Racism has historically been entrenched in both nursing and nursing education in the United States, despite deliberate efforts to raise awareness about how racism can cause health disparities in ethnic minority patients. To date, approaches to racism in nursing have followed Leininger’s Theory of Nursing, and have focused on teaching cultural competence skills. This has had the unintended consequence of discouraging discourse about racism in nursing through white silence, and whiteness and colorblindness ideology. This article considers nursing in the United States and aims to deconstruct how language to address racism in nursing has been used historically; explain why using this language has not been successful; and describe innovative approaches to racial discourse to directly address racism in healthcare and nursing education. We offer implications for practice and education, proposing instead to teach skills in norm-critical thinking and discourse to nurse faculty and nursing students, eventually empowering the entire profession of nursing with skills to identify institutionalized racism, engage in discourse about it, and dismantle it.
Key Words: nursing; racism, communication barriers, education, nursing, nursing care, race factors, healthcare disparities, professionalism, organization and administration, nursing education research, socioeconomic factors, policy, Leininger
Like many Western countries, the United States (U.S.) struggles with both overt and structural racism embedded throughout its governmental, business, and social systems (Iheduru-Anderson & Wahi, 2020). The profession of nursing in the United States is not spared from racism, largely due to its historical entanglement with colonialism, and enslavement of Africans who were brought against their will to the country (Esenwa et al., 2018; Waite & Nardi, 2019). Ethnic minority (EM) nurses, especially those who are indigenous peoples or immigrants from predominantly black African countries, face racism in U.S. practice settings, and EM nursing students and faculty experience racism in academia (Ezeonwu, 2019; Iheduru-Anderson & Wahi, 2018; Jose, 2011; Scherer et al., 2019; Waite & Nardi, 2019; White, 2018).
Theoretical Approaches to Racism in Nursing
Racism is responsible for inequities in nursing, as well as patient health.Racism is responsible for inequities in nursing, as well as patient health (Esenwa et al., 2018). As EM patients continue to receive fewer and lesser quality healthcare services than non-EM patients, U.S. governmental agencies and nursing organizations have prioritized eliminating health and healthcare disparities (Agency for Healthcare Research and Quality [AHRQ], 2014; American Association of Colleges of Nursing, 2017; American Nurses Association [ANA], 2018; Nelson, 2016). Ironically, in the United States, the nursing profession, despite its own entrenched racism, has been called to lead this effort (AHRQ, 2014; ANA, 2018; Phillips & Malone, 2014).
This theory did not directly address racial disparities or racism among actors or structures in the healthcare system...In 1988, Dr. Madeleine Leininger published “Leininger’s Theory of Nursing” which held that the concept of “cultural care,” based on the anthropological definition of culture, provided the optimal lens through which to study, explain, and predict nursing knowledge and care practice. Leininger proposed that using this theory would ultimately lead to “culturally congruent” nursing care practices (Leininger, 1988; Walter P. Reuther Library, 2012). This theory did not directly address racial disparities or racism among actors or structures in the healthcare system, nor the history of entrenched racism permeating U.S. society. For these reasons, it is unclear why Leininger’s Theory formed the foundation used by nurses in the United States to engage in discourse on racism in U.S. health and healthcare.
A landmark paper by Barbee (1993) cited characteristics of the nursing profession that make it susceptible to perpetuating racism. These included wanting to avoid conflict and to project the perception of fairness, which leads nurses away from confronting their own inevitable unconscious biases. Perhaps the indirect language in Leininger’s Theory provided a seemingly “safe” entrée for nurses to begin discourse on racism. The term “culturally congruent care” became a code phrase, and this code phrase gave way to another code phrase – “transcultural nursing” – which in turn gave way to a more current code phrase, “cultural competence” (Marion et al., 2016). These code phrases ostensibly refer to skills that can be learned to deliver culturally competent care; however, actually measuring these skills or linking them with any sort of quality care delivery in research remains elusive (Gallagher & Polanin, 2015; Govere & Govere, 2016; Shen, 2015).
No provision in cultural competence theory includes training for skills to directly confront the effects of racism...No provision in cultural competence theory includes training for skills to directly confront the effects of racism on individuals, healthcare delivery, nurses, institutions, or the rest of society (De Jesus et al., 2016; Marion et al., 2016). Therefore, unwittingly, cultural competence became a strategy for diluting the issue of racism through the use of indirect language. This provided a cover, and even a sense of confidence, in those who felt that they were addressing racism through the practice of cultural competence, effectively creating a distraction from the structural racism and unconscious bias in U.S. agencies and institutions which perpetuate racism (De Jesus et al., 2016). As evidence of this phenomenon, the ANA adopted Standard 8 to increase “culturally congruent” care, citing the historical theoretical foundation that began with Leininger’s theory (ANA, 2015; Marion et al., 2016).
By 2015, it became evident that unchecked racism in nursing was threatening the very foundations of the U.S. healthcare system (Baptiste, 2015). Given the high rates of EM nurses educated in other countries migrating to the United States over the 2000s, the effects of racism included damage to the health and employment opportunities of EM nurses and has led to high rates of costly turnover (Baptiste, 2015). This high turnover, coupled with the poor treatment of and EM nurses by coworkers, has led directly to lower quality patient care (Baptiste, 2015).
There currently is no consensus of a framework for direct discourse, discussion, and dialogue about eliminating racism in nursing in the United States.There currently is no consensus of a framework for direct discourse, discussion, and dialogue about eliminating racism in nursing in the United States. Racism in nursing has been examined through many different lenses, including historical (Brathwaite, 2018; Esenwa et al., 2018); lived experience (Holland, 2015; Iheduru-Anderson, 2021; Iheduru-Anderson & Wahi, 2018; Jose, 2011); and social structures (Carter et al., 2015; Schroeder and DiAngelo, 2010). This article solely considers nursing and nursing education in the United States. Our aim is to view this issue through a vernacular lens, and to deconstruct how language to address racism in nursing in the United States has been used historically. In the article, we will also explain why using this language has not been successful and will make recommendations to nursing leaders for stronger ways to directly address racism in healthcare and nursing education.
Whiteness, Colorblind Ideology, and Influence on Racial Discourse in Nursing
Puzan (2003) described “whiteness” in nursing. Citing literature from both nursing and sociology, she explained that the whiteness concept holds that “white” is a socially-constructed category of race where non-white people are racially “designated,” rather than race as a preordained biological property of an individual (Puzan, 2003). Hence, those perceived as whites escape being designated, and therefore, what whites say becomes seen as “neutral” or normal, rather than situated in the context of history and ideology (Puzan, 2003).
DiAngelo (2011), who studies whiteness, described the seemingly paradoxical situation where in a room filled with white employees, a white man became incensed when the word “racism” was brought up by a white facilitator, insisting that white people cannot get jobs anymore, even though all the employees in the room were white. DiAngelo (2011) named the phenomenon “white fragility” as when white-identified people are in a state where a minimal amount of racial stress triggers a defensive reaction. These negative reactions to racial discussions in whiteness environments serve to silence discussions of race and racism, which DiAngelo (2012) called “white silence.” She describes and deconstructs different rationales put forth to defend white silence, such as “I don’t want to be misunderstood”, and “I already know all this” (DiAngelo, 2012).
Colorblind ideology holds that discussing race should be avoided...White silence appears to impact racial discourse in all facets of nursing in the United States. In a study where 22 U.S. white doctors and nurses were interviewed, they used “colorblind ideology” to avoid confronting racism (Malat et al., 2010). Colorblind ideology holds that discussing race should be avoided, as one should project oneself as being “colorblind” and not acknowledge that one perceives racial differences between people (Malat et al., 2010). Colorblindness also holds that racism is in the past, and that any racial inequities can be explained using a rationale in colorblind ideology (Malat et al., 2010).
...nurses are reluctant to explicitly name racism and recommended that it be explicitly named and addressed.As evidence of whiteness and colorblind ideology, Thurman and colleagues (2019) conducted a review of 29 papers that were focused on structural or institutionalized racism in nursing, and observed that only three had received funding (Thurman et al., 2019). A review of nursing literature by Iheduru-Anderson et al. (2020) indicated that nurses are reluctant to explicitly name racism and recommended that it be explicitly named and addressed. In another study of healthcare providers, racial inequity in medical treatment was blamed on the behavior of black patients (e.g., not following recommendations or properly seeking care) and no consideration was given to historical inequities suffered by black people in the United States (Malat et al., 2010). A study of 21 healthcare workers in Minnesota asked their opinions on healthcare disparities and found that participants used colorblindness ideology to semantically avoid confronting structural racism (Cunningham & Scarlato, 2018).
The impact of the whiteness on discourse in nursing can be seen clearly in a survey of 56 healthcare professionals in the Midwestern US (Shepherd et al., 2019). Counterintuitively, participants expressed high levels of confidence that they had been well-trained in cultural awareness and cross-cultural care, communication, and perspectives, even though most had not undergone formal training (Shepherd et al., 2019). Further, the participants were unable to identify the principles of systemic cross-cultural approaches, such as recognition of racism, power imbalance, and entrenched cultural biases; and the need for self-reflexivity (Shepherd et al., 2019).
...many educators do not have the skills to appropriately address racism in the classroom.While nurse educators and students are aware of racism in nursing, many educators do not have the skills to appropriately address racism in the classroom (Nairn et al., 2012). In a U.S. study, Holland (2015) interviewed ten white bachelors of science in nursing (BSN) faculty at a college in the Midwest, and found that whiteness obscured their ability to teach about race. The participants reported being uncomfortable talking about racism and issues around race, largely citing thinking reflecting whiteness and colorblind ideology. This led Holland (2015) to conclude that the participants did not have the necessary preparation to teach about race, racism, and antiracism. In a study of internationally recruited nurses (IRNs) who served as mentors to white nursing students in the United Kingdom, whiteness permeated the students’ perceptions of their mentors; students regarded IRNs as culturally different, and then used these differences as justification as to why IRNs were inferior (Scammell & Olumide, 2012).
Antiracist approaches teach skills to identify, name, and challenge norms, structures, and institutions that keep racism in place...Hall and Fields (2013) reviewed the literature for guidance in promoting discourse on racism in nursing without running into whiteness-imposed barriers. The authors called white nurses to actively recognize their white privilege and identify implicit biases broadcast by their behavior (Hall & Fields, 2013). DiAngelo recommended an “antiracist” approach as a way to break through this discourse barrier (DiAngelo, 2012). Antiracist approaches teach skills to identify, name, and challenge norms, structures, and institutions that keep racism in place as a way to dismantle racism (DiAngelo, 2012).
Innovative Approaches to Racial Discourse in Nursing
Critical race theory (CRT) focuses on examining the production of knowledge, norms, and conventions that reproduce and continue to enforce racialized power structures (Cunningham & Scarlato, 2018). Rooted in the U.S. Civil Rights movement, CRT emerged as a framework useful for guiding criticism of the legal system for playing an outsized role in racially-based oppression, and has also become a useful guide to understand racism on college and university campuses (Ackerman-Barger & Hummel, 2015). In their review of discourses with the potential to disrupt traditional nursing education, Tengelin and Dahlborg-Lyckhage (2017) categorized CRT and antiracist approaches under the umbrella of building “norm-critical competence.” By this, the authors specifically refer to building skills in nurse educators in “norm criticism” which promotes awareness and criticism of institutionalized power structures that impact society (but healthcare in particular) (Tengelin & Dahlborg-Lyckhage, 2017).
...self-reflexivity is already included in nursing pedagogy, and teaching how to use self-reflexivity to uncover unconscious biases could be a way of teaching norm-critical thinking skills...While CRT can be seen as a norm-critical theory that can be used to guide the design of studies and interventions in nursing and nursing education, to impact racial discourse in nursing, nurses will need to acquire skills in norm-critical thinking and discourse. This could come in several forms. First, self-reflexivity is already included in nursing pedagogy, and teaching how to use self-reflexivity to uncover unconscious biases could be a way of teaching norm-critical thinking skills that could lead to norm-critical discourse (Buetow, 2019; Taylor et al., 2008).
Secondly, Burgess, Beach and Saha (2017) argued that mindfulness could be used by clinicians to help them uncover implicit biases about patients so they can intervene to reduce health disparities. Polinska (2018) also described teaching mindfulness meditation to African American women as a way to help them combat “white ignorance.” A state of mindfulness cultivates a non-judgmental approach to looking at one’s thoughts, so as to accept these thoughts and be less judgmental of them (Polinska, 2018).
A state of mindfulness cultivates a non-judgmental approach to looking at one’s thoughts...A third approach could be to train nursing faculty in norm-critical skills. Carnes and colleagues (2012) developed a workshop curriculum on “bias literacy” aimed at teaching science, technology, engineering and math (STEM) faculty how to identify unconscious gender biases, and how to counteract them in the development of curricula. The workshop teaches specific actions that can be taken by the educator to develop anti-bias curricula, such as representing women in STEM roles throughout the curriculum. In the workshop evaluation, faculty reported examples of having the skills to identify their own gender biases and correct for them (Carnes et al., 2012). Parallel workshops could be used to teach nursing faculty anti-bias skills.
DiAngelo’s (2012) idea of an antiracist intervention was tested at the University of Washington School of Nursing (SON), which engaged in a project with two aims: 1) implementing faculty-staff workshops that addressed how implicit norms, behaviors, and practices negatively impacted the work climate, and 2) developing and institutionalizing a more explicit, inclusive, and accountable statement about diversity at the nursing program (Schroeder & DiAngelo, 2010). In their two-day Un-doing Racism workshop, eight educators participated (six were white), and the feedback from participants suggested that this approach had been effective to teach norm-critical skills (Schroeder & DiAngelo, 2010). They provided examples of participants identifying and naming institutionalized structures that led them to awareness of a default, unconsciously white “standard” that they needed to challenge to provide quality education for students of color (Schroeder & DiAngelo, 2010). Several reported being “less afraid” to talk about how racism is impacting how they act and nursing education in general (Schroeder & DiAngelo, 2010).
...having nursing leaders adopt, promote, and role model norm-critical skills and discourse will be necessary to promote these behaviors.Finally, having nursing leaders adopt, promote, and role model norm-critical skills and discourse will be necessary to promote these behaviors. In her recent editorial, Ludwig-Beymer (2018) remembers an incident from over 15 years ago, where a patient refused to be treated by a black nurse. In that case, the president did not back down to the patient with this racist demand. But the author noted that in October 2017, Spectrum Health System, a U.S. health system, was sued by a black nurse because she said it honored a white patient’s request for no black caregivers (Ludwig-Beymer, 2018). Any antiracist efforts in nursing and nursing education will not be successful without the backing of nursing and academic leadership.
Implications for U.S. Nursing Practice and Education
Up to now, teaching cultural competence, diversity, and related concepts was thought to be the correct approach to addressing racism in nursing. Even though cultural competence did not address racism in nursing, attending cultural competence workshops has become institutionalized in nursing. To empower nurses at all levels, including educators, leaders, students, and those in the healthcare setting, to dismantle racism, we recommend that these offerings should immediately be replaced with workshops that teach skills in norm-critical thinking and discourse. As previously described, these educational events could take various forms, but should be specifically evaluated for teaching applied norm-critical skills.
...the priority audience for these workshops is nurse educators.Although the entire profession of nursing will need to learn these skills, the priority audience for these workshops is nurse educators. If nurse educators learn and teach using norm-critical skills and model norm-critical behavior and discourse, students are likely to follow, and bring these experiences with them into their future careers in leadership, healthcare, and academia.
...such a course of action will empower nursing students and faculty, and later the entire profession of nursing...In the United States, discourse taught and used in nursing and nursing education, intended to address racism in nursing and healthcare, did not reach that goal. It also caused the unintended consequence of silencing direct discourse about racism in nursing and nursing education through white silence and colorblind ideology. This article proposed that U.S.-based leaders in nursing and nursing education instead pivot toward teaching of norm-critical thinking and discourse. Eventually, such a course of action will empower nursing students and faculty, and later the entire profession of nursing, with skills to identify institutionalized racism, engage in discourse about it, and consequently dismantle it.
Acknowledgment: This article was funded through faculty research funding provide by Central Michigan University.
Kechinyere C. Iheduru-Anderson, DNP, RN, CNE, CWCN
Dr. Iheduru-Anderson is a registered nurse and holds a DNP and CNE and CWCN certifications. She is the inaugural Nursing Program Director at the Herbert H. and Grace A. Dow College of Health Professions at Central Michigan University in Mount Pleasant, Michigan. Her research interests include improvement of nursing education and administrative policy.
Monika M. Wahi, MPH, CPH
Ms. Wahi is a Boston-based epidemiologist and biostatistician with over 20 years of experience participating on research teams, conducting research and publishing in the peer-reviewed literature. She holds an MPH and a CPH and has published a line of research studying how to improve provider education to improve quality of care.
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