Tag: diversity

We need more than diversity in nursing.

I wrote a piece for the Spring 2018 edition (Issue 23) of the Hive (the Australian College of Nursing’s quarterly publication). Cite as:DeSouza, R. (2018). Is it enough? :Why we need more than diversity in nursing. The Hive (23, 14-15). You can also download a pdf of the article for your own personal use.

Diversity is a hopeful, positive and celebratory idea, it generates more happiness than words like inequity, racism and privilege. It feels good for a large number of people precisely because it is depoliticized (Hall & Fields, 2013). It does not demand accountability. It does not demand transformational change of our minds or our environment, but requests that we continue to put up with difference or to tolerate it (Bell & Hartmann, 2007). What does it mean for our profession to be diverse? And is it enough?

Is it enough, when we have a yawning chasm of health inequity and disparity, of deaths in custody, of punitive policy aimed at Aboriginal Australians? Is it enough, in an era of devastating Islamophobia and racism enabled by nationalist right wing xenophobia? Is it enough, when politicians challenge group-based rights and argue that they undermine social cohesion and “our way of life”, maligning and scapegoating already vulnerable groups like African youth. Is it enough, when media only catapult the spectacular and exceptional into our view. Is it enough, when the entire world is condemning Australia’s abhorrent offshore policy of deterrence and detention. Yes, we need to recognise difference, but we must also understand how differences are connected to inequalities. As Mohanty observes: “diversity by passes power as well as history to suggest a harmonious and empty pluralism” (Mohanty, 2003, p. 193).

We might be ticking the diversity boxes and celebrating diversity — whether in University brochures and websites or on Harmony Day — but do our combined activities address health disparities? The problems of inequity and disparity are bigger than us but we can be accountable for the parts we play in larger political struggles. For a politics of equity, we also need to consider race, disability, ethnicity, class, gender, sexuality, and religion and integrate these into our analyses of our social world. We need to expand the frames we use to look beyond individual behaviour and to consider social and systemic issues, and call for systematic interventions to address inequity. ‘Celebrating’ cultural difference isn’t the same as action, as fighting for justice. As (Perron, 2013) notes, nurses can be both caring for individuals and advocating for the collective rights to equitable care, they aren’t mutually exclusive.

Diversity assumes that care is still a neutral technical activity
As nursing emerged from being a class of handmaidens to the medical system to the dynamic profession it is today, we have understood it to become an intellectual, cultural and contextual activity. This means it is also a political activity (De Souza, 2014). Nursing is connected to systems of power and privilege. Nurses and clients bring multiple ways of being in the world into the world of care and yet we only privilege some of these ways of being. Iris Marion Young describes oppression as being “the disadvantage and injustice some people suffer not because of a tyrannical power coerces them but because of the everyday practices of a well-intentioned liberal society…” (Young, 1990, p. 41). There continue to be clear links between institutional bias in health care systems and health disparities (Hall & Fields, 2013). Let’s ask ourselves what practices we enact every day that contribute to inequity?

Diversity maintains whiteness at its core
In diversity talk in nursing there’s an assumed white centre with difference added. White people are conceived as the hosts and people of color viewed as guests and the perspectives of Indigenous people are erased. Allen (2006, pp. 1–2) calls this the ‘white supremacy’ of nursing education: an assimilationist agenda that converts diverse groups people into a singular kind of nurse, which can then add ‘others’ into the mainstream to create a multicultural environment. But, this addition reinforces rather than displaces whiteness from the centre of structures and processes of educational or clinical institutions (p.66). It’s important that we focus on whether nurses reflect the communities that they serve. But representation in the workforce doesn’t mean that the people who are culturally different have a voice in the corridors of power. There are questions also about “who’s at the decision-making table and who’s not. And what’s on the agenda and what’s not” (Brian Raymond, 2016).

Diversity focuses on sensitivity and respect rather than on the social and historical
Race and racism are determinants of health inequities (Krieger, 2014) therefore it follows that a key area where nurses could intervene is to address discrimination. It is inadequate for us to provide individualised sensitive and respectful care while ignoring the historical and structural conditions that shape health and healthcare. As nurses, we understand more than most that life is an uneven playing field – we need to bring this knowledge to the way we work as a profession. Cultural sensitivity and awareness tend to assume that racism is “out there”, rather than something that is also enacted within healthcare systems. Our claims to colorblindness reinforce the problem, as” treating people the same” doesn’t take into account their differing needs, which is one definition of what care is.

Spotted at my local market

Creating a meaningful diverse and multicultural nursing profession
in an era where both patient populations and the nursing workforce are becoming more diverse, where are the spaces for nurses to talk about both institutional and societal racism and how they impact on care? How can nurses broaden their focus from the micro-level to see the big picture, especially when they labor in unstable and under-resourced working environments (Allan, 2017)? Nurse educators must confront our own resistance to teaching about race and racism (Bond & Others, 2017) – the recent debates about the inclusion of cultural safety into the Nursing and Midwifery Codes of Conduct reflect now far we have to go. Our curricula must more explicitly embed anticolonial and intersectional perspectives into learning experiences in order to prepare nurses for not only understanding how structural inequities affect health but also for the skills to counter them (Blanchet Garneau, Browne, & Varcoe, 2016; Thorne, 2017; Varcoe, Browne, & Cender, 2014). In Australia, the Indigenous Health Curriculum Framework developed by the Committee of Deans of Australian Medical Schools, recognised the critical need to teach students about racism. In particular, it asks us to see the connection between history and current health outcomes; to be able to identify features of overt, subtle and structural racism or discrimination and to be able to address and help resolve these occurrences.

Viewing nursing as a neutral, universal activity where appreciation, sensitivity and respect are adequate, prevents us from considering nursing as a political activity where power is at play. Conversely, embedding an understanding of the historical, structural and systemic factors that shape health, into our practice will allow us to create a meaningfully inclusive – and more caring – profession. This however, requires courage, commitment and accountability. Do we have it?

References

Allan, H. (2017). Editorial: Ethnocentrism and racism in nursing: reflections on the Brexit vote. Journal of Clinical Nursing, 26(9-10), 1149–1151.
Allen, D. G. (2006). Whiteness and difference in nursing. Nursing Philosophy: An International Journal for Healthcare Professionals, 7(2), 65–78.
Bell, J. M., & Hartmann, D. (2007). Diversity in Everyday Discourse: The Cultural Ambiguities and Consequences of “Happy Talk.” American Sociological Review, 72(6), 895–914.
Blanchet Garneau, A., Browne, A. J., & Varcoe, C. (2016). Integrating social justice in health care curriculum: Drawing on antiracist approaches toward a critical antidiscriminatory pedagogy for nursing. Sydney: International Critical Perspectives in Nursing and Healthcare. Google Scholar. Retrieved from http://sydney.edu.au/nursing/pdfs/critical-perspectives/blanchet-garneau-browne-varcoe-integrating-social-justice-2.pdf
Bond, C., & Others. (2017). Race and racism: Keynote presentation: Race is real and so is racism-making the case for teaching race in indigenous health curriculum. LIME Good Practice Case Studies Volume 4, 5.
Brian Raymond, M. P. H. (2016, August 2). How Racism Makes People Sick: A Conversation with Camara Phyllis Jones, MD, MPH, PhD | Kaiser Permanente Institute for Health Policy. Retrieved August 17, 2018, from https://www.kpihp.org/how-racism-makes-people-sick-a-conversation-with-camara-phyllis-jones-md-mph-phd/
De Souza, R. (2014). What does it mean to be political? Retrieved August 21, 2018, from http://www.ruthdesouza.com/2014/08/03/what-does-it-mean-to-be-political/
Hall, J. M., & Fields, B. (2013). Continuing the conversation in nursing on race and racism. Nursing Outlook, 61(3), 164–173.
Krieger, N. (2014). Discrimination and health inequities. International Journal of Health Services: Planning, Administration, Evaluation, 44(4), 643–710.
Mohanty, C. T. (2003). “Under Western Eyes” Revisited: Feminist Solidarity through Anticapitalist Struggles. Signs: Journal of Women in Culture and Society, 28(2), 499–535.
Perron, A. (2013). Nursing as “disobedient” practice: care of the nurse’s self, parrhesia, and the dismantling of a baseless paradox. Nursing Philosophy: An International Journal for Healthcare Professionals, 14(3), 154–167.
Thorne, S. (2017). Isn’t it high time we talked openly about racism? Nursing Inquiry, 24(4). https://doi.org/10.1111/nin.12219
Varcoe, C., Browne, A., & Cender, L. (2014). Promoting social justice and equity by practicing nursing to address structural inequities and structural violence. Philosophies and Practices of Emancipatory Nursing: Social Justice as Praxis, Eds PN Kagan, MC Smith and PL Chinn, 266–285.
Young, I. M. (1990). Throwing Like a Girl and Other Essays in Feminist Philosophy and Social Theory. Monograph Collection (Matt – Pseudo).

Developing diversity in the workforce

Published in Kai Tiaki: Nursing New Zealand 1410.10 (Oct 2008): p23(1).

Identifying barriers, opportunities and strategies to integrate and develop a diverse health workforce was the aim of a workshop at the recent Diversity Forum in Auckland.

“Capitalising on a diverse health workforce” was hosted by the Centre for Asian and Migrant Health Research at the Auckland University of Technology (AUT) and opened by dean of the Faculty of Health and Environmental Sciences at AUT’s North Shore campus, Max Abbott. He recounted how pivotal overseas health professionals were to his recovery during a recent hospital stay.

Nurse consultant-recruitment at North Shore Hospital, Waitemata District Health Board (DHB), Carat Frankson, identified some bottlenecks to the registration of overseas nurses, in particular passing the International English Language Testing System (IETLS) exam, getting a job offer and finding employment opportunities for spouses. Other bottlenecks included organising passports and visas, selling and buying houses, finding schools, living costs, climate, separation from family, loss of familiar surroundings, religious practices, cultural backgrounds and the financial costs of moving from one country to another. Strategies the DHB provided in order to embrace a diverse nursing workforce included:

  • coaching, support, mentorship and supervision in the work environment;
  • introduction to the New Zealand cultural context and context of nursing at the DHB;
  • education in the principles of the Treaty of Waitangi; and
  • education in the values of the Waitemata DHB: integrity, compassion, openness, respect and customer focus.

The process could be mutually beneficial, Frankson said. “It is our responsibility to introduce and support new recruits into the New Zealand way of life, offering them cultural support. Incorporating and including immigrants into our communities is a responsibility we all share.” White these health professionals benefitted our workforce, they could also benefit other areas of society, eg schools, Libraries, universities, community centres, religious centres and the legal system, she said.

Auckland DHB clinical nurse educator, Roanne Crane’s presentation on integrating overseas-trained health professionals into the DHB identified some of the issues facing overseas registered nurses, such as Language, manoeuvring through the New Zealand registration process, socialisation, cultural differences, unprincipled agents and assumptions/racism.

Reducing health inequalities

Workforce development consultant at Counties Manukau DHB, Elizabeth Ryan, discussed the increasing demand for health services. The population was ageing, with the number of people over 65 projected to more than double between 2001 to 2021; a third of deaths occurring everyday in Counties Manukau were from potentially preventable conditions; and workforce demand would outstrip supply, with shortages nationally of up to 40 percent predicted by 2021, including in South Auckland. Having an ethnically diverse workforce was a key strategy in reducing inequalities in health, she said. The workforce needed to reflect the community being served in order to deliver quality health services in a culturally-appropriate manner. Ethnic matching was associated with greater patient satisfaction and better patient-reported outcomes.

She highlighted initiatives such as increasing the number of high school students studying health courses, with an emphasis on Maori and Pacific students, increasing numbers pursuing health at mid-career level, especially males/ Maori and Pacific people, collecting accurate demographic data, developing an affirmative action policy and the pilot programme which wilt see around 50 Pacific-Island trained nurses gain registration in New Zealand annually over the next three years.

Meeting the challenge of institutionalised racism was tackled by Auckland University researcher Nicola North. Of note was the complex and subtle set of skills that international medical graduates (IMGs) and international registered nurses(IRNs) needed to acquire, eg understanding cultural differences, familiarity with the culture of the new community of practice, fluency with the nuances of professional communication, and understanding the behaviour and values expected. To meet the challenge, North suggested several factors needed to be addressed: self-reflection as a society, a focus on immigration and settlement structures and processes, even-handed behaviour from registration councils, finding employment, smoothing the process of joining the new practice community and, lastly, getting real. “We need to acknowledge we need IMGs and IRNs more than they need us,” she said.

In the final part of the workshop, the group considered the question: What would a health system that capitalised on its diversity look like? Answers included:

  • recognising skills and supporting people financially;
  • ensuring the health workforce reflects the population demographics;
  • passing on success stories to the media;
  • rewarding and acknowledging cultural competence;
  • fostering diversity at all levels, including around decision-making, to develop new ideas and treatments;
  • consolidating, streamlining and integrating information systems to free up funding for initiatives;
  • growing the inter-cultural communication capacity of the entire workforce, eg educating people about how to deriver bad news to patients;
  • including diversity at art education levels;
  • focusing on areas of under-representation and targeting them specifically; and
  • ensuring support mechanisms are developed to take into account cultural differences, eg around employee disputes.

New York author Margaret Visser argues that change and diversity are necessary to human growth and evolution: “Machines like, demand, and produce uniformity. But nature loathes it: her strength lies in multiplicity and in differences. Sameness, in biology, means fewer possibilities and, therefore, weaknesses.” (1)

Reference

(1) Visser, M. (1999) Much depends on dinner:. The extraordinary history and mythology, allure and obsessions, perils and taboos, of an ordinary meal. New York: Grove Press.