2020 was a year of reckoning with racial injustice in the United States. Racial tensions soared over the spring and summer, after several Black men and women were killed by police, culminating in the murder in May of George Floyd in Minneapolis. Protests erupted across the country; fueled by decades of frustration and centuries of oppression, people of all backgrounds took to the streets to demand racial justice.
In August, AJN hosted a webinar, “Nursing's Role in Addressing Racism,” moderated by Kenya V. Beard, EdD, AGACNP-BC, CNE, ANEF, FAAN, dean of nursing and health sciences at Nassau Community College, chair of the American Academy of Nursing (AAN) Diversity and Inclusivity Committee, and AJN editorial board member, in which participants examined the role of racism in nursing and considered what nurses can do, individually and collectively, to address structural racism within the profession and move toward health equity and a more racially just society. “It's clear at this moment in time in America,” said panelist Ann Kurth, PhD, MPH, CNM, FAAN, dean and Linda Koch Lorimer Professor at the Yale University School of Nursing, that we “have to get our house in order.” To follow is an overview and report on this panel discussion. (You can view the webinar and earn Nursing Continuing Professional Development credit at http://bit.ly/3mpD642.)
THE LEGACY OF RACISM
Black nursing history has recorded the ways in which Black women were refused admission to the first nursing schools and membership in nascent nursing organizations. Yet, despite these barriers, by the late 1920s, there were 36 Black nursing schools in the country (though far short of the hundreds of Whites-only schools). Panelists recalled the barriers they encountered in their early days as nursing students.
‘We were “colored” then.’ Panelist Bernardine Lacey, EdD, RN, FAAN, founding dean of Western Michigan University's School of Nursing, recounted her time in the early 1960s at an integrated school of nursing, which “admitted a select number of what we were called then . . . eight ‘colored’ nurses in a class of 64 White nurses.” The Black students were relegated to the back of the classroom, weren't housed in the same dormitories as the White nurses or allowed to eat in the dining room and were denied amenities available to the White nurses. “I could not walk through the front door of the hospital,” said Lacey. “Even though I was going there to do my clinical experience, I had to go around to the back or the side to enter.” (To read more about Lacey's story, see “‘You Don't Have Any Business Being This Good’: An Oral History Interview with Bernardine Lacey,” August 2020.)
‘They wanted a real nurse.’ Panelist Virginia W. Adams, PhD, RN, FAAN, cochair of the AAN Diversity and Inclusivity Committee, recounted how, after the passage of the Civil Rights Act of 1964, “what was written in the laws at that time didn't automatically influence the attitudes and beliefs of the oppressors. The behaviors continued.” According to Adams, many hospitals ignored the new laws and continued to segregate based on race, using a “paper ruse to look like they were complying.” When Black hospitals had to close in accordance with the law, some of the nurses were hired by White hospitals, “but the positions they had held, the leadership positions, were not offered to them.” Adams recalled her experiences with integration as a nursing student. “In my senior year, we were actually part of the forced integration of the hospitals, and that was not a pleasant experience. We were not welcomed by the nurses, and sometimes the patients were hostile.” As a new nurse working in a veteran's hospital, she says, one patient refused her care, telling her he wanted a “real nurse” and introducing his friends by saying, “‘These are my buddies, and they're from the Ku Klux Klan.’”
Panelist Dayna Bowen Matthew, JD, PhD, dean and Harold H. Greene Professor of Law at the George Washington University Law School, observed that “structural racism is a system. It goes beyond the individual bias. . . . But it reflects those individual preferences, biases, and attitudes in a system of institutions that are organized by this thing we call race.” She described how structural racism leads to the organization of opportunity and value according to racial hierarchy. “This is not done necessarily explicitly anymore. But, historically, laws that segregated during the 1900s by housing . . . well, they organize our housing system even today.” She continued,
“Just look at the data that's coming out of the COVID-19 crisis. . . . You go on the CDC [Centers for Disease Control and Prevention] website, and . . . what you see is that Native Americans, African Americans, and Latinx Americans are experiencing morbidity and mortality by multiple times greater than White Americans. . . . Now, some people say that's because of underlying comorbidities, . . . [but it's] discrimination in housing, discrimination in education, discrimination in criminal justice—those structural inequalities are what are producing underlying comorbidities.”
Kurth highlighted recent findings from the Jackson Heart Study, indicating that racism—not race—is a predictor of poor health outcomes. The study, published in the September Hypertension, found that the chronic stress of lifetime discrimination doubled the risk of hypertension in African Americans, regardless of other risk factors.
Panelist Sheldon D. Fields, PhD, FNP-BC, AACRN, FNAP, FAANP, FAAN, first vice president of the National Black Nurses Association, noted that “nursing is 80% White, [and as such] structural racism is ever-present and playing out in the practice setting in many conscious and unconscious ways.” His statement is supported by multiple studies examining the experience of Black nurses and students in clinical and academic settings. Participants across studies consistently describe experiences of racism and discrimination, including feeling invisible and being passed over for promotions.
Adams recalled that when she was hiring Black faculty in her capacity as a dean, “There were faculty who actually shunned them, did not welcome them, and it was very clear they didn't want them to be there.”
ACHIEVING RACIAL EQUITY
Achieving racial equity in nursing and health care requires that the nursing profession represents and reflects the population it serves. Moving toward representative diversity in nursing starts with nursing education programs—increasing diversity in enrollment and ensuring all students achieve success. All the panelists stressed the need for the profession to examine how nursing education perpetuates structural racism, including in the curriculum, testing, and admission policies that create barriers to applicants and students from marginalized groups.
Kurth explained that this needs to happen on three levels: (1) the individual and school, (2) the health system, and (3) accrediting bodies:
“How are we doing holistic admissions? How is the curriculum really reflecting what racism is, or do we just talk about racialized groups? How do we achieve success and equity for the different backgrounds that students come into nursing schools with? . . . The remediation literature—how do we get all students to success in nursing schools—is surprisingly sparse, so I think we need more research in that space. . . . What's in NCLEX [National Council Licensure Examination]? . . . Are there racialized assumptions in the way some of the questions are framed?”
Reaching a more representative faculty body is an even greater challenge. Student diversity has steadily increased over the last decade, according to the American Association of Colleges of Nursing, which cites the proportion of diverse students to be about 30%; however, the proportion of diverse faculty lags behind, at only about 16%. Adams observed that White faculty are the gatekeepers. She called on them to examine how they conduct faculty searches and make hiring decisions and to provide Black faculty with the resources and support they need to be successful:
“One of the things that institutions have a habit of doing . . . when they get token Black faculty, is to load them up with a lot of service obligations, and White faculty don't have those same obligations. So, a part of that is to make sure the practices, the policies, your hiring practices . . . examine those. . . . Talk to [Black faculty members] about how to achieve tenure, invite them to [be a part of] your research projects. . . . But the most important thing is to just have the conversation about who they are, where they're coming from, and their history, to begin to have an understanding of what they're facing.”
Kurth added that it's important to look at promotion policies and tenure materials and faculty reviews. “Is antiracism embedded in what's rewarded for promotion and tenure?” she asked.
Increasing student and faculty diversity is critical, but that alone is not enough. As panel moderator Beard said, “We have to make sure we are graduating a group of students that are prepared to dismantle structural racism.” According to Kurth, that demands interrogating our own biases, paying attention to how racist heuristics are embedded in what is taught, and having clear antibias material in the curriculum through the doctoral level. This is not easy. Panelist Mary A. Maryland, PhD, ANP-BC, FAAN, an NP at Oak Street Health, emphasized the challenges of recognizing bias. “Being willing to ask the question: ‘Is this the way it's always done?’ Putting up your antennae, paying attention. . . . It involves some risk taking.”
Addressing structural racism is the responsibility of all nurses. Fields noted that nurses are called on to do so in the American Nurses Association's Code of Ethics for Nurses with Interpretive Statements, specifically in Provision 6, which, he says, “underscores how each individual nurse must be aware of their practice-setting environment, the cultural norms, and the practices that may be promoting structural racism.” He added that nursing must “use the power that it has to directly influence these issues of structural racism in all of its settings, because it has a direct [impact] on your work environment and the very quality of care that you deliver. To not address the issues is to act unethically, [which] violates our social contract with society.”—Karen Roush, PhD, RN, FNP-BC, news director