Coronavirus disease 2019 (COVID-19) disproportionately impacts Black Americans. While social contributors to health have been widely discussed, conversations of foundational contributors such as systemic racism, explicit bias, and implicit bias are also critical. NPs are a ready workforce equipped with the leadership, skills, and abilities to contribute to achieving health equity. The disproportionate toll of SARS-CoV-2, the virus that causes COVID-19, on Black Americans has stimulated robust conversations around racial and ethnic health inequities. However, as Waite and colleagues stated, “Race itself does not drive disparate outcomes—rather, racism is the culprit.”1 Structural racism is a foundational contributor to how systems and societies perpetuate discrimination based on race. These discriminations, seen in housing, credit, employment, media, criminal justice, and healthcare, leave Black individuals vulnerable to poorer health outcomes. Therefore, structural racism and its distillations must be treated as a social determinant of health.1
While there has been much discussion surrounding disparities in the ability to social distance, low socioeconomic status resulting in vulnerable insurance status, and Black Americans holding a significant portion of essential, frontline jobs (for example, service workers), it is important to specifically address the role of healthcare professionals in how these disparities continue to play out. Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare, the Institute of Medicine's (IOM) 2003 landmark report, offered evidence that health disparities exist in part due to lower quality healthcare provided to racial/ethnic minorities than to White Americans, often due to implicit racial bias among individual healthcare providers.2
While explicit bias correlates higher with discriminatory behavior, implicit bias has been expressly linked with poor patient-provider communication and trust, contributing to health disparities.3,4 Implicit bias has also been associated with disparities in treatment recommendations, appropriately prescribing pain medication, and with access to COVID-19 testing.
The risks of implicit bias are well established, and the CDC cautioned healthcare providers about this risk in its guidance on COVID-19.5 Healthcare providers on the frontlines still had to warn the population due to questionable guidelines on rationing scarce supplies that could unfairly bias people of color.6 Guidelines that factored in comorbidities, such as hypertension and asthma (which are disproportionately experienced by Black patients), risk rationing life-saving treatments unjustly. Other guidelines proposed more nuanced ways of rationing care, should they become necessary.7 Frontline NPs and healthcare professionals must approach their practice with a health equity perspective to avoid perpetuating the injustices in our healthcare system, remaining acutely aware of the ways that their practice intersects with health equity.
NPs possess the education, knowledge, skills, and experience necessary to provide basic and comprehensive primary, acute, and mental healthcare services across the lifespan. NPs are ideally positioned to improve access to care, contribute to efforts to reduce health disparities, and lower the cost of providing care. As the NP role and practice authority continues to expand, NPs must recognize the potential of their role to address disparities in health and promote health equity. In addition, as current and future leaders in the health system, and one of the fastest growing segments of the healthcare workforce, NPs are in an optimal position to respond to the inequities illuminated by COVID-19. This article discusses sustainable individual level actions that NPs can take to address health equity and the role of healthcare organizations to support these efforts during and after the pandemic.
Clinicians have a professional responsibility to examine how their role can advance the goal of health equity. NPs can promote health equity in their clinical practice with self-reflection leading to intentional action. These ideas aim to stimulate discussion and open conversations that can catalyze change within the individual and organizations where NPs practice.
Address and mitigate their own bias. Everyone has biases, and the first step is acknowledging these biases and working to change the stereotypical thinking that drives them. Self-evaluation is the initial step, and the Harvard Implicit Association Test (controversies notwithstanding) is the most utilized tool for this critical step of self-assessment.8 However, long-term reduction in bias is accomplished through a combination of awareness, concern regarding the effects of bias, and applying strategies to reduce bias.9 Mitigating biases using evidence-based methods such as counter-stereotypic imaging, perspective taking, and increasing engagement with different groups is important.9,10 One-time implicit measures do not necessarily result in explicit bias or behavior change.11 Therefore, this work should be ongoing and include both cultural humility and more foundational concepts of structural competency.1,12
Structural competency is the ability to understand and define how societal systems and structures impact individual and population health.13 Woolsey and Narruhn developed a pilot study for doctor of nursing practice (DNP) students to evaluate a structural competency training.13 The 3-hour training increased knowledge of structural terminology, but participants suggested the need for more concrete tools for addressing “isms,” which is encouraging, as simply not being racist is not enough. NPs must strive to develop tools to be antiracist to effectively reach health equity in their clinical practice. These are areas where more research is needed and would be ripe for a clinical/hospital-wide project to build from current evidence.14
Look for and eliminate bias in documentation. Words documented in a patient chart can communicate a lot more than the clinical status of the patient. The potential for biased documentation to influence help received dates back to the 1918 influenza pandemic where descriptions of a patient's “moral failings” of being an unmarried mother cast a shadow over their request for help with food and economic challenges.15 In 2018, a research team compared the treatment response of healthcare providers to a patient presenting in acute sickle cell crisis based on the written documentation provided in the health record.16 Notes that were more stigmatizing resulted in negative attitudes toward the patient and suboptimal pain management. NPs can begin to look for ways that their documentation may present a biased portrait of the patient. It is important to practice learning how to look for bias in documentation and patient encounters by using guided reflection/debriefing activities to discuss how these might impact care.4,17
Incorporate concepts in preceptorship. Precepting is an essential component to teaching the next generation of NPs. Effective role modeling of culturally humble patient care is necessary but not sufficient. NPs serving as preceptors have a responsibility to share in the active teaching and evaluation of students regarding health disparities, implicit bias, and structural competency concepts. Additionally, a lack of structural competency and bias training for NP preceptors may result in a conflict between NP preceptors and a diverse student body, leading to suboptimal learning experiences and biased student evaluations.18 Therefore, NP preceptors require ongoing equity training and self-reflection related to the intersections that emerge from the triad of the student, patient, and preceptor.
Wilson-Mitchell and Handa conducted three diversity and equity workshops for nurse midwife preceptors. Feedback from participants suggested role playing, educational resources, and critical self-reflection as the preferred methods for learning. Future research should address best practices to incorporate these concepts into preceptorship.18
Addressing health equity in clinical practice requires a response from NPs both individually and collectively. NPs may feel overwhelmed at the magnitude of the problem, and struggle to see how their actions at the bedside and community can make a difference more broadly. NPs are leaders on the healthcare team and are empowered to address questionable practices from patients and colleagues in a professional and direct way. The ability to hold others accountable for their behavior is imperative to eliminating disparities and a core principle of antiracism. In addition, as clinical leaders, NPs are in a prime position to engage with policymakers at the local, state, and national levels to stimulate systemic change.
Organizational level recommendations
Addressing disparities with an organizational or top-down approach has the potential to improve effectiveness of strategic plans and activities focused on providing equitable care. Organizational level actions lead to opportunities in population health to improve health outcomes of the most vulnerable populations.
Bias and structural competency work. Institution-wide implicit and explicit bias training as well as antiracism training are critical for all employees. Training efforts may be futile if contextual influences of bias, such as structural racism, are not addressed. Sukhera and colleagues conducted an organizational implicit bias recognition and management training and found that despite training, participants may resist behavior change based on an organization's sociocultural norms.19,20 Therefore, organizations must ensure that in addition to antiracist/bias trainings, organizational culture is an institutional priority with inclusive and visible messaging to facilitate employee buy-in.19,20 Sukhera and colleagues evaluated an intervention using an instrumental case study in a healthcare setting that allowed the physician and nurse participants to role-play scenarios based on mental health bias.20 This method showed promise in increasing participants' individual agency to exhibit positive behavior and role model for others, which may contribute to a more equitable workplace.
Additionally, interdisciplinary training may not be common outside of the workplace and may offer an opportunity to improve workplace culture as well. Marcelin and colleagues suggest that organizations conduct regular organizational culture surveys to ensure trainings on bias/structural competency lead to long-term positive change.21 There is little research on organization-wide interventions to address racial bias beyond knowledge-based training; therefore, future research should address best practices for implementing interventions resulting in sustained change.
Institutional policy development. Organizations have a responsibility to their staff, patients, and the community to ensure that standards of care that value health equity are interwoven into the institutions' goals and priorities.22 Clear statements of the organization's commitment to this are important, but it is also critical to develop antiracist policies that do not tolerate explicitly biased behavior, overt racism or explicitly biased or microaggressive behavior. Because the patient-provider relationship is an important determination of patient satisfaction, the IOM recommends that organizations strengthen guidelines for reasonable patient loads and time allowances for visits that enhance patient satisfaction.2 The IOM goes on to recommend financial incentives that reward practices that foster trust and promote patient-provider communication.2 Policies or procedures that incorporate patient satisfaction in annual evaluations may offer some promise. In addition, organizations may disaggregate data on clinical outcome metrics and patient feedback surveys by relevant demographic data (for example, race and ethnicity as a proxy for racism, economic status, and/or migratory status) to identify potential problem areas for further action.
Diversify workforce. Studies show health outcomes of patients from minoritized groups improve when there is diversity within the healthcare workforce.2,23,24 Patient comfort, trust, cultural understanding, and engagement all benefit when a practitioner's and patient's race and preferred language align. Therefore, intentional efforts to increase the critical mass of NPs from underrepresented groups are necessary.2 However, simply adding underrepresented groups to the workforce is not enough. Making the environment inclusive is a task that must be done with intentionality and reverence to ensure the ability to retain members of underrepresented groups in the organization. Some strategies include creating an organizational practice of assigning mentors for NPs from underrepresented groups, ensuring diversity on organizational committees, and an organizational commitment to equitable promotion practices.20 More research is needed in this area.
Patient education and empowerment. Patient engagement may improve health outcomes and patient care, and reduce healthcare costs.25 However, Black patients demonstrate lower patient engagement levels when compared with White patients.25 “Culturally appropriate patient education programs offer promise as an effective means of improving patient participation in clinical decision making and care-seeking skills, knowledge, and self-advocacy.”2 Dedicating time and space to educational programs aimed at empowering patients to advocate for their healthcare needs and an antiracist, bias-free environment are both critical to patient-centered care and may reduce health disparities. While interventions aimed at increasing patient empowerment have mostly been based on specific chronic health conditions, there are implications for healthcare organizations. The use of technology, such as augmented or virtual reality platforms, can offer patients constant access to their health records and a virtual concierge or health coach.26
The racial and ethnic disparities in COVID-19 morbidity and mortality stimulate broader discussions about how NPs can take and sustain action to address health equity in their practice. For many years, nurses have been the most trusted of healthcare professionals as well as serving in the greatest numbers on healthcare teams. Nurses are represented in every healthcare arena, from acute care, community and occupational, to population health. Nursing has much to contribute to health policy and research—both of which are essential to confronting the underlying causes of health inequity. Health inequity can and should also be addressed in the day-to-day practice of nursing, extending beyond the pandemic. This begins by addressing the root causes of health inequity and continues with building capacity in NPs to address individual bias, aggressively mitigate biases, and use their leadership to advocate for bias training and antiracist policies, thereby using their untapped potential to improve health equity in their clinical roles.
1. Waite R, Sawyer L, Waite D. A call to action for community/public health nurses: treat structural racism as the critical social determinant of health it is. Public Health Nurs
2. Smedley BD, Stith AY, Nelson AR, eds. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care
. Vol. 94. Washington, DC: National Academies Press; 2003.
3. Burke SE, Dovidio JF, Perry SP, et al. Informal training experiences and explicit bias against African Americans among medical students. Soc Psychol Q
4. Schultz PL, Baker J. Teaching strategies to increase nursing student acceptance and management of unconscious bias. J Nurs Educ
5. Centers for Disease Control and Prevention. COVID-19 in racial and ethnic minority groups. 2020. www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/racial-ethnic-minorities.html
7. Tobin-Tyler E. In allocating scarce health care resources during COVID-19, don't forget health justice. Health Aff Blog
. 2020. doi:10.1377/hblog20200422.50144.
8. Project Implicit 2011. Harvard University. 2011. https://implicit.harvard.edu/implicit/takeatest.html
9. Devine PG, Forscher PS, Austin AJ, Cox WTL. Long-term reduction in implicit race bias: a prejudice habit-breaking intervention. J Exp Soc Psychol
10. Teal CR, Gill AC, Green AR, Crandall S. Helping medical learners recognise and manage unconscious bias toward certain patient groups. Med Educ
11. Forscher PS, Lai CK, Axt JR, et al. A meta-analysis of procedures to change implicit measures. J Pers Soc Psychol
12. Ansari D. Teaching the social determinants of health during the COVID-19 pandemic. 2020. http://somatosphere.net/2020/teaching-social-determinants-health-covid19.html/
13. Woolsey C, Narruhn R. Structural competency: a pilot study. Public Health Nurs
14. FitzGerald C, Martin A, Berner D, Hurst S. Interventions designed to reduce implicit prejudices and implicit stereotypes in real world contexts: a systematic review. BMC Psychol
15. Bristow NK. “It's as bad as anything can be”: patients, identity, and the influenza pandemic. Public Health Rep
. 2010;125(suppl 3):134–144.
16. Goddu AP, O'Conor KJ, Lanzkron S, et al. Do words matter? Stigmatizing language and the transmission of bias in the medical record. J Gen Intern Med
17. Johnson R, Richard-Eaglin A. Combining SOAP notes with guided reflection to address implicit bias in health care. J Nurs Educ
18. Wilson-Mitchell K, Handa M. Infusing diversity and equity into clinical teaching: training the trainers. J Midwifery Womens Health
19. Sukhera J, Watling CJ, Gonzalez CM. Implicit bias in health professions: from recognition to transformation. Acad Med
20. Sukhera J, Milne A, Teunissen PW, Lingard L, Watling C. Adaptive reinventing: implicit bias and the co-construction of social change. Adv Health Sci Educ Theory Pract
21. Marcelin JR, Siraj DS, Victor R, Kotadia S, Maldonado YA. The impact of unconscious bias in healthcare: how to recognize and mitigate it. J Infect Dis
. 2019;220(suppl 2):S62–S73.
22. Rimnac CM. Minimizing workplace bias—what surgeons, scientists, and their organizations can do. Clin Orthop Relat Res
23. Poghosyan L, Carthon JMB. The untapped potential of the Nurse Practitioner workforce in reducing health disparities. Policy Polit Nurs Pract
24. Gomez LE, Bernet P. Diversity improves performance and outcomes. J Natl Med Assoc
25. Chen J, Mullins CD, Novak P, Thomas SB. Personalized strategies to activate and empower patients in health care and reduce health disparities. Health Educ Behav