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Justice, Equity, Diversity, & Belonging-nursing Principles for Improving Patient Health Outcomes

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On Saturday, August 26, 2023, thousands of individuals gathered in Washington DC to commemorate the 60thanniversary of the March on Washington for Civil Rights and to recognize the famous “I Have a Dream” speech by Dr. Martin Luther King, Jr.  Throughout that weekend, media outlets covered the events and conversed on how far or how not so far society has come.  In watching one of the most widely recognized speeches of all time, I contemplated the same, joyfully considering how far we have come and woefully how far we have yet to go in the actualization of “the dream.” Although, not born in 1963, as an African American woman growing up in the U.S. and having traveled the world as a child of a U.S. serviceman, I have felt the sharp sting of racism, discrimination, and the sense of not belonging.  In reveling in the events celebrating the “I Have a Dream” speech, I considered my role as a registered nurse, educator, and leader, as well as nursing’s role in eliminating structural racism and discrimination to achieve equitable healthcare for all.  These thoughts recalled to my mind principles widely mentioned in today’s society but inherent to the profession of nursing, diversity, equity, inclusion, and belonging (DEIB), as well as the meaning of health equity and justice and the impact these have on patients, families, and communities that my profession, nursing serves.

In 2002, the Institute of Medicine published its groundbreaking report Unequal Treatment, Confronting Racial and Ethnic Disparities in Health Care (Institute of Medicine, 2003), and since that time, nursing has diligently been working to eliminate health disparities and improve patient outcomes.  Globally, public and private institutions, corporations, and organizations have adopted DEIB principles and incorporated them into their mission, vision, and values.  But questions remain: What do these principles mean, how is their meaning understood and actualized, and why are they important? A recent story I read illustrates the impact of how the lack of understanding of DEIB manifests itself in health care.  An EMT was transporting a 95-year-old African-American woman to the hospital for shortness of breath and difficulty breathing.  Despite her physical condition, the patient was concerned about the appearance of her hair in fear that healthcare providers would not take her health concerns seriously based on the physical appearance of her hair. In spite of her physical condition and reassurance from the EMT, the patient’s concern was her hair. Not out of vanity about her appearance but because she was concerned her appearance would cause healthcare providers not to take her health seriously. The EMT obliged the patient and neatly braided her hair.  This example is one of many in which evidence supports the concerns that people of color have when seeking health care. The negative impact is that people die. In the greatest nation in the world, with some of the greatest technological advancements in healthcare, this should not be so, and it should concern all healthcare professionals. Not only should it concern us, it should implore us to take contemplative and radical action.

The principles of DEI are rooted in history as far back as the 18th century when a Quaker, Benezet, advocated that all students should have equal access to education (Vivian, 2023).  The concept of belonging is much newer and is defined as the feelings of acceptance and inclusion by members of a group. In healthcare, it is the feeling of being valued, respected, and included as a member of a unit.  In thinking about diversity, equity, and inclusion, I imagine a quilt of many fabrics with different textures, colors, patterns, and sizes sewn together. Individually, each fabric has different textures and patterns; while different, each is equally valuable and contributes to a beautiful quilt. Similar to quilts, this country is comprised of people, whether native to the U.S. or another country; each person has their own unique history, culture, values, beliefs, and life perspectives that they bring to the shared spaces we inhabit as we move through our daily lives.  It is these interactions and encounters that enrich us and offer opportunities for us all to experience, learn, and grow as human beings.

Though DEIB principles have been around for a while, they have become socially acceptable catchphrases, often without the depth necessary to illicit the type of meaningful change needed. In 2020, the COVID pandemic placed a glaring spotlight on the stark reality of the health disparities and inequities of black and brown persons, with dire consequences. That same year, in full view of the world, the murder of George Floyd highlighted ongoing issues of systemic racism and inequality for individuals of color.  These two separate but intertwined events required all of us to examine ourselves and the world in which we live and ponder deeply about what more could and should be done.  The outcome was a targeted focus on DEIB principles and a reexamination of the work around ensuring that these principles are actualized.

  While great strides have been made in our efforts to learn and be accepting of each other, the reality of recent setbacks is undeniable.  This year, there have been landmark changes in protections for individuals previously protected. State legislatures across the nation have begun enacting laws prohibiting DEI offices, programs, and training at public universities. Nationally, the Supreme Court ruling on June 29, 2023, set aside decades of precedence prohibiting the use of affirmative action in college admissions. These decisions affect years of progress for individuals of color and will have an impact for years to come.  Even though many organizations, including nursing and healthcare institutions, released statements decrying these decisions and affirming their support for DEIB, the impact of these rulings has the potential to impede progress made toward eliminating health disparities and achieving health equity.

The question at large becomes what can and, moreover, what will the profession of nursing do to reduce health disparities and achieve health equity? Whatever we are doing is not enough; just consider the continued rise in maternal mortality rates. Reducing health disparities can be achieved when the healthcare workforce, including nursing, mirrors the population they serve.  Multiple studies have identified improvements in the quality of care and patient outcomes, in addition to a reduction in healthcare costs when the providers of care reflect the current U.S. population.  Although the nursing profession is striving to diversify its workforce, we continue to lag behind the general population.  Of the 5.2 million registered nurses, only 20% identify as a nurse of color, while nationally, approximately 40% of the population identify as a person of color (Smiley et al., 2023).  To improve these numbers, we must create educational opportunities and support for diverse students.  We must also support efforts to create inclusive environments and foster understanding so that diverse students thrive during the educational process. Furthermore, we must support institutions that educate a large proportion of diverse students, such Minority Serving Institutions, which include Historically Black Colleges and Universities (HBCUs), Hispanic Serving Institutions (HSIs), Tribal Colleges and Universities (TCUs), and Asian American and Pacific Islander Serving Institutions (AAPISIs).  Together, these institutions educate over five million students, including nurses, and can significantly contribute to improving the diversity of the healthcare workforce.

Birthed from the 1918 flu pandemic, Prairie View A&M University’s College of Nursing was created over 100 years ago to address health disparities and has remained one of the largest producers of African-American baccalaureate-prepared registered nurses in Texas. The College of Nursing has over 5,000 graduates across all educational levels, who have gone on to provide high-quality care across the healthcare spectrum and serve in leadership roles within the Texas Medical Center (TMC), Texas, the nation, and the world. The faculty of PVAMU CON is committed to educating diverse nurses and has the phenomenological experience of understanding that the knowledge, skills, and cultural competence of our graduates are needed and will directly impact the profession and the quality of care patients, families, and communities receive.  Supporting DEIB initiatives, HBCUs such as PVAMU College of Nursing and other MSIs continue to increase much-needed diversity in nursing. Diverse nurses mean one day, patients will not have to consider how they will be perceived when seeking care and that all care will be equitable and just. In reflecting on the “I Have a Dream” speech, the question posed is, “When will you be satisfied?” As healthcare professionals, we cannot be satisfied until the dream is actualized, and that dream is a healthcare workforce reflective of the population it serves and a healthcare system without disparities that provides equal and just health care for all.

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