Secondary Logo

Beyond the Asterisks*

Alexander, G. Rumay

Nursing Education Perspectives: May/June 2019 - Volume 40 - Issue 3 - p 131
doi: 10.1097/01.NEP.0000000000000506
DEPARTMENTS: President’s Message

About the Author G. Rumay Alexander, EdD, RN, FAAN, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.

The author has declared no conflict of interest.



The continuation of signals ignored, decisions deferred, and changes postponed all create the future. So do the aggregate consequences of choices, actions, and actions deferred. The way we use our minds and the kinds of problems we solve shape the way we think. In fact, private decisions typically will be revealed publicly, and the consequences and every choice we make have a future. Nowhere is that more true than when institutions make fear-based decisions on when and how to use data. And we in the health care space are just as guilty.

The absence of data, or presence, reinforces invisibility, and where presence is hidden by ever-present asterisks and footnotes, individuals are further marginalized. Algorithms, which are not subjective (although they contain the biases of the creator), and statistics do not capture the effects that marginalization has on groups or even individuals. Many researchers espouse that invisibility is an intentional act involving an active “writing out” of the story of a particular group, often serving to maintain a status quo that benefits the dominant group. What might this look like? I’m so glad you asked. It looks like: exclusion from institutional data and reporting, omission from curricula, minimal presence or even absence from research and literature, and being virtually written out of the history/story. In particular, data on some members of humanity are generally not reported or discussed in quantitative research findings. Such data are deemed not statistically significant or do not register as “big” in big data, thus the deployment of the asterisk mentality. No single research method can fully capture the complex layers of bias that we all bring to the workplace, because we bring our biases with us.

The consequences are a serious lack of understanding of, dialogue on, and application of culturally appropriate solutions to many of the problems of the present that are inherent to our vastly diverse patients, workforce, and academic environments. Nursing education and practice in the United States happen within the social, cultural, and historical context of many forms of oppression, including institutionalized racism (Schroeder & DiAngelo, 2010). The science community prizes objectivity, but research indicates that objectivity is not necessarily reflected in the behaviors and choices of scientists. Implicit biases insinuate and situate themselves, inflicting hurt, harm, and destruction in the production of the best science, including questions asked and the research agendas set (Malcolm, 2015).

Like it or not, the present agenda of society promotes the ever-increasing gap between the haves and the have nots and fuels quests for legitimacy that are becoming more frequent and prevalent. All the places where we create community are under siege and attack. Committing to transform or improve the workplace and the “world place” will infuse hope and a sense of belonging. The counterattack is to work fiercely on moving beyond the asterisks, to accept the challenge to move beyond acknowledgement/rhetoric to ask questions, to engage in courageous dialogue, and to conduct culturally relevant research on issues that are not necessarily generically common but are seriously inclusive and experienced by members of our world.

Equity, justice, and excellence should never be pitted against one another. We must boldly explore huge existential threats, starting with the dynamics at play throughout our systems and the manner in which relegation can and often occurs. Once someone is dehumanized, everything else is possible. The further apart diversity and equity are, the less effective both will be in assaulting threats to human dignity. Tensions among diversity, equity, and excellence still exist. Rather than difference being a stimulus to learn, the emphasis and insistence on conformity has become an attractive distractor as we seek to create inclusive environments that support human flourishing as the end goal. Allport (1954) considered conformity an essential concept for understanding prejudice. It leads to norms, an insistence on fitting in rather than belonging, “the experiences of personal involvement in a system or environment so that persons feel they can do their best work because they can participate fully on the chances an organization offers to learn, create, to discover and to achieve.” This insistent persistence leads to what has been referred to as “psychological homelessness,” that is, “[feeling] out of place, on the edge of the circle, disconnected from the life-giving heartbeat of the community” (Cleveland, 2012).

Discriminatory norms are typically cumulative and therefore build and reinforce themselves, which explains their tenacity among generations. In other words, presence matters. There are no quota formulas or algorithms when it comes to diversity of presence. There must be enough demographic diversity in informal interactions to obtain diversity of perspective. Assumptions and beliefs undergird all interactions with others: patients, colleagues, leaders, and students. Many forms of discrimination and bias develop because positive emotions, such as admiration, shared race or ethnicity, or age, even birthdays, not to mention empathy and trust, are reserved for the in group (Greenwald & Pettigrew, 2014).

So, I make a request of you, nurse to nurse. As there are no quota formulas or algorithms when it comes to diversity of presence, consider what one thing are you willing to do to make our core value of diversity not an asterisk but a reality? Inquisitively,



Back to Top | Article Outline


Allport G. W. (1954). The nature of prejudice. Cambridge, MA: Addison-Wesley.
Cleveland C. (2012). Psychological homelessness in your church [Web log post]. Retrieved from
Greenwald A. G., & Pettigrew T. F. (2014). With malice toward none and charity for some ingroup favoritism enables discrimination. American Psychologist, 69(7), 669–684. doi: 10.1037/a003605
Malcolm S. M. (2015). Science, all inclusive [Editorial]. Science, 349(6249), 671. Retrieved from
Schroeder C., & DiAngelo R. (2010). Addressing whiteness in nursing education: The sociopolitical climate project at the University of Washington School of Nursing. Advances in Nursing Science, 33(3), 244–255.
© 2019 Lippincott Williams & Wilkins, Inc.