Integrating the 3Ds: A Nursing Perspective (2024)

Disconnects

The first disconnect is what the nursing profession says about the value of diversity and what the nursing profession has been able to achieve in relation to a diverse workforce. The high value placed on a diverse workforce is evident from examining mission, value, and position statements of major professional nursing associations, schools and colleges, and health-care systems. For example, the American Association of Colleges of Nursing states that “racial and ethnic diversity of health professions faculty and students helps to ensure that all students will develop the cultural competencies necessary for treating patients in an increasingly diverse nation.”¹ Similarly, the National Advisory Council for Nursing Education and Practice affirmed that minority nurses are significant contributors and leaders in the development of models of care that address the unique needs of racial/ethnic minority populations.² Further, increasing their numbers is viewed as a major strategy in reducing the health disparities that exist within the nation's population.³ Similarly, numerous researchers and policy makers have recognized the practice, research, and educational benefits of racial/ethnic diversity and the adverse consequences that the absence of diversity poses for patients and communities.^4,5

Despite the nursing field's profession to value diversity, statistics show otherwise. Racial/ethnic minority groups are vastly underrepresented in nursing, comprising just 17% of registered nurses (RNs) in the United States, compared with 35% of the U.S. population.⁶ The disparity is even starker with regard to representation of specific subgroups. For example, Hispanic and African American people comprise 3.6% and 5.4% of the RN population, respectively, compared with 15.4% and 12.2%, respectively, of the U.S. population. The underrepresentation also exists in graduate education: Latino and African American people comprise only 3.5% and 6.3% of advance practice RNs, respectively.⁶

The disconnect between what has been said about diversity and what has been achieved begs several questions. What do existing nursing workforce data tell us about nursing's commitment and capacity to address issues of equity and social justice? Does the nursing profession lack the capacity or the commitment to diversify the nursing workforce? Are the benefits of a diverse health professions workforce perceived as only impacting minority populations? Most importantly, if nursing cannot diversify the workforce in contexts in which they lead (e.g., schools of nursing, health-care settings, and professional organizations), how can we demonstrate to others that the nursing profession is prepared to lead in such areas as education, research, and practice, which focus on health disparities and SDH?

While the focus on diversity has been centered primarily on numbers, attention to diversity in both educational and practice approaches must also be addressed. Nursing must focus on substance; that is to say, the quality of the experience, the cultural humility that must be taught to all nurses and, thus, integrated into nursing practice, and the cultural safety that must be provided to all providers and recipients of nursing care.⁷ Further, nursing education and the delivery of clinical practice must be reframed to address the health and health-care needs of underserved and minority populations. Aside from immediate health concerns, underserved populations often contend with myriad issues that challenge access to health care, timely utilization of health-care services, and proper management of morbidities.^8,9 Some of these issues include poor health literacy,¹⁰ lack of transportation,^11–13 poor access to healthful foods, and lack of safe environments for physical activity.⁹ Consequently, direct primary care can be only partly successful if these other barriers—and other SDH—are not addressed.

Yet, addressing SDH in nursing curricula remains a challenge. A major disconnect lies in the changing health-care needs of the country and the persistent grounding in classic or “textbook” presentations of patients and common chronic diseases. For example, a student may learn that therapeutic lifestyle changes (e.g., diet, physical activity, and smoking cessation) are a necessary, and often primary, component of -hypertension management.¹⁴ A client without stable housing, however, may have competing demands, no steady source of food, or bigger concerns than daily exercise.

Traditional modes of graduate education, mainly the preceptorship model where students are paired with one health-care clinician (usually within a health system), provide students with the foundation and tools necessary to care for patients' health.¹⁵ However, they might not stress the role of the nurse within the community or a community health center (CHC) where the health-care needs of patients with complex comorbidities and influences may be different.¹⁶ While the preceptorship model remains the key component for providing experiential learning opportunities in nursing education, clinical sites are limited in both quality and quantity.¹⁷ In many instances, these limitations can impede students' opportunities to understand the influence of social determinants on health in a meaningful way. Students' exposure to SDH often occurs in the classroom setting, without the clinical experience necessary to integrate and apply foundational learning.

Discrimination

Another barrier to addressing diversity, disparities, and SDH in nursing and other health professions is discrimination. As noted civil rights leader, Dorothy Height, states:

“… covert discrimination is the problem … and it is more difficult than … overt. Unless we acknowledge that racism exits, we will never eliminate it…. If people define racism only as certain attitudes, then the only solutions they will seek are … ways of changing these attitudes. If … racism is seen as pervasive, fundamental, and systemic, then the solutions sought will be different and deeper in character.”¹⁸

While not unique to nursing, examples of covert discrimination persist in part because of a common belief that educational merit can be fairly and objectively assessed, and because of the lack of research that predicts educational and practice outcomes.^4,19 The failure to challenge these beliefs and assumptions gives rise to practices and guidelines that perpetuate the lack of diversity in educational settings.^4,20,21

The development of practices and guidelines to promote diversity in educational settings is complicated by conflicting perspectives about the causes of and solutions to addressing educational disparities. Numerous polls highlight the differences in perspectives between majority (white) and minority (Hispanic and African American) individuals on issues such as whether discrimination persists and whether it is a barrier to educational and economic mobility. There are also different perspectives on the role of government in providing educational and economic opportunities, as well as assistance for minority groups and immigrants to reduce educational and other disparities (e.g., merit scholarships, community service, and affirmative action). These differences illustrate the fundamental gap between the powerful hope for a society in which race does not influence one's opportunities in life and the reality of a society where race/ethnicity still organize society and individual experience for most people.²²

Dissemination

The longstanding funding by the Health Resources and Services Administration's (HRSA's) Nursing Workforce Diversity Program, as well as other sources, supports our understanding of health disparities and the influence of SDH, and provides a strong basis for continued action. For example, many successful models and strategies necessary to ensure success in recruiting and retaining racial/ethnic minority students and those from disadvantaged populations have been identified. These strategies include mentoring, financial and social support, developing supportive environments that include a critical mass of underrepresented minority health professions students and faculty, and consistent policies and leadership to expand diversity efforts beyond recruitment.^1,23–25 Thus, efforts and support should focus on the replication, adaptation, dissemination, and scale-up of successful models.

Successful models of dissemination, replication, and scale-up have been established. For example, the Agency for Healthcare Research and Quality has established an Innovations Exchange, a comprehensive website that provides quality tools, evidence-based innovations, and insights from experts designed to address issues, improve health-care quality, and reduce disparities.²⁶ The Centers for Disease Control and Prevention, through its Diffusion of Effective Behavioral Interventions project, provides information on evidence-based interventions and supports the use of interventions with demonstrated potential to reduce new human immunodeficiency virus (HIV) infections.²⁷ The National Cancer Institute, through its Research-Tested Intervention Programs,²⁸ provides useful information about cancer control interventions and access to research-tested materials. These resources have two important elements in common: the promotion of evidence-based approaches to end users and a focus on racial/ethnic minority and disadvantaged populations. Similar strategies aimed at increasing access, diffusion, and scale-up of evidence-based approaches to increase diversity of the nursing workforce and the care delivered to diverse populations should be considered.

Durability

The first step in addressing disparities and SDH is understanding that there are no easy answers or quick fixes. Overcoming these challenges requires sustained efforts and strategies that move beyond funded programs and institutions into expanded use of innovative programs. Programs can be catalysts to create new partnerships and alliances that cross institutional and professional boundaries and should be used to develop infrastructures needed to sustain efforts to address disparities and increase diversity. Nurses need to focus not only on improving patient outcomes but also on improving the capacity of their institutions and/or settings to address disparities and SDH. Collectively, nurses can and should garner their expertise to create standards, norms, and policies that support addressing diversity and SDH.

An important resource in addressing disparities and SDH lies in professional nursing racial/ethnic minority nursing associations, such as the American Assembly for Men in Nursing, the Asian American/Pacific Islander Nurses Association, the National Alaska Native American Indian Nurses Association, the National Association of Hispanic Nurses, the National Black Nurses Association, and the Philippine Nurses Association of America. For decades, these national associations and their local chapters have worked in their respective communities and within nursing to address health disparities and increase diversity. Already, there is a wealth of expertise within coalitions and networks whose prioritization of efforts and approaches can inform and inspire similar efforts by others. These associations have demonstrated their durability through their longstanding commitment to addressing issues of diversity and disparities.

Data

The collection and use of data to inform and evaluate our approaches to advancing diversity and reducing disparities are critical. However, there are significant obstacles to obtaining relevant data—particularly data related to the categorization of race/ethnicity—and reluctance in some cases to self-report. Moreover, while such data are necessary to address and advance diversity and eliminate disparities, there are often political barriers to collecting race/ethnicity data.²⁹

For example, specific data needed to advance diversity include workforce data by gender and race/ethnicity, and also include predictors of academic success for all students, as well as those who are underrepresented in nursing. From a disparities and SDH perspective, we need to examine the impact of providers' race/ethnicity as it affects health outcomes, as well as the effects and impact of the nursing workforce in reducing/eliminating disparities in care, access to care, outcomes of care, and cost. Ultimately, racial/ethnic minority nurses are not the only ones who should be held accountable for improving health outcomes for the underserved; the responsibility falls to all health professionals. Finally, in relation to specific funded programs, improvements are needed in the evaluation of and accountability for outcomes of funded programs, as well as the predictors of practicing in underserved areas. Recent changes in reporting requirements to address these data needs by HRSA, including the Division of Nursing, are a step in the right direction.

Addressing data needs

The Oregon Center for Nursing (OCN), a nonprofit coalition, promotes a robust workforce of well-prepared nursing professionals who are dedicated to providing care and leading change to meet the health needs of our communities.³⁰ As part of its efforts to ensure nursing school applicants and enrolled student pools were representative of the general population, OCN created the Nursing Student Admissions Database (NSAD) Project. The purpose of this annual data collection of all Associate Degree in Nursing and Bachelor of Science in Nursing programs throughout the state was to accurately track and report admissions and enrollment trends at the applicant (vs. the program) level. This collaborative effort provides a source of accurate and rich data to inform policy and programmatic -interventions. An important first step the OCN took to increase diversity in the nursing workforce was to ensure that the nursing school applicant and enrolled student pools were representative of the general population. Data from the NSAD revealed that applicants from underrepresented racial/ethnic minority groups who met qualifications for nursing schools were admitted at rates similar to white students. These data were critical to inform future action to promote diversity in the workforce. Importantly, this effort demonstrates how, working in a broad-based coalition, the OCN was able to collect data that many had deemed impossible to collect. The establishment of the NSAD is an example of an action that will lead to ensuring that these efforts are sustainable and durable.

Addressing durability/sustainability of funded programs

The Juntos Podemos (“Together we can”) program at the University of Texas Health Science Center at San Antonio (UTHSCSA) is designed to reduce the negative effects of some of the educational and social disparities students may be experiencing in nursing school. This program, funded by a Nursing Workforce Diversity grant from HRSA's Division of Nursing, has many components that have been successful in other diversity programs. Central to the program is a protégé-to-mentor model, in which students progress in their roles. In addition to providing learning and social support, Juntos Podemos has been successful in engaging families and community leaders in different aspects of programmatic and advisory efforts. The outcomes of the program are impressive: more than 300 students participate; there is a 100% National Council Licensure Examination pass rate, and, importantly, 43% of Juntos Podemos students are enrolled in graduate school. While initially targeting minority and disadvantaged students, Juntos Podemos has now opened its programs to all UTHSCSA students who express interest in the programs. The program has become a central resource for all of the school's students. As a result, efforts are underway to sustain the project once funding has ended, including developing an endowment fund and a minority faculty recruitment plan. The involvement of nontraditional stakeholders (e.g., families and community leaders), the demonstrated success of the data-driven program, and the school's investment in the program continue to support the sustainability of this important resource.

Addressing SDH in practice settings

Adequate access to preventive care is a critical factor in reducing health-care disparities. The potential for reducing these disparities exists not only in the expansion of physical access but also in diversifying the delivery of care. The Institute of Medicine's (IOM's) “Crossing the Quality Chasm: A New Health System for the 21st Century” report identified patient-centered care (PCC) as an indicator of quality care. PCC was defined as “providing care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions.”³¹ As advocates of health promotion and risk reduction, nurses can work as leaders in patients' care to address issues that impact health. In fact, PCC obligates nurses to work as teams to meet the health-care needs of their clients. A true commitment to PCC and decreasing health-care disparities would be reflected in practices that expand beyond the traditional model of primary care in which clinics maintain “regular business hours,” providers dictate plans of care, and the burden of accessing care is entirely on the patient. Following are examples of different models of health-care delivery.

Dedicated to delivering PCC are CHCs such as nurse-managed health centers and federally qualified health clinics (FQHCs). Even caring for more complicated patients³² with fewer resources,³³ CHCs have demonstrated delivery of high-quality care to underserved populations.³⁴ CHCs uniquely serve uninsured and Medicaid recipients by increasing access (e.g., offering extended hours) and providing diverse support services to enhance primary and preventive care services.³⁵ For example, some FQHCs provide nutrition counseling, social workers, community health workers, and legal services. Learning how to best collaborate with these services can increase the likelihood of attaining the goals of providing quality and efficient primary care.

Another critical component of PCC is empowering patients to be in charge of their health. One means of supporting patient empowerment is through shared medical appointments (SMAs). This model provides for longer periods of patient-provider contact and creates an environment in which patients problem-solve their challenges either individually or in collaboration with group members. The SMA model has shown promise with group prenatal care,³⁶ as well as with chronic diseases such as diabetes³⁷ and osteoporosis.³⁸ The positive health outcomes from this health-care delivery model exemplify how diversifying delivery of primary care can be beneficial.

Delivering care through mobile vans is another avenue for expanding and diversifying health care. Mobile vans have been used to deliver primary care in rural areas,³⁹ reproductive health services,⁴⁰ prenatal care,⁴¹ breast cancer screening,⁴² and HIV testing.⁴³ The advent of electronic medical records and -telecommunications can support the feasibility of increasing the use of mobile vans to deliver quality, routine care in medically underserved areas. Delivering care by mobile vans not only expands access but also creates opportunity for providers to gain perspective into their patients' environments, and to work accordingly with their patients in developing personalized plans of care. Maintaining consistent presence in a community can also help to build trusting relationships that support the development of population-based solutions for sustainable healthy living.

Addressing SDH in educational settings

To address health disparities, it is necessary for all providers to be aware of and understand the impact of social determinants on health. Educating providers in health-care settings and communities dedicated to delivering care to the underserved, such as in CHCs,⁴⁴ is one way to increase providers' awareness of the types of collaboration needed to address the complexities of health and health care in underserved communities. Clinical experiences in CHCs support the development of a comprehensive set of clinical assessment skills. Because of lack of insurance or underinsurance of patients, students are encouraged to develop treatment plans that are truly individualized. Furthermore, the complexity of patients and patient populations enhances and strengthens students' physical assessment and history taking. Without the ability to refer to other resources immediately, students must create a prioritized list of problems and determine the best approach and order of treatment. In addition, the frequent exposure to unmanaged mental illness and substance use provides students with sharpened motivational interviewing and counseling skills. The competing demands of patients may impede adherence to traditional treatment plans; thus, students are encouraged to become resourceful in creating treatment plans that take into account the unique demands and priorities of patients when “optimal health” may not be attainable.

Experience with vulnerable individuals and populations, and clinical experiences within these sites, can encourage lifelong community partnership and engagement. In an effort to provide graduate students these types of real-world experiences, the University of Michigan uses clinical preceptors in a variety of community settings. At one clinical site, students are placed with nurse practitioners who have a clinical practice in a local homeless shelter. Students are exposed to patients with complex medical concerns that are complicated by lack of insurance or underinsurance and other social concerns such as unstable housing, unemployment, or unsafe social situations. Students spend time with patients to truly understand their competing demands and create individualized treatment plans. They are also encouraged to spend time with patients outside of traditional clinical hours by attending court cases for Social Security disability claims, psychiatric care appointments, and social work sessions. At another site, students are paired with a nurse practitioner who provides care to homeless or runaway teenagers. Students are integrated into the multidisciplinary team and actively participate in managing many social issues. Finally, at another site, students are paired with a nurse practitioner who makes “house calls” to those patients who are underinsured or uninsured. Evaluating patients outside of a clinical examination room provides a unique experience and challenges students to hone their examination and clinical decision-making skills.

In addition to one-on-one clinical experiences in community settings, students are also able to interact with patients in groups or at the community or population level. They have organized and participated in community health fairs, tuberculosis screening and treatment, and clinical trips to local jails and health departments. These community-based clinical experiences at all levels of nursing preparation are imperative to prepare future clinicians to provide exceptional care to patients, regardless of social circ*mstance. As Hunt suggests, students' experiences with diverse and underserved populations allow them to “observe firsthand the health-care issues facing those who live in poverty.”⁴⁵ Ideally, it is this firsthand experience that would serve as a catalyst for nurses to remain committed to providing clinical services for the underserved populations and propel them to advocate for policies that support healthy communities for all people.

Addressing the 3Ds: an opportunity

The Campaign for Action is a collaborative effort supported by the Robert Wood Johnson Foundation and the American Association of Retired Persons designed to advance the recommendations of the landmark IOM report, “The Future of Nursing: Leading Change, Advancing Health.”^5,46 The Campaign focuses on three pillars for action: advancing education transformation, removing barriers to practice and care, and nursing leadership. Cross-cutting strategies or threads that will be addressed in these pillars include inter-professional collaboration, diversity, and data. The work of the Campaign is facilitated by state action coalitions, which are composed of a nurse and non-nurse leader. Each state determines the specific area and strategies it will address, and the Campaign provides technical assistance and support.

While specific strategies to advance diversity were not explicit in the IOM report, the Campaign established a Diversity Steering Committee to advise the Campaign on diversity strategies and the development of a national diversity action plan, and to provide targeted technical assistance to state action coalitions. A central Campaign dashboard will track several diversity indicators. A central tenet of the Diversity Steering Committee is that increasing the diversity of the nursing workforce and faculty will narrow the health disparities gap. Further, diversity should be integrated as a central component of all initiatives: a focus on nursing with diversity, not nursing and diversity.

The Campaign for Action and the Diversity Steering Committee are building on a strong and diverse infrastructure that provides opportunities for collaboration among an array of diverse partners at the local and national level to address diversity and health disparities. There are numerous opportunities and support being afforded by the Campaign, including data monitoring, dissemination of best practices, and targeted action that can be leveraged to advance the 3Ds.

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