Health equity

Objectives17

Analyze the dimensions of diversity in self, patients and staff

Implement strategies related to cultural humility to ensure patient safety and high-
quality outcomes of care for diverse populations and bridge the disparity gap to strive
towards health equity

Identify nursing actions to promote health equity

Discuss health disparities and their impact on patient outcomes

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Cultural humility vs. cultural competency12,17
There has been a purposeful shift from cultural competence to cultural humility in
nursing

Cultural humility Cultural competency

a set of congruent behaviors,

lifelong approach to learning
attitudes and policies that come
about diversity, individual bias
together in a system or agency
and systemic power in health
or among professionals,
care interactions.
enabling effective work in
cross-cultural situations.

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Health equity6,9,12,17
While there are many definitions of health equity, there are 3 definitions commonly used:

CDC Health People 2030 WHO

• When every person has the • The attainment of the highest • The absence of avoidable,
opportunity to attain their “full level of health for all people unfair or remediable difference
health potential” • Valuing everyone equally with among groups of people
• No one is at a disadvantage focused and ongoing societal
efforts
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8-second definition5

“Health equity means everyone has a fair

and just opportunity to be as healthy as
possible.”

- (Braveman, Arkin, Orleans, Proctor , Plough, 2017)

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History8
The Tuskegee experiment
• Syphilis study
• 1932 to 1972
• 600 black men were recruited by the
promise of free medical care
• Told they were being treated for “bad
blood” but only received placebos even Picture from www.cdc.gov/tuskegee
when the cure was discovered in 1947

In 1997, the U.S. government issued a formal apology

“….hundreds of men used in research without their knowledge and consent……they had found
hope when they were offered free medical care by the United States Public Health
Service…..they were betrayed…….they were lied to by their government.”

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History11
The Puerto Rico Pill Trials
• First human clinical trials of birth control pills
• 1955
• Targeted poor, uneducated women
• Told they were taking a drug that prevented
pregnancy, but not that this was a clinical trial
• Women in the study complained of nausea,
dizziness, headaches, stomach pain and
vomiting; three women died
Photo from: https://www.pbs.org/wgbh/americanexperience/features/pill-
• Dosage was dramatically lowered and only puerto-rico-pill-trials/

then was the drug FDA approved

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Common terms17

Race or racial group People who share a common ancestry from a particular region

Ethnicity or ethnic group Belonging to a group of people who share a common culture

A system of unjust or prejudicial treatment based on an ethnic or racial

Racism group
Unjust or prejudicial treatment of different categories of people passed
Discrimination on a wide range of characteristics
Health disparity or Avoidable health differences that put an economically or socially
inequities disadvantaged group at a further disadvantage

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Equality vs. equity4,17

Equality Equity
• Definition: Treating each person the same, • Definition: Focuses on the equality of the
offering them the same tools and opportunities outcomes by taking individual needs and skills
regardless of their differences into account
• Example: Every student in a classroom is given • Example: Every student is provided the type of
the same materials (e.g., desk, books) regardless desk and learning materials based on their
of physical and learning differences individual needs
Image Credit: Interaction Institute for Social Change | Artist: Angus Maguire

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Evidence of health equity1

AHRQ’s National Healthcare Quality and Disparities Report

• Congress mandated to provide an overview of the quality of healthcare and
disparities experienced by different racial and socioeconomic groups
• From the 2021 report:
- Blacks, American Indians and Alaska Natives (AI/ANs), and Native
Hawaiians/Pacific Islanders (NHPIs) received worse care than Whites
for approximately 43% of quality measures.

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Social determinants of health9,17

What is it?
• Conditions in the environments that affect a
wide range of health, functioning and quality of
life outcomes and risks

Nurses’ role:
• Engage with patients and families
• Assess and understand social needs
• Improve health equity at the individual and
system levels

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11
Activity: Social determinants of health (SDoH) 9,17
SDoH Categories
Economic stability Employment, food insecurity, housing instability, poverty
Education access Early childhood education and development, enrollment in
and quality higher education, high school graduation, language and
literacy
Social and Civic participation, discrimination, incarceration, social
community context cohesion
Healthcare access Access to health care and primary care, health literacy
and quality
Neighborhood and Access to foods that support health eating patterns, crime
built environment and violence, environmental conditions, quality of housing

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Implicit bias17
Can affect our feelings and
Attitude or stereotype
attitudes

Developed over the course of

Activated involuntarily
our lifetime

Affects people of color,

various ethnicities, ages, Affects our understanding,
Implicit bias
sexualities, gender and actions and decisions about
(unconscious)
body types people, ideas or things

Determined by both direct

and indirect messages Comes from your
background, environment
and personal experiences
Rests in our unconscious

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RN role17
Individually, educating yourself on implicit
Awareness bias and any that you may hold
approach patient care with an attitude of
Education
cultural humility

Collect accurate patient data, including

Data collection
race, ethnicity and language
Sort data from different angles to learn
Stratification of data
more about a population or disparity
Interprofessional cultivate effective partnerships and
partnership promote resources to increase
awareness
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RN role17
Individually, educating yourself on implicit
Awareness bias and any that you may hold

Education approach patient care with an attitude of

cultural humility
Collect accurate patient data, including
Data collection
race, ethnicity and language
Sort data from different angles to learn
Stratification of data
more about a population or disparity
Interprofessional cultivate effective partnerships and
partnership promote resources to increase
awareness
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RN role17
Individually, educating yourself on implicit
Awareness bias and any that you may hold

Education approach patient care with an attitude of

cultural humility
Collect accurate patient data, including
Data collection
race, ethnicity and language
Sort data from different angles to learn
Stratification of data
more about a population or disparity
Interprofessional cultivate effective partnerships and
partnership promote resources to increase
awareness
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RN role17
Individually, educating yourself on implicit
Awareness bias and any that you may hold

Education approach patient care with an attitude of

cultural humility
Collect accurate patient data, including
Data collection
race, ethnicity and language
Sort data from different angles to learn
Stratification of data
more about a population or disparity
Interprofessional cultivate effective partnerships and
partnership promote resources to increase
awareness
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RN role17
Individually, educating yourself on implicit
Awareness bias and any that you may hold

Education approach patient care with an attitude of

cultural humility
Collect accurate patient data, including
Data collection
race, ethnicity and language
Sort data from different angles to learn
Stratification of data
more about a population or disparity

Interprofessional cultivate effective partnerships and

partnership promote resources to increase
awareness
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Nursing ethics
Objectives

Demonstrate ethical awareness

Use the principles stated in the ANA Code of Ethics when making ethical decisions in
practice

Determine self-care strategies and available resources to manage moral distress and
promote moral courage when conflicts arise between nursing care, hospital standards
and the patient's beliefs/wishes

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Principles of ethics

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ANA code of ethics3,5,18

What is it?
• Professional performance standards,
responsibilities and duties a nurse must What are the interpretive statements?
adhere to
• Consists of 9 provisions to guide nursing Statements which help nurses understand
practice how each provision applies to their unique
practice.
Why is it important?
• Guides nurses through complex moral and
ethical scenarios that arise in nursing

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Provisions

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 “Respect the unique cultures,
values, roles/responsibilities and
expertise of other health
professions and the impact these
factors can have on health
outcomes”
-(Interprofessional Education Collaborative, 2016)

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Principles of ethics5,18

Ethics are the moral foundation that

determines how a person will act or
behave.

Principles include:
• Autonomy
• Beneficence
• Non-maleficence
• Justice

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Ethical principles18
All people should have the power to make
Autonomy informed decisions for themselves and
exercise their capacity of self determination

Beneficence Act of doing good and preventing harm of

another without personal benefit

Non-maleficence Commitment to not harm patients

Justice Treating all patients fairly and equally

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Ethical principles18
All people should have the power to make
Autonomy informed decisions for themselves and
exercise their capacity of self determination

Beneficence Act of doing good and preventing harm of

another without personal benefit

Non-maleficence Commitment to not harm patients

Justice Treating all patients fairly and equally

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Ethical principles18
All people should have the power to make
Autonomy informed decisions for themselves and
exercise their capacity of self determination

Beneficence Act of doing good and preventing harm of

another without personal benefit

Non-maleficence Commitment to not harm patients

Justice Treating all patients fairly and equally

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Ethical principles18
All people should have the power to make
Autonomy informed decisions for themselves and
exercise their capacity of self determination

Beneficence Act of doing good and preventing harm of

another without personal benefit

Non-maleficence Commitment to not harm patients

Justice Treating all patients fairly and equally

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Impaired capacity6,15,18

Can the patient understand their situation and

make an informed decision about their care?

At risk populations:
• Intoxicated
• Psychiatric illness
• Patient with dementia
• Minors

Remember: the priority is the patient and their wishes

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Autonomous decision-making18

1 2 3
Can the patient Was any Did the patient's
comprehend the information information
benefits and omitted? remain
consequences confidential?
for their
decisions?
Informed consent Truthfulness Confidentiality

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 Ethical dilemmas in nursing19
26%

Protecting patient rights 64%

Autonomy and informed 32%

consent to treatment
Advanced care planning

Staffing patterns that

negatively impact work
Surrogate deision making
37%
End-of-life decision making

61%
14%
Questionnaires were used in this analysis

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Ambulatory and home care ethical dilemmas12,13

• Scope of practice concerns

• Insufficient RNs available
• Limited time with patient
• Insufficient RNs in leadership roles
• Access concerns

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Ethical decision making

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STOP model9,18
Consider all factors and make the best decision
• Respect the patient’s autonomy
• Remember the patient’s right to make decisions
• Don’t take it personally

S
STANDARDS
T THOROUGH
O
OUTCOMES
P PERSONAL VALUES
Consider nurse practice act, Consider the context of Consider whether your Reminds you to make sure
nursing standards of practice, your decision, including decision is in the best interest your decision is consistent
ethical codes and institutional relevant history, unspoken of the patient and shows with your character and
policies rules, personalities and respect for all concerned personal values
other elements in addition parties and society
to the facts

*Insert your organization’s ethical decision-making model

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Refusal of care18

How should I document refusal of care?

Include the following in your documentation:

• Education attempts about the problem and
proposed treatment or medication
• Patient’s understanding of the risks and
consequences of treatment and refusal of
treatment
• Patient’s reasoning for refusal of treatment
• Patient’s understanding or plans to continue
education

*Discuss your organization’s refusal of care policy

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Moral distress2

Knowing the ethically correct action to

take but you are constrained from taking it

What to do:
• Determine what you are experiencing
• Gauge the severity
• Identify
• Take action

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Effects of moral distress18

Feelings Physical symptoms

• Frustration • Sleeplessness
• Anger • Nausea
• Sadness • Migraines
• Psychological/physical exhaustion • Gastrointestinal upset/digestive
• Helplessness disorders
• Distress • Tearfulness
• Depression • Physical exhaustion
• Guilt • Headache

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Moral courage and moral resilience7,11,16,17,18

Reflection has been shown to help nurses grow their moral courage and resiliency

Moral courage Moral resilience

• Objectively speak up and provide • Capacity of an individual to sustain or
facts that support a different approach restore integrity amid moral
or ethical concern complexity, confusion, distress or
setbacks and preserve or restore
integrity in response to moral
adversity

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Setting boundaries14
Boundary violations can result when there is confusion between the needs of the nurse
and those of the patient.

Nurse’s responsibility Red flag behaviors

• Be cognizant • Discussing personal information with
• Recognize feelings and behaviors patients
• Be aware of the behavior of other • Engaging in inappropriate behaviors (e.g.,
professionals flirting, keeping secrets, speaking poorly
about coworkers) with patients
• Always have the patient’s best interest
in mind • Spending more time with certain patients

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 What are the
consequences of
avoiding ethical
dilemmas in nursing?8

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Customizable references
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