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Millions of Americans experience poor health outcomes. Often, this is due to factors outside of their control, such as where they live or where they work.These factors can result in health inequities一systematic differences in opportunities to achieve optimal health between groups of people. Often, these differences lead to unfair or delayed treatment, preventable diseases, and adverse health outcomes.
The Future of Nursing 2020-2030 report strategizes how nurses can work to achieve health equity. But first, we must understand the reality of health inequity and how it impacts people across the nation. We’re going to hear from health equity experts, nurses, and physicians who have witnessed the impact of health disparities on the individuals they care for and explore the causes behind poor health outcomes, the social determinants of health that influence an individual’s health outcome, and how health inequities can impact the entire wellbeing of the nation.
The United States has some of the poorest health outcomes. Health disparities run deep, leaving many people without equal opportunity or access to care. As long-time advocates for health equity, nurses are in unique positions to address the root causes of poor health, reduce health disparities, and improve the health and well-being of the nation.
In this 8-part series from the National Academy of Medicine, we explore practical strategies for the nursing profession to advance health equity. We’ll hear stories and experiences of frontline nurses and other health experts from a wide range of settings. These strategies reflect the recommendations from the report The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity.
If you’re a nurse, involved in any health sector, or want to know how to create a better future for all Americans through improved health outcomes, this podcast is for you.
Scharmaine Lawson (00:16):
Health equity, health disparities. Perhaps you've heard these terms before. If you haven't, we encourage you to listen to the last episode where we introduced them. These terms carry a lot of weight and they impact us every day. In The Future of Nursing Podcast, we're exploring how nurses can promote health equity. But before we establish those strategies, we have to understand what health equity really means and what reality looks like for millions of people who experience health disparities.
Scharmaine Lawson (00:45):
In our last episode, we heard from Dr. Felicia Bowen. Dr. Bowen was reflecting on her time as a nursing student in Macon County, Alabama, one of Alabama's poorest counties. Dr. Bowen would travel down dirt roads to visit her patients in the community, and she'd find that they weren't receiving the care they truly needed. It left her with a big question.
Felicia Bowen (01:06):
What was the barrier to keep them from getting the medication that they needed? A lot of times it was transportation. These are people who lived in rural communities, and the nearest hospital may have been 30, 40 miles away. What's the big deal? You hop on a train or you get in your car to go, or you get a family member to take you. Well, there are no trains. There is no public transportation. And the family member may or may not have transportation, or the transportation may not be reliable enough to go 30 or 40 miles. You don't know if the car's going to break down or if you're going to be able to get back.
Scharmaine Lawson (01:41):
Dr. Bowen is now a nationally certified pediatric nurse practitioner, and she's also the inaugural associate Dean for diversity, equity, and inclusion for the University of Alabama at Birmingham School of Nursing. During her career, she realized that she needed to look beyond the clinic doors and look at the full scope of patients' lives if she truly wanted to understand their health outcomes.
Felicia Bowen (02:08):
What are the things that are going on in their life? They come to the hospital or treatment facilities. That's a snapshot in time. But the things that really keep people healthy or make them ill, they happen in the community, in their homes and in their neighborhoods.
Scharmaine Lawson (02:25):
What Dr. Bowen was observing was the impact of health disparities caused by social determinants of health. According to the US Department of Health and Human Services, social determinants of health are the conditions of the environment where people are born, where they live, work, play, worship, and where they end up aging. These environmental conditions affect their health, their ability to function, and their overall quality of life. It's these determinants that decide whether a person will have health equity or not.
Felicia Bowen (02:57):
Health equity is having access to those resources that everyone else would be able to have access to so that people can live their best life. And that might be being able to get to a provider, being able to get to a facility that has providers with certain resources, being able to get supportive equipment or therapies after being ill, having insurance that will pay for everything that you need so you don't have to decide, "Am I going to eat this month, or am I going to take care of my hypertension this month?" That's health equity, when we get to a point where everybody has that. But in the absence of it, and we're not there yet, we have health disparities.
Scharmaine Lawson (03:57):
This is The Future of Nursing, a series from the National Academy of Medicine. Based on the recently published report, The Future of Nursing 2020-2030: Charting a Path to Achieving Health Equity. I'm Dr. Scharmaine Lawson. I'm a nurse practitioner, and I'll be taking you through the stories of nurses confronting health disparities. And together, we'll learn how nurses can draw from their unique skills, knowledge, and dedication to address health inequities and overall improve the health and wellbeing for all. In our last episode, we learned that the United States has some of the poorest health outcomes despite the money it spends on healthcare. In this episode, we're going to examine the causes behind these health outcomes and explore how nursing capacity and expertise can be strengthened to reduce these disparities and promote health equity for all.
Scharmaine Lawson (04:50):
So how do health disparities happen? It starts with social determinants of health. These are factors within the community that people don't get to decide for themselves. They're typically born into it. Are they born into an area that has safe housing or into an area with a history of racism and violence? Do they have access to decent education and transportation? How close is the nearest grocery store with nutritious food? Do they live in an area where the air and water might be polluted? What language do they speak? And what is their literacy level? The factors may vary, but these determinants can lead to health disparities.
Scharmaine Lawson (05:31):
Philadelphia, Pennsylvania is a city where there are a lot of environmental conditions that have adverse effects on the population. Dr. Gloria McNeil saw this firsthand. Dr. McNeil is associate vice president for community affairs and health at National University. There she's the project director of nurse-led clinics. Over the last 25 years, dr. McNeil has overseen four nurse-led clinics. Her first clinic was in Philadelphia where she and her team set out to address the problem of immunization rates in children ages zero to five.
Gloria McNeil (06:03):
Children were acquiring measles, which is a totally preventable infectious disease, at an alarming rate. And they were ending up in our intensive care units or either succumbing to the disease.
Scharmaine Lawson (06:18):
Dr. McNeil couldn't let this problem go unaddressed, which is why she started the nurse-led clinics.
Gloria McNeil (06:25):
So we have students and eight schools of nursing collaborating in this initiative. We set out to correct those numbers in the city and did very well over that summer experience. So I continued on with nurse-led clinics, designing them at other universities at which I've held appointments to where I'm now at National. And what has been clear to me is the health equity problem in the United States because health equity, as you say, is so complex, but it's determined really by the zip code in which you live.
Scharmaine Lawson (07:01):
Low immunization rates were the result of other problems, problems caused by health disparities that were defined by a zip code. Dr. McNeil knew early on that your zip code can have a major impact on your health outcome.
Gloria McNeil (07:17):
And so I think there are a number of factors, sociopolitical factors that impact what goes on in certain zip codes and why the individuals in those zip codes are so unhealthy. And so health equity needs to be addressed from a variety of perspectives. So to me, health equity is determined by more than just your access to care. It does depend on where you reside.
Gloria McNeil (07:45):
So I was born and raised in public housing and in an underserved community. So I'm keenly aware of what that means, and the presence of, for example, underperforming schools, elementary, junior high and high schools, food deserts, crime, poor access to care. All of these are matters that impact your health, are putting resources in some sections of the city, but not in others. And so when you're impacted in that manner, your health is in jeopardy.
Scharmaine Lawson (08:22):
This is why the need for health equity is urgent. But what does it mean to achieve health equity? To answer that, we hear from Dr. Winston Wong. Dr. Wong is a family physician who currently serves as a scholar in residence at Kaiser Permanente, UCLA Center for Health Equity. And he spent much of his career focusing on the pursuit of health equity.
Winston Wong (08:45):
Health equity boils down to whether we have accomplished in our society, in our nation, the opportunity for every individual to have a fulfilling life that is not determined upon the circumstances of which they might have been born into that would have made some deleterious impact on their health outcomes. What we're trying to achieve with health equity is to ameliorate the effects that people have been born into or have been put into in terms of a situation that does not give them the same availability and opportunity for a fulfilling life free from suffering. And we have yet to accomplish that because I think we know that in our country, in our society, depending on your life conditions, people are going to have radically different outcomes relative to suffering, longevity, and care and treatment. So equity is the elimination of those social factors, political factors, community factors that give way to what we see as disparate and unfair and unequal opportunities towards a fulfilling life.
Scharmaine Lawson (10:09):
Ignoring health equity can lead to negative consequences.
Winston Wong (10:15):
So when we are unable to achieve health equity, we basically suffer as a population. We see the decline of longevity with regards to the US population as a whole. We see more chronic disease. We see more mental health distress, and we see greater dissatisfaction with the healthcare system.
Scharmaine Lawson (10:38):
Dr. Wong has seen his patients affected by gaps in healthcare, gaps such as language barriers that lead to patients and their caretakers not receiving full or clear explanations of what their next treatment steps are. These barriers can lead to larger health inequities, and Dr. Wong personally experienced a moment where this happened.
Winston Wong (10:59):
I do remember seeing a patient at a community health center where I was a primary care provider, where a father was very distressed because he had learned that his adult daughter had been hospitalized for psychiatric care at an emergency medical facility. But when I asked him in terms of what he knew about his daughter's diagnosis, what kind of prognosis she had, and if he knew of any attempts for a follow-up for her care, he basically said, "I don't have any information."
Winston Wong (11:43):
And why did he not have any information? It's because in that situation, the hospital that had taken care of his daughter did not have a bilingual translator available to the community, did not know how to communicate effectively how follow-up care would be done, was not equipped to really afford the kind of conversation and support that this father who did not speak English himself really needed to care for his daughter who was experiencing a serious mental illness instance.
Winston Wong (12:24):
And it was a tragedy. It was a tragedy for me to hear because I just didn't understand on the nature of their circumstances why such an inequitable outcome had to be. There's no justice in the fact that a father has no understanding of why his daughter was hospitalized, what her outcome would be, and how to care for her.
Scharmaine Lawson (12:49):
Because of a language barrier, this family didn't know how to follow up with treatment after a medical emergency. A language barrier is just one example. Other times, it can be a cultural barrier or varying levels of health literacy. People from all backgrounds need healthcare, and healthcare systems need to be prepared to treat and communicate with everyone.
Winston Wong (13:11):
And the only way we can understand that is because our system was not equipped, not prepared, as well as essentially did not care for people that had different life experiences than the mainstream population that it was really set up to address. Well, for one thing, as the primary care provider, I think our system would have been much better if we were contacted fairly immediately when this patient was hospitalized for her mental illness, and the communication would have enabled us to reach out to the father as well.
Scharmaine Lawson (13:52):
Unfortunately, this is a common experience.
Winston Wong (13:56):
I think across the country, this is generally what's happening. In certain communities, I think we've become more understanding of the diverse needs of our communities, have made up some ground. But I hate to say, but I think that's more the typical story than it is the other with regards to really having the services and the personnel equipped to do the follow-up for people that come from outside of mainstream circumstances.
Winston Wong (14:24):
When our country is unable to really confidently say that we've achieved health equity, our entire system fails for the entirety of our population, because it really manifests itself in terms of the failures we have in terms of having the system set up so that not only do we have the right personnel, the right nursing and physicians and other healthcare team available to help navigate a patient through many difficult situations in their healthcare journey, we don't have the data to substantiate what's really happening.
Scharmaine Lawson (15:04):
The people that live within communities that are affected by disparities and education or housing or food access or people who are marginalized and historically discriminated against, these groups tend to suffer in ways that could be prevented.
Gloria McNeil (15:19):
So what happens in many of these communities is that individuals at the beginning stages of a disease will not seek assistance because it's not available to them. There are no private doctors' offices in the community or nearby. And so they wait until the condition becomes so severe that they have to be taken to the emergency room. And sometimes, it's too late. So if their condition would have been addressed much earlier on, they would have had better outcomes.
Scharmaine Lawson (15:52):
So how can we address people's health conditions before they become too severe? We need to change the focus of our health systems.
Winston Wong (16:01):
We don't have the mindset of prevention and the proactive understanding of the social factors that contribute to why people have greater barriers in terms of achieving optimal healthcare. We don't have the educational system to really target individuals that are going to help fortify our healthcare system with the personnel that's going to be able to meet the future of the diversity [inaudible 00:16:33] populations we have. I think if we build a system that is really around equity, we're going to have a much more prepared system and arguably a more person-centered system that's going to be much more able to achieve health equity as well as satisfaction, improve public health outcomes.
Scharmaine Lawson (16:55):
There are some things that are out of people's control. For example, someone who earns minimum wage cannot buy a car to get to their medical appointments. But there are things that we as providers can control and influence, such as better education for healthcare providers and nurses. At the end of the day, we must do what we can to address health equity, because the outcome of people's health shouldn't be decided by factors out of their control.
Kenya Beard (17:21):
Health equity is the right for every individual to achieve their highest level of health, regardless of where they are.
Scharmaine Lawson (17:30):
That's Dr. Kenya Beard. Dr. Beard is the associate provost for social mission and academic excellence at Chamberlain University. Throughout her career, Dr. Beard has led research on diversity, equity, and inclusion in academia, and has also researched specifically how access and quality of care impact health outcomes.
Kenya Beard (17:49):
We should be able to provide access and a high quality of care that sets the stage for individuals to achieve that highest level of health.
Scharmaine Lawson (18:00):
According to Dr. Beard, to achieve health equity, there's one thing that healthcare systems need.
Kenya Beard (18:06):
Healthcare system leaders have to wholeheartedly believe that health equity cannot be achieved without nurses.
Winston Wong (18:21):
We have to embrace the concepts of health equity as not being a question of caring for exceptional populations or special populations, but thinking about this as a core element of how we achieve better health. We have to be able to train that workforce to look at the broad number of impacts that result in health equity and health inequity, including looking at social determinants of health, all those different factors that occur outside of the healthcare delivery system, to give rise to different elements of health disparities in health inequity. So if we look at that aspect in terms of how nurses can play a much more explicit role in terms of addressing social determinants of health and social factors, and incorporate that into a operationalized system of acknowledgement, professional support, as well as training, we're going to make some great headways in terms of achieving health equity.
Scharmaine Lawson (19:27):
To address health equity, it's important that nurses are able to see and understand the social determinants of health impacting their patients. Dr. McNeil, who we heard from earlier, grew up in an underserved area. Because of this, she was able to recognize the things happening outside of the clinic that affected her community.
Gloria McNeil (19:47):
Because I saw that firsthand myself, I felt that once I had an opportunity to make a difference, that I would do so, and go back and give back to the neighborhoods and help.
Scharmaine Lawson (19:59):
Not only did she start nurse-led clinics, but she also implemented another effective way of reaching her community members.
Gloria McNeil (20:06):
While I had mobile units for a while moving around in these underserved communities providing care, I found that there was still an element of trust that needed to be addressed. And so I changed it from having a mobile unit to actually embedding the clinic inside of recognized community entities. So I positioned the clinic in churches, in drug rehabilitation centers, and in Salvation Army locations, where if there were room that wasn't being used, that we can convert that room into a clinic and be able to address healthcare needs in that manner. And I found much more success with that approach because the patients already attended that church or already resided in that drug rehabilitation and so forth. And so it was familiar surroundings to them, and they felt they could trust us more and better. And so we were able to increase the numbers of underserved patients in these areas where access to healthcare was so negligent.
Scharmaine Lawson (21:16):
Dr. McNeil was able to provide care to patients that may not have received it had the clinic not been in a setting that the patients were comfortable and familiar with. As trusted professionals that spend significant time with patients and families, it's important that nurses are at the forefront of implementing models of care that address social determinants of health.
Winston Wong (21:37):
Certainly from a public health perspective, it's not only just for the public health structure, but also elevate the prestige and visibility and acknowledgement of nurses at being at leadership roles in terms of understanding all the different dimensions and operationalizing how those aspects of social determinants get incorporated into wellness models, new models of care, and extending into partnerships with other parts of the healthcare and medical system.
Scharmaine Lawson (22:10):
When it comes to implementing models that address social determinants of health, nurses face a historic challenge, systemic racism and discrimination both in and out of the healthcare system.
Kenya Beard (22:26):
We know that racism is inherent in every system, education system, housing, employment, the criminal justice system, and even healthcare systems. I know that as providers, we espouse to be altruistic and egalitarian, but racism affects the systems that we work in. So we have to recognize how racism harms everyone, not just the victim. It creates an atmosphere of mistrust.
Scharmaine Lawson (22:56):
Dr. Beard remembers a time outside of the traditional health system where she saw how deeply systemic racism affected her family.
Kenya Beard (23:06):
I remember when my son came home from his second year of college and he said, "Mom, I didn't know that being an African-American was a risk factor for having a low IQ." And I said, "What? What are you talking about? Who told you that?" And he says, "My teacher told me that, the professor." So I'm asking him, "Give me the professor's name. I'm going to email her. This is ridiculous." And then he says, "No, no, Mom, don't blame the professor. He said it's in my textbook." "It's in your what?" He said, "Yeah, my Intro to Psychology textbook. I'll show it to you." So we opened up the book, and there in a box, risk factors for having a low IQ, number for, the African-American family. Should not have been there, but this is false rhetoric from the '50s, the '40s, the '30s, about the intellectual inferiority of minorities, African-American specifically.
Scharmaine Lawson (24:11):
While this experience didn't happen within the clinical setting, it shows that systemic racism and discrimination are deeply embedded in places like schools. And this ultimately has adverse effects on society. Last episode, we heard from Dr. Williams, the co-chair of The Future of Nursing 2020-2030 report. Dr. Williams developed a way to track how systemic racism and discrimination affect people not just in their day-to-day activities, but in their overall health outcomes as well.
Dr. Williams (24:45):
The study of interpersonal discrimination affecting health is less than 30 years old, but the science is overwhelming. They are what I would want to say, it's both discrimination in big things, of being treated unfairly at work, or not being hired for a job. Those are big things. But the strongest evidence comes from what are called the day-to-day indignities.
Dr. Williams (25:09):
I developed a scale called the everyday discrimination scale that captures little things like being treated with less courtesy and respect than others, receive poorer service than others at restaurants and stores, people acting as if you are not smart if they're afraid of you, just little indignities. And what we find just to illustrate with every discrimination, the people who score high on everyday discrimination, there's a higher rate of incident breast cancer linked to everyday discrimination, higher rate of incident metabolic syndrome, higher rate of hypertension, higher rate of inflammation, higher rate of atrial fibrillation, higher rate of C-reactive protein, higher rate of obesity, just higher rate of mental health problems. So a broad range of outcomes.
Scharmaine Lawson (25:51):
The day-to-day indignities, as Dr. Williams calls them, can result in adverse health outcomes. For nurses to address health equity, they need to be educated on how to identify these indignities and other barriers in order to provide the best care for people.
Kenya Beard (26:08):
Healthcare challenges like racism bias and social determinants of health, and some have very little training in these areas. So the right for everyone to achieve their highest level of health is denied when we fail to provide nurses with the tools to understand and mitigate behaviors that include implicit bias and racism. I feel that I know I've personally witnessed the frustration, which could trigger the early departure from the profession. I've witnessed some nurses feeling angry, which could cloud your thought processes. And I've seen nurses engage in work arounds, practices that undermine the quality of care because they feel that there's no other option. So when I'm asked who's responsible, we are all responsible for educating nurses and healthcare providers about the social determinants of health, about racism, and about ways to mitigate bias.
Winston Wong (27:08):
I think it's absolutely essential to addressing health equity in that the way that our healthcare workforce, our nursing workforce is able to understand and address, acknowledge racism and discrimination, sexism within itself as a profession and how we root it out is only going to make the profession stronger to be able to be a forceful agent for change for the community as well.
Scharmaine Lawson (27:40):
It's important to point out that health equity affects both patients and clinicians. Nurses experience sexism, racism, and discrimination within the healthcare setting. This discrimination can be based on their language, accent, sexual orientation, perceived disabilities, and/or elitism. As Dr. Beard said, these challenges make it really difficult for nurses to deliver the best quality care.
Winston Wong (28:05):
I want to emphasize too that within our nurses, they're often the target of racism, discrimination, sexism, and condescending attitudes within our healthcare delivery system. And I think these need to be acknowledged as being forces that are not contributing to enable our nurses to advance in terms of achieving health equity.
Winston Wong (28:36):
So even in the last couple of days, I heard friends of mine who are nurses who told me that some patients themselves had expressed these racist vitriols against him because he was a person of color. And of course, our patients under duress and they come from many different walks of life, but not to acknowledge that nurses, particularly nurses who are people of color confront various aspects of discrimination and racism every day is not to take seriously the kinds of stress, mental health issues, and duress that they face every day. And that as much as we celebrate the role they play as champions, we also need to support them as much as we can with regards to suffering from aggressions.
Scharmaine Lawson (29:37):
The Future of Nursing 2020-2030 report acknowledges that nurses need to be supported when they experience sexism, racism, and discrimination. The report also acknowledges how nurses can increase their own capacities to support patients who may experience similar obstacles.
Kenya Beard (30:01):
I really appreciate reading in the report that no one is immune from hate and bigotry, but everyone has the capacity for empathy, understanding, and solidarity, and a shared hope for a more just and equitable world.
Scharmaine Lawson (30:24):
So what can be done to help the nursing workforce empathize and work to understand how health inequities are affecting their communities? There are several strategies, but we're going to focus right now on one, and that is to increase diversity within the nursing workforce itself.
Winston Wong (30:41):
One of the big challenges about the nursing profession is that it's actually a crucible for a lot of issues we've had in terms of how we fortify the profession of nursing itself. The last report dealt with trying to look at diversity as traditionally the nursing workforce has been predominantly made up of women, and increasingly how do we make sure that it becomes diverse, including men, and including obviously more people of color into the profession. So it's very interesting in that the nursing workforce itself becomes reflective of what we want to do with the system overall and our public health structure priorities overall.
Scharmaine Lawson (31:29):
Dr. Wong had a moment in his career where he saw why it was so important to not only have a diverse nursing workforce, but specifically nurses who share similar backgrounds and reflect their communities. Before Dr. Wong shares, we want you to be aware that this story contains elements that deal with infant loss and may be triggering for some listeners.
Winston Wong (31:51):
I think I had an experience where a woman... And it's a very long and complicated story, but immigrant woman who really just basically had a fifth grade education in her homeland, Chinese-speaking, was pregnant with a baby that had a diagnosis of a hereditary base disease, a bloodborne disease called thalassemia.
Winston Wong (32:17):
And I recall that one of the attempts that the hospitals wanted to do was to make sure that the patient understood the consequences of her pregnancy by having her sit down with a genetic counselor. And it was through our nursing staff that really was really able to sit down with my patient, our patient, and really understand the circumstances of how she understood her pregnancy because this was her first pregnancy, and she didn't understand how a fetus that was moving could potentially be unhealthy, or even in this case, stillborn.
Winston Wong (33:03):
And it was through the painstaking work, conversation, and empathy that those nurses provided with that patient that helped her actually cope with the fact that that baby died within 24 hours of birth.
Scharmaine Lawson (33:23):
This patient was going through a tragedy. And if she hadn't been surrounded by a group of nurses who related to her background, things may have gone differently.
Winston Wong (33:32):
And without that context, not only through language, but understanding what it means to be an immigrant woman with your firstborn in a foreign country, so to speak, I think the long-term consequences of that would have been disastrous if it weren't for the nurses that really stood by her to help her go through the process of dealing with a very difficult pregnancy and also the aspect of grief that would come with the baby that subsequently did not live long.
Scharmaine Lawson (34:06):
Dr. Wong would never forget this experience. It showed him why it was so necessary to increase diversity in the nursing workforce.
Winston Wong (34:15):
I think patients recognize very intuitively that they're being cared for by a person who is able to empathize and is able to understand the conditions in which they face. Now that doesn't necessarily mean 100% of my background is the same as the nurse who cares for me, but I think we want to be able to say that our nursing workforce has a number of people that come from different walks of life that cross set with the number of people that we're caring for in our healthcare settings and make sure that they populate all aspects of the caring aspect of healthcare, whether that be in a primary care setting, in the hospital setting, whether that be in a long-term care setting, or whether that's in public health and/or prevention and education. There's no boundary between being a nurse one day and being a part of the community the next day. You basically are those two things concurrently.
Scharmaine Lawson (35:27):
It's everybody's right to have a fair and just opportunity to be as healthy as possible. With nurses being so embedded in their communities, they have a unique to recognize the social determinants of health experienced by their patients and work to make sure their community is receiving the care it needs. Health equity can be achieved, but only if we work together to strengthen the capacity and expertise of nurses, and it's going to take a much larger effort from systems and education, healthcare, and policy.
Kenya Beard (36:01):
It will take a strong nurse to pull off the ideals of health equity. And if we work together, we can amass the strength to create a healthier nation.
Gloria McNeil (36:12):
So I think we've come a long way. We still have a ways to go, but I'm very encouraged about the positive direction that we're making right now. And I think if we just continue on and advance some of the things that I've already addressed, that we will make a decided difference for the healthcare outcomes for the people in this country.
Scharmaine Lawson (36:33):
Now that we understand what health equity is and why nurses are critical in achieving health equity, it's time for the next step, preparing nurses to understand these issues and know how to confront them. In our next episode, we're going to dive deeper into how nursing schools can strengthen education curricula to better prepare nurses to work in and with communities. And we'll also be exploring how we can actually diversify nursing school classes and faculties. Until then, if you want to learn more about the report or read it yourself, which we always recommend, you can visit the report homepage at nap.edu/nursing2030. Thanks for listening.