Compassion and equity-focused clinical genomics training for health professional learners.

There remains an urgent need for expanded genomics training in undergraduate medical education, especially as genetic and genomic assessments become increasingly important in primary care and routine clinical practice across specialties. Physician trainees continue to report feeling poorly prepared to provide effective consultation or interpretation of genomic test results. Here we report on the development, pilot implementation, and evaluation of an elective offering for pre-clinical medical students called the Sanford Precision Health Scholars Immersive Learning Experience (PHS), which was designed leveraging genetic counseling expertise as one means to address this need. This 9-week course, piloted in Fall 2021 at UC San Diego, afforded students the opportunity to build technical skills and competencies in clinical genomics while identifying, addressing, and engaging with pervasive health disparities in genomics. Interactive exercises focused students' learning on strategies for empathic and compassionate patient interactions while supporting the application of concepts and knowledge to future practice. Upon completion of the course, participants reported increases in confidence related to skills required for clinical genomics practice. Drawing on learnings from this pilot implementation, recommendations for refining the program include deepening pedagogical engagement with ethical issues, expanding the offering to trainees across health professions, including pharmacy students, and incorporating an optional experiential learning component. Educational offerings, like PHS, that are designed with the input of genetic counseling expertise may ease pressures on the genetic counseling profession by building a more genomic-literate healthcare workforce that can better support efforts to expand access for patients.

Integrating nurse practitioners into primary healthcare to advance health equity through a social justice lens: An integrative review.

AIM: To develop a framework to guide the successful integration of nurse practitioners (NPs) into practice settings and, working from a social justice lens, deliver comprehensive primary healthcare which advances health equity. DESIGN: Integrative review. METHODS: The integrative review was informed by the Whittemore and Knafl's framework and followed the Preferred Reporting for Systematic Reviews and Meta-Analyses guidelines. Quality was assessed using the Johns Hopkins Research Evidence Appraisal Tool. Findings were extracted and thematically analysed using NVivo. A social justice lens informed all phases. DATA SOURCES: Databases, including CINAHL, PubMed, Scopus and Web of Science, were searched for peer-reviewed literature published in English between 2005 and April 2022. RESULTS: Twenty-eight articles were included. Six themes were identified at the individual (micro), local health provider (meso), and national systems and structures (macro) levels of the health sector: (1) autonomy and agency; (2) awareness and visibility; (3) shared vision; (4) leadership; (5) funding and infrastructure; and (6) intentional support and self-care. The evidence-based framework is explicitly focused on the components required to successfully integrate NPs into primary healthcare to advance health equity. CONCLUSION: Integrating NPs into primary healthcare is complex and requires a multilevel approach at macro, meso and micro levels. NPs offer the potential to transform primary healthcare delivery to meet the health needs of local communities. Health workforce and integration policies and strategies are essential if the contribution of NPs is to be realized. The proposed framework offers an opportunity for further research to inform NP integration. IMPACT STATEMENT: Nurse practitioners (NPs) offer the potential to transform primary healthcare services to meet local community health needs and advance health equity. Globally, there is a lack of guidance and health policy to support the integration of the NP workforce. The developed framework provides guidance to successfully integrate NPs to deliver comprehensive primary healthcare grounded in social justice. Integrating NPs into PHC is complex and requires a multilevel approach at macro, meso and micro levels. The framework offers an opportunity for further research to inform NP integration, education and policy. SUMMARY STATEMENT: What problem did the study address: The challenges of integrating nurse practitioners (NPs) into primary healthcare (PHC) are internationally recognized. Attempts to establish NP roles in New Zealand have been ad hoc with limited research, evidence-informed frameworks or policy to guide integration initiatives. Our review builds on existing international literature to understand how NPs are successfully integrated into PHC to advance health equity and provide a guiding framework. What were the main findings: Six themes were identified across individual (micro), local health provider (meso) and national systems and structures (macro) levels as fundamental to NP integration: autonomy and agency; awareness and visibility of the NP and their role; a shared vision for the direction of primary healthcare utilizing NP scope of practice; leadership in all spaces; necessary funding and infrastructure; and intentional support and self-care. Where and on whom will the research have an impact: Given extant health workforce challenges together with persisting health inequities, NPs provide a solution to delivering comprehensive primary healthcare from a social justice lens to promote healthcare access and health equity. The proposed evidence-informed framework provides guidance for successful integration across the health sector, training providers, as well as the NP profession, and is a platform for future research. REPORTING METHOD: This integrative review adhered to the Preferred Reporting for Systematic Reviews and Meta-Analyses (PRISMA) method. PATIENT OR PUBLIC CONTRIBUTION: No patient or public contribution.

Shedding new light for nurses: Enhancing pressure injury prevention across skin tones with sub-epidermal moisture assessment technology.

AIM(S): To assess the effectiveness of sub-epidermal moisture (SEM) assessment technology in the detection of early-stage pressure damage in a critical care unit (CCU) and dark skin tone patients and its impact on hospital-acquired pressure injury (HAPI) incidence. DESIGN: Quality improvement study employing Kurt Lewin's change model emphasizing planning, implementation, evaluation and sustainable change. METHODS: The study evaluated 140 adult patients admitted to the CCU over a 24-week period, from July to December 2022. Retrospective analysis of standard PI care pathways was performed in 90 patients admitted during a 12-week pre-implementation period. Fifty patients were admitted through the subsequent 12-week implementation period. SEM assessments were performed daily at the sacrum and heels and interventions were applied based on SEM assessments; SEM delta ≥0.6 indicating localized oedema or persistent focal oedema. Statistical analyses were performed on anonymized data. RESULTS: Pre-implementation HAPI incidence was 8.9% (N = 8/90). All eight patients were African American with varying skin tones. A 100% reduction in HAPI incidence was achieved in the implementation period which included 35 African American patients. The relative risk of HAPI incidence was 1.6 times higher in the pre-implementation group. CONCLUSION: Implementing SEM assessment technology enabled equitable PI care for all population types and resulted in a 100% reduction of PIs in our CCU. Objective SEM assessments detected early-stage PIs, regardless of skin tone and enabled providing interventions to specific anatomies developing tissue damage as opposed to universal preventive interventions. IMPLICATIONS: PI care pathways relying on visual and tactile skin assessments are inherently biased in providing equitable care for dark skin tone patients. Implementing SEM assessments empowers healthcare practitioners in driving objective clinical interventions, eliminates bias and enables positive PI health outcomes. IMPACT: Implementing SEM assessment technology had three main effects: it detected early tissue damage regardless of skin tone (detection effect), enabled anatomy-specific interventions (treatment effect) and prevented PIs across all population types (prevention effect). The authors have adhered to the Standards for Quality Improvement Reporting Excellence (SQUIRE) 2.0 guidelines. PATIENT OR PUBLIC CONTRIBUTION: No patient or public contribution. What does this paper contribute to the wider global clinical community? Addressing health inequities in pressure injury prevention; Demonstrated effectiveness across patient populations; Resource optimization and enhanced patient safety.

Community Health Worker Integration with and Effectiveness in Health Care and Public Health in the United States.

Community health workers (CHWs) have worked in a variety of settings in the United States for more than 70 years and are increasingly recognized as an essential health workforce. CHWs share life experience with the people they serve and have firsthand knowledge of the causes and impacts of health inequity. They provide a critical link between marginalized communities and health care and public health services. Several studies have demonstrated that CHWs can improve the management of chronic conditions, increase access to preventive care, improve patients' experience of care, and reduce health care costs. CHWs can also advance health equity by addressing social needs and advocating for systems and policy change. This review provides a history of CHW integration with health care in the United States; describes evidence of the impact of CHW programs on population health, experience, costs of care, and health equity; and identifies considerations for CHW program expansion.

The Healthy Democracy Kit: design, implementation, uptake, and impact of a novel voter registration toolkit for healthcare settings.

BACKGROUND: Access to voting is increasingly recognized as a social determinant of health. Health equity could be improved if healthcare workers (HCWs) routinely assessed the voter registration status of patients during clinical encounters and helped direct them towards appropriate resources. However, little consensus exists on how to achieve these tasks efficiently and effectively in healthcare settings. Intuitive and scalable tools that minimize workflow disruptions are needed. The Healthy Democracy Kit (HDK) is a novel voter registration toolkit for healthcare settings, featuring a wearable badge and posters that display quick response (QR) and text codes directing patients to an online hub for voter registration and mail-in ballot requests. The objective of this study was to assess national uptake and impact of the HDK prior to the 2020 United States (US) elections. METHODS: Between 19 May and 3 November 2020, HCWs and institutions could order and use HDKs to help direct patients to resources, free of cost. A descriptive analysis was conducted to summarize the characteristics of participating HCWs and institutions as well as the resultant total persons helped prepare to vote. RESULTS: During the study period, 13,192 HCWs (including 7,554 physicians, 2,209 medical students, and 983 nurses) from 2,407 affiliated institutions across the US ordered 24,031 individual HDKs. Representatives from 604 institutions (including 269 academic medical centers, 111 medical schools, and 141 Federally Qualified Health Centers) ordered 960 institutional HDKs. Collectively, HCWs and institutions from all 50 US states and the District of Columbia used HDKs to help initiate 27,317 voter registrations and 17,216 mail-in ballot requests. CONCLUSIONS: A novel voter registration toolkit had widespread organic uptake and enabled HCWs and institutions to successfully conduct point-of-care civic health advocacy during clinical encounters. This methodology holds promise for future implementation of other types of public health initiatives. Further study is needed to assess downstream voting behaviors from healthcare-based voter registration.

Advanced practice nurse case managers improve efforts by US hospitals to address patient social needs.

AIMS: US hospitals are focussing more than ever on meeting important patient social needs. Patients often make multiple trips to hospitals related to nonmedical issues that could likely be averted through the increased integration of case management strategies. Although the percentage of hospitals using advanced practice nurses (APNs) in this role is still relatively low, we explore the idea that employing APN case managers improves hospitals' abilities to alleviate hospital overusage. DESIGN: The study used a cross-sectional design. METHODS: We used the 2021 American Hospital Association data set, which includes 5855 hospitals, of which 4315 were general medical hospitals. RESULTS: Using descriptive statistics and Poisson regression, we discovered that employing APN case managers in US acute care hospitals is associated with an increased likelihood that hospitals will implement strategies addressing patient social needs. CONCLUSIONS: When hospitals screen patients for social needs and formulate and implement internal and external strategies designed to meet patient social needs, many stakeholders stand to benefit. Should more hospitals observe such benefits when utilizing an APN case manager model, it will likely proliferate, and demand for APNs could accelerate further. IMPACT: Following the reduction in unnecessary patient visits and readmissions, hospitals' scarce resources are freed up to offer timely care to patients that are truly medically in need. Furthermore, financial performance improves under this scenario. APNs play a critical role in enabling hospitals to realize such benefits. PATIENT OR PUBLIC CONTRIBUTION: No patient or public contribution. We used archival data in this study.

Intervening in the Cancer Care System: An Analysis of Equity-Focused Nurse Navigation and Patient-Reported Outcomes.

BACKGROUND: Nurse navigation can improve quality of cancer care and reduce racial disparities in care outcomes. Addressing persistent structurally-rooted disparities requires research on strategies that support patients by prompting structural changes to systems of care. We applied a novel conceptualization of social support to an analysis of racial equity-focused navigation and patient-reported outcomes. METHOD: We applied an antiracism lens to create a theory-informed definition of system-facing social support: intervening in a care system on a patient's behalf. Participants were adults with early-stage breast or lung cancer, who racially identified as Black or White, and received specialized nurse navigation (n = 155). We coded navigators' clinical notes (n = 3,251) to identify instances of system-facing support. We then estimated models to examine system-facing support in relation to race, perceived racism in health care settings, and mental health. RESULTS: Twelve percent of navigators' clinical notes documented system-facing support. Black participants received more system-facing support than White participants, on average (b = 0.78, 95% confidence interval [CI]: [0.25, 1.31]). The interaction of race*system-facing support was significant in a model predicting perceived racism in health care settings at the end of the study controlling for baseline scores (b = 0.05, 95% CI [0.01, 0.09]). Trends in simple slopes indicated that among Black participants, more system-facing support was associated with slightly more perceived racism; no association among White participants. DISCUSSION: The term system-facing support highlights navigators' role in advocating for patients within the care system. More research is needed to validate the construct system-facing support and examine its utility in interventions to advance health care equity.

SWOT Analysis and Recommendations for Community Health Workers and Stakeholders Responding to COVID-19 Health Inequities.

Background. By 2023, 1,080,000 cases of COVID-19 have been reported in Harris County. Systemic inequity and vaccine hesitancy have contributed to COVID-19 disparities. Community Health Workers provide health education and instrumental support to alleviate health disparities among vulnerable communities. We conducted an analysis of Strengths, Weaknesses, Opportunities, and Threats (SWOT) analysis in June 2022 among a broad coalition of Community Health Work stakeholders to better understand the local landscape in the context of the COVID-19 pandemic. Methods. We recruited 33 community health workers and industry stakeholders in Harris County, Texas, to participate in the SWOT analysis. Participants were asked to describe their opinions on the SWOT facing the Community Health Work landscape and then rank the outcomes of the analysis to prioritize action. Results. A total of 19 themes were identified. Weaknesses included lack of respect and resources for Community Health Workers and poor coordination and capacity among the workforce infrastructure. Limited funding and lack of appreciation for Community Health Workers were deemed important threats. Diversity and community connection were critical strengths, and strong education, training, and raising awareness for community health work were considered opportunities to overcome identified weaknesses and threats. Discussion. Increased funding, greater coordination, greater respect, and amplified training can improve capacity for Community Health Workers and, therefore, improve public health outcomes for respiratory illness and viral infections such as COVID-19. This analysis helps fill an important research gap on the topic Community Health Workers responding to public health crises with racially disparate outcomes.

Disability research must be a priority for nurses to advance health equity.

Disability results from an interplay between health conditions and environmental and personal factors. People with disabilities face substantial and ongoing health inequities; however, research to mitigate these inequalities is lacking. There is an urgent need for a better understanding of the multilevel factors that influence health outcomes in people with visible and invisible disabilities across all the lenses of the National Institute of Nursing Research strategic plan. Disability research must be a priority of nurses and the National Institute of Nursing Research to advance health equity for all.

The Role of the School Nurse in Suicide Prevention: Implications for Equitable Care of Vulnerable Youth.

The rising rate of youth suicide in rural Eastern North Carolina reflects the national trend. Although school nurses have been regarded as the gateway professional for mental health services, their role in suicide prevention is not well understood. The purpose of this study was to explore school nursing practice regarding suicide prevention of school-aged children in one vulnerable region of the United States. Focus groups and surveys were collected from 35 school nurses in six school districts. Findings indicate that suicide protocols inclusive of the school nurse can facilitate their role in suicide prevention. Variation of school nursing practice existed between and within districts. These variations in school nursing practice highlight the need for school districts within the state and across the country to examine their policies and practices for mental health equity. Barriers such as higher caseloads, role disconnect, and lack of specialized training contributed to variations in practice.

Inequities in the care of older adults: Identifying education gaps in geriatric medicine fellowship.

The past year amplified inequities in the care of older adults. Milestones focused on social determinants of health (SDOH) are lacking within Geriatric fellowship training. A virtual learning collaborative GERIAtrics Fellows Learning Online And Together (GERI-A-FLOAT) was developed to connect trainees nationwide. To address gaps in education around SDOH, a needs assessment was conducted to inform a curricular thread. A voluntary, anonymous survey was distributed to fellows through a broad network. We sought to understand prior curricula trainees had that were specifically focused on SDOH and older adults. Respondents prioritized topic areas for the curriculum. Seventy-five respondents completed the survey. More than 50% of participants indicated no training on homelessness, immigration, racism, or LGBTQ+ health at any level of medical training, with more than 70% having no training in sexism or care of formerly incarcerated older adults. The most commonly taught concepts were ableism, ageism, and poverty. Respondents prioritized the topic of racism, ageism, and ableism. There is a lack of consistent SDOH curricula pertaining to older adults across all levels of training. This needs assessment is guiding a curricular thread for GERI-A-FLOAT and ideally larger milestones for fellowships. The time is now to prepare future geriatricians to serve as change agents.

Racial Diversity Among American Cardiologists: Implications for the Past, Present, and Future.

In the United States, race-based disparities in cardiovascular disease care have proven to be pervasive, deadly, and expensive. African American/Black, Hispanic/Latinx, and Native/Indigenous American individuals are at an increased risk of cardiovascular disease and are less likely to receive high-quality, evidence-based medical care as compared with their White American counterparts. Although the United States population is diverse, the cardiovascular workforce that provides its much-needed care lacks diversity. The available data show that care provided by physicians from racially diverse backgrounds is associated with better quality, both for minoritized patients and for majority patients. Not only is cardiovascular workforce diversity associated with improvements in health care quality, but racial diversity among academic teams and research scientists is linked with research quality. We outline documented barriers to achieving workforce diversity and suggest evidence-based strategies to overcome these barriers. Key strategies to enhance racial diversity in cardiology include improving recruitment and retention of racially diverse members of the cardiology workforce and focusing on cardiovascular health equity for patients. This review draws attention to academic institutions, but the implications should be considered relevant for nonacademic and community settings as well.

Community health workers and health equity in low- and middle-income countries: systematic review and recommendations for policy and practice.

BACKGROUND: The deployment of Community Health Workers (CHWs) is widely promoted as a strategy for reducing health inequities in low- and middle-income countries (LMIC). Yet there is limited evidence on whether and how CHW programmes achieve this. This systematic review aimed to synthesise research findings on the following questions: (1) How effective are CHW interventions at reaching the most disadvantaged groups in LMIC contexts? and (2) What evidence exists on whether and how these programmes reduce health inequities in the populations they serve? METHODS: We searched six academic databases for recent (2014-2020) studies reporting on CHW programme access, utilisation, quality, and effects on health outcomes/behaviours in relation to potential stratifiers of health opportunities and outcomes (e.g., gender, socioeconomic status, place of residence). Quantitative data were extracted, tabulated, and subjected to meta-analysis where appropriate. Qualitative findings were synthesised using thematic analysis. RESULTS: One hundred sixty-seven studies met the search criteria, reporting on CHW interventions in 33 LMIC. Quantitative synthesis showed that CHW programmes successfully reach many (although not all) marginalized groups, but that health inequalities often persist in the populations they serve. Qualitative findings suggest that disadvantaged groups experienced barriers to taking up CHW health advice and referrals and point to a range of strategies for improving the reach and impact of CHW programmes in these groups. Ensuring fair working conditions for CHWs and expanding opportunities for advocacy were also revealed as being important for bridging health equity gaps. CONCLUSION: In order to optimise the equity impacts of CHW programmes, we need to move beyond seeing CHWs as a temporary sticking plaster, and instead build meaningful partnerships between CHWs, communities and policy-makers to confront and address the underlying structures of inequity. TRIAL REGISTRATION: PROSPERO registration number CRD42020177333 .

Health equity knowledge development: A conversation with Black nurse researchers.

Can the institutional systems that prepare Black nurse researchers question the ways their systemic pathways have impacted health equity knowledge development in nursing? We invite our readers to keep this question in mind and engage with our conversation as Black nurse researchers, scholars, educators, and clinicians. The purpose of our conversation, and this article, is to explore the transactional impact of knowledge development pathways and Black faculty retention pathways on the state of health equity knowledge in nursing today. Over a series of conversations, we discuss the research exploitation of communities of color, deficit research funding, knowledge capitalization, the marginalization of diversity as a continuous process, a lack of sociocultural authority, and our thoughts on solutions. We conclude by using the wisdom of a generation to answer our initial question.

Leveraging the resources of foundations to advance health equity.

BACKGROUND: Foundations that support health and health care related issues are bell weathers for our nation's most pressing challenges in this area. The new National Academy of Medicine report, The Future of Nursing 2020 to 2030: Charting a Path to Achieve Health Equity has been perfectly timed to provide foundations with the additional research and evidence they need to support health equity efforts through the utilization of the nursing workforce. Many foundations are thinking beyond traditional grant-making to align more of their assets with mission in creative ways. CONCLUSION: Funders are investing in strategies along a downstream-upstream continuum to promote health equity. This paper is aimed to encourage nurses to approach philanthropy as important partners in their efforts to advance health equity.

How to leverage innovation models to achieve health equity: Build. Measure. Share.

The Future of Nursing 2020 to 2030: Charting a Path to Achieve Health Equity (2021) highlights inequality throughout healthcare. People of color exhibit lower life expectancy levels than their White counterparts. LGTBQ individuals are 2.7 times more likely than heterosexuals to experience a violent crime . Lower-income individuals report their health status at lower levels than high-income earners. Health and healthcare in America are not equitable. With only 58% of healthcare organizations considering "Heath Equity" as a top-three priority, there is a substantial and dire need for innovation to fill the gap between the healthcare that is needed and what is being provided. This article explores the Build. Measure. Share. model for healthcare innovation as an approach to encourage and empower healthcare professionals to take meaningful steps toward creating an equitable and just health system.

Physician distribution across China's cities: regional variations.

BACKGROUND: Distribution of physicians is a key component of access to health care. Although there is extensive research on urban-rural disparities in physician distribution, limited attention has been directed to the heterogeneity across urban areas. This research depicts variations in physician density across over 600 cities in the context of China's rapid urbanization. METHODS: Data came from National Census Surveys and China statistical yearbooks, 2000-2003, and 2010-2013. Cities were characterized in terms of not only administrative level but also geographic regions and urban agglomerations. We analyzed variations in physician supply by applying generalized estimating equations with an ordinal logistic linking function. RESULTS: Although overall physician density increased between 2003 and 2013, with population and socioeconomic attributes adjusted, physician density declined in urban China. On average, urban districts had a higher physician density than county-level cities, but there were regional variations. Cities in urban agglomerations and those outsides did not differ in physician density. CONCLUSION: Despite the reduced inequality between 2003 and 2013, the growth in physician density did not appear to be commensurate with the changes in population health demand. Assessment in physician distribution needs to take into account heterogeneity in population and socioeconomic characteristics.

Nurses in advanced roles as a strategy for equitable access to healthcare in the WHO Western Pacific region: a mixed methods study.

BACKGROUND: The Western Pacific region constitutes one-quarter of the world's population and has diverse health needs. While dialogue on and promotion of advanced practice nurses are ongoing, this study investigated the current responsibilities of nurses in advanced roles, future healthcare needs, and the implications of these components for nurses' professional development within the Western Pacific region. METHODS: This study employed three phases, a descriptive survey on the current status of nurses in advanced roles in the Western Pacific region, followed by a Delphi survey, and exploratory interviews. A total of 55 national experts with clinical, academic, and/or government-related backgrounds from 18 countries participated from December 2017 - December 2018. The descriptive survey via email to identify the status of nurses in advanced roles and a working definition was developed. This formed the basis for the Delphi survey, which identified key barriers and challenges for enhancing the development of nurses in advanced roles within the country (round 1) and for the region (rounds 2 and 3). Lastly, semi-structured individual interviews were conducted to identify strategies for establishing nurses in advanced roles to improve equitable access to healthcare. RESULTS: Thirty-seven roles and characteristics were identified and categorized for nurses performing advanced roles. Emergency care, critical care, elderly health, child health, and rural/remote communities were identified as fields with particular need for nurses in advanced roles in the Western Pacific region. Providing effective services, influencing government leadership, and advocating for health system sustainability were deemed necessary to improve equitable healthcare access. We found that nurses in advanced roles are not limited to clinical tasks within the hospital but are poised for active participation in primary healthcare, education/teaching, professional leadership, quality management, and research. CONCLUSIONS: Demand for nurses in advanced roles is high in the Western Pacific region and 15 items were identified across five core strategic areas to enhance development of nurses in advanced roles. Governmental-level recommendations include establishing legislative protection, improving systems for remuneration, strengthening supportive channels, and conducting national needs assessments.

Media framing of emergency departments: a call to action for nurses and other health care providers.

BACKGROUND: As part of a larger study focused on interventions to enhance the capacity of nurses and other health care workers to provide equity-oriented care in emergency departments (EDs), we conducted an analysis of news media related to three EDs. The purpose of the analysis was to examine how media writers frame issues pertaining to nursing, as well as the health and social inequities that drive emergency department contexts, while considering what implications these portrayals hold for nursing practice. METHODS: We conducted a search of media articles specific to three EDs in Canada, published between January 1, 2018 and May 1, 2019. Media items (N = 368) were coded by story and theme attributes. A thematic analysis was completed to understand how writers in public media present issues pertaining to nursing practice within the ED context. RESULTS: Two overarching themes were found. First, in ED-related media that portrays health care needs of people experiencing health and social inequities, messaging frequently perpetuates stigmatizing discourses. Second, media writers portray pressures experienced by nurses working in the ED in a way that evades structural determinants of quality of care. Underlying both themes is an absence of perspectives and authorship from practicing nurses themselves. CONCLUSIONS: We recommend that frontline nurses be prioritized as experts in public media communications. Nurses must be supported to gain critical media skills to contribute to media, to destigmatize the health care needs of people experiencing inequity who attend their practice, and to shed light on the structural causes of pressures experienced by nurses working within emergency department settings.

Nurses as agents of disruption: Operationalizing a framework to redress inequities in healthcare access among Indigenous Peoples.

Health equity is a global concern. Although health equity extends far beyond the equitable distribution of healthcare, equitable access to healthcare is essential to the achievement of health equity. In Canada, Indigenous Peoples experience inequities in health and healthcare access. Cultural safety and trauma- and violence-informed care have been proposed as models of care to improve healthcare access, yet practitioners lack guidance on how to implement these models. In this paper, we build upon an existing framework of equity-oriented care for primary healthcare settings by proposing strategies to guide nurses in operationalizing cultural safety and trauma- and violence-informed care into nursing practice at the individual level. This component is one strategy to redress inequitable access to care among Indigenous Peoples in Canada. We conceptualize barriers to accessing healthcare as intrapersonal, interpersonal, and structural. We then define three domains for nursing action: practicing reflexivity, prioritizing relationships, and considering the context. We have applied this expanded framework within the context of Indigenous Peoples in Canada as a way of illustrating specific concepts and focusing our argument; however, this framework is relevant to other groups experiencing marginalizing conditions and inequitable access to healthcare, and thus is applicable to many areas of nursing practice.