Nursing’s Role in Advancing Health Equity - Suzanne Miyamoto, CEO of the American Academy of Nursing

JANNAH AMIEL: Hi, I'm Jannah Amiel and today on Raise the Line, I'm happy to be joined by Suzanne Miyamoto, CEO of the American Academy of Nursing. Suzanne Miyamoto has developed a strong reputation as a leader with policy expertise, having previously served as Chief Policy Officer of the American Association of Colleges of Nursing. She's also worked with the National Institutes of Health, The Joint Commission's Nursing Advisory Council, and the Nursing Community Coalition. Also, she teaches policy to nursing students at Georgetown University. She was a 2014 executive nurse fellow at the Robert Wood Johnson Foundation and was inducted as a fellow of the American Academy of Nursing in 2015. Thank you so much for being with us today; that was a lot!

SUZANNE MIYAMOTO: Thank you, I appreciate it. It's my pleasure to have the opportunity to be with you all and share a little bit about the insights of what's happening.

JANNAH AMIEL: I'd love to hear it. Can you first just get us started by telling us a little bit about your background? What led to your interest to health care?

SUZANNE MIYAMOTO: I'm originally from Michigan; my family owned a small manufacturing business. So I wasn't really exposed to healthcare per se. I remember filing blueprints of machine parts. I didn't really have that lens of going into healthcare. I wasn't really sure, growing up, exactly what I wanted to do. But in high school, they had an opportunity for me to volunteer at a hospital. I delivered flowers to different patient rooms, and I got to interact with individuals and families. There was just this connection that you started to feel being around people. I really saw the appreciation for healing and even just those small moments of the humanity of sharing, delivering the flowers, or saying good morning or giving that opportunity to make that personal connection. I wanted to explore it further. I actually have two aunts who were in the nursing field, but I never really asked too much about their career until I had that experience going into the hospital.

JANNAH AMIEL: That's awesome. I actually have an aunt, I want to say it’s second or third, who also was a nurse, I recently found that out in the fall. It’s really exciting to define that you've got a family member who's also in the field as well.

SUZANNE MIYAMOTO: Absolutely.

JANNAH AMIEL: I want to talk to you a little bit about policy. Nursing leadership, in particular, is really, I would say, the cherry on top of my nursing pie. I'm really interested in how you went from working as a registered nurse—I think about your early years working as an RN, bedside, that patient-centered care in the workforce—to policy. I'm curious what that journey looked like for you.

SUZANNE MIYAMOTO: Yes, it is different for each nurse, how they kind of make their path. The first position that I had after graduating from nursing school was actually in Detroit, and I worked in postpartum. I graduated from nursing school at a time where new grads could be hired into any unit because there was such a demand for nurses. I just remember going into patient rooms and using the translator phone—something that I hadn't done in nursing school, per se—and I just began to wonder how could care be delivered differently. Were there better ways to connect with patients where English isn't their first language? 

While I was still young in my career, I was interested in health equality and health equity before I even knew the words or the frame to really put around them. Because you just started to be inquisitive. You're taught to think about, how does this impact the family? How does it impact the patient? It led me, some of these questions I had, to graduate school. 

In graduate school, I worked on a research project that supported women with anorexia and bulimia, and again, to further question about mental health services and how we were providing mental health care. Were we looking at the whole person? Is there a better way to do it? It all coalesced around system-level reform and that outlet for me could be policy, and looking at it from an institutional level or on up to the national level. There was an actual lobbyist who had worked on Capitol Hill and had worked in the Clinton administration, and she was talking about some of the work that she did, and I just remember running up to her after the end of class saying, “I want to do what you do. How do I get there?” So, it just kind of came all together.

JANNAH AMIEL: That's awesome. So with the guests that we've had coming through Raise the Line, one of the themes that is popping up a lot is healthcare leadership, and policy. Just reflect on the work of the registered nurse. So much of what we do really is about being the leader at the bedside and trying to implement changes and implement new ideas and better practices. Sometimes that's very difficult to do; we have it in our head, but to your point, running after her after class, it's like, “How do I get there?” 

If I think about nursing academia, there's not, in my opinion, a ton of focus on this policy piece which seems to be just as important as it is to know clinical skills. So I'm curious, where do you see nursing fitting into that picture of population health and health equity? How do we play a role in that, and how do we prepare ourselves to do it?

SUZANNE MIYAMOTO: I think that is an incredible question. Thank you for putting that frame around it, that it's not just us clinically being at the bedside, because nurses are front and center. What we learn and what we discover, from addressing population health and health equity, is that time with a patient's families, that community -- when we engage, we're engaging in their environments -- and then we're closely collaborating with that interdisciplinary and multidisciplinary team. So when nurses are in these roles, whether it be in the acute care setting or out in the community working in public health, we see the balance, the challenges, and the barriers to achieving our goal of health equity. 

As we're going through the process of trying to support individuals and their families and then populations, we have to also understand and learn along with them some of the conscious and unconscious biases that we may have bringing to our care. I think there has been in the past -- and even more so, now -- that honor and owning our responsibility of what it means to be a nurse, and how that care impacts the individual, the family, and the patient. It's like the idea of precision health, it's really thinking about how precise we can be in offering care to that unique individual. 

I think one of the reasons why I'm so proud to be at the American Academy of Nursing, our mission is to improve health equity by impacting policy through nursing leadership, innovation, and science. That is really where it comes together, of all of those pieces of where nurses are leading in the community, where they're inventing new ways of care model designs, and then our research. The academy set a vision of healthy lives for all people. So I see nurses right front and center in those discussions, in that impact. But as you said, there are challenges and barriers to figuring out how we are front and center and all of that.

JANNAH AMIEL: Yes. What do you think about those challenges and barriers? One of the things I think about is education. In my grad program, for instance, I had a leadership track that was a purposeful thing to try to learn those skills and see, how could I show up and show out for the community that needs me? But what does that look like for you as far as the nurse who's thinking, “I do want to show up, and I want to overcome these barriers and these policies, but I don't know how to do it. I don't know where to start. Do I get a mentor? Do I take a class? Do I join a board? How do I do that?”

SUZANNE MIYAMOTO: It's a really interesting question, and I think a couple of pieces come to mind. One of the things that we know as we go through our nursing careers to whatever track we decide to take, is really, there's so much to gain from experience. I think everyone makes that assumption that it's from zero to 60, very quickly, and there are so many steps and experiences along the way that give us that background. 

One of the things that I think is a challenge, but also an opportunity for us as a profession is, when I was working as a lobbyist and in my role at the American Association of Colleges of Nursing, there were so many voices. Every single healthcare organization, professional organization, professional society had a voice on the Hill, and how did you make that voice rise above over time? It really is in coming back to the evidence and personal connections that are paramount. This is where you think about nursing as an evidence-based discipline and our personal connections, we are just so poised to be engaged in those opportunities. As we know, we have these national representatives, but they want to know what's happening in their communities. They want to know what's happening in their seats. Members of Congress want to hear our leaders, want to hear from those nurses that are experiencing back home. I think one of the most interesting ways to build that voice, and overcoming those multiple voices, is finding partnerships -- the unlikely ones, and the likely ones -- and they really come together for the most compelling cases. 

Find someone that's doing work in an area that you're focused on, or you're passionate about. Study your issue. Make sure that you have that evidence to go along with that personal connection. If it's policy work that individual nurse is striving towards, the national and state organizations are a resource. It doesn't necessarily have to be a national or state nursing organization, it could be something focused on Alzheimer's, or it could be focused on another area of disease that a nurse may be interested in learning more about. There are these small steps, that we have to remember are really important and give us so much experience that builds that leadership and that career over time.

JANNAH AMIEL: Yes, I love that. I love that you mentioned the voice, using your voice and uplifting your voice, and being empowered in that way. The small steps really stick with me, because oftentimes, when we think about wanting to implement a change and wanting to lead, we think about a big level: “I'm going to march to DC, and I'm going to do this new thing!” But we do forget that we inform policy, and we do implement changes, on maybe what we think is a small scale and don't really consider it. That could be like a bedside nurse who has an idea, or who's recognized some type of gap or problem, and brings that up to the manager, and says, "Hey, this is what I recognize, and this is what I think that we might be able to do. I've thought about it, and here's the potential solution of how we can meet that." That's leadership. I think sometimes that gets lost. That gets lost in the sense of, you know, “If you really want to make a change, you've got to be way up here!” But to your point, exactly, and beautifully said, change starts really at your feet. 

SUZANNE MIYAMOTO: I had one really incredible nurse once say to me, “You are a leader from whatever seat you sit in. It does not matter.” It is being able to make your case, having your evidence, and really making those personal connections that are so strong and can carry that voice, even when you're not at the table.

JANNAH AMIEL: Yes, that's awesome. I agree with that. I often wonder, and it always bring me back to nursing academia since I'm in education, but there's always a big part of me that feels like we wait too long in nursing to start to have these conversations about leading and about how we can influence policy in our communities and nationwide. I always wonder, what does the world look like when we start to encourage and really fill up nurses with this idea from the beginning—when they're in their pre-licensure program—versus waiting until, if you've been in the field for years and years, and maybe you felt like you had this urge or this desire, but you didn't quite know how to step out and do that. My students are tired of me saying this, for sure, but I think that when we start to have those conversations really early, and empowering those nurses to use their voices, it looks like a very different world to me.

SUZANNE MIYAMOTO: I will tell you, I wouldn't be where I am now if I didn't have educators like yourself. I was very fortunate in nursing school to have professors and Ph.D. chairs that said, “Suzanne, just go for it.” I always feel blessed that they felt confident and encouraging in what I could do in the future. I always wanted to make sure that in my career, I give that back as early as possible because it is paying it forward, if you will, that we don't have to wait forever. There are brilliant ideas and such compassion at any level at any age, and we have to tap it.

JANNAH AMIEL: Yes, I agree with that. So we can't ever have a conversation without, of course, bringing up COVID. I'm curious, in your particular role, and what you do day-to-day, in what you've seen, what do you feel, or what have you identified of what's COVID revealed about our health care system? Are there steps that we can take to strengthen that? More specifically, in nursing. What's nursing's role in what we've seen that potentially is broken or has been broken by COVID?

SUZANNE MIYAMOTO: There's going to be a day where that isn't the front and center question or part of the conversation.

JANNAH AMIEL: Looking forward to it!

SUZANNE MIYAMOTO: I know we all are. But there are just so many lessons that we're learning and realization of how broken in places the system is. My first thought goes to, essentially, our public health infrastructure. For years, we've been underfunding the public health infrastructure or not building up the resources, to have nurses to have other health professions in the community doing that essential work. For so many people, they heard of contract tracing for the first time and public health nurses are like, “Well, that is not new.” There's just so much that I think we're learning. 

But I think, going back to that overall question, we do have structural and resource barriers that have really prevented us from attaining a more equitable system. The pandemic has really brought to life the inequities across the system, and even more front and center. I think that there is a need, and a growing desire, to address those. One of the things that I think is really important in our progress towards addressing them is representation. I do think we need more representation at the decision-making tables. Because we know that no single health professional, no single person that has a finance background or a policy background have the holistic view or the entire lens of what the problems are. So I think there needs to be a more conscious focus on considering what voice we have not heard from. That will be critical in the success of our work. Ultimately, that creates more buy-in, that creates more consistent messaging, and that creates more trust in the system and the process.

I think what we saw throughout the pandemic was trust ebbing and flowing because we were getting different messages, and it was being shared in different ways. Even within the healthcare community, it was almost that perfect storm of all of these factors converging at once. As we look forward, I hope that our leaders may continue to think through what voice isn't here, what perspective isn't here, to really make sure our decision is the best for the community we're trying to serve.

JANNAH AMIEL: Very good. Not related to COVID, but in that same vein, as you're talking about representation and being present, you've alluded a lot to nurses being uniquely positioned to meet different needs and to share ideas and solutions. Aside from health care, would you encourage nurses to join boards that are not healthcare related, but can represent the community from a different perspective? Is that helpful in leadership and developing those skills?

SUZANNE MIYAMOTO: Absolutely. I couldn't agree more, because I think one of the really important perspectives is it takes a full team. It's so many voices, and nurses have the expertise, beyond their clinical day-to-day, or their work day-to-day, and more and more, we see the board is looking for those diverse perspectives and those diverse lenses. While there are still some traditional seats that help make the board move and run, it is important to think about how we can incorporate them. So absolutely.

I will say, I went to school to become a nurse, and yet I was seeking out opportunities that are outside of healthcare because I think we're all enriched with hearing, learning from others. I've spent the majority of my career working in policy. If I hadn't learned from individuals that were lobbyists, that were analysts, that were members of Congress and their staff -- more importantly, their staff -- I wouldn't have had as much of a successful career. So, bringing collaboration and partnerships is so important. Learning how to take that passion you have and message that into the community in a way that will resonate. I don't necessarily have that expertise as a nurse, but somebody else will. So, building those teams for impact brings all voices to the table.

JANNAH AMIEL: That's fantastic, and such a good point there. I feel like all knowledge that we can get from others—we talked about interdisciplinary and multidisciplinary, but even outside of healthcare—it's invaluable. That's a fantastic point. 

So, we're a teaching company, and we love to fill knowledge gaps. I'm curious if there's any topic that you'd like to educate us on that you think that everyone ought to know?

SUZANNE MIYAMOTO: That is a really great question. One of the things, as you know, about our profession, is it is incredibly enriching and flexible. There are so many opportunities for individuals to move down. I think that one of the things that we've seen over the course of the pandemic is really the importance of individuals that have seen what this disease has brought, how has it impacted communities and has impacted families. But going back to that piece that I mentioned earlier about public health: public health is such a core critical function within our country and around the globe. I think we need to hear more about that infrastructure and how we deploy our efforts. I think about Rear Admiral Susan Orsega, who is the acting surgeon general. Hearing her lens on what it has been like -- and she's been deployed for Ebola in Africa, and has worked through some of the natural disasters -- so how we take that additional lens of the public health and policy infrastructure would be, I think, really exciting for people to learn more about and understand why they're in uniform, and where their work lands.

JANNAH AMIEL: I agree with that; that would be fantastic. I think we're going to have to bring that back to the team. Now, for any nursing students -- or even a registered nurse who's practicing right now and listening to this podcast -- who are thinking about utilizing their voice to implement some type of change, but at this moment they're thinking, "No, no, no, I can't do it, this is not going to matter. This is not my role." What would you say to them?

SUZANNE MIYAMOTO: Why not? If not now, why not? I reflect on my 22-year-old self-thinking, how did I just decide, “I'm going to move out to Washington, DC.” A couple of years later, I literally packed up a U-Haul out to Washington, DC and started working, and just said, “I'm gonna find a job. I don't care how long it takes; I'm going to find a job.” 

There were a lot of barriers and challenges to that process, but if not now, when? I think as we go through this process, we just need to give ourselves that confidence and that encouragement. We have a staff meeting each week and we bring quotes for inspiration to the team meeting. The one from last week that I think helps in this moment is: we are all leaders in our own right, in our own way, and we have to find our own confidence in our own voice and our own stride. Oftentimes we think to ourselves, “Well, I haven't reached that piece or that pinnacle, and I haven't received this credential yet.” We think about how we can find mentors that help us get beyond those preconceived notions we have for ourselves.

It's not just the stereotypes others may have of us, but the stereotypes we have of ourselves that can be barriers. I don't have the exact quote on that, but it was Representative Shirley Chisholm who talked about recognizing not only those stereotypes of others, but those of ourselves. But the one quote that resonated -- as I think about looking for mentors and looking for individuals - was from Maya Angelou. She said, basically, “I've learned that people forget what you said, people forget what you did, but people will never forget how you made them feel.”

I've had so many great mentors. I know that those leaders made me feel that I could take on the biggest challenge and drive for change. I think you have to surround yourself with people that say, “Go do it. Open your lens, open your voice.” Those individuals are the ones that are truly authentic and compassionate. They give grace, and they're intelligent. In this day and age where we have so many barriers pressing down on us, find the people that give you that light and bring it back to the world. 

JANNAH AMIEL: That was beautifully said. I am feeling more energized about nursing than I did when I woke up this morning. That was fantastic and I absolutely agree with that. Thank you so much, Suzanne, for being with us today. This was great.

SUZANNE MIYAMOTO: It was my pleasure and thank you for your time. I wish you the best of luck in your career. Please keep mentoring those students to be authentic and find their life.

JANNAH AMIEL: Absolutely. We need them. Thank you so much. I'm Jannah Amiel. Thanks for checking out today's show. Remember to do your part to flatten the curve and raise the line. We're all in this together.