Leading the Charge
By Ashley Primis
Faculty members of Penn Nursing have long looked beyond assumptions and surface level information to unearth the deeper connection between a person’s health and their environment. In doing so, they become something like health care anthropologists, hoping to discover the linchpin that will change a cohort’s future. And the events of last summer—namely the killings of George Floyd and Walter Wallace, Jr., among other Black Americans—thrust their holistic and empathetic problem-solving approach into the mainstream, giving momentum and a newfound awareness to their research and teachings. “Our faculty have long been concerned with advancing social justice— through community engagement and focusing on social determinants of health,” says Dean Villarruel. “Our work in this space is really impactful.”
This push for a more evolved view of health care has also come from the student body. The Dean notes that when she first began teaching, students didn’t embrace community work as much, but now “you have students saying they want more community exposure. So, it’s been a shift not only in the faculty, but also in the mindset of what students want and see.”
The faculty and leadership have also looked inward. They want to ensure there is diverse representation and equitable experiences in the student body and faculty, knowing that is key to imparting real change. “Social justice has always been a concern for us as nurses, but with everything that’s been happening the last few years, we as an entire faculty have been cognizant of examining or reexamining our own processes,” says Assistant Professor of Nursing Dalmacio Dennis Flores, PhD, ACRN.
And while all acknowledge there is plenty of work to be done internally and externally, some point out how tangible advancement has been. “My research on racial disparities has been published since 2010,” says Terri Lipman, PhD, CRNP, FAAN, Assistant Dean for Community Engagement. “For most of that time, editors would not agree to using the word ‘racism’ as a driver of health inequities. I had to change the language to ‘bias.’ Times have changed and the importance of naming “racism” has been recognized. There is a great deal of work to be done but we are headed in the right direction and nursing is poised to lead.”
They’re Ensuring Research is Equitable
Research is the bedrock of so much in health care: It informs policies and programs and is used to educate the next generation. However some faculty members believe it’s not just about what the data prove, but about how the research is being conducted in the first place. “We base much of our practice on research and clinical trials,” says Assistant Professor Adriana Perez, PhD, RN, CRNP, ANP-BC, FAAN, FGSA. “And yet, we exclude certain individuals without scientific justification.” Which means, says Perez, the outcomes are not truly “representative of our country.”
In Perez’s work involving older populations, she noticed that only two percent of trials involving Alzheimer’s disease include the Latinx population. One possible reason why many immigrant and cultural groups in America are often excluded? The language barrier. But thanks to a grant from the National Institute on Aging, Perez is embarking on a study that will specifically look at health disparities when it comes to Latinx and age-related disease. The study is guided by a community health advisory board with Spanish language intervention delivered by bilingual community health workers. “All of my work, both as a nurse practitioner and a scientist, has been focused on ensuring that our research is equitable and centers the voice of historically excluded communities. Focusing only on the science is not enough to advance health equity.”
Similarly, Terri Lipman recognized that her own work on childhood diabetes was misdirected: Despite large-scale programs at CHOP that were specifically designed to address disparities, not much was changing. “Our programs improved diabetes care for well-resourced children, but we had not moved the needle for marginalized children. We failed,” says Lipman. To understand why, she and her team integrated community health workers into their research with the goal that “a team member who shares the lived environment of our most vulnerable patients will be able to identify and address social determinants of inequality.” (One key example: food insecurity, something not previously identified.) Early indicators show that changing that power structure—from health care professionals to community members—has had a positive impact and has strengthened Lipman’s belief that “community health workers need to be embedded in the infrastructure of health systems.”
With her adult and teen advisory boards, Associate Professor of Nursing Bridgette Brawner, PhD, MDIV, APRN, also learned the value of having community members involved in her studies. (Her research has looked at everything from STIs to mental health in teens.) “My community partners are literally involved from the beginning, before fingers even go to the keyboard to write the grant applications,” says Brawner. “We ask them what the major issues are and how we can have the most immediate impact.” They’ve helped her identify structural barriers, interpret data in different ways, and counter existing narratives. “It helps me move from the individual, to the neighborhood or the community, as the unit of analysis.”
They’re Looking Deeper to Social Determinants of Health
Social determinants of health. It’s an academic-sounding phrase that describes the simplest of truths: Someone’s physical and mental health—past, present, and future—is directly affected by the environment they live in. And that’s exactly why many nurses at Penn have focused on tackling those larger issues. (Things like finances, emotional support, neighborhood conditions, transportation, technology, and food access; stuff that has nothing to do with clinical visits.) “As a nurse, I look at individuals within the context of their families and their neighborhoods. And once you do that, you have to think broadly about the many factors that worsen health or can make health better,” says Associate Dean for Research and Innovation Therese Richmond, PhD, Rn, FAAN. “It’s virtually impossible, I think, as a nurse, to not see the inequities in the world.”
Keeping those inequalities part of every conversation is the foundation of Richmond’s varied work. Her NIHfunded research focuses on the recovery of urban Black men after suffering serious injuries and how where they come from and return to can be a hinderance to their healing. She has often engaged with community partners and collaborated with geographers, psychologists, and others, to see the whole picture, knowing that recuperating fully—in essence, getting back to work, life, family—is paramount. “How do we help this group that bears a disproportionate burden of both violence and poor outcomes do better?” she says. “You can’t really isolate injury from the life journey. We look at the details: What are the violence levels in their neighborhood, how much discrimination are they exposed to?” And as the only nurse appointed to the advisory committee of the federal government’s Healthy People 2030 initiative, she is committed to keeping macro social determinants central to the conversation. “It’s a good example of how nurses can inform the agenda and framing of a national program that often drives funding priorities,” says Richmond.
Assistant Professor of Nursing Sara Jacoby, PhD, MPH, who also studies trauma, sees the connection as very practical: Long-term recovery hinges on social and family relationships, having a supportive physical environment, as well as financial security. “There’s plenty of evidence that psychological symptoms after injury are as important as physical symptoms to recovery,” says Jacoby. Through her research and interventions, she wants to make sure those who have contact with someone who is injured—be it police, first responders, or hospital staff—understand their role in positive outcomes. “When someone feels disenfranchised from a health system— whether that’s because of the perception of racism or because it’s hard to find transportation for clinical visits— the assumption too often is that if they don’t return for services then they are healed or don’t want further support.” In one study she did in Philadelphia, following up with people one to three years after their injuries, it was clear that was not the case. She brings this perspective to her teaching, as well as the committees she sits on. “It’s another way to encourage researchers to think about what they do and then figure out how to advocate for policies and programs.”
They’re Making Sure Marginalized Young Populations Are Seen (and Supported)
When it comes to the intersection of social justice, health care, and children and their families, Terri Lipman sees a new perspective emerging: “A great deal of research on racial disparities has focused on placing the blame on patients for disparities in outcomes,” says Lipman. “More recently, health care providers have been flipping the lens, and engaging in self-reflection to determine how we are complicit in the structural racism that drives inequities.”
That evolved thinking often leads researchers to look at micro-level data and interventions, things that had been overlooked. One example: In the past, perhaps all schools did to combat the spread of STIs was hand out condoms. But as the new thinking goes, it’s not just about access, but about changing behaviors. Bridgette Brawner saw a correlation between stress-management, depression, substance abuse, and sexual risk behavior. And in her programs, she’s been able to work with youth to help them identify and come up with coping mechanisms for emotional triggers (think: seeing your partner kiss someone else) that could lead to larger life-altering behaviors (think: unprotected sex). “We have youth, saying in their own words, how feeling lonely, angry and depressed impacts behaviors they engage in,” says Brawner. “Research is a tool that can be used to advance social justice because it gives us the evidence to be able to see what is going on and the ability to strategically intervene.”
Department of Family & Community Health Chair and Albert M. Greenfield Professor of Human Relations José A. Bauermeister, PhD, MPH, and Assistant Professor Dennis Flores conduct research that broadens the lens: They look at the challenges LBGTQ youth face and the impact these challenges have on long-term health outcomes. Flores, specifically, has turned to the family unit, helping to “figure out ways parents can facilitate the coming of age of these adolescents.” His premise is that teenagers who are supported emotionally will make better sexual health choices and be more proactive about their overall health. “The younger kids are when they come out, the longer the opportunity for parents to be active in making sure these kids are healthy and feel accepted,” says Flores. “Early behaviors learned at home have a big impact on their health once they leave the home.”
And, adds Bauermeister, the positive benefits of this kind of research, and conducting it in partnership with youth, are invaluable. “We’re always seeking input from younger people to make sure what we are doing is relevant to them,” he says. “They feel a pride and ownership in the work.”
They’re Educating and Diversifying The Next Generation of Nurses
“Things will not change unless we have a workforce that represents the populations being served,” says Adriana Perez, of the need to have more people of color and different ethnic groups in nursing. It’s true: According to a 2017 survey in the American Association of Colleges of Nursing, 80 percent of RNs are Caucasian, while minorities are expected to be the majority in this country in the next 20 years. On top of her research, mentoring, and clinical work, Perez is immersed in multiple programs to ensure professional diversification.
She has been an integral member of the Future of Nursing: Campaign for Action, which is supported by AARP Foundation, AARP, and the Robert Wood Johnson Foundation. In that, she works with other area schools to create mentoring relationships and a pipeline of opportunities for Hispanic, Native American, and Black students who might be interested in the field. “It’s not just about diversifying the workforce but ensuring that students have the resources they need for a successful transition into nursing.” (Worth noting: the School has recently decided to waive GRE requirements for PhD programs, in an effort to remove some barriers.)
Many faculty members also make sure to thread the tenets—or at least plant the seeds—of social justice as part of their teachings. Terri Lipman and Dennis Flores co-teach a class about social determinants of health, which takes a deep dive into specific issues that affect underserved and overlooked populations so, says Flores, “new nurses can be instrumental in advocating more effectively for patients.”
For Lipman, having students be active, engaged, and connected to the community is imperative to building well-rounded nurses. Last fall, she led two efforts involving the Census and the presidential election. Students worked with the City and Philly Counts to make thousands of calls to encourage Philadelphians to complete the Census. And Penn Nursing had the highest percentage of students in the University registered to vote. “Census completion and voter registration are social justice issues and are crucial in building the social programs that serve the most vulnerable populations,” says Lipman.
They’re Looking Back to Inform The Future
For over 25 years, the Barbara Bates Center for the Study of the History of Nursing has valued historical context in the field of nursing—an understanding of how and why we got here is essential to addressing the racism in nursing and medicine that’s present today. And with the increasing awareness of the intersection between social justice and health care, it’s never been more relevant. “We’ve always been advocates for patients and social justice,” says Director Emeritus, Julie Fairman, PhD, RN, FAAN. “But there are a lot of things that happened that we would like to forget.”
Through her published work, current Bates Center Director and Carol E. Ware Professor in Mental Health Nursing Patricia D’Antonio, PhD, RN, FAAN, has proven time and again the impact nurses have on racial, gendered, political, and social norms. And Fairman—who has written four books and continues to teach—is currently researching nursing during the Civil Rights era, which is helping her make connections to the racism and lack of diversity in nursing today. One example? Black nurses were not admitted to many state nurses associations— groups that foster, encourage, and advocate for their members—until the mid-1940s, when they were pressured by the ANA. Even then, states created barriers to Black nurses’ participation by doing things like holding meetings at segregated hotels or other venues. She’s committed to looking at incidents when nurses were complicit in racist practices, like when they helped identify children from immigrant and Native American families to be removed in order to “Americanize” them, removed Black patients from white hospitals, and believed in segregation. While aware of the many inequities and racism that exists within nursing today, she also connects her current research to the positive things she sees, like the many nurses who try to dismantle racist health and education systems and participate in social justice movements. She believes that “we haven’t always been successful at addressing racism in the past,” but that “historians can lay the foundation for the discipline to acknowledge the past to gain a more equitable future. We need to tell the stories.”