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Diversity, equity, and inclusion

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By: Sofia Carreno, MSN, RN; Jessie Reich, MSN, RN, ANP-BC, CMSRN; Andrea Blount, MPH, BSN, RN; Jeanette Bioteau, RN, MSN, CBC; Brianna Gravina, MSN, RN; and Annie Perng, MSN, CRNP, CWOCN 

Elevate clinician voices through an interprofessional core council.

Takeaways:

  • Diversity, equity, and inclusion (DEI) efforts strive to improve healthcare for everyone.
  • Health equity requires supporting nurses and providing them with the tools they need for success.
  • Collaboration among aligned groups promotes bidirectional learning, enhances coordination, and ensures visible DEI efforts.

The Hospital of the University of Pennsylvania (HUP), which has received Magnet® recognition four times, is a large urban academic medical center that serves patients and families from the local Philadelphia community as well as globally in partnership with Bots­wana, Guatemala, and Vietnam. HUP’s national and international reach includes specialty services such as bilateral hand transplants, uterine transplants, and chimeric antigen receptor T-cell therapy. However, the mission to support those in the Philadelphia community is particularly strong. For example, the Penn Medicine Cares Program has funded 780+ staff-driven community outreach projects since 2012 and the COVID-19 community vaccination clinics administered nearly 8,000 doses over 3 months via an equity focused, “no-line,” neighborhood-based mass vaccine clinic model.

With over 33,473 adult admissions and more than 5,000 births each year, HUP is one of the busiest, most diverse hospitals in the region. Our nursing staff is 74% White, 11% Black, 10% Asian,  3% Hispanic/Latino, and less than 1% American Indian or Alaskan Native. We have 87% female and 12.6% male nurses. HUP has designated building diversity as a priority, and shared governance provides a platform for shaping these efforts.

DEI and shared governance

HUP established shared governance nearly 2 decades ago as part of its first Magnet journey, and nurses at all levels have continued to evolve and advocate for structures and processes to meet the needs of contemporary nursing. For instance, based on nurse feedback, HUP developed an interprofessional Diversity, Equity and Inclusion (DEI) Core Council (the organization’s previous Cultural Competency Committee lacked connection to executive leadership). Clinical nurses recognized the opportunity to leverage the Magnet culture to improve the visibility and strength of DEI initiatives by including the committee as part of the formal shared governance structure. This shared governance connection provides opportunities for promoting large DEI initiatives through interprofessional clinical groups for bidirectional communication, input, and socialization. (See HUP shared governance structure.)

HUP shared governance structure

HUP’s DEI Core Council, formally established in 2019, developed its purpose, mission statement, and annual goals in alignment with the nursing strategic plan. The emergence of such councils are essential for the role that nurses play in healthcare. The Future of Nursing 2020–2030: Charting a Path of Health Equity highlights this role specific to diversifying the nursing workforce and preparing nurses to tackle health equity and determine steps to dismantle racism within the profession. Nursing education programs must embrace public health concepts such as social determinants of health, but applying these concepts to the bedside requires more focused staff engagement and opportunities.

DEI and Magnet

Establishing the DEI Core Council also strengthened HUP nursing’s alignment with the American Nurses Credentialing Center’s (ANCC’s) 2023 Magnet® Application Manual. The manual contains standards to support DEI initiatives in many of its components. In the Organizational Overview (OO), the OO7 standard requires that organizations demonstrate their policies (or the equivalent) to support workplace advocacy regarding DEI among other critical elements of a positive work environment. This component source of evidence (SOE) has evolved from the 2019 Magnet® Manual to now include equity and inclusion. The new OO8 standard requires that organizations demonstrate their policies (or the equivalent) to support initiatives for patients and families regarding DEI and cultural competence.

In the manual’s Transformational Leadership (TL) section, the new TL2 standard requires organizations to provide an example of a nurse director or nurse manager participating in the promotion of DEI activities in alignment with the strategic plan. Although not new to the 2023 manual, two SOEs in the Structural Empowerment (SE) section, SE13a and SE13b, require organizations to provide examples of how culturally and/or socially competent care is provided.

HUP demonstrated their adherence to the standards with several examples, including staff annual training for nurse-led hospital-wide naloxone distribution; organizational support for nurse volunteers that includes providing space, marketing, and flexible scheduling; and cultural humility campaigns. In addition, increasing nurses’ awareness of social determinants of health assessments at the bedside and developing and improving health equity efforts strengthens HUP’s work to provide quality care. Health equity initiatives also include developing an in-house food pantry for the community and using birth certificates that include Parent 1 and Parent 2 for same-sex couples.

Elevating HUP’s DEI Core Council occurred before release of the 2023 ANCC Magnet® Application Manual. However, the intent of restructuring the committee as a formal shared governance council coupled with the new and enhanced Magnet standards, support the needs of the contemporary nursing workforce, and helps the organization meet Magnet requirements.

The timing of DEI Core Council formalization coincided with the COVID-19 pandemic and the killing of George Floyd, which highlighted the prevalence of racial injustices in our communities and in healthcare systems across the country. Because the DEI Core Council was well-established and well-respected (from its years as the Cultural Competency Committee), the work of past chairs helped to model work done across the health system. In 2020, DEI Core Council membership grew in response to its support and promotion of dialogues and initiatives that lead to change. (See DEI Core Council members at work.)

DEI Core Council members at work

Diversity, Equity, and Inclusion (DEI) Core Council members achieve visibility within the organization and have access to leadership training and professional development opportunities. They’re being promoted to formal leadership positions, authoring internal nominations, and participating in hospital-wide panel discussions.

Council members also have developed an initiative for elevating concerns seen in practice so that topic experts can be engaged to offer guidance and insight. For example, one member voiced a lack of confidence in how to care for a patient who demonstrated racism toward staff. To address the complexity and nuances of this topic, the council invited the hospital ethics director to lead a meeting and provide a framework, scripting, and resources for employees when managing similar situations. Council members found this session informative and worked in their areas of practice to share the information. Another member expressed concern about how best to show sensitivity toward cultures they’re unfamiliar with. The director of pastoral care partnered with council leadership to develop best practices in caring for patients whose cultural beliefs may be different than the clinician’s.

Through their work, members have become experts at operationalizing a DEI council and have provided guidance and mentorship to other organizations, within the HUP health system and across the country, that want to establish similar groups. And although the pandemic created many challenges, it also provided opportunities for innovation. For instance, the decision to shift shared governance meetings from in-person to virtual initially proved clunky for council members, but over time the flexibility of virtual meetings allowed employees off campus and throughout the entire health system to participate and ensured a robust DEI Café speaker pool.

Operationalizing the DEI Core Council

In alignment with the Magnet model and HUP’s shared governance bylaws and organizational structure, the DEI Core Council meets once per month and includes representation from clinical nurses, interprofessional clinicians, nurse educators, advanced practice nurses, and nursing directors. Interprofessional representation on the council includes pastoral care, social work providers, and ancillary staff. This robust representation supports a safe space, trust of colleagues in different roles, and an overall culture that promotes lifelong learning.

Foundational to this culture is trust built via communication with members and staff, which HUP supports through its high-reliability journey, including steps to increase psychological safety and speaking up about errors. The council serves as a model for how interdisciplinary teams can achieve these aims. Each month, the clinical nurse chair and clinician co-chair lead a 1-hour council meeting. After this formal meeting, internal and external subject-matter experts facilitate the DEI Café, an educational discussion series focused on various DEI topics. HUP provides continuing education credits at no cost to all who attend these sessions.

The council’s executive sponsors frequently meet with the chair and co-chair to provide strategic direction and operational guidance to aid achieving the council mission—to create a culture that’s inclusive of diverse patients, families, and employees. In addition, the clinical nurse chair and executive sponsor attend the monthly board of nursing meetings. The board, chaired by a clinical nurse and the chief nursing executive, serves as the shared governance oversight committee and provides a venue for bidirectional communication among nurses at all levels.

The philosophy of Gracious Space, adapted from the book Gracious Space:A Practical Guide to Working Better Together, sets the tone for DEI Core Council meetings and work. The book’s authors define Gracious Space as “the spirit of inviting the stranger and learning in public. Gracious Space includes actively listening to new thoughts or conflicting ideas, giving opinions without fear of criticism, holding off judging others based on different perspectives or culture, and stepping back to reflect on unconscious biases and assumptions.” Each meeting begins with a council member reading the Gracious Space statement to set the meeting’s intention.

DEI Core Council outcomes

DEI Core Council achievements include specific, measurable, attainable, relevant, and time-based (S.M.A.R.T) goals; the DEI Café; community service projects; and council member recognition.

S.M.A.R.T. goals 

The DEI Core Council developed its 2022 S.M.A.R.T. goals in alignment with HUP’s nursing strategic plan, which parallels the organization’s strategic priorities, including broader organizational DEI initiatives. The goals include rounding on units throughout HUP from April to December to recruit additional members and engage in meaningful dialogue with frontline employees, and partnering with health system entities to explore useful trauma-informed care tools for healthcare workers and patients by August 2022. DEI Core Council members will use the tools to support and build resiliency in families, communities, and organizations as they overcome traumatic events.

DEI Café 

The DEI Café has been the platform for many discussions about DEI in the workplace, especially the delivery of culturally and socially competent care. Examples include the impact on lack of data and stereotypes about Asian Americans, Latinx mental health care and burnout, patient-first language and stigma of substance use disorder, reducing isolation for LGBTQ and gender-diverse people, and the health system’s chief medical officer’s book club.

Community service and recognition 

Members of the council have participated in community service initiatives such as clean-ups at neighborhood public parks and health fairs. In addition, the organization has recognized members of the DEI Core Council for their work and achievements. The council chairperson was selected as the recipient of the hospital-wide shared governance leadership award, which recognizes clinical nurses who demonstrate dedication and leadership by inspiring their peers, driving change through interdisciplinary decision-making, and using evidence-based decisions and research. The chairperson also was nominated and selected to be the face of this year’s system-wide campaign focused on building capacity regarding cultural humility.

Growth opportunities

As noted in the Future of Nursing Report 2020–2030, health equity can’t be achieved without first supporting nurses and equipping them with tools and support for success. Collaborating with aligned groups across the health system enables bidirectional learning and enhances a coordinated, visible approach to DEI. Through this council, HUP has developed a framework to foster a culture of trust, safety, and inclusion that can be replicated across the country.

Sofia Carreno is the nursing professional development specialist for community engagement, Jessie Reich is the director of Magnet and patient experience, Andrea Blount is the patient education specialist, and Jeanette Bioteau is the chair of the Diversity, Equity, and Inclusion Core Council at the Hospital of University of Pennsylvania in Philadelphia. Annie Perng is a nurse practitioner and Brianna Gravina is a nurse manager at Penn Medicine in Philadephia.  

References

American Nurses Credentialing Center. 2023 Magnet® Application Manual. Silver Spring, MD; American Nurses Association; 2022.

Bryant T, Pruski BB, Yarbrough CBR. Diversity, equity, and inclusion in the 2023 Magnet® Application Manual. J Nurs Adm. 2022;52(6):322-3. doi:10.1097/NNA.0000000000001154

Laurencin CT, McClinton A. The COVID-19 pandemic: A call to action to identify and address racial and ethnic disparities. J Racial Ethn Health Disparities. 2020;7(3):398-402. doi:10.1007/s40615-020-00756-0

Laurencin CT, Walker JM. A pandemic on a pandemic: Racism and COVID-19 in Blacks. Cell Syst. 2020;11(1):9-10. doi:10.1016/j.cels.2020.07.002

National Academy of Medicine. Future of Nursing 2020-2030: Charting a Path of Health Equity. Washington, DC: The National Academies Press; 2020.

Scott E. 4 reasons coronavirus is hitting black communities so hard. The Washington Post. April 10, 2020.

Key words: Diversity, equity, inclusion, interprofessional collaboration, shared governance, Magnet

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