The fundamental mission of every healthcare provider is to first do no harm. Unfortunately, however, for far too long systemic inequities in the healthcare system have perpetrated and perpetuated harm.
Both implicit and explicit biases have strongly determined healthcare processes, including informing how patient pain is understood, diagnosed, and treated. Stereotypes relating to gender, race, and ethnicity have contributed to a pattern of delayed and erroneous diagnosis and inappropriate or insufficient palliative care. And as a result, untold numbers of female and minority patients have been consigned to suffer needlessly.
But there is hope, and nurses are helping to provide it. By prioritizing workforce diversity, qualified healthcare professionals enjoy greater career opportunities, and diverse patients increasingly receive the pain control they need. This article examines the importance of diversity in the healthcare industry and its implications for improving palliative care for diverse patients.
Biases and the Treatment of Pain
Generally, healthcare providers enter the field because they genuinely want to help people. Of course, financial security and social prestige are a perk, but no matter your particular role, the work is incredibly emotionally, cognitively, and physically demanding. Nevertheless, it is a profession you enter or remain in with a sense of a higher calling and a deeper purpose.
But, no matter how well-intentioned, healthcare providers are still very much human, and as such, they are shaped, both consciously and unconsciously, by the society in which they live. And that means that systemic biases have almost inevitably seeped into the care provider’s consciousness, contributing to the formation of false and dangerous stereotypes.
Research has shown, for example, that racial stereotypes concerning African-Americans have contributed strongly to the mismanagement of Black patients’ pain. These stereotypes are generally rooted in misperceptions of biological differences between African-American and Caucasian patients. This includes the false belief that Black patients have a higher pain tolerance than whites and the false presumption that Black patients are more likely to abuse drugs.
Implicit and explicit gender biases are also ubiquitous in modern medical practice. For example, female patients complaining of pain are more likely to experience treatment delays than male patients reporting the same or similar symptoms. Women’s pain symptoms, for instance, are significantly more likely to be attributed to emotional or psychological etiologies than men’s. This increases the likelihood that their pain will go untreated or under-treated, and severe disease symptoms will go unrecognized, thus delaying treatment.
Diversity and Cultural Competence in Healthcare
Nurses are at the front lines of patient care. They provide the majority of hands-on patient care, and, in general, their interactions with patients are more frequent and substantive than those of physicians.
For this reason, diversity in the nursing sector is particularly critical in redressing inequities in treating patients’ pain. Culturally competent patient care almost inevitably ensures that nurses derive from various ethnic, racial, socioeconomic, and gender backgrounds.
More specifically, this means that nurses with high cultural competence will better understand, recognize, and respond to culturally-specific manifestations of patient pain.
For instance, women or patients from specific cultural or religious backgrounds may feel reluctant or unable to express their symptoms, especially if these pertain to “taboo” areas. Nurses from similar backgrounds are more likely to have the cultural competence to identify and overcome these cultural taboos.
This enables them to formulate strategies that help patients express their concerns in more comfortable and culturally acceptable ways. In addition, by enhancing the dialogue with patients, nurses can provide physicians with more comprehensive and accurate case notes, increasing treatment efficacy.
Addressing Medical Anxiety
Promoting diversity in nursing doesn’t just equip healthcare teams to understand and address cultural differences among patient populations effectively. Diversity also enables healthcare teams to recognize and remediate systemic healthcare disparities’ profound and long-enduring impacts.
There is mounting evidence, for example, that minority patients are far less likely than Caucasians to be satisfied with their quality of medical care. Deficiencies in minority patient care can be linked to various factors, from the lack of healthcare access to a shortage of interpreters for patients who do not speak English.
These care deficiencies can instigate severe medical anxiety in patients, particularly for those who have experienced significant physical or emotional trauma in past medical encounters. Nurses from similar backgrounds may have also experienced such challenges in the healthcare system, whether for themselves or someone they love. And as such, they are more likely to be able to accurately anticipate or ascertain signs of medical anxiety in female and minority patients.
Equipped with such insight, diverse nurses can lend a measure of patient support and empathy that comes from understanding and experience. And, importantly, they can more effectively advocate for patients and their unique needs, particularly in treating pain.
Disparities in the healthcare system have for too long led to deficiencies in palliative care for minority and female patients. By promoting diversity in the nursing profession, however, the needless suffering to which diverse patients have been subjected can finally end.
Culturally competent nursing mentorship for nursing students, nurses, or faculty often remains challenging when the mentor needs to reflect on the mentee. Understanding diversity in higher education and the strategies to improve culturally competent guidance is looked at through the lens of mentoring.
The term ‘mentor’ was adopted from Mentor, a Greek mythological figure in Homer’s “Odyssey.” Mentor was placed in charge of Odyssey’s son, Telemachus. Their mythological relationship consisted of Mentor imparting wisdom, guiding, and sharing knowledge with Telemachus. In modern times the word mentor has come to mean a very experienced and trusted advisor. A mentee is the term for the person in the position of receiving the mentor’s training, guidance, advice, or wisdom (Grant & Hazel, 1993).
Becoming a nurse, advancing a nursing degree, or being a nursing professor all require skills and knowledge to be learned. A part of that learning comes from mentor-mentee relationships. Ideally, each nursing student or new faculty should have an available mentor sensitive to the mentee’s needs. Mentors that reflect or identify with their mentees would be optimal (Schuler, 2021). However, in the absence of availability, the mentor must practice culturally competent mentorship. The importance of the mentorship role becomes evident when the mentee does not reach their full potential or partake in opportunities within the profession.
U.S. Census Statistics and Nursing Numbers
According to the U.S. Census Bureau (2020), 57.8% of the American population is White, forming the majority; Hispanic and Latino Americans are the largest ethnic minority comprising 18.7%; Black or African Americans are the largest racial minority making up 12.1% of the population. Also noted on the census was an increase in multicultural populations. Additionally, according to the National Council of the Board of Nursing statistics (2021), ethnic/racial minorities represent 19.2% of the RN workforce. According to the numbers that represent the U.S. population and the population of the nursing workforce, there is a representation of minority nurses ranging from the bedside to academia.
However, the reality of these numbers is striking. Due to the lower numbers of minorities in the nursing field, mentors must commit themselves to cultivate culturally appropriate mentoring relationships. Working within the framework of who is represented then requires solutions to effective and appropriate mentoring. Employing creative and Evidence-Based Practice (EBP) mentoring styles is mandatory for successful mentor-mentee relationships.
Mentoring advances the science of nursing; it helps develop and move forward the discipline along with its leaders and educators. However, cultural awareness and carefully suited mentoring styles to accommodate minoritized mentees are imperative for successful outcomes. Diversity is defined as different or varied. Whether the diversity is cultural, racial, religious, gender, class, or sexual orientation of a mentee, it must be acknowledged and understood by the mentor to help build a stronger mentoring relationship. This will add to the mentee’s development and foster meaningful results (Dirks, 2021).
Some causes of the underrepresentation of minorities in nursing have been noted as lack of opportunity, educational finances, emotional and social support from the discipline, and lack of diversified mentors (Firth, 2021). However, when focusing on the need for diversified mentorship in the formation of nursing students, new nurses, RN to BSN students, and new nursing faculty, there are many obstacles for the mentor.
Some examples of challenges a mentor may face include assessing a mentee’s motivation, having the proper time to mentor, setting reasonable goals, and the mentor’s ability to properly assess the mentee’s knowledge, skills, or background. One prominent challenge in mentee assessment is correctly identifying diversity to incorporate appropriate mentoring into the relationship. Schuler (2021) states that nurse mentees recognize support and are thankful for shared insights from culturally competent mentors.
While acknowledging the low numbers of minority students, nurses, and faculty, how then will professors of any ethnic, racial, religious, or any diverse background be a mentor to their diverse minoritized students or new faculty? The answer is already in practice.
The very steps that the professors teach their nursing students to form nurse-patient relationships regarding cultural diversity. The movement to include culturally competent care in nursing is currently operational in practice and academia. Nursing professors teach their students to be culturally competent as it is woven throughout EBP curricula (Hung et al., 2019). Students are taught the values and how to incorporate, accommodate, and respect culture into their healthcare-providing practices. This level of teaching students culturally competent care must be transferred and utilized with mentor-mentee relationships between professors and students, nurse administrators and new nurses, and professors and new faculty.
First and foremost, the mentor must self-reflect on their thoughts and feelings. They must recognize any biases and explore how this will affect the mentoring relationship, therefore working to acknowledge and eliminate them honestly. Secondly, they must get to know their mentees through inquiry. Asking mentees to share their backgrounds and how they prefer to learn is an act of openness and accommodation.
Thirdly, the mentor must create an atmosphere of judgment-free mentoring to allow the mentee to receive the advice in their way.
Finally, and perhaps most importantly, the mentor and mentee must commit to being open, honest, and respectful in their roles. Without their commitment, the relationship is not built on a trusted foundation, and all that follows may be tainted. The lack of diverse nursing mentors may or may not be able to be wholly addressed by looking purely at the census numbers.
As nursing advances, there is a recommendation to include and support minoritized nurses in all roles of the profession. Regardless, whoever is in the role of mentor, must accept the current challenges and comply with the prerequisite to pledge to deliver EBP culturally competent guidance using the above-mentioned mentoring strategies.
Firth, S. (2021, August 12). Why are they so few people of color in nursing? Washington Correspondent, Medpage Today. https://www.medpagetoday.com/nursing/nursing/94025
Grant, M., & Hazel, J. (1993). Gods and Mortals in Classical Mythology. Springfield: Merriam-Webster.
Hung, H., Y., Wanf, Y., W., Feng, J., Y., Wang, C., J., Lin, E., C., L., & Chang, Y., J. (2019). Evidenced-based practice curriculum development for undergraduate nursing students:The preliminary results of an action research study in Taiwan. Journal of Nursing Research, 27(4), 30. doi: 10.1097/jnr.0000000000000298
Schuler, E. (2021). Evaluation of an evidence-based practice mentorship programme in a paediatric quaternary care setting. Journal of Research in Nursing, 26(1-2),149-165.
Frontier Nursing University (FNU) named Dr. Paula Alexander-Delpech, Ph.D., PMHNP-BC, APRN, as its Chief Diversity and Inclusion Officer (CDIO).
Previously, Dr. Alexander-Delpech served as the Interim CDIO since January and guided the planning and programming for FNU’s 12th annual Diversity Impact Conference held in June.
Dr. Alexander-Delpech serves as co-chair of the President’s Task Force on Diversity, Equity, and Inclusion (DEI) and the Faculty, Staff, and Preceptor Development and Retention sub-committee of the DEI Task Force.
Performing at the Highest Level
“Dr. Alexander-Delpech has performed at the highest level as our Interim CDIO,” says FNU President Dr. Susan Stone, CNM, DNSc, FAAN, FACNM. “We know she will continue to provide the direction, passion, and leadership necessary to further the essential work of FNU’s Office of Diversity, Equity, and Inclusion. She has tremendous energy and has brought forth a number of new initiatives to build upon our existing DEI efforts, which are so important to the future of healthcare.”
Nurse Educator DEI Faculty Fellowship
Dr. Alexander-Delpech presented “The Development of A Faculty DEI Fellows Program” at the American Association of Colleges of Nursing’s Diversity Leadership Institute. Under her leadership, FNU plans to launch a Nurse Educator DEI Faculty Fellowship program this fall. Eight faculty members will be selected as Fellows and will attend a 12-week DEI training and then be assigned at least four more faculty whom they will coach for 12 weeks.
The Office of Diversity, Equity, and Inclusion oversee the development of five new student interest groups (SIGs), which hold their first meetings in June. The five SIGs are International Students in Nursing, LGBTQIA+ Students in Nursing, Men in Nursing, Military/Veterans in Nursing, and Students of Color in Nursing.
Delivering Equity and Diversity in Healthcare
“It has been a pleasure working with Dr. Alexander-Delpech,” says FNU Dean of Nursing Joan Slager, DNP, CNM, FACNM, FAAN. “She is passionate about creating opportunities for our faculty and our students to grow in their expertise in teaching about and delivering equitable healthcare.”
“I am so honored to accept the role of Chief Diversity and Inclusion Officer at Frontier Nursing University,” Dr. Alexander-Delpech says. “We always think about DEI as it pertains to our curriculum or profession, but when people start talking about it in their personal lives, that means people are making changes. The ripple effect is happening. At FNU, we are ahead of the game. When we talk about DEI work, FNU has surpassed a lot of other universities.”
Diversity is a worldwide issue that touches nearly every topic. In nursing, it includes all of the following: gender, veteran status, race, disability, age, religion, ethnicity, socioeconomic status, sexual orientation, education, nationality, and physical characteristics. How? Because every day, medical professionals everywhere (especially nurses) encounter people from every race, religion, ethnicity, cultural background, gender, sexual orientation, etc. Every interaction creates diversity and as such the issues that surround the topic are just as vast and as numerous.
The American Nurses Association (ANA) defines diversity awareness as “acknowledgment and appreciation of differences in attitudes, beliefs, thoughts, and priorities in the health-seeking behaviors of different patient populations.” But diversity is more than just a definition. Diversity in nursing means knowing how to respond if a patient becomes violent towards you for your culture, gender, or religion, or what to do next if a medical professional refuses to give you treatment because you identify as LGBTQ. While the ANA urges nurses to grow professionally and personally in their efforts to understanding diversity issues and translating those learnings to quality care for every patient, diversity efforts often involve complex issues that can’t be solved with a simple “yes, we will do better” response. True diversity efforts require action to succeed, so here are some ways to break down diversity barriers like stereotyping and close-mindedness in order to provide better health care for your patients.
Live, Work, and Breathe Diversity in Everything You Do
The number one most important thing you can do to promote diversity and inclusivity in your organization is to communicate everything as clearly as possible. Think about it. Have you ever had a supervisor who did not communicate their expectations clearly to you? Did you ever have a conversation with a patient that was downright awkward or uncomfortable because of the personal or cultural differences between you? Was there a lot of ambiguity in what they asked from you? How well did you work with that supervisor? People get frustrated, scared, flustered, upset, and discouraged. Situations escalate. The key to avoiding miscommunication in the health care space is to incorporate strong diversity efforts. Here’s why:
When diversity and representation is lacking, it’s hard for people to feel welcome. The balance of diversity in the world of medicine starts with culture and beliefs. The best way for health care providers and hospitals to get in on this? By increasing diversity efforts in hiring. Having nurses on staff that can understand the demographics of their patients, communicate, and relate to their individual struggles will improve the lives of patients and the fulfillment of the nurses hired. Why? Because it opens the door to reaching an understanding of your patient’s morals, values, language, religion, and other demographics (i.e., it makes them more comfortable in their environment).
But communication is a two-way street, therefore listening is just as important. When a diverse workforce of nurses exists, they can more effectively listen to what is bothering their diverse population of patients. This is made possible because not one nurse can relate to every cultural background, speak every language, or identify with every gender identity or sexual orientation. Nurses that actually exist in these spaces can make quality suggestions and treat their patient for the best results. In other words, hiring African American, Asian, Muslim, Christian, LGBTQ, transgender, male and female (and many many more backgrounds, religions, identities) nurses are vital to the overall care of every patient.
This communication is not only between health care providers and seekers. It is also along the health care provider plane. Clear and consistent communication among nurses and doctors will help lead to smooth transitions in providing care for a patient. Staffing a diverse workforce will lead to breaking down the barriers of stereotypes and keeping an inclusive and respectful mind when providing healthcare.
Breaking Down Stereotypes
The first major barrier is breaking down stereotypes. Stereotypes are defined as “a widely held but fixed and oversimplified image or idea of a particular type of person.” They have become fatal fallacies in our society, and in the medical profession, they can be a major player in increased discomfort between patients and nurses alike. Categorizing someone into a group or as an image of something they don’t identify with puts a strain on their livelihood and overall health. As a consequence, especially from a nursing standpoint, it can hinder a nurse’s ability to give proper medical treatment and impedes a patient’s ability to recover. No nurse or patient should feel negative pressures from their social environment for their background, especially when receiving medical treatment. Therefore, it is crucial that we attempt to break down stereotypes to help improve the acceptance and abundance of diversity in nursing to advance the openness and inclusivity of treatment and recovery for people of all backgrounds.
Shattering stereotypes is difficult. The Wisconsin Network for Research Support (WINRS) and the Community Advisors on Research Design and Strategies (CARDS) aimed at doing so through the power of “The Personal.” For six plus years, the University of Wisconsin has been funding meetings between these groups. The CARDS were people who were giving advice to researchers who want candid feedback on how they can improve their methods from those who are deemed “hard to reach.” The CARDS were made up of those who come from diverse racial, socioeconomic, and educational backgrounds. At the end of the research, WINRS found two things that can help break down the stereotype barriers:
An open-ended question that has been thoughtfully planned out
Allowing researchers to explain why they personally got into research
The reasoning behind the questions were so they would bring out past experiences in members that provoked positive emotions and reinforced human connection. Establishing an emotional experience makes it easier for people to connect. Justification for the second finding was because CARDS members originally thought they were in it only for the money.
So, what can we learn from this study on stereotypes? The biggest thing we can learn is that disconnect between groups of people is cause for concern. Stereotypes stem from a lack of understanding between groups. At the end of the day, both parties of guest researchers and CARDS members received feedback from those who they didn’t think it was possible. This can be translated into day-to-day care for patients. Finding a common ground between nurse and patient can lead to effective communication and better health care for all. In other words, the key to defeating stereotypes once and for all is with understanding, respect, and compassion.
Creating an inclusive culture in health care is incredibly important in today’s world. Duquesne University explains that inclusive nursing practices begin in the classroom. Madeleine Leininger, a nurse anthropologist, developed the idea of “transcultural nursing,” which is nursing based on a patient’s cultural considerations. Teaching transcultural nursing is a stepping stone to inclusion. Interweaving the idea of providing care based on a patient’s cultural beliefs can help establish an inclusive mindset that is respectful to the patient and will translate over to your coworkers.
Developing an inclusive and respectful mindset starts at building strong relationships and understanding, much like breaking down diversity barriers. While efforts have increased to teach transcultural nursing in the classroom, organizations have been created to help support nurses and patients where they can access resources and communities to help them adjust.
The ANA works tirelessly to be a resource for all nurses of every background so they feel welcomed and comfortable. They offer resources from a number of communities, such as the Gay and Lesbian Medical Association and the U.S. Department of Health and Human Services Office of Minority Health. They also offer resources that help you treat patients that are obese, mentally ill, or the elderly. By providing access to all of these communities in one place, the ANA wants to create an industry that is able to treat patients from every walk of life.
Diversity is the key to providing the best health care possible. Understanding how to break down the barriers of stereotyping patients and creating a culture of inclusion within a practice are the two biggest challenges that nurses face today. That is made even more difficult when it comes to being a traveling nurse. Institutes like ANA and WINRS work so hard to educate nurses and medical professionals to knock down the blockades that hinder diversity in nursing.
As Black History Month draws to a close, now is an excellent time to reflect on all the nurses who paved the way for today’s increasingly diverse nursing workforce.
The numbers still don’t reflect the levels of diversity in the country as a whole, or even necessarily in the settings where they work, but African-American and black nurses are entering the nursing profession and earning advanced nursing degrees in greater numbers than ever before.
According to the Bureau of Labor Statistics, the nursing workforce is achieving greater diversity, but there’s still a long way to go. While the 2015 National Nursing Workforce Study stated 19.5 percent of nursing respondents reported a racial or ethnic minority background, the rate was even higher among newly registered nurses.
With a nod to early black nurses like Sojourner Truth or Harriet Tubman, who each paved the way for minority nurses to follow, nurses are expanding into many specializations and gaining higher degrees. With the current push to have 80 percent of nurses educated with a completed bachelor of science in nursing by 2020, higher ed and advanced degrees are an important part of getting ahead in nursing. Of the 176,000 nurse practitioners, 8.5 percent are African-American. And of the 3,102,000 registered nurses, 11.9 percent are African-American.
Minority nurses continue to make big strides in increasing the diversity of the overall nursing population. According to American Association of Colleges of Nursing (AACN) figures, the percentages of black or African- American nurses earning master’s or doctoral degrees has increased significantly in the past 10 years.
In 2006, 10.6 percent of those earning doctoral degrees were African American. In 2016, that percentage jumped to 16.2. And in those same years, the number of those earning master’s degrees also saw a percentage jump. In 2006, 11.3 percent of those going for a master’s degree were black. Ten years later, the percentage was 14.3. Overall, the percentage of minority nurses seeing nursing degrees hovers at about 30 percent of the total.
All that good news helps patients who say they want to see a diverse workforce in the healthcare professions. Many patients feel comfortable with someone who looks like them, but, more importantly, a diverse workforce helps spread culturally competent nursing practices. The entire nursing staff may not represent the ethnic diversity in a given setting, but they can learn from those who might understand certain cultural traditions, languages, or practices. All that understanding makes for better patient care and outcomes and an especially effective nursing staff.
So as Black History Month draws to a close, take a few moments to reflect on how far African-American and black nurses have come and the essential care and understanding they provide to the public. And take a moment to take pride in being part of that.
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