On June 18 nurse practitioner and nursing educator Kenya Beard and CHMP senior fellow Jim Stubenrauch and I will be leading Narratives of Diversity: Encouraging Cultural Responsiveness, a daylong event in which we’ll use exercises in reflective narrative to explore issues of diversity and marginalization in health care and health professions education. Our goal will be to foster awareness and generate ideas for making academic and clinical settings more inclusive (the event will be held at the CUNY Graduate Center in New York).
Kenya and I talked earlier this week about her work in promoting multicultural education as a way of increasing diversity in the health professions. Kenya has been a nurse for 28 years, in the emergency room, in a medical-surgical unit, and in home care. She got her doctorate in 2009 and for several years has been on the faculty at the Hunter–Bellevue School of Nursing, where she’s also the founding director of the Center for Multicultural Education & Health Disparities, which “seeks to promote educational reform and restructure institutions in an attempt to strengthen multicultural awareness and workforce diversity.” She is a faculty scholar at the Josiah Macy Foundation, and in 2013 the National Black Nurses Association named her nurse educator of the year. She recently received the Witten Award for Educational Excellence at Hunter College. The following is a lightly edited transcript of our conversation.—Joy Jacobson, CHMP senior fellow, @joyjaco
You’ve worked as a nurse practitioner in home care for a long time. How does your work with patients open your eyes to health care disparities?
When I became a home care nurse I had some patients who were African American grandmothers. I would say, “Miss T, you want your blood pressure under control!” I wanted them to live; I didn’t want them to be a statistic. I would go to the cabinet and say, “This soup is very high in sodium. The sodium is killing you. You have to get rid of this soup.” The next week I’d go back and see the same soup. I never said, “Tell me what’s important to you.” I had to realize I lost some of my identity. It was more like, “Now I have the credential, and let me tell you what you need to do to get better. Let me help you.” We tend to do that.
Isn’t that how a nurse helps a patient?
When I went to school the focus was on educating your patients to help them make autonomous decisions. But when you dissect it—how are we helping them make those decisions? Were we taught from an ethnocentric lens? Joseph Betancourt is a physician at the Disparities Solutions Center at Massachusetts General Hospital, and he says the first thing we need to ask patients is what the disease means to them and what they call it in their culture. We need to take the time. And we don’t have enough time. We have to take the time to listen to patients. If we don’t take the time, the outcomes are going to be what we have had for the last 60 or 70 years, which is health care disparities. A report came out a few years ago that said we spent over a trillion dollars in three years related to health care disparities.
It’s about the nurse being comfortable supporting the patient’s cultural beliefs and decisions even when they conflict with ours. That can be a hard pill to swallow. We’re in it to save lives. We’re not taught to say, “If the person is okay with this we should support that.” Instead we sometimes imply, “Your cultural beliefs are wrong. You need to listen to me!”
You talk about multicultural education. How is that different from the traditional health professions education?
Everyone comes in for an in-service on cultural competence and they check it off like fire safety. But multicultural education is a reform model that looks at the whole institution. James Banks says it has five dimensions, the first of which is content integration. Where are we getting this content from? For example, many curriculums add on separate books for LGBT concerns and the elderly. But it can’t just be an add-on. We have to see how different populations view illness and disease.
I have classrooms that are so diverse. One student of mine who was Hispanic explained to the class that there was no way in the world her grandmother would change her diet. There was a certain staple in the grandmother’s diet that was contributing to her high blood sugar. She was okay dying at 70 because her quality of life was so great. We did a role-play where an NP said, “We’ve got to get the hemoglobin A1c below 7; she has a 7.6.” The institution isn’t getting full reimbursement unless they have those kinds of outcomes. You can’t operate unless you have full reimbursement. So the philosophy is “Treat to target! Get her under 7!” They began the role-play and my students reminded me that we have no idea what to do when a patient doesn’t listen to us. But by listening to the patient they realized—oh, she does care! It blows their mind. They come away saying, “How do I help get her blood sugar under control without disrespecting her beliefs and values?” It has to start with a healthy relationship.
Many people might assume that health care providers know how to have relationships with patients.
We have a lot of assumptions that are contributing to health care disparities. The system is set up so that nurses assume that when patients are discharged with prescriptions that they will get them filled. If someone doesn’t take his prescription and ends up coming back he’s what some ER nurses call a frequent flier. Sometimes nurses never ask patients. We’re trying to change the system because of health care disparities. Diversity, cultural competence, and health literacy—those three things are crucial to improving the health of the nation.
What about access? What’s happened as a result of improved access to health care for minorities?
Healthy People 2010 and Healthy People 2020 were all about access and quality care. And the ACA is broadening access for minorities. But if I have chest pain at the age of 48 and someone with blonde hair does too, she’s likely to have better outcomes. Why is that? We have to have conversations people aren’t prepared to have, about race, power, and privilege.
You can’t superimpose new initiatives onto old systems and just say “Do it.” Just like we couldn’t impose desegregation on educational systems without some negative ramifications. I am a product of that. They could bus you in but the teachers didn’t have to like you. I was told, “Just be glad you have an opportunity to have the books that the others have.” We had access but at what cost? I remember my first-grade teacher. One day she told us not to erase anything. I went to erase and she said, “Hey, I said no erasing!” And she bit my pencil eraser off with her teeth. My parents said she probably thought I was cheating. They always told me I had to look down at my paper: “Some teachers will think in order for you to get the A you must have cheated.”
I went to a public school where students were bussed in and where some teachers didn’t want to teach us. Are we doing the same thing with health care 50 years later? We talk about diversity, but if we impose it on a system that’s not ready for it, we’ll have tremendous chaos. A provider might get labeled for having bad outcomes from CMS [the Center for Medicare and Medicaid Services]. That person might look at the patient and think, “My outcomes are bad because of you.” I have seen it happen in education. I was at a meeting where someone said their nursing-exam pass rate was low because “we let them in.” My back got all sweaty. I wanted to say, “Hello, I’m in the room, I heard you!” I now welcome those moments. We can’t change anything unless we bring out what people really believe.
How can we encourage people to start examining their beliefs? I imagine not everyone welcomes that opportunity.
Banks talks about prejudice reduction. We all come with biases and we’ve got to expose them. If I’m raised in a household where my parents are saying, “Some of your teachers won’t want to teach you. They might think your scores will make them look bad,” now my lens is jaded. I think: were my parents right? Your beliefs and experiences are going to determine what you see as your reality.
We are all going to have different experiences. There’s no right or wrong; our differences shouldn’t tear us apart. Respect and empathy mean you don’t have to like it, just understand how a person could think that way. We need to build an environment to allow faculty to look in the mirror and ask: what’s working? What’s the hidden curriculum? You have your teaching philosophy. But are you asking your students what they need to succeed? If you do they might say, “I can never find him during office hours” or “When I asked her to explain she said I need to look it up, that I should know it.” What are your biases and assumptions?
Have you worked with doctors as well as nurses around these issues of diversity?
When I did a workshop on cultural competency recently none of the physicians came. When I asked one of my colleagues why, she said that physicians had to put cultural competency in the curriculum years ago. Some think it’s old hat, but health care disparities are still happening. We need to have a discourse on cultural competency in the clinical setting and we need to do it as educators.
People need to talk about diversity initiatives. I’m not there to be the citadel of knowledge. People need a platform to engage in a discourse that allows them to talk and vent. They are in institutions where they sometimes feel marginalized, and they want to be part of a movement that empowers everyone.
How do you help people handle the discomfort that can come up when we start to talk about diversity?
Bob Kegan has written about the orders of consciousness. As children it’s all me me me. But in the fifth order of consciousness it’s not all about you. You’ve shifted to asking what’s best for you and for other people. Most adults never reach the fifth order. But this order is along the lines of Gandhi and Martin Luther King, people who see beyond themselves and see their role in society as making a positive difference. That’s about 5% of the population. The first step is raising awareness.
Kegan plays this movie clip where one man kills another in a religious war and feels tremendous guilt that the son is now an orphan. Gandhi tells the man that he should raise this young boy. But he has to raise him in the religion of his father. That’s what being at that higher order of consciousness is about. Being able to see our interdependence on others and realizing that by helping others we help ourselves. But how do institutions foster patient-provider relationships that recognize our interconnectedness?