My name is Dr. Courtney Brown, and I'm here today to present to you about the new AACN, American Association of Colleges of Nursing, DMP Essentials, and really was a new re-envisioning of the professional nurse. Now, like you, I just underwent a progression, degree progression within my own nurse anesthesia program. And so we utilize, as many of you all did, the prior 2006 AACN DMP Essentials to create coursework and curriculum that would meet those essentials of an advanced practice nurse with a DMP degree. However, in April of 2021, AACN had a task force and also ratified a new set of AACN Essentials. And within them are several competencies related to diversity, equity, and inclusion that were not found present in the prior Essentials. So in my role here today, if you'll give me the chances to show you not only what those Essentials are, a little bit of the history, as well as looking at ways that perhaps you can be creative in interweaving some of those Essentials throughout your current curriculum as in lieu of a course. So here's my disclosure statement. I have no financial relationships with any commercial interests related to the content of this activity and will not discuss off-use label and off-label use during my presentation. So here are outcomes. I'd like you to identify five of the new AACN Essentials in 2021 that relate to diversity, equity, and inclusion. The learner will describe the paradigm change from race-based to race-conscious medicine. And then the learner will locate resources which are now available at AANA in the Knowledge Network that can be used to meet your new AACN Essentials. So here is our agenda. We'll cover those Essentials. We'll talk about how racism leads to race-based medicine and research and from race-based to race-conscious approaches, both within medicine and within your curriculum. So along with our AACN Essentials, AACN also promoted the use of competency-based education. This is stark and contrastingly different from most of our educational models. Within this system, instead of perhaps creating tests to measure content and knowledge, knowledge content at one point in time, competencies are those that you actually have more or less multiple opportunities to demonstrate that competency throughout a curriculum. So those can be linked to both a system of instruction, assessment of those competencies, feedback, self-evaluation, or reflection, and also any type of academic reporting that's based on the students demonstrating, meaning higher levels blooms, that they've learned the knowledge, attitudes, motivations, and those self-perceptions and skills expected of them as they progress through the education. Now, what competency-based education is not is a checklist of tasks, a one-and-done experience or simulation or demonstration. It's not isolated in one sphere of care or context. They really want whatever is presented and measured to be transferable both between coursework as well as multiple contexts, such as in clinical practice and in the classroom setting. And it cannot be solely demonstrated on an objective test, which is how a lot of our curriculum, I would assume, currently is constructed. So let's look at those new essentials. In terms of domain 2 and 2.2, this new competencies apply individualized information, such as pharmacogenetic and environmental exposure. That's already found present in a lot of our curriculum. This is prior COA standard. What's a little less commonly found in our curriculum based on COA standards is facilitating difficult conversations and disclosure of sensitive information, challenging biases and barriers that impact population health outcomes. So it's not just the understanding of what those are, but expecting a learner to challenge those barriers. Evaluating the ability of policy to address disparities and inequities. Demonstrating leadership skills to promote advocacy efforts that include principles of social justice, diversity, equity, and inclusion. 6.1, role model respect for diversity, equity, inclusion, and team-based communications. And then practice self-assessment to mitigate conscious and implicit biases towards other team members. And they continue also, 7.1, design policies to impact health equity and structural racism within systems, communities, and populations. Evaluate health policies based on an ethical framework considering cost effectiveness, health equity, and care outcomes. And it continues on through designing system improvement strategies, suggesting solutions for unethical behaviors observed, advocating for practices that advance diversity, equity, and inclusion, as well as modeling respect for all team members. So some of those could probably be measured simultaneously. But these comprise of the ones that are most specific to diversity, equity, and inclusion. Now, learning experiences competency-based education, and this is coming from the AACN guidelines and a little bit of their visions, demonstrated across all spheres of care in a multiple context. And so when you're designing your curriculum as it relates to some of these outcomes, you actually have to scaffold and stage them. It'll depend on the developmental stage of the learner, as well as where they are in their curriculum as a whole. Some clear expectations are made explicit to learners, employers, and public. So these are things that we'll have to demonstrate to our stakeholders. And it is the result of determined, planned, and repeated practice. And that's what competency-based education is very different from outcome-based education, where you're measuring it as a final piece. The other is that it's integrative and experiential. So a lot of other types of case-based or problem-based approaches fit well with this design, as well as visibly demonstrated over time. Those types of things would indicate that you will probably need to develop and revise and use some good quality rubrics to identify if these skills, knowledge skills, and attitudes are being demonstrated throughout the curriculum. And again, they are transferable across those multiple spheres and into their professional career. So in terms of the future of nursing 2020, this is one of the resources I highly recommend that you and your faculty, and perhaps even recommend to your clinical faculty, undertake going through. I wanted to point out with the committee of this particular white paper is, first of all, it's based out of the Academy of Sciences, Engineering, and Medicine, the National Academies. If you look on the list of the committee members, several are actually medical physicians, public health nurses, social scientists. You won't find many advanced practice nurses at the bedside being taking part of this. Often these are done by deans of schools of nursing, who see what society is leaning towards in their future and create vision statements on and pathways and guidelines of how we should get there as in recommendations. In particular to diversity, equity, and inclusion, I found chapters three through five the most impactful for framing thoughts around what we could do within our own curriculum. And this was actually also produced in just May of 2021. And within there, you found their overarching vision. They evaluated evolving trends, demographics of our changing United States, demographics of our healthcare workforce, new technologies such as telemedicine and telehealth, public health emergencies as we are just currently undergoing with COVID-19, attitudes towards racism and equity. And all of those drove key areas for strengthening nursing. So at the very top, you'll see that the nursing roles that they envision should involve looking at workforce, leadership, education, well-being, and emergency preparedness and response. And within those contexts, there's also payment laws, policy, and regulations. In the center there of it all, that kind of is that centerpiece, is between both medical and social, you have structural and individual determinants of health. And so they're looking at really the individual, and this includes our patients, as well as our students, as well as us, as being part of a larger structural system. And diverse populations and settings are sort of all around this at the same time. And if people are paying attention to those social determinants of health, then they're able to more appropriately impact health equity and healthcare equity to improve individual and population health. Now, again, what was also interesting within this report is they did a survey in 2019 and the number of graduates in nursing programs in the United States and territories. So this includes other territories such as Puerto Rico. And within that, charting in the name of the report was also charting a path to achieve health equity. They mentioned that the number of graduates in 2019 was approximately 7,944. Now fast forward to probably closer to 2030, and we will both add and take up a larger proportion as we are the only advanced practice specialty that fully embraced moving our licensure, direct degree to licensure to DNP. So with that, I find it interesting that we were not as, they were not as inclusive of our area of advanced practice nursing when they were fielding a team of committee members for this report. Although looking at those individuals' areas and domains of practice, several of them in family practice, internal medicine, frontline, at the primary care sites, you can see why they would also select nursing as being one of the main answers to issues with social change and health equity as we are right there at the bedside with the patients. Right? So then what does this mean to us? So let's translate all of that great high-level discussion, and let's bring it down into our domain as both nurse anesthesiology educators and nurse anesthesiology practitioners. So looking at those competencies, if we're going to potentially be adopting those, one piece that I would like to say in here is more than 50% of nurse anesthesia programs exist within a school of nursing, and those schools of nursing will have what we call CCME accreditation. And those accreditation standards are in addition to COA standards. Those programs that are not housed within the school of nursing will probably be waiting to see which of those COA adopts to consider for what we want to include in our nurse anesthesiology educational requirements from their standards. That being said, a fair number of them probably are things that you can look at now and incorporate that are likely to be included. And if you are in a school of nursing, you're probably already part of teams of looking at how are we going to do this. And so some of these are maybe newer to our early career educator or certainly newer to our clinicians who are not partaking of this education with these competencies versus the educators that are within schools of nursing. This has probably already been a topic of conversation. Now, in terms of translated for the nurse anesthesiology educator, these competencies must integrate multiple opportunities to track, trend, and measure your outcomes. So when looking at those competencies, a lot of times you can, like we did when we progressed our degree from master's to doctoral, we looked at what the AACN had under the essentials and mapped to our learning outcomes. However, now it can't just be a one activity or one time where you assess. Competency-based means a point where you introduce an early developmental part of that competency, you reinforce, and then a student at some point has to demonstrate mastery of those competencies. That was going to require much more of a curricular map. You're going to have to be able to demonstrate this over multiple attempts, especially when designing and integrating. So you'll need to look at both your learning strategies, your student learning outcomes, and your assessment measures, whether via a test or whether via a simulation outcome or problem-based learning activity with a rubric. Now, scaffolding learning meaning involved starting with knowledge first and attitudes, moving on to skills. And those need to be also mapped from years one through three, as most of our programs are 36 months. Incorporate measures of competencies and clinical evaluations. Again, they're looking for a demonstration. And most of us, a fair number of us, have already got a clinical evaluation tool that is staged from a first semester clinical student to a final semester clinical student. So that's a great way of incorporating those competencies across those rubrics. However, then your faculty are going to, and your clinical faculty especially, are going to require a lot of development on what are we meaning by those outcomes. Consider the use of a thread. A thread is something that is longitudinal. So if you're thinking of courses being very sequential, we would consider that somewhat of a vertical curricular map. We start here with basics of anesthesia, followed by advanced principles of anesthesia. That's very what we call vertical. Horizontal threads are those that start in semester one, or even prior to semester one, if you have pre-matriculation coursework, all the way through the entirety of the program. The beauty of that is that with competency-based outcomes, it is much easier to track longitudinally, but it makes it challenging because now you have multiple course directors who may have to touch on those threads. So I would highly recommend the use of a thread director if you're going to be creating a diversity, equity, inclusion thread throughout your curriculum. Other things you can consider is incorporating multiple types of journals, student reflections, and self-evaluations to also measure those attitudes, motivations, and self-perceptions. Put some of the onus on documenting the progress of the student on the student, and that will help you as well as an educator maintain some of that. This is just an example of what curriculum templates and blocks and threads look like. Again, most of us probably have more of a block-style curriculum, where we map our courses to our student learning outcomes and to COA standards and AACN standards. However, again, if you think about it, there's probably a fair number of threads. I would argue that our clinical components of most of our programs are a thread, as we have increasing levels of complexity and introduction of skills across those that build upon each other to form our graduate. Well, think of other things that you could potentially weave throughout the curriculum. Health and wellness is a great idea, but so is diversity, equity, and inclusion. Now, in terms of those threads of being longitudinal, not every AACN domain requires a course and would benefit from a longitudinal pathway. Again, I would highly recommend having one thread director who can really scaffold all the learning and make sure it's woven together appropriately across the curriculum. You want to consider how often to assess the thread outcomes and what types of assessments you're going to use, whether they be some can be student evaluations, some can be, for example, validated reliable tools. And then it is a horizontal rather than a vertical plan of delivery. And there are other new AACN essential domains that may lend itself to a thread as well. Now, you may say this is an example of why I would argue that threading, potentially for this particular sensitive area that requires more frequent touch points, is important. This particular study by Hoffman et al. in 2016, they had two parts of the study. In the first part of the study, they asked lay people in an online survey to agree or disagree with whether these statements are true. Those statements that are black are those that are false. Those statements with the asterisk are those that are correct. The lay individual in study one showed signs of getting things wrong 22% of the time. You would think that medical providers or medical professionals would be much more up to date, but we all are products of where we were brought up. And this, by the way, the online sample and the following samples were of white participants. They specified white participants to see if they had false, what we call false, endorsing beliefs. Now, the beliefs, these beliefs are actually coming out of what we would call race-based medicine ideology, where a particular race is considered having biological differences and not specifically to race being a social cultural construct. What they found is they differed from years one, two, three, and four, which is why it's so important to introduce these concepts early and often throughout the curriculum. If you look at the bottom, that final percent composite of those 11 beliefs, you see the percent in terms of mean items and the composite of mean percent items that they got incorrect as well as the means. And again, they did seem to improve, but even as in their residency, they example mostly had upwards of 58% that still ascribed to biological erroneous false beliefs where they conflate race with biology. Now, this has more than just an understanding implication, and this is why I'd like to just make a point on this slide. So the second part of the study was to measure how they rated the actual patient's pain levels. And if you look here, they did diverge between average pain rating between white and black participants, where they actually rated black participants' perceptions of pain lower based on their false beliefs. So, and then they also looked at endorsement of false beliefs and average pain rating as well. And the final piece was really what drove it home is whether or not they changed how they treated the patients. This is an example of how these erroneous race-based approaches can affect patient care. This is a great article that I've provided in a list of resources for you and your faculty to review and maybe present to your student learners for how these things perpetuate healthcare disparities over time. And just looking at here, the actual portion recommending accurate treatment were completely different between those that had low false beliefs versus those that had high false biological beliefs or what we would call race-based approaches. So let's talk about where some of this arose from. Again, this is just one option that you could choose to present to either your student learners or your faculty or you yourself may not be as aware of. Let's talk about racism in healthcare. So the American Medical Association was established in 1847 and it perpetuated the belief that black patients had a higher tolerance of pain. And they actually attributed that the differences in the organic and physical characters imprinted by the hand of nature on the two races made it obvious that the same medical treatment which would benefit a pure white man would often injure or kill a Negro. That is a quote from a Southern white physician. So after the Civil War, the Freedmen's Bureau was established by Congress. And within there, by the 1890s, they had the codification of segregation which was adopted by almost all Southern states. Racism continued to predominate in medicine and blame was placed on the black residents themselves, citizens themselves. So in 1829 and 1929, the infant mortality for Southern black population was 98.4 per thousand, while for whites, it was 60.2. So at that point with segregation, the movement came about that black medical schools were created between 1869 and 1900. Prior to the Flexner Report, which I'll talk about, there were actually 11 historically black medical colleges. Then in 1910, the Flexner Report came out and it was a report to the Carnegie Foundation which created a standardization of medical education. And it was a biomedical model. And through that change in curriculum, only two black medical schools survived under the new model that continued today, Meharry Medical College and Howard University College of Medicine. Prior to World War II, each produced less than 20 black physicians annually. And between 1902 and 1946, an average of 54% of Meharry's graduates and 26% of Howard's failed their medical boards, which were created based on that biomedical model through the standardization and the other schools. So black physicians, the black hospital movement that occurred between 1865 and 1960s, and then black physicians were systematically excluded from the AMA and to the civil rights area of the 1960s. Now in the Flexner Report, here's a quote, the Negro must be educated not only for his sake, but for ours. Furthermore, he noted that 10 million of the Negroes live in close contact with 60 million whites. Not only does the Negro himself suffer from hookworm and tuberculosis, he communicates them to his white neighbors. So this is the dark history of how we lost so many opportunities for black physicians to obtain their medical licensure, but it also was also a symptom of segregation of care, which continued on. Also been the backdrop of this is the eugenics movement, which began in 1904 and ranged between 1921. It was the rate of institutionalization of people-mindedness during that timeframe tripled. It was spurred by Charles Darwin's theories of natural selection and Mendel's early genetics. Outspoken supporters included Theodore Roosevelt, Alexander Graham Bell, J.D. Rockefeller, and many other prominent figures. At that timeframe, 32 states passed eugenic sterilization laws. Most were Southern. They had forced sterilizations on men, women, and children deemed of inferior quality. A fair number of those were working with state funding institutions. And then those policy underwent repeals between the 1960s and the 1970s. And it was yet another proxy for white supremacy meant to exert power and privilege. Now in 1984, the Heckler Report was produced. The Secretary of Health and Human Services released a task force in October, 1985. And it was the first time that the federal government outlined the picture of healthcare disparities based on race. The task force defined minorities as Blacks, Hispanics, Native Americans, Asian, Pacific Islanders. It paid particular attention to the higher rate of deaths of Blacks and other minorities in comparison with whites, knowing that there were 59,000 greater deaths for Blacks each year, higher than for any other racial ethnic group. This was the first ever national government examination of differences in health in USA by race. It elevated the term healthcare disparity. And here we are almost 20 years later, actually doing some more instrumental, incremental approaches to reduce them. So in 2004 and 2008, we had these two publications out of the National Academies of Medicine, formerly known as Institute of Medicine. And these also promoted both having more education on healthcare disparities. They also outlined, especially in unequal treatment, how to confront racial and ethnic disparities in healthcare. If your faculty have not read these particular books or how they recommend them, they help provide some great context to bring to students during your presentations and also the call for why this is important. We can't have a separate but unequal system to this day in 2021. Then fast forward to 2030 and beyond, Healthy People 2030 and Beyond, the U.S. Department of Health and Human Services Office of Disease Prevention and Health Promotion. This is one of their major projects. They have a vision where a society in which all people can achieve their full potential for health and well-being across the lifespan. They recommend starting from local and go global. So their four steps are identify needs of your local priority areas. These are for learning healthcare systems to do and achieve. Set relevant targets using their national benchmarks to compare and contrast how you're actually doing on your targets. Finding practical tools and then monitor national progress. And then Healthy People 2030 and Beyond also had 23 leading health indicators which span the lifespan. All what we call LHIs are core objectives with 10-year targets. They focus on what we call upstream measures such as risk factors and behaviors rather than the disease and outcomes. So it's focused on prevention, not disease treatment. And they address issues of national importance. They address high priority public health issues that have a major impact on health outcomes. They're modifiable and they address social determinants of health, health disparities and health equity. And they have new data periodically and preferably annually. And so those are people who participate in these programs are able to track and trend and monitor their progress for institutions. Now the social determinants of health, the things that go into why people have the disparities are education access and quality, economic stability, social community context, neighborhood and built environment and access and quality of healthcare. And so therefore this is where if they're re-envisioning the role of nursing in general, this is somewhat where they are focusing the new nursing curriculum and paradigm on how to identify your local community's needs and how to meet those needs to prevent disease rather than treating them once they arrive with their comorbidities. Now, racism is what led to race-based medicine. I read you some pretty powerful quotes, very racist quotes from our past. However, it's interesting to note that there is not a single, there's very few. I believe there's three total diseases that have been linked to an actual racial profile. Everything else is driven by environmental, epigenetic changes. I'm sure I could channel my inner Edwin Oroke to also identify some of those. And they've been developed over time. And so the other pieces, they're also socially and culturally derived. So we'll talk about that. So before we can talk about that, I need to teach you a little bit of a new language. So with that diversity, number one, how you define it drives how inclusive you are. So you don't have to be specific to any particular culture, how you define diversity. When I think of diversity, I think of biodiversity and I think all the wonderful differences that our world has in terms of biology. And there's definitely not one size fits all. Inclusion is that sense of belonging where you're one with a group, where your differences are both appreciated and also noticed. Healthcare disparity is a racial or ethnic difference in the quality of care not due to access related factors or clinical needs, preferences, and appropriateness of the intervention. And this is from the Institute of Medicine. Health equity is parity in access and quality. So equity pairs both the access and the quality together, looking at those learning, those LHIs. And the preferred terminology, this may be new for some individuals. I hear, and I still occasionally say African-American, that's not actually preferred anymore. So part of being very inclusive is understanding what the preferred terminology is of individuals from any particular group or even it's just an individual. And so sometimes you have to explore those when your students or your learners come on site is to ask them their preferred name and their preferred pronouns. So unpreferred would be African-American, whereas preferred would be either black or person of color or black and brown communities, or even just non-white. So understanding and definitions today. So now that I've just described to you how race is really not a biological construct, it's socio-culturally defined across the entire globe, really. Physical characteristics used to identify racial groups vary by geography and do not correspond with underlying biological traits. And genetic research shows that humans cannot be divided into biologically distinct subcategories. This is something that people do to other people. Now, race-based medicine, as I mentioned, it uses race as a biological risk factor for disease. I'm gonna show you the errors of doing this by the fact that it's not biologically driven. What you're seeing when you see researchers pair up different racial backgrounds is people ascribing to a particular race, which is part of who they are. It's not part of their internal environment in terms of what they are. So let's just clarify that. Precision medicine is probably, and for sure the future, where you account for individual differences in the genes, environment, and the lifestyle. And that's where you have, for example, that targeted immunotherapy as examples of precision medicine. So in essence, race-based medicine perpetuates those false beliefs, as I showed you in a previous study by Hoffman et al about differences in biology that directly lead to healthcare disparities. And then narrowing clinical decision-making leads to misdiagnoses or mistreatment, as I mentioned with sickle cell anemia reinforcing. And then there's also the reinforcement of racial implicit biases, which are part of what you saw also in that Hoffman study. So just some people confuse equality and equity. Equality would be, for example, giving everybody who wants an America bike and say, there, you got a bike. Equity, again, it's both access and quality. Not every bike is accessible to people who are, example, in wheelchairs, or not every bike is at the right size for every individual. So it's giving every individual the quality and access of healthcare rather than trying to give them a one-size-fits-all approach. Now, there are different types of biases and definitions, and this came from the center of social inclusion. So institutional explicit would be, for example, policies which explicitly discriminate against a group. So for example, programs refusing to hire people of color. Institutional implicit are those policies that negatively impact one group or another. So programs that focus on youth show the most promise. Individual explicit is prejudice in action or discrimination, such as an art educator or a nurse anesthesia educator verbalizing historically great art hasn't been created by people of color. A conscious individual implicit or unconscious attitudes and beliefs that we all have. There should be no self-loathing regarding implicit biases. These are things that are part ingrained in society that we are bombarded with that unfortunately can lead to stereotyping. So it's something that you need to create a self-dialogue about. So for example, an art teacher educator fails to teach painting to students how to mix paint to create various skin pigments. With these types of biases, you need to separate impact from intent. Clearly that art educator did not intend to leave that out, but they need to acknowledge that that may have a negative impact for a person of color or a student of color. So biases lead to stereotyping. Stereotyping leads to racism and racism leads to micro and macroaggressions. Now this is a kind of socially charged word. I like to kind of reduce any kind of charge to it. The way that it's been described by some is the cut of a thousand nicks. You know, it's not intentional, but it's there. And therefore it can over time. And they've already shown in literature that racism can lead itself to disease burden over time. So paradigm shifts are currently occurring. You can probably already take note of what's happening in your own medical centers and institutions and campuses and universities. Number one, relationship-based care models in hospital settings and educational programs are definitely on the rise, if not the predominant way of doing things now. Allyship, and we'll talk about that, is on the rise. Community-based participatory research models for any public health disparity. That's where they invite members of the community interest in to help design interventions and research and then get to take part in the research methodology as well, and then read and partnering with those communities' interests rather than coming in and being kind of the sage on the stage. You're more the guy by the side. Also redefining health as a human right and a societal issue to be solved through deconstructing structural racism. These are the paradigm shifts that are at breast right now and have been for a little while. So in terms of race-based or race-conscious health care, I walked you through a couple of examples, but in terms of race is ill-defined, we define it ourselves. And therefore we ascribe biological significance to our own categorizations. In terms of research, it can actually skew epidemiological and clinical studies, which they link race to disease, but really if race is a proxy for sociocultural, then they're really linking it to those sociocultural differences. So the medical education, they'll have racial groups being understood as inherently disease, which I showed you evidence of. And in clinical practice, they'll have healthcare stereotyping and biases, which all lead to healthcare disparities. Now, in terms of race-conscious medicine, again, if you know that race is defined as social power construct, you can study then the effects of structural racism and look for them. The consequences of racism on health are taught, and then support provided to overcome structural barriers to health, which are straight out of those AAC and essentials, and now will ultimately reduce health inequities starting at the source of where they begin or the social determinants of health. So here's just an example where race-based medicine, you can give an actual concrete example to both your students, or if you're a clinician, to your clinical providers within your hospital. For example, the American Heart Association's Get With The Guidelines Heart Failure program. They actually had input variables that included race and non-Black races, and they added three points to the risk score for the patient identified as non-Black. This addition increased estimate probability of death, okay? So what that does as an equity concern is the original study envisioned using the score to increase the use of recommended medical therapy in high-risk patients, and reduce the resource utilization of those at low risk. But by default, if you add three points to those that are non-Black, then the race correction in regards to Black patients are at lower risk and reduce their availability of clinical resources. That's a healthcare disparity, and that's where equity is a concern. Let's look at nephrology. Estimated glomerular filtration rate for end-stage renal disease patients. They look at both serum creatinine, age, and sex, and then you probably see race corrected on your lab reports. The problem with race corrected is that both equations report higher GFR values given the same creatinine measurement for patients identified as Black, suggesting better kidney function. So unfortunately, the equity concern is those with higher GFR values, they have delays in referral to specialist care or listing for kidney transplantation. This particular article by Vias et al was produced in the New England Journal of Medicine. So these are very, in 2020 even. So this is very cutting edge knowledge of how race-based approaches have really infiltrated. they started back in the 19, really the 1800s, and they have perpetuated even to 2020. And now they've envisioned nursing as looking at how do we deconstruct this? How do we remove these barriers? How do we re-envision to be more race conscious and looking at social determinants of health upstream rather than waiting for disease to progress downstream or creating systems that are discriminatory towards people who are non-white. So the one particular article that I'm gonna kind of highlight here is one that's one of my personal favorites. And it's on the principles of a cultural humility by, and it was a term coined, although there are some disagreement in literature who coined it first, with Turvaline and Murray-Garcia in 1998 in their seminal article, A Cultural Humility Versus Cultural Competence, A Critical Distinction Defining Physician Training Outcomes in Multicultural Education. What's really interesting in the article, as you should read it, is they use a nursing example to define lack of cultural humility. I found very interesting. So at any rate, that'd be one to put on one of your reading lists for both yourselves, your faculty, your clinical faculty, and your students, in that they mentioned three main kind of pillars, which is lifelong learning and critical self-reflection, recognizing and challenging power imbalances, and of course, institutional accountability for things like I just showed you on the slide before about how these things can actually be adopted by entire institutions. And this is, for example, from my own healthcare institution in terms of health equity research is a high priority. Being learning healthcare systems, they have to now demonstrate how they're improving the communities that surround them. So this is not just specific to nursing. This is medicine. This is healthcare systems. This is the healthcare system of the future. And so they're going to, of course, these are our we will, we plan, we will. And so they're gonna create an enterprise-wide research health equity, diversity, inclusion leadership council for community outreach and creating research and healthcare partnerships within the communities that we serve. So this is the future of where things are going, and it will come to pass that both the students coming to our programs have already had AACN developmental competencies that lead to our competencies, but this is also the world that we're setting our students and that we will be expected as CRNAs and educators to operate within. So it's very exciting to be here at the center of where the change is at this point in time. So now onto the fun stuff. I created some toolkits of resources for you specific to these topics. They are just a plug-in. There's gonna be some that are plug-and-play. I'm gonna go through one in particular that I will make available in there. Others are gonna be a list of resources that you and your faculty can explore, and as well, and I'll continue to try to add to it, and I suggest others to send me your great ideas to maybe add to that toolbox and toolkit for you. And so it could be something that will be a resource for you and future educators as well. So here's one in particular, how we applied in one module of our DNP program. Now, yes, I am just now starting to map the new AACN Essentials. So if you look under the program outcomes, those are right from the previous 2006 AACN Essentials. Few words changed here and there as our program outcomes. This is a particular course on professionalism, how to become a professional CRNA. And our course objectives, for example, identify the intersections of self and career, the practice of nurse anesthesia, implement an approach to working effectively with patients from different cultural backgrounds by applying concepts of cultural humility, and apply the concept of professionalism and professional advocacy to effect improvement of population-based care and patient access to high-quality care. And those are all gonna be back now to these wonderful AACN DEI competencies. So it's a matter of weaving things together, take what you currently have, look at if all the modules could maybe add a piece to them as well. And the course activities that I'm gonna show you a couple of examples of, so you can see where these demonstrate back to the both the program outcomes, course objectives, and AACN Essentials. So here's our actual, and a lot of these resources, I just went over with you, so you're now more familiar with what I'm presenting to you. I had a section that the students had to read on history of race-based medicine. I provided them with the actual Flexner Report, as well as from race-based to race-conscious medicine with those algorithms that I showed you. And then demographics, of course, of the US healthcare workforce, beginning with that Heckler Report in 1985, and going on through the AACN Colleges of Nursing and the Sloan Commission on Missing Persons. And then I followed those up with diversity, equity, inclusion, and professional nurse anesthesiology practice, where I'll go over, for example, cultural humility versus cultural competence, the American Medical Association Journal of Ethics, our own code of ethics, as well as our diversity and inclusion resources, which were awesome, also a place to look. And then February of 21, AANA position statement on CRNA provider activities related to DEI, all great foundational material. And then I provided optional resources as well as you see here. Now, I'll turn to module assignments. One, I had review module presentation, set aside time to review an article in the health affairs, links to that journal site, on implicit bias and explicit bias in healthcare. And the assignment was to write a brief two-page essay that demonstrates reflection on the following. And again, this was a self-reflection. I had them tell me a story where you realized you exhibited implicit bias, can be personal or professional. What was your initial reaction? What was the unintended or intended outcome for the recipient? And if you could wave a magic wand and have a redo of that event, how would it look different after your reading and reflection? Meaning were there pearls that you or another could use, or did you or another actively intervened at a time that you'd like to share of that proud moment? And I had a variety of responses, but they all showed nice, beautiful, critical self-reflection. This was not beyond a BSN, a DMP, entry-level degree person. Again, they're coming in, having been in the ICU, having been experienced and seen racism in healthcare already. So example of responses. The first one, after being pulled to another unit for the day, I wrongly assumed that the black nurse was a CNA or certified nursing assistant, rather than an RN. She asked if I needed any assistance. And having seen many black CNAs on my unit caused me to think she must also be a CNA. She said she felt guilt and embarrassment, but there's nothing wrong with being a CNA, of course, but it was wrong of me to assume that all black healthcare providers are CNAs. So, and she went on to discuss about how she would repeat this encounter by simply introducing herself and ask that colleague to do the same. So what a great way of just weaving in prior experience, self-reflection, a candid moment, and also looking forward at what they could do better in their own future iterations of that, which is the skill that we're really trying to cultivate because we did choose the culture of humility model within our program. Another example, I witnessed a patient who was a person of color who received care from a clearly biased nurse. This was one that that patient had chronic pain, was clearly in pain, but the nurse said with all their opiates, they couldn't believe the patient was still experiencing pain. He says, how can we ever move towards a more equitable system? These situations allow us to become change agents. So this individual already saw opportunities taking this information and providing it in a way that another provider that they can counsel. So that's, again, going back to those AAC and essentials, and how can you role model being a champion of diversity, equity, and inclusion? So another module two assignment was a discussion forum where they would discuss with each other on a discussion board. So they had to pick one of the two prompts below. I'll mention the first and fourth as those are my examples. Again, all of these are gonna, all these slides are available to you. The first was review the articles presented on heading race and medicine research. Do you find any race-based policy, clinical indices, and racial disparities still perpetuated in your area nursing practice or nursing facility? We give this in first semester. This is our first semester student who just left the ICU. When I mentioned doing it early and often, that's what I mean by getting them to think about these concepts early. Also kind of sets the stage for later developmental activities that you wanna weave in later. The final one that a lot of individuals seem to gravitate towards answering were read Turvelon's article. Which framework do you gravitate towards being culture humility versus cultural competence? Is this vision in alignment with AANA? So I had them go look at AANA's materials or the nursing profession. Be sure to cite your references to inform the audience. So this was more of a scholarly dialogue where they had to include citations and do it more from an evidence-based approach. So here's your examples. When reading the article by Vias, I recognize that the race-adjusted EGFR is still common practice in the large teaching hospital that I work in. What an interesting aha moment that we're still doing these things even despite places like Vanderbilt reversing, I believe it was Vanderbilt and Columbia reversing their stance on these things. So, and here they went on to report how they were just really forward with it. If you're really trying to create a change within your students and their attitudes or knowledge, you have to hit them both the heart and the head initially or attitudes and thoughts about it. And some of these reading these articles do that for you where you don't have to create a moment in time for that. The other individual also looked at the Vias article as well. So really, really good feedback there. So I just thought I'd share those with you. So another word of advice, lessons learned, not only from our own department, but across our institution. You as faculty or you as a provider can and will make mistakes along the way. Just give yourself the grace to understand that that's going to occur. So, but you have to, a starting point begins with your own mindset. So knowing that this is coming, knowing you're going to have to go for it at some point. So start thinking about, are you comfortable with this information? Approach conversations about racism with a growth mindset, seeking to understand another person's point of view rather than affirming your own. Learn more about cultural humility, humanism and self-reflective exercises. There's a world replete of these. If you experience discomfort or anxiety that comes from a place of unfamiliarity, when you talk about race, racism or health disparities, think about, approach that discomfort with inquiry. Why am I feeling this way? Why am I having this reaction? Is this a common reaction? I will tell you it is a very common reaction and I'll put some resources in there for you to explore that. Now challenge yourself to grow more diverse, personal and professional connections. Sometimes there are already things going on within your institution or clinical setting that have opportunities for you to connect with people from different backgrounds, irrespective. And then distinguish intent from impact. I have a couple of slides regarding that coming up. If you do make a mistake within these discussions, apologize, say, I am sorry, I didn't mean to offend you. Then take ownership and clarify with an individual, what was it about that statement to help me understand how I can state that in a better way from my own personal viewpoint. Now, in terms of, now this is gonna get to a little more dicier area of the conversation. We talk about descriptions of racial trauma. I mentioned about how microaggressions are really a symptom of racial biases and implicit biases often. Again, the thing is you need to pull apart your intent does not prevent you from making an impact. And the impact on that individual is the part that you need to focus on. No, most people understand that something you may have said was not intended to be perceived in a particular way, but because you may not have the lived experience of the individual that you say things in front of, that doesn't reduce that impact. It just means that you have to account for it. Now, in terms of active bystander, that's one great training that you can give your students as well on the internet. That's the act of interrupting a potentially harmful interaction. If somebody perceives it, often the person that is receiving the racial trauma or the microaggression is still processing, what did they say? Did they say what I think they said? So the observers are usually the individuals that recognize it before, or even at the same time as a person being affected, and they can employ some strategies, and that's what active bystanders do. They can confront the situation, interrupt, they can alert others, redirect attention, or engage after. And those are the main four kind of options, and there's other models out there as well. So let me just give you a brief, and these are also, I'll just touch on two of them, examples of racial microaggressions. So, and they've been categorized by themes by Sue et al. Sue et al was a great group of researchers who did this from really kind of a thematic approach for people who had felt this. So colorblindness, I have seen frequently in social media and other locations, is statements that indicate that a white person does not acknowledge race. They think we're living in a post-racial era. So when I look at you, I don't see color. America is a melting pot, and there's only one race, the human race. The problem with these statements is that you're denying a person of color their racial ethnic experiences. You're basically saying assimilate or acculturate to the dominant culture. And you're denying that culture is part of who they are and what they are. So again, I'm sure that those statements when made were not intended to cause that effect, but that's the actual impact. Another one is alien in your own land. So when you ask a person who has a different name or background from what you would consider your traditional neuroscientist, you should, where are you from? Where were you born? You speak really good English. In that situation, even whether it was not intentional to offend the individual, but what's being received by the person receiving that is you're not a true American and you are a foreigner or alien in your own land. Frequently those are actually being stated to people who were born race and they're full American again, but because you're using that, you're creating a division and othering that other individual. So these are just things to be very careful of. The other one that I seen a lot in our profession is I believe the most qualified person should get the job and everyone can succeed in a society if they work hard enough. And that is themed under the myth of meritocracy. And here's the message, people of color are given under extra unfair benefits because of their race. Meaning they're saying that a person of color is lazy or incompetent if they can't achieve the same outcomes. That's the impact on the individual that you say these things to, if they are a person of a different background or a different color, a person of color. And here's just a couple more. Again, I'll provide this in the resources. Again, even in our own example of our student who gave that account of the CNA, they were also a nurse of color and yet they had treated their own fellow nurse of color as a second class citizen where they assumed that that person of color who was a nurse, a fellow nurse was a service worker or a CNA, however you wanna define that. So anyway, just thought I would point those out. So key points, nursing has been re-envisioned. These National Academies of Medicine, the American Association of Colleges of Nursing, all of our main leaders at the levels of national governments have already done that. And so we have to learn to evolve. I've presented to you about the fallacies of race-based medicine, so race-conscious medicine. You have to deconstruct some of that in people's mind's eye. Present these types of topic early and revisit them often. Racism in medicine provides a context and drives change, meaning revisiting where the roots were and how they're perpetuated today really creates those aha moments for the audience to understand that we are not in a post-racial society yet. And so therefore, let's look at what things are still being done today that demonstrate racism in medicine. Now, I would highly recommend that you strongly consider the use of a longitudinal thread for those AAC and essentials related to DEI outcomes. It will just simply be more impactful if revisited throughout the curriculum and allows you to demonstrate growth and development of your professional nurses within your programs. Build buy-in with faculty, both didactic and clinical. Again, these DEI outcomes may be incorporated into your clinical competencies, and that's a great way of showing you demonstrate. Again, make good use of available resources. You will be shocked at how many resources are currently available, both within and outside of your institution. So partner. It is the best thing you can do is to partner with other groups, and they've already explored these and can help deliver these, and so that takes less of the onus on you. Also make good use of the educator portal for freely shared tools and resources that will help you as you build, and this is definitely a building process towards these new AAC and essentials. So I thank you for your attention. Be sure to be on the lookout for some of those questions, and I'll continue to build within the educator portal for your benefit and share any resources that I come across. Thank you. And here's my resources, and I will have some companion documents to these references as well that can help you identify quickly which ones you can utilize.

AACN DNP Essentials

diversity

equity

inclusion

race-conscious medicine

nursing education

implicit bias

cultural humility

health equity