Journey to Equity: Strengthening the Profession of Nursing

Copyright © 2022 ANA. All rights reserved. No part of this book may be reproduced or used in any form or any means, electronic or mechanical, including photocopying and recording, or by any information storage and retrieval system, without permission in writing from the publisher.

About the American Nurses Association

The American Nurses Association (ANA) is the only full-service professional organization representing the interests of the nation’s 4.3 million registered nurses through its constituent/state nurses associations and its organizational affiliates. The ANA advances the nursing profession by fostering high standards of nursing practice, promoting the rights of nurses in the workplace, projecting a positive and realistic view of nursing, and by lobbying the Congress and regulatory agencies on health care issues affecting nurses and the public.

American Nurses Association

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Cataloging in Publication data available from the Library of Congress

ISBNs

Print 978-1-947800-85-4

ePDF 978-1-947800-86-1

ePUB 978-1-947800-87-8

Mobi 978-1-947800-88-5

SAN: 851-3481

Dedication

This book is dedicated to all future nurses who will truly represent the communities they serve. Our thanks to everyone who collaborated to share their own journeys with us and our readers. The nursing profession can and must lead the way to equity, and we challenge our colleagues to use this book as a template to create a future where equity in health care is truly attainable.

—Carol Susan Sue Johnson,

PhD, RN, NE-BC, NPD-BC, FAAN

—Pamela S. Dickerson,

PhD, RN, NPDA-BC®, FAAN

Contents

Foreword by Launette Woolforde

Introduction

1. Beginning the Journey

Carol Susan Sue Johnson, PhD, RN, NE-BC, NPD-BC, FAAN

2. Overcoming Adversity: A Journey to Becoming a Nurse Leader and Entrepreneur

Larissa Africa, MBA, BSN, RN, FAAN

3. Unbeatable Determination

Frank Baez, BS, RN

4. I Can, I Will, I Must

Judith Cullinane, PhD, MSN, RN, CAGS, CCRN-K

5. A Space for Everyone: Visibility in Nursing Through Service, Mentorship, and Leadership

Sasha DuBois, MSN, RN

6. If You Can Count Them, There Aren’t Enough

Greg Durkin MEd, RN, NPDA-BC®

7. Transforming Nursing From the Old Guard to the Future

Ernest Grant, PhD, RN, FAAN

8. My Journey From Immigrant to Nurse Leader

Sun Jones, DNP, RN, FNP-BC

9. Nursing Across Three Countries and Two Continents

Aniko Kukla, DNP, RN, CPNP

10. Learn to Become the Learner

John Lowe, PhD, RN, FAAN

11. Breaking Barriers With Inclusiveness

Elizabeth McClure, DNP, MS, RN, NPD-BC

12. From the Pearl of the Oriental Seas to Global Nursing Leadership

Cora Canlas-Munoz, PhD, RN

13. Equity in Nursing: Through the Eyes of an Immigrant

Karen Ofafa, MPH, BSN, RN, CSSBB, CPHQ

14. Ka Waiwai Aloha o Ko‘u Makuahine

Mary Frances Mailelauli‘i Oneha, PhD, RN, APRN, FAAN

15. Finding and Living My Passion

Shannon Whittington, MSN, RN, CCM

16. Continuing the Journey

Pamela S. Dickerson, PhD, RN, NPDA-BC®, FAAN

References

Foreword

Diversity, Equity, and Inclusion: How Far Have We Really Come?

Launette Woolforde,

EdD, DNP, RN, NEA-BC, NPD-BC, FAAN

Chief Nursing Officer, Northwell Health

Diversity, equity, and inclusion. These terms have increased exponentially in popularity. However, the question remains about how much progress we have truly made in each of these areas. Certainly, as a nation, we are a more diverse population. Equity and inclusion, however . . . well, that journey continues. I find it interesting that diverse has now taken on a new definition as a way to identify a person. All too often, when inquiring about whether an individual is a person of color, for example, the substitute question asked is, Are they diverse? I am left to wonder when a diverse person became a pseudonym for a non-White person. I always thought that being diverse or coming from a diverse background meant you had several different elements such as racial, cultural, or other representations in your background. I question this new definition of diverse, and whether labeling someone who likely already experiences other labels, as diverse, isn’t more alienating than anything else. It reminds me of the stores I would visit to purchase personal items. It was always odd to come upon the aisle labeled ethnic products. Of course, that was the aisle for (usually skin and hair) care products for non-White people who had now been termed ethnic. Ultimately, the message it sends is that the items for White people are normalized, need no label, and just go in a regular skin and hair care products aisle, and then there’s the aisle for the other people. Similarly, there’s the concept of nude. I always think of this in relation to pantyhose or shoe shopping. There’s not just the difficulty of finding inclusivity in tones, but there’s the hijacking of the definition of nude. I’ve always known nude to be representative of naked or transparent so that nude pantyhose would make my legs appear nude, or without covering. Yet whenever I purchase nude pantyhose, or nude shoes for that matter, I have to ask myself, Nude according to whom? This is not nude; it’s clearly light beige. It’s anything but nude. The term diverse has become redefined to normalize Whiteness and serves as one of the many reminders in society of hierarchy, power, and inequity that are glaring to those subjected to it daily. Those who are not subjected to those inequities are often oblivious and may even deny its truth or find derogatory names to call those who speak about it.

I am, among other things, a Black woman. In many cases, representation by someone like me helps to create diversity in groups that have been plagued by homogeneity. I think about how often, by virtue of being the only one, the one who brings diversity to the group, I become the representative of my entire race, bearing much more responsibility than anyone else in the group. Nonetheless, this does not make me diverse. I do wonder what it is like to live free of these and so many other daily burdens and just be you. Someone who comes with only favorable preconceived notions, inherent inclusion, and for whom matters like these are mere abject conversation.

To be diverse means to be inclusive or representative of many elements. Diverse is not a person, nor should it become another label for those outside of the mainstream or marginalized groups to bear. Everyone has a hand in diversity. There are those who equate diversity strategies with unfairness, almost like a robbery of opportunity for some. Aiming for diversity does not mean exclusion of; it means more than just. A diverse setting is one where people from a mainstream group are represented along with people from nonmainstream groups. A single person in that group is not the diverse one; it is the presence of varying representations that makes the group diverse.

Health care can represent one of the most inequitable experiences one can have. In March of 1966 at a meeting of the Medical Committee for Human Rights in Chicago, in reference to the disparate medical care received by Black people, Dr. Martin Luther King Jr. stated,

We are concerned about the constant use of federal funds to support this most notorious expression of segregation. Of all the forms of inequality, injustice in health is the most shocking and the most inhuman because it often results in physical death. (Mt. Vernon Register News, 1966, p. 5)

Healthcare inequities persist today. Communities comprised primarily of people of color are consistently and disproportionately exposed to pollution, environmental hazards, and discriminatory practices that put them at greater risk for almost all illnesses. The age-old pandemic of racism underscores inequities, and its manifestations are heightened in times of crises.

Nurses have a unique opportunity to advocate for equity in care delivery. Nurses collaborate with other members of the care delivery team and contribute to the development and execution of the plan of care. Incorporating equity awareness should be an integral part of our role and practice.

Attention to diversity and inclusiveness exposes the need to examine ourselves and the inclusiveness, or lack thereof, of our settings and of our practice (Woolforde, 2018). Everyone plays a role in the journey to equity, either by actively taking steps toward improvement, by promulgating environments and processes that perpetuate inequity, or through standing by, another mechanism that promulgates inequity but allows the bystander to find ways to absolve themselves of accountability.

So, what are three steps every person can take to help build a healthcare system and an environment that fosters diversity, inclusion, and equity?

Understand Your Community

While there are constants in health care that haven’t changed in centuries, such as handwashing as the most effective method to prevent the spread of infection, we have to go beyond the routine and aim to understand the composition and needs of the communities we serve. We must then adjust education and care planning to meet the needs of the community. We should point out and address the disparities and place emphasis on adjusting planning and resources according to these realities in order to achieve optimal wellness. Inequities might be related to language, lack of cultural awareness among staff, lack of cultural awareness integration into the plan of care, and more. Having a diverse workforce that is reflective of the community helps to mitigate these divides. These changes can translate into significant improvements in health outcomes and great satisfaction among those providing care—not just those receiving it.

Educate Yourself

Nurses spend a lot of time educating others. Equally important, however, is educating oneself, not just on the latest in clinical care but on one’s own biases or lack of knowledge about the community one serves and how to modify plans and care to address needs. Nurses have the power to design and deliver initiatives that incorporate equity considerations and demonstrate for others across professions how this is done.

Build an Army of Advocates

Nurses interact with a wide variety of care providers at all levels of practice. Role-modeling advocacy practices is an important part of our responsibility. Take a stance on unequal treatment and build an army of people who have learned from you that they, too, must do the same. Trade fear for fearlessness. Advocating for equity is not a spectator sport. Nurses cannot and should not stand on the sidelines while inequity grows deeper roots. We can be champions of the equity message.

There is no healthcare issue that can truly be considered someone else’s problem. What affects one affects us all. The effects may not be immediate or obvious to all, but in time inequity will cause harm to more than just the groups on the margins. There are many ways for nurses to advocate for equity, and the first step is to recognize it as a critical part of our role and responsibility.

Introduction

The American Nurses Association (ANA), the American Association of Colleges of Nursing (AACN), the National Academy of Medicine (NAM), the Association for Nursing Professional Development (ANPD), and numerous other organizations have recently highlighted the significant need for diversity, equity, and inclusion in nursing education and practice. While data show increasing diversity within the U.S. population, the nursing profession continues to lag in recruitment and retention of nurses representing the residents of the communities they serve. The above organizations have created executive-level goals and priorities for achieving a more balanced nursing workforce, though there are currently no grassroots initiatives to provide strategies for realistic, attainable, and meaningful change.

Journey to Equity evolved from a conversation in March 2021 between the coeditors who initially planned to develop and publish a white paper on the topic. Over the next several weeks, they discovered that health equity required more than a single paper, and the result was the creation of this book. As the coeditors could not represent the diverse populations impacted by inequities in our population and profession, they sought the input of nurse leaders who represent these communities.

As communities diversify, the nursing profession must rise to the challenge of truly representing the communities they serve. In this book, a historic perspective evolves into a nursing process approach that incorporates the personal stories of nurses with diverse racial, gender, and ethnic backgrounds who share their journeys and their recommendations for the future. This is a template for K–12 schools, community and healthcare organizations, academic and continuing nursing education advocates, and professional associations and organizations to facilitate the growth and success of underrepresented groups in the nursing profession.

Journey to Equity will help readers develop an action plan that meets ANA, AACN, NAM, ANPD, and other initiatives for diversity, inclusion, and equity as nurses lead change and improvement in health care now and into the future.

1. Beginning the Journey

Carol Susan Sue Johnson, PhD, RN, NE-BC, NPD-BC, FAAN

Why should we be concerned about equity in nursing and health care? What is the impact of equity on social determinants of health and health outcomes? These questions are essential to understanding the context of the Future of Nursing 2020–2030: Charting a Path to Achieve Health Equity (National Academies of Science, Engineering, and Medicine [NASEM], 2021) . This momentous report can change the U.S. healthcare system by leveraging nurses’ contributions to achieve health equity. If the nation is to thrive, everyone must live the healthiest possible life, and helping people achieve this goal is an essential role of nurses in all settings.

However, a diverse nursing workforce must be developed to meet the challenges of inequities in health and health care access in immigrant, rural, and marginalized populations within communities. The stories included here chart the personal and professional journeys of nurse leaders who are representative of racial, ethnic, immigrant, and gender identity groups. Their challenges and successes provide a blueprint for others to seek nursing careers and guide marginalized populations to health equity.

The majority of registered nurses in the United States are White women, despite attempts in recent years to diversify the profession. As the country itself becomes more diverse, nurses must reflect the people and communities they serve to ensure that individuals receive culturally competent care. Equitable health care services must become a reality as we begin the journey to equity. With this in mind, the ANA Enterprise 2020–2023 Strategic Plan established the vision of a healthy world through the power of nursing by evolving the practice of nursing to transform health and health care (American Nurses Association [ANA], 2020). To achieve this goal, ANA is committed to addressing racism in nursing in collaboration with multiple nursing organizations in the National Commission to Address Racism in Nursing, while promoting diversity, equity, and inclusion (ANA, 2021b). Our patients/clients and our profession deserve nothing less.

The Context of the Nursing Profession

How does nursing compare to the population of the United States?

Two pieces of data are essential to address this question. Every 2 years, the National Council of State Boards of Nursing (NCSBN) and the National Forum of State Nursing Workforce Centers conduct the only national-level survey about the entire U.S. nursing workforce. Data from 2020 provide valuable information about the diversity of the nursing workforce (Smiley et al., 2021).

Table 1-1. Gender Distribution of Registered Nurses 2020

Male nurses have increased 0.3 percentage points from 2017, and 2020 was the first time the category of other could be selected, resulting in selection by 0.1% of nurses. Male nurses also account for 13.6% of all multiracial nurses and 34.3% of nurses identifying as Native Hawaiian or other Pacific Islanders.

Table 1-2. Race of Registered Nurses 2020

Nurses who reported being Asian represented the largest non-White/Caucasian racial group in the workforce, although there was a slight decrease (0.3 percentage points) from 2017. The proportion of Black/African American registered nurses increased 0.5 percentage points from 2017. Middle Eastern/North African was a new category in 2020. Nurses reporting being Hispanic/Latinx increased 0.3 percentage points from 2017.

Table 1-3. Hispanic or Latinx Ethnicity of Registered Nurses 2020

It is critical to examine statistics on the nursing workforce in relation to that of the U.S. population, as reflected in the 2020 United States Census Data. Although a final report is not yet available, there is sufficient data to determine changes in racial and ethnic composition of the United States in 2020 (U.S. Census Bureau, 2021a).

Table 1-4. Racial and Ethnic U.S. Census Data 2020

Although the White/Caucasian population remained the largest race or ethnicity group in the 2020 census, this population declined by 8.6% since 2010. The Hispanic/Latino population grew 23% in the same time period. The Black or African American population grew 5.6%, and the American Indian and Alaska Native population grew 27.1%. The Asian population grew 35.5% in the years between 2010 and 2020.

Sexual orientation and gender identity were unavailable in the 2020 census data but are currently tracked in the U.S. Census Bureau’s Household Pulse Survey. This process began in July 2021, and the following data is from July 27, 2021, to September 13, 2021, for population members aged 18 years and over (U.S. Census Bureau, 2021b).

Table 1-5. U.S. Gender Identity and Sexual Orientation According to the Household Pulse Survey 2021

Gender Identity

Sexual Orientation—Which best represents how you think of yourself?

Since the racial/ethnic/gender makeup of each community is different, for this data to be useful in building an equitable nursing workforce, it must be examined on a local basis by communities throughout the United States. If the nursing profession is to truly reflect community racial/ethnic/gender composition, emphasis on education for upward mobility must begin during middle and high school years for students in these groups. Visibility of nurses in these settings and at after-school programs for these students (including males) will enhance role modeling and students’ awareness about nursing practice and opportunities.

The History of Equity in Nursing Education and Practice

Florence Nightingale is credited as the founder of modern nursing, but nursing has existed since ancient civilizations throughout the world. Religious orders cared for the sick in the Middle Ages, and the Crusaders established and staffed hospitals during the Crusades to control religious sites in the Middle East. The Reformation in England in the 16th century initiated the Dark Period of Nursing between 1550 and 1850, when women from the dregs of society, including convicts, were assigned as nurses with no training or experience. Nursing became a women’s occupation, and as medicine advanced, nursing remained mired in squalor in hospitals and asylums. The only bright spot was the work of religious orders, like the Sisters of Charity who took charge of hospitals, asylums, and charity work in France. Unfortunately, England’s nurses were illiterate, untrained, inconsiderate, and frequently alcoholic. They routinely labored long hours for little pay and supplemented their meager income by taking bribes or stealing from their patients (Donahue, 2011).

Nursing was not an occupation for gentlewomen in the 1850s until Florence Nightingale (1820–1910) determined that nursing was her calling and changed nursing education and practice from then until today (Cook, 1913a, 1913b).

Nursing Education

Although she was well educated for her time, Florence Nightingale’s formal nursing education consisted of 2 weeks of observation in 1850 at Kaiserswerth Institute in Germany and one month of rudimentary training there in 1851. In February of 1853, she went to Paris, where she observed hospitals and nurses, but family matters required her to return home without enrolling in an apprenticeship program (Cook, 1913a). Her subsequent service in the Crimean War resulted in the establishment of the Nightingale Fund by the British people to recognize the contribution of Nightingale and her nurses. In 1861, this fund supported the first nurses’ training program—the Nightingale Training School at St. Thomas’s Hospital in London (Dossey et al., 2005). The Nightingale School served as a template for other nurse training programs both in England and the United States.

There were no nursing schools in the United States until the New England Hospital for Women and Children in Boston started one in 1872. The first applicant, Linda Richards, graduated a year later as the first trained American nurse. Her education consisted of lectures by physicians on medicine, surgery, and obstetrics. Clinical work from 0530 to 2100 required the five students to care for six patients each. Students learned from female interns how to take vital signs and provide physical care. There were no textbooks and no entrance or final exams. Richards wasn’t satisfied with her own knowledge and skills. She eventually became superintendent of the nurse training school at Massachusetts General Hospital and convinced the trustees that she should spend time in England gaining experience at their training schools. In May 1877, Linda Richards met Florence Nightingale and was able to spend time at St. Thomas’s Hospital, King’s College Hospital, the Royal Infirmary, and hospitals in Paris with Nightingale’s blessing. Richards held numerous leadership positions in her career due to the knowledge she acquired beyond her basic nursing education (Richards, 1911).

Richards’s experience in nursing education mirrored many of her contemporaries. During the rest of the 19th and 20th centuries, nursing education gradually progressed from total subservience and servitude to classwork, textbooks, and examinations for proficiency. Nurse leaders in education such as Isabel Hampton Robb, Adelaide Nutting, Annie Goodrich, Elizabeth Carnegie, and Virginia Henderson advanced nursing education toward professional status (Johnson, 2016). Over time, many diploma schools gave way to associate degree and baccalaureate nursing programs, and nurses pursued master’s and doctoral education to elevate the profession.

Diversity in Early Days of Nursing in the U.S.

Nightingale focused her school on White women, and most American training schools did the same. The first African American trained nurse was Mary Eliza Mahoney, who enrolled in 1878 in the training program at the New England Hospital for Women and Children. Her experience was similar to that of Linda Richards, working 16-hour days on wards with responsibility for six patients. During the 16-month course, the majority of students dropped out and Mahoney was one of only four graduates from a class of 42 (Johnson, 2016). Her career will be profiled under the nursing practice section.

Elizabeth Carnegie attended the Lincoln School for Nurses in New York City after graduating