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 3: Preparing Nurses to Better Understand and Address Health Equity
As the U.S. population becomes increasingly more diverse, nurses must be prepared to treat people from all backgrounds and experiences. However, schools and health systems have not always equipped their nurses to understand, identify, and act in addressing health inequities.
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.
The Future of Nursing Podcast — Download the PDF
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
Millions of Americans experience poor health outcomes. Often, this is due to factors outside of their control, such as where they live or where they work. These factors can result in health inequities一systematic differences in opportunities to achieve optimal health between groups of people. Often, these differences lead to unfair or delayed treatment, preventable diseases, and adverse health outcomes. The Future of Nursing 2020-2030 report strategizes how nurses can work to achieve health equity. But first, we must understand the reality of health inequity and how it impacts people across the nation. We’re going to hear from health equity experts, nurses, and physicians who have witnessed the impact of health disparities on the individuals they care for and explore the causes behind poor health outcomes, the social determinants of health that influence an individual’s health outcome, and how health inequities can impact the entire wellbeing of the nation. In this episode, we hear from Dr. Felesia Bowen, Dr. Gloria McNeal, Dr. Winston Wong, Dr. David Williams, and Dr. Kenya Beard.
The Future of Nursing Podcast — Download the PDF
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”.
The Future of Nursing Podcast — Download the PDF
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
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. 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 well-being 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.
The Future of Nursing Podcast — Download the PDF
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.
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