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Racial disparities still exist in healthcare

Nurses can help bridge gaps in care for black patients
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By Lisette Hilton
EDITOR'S NOTE: Lisette Hilton is a freelance writer.
Seattle Children’s: Ranked among 150 Great Places to Work in Healthcare
Although health disparities continue to exist among blacks in the U.S., experts say nurses can help bridge the gaps by better understanding black patients and providing culturally competent care.
Health disparities are systemic. Although people might be making poor choices, those choices are often based on having limited options, according to Deborah Riddick, JD, RN, director of Health Policy and Government Relations at Oregon Nurses Association.

“It’s the structures, like whether or not the infrastructure can accommodate places for them to get good healthy food at a reasonable cost,” Riddick said. “It’s about transportation. Is their environment safe? Is there housing?”
What’s going on?
The death rate for blacks fell 25% from 1999 to 2015, but life expectancy remains four years less than that of whites, according to the U.S. Centers for Disease Control and Prevention’s Vital Signs report released May 2, 2017. Young adult and middle-aged blacks are more likely to live with or die from diseases that are more common in older white American men and women, including heart disease, stroke and diabetes. For instance, as many as one in 100 African-American adults develop heart failure before age 50, which is 20 times the rate of whites of the same ages, according to the U.S. Department of Health and Human Services Office of Minority Health. Blacks are also more likely than whites to have disease risk factors. The CDC reports blacks ages 35 to 64 are 50% more likely to have hypertension; blacks ages 18 to 49 years are twice as likely to die from heart disease; and blacks have the highest death rate for all cancers combined compared with whites.
“We’ve known for quite some time that there are dramatic racial disparities and generally they’re not well explained by any one factor,” said Eric Schneider, MD, senior vice president for policy and research at The Commonwealth Fund.

“If you take a condition like renal failure and the use of kidney transplantation and dialysis, you see racial disparities with blacks being less likely to get renal transplants for treatment of that disease," Schneider continued. "Studies have shown that is a result of a chain of events where blacks are less likely than whites at every stage to get the diagnosis of kidney failure, to be treated for kidney failure with the right medication, to adhere to those treatments, to be listed for transplantation and to receive a kidney. That’s just one example. There are several others.”
Social determinants are far-reaching, according to Katie Boston-Leary, BSN, MHA, CNO of University of Maryland Prince George’s Hospital Center, in Cheverly. “This does not assume that every African American has issues with transportation and finances, but for when that’s real, where are these clinics?” Boston-Leary said. “What are the barriers to getting to clinics? What are the hours of these clinics? In our hospital, we have a number of our own staff that have two or three jobs, so when would they get to go if they work long hours and work weekends.”
Eric Schneider, MD
Deborah Riddick, RN
“It’s the structures, like whether or not the infrastructure can accommodate places for them to get good healthy food at a reasonable cost. It’s about transportation. Is their environment safe? Is there housing?”
— Deborah Riddick, RN
All of these are systemic issues that impact health decision-making, according to Riddick. “For someone who doesn’t have those basic needs met — food, shelter, safety, support — [common sense] says that I’m going to take care of the things that matter the most right now, and I’ll continue to manage and navigate based on that,” Riddick said.
Katie Boston-Leary, RN
Nurses act
The American Association of Nurse Anesthetists issued a press release in February about the importance of providing culturally competent care for blacks in order to reduce healthcare disparities,  launching the Diversity and Inclusion Task Force to further integrate cultural sensitivity, diversity, inclusion and equity for all minorities within the profession. 
Jorge Valdes, DNP
Among the task force’s goals is to create a more diverse and inclusive workforce among nurse anesthetists and to teach cultural competence and how to deliver care that is sensitive to cultural nuances, according to Jorge Valdes, DNP, CRNA, ARNP, who chairs the AANA task force.

Cultural nuances that can impact blacks’ healthcare decisions include that they are more likely to distrust healthcare providers and the system; they tend to fear cancer surgery because they believe it might cause cancer to spread; and older blacks might seek treatment from home remedies, prayer, spiritual healers and advice from family and friends, according to the AANA press release, which referenced various sources.
“When you deliver care from that understanding, you start forming more trust,” Valdes said. “By forming more trust, people will seek healthcare more. That is exactly what the research points to as far as African Americans are concerned.” Valdes referred to an October 2016 research report in Cancer Control as an example.

Solutions and steps nurses can take
Solving cultural disparities in care means realizing the problem, according to Schneider.
“Cultural sensitivity and the structural bias is pretty pervasive throughout our system,” Schneider said. “Many hospitals, clinics and other organizations are starting to use cultural sensitivity training to try to get at some of the unconscious biases that occur in the workplace."

Unconscious bias, according to a Forbes article, happens when nurses, doctors, patients and others quickly judge and assess people and situations without realizing it. These judgments and assessments can be influenced by feelings and attitudes people have towards people based on race, ethnicity, age, appearance, accent and more.  Another aspect of solving cultural disparities is being aware of patients' perceptions, even mistrust, according to Schneider. “But the really important part of cultural sensitivity training is for nurses, physicians or others to look at their own biases and better understand the ways in which they often unconsciously interact in ways that are discriminatory,” he said. Addressing social determinants and disparities are core to nursing, Riddick said. Nurses in charge of discharge planning should think of physicians’ recommendations in terms of patients’ realities, not on the best-case scenario, according to Riddick. The goal, she said, is to reasonably tailor the care plan to what a patient can do, so they can have success and they will be able to take care of themselves. “That’s the best plan — a plan that is responsive to a patient’s realistic needs, not idealistic needs,” Riddick said.

Communication barriers can impede quality care, but nurses can overcome especially language barriers, according to Valdes. Valdes practices in Miami, Fla., where there’s a large Haitian population, he said. So, he has learned key Creole phrases to help better communicate with patients. He’ll also use Google’s translate option to overcome language hurdles. Nurses need to own taking the extra steps to ensure African-American and other patients can overcome barriers to receive the care they need, according to Boston-Leary. “As nurses, we have that rapport already,” Boston-Leary said. “We have their attention. That’s an opportunity to have those conversations. We need to own every part of understanding what happens to that patient once they go home. As leaders, we need to make it so that it’s possible.” Nursing leaders need to make sure staff nurses have the time to build relationships with patients to better understand barriers. She also suggested arming nurses with data that shows how many patients got their follow-up care, for example, to help nurses understand how they can impact the community. Achieving more diversity in the nursing workforce should also help to build cultural awareness and responsiveness, according to Riddick.

Editor’s note: Content courtesy of Seattle Children's.
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