护士在减少重症患者不平等方面的作用

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Gerontological nurses are uniquely positioned to reduce the substantial health-related inequalities faced by seriously ill older adults and their families. Older adults from minoritized populations often suffer most. Minoritized populations negatively impacted by health inequities can include those from under-represented racial/ethnic, gender, or religious groups; migrants or refugees; individuals with different abilities; lower education and/or literacy levels; lower socioeconomic status groups; sexual orientation; or any other measures of disadvantage that serve as social determinants of health (Weinstein et al., 2017).

The United States has a long history of injustice toward minoritized racial and ethnic groups in health care, even under the guise of health-related research. Well-known instances, such as the Tuskegee Syphilis Study and the Henrietta Lacks (“HeLa” Cells) Story are just two examples of the horrific pattern of injustices toward African American individuals. These unethical practices are unfortunately not a thing of the past. In the midst of the coronavirus disease 2019 (COVID-19) pandemic, inmates at an Arkansas prison were reportedly unknowingly given an antiparasitic drug to treat their COVID-19 infection, use of which had been warned against by U.S. federal health officials (DeMillo, 2021). In less obvious fashion but ever present, COVID-19–related pandemic inequities have impacted older adults residing in nursing homes (Hege et al., 2022) and elsewhere. This disparity has also been remarkably apparent in high infection and death rates among individuals of lower socioeconomic status and/or minoritized racial/ethnic groups (Figueroa et al., 2021). Health inequities extend to serious illness care as well.

Serious illness is defined as a health condition that includes a high mortality risk and either negatively impacts a person's daily function or quality of life, or excessively strains their family caregivers, such as Alzheimer's disease and related dementias or heart failure (Kelley & Bollens-Lund, 2018). Much of the disparities observed in serious illness care outcomes are related to systemic inequality. For instance, older African American and Asian American individuals are less likely to use hospice and are more likely to have multiple emergency department visits, hospitalizations, and intensive treatments than White American individuals (Aaron et al., 2021; Jia et al., 2022; Ornstein et al., 2020). Root causes of these disparities include systemic racism, implicit and explicit biases, discrimination, and historical traumas that result in lack of cultural sensitivity and mistrust in the health care system (Weinstein et al., 2017).

Understanding and effectively using health-related and decision-making terminology also plays a key role in promoting health equity (Moss et al., 2018). In serious illness care, few interventions are culturally tailored specifically for disadvantaged and minoritized populations (Jones et al., 2021). Geriatric nurses must act to address these challenges at individual, population, and systems levels. We must also diversify our workforce so that the population of geriatric nurses, and nurses in general, matches the populations we serve.

The good news is that there are tangible ways in which geriatric nurses can use their positions of power to promote equity in serious illness care through practice, research, education, and advocacy. First, we must acknowledge that inequities exist and individuals who are experiencing inequities cannot overcome them alone. Nurses must therefore speak up when we observe discriminatory behaviors and commit to allyship in our practice as part of our commitment to our patients and colleagues.

Second, we need to increase awareness of our own implicit biases and not make assumptions or sweeping generalizations about people from minoritized groups, as this promotes negative stereotypes. Cultural humility and individualization are key. For instance, in goals of care discussions, we cannot assume that an individual of a specific cultural group would or would not want aggressive care and therefore not address the full range of available options. Similarly, multiple studies have shown that clinicians, including nurses, under-assess pain in racial/ethnic minority groups and are more likely to be biased against administering strong pain medications (Estrada et al., 2021; Green et al., 2003; Moore, 2018). We also need to speak up when we observe other's biases, implicit or explicit, negatively affecting care. We must perform thorough unbiased assessments that give patients and families what they need to promote equity through optimal quality of life, instead of offering everyone the same level of service regardless of their needs.

Third, nurses must seek to better understand the needs of underserved older adults and their care partners, how the particular disparity came to be, and commit to being part of the long-term solution. We can do this by asking those affected about their circumstances, listen without judgement, engage with historical literature written from the perspective of those afflicted, allyship, respond with empathy, and take other action steps as outlined in this editorial.

Fourth, advocacy for institutional, state, and federal policy changes that promote equity for older adults living with serious illness and their families is needed, including the promotion of workforce diversity in long-term care settings, addressing social determinants of health, and ensuring equity in access to research trials. Participation in advocacy days through community-based and professional organizations to elevate the need for health policy changes that are focused on reducing inequities is imperative.

Finally, the conduct of conceptually sound research that focuses on reducing health inequities in serious illness management must be increased. Using appropriate frameworks, such as the National Institute on Aging Health Disparities Framework (Hill et al., 2015), and using participatory research methods (Elk & Gazaway, 2021), as applicable in the communities we serve, are two steps toward ensuring our research results in improved care for those who are discriminated against. Regardless of the area of scientific inquiry, researchers must view their research through a health equity lens to ensure the best opportunities for people from as many diverse backgrounds as possible are included. It is evident that the time for describing the problems that exist using descriptive research alone is well passed; we must better understand the pathways that lead to discrimination and intervene (Bullock & Makaroun, 2022). It is incumbent upon us to develop diverse and inclusive interdisciplinary teams led by nurses to innovatively address these issues, not just through inclusion of diverse populations, but through tailoring of interventions at the individual, population, and systems level to address inequities and structural racism. This inclusion incorporates advocacy for research funding levels that are requisite to the conduct of all research in rigorous, meaningful, and equitable ways. We also, whether through individual clinical practice, education, research, or practice change programs, should engage the communities we serve to ensure we are addressing what matters to them in serious illness care.

The integration of serious illness care into primary care services is one key way we can also reduce inequities via primary care practices, where many nurses serve. These practices tend to be located in community-based settings and have strong relationships with patients and families they serve. In this setting, nurses and other health care providers can perform primary palliative care and refer to specialty palliative care, including telephonic nurse-led care or advance practice RN (APRN)-led specialty practice. APRNs also understand patient and family needs, which could lead to earlier referral to hospice services, reducing non-beneficial and fragmented care that can reduce quality of life as individuals approach the end of life.

As the most trusted profession (Saad, 2022), nurses are held with high esteem. Therefore, it is imperative for us to understand the complex factors that influence serious illness care needs of older adults and their families, particularly among minoritized populations. By focusing on reducing inequities of seriously ill older adults, nurses can ensure that all patients and families, regardless of background or other identities, receive the desired health care they need and deserve.

全文翻译（仅供参考）

老年护士在减少重病老年人及其家人面临的与健康相关的重大不平等方面具有独特的优势。来自少数族裔的老年人往往受害最深。受到健康不平等负面影响的少数群体可能包括来自代表性不足的种族/民族、性别或宗教群体的群体；移民或难民；具有不同能力的个人；较低的教育和/或识字水平；社会经济地位较低的群体；性取向；或任何其他作为健康社会决定因素的劣势衡量标准（Weinstein 等人，2017 年）。

美国在医疗保健领域对少数种族和族裔群体的不公正历史由来已久，即使是打着健康相关研究的幌子也是如此。众所周知的例子，如塔斯基吉梅毒研究和亨丽埃塔缺乏（“HeLa”细胞）故事只是对非裔美国人不公正的可怕模式的两个例子。不幸的是，这些不道德的做法并没有成为过去。据报道，在 2019 年冠状病毒病 (COVID-19) 大流行期间，阿肯色州监狱的囚犯在不知不觉中被给予了一种抗寄生虫药物来治疗他们的 COVID-19 感染，美国联邦卫生官员已警告不要使用这种药物 ( DeMillo, 2021）。以不太明显但一直存在的方式，与 COVID-19 相关的大流行不公平已经影响了居住在疗养院（Hege 等人，2022 年）和其他地方的老年人。这种差异在社会经济地位较低和/或少数种族/民族群体的高感染率和死亡率方面也非常明显（Figueroa 等人，2021 年）。健康不平等也延伸到严重的疾病护理。

严重疾病被定义为一种健康状况，包括高死亡率风险，或者对一个人的日常功能或生活质量产生负面影响，或者对家庭照顾者造成过度压力，例如阿尔茨海默病和相关的痴呆症或心力衰竭（Kelley & Bollens-Lund , 2018 年）。在严重疾病护理结果中观察到的许多差异与系统性不平等有关。例如，与美国白人相比，年长的非裔美国人和亚裔美国人不太可能使用临终关怀，并且更有可能接受多次急诊、住院和强化治疗（Aaron 等人，2021 年；Jia 等人，2022 年） ;奥恩斯坦等人，2020）。这些差异的根本原因包括系统性种族主义、隐性和显性偏见、歧视和历史创伤，导致缺乏文化敏感性和对医疗保健系统的不信任（Weinstein 等人，2017 年）。

理解和有效使用与健康相关的决策术语也在促进健康公平方面发挥着关键作用（Moss 等人，2018 年）。在重病护理中，很少有专门针对弱势群体和少数群体的文化干预措施（Jones 等人，2021 年）。老年科护士必须采取行动，在个人、人群和系统层面应对这些挑战。我们还必须使我们的劳动力多样化，以便老年科护士和一般护士的人口与我们服务的人口相匹配。

好消息是，老年科护士可以通过实践、研究、教育和宣传以切实的方式利用他们的权力地位来促进严重疾病护理的公平性。首先，我们必须承认存在不公平现象，正在经历不公平现象的个人无法单独克服这些问题。因此，当我们观察到歧视性行为并承诺在我们的实践中结盟时，护士必须大声疾呼，这是我们对患者和同事的承诺的一部分。

其次，我们需要提高对自己隐性偏见的认识，而不是对来自少数群体的人做出假设或笼统概括，因为这会助长负面刻板印象。文化谦逊和个性化是关键。例如，在护理讨论的目标中，我们不能假设特定文化群体的个人会或不会想要积极的护理，因此无法解决所有可用选项。同样，多项研究表明，包括护士在内的临床医生对种族/族裔少数群体的疼痛评估不足，并且更有可能对使用强效止痛药产生偏见（Estrada 等人，2021；Green 等人，2003；Moore , 2018）。当我们观察到他人的偏见，无论是隐含的还是外显的，对护理产生负面影响时，我们也需要说出来。我们必须进行彻底公正的评估，为患者和家庭提供他们需要的东西，以通过最佳生活质量促进公平，而不是为每个人提供相同水平的服务，而不考虑他们的需求。

第三，护士必须设法更好地了解服务不足的老年人及其护理伙伴的需求，了解这种特殊差异是如何产生的，并致力于成为长期解决方案的一部分。为此，我们可以向受影响的人询问他们的情况，不加判断地倾听，参与从受影响者的角度撰写的历史文献，结盟，以同理心回应，并采取本社论中概述的其他行动步骤。

第四，需要倡导机构、州和联邦政策变革，以促进患有严重疾病的老年人及其家人的公平，包括促进长期护理环境中的劳动力多样性，解决健康的社会决定因素，并确保公平获得研究试验。通过以社区为基础的专业组织参与宣传日，以提高以减少不平等为重点的卫生政策变革的必要性。

最后，必须加强概念合理的研究，重点是减少严重疾病管理中的健康不平等。使用适当的框架，例如国家老龄化健康差异框架研究所（Hill 等人，2015 年），并使用参与式研究方法（Elk & Gazaway，2021 年）)，适用于我们服务的社区，是确保我们的研究成果改善对受歧视者的护理的两个步骤。无论科学探究的领域如何，研究人员都必须从健康公平的角度看待他们的研究，以确保为来自尽可能多不同背景的人们提供最佳机会。很明显，仅使用描述性研究来描述存在的问题的时代已经过去了。我们必须更好地了解导致歧视和干预的途径（布洛克和马卡罗恩，2022）。我们有责任建立由护士领导的多元化和包容性的跨学科团队，以创新方式解决这些问题，不仅通过包容不同的人群，而且通过在个人、人群和系统层面定制干预措施来解决不平等和结构性种族主义。这种包容包括倡导以严格、有意义和公平的方式进行所有研究所必需的研究资助水平。无论是通过个人临床实践、教育、研究还是实践变革计划，我们都应该让我们服务的社区参与进来，以确保我们在严重疾病护理中解决对他们重要的问题。

将重病护理纳入初级保健服务是我们还可以通过许多护士服务的初级保健实践来减少不平等现象的一种关键方式。这些实践往往位于以社区为基础的环境中，并与他们所服务的患者和家庭建立了牢固的关系。在这种情况下，护士和其他医疗保健提供者可以进行初级姑息治疗并参考专业姑息治疗，包括电话护士主导的护理或高级执业 RN (APRN) 主导的专科实践。APRN 还了解患者和家庭的需求，这可能会导致更早转诊到临终关怀服务，减少非有益和分散的护理，这些护理会随着个人接近生命的终结而降低生活质量。

作为最值得信赖的职业（Saad，2022 年），护士备受推崇。因此，我们必须了解影响老年人及其家人，特别是少数族裔的严重疾病护理需求的复杂因素。通过专注于减少重病老年人的不平等，护士可以确保所有患者和家属，无论背景或其他身份如何，都能获得他们需要和应得的所需医疗保健。

原文链接：

https://journals.healio.com/doi/10.3928/00989134-20220629-01

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