Jasmine Travers (00:03): As we talk about these terms, right, they can be very much emotionally charging. If I say structural racism, or that was a racist policy, and you made this racist policy, that person is going to internalize that. People are going to be defensive. The terms of structural racism, instructional inequities, whatever it ends up being, it’s not to say you’re a bad person. It’s more so to bring light to inequities that are inherent within our system.
Nacole Riccaboni (00:33): Jasmine’s right. When we get real about unequal access to care, or even why it’s harder for some nurses to rise through the ranks than others, it can become an emotionally charged conversation. As a person that experienced that, it sure was for me, but that’s not a reason to avoid these tough conversations. They’re really important. So important we’re devoting an entire second season to them. And we’re here to understand these issues. We’re not here to blame or shame anyone.
In the first episode, you’ll learn about the language of health equity. And if you don’t know what that means exactly, you’re not alone. I didn’t either. Talking to Jasmine helped me understand the social determinants of health, what people mean when they talk about health disparities, and yes, how structural racism impacts our patients and our profession. This conversation helped me to really connect the concepts to the care that I give. And I hope it does the same for you.
I’ll spend the rest of the season talking to nurses who found ways, both big and small, to level the playing field of our healthcare system. My name is Nacole Riccaboni. I’m a critical care nurse working in Florida and your host for SHIFT Talk’s season two. SHIFT Talk is a podcast that brings nurses together to talk about the challenges we’re facing on and off the clock. This season, we’re interviewing nurses who are working to ensure that all patients can have access to the resources and care that they need to be healthy.
And that’s called health equity, by the way. We’re going beyond the clinical and looking at the social factors that impact health, from a person’s zip code, to their health, to even their job and even structural racism. No healthcare provider knows more about nurses’ lives than nurses, right? We can really make an impact here, folks.
This podcast is brought to you by SHIFT, an entertaining nursing community for today and tomorrow’s change-makers. SHIFT is sponsored by the Robert Wood Johnson Foundation. Follow us on Instagram @shiftnursing. And for more amazing stories and real talk about nursing, head over to shiftnursing.com. One final note, this episode was recorded in July, so please keep that in mind as you listen to this great conversation. Now let’s dig in.
Nacole (02:50): Welcome, Jasmine. Can you introduce yourself to our amazing listeners?
Jasmine (02:54): Definitely. Thank you, Nacole. And just thank you for having me here. I’m so excited. I’m Jasmine Travers. I am an assistant professor at New York University Rory Meyer’s College of Nursing, and I’m also a health services researcher who focuses on improving long term care delivery for older adults.
Nacole (03:11): Well, we’re so glad that you’re here to talk to us, Jasmine. Thank you so much. And I can’t wait to get into you explaining all the definitions because even as a nurse practitioner, and even as a doctorate student, when I hear health equity, social determinants, health disparities, sometimes they all get mushed together.
Jasmine (03:27): Yes. I would say they have their own lanes, but they feed into each other in many ways. So in some ways you can probably see it as like a funnel when it comes to the structural inequities and thinking about health disparities. There’s some things that I want to just kind of put out there, Nacole. And you know, as we talk about these terms, they can be very much emotionally charging because we’re like, oh, structural racism or saying like health disparities, all these different words are racist or sexist and ageist and all these terms.
It’s hard for us to actually fathom these words and kind of take them in because it feels like shame. So if I say “structural racism,” or “that was a racist policy,” and you made this racist policy, that person is going to internalize that. People are going to be defensive because they’re saying, “You know what? You’re saying that I am a bad person and I am not a bad person.” The terms of structural racism, instructional inequities, whatever it ends up being, it’s not to say you’re a bad person. It’s more so to bring light to inequities that are inherent within our system, that we need to recognize how we might be perpetuators of a long standing system that drives these inequities. We’re good people. We’re decent people, but we don’t recognize different biases that we have, different privileges that we have, different ways that we lack understanding of issues.
Nacole (05:02): So I’m glad you’re here to explain all of that for us. Can we start with health equity?
Jasmine (05:08): Sure. So health equity means that everyone has a fair and just opportunity to be as healthy as possible. So with that, you think about removing obstacles to health, such as poverty, discrimination, and their consequences.
Nacole (05:25): Now, what about the social determinants of health? Can you give us some examples of what those are and how they impact their person’s health and their ability to access healthcare?
Jasmine (05:34): So the social determinants of health are going to be those factors that I just alluded to when thinking about health equity. So those factors that are going to drive inequitable experiences. So that’s going to include things such as broadly, where a person is born, where they work, where they live, their age, but specifically looking at income, your education, whether you’re employed, if you have food insecurity. So you’re not able to access healthy foods. You don’t have grocery stores, full grocery stores in your neighborhood, housing, those types of things. Safety within a neighborhood, violence, what crime looks like.
Nacole (06:15): Would the location of hospitals or urgent care facilities be a social determinant of health?
Jasmine (06:20): It definitely would be. So when thinking about environment and the neighborhood that you live in, that is going to speak to what access you have. So it’s going to speak to the access to safe neighborhoods. It’s going to speak to the access to affordable housing or a clean environment, clean air. And then when thinking about access to hospitals, access to pharmacies, for example, being able to get prescriptions, being able to get vaccines. So that may be fewer in more disadvantaged areas. Where your zip code is, is a determinant of health, because that’s going to lead to what resources, what services, what type of neighborhoods you are in.
Nacole (07:05): Gotcha. Gotcha. Now, that makes sense to me. Now, what about health disparities?
Jasmine (07:09): So health disparities is pretty much the product of these inequities. There are differences in gaps, in the quality of health and healthcare, and this stems across racial, ethnic, and socioeconomic groups. So just thinking about more of your disadvantaged groups and these differences in health outcomes, healthcare access, that we might see. Just an example, in New York where I live and going back to where you live and in your environment, when thinking about the subway system, if I were coming from downtown Manhattan where the life expectancy is 86 years old and traveling to the East Harlem side where the life expectancy is about 77 years old, that’s a nine year difference where that’s an 18 minute ride on the subway. So every stop on the subway pretty much is like a six month decline in the life expectancy. So as I’m riding down the subway, the farther I go uptown towards areas such as Harlem and the Bronx, my life expectancy is decreasing.
Nacole (08:19): Now, can you talk a little bit about structural racism and structural inequalities and how those kind of relate to the why behind some of the concepts we’ve talked about today?
Jasmine (08:29): Definitely. Structural racism is public policies within a system, public policies, practices, processes within a system that perpetuates racial group inequity. And just thinking a little bit above that, structural inequities are going to be public policies within the system that perpetuates inequities among groups for whatever reason. So it could be among older adults where that could be rooted in ageism. It could be among sexual and gender minorities. So there could be a number of inequities that affect people because of who they are. So it’s not just structural racism, where there is definitely a lot of that, these racist policies and practices, but when thinking about structural inequities and seeing how policies and practices affect disadvantaged groups, it’s something to also just recognize.
Nacole (09:25): Even me, as an African American female with some medical knowledge, I’ve had very disturbing experiences in healthcare. I recently had a very complicated C-section. Before that I had another subpar medical experience. And I think sometimes things are complicated because of the color of your skin. And again, I can’t really quantify that or give evidence, but I’ve had people that are on the same floor as me with the same care and we have drastic and completely different experiences. And I never really understood why. I mean, I’m really glad you’re going over these definitions because I mean, I clearly know why now, but as a black person in the South, these things are true. I’ve experienced them even as a nurse practitioner. And it’s very, very sad. Now, going back to the beginning of your career, what was your experience as an ICU nurse like, and what issues caused you to leave bedside nursing and become a researcher?
Jasmine (10:23): When I first started as a nurse, it was really my heart to make a difference in the lives of those who I cared for. So that was definitely a passion of mine. And coming in, I started at a large academic hospital center, started through a residency, which was phenomenal, and started on the step-down unit. I ended up doing some overtime in another step-down unit that was connected to an ICU. And for new nurses, which is pretty much the same thing for today, typically you don’t enter into the ICU right away. You usually have to be a year in. Because I was doing overtime on that unit and the nurse supervisor really liked me, she asked me to apply and I did, and I landed a position in the ICU, which was the best experience possible that I could have working as a nurse.
But I did notice the differences in how nurses of color were treated, how they were mentored, how they were supported on that unit, and also how patients were treated and responded to. So seeing that is what drove me to want to understand these issues more, understanding that on this unit, I was one person, right? And of course one person can make a difference, I would say, on a larger level, but I wanted to be able to do that in a way that it reached more people. So I wanted to understand these issues more. I wanted to understand why weren’t there diverse workers working in specialty units, why there weren’t more diverse workers working in leadership positions, why did we treat different demographics, populations, compared to others? So that’s what led me to my PhD to understand these issues and then see how I may be able to make a difference in these issues on a macro level, thinking about policies, practices, processes, research, education.
Nacole (12:23): So you being told that that’s just how things are was not going to be good enough for you. You wanted to find out the why.
Jasmine (12:29): Exactly. No, I didn’t want to just sit there and be like, “Oh my goodness…” I mean it seemed like, all right, this is how things are, but that didn’t sit well with me. I’m like, “No, this is not how things should be. So how can we actually change things?”
Nacole (12:45): Oh, that’s great to hear. Good for you. Now in terms of difference, was it difference in care or difference in perspective when you did see these problematic issues on your floor?
Jasmine (12:54): I would say both. So when it comes to difference in care, and the different ways we approach patients. So for example, if a white patient complains of pain, it was not necessarily an issue. It was like, “Oh, this person is having pain. Let’s see how we can control their pain.” But if a patient of color was complaining of pain, you had to go down this whole lieu of, “What’s going on? This person’s a pain seeker.” So it was almost ruling them out in a way of saying, “What says to us that this person is not just a pain seeker?” On the flip side, it was more so, “You know what, they must be in pain, let’s go and approach their pain in the ways that they need to have relief.” So that’s an example of what I would see in regards to different care and different approaches depending on what the patients looked like.
And then just when it came to staff, I would see just the barriers that there were for people of color to actually succeed on the unit, if they did in fact, get through the process. It was almost like you were going through a hazing process, right? And I would see that, and that would bother me very much. When it came to me precepting new nurses, they actually would have a lot of the nurses of color orient with me. Or for me, I only had the nurses of color orientating with me, I never actually oriented a nurse who was not of color. So in some ways I think that there’s some things wrong with that, and in other ways I’m glad that I was able to orient the nurses of color, because there were some nurses that I know would have had a challenging time actually being able to pass orientation, if you would say, just because of the ways that they were being treated.
When thinking about the nurses that I was orientating, for example, there was a gentleman that I was orientating and they were always attacking him, coming after him, where I was supporting him. He was a brilliant nurse. He was a scientist beforehand, chemist, and currently now just finished his PhD at University of Pennsylvania. So that’s the extent of which this bright person, if they had the wrong preceptor who just had no good intentions for him, he would have never actually gone through to the ICU. Only because I was his preceptor was he able to actually finish his experience in a way that he still thrived, and actually it was me just really advocating for him. And without that, he would’ve never had that advocacy and he would have not done as well as he actually did.
Nacole (15:39): Yeah, I definitely have seen that when I was a new nurse, where there seemed to always be a problem. Clearly you don’t really have any evidence of if that statement is true or false, if you’re just targeting me or I’m not a good nurse, but it seems that all my other counterparts were doing well and we were doing the exact same thing, but there was always a problem with me. And yes, I had a very, very bumpy preceptorship. And even now as a nurse practitioner, African American females or even males within our group is a very, very, very small number. So I totally understand. Can you also talk about workforce diversity? What did you personally observe as an ICU nurse and what did you study since?
Jasmine (16:20): Diversity in the nursing profession changed based on where you were at in your specialty. So for example, on the med surge unit, you would see more diversity. You would see more people and nurses of color working on those units. Now, would you see necessarily nurses in leadership on that unit? Most likely not, very minimally. But as you started going to other specialties, such as ICUs, the diversity decreased. It would be primarily non people of color, and in leadership, it was pretty much none in those areas. And that is something that is a problem when it comes to opportunities to be in those roles, for one, and how we actually view who technically is supposed to be in those roles.
And just like how you kind of alluded to earlier, Nacole, you’re like, “Well, these are things that it seems that way, but you can’t ever actually put your hand on it.” Right? For me, this is what I saw when it came to the specialty units, when it came to my hospital, the higher you’d go in leadership there were just never people of color in leadership. And what you take from it and just the experiences and just the feelings that you have from those who are working around you, it just didn’t seem like those were opportunities that were achievable for specific racial and ethnic groups. And it was kind of unspoken.
So even my own colleagues though, who were looking to apply for positions of leadership on our unit, I have a good friend of mine, she had to apply multiple times. And not to say that, okay, everyone should get a position on their first try, but it was very much different for her when it came to applying for positions. She was qualified and she had an advanced degree, which we are seeing greater proportions of people of color getting advanced degrees when compared to people of non color. But advanced degrees is not equating to advanced career opportunities for us people of color in these areas. So, that’s the thing. Despite having these advanced degrees, we always, people of color, it’s this notion of we’re always needing to work 10 times, 15 times, a hundred times harder than the next person and we still struggle.
Nacole (18:42): I had a similar experience where it’s just I started working on the floor and they had told me, “You’re not going to go anywhere else.” I was like, “What do you mean?” And they’re like I said, “No, I want to be like a charge nurse.” They’re like, “Yeah, it’s not happening here.” And it was my coworkers. I said, “What do you mean?” I said, “I’m doing a great job. I’m getting like raises. Yeah, I’m doing good.” They’re like, “You’re never going to be charge nurse here. I tell you that right now. You need to just realize that and just be okay where you’re at and just relax on the goals because it’s not going to happen and you’re going to get frustrated.” And I was like, “No, I don’t know what you guys are talking about.” And then you realize like, oh, that’s true. Okay. This is my ceiling. And like you said, none of the leadership looks like me. I would apply and apply and apply. And you’re like, “What’s the reason?” Well, it’s just not, it’s not, it doesn’t suit you. I was like, “What does that even mean? Like, can you give me examples?” It just doesn’t suit you. You should just stay where you’re at. You’re doing a great job where you’re at is what I kept hearing. And it was like, what is that? I said, “Am I doing bad?” And they’re like, “No, you’re great in your position, but you’re great there. You’re just great right there.” And you never really truly know what’s behind that and what that means. But yeah, I felt like that was definitely a component of my experience in particular.
Jasmine (19:58): Definitely. In a qualitative study of 30 nurses of color, those same sentiments were coming out. White nurses would be like, “Yeah, you’re a good nurse. You’re a great nurse, but I wouldn’t want you being a superior to me.” Those are issues. This current lack of diversity in the nurse workforce, in our student populations and faculty impedes the ability of nursing to achieve excellent care for all. If we are all just one minded, one backgrounds, all share the same thoughts, we’re not going to see the blind spots. We’re doing such a harm. And as a profession, as a nursing profession, we made an oath that we will do no harm to our patients, right?
That’s making sure that our patients are receiving dignified care, that they are being respected, that we are reducing if not eliminating health disparities. So those are significant responsibilities as nurses that we have when it comes to ensuring that we are providing the best care to our patients, and that includes having a diverse nurse workforce, having diverse perspectives, having people that are going to be able to push the needle, question things that we probably wouldn’t even have thought of because of our isolated mindsets.
Nacole (21:22): Now I’ve talked to some nurses who feel as if it’s not their job to address diversity of staff or even health disparities among patients. What would you say to those nurses?
Jasmine (21:33): I would say it’s everyone’s job when it comes to diversity and disparities. And what I shared before in regards to code of ethical conduct, one of them is beneficence, which is doing good and the right thing for the patient and ensuring that patients don’t experience health disparities. So that’s experiencing health outcomes, decreased access to care and such for no reason. And then also ensuring that patients have a diverse group of individuals serving them is important. So I would say that hands down, that is all of our jobs and being able to pursue that and really understand what that looks like is also critical.
Nacole (22:22): Now I want to talk about what nurses can do once they understand these issues and if they want to act, so what they can do inside the profession while at work.
Jasmine (22:32): So, the first thing that we can do is acknowledge these issues and our role in perpetuating these issues. And this can look like a gamut of things. It could be something as simple as, for example, I’m a nurse of color. In some instances I may be the person who is being disadvantaged and then in other instances, I’m the person at the advantage as well. And I have to see that in its totality also. So for example, during the pandemic, I’m a nurse, there are all these benefits for nurses and physicians as well. So thinking about free bike memberships, hotel stays, if you needed to quarantine and such. Where I’m like, that’s great that they’re doing that for nurses. But then when it came to nursing assistants and those working in nursing homes, those same benefits were not given to those healthcare workers.
Nacole (23:27): Oh yeah, you’re right. I didn’t think about that.
Jasmine (23:29): Exactly.
Nacole (23:29): Oh my gosh.
Jasmine (23:31): Exactly. And in New York, healthcare workers, hospital workers were being celebrated at 7:00 PM. I’m not sure if that was happening in Florida.
Nacole (23:39): With the clapping? Yeah.
Jasmine (23:40): Yes, exactly. The clapping at 7:00 PM, but that wasn’t happening for nursing home workers. So in one end, I’m appreciative because, oh yes, I’m finally being recognized as a nurse. I’m being provided benefits and supports and such, and people are clapping for me. On the flip side when thinking about others who are not being recognized, nursing assistants, when it came to hotel stays, they were not getting free hotel stays in the nursing homes. Well, these nursing assistants work with the residents the majority of the time.
They’re the primary caretakers of the residents in the nursing home setting, so they were at most risk for getting COVID. Last year, nursing assistants had one of the most dangerous jobs in America. And then thinking about how much they get paid. So it’s like a median of $11 to $13 an hour and they were not given hotel stays for free to quarantine. Many of them did contract COVID. They’re only getting paid very minimally. They live in congregate housing and not every nursing assistant lives in congregate housing, but those are some of the characteristics of the nursing assistants and having to take public transportation.
So all the risk, but then had to endure. But at the same time, they were told to pay for hotels to quarantine. Where was that going to come from? So immediately when things like that started to come to my mind, I was just swelling up in tears because recognizing my privilege was great to have all of these perks, to have hotel stays. But for me, I could pay for it. But when thinking about other disciplines, particularly nursing assistants, they couldn’t even afford that. So who are we really trying to protect and help and serve?
Why did it matter to help me with hotel stays when I could have paid for it? Which, I mean, that’s great and that’s showing that you see me as a nurse, but then what about those who just can’t even provide that for themselves and we’re not even supporting them? So those are ways that we need to just first say, “Hey, let me see how I may be a part of the issues that we are seeing when it comes to structural inequities or structural racism.” Really understanding that and really recognizing our biases that we may hold. That’s the first thing that I want us to start doing.
And then as we start doing that, becoming involved, getting our voices out there. So you may join a committee within your hospital setting if you’re in the hospital or in the nursing home setting or a community board or in your professional organizations. Joining committees, talking, being a part of the table, being a part of the decision making, so that when, for example, you’re planning for the next COVID or whatever pandemic, and you’re saying, “What groups need to be prioritized?” It’s not just about the who, but it’s about the how.
And you’re like thinking, well, these are things that we need to consider. Like I’m kind of understanding this whole idea of structural determinants of health. We just need to at some point move from the discussion once we start to understand these issues to actual institutional change.
Nacole (26:58): Yeah. Because I have many great ideas about how to change organizations or how to change processes. But after talking to you, when you try to explain that the how is as important, that’s harder to conceptualize and that’s harder to do, but that’s what’s most important. Now I’ve been out of school for a while, but it’s my understanding that students who are in nursing school today are being educated about these issues. But what about the nurses that are further along in their career?
Jasmine (27:30): That’s a good question. So that’s a thing that I like about new nurses, for one, I’ll just start off with that. When I started off with the nurse and then as I went along my first years and I would precept students and I’m like, “Oh my goodness, I can’t believe they gave me a nurse that precepts.” And then along the road, and I started understanding that there’s a difference between the newer nurses and the more senior nurses, I would say. And that difference is that there’s a group, which is the new nurses, who do things how they’re supposed to be done, and they get all this new knowledge, updated information and then there’s a group, the senior nurses, who do things how they’ve always been done, right?
And I see both aspects of it, and especially now I can appreciate the differences between doing things how they’re supposed to be done and how they’ve always been done. But doing them how they’ve always been done in many ways can create more harm than good and specific to when thinking about diversity issues and structural inequities and such, and being extra sensitive and attuned to diverse populations, these types of information, knowledge, conversations, they’re so different than what they were like when I was back in school probably 15 years ago. They’re so different. For me, I don’t even really understand when it comes to saying the pronouns and all this kinds of stuff, I need more education on that. So you don’t even recognize how you are maybe disrespecting a person because you’re not approaching them in ways that they want to be approached, but it’s because you don’t know. Where newer nurses are getting this information.
They’re being educated on that, which is great. So what is there for more seasoned nurses who’ve been in the game and aren’t really necessarily getting that education in the ways that the newer nurses have gotten it? So for one, I would say that’s also the responsibility of the institution because we do need to get in-services. These are issues that we all need to understand and be better at when it comes to just serving our patients. So in-services is something that we can do. There are webinars on these issues that are just presented for people to really understand. There’s been a number of structural inequity, structural racism, health disparities, webinars that have been provided on the national level. So when thinking about the National Academies of Science, Engineering, Medicine, they’ve been doing series under structural inequities. Even a lot of nursing associations have been doing a lot of series and webinars on these issues.
So just thinking about how do we really get plugged in to our profession by attending these additional types of offerings. There’s just still a need for us to think about how do we make sure that nurses across the board, no matter whether they’re in public health, whether they’re in acute care, whether they’re working in community settings, outpatient, or in academic settings, how are they getting this information? So even thinking about the governing body, when it comes to nursing, we’re renewing our certification every couple of years. So is there a requirement to actually just give us the updated knowledge and what does that look like?
Nacole (31:07): For sure, because I personally learned something new about my community and something in general in the form of the disease processes every shift. And you have to kind of be a lifelong learner if you’re working in healthcare, because it’s all about communication and dealing with people. And as you say, as time goes on, you learn different things and you have to keep learning.
Jasmine (31:28): Exactly. That is so key, Nacole. Lifelong learner.
Nacole (31:34): I’m such a nerd.
Jasmine (31:35): You just commit to that. You never stop learning. And it’s important, it’s very much important that we never stop learning. We’re only going to do better by our patients when we are continuously hungry for education and whatever that may look like, whether it’s going back to school, attending in-services, webinars, reading, newspaper articles, whatever the case may be.
Nacole (32:02): Even if a nurse is busy and he or she feels like they don’t have the time to maybe intake all this information and all this new knowledge, just break it up into chunks. I know there’s some webinars that are 15 minutes, 30 minutes, just find the time, but definitely take these opportunities to learn because they are out there and available to you.
Jasmine (32:21): I agree. And I love that how you said, break it up in chunks. And everyone has their different hobbies, different opportunities for downtime. I run a lot. So I will curate a list of articles in an app called Get Pocket that actually can read the articles in an audible form to me as I’m running. So that’s how I get caught up.
Nacole (32:42): What is it called? Oh my God. What is that called?
Jasmine (32:45): It’s called Get Pocket.
Nacole (32:46): Oh, I’m on it. Okay. I got that. Okay.
Jasmine (32:48): Yeah, no, it’s great because you’re going to these different links. There’s a lot of information coming out and in the morning times, I can’t go through of these different articles. So what I do is just copy the link into the Get Pocket web browser, but it automatically feeds to my phone app. And then when I go for a run, I just play it and they’ll play whatever articles that I have on there and it’s just reading it to me. And you can have it read to you by a number of different types of voices as well, so it’s kind of fun in that way.
Nacole (33:20): Oh, great resource. Thank you. I can’t wait to do it. Thank you so much. I’m so excited.
Jasmine (33:24): Sure, sure.
Nacole (33:26): Awesome. Thank you so much for taking the time to talk to me and our amazing listeners out there about all those confusing definitions regarding health equity, determinants, health disparity, structural racism, and even structural inequities. I’ve learned so much from you.
Jasmine (33:41): Definitely. Thank you, Nacole, for having me. And I just want to say, I hope the listeners are just keyed up for the next exceptional speakers that will be on and really trying to lend an air to how they may see themselves in those roles as well to also look to make a difference in the populations that we have pledged to serve.
Nacole (34:03): Oh, I completely agree. Thank you. Thank you so much for your time.
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