培养价值文化：呼唤共鸣的领导力

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Over the course of many years, our nation has witnessed visceral, alarming acts of hate and racial injustices. Images of life and death, which are vivid and daunting ever-present reminders of the social inequities and racial injustices, contribute to the often-silent fears and generational stressors plaguing our nation's marginalized populations. These stress-ors perpetuate health inequities, contributing to the poor health outcomes pervasively illustrated by the disproportionately high infection and death rates of racial and ethnic minorities in the United States during the coronavirus disease 2019 pandemic (Centers for Disease Control and Prevention, 2020). Evidence supports that a diverse health care workforce, reflective of the population, improves trust, retention, engagement, and reduces health disparities. Investing in our nursing workforce and the structures that support our vitality is critical to addressing health reform and requires that we work together across health professions to successfully address discrimination and bias. The Josiah Macy Jr. Foundation (2020) commissioned report, Addressing Harmful Bias and Eliminating Discrimination in Health Professions Learning Environments, is a blueprint for change and timely response to the consensus vision statement calling for “Our nation's health professions learning environments—from classrooms to clinical sites to virtual spaces—should be diverse, equitable, and inclusive of everyone in them, no matter who they are. Every person who works, learns, or receives care in these places should feel that they belong there.” So how do we move toward a health care system that is diverse, equitable, and inclusive?

The movement begins with recommendations that support successful and sustainable pathways into the workforce that eliminate discrimination and address bias including (1) build an institutional culture of fairness, respect, and antiracism by making diversity, equity, and inclusion top priorities; (2) develop, assess, and improve systems to mitigate harmful biases and eliminate racism and all other forms of discrimination; (3) integrate equity into health professions curricula, explicitly aiming to mitigate the harmful effects of bias, exclusion, discrimination, racism, and all other forms of oppression; and (4) increase the numbers of health professions students, trainees, faculty, and institutional administrators and leaders from marginalized and excluded populations. But how? A macro-level discussion focuses on strategies centered on “culture change” and highlights case studies of bias and discrimination. Examples include how to address bias and discrimination against patients by their providers and the health care system, discrimination directed at providers from patients, and discrimination (structural and interpersonal) against health professions students. All are important tenets when addressing bias and discrimination, but what was not discussed is the bias and discrimination experienced across health professions. The ongoing leveling, hierarchies, and submission result in an environment of miscommunication, burnout, turnover, mistrust, indecision, and inability to practice to the full extent of licensure. The latter impedes pathways into nursing practice and academia. The health professions hierarchy and subsequent scaffold of physician privilege is slowing the progress of addressing bias and discrimination in our educational institutions and health care settings and contributing to health disparities and lack of access to care.

When envisioning a hospital Board of Trustees, often they are not representative of the patient population. Many are physicians and none are nurses (so not representative of the health care team). In academia, colleges of medicine are usually more highly resourced than other health professions colleges and, often but not always, the Dean of Nursing reports to an Academic Health Center Director, who is often a physician. In practice, most standing committees include physicians, again typically older, White, and male, with few if any other health professionals, who develop and enforce policy about quality, finance, governance and planning, compliance, strategic planning, and physician relations. Interesting that although nurses are the vast majority of professionals employed by hospitals, physician relations, instead of human relations, is the nomenclature reflecting the long-standing cultural bias toward physicians as the “captain of the ship.” The hierarchy continues with physician dominance over the scope of practice of the nurse and the advanced-practice nurse. The bedside nurse's information is often ignored or under-valued because of a physician-focused framework. Barriers to scope of practice expansion for advanced-practice nurses translate into decreased access of care despite excellent outcomes. The entire team must be valued, engaged, and heard. All need a seat at that table where decisions are made.

Health care will be better when nurses are respected (and feel this value) in the workplace. Students will follow pathways into nursing when they see nurses valued in educational and hospital systems. The nurse faculty shortage will be addressed when colleges of nursing receive fair compensation and equitable resources. We must cultivate a culture of value, one that is characterized by fairness, respect, antiracism, and inclusion as stated in the Josiah Macy Jr. Foundation (2020) report. And, it is not missing for the authors that racial and ethnic minority representation is missing from authorship, and that the onus is on us. Cultivating a culture of value will require resonant leaders to stop compromising human capital for a bottom line that does not serve our population equitably. We need trusting, engaged, respected relationships between nurses and physicians, in addition to other health professionals, to support inclusive health professions' learning and practice environments so that health equity can be achieved.

Angela Clark, PhD, RN, CNE, FAAN

clark3ak@ucmail.uc.edu

Denise K. Gormley, PhD, RN, FNAP

Christine Colella DNP, APRN-CNP,

FAANP

Greer Glazer RN, CNP, PhD, FAAN

University of Cincinnati College of

Nursing

全文翻译（仅供参考）

       多年来，我们的国家目睹了发自内心的、令人震惊的仇恨和种族不公正行为。生与死的画面，生动而令人生畏的时刻提醒着社会不平等和种族不公，助长了困扰我们国家边缘化人口的常常无声的恐惧和代际压力。这些压力或因素使健康不公平现象长期存在，导致健康状况不佳，这体现在 2019 年冠状病毒病大流行期间美国少数族裔的感染率和死亡率过高（疾病控制和预防中心，2020 年））。有证据表明，反映人口的多元化医疗保健劳动力可以提高信任度、保留率、参与度并减少健康差异。投资于我们的护理人员和支持我们活力的结构对于解决卫生改革至关重要，并且需要我们跨卫生专业共同努力，以成功解决歧视和偏见。  Josiah Macy Jr. Foundation ( 2020 ) 委托报告，解决有害偏见和消除卫生专业学习环境中的歧视, 是改变和及时响应共识愿景声明的蓝图，呼吁“我们国家的生专业学习环境——从教室到临床站点再到虚拟空间——应该是多样化、公平和包容的，无论他们是谁是。每个在这些地方工作、学习或接受护理的人都应该感到自己属于那里。” 那么，我们如何迈向多元化、公平和包容的医疗保健系统呢？

       该运动首先提出了一些建议，这些建议支持成功且可持续地进入劳动力市场，消除歧视和解决偏见，包括 (1) 通过将多样性、公平和包容作为首要任务，建立公平、尊重和反种族主义的制度文化；(2) 开发、评估和改进系统，以减轻有害偏见并消除种族主义和所有其他形式的歧视；(3) 将公平纳入卫生专业课程，明确旨在减轻偏见、排斥、歧视、种族主义和所有其他形式的压迫的有害影响；(4) 增加来自边缘化和被排斥人群的卫生专业学生、实习生、教师和机构管理人员和领导者的数量。但是怎么做？宏观层面的讨论侧重于以“文化变革”为中心的战略，并强调偏见和歧视的案例研究。示例包括如何解决其提供者和医疗保健系统对患者的偏见和歧视，针对患者的提供者的歧视，以及对卫生专业学生的歧视（结构性和人际关系）。在解决偏见和歧视时，所有这些都是重要的原则，但没有讨论的是卫生专业所经历的偏见和歧视。持续的等级调整、等级制度和提交导致了一种沟通不畅、倦怠、人员流动、不信任、优柔寡断和无法充分练习执照的环境。后者阻碍了进入护理实践和学术界的途径。

      在设想医院董事会时，他们通常不能代表患者群体。许多人是医生，没有人是护士（因此不代表医疗团队）。在学术界，医学院通常比其他卫生专业学院资源更丰富，而且，通常但并非总是如此，护理学院院长向通常是医生的学术健康中心主任报告。在实践中，大多数常设委员会包括医生，通常是年龄较大的白人和男性，几乎没有其他卫生专业人员，他们制定和执行有关质量、财务、治理和规划、合规性、战略规划和医生关系的政策。有趣的是，虽然护士是医院雇佣的绝大多数专业人士，但医生关系，而不是人际关系，是反映长期以来对医生作为“船长”的文化偏见的命名法。随着医生对护士和高级执业护士的执业范围的支配，这种等级制度继续存在。由于以医生为中心的框架，床边护士的信息经常被忽视或低估。尽管结果很好，但高级执业护士执业范围扩大的障碍转化为护理机会减少。必须重视、参与和倾听整个团队。所有人都需要在做出决定的那张桌子上占有一席之地。由于以医生为中心的框架，他们的信息经常被忽视或低估。尽管结果很好，但高级执业护士执业范围扩大的障碍转化为护理机会减少。必须重视、参与和倾听整个团队。所有人都需要在做出决定的那张桌子上占有一席之地。由于以医生为中心的框架，他们的信息经常被忽视或低估。尽管结果很好，但高级执业护士执业范围扩大的障碍转化为护理机会减少。必须重视、参与和倾听整个团队。所有人都需要在做出决定的那张桌子上占有一席之地。

       当护士在工作场所受到尊重（并感受到这种价值）时，医疗保健会更好。当学生看到护士在教育和医院系统中受到重视时，他们将遵循进入护理的途径。当护理学院获得公平补偿和公平资源时，护士师资短缺问题将得到解决。我们必须培养一种价值文化，一种以公平、尊重、反种族主义和包容为特征的文化，如 Josiah Macy Jr. 基金会（2020 年）所述） 报告。而且，作者并没有错过作者身份中缺少种族和少数族裔代表的情况，并且责任在我们身上。培养一种价值文化将需要有共鸣的领导者停止为了不公平地为我们的人民服务的底线而牺牲人力资本。除了其他卫生专业人员之外，我们还需要护士和医生之间建立信任、参与和尊重的关系，以支持包容性卫生专业人员的学习和实践环境，从而实现卫生公平。

安吉拉克拉克，博士，注册护士，CNE，FAAN

clark3ak@ucmail。加州大学。教育

Denise K. Gormley，博士，注册护士，FNAP

克里斯汀科莱拉 DNP，APRN-CNP，

FAANP

Greer Glazer 注册护士、CNP、博士、FAAN

辛辛那提大学学院

护理

原文链接：

https://journals.healio.com/doi/10.3928/01484834-20211204-01

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