Diversity, equity, and inclusion (DEI) are hot topics in the healthcare world, but including a DEI module in our yearly education isn’t enough to address these issues. Policy is a valuable tool, but actual change needs to come from a more personal level, from each and every staff member.
Before we can have a meaningful conversation about DEI that might lead us toward significant change, we need to understand the meaning of diversity, equity, and inclusion and why it is important in healthcare.
First, the issues often relate to our biases, especially those so deeply ingrained in our life circumstances that we aren’t aware of them. We can’t advocate for what we don’t understand, and if we don’t advocate for change, we will stay in our “safe” silos, which only strengthens the idea that we are separate and different.
Understanding that we are separate and different and what that means is the first step in making diversity, equity, and inclusion a part of our workspace and nurse recruitment.
Diversity
Diversity is simply including people with different backgrounds. For example, when healthcare systems conduct nurse staffing while considering different cultural, gender, religious, sexual orientation, and socioeconomic backgrounds, the staff benefits from exposure to differences among coworkers, and patients feel more comfortable knowing they aren’t alone.
Our healthcare system has been lacking in diversity from the beginning, and although we’ve seen a lot of progress since the days when only white males could practice medicine, we are far from diverse.
In one study, over 56% of physicians identified as White and 64% as male, according to the Association of American Medical Colleges (AAMC). According to Minority Nurse, about 75% of RNs identify as White, and 91% are female. So if most doctors and nurses are white, most doctors are male, and most nurses are female, who are we really serving?
When we don’t have a common background, it’s easy to make the mistake of seeing the patient through our own lens instead of their reality. Our lenses place them where we want them to be—fully able and capable of taking the steps we want them to take for their health. The outcomes we desire assume the tools, processes, and understanding are within their reach and that they have the same goals we do.
Textbook knowledge can never make up for the lack of diversity in our own lives. And our lack of understanding of our patients’ reality can lead to misunderstanding or errors in care, creating inequity. Hiring a diverse workforce promotes understanding and creates a more comfortable environment for patients and coworkers alike.
Equity
Equity is a concept that often gets confused with equality. In healthcare, equality means giving everybody the same resource or opportunity to achieve their health goals. Equity is recognizing that each person has different circumstances and honoring that by allocating opportunities and resources to allow them to reach an equal outcome.
Simply giving someone an opportunity isn’t enough if they don’t have the means to use it. Equity can only be achieved when nobody is allowed to be disadvantaged due to age, race, ethnicity, nationality, gender identity, sexual orientation, geographical background, or socioeconomic status.
Access to life-saving medication is an example of inequity we see every day. A medication that costs hundreds of dollars every month may not be out of reach for someone with superb insurance coverage and a large bank account. For someone whose job doesn’t offer prescription coverage or who doesn’t make a living wage, that life-saving medication is technically available but far out of their reach. Far too many patients fail to fill the prescriptions they need for this reason.
Healthcare policy can promote equity, but we can also change how we treat and educate patients. In our medication example, we could address a patient’s ability to obtain a prescription before they leave the office or hospital. No patient should walk out the door with a prescription they can’t fill.
Inclusion
Inclusion is about deliberately creating a respectful and safe environment for all staff and patients. Inclusion means giving patients and staff a voice in giving and receiving care and encouraging diversity. Healthcare isn’t the place for a one-size-fits-all approach. We must all strive to embrace diversity and promote equity.
Nurses Are Uniquely Positioned to Champion DEI
Nurses may have little say in enacting policy within their healthcare systems but are very likely the first and last staff member a patient sees and the role they interact with most frequently. That close relationship with our patients makes nurses the most important role to champion diversity, equity, and inclusion with our patients, in nursing education, and within our own workspaces.
One of the most essential directives we learned in nursing school may have been to meet patients where they’re at. Let’s add and coworkers to that and, together, we can create a more effective healthcare system that serves all people.
Nurses inevitably encounter situations that cause moral distress. At the height of the Covid-19 pandemic, though—when there was no vaccine, and it was still assumed that for at least two years there would be no protection beyond masking and social distancing—moral distress became a daily ordeal for many frontline nurses.
Among those hardest hit by moral distress were the nurses of color working through a pandemic that exacted a disproportionate toll on Black, Filipino, Latino, and Native American minorities. Their experiences during the early days of Covid are at the core of a new study from researchers at DePaul University’s School of Nursing. In interviews with a diverse group of nurses located across the US, investigators found that moral distress was an almost inevitable affliction when lack of support made it impossible for nurses to provide high-quality care based on their training.
Nurses on the frontlines faced unrivaled psychological and physical demands during the pandemic, noted researchers. Voices of nurses from this moment in history could help inform policies and laws to improve retention and reduce burnout among nurses in the U.S. “People need to listen to nurses more, and nurses need to feel empowered to share their experiences at every level of leadership,” said principal investigator Shannon Simonovich, PhD, RN, an assistant professor of nursing at DePaul.
“Diverse nurses caring for a diverse patient population”
In 2020, many news stories about health care heroes featured white, female nurses, Simonovich said. In reality, nurses from many personal, ethnic and geographic backgrounds with a varying levels of education were caring for COVID-19 patients.
Simonovich recruited a diverse group of DePaul nurse researchers to conduct the study, which in turn helped recruit a diverse group of 100 nurses to be interviewed, according to assistant professor and coauthor Kashica Webber-Ritchey. “We captured the voices of diverse nurses caring for a diverse patient population that was being disproportionately impacted by COVID-19,” Webber-Ritchey said. In the DePaul sample, 65% of the nurses identified as a member of a racial, ethnic, or gender minority group.
Many nurses from these represented populations have lost their lives to COVID-19. Researchers at DePaul cite a tally that more than 3,300 U.S. nurses, doctors, social workers and physical therapists died of COVID-19 between February 2020 and February 2021.
DePaul researchers conducted interviews between May and September 2020, asking nurses to describe their emotions. Nurses reported moral distress related to knowing how to treat patients and protect themselves, but not having the staff, equipment or information they needed. As a result, they reported feeling fear, frustration, powerlessness and guilt.
The toll of frustration, stress, and guilt
This qualitative study is believed to be the largest of its kind from this period—a time of great uncertainty about the virus that causes COVID-19 before the development of vaccines. Highlights include:
Study participants described many forms of frustration while providing patient care, including frustration with healthcare leadership being out of touch with those on the frontlines.
Nurses felt powerless to protect themselves and others from contracting COVID-19.
Nurses described being placed in difficult patient care experiences that resulted in guilt around letting down patients and their families, as well as fellow members of the healthcare team.
““We are a largely female profession, and we don’t complain enough when things are tough.”
The burden nurses have shouldered during the COVID-19 global pandemic calls for research that describes and examines the emotional well-being of nurses during this unprecedented time in contemporary history, write the researchers. As the media coverage of nurse heroes fades, the narratives in this study should be a call to action, says Kim Amer, an associate professor with 40 years of nursing experience.
“Nurses need to come together as a profession and make our standards and our demands clear,” Amer said. “We are a largely female profession, and we don’t complain enough when things are tough. As a faculty member, we teach students that it’s OK to refuse an assignment if it’s not safe. We need to stand by that.”
The DePaul research team calls for clear, safe standards for nurses that will be legally binding and hold hospitals and health care agencies accountable. “We go into nursing with the intention of saving lives and helping people to be healthy,” said Simonovich. “Ultimately, nurses want to feel good about the work they do for individuals, families and communities.”
Investments by healthcare organizations and policymakers in mental health resources could help promote psychological resilience in nurses, noted Webber-Ritchey. “Taking time to speak to nurses to understand their needs and provide support would help with addressing moral distress,” she said.
Two recent papers by UIC College of Nursing faculty found that microaggressions – common, subtle indignities – can be just as harmful as a major discriminatory event, contributing to negative mental and physical health outcomes in bisexual women.
Associate professor Wendy Bostwick, PhD, MPH, and assistant professor Ariel U. Smith, PhD, RN, were co-authors on both papers, one published in the Journal of Bisexuality and the other in Psychology of Sexual Orientation Gender Diversity, a publication of the American Psychological Association. Both relied on findings from the Women’s Daily Experience Study of 112 ethnically and racially-diverse bisexual women.
Bostwick is principal investigator on a National Institute on Minority Health and Health Disparities grant which funded the Women’s Daily Experience Study, one of the first ever to focus on bi-identified women and mental health. Participants completed a baseline survey, followed by 28 days of e-diaries to capture microaggressions that they may have experienced during the previous 24 hours.
“The old saying goes, ‘sticks and stones may break your bones, but words can never hurt you,” Smith says. “But you look at the data and realize that’s simply not true. Microaggressions that someone has experienced over a lifetime are correlated with mental and physical ailments they experience even today.”
The researchers looked at microaggressions related to sexual orientation, race and gender. Microaggressions could include denying a person’s bisexuality—suggesting it’s “just a phase”—or a rude or insulting comment about lesbian or gay individuals. A comment minimizing or denying the existence of racial discrimination is an example of a racial microaggression.
Participants reported an average of eight microaggressions of any type in the previous month, with almost all women—97%—reporting at least one microaggression throughout the duration of the study.
Gender-based microaggressions were reported the most frequently. Women reported being sexually objectified on more than 15% of the days recorded.
The papers also found microaggressions were associated with poor mental health and binge drinking, smoking and marijuana use. The most consistent finding was an association between microaggressions and anxiety.
“Our findings suggest that for bisexual women, the weight of denigrating comments about their sexual identity, gender and race can contribute to poor health outcomes—whether such comments happened last year or yesterday,” Bostwick says. “Of course, these comments are situated in a larger context of systemic inequities, which may render bisexual women with fewer resources to cope when confronted with dismissive and disparaging comments about core aspects of who they are and their own lived experiences.”
Bisexual women of color were a majority in the study—57%—a group that is notably absent in the literature, the researchers say. Latina bisexual women reported worse health outcomes than Black and White bisexual women in their daily diaries. Smith says the impact of microaggressions on bisexual women of color is an area where further research is needed.
“So often we focus on the large discriminatory events, like being denied housing or being fired from a job,” Smith says. “These subtle comments and slights can be just as harmful. That’s why it’s important to address it through education – understanding and recognizing what a microaggression is and then adapting policies to raise awareness.”
Co-authors included UIC Nursing visiting research specialist Larisa Burke, MPH, Amy L. Hequembourg, Alecia Santuzzi and UIC Nursing professor emerita Tonda Hughes, PhD ’89, RN, FAAN.
Going to school while working full-time as a nurse and raising a four-year-old with her husband isn’t easy, so Ashley Willie knew she wanted an online nursing program with supportive instructors and a flexible schedule.
DNP student Ashley Willie, MSN.
Willie, who is pursuing a doctorate in nursing online through Penn State World Campus, where she also received a master’s in nursing, said she wanted professors who were inclusive and available to meet with students.
“I wanted instructors who were interested in their students’ personal and career goals as well as their educational goals,” she said.
In addition, she said, “I was looking for a program that didn’t require me to be online at a certain time. I wanted more freedom and autonomy.”
Willie said prospective nursing students should look at what kind of financial support and resources are available for minority students, as well as what past and current students and instructors have to say about the program. And of course, they should check the matriculation rate and accreditation of a school, she said.
Financial support: putting your money where your mouth is
Sheldon Fields, the inaugural associate dean for equity and inclusion at the Penn State Ross and Carol Nese College of Nursing, agreed that prospective students should look at what kind of financial resources an institution commits to multicultural students.
Sheldon Fields, PhD, RN, CRNP, FNP-BC, AACRN, FNAP, FAANP, FAAN. Associate Dean for Equity and Inclusion, Ross and Carol Nese College of Nursing.
“To put their money where their mouths are, schools need to be committing resources — sponsoring lecture series, offering scholarships, resources specifically focused on supporting multicultural students,” he said.
Fields, who has been a nurse for 30 years, said schools should have a clear stance on diversity, equity and inclusion that is reflected in their mission statement and their strategic plan, which should be available online, and should also teach diversity, equity and inclusion issues as part of their undergraduate and graduate curricula.
If there are no multicultural nursing student groups and the topic appears to be ignored, “It’s a big red flag,” Fields said. “A multicultural student is not going to find support for who they are, for the unique perspectives and talents that they bring, and the needs they have.”
Fields urged prospective students to look carefully at a school’s nursing faculty.
“It’s one thing to say you want a diverse faculty; it’s another to actually make it happen,” he said.
Denita Wright Watson, associate director of equity, inclusion, and advocacy for the Penn State World Campus Student Affairs office, urged students to seek out institutions that focus on addressing health care disparities, inequities, and bias in health care and that are focused not only on attracting diverse talent, but also retaining it. Schools should go beyond lip service to invest in students’ academic and professional success, she said, by providing professional development opportunities and other career services, as well as supporting students’ personal well-being through mental health support, student identity groups and DEI–related programs.
Ask questions
Denita Wright Watson, MLD, Assoc. Director of Equity, Inclusion, & Advocacy for Student Affairs. Penn State World Campus.
Students should ask, “What support is out there for me, beyond academic support?” Wright Watson said. “What support is there to aid in my growth as a person?”
Prospective students should “scour and scour” a school’s website not only for their mission and values statements, but also to see what service projects the institution is involved in and what kind of speakers and events are offered, Wright Watson said.
“Google should be their best friends,” she said. “Just ask questions: Why should I pick this university? Why should I pick this program? What are they doing to meet the needs of underserved students and communities?”
Fields added: “Ask them, ‘What did you learn in a program about diversity, equity and inclusion?’ If they tell you nothing — run the other way.”
Feeling valued
Willie agreed that it’s important to look for an institution that recognizes health care inequities and equips students with tools to help reduce health care disparities, seeking to improve health care outcomes at both the individual and the population levels. An example of that is teaching students methods of recognizing vulnerable populations and using evidence-based tactics to improve health care literacy and health and wellness, she said.
All her professors at Penn State have valued both her cultural and professional background and make time to meet with individual students to discuss their goals and aspirations, Willie said.
“For me this is very important because not only do I feel valued individually, I feel like the instructors are invested in my success as a woman of color.”
Family nurse practitioners (FNPs) are needed now more than ever, especially in our fast-growing-but-underserved Latinx communities.
Latinx patients disproportionately report not having a usual source of healthcare and face challenges when trying to find a provider. They are also more likely to live in a community that is experiencing a provider shortage, so they often seek out care in community health centers.
FNPs are more likely to work in these health centers and can ensure Latinx families have access to the care they need.
Dedicated to Diversity and Inclusion
In Arlington County, home of Marymount University’s physical campus, Latinx residents comprise 20-25 percent of the population, the largest concentration in the state. Marymount University’s student population reflects the local demographic, with 25 percent of its undergraduate students identifying as Latinx or Hispanic.
Marymount is dedicated to the idea that diversity is a shared value lived by students, faculty, and staff. Those efforts were recognized when they were named the first Hispanic-Serving Institution (HSI) in Virginia.
Marymount also supports its Latinx students through a recent initiative called ¡Avanzamos! (“Moving Forward Together”), which ensures campus-wide programs and student-success efforts include issues that impact their Latinx student population. ¡Avanzamos! is part of a larger effort to promote diversity and inclusion entitled, “You Belong Here,” which brings together students, faculty, and staff who understand the challenges and needs associated with discrimination and inclusion.
The time has never been better for nurses who want to complete a Family Nurse Practitioner program. Marymount’s online nursing programs prepare nurses for a career as an FNP, allowing them to help underserved populations across the country, including Latinx communities.
Marymount offers several FNP programs for nurses with various levels of education.
For BSN-prepared nurses, Marymount’s online DNP-FNP program teaches skills needed to be a nurse leader who not only offers compassionate care but improves patient outcomes by providing the best patient care across multiple populations in a complex, ever-changing environment.
Marymount’s CCNE-accredited online MSN-FNP program, also designed for nurses with a BSN, utilizes a curriculum strongly focused on ethics and evidence-informed care. Learn from practicing FNPs who are experts in their field and translate theoretical knowledge from the sciences and humanities into the delivery of advanced nursing care to diverse populations.
Marymount’s FNP post-master’s online certification prepares nurses who already have an MSN degree to build on existing knowledge to optimize patient care and be at the forefront of the ever-changing healthcare landscape.
Marymount’s online FNP programs offer a unique opportunity to balance work and school, achieve career goals, and obtain the knowledge and skills needed to sit for the AANP or ANCC family nurse practitioner certification exam after graduation.
To ensure all students can concentrate fully on working and studying, Marymount’s Clinical Placement Team coordinates all aspects of the clinical placement process to ensure the successful completion of clinicals at a placement site within a reasonable distance to the student’s home.
The report studied how different groups have fared financially since the recession of 2008. The study examined the wealth holdings and the medial household earnings of white, black, and Hispanic households. It revealed that while all groups saw their funds decline significantly, white households have rebounded better than black or Hispanic households, with Hispanics faring the worst.
According to the study, in 2007, white households held a median net wealth of $183,100 with median household earnings of $63,900. Black households held $39,00 in median net wealth with $39,100 in earnings. Hispanic households held $59,300 with income of $44,000.
By 2016, white households had $132,100 of net wealth with $67,200 in median earnings. Black households had $18,300 in net wealth and $37,000 in median earnings. Hispanic households held $24,400 in net wealth and median earnings of $38,000.
The significant drops in both total net wealth and median household earnings means minority families have less money to pay for everyday costs and little if any income left to save for retirement. And although the study did mention that at the moment Social Security will up the replacement rates for low earners, that’s little comfort for families who aren’t able to save for their futures right now.
The study estimates that half of all households in the United States are at risk for being prepared for retirement, the figures are different for each group. About 48 percent of whites, 54 percent of blacks, and 61 percent of Hispanics are at risk of not having enough to fund their retirement years. And if you are a caregiver to someone and a nurse, you have a distinct challenge.
What does that mean for retirement security and making good financial decisions? Saving any money at all is better than saving nothing. Taking a hard look at where your money goes now is a good first step. Then set a goal. If you want to save $50 a month, you’ll either need to reduce your spending or make more money. That could mean eliminating some things like buying take-out food or drinks. Coffees, sodas, and iced teas are rarely worth the price away from home. Packing meals and snacks to bring to work or to tide you over for a long day of clinicals and classes also makes a difference. Examine your cable bill, your phone costs, your entertainment expenses, and clothing expenses. Keep only what is absolutely necessary.
If there’s little space to reduce your expenses, think of ways to bring in a little more income and put it aside for retirement. Whether it is selling clothes online, tutoring nursing students, or taking a short-term consulting job, extra income can make a big dent in retirement goals.
Whatever you do, don’t sell yourself short. You are saving for your own future, and that alone is worth making it a priority.
