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Feature: NCPD Connection

An introduction to equity, diversity, and inclusion

Sanchez, Michelle MSN, RN, CPHQ

Author Information
doi: 10.1097/01.NME.0000767256.35504.ef

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As nurses, we have a unique opportunity to assume an active role in equity, diversity, and inclusion (EDI) through unit and hospital quality improvement initiatives. Using EDI instead of the more common DEI (for diversity, equity, and inclusion) is a choice many are making to put equity first in the conversation. This article offers historical and current perspectives, definitions of EDI principles, and action steps you can take at your organization.

EDI defined

US history is filled with social movements of groups seeking to gain respect and equal rights from a person or group of higher privilege. Modern civil, women's, and gay rights movements have their beginnings within the last 175 years. The Civil Rights Act, which prohibited discrimination based on several factors, brought EDI into the workplace. However, EDI mean much more than their modest introduction in 1964 with the Civil Rights Act.

Equity

You're probably familiar with your employer's equal opportunity policies and have completed training on providing individual, culturally competent, age-specific care. Although we must continue to complete training and education required by employers, licensure agencies, or other regulatory bodies, nurses should also strive to build an inclusive culture within their sphere of influence. This benefits all employees, patients, families, and key stakeholders with whom you or your staff may interact.

In practice, equity and equality are easily confused, but it's important to be aware of their subtle differences. Equality often refers to treating people the same without considering their unique or individual needs. This can be difficult to employ and doesn't contribute to EDI. Equity is the active recognition that we're all different individuals who face different challenges and opportunities based on our starting point. Thus, individuals may need different accommodations. In a best-case scenario, removal of barriers is the ultimate success of equity. From the equity perspective, we can see that treating everyone equally, or applying equality, doesn't help everyone reach the same result (see Equity vs. equality).

Diversity

Diversity requires understanding that we all have different facets or parts of ourselves that may or may not be known to others. According to diversity and inclusion expert Jennifer Brown in her book How to Be an Inclusive Leader, these “diversity dimensions are the parts of our identity that make us who we are.” Every person has parts that are out in the open, known to a select few, or hidden from all. These facets make us each unique and special; they're also what creates a diverse group.

Each person determines what they'll share with others, which may be complicated based on many factors. What's shared in the workplace may be different than what we share in our personal lives. Someone may try to hide their appearance; intentionally withold information; or avoid certain topics, people, or groups to circumvent association or negativity related to a particular dimension of themselves. Empathy, kindness, and avoiding judgment go a long way when fostering diversity.

Inclusion

Inclusion is about creating a space where everyone is welcome to be who they want to be without fear of judgment or retribution. Once we're able to understand ourselves, we can begin to move forward in our path of action to be more inclusive, starting with our own acts of omission or commission. As with any change, there's inevitable discomfort as we recognize the ways in which we haven't acted equitably. Knowledge becomes power and influence to identify what we won't allow in our presence or support and how to continue to drive action. Inclusion means extending a sense of belonging to all and acknowledging individual diversity.

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Equity vs. equality

Consider what this might look like on your unit. You could initiate a discussion task force to dive deeper into these topics, which may include partnering with human resources and/or EDI experts to understand your organization's strategic position and engage in related activities safely and constructively. Remember, engaging authentically and with humility, not defensiveness, is key. Next, you can use the shared governence structure to disseminate this information. The American Nurses Association's (ANA) Civility Best Practices for Nurses provide guardrails for interactions and behavior on the unit (see ANA Civility Best Practices for Nurses). Employing these best practices helps create a culture of inclusiveness, especially when all staff members are empowered to speak up for any reason.

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ANA Civility Best Practices for Nurses

Privilege, bias, and intersectionality

The start, pathway, and end point of any journey are different for each person and are influenced by privilege, bias, and intersectionality.

Privilege

Unless you've had extensive training in EDI, you may not realize that privilege can be attached to so many parts of our lives and yet it isn't available to or the same for everyone. This can include the body we're born with, where we're born, and what we believe. Someone who works hard to achieve something may not see that they had a privilege in reaching that goal, which would've been much harder or impossible for someone else. It's important to recognize that privilege can exist in many domains and may have invisible benefits that serve the person with the privilege and lessen the difficulty of the journey.

Shame can be associated with having or lacking a particular privilege—it's personal and, therefore, complicated. Honestly evaluating your own privilege(s) is an important first step to developing awareness and taking further action (see Evaluating privilege).

Bias

Bias exists when an individual or group isn't aware of a privilege they hold and doesn't acknowledge that others may not have the same opportunities. Unconscious bias can come from beliefs deeply rooted in our history and upbringing. People may gravitate toward others who look, think, or act like them, which contributes to confirmation bias—the tendency to interpret new evidence as confirmation of existing beliefs or theories. Although we can't undo what our journey has been, we must maintain continuous awareness that there's always a different perspective to consider.

Intersectionality

You may have realized in assessing your own privilege(s) that there's a combination of answers that make you unique. The combination of one or more of these areas is known as intersectionality. For example, individuals may express their areas of privilege in a work setting, whereas they may feel freer to express their areas of disadvantage in a personal setting. In some cases, the individual may have so much shame associated with their areas of disadvantage that they aren't comfortable expressing them at all. Viewing yourself and others honestly and without judgment is key to moving forward and taking action authentically.

Social determinants of health

When comparing recent US Census Bureau data with the 2020 National Nursing Workforce Survey, we can see how nurses are and aren't representative of the US population across several indicators (see US population/RN characteristics). After gaining more understanding of these data and the areas of privilege that represent our diversity dimensions, we can make connections to social determinants of health (SDOH). According to the US Department of Health and Human Services Office of Disease Prevention and Health Promotion, “SDOH are the conditions in the environments where people are born, live, work, play, worship, and age that affect a wide range of health, functioning, and quality of life outcomes and risks” (see A closer look at SDOH). If unaddressed or ineffectively addressed, SDOH can result in health disparities and inequities.

The access to resources that contribute to health and positive outcomes is determined by others, not the individual. This is where you can truly appreciate that a lack of access is a systemic problem and not related to individual choice. An example may be the lack of a grocery store in an urban neighborhood preventing access to fresh fruits and vegetables. Another example is the lack of parks or a safe space for children in an urban area to play outside.

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2019 US Census 2020 National Nursing Workforce Survey
US total Population estimate July 1, 2019 328,239,523 Active RN licenses 4,948,914
AGE AND GENDER
Age <18 28.3%
Age 18-65 55.2% Age <30 8.4%
Age 30-39 19.5%
Age 40-49 19.0%
Age 50-59 21.8%
Age 60-64 12.2%
Age ≥65 16.5% 19.0%
Female 50.8% 90.5%
Male 49.2% 9.4%
Other .1%
RACE
White/Caucasian 76.3% 80.6%
Black or African American 13.4% 6.7%
American Indian or Alaska Native 1.3% 0.5%
Asian 5.9% 7.2%
Native Hawaiian or other Pacific Islander 0.2% 0.4%
HISPANIC ORIGIN
Not Hispanic or Latinx 60.1% 94.4%
Hispanic or Latinx 18.5% 5.6%
OTHER
Owner-occupied housing 64%
Households with a computer 90.3%
Households with broadband internet subscription 82.7%
Education/Highest level of nursing education Age ≥25 with bachelor's degree or higher 32.1% Diploma 6.7%
Associate degree 28.1%
Baccalaureate degree 48.1%
Master's degree 14.9%
Doctoral degree 2.1%
Age ≥16 mean travel time to work 26.9 minutes
The US Census Bureau doesn't offer nonbinary or other options.
Sources: Smiley RA, Ruttinger C, Oliviera CM, et al. The 2020 National Nursing Workforce Survey. J Nurs Reg. 2021;12(Suppl 1):S1-S96.
US Census Bureau. Quick facts United States. 2019. www.census.gov/quickfacts/fact/table/US/PST045219.

From the hospital and health system perspective, there are opportunities to ensure that barriers to care are minimized for individuals within the community. There may be opportunities to support initiatives that bring in resources to address SDOH. Expanding or offering opportunities for employees to volunteer in these initiatives or with established, reputable national organizations, such as United Way, Big Brothers Big Sisters of America, and Habitat for Humanity to name a few, is beneficial. These efforts provide meaning to staff, improve the community and, ultimately, improve the health and safety of the population.

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Domain Goal
Economic stability Help people earn steady incomes that allow them to meet their health needs.
Education access and quality Increase educational opportunities and help children and adolescents do well in school.
Healthcare access and quality Increase access to comprehensive, high-quality healthcare services.
Neighborhood and built environment Create neighborhoods and environments that promote health and safety.
Social and community context Increase social and community support.
Source: US Department of Health and Human Services Office of Disease Prevention and Health Promotion. Healthy People 2030. https://health.gov/healthypeople/objectives-anddata/social-determinants-health.

From the unit or individual nurse perspective, it may feel challenging to have an impact on SDOH. Consider your sphere of influence to identify areas of opportunity to impact the most underserved patients using the PEACE Model (see The PEACE Model: Evidence-Based Practice Guide for Clinical Nurses). A place to start may be to consider the American Association of Critical-Care Nurses' Synergy Model. The domains in this model include diversity, within which we can match nurse competency with patient need for optimal patient care.

There are numerous ways to assess the efficacy of the current collaborative processes employed on your unit and within your facility or health system, which could result in improved identification of patient need and access to resources critical for health. For example, consider the ways in which discharge planning can be enhanced to ensure that patients and families have needed resources as they transition back to the community.

Finally, there are opportunities to partner with quality professionals to assess the provision of care based on patients' unique demographic identifiers. You may be surprised to find that certain groups of patients achieve strikingly different outcomes in specific indicators such as readmission rates. As more information emerges, there are opportunities to perform additional research to highlight these gaps and develop innovative solutions to address them within the hospital.

Other steps to take

With an investment in time, reflection, and understanding, nurses can have an impact through EDI initiatives. As you lead this work, it's important to recognize that there will be discomfort along the way, yours and others—it's part of the process. Entering this space authentically with empathy will result in conversations that uncover where growth can occur. Start with your own discovery. Remember, you may not have helped create our current social climate, but you can help affect a positive change within it.

Be aware of microaggressions—statements or small actions in response to a stereotype about a particular group of people. As you begin your discovery, be mindful of the common sayings you use that may be based on a stereotype. Removing these from your conversations is a great place to start. Also be thoughtful of how the things you say may be received by others. A simple “Hi, how are you today?” can be answered very differently when you're fully present. After asking, give the person to whom you're speaking time for a response or invite more than the typical “Good, how are you?” Explore what challenges or barriers the individual may be encountering or anticipating encountering. Questions you can ask include “How do you think today will be for you?” and “What could help you have a better day?” These aren't new questions but changing the focus of what you're listening for inevitably brings up what needs improvement, which you must welcome and be open to.

The more knowledge and experience you gain, the more you'll increase your mindfulness. As this mindfulness influences your behavior, you'll begin to see positive changes in those around you. Ultimately, your coworkers will begin to ask their patients and colleagues the same questions, creating an empowered and engaged unit culture that fosters EDI.

The Inclusive Leader Continuum identifies a useful pathway: unaware, aware, active, and advocate. As with any continuum, there will be movement across stages as your understanding and actions change with deepening perspectives. The beginning two stages focus on the individual's thoughts and actions, whereas the latter two focus on the public and organizational perspective. Knowing where you've been, where you're trying to get to, and that you'll continue to grow as you increase your knowledge will benefit you and everyone around you.

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P Problem identification: Formulate the clinical question (PICO)
P—Patient population
I —Intervention
C—Comparison of intervention
O—Outcome
E Evidence review: Review evidence relevant to your clinical question by searching databases.
A Appraise evidence: Appraise the evidence that appears highest in the hierarchy of scientific evidence for its quality and applicability to practice.
C
  1. Change practice or Conduct research: If evidence is sufficient, embark on an improvement project to address practice change.

  2. If evidence is insufficient to warrant practice change, conduct research.

E
  1. Evaluate and disseminate findings: Evaluate the impact of the implemented practice change and research results.

  2. Disseminate findings through publication, oral presentations, and poster presentations.

Source: Rivera RR, Fitzpatrick JJ. Supplemental materials for The PEACE Model for Evidence-Based Practice for Clinical Nurses. Sigma Repository. 2020. https://sigma.nursingrepository.org/handle/10755/21383. Reproduced with permission.

It's important to recognize that you can't force others or your facility to engage in these activities. Diversity and inclusion, including recruitment, are workforce strategies to be determined at the systems level, but you may have opportunities to collaborate in this work. Preparing yourself through the abovementioned steps will allow you to help your organization strive to create a culture of inclusivity.

Diversity is fairly easy for organizations to measure; however, it isn't easy to measure an inclusive culture, which has a more profound impact on staff satisfaction, engagement, retention, collaboration, and effective decision-making. Additionally, inclusivity can result in increased innovation, efficiency, and financial performance. The return is worth the time invested in this work.

A positive force

We continue to see the world around us evolve. As the demographics and diversity of nursing change, we must educate ourselves to be models and mentors for others and create cultures of inclusivity. When we do, innovation and success will follow. There will always be steps forward and challenges along the way but no matter what your diversity dimensions are, we all have a responsibility to make this world a kinder, gentler place for all.

Evaluating privilege

A yes response to each question indicates a privilege in that area.

  • Were you born in the US?
  • Did you grow up middle class?
  • Are you White?
  • Are you male?
  • Did you attend college?
  • Did you grow up in a stable home environment?
  • Do you have stable housing?
  • Are you thin, tall, or conventionally attractive?
  • Can you show affection for your romantic partner in public without fear of ridicule or violence?
  • Do you get time off for your religious holidays?
  • Do you feel comfortable walking home alone at night?

A yes response to each question indicates a disadvantage in that area.

  • Did your ancestors come to the US by force?
  • Have you ever been diagnosed as having a physical or mental illness or disability?
  • Did you take out loans for your college education?
  • Have you ever been the only person of your race/gender/socioeconomic status/sexual orientation in a classroom or workplace setting?
  • Would you think twice about calling the police when trouble occurs?
  • Have you ever felt like there wasn't adequate or accurate representation of your racial group, sexual orientation group, gender group, and/or disability group in the media?

Source: Brown J. How to Be an Inclusive Leader: Your Role in Creating Cultures of Belonging Where Everyone Can Thrive. Oakland, CA: Berrett-Koehler Publishers; 2019.

INSTRUCTIONS An introduction to equity, diversity, and inclusion

TEST INSTRUCTIONS

  • Read the article. The test for this nursing continuing professional development (NCPD) activity is to be taken online at www.nursingcenter.com/CE.
  • You'll need to create an account (it's free!) and log in to access My Planner before taking online tests. Your planner will keep track of all your Lippincott Professional Development online NCPD activities for you.
  • There's only one correct answer for each question. A passing score for this test is 7 correct answers. If you pass, you can print your certificate of earned contact hours and access the answer key. If you fail, you have the option of taking the test again at no additional cost.
  • For questions, contact Lippincott Professional Development: 1-800-787-8985.
  • Registration deadline is September 6, 2024.

PROVIDER ACCREDITATION

Lippincott Professional Development will award 1.5 contact hours for this nursing continuing professional development activity.

Lippincott Professional Development is accredited as a provider of nursing continuing professional development by the American Nurses Credentialing Center's Commission on Accreditation.

This activity is also provider approved by the California Board of Registered Nursing, Provider Number CEP 11749 for 1.5 contact hours. Lippincott Professional Development is also an approved provider of continuing nursing education by the District of Columbia, Georgia, and Florida, CE Broker #50-1223. Your certificate is valid in all states.

Payment: The registration fee for this test is $17.95.

REFERENCES

Advisory Board. Cheat sheet: inclusion. 2020. www.advisory.com/Topics/Culture/2020/07/Inclusion.
    American Association of Critical-Care Nurses. AACN synergy model for patient care. www.aacn.org/nursing-excellence/aacn-standards/synergy-model.
      American Association of Critical-Care Nurses. Synergy for Clinical Excellence. 2nd ed. Burlington, MA: Jones & Bartlett Learning; 2017.
        American Nurses Association. Civility best practices for nurses. www.nursingworld.org/~4afd0d/globalassets/practiceandpolicy/health-and-safety/incivility.jpg.
          Bourke J. The diversity and inclusion revolution: eight powerful truths. Deloitte Review. 2018. www2.deloitte.com/us/en/insights/deloitte-review/issue-22/diversity-and-inclusion-at-work-eight-powerful-truths.html.
            Brown J. How to Be an Inclusive Leader: Your Role in Creating Cultures of Belonging Where Everyone Can Thrive. Oakland, CA: Berrett-Koehler Publishers; 2019.
              Oluo I. So You Want to Talk About Race. New York, NY: Seal Press; 2019.
                Rivera RR, Fitzpatrick JJ. Supplemental materials for The PEACE Model for Evidence-Based Practice for Clinical Nurses. Sigma Repository. 2020. https://sigma.nursingrepository.org/handle/10755/21383.
                  Smiley RA, Ruttinger C, Oliviera CM, et al. The 2020 National Nursing Workforce Survey. J Nurs Reg. 2021;12(Suppl 1):S1–S96.
                    University of Washington. Mapping American social movements project. https://depts.washington.edu/moves.
                      US Census Bureau. Quick facts United States. 2019. www.census.gov/quickfacts/fact/table/US/PST045219.
                        US Department of Health and Human Services Office of Disease Prevention and Health Promotion. Healthy People 2030. https://health.gov/healthypeople/objectives-and-data/social-determinants-health.
                          Zurek C. Why diversity and inclusion are essential to engaging today's workforce. Rewards Recognition Network. 2017. https://rewardsrecognitionnetwork.com/Why-Diversity-and-Inclusion-are-Essential-to-Engaging-Todays-Workforce.
                            Wolters Kluwer Health, Inc. All rights reserved.