Nursing is in a strong position to serve as an instrument for the protection of humanity and social justice. Several nursing organizations, including the National Hartford Center of Gerontological Nursing Excellence, American Nurses Association (ANA), and the American Academy of Nursing, have issued recent formal statements denouncing systemic racism to ensure that all Americans, but specifically African Americans, receive equal treatment. Yet, few, if any, prominent gerontological nursing voices have addressed these issues specifically in diverse older adult populations to date.
Our commitment is and should be greater now than ever before. The intersecting social justice issues of COVID-19 and racially motivated killings in the African American community by police and others call for nothing less; together, these form a new set of intersecting health problems or a syndemic. Alarming evidence is emerging that African American older adults with comorbidities are hospitalized with COVID-19 at a rate 4.5 times higher, resulting in higher mortality, compared to non-Hispanic White older adults (Carnethon et al., 2017; Centers for Disease Control and Prevention, 2020), while acts of racism have become more visible in the current daily fabric of the United States (Serchen et al., 2020). Therefore, we first call attention to critical concepts underlying COVID-19 and racism in African American older adults and then issue a call to action to gerontological nurses to address this pernicious intersectionality with culturally relevant ways of caring for African American older adults during tumultuous times.
Intersectional Factors Driving Racial Disparities
Intersectionality posits that people and their health outcomes are not reduced to a single factor but that many contextual and reciprocal factors contribute to their identity and health (Collins, 2015). African American older adults have endured a lifetime of layered effects of racism, colorism, ageism, classism, and sexism—internal stressors that compound existing health and chronic illness.
Social (In)Justice and Health
The ANA (2015) Code of Ethics explicitly states that it is the responsibility of nurses to enforce social justice for the protection of human rights of the vulnerable, older population, homeless, and stigmatized groups. Social justice principles assert that everyone deserves fair and equitable opportunities and treatment through the just distribution of products, services, and resources within a societal context (Valderama-Wallace, 2017). However, “othering” perpetuates the view of “us” versus “them” and results in one group being treated differently, unjustly, or as inferior to another group. To enact the ANA's principle, nurses must take an in-depth look at the intersection of history, human rights, and dignity in health. Civil rights leader, the late Reverend Dr. Martin Luther King Jr. (1966) recognized that “of all the forms of inequality, injustice in health care is the most shocking and inhuman because it often results in physical death.” Nurses are ideally situated to apply a rights-based approach to health justice for African American older adults; the right to timely COVID-19 testing, fair triaging, treatment, and most importantly, a right to life!
Social Determinants of Health
In his recent book, Coates (2015), a noted African American intellectual states, “Never forget that we were enslaved in this country longer than we have been free” (p. 70). This sobering statement calls for us to pause and consider how the unconscionable harms of slavery, Jim Crow, and current acts of police brutality have fueled oppressive conditions and adversely impacted the health of Black communities over time. Despite 155 years since the Emancipation Proclamation, many African American individuals remain in endemic conditions of chronic despair: the inequities of health care, multiple chronic illnesses, socioeconomic disadvantage, educational inequity, stress, overt and covert racism, and increasing racial violence. Lack of equitable resources in the community range from access to care to institutional policies to financial security. Social determinants of health in nursing currently tend to be atomistic in that they consider one or more factors as adding risk for poor patient outcomes. However, using intersectionality in nursing as a lens to view our patients provides a more holistic and comprehensive way of understanding protective and mal-adaptive factors that lead to health outcome disparities. In light of these multiple intersecting risk factors, our question is: “How can older African American individuals hope to fight off COVID-19 when they live in a perpetual state of trauma and are already fighting for their daily survival?”
The African American Village
Historically, the African American “Village” refers to a tight-knit community of familial and non-familial people with shared values, resources, and spiritual connection based on a shared history (Brisbane et al., 2010). The “high touch, high contact” social structures of the African American community have assured the community's survival during slavery and Jim Crow. However, at the present time, this supportive social fabric is weakening under the toxic storm of mortality and illness of African American older adults from the COVID-19 pandemic and racial killings at the hands of the police and others. To understand the emerging pattern of increased racial inequality due to post-COVID-19 effects on the African American community, we must examine the existing relative burden of social vulnerability in our neighborhoods.
The African American community includes survival structures, such as the African American family and church. COVID-19 exposure is increased within both structures, changing these structures from sources of survival to sources of contagion. A large proportion of African American individuals live in close, crowded communities and multigenerational households. An infectious agent such as COVID-19 spreads quickly in this setting due to proximity, necessitating a multifactorial approach to prevention. COVID-19 and racism are viewed not merely as external pathologies but also intensely internalized spiritual issues in the African American community. Thus, the African American church in the community, which is a historic refuge and present-day shelter from racism, mainly as a source of strength and faith-building, has become a source of COVID-19 contagion for African American older adults, resulting in mental health issues and “testing of their faith.” Although the “village” has been a community strength for many African American generations, the increased mortality rates and changing socio-cultural dynamics add to these foundational cracks. COVID-19 statistics are staggering and focusing merely on the number of documented positive cases and mortality rates runs the risk of seriously neglecting the aforementioned risk factors that can be addressed to slow the rate of infection in older ethnic minorities.
A Call to Action
Given the intersection of social injustice, social determinants of health, and the fraying social fabric in the African American community, now is the time for nurses to turn the tide on oppressive rhetoric and health disparities and flatten the inequities curve. More than ever, during the “2020 Year of the Nurse and Midwife,” nurses need to unite and honor the legacies of nursing pioneers, Florence Nightingale and Mary Seacole, to ensure that the care of “Black and Brown” older adults is a priority. Common fears among African American individuals are that providers are allowing African American patients to die, the government introduced COVID-19 into the African American community, and the potential vaccine will cause sickness. These fears are a result of years of systemic mistrust and mistreatment. Nurses must act as advocates to ensure specific vulnerable communities have access to medications, medical supplies, healthy foods, and social contact.
Table 1 provides several culturally salient recommendations for nurses to use when working with African American older adults. Application of these select recommendations may help stem implicit and explicit bias in personal interactions between patients of color and their health care providers.
Recommendations for Practice
Where do we go from here? Hopefully not back to “normal,” in which we were failing this at-risk group of older adults who remain at the margins of a democratic society built upon the principle that all men are created equal. Nurses must contribute to the creation of a “new normal” in which African American older adults will not receive health care based on the color of their skin but based on their standing as fellow human beings. Now is the time to right the wrongs of the past and achieve that “more perfect union.”
Staja Booker, PhD, RN
The University of Florida
College of Nursing
Department of Biobehavioral Nursing Science
Lakeshia Cousin, PhD, APRN
Applied Postdoctoral Fellow
Division of Population Science
Health Outcomes & Behavior
Moffitt Cancer Center
Harleah G. Buck, PhD, RN, FPCN, FAHA,
Coordinator of Chronic Illness Initiatives
University of South Florida
College of Nursing
- American Nurses Association. (2015). Code of ethics for nurses with interpretive statements (2nd ed.).
- Brisbane, F., Epstein, L., Pacheco, G. & Quinlan, J. (2010). Cultural competence for health care professionals working with African-American communities: Theory and practice. United States Department of Health & Human Services.
- Carnethon, M. R., Pu, J., Howard, G., Albert, M. A., Anderson, C. A., Bertoni, A. G., Mujahid, M. S., Palaniappan, L., Taylor, H. A. Jr.. & Willis, M. (2017). Cardiovascular health in African Americans: A scientific statement from the American Heart Association. Circulation, 136(21), e393–e423 doi:10.1161/CIR.0000000000000534 [CrossRef]
- Centers for Disease Control and Prevention. (2020). Coronavirus disease 2019 (COVID-19) - Cases, data & surveillance. https://www.cdc.gov/coronavirus/2019-ncov/covid-data/data-visualization.htm
- Coates, T. A. (2015). Between the world and me. Spiegel and Grau.
- Collins, P. H. (2015). Intersectionality's definitional dilemmas. Annual Review of Sociology, 41, 1–20 doi:10.1146/annurevsoc-073014-112142 [CrossRef]
- King, M. L. Jr.. (1966, March25). Presentation at the Second National Convention of the Medical Committee for Human Rights, Chicago, Illinois.
- Serchen, J., Doherty, R., Atiq, O. & Hilden, D. (2020). Racism and health in the United States: A policy statement from the American College of Physicians. Annals of Internal Medicine. Advance online publication. doi:10.7326/M20-4195 [CrossRef]
- Valderama-Wallace, C. P. (2017). Critical discourse analysis of social justice in nursing's foundational documents. Public Health Nursing, 34(4), 363–369 doi:10.1111/phn.12327 [CrossRef]
Recommendations for Practice
|Expand contact tracing questions beyond the family to church or social gatherings (e.g., When was the last time you've been to church? Did you interact closely with anyone who appeared sick?).||Discredit patients' symptoms and reports of changes in health status. Take seriously their concerns of “high fevers,” “not feeling well,” and “I can't breathe.”|
|Stress physical distancing rather than social distancing. Encourage social interactions and gatherings by phone, web conference, drive-by celebrations, and letters/cards.||Limit care based on race, socioeconomic status, older age, and cognitive status. Provide evidence-based nursing care equally to all patients.|
|Eradicate common misconceptions of contracting COVID-19 through evidence-based education. Ask older adults what they know about transmission routes, listen respectfully and then provide information that might be missing or dispel any misinformation.||Assume that culturally concordant patient assignments promote equality. Rather, it perpetuates systems of “separate but equal” with nursing patient assignments.|
|Gather more culturally tailored information in a history and physical. Identify and understand the cultural and socioeconomic barriers that are unique to African American individuals. Also identify what their biggest concern is, answer it, create an effective plan around this topic, and share additional Centers for Disease Control and Prevention guidance.||Ignore the importance of emotional intelligence and caring competence in the nursing profession.|
|Conduct regular mental health checks. The chronic stress of dealing with generational trauma, rapid deaths, racism, violence, discrimination, and injustice can negatively impact mental and cognitive health. Depression, suicide, and substance use may be prompted by a tsunami of adverse life events.||Disrespect older Black American individuals by referring to them with nicknames or other derogatory terms such as “sweetie,” “honey,” or “girl/boy.” Refer to them as Mr./Ms. or Sir/Madam.|