“To begin, we must acknowledge that from 1916 until 1964, ANA purposefully, systemically and systematically excluded Black nurses…”
The American Nurses Association (ANA) is taking a meaningful first step to acknowledge its own past actions that have negatively impacted nurses of color and perpetuated systemic racism. With the release of a formal racial reckoning statement on July 12, ANA is beginning a multi-phase journey of reconciliation, forgiveness, and healing. The Journey of Racial Reconciliation is the name for ANA’s racial reckoning journey as it seeks to address past racial harms from as far back as the formation of the association in 1896.
From the ANA statement:
“Similar to the concerns raised by Black nurses, in 1974, led by Dr. Ildaura Murillo- Rhode, a group of 12 Hispanic nurses who were also members of ANA came together to consider establishing a Hispanic Nurses Caucus within ANA because ‘ANA was not being responsive to the needs of Hispanic nurses.'”
“We know that ANA’s work to reckon with our historical and institutional racist actions and inactions is long overdue. Racism is an assault on the human spirit, and we want to be accountable for our part in perpetuating it. We have certainly failed many nurses of color and ethnic-minority nursing organizations, undoubtedly damaging our relationship with them and in so doing, diluting the richness of the nursing profession. We ask forgiveness from nurses of color as a first step to mend what is broken,” said ANA CEO Loressa Cole, DNP, MBA, RN, NEA-BC, FAAN.
“ANA recognizes that issues of racism persist today and continue to harm nurses of color. Findings from the Commission’s 2021 national survey on racism in nursing (n = 5,600) noted that racist acts are principally perpetrated by colleagues and those in positions of power. Over half of nurses surveyed (63%) said they had personally experienced an act of racism in the workplace with the transgressors being either a peer (66%) or a manager or supervisor (60%). Fifty-six percent of respondents also noted that racism in the workplace has negatively impacted their professional well-being.”
On June 11, 2022, the ANA Membership Assembly, ANA’s highest governing body, took historic action to begin a journey of racial reckoning by unanimously adopting the ANA Racial Reckoning Statement. Please read the entire statement and stay connected with ANA on its journey.
That advice about timing resonated last month as she prepared to donate a kidney to her mentor, professor and faculty colleague. Professor and biostatistician Vicki Stover Hertzberg, PhD, who directs the school’s Center for Data Science, had been waiting nine months for a transplant after being diagnosed with kidney failure.
The two professors’ personal relationship is only one aspect of their remarkable story.
Both long ago had personal experiences that made them aware of the high need for living kidney transplants and the safety of donation. At the nationally No. 2-ranked School of Nursing, both women work on a research team that studies renal issues and other health problems related to heat exposure in farmworkers and published their findings in March. Both say their life-giving partnership reflects their school’s caring connections.
Chicas was only one of several Emory employees who answered Hertzberg’s call for potential donors in mid-2021. While others matched enough to donate, Chicas was the closest match.
“So much science has gone into it for such a long time, and to be able to use that science to help Dr. Hertzberg be healthier and live longer, it’s awesome. And I get to be a part of it.”
—Roxana Chicas, PhD, RN
“I have no words to express my gratitude for the individuals who came forward including those who ultimately, for one reason or another, could not be a donor,” Hertzberg said before the March 15 transplant surgery. “And for Roxana to do this is just phenomenal. I find it very overwhelming and very humbling.”
Most of us only need one kidney
Chicas’ first job at a pediatric office in Atlanta, when she was 18, exposed her to kidney issues and solutions. She translated for pediatric nephrologist Stephanie M. Jernigan, an associate professor of pediatrics at Emory School of Medicine.
“Children who were born with just one kidney often lived perfectly normal lives,” she says. “Other children who had kidney transplants did very well, even though it’s a very invasive surgery.”
She also learned to see her own intellectual potential.
Having come from El Salvador at age four and undocumented, Chicas had received temporary protective status that allowed her to work for the pediatricians. She helped them communicate with families who only spoke Spanish, and thought she might be smart enough to become a medical assistant so she could help them more. Pediatrician A. Gerald Reisman, MD, urged her to try nursing instead, and at age 28, Chicas enrolled in what is now Perimeter College at Georgia State University.
That educational decision led to Bridges to the Baccalaureate, an Emory program that nurtures minority students in research. With School of Nursing Dean Linda A. McCauley, PhD, RN, FAAN, as her advisor, Chicas got a BSN and went directly into the doctoral program. She joined McCauley’s team working on farmworker health, which felt personal because her mother, Maria Chicas, farmed in El Salvador. Farmworkers are 35 times more likely to die from heat-related illnesses than any other profession, she says.
“My goal is to do great science that will really improve the working conditions of agricultural workers,” Chicas says. “They are the backbone of this country and the globe. They feed us, and I think we need to value them more and recognize their worth, and they should be treated with dignity and given the same benefits that sometimes we take for granted. Many of them are undocumented and live in poverty, and I hope that I can be a part of a movement to better their lives.”
Heat-related illnesses affect kidney function, and Chicas did a postdoctoral stint in renal (kidney-related) medicine at the Emory School of Medicine. The research team measures indicators of health like core body temperature and kidney function.
“I got lucky, because I could have been working out in the field,” Chicas says. “I’m not there because of sacrifices that my mom made, and many other Latino parents have made and by having a mentor who told me that I can be a professional.”
A mentor in need
Hertzberg became Chicas’ professor and research teammate. From Florida to Mexico to Brazil, Chicas was in direct contact with farmworkers while Hertzberg worked to tell the story of the collected data.
“A wonderful mentor,” Chicas, 39, calls Hertzberg, 67. “She taught me that you can be smart and be strong in your career, and yet still be very kind.”
As the director for the nursing school’s Center for Data Science, Hertzberg is an internationally-recognized expert on “big data” and its impact on health care. She is widely known for her work measuring the social contacts in emergency departments and disease transmission on airplanes.
“Mentoring is what graduate education is all about,” Hertzberg says. “You learn a lot from each other. Part of it is just kind of a natural process because we’re engaged through research activities and part of that is just kind of understanding how the world works and what makes people tick. Roxana is incredibly driven and intrinsically kind, and always keeps me and our team focused on issues that our partner community experiences in ways that we don’t.”
On the farmworker longitudinal study, newer data relates to 25 markers of kidney function disease because of a relatively recent phenomenon called chronic kidney disease of undetermined etiology (CKDu). “Young farmworkers who had been feeling fine or really healthy all of a sudden wake up sick,” Hertzberg says. “Lo and behold, they have kidney failure and need dialysis.”
In late 2020, Hertzberg’s own bloodwork showed acute kidney injury, and when restrictive diet didn’t improve function enough, she was referred for a kidney transplant in mid-2021.
Like Chicas, Hertzberg had learned about the disease long before through a family friend and others. She reached out to her network by email and social media.
“Ideally a living donor is best,” she wrote. “A kidney from a living donor lasts on average 25 years, while a kidney for somebody who is about to have life support turned off is on average 12 years. Obviously, the 25 years is my preference…. the wait for a kidney from the person on life support will take three to seven years.”
“I knew it’s a pretty big surgery, but I was just like, ‘I have an extra kidney. I’m pretty healthy,’” she says. “And I called my mom and asked her what she thought and she was like, well, if that’s what you feel that you’re called to do, then go for it. And I was like, Okay.”
When she found out that there was competition to give a kidney to Hertzberg, Chicas told herself, “If God wants me to be the donor, then I’m going to match. So much science has gone into it for such a long time, and to be able to use that science to help Dr. Hertzberg be healthier and live longer, it’s awesome. And I get to be a part of it.”
Hertzberg even had colleagues clamoring to organize her meal train. This loyalty is partly from working at Emory since 1995, and supporting so many people and projects with her expertise. She served on dissertation committees for Chicas in 2020 and (at the University of Cincinnati) for McCauley in 1988.
Christian Larsen, MD, DPhil, professor of surgery in the Division of Transplantation at Emory and former dean of the Emory School of Medicine, transplanted Hertzberg’s new kidney last month. Larsen and Hertzberg knew each other through their collaborative research. From 2005 to 2010, they teamed-up on a protective immunity project studying aspects of the immune system in kidney transplant patients.
“This is not a road I would have chosen for myself,” Hertzberg says. “So I’m trying my hardest to learn the lessons along the way and to keep being positive. I want to dance at my grandchildren’s weddings, and the oldest one is soon to be five years old.”
Chicas believes that her success, her mentors and her organ donation have proved her favorite quote.
“Mother Teresa said, ‘If you can’t feed 100 people, then feed just one,’” she says. “I’m not a philanthropy. I’m not a billionaire. But I feel like there are certain things that I can do.”
Changes in the status of women’s reproductive health and protections have been at the forefront of new headlines in recent weeks. The leaked Supreme Court documents indicating that the justices are on the precipice of turning over 50 years worth of reproductive health precedent has a lot of people pausing to consider the implications of losing something they have largely taken for granted. Many women are recognizing that if Roe v. Wade is overturned, they will have less bodily autonomy than corpses often have in their home states.
Of course, for many women – particularly minority women in deeply conservative states – these rights were slipping away long before this. In many of these states, the number of reproductive health clinics is extremely limited and causes undue burdens on women trying to access them. Multiple studies on the topic have shown that minority women, especially those from poorer backgrounds, are the most likely to face difficulties accessing any sort of reproductive healthcare than their more affluent, white peers.
Regardless of where our personal beliefs related to abortion rights fall, we can all agree that women having better access to reproductive healthcare is a valuable endeavor. For many nurses out there, this means striving to break down barriers that limit healthcare access. It also means becoming an advocate for health equity. But how does one become an advocate within their own community?
Address Inequalities
Many of the inequalities that nurses see every day aren’t easy ones to just address and deal with. Rather, they are ingrained, pervasive community and cultural issues that will take years to fully unpack and start to address in a positive manner. However, there are things that nurses can do to help address some of the healthcare inequalities that minority women face regularly.
Perhaps one of the most powerful things nurses can do to help address health disparities is to recognize and empathize with the differences. Minority nurses with a background in minority communities are in the position to play a unique and powerful role here. Who better to build a bridge of understanding and trust than someone who already has an understanding of the social, cultural, and economic factors that may be influencing healthcare choices.
Immediately addressing any form of blatant discrimination.
Advocating for policies that promote human rights and equity.
Working with numerous professionals across disciplines to ensure patients are receiving holistic healthcare.
Encouraging medical trials that are inclusive and address the concerns of minorities.
Seeking out and promoting other professionals that are striving to address equity issues in their communities.
Encourage Screenings
When working directly with patients there are a few things that can be done to help decrease health disparities. Arguably the most important is building trust in the community, which most certainly will not happen overnight. Small steps to start can include things like doing preventative health education out in the community, finding strategies that can help with payment for medical services, and being available for health-related questions without requiring an appointment.
Unfortunately, minority women are typically at greater risk for developing a number of diseases. For instance, African American women are twice as likely to develop breast cancer. Likewise, African American women are more likely to develop high blood pressure earlier in life than white women. There are many factors that influence this, but ultimately detection is one of the best forms of prevention.
Women can benefit from regular health screenings, but many are reluctant to do so. Going to the doctor’s office is uncomfortable, time-consuming, and potentially expensive. Helping women, especially minority women, understand the value of preventative health screenings over the long term is a vital role that nurses can play. Promoting more screenings can be one straightforward way to catch and treat issues before they become life-altering health problems.
Soft Skills Matter
Minority women, particularly women of color, are more likely to face negative health outcomes than other groups. Ingrained inequalities and cultural perceptions of the healthcare system play a major role in this. As nurses work to address these health disparities it becomes apparent that not only is a deep knowledge of nursing and healthcare important, but so are the soft skills that help convey the message.
For example, soft skills such as empathy are critical to understanding and adequately responding to the difficulties that some patients are facing. Empathy can lead to better, more realistic health prescriptions and outcomes. Patients are also more inclined to trust and listen to someone that shows an understanding and compassion for the information they are providing about themselves and their health.
Communication is another important factor. Even the best messages can be lost if they are not delivered in an understandable and relatable way. Patients do not like to feel talked down to and many very deeply want to understand the healthcare system before they have to make major decisions within it. Clear communication about procedures, health factors, costs, and outcomes are also imperative for building trust and making patients feel comfortable about their health choices.
Healthcare inequalities are significant for some demographics of the population, particularly minority women seeking reproductive healthcare. Nurses can make a real difference in starting to address some of these disparities by becoming advocates for their patients. It involves building trust, showing empathy, and encouraging positive health choices. None of it is easy, but it can add up to make a powerful difference in local communities.
Maria Rodriguez Shirey, Ph.D., associate dean for Clinical and Global Partnerships and inaugural holder of University of Alabama Birmingham‘s (UAB) Jane H. Brock – Florence Nightingale Endowed Professorship in Nursing, became dean of the UAB School of Nursing on June 1 following a national search. Shirey is succeeding Doreen Harper, Ph.D., holder of the Fay B. Ireland Endowed Deanship in the School of Nursing, who announced her intent to retire in 2021.
“Dr. Shirey’s work within the university, the community and the world at large is a testament to her abilities to lead this ever-growing school. We are confident that she will continue to propel the world-class academic, research and clinical enterprises in the School of Nursing,” said Provost Pam Benoit.
“As a Health Promoting University, it is essential that our leadership embraces the challenges of advocacy for local and global well-being, and we are fortunate to have a demonstrated champion in Dr. Shirey,” said President Ray Watts.
Shirey, a tenured professor of nursing at UAB since 2013 who is board certified in advanced nursing executive practice and health care management, is eager to assume her new role as the fifth dean in the school’s 70-plus year history. Provost Benoit thanked outgoing Dean Doreen Harper for her service, calling her a driving force of positive change who elevated the success and reputation of the school in her 17 years as its leader. “Dr. Harper’s vision for the School of Nursing has brought international acclaim to UAB and its community and has produced countless nurse leaders who continue to transform health care,” she said.
Shirey, who previously chaired the SON Department of Acute, Chronic and Continuing Care, has strategic, financial, human resources and operational responsibility for the school’s multiple community partnerships, the faculty practice enterprise and the Pan American Health Organization/World Health Organization (PAHO/WHO) Collaborating Center for International Nursing.
Shirey’s areas of scientific focus on leadership science and health services outcomes research across the health care continuum. Since joining the UAB School of Nursing in 2013, she has extended her leadership and health services outcomes research focus and funding to test the efficacy and comparative effectiveness of interprofessional collaborative practice care delivery models advancing access to care, population health, care transitions and health equity addressing disparities in vulnerable populations with chronic diseases in urban and rural community settings. For her career contributions to advancing leadership and health systems science, Shirey was recognized in 2019 by the American Organization for Nursing Leadership Nurse Researcher Award.
She also has held several other administrative leadership positions in the school, including as the leader of its diversity, equity, and inclusion initiatives. Most notably in the clinical realm, Shirey was the founding director for the nurse-led Heart Failure Transitional Care Services for Adults Clinic in UAB Hospital in 2014 and continues to consult with its executive leadership.
Her current roles include co-leadership of philanthropic grant processes for community-based projects in the school and interim co-director of the PAHO/WHO Collaborating Center for International Nursing.
Shirey is a senior scientist in two universitywide centers — Minority Health & Health Disparities Research Center and the Center for Outcomes and Effectiveness Research. She also serves on the leadership committee of Live HealthSmart Alabama, winner of UAB’s first Grand Challenge competition, which is a key component of UAB’s strategic plan, Forging the Future.
Shirey’s service extends beyond the school to the university and its health system. She has had an integral role as leader in the UAB Nursing Partnership and is a member of the new universitywide Community Engagement Council and the UAB/St. Vincent’s Urgent Care Alliance Taskforce. Her work in the community currently includes an advisory role with the National Family Partnership of Central Alabama.
She is a fellow of the National Academies of Practice, Academy of Nursing Education, American Academy of Nursing and American College of Healthcare Executives.
Shirey earned a bachelor of science degree in nursing from Florida State University plus a master of science in nursing from Texas Woman’s University and a master of business administration from Tulane University before completing her doctorate in nursing science at Indiana University.
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.
