The Role of Nurses in Eliminating Health Disparities and Achieving Health Equity

BACKGROUND

The COVID-19 pandemic has laid health disparities bare for all who wish to see. Racial/ethnic minority population account for a disproportionate number of cases and deaths from COVID-19 compared to white population (Garg et al., 2020). These disparities are especially staggering among African American and Hispanic communities, where COVID-19 death rates are three times higher than would be expected for their proportion of the population (Godoy & Wood, 2020). Indeed, where we live, work, and play matters. Health disparities adversely affect groups of people who systematically experience greater obstacles to health based on their race or ethnicity, religion, socioeconomic status, gender, age, and geographic location; mental health, cognitive, sensory, or physical disability; sexual orientation or gender identity; nationality or immigration status (Healthy People, 2020). Disparity is especially prevalent in mental health care - fueled by stigma, discrimination, and social exclusion (i.e., social disadvantage). One of the four overarching goals of Healthy People 2020 is to achieve health equity, eliminate disparities, and improve the health of all patient populations.

Nurses are the largest and most trusted health care workforce and have both professional and moral responsibility to acknowledge, lead, and act to eliminate health disparities and achieve health equity. However, similar to other health professionals, most nurses indicate that they do not have requisite preparation and, therefore, are not practice-ready to meet the need of patients from diverse backgrounds (Fleckman, Corsco, Ramirez, Begaleiva, & Johnson, 2015; Institute of Medicine, 2011). Nursing students’ preparation and nurse clinicians’ continuing education are increasingly important not only due to the disparities in health outcomes described above, but also due to the increasing diversity of the U.S. population as a whole. According to a U.S. News report, 70 percent of the largest cities in the United States of America (U.S) are more diverse than they were ten years ago (McPhillips, 2020). The population of the U.S. has also seen a significant rise in immigrant population to 13.6% - an all-time high (Radford, 2019). This growth in the diversity in the U.S. compounds the health care needs of all patient populations. Therefore, we must prepare nurses to take care of all patients by leveraging their spheres of influence at individual, organizational, and policy levels (Institute of Medicine, 2009).

INDIVIDUAL LEVEL

At the individual level, nurses’ interactions with patients is critical in eliminating health disparities. Research show that training health care providers to improve their communication with patients during clinical encounters leads to positive patient behavior change and outcomes (Alegria et al., 2018). First, nurses need to be aware of implicit bias or stereotypical assumptions about patients with different backgrounds. Left unchecked, biases have negative effects on nurse-patient interaction during clinical encounters (Hall et al., 2015; Marcellin et al., 2019). Nurses must invite and support all patients’ participations in all aspects of care, irrespective of patients’ levels of education, language, or racial or ethnic backgrounds or clinical characteristics (Alegria, 2018). For example, patients with low-educational attainment may need information provided in terms they will understand. Patients who do not speak English fluently may need an interpreter (Murillo, 2013). Even patients with high educational attainment who are diagnosed with new illness need nurses to explain the illness, potential etiology and treatment options. Patients bring talents and strengths by virtue of their lived experiences to the clinical encounter providing opportunities for nurses to amplify or activate patients’ voices. Nurses should attend, facilitate, and support patients’ voices to ask questions, express opinions, and share decision-making about their care (Alegria et al., 2018). Nurses’ reinforcement leads to accumulation of patients’ cultural health capital (Shim, 2013) – increased illness self-management and better health outcomes.

ORGANIZATIONAL LEVEL

At the organizational level, care structure and delivery needs to be patient-centered. Care organization must remove draconian rules that are punitive to patients’ efforts to navigate convoluted and fragmented health systems (Oruche, Downs, Holloway, Draucker, & Aalsma, 2014). For example, many health care organizations impose the 15-minute rule that says if a patient is 15 minutes late, then that patient has to reschedule the appointment. For socioeconomically disadvantaged patients, such rules pose unjustifiable hardships. Many patients often take multiple public buses from their home, place of work, or school to the clinic: Only to be told to reschedule. It will be more productive if health care organizations take a more patient-centered strategy, applaud patients for efforts to get to appointments, work collaboratively with patients to facilitate health care access and utilization to reduce health disparities. For example, availability of clinics appointments on weekends such as Saturdays should be standard practice, which will increase access to care and mitigate school absences and loss of employment for patients. Additionally, health care organizations can collaborate with community centers or organizations to provide services in areas that have limited resources or access to healthcare services (Kuehn, 2019).

POLICY LEVEL

At the policy level, nurses can advocate for policies that support patient-centered care access and utilization. First, to facilitate patients’ voice and participation in all aspects of care, nurses can advocate for broader adoption of cultural and linguistically appropriate service (CLAS) standards (Murillo, 2013) not just organizations that receive federal dollars. Nurses should push for provision of professional interpreter services by all health care facilities and systems. Second, COVID −19 pandemic has catapulted delivery of mental health services using telehealth. There are legislative efforts to codify recent emergency waivers for telehealth (Portnoy, Waller, & Elliott, 2020). Nurses’ advocacy and support of telehealth legislations will improve care access all patient populations.

CONCLUSION

Given the diversity of the U.S. population, there is strong precedence to prepare nursing students to provide care to all patient populations. This charge requires targeted awareness, competencies, and strategies at the individual, organizational, and policy level. In this article, we highlighted nurses have a responsibility to check their biases; support, facilitate, and empower patients’ voices and participation in all aspect of care decisions; and advocate for organizational and policy actions to eliminate health disparities and achieve health equity for all patient populations in the U.S.