Minister to the world in a way that can change it. Minister radically in a real, active, practical, and get your hands dirty way.
—Chimamanda Ngozi Adichie, author
Creating a future in which opportunities to optimize health are more equitable will require disrupting the deeply entrenched prevailing paradigms of health care, which in turn will require enlightened, diverse, courageous, and competent leadership. The seminal Institute of Medicine report Crossing the Quality Chasm: A New Health System for the 21st Century (IOM, 2001) calls for broad and sweeping transformation of the health care system in order to improve the quality of care. It identifies six aims for improvement that define quality health
care: to provide care that is safe, effective, patient-centered, timely, efficient, and equitable (IOM, 2001). The Institute for Healthcare Improvement (IHI) has found that progress on health equity has lagged behind that on the other five aims, calling it “the forgotten aim” of health care (Feely, 2016). The Crossing the Quality Chasm report emphasizes the importance of leadership in achieving the six aims, noting that leaders have a wide variety of roles and responsibilities that include
creating and articulating the organization’s vision and goals, listening to the needs and aspirations of those working on the front lines, providing direction, creating incentives for change, aligning and integrating improvement efforts, and creating a supportive environment and a culture of continuous improvement that encourages and enables success. (IOM, 2001, p. 137)
It must be emphasized that having this type of leadership only at the top of an organization or initiative is not enough. Rather, leadership is needed at multiple levels to “provide clear strategic and sustained direction and a coherent set of values and incentives to guide group and individual actions” (IOM, 2001, p. 137) and to ensure that health equity is a strategic priority at every level (Feely, 2016).
This chapter focuses on how nurse leaders can, and do, address social determinants of health (SDOH) and health equity in all settings and all nursing roles. It begins by articulating how nurses are well suited to lead in such efforts, and then outlines the committee’s vision for nursing leadership specific to these challenges in the future. Next is a discussion of the competencies that will enhance nurses’ ability to lead effective change. Finally, the chapter explores ways to help achieve the committee’s vision for nursing leadership through training and leadership development specific to advancing an agenda of greater health equity.
NURSES LEADING IN HEALTH EQUITY
Nurses have a rich history of both advocacy and the provision of holistic care that includes meeting social needs of individuals and focusing on SDOH. As presented in this report, there are numerous examples illustrating how nurses are already working effectively as leaders on equity issues across a variety of settings. If nurses are to build on this rich tradition, it will not be enough for them to see themselves as leaders; the organizations that employ them will have to provide them with ample opportunities, resources, and mentorship to fully realize their leadership potential. This is the case even for nurses who are self-employed, who can benefit from opportunities provided by the external systems around them.
Nursing’s Focus on Social Determinants
Nurses have always been key to the health and well-being of individuals and communities, but a new generation of nurse leaders is now needed—one that recognizes the importance of SDOH and diversity and is able to use and build on the
increasing evidence base supporting the link between SDOH and health status. Today’s nurses are called on to lead in the development of effective strategies for improving the nation’s health (Lathrop, 2013; Ogbolu et al., 2018) with due attention to the needs of the most underserved individuals, neighborhoods, and communities and the crucial importance of advancing health equity.
Leadership can be defined as a process of social influence that maximizes the efforts of others toward achievement of a goal (Kruse, 2013). Leaders set direction, build an inspiring vision, press for change, and create new ways of thinking and doing. Nurses as a professional group manifest many of the characteristics of strong leadership—including courage, humility, caring, compassion, intelligence, empathy, awareness, and accountability—that are essential to leading the way on health equity (Shapiro et al., 2006). In addition to their deep understanding of how health intersects with SDOH (Olshansky, 2017), they have a holistic view of people across systems and settings, they are active listeners, they establish therapeutic relationships, and they practice person-centered care. Increasingly, nurses are serving as innovators and codesigners of health care in their roles in the public health and health care systems (Jouppila and Tianen, 2020), and by continuing to learn and apply improvement and innovation skills, will be able to help create new care models for the decade ahead. Given the wide range of settings and roles in which nurses at all levels serve (see Chapter 1), their leadership in this regard can have broad and far-reaching impacts on equity in health and health care.
THE COMMITTEE’S VISION FOR NURSING LEADERSHIP
Implementing change to address SDOH and advance health equity will require the contributions of nurses in all roles and all settings, and recognition that no one nurse can successfully implement change without the collaboration of others. Clinical nurses manage the nursing care of patients and coordinate care, making decisions and communicating with families and other health care professionals. These nurses can influence clinical practice environments and local organizational culture, as well as organizational processes and policies, often working with members of other health care disciplines. Public health and school nurses and other community-based nurses engage with the community to identify and address individual- and community-level needs, often working with professionals from other disciplines and sectors. Some nurses serve on boards, manage organizations, direct programs, and have direct responsibility for developing policies and practices. Nurses leading community organizations often lead team members and partner with community members and organizations in other sectors. Nurses serving on health care boards can exert leadership influence on the organization’s policies and structures while not leading day-to-day organizational operations. Still other nurses work with but outside the health care system, advocating for and working toward public- and private-sector policies and structures that can have positive impacts on health and well-being. These nurses (e.g., a public health
nurse advocating for more equitable transportation policy) may lead individuals and organizations as part of a multidisciplinary, multisector coalition. And nurses with formal leadership roles, such as nurse managers, chief executive officers (CEOs), and deans, can use their positions to establish organizational cultures and implement practices that advance health equity. In addition to collaboration among members of the nursing profession and across other disciplines and sectors, the creation of enduring change requires the involvement of individuals and community members. Rather than a more hierarchal system of leadership, collaborative leadership assumes that everyone involved has unique contributions to make and that constructive dialogue and joint resources are needed to achieve ongoing goals (Eckert et al., 2014).
Each of the various leadership roles described above involves different skills and responsibilities, as shown in the framework for nurse leadership in Table 9-1. It is important to note that an individual nurse may lead in multiple areas of this framework and can lead in both formal and informal capacities. While some nursing positions (e.g., CEO, dean, nurse manager) entail more explicit leadership responsibilities, all nurses can lead according to their own interests, capacities, and opportunities. For example, a staff nurse who has no official leadership position in the workplace can lead others by modeling behaviors that promote a culture of diversity, equity, and inclusion, and can also lead beyond health care through involvement in political advocacy. As noted earlier, fulfillment of this potential will require support, encouragement, mentorship, and advancement opportunities, with nurses operating to the full scope of their education, training, and expertise.
The subsections below detail the leadership roles nurses can play at the four levels shown in Table 9-1: leading self, leading others, leading health care, and leading beyond health care. Nurses engaging in each of these leadership levels are important to advancing health equity. Together, the various roles at these four levels constitute the committee’s vision for nursing leadership.
Before nurses can lead others, they need to be able to lead themselves. To address SDOH, nurses need to understand and acknowledge how social determinants affect them personally, and to be aware of implicit biases that may influence the decisions they make and the outcomes of the people and communities they serve. They must understand and manage their own emotional responses, invest in their own physical and mental health, serve as role models for others, and continue their personal and professional development. Nurses can lead at this level by advocating for themselves and others in the workplace, functioning as effective team players, and developing coping and self-care skills (NASEM, 2020).
Part of leading oneself is seeing oneself as a leader and viewing leadership as an integral part of one’s role. One barrier to effective leadership is that not all nurses see themselves in this way or have the bandwidth to take on or un-
|Leadership Role||Nurses Leading Self||Nurses Leading Others||Nurses Leading Health Care||Nurses Leading Beyond Health Care|
|Engage the community||Get to know the community and its unique strengths and needs||Facilitate opportunities to become involved in the community||Assess community needs and engage with the community and other partners to address them||Lead and work with community, state, and national coalitions to address structural and systemic barriers|
|Represent and communicate the nursing perspective||Provide the nursing perspective with other health professionals, patients, and communities||Lead and serve groups, serve as a union representative, participate in interprofessional collaboration||Lead and participate in multisectoral collaborations, serve in professional associations and organizations||Serve on boards and expert panels, pursue and appointed political positions, hold C-suite positions|
|Advocate||Advocate for self (e.g., report workplace hazards and bullying, speak up for self)||Advocate for others, help other nurses be healthy and well, advocate for patient and community needs||Advocate for organizational policies and structures that support nurses and promote equity||Advocate for legislative and regulatory changes at the community, state, and national levels|
|Improve equity||Practice nursing with compassion and cultural humility, understand and address own bias||Set a culture of equity, diversity, and inclusion||Lead with a health equity lens; implement policies and systems that promote equity and address racism, discrimination, and bias in the organization||Work to dismantle structural racism and discrimination|
|Improve health care||Provide quality health care||Encourage innovation and quality improvement workplace||Implement programs and lead/translate research and evidence to improve quality of care, address structural barriers, and reach underserved populations||Pursue policies and systems at the state and federal levels that ensure access to quality care for all|
SOURCE: CCL, 2010.
derstand what leadership entails (Dyess et al., 2016; Sherman, 2019). Given the right environment and support, however, nurses can overcome these barriers. (See Chapter 7 for further discussion of implicit bias and Chapter 10 for further discussion of self-care.)
In the pursuit of health equity, nurses have the opportunity to lead others, including other nurses, students, health care professionals, staff, community members, and partners. Leading others may occur in a wide range of contexts, including working with clinical nurse managers, community organization leaders, nurses engaging in policy development, and educators and research teams. Leading and managing effective teams requires building and maintaining trusting relationships among team members, communicating effectively, and supporting each team member. In this role, nurses can leverage and actively promote diversity within their teams and create an atmosphere of equity, inclusion, innovation, support, and growth. As team leaders, they can use their position to motivate and empower others to work to identify and address social in addition to health care needs, take action on health equity, and provide the tools and resources needed to do so.
One example of nurses leading others in pursuit of health equity is Cultivando Juntos, a community wellness program aimed at helping farmworkers live longer, healthier lives (Berger, 2019). Two nursing students designed the program, which has expanded to include a biostatistician, a postdoctoral fellow, and undergraduate nursing students. The team meets with local Hispanic farmworkers to discuss their health and well-being and to conduct demonstrations on cooking healthy food. Baseline and longitudinal data are collected across the program to track progress on outcomes that include HgbA1c and lipid levels and body mass index (Berger, 2019). This program is an example of nurses leading others by bringing multiple sectors together to engage with a community in order to address the community’s needs.
Nurses Leading Health Care
Nurses lead in numerous ways within health care, both in health care organizations and beyond their organizational boundaries. Within an organization, nurses can assess the organization’s readiness to address issues of equity and recommend related improvement. For example, a staff nurse on an inpatient unit can advocate for incorporating an assessment tool that can systematically collect data on SDOH within the electronic health record. Or a nursing director within a health care organization can engage other leaders, as well as members of the community, in initiating a healthy foods program within the hospital and connecting with related community-based agencies. Nurses can also identify and disseminate best and evidence-based practices to ensure equitable health
care services within departments and across patient populations, improving and sustaining a supportive culture of care for both staff and those they serve, and advocate for policy changes that address population health and SDOH at the organizational and public policy levels. Nurses leading at higher levels within health care, such as nurse CEOs, chief nursing officers (CNOs), and chief operating officers, can work collaboratively with their organization to set direction and develop a vision and strategies for advancing organization-wide goals that include the drive for greater health equity through engagement with SDOH to meaningfully impact communities served by the health system. Successful organizational leaders can span boundaries between disciplines and sectors in an inclusive way to create meaningful, respectful, and sustainable partnerships to address issues of health equity. For example, public health nurse leaders can bring together representatives of the community served along with leaders from other sectors, including health care, transportation, housing, and food security, to address community needs (see the section below on leading multisector partnerships).
Nurses also have the capacity to lead in health care more broadly. For example, a nurse can seek to influence SDOH by working with a specialty organization such as the National Black Nurses Association, which focuses on the professional development of Black nurses and the delivery of culturally competent care, or serve as a leader for the Council of Public Health Nursing Organizations (CPHNO) or the National Rural Health Association. Many nurses also serve on boards of health care organizations, where they can provide their unique perspective on health-related issues facing individuals, families, and communities (Harper and Benson, 2019). And nurses can serve as leaders in a variety of interprofessional contexts within health care; an example is a nurse researcher leading a multiorganizational research team. In each of these contexts and roles, nurses can share nursing’s perspective and expertise while collaborating with others to address health disparities, SDOH, and health equity.
Leading Beyond Health Care
Nurses have myriad opportunities to lead entirely outside the traditional boundaries of health care, in both the public and private sectors. In the public sector, they can lead through positions in local, state, and national government organizations, such as departments of human services, public health, and education. Nurses can be appointed to senior government positions or stand for election to political office, positions in which they can use their expertise and voice to advocate for policy change in the areas of SDOH and health equity. Applying her expertise, U.S. House of Representatives member Lauren Underwood, a registered nurse, discussed the disproportionate health and economic impacts of COVID-19 on communities of color, particularly Black Americans, in a Committee on Education and Labor virtual hearing in June 2020, calling these disparities
A number of other nurses serve in state legislatures, the U.S. Congress, state and federal executive branch positions, and national and state commissions and committees. Nurse leaders also can bring nursing perspective and expertise to private organizations. For example, Microsoft employs a CNO, and AARP has been served by several nurse CEOs. Nurses can facilitate and convene multisector partnerships, leading efforts to disseminate and implement interventions aimed at improving population health, and can engage communities and partners through local, regional, and national networks. Just as nurses serve as board members within health care, they can also serve on boards for programs or organizations that are outside of health care but have impact on health. The Nurses on Boards Coalition works to create opportunities for nurses to participate in a wide range of boards outside of health care, from boards of local schools or places of worship to those of Fortune 500 companies and large international corporations (Harper and Benson, 2019). In the next 10 years, nurse leaders in these types of positions can become drivers for change within their communities by advocating for social change and health equity, and bringing nursing’s perspective to organizational and public policy-making discussions.
LEADERSHIP COMPETENCIES FOR ADVANCING HEALTH EQUITY
While nurses’ specific leadership roles vary depending on the focus of their work, the setting in which they work, and the people whom they lead, there are certain skills and competencies on which all nurse leaders need to draw as they work to advance health equity by creating a vision and culture of equity, putting the necessary structures and supports in place, and working both within and across boundaries to achieve the vision of health for all. The committee identified eight skills and competencies that are essential for nurse leadership in nearly every setting, which are described in turn below:
- visioning for health equity,
- leading multisector partnerships,
- leading change,
- innovating and improving,
- teaming across boundaries,
1 The full committee hearing is available at https://edlabor.house.gov/hearings/inequities-exposed-how-covid-19-widened-racial-inequities-in-education-health-and-the-workforce- (accessed April 8, 2021).
- creating a culture of equity,
- creating systems and structures for equity, and
- mentoring and sponsoring.
Visioning for Health Equity
In all types of work, a leader is responsible for articulating a vision, setting direction and goals, and developing clear expectations for individuals and teams. Nurse leaders are no exception, whether the vision they create is for providing quality patient care in a clinic, meeting the needs of a community, setting the direction and goals for an organization or company, or redesigning the nation’s health care system. In the context of this report, nurse leaders at all levels and in all settings can work collectively with others to develop and communicate a clear and compelling vision for a future state of greater health equity. The creation of a vision for greater health equity can be squarely rooted in existing data demonstrating profound differences in care quality and health outcomes among people of color compared with their White counterparts (Betancourt et al., 2017).
The most effective visions are a shared product (Boyatzis et al., 2015). Nurse leaders can articulate ideas for a vision, and develop a shared vision by working collaboratively with others. Fully understanding the needs, hopes, and aspirations of a community or population is critical to achieving an effective shared vision (Kouzes and Posner, 2009). To this end, nurse leaders can engage in dialogue with community members, whether that community consists of patients in a clinical setting; a subpopulation such as juveniles in the justice system; or residents of a neighborhood, city, or state. Regardless of the specific target community, this engagement requires a nurse leader to apply such skills as listening, acknowledging, and collaborating in order to create trusted relationships that are needed to build community-centric, community-informed solutions to complex health and social needs. Additionally, data collection and analysis to identify, assess, and prioritize opportunities for advancing health equity is essential (Wesson et al., 2019).
Nurses can work with communities to identify and address their needs in a number of ways, including collecting and analyzing data, leading community meetings, presenting at city council meetings, and working to implement and evaluate strategies for eliminating health disparities. One established mechanism in which nurse leaders can engage is community health needs assessments, which are a statutory requirement for nonprofit hospitals (see Chapter 4 for a fuller description). Ensuring that these needs assessments explicitly target health disparities and prioritize SDOH and that they are conducted with input from members of the community on which they focus are examples of the considerations nurses can advance while helping to align community needs with culturally sensitive and relevant resources. Nurse leaders in both health care systems and public health (the entities involved in developing these needs assessments) can use these data
to develop nurse-led and other innovative solutions for meeting the identified needs (Swider et al., 2017).
Leading Multisector Partnerships
Strategic partnerships involving a broad range of stakeholders are essential to address factors that perpetuate structural inequities in health and health care (NASEM, 2017). In the Framework for Achieving Health Equity of IHI, developing partnerships with community organizations is identified as one of the framework’s fundamental elements (Laderman and Whittington, 2016). Nurses are skilled in working on and leading clinical teams. However, the role of the interprofessional health team is evolving beyond individual clinical encounters and extending beyond the walls of health care systems into the communities where people live (NASEM, 2019a; Pittman, 2019). Multisector models involving innovative interprofessional collaboration among, for example, police, emergency services, the legal system, housing, and public works and the health care system are showing promise and demonstrating positive health outcomes for underserved populations (Hardin and Mason, 2020).
The ability to develop and lead multisector partnerships is critical to achieving health equity for a number of reasons (NASEM, 2017). First, community needs are complex and wide-ranging, and necessarily involve actors from multiple sectors (e.g., employment services, education transportation, health). Collaboration across sectors is essential to break down existing silos that are counterproductive to improving health and health care (NAM, 2017). Second, collaboration among partners introduces “more expertise and knowledge than what resides in any one stakeholder group” (Wakefield, 2018), and multisector partnerships can leverage unique skills and resources from multiple stakeholders (e.g., faith leaders, philanthropists, researchers). Third, working with community partners can help nurses reach underserved populations, including the homeless, recent immigrants, and non-English-speaking families. Fourth, multisector partnerships increase a community’s capacity to make sustainable changes by bringing energy, expertise, and perspectives from multiple arenas. Fifth, multisector partnerships can simultaneously address upstream, midstream, and downstream SDOH and ensure alignment of efforts across these levels. Finally, bringing people together from multiple sectors can facilitate and encourage creative approaches; the intersections across boundaries are “where the promise of innovation lies” (Pittman, 2019, p. 27). As Johansson (2004, p. 2) puts it, “When you step into an intersection of fields, disciplines, or cultures, you can combine existing concepts into a large number of extraordinary new ideas.”
It is important for multisector partnerships to be formal, structured, and collaborative relationships (Siegel et al., 2018) in which partners have mutual respect for one another, and time and attention are devoted to maintaining those relationships (Chandra et al., 2016). Trust among partners is also essential for a collaborative relationship, and once established, can serve as a foundation for
future collaborations (Wakefield, 2018). Nurses leading and engaged in multisector partnerships can help ensure that collaborative efforts are based on an understanding that health is a value shared among all partners (Erickson et al., 2017; Mason et al., 2019; Realized Worth, 2018).
Nurses need to be able to build partnerships that include a focus on integrating clinical and nonclinical services and ensuring access to health and human services. Collaborative multisector efforts are common in the work of public health nurse leaders, and their experience and expertise can inform new approaches. Nurses currently have limited opportunities to learn from such efforts working in traditional health care systems. There is a need to start providing nurses with substantial exposure to experiences that involve developing and maintaining effective cross-sector partnerships, rather than what is often quite limited observational experience in public health and other social services settings.
While nurses have long worked at the intersection of individuals, families, other health professionals, social workers, educators, and others to improve health, more nurses will increasingly need to apply and expand this skill set to participating in or leading community-engaged multisector partnerships. The Crossing the Quality Chasm report (IOM, 2001) calls for health care leaders to invest in their nursing workforce to enable nurses to achieve their full potential as individuals, team members, and leaders. Going forward, then, there is an expanding need to build and engage teams that reach beyond health care to include other sectors. Just as working in health care teams represented a “fundamental shift” in perspective in 2001 (IOM, 2001, p. 139), so, too, working across health and social sectors for the benefit of individuals and communities will require a fundamental shift in perspective, resources, and academic preparation.
Reducing disparities and achieving health equity will require nurse leaders to be skilled in leading change. To be effective, these efforts will need to be anchored in the theoretical constructs of change management and occur at multiple levels, within clinical practice, organizations, communities, populations, health authorities, and nations (Browne et al., 2018). Evidence suggests that health care leaders are knowledgeable about disparities and what can be done to eliminate them, but that a number of barriers to successful change exist (Betancourt et al., 2017). These barriers, including a lack of leadership buy-in, competing organizational priorities, existing culture, and ineffective execution, can be addressed through effective change management (Betancourt et al., 2017). Effective change management requires that individuals learn and apply new behaviors and skills, as well as lead and collaborate with others in driving change within and outside of the organizations where they work. Empirically based interventions to drive change that can reduce health disparities include developing a vision for change (as discussed above), aligning executive support, engaging a coalition of com-
mitted stakeholders, setting expectations, establishing clear goals and a plan for change, anchoring change in the existing culture, measuring progress, iterating as needed, and communicating status reports and results (Betancourt et al., 2017). Nurses at all levels can exert substantial influence on SDOH by using their experience and knowledge to engage in such change management efforts.
Innovating and Improving
Changing the prevailing health care paradigm to address SDOH and advance health equity will require innovation. The U.S. Department of Commerce’s Advisory Committee on Measuring Innovation in the 21st Century Economy defines innovation as the “design, invention, development, and/or implementation of new or altered products, services, processes, systems, organizational structures, or business models for the purpose of creating new value” (ESA, 2007). For the complex work of eliminating disparities and impacting SDOH, knowledge and skill in innovation will be an important competency for nurses. Nurse leaders can facilitate the creation of innovative approaches by challenging the status quo, breaking down traditional barriers to change, teaching and encouraging team members to solve problems using design thinking, identifying best practices, and facilitating the translation and adoption of new ideas.
Virtually all nurses have opportunities to innovate by developing new ideas for improving health and translating these ideas into practice and policy. Over the past several years, nurse-designed and nurse-led innovations addressing SDOH among underserved populations have increasingly appeared in the literature. As described in Chapter 4, for example, nurses in the Netherlands developed and implemented Buurtzorg, an innovative nurse-led, nurse-run organization of self-managed teams that provide home care to individuals in their neighborhoods (Monsen and de Blok, 2013). Similarly, the SOAR (Supporting Older Adults at Risk) program reimagined how to prepare and support frail older adults in the transition back to their homes following a hospital admission. The program addresses issues of transportation, nutrition, and medication access (IHI, 2018).
Yet, while some nurses are already leading efforts focused on health equity in their work settings and communities, this focus is not consistent across the profession. It is a leader’s responsibility to create an environment that allows for innovation (IOM, 2000). Leaders can provide a forum for continual innovation in and testing of strategies for improving population health and health equity, and ensure that their organization is flexible and able to adapt to those changes (IOM, 2001). For example, leaders of front-line health teams can encourage team members to share their own observations and ideas for improving patient health and facilitate the transfer of new ideas across professional boundaries (IOM, 2001). Likewise, nurse leaders working in the community or in multisector partnerships can encourage communication and collaboration without regard for traditional boundaries and recognize that innovative ideas can surface from an array of
individuals across sectors, such as those working in aging-related services or Medicaid managed care organizations.
Nurses have a rich tradition of working creatively to solve problems and improve the quality of care in clinical settings (Thomas et al., 2016), and these experiences and skills can apply to efforts designed to address SDOH. These types of initiatives require systematic, continuous, data-driven, and rigorous processes of assessment, innovation, implementation, evaluation, and diffusion or translation of the evidence or best practices into tangible strategies or policies for improving population health. For example, IHI’s Model for Improvement for quality improvement initiatives uses a Plan-Do-Study-Act (PDSA) cycle that involves planning exactly how the intervention will be implemented; implementing it; studying whether and how it is being conducted; and then acting to either adapt it, adopt it as a standard practice, collect more data, or abandon it (IHI, 2020). This model has been used with great success in the clinical setting. Transforming Care at the Bedside (TCAB), was one such model using the PDSA cycle. A partnership between the Robert Wood Johnson Foundation and IHI, TCAB created learning collaboratives at the front lines of care on medical-surgical units that engaged nurses and other front-line staff in generating and testing ideas that led to processes and practices that improved the efficiency, safety, and satisfaction of care.3 This process has the potential to be equally successful in addressing SDOH and health equity (IHI, 2020).
Teaming Across Boundaries
As nurses work within and across organizations to address SDOH and advance health equity, they will need the skills to develop, engage, and lead cross-boundary teams. Cross-boundary teaming is a strategy for driving innovation that engages diverse stakeholders and subject-matter experts to expand the range of views and ideas on which teams can draw (Edmondson and Harvey, 2018). In cross-boundary teams, individuals work across knowledge boundaries. Teams are diverse in expertise, knowledge, and educational background, characterized by deep-level differences or what Edmondson and Harvey call “knowledge diversity” (p. 3480).
Addressing SDOH and advancing health equity will require a cross-boundary team approach that includes not only people from different disciplines and sectors but also individuals and organizations from within the community. Regardless of the composition of the team, the cross-boundary team leader will need to support each team member, balance the use of resources, facilitate communication, and ensure the team’s effectiveness. A leader’s job is to “optimize the performance of teams that provide various services in pursuit of a shared set of aims” (IOM, 2001). Evidence suggests that high-performing team members listen to one an-
3 See http://www.ihi.org/Engage/Initiatives/Completed/TCAB/Pages/default.aspx for more information about TCAB (accessed April 8, 2021).
other and show sensitivity to feelings and needs (Duhigg, 2016). To support the team and optimize its performance, a nurse leader will need to work to help its members achieve their full potential, both individually and collectively. This investment may include providing support and time for self-care, providing access to and time for ongoing professional development, and supporting individuals as they seek higher levels of education and responsibility. Facilitating nurses’ well-being and self-care is one particularly important way in which nurse leaders can support and optimize cross-boundary teams (see Chapter 10 on the importance of facilitating nurse well-being).
Creating a Culture of Equity
Nurse leaders in many positions of authority, including academic leaders (DeWitty and Murray, 2020), journal editors (Villarruel and Broome, 2020), educators (Graham et al., 2016), and managers (ANA, 2018), can act to call out and dismantle racism. To advance equity in society, nursing needs first to work to create a culture of equity within the profession itself. Nursing has a history of racism that continues to impact the experiences of nursing faculty, nurses in practice, communities, and patients (DeWitty and Murray, 2020; Iheduru-Anderson, 2020a; Villarruel and Broome, 2020; Waite and Nardi, 2019; Whitfield-Harris et al., 2017). The nursing profession’s substantive and sustained attention is required to address and eliminate racism in nursing and in broader organizations where nurses work. Waite and Nardi (2019, p. 20) call on nurse leaders to “urge their colleagues and students to characterize, name, contest, and transform the norms, traditions, structures, and establishments that preserve White supremacy through continued effects of American colonialism.” Over the past few years, the nursing literature, including statements issued by national nursing organizations, has reflected increased attention to these issues.
Nurse leaders must acknowledge existing disparities and facilitate open, honest, and respectful discussions about factors that drive disparities (Oruche, and Zapolski, 2020; Purtzer and Thomas, 2019) and the challenges staff face as they engage in this work within organizations and with communities. It will be essential for these discussions to include opportunities for and support of the expression of patient and community perspectives (NASEM, 2017). Specific strategies for promoting equity and inclusion include (1) creating safe spaces to engender trust and open communication; (2) reassessing recruitment and advancement processes; (3) examining and redesigning equity policies, procedures, and practices; (4) requiring a diverse pool of applicants for applicant selection; (5) moving from mentorship to sponsorship, which focuses on protégé advancement; (6) creating an infrastructure to monitor and track progress with development programs; and (7) dismantling racism, including applying an equity lens to all practices (Fitzsimmons and Peters-Lewis, 2021). Nurse leaders need to set an example of inclusion and confront negative and toxic cultural norms in
nursing, such as bullying and in-fighting (Kaiser, 2017). Nurse leaders need to be knowledgeable about and able to lead others in cultural humility and culturally competent practices, which are critical for reducing health disparities and improving access to high-quality health care (Powell, 2016).
In a recent analysis of six models of cultural competence, Botelho and Lima (2020) argue that existing approaches to the delivery of culturally appropriate care may assist with cultural respect, but tend to oversimplify patients’ cultural experiences and overlook the complexities associated with power dynamics (Botelho and Lima, 2020). They propose the practices of not only cultural humility but also relational ethics4 to facilitate cross-cultural work. To practice cultural humility, clinicians relinquish their role as experts in a culturally diverse world where power imbalances exist and embrace an attitude characterized by constant questioning, openness, self-awareness, absence of ego, and self-reflection and -critique, willingly interacting with diverse individuals. Practicing with cultural humility can foster mutual empowerment, respect, partnerships, optimal care, and lifelong learning (Foronda et al., 2016, p. 213). (See Chapter 7 for further discussion of cultural humility.)
Creating Systems and Structures for Equity
Nurse leaders at all levels and in all settings can help create systems and structures that promote equity and do not unintentionally exacerbate inequalities through unintended incentives. For example, working midstream (see Chapter 2), a nurse leader who oversees a home visiting program can educate around the concept of equitable care and establish expectations of nurses that encourage the provision of equitable care, including meeting social needs, rather than orienting nursing’s interventions to the volume of visits they make (IOM, 2001). A nurse leader who manages an organization can develop organization-wide policies that put equity at the forefront of the staff’s work, and ensure that the provision of services does not exacerbate existing inequalities. Upstream, a nurse leader can influence government policy by advocating for policies that improve equity, such as a city transportation policy that prioritizes traditionally underserved rather than higher-income neighborhoods, or by highlighting exposure to noise pollution and associated health impacts related to building low-income housing near railroad tracks.
The goal of health equity is more likely to be achieved when it becomes deeply ingrained in official systems and structures and becomes inherent in a cultural shift that includes inner reflections on bias and structural racism (Chin, 2020), rather than being pursued through one-off initiatives or well-intentioned
4 Relational ethics is defined in health care as actions that take place within relationships and consider the existence of the other (i.e., patient, nurse) (Bergum and Dossetor, 2005). Core tenets include mutual respect, engagement, embodied knowledge, environment, and uncertainty; the most important tenet is mutual respect (Pollard, 2015).
efforts that are not formalized. Systems and structures are never neutral—they either entrench or dismantle existing health inequities. Nurse leaders have a responsibility to advocate for and build systems that promote equitable health for all.
Mentoring and Sponsoring
The transformation toward a health system that is more equitable and just will require explicit preparation of and support for future nurse leaders in multiple settings (AACN, 2016). A key strategy for achieving this goal is mentorship and sponsorship of the next generation of nurses and nurse leaders. Mentoring is critical across the trajectory of nurses’ professional lives, particularly as they take on new and increasingly complex leadership roles (Vitale, 2018). Given the overarching need for nurse leaders with expertise and commitment to achieving equity in health and health care, and given the need for more nurses with expertise in such priority areas as care for the aging, maternal mortality, mental and behavioral health, rural health, and public health (see Chapter 3), mentoring is critical to building and supporting the next generation of nurses.
Mentoring is associated with positive benefits, including professional development, greater skills, a better fit with one’s choice of specialty, and greater life–work balance (Disch, 2018). In mentoring new nurses in the application of concepts related to health equity or in needed specialty areas as identified above, nurses with experience can encourage collaboration among nurses of different ages and at different professional development stages. In general, a lack of support and mentoring by senior nurses has negative impacts on well-being and workforce turnover (IOM, 2011), and mentoring is therefore a critical part of building capacity in the profession and of mitigating the loss of knowledge and experience that results when retiring nurses leave the profession.
A particularly critical role for nurse leaders is mentoring nurses from traditionally underrepresented communities to build a more diverse nursing workforce and increase the number of nurses from underrepresented groups in leadership positions (Phillips and Malone, 2014). Mentoring is a critical component of recruiting, supporting, and advancing nurses of color through the ranks of leadership (DeWitty and Murray, 2020; Iheduru-Anderson, 2020b; Whitfield-Harris et al., 2017). As discussed in Chapter 3, diversity in the nursing workforce—and in nursing leadership in particular—is essential to achieving health equity. There are relatively few nurses of color in leadership positions, particularly in more senior executive positions (Phillips and Malone, 2014; Schmieding, 2000). A 2019 National Academies report on increasing the number of professionals of color in science, technology, engineering, and mathematics found that structured mentorship programs in minority-serving institutions5
can improve leadership diversity in nursing and the health care field generally (NASEM, 2019b). One such effort is being led by the Center to Champion Nursing in America (CCNA) in its convenings of mentor training programs with historically Black colleges and universities (HBCUs). CCNA will continue to convene mentoring programs in Hispanic- and American Indian–serving nursing schools as well (CCNA, 2020).
Serving as a sponsor becomes even more critical than mentoring when a more active role is required to help nurses rise in leadership ranks (Williams and Dawson, 2021). The expectations of a sponsor include being a staunch advocate for career advancement for the protégé, including making assignments and connecting the protégé to key decision makers while keeping her or him protected from negative influences. Sponsors take advantage of the organizations and people in their sphere to present their protégés in the most positive light, with the goal of career advancement. This more active approach has been shown to be especially helpful in helping nurses of color rise in the leadership ranks (Beckwith et al., 2016).
ACHIEVING THE COMMITTEE’S VISION OF NURSE LEADERSHIP
As previously noted, many nurse leaders are currently focused on incorporating equity into their work. To achieve the committee’s vision, however, a significant investment in broader and deeper development of nurse leadership will be needed. New and established nurse leaders—at all levels and in all settings—are needed to lead change that results in meeting social needs, eliminating health disparities, addressing SDOH, and ultimately achieving equity in health and health care, with the aim of improved health for all individuals and communities. Nurse leaders need to both develop and expand the leadership competencies described in this chapter, and implement strategies targeted to achieving diversity among nurse leaders. Nurse leadership competencies and knowledge can be developed through approaches that encompass education, fellowships, and nursing organizations, as discussed below.
Increasing Diversity in Nurse Leadership
Diverse leaders can serve as particularly important role models, provide guidance and mentoring for other nurses, influence the allocation of resources, and shape policies aimed at eliminating inequities (Phillips and Malone, 2014). The prior The Future of Nursing report identifies the need for a renewed focus on diversity in nursing, calling for the development of novel education models that promote respect for diversity along a number of dimensions, such as race, ethnicity, geography, background, and personal experiences (IOM, 2011). Even when nurse leaders hold similar positions, salary disparities are seen among racial and ethnic groups. Among nurse leaders with the highest salaries (ranging
from clinical staff to C-suite executives), only 11 percent are Black, compared with 27 percent who are Asian American, 25 percent who are Hispanic, and 21 percent who are White. Not only are few Black nurses in positions of leadership at all, but even fewer advance to careers as nurse executives (Iheduru-Anderson, 2020a; Jeffries et al., 2018).
Understanding and addressing the reasons for the diversity gap in nursing leadership is essential. The existing literature identifies racism as a significant factor (Iheduru-Anderson, 2020a). Nursing’s roots in the United States have been shaped within the context of colonialism, a history that has influenced the makeup of the profession’s leaders (Waite and Nardi, 2019). As discussed earlier, acknowledging and addressing how racism has been internalized and how it has manifested within the field, including in the advancement of nurses of color, is key (Brathwaite, 2018; Waite and Nardi, 2019). Other barriers include stereotyping; a lack of career development opportunities (Carroll, 2020); a lack of mentorship (Ihederu-Anderson, 2020b); inadequate support systems; isolation; the perception of being overlooked for positions in contrast to White counterparts (Kolade, 2016); and the cultural taxation or diversity tax (Gewin, 2020), characterized by the role assigned to the ethnic representative of a group involving the expectation that this individual will provide unofficial diversity consultation.6
Numerous innovative programs aimed at cultivating diversity in nursing leadership have been developed and implemented. A number of these programs target nurses early in the trajectory of development (in prebaccalaureate or baccalaureate programs), while others are aimed at later stages of professional growth. Examples of programs focused on early leadership training include EMBRACE (Engaging Multiple communities of BSN [bachelor of science in nursing] students in Research and Academic Curricular Experiences), which was developed to provide comprehensive experiences in research and leadership for undergraduate students of color who are underrepresented in nursing, and the Duke University School of Nursing’s Making a Difference program (Carter et al., 2015; Stacciarini and McDaniel, 2019). Likewise, the University of North Dakota has a program called Recruitment & Retention of American Indians into Nursing (RAIN), which provides academic support and assistance to American Indian nursing students, from prenursing programs through doctoral education (UND, 2020). (See Chapter 7 for further discussion of recruiting and supporting underrepresented students.) To fully support the goal of diversity in nurse leadership, such programs will need to be evaluated and scaled.
Nursing Education, Fellowships, and Certificates
While nursing school curricula often include some information about public health, SDOH, and health equity, they do not always prepare students to engage
6 Cultural taxation refers to the phenomenon whereby faculty who are individuals of color are asked routinely to take on extra, uncompensated work to address a lack of diversity in their institutions.
fully with and serve as leaders on these issues. Nursing education traditionally has emphasized the development of clinical skills over leadership and management skills (Joseph and Huber, 2015). As discussed in Chapter 7, the American Association of Colleges of Nursing’s (AACN’s) Essentials7 provides an outline for the necessary curriculum content and expected competencies for graduates of baccalaureate, master’s, and doctor of nursing practice (DNP) programs. Introducing the concept of health equity in school is a necessary first step in professional role development and leadership, but nurses also need to take every opportunity to supplement their preparation through continuing education.
A number of fellowships support education in leadership skills with a focus on health equity and community health.8 Nearly all of these fellowships are interdisciplinary, bringing together professionals from multiple sectors, including health care, business, community organizing, education, and the law. These types of fellowships present opportunities for nurses to grow their leadership skills, to collaborate and innovate with professionals from multiple disciplines and sectors, and to develop and implement projects within their areas of interest that relate directly to achieving health equity. In addition to equity-specific fellowships, a wide variety of fellowships available for nurses are focused on general leadership skills that can be transferred to any area and any setting, including addressing SDOH and pursuing health equity.
One fellowship specifically for nurses and focused on equity is the Environmental Health Nurse Fellowship, which trains nurses to work with communities to address environmental health threats. In 2019, the Alliance of Nurses for Healthy Environments (ANHE) launched this fellowship to focus on environmental health equity and justice and on the disproportionate impact of environmental conditions on underserved groups. The 30 fellows, all of whom are nurses, work with mentors to help communities identify environmental needs and build support for community-driven solutions (ANHE, 2019).
The Global Nursing Leadership Institute9 (GNLI) fellowship, sponsored by the International Council of Nurses and supported by the Burdett Trust for Nursing, is available to nurses worldwide. This fellowship is focused on policy leadership, with a special emphasis on strengthening political and policy understanding and influence. Its framework includes in-depth work on the United Na-
7 The February 2021 final draft (AACN, 2021) is available at https://www.aacnnursing.org/Portals/42/AcademicNursing/pdf/Essentials-Final-Draft-2-18-21.pdf?ver=hNeCl7OjgamIA9sHgDi_Yw%3d%3d×tamp=1613742420447 (accessed April 8, 2021).
8 See, for example, the Atlantic Fellows for Health Equity at The George Washington University Health Workforce Institute, the Diversity and Health Equity Fellowship of the American Hospital Association, and the Robert Wood Johnson Foundation’s Health Policy Fellows and Culture of Health Leaders programs.
9 See https://www.icn.ch/what-we-do/projects/global-nursing-leadership-institutetm-gnli (accessed April 8, 2021).
tions’ Sustainable Development Goals, which reflect multiple SDOH. The focus of 2020 was on health disparities in the context of the COVID-19 pandemic.
Many certificate programs in the United States can help nurses develop leadership skills that can be leveraged to lead work in equity in health and health care. Examples include the Health Equity Certificate at the University of Pittsburgh School of Public Health10 and the Graduate Certificate in Health Equity at the Vanderbilt University Medical Center.11
The Role of Nursing Organizations
Most professional nursing organizations recognize and specifically call out leadership as an essential competency for nurses in all settings (NAHN, 2020; NCEMNA, 2020; NLN, 2005; Quad Council, 2018). These organizations offer leadership courses, resources, and support, most pertaining to leadership in general rather than leadership on health equity, for current and aspiring nurse leaders. Nursing organizations also have undertaken specific initiatives to develop and support nurse leaders that include content related to equity in health and health care. Examples include the following: (1) the American Public Health Association Public Health Nursing Section, with the vision of advancing social justice and equity to achieve population health for all12; (2) the Future of Nursing: Campaign for Action, with the vision of working toward an America in which everyone can live a healthier life, supported by nurses as essential partners in providing care and promoting health equity and well-being13; (3) the Black Coalition Against COVID-19,14 an interprofessional multisector coalition, co-led by the National Black Nurses Association, focused on urgently mobilizing and coordinating all available community assets in a collaborative effort with the government of Washington, DC; and (4) the National Coalition of Ethnic Minority Nurse Associations (NCEMNA), which stands as a unified force advocating for equity and justice in nursing and health care for ethnic minority populations.15 In addition, professional associations offer nurses an opportunity to build leadership competencies by leading within the association. While some nursing associations are small and others large, each can offer nurses an opportunity to meet other nurses, join boards and workgroups, and help guide the association’s direction, especially toward the goals germane to this report.
Nursing associations that are organized around a racial or ethnic identity may offer a particularly good opportunity for underrepresented nurses to hone their
10 See https://catalog.upp.pitt.edu/preview_program.php?catoid=73&poid=23709&returnto=6375 (accessed April 8, 2021).
11 See https://www.vumc.org/healthequity/graduate-certificate-health-equity (accessed April 8, 2021).
12 See https://www.apha.org/apha-communities/member-sections/public-health-nursing (accessed June 7, 2021).
leadership skills. The NCEMNA is an umbrella organization of five national ethnic nurse associations: the Asian American/Pacific Islander Nurses Association, the National Alaska Native American Indian Nurses Association, the National Association of Hispanic Nurses (NAHN), the National Black Nurses Association, and the Philippine Nurses Association of America. One of the five strategic goals of the NCEMNA is to “promote ethnic minority nurse leadership in areas of health policy, practice, education and research” through the implementation of leadership development and mentorship programs (NCEMNA, 2020).
All nurses have the capability to lead and engage in meaningful roles in addressing SDOH and health equity, with their specific roles and functions depending on individual interests, capacities, and opportunities.
Conclusion 9-1: Nurse leaders at every level and across all settings can strengthen the profession’s long-standing focus on social determinants of health and health equity to meet the needs of underserved individuals, neighborhoods, and communities and to prioritize the elimination of health inequities.
Given that social determinants that affect health exist largely outside of the health care system (e.g., poverty, literacy, housing, transportation, and food security), addressing SDOH and eliminating health disparities will require collaboration and partnership among a broad group of stakeholders. Public health nurses have a long history of working collaboratively to meet social needs and address SDOH, and their experiences can be used as models for other nurses seeking to work collaboratively across sectors.
Conclusion 9-2: Achieving health equity will require multisector collaboration, and nurse leaders can participate in and lead these efforts.
Conclusion 9-3: Many community and public health nurse leaders have expertise and experience in leading cross-sector partnerships to meet social needs and address social determinants of health, and their expertise can be leveraged to inform the broader nursing profession in both practice and education.
Racism and discrimination are deeply entrenched in U.S. society and its institutions, and the nursing profession is no exception. Nurse leaders have an important role to play in acknowledging the history of racism within the profession and in moving forward to dismantle structural racism and mitigate the effects of discrimination and implicit bias on health. Role modeling listening, engagement,
and inclusivity within and outside of nursing will be necessary to foster trust and achieve needed change. A critical part of these efforts will be building a more diverse nursing workforce and supporting these nurses in their pursuit of and success in leadership roles.
Conclusion 9-4: Nurse leaders have a responsibility to address structural racism, cultural racism, and discrimination based on identity (e.g., sexual orientation, gender), place (e.g., rural, urban), and circumstances (e.g., disability, mental health condition) within the nursing profession and to help build structures and systems at the societal level that address these issues to promote health equity.
Conclusion 9-5: A critical role for nurse leaders is mentoring and sponsoring nurses from traditionally underrepresented communities in order to build a more diverse nursing workforce and increase the number of underrepresented nurses in leadership positions.
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