What being a nurse has taught me about health equity and social justice

“Social determinants of health” was not a subject I had much considered before stepping inbounds of nursing school. 

The privilege oozing from that statement makes it hard to write out loud.

I am decidedly average when compared to the majority of nurses I work alongside. Which is to say, we are 75% white and 90% female, with a median age of 44.6. This, in contrast to the diverse populations we serve, is a problem. We know representation matters, and it can extend into life or death scenarios when woefully absent in healthcare settings. I certainly experienced the ill-effects of this discrepancy while working in the ED of major metropolitan hospitals throughout my bedside career.

For the most part, I witnessed my nursing colleagues treating our patients with kindness and compassion. Cultural competence—a subject breezed over in my very white, middle-upper class nursing school—was practiced with diligence and respect. 

For the most part. 

That is, until a patient would come in displaying…less than desirable behaviors. Patients perceived to be drug-seeking, “welfare state residents,” or who had obvious struggles with mental health were unquestionably treated with a heaping spoonful of bias—and, in many cases—not unconsciously. 

Time and time again, I witnessed certain patients being treated unfairly. Left for a few minutes longer before an initial assessment was started, delays in answering call bells, and providing the lower range of pain medications available were just a handful of the ways my fellow care providers wove their opinions throughout their care. 

Anyone deemed a “frequent flyer” to the ED experienced these types of passive-aggressive care tactics almost every time they came in. Being dismissed and ignored by those they sought help from, of course, only made them more insistent in their requests; this in turn solidified the perception that frequent flyers are ungrateful, needy and wasteful of health resources. As if the care we nurses provided was limited, designed to be doled out in some kind of messed up meritocracy. As if certain patients didn't “deserve” care.

POC—another cohort of patients “the average nurse” sometimes struggled with—were generalized to be aloof and disinterested in the care being offered. Truthfully, I too sometimes found it difficult to establish a rapport with patients-of-color. 

A baseline level of trust is necessary to engage any patient into being an active participant in their care. While I now understand the deeply-rooted systemic racism that has paved the distrust towards the medical community at large, at the time, it felt like a personal failing.

These types of biases popped up consistently yet infrequently while working in med-surg and in the neuro-ICU. But in the ED, with its condensing of human behavior, the ugly aspects of healthcare delivery was highlighted with a particularly glaring spotlight on the daily. Health inequity and injustice seemed to be an accepted part of the culture there.

I noticed these types of bias becoming more brazen just before I left the bedside in 2015. Political messaging always seems to seep its way into places it doesn’t belong, and the hospital environment is no exception.

Flies on the wall in the nursing station would have overheard conversations focused on healthcare delivery—specifically the evils of “Obamacare,” and the inevitability of bureaucracy’s heavy hand ruining it for all. The subtext here being, all of the good and deserving patients. 

It wasn't just the healthcare providers echoing in this chamber, patients sometimes came in with a “holier than thou” attitude, demanding private rooms and citing because of their superior insurance coverage. (While VIP patients certainly exist, it definitely has nothing to do with what policy you’re under.)

Nurses I once admired bemoaned anyone coming into an emergency care environment for a chronic health issue. They never seemed to consider the barriers in place (the very systems they voted to keep running) that kept these same patients from accessing outpatient care. 

There’s no doubt in my mind that these disappointing nursing practices had a direct impact on the care these patients received. A large part of nursing is patient education, focused on disease prevention and best-practices for managing chronic illness. When a nurse believes a patient to be less-than deserving of the very best care, or disinterested in their own health, or one of the very skewed biases that wholly comes from the nurse’s personal beliefs and not the patient’s, she is failing that patient. 

And we are failing them, too, by extension.

Now, these are just my personal observations, specific to a handful of hospitals in a certain geographic area. But, I’ve now spoken with enough nurses, read enough accounts, seen enough news coverage, followed enough of the studies and statistics that clearly delineate this—health inequity and injustice—being a problem nationally. Plus, I think any sentient being these days really doesn’t need to see the receipts on this problem to know it's a problem.

I wish I had a clear idea of where to go from here. What I can surmise is that we work in a terribly flawed system, one that keeps in place these terribly flawed practices. I think the best we can hope for now, is each of us aiming to be our own small pebbles of influence—fling us into a vast expanse of water and watch the ripples of change that emerge. One day they will reach a distant shore. 

Of note—there are a number of fantastic nurses and organizations leading the charge to hock some big boulders of change into our flawed healthcare delivery system. For more info and ways to dive in yourself, check out The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity—A Consensus Study from the National Academy of Medicine, the Robert Wood Johnson Foundation (RWJF), the nation’s largest philanthropy dedicated to improving health and health equity, and the very first National Commission to Address Racism in Nursing launched by leading nursing organizations.