February 2, 2021

Episode 44: Making nursing more diverse

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Description

Today’s episode kicks off a series of interviews in support of Black History Month. For the next four weeks, we’ll be featuring conversations with leading voices in the Black nursing community around topics like building a more diverse nursing workforce, creating inclusive workplaces and providing equitable patient care.

Our first conversation is with Dr. Rumay Alexander. Rumay is currently a professor in The University of North Carolina at Chapel Hill’s School of Nursing. She was also the first nurse ever to serve as the university's Associate Vice-Chancellor/Chief Diversity Officer. Throughout her career, she’s been “the first” or “the only” in many of her roles, whether it was the first woman, the first African American or the first person ever to hold a given role. It’s a perspective that has shaped much of her career and her passion for topics like diversity, inclusion, belonging and justice. 

Dan and Rumay talk in depth about how to make nursing at both the bedside and in academia more representative of the population overall. Rumay shares the strategies she used to widen the funnel of students at UNC, her thoughts on what good leadership looks like when it comes to advancing the cause of diversity, and how COVID-19 has actually been helpful in opening our collective eyes. 

Links to recommended reading: 

Podcast

Transcript

Dan:
Welcome to the show.

Rumay:
Thank you, Dan and thank you for having me.

Dan:
I'd love to dive in, again, to the way you described it was, "I've had these roles that never existed and I've built them and then they always hire people into it after but I'm always that pioneer." Can you talk about some of those roles that you've had, where you were the pioneer, leading the way there?

Rumay:
Sure. Even upon my graduation from nursing school, I ended up in a position that had not necessarily been occupied by a nurse before and that was with the Tennessee Hospital Association and I was the senior vice-president for clinical and professional practices. So, as you know, nurses occupy the largest part of the workforce in hospitals and hospital associations, literally, represent their membership at the policy-making levels. So, how do you have that kind of a role in not have nurse executive helping you understand and putting forth policy and practices, perhaps that makes sense for nurses and the nursing practice? So, that was the first position, which really allowed me to have some say at the policy-making levels, including lobbying at the state and the national level. I was in that position for quite a while and after leaving that position, that position was filled. So, that need to have the translator, if you will, of those who actually do practice with those who are making policy, was one of those groundbreaking positions.

Rumay:
But then, I also made a foray into academia and my work was completely centered around justice and equity and fairness and inclusion and belonging. And again, this role was one that typically had not been a formal position in academia. So, when I came to UNC Chapel Hill School of Nursing, I was its first full-time director for diversity and inclusion. That led to a good bit of work in the space and helping the campus to understand how important it was to explore that area, to take a look at all the policies and practices, to pay attention to the ways in which we advantage some and disadvantage others or privileged some and do not privilege others or include some and don't include others and how that affected the lives. Not only of patients because this was a nursing school and the delivery of healthcare but what happens in the academic space and education space, that makes it possible for us to have a diverse workforce. Who again, can bring those same, kinds of, experiences and differences of perspective to the table. As you know, that makes for the richest policy-making and decision-making possible.

Rumay:
And so, just demonstrating and working on, what I would call, change management, married to strategic effort by design, is what I was doing. And again, that was a new space, that space because it was the first on the campus to be full-time, parlayed into becoming the associate vice-chancellor for diversity and inclusion and the university's chief diversity officer and again, they've never had a nurse in that space. So, I ended up, again, in one of those positions where I am crafting what that looks like and the way that functions and what it takes to make real, our efforts in that inclusion and equity work. So, those are examples of some of the groundbreaking places that, I think, I've had a chance in my career to be a part of.

Dan:
Yeah. That's a wonderful pathway and so needed. Some of the work that I was involved with at the Kaiser Permanente School of Medicine was very much in the admissions process and they wanted to redesign the whole admissions process to, not exclude but include and actually move away from the numbers, MCAT scores and those types of things and move more towards the life experience stories and passion and alignment with the vision, mission and values of the school. In your role as chief diversity officer or chancellor of diversity, what are some of the changes that you made, maybe specifically to nursing and admissions, to open up the funnel, I guess, to attract more people and then also change the processes, so that certain people aren't weeded out from the traditional way we used to do things?

Rumay:
Great question. And serious hard work because now, you are talking about opening the minds of people and asking them to follow you into a way of thinking that, perhaps, unintentionally and sometimes with intention but most of the time unintentionally, about how we perceive others and their abilities and their talents, since talent and opportunity don't have race or gender or sexuality or generation or body size. And so, a lot of the work was in, how do you prep those who will be making the decisions to open the mindset and to consider alternate ways of those traits they believed that were necessary or were promising or were needed for someone who was going to fill those roles? So, I remember one of the big pieces was around admissions and the way we defined leadership. When I arrived, that leadership was often determined as if you were a president of a sorority or fraternity or you had been a part of some volunteer organization where you were the leader.

Rumay:
In many instances, our students, who were not white, had other ways of demonstrating their leadership and it didn't necessarily fit those parameters. And so, the vivid example that came to mind when you asked the question was, we had an applicant who indicated that she had led Bible study, this happened to be an African-American applicant and they didn't want to include that as leadership. And part of my role was to challenge the discussion. I was not an official member, I was ex-officio actually to the committee but I was there to give advice and to hear the conversation, so I could see how they might be missing talent or looking at something through the traditional lens, quite frankly. And so, I remember her saying, "can we just discuss this for a minute?" And I went on to explain what goes on in Bible study and how there are as many interpretations as there are people in the room.

Rumay:
And I remember saying to them, "do you know what it's like to lead Bible study?" If you've ever led Bible study and you get to do it again and again and again, you have demonstrated leadership at its utmost. And so, we started including not excluding but saying, in addition to those things that you have counted as leadership in the past, add Bible study to that or add that they've been a part of some other church activity or community activity that you may or may not be familiar with. There were some discussion about how we might need to blind some data, so that people would have a more open view of the applicant rather than a preconceived view. What I mean by that is, sometimes, depending on where you went to school and the zip code, because you know the zip code is the great determinant as related to health but it's also education.

Rumay:
And sometimes when individuals would see that information, they immediately had an idea about who this person was, their abilities, the pedigree, if you will, of the school they went to, over against looking at the application in a unbiased sense. So, that became where we started every search that we did for a faculty committee or a faculty hire or search piece or if we were looking at a student to blind that kind of data, so that the person got the greatest chance of being seen as an individual as presented. So, those are examples of the kind of work that we engaged in and making sure that before every search or before every admissions process, we took the committee through a educational refresher process on implicit bias because that's a slippery slope. It's something you have to work with all the time and you can't eliminate it but you can reduce it, by making people aware of how it's impacting the decision making.

Dan:
Yeah. And part of it is the leadership aspect as well, like you mentioned, sitting in and being able to observe some of the things that are going on, as almost a third-party or ex-officio, to not be part of it but look at it and then coach. But what I found also and this was also at some of the med school work was, the leadership created a safe space to bring this stuff up. So, even in faculty meetings, when we would talk about building whatever it was, mission process to curriculum to designing, the simulation or whatever it was, it was okay to call out if someone felt uncomfortable about the direction it was going, specifically around diversity and inclusion and that kind of stuff. That, I think, takes a special spark to do because sometimes you see it, you feel uncomfortable about it but you don't feel okay speaking up about it. Can you talk about some of the leadership characteristics or tactics to create that safe space, to even just have those conversations behind closed doors?

Rumay:
Yes. I believe that, one, who ever is leading that kind of an initiative has to be approachable. This is not about judgment and it's the judgment that gets us in trouble. So, if we can cultivate the ability to hold multiple perspectives without judgment, we're in the best space. One of the things I developed was a courageous dialogue series and I might use a book, a movie, a song, I even brought in a student theater to play out scenarios and the audience could watch the scenario and then be able to talk to the characters while they're in character about what they're saying and doing. In fact, that was probably one of the most interesting because I helped the theater group with some examples of things that had happened in the school themselves and had them play out the roles, so that people could see themselves in action.

Rumay:
And the funny part of that is that, they were like, when it was over, "well, who actually does that? And I said, "you do. These are actual incidents that happened in this school." And so, the ability to have that out of body experience, if you will, and see it on display and to have discussion and it's really easier for people to point out what other people did, over against themselves because we all have our blind spot. And so, using a book that you dissect and talk about the characters and the issues and what they said and how hurtful that was to another character in the book and how that hurt character dealt with the situation and was either dissed in some way or de-legitimized in some way. Or the way anger showed up or the way prejudice showed up or unfairness, if you will, were all ways for us to study it, in a way that the finger was not pointed at any individual and assaults on self-esteem were not the scope.

Rumay:
It was, how do we better relate? How do we come together? How do we give each other that space to make errors? Because we're all biased. That's not any one group's issue. And how we understand policies and practices that we did for someone instead of with someone and therefore, what we did for someone might actually make it worse for them because we did it based on our values and beliefs over against understanding theirs.

Rumay:
Part of that was looking at the curriculum and how we infuse in the classroom, concepts and practices and discussions and quite frankly, inclusion of some people who might've been left out of previous history, in the ways we've talked about it and understanding a changing world with a changing demographic and as nurses, who we are providing care for or we're on the team with. So, professions are cultures and just like denominations of religions are cultures. Not to mention racial, ethnic group cultures and practices and just helping them to understand that cultures are what the great philosophers, the temptations, described as, the way you do the things you do.

Dan:
I love that. And I think you bring up a good point there. And I think some people default right to, "well, this is a race thing or a sexual orientation thing or whatnot." And it goes deeper than that. This dives into the way that physicians and nurses interact in a hospital system. There's bias in that interaction and there's assumptions made about both professions and how they should show up in their role within the team, that also drive a lot of decision making that has negative outcomes as well.

Rumay:
Exactly. Including the intelligence of one versus the other. They do different work and it takes excellence in both their spaces or all the spaces on the team, to make it the best for the patient. And when those cultures clash, communication often drops and the patient suffers as a result of that. So, one of the big things I teach is that, all encounters are cultural encounters, there's no such thing as not having a cultural encounter. Even if everybody in the room, when you walk in, looks the same by skin color or they look the same by gender, there's still a great deal of cultural encounter going on there. And so, in the interaction with a patient, you got the provider's culture, you got the patient's culture, you got the culture of the healthcare facility, you got the culture of whether it's rural or urban in terms of location in the state, you got the culture of the state, is it a Southern state or Northern state? Is it on the East Coast? Is it on the West Coast? You got the United States culture.

Rumay:
So, these are invisible pieces that, when individuals interact with each other, are coming to the fore and people don't think about those things.

Dan:
Let's dive into nursing around the culture piece. As far as diversity inclusion goes for the profession, where does nursing stand at the most?

Rumay:
We're making slow strides but we've sort of been stuck in that 10 to 12% space of diversity, overall, as it relates to demographics, okay? Again, it depends on which dimension of diversity you're talking about. And so, this actually brings up, for me, so that you understand my definition of diversity is, diversity is the ways we differ. And it's a fact that typically you can measure, often people want to measure it by numbers, right? Representation of different groups. Equity, on the other hand, is a practice. And how do we practice equitable care, knowing that not everybody needs the same thing? So, the assumption that, if you treat everybody the same, you're treating everybody fairly, is not necessarily true. Equity is about having that same opportunity. Fairness might mean you need to make adjustments, based on where they start out. And the reason that that statement, treating everybody the same is treating everybody fairly, is not true because the assumption underneath it is not true.

Rumay:
Not everybody starts out in the same place. We historically have placed some people in disadvantaged situations and through no fault of their own but that does advantage them and disadvantage others. And so, the race isn't starting out at the same starting line, you got some people naturally set up to be behind. But inclusion is the goal that you're after. So, we have not diversified well in nursing, in terms of, as long as we have been talking about it. And, particularly, since people started incorporating it as part of the needed work in grants, that's part of the criteria, they were looking for those pieces. And so, you would think as long as we've been encouraging it and writing about it and talking about it, it would be greater but still, about 86% of the leadership of nursing, the top leadership, is still predominantly white and female.

Dan:
Yeah. I was just remembering, as you were speaking, about my experience in a nursing school as well and the majority of the books and this, sort of, seems small but the majority of the books, the nurse was always she. And so, the six males in our group, that felt very weird to us that it never said he, so you already felt out of the loop. Already being a male nurse has its societal views as well and I think that's amplified with other structural issues that we have, related to inclusion and diversity within the profession. So, what does nursing do to change it? How do we get more diverse nurses into the pipeline and ensure that they're successful and become the practitioners that take care of the population?

Rumay:
I think we have to be very intentional. It's by design, it doesn't happen by default. And as I, often when I'm doing consultation, say to people, "get the words off the walls and into the halls," so that we're literally living out what we say we need and believe in. So, given that we're the most trusted profession, given that we spend more time with the patient than anyone else, given the fact that if you look demographically what's happening to the population, the fertility rates have declined for the past quarter century, especially among native born white women, we need to pay attention to who's having the babies. So, we've got many more babies who demographically look very different from who's the majority in nursing, at this time, whether that'd be in the teaching aspects or the practice aspects.

Rumay:
Given that boomers began turning 65 at the rate of 10,000 per day in 2011 and that's been projected to continue through 2029. Given that deaths exceed births, among whites, in that same time period. We've got to be intentional by design, that means our recruiting practices need to reflect that demographic change. People shop these days, even on the websites, they look at the information about who's in the school, who teaches in the school, who leads in the school, what kind of supports are in the school. There needs to be succession planning, there needs to be the creation of inclusive classrooms, where you're bringing in a number of people from different backgrounds and something as simple as looking at the syllabus and the reading assignments have a diversity of authors that you have, in terms of textbooks and reading. In other words, you give cues that you are sensitive to these pieces and you pay attention to it. Diversity and inclusion has to be threaded through out the curriculum. It should not be a side piece that you all of a sudden add into a conversation.

Rumay:
It requires, not in all black or an all white or all Hispanic or all native American faculty, it requires that blending and mix by intentionality at every aspect. And I tell all spaces and places that I'm in, that they should constantly ask in every meeting, every committee meeting, "who's missing from the table and how do we get those folks at the table?" The students need to be able to identify with someone who's had to navigate the same space they had to navigate and we need mentors. Many, no one person can be the, be all mentor for another. Myself, I had mentors that were male, I had mentors that were white, I had mentors that were African-America, I had mentors that were not the first-generation in their family to go to college but I also had mentors who were first-generation or even a mentor who you've been the only person of color on the team and you've had to work the space and you have been successful. Only somebody who's done that can tell you how to do it.

Dan:
It brings up the same topic that we were talking about earlier, which is, diversity breeds change and innovation. It supports it, it provides a different perspectives to create successful movement forward into the future and it's the same with your personal career. You need to have diversity of mentorship. You need to tap into people who have navigated similar things in your life, is not exactly the same as the person next to you or with the same skin color or orientation or whatever. And so, if you can diversify that, then that makes you a more rich person to go out and help address these issues we've been talking about.

Rumay:
Absolutely. And the other thing that doesn't happen is, you need sponsors. You need people who will vouch for you when you're not at the table. Who will call into question unfair practice or inequitable practices when you're not at the table. And it should never be just the burden of the minority individual, however, we're defining minority. And in this case, I mean lesser number, okay? Not the ability. To be always the one to call out those kinds of conversations that really are putting one group in a space that's lesser than or greater than.

Dan:
Yeah. I think that is a great point to hit on too, which is, what are we looking for in the profession? And let's round that out. Who has those skillsets, that background, that passion, for the profession and not whose parents were all... you have a lineage of 100 years of nursing in your family. That's not the only factor here, people bring different experiences from different aspects. That's why I like the accelerated bachelor's programs too, it brings a whole new perspective into the profession. Engineers and musicians and blue collar and all this stuff that's just amazing into the profession. What are your thoughts on that?

Rumay:
I think that richness of putting all those factors together and bringing those in, just again, as you so nicely said, brings a richness and a depth to what we're about. And I was just thinking a minute ago, sometimes I've been in meetings where some of the discussion and the way it's stated, it's so loaded with triggers, right? And trigger words and power plays and who has the real authority to make or break someone's career. And so, one of the things I've really been devoted to, is making the implicit explicit because where the implicit is not made explicit injustices flourish. Until we have that honest conversation and we're willing to make those adjustments and pivot to, as you said, the traits and the qualities that we're looking for in nurses, we're going to continue to have this problem. And every now and then, you have to deliver a little eloquent rage about what's going on in the space.

Dan:
Good trouble, right?

Rumay:
Good trouble, every single day. So, there's usually something that comes up that, you can show your rage in an eloquent way. I do think these labels, they really do create issues for us because labels put people on a path and then we treat people like the labels we put on them, when in fact we all have multiple, multiple forms of identity and we bring all those with us. I think the other really big era I see is organizations say they want diversity but then once they get people from different backgrounds and perspectives and experiences, then all of a sudden they want to assimilate them or conform them, to the way we've always done it rather than accepting that they do bring different, they do bring another way of looking at it. So, it's one of the most unfair things I think you can do, it's misleading. We want the diversity but once we get you, we need you not to be you, we need you to assimilate. You need to do it the way we think it's best.

Dan:
I had an experience like that in one of my organizations and I was told, for the first two years you work here, you're part of the solution and after two years, you're part of the problem because you do get assimilated and you start following the same pattern as every decision maker. And this was in an innovation role and so, my whole job was to be disruptive and challenge things. And I was like, "well, then I'm never going to pass that two year mark, I'm going to have to intentionally be disruptive every single day." And I think that's also something that, if you go into those organizations, you have to intentionally challenge the status quo every day, in order to shift the culture to be not assimilate but to be you in a way that supports the mission of the care or the organization but it's also allowing you to express who you are.

Rumay:
And it's tiring work. And if you're putting all the burden on the people who are, by number, in the minority, it's invisible workload and very stressful and it does get in the way of you being able to give full performance or full attention because you're now having to siphon some of that energy into exactly what you just talked about and that is pushing against some of that. And so, if we want them to be at their most efficient selves, then that sense of belonging, that sense of welcoming difference, that sense of not judging, that sense of not othering or labeling people or creating the us versus them, is an important piece. And so, what's worse is, if we say one thing but we do another, the hypocrisy of that, runs people away. And COVID, with all its fervor, has had one good side to it, at least and there are others.

Rumay:
But one big one is, it's pulled the blanket back and exposed a number of systemic issues, in the way we deliver health care, in the way we think about each other, how we treat each other, the way we've set systems up and continue to try to rig systems so that the power stays in certain spaces and not in other spaces. And that's one of the things that I think it's made evident to people who believed that, particularly, since the 60s, things have gotten so, so, so much better and only to see some of this playing out now. Things they thought had gone away or that didn't exist any longer are becoming very prevalent and are coming to the surface. And it's basically saying, we've got unfinished business. We didn't talk about it because we didn't know how to talk about it in many instances. And when people did talk about it, they got the label of being violent or being a pot stir or creating trouble, over against let's, as Louie [inaudible 00:30:44] would say, put some light on the situation so we can disinfect it.

Dan:
I love it. I keep saying, the worst thing that could happen is we go back to the way it was before COVID. This should catalyze us into an entirely new system, of healthcare, of the nursing profession, of so many different things. We just have a huge opportunity to just, we see it now, then we got to address it.

Rumay:
Yeah. And culture is really, really hard to change. Experts tell us that, typically in the business world, it takes about seven to 10 years to change a culture. That's constant assault on the things that don't line up with who we say we are and what we want to be about, as you've indicated. But in academia, is twice as long, it's much slower and that's because many of the processes and policies there favor those who are tenured or who it designed tenure for. And at the time the tenure was developed, it did not have certain groups in mind. And so, those groups are now dominant on the campus but the rules were designed for another set of folks in an exclusionary way. And so, if you want to really get into some serious situations that are inequitable, that space is loaded with them.

Dan:
Yeah. And like you said, there's unfinished business that needs to be addressed. And I'm hoping we have courageous leaders, in the ranks, that are willing to continue the fight and step up. And I think nursing's a perfect place and hopefully a safer place to be able to do that. And we push this profession forward to lead the way and other health professions can see that light and follow us as well.

Rumay:
Yes. I'm encouraged by some of the conversations I've seen of late and the way our students are, really, beginning to point out inconsistencies without a certain group saying, "see? They're doing it to us again." And where we're being, what I call, upstanders for each other, not by standards. I'm glad that didn't happen to me, I'm going to stay quiet and hope that won't happen to me. But I see some true upstanders coming forth and that's the skillset we need and I see it in the diverse set of students that we have. And it's a wonderful blend of, what's also changing demographically in the world. Family dynamics or constitution of families now is different, marital status is different.

Rumay:
There are all these things that in the past would have just been snuffed out, that people are really fighting for as the rights of individuals and that we're all a part of humanity and we all need the same things, care, respect, self-esteem, the ability to flourish, the ability to live out our dreams and hopes and desires and to bring to the table rich, new, ideas that are just judged on the idea, not who brought it.

Dan:
Yeah. I think that's a great message. And for all the listeners out there, we have a lot of frontline nurses, we have a lot of nurse leaders, I think those are amazing words to move forward by. One thing we like to do is, hand off a nugget of information to our listeners to wrap up the show. What would you like to hand off to our listeners after our conversation today?

Rumay:
Two things. One, is a statement that I use all the time and the other one is one that my mother used to say to me and my two sisters all the time, that works well and that I also say. So, I encourage people to revolt at your own level. Not all of us see ourselves marching up to Washington and sitting in front of a legislative body, making a report or a request. We can revolt at our own levels and do things that advanced forward, being kind and merciful to each other and making the space for those hard conversations and truly understanding and making the world better together. And the second one comes from my mom, here you go. You can't talk your way out of what you behaved your way into.

Dan:
I love that.

Rumay:
And we have continued to do that. We've got to stop trying to talk our way out of what we behaved our way into. The behavior has to line up with the talk. It can't just be, do the talk and then act differently. And when we align those two, you get to see all the changes that you and I have been talking about, that we still say is unfinished business.

Dan:
Yeah. Well, thank you so much for those two nuggets, they're amazing to wrap the show up and I couldn't agree more, with both of them. Dr. Alexander, thank you so much for being on the show today. Where can we find you? Where do you live online that people may want to reach out and learn more from you?

Rumay:
Wow. I do a lot of presentations and qualitative types of articles that talk about experiences. But if you go to UNC Chapel Hill, I think you'll find me fairly easily. Or the National League for Nursing is another place, I am the immediate past president of the National League for Nursing, which is the oldest nursing organization in the country, with over 40,000 nurse educators as members and over 1,200 schools of nursing. I am told if you just go in and Google my name, I pop up all over the place.

Dan:
I can attest to that. You do pop up all over the place, which is a good thing because that means you're an influencer.

Rumay:
I am afraid to look but I have been told there's pages and pages so, I'm easy to find. And thank you.

Dan:
Of course, happy to have you. And we'll put some of the links in the show notes so people can easily get some of those articles and see some of your work. Thanks again for being on the show, everyone go out and make some good trouble and we'll see you on the next show. Thanks so much.

Dan:
Thank you so much for tuning in to The Handoff. If you liked what you heard today, please consider leaving us a review and subscribing on Apple Podcasts or wherever you listen to podcasts. And for more information about Trusted, please visit trustedhealth.com. This is Dr. Nurse Dan, see you next time.

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