Nursing has always held health equity as a critical value in many ways. Nurses strive to deliver the best care to all patients, independent of socioeconomic status, gender, race, or other factors.
Health equity arguably gets even more attention than in the past. And that attention also occurs in nursing schools, where nurses are presented with the concept of health equity.
In this article, we examine how various schools teach health equity. But first, let’s define the term.
“Equity should mean that people have the opportunity to get what they need when they need it,” notes Alicea-Planas, associate professor of nursing at Egan and practicing nurse at a community health center in Bridgeport, CT. “That’s something that has historically been lacking for certain communities within our healthcare system.”
Health equity means that “everyone has the ability and opportunity to be healthy and to access healthcare to help them maintain health,” says Latina Brooks, PhD, CNP, FAANP, associate professor at Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, Ohio. Brooks also directs the MSN and DNP programs at Frances Payne.
Beyond Accessibility
The CDC notes that achieving health equity requires ongoing efforts to address historical and contemporary injustices; overcome economic, social, and other obstacles to health and healthcare; and eliminate preventable health disparities.
Health equity isn’t just about access to healthcare, notes Elaine Foster, PhD, MSN, RN, vice president of nursing, Education Affiliates. It can also relate to whether a diabetic patient, for instance, knows what to get checked. “I think sometimes we’ve put a very narrow description on health equity, and I think if you were to flesh it out, it goes beyond that accessibility,” Foster notes.
“You can even take health equity that next step and say, Do you have an advocate or do you have someone who knows to push the envelope?” says Foster. “We have to be active participants in our healthcare these days to get what we need.”
Besides accessing resources, health equity involves “understanding how to navigate our healthcare system,” says Alicea-Planas. “It is understanding the information that’s being provided to us by healthcare providers and being able to use it for patients to do well on their health and wellness journey.”
Teaching Equity
At various schools, health equity is integrated throughout the course of study. For instance, at Adelphi University College of Nursing and Public Health, Long Island, New York, health equity is threaded throughout the undergraduate and graduate curriculum in various courses, notes Deborah Hunt, PhD, RN, Dr. Betty L. Forest dean and professor. For example, in the school’s community health course, there is a focus on vulnerable and underserved populations. In the childbearing course, Hunt notes, there is a focus on health disparities and maternal and infant mortality.
Foster notes that health equity is threaded into the curriculum at the 21 nursing schools within the Education Affiliates system. Likewise, at Frances Payne Bolton, health equity is integrated into courses. However, Brooks notes that some courses go more in-depth, such as discussing health equity in vulnerable populations.
At Egan, introductory courses talk a lot about health equity and social determinants of health, notes Alicea-Planas, as do clinical courses. “I think a big part of understanding health equity is also understanding social determinants of health,” says Alicea-Planas. “I am super excited that now in the nursing curriculum, we have lots of conversations around those social determinants of health and how they influence people’s ability to attain their highest level of health.”
The Takeaways
One crucial learning that Alicea-Planas hopes students take away is that for students who haven’t been exposed to many people from different backgrounds, it’s essential “to understand how historically our healthcare system has treated certain communities of color. That factors into people’s feelings about how doctors or nurses treat them, influencing their ability to seek care.”
Foster hopes that students learn that no matter what the patient’s background, “Everyone is entitled to good, nonjudgmental care within the healthcare system.” Students must learn “not to impose our beliefs, our judgment on someone. Because until we get rid of that type of judgment, we will never overcome issues with health equity because we’ve got to first check our beliefs and opinions at the door and say I’m going to give the best care possible to these patients.”
Nurses’ hearts and minds are like living libraries of patients’ stories. In the intimate container of trust created in the nurse-patient relationship, a tapestry of memories, confessions, and reflections are woven, and the nurse is privileged to be privy to such soulful sharing.
As nurses, what are we to do when we’re the repositories of so much of the richness of our patient’s lives, including the tragic, the comedic, and the mundane?
Holding the Tapestry
Since patients’ stories are shared in the space of a therapeutic relationship, our first responsibility is to maintain the confidentiality of this sacred information. Throughout a long nursing career, the stories we hold in our hearts naturally accumulate — some blend, some are forgotten, and some are so poignant that they stay with us in almost crystalline clarity for the remainder of our lives.
Working in a psychiatric or mental health milieu, we might be lucky enough to have clinical supervision to unburden ourselves with a mentor or supervisor. There may also be team meetings where patient stories are shared, we compare notes with colleagues, and the puzzle pieces of our patient’s lives are examined for clues as to how we can best serve their healing.
In a busy hospital unit, emergency department, or other settings, stories might be harder to share among colleagues, and we may leave certain shifts feeling as if the weight of our patients’ lives is pressing down upon our shoulders.
Hospice work can sometimes bring opportunities for debriefing, especially when a patient is heading toward death or has already passed away. Hospices, where this practice is the norm, allow nurses, chaplains, aides, and other staff members to laugh, cry, and ponder the deeper meaning of patients’ lives.
Wherever we work, the tapestry is still in our possession, whether it be in a functional, healthy way or a manner in which we are hurt by the suffering we witness and hold.
Unburdening Our Hearts
If you work in an environment where sharing patient stories and unburdening your heart isn’t the cultural norm, you have to find other ways to process what you see, hear, and experience. There are places outside of work where it’s safe to talk, but you’ll need to actively pursue finding the right place to process the tragedy, trauma, and human dramas you hold in your mind and heart.
Employee Assistance Programs
EAPs are workplace-sponsored confidential counseling and mental health services made available at no cost to staff members needing support. Myths about employers having access to EAP counselors’ and therapists’ treatment notes are untrue — your sessions with EAP personnel are entirely confidential. In this setting, you’re free to talk about your patients (leaving out all HIPAA-related identifiers) and receive supportive feedback.
Discussing personal matters that have nothing to do with work is also fair game during EAP sessions. So whether you’re having issues related to your marriage, home life, or anything else, these topics can be addressed.
Faith leaders
For many individuals, their faith is an aspect of their lives where they feel safe. If your church, synagogue, mosque, or another place of worship is where you feel you have the greatest chance of finding solace from work stressors, speaking with your faith leader might be the best setting for you to unburden yourself.
Priests, imams, rabbis, and other religious leaders hear countless stories of human suffering and difficulty, and the insights you receive from conversations with such individuals could be the key to understanding your patients while also using their stories in the context of your healing.
Your 12-step sponsor
If you’re involved in a 12-step program, your sponsor may be one of the most trusted people in your life. Patients’ situations and stories can be traumatizing for us, so if you feel particularly triggered or overly burdened by something you heard, this could be appropriate to bring to your sponsor for contemplation and discussion.
Therapist or counselor
Finally, your therapist or counselor can be your go-to as a safe place to discuss what you hear and experience at work. Since your relationship with your therapist is built on trust and complete confidentiality, you can freely share without fear.
The Honor and Privilege
It is both an honor and a privilege to be trusted enough by a vulnerable patient to be on the receiving end of their stories. Patients tend to trust nurses, and that connection can run deep, although we can sometimes suffer our own pain in response to what we witness in the patient.
There’s no shame in experiencing your distress as a caregiving professional. Secondary or vicarious traumatization is no joke; what you feel doesn’t have to make logical sense for it to be altogether real. Emotions are not inherently logical. Thus your reaction is appropriate. However, if your response includes falling into addictive or harmful patterns of behavior or thought, you must seek professional support immediately.
While you can honor the stories patients tell you, you must also take the time to honor the story generated inside of you in response. Seek help and support when and if you need it, and carry this richly woven tapestry of feeling with tenderness and an acknowledgment of its utterly sacred nature.
Minority Nurse is thrilled to feature Keith Carlson, “Nurse Keith,” a well-known nurse career coach and podcaster of The Nurse Keith Show as a guest columnist. Check back every other Thursday for Keith’s column.
Between the role’s autonomy and the hours’ flexibility, there’s never been a better time to be a Nurse Practitioner (NP).
What are the advantages of becoming an NP? Unfortunately, we don’t have nearly enough space to list them all, but our sources will give you a good idea of some.
Benefits of Becoming an NP
“I believe that nurse practitioners bring a unique perspective to the relationship with our patients. Our educational foundation is rooted in the nursing model, whereas physicians are trained in a more traditional medical model. Nurse practitioners are accustomed to treating the entire patient rather than solely treating a disease or condition,” says Teresa Cyrus, DNP, APRN, FNP-C, co-owner of Integrative Geriatrics, a practice that provides care to underserved adults and seniors in rural Minnesota.
“I believe it is a more holistic approach to patient care. For example, if my patient is being seen for frequent falls, I can visit their home to determine what may be contributing to them. In addition, I will check in with the nursing staff and the patient’s family to get additional perspectives when developing a treatment plan, and then continue to monitor the patient closely after our visit,” she says.
Cyrus, an assistant professor at St. Catherine University in St. Paul, adds that NPs have been filling roles where it’s been more difficult to recruit physicians in geriatrics, family practice, and rural areas. “In the past several years, I have also seen an increase in NPs working as hospitalists, in more nuanced specialty areas, and even as medical directors.”
Role of NP is Changing
In many states, the role of the NP has or is changing.
“NPs’ role and scope of practice have expanded depending on the state where they are licensed to practice. For example, in my state, NPs can practice independently. That means they can own, manage, and operate their clinics without a collaborating physician,” explains Rei Serafica, Ph.D., who is a full-time faculty member at the University of Nevada, Las Vegas School of Nursing and works once a week at an inpatient psychiatric mental health facility in North Las Vegas.
“Some NPs are entrepreneurs, consultants, educators, and even researchers. Some NPs work in academics like me. We are [training] future NPs, and we also manage and balance our careers by devoting a day to practice as NPs to maintain our professional skills and credentials. In other words, it is a dynamic profession that offers flexibility and multiple career opportunities.”
Opportunities for NPs Are Endless
The opportunities seem endless regardless of the type of NP a nurse chooses to become.
“The healthcare system has found relief in employing us in all sectors. NPs are seen everywhere now—from clinics to hospitals and are at the front, cutting-edge of clinical research, faculty, and teaching,” states Isra Hashmi, FNP-BC, who works in private practice. She adds that job security is a big relief because not only are NPs not going anywhere, and their career is only expected to grow.
Nicole Beckmann, Ph.D., APRN, CPNP-PC, embodies the diversity of working as an NP, as she has worked in three different specialties over 15 years of practice.
“[I] find this to be one of the important ways I can continue to grow professionally and challenge my skills. Additional benefits include increased autonomy in decision-making and management of health conditions. Nurses use their holistic approach to patient care to see patients’ health problems in the context of their lifestyles, personal goals, and preferences. In addition, nurses recognize their patients as people, learning each patient’s story, priorities, and unique needs. [We] bring this approach to the patient/provider relationship to diagnose conditions and partner with patients to determine the best treatment options. Patients appreciate this connection and the meaningful relationships they form with their NP providers. This is what makes being a nurse practitioner so satisfying.”
Hours are Long, But Have an Upside
As for hours, NPs may still have to work long hours, but Beckmann explains the upside of it.
“Depending on the work setting of the nurse practitioner, hours may include evening, overnight, or weekend shifts. However, this also means that nurse practitioners can choose a position and work schedule that fits their lifestyle. For example, part-time positions, extended shifts, and block scheduling may allow for long periods off or for the nurse practitioner to have the work/life balance they seek,” she says.
Cyrus says she loves her job, “Being an NP is tremendously rewarding, and I encourage any nurse who expresses interest to pursue that calling.”
The Magnet designation for hospitals emerged in 1990 under the auspices of the American Nurses Credentialing Center (ANCC) as a strategy for catalyzing and recognizing the highest possible standards for quality nursing care.
Since its inception, Magnet has given ambitious hospitals something concrete to strive for. Magnet has also allowed nurses to identify facilities that deliver optimal patient care while creating positive workplace cultures for nurses who care about their work and what their employers stand for.
Walking the Talk
As of this writing, fewer than 600 hospitals hold Magnet status, and since there are over 6,000 hospitals in the U.S., we can see that Magnet status remains the exception, not the rule.
Magnet standards make sense when we consider what makes a hospital stand out. We can understand why some nurses are drawn to seeking employment at facilities prioritizing achieving and maintaining Magnet status.
From another perspective, while Magnet designation is an impressive achievement, we can be sure there are plenty of excellent non-Magnet hospitals where nurses lead satisfying and robust careers while delivering outstanding care. However, there are Magnet-designated hospitals where things may not be as perfect as they might like us to believe, and much work remains to be done for those institutions to walk their talk.
As boots-on-the-ground professionals, nurses know the inner workings of healthcare employers and facilities. While a certificate from a certifying body is all well and good, nurses want to see the evidence in their day-to-day environment. What aspects of Magnet do nurses want to see and experience? A few might include:
Shared governance
Quality improvement initiatives
Advancement of nursing practice
An emphasis on evidence-based practice
Transformational leadership
Career advancement and a leadership track
No matter where they work, nurses want to feel respected, acknowledged, and rewarded for their dedication. They want a workplace free of incivility and to be treated as more than just cannon fodder on the front lines of the battle against disease.
Hospital organizations that walk their talk hold nurses in the highest esteem. Seasoned nurses are recognized for their expertise and institutional memory, and new nurses are embraced as the representatives of the future that they truly are. Everyone’s place should be valued, and nurses should feel that they are part of something bigger than themselves, but where individual gifts hold meaning.
Like Attracts Like
When we consider the nature of a magnet, we think of how a magnet attracts objects with similar properties. In contrast, those unlike the magnet are repelled or completely unattracted by the magnet’s force.
Imagine being a fly on the wall of the brainstorming sessions that occurred in the late 1980s when the ideas that led to Magnet status were still gestating. The concept of magnetism may have yet to emerge immediately during those conversations. Nevertheless, many ideas may have been floated in those early days, and who knows how the process eventually resulted in magnetism bubbling to the surface.
These days, we’re accustomed to the notion of a Magnet hospital. Acute care facilities want their nurses to be the best, and savvy patients aware of the Magnet designation may seek care at facilities holding such status.
Focus on Quality Nursing Care
If approximately 10 percent of American hospitals are Magnet-designated, what are the remaining 90 percent focused on, and what do their nurses experience? Do they feel that something is missing? Perhaps. Are there non-Magnet community hospitals without the resources to dedicate to pursuing Magnet status that still shines like healthcare stars? Without a doubt. Are there facilities where satisfied patients receive optimized, high-quality care from incredible nurses devoted to doing their best every day? Absolutely!
We all know that certification is no panacea — institutions are bureaucracies made up of people, and human beings (and many bureaucracies) are inherently flawed. Still, doing one’s utmost to achieve a worthwhile goal can give meaning to our work, and a collective dedication to Magnet certification can empower everyone.
If you work at a Magnet facility, consider whether it meets your expectations. And if you work at a non-Magnet hospital, how does your hospital show up on the positive side of the quality equation? Hopefully, your employer sees you for who you are, values your contributions, recognizes your gifts and pays you well for your dedicated service.
You can be a human magnet for positivity, excellent nursing practice, high-quality patient care, and a happy, satisfying career. And if the Magnet process is part of making your career successful, all the better.
Minority Nurse is thrilled to welcome Keith Carlson, “Nurse Keith,” a well-known nurse career coach and podcaster of The Nurse Keith Show as a guest columnist. Check back every other Thursday for Keith’s column.
We’ll be at the 2022 ANCC National Magnet Conference® October 13-15 at the Philadelphia Convention Center in Philadelphia, PA. Stop by booth 2018. We look forward to seeing you there!
RaDonda Vaught, RN, was not the first nurse to be prosecuted for making a mistake, but the circumstances and her trial were the most public.
Nurses from around the country watched and spoke out, supported her, and shared similar issues about the environment of care that she worked in, the failure of organizations to support nurses after self-disclosure, and the lack of trust in non-punitive response to error.
We learned that organizational system issues were present and acknowledged, yet RaDonda was held individually accountable, prosecuted, and convicted. (Department of Health and Human Services, 2018) This punitive response to the error is the biggest reason for the lack of trust in just culture. It can cause nurses to suppress patient safety information as they attempt to protect themselves, their licenses, and their livelihood.
Healthcare Environment Can be a Chaotic Place for a Nurse
The healthcare environment is an ever-changing, distraction-ridden, and often chaotic place nurses work. Nurses have learned to develop workarounds of procedures to care for patients within systems riddled with roadblocks and a lack of staff. They drift from ideal practice interventions and are forced to multi-task most of their day. These behaviors are often mistaken for autonomy rather than the root cause until that mistake is grave or deadly. This environment of care is ripe for error and unsafe patient care outcomes.
When direct care nurses and nurse leaders fully understand how the environment impacts patient safety, they can develop a better awareness of the behavioral choices nurses make when providing care and build ways to decrease the likelihood of error. The first and most crucial part of arming yourself with knowledge about why mistakes happen is understanding the difference in behaviors.
Human error is unintentional and not considered a behavior at all. It is an outcome of the fallibility of being human. Risky behaviors occur when we drift away from policy and procedure and develop habits that we think are safe because we don’t appreciate the risk of injury. Reckless behavior is a conscious disregard for a known risk, understood by the person, and the action is taken anyway. It is intentional. (Institute for Safe Medical Practices, 2022)
Healthcare is not perfect, and mistakes will be made no matter how careful a person’s actions and behaviors are. It is a mistake to expect no mistakes! Organizations should strive to be reliable, not perfect, and provide an atmosphere that includes and promotes systems that catch mistakes before they reach the patient. (Rodziewicz, Houseman, and Hipskind, 2022)
What Every Nurse Can Do
Direct care nurses can improve the environment of care and decrease the possibility of making mistakes by:
Speaking out and sharing concerns about the culture of safety with your leaders. Nurses are the most vital source of error identification in all organizations and all circumstances.
Insist on duplication and validation processes for high-risk injury interventions. Embrace teamwork by helping each other to ensure that clinical practice is correct.
Become active members of shared governance committees and assist in developing policies driven by real practice, not ideal environments. The best policies have multiple decision trees to the desired outcome, for example, “if this occurs, then do that .”Policies can then incorporate the known workarounds so that leaders understand the multiple avenues nurses may need to take to provide efficient and effective care.
Learn about the incident management and investigation processes in your organization. Volunteer as “subject matter experts” so investigators understand how nursing care is provided, and the incident analysis is fair.
Nurse leaders ensure that the care environment is safe. Actions they take can include:
Create real fixes when systemic or other issues are raised and praise those nurses who are brave enough to raise their voices.
Avoid quick responses and decisions to occurrences and let the investigation take its course.
Stand by staff when human errors or risky behaviors happen. Console nurses who make mistakes and avoid causing them more harm from the punitive response.
Promote transparency of the investigative process and promote legal support for nurses who may be held individually accountable.
Promote teamwork and consider alternative nursing delivery methods that can be flexed as acuity increases and decreases
Develop on-site resources for self-care and staffing schedules that enable nurses to take advantage of them. Stress, lack of sleep, poor nutrition, and lack of exercise can create cognitive changes that cause a lack of appreciation of risky decisions that direct care nurses can make. (Okpala, 2020)
Finally, all nurses need to become politically active. By participating in local and state governments, nurses can educate elected officials who may need help understanding the healthcare environment and expect perfection in care. In addition, nurses must help to create or support legislation that protects healthcare workers from legal prosecution. A culture of safety in healthcare takes a village!
Institute for Safe Medical Practices. Criminalization of human error and a guilty verdict: A travesty of justice that threatens patient safety. ISMP Medication Safety Alert 27(7). Published April 7, 2022. Accessed September 25, 2022 https://www.ismp.org/sites/default/files/attachments/2022-04/20220407_0.pdf
Okpala P. Nurses’ perspectives on the impact of management approaches on the blame culture in health-care organizations. Int J Healthcare Manage. 2020; 13(S1): 199–205. doi: 10.1080/20479700.2018.1492771
Rodziewicz TL, Houseman B, and Hipskind JE. Medical Error Reduction and Prevention. Updated May 1, 2022. StatPearls. Treasure Island, FL: StatPearls Publishing; 2022: 42-44. Accessed August 2, 2022 https://www.ncbi.nlm.nih.gov/books/NBK499956/#_NBK499956_pubdet_
