During one of my first clinical rotations as a nursing student, a “well-meaning” clinical instructor demonstrated the fundamentals of wound care at the bedside of a patient. As I began to mirror her, my white instructor jokingly called out, “Work, slave, work!” Despite feeling attacked, I did not stop caring for the patient, nor did I respond to the comment. When I relayed this experience to faculty at my nursing program, they asked if I thought the instructor's intention was to be racist. This anecdote illustrates what I believe is a fundamental misunderstanding about racism that not only permeates nursing education, but subsequently undermines our discipline's ability to engage in efforts to dismantle it.
I became a nurse because I am a Black woman. Witnessing the poor health and premature deaths of those in my community drew me to nursing because of its long history of attention to patient welfare and participation in public health initiatives (Thurman & Pfitzinger-Lippe, 2017). Unfortunately, through my educational experience, I realized that my Black identity was something I needed to leave at the classroom door, an “exchange” for my nursing education. This experience, and similar microaggressions, prompted my examination of the current state of racial justice content in nursing education. I have sought to identify gaps in racial justice education, determine promising approaches for addressing these gaps, and ultimately develop a list of recommendations for nursing education programs.
The identifier “Black” has been intentionally capitalized throughout this article to denote respect in referring to “a people, a race, a tribe” (Tharps, 2014, p. 1), a point that Lori L. Tharps, assistant professor of journalism at Temple University elaborates on in her New York Times article The Case for Black With a Capital B (Tharps, 2014). The use of black and Black is also helpful in distinguishing between color and race (Yin, 2017). Additionally, white is not capitalized due to the white majority not evolving under the same identity struggles of those racialized as Black, and due to a fundamental difference in how most white or Black people self-identify (Perlman, 2015).
Racism has an ever-evolving definition, and far-reaching implications. The World Health Organization (WHO) has named racism as a social determinant of health (WHO, 2010). Although people of any race can exhibit racial prejudice, in the United States, white people have the institutional power (Williams & Sternthal, 2010). This leads us to understand racism as “organized systems within societies that cause avoidable and unfair inequalities in power, resources, capacities and opportunities across racial or ethnic groups” (Paradies et al., 2015, p. 2).
There is mounting evidence of the negative health effects of racism. Studies have linked racism to higher mortality rates, earlier onset of more severe and progressive diseases, and higher levels of comorbidity and impairment (Williams & Mohammed, 2013). The COVID-19 pandemic has further illuminated these inequities. Additionally, the public attention to the police murders of George Floyd, Breonna Taylor, and Elijah McClain, among others, has shed light on how deadly it is to be racialized Black in America. Conversely, being socially identified as white has significant advantages. Jones et al. (2008) found that “being classified by others as white is associated with large and statistically significant advantages in health status, no matter how one self-identifies” (p. 496). Furthermore, research shows that economic resources and psychological assets better protect whites than Blacks. Whites benefit from unequal health gains compared with Blacks in the United States, even when equal resources are provided (Assari, 2018). Significant evidence shows that when controlling for other social determinants of health (i.e. income, education), racialized health inequities persist (Williams & Mohammed, 2013). Noonan et al. (2016) conducted a nationwide literature and statistical review of African American health that confirms that African Americans remain the least healthy ethnic group in the United States and highlight racism as a major contributing factor (Noonan et al., 2016).
Jones (Kumanyika & Jones, 2015), a leader from the field of public health, offers a promising set of guidelines that are relevant to nursing education reform by broadening the national discussion to one that acknowledges how racism affects the health of individual patients and the overall well-being of the United States. She distinguishes social determinants of health (i.e., poverty) and social determinants of equity (i.e., racism) and charges those in health care with three tasks: (a) put racism on the agenda by explicitly naming it as a force behind social determinants of health; (b) specifically discuss how racism is operating within our structures, policies, practices, norms, and values; and (c) strategize and act with community organizations to address the structural factors that shape the unequal conditions of people's lives (Kumanyika & Jones, 2015). Jones provides a starting point for critiquing nursing curricula and an approach for enacting structural change rather than continuing to teach racism as a personally mediated issue.
Nurses are on the frontlines of health care. To adequately prepare them to advance the fight against racial inequities and to care for patients whose health is negatively affected by racism, educational institutions must incorporate relevant content. Chinn (2020a) highlights that although nursing recognizes some of the inequities faced by people of color, it largely treats cultures of color as “other” or “interesting curiosities,” rather than acknowledging the prevalent dynamic of white privilege as a driving force for these inequities in health outcomes. In line with its espoused values, the nursing profession has a moral and ethical responsibility to help eliminate these health inequities. A structural shift in nursing education is needed that goes beyond simply acknowledging differences in outcomes by race.
At the University of Washington School of Nursing, the Sociopolitical Climate Project was designed to change the status quo of whiteness in nursing education through an antiracist pedagogical approach. They assert that addressing a climate of white privilege in institutions presents a specific challenge for nursing due to the strong identity of a caring profession that perpetuates color blindness and makes it difficult for nurses to come to terms with their role in oppression. The authors discuss creating training for faculty and staff to examine how unaddressed norms and practices contribute to the racist climate. Several action plans included creating and publishing a climate project website, including readings and activities, disseminating a monthly schoolwide email on the Diversity Committee meetings that included a journal article related to antiracism and social justice, and instituting an online graduate-level course on antiracism called Privilege, Oppression, and Social Justice in Health Care. The authors underscore how slow-moving and difficult changing the sociopolitical climate can be and wrote, “Such change can and does occur, but requires institutional commitment, innovative leadership, patience, long-term strategies, short-term actions, and strong administrative support” (Schroeder & DiAngelo, 2010, p. 250).
Although some nursing education programs have incorporated content related to racial justice into curricula, this has mostly been in silos across the United States and, so far, is not a standard expectation within nursing education. There is a pressing need for nursing education to address glaring racialized health inequities in the United States in a much more systematic manner. I offer the following recommendations to accomplish this.
Adopt an Explicitly Anti-Racist Position
The ideologies and culture of racism, oppression, and eurocentrism that permeate all institutions of education must be explicitly named and deftly addressed. Understanding cultural differences alone is insufficient to address the ways in which people are kept structurally unhealthy (Allen et al., 2013). It is crucial to move away from whiteness being viewed as invisible or neutral and openly discuss it as an identifier associated with unearned privileges and unaddressed racism. Being both explicit and action oriented in our intentions is necessary for changing the culture in nursing education. All nursing programs should review their diversity statements and evaluate both their programs' stated commitment to anti-racism work, and the actual work being implemented.
The complexities of racism in health care cannot be addressed by just one faculty member or one student group. Additionally, this educational endeavor should not fall solely on faculty of color. Bosher and Pharris (2009) framed dismantling racism as an essential nursing intervention for health, one that white educators must engage in. Requiring participation in anti-racist training for all levels of faculty and staff signals a schoolwide commitment to anti-racist education. Implementing specific grants to incentivize anti-racism and equity work, and creating equity leadership awards are both ways to show a commitment to anti-racism and to the faculty who are invested in doing the work (Effland, 2017). Perhaps most importantly, academia must not expect Black and Brown faculty and students to conduct free labor to progress our profession. Often the burden of racial justice work falls onto those who suffer the most from racism and consequently feel most compelled to act. This work goes largely unpaid and underappreciated.
Mandating a yearly anti-racism training for all faculty can create a common language and foundation for educators to build upon. After feedback from students in a Power and Privilege course, Gordon et al. (2016) decided to implement an 11-week adapted course for faculty. All white faculty were encouraged to attend, and faculty of color were invited to review the syllabus, give feedback, or audit the course, which was offered twice per year (Gordon et al., 2016). A mandated yearly course, with an optional secondary course, would ensure all faculty have a base knowledge of anti-racism praxis while giving further learning opportunities to those with specialized interests.
Institute a Power and Privilege Course for All Incoming Students
The Power and Privilege course implemented in one midwifery program (Gordon et al., 2016) is a tested model that could be adapted for other nursing programs. Although it is a hybrid course, taking place both online and in-class, Wear et al. (2017) have suggested that the course conversations are best held in-person in small groups. Depending on a nursing school's educational delivery mode, either format would be reasonable. Gordon et al. (2016) recommends starting the course with establishing a common language and specific community agreements that all participants comprehend. Three components of their course should be standardized across nursing education: (a) a strong foundation in what racism is and its history in the United States; (b) integration of current events where racism is dynamic; and (c) use of journaling as a reflective and core practice (Gordon et al., 2016).
Implement Intersectionality as a Core Competency
To holistically treat patients from historically oppressed groups, we must understand the idea of interlocking systems of power and oppression (Crenshaw, 1989). Intersectionality was born from Black feminism to critique the tendency of social justice movements to separate out targets of oppression, such as gender and race, leaving out Black women. It offers an approach to teaching nursing students about racism and oppression that goes beyond the notion of cultural competence. The current Black maternal health crisis provides an exemplar for integrating the theory and practice of intersectionality into nursing curricula by offering a framework for nursing students to recognize the many intersecting identities and the realities of a pregnant or parenting Black woman. Employing a “one-size-fits-all” model rather than addressing the specific and intersecting needs of women during prenatal care does a disservice to the health and well-being of both mother and child (Gennaro, 2016). Given the expansiveness of intersectionality, it can be applied throughout any class, including, but not limited to, Maternal–Child Health.
Instituting nursing curricula that integrate an understanding of racism and its effects on health, offers a promising upstream intervention for the negative health care interactions many Black people experience. Making these changes at the educational level engages future nurses at a time when they are eager to learn. For example, critical antidiscrimination pedagogy, which is rooted in intersectionality, could be used to teach about diabetes in nursing education. Although diabetes is often cited as disproportionately affecting Black patients, there is little discussion of why or what to do about it. If nurse educators used critical antidiscrimination pedagogy when teaching about diabetes, they would draw attention to the role of poverty and racial discrimination in diabetes etiology. This could then inform class discussion on power dynamics that includes how income, racism, and gender inequities affect food security and access to health care, which have a well-documented impact on diabetes management and outcomes (Spanakis & Golden, 2013). Furthermore, these connections expose the legacy of colonization and the growing evidence about the role of epigenetics in the epidemic of diabetes among Indigenous people. Armed with such intersectional understanding alongside more traditional curriculum on diabetes care, nursing students would be better equipped to successfully manage those at greatest risk for diabetes: Black and Indigenous people (Spanakis & Golden, 2013).
Foster Community-Academic Partnership
Engaging with community activists and those directly affected by racialized health inequities is crucial. Lu et al. (2010) propose a 12-point plan to address the Black–white gap in birth outcomes. Although four of their points address the needs of the individual Black woman, their remaining eight points move beyond the individual level and address community systems and social and economic inequities that affect the health of the mother. To address the Black–white gap or other health inequities, Lu et al. (2010) make clear that we must partner with stakeholders in communities of color. Building relationships with communities of color creates opportunities for nursing students, through potential clinical placements to get authentic exposure to cultures within which they may be unfamiliar. This not only creates a richer clinical experience and better equips health care providers to manage racial inequities, but it can also help in building trust that is greatly needed between nursing and marginalized communities (Lu et al., 2010).
Utilize Transdisciplinary Resources
Nursing should not simply look to medical academia to address racial health inequities but also to those who have been doing racial justice work to draw on their collective wisdom. Some examples of promising transdisciplinary resources are Medical Apartheid (Washington, 2006), which provides an important historical context for the complex relationships between Black people and the health care system, and Killing the Black Body (Roberts, 1997), which helps expand understanding of the intersections between health and racism. Additionally, documentaries such as I Am Not Your Negro (Peck & Baldwin, 2017) and Whose Streets? (Folayan & Davis, 2017) can provide students with insight into movements they can join with and learn from.
Using Black maternal health as an example, a curriculum could include cross-disciplinary resources such as the books Radical Reproductive Justice and Battling Over Birth (Oparah et al., 2018), as well as content generated by Black-run organizations such as the Black Mamas Matter Alliance and Sister-Song.
Robin DiAngelo's best-selling book, White Fragility (2018), demonstrates that more white people are attempting to engage with the racial justice movement and beginning to grapple with their own identities. Although this book provides some with a relatable entry into anti-racism work, it is critical to uplift books written specifically by Black authors. Doing so helps readers have an authentic view of race in America and shift from the standard white gaze on Black experiences. Chinn (2020b) called for those in the nursing profession to “find, read and cite nursing literature authored by nurses of color. Learn the names of these authors and seek out their work. If you teach, make sure you include this literature in your syllabi” (para. 8). I would expand on this critical direction to include literature from disciplines outside of nursing authored specifically by Black authors. It is vital we incorporate knowledge from all disciplines to expand nursing's understanding and engagement in the fight to dismantle white supremacy and create a just society.
Nursing fulfills a unique role within our health care system and has both the opportunity and responsibility to contribute to dismantling racial inequities in health. To prepare graduates to address the challenges of an inequitable health care system, an understanding of racism must permeate nursing education programs and not be confined to a specific course or faculty member. There are no quick fixes to health inequities; they are rooted in racism and discrimination that has been woven into the fabric of American society. However, by exposing nursing students to the pedagogical approaches identified, as well as implementing the outlined recommendations, nursing institutions can prepare the future workforce to be change agents. As freedom fighter and scholar Angela Davis reminded us, “In a racist society it is not enough to be nonracist—we must be anti-racist” (Murphy, 2018, para. 1).
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