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Diversity, Equity, and Inclusion

What Will It Take To Achieve Health Equity?

Leaders say improving equity requires an honest look at all factors at play

By Lisette Hilton
Martha A. Dawson, RN
Eun-Ok Im, RN
Adrianna Nava, RN
o better meet America’s health needs and contribute to a Culture of Health, the nursing workforce needs to reflect the country’s multitude of ethnicities, races, cultures, and communities. Such diversity will ultimately increase health equity and help transform the way people get their health care,” according to the
Health equity is a tall order. According to the Centers for Disease Control and Prevention (CDC), health equity happens when all people have the opportunity to attain their full health potential, without social position or other socially determined circumstances standing in the way.
“Health inequities are reflected in differences in length of life; quality of life; rates of disease, disability, and death; severity of disease; and access to treatment,” according to the CDC.
Nurses can play important roles in achieving health equity. talked with members of the Campaign for Action’s Equity, Diversity, and Inclusion Steering Committee to help nurses better understand challenges and possible solutions for achieving this goal in the U.S.
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Improving Data Collection, Increasing Diversity in Leadership

Adrianna Nava, PhD, MPA, MSN, RN, President of the National Association of Hispanic Nurses (NAHN), said the biggest obstacle for achieving healthcare equity is the lack of consistent and systematic socioeconomic data collection, including race/ethnicity, within healthcare organizations.
“Typically, health outcomes are measured and reported in aggregate with outcomes by race/ethnicity not usually being the focal point,” Nava said. Nurses might have opportunities to review nursing-sensitive indicators to update health outcomes to include measures related to health equity, which would demonstrate nurses’ value in promoting health equity in the U.S., Nava continued.
“There may be an opportunity for nurses to review our nursing-sensitive indicators to determine how to update these to include structure, process, and outcome measures related to health equity, which would demonstrate the value of nurses in promoting health equity in the U.S.," she said.
Another health equity obstacle is the lack of racially/ethnically diverse leaders in senior level positions of leadership within healthcare organizations.
“Priorities can shift when different points of view and voices are brought to the table,” Nava said. “In addition, discrimination and racism may be spoken about more often, with discussions on how to improve the work environment for staff, visitors, and patients.”
One important solution for overcoming these obstacles to health equity is for nurses to get involved in unit or department-level quality improvement programs. Nurses should learn how to track data and use basic quality improvement tools to potentially help to address and fix problems, according to Nava.
“Once you participate in the local unit, share your work with other units, with your system leadership, and potentially in practice journals,” Nava said. “At all nurses’ levels and workplaces, nurses can learn the tools necessary to improve their workplaces and delivery of care for their patients. As active participants in quality improvement initiatives with a focus on health equity, we can get one step closer to closing racial/ethnic disparities in health care.”

Getting Out of the Comfort Zone

Inequity is entrenched in many aspects of life that impact health outcomes, according to Martha A. Dawson, DNP, MSN, RN, FACHE, President/CEO, National Black Nurses Association (NBNA) and Associate Professor of Nursing at the University of Alabama at Birmingham.
Blaming the underserved for poor health outcomes, unequal treatment, and disrespect toward racial and ethnic patient populations in practice settings, which is well documented in the literature, is an obstacle to achieving healthcare equity, according to Dawson. There are systemic and institutional laws and policies that fuel wage inequity, as well as barriers to promotions, housing, safe environments, and more. These are political determinants of health that drive the social determinants of health.
Insurance coverage, which should be based on an equal playing field, is based on who can afford it, with those who are paid more being able to afford better insurance, according to Dawson. However, for Black and Brown patients, equal insurance does not translate to equal care.
Other obstacles, according to Dawson, can still be found in many institutions. For example, many major academic medical centers pay for employees’ children to attend their universities. However, the children of many of their non-professional staff who work in food and environmental services may not meet the admission criteria for acceptance to these universities.
What leaders learn and hear might make them uncomfortable, but that is what it takes to change institutions and create new models of leadership needed for health equity, according to Dawson.
There also are barriers that prevent Black and Brown children from considering and understanding the scope of healthcare careers and the many high-paying options available, especially during the technology age. Our goal should be for employees to envision a better future for their children.
Like Nava, Dawson thinks diversity in leadership can make a difference. “Consider diverse leadership and support them in providing critical feedback and direction versus just being at the table,” she said.
What leaders learn and hear might make them uncomfortable, but that is what it takes to change institutions and create new models of leadership needed for health equity, according to Dawson.
“This level of change has to start at the top,” she said.

The Need To Lift Language Barriers, Stop Stereotyping

For Asian Americans, language barriers make up the biggest obstacle in the U.S. healthcare system, according to Eun-Ok Im, PhD, MPH, RN, CNS, FAAN, President of the Asian American Pacific Islander Nurses Association (AAPINA). “Going through U.S. healthcare systems as a non-native speaker with a strong accent is not easy for most of them, even for healthcare providers including nurses,” said Im, who also is Senior Associate Dean for Research and Innovation and Professor and Edith Folsom Honeycutt Endowed Chair at Emory University's Nell Hodgson Woodruff School of Nursing. Another challenge is the stereotype that Asian Americans are an ideal immigrant group with high resources.
“Many of them lack resources and support, but we tend to assume that they are doing just fine,” she said. “A large portion of Asian Americans do not have health insurance that could adequately cover their healthcare needs, and many of them fly back to their countries of origin to get affordable health care.”
Because the Asian culture emphasizes obedience and respect for authority, including healthcare providers, many Asian Americans may not challenge inequities that they experience in healthcare systems or institutions.
“Asian Americans rarely complain about their pain and symptoms, including psychological symptoms,” Im said. “They tend to internalize discriminative experiences and rarely express concerns.” Im agrees that unequal treatment and respect toward racial and ethnic populations in practice settings is a barrier to healthcare equity, as are systemic and institutional laws and policies. Since a large portion of Asian Americans are immigrants, the laws and policies related to immigration (documented and non-documented) could greatly influence health equity among Asian Americans, Im said.
To overcome these barriers, it is important to train and educate healthcare providers, including nurses, about cultural humility, respect, and competence. Advocating to make changes in the level of laws and policies that could be detrimental to the equitable healthcare workforce and services also is key, Im said.
Lisette Hilton is a freelance writer.