A Disturbing Narrative

Lovoria:
When COVID-19 first started and more of the data started to emerge about the disparities among Blacks and other populations of color, I was really disturbed by some of the narrative. To me, the discussions in articles and opinions in the newspapers seemed to blame Blacks for their poor health outcomes. I heard things such as, oh, we know that COVID-19 mortality is higher among people who have diabetes, obesity, underlying lung disease, etc. And we know those things to be true. But what was missing in the literature that was most disturbing to me, was that there wasn’t an acknowledgement regarding why. Why is it that Blacks have more obesity, diabetes, more cardiovascular disease? It’s because of the structural racism, the health inequities that have persisted across this country for 400 years,

Nacole:
Health equity and structural racism. It can be hard to understand how these topics relate to our shifts. That’s why I’m so glad I got to talk to our guest Lovoria. Lovoria is a family nurse practitioner, a professor and a researcher. We talked about the fact that Blacks are almost four times more likely to die from COVID than whites. And we also talked about the why, because that’s the only way we can fight the false narrative that Blacks have to blame for their own deaths. My name is Nacole Riccaboni. I’m a critical care nurse working in Florida and your host for Shift Talk. This podcast is brought to you by Shift, a new community for nurses ready to make a change. Shift is sponsored by the Robert Wood Johnson Foundation. Follow us on Instagram at shiftnursing, and for more awesome stories and real talk about nursing, head over to our website at shiftnursing.com. One final note, this episode was recorded in mid-July, and things with COVID might’ve changed between now and then. Let’s begin.

Nacole:
Lovoria, why don’t you tell me about your experiences coming up in the nursing kind of profession in general?

Lovoria:
Oh, wow. So I believe, I don’t recall ever wanting to be anything other than a nurse, even from a little girl. Now when I think back on it, I recall my mom telling me that I was going to be a nurse.

Nacole:
Oh did she?

Lovoria:
So maybe that influenced my decision.

Nacole:
It was meant to be.

Lovoria:
But so I never planned on being anything other than a nurse. And so I graduated from high school pretty young, I was 17, and immediately started the community college in Kentucky. Nacole you’re, I believe you’re younger than I am, but in those days nursing school was about the strongest surviving.

Nacole:
For sure, yeah.

Lovoria:
You know that we have to pass NCLEX. So when I look back on it and I look in the literature, there was this process of really weeding out what was thought as the weaker students.

Nacole:
For sure.

Lovoria:
So we could be dismissed from the program for anything.

Nacole:
Oh my gosh. I’m nervous for you. Oh, really?

Lovoria:
Oh yeah.

Nacole:
Oh my gosh.

Lovoria:
We had three chances to perform a foley insertion. We had three chances to wash our hands in the way that they had taught us to wash her hands. A couple of chances to write a paper in the way that they wanted it to be written. So as a result of that, I actually was dismissed from that program, even though I had an A average. I was dismissed because of a paper. After every paper, after every exam, there was a period where students were called into a private room, and we would see them leave. And it would be as a result of that one assignment.

Nacole:
That’s insane!

Lovoria:
Oh yes.

Nacole:
That is insane.

Lovoria:
So I tease my students now, and I tell them that there is no reason why you should not succeed, because we provide so many resources for our students now. And we try to, too, once they’re accepted to the program, you know, we really do all that we can to retain our students now. So very supportive environment in nursing school compared to the way it was when I was a student.

Nacole:
I ended up getting a C myself in pediatrics, and you’re only allowed one C, and I was almost getting my next C, and I was crying. And my husband’s like, yeah, but you’re passing, and I was like, you don’t understand, you don’t get it. It’s so stressful. I thought I was having a nervous breakdown. And looking back, you just forget how intense it was.

Lovoria:
Yes.

Nacole:
You weren’t in competition, but you were in competition with other students. And you would share your grades and you’d do groups. I remember it being the most stressful part of my entire life. Even with two kids now, I had no kids back then, and I was just constantly studying, constantly stressed out. You’re constantly scared, it was the most terrifying two years of my entire life.

Lovoria:
Yes, very similar now. I mean, there’s no way around it. Nursing is a very challenging major, but the difference now I believe is the support that we provide for mental health. We try to recognize students who are having challenges early and provide resources for tutoring, etc. for them. And that simply is not the way it was for me.

Nacole:
Yeah. I think now they’re trying to focus on building a community, which, every student needs that support system. Back then, I guess they assumed that you would figure it out on your own. I don’t know, but I felt very isolated, like you said. I was just scared. And my family, we don’t have a lot of medical professionals, so I couldn’t really bounce off my fear or my hesitation or my lack of knowledge with anyone else around, like my family.

Lovoria:
Absolutely. And I think that’s another challenge for our students of color. Even though I knew I wanted to be a nurse, I didn’t know any nurses. I was from Kentucky, which is a predominantly white state. And once I completed my program of study, I was one of two Black nurses at the entire hospital. So we didn’t have that socialization into the profession. I have yet to have a faculty member who reflected my image.

Nacole:
Yeah. Same here. Same here. For sure.

Lovoria:
Yeah.

Nacole:
So you wanted to focus on the preventative measures?

Lovoria:
Absolutely.

Nacole:
Okay.

Lovoria:
And really trying to understand how the systems that are necessary to help people at the individual level change their behaviors. Most of the time I use social cognitive theory, and I use the theory of planned behavior a lot, but I always approach it from an ecological model. Meaning there’s the individual, then there’s interrelationships, there’s an environment, then there’s policy. So I try to address all of those levels of influence that a person experiences when they’re trying to change their behavior.

Nacole:
That’s smart, because a lot of people think that behavior is based on that one individual, and they don’t ever factor in the environment, the relationship dynamics, finances, their circumstances. That’s so good to hear.

Lovoria:
Social determinants of health is actually what you’re describing.

Nacole:
Oh, really? Oh, look that, I didn’t know that.

Lovoria:
All of these things that, just because of our zip code, our occupation, our neighborhood environment, all of those things that really explain why we have the conditions that we have.

Nacole:
Because in the hospital, I’m only with patients for a couple of hours, a couple of days. I wish I could assign a social worker or even someone outpatient to manage those chronic issues. Because if they’re not buttoned up and taken care of, they’re going to come right back.

Lovoria:
Yes.

Nacole:
And like you said, I’ve heard a lot of people say, you know, I feel like all I’m doing is giving out pills. And it’s like, yeah, because the hospital’s not where you’re going to get that well-rounded care.

Lovoria:
Absolutely.

Nacole:
We focus on one disease process. We fix a couple of things and we send you out there, but you need someone on your team out there in the world.

Lovoria:
Absolutely. And in primary care, you know, we’re seeing patients every 15 to 30 minutes, if we’re lucky. I know some practices that are seeing in 10 to 12 minutes, and you know, you can’t do much within that constricted timeframe other than, what’s bothering you today?

Nacole:
I know.

Lovoria:
Address that. And that’s not how we’re even educated as nurses. We’re very holistic.

Nacole:
So talk to me about the inequalities and challenges that you see in the minority communities in your area.

Lovoria:
Oh wow. The inequalities that I see related to health, they’re not just in my area. And that’s what really makes it so disturbing to me that, you know, what I see with obesity rates in the state of Kentucky, diabetes rates, cardiovascular disease, and for Kentucky, cancer. So what I see in Kentucky is really just what’s exemplified across the nation and what we see among Blacks and their poorer health outcomes and disparate rates of morbidity and mortality.

Nacole:
You spoke out about the kind of COVID-19 racial inequalities. Can you dive a little deeper into that?

Lovoria:
When COVID-19 first started and more of the data started to emerge about the disparities among Blacks and other populations of color, I was really disturbed by some of the narrative. To me, the discussions in articles and opinions in the newspapers seemed to blame Blacks for their poor health outcomes. I heard things such as, oh, we know that COVID-19 mortality is higher among people who have diabetes, obesity, underlying lung disease, etcetera. And we know those things to be true. But what was missing in the literature that was most disturbing to me was that there wasn’t an acknowledgement regarding why. Why is it that the Blacks have more obesity, diabetes or cardiovascular disease? It’s because of the structural racism, the health inequities that have persisted across this country for 400 years. And so let’s talk more about addressing that and looking at things within the lens of social justice. Then we won’t risk blaming people for being more at risk. And we’re not acknowledging when we talk about COVID-19 that some of the privileges — such as working from home, not using public transportation, being able to have our groceries delivered to our homes — that those are privileges that oftentimes communities of color simply don’t have. And I think within the profession that we are in the best position to really influence broader discussions. And it’s difficult, speaking up to our colleagues about, you know, have you considered that this individual can’t socially distance when they live in a home with several generations, and the young adults are having to go to work, and they’re working in frontline positions, and they’re coming home. And the house simply isn’t large enough to accommodate social distancing.

Nacole:
For sure. Now you mentioned different narratives, but how do you feel nurses really play into the false narratives about Blacks and minorities when it comes to them getting sick during the COVID-19 pandemic?

Lovoria:
Oh, there’s a word that I hear in the profession so frequently, and that word is noncompliant.

Nacole:
I didn’t mean to laugh. It’s so true. They love using that word for everything.

Lovoria:
Yes.

Nacole:
Oh it’s hilarious.

Lovoria:
And I just think that nursing must drive the narrative about what it takes to be compliant, to be able to follow the instructions. You know, we have to consider health literacy. We have to consider all social determinants of health, you know, does this person, number one, have access to get the prescription filled that we provided for them? Is this person able to have transportation to go and pick up the prescription? Where does this person work? Are they able to take a break? If it’s something that we’ve prescribed three times a day, are they able even to take a break at two o’clock to go and take what we prescribed for mid-day?

Nacole:
Yeah!

Lovoria:
So really just thinking about the patient holistically and really thinking about social determinants of health in every patient encounter.

Nacole:
And you have to dive deeper to find out why, if you’re going to use your term of noncompliance, why are they noncompliant?

Lovoria:
Absolutely.

Nacole:
Because so many times, you can give me a prescription, but if I don’t have a car or if the pharmacy is 40 miles away, I can’t take the medicine.

Lovoria:
Yes. Or what about, when I go to the pharmacy and the person is dismissive to me, they hand me the prescription, but they don’t explain how to take it like they did for the person who didn’t look like me in the line ahead of me? And this person got a full explanation. This is how you take you, take it with food and take it on a full stomach.

Nacole:
Yeah.

Lovoria:
And all of this clear explanation. And the person of color comes to the counter, and they’re handed the prescription.

Nacole:
Now explain to me, or tell me, how you think certain individuals and their bias like impacts the way they treat patients?

Lovoria:
Well, I think, you know, as a profession, we know that nursing is a predominantly white profession. The latest data, I recall seeing that white nurses comprise 73% of the profession and for Black, non-Hispanic blacks, it’s only about 8%. And then as we move up the educational level to nurse practitioners and PhD-prepared nurses, you know, those numbers shrink even further. I believe that for PhDs it’s only about 0.5 to 1% are Black in nursing. So what happens with that is that when we’re surrounded with people who are just like us, the same background, it’s very difficult, almost impossible, to develop solutions that are different, that are innovative, are strategies that can address health inequities, when we’re all white, we’re all middle-class, all of our friends and family have access to care, don’t experience racism. So it’s very hard to really have a perspective that’s broad, when we’re all coming from pretty much the same lived experience. That’s how they’re compounded. That’s how they’re perpetuated. It’s because there aren’t enough people of color who are challenging those biases and perspectives. Our governor’s very compassionate, concerned about the health of all Kentuckians. But one thing that he advocated for was more testing in these communities. And that’s great. We definitely need more testing and contact tracing among African American communities, but drive-through testing, something as simple as drive-through testing. When that idea is formed with the perception that everyone has a car.

Nacole:
Yeah. That’s fair. Everyone has a car and means to get there. Yeah, that’s true.

Lovoria:
And then we’re getting reports back of people taking the bus to drive-through testing and being turned around because of it.

Nacole:
Yeah, because you have to, you have to be in a car. Yes. Even here in Orlando, it said, if you did not have a car, you will not be tested. Yeah. I didn’t even think about that. Wow. Wow.

Lovoria:
So that’s why it’s always beneficial to have people at the table that reflect the population that you’re trying to help.

Nacole:
For sure.

Lovoria:
And they will bring these issues up. And then strategies are developed that really take into account all of the potential barriers to whatever it is that you’re proposing.

Nacole:
That makes total sense. Now, talk to me about the larger context of systemic racism in terms of healthcare.

Lovoria:
So with structural racism, that foundation that really provides privilege or opportunities for others, that are inherent in the structure, and really excludes others, such as redlining, for instance. You know, back in the fifties, this practice of redlining, where white people were really encouraged not to live in certain areas. And as a result, there are some neighborhoods in the United States now that are still predominantly black because of racism and banking and real estate practices from the fifties. So if you have that, and what we know for red lining is that in those communities, then the schools are poor. There are fewer grocery stores. So as a result, what happens over time is that those people living in those communities have fewer opportunities for success. Now that builds into the healthcare system. Because if you have students who are poorly educated from elementary school, all the way through high school, they are less likely to be able to enter college.

Nacole:
For sure.

Lovoria:
And even if they can enter college, the data shows that it takes them longer to complete a four-year degree, compared to their white counterparts. And if they enter the healthcare professions, they’re less likely to succeed. And it all stems back to just the structure of historic racism in the nation, that really sets some people up for success and other people for failure.

Nacole:
So tell me, what advice would you give nurses who recognize a need for change, but are unsure about what action they need to take?

Lovoria:
The first thing I would say to them is to educate themselves. Because nursing is predominantly a female profession. So I don’t want to go off into this discussion of intersectionality, but it does affect us as a profession. So when we’re at the table, we have to have a voice and we have to find that voice. And the best way to find that voice is to really be well-educated on what we’re going to speak about so that we can clearly articulate the issues that are facing us. And that’s what makes people listen to what’s being said, just being able to lean in and speak with authority about the issue. So first educating ourselves, and then trying to get on committees to affect change. Because what happens when you join the committee is that you get a community of people who want to change the system. And it’s not always people that reflect your image. And that’s what makes it more positive, is that you have people from diverse perspectives with a concern for one particular issue, and you’re able to really affect change and get some action behind it.

Nacole:
How do you deal with colleagues or work associates who don’t understand social determinants and how that intersects with a systemic racism in healthcare?

Lovoria:
I deal with it with patience. Because one of the first things that I had to do as diversity director is try to understand how other people develop the thoughts and ideas that they have. And then in that way, I’m able to speak to them in a way, to help them understand how, the way they formed that perspective.

Nacole:
Yeah.

Lovoria:
It, yeah. So that’s how I approach it is, it’s really understanding where they come from and why they believe what it is they believe, and addressing it from that perspective.

Nacole:
That’s very smart, because if I don’t understand your perspective, I don’t even know where to begin.

Lovoria:
Exactly. And not making people feel bad. Because people who do things that exclude others, it’s not because they’re racist. It’s because they haven’t considered another perspective.

Nacole:
Right.

Lovoria:
And that’s easy to do when you’re surrounded by people who think like you do, live like you do, have the opportunities that you have.

Nacole:
Yeah. Because maybe they’ve never encountered those barriers before. So I can’t really blame you for not knowing they exist.

Lovoria:
Exactly.

Nacole:
Yeah. So what does the future of nursing look like to you?

Lovoria:
What does the future of nursing look like? I think we’re moving in the right direction as far as the preparation for nursing being a bachelor’s degree.

Nacole:
Oh, for sure. I agree.

Lovoria:
And, you know, the Institute of Medicine really was helpful in helping us frame the importance of having nurses who are bachelor’s prepared. So we’re seeing many programs of study across the nation with RN to BSN programs, LPN to RN programs. And so I think, as we move forward, that we’re definitely going to be a more educated profession, and we already are well, I believe. Right now, greater than 70% of the profession are bachelor’s prepared. So we’re headed well in that direction. I do, I’m encouraged by increased diversity, as I’m more encouraged about the attention to it. And I believe with attention to lack of diversity in the profession, that over time, we’re going to see an improvement in that number of diverse nurses.

Nacole:
Yeah, I agree. So I just wanted to circle back about you talking about your colleagues and widening their kind of views on systemic racism and social determinants of health. Do you talk to them about racism in general, or the social determinants separately, or is it kind of a general, overall conversation?

Lovoria:
I don’t believe that you can talk about social determinants of health without talking about historic racism.

Nacole:
I agree completely.

Lovoria:
So, yes, it’s always within the context of that, because it’s the why. We can talk about, that people of color are more likely to be obese. They’re more likely to work, regarding COVID-19 and frontline positions. They’re more likely to have diabetes. They’re more likely to live in neighborhoods that have food deserts. And that begs the question, why is that? And you can’t discuss the why of that without going back 400 years.

Nacole:
For sure. And sometimes I read the articles and I see all the statistics and I say, you know, the numbers are great. That’s great to know, but what are we doing about the information that we now have?

Lovoria:
Yes.

Nacole:
What actions are we going to do with the information that we now have? You telling me the statistic is great, but what actions are next, or what conversation needs to be had from said information?

Lovoria:
Oh yeah, absolutely. And one thing I focus on within my university is community-based interventions that include our students. Because if we think about our students, if we think about our white student. This might be a student who comes to us, never having had a true relationship or an experience, a real authentic experience, with a person who’s unlike themselves. Now we’re going to allow them to go four years of school and go out into the world without having that experience. So if we build that into our community nursing course, then students are given the opportunity to be comfortable with someone who’s unlike themselves and to serve.

Nacole:
For sure.

Lovoria:
And Nacole, another thing we need to talk about is, I’m a fellow in the Association for Nurse Practitioners.

Nacole:
Oh are you?

Lovoria:
Yeah. We need to talk about getting you into the fellowship.

Nacole:
Yeah. Oh my God. I’m about to have a nervous breakdown. I’m so excited.

Lovoria:
Do you come to the AANP Conference?

Nacole:
No, I haven’t. Cause the last time I had a work conflict, and now with the whole COVID thing. But I, in my area, I don’t, like I said, my family backgrounds are not medical. So I only get to talk about this stuff with people at work, and we all have different, you know, varying backgrounds. So I would love, love to meet you in real life if I could. Miss Lovoria, have a good morning. This was a great, great conversation. I feel like warm and whole, I don’t know what you did to me, but you made me feel so much better.

Lovoria:
Well. I’m glad. You guys take care.

Nacole:
You healed me.

Lovoria:
It was a pleasure meeting you all.

Nacole:
You too. Take care.

Lovoria:
Bye bye.

Nacole:
Bye.

Nacole:
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