ANA Position Statement: The Nurse’s Role and Responsibility in Unveiling and Dismantling Racism in Nursing

Effective Date: 2022
Status: Position Statement
Written by: ANA Center for Ethics and Human Rights
Adopted by: ANA Board of Directors

As individuals and a collective, we strive to remove the veil that systemic racism has placed over the eyes of our society so that we may clearly see the way forward. We invite those who read this to do so with a vision of the great potentiality of our profession and the immense power nurses have in shaping how, when, and why we bring health and healing to our patients, our communities, and one another.

Purpose

This position statement has two purposes: first, to address the nursing profession’s adoption and perpetuation of racist systems and structures, which have resulted in profound inequities and harm, and to “allow for the bandage that covers the wound of inhumanity to start to peel away” (ANA, 2021, p. 21); and second, to propose an emancipatory way forward that is an approach to nursing practice fundamentally aimed toward social justice. This position statement is written for nurses with little to no knowledge of racial injustices and for nurses who have vast knowledge, research, and experience either personally or professionally with dismantling racism in nursing. Practicing emancipatory nursing enables nurses to actively engage in the dismantling of these systems and begin to cocreate a “more just and equitable (healthcare) system” (Chinn & Kramer, 2021).

Statement of ANA Position

ANA is committed to decolonizing the nursing profession through the active dismantling of systems, structures, policies, and narratives that make possible the racial injustices and health inequities that are both experienced and facilitated by the profession. ANA recognizes that deconstructing these systems is essential to overcoming racism and inequality. Decolonizing the nursing profession includes:

• Publicly recognizing the profession’s historic and pervasive involvement in supporting and promoting white supremacy, or white Eurocentric prioritization of all sectors of society, and perpetuating practices and models that are racially unjust and violent.
• Understanding the impact of structural racism and its significant role as a social determinant of health.
• Recognizing how the profession’s perspectives, actions, and beliefs perpetuate racism and white privilege as powerful dynamics that continue to shape nursing practice and the healthcare system.
• Resisting practices, models, and funding structures that dehumanize patients, nurses, and the profession, including those that prioritize profits and productivity over well-being.
• Transforming nursing through an emphasis on reflective practices, engaging in difficult conversations and actions oriented toward liberation from oppressive and racist practices.

ANA recognizes that speaking explicitly about both historic and current racial violence in health care and specifically the nursing profession is a requisite to our social justice mandate “to address unjust systems and structures” (ANA, 2015, p. 36). Nurses must speak truth to power by addressing racism in their own systems and use their influence to advocate for transformative action-oriented processes (including but not limited to policies and initiatives) that mitigate racial injustice and inequality and promote social justice.

As a profession, we must accept our ethical duty as allies and coconspirators in the fight against racism. We invite you to hold us accountable for our language and actions as we move toward healing and unity.

Recommendations

ANA recommends that all nurses engage in ongoing, critical self-reflection to identify and address those biases, fears, and racist assumptions that may affect the provision of respectful care that values the human dignity of all persons (ANA, 2015). To that end, nurses must:

• Educate themselves, through intentional reading, to understand the history of racism and historical trauma and their role in creating and perpetuating health disparities (Waite & Nardi, 2021).
• Move beyond the focus on patient behaviors and compliance with prescribed interventions and actively engage with and attend to the socially constructed disparities and inequities both experienced and propagated by our profession.
• Take action when we witness or experience microaggressions in the health care profession and bring it to the attention of health care administrators.
• Nurses and all health care professionals must avoid such nursing diagnoses as “noncompliance” when the patients are in fact living the consequences of disproportionate suffering (Boyd et al., 2020).
• Identify that the racialization of specific groups is a marker of social differences that leads to inequality in access, treatment, and outcomes based on the perception of physical characteristics (Doty et al., 2022).
• Plan their advocacy and care with an understanding that race is an ascribed social category resulting in inequality and health outcomes that result in significant biological consequences (Roberts, 2019).
• Take upon themselves the responsibility both to learn about the profession’s history and to unlearn the racist practices that sustain inequity and harm.

All nurses must invest in the development of advocacy skills at the policy level to address social determinants of health (ANA, 2021; Kuehnert et al., 2021; Williams et al., 2018) or the causes of the causes of illness and suffering (Kagan et al., 2014). For example, environmental racism results in intentionally neglected communities suffering the consequences of climate change in unjust and unequal ways. Climate-related crises, including unrelenting heat in the summer and poor air quality due to uncontrolled wildfires, disproportionately harm those living in poverty in the United States. For those unjustly affected by climate-related health problems, impoverished people experience compounded systemic inequities, as they are frequently shut out of accessing health care in a structure that is designed to extract profits (LeClair et al., 2021).

All nurses must acknowledge and recognize the very tangible risks associated with decolonizing nursing, as the act itself is a threat to the very function of our current health care system. The threats have been and will continue to be the most severe for BILPOC (Black, Indigenous, Latine, People of Color) nurses. All our voices and efforts are critical in dismantling a system built on and scaffolded by white supremacy. The risks associated with speaking up and engaging our colleagues in accountability conversations are far less than those associated with allowing violent racial injustices to continue unaddressed. Those nurses committed to the future of our profession must find a community of shared efforts in which they may seek encouragement, support, and continued accountability and learning.

ANA recommends that nurse educators and academic nurse leaders understand their essential roles in student professional formation and the development of moral character required for the practice of advocacy and provision of equitable, respectful care (ANA, 2015, 2021; Fowler, 2015). All nurse educators and academic leaders must:

• Acknowledge that they may lack the experiences, resources, and pedagogical preparation to effectively teach about racism and racial injustices.
• Recognize that to end American colonialism in nursing education, there is need for widespread change in nursing curricula and an assessment and correction of how nursing education is delivered and by whom (Waite & Nardi, 2017).
• Examine curricula for the inclusion of BILPOC nurses (e.g., Mary Mahoney, Mary Seacole, Susan King Taylor, Ildaura Murillo-Rohde, and others) as cofounders and contributors to modern nursing practice.
• Reflect on their privileged position and consider the values and assumptions that may perpetuate oppressive and discriminatory teaching-learning practices.
• Engage in professional development to learn how to create inclusive environments and develop and teach content through a critical anti-racist lens (Woolsey & Narrhun, 2018; Garland & Batty, 2021).
• Identify, critique, and challenge decisions to leave out the perspectives and contributions of BILPOC authors and thought leaders in the development of nursing knowledge (Waite & Nardi, 2017).
• Examine the barriers that impede the entry of BILPOC students into the profession. These include admission criteria that rely only on metrics that disproportionately exclude minoritized groups (TEASs, SATs, and GREs) rather than a holistic assessment that considers life experiences and personal attributes as indicators of potential student success (Hampton et al., 2021; National Academy of Sciences, Engineering & Medicine, 2021).
• Recognize that words matter and inclusive language invites discussion. Language is dynamic and, when used properly, should consider social and situational contexts. Words such as “refuse,” “noncompliant,” and “nonadherent” contribute to health disparities (Sun et al., 2022). Words such as “vulnerable” and “marginalized” should be used infrequently unless they are clearly defined (AAP, 2022).
• Review test questions with a critical lens and remove any referrals to race/ethnicity in the stem or answer to the question in which the relationship between the race/ethnicity and the health situation is not clearly relevant (Ripp & Braun, 2017).
• Develop policies and resources to enhance the recruitment and retention of BILPOC faculty and establish collaborative mentorship programs to support their career advancement (Crooks et al., 2021).

ANA recommends that nurse researchers affirm a commitment to developing strategies to reduce health disparities and unjust structures and processes that affect communities (ANA, 2015). All nurse researchers must:

• Clearly define race as a sociopolitical, not biological, framework.

• Name racism in all its forms and mechanisms and use critical frameworks, including critical race theory, to discuss racism and its relationship to the study findings (Boyd et al., 2020).
• Address oppressive structures that create health inequities through collaborative, emancipatory research and knowledge development processes such as community-based collaborative action research or participatory research. The goal of these partnerships between those experiencing inequities whose voices should be privileged and nurses is to promote equity, health, and social justice (Pharris & Pavlov, 2014; Schultz et al., 2020).
• Identify the ways in which research is used as a technique of power and cultivate more expansive research methods, theories, and philosophies (Rabelais & Walker, 2021).
• Advocate for equitable funding models and hold funding organizations accountable for inequitable distribution of research funds amongst BILPOC researchers (Crooks et al., 2021; Kippenbrock & Emory, 2021).
• Identify and advocate for the dismantling of the racist context underlying evidence-based research results (Hardeman & Karbeah, 2020).

All nurses are ethically obligated to “collaborate in altering systemic structures that have a negative influence on individual and community health” (ANA, 2015, p. 18). Nurses in formal leadership roles should openly challenge racist practices, as they are in a unique and privileged position to speak the truth on behalf of nurses and those in our care. ANA recommends that nurses in formal leadership roles:

• Be an example in identifying and resolving enculturated white-supremacist leadership practices that harm our profession (Waite & Nardi, 2019).
• Explicitly denounce and resist institutionally built racist structures and processes that are created through policies, budgets, or practices that ultimately result in disparate care provision and cause irreparable harm.
• Support specific, intentional workplace training in reflecting on racism, having conversations about racism, and responding to racist practices for all employees (Waite & Nardi, 2017).
• Implement a routine organizational assessment to determine whether written goals are in place and used to unveil and dismantle racism in the organization and assess whether BILPOC individuals have decision-making powers and are included in the processes, proposals, and funded initiatives (Nardi et al., 2020).

Narrative Introductions

The following section contains narrative introductions from the authors of this position statement. These introductions are written in acknowledgement of each author’s social location and to describe the humility and respect offered in efforts to address and combat racism in the nursing profession.

Yes, I speak in a professional manner. No, you do not have to be shocked by that. Yes, my hair can be styled in a myriad of beautiful ways. No, you may not touch it. Yes, I will indeed be your nurse. I will be taking care of you today. Becoming a nurse did not remove the plague of microaggressions from my day-to-day interactions. It seemed to intensify them. While being the one or one of a few Black women in academic and work settings is not foreign to me, the racial battle fatigue has set in, and the polarizing events of 2020 compounded with a pandemic have left me weary, yet I’m more motivated than ever to create real change. I am a Black woman. Kara

I grew up in a diverse, yet segregated, neighborhood in NYC during the 1950s and ’60s and many members of my family were, and remain, racist. As a child I didn’t question their words and actions, but as I grew older, worked with, and cared for and about people of color, I began to see how these white supremacist beliefs were pervasive and deadly. I’ve been a nurse for almost 50 years and continue this unveiling and unlearning/learning journey. I am a white woman. Cathy

There is no beginning for me and there is no end. I realized that being Black was a thing when I was 8 years old and at a track meet. A white girl told me, “My daddy says I can spit on you because you’re Black,” and I remember saying something smart back to her. To me it was just a mean girl, but as I grew up, I realized that it was really a deliberate bias and racism handed down from generation to generation like you would the family silver. Being a Black nurse is being seen when you don’t want to be and not seen when you should be. For most of my career, it has been those everyday slights that have added up to a sum total feeling of unwelcomeness, in some ways pervasive and in other ways blatant. I’m called to this work because I believe that to move forward, I have to be a clarion call. I am a Black, cisgender, neurotypical, able-bodied woman. Nikki

In my upbringing I was taught many things about racism. I was taught to be colorblind, that a long time ago a man named Dr. Martin Luther King Jr. marched, and that racism was abolished. I was taught that anyone who works hard enough can have everything they need to take care of themselves. So, I worked very hard and I became a nurse. I went to Haiti after the 2011 earthquake, and I saw the consequences, suffering, and death of white-saviorism and oppressive violence. I was no longer colorblind. I worked in a juvenile detention center, where I saw more Black people in one place than I had ever seen before. I learned that there was more to success, health, and even survival than working hard. I am now a nurse, working and living through the COVID-19 pandemic, and I witness the ways in which intentionally neglected communities of Black and Brown people suffer and die at the hands of our health care system. I can no longer live a life pretending racism is a thing of the past. I am a white, cisgender, straight, able-bodied woman. Danisha

I grew up in the South. Although segregation ended years before I was born, my town continued to perpetuate that division. But my family “wasn’t racist.” I graduated from a high school named after a confederate general. The confederate flag was easy to spot at many school-sponsored events. But I “wasn’t racist.” I attended college and graduate school and developed a diverse group of friends through my many decades. But I “wasn’t racist.” I couldn’t be; I had Black friends! For years I practiced nursing and mindlessly observed—without truly seeing—the health disparities Black and Brown families experienced. But I “wasn’t racist.” I stood by as my Black and Brown clinical colleagues were assumed to be in nonclinical roles. But I didn’t make those assumptions, because I “wasn’t racist.” Except, I was. A slow unveiling occurred over my lifetime. Now I see the enormous impact of white supremacy, structural violence, systemic racism, and health disparities. I gave myself a pass throughout my life, turning a blind eye to the depths of the pain and injustice I failed to truly understand. I now realize my silence and lack of action perpetuated these harms. I am still on this journey of unveiling and now strive to be anti-racist. I am a white, cisgender, able-bodied, straight woman. Stacy

The authors of this paper write with a deep sense of epistemic humility—an acknowledgement that the words of this document are filtered, crafted, and communicated through our collective lens. We assert the limitations of our abilities to both grasp and communicate the depths and extent of the racial injustices both committed and experienced by nurses. We acknowledge that our words are framed by both the privileges and challenges of our lived experiences as we navigate a profession so deeply entrenched in both the beauty and the heartache of humanity. Our racial reckoning is ongoing.

Background

The Unveiling—Reconciling the Nursing Profession’s Racial Violence
Engagement in racial justice through balancing the benefits and burdens of all people is a professional expectation of nurses. Despite this, social justice, including racial justice, remains poorly understood and negligibly practiced. Nursing history documents the profession’s ethical obligation to advocate for oppressed groups and resist forces that harm people (ANA, 2015; Fowler, 2015). However, the collective nursing profession has historically and pervasively failed to address this violence—the injustices and health inequities that are both experienced and facilitated by the nursing profession and that have resulted in harm. To begin the work toward racial justice in practice, we must make the notable failures of the profession visible and acknowledge our historical and current role in social injustices, and we must specifically address the profession’s role in racism.

Despite volumes of work and decades of evidence on disparities in health outcomes for BILPOC communities (McLemore et al., 2018; Nardi et al., 2020; Canty, 2020; Yearby, 2018), the nursing profession has remained unmoved by not only our role and responsibility in racial justice but our own unjust racial violence. While individual examples of overt racism may be easier to address, until we make visible the racism sustained through nursing’s theoretical and historical foundations, we will continue to sustain and strengthen white supremacy, and any solutions created to “end racism” will be in vain (Louie-Poom et al., 2021). Racism is deadly, and there is no room for anything less than persistent and explicit identification and reckoning with both systemic and individual upholding of white supremacy (Inheduru-Anderson, 2021). The time for unveiling the truth and reconciliation is long overdue, and we must no longer tolerate, nor make space for any efforts to keep our profession in, privileged hiding from the truth.

Unveiling Professional Organizations
To begin, we must acknowledge that ANA purposefully and systematically excluded nurses of color. It was not until 1951 that Black nurses were permitted membership. There have been 37 ANA presidents since its founding, only three of whom have been people of color. To learn more about ANA’s Journey of Racial Reckoning, click here. The pervading white supremacy within nursing professional organizations led intentionally marginalized groups of nurses to create their own organizations to address the needs of their communities and elevate their own voices. These organizations include the National Black Nurses Association (NBNA), Chi Eta Phi Sorority, Inc., the National Association of Hispanic Nurses (NAHN), the Philippine Nurses Association of America (PNAA), the Asian American Pacific Islander Association (AAPINA) and the National Alaska Native American Indian Nurses Association. As a result of the persistent lack of diversity and professional support amidst increasing health disparities, the National Coalition of Ethnic Minority Nurses Associations (NCENMA) was formed consisting of the five ethnic nurses’ associations. Members of these organizations have dedicated tremendous time and resources to healing the ailments inflicted by white supremacist violence.

Unveiling—The Image and Role of the Professional Nurse
The role of the professional nurse is entrenched in racism. The celebration of the Eurocentric colonizing model of Florence Nightingale’s training program for White European women of the “right caliber” is still seen today in the persistent erasure of historic BILPOC nursing leaders and the dearth of BILPOC in nurse leadership (Moore & Drake, 2021). The scarcity of acknowledgement and respect for nursing founders like Mary Seacole, Sojourner Truth, Susie King Taylor, and Mary Mahoney aligns hauntingly with the BILPOC nurses of today’s experiences of being unsupported, isolated, and discriminated against in their work as nurses. Institutions are resistant to enacting explicit antiracist policy and instead focus on outward-facing performative statements of diversity and inclusion. BILPOC nurses, particularly Black nurses, face significant racial barriers to career advancement (Iheduru-Anderson, 2020a, b). Manifestations of injustice toward nurses persist in lack of representation of people of color in nursing leadership positions, nursing schools being predominantly composed of white cisgendered female faculty, and continued over-disciplining of nurses and nursing students of color (Bell, 2020; Coleman, 2020).

Unveiling—Colonizing, Capitalism, and Nursing Practice
The nursing profession’s upholding of a health care system that commodifies both health and nurses themselves contributes to life-threatening health disparities and erodes the discipline’s ethical mandate to actively promote equity and social justice. A system that prioritizes profits through rationing care and prioritizing health care delivery to those with financial means is one that is dehumanizing (Jenkins et al., 2021). Many years of research has made visible the ways in which colonizing white supremacist tools such as capitalism disproportionately and fatally harm Black and brown communities (Waite & Nardi, 2019). The devastating effects of the COVID-19 pandemic on some of these communities is an example of how racial inequality aligns with socioeconomic exploitation and deprivation to reinforce health disparities and contribute to adverse outcomes (Pirtle, 2020; Oh, 2022). Health care, and therefore the nursing profession, is both a historic and current driver of this inequality (Dillard-Wright & Shields-Haas, 2021).

Unveiling—Nursing Education
Nurse educators are obligated to “firmly anchor students in (the) … professional responsibility to address unjust systems and structures … through content, clinical and field experiences, and critical thought” (ANA, 2015, p. 35). Nursing education in general, however, has been criticized for delivering curricula that perpetuates Eurocentric normativity and fails to address racism and oppression. The non-inclusion of racism as a social and theoretical nursing construct is compounded by white dominance in the profession and among leadership and faculty. This dominance may contribute to institutions that are discriminatory and unsupportive of BILPOC students and faculty (Bell, 2020; Crooks et al., 2021; Kim et al., 2022).

Before nurse educators can create and provide a decolonized, emancipatory pedagogy, they must first acknowledge their own racial privilege and complicity in maintaining unjust systems and practices (Chinn & Kramer, 2021). Nursing curricula must be built on a foundation that recognizes the oppressive forces that take political, social, and economic control of a group of people in order to exploit them. Colonialism has led to anti-Black sentiment and white supremacy. Developing an antiracist identity and pedagogy will require a commitment to personal and professional knowledge development regarding racism in conjunction with humility, vulnerability, and constant reflexivity (Garneau et al., 2017; Waite & Hassouneh, 2021).

Incorporating an antiracist pedagogy that integrates structural competence may prepare students to understand their social privileges and focus attention on their ethical responsibility to address “unjust systems and structures.” Structural competence moves beyond cultural competence, which may lack a critical perspective of upstream determinants of health and illness, to increase awareness of the social, political, and economic circumstances influencing health disparities. As the downstream outcomes of systemic racism and components of historical trauma, these disparities can be transmitted across multiple generations (Mulligan, 2021; Sullivan, 2013).

Nurses who are structurally competent not only recognize the factors that affect individual health and have the skills to enact appropriate interventions (Woolsey & Narrruhn, 2018), but also address the systemic causes of health inequities and act to effect institutional and policy change. An understanding of critical theories such as feminist, gender, race, disability, etc., is a powerful foundation for understanding antiracist concepts such as intersectionality and decolonization in order to move beyond the individual toward structural level factors (Coleman, 2020; Fowler, 2015).

The proliferation of diversity and inclusion policies and departments in schools of nursing has not significantly impacted the persistent institutional racism that affects recruitment and retention of BILPOC students and faculty (Crooks et al., 2021). Use of terms such as “diversity” and “inclusion” may, in fact, be self-congratulatory and prevent engagement in critical discourse and actions that challenge the status quo of white privilege and racial injustice (Bonini & Matias, 2021). One initiative, the establishment of the Center for Antiracism in Nursing at the University of Washington, is an example of an approach designed to overcome the oppressive culture within schools of nursing. With an aim “to reconcile and find resolve within its own walls that have promoted anti-blackness and white privilege,” the Center’s goals include, among others, cultivation of antiracist teaching practices and support of students from underrepresented and historically excluded groups. Additionally, associate degree nursing programs are recognized for providing opportunities for BILPOC students who may not be able to afford or are denied admission to Bachelor of Science in Nursing programs because of criteria that reflect entrenched structural racism. Rectifying the funding inequity of two- and four-year institutions is necessary to address disparities in resources and opportunities for BILPOC nurses, which will ultimately increase diversity of the profession and contribute to quality health care (Hampton et al., 2021; Mohammed et al., 2021).

ANA Foundational Documents

The following is relevant and supportive content from these documents.

Code of Ethics for Nurses with Interpretive Statements

Provision 1: “The nurse practices with compassion and respect for the inherent dignity, worth, and unique attributes of every person.”

Nurses are obligated to affirm and preserve the human dignity of all those with whom they have contact, including patients, family members, and colleagues, across all roles and settings. (Fowler, 2015). As an offense against human dignity and a tool of oppression, racism denies the inherent equality of individuals and communities based on a socially constructed category of race designed to sustain white supremacy. To confront racism, all nurses must engage in ongoing, critical self-reflection to identify and address those biases, fears, and racist assumptions that may diminish or offend the human dignity of every person.

Interpretive statement 1.3: “Nurses are leaders who collaborate in altering systemic structures that have a negative influence on individual and community health.”

Racism is perpetuated through economic, political, and health care delivery systems or structures that foster health inequities and privilege dominant groups. Nurses must be prepared academically and experientially to recognize and address the connection between these factors and individual or community health and collaborate to effect change at institutional and policy levels. This preparation will require the transformation of curriculum from one that focuses on individual, behavioral, or cultural interventions to one that integrates structural factors.

Provision 6.3: “Nurses are responsible for contributing to a moral environment that demands respectful interactions among colleagues, mutual peer support, and open identification of difficult issues.”

BILPOC nursing students and nurses across academic and practice areas report experiencing or observing racist acts. These affronts to human dignity are often perpetrated by peers and those in supervisory or leadership positions and contribute to a toxic, uncivil environment where diversity and inclusion may be proclaimed but never realized. To successfully reduce health disparities, the nursing workforce must reflect the population it serves by recruiting and supporting students and nurses of color. Nurses are obligated to reflect on their interactions with all colleagues and eliminate those racist attitudes, statements, and behaviors that are discriminatory, insensitive, or dismissive.

Provision 8: “The nurse collaborates with other health professionals and the public to protect human rights, promote health diplomacy, and reduce health disparities.”

This provision affirms the profession’s commitment to health as a universal human right in conjunction with a corresponding obligation to provide collaborative, equitable health care (Fowler, 2015). To reduce health disparities and uphold our mandate to ease suffering, we must understand and address those entrenched structural health inequities that are the legacy of historical systems like colonialism and slavery. As seen in the COVID-19 pandemic, the outcome of this persistent structural violence may include continuing suffering and death of people of color and other marginalized populations (Grace & Milliken, 2022). Our ethical responsibility as advocates involves not only speaking up for or acting on behalf of individuals or groups but taking collaborative action to achieve health equity for all from the local to the global level.

Provision 9: “The profession of nursing, collectively through its professional organizations, must articulate nursing values, maintain the integrity of the profession, and integrate principles of social justice into nursing and health policy.”

This provision identifies the role of professional nursing organizations “in social ethics and issues of social justice,” including reform of the profession to ensure that it lives up to its own values (Fowler, 2015). The central value and image of nursing as caring can conceal the presence of pervasive racism. Unveiling and eliminating the stigma of racism may allow the profession to fulfill our ethical mandate of promoting racial justice and social justice, as there cannot be one without the other. While this reformation and moral reckoning has begun, much work remains to be done by both individuals and professional organizations to embed antiracism in all aspects of nursing practice and policy.

ANA National Commission to Address Racism in Nursing
The diligent efforts of ANA’s National Commission to Address Racism in Nursing (2021) led to a working definition of the term “racism” that nurses can use to reflect on their own experiences with and around racial injustice. Racism is defined by the Commission as “assaults on the human spirit in the form of biases, prejudices, and an ideology of superiority that persistently causes moral suffering and perpetuates injustices and inequities” (p. 2). The Commission recognized that “failure to call out racism in nursing contributed to ignorance on the part of students, the profession, recipients of nursing care, and the broader public, resulting in both physical and moral harm” (p. 3).

Social Policy
While not directly addressing the nurse’s role and responsibility in ending racial injustices, ANA’s 2010 Social Policy Statement states that societal concerns may garner extensive attention and subsequent action by the nursing profession, and that nursing has an active and enduring leadership role in public and political determination of several key areas of health care, including the organization, delivery, and financing of quality health care. This role includes addressing complex issues such as health disparities and the lack of safe, accessible, and available health care services.

Scope and Standards of Practice
The revised document (2021) contains several sections that focus on injustices, and the nurse’s responsibility to engage in advocacy actions to address the social determinants of health and develop a more diverse and inclusive workforce. Nurses are called upon to confront “unjust systems and structures and use their voices to advocate for transformative action-oriented policies and initiatives that mitigate inequality and promote social justice” (pp. 25–26). Integration of content across the academic curriculum on racism, health equity, and provider implicit bias is recommended as a strategy to develop structural competency.

Summary

In this document, we have presented the unveiling—a proposed reconciliation of the nursing profession’s racial violence. The foundational documents have been reviewed, demonstrating the lack of clear language and direction on the matters of racial injustice in the profession. The most foundational of recommendations have been made and references and resources have been provided. This document has been written using the guidance and teachings of countless scholars and advocates who came before us and are amongst us. We honor the work they have done and acknowledge the risks they have taken in their truth telling. We write with great hopes for the future of our profession and for the people who entrust us to care for them. As nurses, we are invited into the sacred spaces of birth, death, pain, suffering, and healing, and with this privilege comes an obligation to resist all forces that work to dehumanize our patients and ourselves. We must begin with the unveiling—an honest exposure and reckoning with the racial injustices both committed and experienced by our profession. As we look to the future, we yearn for the time when we may all experience authentic human connectedness absent of racial injustice and void of the dehumanizing forces that prevent all of us from achieving health, wellness, and safety.

Note: The authors wish to acknowledge the importance of using inclusive, affirming language. Language continues to evolve, and we seek to continue to update our language to demonstrate our commitment to diversity, equity, and inclusion. Please send suggestions, concerns, and ideas to ethics@ana.org.

Glossary

ally - “Allies are often involved in activism by sticking up for or standing with a person or group in a subjugated community” (Waite & Nardi, 2021, p. 23).

anti-racist - one who explicitly and purposefully fights against racist ideals, policies, systems, and behaviors; the antithesis of white silence.

co-conspirator - “White allies advance to accomplices or co-conspirators when they use their power and privileges all the time, actively fighting against white supremacy and the white privilege they receive from the system” (White & Nardi, 2021, p. 23).

colonialism - the policy or practice of acquiring full or partial political control over another country, occupying it with settlers, and exploiting it economically.

commodify - to turn something, or someone, into a commodity. A commodity is something that, or someone who, is reduced to its or their value as something that can be bought or sold.

critical race theory - a term developed by Kimberle Crenshaw (1989; 1995). It is “the practice of interrogating the role of race and racism … (and) critiques how the social construction of race and institutionalized racism perpetuates a … caste system that relegates people of color to the bottom tiers. CRT recognizes that race intersects with other identities, including sexuality, gender identity, and others … and recognizes that racism is not a bygone relic of the past. Instead, it acknowledges that the legacy of slavery, segregation, and the imposition of second-class citizenship on Black Americans and other people of color continues to permeate the social fabric of this nation” (George, 2021, para., 2).

decolonization/decolonizing - the process of exposing, resisting, and transforming the influence of colonized practices and thought (Chinn, 2020).

disability - any condition of the body or mind (impairment) that makes it more difficult for the person with the condition to do certain activities (activity limitation) and interact with the world around them (participation restrictions) (CDC, 2020).

emancipatory nursing - an approach to nursing practice, theory, research, policy, and education that is fundamentally aimed toward social justice. This means unveiling the structures that sustain health inequality, forming alliances that work to achieve equity, and claiming allegiance on behalf of those who are disadvantaged (Chinn & Kramer, 2021).

historical trauma - multigenerational trauma experienced by a specific cultural, racial, or ethnic group. It is related to major events that oppressed a particular group of people because of their status as oppressed, such as slavery, the Holocaust, forced migration, and the violent colonization of Native Americans (Administration for Children and Families, 2020).

implicit bias - refers to the attitudes or stereotypes that affect our understanding, actions, and decisions in an unconscious manner. These biases, which encompass both favorable and unfavorable assessments, are activated involuntarily and without an individual’s awareness or intentional control (Joint Commission, 2022).

intersectionality - a term developed by Crenshaw (1989) that examines how social structures and related identity categories such as gender, race, and class interact on multiple levels to create social inequality.

liberation - the securing of equal social and economic rights.

microaggression - a comment or action that subtly and often unconsciously or unintentionally expresses a prejudiced attitude toward a member of a marginalized group.

pedagogy - the method and practice of teaching, especially as an academic subject or theoretical concept.

racism - assaults on the human spirit in the form of actions, biases, prejudices, and an ideology of superiority based on race that persistently cause moral suffering and physical harm of individuals and perpetuate systemic injustices and inequities (National Commission to Address Racism in Nursing, 2021).

reconciliation - a method of facilitating frank engagements between marginalized communities, police, and other authorities that allows them to address historical tensions, grievances, and misconceptions, and to reset relationships (adapted from the National Initiative for Building Community, Trust, and Justice, 2022).

resist - an overt recognition of a hostile or threatening force and a positive effort to counteract or repel it (Merriam-Webster’s Dictionary, 2022).

structural or systemic racism - macrolevel conditions (residential segregation and institutional policies) that limit opportunities, resources, power, and well-being of individuals and populations based on race/ethnicity and other statuses including but not limited to gender, sexual orientation, gender identity, and disability (NIH, 2022).

structural violence - the social arrangement that puts people in harm’s way; it is built into the fabric of society and political and economic organizations and creates and maintains inequalities between different social and marginalized groups. It is characterized by an enduring pattern of harm (Burton et al., 2020; Montesanti & Thurston, 2015).

truth - sincerity in action, character, and utterance (Merriam-Webster’s Dictionary, 2022).

unveiling/unveil - to reveal or make visible by or as by removing a veil or covering from; disclose (Collins English Dictionary). The presentation or announcement of something in public for the first time.

white privilege - the set of social and economic advantages that white people have by virtue of their race in a culture characterized by racial inequality (Merriam-Webster Dictionary, 2022).

white supremacy - “a political, economic, and cultural system in which whites overwhelmingly control power and material resources, conscious and unconscious ideas of white superiority and entitlement are widespread, and relations of white dominance and non-white subordination are daily reenacted across a wide array of institutions and social settings” (Caswell, 2017, p. 224, as quoted in Waite & Nardi, 2021, p. 20).

Resources for Liberation in Nursing

After reading this document, many may feel even more conflicted, and experience shame, anger, fear, or a sense of loss. We want you to understand that these are all normal reactions to such a monumental task nurses have to take on to become socially conscious and to liberate racialized bodies from oppression. For those that are seeking ways to take more deliberate action, we encourage you to utilize and apply this document in your lecture halls, on your bedside units and in your board rooms. The document alone has many great offerings and directions for a way forward as well as giving us all much to reflect upon. For those who wish to continue drilling down further, we have compiled a list of resources for more liberation.

Ally or: What it Means to Act #InSolidarity. https://movetoendviolence.org/blog/ally--means-act-insolidarity/

Akparewa, N. (2021). The Clinician's Guide to Microaggressions and Unconscious Bias: Racial Justice in Healthcare.

Hammond, J., Massey, A., & Garza, M. (2020). African American inequality in the United States. Harvard Business School. https://www.tuck.dartmouth.edu/uploads/content/African_American_Inequality_in_the_United_States_(HBS_Case).pdf

Ibram X. Kendi defines what it means to be antiracist. https://www.penguin.co.uk/articles/2020/june/ibram-x-kendi-definition-of-antiracist.html

Nurse Champions for Justice. https://nurse-champions-for-justice.mn.co/

The difference between being “not racist” and antiracist. https://www.ted.com/talks/ibram_x_kendi_the_difference_between_being_not_racist_and_antiracist/transcript?language=en

University of Maryland School of Nursing, In UniSON: Together We Commit, Together We Act. https://www.nursing.umaryland.edu/about/diversity/unison/

University of Washington School of Nursing: Center for Antiracism in Nursing. https://dei.nursing.uw.edu/center-for-antiracism-in-nursing/

Acknowledgement: ANA acknowledges former Ethics Advisory Board (EAB) member Catherine Robichaux, PhD, RN, Alumna CCRN, current EAB members Danisha Jenkins, PhD, RN, CCRN, NEA-BC, Stacy Smith MA, MLS, RN, HEC-C; guest author Nikki Akparewa, RN, MSN/MPH; and Center for Ethics and Human Rights Senior Policy and Ethics Advisor, Kara Curry, MA, RN, HEC-C who contributed to the drafting of this document on behalf of the ANA Ethics Advisory Board.

Column Editor

Liz Stokes, PhD, JD, RN
Email: liz.stokes@ana.org

Liz Stokes is the Director of the American Nurses Association Center for Ethics and Human Rights and demonstrates expertise in writing public policy on ethical issues including medical marijuana, assisted death, intellectual disabilities, and women's reproductive health. She is an international speaker on the Code of Ethics for Nurses is published in the Journal of Nursing Regulation and the Journal for Nurse Practitioners. Liz also serves as an Associate Editor for the Journal of Bioethical Inquiry. Liz's sphere of influence as a nurse-attorney combined with her education in bioethics enables a unique contribution to nursing, ethics, law, and policy.

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