we know that hospitals are actually demonstrating that it’s important. Dr. Sharmaine Lawson (07:56): There are several things that institutions can do to prioritize nurse wellbeing and monitor for burnout. It starts with leadership choosing to routinely check in on their nursing staff. Dr. Fidel Linda Lim (08:07): Just sensing something from a staff member, having that extra feeling that, Gee, one of my staff maybe is not feeling well today, or maybe this is something unique or a new experience that he needs to to process. Dr. Sharmaine Lawson (08:23): That’s [Dr. Fidel Linda Lim. 00:08:25]. Dr. Lim has worked in nursing for 33 years, both in critical care and as faculty in nursing education. Throughout his career, Dr. Lim has seen why it’s critical for nurse managers to consistently check in on their staff. Dr. Fidel Linda Lim (08:41): So it’s a personal commitment by the nurse manager on a given day. You know, suddenly a stress environment or a crisis comes in, you’re trying to balance your staffing. That random check-in huddle with your staff, I think is vital in showing your support. Dr. Sharmaine Lawson (09:02): One of Dr Li’s former students is a practicing frontline nurse. Frank Boz is a nurse in the cardiothoracic intensive care unit. During the height of the COVID 19 pandemic, he personally experienced how the right kind of support from hospital leadership can make a world of difference in difficult times. Frank Boz (09:21): During the COVID 19 pandemic, it was a very stressful situation. We were overwhelmed with the amount of patients and admissions and the amount of work and the leadership, the institution I work, they were rounding on the staff and holding staff meetings and also having town halls where the staff was able to come in and ask questions so that they can have their concerns answered and that everyone can be kept in the loop. And that we all had a sense of what was going on and where we were standing at the time. And that sense of transparency, that communication from leadership, from management to the staff, really provided me with the support that I didn’t expect, especially when during this time we were all overwhelmed with the amount of work. We were overwhelmed with the amount of patients we had to take care of as staffing was also an issue. And just to have the managers, the leadership, round on you on your busiest days, on your busiest moments, meant really a lot. It provide a sense of ease to myself and to my colleagues as well. And I think that idea of having open communication and transparency between leaderships and nursing staff and healthcare workers meant a lot for a lot of us. Dr. Sharmaine Lawson (10:44): Open communication and transparency between leadership and nursing staff can help create an environment where nurses not only feel cared for, but they also feel safe to request support. Therefore it’s so important that hospital leadership commit to personally supporting each member of their staff. When it comes to situations that cause burnout, the responsibility to support nurses doesn’t just fall on nursing leadership. It’s the responsibility of the health system overall. But according to Dr Beard, our health system has not been known to fully support nurses. Dr. Kenya Beard (11:24): It’s difficult because we have inherited systems that have not always been kind to nurses or really appreciated the role of a nurse. And I use the example, if I was a surgeon and I was in the middle of surgery, no one would interrupt that surgery to ask me to come out and address an issue with one of my patients who had surgery, who might have an infection now, and they might need something. There would be someone else to deal with that. And that’s how the system is designed to support surgeons. But where is that support for nurses? Dr. Sharmaine Lawson (12:10): When nurses are under supported, it’s not just their wellbeing that suffers. Dr. Kenya Beard (12:17): So when nurses cannot keep up with external demands and they feel that they are under supported, everyone suffers. Hospitals suffer because when nurses leave prematurely, it costs hospitals millions of dollars. And we cannot simply replace nurses without thinking about the collateral damage that a nurse’s departure has on an institution. When a nurse leaves, they leave with knowledge and besides the hospital suffering, patients end up suffering because the quality of care is jeopardized. Dr. Sharmaine Lawson (12:53): When nurses suffer from burnout, the entire health system suffers. Patients may not receive the best quality of care. Hospitals may experience high turnover rates and costs of care may increase as well. Costs of nurse turnover are high. Hospitals can end up spending between $3.6 to $6.1 million a year, just on turnover alone. To prevent this structures in the health system need to change. Dr. Marshall Chen (13:27): The bigger solution is redesigning our systems of care so that nurses don’t get burned out. That nurses should not be in this position where they’re under difficult work circumstances that cause the poor wellbeing or the burnout. Dr. Sharmaine Lawson (13:46): That’s Dr. Marshall Chen. Dr. Chen is a general internist and health equity researcher at the University of Chicago and was also a member of the Future of Nursing 2020-2030 Committee. Both Dr. Chen and Dr. Beard recognize that to redesign systems of care, we need to figure out exactly what in the health system has contributed to nursing burnout. Dr. Kenya Beard (14:09): We have to recognize and own up to the ways in which some of our policies and practices have historically undermined the wellbeing of nurses. For example, when we arbitrarily assign a nurse to X number of patients, what are we saying? That the needs of the patients, the experience level of the nurse, the situation, or the dynamics of the institution, those things don’t matter? To say that a everyone can take care of X number of patients is faulty reasoning and contributes to burnout. Secondly, since wellbeing is so critical to the role of nursing, it has to be an integral component of evaluations. Nurses should be asked what they’re doing, what they need and what the institution can do to better support wellbeing. Dr. Sharmaine Lawson (14:57): To better support others, nurses must be fully supported by the health system. Throughout his research Dr. Marshall Chen has observed that health systems need to adopt a more holistic approach. One that acknowledges the needs of both the nurse’s wellbeing and the individuals they care for. Dr. Marshall Chen (15:17): Nurses are the health providers. They would love systems where they have the time to comprehensively address the medical and social needs of patients. Right now, they’re not supported for that. Specialist social needs really is an afterthought because even though everyone knows it’s important, the systems don’t pay for spending a lot of time with patients to address social needs. So that’s an example, a very concrete example of how we need to have the two-prong approach, both supporting the nurses who does not have wellbeing at the same time, creating the best possible systems of care to address patients medical and social needs. That will also enable nurses and other health professionals to have a better wellbeing. Dr. Sharmaine Lawson (16:06): We have to acknowledge however, another major issue that impacts nurses health and wellbeing, and one that can also contribute to burnout: structural and cultural racism and discrimination. These issues have always been present, but are now receiving the widespread recognition it has long deserved. Historically nurses have encountered racism and discrimination from employers, colleagues, and patients. These racist and discriminatory actions can be made against themselves or against their colleagues. Marcus Henderson, the frontline nurse, who we heard from earlier experienced a moment like this during the summer of 2020, Marcus Henderson (16:52): I was taking care of a patient, a white patient, a white child, from a suburb of the city and I deal every day with anxious parents or guardians who are worried about their child being in the hospital and trying to kind of ease their anxiety, talk to them about the experience. But this child’s parent was particularly challenging. And at this time their was no hospital visitation. So no parents could come in and see their child. They could only speak with them over the phone and if we had Zoom capabilities which was only during the week. And this mother drove up to the hospital and came to the lobby and requested to speak with the nurse. So I do my job as I would with any patient. I walked up to the front lobby, the mother is there, anxious, and I begin talking with her about what’s going on, what to expect, call on Monday morning, ask to speak with your social worker and ask these questions. Kind of like helping her to advocate for herself and her son. And the woman looks at my colleague sitting at the front desk, a black woman. She turns her back to the woman sitting at the front desk and looks at me and says, “Is it those kind of people that work [inaudible 00:18:00] here? Because my son isn’t exposed to those people.” I was in shock. I never said anything about race. I just said, “Your son is doing well in the unit. He’s interacting with all of the children. He’s playing appropriately. He’s excited. He has a bright affect. He’s very engaged in groups and in therapy. So your son has not identified any issues with his interactions with other patients on the unit and our staff on the unit.” Dr. Sharmaine Lawson (18:33): Marcus found himself in a dilemma. He had to address the patient’s family member, but he also didn’t quite know how to immediately address their racist behavior. Marcus Henderson (18:45): Most of the patients that I work with are children of color and the staff that I work with, most of them are people of color. And I remember reflecting on that experience of was I wrong to not call out her acts of racism in that moment? I think that I had the appropriate response. I didn’t feed into the prejudices and the racism that she was giving off. Dr. Sharmaine Lawson (19:07): Marcus was also unsure of how to handle this situation because of his own identity and lived experience. Marcus Henderson (19:15): I’m biracial, I’m African American and white. Most people don’t recognize that, but I think what just struck me the most was that she just had the audacity and she felt comfortable enough to look at me, say, okay, this is is a white man. So I’m going to ask him about the black staff here. That really was like this pivotal moment in my life that I was like, no, I can stand up for my colleagues. I can stand up for my family and people in my community that experience racism and discrimination because I lived experiences living in both worlds. Dr. Sharmaine Lawson (19:50): Marcus decided he could stand up for his colleagues and his community that have frequently experienced racist and discriminatory behavior. But even when nurses choose to stand against racism, racist actions still impact their wellbeing and their ability to provide high quality of care. Marcus Henderson (20:12): That happens all the time where patients say, “Can I get a new nurse?” I’ve heard where patients would request a new nurse because they didn’t want the black nurse that was caring for them. I think it’s really hard because clearly it can evoke a very emotional reaction when someone’s speaking to you and using racist language that’s directed towards yourself or your colleagues. I mean that evokes a really emotional response. So it’s really hard sometimes to kind of keep those emotions in, to maintain professionalism and go about your day in providing the services and the care that you’re there to provide. Dr. Sharmaine Lawson (20:54): Nurses are still human. It’s difficult for nurses to contain their emotions and maintain professionalism if a patient is hostile because of a nurse’s race or appearance. Some times a patient rejects their nurse or a nurse experiences discrimination because of their nationality, sexual orientation or disability. Nurse managers must acknowledge that this puts nurses, especially nurses of color, in a situation that can negatively affect their wellbeing. And they must be willing to support and protect the dignity of their staff through it. Marcus Henderson (21:32): I think many nurses like myself sometimes are uncomfortable with addressing that head-on themselves. So I think it really is important for leadership, your immediate supervisor, your nurse manager, whomever is supporting you at that moment in time, who comes in and kind of reiterates the kind of environment that the workplace is. This is an anti-racist work environment. We’re about inclusivity, excellence, diversity, and we pride ourselves in providing high quality care, regardless of who the individual that’s providing your care or the who the patient is. I think it’s important that the institution acknowledges when those things occur, holds themselves accountable, whether it’s a patient that’s committing the act, whether it’s a peer, a colleague, whomever, that there’s, there’s acknowledgement that it exists. There’s accountability and actions taken when it happens. Dr. Sharmaine Lawson (22:24): So what can institutions do to support nurses when they’re imp impacted by racism and discrimination? Marcus Henderson (22:32): I think first and foremost, institutions need to take a zero tolerance stance on any form of violence, of racism, discrimination, bullying, incivility, within the workplace. I think first and foremost, it’s a zero tolerance stance that if any of these things occur, it’s unacceptable. And we are going to do something about it. Dr. Sharmaine Lawson (22:57): After making it clear that racism and discrimination from anyone is not tolerated. Health systems must examine why these biases exist in healthcare in the first place. Dr. Marshall Chen (23:10): We need to have that hard look inwards within the health professions of why is there bias and structural racism within healthcare generally, or the nursing profession. What can we do to recruit more nurses of color into the profession? What can we do to support them when they’re in the profession so there aren’t these both outright explicit structural biases, as well as implicit biases that people have in all. We can do much better within healthcare. Nurses in basically all of healthcare would do much better regarding addressing the issues of structural racism within our professions. Dr. Sharmaine Lawson (23:53): Health systems may not be able to stop patients from speaking or committing racist acts, but health systems can support their nurses and fully back them should a nurse encounter racism. Health systems may not be able to stop harassment or discrimination, but health systems can examine the biases that perpetuate it. Frank Boz (24:13): I believe that institutions should have guidelines and standards against discriminations. They should reinforce, monitor and follow that these guidelines are being met just to make sure no one is feeling discriminated against. They should also have channels for nurses to be able to express themselves if they’re being discriminated against. They should make nurses aware that if they feel a certain way, they can speak up. Dr. Sharmaine Lawson (24:44): Hospitals can and should set up a clear system where nurses can safely report incidents of racism, incidents of bullying from peers or incidents of workplace violence. The problem with this is that many nurses are hesitant to report these issues. Marcus Henderson (25:01): Many nurses and other individuals are afraid to report incidents of violence, experience of racism, discrimination, being bullied by peers, because when they report, it is again the nurse is blamed or there’s retaliation against the nurse for reporting such an incident. Dr. Sharmaine Lawson (25:22): Dr. Regina Cunningham, who we heard from in our last episode is a CEO at the hospital at the University of Pennsylvania, and was a member of the Future of nursing 2020-2030 Committee. Throughout her career she’s also witnessed why nurses feel so discouraged to report problematic situations. Dr. Regina Cunningham (25:41): They should make sure that reporting issues is not something nurses are penalized for. I mean, sometimes nurses are afraid to report issues within an organization because they’re afraid that they’ll somehow be penalized for it. Dr. Sharmaine Lawson (25:53): Unfortunately, what Marcus and other frontline nurses have observed is that when nurses report certain incidents, employers don’t always prioritize supporting them in return. Marcus Henderson (26:04): The frame is not, I’m so sorry this is happened to you. Let’s work to ensure it doesn’t happen again. It seems as though that employers and institutions are trying to maintain the status quo or protect themselves rather than protecting the people that work there. Dr. Sharmaine Lawson (26:21): There’s no point to a reporting system if the employer doesn’t take the nurse seriously, and if the employer doesn’t take the nurses concern seriously, the nurses will never be fully supported. A reliable reporting system must be thorough. And employers must take several steps to find the root causes behind workplace incidents. Marcus Henderson (26:47): But if we have a system of reporting where an individual reports an incidence of violence or racism, discrimination, bullying, and then that triggers a process of let’s get to the root cause of what happened. Let’s really take in all the facts and information. Let’s examine how the system itself, how the institution itself, through its policies, procedures, structures and practices, might have contributed to this issue occurring. What prevention strategies do we have in place already that failed to protect the individual from experiencing this issue? And then taking that at, and actually developing solutions to the problem and ensuring that it doesn’t happen again. So it’s taking that more proactive approach with reporting rather than a retaliatory and reactive approach to reporting, I think is very, very important. Dr. Sharmaine Lawson (27:39): Like we mentioned before, employers can’t always control the actions of others. They can’t stop a patient from making a racist statement. They can’t control if one nurse decides to bully their colleagues and they may not be able to immediately stop a patient’s attempt to physically or verbally assault nursing staff, but they can control how they respond to these situations. And they can and should respond by not tolerating poor behavior, listening to the nurse, investigating the situation, providing resources and support to that nurse, and then taking the next step by looking at what root causes lay behind the situation. Nurse leaders can shape the day to day work life of nurses. They have the power to set the culture and tone of the workplace. They can develop and enforce policies and they can serve as exemplars of wellbeing. When it comes to supporting nurses, it’s the responsibility of policymakers, employers, nursing schools, professional associations, and nurses themselves. Nurses must consistently check in with themselves and monitor if they are supporting their own wellbeing. Are they getting enough sleep? Are they incorporating physical activity and a healthy diet into their lifestyle? How is their mental health? And if they notice that their well-being is struggling, they must then ask themselves why? As nurses support their own health and wellbeing, employers must do everything possible to create safe work environments that alleviate the natural stressors and demands of the nursing profession. And to do this, health systems must be willing to invest their resources into supporting nurses. Dr. Regina Cunningham (29:35): There’s always a finite amount of resources. So when you say something’s a priority, it often means that you are going to invest resources in getting it done. So organizations need to prioritize. They need to take a long view here because we know that by supporting nurses to do this work, we know that environments that support nurses actually have improved outcomes. I mean, there’s decades of empirical evidence about this, about the importance of supporting nurses in the work environment and how that connects to better outcomes for patients. Dr. Kenya Beard (30:09): That’s how we begin to right the ship. And we could take a lesson from the airline industry and create a culture where it is expected that nurses put the oxygen mask on themselves first. And when there’s turbulence, there’s an audible, flight attendants, take your seats. However, it’s my belief that nurses tend to put the mask on others at their own expense. Dr. Sharmaine Lawson (30:34): Nurses are taking on more responsibilities to address health equity, but we can’t expect them to care for patients, advance health equity, and improve the health of the nation until health systems implement structures that support and protect nurses health and wellbeing. In our next episode, we’re going to look at the barriers that stand in the way of nurses practicing to the full extent of their education and training. And we’re also going to explore how nurses contributions can be valued more until then, if you want to learn more about this topic and what your organization can do to fully support nurses, check out the Future of Nursing 2020-2030 report. You can visit the report homepage at nap.edu/nursing 2030. As always, thanks for listening.
Episode 3: Preparing Nurses to Better Understand and Address Health Equity
Now more than ever, nurses must be prepared to recognize when an individual is struggling due to health disparities and feel equipped to deliver the appropriate care to that person. In this episode, we hear the stories from nurses and other health experts that explore how educators and employers can better prepare nurses to understand and address health equity through strengthening nursing school curricula, mitigating implicit bias, and increasing diversity in the nursing workforce.
Episode 3: Preparing Nurses to Better Understand and Address Health Equity
Dr. Scharmaine Lawson (00:16): The demographics of the United States are shifting and the population is becoming increasingly diverse. With the landscape changing like this, nurses need to be prepared to recognize health inequities and address them now more than ever. This kind of preparation doesn’t just happen naturally. And historically, schools and health systems have not thoroughly equipped their nurses to understand, identify and act in addressing health disparities. If nurses aren’t trained to tackle health inequities, the health outcomes of the nation will suffer. Remember Dr. Bowen? We heard from her in our last two episodes. Early in her career, she saw the impact of health disparities on her patients every day. There was one moment though that stood out to her and made her realize when nurses are not trained or equipped to address health equity issues, patients can really suffer. And just a forewarning, this story contains graphic elements that might be unsettling to some listeners.
Dr. Bowen (01:16): I was a young nurse, was working a Saturday in our little acute care center. I was on active duty in the military and a retirees’ wife. This woman’s family brought her in and she couldn’t walk, so we put her in a wheelchair, brought her into a room and they were just sobbing. My mom, she was up, she was doing well, now she’s incontinent. The woman was alert and oriented but just really weak though. It was time for me to do my assessment and I went to listen to her chest and her shirt, it was just wet with liquid on the chest. And when I opened the shirt, there was this huge tumor that had lifted away from her chest. And I thought, oh my God, how did this happen? She had breast cancer and she was dying. That’s when things really hit me in the face, like she shouldn’t be coming in like this. Where was all of the in between care? Why didn’t anybody find this sooner?
That interaction has just been drilled in my head and I will never forget that woman or her family and was like, well, where is she going to go? She needed to be at a major medical center. At that time, I know the only treatment that she would’ve gotten would’ve probably have been palliative at that time to maybe help reduce pain, but there were no resources to even get her there. There were no resources to get her there. She just wanted to go home and get her affairs in order because she knew that she was going to die.
Dr. Scharmaine Lawson (03:10): The nature of this moment was tragic enough as it was, but what really stood out to Dr. Bowen was that she had never been prepared to deal with a situation like this.
Dr. Bowen (03:22): That was really, really hard for me. That was super hard. I felt like, here I am a nurse, why am I okay? I wasn’t okay. But this lady’s just going home and I didn’t have the skills. I didn’t have the skillset. I didn’t know what to call it. I just knew it was not fair. Now, looking back, I recognize that what I was seeing was one of the most ugliest pictures of health disparities where black women usually enter healthcare system with cancers that are more advanced and they die when we have all of this really good treatment out there, but you’ve got to get people in. We’ve got to get them the preventive care that they need. I don’t want any other nurse to ever experience that.
Dr. Scharmaine Lawson (04:14): Now Dr. Bowen is determined to prepare student nurses so that when they face a situation like this, they’ll know exactly what steps to take to achieve a better outcome.
Dr. Bowen (04:25): And we need to teach our students that. We need to help them so that they’re empowered so that they can be advocates on behalf of the patient. A lot of people say I’m going to go home. What that means is I’m giving up because no one’s going to do anything for me. How can we be a voice for them, and I wasn’t a voice for her or her family. I didn’t know how to use my voice.
Dr. Scharmaine Lawson (04:52): When health disparities threaten people, whether they are patients in the hospital or individuals in a community, nurses should feel empowered to use their voice.
This is the Future of Nursing, a series from the National Academy of Madison based on the recently published report, the Future of Nursing 2020-2030, charting a path to achieve health equity. I’m Dr. Scharmaine Lawson. I’m a nurse practitioner, and I’ll be taking you through the stories of nurses confronting health disparities, and together we’ll learn how nurses can use their unique skills, knowledge, and dedication to address health inequities and overall improve the health and wellbeing of the nation.
In our last episode, we discussed health equity, how it impacts people and why we need nurses to improve the health outcomes of the nation. In this episode, we’re going to look at how we can better prepare nurses to understand and tackle the problems that arise from health inequities. We have to first acknowledge, however, that health equity has not been a critical component of nursing school curricula. Employers have not consistently trained their nurses to always recognize social factors that impact health and nurses may even come into their positions with their own prejudices and biases. What this means is that right now, many nurses are not prepared to treat people from all backgrounds and experiences.
Dr. Bowen (06:34): We need our different skillsets. When I was in school, there may have been transgendered patients but I wasn’t taught how to care for them. It’s important that our nursing students come out with that information. How do you do a health history on a transgendered male or a transgender woman? We have knowledge, we have language, we have skills, we have tools. We need to equip our young nurses to be able to enter their careers with a toolkit and a skillset that they need to be able to care for all people.
Dr. Scharmaine Lawson (07:15): It’s urgent to fix this lack of preparation because nurses across all settings are in some of the best positions to address health inequity when they meet with the people they care for.
Dr. Regina Cunningham (07:27): They’re often the group that spends the most time interacting with patients who are with the people that they care for.
Dr. Scharmaine Lawson (07:33): That’s Dr. Regina Cunningham. Dr. Cunningham is the chief executive officer of the hospital at the University of Pennsylvania. She started her career as an oncology nurse before eventually going into nursing administration. Throughout her career, she saw the unique skills that nurses bring when it comes to recognizing social determinants of health.
Dr. Regina Cunningham (07:52): I think that it helps them to establish relationships and an understanding of the unique needs of people, their unique perspectives and their circumstances. So what is the context that they’re coming in with? Where do they live? Where do they work? What is it about their sort of personal situation circumstances? And we know that all of these things have an important impact on health outcomes and health equity. And so nurses’ ability to communicate and understand people where they are is a huge benefit in terms of thinking about health equity. They bring clinical knowledge and a multiplicity of competencies to the table. So they have, in addition to their clinical knowledge, knowledge about health promotion. They understand systems thinking, which is really important as we think about health equity.
They have an understanding of how healthcare systems work and how communities work, how the public health system works, and they have a history, a long history of focusing on people’s social needs. So you could look back in time and look at the role of nursing in terms of addressing these social needs. So that’s also important. They also have a lot of complex problem solving skills which also come into play as you think about the complexities that we’re challenged within the health equity space. And probably very importantly, they are a group that the public has a great deal of trust in. And so, all those are important variables and when we think about driving improvements in health equity, these are some of the unique characteristics that nurses would bring to a professional team table.
Dr. Scharmaine Lawson (09:28): Nurses have the unique knowledge and position in a healthcare system that allows them to advance health equity. But to do this, they need to be properly educated and prepared both in school and in the workplace to understand all the factors that impact patient health outcomes.
Dr. Noelene Jeffers (09:44): It’s really important, I think, to make sure that our nurses are structurally competent.
Dr. Scharmaine Lawson (09:50): That’s Dr. Noelene Jeffers. Dr. Jeffers is a certified nurse midwife at Unity Healthcare in Washington, DC, and is also a post doctoral fellow in maternal and child health at the John Hopkins School of Public Health. In her experience, Dr. Jeffers has realized that nurses need to learn about the deeply rooted issues that influence health outcomes.
Dr. Noelene Jeffers (10:11): Do they understand how the diseases, disorders, experiences of patients are completely influenced and driven by things like racism and other biases and oppressions. We’re not currently doing a great job of that, but it needs to be fully integrated into how we structure our curriculum, how we structure our classes and making sure that our students are familiar with and that they feel comfortable with trying to identify like, hey, what’s actually going on here? Are we educating nurses about these root causes? Is racism a word that is even spoken about on a daily basis? Are we really fully integrating anti-racism, anti-oppression, anti-bias frameworks into our curriculum?
Dr. Scharmaine Lawson (11:12): This begs the question, whose responsibility is it to prepare nurses to understand health equity?
Dr. Regina Cunningham (11:18): It’s a lot of different people’s responsibility. Let me start with nurses themselves. I mean, nurses have a responsibility to educate themselves. It’s the responsibility of nurses themselves to ensure that they are keeping up to date. As they get continuing education, that they’re keeping their education up to date.
Dr. Scharmaine Lawson (11:36): Nurses bear the responsibility to continue their education. But it’s not just on nurses to prepare themselves to deal with health equity issues. All healthcare organizations share the responsibility to educate and equip their nurses to advance health equity.
Dr. Regina Cunningham (11:57): I feel like there are things that we need to do as healthcare organizations in order to help advance health equity. We need to educate nurses that are already in practice as I mentioned before. We need to begin to incorporate elements of these issues into everyday practice. And just to give you an example to kind of bring that to life, we know that factors like housing and food security, these are important issues for patients. And so nurses in the acute care setting can incorporate some of these things into their systematic assessments that they do when patients come into the hospital. They can look at those data and incorporate them into the planning process that goes around sending patients back home after they’ve been in the hospital.
Dr. Scharmaine Lawson (12:43): It is essential to specifically train and educate nurses to consider these social factors during patient assessments. It will allow nurses to better understand the various factors, both medical and social, that impact an individual’s health outcomes. The first strategy that can help better prepare nurses to recognize and identify the factors that impact patient health outcomes is to adjust the nursing curriculum.
Dr. Regina Cunningham (13:15): If we really want to drive health equity in this country, then we must support and prepare nurses to be able to do that because this wasn’t included in their historical curricular content. And not just in the didactic component, but it really hasn’t been a focus of the clinical education or the clinical experiences that nurses have while they are in school.
Dr. Scharmaine Lawson (13:39): We heard from Dr. Bowen at the beginning of this episode. Dr. Bowen understood that there were certain things that adversely affected health outcomes in the community she practiced in, but she also realized that many student nurses may not be educated in recognizing these things as health disparities.
Dr. Bowen (13:57): When you drove through the neighborhoods, you look at what’s there. Are there playgrounds? Where is the nearest grocery store? All of those things that I just knew if I went into a certain community, there wasn’t going to be these resources that I need. I didn’t know that there was something called a food desert. I didn’t know it was called a food desert. I just knew that in certain towns and certain parts of towns, people didn’t have access to the pharmacy, to a good grocery store. Kids didn’t have beautiful playgrounds or parks to play in.
Dr. Scharmaine Lawson (14:30): People who experience food insecurity are likely to have poor health outcomes because they don’t have access to nutritious foods. And kids who live far from playgrounds may experience poor health outcomes because they don’t have a safe place to run and play. These are the kinds of things that nurses need to be aware of when these individuals walk through the clinic doors. But teaching nurses to recognize social determinants of health and diversity, equity and inclusion, well, let’s just say it takes more than just inserting one course into the curriculum.
Dr. Bowen (15:05): People think, oh, there’s a course, like I worked someplace before and we have had a course. DEI is not a one course thing. It affects every part of a person’s life. And so it needs to be threaded throughout the curriculum. It’s not just black/white, it’s young/old, it’s around resources, it’s economics, and black, white, purple or brown. If you don’t have money, you’re probably going to have poor health. So if you don’t have money, you’re probably not going to live in the best neighborhoods or the best homes. Your homes may not be safe for your kid. It’s 2021 but there are still homes that have lead paint in them. There’s still homes where the pipes are not earthed and children are becoming lead poisoned.
Dr. Scharmaine Lawson (16:00): Nursing curricula needs to have these topics on health equity integrated throughout all courses. We mentioned earlier, however, that historically, health equity has not been prioritized in nursing school curricula or has only been found in one course, often public health nursing, at the end of the curricula.
There are a few unfortunate reasons for this.
Dr. Regina Cunningham (16:24): Health equity hasn’t been addressed and prioritized in curricula in nursing education because it hasn’t been identified as an important priority for nursing. One of the benefits of the National Academy of Medicine report on the Future of Nursing 2020-2030 is that providing this clarity and providing this direction will provide a sense of where schools need to go and what they need to focus on for the future of nursing. So it gives us an opportunity to kind of refocus and to look at what really needs to be done.
Dr. Scharmaine Lawson (16:57): Not only has health equity not been identified as a priority for nursing, but nursing curricular is already so full of information. Dr. Greer Glazer has spent a lot of time examining this issue throughout her career. After years working as a staff nurse in women’s health, Dr. Glazer became the Dean at the University of Cincinnati College of Nursing.
Dr. Greer Glazer (17:19): Well, one thing is this, our curricula are jam packed with many, many facts and lots of information about diseases, medical conditions, a lot of sciences, microbiology, organic chemistry, all kinds of things. So there’s a real question here on what can be taken out of our curriculum so that it’s replaced by these things that have been identified in the Future of Nursing report like delivering person-centered care so we have content on cultural humility, trauma-informed care, motivational interviewing, lots more on mental health, substance abuse, elderly, information technology, data analytics, policy. So we’ve got so much content that we may touch on but it really needs to be covered in a much more in-depth way. And we’re not going to be able to do that unless we take away some things.
So we really have to be able to take a look at all of our curricula and decide what’s really important now and if we really want to achieve health equity in the United States, what is it that we need to make room for and then what can we take out? It will mean a real transformation of our curriculum because we’ve done very little with health equity. We address these things in a cursory manner in community health nursing courses. There is a course in almost every nursing school on community health nursing. We talk about some of the social determinants but as far as our assessment of factors, our intervention with these factors, our evaluation with these factors, we have a long way to go.
Dr. Scharmaine Lawson (19:11): Adjusting the curriculum is not just a one time fix because like we mentioned earlier, with each year, the population of the United States becomes more and more diverse.
Dr. Regina Cunningham (19:23): In order to really effectively prepare the next generation of nurses, schools need to sort of constantly assess their curricula and make sure that it’s really reflecting contemporary practice and the changing trends. And so in this case, as we outline the plan for nursing, the role that nursing can play in health equity, this is an important contribution changing how we look at curriculum.
Dr. Scharmaine Lawson (19:44): There are many topics on health equity and social determinants of health that must be integrated throughout nursing curricula. Earlier, we heard from Dr. Noelene Jeffers. On top of being a certified nurse midwife, Dr. Jeffers is also an adjunct faculty member at Georgetown School of Nursing. She’s seen some topics come up in her classes over and over again, topics that she realized must be incorporated into the nursing curriculum.
Dr. Noelene Jeffers (20:12): Oftentimes something that may come up either in my classes or even in my clinical practice is sort of the use of the term non-compliance and like, oh, what do we do about this patient that’s non-compliant and whatnot. When you’re thinking about sort of teaching nurses what it means to be structurally competent, sort of aware of how social determinants of health are shaping clients and their experience of health and their outcomes, examining sort of the use of the phrase non-compliance is a great start. Why, because, hey, non-compliance is completely born out of our tendency to blame clients and patients instead of being aware of, hey, what’s going on in their life, in their individual life, and what’s going on with sort of the system and the structures around them that’s sort of contributing to this.
So, hey, they haven’t been to their last two prenatal visits. Okay. It’s not likely that they don’t care about their health or the health of their baby. In fact, what’s more likely is that, hey, they may live in a maternity care desert and they may have to take two buses and a train in order to get to their prenatal visit. They just don’t have the transportation. So thinking about sort of what barriers our clients are facing instead of blaming them I think is… That’s just sort of one example that I could potentially utilize, but sort of reframing what has historically been seen as sort of individual deficits.
Dr. Scharmaine Lawson (21:52): It’s this kind of thinking that advances health equity. With this kind of thinking, nurses can look at an individual’s home and personal life and ask what other factors might be influencing this health outcome. This enables nurses to look at an individual’s poor health outcome and not immediately blame them for it. By prioritizing health equity in nursing curricula, nurses can gain the foundational knowledge of what social determinants of health are, how to notice them when they impact an individual and what steps can be taken to deliver the best quality care to that person. There’s another step that needs to be taken to prepare nurses to work with people from all backgrounds and experiences. During school, student nurses go through clinical rotations where they get supervised, hands-on experience working in a clinical setting. However, most of these rotations happen within the hospital setting and this may not set up nurses to understand and identify social determinants of health in various communities.
Dr. Greer Glazer (22:53): We need to be able to provide clinical experience in every one of the clinical specialties. So it’s pediatrics, women’s health, adult, geriatrics, psychiatric nursing. All of the areas that we do clinical, there should be experiences out of hospital. Should be out in the community, should be in community centers, should be in federally qualified health centers, should be in people’s homes, in places of employment, in schools. There’s so much to be said and there’s a lot written in the report about the benefit of school-based health clinics and people receiving care in schools. But I would bet that very few nursing students get experiences in those places.
Dr. Scharmaine Lawson (23:38): If nurses aren’t educated and trained in community settings, it’s going to be difficult for those nurses to then recognize the impact of social determinants of health outside of outpatient and traditional care settings. By expanding clinical rotation sites to community settings, nurses can have a supervised experience as they learn what it means to recognize inequities and advance health equity.
Dr. Regina Cunningham (24:03): Moving a little bit away from some of the very traditional spaces where nurses have had their clinical training is very important in advancing health equity as well. So thinking about more community experiences, more clinical experiences in non-traditional spaces such as more community settings, community centers, schools, the school nursing as a clinical experience, prisons, other types of environments are really, really important for nurses to gain some clinical experience. So moving away from some of the very acute care focused hospital type experiences is something that will also be really important.
Dr. Scharmaine Lawson (24:45): It has to be acknowledged that while strengthening curriculum and expanding where nurses train are necessary steps, there are still other obstacles nurses will face when working in and with communities and these obstacles will stem from their own personal biases. This goes for student nurses and nurses who have been practicing for years. Dr. Kenya Beard, who we heard from last episode, remembered an experience where she personally saw what happens when a nurse’s implicit bias gets in the way of caring for someone.
Dr. Kenya Beard (25:18): We don’t prepare nurses to talk about race and racism and what happens. That fuels frustration and nurses feeling anxious and upset. So family members in the hospital, he received pain medication and the pain medication didn’t work. The pain was getting worse. So when I brought this to the nurse’s attention, when she came into the room, the first thing she said was, do you have a drug problem? So I called her out on this after the fact and I spoke to her and the nurse manager. The nurse was upset that I would have the audacity to suggest that racism played a role in the question that she asked.
And I was trying to make this a teachable moment where she could understand that all of us, we all have inherent biases and we have to talk about them because not talking about it, muting the conversation does nothing to help us to move to where we need to get to. She had a hard time understanding that, but then I had to realize she had not been trained to deal with bias. So when someone presented it to her, she didn’t have the skills nor the capacity to respond in a way that was humbling, that could recognize, wow, why did I ask that question?
Dr. Scharmaine Lawson (26:52): This can be a common experience in many health settings and it’s important to understand that it’s not just a select few who are clouded by their own prejudices and biases. The co-chair of the committee that authored the Future of Nursing report, Dr. David Williams, made it clear that everyone has implicit biases.
Dr. David Williams (27:13): Implicit bias is something real. I like to tell my students that I think of myself as a prejudice person. You look at me with surprise. I said, yes, I think of myself because I would like to think of myself as a normal human being. And I say, if you are a normal human being, you’re probably prejudiced. Not just racially prejudiced because it’s not just about race. Every culture, every society has in groups and out groups, groups that are viewed positively and groups that are viewed negatively. And what research finds is when we meet someone for whom we have a deeply embedded stereotype in our mind, negative stereotype, we will treat that person differently. Maybe you don’t have a racial stereotype, but what are the negative stereotypes you have about fat people, about gay people, about women, about old people, all of these biases that shape what we do.
Dr. Scharmaine Lawson (28:05): To effectively tackle health inequities, nurses must honestly confront their own biases. But schools and healthcare systems should also support nurses by guiding them through this process and protecting them from any retaliation.
Dr. Kenya Beard (28:22): I think we have to examine policies and practices that have created inequities and have the courage and conviction to call out disparities, ensure that all nurses are protected from retaliation, that all nurses are trained on implicit bias and how it emerges, especially when we’re feeling anxious are rushed or afraid.
Dr. Scharmaine Lawson (28:47): Mitigating bias in healthcare systems requires more than implicit bias training because unfortunately, some people’s minds are already made up.
Dr. Noelene Jeffers (28:56): I know that there has been a lot of energy around sort of, okay, let’s bring in implicit bias trainings into the workplace. I think that we don’t have good evidence about whether or not implicit bias is going to change the hearts and minds of individual nurses and other healthcare providers. But I think it’s definitely something that we should be researching. So I think that at this point, in many ways it almost becomes less about sort of convincing people that are racist not to be racist anymore and it’s more about putting systems and structures in place to decrease the impact of racism on health and healthcare.
Dr. Scharmaine Lawson (29:39): There is a strategy to decrease this impact that biases, racism, and discrimination may have on health outcomes. We briefly talked about it in our last episode on health equity. To better prepare health systems to treat people from all backgrounds, it is critical to diversify the nursing workforce.
Dr. Greer Glazer (29:59) The real issue, I think, is people want to be cared for by people that they think understand their experience, look like them, understand language. There are a lot of studies that indicate that people that are being cared for by health professionals want to have healthcare professionals that match their ethnicity, their race, their language, their sexual orientation, their ability, disability, all of these things. People feel more comfortable, people feel that they get better care, and they feel as if they’re understood.
Dr. Scharmaine Lawson (30:39): So where do we even begin to diversify an entire workforce? It starts with nursing schools, both students and faculty.
Dr. Bowen (30:48): I would think one of the easiest and low hanging fruit in terms of metrics that we have is that every nursing school has nursing faculty and nursing students that look like the communities and the states that they’re in. If you are situated in an area where your town or your state is 30% Latinx but you only have 2% in terms of student population or faculty, that’s a problem. So what can we start to do now to bring in Spanish speaking students, Spanish speaking faculty who look like the communities that they’re in and mirror them.
Dr. Scharmaine Lawson (31:36): The challenge here is a difference in resources. Students who are marginalized typically don’t have equal access to the resources that will allow them to get accepted into nursing school.
Dr. Bowen (31:50): If they’ve taken those tests, what we do know is that all students who’ve had the opportunity to go to study classes, prep classes, take the test a few times. The more you take it, the better you are at it. And that comes from what, having resources. And so for a lot of our black and brown and even poor white students, they don’t have the opportunity to start going to SAT prep courses when they’re in junior high school. They don’t have the opportunity to take the SAT every year of high school or to go to the tutors. Those are barriers. And so it doesn’t mean that those students who are black, brown and maybe poor white, come from rural communities or under resourced communities, it doesn’t mean that they’re less intelligent or less capable of being a nurse.
Dr. Scharmaine Lawson (32:47): To diversify nursing school classes, schools must begin recruitment outreach to underrepresented students in K-12 education and schools must also adopt what we call a holistic admissions process where prospective students are evaluated on more than just their academic achievements and GPA.
Dr. Greer Glazer (33:07): There’s an ample amount of data that shows that when you use other criteria that you deem important in future workforce like ethics, like somebody is ethical, like somebody’s communication skills are great. With nursing, and I really want to get this across, nurses are intelligent. It’s not just about people being caring and taking care of people. You have to be intelligent to be a nurse. So it’s a combination of factors that we’re looking for. More and more people are admitting into schools now using a holistic admission process.
Dr. Scharmaine Lawson (33:44): Nursing schools must work to diversify their student bodies, but it’s equally important to work at diversifying the faculty as well.
Dr. Bowen (33:53): Do we have faculty who are from the LGBTQ community? And if not, then what can we do to recruit faculty? There has to be an intentional effort. What are we going to do to first of all get into a situation or get into places and spaces where different faculty are. There’s HBCUs, there’s Hispanic serving universities that have nursing program, that have DNP programs, that have PhD programs. We all know that people usually graduate around May. So why not be there in those spaces recruiting nurses. How about providing some financial assistance so that they can move to these places where there aren’t large populations and providing some assistance so that they can get their program of research off the ground.
Dr. Scharmaine Lawson (34:50): To sustain a more diverse faculty, schools can’t just hire people and leave it at that. They need to provide additional resources to these faculty members because as Dr. Bowen has observed, diverse faculty take on an extra workload that usually goes unnoticed.
Dr. Bowen (35:09): Because there is the brown tax. So when someone sees that there’s a black or brown faculty, they’re going to navigate to them, or that, gee, here’s a faculty member who’s gay like me. I want to go and be with them and talk to them. Maybe they can understand the things that I’m going through. And so then all of a sudden you’re mentoring so many students that you can’t get your work done. And then what happens? You don’t get tenured, you get booted out, and we have this revolving door. And so for people who don’t understand that, it’s just like, well, they couldn’t cut it here. No, we have to make things equitable and that’s where we talk about giving the extra resources and the supports because probably the other faculty don’t have the five black students or the five Latinx students or Asian students, whatever the case may be in terms of that diverse student right there with that one diverse faculty person. So I think that those are some of the things, those are all good starting points, but we have to recognize that there’s a problem.
Dr. Scharmaine Lawson (36:16): All of these changes that we’ve discussed can receive pushback because these changes will require a shift in the culture and will change where we allocate resources.
Dr. Greer Glazer (36:28): There’s all kinds of programming that is evidence-based but it takes money and it takes will and it takes persistence and it takes the desire to make it happen. So that I think is where we need to focus our efforts.
Dr. Scharmaine Lawson (36:48): But even though these changes may come with a cost, they are worth implementing if it means we can get one step closer to improving health outcomes across the nation.
Dr. Bowen (37:00): I would challenge us to just keep moving forward, keep thinking outside of the box, including people, making your spaces a place where people want to come and where they can truly thrive. That’s what I would like to see when we get to 2030 and I really don’t think that that’s something that’s impossible. I think it’s extremely doable. We just have to want to do it.
Dr. Scharmaine Lawson (37:29): All systems have to prepare nurses to tackle health inequities, whether it’s through strengthening curriculum, expanding clinical rotations, working to mitigate bias, or increasing diversity in schools and workplaces. Nurses must be prepared to recognize when an individual is struggling due to health disparities. And it doesn’t end there because nurses must also feel equipped to take the next steps in getting the proper care to that person. As Dr. Bowen said earlier, nurse should always feel empowered to use their voices to ensure individuals and communities get the best quality care. It’s the responsibility of all health systems to prepare nurses for these moments and it’s also their responsibility to help nurses see themselves as powerful agents for change, especially when it comes to advancing health equity.
Dr. Regina Cunningham (38:24): When you think about health equity in kind of the big picture, it seems like, wow, what can I do about health equity? I mean, what can one person do about health equity? But the truth of the matter is in the report, our hope is that every single nurse sees themselves in that report and understands their potential role. So it doesn’t matter if you are a nurse in a community setting like we’ve been talking about or if you are a nurse in an acute care hospital setting, or if you’re a nurse in an organization that really doesn’t directly deliver healthcare services but does something related somehow to the healthcare industry, that you have an opportunity to see yourself, to understand the impact that these complex issues have on people and on outcomes, and to be able to affect change. We also talk about every nurse seeing themselves as a leader. You don’t have to be in a formal leadership role to say that you’re a leader.
I mean, every nurse can effect change at whatever level they are working at.
Dr. Scharmaine Lawson (39:28): As we work to prepare our nursing workforce to achieve health equity, there’s a big caveat that threatens this mission, and it’s the lack of support for nurses. Perhaps you’re a nurse listening to this and you’re thinking, I want to advance health equity but I’m not even supported in my current role. Perhaps you’ve witnessed your colleagues struggle to deliver high quality care and address health disparities because they weren’t supported to carry these tasks out in the first place. In our next episode, we are going to cover what it means to fully support nurses because if nurses aren’t fully supported, how can we expect them to step up as leaders to address the complex issues of health equity. Until then, if you want to learn more about the report or read it yourself, which we always recommend, you can visit the report homepage at nap.edu/nursing2030. As always, thanks for listening.
Episode 2: Health Equity
Episode 2: Health Equity
Scharmaine Lawson (00:16):
Health equity, health disparities. Perhaps you’ve heard these terms before. If you haven’t, we encourage you to listen to the last episode where we introduced them. These terms carry a lot of weight and they impact us every day. In The Future of Nursing Podcast, we’re exploring how nurses can promote health equity. But before we establish those strategies, we have to understand what health equity really means and what reality looks like for millions of people who experience health disparities.
In our last episode, we heard from Dr. Felesia Bowen. Dr. Bowen was reflecting on her time as a nursing madirt roads to visit her patients in the community, and she’d find that they weren’t receiving the care they truly needed. It left her with a big question.
Felesia Bowen (01:06): What was the barrier to keep them from getting the medication that they needed? A lot of times it was transportation. These are people who lived in rural communities, and the nearest hospital may have been 30, 40 miles away. What’s the big deal? You hop on a train or you get in your car to go, or you get a family member to take you. Well, there are no trains. There is no public transportation. And the family member may or may not have transportation, or the transportation may not be reliable enough to go 30 or 40 miles. You don’t know if the car’s going to break down or if you’re going to be able to get back.
Scharmaine Lawson (01:41): Dr. Bowen is now a nationally certified pediatric nurse practitioner, and she’s also the inaugural associate Dean for diversity, equity, and inclusion for the University of Alabama at Birmingham School of Nursing. During her career, she realized that she needed to look beyond the clinic doors and look at the full scope of patients’ lives if she truly wanted to understand their health outcomes.
Felesia Bowen (02:08): What are the things that are going on in their life? They come to the hospital or treatment facilities. That’s a snapshot in time. But the things that really keep people healthy or make them ill, they happen in the community, in their homes and in their neighborhoods.
Scharmaine Lawson (02:25): What Dr. Bowen was observing was the impact of health disparities caused by social determinants of health. According to the US Department of Health and Human Services, social determinants of health are the conditions of the environment where people are born, where they live, work, play, worship, and where they end up aging. These environmental conditions affect their health, their ability to function, and their overall quality of life. It’s these determinants that decide whether a person will have health equity or not.
Felesia Bowen (02:57): Health equity is having access to those resources that everyone else would be able to have access to so that people can live their best life. And that might be being able to get to a provider, being able to get to a facility that has providers with certain resources, being able to get supportive equipment or therapies after being ill, having insurance that will pay for everything that you need so you don’t have to decide, “Am I going to eat this month, or am I going to take care of my hypertension this month?” That’s health equity, when we get to a point where everybody has that. But in the absence of it, and we’re not there yet, we have health disparities.
Scharmaine Lawson (03:57): This is The Future of Nursing, a series from the National Academy of Medicine. Based on the recently published report, The Future of Nursing 2020-2030: Charting a Path to Achieving Health Equity. I’m Dr. Scharmaine Lawson. I’m a nurse practitioner, and I’ll be taking you through the stories of nurses confronting health disparities. And together, we’ll learn how nurses can draw from their unique skills, knowledge, and dedication to address health inequities and overall improve the health and wellbeing for all. In our last episode, we learned that the United States has some of the poorest health outcomes despite the money it spends on healthcare. In this episode, we’re going to examine the causes behind these health outcomes and explore how nursing capacity and expertise can be strengthened to reduce these disparities and promote health equity for all.
So how do health disparities happen? It starts with social determinants of health. These are factors within the community that people don’t get to decide for themselves. They’re typically born into it. Are they born into an area that has safe housing or into an area with a history of racism and violence? Do they have access to decent education and transportation? How close is the nearest grocery store with nutritious food? Do they live in an area where the air and water might be polluted? What language do they speak? And what is their literacy level? The factors may vary, but these determinants can lead to health disparities.
Philadelphia, Pennsylvania is a city where there are a lot of environmental conditions that have adverse effects on the population. Dr. Gloria McNeal saw this firsthand. Dr. McNeal is associate vice president for community affairs and health at National University. There she’s the project director of nurse-led clinics. Over the last 25 years, dr. McNeal has overseen four nurse-led clinics. Her first clinic was in Philadelphia where she and her team set out to address the problem of immunization rates in children ages zero to five.
Gloria McNeal (06:03): Children were acquiring measles, which is a totally preventable infectious disease, at an alarming rate. And they were ending up in our intensive care units or either succumbing to the disease.
Scharmaine Lawson (06:18): Dr. McNeal couldn’t let this problem go unaddressed, which is why she started the nurse-led clinics.
Gloria McNeal (06:25): So we have students and eight schools of nursing collaborating in this initiative. We set out to correct those numbers in the city and did very well over that summer experience. So I continued on with nurse-led clinics, designing them at other universities at which I’ve held appointments to where I’m now at National. And what has been clear to me is the health equity problem in the United States because health equity, as you say, is so complex, but it’s determined really by the zip code in which you live.
Scharmaine Lawson (07:01): Low immunization rates were the result of other problems, problems caused by health disparities that were defined by a zip code. Dr. McNeal knew early on that your zip code can have a major impact on your health outcome.
Gloria McNeal (07:17): And so I think there are a number of factors, sociopolitical factors that impact what goes on in certain zip codes and why the individuals in those zip codes are so unhealthy. And so health equity needs to be addressed from a variety of perspectives. So to me, health equity is determined by more than just your access to care. It does depend on where you reside.
So I was born and raised in public housing and in an underserved community. So I’m keenly aware of what that means, and the presence of, for example, underperforming schools, elementary, junior high and high schools, food deserts, crime, poor access to care. All of these are matters that impact your health, are putting resources in some sections of the city, but not in others. And so when you’re impacted in that manner, your health is in jeopardy.
Scharmaine Lawson (08:22): This is why the need for health equity is urgent. But what does it mean to achieve health equity? To answer that, we hear from Dr. Winston Wong. Dr. Wong is a family physician who currently serves as a scholar in residence at Kaiser Permanente, UCLA Center for Health Equity. And he spent much of his career focusing on the pursuit of health equity.
Winston Wong (08:45): Health equity boils down to whether we have accomplished in our society, in our nation, the opportunity for every individual to have a fulfilling life that is not determined upon the circumstances of which they might have been born into that would have made some deleterious impact on their health outcomes. What we’re trying to achieve with health equity is to ameliorate the effects that people have been born into or have been put into in terms of a situation that does not give them the same availability and opportunity for a fulfilling life free from suffering. And we have yet to accomplish that because I think we know that in our country, in our society, depending on your life conditions, people are going to have radically different outcomes relative to suffering, longevity, and care and treatment. So equity is the elimination of those social factors, political factors, community factors that give way to what we see as disparate and unfair and unequal opportunities towards a fulfilling life.
Scharmaine Lawson (10:09): Ignoring health equity can lead to negative consequences.
Winston Wong (10:15): So when we are unable to achieve health equity, we basically suffer as a population. We see the decline of longevity with regards to the US population as a whole. We see more chronic disease. We see more mental health distress, and we see greater dissatisfaction with the healthcare system.
Scharmaine Lawson (10:38): Dr. Wong has seen his patients affected by gaps in healthcare, gaps such as language barriers that lead to patients and their caretakers not receiving full or clear explanations of what their next treatment steps are. These barriers can lead to larger health inequities, and Dr. Wong personally experienced a moment where this happened.
Winston Wong (10:59): I do remember seeing a patient at a community health center where I was a primary care provider, where a father was very distressed because he had learned that his adult daughter had been hospitalized for psychiatric care at an emergency medical facility. But when I asked him in terms of what he knew about his daughter’s diagnosis, what kind of prognosis she had, and if he knew of any attempts for a follow-up for her care, he basically said, “I don’t have any information.”
And why did he not have any information? It’s because in that situation, the hospital that had taken care of his daughter did not have a bilingual translator available to the community, did not know how to communicate effectively how follow-up care would be done, was not equipped to really afford the kind of conversation and support that this father who did not speak English himself really needed to care for his daughter who was experiencing a serious mental illness instance.
And it was a tragedy. It was a tragedy for me to hear because I just didn’t understand on the nature of their circumstances why such an inequitable outcome had to be. There’s no justice in the fact that a father has no understanding of why his daughter was hospitalized, what her outcome would be, and how to care for her.
Scharmaine Lawson (12:49): Because of a language barrier, this family didn’t know how to follow up with treatment after a medical emergency. A language barrier is just one example. Other times, it can be a cultural barrier or varying levels of health literacy. People from all backgrounds need healthcare, and healthcare systems need to be prepared to treat and communicate with everyone.
Winston Wong (13:11): And the only way we can understand that is because our system was not equipped, not prepared, as well as essentially did not care for people that had different life experiences than the mainstream population that it was really set up to address. Well, for one thing, as the primary care provider, I think our system would have been much better if we were contacted fairly immediately when this patient was hospitalized for her mental illness, and the communication would have enabled us to reach out to the father as well.
Scharmaine Lawson (13:52): Unfortunately, this is a common experience.
Winston Wong (13:56): I think across the country, this is generally what’s happening. In certain communities, I think we’ve become more understanding of the diverse needs of our communities, have made up some ground. But I hate to say, but I think that’s more the typical story than it is the other with regards to really having the services and the personnel equipped to do the follow-up for people that come from outside of mainstream circumstances.
When our country is unable to really confidently say that we’ve achieved health equity, our entire system fails for the entirety of our population, because it really manifests itself in terms of the failures we have in terms of having the system set up so that not only do we have the right personnel, the right nursing and physicians and other healthcare team available to help navigate a patient through many difficult situations in their healthcare journey, we don’t have the data to substantiate what’s really happening.
Scharmaine Lawson (15:04): The people that live within communities that are affected by disparities and education or housing or food access or people who are marginalized and historically discriminated against, these groups tend to suffer in ways that could be prevented.
Gloria McNeal (15:19): So what happens in many of these communities is that individuals at the beginning stages of a disease will not seek assistance because it’s not available to them. There are no private doctors’ offices in the community or nearby. And so they wait until the condition becomes so severe that they have to be taken to the emergency room. And sometimes, it’s too late. So if their condition would have been addressed much earlier on, they would have had better outcomes.
Scharmaine Lawson (15:52): So how can we address people’s health conditions before they become too severe? We need to change the focus of our health systems.
Winston Wong (16:01): We don’t have the mindset of prevention and the proactive understanding of the social factors that contribute to why people have greater barriers in terms of achieving optimal healthcare. We don’t have the educational system to really target individuals that are going to help fortify our healthcare system with the personnel that’s going to be able to meet the future of the diversity [inaudible 00:16:33] populations we have. I think if we build a system that is really around equity, we’re going to have a much more prepared system and arguably a more person-centered system that’s going to be much more able to achieve health equity as well as satisfaction, improve public health outcomes.
Scharmaine Lawson (16:55): There are some things that are out of people’s control. For example, someone who earns minimum wage cannot buy a car to get to their medical appointments. But there are things that we as providers can control and influence, such as better education for healthcare providers and nurses. At the end of the day, we must do what we can to address health equity, because the outcome of people’s health shouldn’t be decided by factors out of their control.
Kenya Beard (17:21): Health equity is the right for every individual to achieve their highest level of health, regardless of where they are.
Scharmaine Lawson (17:30): That’s Dr. Kenya Beard. Dr. Beard is the associate provost for social mission and academic excellence at Chamberlain University. Throughout her career, Dr. Beard has led research on diversity, equity, and inclusion in academia, and has also researched specifically how access and quality of care impact health outcomes.
Kenya Beard (17:49): We should be able to provide access and a high quality of care that sets the stage for individuals to achieve that highest level of health.
Scharmaine Lawson (18:00): According to Dr. Beard, to achieve health equity, there’s one thing that healthcare systems need.
Kenya Beard (18:06): Healthcare system leaders have to wholeheartedly believe that health equity cannot be achieved without nurses.
Winston Wong (18:21): We have to embrace the concepts of health equity as not being a question of caring for exceptional populations or special populations, but thinking about this as a core element of how we achieve better health. We have to be able to train that workforce to look at the broad number of impacts that result in health equity and health inequity, including looking at social determinants of health, all those different factors that occur outside of the healthcare delivery system, to give rise to different elements of health disparities in health inequity. So if we look at that aspect in terms of how nurses can play a much more explicit role in terms of addressing social determinants of health and social factors, and incorporate that into a operationalized system of acknowledgement, professional support, as well as training, we’re going to make some great headways in terms of achieving health equity.
Scharmaine Lawson (19:27): To address health equity, it’s important that nurses are able to see and understand the social determinants of health impacting their patients. Dr. McNeal, who we heard from earlier, grew up in an underserved area. Because of this, she was able to recognize the things happening outside of the clinic that affected her community.
Gloria McNeal (19:47): Because I saw that firsthand myself, I felt that once I had an opportunity to make a difference, that I would do so, and go back and give back to the neighborhoods and help.
Scharmaine Lawson (19:59): Not only did she start nurse-led clinics, but she also implemented another effective way of reaching her community members.
Gloria McNeal (20:06): While I had mobile units for a while moving around in these underserved communities providing care, I found that there was still an element of trust that needed to be addressed. And so I changed it from having a mobile unit to actually embedding the clinic inside of recognized community entities. So I positioned the clinic in churches, in drug rehabilitation centers, and in Salvation Army locations, where if there were room that wasn’t being used, that we can convert that room into a clinic and be able to address healthcare needs in that manner. And I found much more success with that approach because the patients already attended that church or already resided in that drug rehabilitation and so forth. And so it was familiar surroundings to them, and they felt they could trust us more and better. And so we were able to increase the numbers of underserved patients in these areas where access to healthcare was so negligent.
Scharmaine Lawson (21:16): Dr. McNeal was able to provide care to patients that may not have received it had the clinic not been in a setting that the patients were comfortable and familiar with. As trusted professionals that spend significant time with patients and families, it’s important that nurses are at the forefront of implementing models of care that address social determinants of health.
Winston Wong (21:37): Certainly from a public health perspective, it’s not only just for the public health structure, but also elevate the prestige and visibility and acknowledgement of nurses at being at leadership roles in terms of understanding all the different dimensions and operationalizing how those aspects of social determinants get incorporated into wellness models, new models of care, and extending into partnerships with other parts of the healthcare and medical system.
Scharmaine Lawson (22:10): When it comes to implementing models that address social determinants of health, nurses face a historic challenge, systemic racism and discrimination both in and out of the healthcare system.
Kenya Beard (22:26): We know that racism is inherent in every system, education system, housing, employment, the criminal justice system, and even healthcare systems. I know that as providers, we espouse to be altruistic and egalitarian, but racism affects the systems that we work in. So we have to recognize how racism harms everyone, not just the victim. It creates an atmosphere of mistrust.
Scharmaine Lawson (22:56): Dr. Beard remembers a time outside of the traditional health system where she saw how deeply systemic racism affected her family.
Kenya Beard (23:06): I remember when my son came home from his second year of college and he said, “Mom, I didn’t know that being an African-American was a risk factor for having a low IQ.” And I said, “What? What are you talking about? Who told you that?” And he says, “My teacher told me that, the professor.” So I’m asking him, “Give me the professor’s name. I’m going to email her. This is ridiculous.” And then he says, “No, no,
Mom, don’t blame the professor. He said it’s in my textbook.” “It’s in your what?” He said, “Yeah, my Intro to Psychology textbook. I’ll show it to you.” So we opened up the book, and there in a box, risk factors for having a low IQ, number for, the African-American family. Should not have been there, but this is false rhetoric from the ’50s, the ’40s, the ’30s, about the intellectual inferiority of minorities, African-American specifically.
Scharmaine Lawson (24:11): While this experience didn’t happen within the clinical setting, it shows that systemic racism and discrimination are deeply embedded in places like schools. And this ultimately has adverse effects on society. Last episode, we heard from Dr. Williams, the co-chair of The Future of Nursing 2020-2030 report. Dr. Williams developed a way to track how systemic racism and discrimination affect people not just in their day-to-day activities, but in their overall health outcomes as well.
Dr. Williams (24:45): The study of interpersonal discrimination affecting health is less than 30 years old, but the science is overwhelming. They are what I would want to say, it’s both discrimination in big things, of being treated unfairly at work, or not being hired for a job. Those are big things. But the strongest evidence comes from what are called the day-to-day indignities.
I developed a scale called the everyday discrimination scale that captures little things like being treated with less courtesy and respect than others, receive poorer service than others at restaurants and stores, people acting as if you are not smart if they’re afraid of you, just little indignities. And what we find just to illustrate with every discrimination, the people who score high on everyday discrimination, there’s a higher rate of incident breast cancer linked to everyday discrimination, higher rate of incident metabolic syndrome, higher rate of hypertension, higher rate of inflammation, higher rate of atrial fibrillation, higher rate of C-reactive protein, higher rate of obesity, just higher rate of mental health problems. So a broad range of outcomes.
Scharmaine Lawson (25:51): The day-to-day indignities, as Dr. Williams calls them, can result in adverse health outcomes. For nurses to address health equity, they need to be educated on how to identify these indignities and other barriers in order to provide the best care for people.
Kenya Beard (26:08): Healthcare challenges like racism bias and social determinants of health, and some have very little training in these areas. So the right for everyone to achieve their highest level of health is denied when we fail to provide nurses with the tools to understand and mitigate behaviors that include implicit bias and racism. I feel that I know I’ve personally witnessed the frustration, which could trigger the early departure from the profession. I’ve witnessed some nurses feeling angry, which could cloud your thought processes. And I’ve seen nurses engage in work arounds, practices that undermine the quality of care because they feel that there’s no other option. So when I’m asked who’s responsible, we are all responsible for educating nurses and healthcare providers about the social determinants of health, about racism, and about ways to mitigate bias.
Winston Wong (27:08): I think it’s absolutely essential to addressing health equity in that the way that our healthcare workforce, our nursing workforce is able to understand and address, acknowledge racism and discrimination, sexism within itself as a profession and how we root it out is only going to make the profession stronger to be able to be a forceful agent for change for the community as well.
Scharmaine Lawson (27:40): It’s important to point out that health equity affects both patients and clinicians. Nurses experience sexism, racism, and discrimination within the healthcare setting. This discrimination can be based on their language, accent, sexual orientation, perceived disabilities, and/or elitism. As Dr. Beard said, these challenges make it really difficult for nurses to deliver the best quality care.
Winston Wong (28:05): I want to emphasize too that within our nurses, they’re often the target of racism, discrimination, sexism, and condescending attitudes within our healthcare delivery system. And I think these need to be acknowledged as being forces that are not contributing to enable our nurses to advance in terms of achieving health equity.
So even in the last couple of days, I heard friends of mine who are nurses who told me that some patients themselves had expressed these racist vitriols against him because he was a person of color. And of course, our patients under duress and they come from many different walks of life, but not to acknowledge that nurses, particularly nurses who are people of color confront various aspects of discrimination and racism every day is not to take seriously the kinds of stress, mental health issues, and duress that they face every day. And that as much as we celebrate the role they play as champions, we also need to support them as much as we can with regards to suffering from aggressions.
Scharmaine Lawson (29:37): The Future of Nursing 2020-2030 report acknowledges that nurses need to be supported when they experience sexism, racism, and discrimination. The report also acknowledges how nurses can increase their own capacities to support patients who may experience similar obstacles.
Kenya Beard (30:01): I really appreciate reading in the report that no one is immune from hate and bigotry, but everyone has the capacity for empathy, understanding, and solidarity, and a shared hope for a more just and equitable world.
Scharmaine Lawson (30:24): So what can be done to help the nursing workforce empathize and work to understand how health inequities are affecting their communities? There are several strategies, but we’re going to focus right now on one, and that is to increase diversity within the nursing workforce itself.
Winston Wong (30:41): One of the big challenges about the nursing profession is that it’s actually a crucible for a lot of issues we’ve had in terms of how we fortify the profession of nursing itself. The last report dealt with trying to look at diversity as traditionally the nursing workforce has been predominantly made up of women, and increasingly how do we make sure that it becomes diverse, including men, and including obviously more people of color into the profession. So it’s very interesting in that the nursing workforce itself becomes reflective of what we want to do with the system overall and our public health structure priorities overall.
Scharmaine Lawson (31:29): Dr. Wong had a moment in his career where he saw why it was so important to not only have a diverse nursing workforce, but specifically nurses who share similar backgrounds and reflect their communities. Before Dr. Wong shares, we want you to be aware that this story contains elements that deal with infant loss and may be triggering for some listeners.
Winston Wong (31:51): I think I had an experience where a woman… And it’s a very long and complicated story, but immigrant woman who really just basically had a fifth-grade education in her homeland, Chinese-speaking, was pregnant with a baby that had a diagnosis of a hereditary base disease, a bloodborne disease called thalassemia.
And I recall that one of the attempts that the hospitals wanted to do was to make sure that the patient understood the consequences of her pregnancy by having her sit down with a genetic counselor. And it was through our nursing staff that really was really able to sit down with my patient, our patient, and really understand the circumstances of how she understood her pregnancy because this was her first pregnancy, and she didn’t understand how a fetus that was moving could potentially be unhealthy, or even in this case, stillborn.
And it was through the painstaking work, conversation, and empathy that those nurses provided with that patient that helped her actually cope with the fact that that baby died within 24 hours of birth.
Scharmaine Lawson (33:23): This patient was going through a tragedy. And if she hadn’t been surrounded by a group of nurses who related to her background, things may have gone differently.
Winston Wong (33:32): And without that context, not only through language, but understanding what it means to be an immigrant woman with your firstborn in a foreign country, so to speak, I think the long-term consequences of that would have been disastrous if it weren’t for the nurses that really stood by her to help her go through the process of dealing with a very difficult pregnancy and also the aspect of grief that would come with the baby that subsequently did not live long.
Scharmaine Lawson (34:06): Dr. Wong would never forget this experience. It showed him why it was so necessary to increase diversity in the nursing workforce.
Winston Wong (34:15): I think patients recognize very intuitively that they’re being cared for by a person who is able to empathize and is able to understand the conditions in which they face. Now that doesn’t necessarily mean 100% of my background is the same as the nurse who cares for me, but I think we want to be able to say that our nursing workforce has a number of people that come from different walks of life that cross set with the number of people that we’re caring for in our healthcare settings and make sure that they populate all aspects of the caring aspect of healthcare, whether that be in a primary care setting, in the hospital setting, whether that be in a long-term care setting, or whether that’s in public health and/or prevention and education. There’s no boundary between being a nurse one day and being a part of the community the next day. You basically are those two things concurrently.
Scharmaine Lawson (35:27): It’s everybody’s right to have a fair and just opportunity to be as healthy as possible. With nurses being so embedded in their communities, they have a unique to recognize the social determinants of health experienced by their patients and work to make sure their community is receiving the care it needs. Health equity can be achieved, but only if we work together to strengthen the capacity and expertise of nurses, and it’s going to take a much larger effort from systems and education, healthcare, and policy.
Kenya Beard (36:01): It will take a strong nurse to pull off the ideals of health equity. And if we work together, we can amass the strength to create a healthier nation.
Gloria McNeal (36:12): So I think we’ve come a long way. We still have a ways to go, but I’m very encouraged about the positive direction that we’re making right now. And I think if we just continue on and advance some of the things that I’ve already addressed, that we will make a decided difference for the healthcare outcomes for the people in this country.
Scharmaine Lawson (36:33): Now that we understand what health equity is and why nurses are critical in achieving health equity, it’s time for the next step, preparing nurses to understand these issues and know how to confront them. In our next episode, we’re going to dive deeper into how nursing schools can strengthen education curricula to better prepare nurses to work in and with communities. And we’ll also be exploring how we can actually diversify nursing school classes and faculties. Until then, if you want to learn more about the report or read it yourself, which we always recommend, you can visit the report homepage at nap.edu/nursing2030. Thanks for listening.
Episode 1: The Introduction to The Future of Nursing 2020-2030
Despite spending more money on health care than any other country, vast health inequities still exist in the U.S. Access to and opportunity for quality health care is not equal. While the COVID-19 pandemic did not create health inequities, it brought renewed attention to the fact that our health is determined by many factors outside of medical care.
The health of the nation is at stake, the need for change is urgent. Nurses play a pivotal role in addressing health inequities across the nation. In this episode, we begin exploring the influence nurses have on health care, why nurses are key leaders in addressing health equity, and what practical work must be done to better equip nurses in this mission. Nurse Practitioner Dr. Scharmaine Lawson takes us through the stories of frontline nurses and other health experts to learn how they are confronting health disparities, and also introduces us to the report that provides practical guidance and recommendations for nurses addressing health equityーThe Future of Nursing 2020-2030: Charting a Path to Achieving Health Equity.
Dr. Scharmaine Lawson is a nationally recognized and award-winning nurse practitioner. She is a fellow of the American Academy of Nursing and a Fellow of the American Association of Nurse Practitioners. In addition, Dr. Lawson was the winner of the 2013 Health care Hero award for the New Orleans City Business Magazine, and the 2008 Entrepreneur of the Year award for the ADVANCE for Nurse Practitioner magazine. She is also the author of the first Advanced Practice Nurse children’s book series titled “Nola The Nurse”.
Episode 1: The Introduction to The Future of Nursing 2020-2030
Dr. Scharmaine Lawson (00:16): Macon County, Alabama, it’s one of the poorest counties in the state. Years ago, Felesia Bowen found herself there. She was a student working to complete her bachelor’s of science in nursing at Tuskegee University. As part of the program, she would make visits to patients’ homes within the county. As she made these visits, she noticed that these patients faced a unique set of challenges, but she couldn’t quite find the words for it.
Felesia Bowen (00:41): I was in the midst of health disparities and health equity when I was a student. However, I didn’t have a language for it, right? Like nobody was talking about health equity then, talking about health disparities, going out, especially for community health and going into people’s homes where you went down dirt roads to get to them, or they were bed-bound and who was going to come and see them? Or they didn’t have food in their home, no transportation to get to a provider, gaping wounds, pressure wounds because they couldn’t afford the special beds or the mattresses. And they were at home with family who loved them very much and were doing the best that they could, but there’s lots of equipment and things that we can get to people to help them manage their illness at home or their conditions at home, but they have to be ordered. You have to know to ask for them. So I was seeing that as a student, but again, I didn’t have the language for it.
Dr. Scharmaine Lawson (01:47): What Felesia struggled to find the language for was what we call health disparities. Health disparities are health differences that negatively affect certain groups of people. These are people who have systematically experienced greater social or economic obstacles when it comes to their health. This can be based on their racial or ethnic group, religion, socioeconomic status, their gender, mental health, cognitive, sensory, or physical disability, their sexual orientation, geographic location, or other characteristics that are historically linked to discrimination or exclusion. This is what Felesia encountered with her patients. And unfortunately, it’s the reality for many people in America.
Dr. Sue Hassmiller (02:29): Our country lags behind other developed nations on many important indicators, such as life expectancy, infant mortality, and maternal mortality despite spending much more on healthcare than any other country.
Dr. Scharmaine Lawson (02:45): That’s Dr. Sue Hassmiller. She has served as a senior scholar in residence at the National Academy of Medicine, and also advised the National Academy of Medicine’s president on the topic of nursing. According to Sue, historically, not everyone has had equal access to high-quality healthcare in America.
Dr. Sue Hassmiller (03:05): We have long failed to give everyone a fair and just opportunity for health. It’s not equal in this country. Disparities in healthcare access and outcomes related to race, income and geography are common and have been exacerbated now by this pandemic.
Dr. Scharmaine Lawson (03:24): Health inequity is not new. When we say health inequities, what we’re describing are systematic differences in the opportunities that certain groups of people have to achieve optimal health. The differences among groups vary and this leads to unfair and preventable differences in health outcomes. For too long, people across the nation have not had an equal opportunity to receive the care they need. The health of the nation is at stake and the need for change is urgent. The National Academy of Medicine and the Robert Wood Johnson Foundation set out to find how to chart a path forward to achieve health equity. And what did they find? Nurses are the key to improving the nation’s health. This is The Future of Nursing, a series from the National Academy of Medicine based on the recently published report, The Future of Nursing 2020–2030: Charting a Path to Achieve Health Equity. My name is Dr. Scharmaine Lawson. I’m a nurse practitioner, and I’ll be taking you through the stories of nurses confronting health disparities, and together we’ll learn how nurses can draw from their unique skills, knowledge, and dedication to address health inequities and overall improve health and well-being for all. Throughout the series, you’ll hear more stories from nurses like Dr. Felesia Bowen, who work with patients that are experiencing health disparities every day. You’ll also hear from other nursing experts who are working hard to find the best strategies to promote health equity. I want to introduce you to yet another key player in today’s episode, Dr. Mary Wakefield, the co-chair of The Future of Nursing 2020-2030 committee. Dr. Wakefield has had a long esteemed career as a nurse. Over the course of her career, she’s also worked in several positions in health policy, and she’s witnessed firsthand how the outcomes of people’s health rely on several factors.
Dr. Mary Wakefield (05:38): There’s been an increasing, growing recognition that the health of individuals and of communities isn’t solely the product of access to healthcare, but rather that the health of an individual or the health of a neighborhood is also influenced by an array of other very important factors. Whether or not for example, an individual has a home or they’re homeless, whether the individual has education or perhaps dropped out of school in 10th grade, whether a community is beset by crime, or whether a community has high exposure to toxins in their air that they breathe or toxins in the water that they drink.
Dr. Scharmaine Lawson (06:21): A patient’s health outcome is heavily impacted by what we refer to as social determinants of health. These are factors outside the clinic that include where the patient lives, the economic stability, the access to education and transportation. There are more, but we’ll discuss these more in-depth in a later episode. The question is if these circumstances occur outside of the clinic, then how can nurses have such an important role in improving the health and well-being of a community? Think back to your last doctor’s appointment. When you left the waiting room, who was the first person you encountered? Or perhaps you were in the hospital with a family member, who do you speak with most while your family member was being treated? Regardless of the situation, when individuals from all backgrounds and experiences are seeking care, they first make contact with nurses.
Dr. Sue Hassmiller (07:13): They are often the first and most frequently healthcare contact with individuals, families, and communities. They have a long history of tackling many of the social and economic drivers of health such as access to food, safe housing, affordable transportation. The Robert Wood Johnson Foundation and the National Academy of Medicine wanted to explore how more nurses could address the social determinants of health and advance health equity.
Dr. Scharmaine Lawson (07:46): Nurses on the frontline are the first to get clues in their patient’s cultures, their jobs, and their family dynamics. But when it comes to knowing about the lives of patients outside of the clinic, there’s a certain thing the overall health system has failed to do. Dr. Michael McGinnis, the Leonard D. Schaeffer Executive Officer of the National Academy of Medicine has witnessed this over his career as a physician.
Dr. Michael McGinnis (08:10): Perhaps the most fundamentally important responsibility of the clinical arena generally is to listen, to listen to patients and families about the issues that matter most to them. And in many ways, that’s the area in which we as a health system have failed the most in the listening process.
Dr. Scharmaine Lawson (08:35): When health systems fail to listen, health inequities can increase.
Dr. Michael McGinnis (08:39): Our most important health challenge is health inequities. And nurses can do a great deal to help the nation engage health inequities in an effective manner. Nurses are on the frontline. They deal daily with the challenges of those who are most in need. They’re also individuals who are well-trained and inherently receptive and aware of the need to identify early on the challenges of those who are most disadvantaged in our society.
Dr. Scharmaine Lawson (09:17): Not only can nurses identify the challenges their patients might be experiencing, but many nurses are in positions where they can confront these challenges before the patient even gets to the clinic doors.
Dr. Michael McGinnis (09:30): Many nurses practice on a daily basis in those situations outside the clinic doors, whether it’s as a school nurse on the frontline in school settings, whether it’s a nutritional counselor working in partnership with a food support services enterprise, whether it’s as an ombudsman looking at the broader links to community support and housing in workplaces and beyond. Those who are best equipped to blend and braid the kind of services that are viewed as social in nature or have a fundamental impact on the health consequences for individuals. Nurses are fundamentally important.
Dr. Scharmaine Lawson (10:27): Nurses are uniquely embedded in communities in ways that other clinicians are not. This means that they can address social determinants of health in non-traditional ways.
Dr. Mary Wakefield (10:37): And that really means paying attention to those social needs of a patient. Maybe for example, the food insecurity of a community. That as an example, calls for a significant and sustained shift in how we might educate nurses in terms of topics that they focus on in their undergraduate nursing program, for example. So it’s talking about not just what we do with patients inside health systems like nursing homes, home health agencies, and so on, but how are we affecting issues like food insecurity, homelessness, and other factors outside of healthcare delivery systems? And that takeaway calls for a very significant shift in how we educate and what we educate nurses about.
Dr. Scharmaine Lawson (11:19): It’s because of nurses’ positions in the community and their unique skills that make it so important for them to be on the frontline of addressing health equity issues, but to empower nurses to confront inequities, there’s a lot that needs to be done to better support nurses as they support us.
Dr. Michael McGinnis (11:36): The role of the nursing profession as a linchpin in all dimensions of health and healthcare and the operations of our health system is critical. Nurses work at the frontline, they work in the policy arena, they work in the leading edges of our efforts as a nation to engage issues and activities outside the clinic doors that are fundamentally important to the nation’s health. They’re the catalyst for progress in many ways. So from the perspective of the nation, there is no question that the nursing profession is critical to progress.
Dr. Scharmaine Lawson (12:25): The Future of Nursing 2020-2030 report focuses on how nurses can promote health equity. But to do so, the systems that are in place such as public health care systems, Medicaid and Medicare, private healthcare systems and medical facilities, nursing schools and academia and nonprofit organizations, these systems need to better prepare and support their nurses so that their nurses can then promote health equity. The Future of Nursing 2020-2030 report was actually built on the foundation of another major nursing report. Back in 2011, the Institute of Medicine, what we now refer to as the National Academy of Medicine, released another Future of Nursing report also sponsored by the Robert Wood Johnson Foundation. This report focused on the years 2010 to 2020.
Dr. Sue Hassmiller (13:14): The first report was focused on building the capacity of the nursing workforce. The nursing field came together to strengthen education and advanced practice, promote leadership, and increase workforce diversity. A tall order.
Dr. Scharmaine Lawson (13:29): This first report was critical in progressing the nursing workforce, but the work didn’t stop there.
Dr. Sue Hassmiller (13:35): So the first report built our capacity, and then we asked ourselves, okay, building nursing’s capacity to what end? This is where we’re going to do our work, achieving health equity in this country.
Dr. Scharmaine Lawson (13:50): It was time to establish a new report for a new decade, a decade that brought a pandemic, a summer of climate disasters, and a long-overdue awakening of racism in American systems and institutions.
Dr. Mary Wakefield (14:04): I think in terms of what catalyzed The Future of Nursing 2020-2030 report, what really encouraged this focus was largely based on some very substantial expansion over maybe the last decade or so of research, a research base that has been growing rapidly that has shown a very clear relationship between health, health status, health outcomes, and social determinants of health.
Dr. Scharmaine Lawson (14:36): All reports published by the National Academy of Medicine are based solely on existing evidence. For The Future of Nursing 2020-2030 report, experts carefully and methodology approach the research to gather the most accurate evidence.
Dr. Mary Wakefield (14:51): The conclusions and recommendations in the report are derived from evidence. And so we focused a lot, as I said, on the work of literature searches of reviewing research to inform our thinking and then also site visits to help us better understand what some of the effective models were as well as the challenges to them across the country that involved nurses in addressing social determinants of health with the aim of improving health equity.
Dr. Scharmaine Lawson (15:20): Now we have an evidence-based report filled with recommendations to guide our nursing workforce through the very real challenges they face when it comes to health equity. But this work is going to require the participation of all sectors involved in health because at the end of the day, if nursing isn’t prepared to tackle health equity, it will be near impossible to improve the health of the nation.
Dr. Michael McGinnis (15:43): There is a critical need to reassess the ways in which we educate our health professionals and the way in which we deploy them as team members to be able to work with each other and to have a comfort level in working in multiple venues and circumstances. This report has helped set the stage for accelerated progress of not just the nursing profession, but the whole health system as it moves to meet the challenges and the opportunities of the 21st century.
Dr. Mary Wakefield (16:20): We need a much broader, clearer commitment and actions that ensure that nurses are prepared, not just nurses who already have a lot of this expertise in the community, but that all nurses need to be prepared to drive improvement. And they need to be able to do that by partnering with and leveraging other sectors beyond the health sector.
Dr. Scharmaine Lawson (16:40): As Sue mentioned earlier, the recommendations from the first Future of Nursing report were a tall order. For the 2020 report, it’s no different. But this set of practical recommendations and their resulting policies and actions are possible to implement. Throughout the series, we’ll look closely at each recommendation, but at a glance, this is what The Future of Nursing 2020-2030 recommends.
Dr. Sue Hassmiller (17:05): The report has four key takeaways. The systems that educate, pay, and employ nurses need to do this. They need to permanently remove the barriers to allow them to do their work, value their contributions, prepare nurses to tackle and understand health equity in the first place, and then fully support nurses.
Dr. Scharmaine Lawson (17:30): There is a multitude of systems that should implement these recommendations, systems such as public health care systems, Medicaid and Medicare, private healthcare systems and medical facilities, nursing schools and academia, and nonprofit organizations. These systems can better prepare and support their nurses to promote health equity.
Dr. Mary Wakefield (17:50): There’s a lot of opportunity for nurses to make contributions to these serious challenges with all their inherent complexities, but change needs to occur both to incorporate the expertise that’s currently embedded and expand it. That expertise that’s currently embedded in public health and school. And they’re saying that we ensure that nursing students and graduates of nursing programs learn much more deeply about issues around health equity and that our students when they graduate are prepared to
partner beyond and work beyond the traditional healthcare sector.
Dr. Scharmaine Lawson (18:25): The report also focuses on non-traditional ways that nurses can partner beyond the healthcare sector.
Dr. Mary Wakefield (18:32): When we think about engaging in other sectors, we really need to be thinking about that public policy sector too. So that’s a key takeaway from the report as well. And standing in the way of that goal is I think the need for nurses to be educated to really engage in all of these venues I’ve just described well-informed and recognize this as part and parcel, this kind of work as part and parcel of their role as a nurse. The ways that nurses can engage in health policy to inform health policy and to inform health policymakers so that I as a nurse might be influencing the patients for whom I care on a shift in a hospital, for example, but I as a nurse can also influence the health status of 20,000 patients or 20 million patients by engaging in and informing health policy and informing health policymakers that are writing laws and regulations.
Dr. Scharmaine Lawson (19:32): Nurses can greatly influence the healthcare system in America. Many already have, but we want to be clear, solving health equity does not just fall on nurses. It’s everybody’s responsibility.
Dr. Sue Hassmiller (19:48): What stands in the way of these goals being accomplished? Dismantling structural racism and advancing health equity in this country are really difficult tasks that cannot be accomplished in a single lifetime. And they’re too big for any one sector to solve on its own. So we call upon nurses. Yep, we do, but we need a lot of other people working on this. All of the health professions, those in the organizations that represent the social determinants like housing and transportation and food and access to care. Part of the reason why our country has been so slow to advance health equity is because few leaders and organizations have prioritized it. If every organization made advancing health equity its top priority, we could make our country better and more just for everyone who lives here.
Dr. Scharmaine Lawson (20:48): We’re going to look at each of the takeaways and recommendations much more thoroughly throughout the next episodes. It may not be easy. The reality behind health inequities, systemic racism in healthcare, and the challenges that nurses face in addressing these matters, it can be sad and downright frustrating. But if we want to improve the health and wellbeing for all, it’s work that needs to be done. The co-chair of the report, Dr. David Williams, stressed just how critical a report like this is to improve the health of the people most disadvantaged in society.
Dr. David Williams (21:26): One of the things the committee’s report does, it doesn’t ask nurses to do all of this work of improving healthcare equity, improving health equity, and doing it on their own and doing it without being prepared to do it. There’s a lot in the report of the kinds of investments that need to be made in terms of enabling nurses to practice to the full extent of their training, in terms of ensuring the wellbeing of nurses so that they are equipped and they are cared for so that they can provide adequate care for others, in terms of providing the education and training so that nurses understand the importance of the social determinants. So for example, we are dealing with a challenge, not only of healthcare equity, that they are sometimes differentials in care based on being from a rural area or based on being a racial, ethnic disadvantaged socially stigmatized person, that’s healthcare equity, but it’s also health equity.
Dr. Scharmaine Lawson (22:35): Dr. Williams is stressing that healthcare equity means all individuals and communities should have access to healthcare and high quality care. Everyone should have the opportunity to attain full health potential. No one should be disadvantaged from achieving full health potential because of their social position or any other socially defined circumstance. With nurse’s key role in the health of Americans, there’s an opportunity to chart a path forward to achieve health equity.
Dr. Sue Hassmiller (23:06): And so my hope is that this report will unleash the full potential of all of us, all nurses across the country. Substantial barriers so prevent all nurses from being able to effectively advance health equity.
Dr. Scharmaine Lawson (23:22): Before we explore the practical recommendations of The Future of Nursing 2020-2030 report, we have to know exactly what we’re up against. In our next episode, we’re going to look more closely into health equity, what it means, why it matters, and what nurses are seeing on a front lines when patients are impacted by health disparities. Thanks for listening. To learn more about the report or to read it yourself, which we always recommend, you can visit the report home page at nap.edu/nursing2030.
Introducing the Future of Nursing Series: Trailer
Episode 0: Introducing the Future of Nursing (Trailer)
Bowen (00:04): I went to school for my undergraduate degree at Tuskegee University in Alabama. And so that school is located in Macon County, Alabama, which is still one of the poorest counties in the state. And I was in the midst of health disparities and health equity when I was a student.
Dr. Lawson (00:27): For too long all across America people have faced health disparities. They haven’t had equal opportunity or equal access to receive the care they need.
Bowen (00:37): And so going out, especially for community health, and going into people’s homes where you went down dirt roads to get to them, or they were bed-bound and who was going to come and see them? Or they didn’t have food in their home, no transportation to get to a provider, gaping wounds, pressure wounds, because they couldn’t afford the special beds or the mattresses.
Hassmiller (01:03): Our country lags behind other developed nations on many important indicators, such as life expectancy, infant mortality, and maternal mortality, despite spending much more on healthcare than any other country.
Dr. Lawson (01:19): Health is driven by many factors outside of medical care, such as the neighborhood you live in, your socioeconomic status, your education, and your access to healthy food and reliable transportation. The roots of health inequities run deep. They’re complex and understanding them is critical. There are people who play a pivotal role in addressing these inequities, nurses. Nurses serve a highly diverse population on the front line. Therefore, to advance health equity for all it’s critical to strengthen the nursing workforce capacity and expertise.
McGinnis (01:53): They’re the catalyst for progress in many ways. So from the perspective of the nation, there is no question that the nursing profession is critical to progress.
Dr. Lawson (02:06): This is the future of nursing, a series from the National Academy of Medicine based on their recently the published report, The Future of Nursing 2020 to 2030: Charting A Path To Achieve Health Equity. In this series, we’ll be hearing the stories of nurses and other experts who are confronting health disparities, and together we’ll learn specific strategies for how nurses can use their unique skills, knowledge, and dedication to address health inequities and overall improve health and wellbeing for all. This podcast is for nurses, those involved in any health sector, those in academia, or anyone who wants to know how we can create more equitable health outcomes for all people in America, no matter their experience or background.
Subscribe now to The Future of Nursing on Apple Podcasts, Spotify, or wherever great podcasts are found.
The Report: Read the highly-anticipated report Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity (2021), which explores how nurses can work to reduce health disparities and promote equity, while keeping costs at bay, utilizing technology, and maintaining patient and family-focused care into 2030.
View the recordings and other materials from the 4-part Future of Nursing Webinar series, on-demand here. Listen to discussions addressing how we can support nurses to achieve health equity.
Interactive Resource: Engage with the interactive website that simply walks users through the challenges, opportunities, actions that we can empower nurses with to support the end goal of better, more equitable health outcomes for patients in the U.S.
Help us spread the word!
Tweet this! New podcast series from the NAM! This 8-part series from #TheFutureofNursing2030 will explore practical strategies for the nursing profession to advance health equity. Listen now: https://bit.ly/2YcRVzU #FutureofNursingPod
Tweet this! NAM’s latest #FutureofNursingPod explores the influence nurses have on health care, why nurses are key leaders in reducing equity gaps, & practical next steps to better equip nurses in this mission. Listen now: https://bit.ly/2YcRVzU #FutureofNursingPod #TheFutureofNursing2030
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