Discussing racial inequalities is challenging for nursing faculty and students of all races. Faculty report feeling inadequately prepared to systematically address this topic within clinical and classroom learning environments. This article reports student attitudes of race and health following a case study discussion of racial inequalities present in nursing and healthcare in Charleston, South Carolina between the years of 1883 to 2016. Forty-two students completed a 10-item visual analog scale (VAS) measuring their level of agreement regarding the issues of race and health before and after a classroom lecture. Most students reported an increase in racial tolerance following the lecture. A few students, however, indicated a decrease in racial tolerance following the lecture. Strategies for integrating the curriculum with learning experiences regarding issues of race are discussed.
Key Words: History of nursing, racism, race and nursing education, minority nursing students, minority nursing faculty, classroom strategies for teaching race, Critical Race Theory, social justice
Discrimination, bias, and prejudice on the part of healthcare providers influence caregiving and treatment decisions... Scholars define racism as the economic, political, social, and cultural structures, actions and beliefs that systematize and perpetuate an unequal distribution of privileges, resources, and power between white people and black people (Hilliard, 1992). The direction of this power and how it flows is historic, traditional, normalized, and deeply embedded in the fabric of the United States (Feagin, 2001). Discrimination, bias, and prejudice on the part of healthcare providers influence caregiving and treatment decisions and contribute to disparities in health status (Plough, 2010).
Financial resources impact access to healthcare. Poverty rates for white Americans are 11.6 percent and 25.8 percent for black Americans (Macartney, S., Bishaw, A., & Fontenot, K., 2013). Oppressive structures of higher unemployment, incarceration rates, and disenfranchisement, both intentional and unintentional, interact to maintain this level of disadvantage and poverty in the black community (Cole, 2016).
Professional nursing in the United States emerged in the late 19th century and reflected the deeply entrenched racism present during the time. Professional nursing in the United States emerged in the late 19th century and reflected the deeply entrenched racism present during the time. Racial quotas were present in northern U.S. nursing schools and black women were denied admission to nursing schools in the southern U.S. (Hine, 1989). Black physicians, often barred from practice privileges at local hospitals, collaborated with the black community and opened their own hospitals with schools of nursing to educate black women to provide nursing services (Johnson, 2008)
In 1906, the National Association of Colored Graduate Nurses was created to address the specific needs of the black nurse and to address timely issues such as racial segregation (Watts, 2003). In 1916, the American Nurses Association (ANA) required members to join via state nurses’ associations. At the time, most state nursing organizations denied membership to black nurses, effectively excluding them from this national professional organization (South Carolina Nurses Association Records, nd). Furthermore, many states prevented black nurses from taking the examination to become registered nurses (Andrews, 1929). In agencies who employed black and white nurses, black nurses were often paid considerably less than white nurses (Hine, 1982).
Present-day Nursing and Race Issues
Despite these historical facts, present-day nurses are often resistant to ideas that healthcare providers and/or organizations perpetuate oppressive racial and socioeconomic practices that contribute to health disparity and discrimination (Smedley & Smedley, 2005; Garno & Bennett, 2017; Haider et al., 2015). Nurses are educated to value patient individuality which sometimes fails to address ethnic identity and racial powerlessness (Cortis, 2003). Subsequently, the inherent race-based power differential becomes invisible because it excludes the individual relationship to the community at large and therefore excludes the individual’s relationship to his or her racial groups’ collective history (Cortis, 2003).
Black nurses report feeling professionally invisible and experience an unexplainable inability to advance Black nurses report feeling professionally invisible and experience an unexplainable inability to advance (Wilson, 2007). Increased attrition among black nurses and nursing students in hospitals and academic settings is costly for the affected individuals, organizations, and the profession (Brinkert, 2010). Fewer black nurses advance to leadership positions and become faculty with doctoral degrees. Thus, black nursing students complain of fewer role models during their course of study (Cortisman, 2008).
Complaints from Racial Minority Faculty
...many nursing faculty are uncomfortable discussing the issue of race and avoid the topic altogether A study on racial minority nurse faculty members reports that communication patterns by white nurses were perceived as racist (Robinson, 2013). Racial minority nurses report that their feedback was ignored during meetings, resulting in feelings of powerlessness in decision-making processes (Wilson, 2007) However, many nursing faculty are uncomfortable discussing the issue of race and avoid the topic altogether (Wilson, 2007). While about 40% of instructors reported that they had dealt effectively with bias that appeared in the classroom, an equal 40% said they felt completely unprepared to assist students to openly discuss issues of race and racism (Boysen, Vogel, Cope, & Hubbard, 2009). However, minority nurse faculty who seek to engage students in discourse about racial issues report experiencing ‘backlash’ or a strong, adverse response to the topic in their student course evaluations (Hassouneh, 2006). Classroom discussions about race may provoke powerful, often negative emotions, and create classroom conflicts. Discussing race in the classroom requires that faculty possess excellent communication skills and a high tolerance for conflict (Holland, 2015).
Complaints from Racial Minority Students
When discussing race-related experiences, black students reported white students would disagree, deny that race was involved, and/or find another explanation which denied black students’ experiences. Black students report that white students display non-verbal behaviors such as eye rolling, avoiding eye contact, and becoming quiet or shifting uncomfortably in their chairs when discussing race related issues in the classroom (Sue, Lin, Torino, Capodilupo, & Rivera, 2009). Students report unhelpful teacher responses, including: passively letting students control the dialogue, dismissing the topic as unimportant, changing the subject, and treating racial minority students as though they are experts on the topic of race (Hall & Fields, 2012).
Critical race theory is grounded in social justice... This research is grounded in Critical Race Theory (CRT), an emerging transdisciplinary, race-equity methodology which has its origins in legal studies (Ford & Airhihenbuwa 2010). CRT emphasis on the “ordinariness of racism makes it a logical backdrop for examining institutional as well as individual racism” (Hall & Fields, 2012, p. 26). Critical race theory is grounded in social justice and provides tools for research and practice that can clarify contemporary racial phenomena, and expand the vocabulary used to discuss racial concepts. CRT can be a paradigm for investigating racial bias and health disparities for nursing and healthcare (Ford & Airhihenbuwa, 2010).
Storytelling is fundamental to Critical Race Theory CRT draws on experiential knowledge and critical consciousness to examine the roots of structural racism. Through knowledge production, the theory helps researchers remain attentive to equity (Ford & Airhihenbuwa, 2010). Storytelling is fundamental to Critical Race Theory (Ackerman-Barger & Hummel, 2015; McCoy & Rodricks, 2015) and may serve as catalyst for conversation and change by allowing the “unseen and unknown” to become visible (Ackerman-Barger & Hummel, 2015, p.45). Students, faculty, and nurses have an ethical responsibility to question their biases to prevent them from wrongly influencing practice. Without current and meaningful dialogue about race in the nursing classroom, nurses cannot expect to impact healthcare disparities (Hall & Fields, 2012).
University IRB approval was obtained to survey pre and post student attitudes about race and health, surrounding a presentation of the historical perspective of race and health in Charleston, SC. In particular, the lecture contained the history of nursing in a continuous narrative from 1883-2016 to bring race issues into focus as it has evolved over the 20th century (see Table 1).
Table 1. Timeline of Nursing Education and Race in Charleston, SC
The Ladies Benevolent society in Charleston, SC is formed by elite white women to care for the sick, poor in their homes. They employ lay nurses to provide care (Bellows, 1993).
Opening of first nursing school in Charleston, SC for white women which becomes Medical College of South Carolina (MUSC) School of Nursing. (City Hospital Commissioners Minutes, 1882)
Opening of first nursing school for African American women by Alonzo McClellan at Cannon Street Hospital. He hires Anna DeCosta Banks an African American Charleston women, a graduate of Dixie Institute in Virginia. (Hoffius, 2017).
Ladies Benevolent Society hires Anna DeCosta Banks to make home visits and care for all Charlestonians in their home. She utilizes her students and they are especially important saving lives during epidemics of yellow fever (McGahan & Bustos-Nelson, 2013).
Anna DeCosta Banks becomes a Registered Nurse by jurisdiction of the SC Medical Society (Johnson, 2008).
Ladies Benevolent Society receives contract for home visits from Metropolitan Life Insurance Company. In 1929, Metropolitan Life pressures LBS to hire a white nurse to visit white policy holders. They refuse and the contract is withdrawn. (Buhler-Wilkerson, 2001).
Cannon Street hospital loses its license and school closes. African American students seek assistance from white nursing school at Roper Hospital where they attend and complete their education, utilizing faculty in the classroom and clinical experiences in the hospital to prepare for exams (Chamberlain, 1970).
Roper Hospital receives Duke Endowment grant to open School of Practical Nursing which accepts both White and African American students (Chamberlain, 1970).
The National Association of Colored Nursing Graduates merged with American Nurses Association into a racially integrated organization.
The South Carolina Nurses Association, after polling their members by mail, at the state convention, moved and passed a resolution to accept African American nurses as members (South Carolina Nurses Association [SCSNA] Records, nd).
Rosslee Douglas becomes the first African American nurse to graduate from previously all white nursing school at Medical College of South Carolina (Fox, 2010).
Rosslee Douglas awarded Doctorate of Humane Letters at Medical University of South Carolina for her work in federal funding of minority colleges and educational program development targeted toward minority students (Fox, 2010).
The presentation focused on the intersection of nursing with racial, socioeconomic, gender, and social justice issues during the end of Reconstruction, Jim Crow, World War II, and the Civil Rights movement to the present (see Table 2).
Table 2. Timeline of Legislation, Court Cases, Public Policy, and Race
Plessy vs. Ferguson - Supreme Court Case upheld separation of races in streetcars invoking “separate but equal” mandate. This case was used to justify segregation of educational programs and healthcare facilities. https://www.courtlistener.com/opinion/94508/plessy-v-ferguson/
Rockefeller Sanitary Commission was formed to eradicate hookworm, stating that poor health was a national defense concern, thus the rise of public health (Beardsley, 1990).
Charleston County Health Results was published reporting high incidence of malnutrition, anemia, hookworm, malaria, tuberculosis especially among rural Blacks. Charleston county reported highest infant mortality in the US 330 deaths/1000 live births (Banov, 1921; Banov, 1970).
Sheppard Towner Act provided funds for prenatal care in rural clinics. Public health nurses, both black and white, educated and regulated grannie midwives for in home births throughout South Carolina. Health statistics began to improve (Banov, 1970).
Bolton Nurse Training Act provided funds to educate nurses for WWII producing 124,000 including 3000 Black nurses and funding for historically black nursing schools. Employment for African American nurses improves in military facilities which are racially integrated (Thomas, 2011).
Hill Burton Act provides funds for building hospitals with the stipulation that facilities be racially integrated. Medical College of SC builds its hospital with Hill Burton funds. It is biracial but segregated with one wing on each floor for blacks and another wing on each floor for whites (Beardsley, 1990). The architecture traditionally was an H shape or a U shape.
In the Brown vs. Board of Education case the U.S. Supreme Court struck down “separate but equal “as violating equal protection clause of the 14th amendment. https://scholar.google.com/scholar_case?case=4811241395207655757&hl=en&as_sdt=6&as_vis=1&oi=scholarr
The Civil Rights Act of 1964 prohibited discrimination by race in public places, schools, and any public facilities, making employment discrimination by race illegal. https://www.eeoc.gov/laws/statutes/titlevii.cfm
Federal Government brings lawsuit against Roper Hospital in Charleston, SC for racial discrimination in admissions and employment practices (United States v. Medical Society of South Carolina, 298 F. Supp. 145 (D.S.C. 1969)).
Medical University hospital workers strike for racial discrimination and unequal pay. AFL-CIO in solidarity threatens to close seaport of Charleston with “slow-down” a labor tactic in which employees appear at work but work very slowly to significantly expand time required to off load a ship and therefore create chaos requiring ships to anchor in the harbor and wait to be off loaded, effectively closing the port. President Nixon intervenes. Hospital workers rehired and given significant increase in pay (Charleston Hospital Strike, 1971).
Following the tragic murder of 9 parishioners at Mother Emmanuel church in Charleston, the Board of Trustees of MUSC, in the spirit of racial reconciliation, made a public apology to the hospital workers of the 1969 strike for their ill treatment (Parker, 2015).
Student participation in this study was voluntary. Participating students were informed about confidentiality and anonymity and informed consent was obtained by the researchers. Forty-two students participated; 13 belonged to a racial-minority group while 29 belonged to a non-racial-minority group. Participants were asked to respond to each of the 10 statements using a VAS (Figure 1). Students completed the tool before and after the classroom learning experience. Tools were numbered in order to maintain anonymity and to allow for pre/post comparison. The Cronbach’s alpha for the summed variable was 0.74, which indicated the validity of the internal consistency of the survey instrument.
Figure 1. Survey Tool used Pre/Post Lecture
Do you identify as a minority student? Yes ______ No ______
Please draw a perpendicular hash mark wherever you assume yourself to be for each statement below.
Data Analysis and Results
Student VAS scales were analyzed using a clear template and a number was assigned to each vertical line placed across the horizontal line. A paired t-test was conducted to compare pre and post lecture total scores for all students, i.e. racial-minority group and non-racial-minority group). Significant differences in the total scores of the students before the lecture and after the lecture were found (p= 0.0048). The 95% Confidence interval for overall difference (pre-lecture scores – post-lecture scores) was (-53.62, -10.33). Thirty-one students reported total post-lecture scores that were higher than pre-lecture scores, 10 racial-minority students and 21 non-racial-minority students. The mean pre-lecture scores and post-lecture scores for these 31 students were 499.65 (SD=120.11) and 563.13 (SD=117.29) respectively. Ten students reported post-lecture scores (Mean of 372.40 with SD=169.03) which were lower than pre-lecture scores (Mean of 434.90, SD= 144.05); 2 racial-minority and 8 non-racial-minority students composed this group which researchers identified as a “backlash” response to the lecture. Within this group, the mean pre-lecture score in this racial minority group, of 2 students, was 516 (SD=28.28) and the mean post-lecture score in this group was 480 (SD=39.60). In the non-racial-minority group, of 8 students in the "backlash group," the mean pre-lecture score was 414.62 (SD=155.62) and the mean post-lecture score in this group was 345.5 (SD=179.92).
This class was taught to Junior 1 students during the first semester of their clinical courses. While there were 51 students enrolled in the class, 42 students participated in the pre/post survey. One student did not complete the post lecture VAS and therefore was deleted from the data set. The 51 students included 40 students who were 20 years old, 7 students 21 years of age, and 4 older students who were within 3 years of the other class members. By gender, the class was 47 female and 4 male; by race, 42 students were white, 8 students were black, and one student was Latina/Hispanic. The respondent’s racial status, minority or non-minority, was identified on the pre-post lecture survey. The group was overwhelmingly traditional, baccalaureate students in their junior year, female and white in a southeastern university.
...the impact of race and the history of nursing require exploration to inform current nursing curriculum. To prepare a diverse and inclusive workforce where there is equal opportunity for advancement, the impact of race and the history of nursing require exploration to inform current nursing curriculum. While larger sample sizes are needed to interpret the significance of the “backlash” group, this study provided support for anecdotal faculty observations of a “backlash” group when introducing race discussions in the classroom.
Helms (1990) offered insight into this phenomenon stating there are white people who experience cognitive dissonance during the initial stage of being compelled to identify racial inequality. Resistance to believing racism exists because it contradicts beliefs regarding fairness and meritocracy in the United States (Helms, 1990). A widely held basic belief is that, in this country, an individual is judged on merit versus skin color (Case, 2007). Helms suggested that students are being confronted with the history of white privilege, which may increase feelings of guilt and resentment (1990). Helms identified three stages toward validity of racism for white people: 1.) initial contact with confrontation of pervasive racist attitudes; 2.) the disintegration of those attitudes; and 3.) the reintegration of attitudes informed by the existence of racial inequality (1990). Our results suggest a small portion of students may have experienced cognitive dissonance during this initial contact stage. Perhaps for racial-minority students, lower post-test scores demonstrated discomfort with the topic of historical racism and its consequences.
The importance of history in understanding our current racial climate (Brown & d’Antonio, 1990) has encouraged the use of story-telling and case-based learning within a constructivist, humanistic pedagogy to promote multi-contextual learning experiences (Giddens, 2008). Developing strategies for integration of racial issues into the curriculum, preparing faculty to increase their confidence in discussing such issues, and designing experiences for classroom and clinical settings surrounding issues of race is important, yet challenging.
This strategy is similar to motivational interviewing...This article presents one strategy to offer students multiple opportunities to raise the awareness of racism and its consequences in the classroom. First, the history lecture and discussion is offered to students in the first semester of the nursing curriculum. Second, the addition of a category entitled, “Race/Impact/Potential Health Disparities,” in the care plan assignment provides an opportunity for further research and study to raise awareness of health disparities. In this section of the care plan, students consider patient’s race, impact on health, and racial inequities that might influence health and quality of life. Finally, the faculty have participated in simulation activities designed to increase confidence in leading discussions regarding race.
Faculty responses to sensitive racial issues are guided by the ARTS acronym: Affirmation, Reflection, Teachable moment, and Summary. The faculty member: 1) Affirms by acknowledging the students’ willingness to bring up a difficult sensitive subject; 2) Reflects a statement regarding the circumstance, names associated emotions, and asks for further discussion of the experience; 3) Seizes the opportunity of a Teachable Moment and supports the student by integrating existing literature with the experiences of racial-minority students, requesting peer comments, and providing feedback, and 4) Summarizes what has been discussed and expressed. This strategy is similar to motivational interviewing, which has been very effective in assisting patients to resolve ambivalence and make change (Miller & Rollnick, 2013). Table 3 offers teachable facts that may be considered.
Table 3. Teachable Facts
In the 2010 census, 12.4% of the population identified as African American, only 6% of RNs identify at African American (Budden, Zhong, Moulton, & Cimiotti, 2013).
Numbers of African American faculty in higher education are at 7% in 2016. (National Center for Education Statistics, 2016)
African American students have the lowest graduation rates of all ethnic and racial groups. (American Association of Colleges of Nursing, 2013). Discrimination is known to have a negative impact on intellectual curiosity, persistence, and academic performance as well as attitudes and beliefs about learning (Neblett, Phillips, Cogburn, & Sellers, 2006).
Racial health disparities including poor access, late diagnosis, under diagnosis, misdiagnosis, and under treatment are well-established facts. (Strickland, Giger, Nelson, & Davis, 2007).
REACH (Racial and Ethnic Approaches to Community Health) a program affiliated with the Centers for Disease Control (CDC) issued a reported in 2010 which showed that having local leadership from the Black community helped to decrease some of the healthcare disparities such as access to care. (USHHS, 2016).
Studies on cognitive development show that critical thinking, problem solving capabilities, and cognitive complexity increase when students are exposed to diversity both on campus and in the classroom (Smith & Schonfeld, 2000).
Development of a method for discussion racial issues in a safe and respectful learning environment is critical to the future of the nursing profession. Nursing faculty are composed primarily of white women, and as the non-racial-minority group, may be defensive when discussing race and its impact (Eliason, 1999). Students, both racial-minority and non-racial-minority, may not feel safe to discuss the issue either in the classroom or in clinical experiences due to negative past experiences (Hassouneh, 2006). Minority faculty report feeling invisible (Wilson, 2007). Graduate nurses in minority groups report racial exclusion from their colleagues while working in the hospital and feel professionally isolated (Robinson, 2013). Development of a method for discussion racial issues in a safe and respectful learning environment is critical to the future of the nursing profession. Integrating the issue of race and diversity into the undergraduate curriculum is essential. The presence of multiple minority groups must be equally addressed in curriculum change.
By using history as a lens in the beginning of the students’ educational experience, all students have the same foundation of information on which to build. Race becomes a topic which can, and needs to be, discussed by faculty who feel competent to address salient issues. Proactive development of care plan formats and simulation scenarios where diversity of patients and nurse colleagues are placed by design, and impact of race is studied and understood in a nonthreatening environment, can promote a message of inclusion.
Carole Bennett, PhD, PMHCS-BC
Carole Bennett, Assistant Professor at Georgia Southern University, became interested in nursing history by studying the nursing reports of the Ladies Benevolent Society visiting nurse Anna Decosta, an African American nurse during the early 20th Centuries in Charleston, SC. Dr. Bennett was a student nurse working at MUSC during the 1969 hospital workers’ strike and since then, has been interested in issues related to race. She is currently Clinical Director in the PMHNP tract of the graduate program at GSU.
Ellen K Hamilton, DNP, RN
Throughout her career, Ellen K Hamilton, Assistant Professor at Georgia Southern University, has been a chief nurse executive in large corporate healthcare systems. She is currently teaching leadership and believes that nursing needs a thriving diverse workforce. Because our students are increasingly more diverse she believes they deserve to have a learning and practice environment which is sensitive to their perspective.
Haresh Rochani, DrPH, MPH, MBBS
Haresh Rochani is Assistant Professor at Georgia Southern University and currently director of the Karl Peace Center for bio-statistics. His research mainly focuses on methodological and theoretical development along with applied and collaborative work in the field of missing data, diagnostic medicine categorical data, and efficient sampling designs.
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