Exhorting nursing staff and leadership to pay attention to the need for diversity, equity, and inclusion (DEI) is all well and good, but how do you put into practice ways and methods that make DEI a reality?
“It all starts with self-reflection,” according to Danielle McCamey, DNP, ACNP-BC, FCCP, assistant dean of strategic partnerships at the Johns Hopkins School of Nursing in Baltimore. “We have to truly take an honest inventory of where we are on our respective journeys and where our biases show up in our practices.” McCamey is the founder/CEO of DNPs of Color, an initiative to create and nurture a community of doctor of nursing practice (DNP)-prepared nurses of color.
Having gained that awareness and accepting that you will make mistakes, educate yourself and step outside your comfort zone, she says. “Take inventory of what your circle of friends’influence looks like. Do they represent diverse perspectives and voices? What positions of power and privilege do you hold, and how do you take up space for yourself? How do you show up and advocate for others who may not share the same level of privilege?”
Most important, she notes, is to, “Take action. Utilize your skills, knowledge, and position. If you see something isn’t right, say something. You might save a life in that moment or give someone the gift of recognizing their areas of growth to do better.”
Nurse leaders, she notes, can work to implement DEI policies by including different voices and perspectives at the table to speak on policies. “The more buy-in you have on different levels, the more people will feel included and engaged, and they will work to ensure that DEI culture and policies achieve their intended goals.”
Nurse leaders can advance DEI in various ways, according to Margaret Rosenzweig, PhD, CRNP-C, AOCNP, FAAN, distinguished service professor of nursing and professor of medicine at the University of Pittsburgh School of Nursing. They include:
Ensuring that the vision for DEI is shared and active.
Educating staff and colleagues on how to address bias and promote DEI.
Create events and space for hospital staff to work with the community in assessing needs and promoting health.
According to Crystal Beckford, chief nursing officer (CNO), recruitment and retention of a diverse nursing workforce are key to DEI efforts at Luminis Health Doctors Community Medical Center in Lanham, Maryland. Some 83% of the nursing staff is now diverse.
“We’ve made a concentrated effort to speak, teach, coach, and mentor at area nursing schools, historically black colleges and universities, and community colleges,” notes Beckford. “Our efforts include offering internship opportunities for students that hopefully lead to future employment.”
She notes that this year, she worked closely with the Maryland Hospital Association, nursing leaders, and state lawmakers to pass legislation to create a Pathway to Nursing Pilot Program.Across several pilot sites at community colleges, the program will provide support services to Licensed Practical Nurses (LPNs) to lower attrition rates, increase the number of LPNs and potentially the number of Registered Nurses, and advance educational partnerships with local health systems, according to Beckford.
In addition, Beckford notes that monthly “Coming To The Table” sessions provide a platform for candid conversations that celebrate diversity and encourage mutual understanding. Moreover, the hospital fosters belonging and professional development through several Business Resource Groups (BRGs), with the African American BRG being the largest. These groups offer networking, mentorship, and advocacy spaces, empowering employees to thrive in an inclusive environment.
McCamey received the AACN Pioneering Spirit Award in May, at the National Teaching Institute & Critical Care Exposition.
Certain concepts frequently enter the popular consciousness and become a timely part of the current vocabulary. Diversity, equity, and inclusion (DEI) is one such concept, as are environmental awareness and the science of climate change.
While the overall effect of these terms becoming more popular and part of the general consciousness is very positive, we also have to watch for these concepts being co-opted and used solely for public relations and sloganeering.
In these times of ongoing and profound collective reckoning with issues of systemic racism and a lack of diversity in so many areas of 21st-century life, we need to be vigilant in making sure that the concept of DEI is honored as much more than a slogan. We cannot just pay lip service to diversity, equity, and inclusion—we must live and breathe it.
Adopting DEI
With DEI being more readily adopted by an increasing number of healthcare organizations and institutions, we must hold organizations accountable for paying attention to the nuances of what DEI truly means.
Many of us have come to understand that patients feel more satisfied with their healthcare and are more adherent to recommendations from healthcare professionals when the staff providing their care look like the communities they serve.
When staffing healthcare institutions with diverse staff, issues that must be addressed include where organizations seek pools of potential new hires and inherent biases in hiring practices. For example, recruiting from historically Black colleges and universities is one strategy that could yield a broader field of viable candidates for positions in communities where Black providers would greatly benefit the patient population.
Initiatives such as the American Hospital Association’s Health Equity Roadmap provide tools for organizations to strengthen diversity, equity, and inclusion toward collective transformation through the assessment of:
Diverse representation in leadership and governance
Community collaborations for solutions
Systemic and shared accountability
Organizations like DNPs of Color seek to diversify the ranks of students entering Doctor of Nursing Practice programs and becoming active DNPs. On the academic side, medical schools and other institutions of higher learning that educate our future healthcare providers must also diversify their student communities by actively recruiting a diverse student body.
Specific DEI initiatives have deeper roots and extremely sincere intentions of righting wrongs and turning areas of inequity around. Those that work well and succeed deserve to be replicated by other institutions.
Authoring the Future
Words are powerful, and how we use them is crucial. However, academic and healthcare institutions must move beyond words into purposeful, meaningful action.
Well-worded DEI policies are important because things need to be written down, but the boots-on-the-ground experience of patients, staff, and the wider community matters more. We can ask ourselves how those policies were initiated, how they’re actually operationalized, and where our blind spots might be. We can also take responsibility to speak truth to power when we notice that an organization we’re a part of is not living up to its stated processes or goals.
Moving into new territory and doing the righteous work of righting the wrongs of the past can’t happen overnight. When we’re attempting to undo decades or centuries of systemic racism and a lack of focus on diversity and inclusion, we are relearning the script, both individually and collectively. When we can move beyond words into meaningful actions with real-world implications, we must take this work seriously and give those initiatives the time and funding they deserve.
Our success in DEI is success for all. When everyone feels welcome, represented, seen, heard, and valued, we rewrite the past and author a better future.
Exposure to traumatic stress can have a life-altering negative impact on student nurses. Traumatic stress can challenge effective coping, emotional regulation, and the ability to focus, retain, and recall nursing concepts. According to the Substance Abuse and Mental Health Services Administration (SAMHSA, 2014), the “3 E” conceptualization of trauma are Event (single or cumulative), Experience (neglect, abuse, betrayal), and Effects (anxiety, loneliness, depression, feeling unsafe ) are manifested in various ways in people with exposure to trauma.
An individualized student-centered approach is crucial in understanding and adapting teaching pedagogy in nursing education to realize, recognize, respond, and resist re-traumatization (SAMHSA, 2014)in student nurses with a history of traumatic stress.
This article discusses the concept of trauma-informed pedagogy in nursing education and its significance in promoting equity and inclusion. Trauma-informed pedagogy suggests that past experiences can negatively impact health outcomes and learning (Garfin D. R. et al., 2018). As a result, educators must be able to identify signs of trauma and adapt their teaching methods to meet their students’ unique needs. It discusses the impact of trauma on nursing students’ physical and mental health functioning, and it then delves into implementing principles of trauma-informed pedagogy in the classroom.
Background/Significance
Trauma is defined as an event or set of circumstances that an individual experiences as physically or emotionally harmful or threatening, resulting in lasting adverse effects on their functioning and well-being (Bremner, J. D. 2006). College students, despite their excitement to succeed, often experience severe psychological distress, with 70% reporting such distress. Additionally, 35% of students were diagnosed with anxiety, and 29% had depression (American College Health Association, 2022).
Transgender and LGBTQIA students report higher levels of mental health issues than their straight counterparts. Microaggressions are also experienced by underrepresented students, creating a sense of unsafety on campus. Evidence suggests that Colleges should pivot to a learning space that promotes inclusion and equity. Only 40% of college students think colleges are doing enough to support mental health (Veneable, M.A., & Pietrucha, M. E., 2022).
The Universal Design for Learning ( UDL) recognizes that every student has different learning needs, and a one-size-fits-all approach is an ineffective instructional strategy. Similarly, implementing trauma-informed pedagogy principles within the nursing curriculum is a significant step toward meeting every student’s learning needs and experiences, promoting accessibility, equity, and inclusion in nursing education.
How Traumatic Stress Affects the Brain
Traumatic experiences can affect the brain’s development, structure, and function. It is critical to understand normal brain development to distinguish brain abnormalities. The areas of the brain responsible for stress responses are the amygdala, hippocampus, and pre-frontal cortex (Bremner, J. D., 2006). When an individual is exposed to traumatic stress, there is an increase in the level of cortisol and norepinephrine. Repeated exposure to stress increases the level of cortisol and norepinephrine and affects normal brain functioning and stress regulation, resulting in pathophysiological change(Bremner, J. D. 2006).
Students who are affected by traumatic stress may have difficulty learning concepts, focusing, and retaining information, resulting in course failures and higher attrition rates compared to their peers who have not experienced trauma. Traumatic experiences can cause anxiety and depression in some students. Past and current data suggest that trauma-informed care is critical for the promotion of equity in people with a history of trauma (Han et al., 2021).
Students’ sense of safety is disrupted, and the cumulative effects are difficulty adjusting to college experience, low grades, and high attrition rates. According to (Corello J., 2018), educators should adopt trauma-informed teaching and be compassionate and consistent in the learning environment. Despite the impact traumatic experience has on the brain, there is hope and possibility for students to be successful.
Implications for Nurse Educators
In the Four “Rs in the Trauma-informed approach to teaching student nurses(SMASHA, 2014), the nurse educator must convey empathy, possibilities, and hope to student nurses and focus on “what happened to you, instead of what is wrong with you’. Implementing trauma-informed principles is an issue of equity and inclusion and must be viewed through the lens of disability.
Realization
Research suggests that 66%-85% of youth report exposure to traumatic events by the time they enter college (Read et al., 2011). Additionally, approximately three-quarters of college students, 77 %, experienced moderate to severe psychological distress (ACHA, 2022). Understanding that traumatic experiences can affect the development, structure, and function of the brain, the nurse educator must acknowledge that trauma happened and provide a trusting teaching environment that emphasizes hope and transformation.
Realizing that trauma affects the student’s ability to function optimally, the nurse educator must stay involved in world events that may be traumatic to students: for instance, racism, disability, COVID-19, sexism, sexual harassment, and sexual orientation. Modeling emotional intelligence skills, self-reflection, and situational awareness, the nurse educator can convey trust and transparency when discussing and understanding sensitive topics in the classroom.
Recognize
The nursing process is a framework taught in nursing education to provide care for diverse populations. It begins with an assessment. Likewise, the nurse educator must be able to recognize signs of traumatic stress and respond with empathy, kindness, and understanding. Some signs and symptoms are difficulty focusing on a topic, lack of engagement, absenteeism, anxiety, low grades, and difficulty adjusting to the college environment.
It is essential to acknowledge that the traumatic event happened, and an evidence-based action plan is activated to promote healing and agency to enhance academic success. The nurse educator must be knowledgeable about topics or events that may trigger traumatic stress and develop a lesson plan or teaching strategies to avoid triggers—for instance, disparities in healthcare outcomes for minorities. Nurse educators must adopt several strategies to effectively support students’ learning experiences in teaching sensitive topics. To this end, the nurse educator should consider the value of establishing eye contact with students and facilitating opportunities for them to share their lived experiences. The nurse educator must also demonstrate a genuine interest in the student experience. By applying these strategies, nurse educators can foster an environment that supports students’ learning journey and promotes their well-being.
Respond
When a student goes through a traumatic experience, their sense of safety can be severely affected. As a nurse educator, it is essential to demonstrate emotional intelligence while conversing with such students regarding traumatic stress. Using the student’s name and giving them enough time to contemplate and respond is crucial. In addition, the nurse educator should offer their presence to show kindness and compassion, which can provide comfort and support for the student.
As a nurse faculty member, you can support your student’s academic journey by referring them to the Office of Accessibility and Disability. The office provides essential services to students with disabilities, ensuring they have the resources to succeed in their studies. Letting your students know you are available for office hours and phone calls is essential, as this can help them feel more comfortable and supported.
Creating a respectful and inclusive learning environment is crucial to the success of all students. You can do this by promoting a culture of civility and respect in your classroom and being mindful of your students’ diverse needs. If a student is experiencing anxiety or stress, consider extending assignment due dates to help alleviate their concerns.
Finally, it is essential to recognize that some students may have a history of trauma that could impact their ability to learn. To increase the accessibility and inclusion of these students, incorporate multiple teaching modalities that address the cognitive, psychomotor, and affective domains of learning. Doing so can help ensure that all your students can succeed.
Resist re-traumatization
In a nursing education culture that prioritizes diversity, equity, and inclusion, it is essential to recognize that some college students may have experienced trauma. By intentionally incorporating transformative, trauma-informed practices into nursing education, we can foster a sense of human dignity, promote academic growth, and help students thrive. To prevent re-traumatization, faculty and peers must have zero tolerance for discrimination against students. The learning environment must prioritize civility, human caring, compassion, and consistency (Corello, 2018) while avoiding punitive measures and implementing clear policies and procedures. Sensitive topics should be approached with empathy and understanding, and training modules focused on trauma and its effects can help create awareness and build a strong sense of community.
Conclusion
Integrating trauma-informed practices into nursing education requires comprehensive changes across multiple levels, from micro to macro systems. At the micro level, nurse faculty must demonstrate empathy, benevolence, courtesy, and honor towards individuals who have survived trauma. They must also remain watchful in recognizing, validating, and averting re-traumatization for student nurses who have experienced trauma. By nurturing a learning environment that fosters personal development and transformation, faculty and students can collaborate to establish a warm and accommodating community open to everyone.
References:
1. American College Health Association -National College Health. (2022). Assessment III: Undergraduate Student Reference Group Executive Summary Spring 2022. Silver Spring, MD: American College Health Association.
2. Bremer, J. D. (2006). Traumatic stress: effects on the brain. Dialogues in Clinical Neuroscience, 8(4), 445-61.
3. Carello, J. & Thompson, P. (Eds). (2021). Lessons from the pandemic: Trauma-informed approaches to college, crisis, change. Palgrave Macmillan.
4. Garfin, D. R., Thompson, R. R., & Holman, E. A. (2018). Acute stress and subsequent health outcomes: A systematic review. Journal of Psychosomatic Research, 112, 107-113. doi: 10.1016/j.jpsychores.2018.05.017
6. Han, H. R., Miller, H. N., Nkimbeng, M., Budhathoki, C., Mikhael, T., Rivers, E., Gray, J., Trimble, K., Chow, S., Wilson, P. (2021). Trauma-informed interventions: A systematic review. PLoS One, 16(6), e0253209. Doi: 10.1371/journal.pone.0253209
7. Kubala, J. (2020). Of Trauma and Triggers: Pedagogy and Affective Circulations in Feminist Formations, 32(2), 183-206.
8. Read, J. P., Wardell, J. D., Vermont, L. N., Colder, Ouimette, P., & White, J. (2012). Transition and change: Prospective effects of posttraumatic stress on smoking trajectories in the first year of college. Health Psychology, 32(7), 757-767.
9. SAMHSA’s concept of trauma and guidance for a trauma-informed approach. (2014). HHS Publication No. (SMA) 14-4884. Substance Abuse and Mental Health Services Administration, Rockville, MD.
10. Veneable , M. A., & Pietrucha, M,E. (2022). 2022 College Mental Health Report, Best Colleges.
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