Equity in Nursing: Addressing Inequities in Healthcare

• Equity Lecture: Who, what, why, where and how

• Whakatauki: Kotahi karihi, nāna ko te wao tapu nui a Tāne

Trigger warnings

• Political
• Gender
• Ethnicity
• Discrimination
• Bias
• Opinions
• Colonisation
• The dark side of the nursing profession

Learning outcomes

• Define and explore equity
• Describe what groups inequity affects
• Describe the cause of inequity in Aotearoa
• Describe the nurses role in addressing inequities
• Discuss and produce strategies on how inequities can be addressed

Relationship to science

• Chapter 41 in Understanding Pathophysiology
• Chapter 4 in Lewis's Medical-Surgical Nursing

Bachelor of Nursing Curriculum

• The program focuses on equity for Māori and Pacific populations, mental health, addiction, and primary and community health.
• The principles of Te Tiriti o Waitangi are foundational to the program and are evident in theory and practice.
• An integrated approach enables students, upon graduation, to work in partnership with whānau, hapu, iwi, and across hospital and community settings.
• Graduates gain a deeper appreciation of current and anticipated Aotearoa-NZ health issues.
• Illnesses, diseases, and conditions impact different populations differently.
• Understanding the reason behind these differences is important.
• Assessment and engagement are important aspects.
  • Ex. sore throat
• Purposeful engagement with populations that experience significant discrimination when accessing healthcare is needed.

Racism Definition

• Racism is the marriage of racist policies and ideas that normalizes racial inequities.
• A racist policy produces or sustains racial inequity between racial groups.
• An antiracist policy produces or sustains racial equity between racial groups.
• All policies in every community produce or sustain either racial inequity or equity between racial groups.
• (2019) “Ibram X. Kendi defines what it means to be an antiracist

He aha?

• Ethnic inequities are a defining feature of the health profile of the country.
• Health equity, absence of systematic disparities, can be used as an indicator of racism in health systems.
• The scarcity of tangible reductions in inequity between Māori and non-Māori populations raises questions about the effectiveness of policies to date.
• A possible method to address health inequity: New Zealand might revisit deep-rooted historical, cultural, and systemic issues.

He aha ai?

• Maori sovereignty, arguably a natural entitlement ratified in 1835, has been under attack since before the ink was dry on te Tiriti o Waitangi, as a central practice of establishing the colonial order in Aotearoa.
• Land alienation, economic impoverishment, mass settler immigration, warfare, cultural marginalisation, forced social change, and multi-level hegemonic racism have diminished Indigenous cultures, economies, populations, and rights over more than seven generations.
• The attribution of inequity to surface causes (health practices, psychosocial resources, health system access or social status) ignores the upstream drivers of structural inequity, such as the colonial basis of dominant culture, economic structures, and political and legal systems.
• Health inequities for Māori include a narrative of individual blame, poor health behaviors, and lifestyle choice while failing to acknowledge the history of colonisation and failures of the healthcare system.

Kei hea?

• Inequities exist everywhere.

• Considerable inequities in health status and outcomes for Māori are well-documented.

• During this semester, inequities associated with the diseases discussed will be brought up.

• Examples of inequities that are outside of "health status and outcomes":

• Māori are less likely to:

  • Be screened for cardiovascular disease and prostate cancer
  • Visit a general practitioner (and appointment times are shorter); and
  • Receive life-preserving surgical interventions than non-Māori.

• Māori and Pacific children with asthma are less likely to:

  • Be prescribed an inhaled corticosteroid (ICS)
  • Have an action plan
  • Receive adequate asthma education

• There is evidence of differential access to healthcare services and concerns about the quality of care provided to Māori

• Mental health:

  • Māori have higher rates of admissions and readmissions to secondary care facilities.
  • Māori have higher rates of seclusion, and Māori in forensic facilities receive less treatment
  • General practitioners are reported to underdiagnose mental health problems among Māori.

Whai mana tauorite

• Have Māori made gains towards equity? If so, where?

Ko wai?

• Māori
• Pacific
• Women
• Disabled
• Rainbow community
• Dark skin tones and apart of religious backgrounds

He aha ngaa tapuhi i whawhai ai?

• Why or how is it the nurses' responsibility to address inequities?
  • 80% of direct patient contact
  • Often considered the most trusted health care profession
  • Often the first point of contact when accessing health care
  • Nurses are the largest health care profession (1/67 person in our population is a nurse)
  • Professional and moral obligations to address inequities

Me aha taatau??

• An integrative review of racism in nursing to inform anti-racist nursing praxis in Aotearoa New Zealand
• Indigenous and racially minoritised workforces are underrepresented, with reports of racism and unequal access to education, career opportunities, and pay.
• There has been a resurgence of activity to promote anti-racist and decolonising nursing praxis.
• For Indigenous and racially minoritised nurses, the compounding intersectionality of being Indigenous, Black, or a person of colour, a nurse, often female, and the subsequent experience of racism, patriarchy, and discrimination results in high levels of burnout in an already overburdened and underrepresented workforce.
• A nursing workforce ethnically representative of the community it serves is a key factor in addressing health inequity.
• Racism is the unfair and avoidable disparities in power, agency to exercise authority, resources, and opportunities, which are held in place by organised structures
• Racism has been consistently linked with poorer mental and physical health outcomes and reduced healthcare access.
• Indigenous peoples are particularly disaffected, experiencing exclusionary processes and discrimination resulting from colonizing practices, which remain embedded in society and institutional systems.
• Racist health systems are driven by westernised political, managerial, and biomedical ideologies that are replicated and delivering healthcare that fails to embody Indigenous and minoritised worldviews.
• Health disparities between Indigenous and racially minoritised populations and their (mostly European) settler populations remain unfair and unacceptable.
• Colonial processes have been profoundly racist, privileging white Europeans over Māori ( the Indigenous people of Aotearoa (NZ)).
• Breaches of Te Tiriti o Waitangi (New Zealand's founding treaty) across the health sector have included reduced access to healthcare for Māori, underrepresentation of the Māori health workforce, and racism within the nursing profession.
  • Colonial active resistance was deeply embedded at individual, professional, and institutional levels, which maintained the status quo and persisting inequities.
• This review identified multiple strategies to promote anti-racist praxis which would enable the nursing profession to play a key role to uplift, honour and value Indigenous and racially minoritised nurses for their contributions.

Conclusion

• It is no longer acceptable for non-Indigenous and white nurses to feel paralyzed or to actively resist challenging the impact of racism and racist structures.
• Nurses hold power, are well-positioned to create change, and act as allies.
• Anti-racist praxis affords all nurses the opportunity to transform the health workforce, healthcare, and health outcomes so that everyone benefits.
• It is now more timely than ever for nurses to rise to this challenge.

What is an anti-racist praxis??

• Anti-racist praxis begins with non-Indigenous and white nurses developing critical consciousness to understand their positionality, power, and privilege in the world, particularly the impact of colonization in relation to racism, Indigenous rights and equity.
• Developing genuine and authentic relationships with Indigenous and racially minoritised nurses and communities is necessary for active allyship and the intentional shifting of power and resources.
• Indigenous and racially minoritised nurses require space to dismantle internalised colonial processes, reclaim their Indigeneity and knowledge practices, and identify racism.
• The education of nurses requires a fundamental paradigm shift to embed undergraduate, postgraduate, and professional development programmes with culturally safe pedagogy which promotes anti-racist praxis and equity of health and workforce.
• In Aotearoa (NZ), the articles of Te Tiriti o Waitangi provide an anti-racist framework.
• Anti-racist education requires integral health service delivery, education, managerial processes, and governance.
• There is a pressing need for constitutional reform to promote Indigenous rights and treaties and counter regressive policies that risk cultural erasure.
• Indigenous-centric legislation, policies, and processes will combat colonial and institutionally racist systems.
• Health workforce that is representative of the Indigenous and racially minoritised population requires intentional recruitment and training strategies.
• Retention requires successful transition into a workplace free from racism and intentionally promoting career progression of Indigenous and racially minoritised nurses into leadership positions, including in education and research.

Me aha taatau??

• Māori nurses ask tauiwi nurses to walk beside them to cultivate of social justice, self-reflection, and active allyship that supports an equitable and flourishing environment.

• For tauiwi nurses, allyship asks they become comfortable with uncomfortable and amplify the voices of Māori nurses who offer essential knowledge required for systemic change.

• Understanding the colonial history and how nurses maintain racism as the status quo is the first step.

• Nurse leaders need to commit to growing and strengthening the Māori nursing workforce through intentional culturally safe pathway strategies.

• Nursing education programmes need to prioritize pedagogy, is is creative, consistent, continuous, centres Indigenous knowledge and expertise .

• Strategies to address inequities:

  • White paralysis
  • Allyship
  • Addressing fairness and biases
  • Take it home (collectivism to create ripple effects etc)
  • Have the courage to have uncomfortable conversations especially with those who have done wrong
  • Advocacy/ act of being political
  • Have courage to identify when things are not right - approach in a mana enhancing way
  • Communication is food for leaders - vital aspect
  • Practice Active listening
  • Stand up for others even if it makes you feel slightly uncomfortable

• Reflect on this article and we will break it down a little more next week in tutorial groups

Learning outcomes

• Define and explore equity
• Define equity
• Analyse what groups inequity affects
• Analyse the cause of inequity in Aotearoa
• Describe the nurses role in addressing inequities
• Analyse and produce strategies on how you can address inequities

Whakataukī

• Ahakoa whati te manga, e takoto ana ano te kohiwi