Nursing Notes: Concordance on the Front Lines of Patient Care Delivery

Kenneth Peterson, PhD FNP-BC Jaya Rawla Everlyne Njoroge shown left to right

We are a unique group of nurses in the worcester community leading change and improving health and well-being for many patients. We are nurses, on the front lines of care delivery, modeling effective actions through our commitment and dedication to the values, beliefs, attitudes and behaviors supporting sociocultural, ethnic and racial diversity. In these tumultuous times, where serious health threats and poor outcomes for minoritized and marginalized people in our communities continue to escalate, we need to call attention to essential provider qualities likely to mitigate the inequities of unequal care. In this short piece, we share our thoughts on what we believe matters most in the provider-patient relationship.

On Concordance

Patients deserve respect, dignity, peace of mind and improved health when they participate in health care. Unfortunately, health disparities reveal this isn’t always the case. How we behave and what we do to relate to and engage our patients is key to successful encounters and outcomes of care. These actions are especially important in situations where concordance in the provider-patient relationship is not possible. Concordance – matching gender, race or ethnicity and other patient characteristics to that of the provider – is a popular practice improvement strategy. [1,2] It became popular following the 2003 release of the Institute of Medicine’s report “Unequal Care.” Unfortunately, achieving concordance remains a challenge given the limited sociocultural, racial and ethnic diversity of care providers in the health care workforce. Despite challenges in achieving concordance, we believe that providers can improve in their behaviors and actions supporting respectful, equitable and health-producing care. This improvement process first begins with becoming aware of the unique identities of our patients and ourselves and second from appreciating the learning that results from valuing difference.

On Identity and Difference

Identity is an evolving amalgamation of demographics, beliefs and lived experiences in the context of a broader sociocultural landscape. Identity is multidimensional; it can be fluid and invisible. The complexity of identity has profound implications on the provider-patient relationship. We, and nursing colleagues, as members of minoritized racial, ethnic and sociocultural groups recognize racial, ethnic, linguistic and/ or sociocultural concordance with patients as important factors in building trust, creating patient buy-in and setting up the potential for implementation of effective relationships to improve health and well-being.

In the United States, the context of identity is often one where those with dominant identities hold disproportionate power, often at the expense of those with minoritized identities. Matching every aspect of identity is improbable, if not impossible. Concordance of some aspects of identity is not always possible. Consequently, the provider-patient relationship is not simply informed by a mere matching of identity. We, other colleagues and our patients, having lived experiences of being minoritized and marginalized, value interactions that are collaborative, respectful, nonjudgmental and emanate from an awareness of the effects of bias, discrimination and racism on health.

On Visibility and Trust

We know that marginalized and minoritized groups have a need to build trusting relationships with their health care team due to the historical injustices that have plagued their interaction with health care institutions. Our experiences suggest a concordant provider-patient dyad may eliminate the anxiety that arises from fear of being misunderstood or judged, which in turn facilitates fuller discussions of health problems and treatment decisions. The perception of similarity can lead to higher levels of trust and rapport. Equally, once trust has been established, patients are more likely to follow recommendations, be adherent to medications and increase health care utilization.

The evidence suggests that there is no statistically significant benefit of sex/gender or race/ethnicity concordance. (1,2) However, there is consensus that distrust between patients and their health care teams will further increase the existing gender and racial disparities in health care. Provider-patient concordance might be important in helping patients to understand and navigate the health care system which empowers the patient and allows them to become active participants in their care. It is not feasible to achieve concordance 100% of the time. However, providers who have developed qualities such as cultural competency, language competency and a general understanding of patient beliefs, values, preferences and roles have greater potential to make the health care system less threatening to marginalized and minoritized patients.

On Leadership and Change

Our experiences on the front lines of care delivery suggest to us that skills and abilities leaders use to influence others can evolve from the relationships we have with patients. Benefits are gained from concordant and non-concordant relationships alike. When we are open to the learning that occurs in our interactions with others, we engage and enhance our social and emotional intelligence. This allows us to see others as they are through respectful relations and trust-building actions. When we all value the differences among us, health care delivery will change. +

References

(1) Jerant, A., Bertakis, K., Fenton, J., Tancredi, D., Franks, P. Patient-provider sex and race/ethnicity concordance: A national study of healthcare and outcomes. Med Care 49 (2011): 1012-20.

(2) Hsueh, L., Hirsh, A., Maupome, G., Stewart, J., Patient-provider language concordance and health outcomes: A systematic review, evidence map, and research agenda. Med Care Res Rev 78 (2021): 3-23.