By Susan Sportsman, PhD, RN, ANEF, FAAN
Today’s professional literature and the popular press are full of reports of health disparities throughout our country. The results of these disparities place a terrible toll on the health and well-being of patients and caregivers alike. In addition, the economic impact is significant. Certainly, these problems must be addressed. Yet, what role do Nurse Educators play in reducing these disparities?
The role of the biases (often implicit) of educators in influencing health care disparities was emphasized for me recently when I had a conversation with a former paramedic, discussing his preparation to start IVs. He described how the physician teaching IV insertion recommended that because the skin of Black patients was “tougher” than other races, inserting an IV required more pressure than starting an IV in other situations. This upsetting story stimulated me to think more deeply about health disparities and the role of nurse educators in addressing these issues.
Evidence of the Problem
Recent data from the Kaiser Family Foundation found that before the COVID-19 pandemic, people of color fared worse compared to their White counterparts across a range of health measures, including infant mortality, pregnancy-related deaths, prevalence of chronic conditions, and overall physical and mental health status. As of 2018, life expectancy among Black people was four years lower than White people, with the lowest expectancy among Black men. In addition, low-income people of all races report worse health status than those with a higher income. Unfortunately, the COVID-19 Pandemic has escalated the rates of illness and death in American Indians, Alaskan Natives, and Black and Hispanic groups. It also has taken a disproportionate toll on the financial security and mental health and well-being of people of color, those with low-incomes, LGBTQ individuals, and other underserved groups.
Social factors drive the avoidable differences in health outcomes. A literature review on the subject found that social factors such as economic stability, education, and health care access and quality, neighborhood environment and social and community context matter when health outcomes are determined (Pradcht, Pruitt, Quast, 2021). Recent studies suggest that health system innovation, such as greater coordination of medical and social services, can improve health outcomes and reduce health care expenditures (Pruitt, Emechebe, et. al, 2018; Naadozie, Taylor, et.al, 2019). To emphasize the impact of social disparities on health and to capture the nation’s progress in addressing such disparities, Healthy People 2030 has included social factors such as exposure to unhealthy air, household food insecurity and hunger, and insurance status in the Leading Health Indicators.
Evidence suggest that the experience of my paramedic friend has been found in a broader context. Hoffman, Trawalter, Axt, and Oliver (2016) found 73% of white medical students studied had at least one false belief about the biological difference between races. For example, many (wrongly) believed Black people had a higher pain tolerance than white people. Black children with painful health issues like appendicitis or sickle cell disease were less likely to receive appropriate pain management than white children.
Health care workers of color or who are part of groups that often struggle with health disparities may have more negative experience in their professional lives. A survey from Harvard Medical School, based on data from more than 2 million COVID Symptom Study app users in the U.S., found that health care workers of color were more likely to care for patients with suspected or confirmed COVID-19 and nearly twice as likely as white colleagues to test positive for the coronavirus. Health care workers of color were also more likely to report inadequate or reused PPE, at a rate 50% higher than what white workers reports (Nguyen, Drew, & Graham, 2020).
Addressing the Problem: Nursing Education Organizations’ Responses
Addressing health disparities requires action on the part of all health care providers. Nurse educators play a special role in ensuring that our students can identify social determinants of health and participate in developing and implementing strategies to reduce health disparities for individuals, groups, and populations. In response to this demand, nursing education organizations are emphasizing the need for diversity, equity, and inclusion in nursing specifically and healthcare-at-large. For example, the American Nurses Association has led the organization of the National Commission to Address Racism in Nursing, which includes organizations representing nursing education, such as the Organization for Associate Degree Nursing (OADN), American Association of Colleges of Nursing (AACN), and National League for Nursing (NLN), as well as a number of other nursing organizations. The goal of the Commission, announced on January 25, 2021, is to lead a national discussion by exploring the experiences of nurses of color to develop an action-oriented approach across the spectrum of education, practice, policy, and research.
The membership of the American Association of Colleges of Nursing (AACN) approved The Essentials: Core Competencies for Professional Nursing on April 6, 2021. The Essentials outline ten areas of competence, as well as featured concepts, that are part of nursing practice. Two of the eight concepts highlighted include diversity, equity and inclusion and social determinants of health. AACN also has developed a fact sheet which highlights the need for diversity and inclusion in nursing education.
In 2016, the National League for Nursing (NLN) published Achieving Diversity and Meaningful Inclusion in Nursing Education: A Living Document from the National League of Nursing which outlined concerns related to diversity and inclusion and make recommendations for Deans, Directors, and Chairs and Nursing Faculty and Staff to improve equity in nursing students, faculty and staff. The recommendations for faculty below still have meaning for us all.
- Utilize the NLN toolkit to provide evidence-based approaches to teaching/learning strategies related to the Social Determinates of Health (SDH).
- Raise students’ consciousness about SDH, how to develop an inclusive understanding of the SDH, and how recognizing the shared impact of the SDH on health and wellness leads to new perspectives related to differences and mitigates bias and racism.
- Create partnerships with community agencies to provide experiences that intentionally expose students to address the impact of SDH on patients, families and communities.
- Thread SDH education throughout the program of learning in varied educational settings (e.g., classroom, clinical settings, and simulation-learning environments).
- Be intentional about providing opportunities for students to assess and implement actions to address SDH in a variety of health care settings.
- Develop curricula that strengthen the links between SDH, health equity, and nursing’s social mission.
To emphasize the importance of addressing health disparities in the US, in May 2021 the National Academy of Medicine published a consensus study on the Future of Nursing. The title of this report, a follow-up of to the 2011 landmark Future of Nursing Report, highlights the importance of this issue: The Future of Nursing 2020-2030: Charting a Path to Health Equity. A report brief, Transforming Nursing Education, drawn from this report, speaks specifically to nurse educators, as follows:
- Integrate content on the social determinants of health and health equity throughout nursing education, not just in a handful of courses.
- Extend education and training beyond the classroom and traditional clinical experiences to experiential learning opportunities in communities.
- Cultivate inclusive learning environments that acknowledge and challenge racism in all aspects of nursing education and practice.
- Intentionally recruit, support, and mentor faculty and students from diverse backgrounds to ensure that the next generation of nurses reflects the communities they serve. Nursing accreditors can play a role by requiring standards for student diversity just like other health professions schools.
The NLN concurs with the recommendations of the Future of Nursing Transforming Nursing Education through its report, A Vision for Integration of the Social Determinants of Health into Nursing Education Curriculum. This resource provides references, resources, and reflection questions to help both program administrators and faculty ensure diversity and inclusion strategies as part of their roles in nursing education. In addition, on May 12, 2021, NLN launched a new program, supported by AMI and Elsevier Education, to raise awareness of nurse educators regarding societal inequities affecting health and welfare of communities of color. The program, Taking Aim Initiative: Structural Racism, Diversity, Equity, Inclusion, Implicit Bias, and Social Justice, is a year-long series of webinars, an interactive workshop, and online resources. Specifically, the Taking Aim Initiative will:
- Enable nurse educators to become better informed about the impact of structural racism, diversity and inclusion, and equity on nursing education.
- Address the impact of structural racism on social determinants of health.
- Create a forum for nurse educators to openly dialogue about sensitive issues of bias and racism in nursing education and health care.
- Offer strategies for classroom and clinical instruction to best prepare new nurses to encounter and defuse structural racism on the job.
Nursing education organizations have provided guidelines, references, and resources to help individual nursing programs and faculty prepare students (and ourselves) to address issues of heath disparities in the United States. To achieve this goal, we will be required to examine our own biases, the culture of our organizations, and the state of the curriculum from which we teach. Yet, I am confident that nurse educators across the county can accomplish much to improve health in the areas we serve. I am eager to hear what each of you are planning (or doing) as we move to a more equitable health care system.
AACN (2021) The Essentials: Core Competencies for Professional Nurses. https://www.aacnnursing.org/Portals/42/AcademicNursing/pdf/Essentials-2021.pdf Accessed, 2021.
AACN (2019) Fact Sheet: Enhancing Diversity in the Nursing Workforce https://www.aacnnursing.org/Portals/42/News/Factsheets/Enhancing-Diversity-Factsheet.pdf. Accessed, 2021.
Emechebe, N., Amoda, O., Taylor, P.L., Pruitt, Z. (2019). Passive social health surveillance systems may identify individuals at risk of inpatient readmissions. American Journal of Managed Care. 25(8), 388-395.
Hoffman, K. M., Trawalter, S., Axt, J. R., & Oliver, M. N. (2016). Racial bias in pain assessment and treatment recommendations, and false beliefs about biological differences between blacks and whites. PNAS Proceedings of the National Academy of Sciences of the United States of America, 113(16), 4296–4301. https://doi.org/10.1073/pnas.1516047113. Accessed, 2021.
National League of Nursing (2016) Achieving Diversity & Meaningful Inclusion in Nursing Education: A Living Document from the National League of Nursing. http://www.nln.org/docs/default-source/default-document-library/diversity-toolkit.pdf?sfvrsn=2. Accessed, 2021.
Ndugga, N., Artiga, S. (2021) Disparities in Health and Health Care: Five Key Questions and Answers. KFF (Kaiser Family Foundation) https://www.kff.org/racial-equity-and-health-policy/issue-brief/disparities-in-health-and-health-care-5-key-question-and-answers/ Accessed, 2021.
Nguyen, L., Drew, D., Graham, M., Joshi, A., Guo, C., Ma, W., Mehta, R., Warner, E., Sikavi, D., Lo, C, Kwon, K., Song, M., Mucci, L., Stampfer, M., Willett, W., Eliassen, A., Hart, J., Chavarro, J., Rich-Edwards, J., Davies, J., Lee, K., Lochlainn, M., Varsavsky, T., Sudre, C. Cardoso, J., Wolf, J., Spector, T., Ourselin, S. J Steves, D., Chan, A., on behalf of the COronavirus Pandemic Epidemiology Consortium (2020) Risk of COVID-19 among front-line health-care workers and the general community: a prospective cohort study. Lancet, 5. September, e475-e 483. https://www.thelancet.com/action/showPdf?pii=S2468-2667%2820%2930164-X Accessed, 2021.
Pracht, E., Pruitt, Z., Quast, T., Taylor, P., Kristopher, B., (2021) Executive Summary. Specialty Physicians and Care: Social Determinants of Health. Prepared for Hillsborough County Health. University of South Florida, College of Public Health. May.
Pruitt, Z., Emechebe, N., Quast, T., Taylor, P.L. and Bryant, K.B. (2018). Expenditure reductions associated with a social service referral program. Population Health Management. 21(6), 469-476.
NLN (2021) NLN Launches New Program to Raise Awareness with Nursing Educators of Societal Inequities Affecting Health & Welfare of Communities of Color. A New Release. May 12. http://www.nln.org/newsroom/news-releases/news-release/2021/05/12/nln-launches-new-program-to-raise-awareness-with-nurse-educators-of-societal-inequities-affecting-health-welfare-of-communities-of-color. Accessed, 2021.