Nursing in 3D: Diversity, Disprities, nd Socil Determinnts Using Socil Determinnts of Helth to Link Helth Workforce Diversity, Cre Qulity nd Access, nd Helth Disprities to Achieve Helth Equity in Nursing Shnit D. Willims, PhD, MPH, APRN Kristen Hnsen, MHSA, RN, NE-BC Mrin Smithey, MSHP, RN, NCSN Joseph Burnley, DNP, FNP-C Michelle Koplitz, MPH Kirk Koym, MSN, RN, PHN, CNS Jnice Young, PhD, RN Alexis Bkos, PhD, MPH, RN ABSTRACT It is widely ccepted tht diversifying the ntion s helth-cre workforce is necessry strtegy to increse ccess to qulity helth cre for ll popultions, reduce helth disprities, nd chieve helth equity. In this rticle, we present conceptul model tht utilizes the socil determinnts of helth frmework to link nursing workforce diversity nd cre qulity nd ccess to two criticl popultion helth indictors helth disprities nd helth equity. Our proposed model suggests tht diverse nursing workforce cn provide incresed ccess to qulity helth cre nd helth resources for ll popultions, nd is necessry precursor to reduce helth disprities nd chieve helth equity. With this conceptul model s foundtion, we im to stimulte the conceptul nd nlyticl work both within nd outside the nursing field tht is necessry to nswer these importnt but lrgely unnswered questions. U.S. Deprtment of Helth nd Humn Services, Helth Resources nd Services Administrtion, Bureu of Helth Professions, Division of Nursing, Rockville, MD Address correspondence to: Shnit D. Willims, PhD, MPH, APRN, U.S. Deprtment of Helth nd Humn Services, Helth Resources nd Services Administrtion, Bureu of Helth Professions, Division of Nursing, 5600 Fishers Ln., Room 9-61, Rockville, MD 20857; tel. 301-443-1253; fx 301-443-0791; e-mil <swillims3@hrs.gov>. 32
Using SDH to Achieve Helth Equity 33 Tody, in the United Sttes nd throughout the world, n individul s bility to rech his or her full helth potentil is severely constrined by the individul s socil group nd economic sttus. 1 Indeed, the evidence is overwhelming the dvntged in society experience better nd longer helth when compred with the disdvntged nd this stepwise helth dvntge is ptterned long socil nd clss grdient tht results in systemic nd pervsive helth disprities. One proposed pproch to mximizing the helth potentil of every member of society nd reducing helth disprities is to increse ccess to qulity helth cre nd helth-cre resources. 1 3 Achieving helth equity is gol tht cscdes down through ech of the Helth Resources nd Services Administrtion s (HRSA s) six bureus nd nine offices. HRSA s Bureu of Helth Professions (BHPr) demonstrtes its shred commitment to helth equity by ensuring fir nd equitble ccess to the resources necessry to chieve optiml helth, regrdless of popultion s socil or economic sttus. 4 BHPr hs contributed n evidence-bsed conceptul frmework to the limited but encourging literture tht supports positive correltion between rcilly/ethniclly diverse helth workforce nd improved ptient outcomes. Two evidence-bsed ssumptions in the BHPr frmework linking helth professions diversity to helth outcomes re: (1) helth professionls who re from rcil/ethnic minority groups nd come from socioeconomiclly disdvntged bckgrounds re more likely to serve in resource-poor nd rurl communities, where rcil/ethnic minority groups nd the poor re overrepresented; nd (2) rcil/ethnic nd lnguge concordnce will improve ptient-provider communiction, tolernce, trust, nd decision-mking, thereby incresing ccess to, nd qulity of, the interction tht would result in improved helth outcomes (Figure 1). 5 The Division of Nursing (DN), locted within BHPr, ims to extend the conceptul frmework linking helth-cre workforce diversity to incresed ccess nd qulity to include its potentil impct on popultion helth by describing potentil pthwy connecting diverse nursing workforce to decresed helth disprities nd improved helth equity (Figure 2). The DN supports progrms tht ensure the dequte supply nd distribution of nursing professionls prepred to deliver high-qulity, competent cre. The nursing workforce idelly should reflect the culturl nd socil needs nd vlues of the communities in which they serve. Furthermore, we believe tht equitble ccess to qulity helth cre nd helth resources is criticl to reducing helth disprities nd chieving helth equity. Given this orienttion, we suggest tht nursing workforce diversity is not n end unto itself; rther, we envision nursing workforce diversity s key strtegy for incresing ccess to qulity helth cre nd helthcre resources. Figure 1. Conceptul frmework linking helth professions diversity to helth outcomes, 2006 Deprtment of Helth nd Humn Services (US), Helth Resources nd Services Administrtion, Bureu of Helth Professions. The rtionle for diversity in the helth professions: review of the evidence. Rockville (MD): HHS; 2006.
34 Nursing in 3D: Diversity, Disprities, nd Socil Determinnts Figure 2. Expnded conceptul model linking helth professions diversity to helth disprity nd helth equity outcomes, 2012 Adpted from: Deprtment of Helth nd Humn Services (US), Helth Resources nd Services Administrtion, Bureu of Helth Professions. The rtionle for diversity in the helth professions: review of the evidence. Rockville (MD): HHS; 2006. THE NURSING WORKFORCE DIVERSITY PROGRAM The primry lever in which the DN implements its diversity gend is through its Nursing Workforce Diversity (NWD) progrm. The NWD progrm ws legisltively mndted under Title VIII of the 1989 Public Helth Service Act, with uthority to increse nursing eduction opportunities for individuls from disdvntged bckgrounds (including rcil/ethnic minority groups) who historiclly hve been underrepresented mong registered nurses. 6 The NWD legisltion uthorized individul-level finncil instruments (e.g., scholrships nd stipends), mentoring, nd socil support strtegies s trgeted pproches to ddress the gps in nursing workforce chievement between historiclly dvntged nd disdvntged popultions. As of 2013, the NWD progrm hd wrded pproximtely $160 million in institutionl grnts to U.S. schools of nursing to fcilitte disdvntged individuls nvigtion through the nursing pipeline. The Ptient Protection nd Affordble Cre Act of 2010 expnded the NWD progrm s uthority to increse the workforce of registered nurses with dvnced degrees by ssisting registered nurses with diploms or ssocite degrees to become bcclurete-prepred registered nurses, nd by prepring prcticing registered nurses for dvnced nursing eduction. 7 In 2011, the DN begn comprehensive two-yer evlution of the NWD progrm grnt portfolio to ressess the reltive impct of the progrm s individullevel strtegies nd incentives scholrships nd lons, mentoring nd socil support in nursing school enrollment, retention, nd grdution. One objective of the progrm evlution is to identify grntee projects tht could serve s best-prctice models for diversifying the workforce. The completed progrm evlution is expected to yield ctlogue of successful workforce diversity strtegies tht could be modeled nd scled throughout the country. We hope to lso gin greter understnding of the seemingly intrnsigent multilevel fctors tht impede our bility to dvnce robust workforce diversity gend. In fct, the evlution dt should provide criticl insights regrding the progrm s effectiveness nd will inform our future investments in the nursing workforce diversity portfolio. This initil progrm evlution work redirected nd expnded the DN s thinking to consider innovtive strtegies to ddress the lrger socil nd structurl forces tht provide context for the underrepresenttion of disdvntged socil groups in the registered nurse workforce. The division is convinced tht dditionl socil- nd structurl-level strtegies, such s institutionl ledership buy-in nd multi-sector prtnerships, should complement nd support not supplnt existing legisltion tht directs individul-level strtegies such s scholrships, lons, mentoring, nd socil support ctivities.
Using SDH to Achieve Helth Equity 35 CONCEPTUAL MODEL As prt of the initil NWD progrm evlution, DN stff reviewed the literture within the overrching domins of workforce diversity, helth-cre ccess nd qulity, helth disprities, helth equity, nd the socil determinnts of helth (SDH). The purpose of the literture review ws to gin n overll sense of which progrms nd strtegies were chieving the gretest gins in workforce diversity nd why those progrms nd strtegies were successful. Bsed on the review of the literture, we inductively developed conceptul model with four bsic constructs comprising sequentil set of liner reltionl sttements. The three-dimensionl (3D) conceptul model diversity, disprities, nd determinnts (Figure 3) depicts stepwise reltionship mong nursing workforce diversity, helth-cre ccess nd qulity, helth disprities, nd helth equity, ll within the context of n SDH frmework. The first construct of the model is nursing workforce diversity. Diversity includes those historiclly underrepresented groups in nursing rcil/ethnic minority groups, men, people with disbilities, nd the eductionlly nd economiclly disdvntged s key socil groups requiring trgeted efforts nd dedicted resources to close the chievement gp nd increse their proportionl representtion in nursing. The second 3D construct is ccess to qulity helth cre. Admittedly, helth-cre ccess nd helth-cre qulity re two seprte conceptul domins; in the 3D conceptul Figure 3. Nursing in 3D conceptul model depicting the stepwise reltionship mong nursing workforce diversity, helth-cre ccess nd qulity, helth disprities, nd helth equity 3D 5 diversity, disprities, nd socil determinnts model, the two concepts hve been linked. The model hypothesizes tht ccess to qulity cre implies sfe, timely, efficient, effective, equitble, respectful, nd culturlly ligned cre tht meets helth need. 2,8 The third construct is helth disprities. Helth disprities re those entrenched vritions in helth nd helthcre outcomes tht re closely linked with economic, socil, nd environmentl disdvntge. 1 3 The fourth construct is helth equity. Helth equity is conceptulized s tht highest stndrd of helth ttinble for ll popultions, regrdless of socil group sttus or historicl disdvntge. 1 In the conceptul frmework linking helth professions diversity to helth outcomes, 5 helth outcomes re presented s n individul-level construct. In the 3D model, helth outcomes re frmed t the popultion level s helth disprities nd helth equity. The 3D model is proposed s one potentil pthwy to chieving helth equity from the strting point of diverse nursing workforce strtegy. In August 2012, the DN sponsored n invittionl interdisciplinry summit entitled Nursing in 3D: Workforce Diversity, Helth Disprities, nd Socil Determinnts of Helth. The summit s mission nd gols emerged from the constructs rticulted in the 3D conceptul model. The overrching gol of the summit ws to provide our nursing stkeholders nd grntee communities with the intellectul nd conceptul tools necessry to pply the SDH frmework to dvnce the gend for nursing workforce diversity nd helth equity. Experts in the fields of nursing workforce diversity, helth-cre qulity nd ccess, helth disprities, nd SDH were convened by HRSA to detil the full rnge of cdemic nd helth system fctors, s well s the socil, economic, nd environmentl determinnts tht influence helth workforce diversity nd helth equity. At the conclusion of the summit, there ws sufficient momentum to forge hed with using the 3D conceptul model to frme the DN s nursing workforce diversity gend. Moreover, we believed tht pproching nursing workforce diversity through the lens of SDH would spwn innovtions nd fcilitte the development of effective pproches to reduce, nd eventully eliminte, helth disprities to chieve popultion helth equity. With the publiction of this specil supplement dedicted to the 3Ds, the DN hopes to dvnce the scholrly inquiry round the intersecting gols of incresed workforce diversity, fir nd equl ccess to qulity helth cre nd helth-cre resources, elimintion of helth disprities, nd chievement of helth equity. To tht end, we im to expnd our DN grnt portfolio to include n orgnized nd coherent set
36 Nursing in 3D: Diversity, Disprities, nd Socil Determinnts of novel nd innovtive projects tht test the ssumptions nd constructs in the 3D conceptul model with deliberte ttempt to further refine nd expnd the model nd its utility in nursing. Middle-rnge theories both within nd outside of nursing tht re comptible with the 3D model will need to be utilized to test the model s bsic theoreticl sttements nd ssumptions, estblish priorities for future work, nd further refine the reserch methods nd mesures in the intersecting fields of workforce diversity, helth-cre qulity nd ccess, helth disprities nd helth equity, nd SDH. 9 For exmple, the explortory nd confirmtory work tht is underwy to test the linkge ssumption tht incresing workforce diversity does indeed hve quntifible impct on helth-cre qulity nd ccess needs to be expnded. Similrly, while there is firly consistent evidence to support the theory tht incresing ccess to qulity helth cre for the most vulnerble mong us leds to reduction in helth disprities, 3,10 there is lso competing literture tht presents compelling evidence tht helth disprities re n entrenched feture of our socil fbric nd, despite incresed ccess to helth cre, helth disprities mong dvntged nd disdvntged popultions remin. 1,2,11 13 While work hs lredy begun in the field to understnd the reltive impct of decresing helth disprities on chieving helth equity, this work is still underdeveloped. Until now, the consensus in the field hs been tht the reltionship between helth disprities nd helth equity is inverse nd proportionl, nd, s the rtes of helth disprities decresed, commensurte nd proportionl increse in the rtes of helth equity would occur. In other words, when helth disprities re eliminted, helth equity would be chieved. 1,14 Menwhile, to demonstrte the DN s focus nd commitment to SDH nd helth equity, funding opportunity ws relesed in Jnury 2013 tht requires NWD pplicnts to propose innovtive workforce diversity projects tht offer multilevel, evidence-bsed pproches tht incorporte SDH into strtegies to diversify the nursing workforce with gol of improving popultion helth equity. The relese of the 2013 funding opportunity mkes the urgency to simultneously develop the relevnt mesures nd metrics to chrt progress towrd our gol of helth equity ll the more relevnt. CONCLUSION In summry, the DN ims to crete synergistic work nd ctive enggement mong our professionl peers nd multiple stkeholder communities who shre commitment to increse workforce diversity, ensure ccess to qulity helth cre nd helth-cre resources, nd reduce nd eventully eliminte helth disprities s mens of chieving popultion helth equity. 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