News and Commentary Social Mission and Equity in Nursing Education: Celebrating National Nurses Month with Brigit Carter, PhD, MSN, RN, CCRN

A headshot of Brigit Carter, PhD, MSN, RN, CCRN

This May, we join the nation in celebrating our nursing colleagues during National Nurses Month. In this edition of Macy Notes, I share excerpts from my recent conversation with an exemplary nursing educator and administrator, Brigit Carter, PhD, MSN, RN, CCRN. As associate dean for diversity, equity, and inclusion (DEI) at Duke University School of Nursing, Dr. Carter is the recent recipient of the Josiah Macy Jr. Foundation’s 2022 Award for Excellence in Social Mission in Health Professions Education. She has been instrumental in accelerating DEI efforts across all academic nursing programs at Duke and remains committed to improving outcomes for patients. During our conversation, I asked Dr. Carter to reflect on Action Step 1.4 from our 2021 Macy Conference recommendations and share her thoughts on nursing education’s role in answering the call to action.

Action Step 1.4. Health systems and HPE (health professions education) leaders and educators must collaborate with leaners on educational program direction, working in partnership to evaluate existing policies for bias; implement equitable recruitment policies and practices; foster retention of a diverse student body; develop unbiased and flexible advancement policies; design and evaluate bias-free curricula and assessment; and develop community engagement initiatives.

Holly Humphrey (HJH): Dr. Carter, congratulations on being named the recipient of the Award for Excellence in Social Mission in Health Professions Education (for Individual Excellence)!

Can you begin by telling us a bit about some your initiatives at Duke University School of Nursing that led to this award, as well as how these programs and initiatives can serve as examples for the call to action outlined in Action Step 1.4 from the Macy Conference recommendations?

Brigit Carter (BC): Prior to the development of the associate dean position and the Office of Diversity, Equity and Inclusion (ODEI) at Duke University School of Medicine (DUSON), our community had embraced programs that were designed to create a culture that would nurture our students, staff, and faculty. Dr. Dorothy Powell and then-dean Catherine Gilliss developed the first program designed to increase an interest in the nursing profession. These programs were later supported by Health Resources and Services Administration Nursing Workforce Diversity (NWD) and provided funding to address the barriers to nursing education for underrepresented minority students. Over the past 10 years and more than 200 diverse students later, DUSON has made a significant impact not only on those individuals who participated within these programs but on faculty and staff who have served as educators and mentors to those students. The workforce diversity programs have been partially integrated and financially sustained by the school and will continue to assist in the professional development of future nurses.

Our community has embraced diversity, equity, inclusion, and belonging (DEIB) and committed to addressing inequities by integrating the study of social determinants of health into the curriculum, creating policies that incorporate holistic admissions into undergraduate and graduate programs, embracing programming that contributes to learners’ development in the DEIB space, and reviewing the curriculum for bias. With the development of the ODEI and the framework that guides our efforts, we have the opportunity to identify and address areas for individual growth.

Faculty are offered the opportunity to attend a year-long Teaching for Equity Fellowship, which supports the learning and development of knowledge and skills that strengthen educators’ ability to support and teach students from diverse backgrounds. In addition, the fellowship is designed to strengthen knowledge on handling of challenging topics, especially those that may arise around diversity. Half of the current faculty have attended this fellowship, which strengthens our ability to teach and mentor a diverse student body.

We have also identified foundational trainings that support development of individual self-awareness, how to be a more effective ally, and how to address difficult conversations. The Promoting Empowered Approaches for Critical/Challenging Encounters (PEACE) program provides a supportive infrastructure within the school to assist our community members in navigating challenging conversations or interactions with one another. The facilitators are staff and faculty who receive ongoing training in order to provide strategies for communicating with a community member and to provide support for conflict resolution through conversation.

In collaboration with our Duke Advancement of Nursing, Center of Excellence (DANCE) program, we developed a Mentoring Black Nurses Towards Success program that engages the accelerated BSN student and clinical staff nurses. The clinical nurse mentors the accelerated BSN student by offering support with overall preparedness for clinicals, internships, job applications, and professional development. The clinical nurse is mentored by nurse leaders who assist with developing career interests and strategies to achieve professional development goals.

One of our most recent and significant projects has been connected to Duke Health Moments to Movement initiative, which was designed to address racial and social injustices within the community. A Racial Justice Task Force was formed and more than 180 community members participated in nine committees over a year to develop recommendations and create strategies to advance racial justice in areas of equity accountability, performance measures, and training recommendations.

HJH: What a robust and rich set of programs and practices. You are to be congratulated and commended. In July 2020, you served as the senior author of a paper titled “Creating a culture that values diversity and inclusion: An action-oriented framework for schools of nursing.” Can you reflect on the changes you have seen in nursing education since the publication of this paper? What advice do you have for those schools that are working to change their organizational culture to one that values diversity and inclusion? 

BC: There has been significant progression in the DEIB space. Many nursing schools began to prioritize diversity, equity, inclusion, and belonging and incorporate DEIB into strategic plans, which enables development of priorities for the school that support the DEIB work. Another catalyst was, unfortunately, the murder of George Floyd, as well as inequities that were illuminated by the COVID-19 pandemic, which propelled action across society and from schools of nursing and many of our lead nursing organizations. The American Nurses Association, in collaboration with the National Black Nurses Association, National Coalition of Ethnic Minority Nurse Associations, and National Association of Hispanic Nurses, launched the National Commission to Address Racism in Nursing. American Association of Colleges of Nursing developed a Diversity Leadership Institute to help support and prepare diversity leaders within schools of nursing. The National League for Nursing developed a new initiative, Taking Aim: Addressing Structural Racism, Diversity, Equity, Inclusion, Implicit Bias and Social Justice. 

One of the most significant changes has been the addition of the associate dean for diversity, equity, and inclusion role into many schools of nursing. Human capital resources are required to move this work forward, and schools are successful meeting DEIB goals when leaders have a diversity strategy and a shared vision to achieve those goals.

The ODEI is responsible for developing programming and workshops to support individual growth and development in the DEIB space. This includes foundational training such as implicit bias, cultural intelligence, civility, difficult conversations, and bystander training. It is also important to seek annual feedback from the students, staff, and faculty regarding areas where they would like to see additional programming. One area that was identified that significantly impacts our school community is the ability to recognize and respond to microaggressions in the classroom, laboratory, and clinical settings. We implemented student surveys that enabled us understand the extent to which students experience microaggressions. The responses provided helped inform the faculty about student experiences. Microaggressions is one example, however, if we want to retain our students, clinical nurses, and nurse leaders, it is critical for us to introduce knowledge and skills that address barriers to learning or achieving belonging in a space.

Holistic admission processes are being integrated into schools of nursing, not only for student admissions, but also in hiring practices for staff and faculty, which support the development of a more equitable human resource process. Dashboards have been developed to show the diversity of student populations, which creates more accountability for the recruitment and retention of a diverse student body. Nurse mentor programs have been developed at the local and national levels to promote the professional development of the clinical nurse. This guidance is critical in order to create future nurse leaders within the health systems and in nursing education.

HJH: This action step calls upon HPE leaders and educators to collaborate with learners to achieve the outlined activities (evaluate existing policies for bias; implement equitable recruitment policies and practices; foster retention of a diverse student body; develop unbiased and flexible advancement policies; design and evaluate bias-free curricula and assessment; and develop community engagement initiatives.) What are some of the challenges in collaborating with nursing learners on these areas? Why is it important?

BC: Learners desire the opportunity to be engaged in a setting that responds with equitable practices and policies, to participate in a curriculum that has been designed to be free of bias and rich in health equity, and to learn more about how to incorporate these activities into their future practice.  

Time is often the challenge. Nursing curriculum is often full with mandatory requirements, therefore the onus is on the faculty to integrate these components into their curriculum. It is the faculty’s responsibility to ensure that they enter into a program with true diversity and that resources are available to all students to support academic success. It is the academic setting’s responsibility to ensure that we offer the opportunities to expand knowledge and development around health equity, racial and social justice, and the social mission of nursing.

I don’t put the full responsibility on the academic setting. While we create the opportunities, students should enter into the academic setting with the desire to engage in every opportunity to learn how to provide excellent and equitable care. There must be a willingness to expand knowledge beyond the hospital in order to learn how the communities in which our patients live contribute to their illness and wellness.

HJH: At a time when there is so much distrust in medicine and science, it is all the more laudable that nursing—for the 20th year in a row!—remains the most trusted profession according to an annual Gallup poll. In honor of National Nurses Month, would you please share a bit about your own personal experience as a clinical nurse and what you believe to be key factors for the profession in maintaining this high degree of trust and esteem?

BC: Nurses are at the front line of the experiences of people who enter into the health care system. The nursing profession has embraced holistic care, which enables us to provide unique, individualized support for each patient; to address their physical, mental, emotional, and spiritual needs; and to identify social determinants of health that may present barriers to healing and return to wholeness. I have treasured memories of ushering patients and their families to wellness and through death and dying. They trust me to create experiences for them that will contribute to their ability to bond with their new infant in some of the most challenging situations. We are with them 24 hours a day; we are their advocates and support system. I am still connected with many of my past patients and their families, have attended graduations, weddings, and funerals. I still check on them when they are here for an appointment or hospitalization. A nurse’s care does not end on discharge. Nursing is the art of caring, and we demonstrate that every day through listening, being responsive to needs, showing compassion, and advocating to improve outcomes.

HJH: You continue to serve as a staff nurse in the Duke University Hospital Intensive Care Nursery—why is remaining in clinical practice so important to you?

BC: Simply put, I love caring for the neonatal population and their families. Since 1998, from the day I stepped into the Intensive Care Nursery, this was the passion that guided me, encouraged me to further my education so I can contribute to improving outcomes. I have been unable to practice during the pandemic; despite this, my work continues to support intensive neonatal health. For example, I’m now working on initiatives that address implicit bias in the neonatal units. When I retire from academics, I hope to go back to the bedside.

HJH: Please offer any additional comments or thoughts that you wish you share that we have not covered already.

BC: Every day as a nurse you must ask yourself how you can positively impact a patient, a colleague, or the health care system through day-to-day interactions, advocacy, and leadership. Because the health care system is challenged with many inequalities and inequities, it is our duty to identify strategies that will address imbalances or limitations of the system. While this award was in recognition of individual excellence, I cannot praise my DUSON community enough for their commitment and contributions to making this work come alive. Many departments have developed specific racial justice plans within their spaces to ensure policies and practices produce equitable results. I could not ask for a more dedicated and diligent community in which to serve. I have stood on the shoulders of many and have amazing colleagues who support efforts that address social and racial justice. I have students who have entrusted me to serve as their professional development and growth mentor. I am grateful for a community that believes in me and what we do within the ODEI, which allows us to shine a light on the path to equity.

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