TONL Monthly
September 2020

Equity: Creating a Leadership Culture Beyond Equality

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Vice President & Associate Chief Nursing Officer, University Health System, San Antonio
Director, District 8, Texas Organization for Nursing Leadership
Earlier in my career as a novice leader in healthcare management, one piece of sage advice that my mentors emphasized was for me to treat everyone fairly and equally. As I advanced in my roles, I kept this advice as a core leadership principle. As a backdraft, in 2002, the Institute of Medicine Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care published its seminal work entitled Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare. This publication examined how disparities in treatment occurred in healthcare systems and explored the healthcare experience of persons of color (Smedley et al., 2003). The focus in this era of healthcare was on inequality. More than a decade and half later, the National Academies of Sciences, Engineering, and Medicine (2017) published a new report entitled Communities in Action: Pathways to Health Equity. The focus shifted to health equity.

Health Equity: Completing the Triple Aim Equation

 Misconceptions regarding equality and equity persist. The two terms are not the same and should not be used interchangeably. Over time, the term equality changed its meaning, and its emphasis focused on the similarity of treatment of individuals and groups. Equality refers to the process of treating everyone the same and falls short of taking into account the differences and needs of individuals or the context in which disparities occur (Walden et al., 2018). The concept of equality failed to convey the notion that not all individuals begin at the same starting point and became associated with norms of the dominant male, white, and middle class (Gosepath, 2011).  Equity has become an alternative and linked to social justice. Although there are criticisms that special treatment may occur, equity addresses the social, economic, and political causes of inequality and offers remedies to prevent and avert disparate outcomes (Takeuchi et al., 2018).

 Global Health and Equity. The concept of health equity has received global attention. The World Health Organization (WHO) defines health equity as the absence of unfair and avoidable differences in health interventions and outcomes among groups of people. The key element in this definition is focused on the opportunity for everyone to have the opportunity to attain their full health potential and that no one should be disadvantaged from achieving this potential (WHO, 2020, para. 1).

Focus on Health Equity in the US. The U.S. Department of Health Human Services' 2018-2022 Strategic Plan integrates diversity, inclusion, and equity in five strategic goals particularly about improving access to healthcare, measuring and reporting on healthcare quality and disparities, and strengthening and expanding healthcare workforce to meet America’s diverse needs (Health and Human Services, 2019). The National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP) of the Centers for Disease Control and Prevention (CDC) describes the achievement of health equity as the state by which every person has the opportunity to attain full health potential. The achievement of this potential should not pose any disadvantage to an individual due to social position or other socially determined circumstances (CDC, 2020, para. 1).

 Health Inequities and Healthcare Disparities

Healthcare leaders, regulators, and various healthcare professionals across nations have raised the issue of inequities in health, particularly on the quality of healthcare and justice. The Institute for Healthcare Improvement (IHI, 2020) believes that healthcare inequities and disparities continue to exist. The differences in access to healthcare and treatment and the associated outcomes are systemic but are avoidable. Nurses are at the forefront and positioned to contribute to the achievement of healthcare equity. However, there is a paucity of evidence to demonstrate that healthcare workers, particularly nurses, have propelled the concept of health equity (Estacio, 2019). In the workplace, biases related to stereotypes and gender roles persist despite the progress made towards workplace equality (Walden et al., 2018).

 Addressing Health Equity in Academia. In its eleventh report to the Secretary of the Department of Health and Human Services and the Congress, the National Advisory Council on Nurse Education and Practice (NACNEP) reported the many successes toward the advances in nursing diversity in the U.S.  However, NACNEP cautioned that the U.S. healthcare workforce has not realized the goal of a healthcare workforce that reflects the diverse U.S. population. Several barriers continue to exist including weak minority representations among faculty and in leadership roles in healthcare organizations and underrepresentation of students and applicants to educational institutions for healthcare professions (NACNEP, 2013). The National Education Progression in Nursing (NEPIN) has also examined the linkages between equity and academic achievement. NEPIN aims to ensure that nurses have access to higher levels of education and achievement (Aragon, 2020, para. 1).

Healthcare Organizations and Health Equity. U.S. healthcare organizations that the Joint Commission (TJC) accredits and certifies are required to protect the rights of individuals and prohibit discrimination. TJC (2020) has posted guidelines and resources to assist TJC-accredited healthcare organizations in promoting racial justice and equity. Wyatt et al. (2016) offered a framework that healthcare organizations can follow to achieve healthcare equity. These authors wrote a white paper for the IHI that recommends guidance to reduce healthcare disparities related to racial and ethnic groups, religion, socio-economic status, gender, sexual orientation, age, mental health, and other factors associated with discrimination or exclusion.

Social and Moral Determinants of Health. An understanding of the social determinants of health is critical in addressing health inequities and healthcare disparities effectively. Several screening tools have been developed including a) PREPARE: Protocol for Responding to and Assessing Patient Assets, Risks, and Experiences, b) the Social Needs Screening Tool, c) the Accountable Health Communities Health-Related Social Needs Screening Tool, and d) the Social Needs Screening Toolkit (Lathrop, 2020). Berwick (2020) challenges healthcare leaders to go beyond the social determinants of health and delve deeper into what he calls the moral determinants of health. His thought-provoking insights and questions compel us to think of ways to advocate for better health, beyond what he labels hospitals and physician offices as “repair shops.”

 Call to Action

 The literature offers several ideas to promote a culture of inclusion to influence and inspire nurses to be engaged in professional organizations (Tuazon, 2020). Walden et al. (2018) warned that emerging leaders and seasoned professionals should be aware of the impact of biases in the workplace and recognize how these biases affect the advancement of others and their own. As the Texas Organization for Nursing Leadership continues to advocate for diversity and inclusion, strategies to address equity complete the leadership equation.

Public Policy, Population Health, and Collaboration. To address health equity effectively, nurses must involve themselves and engage in policy development and implementation, promote population health, and forge interpersonal collaboration (Moss & Phillips, 2020). Nurses and nursing organizations must familiarize themselves with the work of the American Association of Retired Persons (AARP) Foundation, the AARP, and the Robert Wood Johnson Foundation (RWJF) on the Future of Nursing: Campaign for Action. The Campaign for Action’s (2020a) mantra explains its main thrust: “America’s 4 million nurses are key to improving health equity and creating communities in which everyone has access to high-quality care.” The American Organization for Nursing Leadership (AONL) is a member of the Campaign for Action’s Champion Nursing Council (Campaign for Action, 2020b).

Academic, Practice, and Research Partnership. NACNEP (2013) identified two primary recommendations to support the mission of eliminating health disparities. These include 1) promote nursing workforce diversity to achieve health equity, and 2) support effective decision-making and evaluation of diversity program outcomes. NEPIN suggests that organizations need to develop new programs strategically to improve diversity, equity, and inclusion and to promote cultural proficiency in teaching, research, service, and practice (Aragon, 2020).

Health Disparities and Health Inequities. The CDC, through the NCCDPHP, has published resources related to health equity and racial and ethnic disparities. These resources include a) REACH – Racial and Ethnic Approaches to Health, b) social determinants of health maps, c) surveillance systems, and d) addressing health disparities among youth (CDC, 2020).

Health Equity as a Strategic Priority. Mate and Wyatt (2017) urge health systems to put health equity as part of their strategic priorities. They offer the following recommendations: a) make health equity a leader-driven priority; b) develop structures and processes to support equity; c) take specific actions to address the social determinants of health; d) confront institutional racism within the organization, and e) partner with community organizations.  Schoonover (2018) explains why health equity matters and offers ways to address health inequities effectively.

 Final Thoughts

 The discussion on equality and equity provokes intellectual debate but also evokes emotional responses. There is evidence in the literature that supports the conceptual and philosophical basis of promoting equity, rather than discussion equality in isolation. I submit that the Health Equity Framework proposed by Cohen et al. (2017) offers a logical and methodical approach. As the Texas Organization for Nursing Leadership (TONL) embarks upon strategies to address diversity, inclusion, and equity, it would behoove its leaders, through the proposed Taskforce on Diversity, Equity, and Inclusion, to utilize this framework. The following questions should inform and guide the proposed strategies: a) are the proposed programs, initiatives, or steps (means/process) following a fair and inclusive process, and b) are the desired targets and results (ends/outcomes) fair? The thoughtful, deliberate, and insightful answers to these questions will lead to solutions and approaches that create a culture of equity among all members, leaders, and stakeholders of the organization. Ultimately, equity in healthcare leads to high levels of organizational performance, promote value to all stakeholders, and sustain organizational excellence (Betancourt, 2020).


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