COVID-19 is hitting minorities harder than other communities. According to the Centers for Disease Control, as of June 12, 2020, the age-adjusted hospitalization rates were reported highest among non-Hispanic American Indian or Alaska Native and non-Hispanic black persons, followed by Hispanic or Latino persons. The CDC clearly states that such racial and ethnic minority groups are an increased risk of the getting COVID-19 regardless of age due to long-standing systemic health and social inequities. It has been found that non-Hispanic American Indian, Alaska Native, and non-Hispanic black persons are hospitalized for COVID-19 at a rate 5 times that of non-Hispanic white persons. Hispanic or Latino person have a rate approximating 4 times that of non-Hispanic white persons.
Why are minorities at increased risk during the COVID-19 pandemic?
For decades, health differences among racial and ethic groups have arisen due to living, working, health, and social conditions. During this pandemic, such conditions have not disappeared but work against minorities by isolating them from the resources they need to cope with such outbreaks.
Living conditions contribute to an increased risk of COVID-19 for minority groups. Many minorities live in highly populated communities due to institutional racism. Such institutional racism occurs through residential housing segregation. An example of this can be seen in the overcrowding in tribal reservations and Alaska Native villages. As a result of such densely populated areas, it acts as a barrier to social distancing. Racial housing segregation is all linked to several health conditions such as asthma which increases the risk of becoming severely ill or death from the virus. Also, certain communities with higher minority populations also have increased exposure to pollution and environmental hazards. The reservation homes of non-Hispanic Native Americans also have been found insufficient in plumbing when compared to the rest of the U.S. As a result, it proves a challenge for handwashing to occur regularly. Some members of minority groups also rely heavily on public transportation, making it difficult to follow through with social distancing. Minority groups also more commonly have multigenerational and multi-family households, which makes it harder to protect older adult family member or isolate sick household members in such limited space available. Minority groups are also over-represented in congregate environments such as jails, prisons, homeless shelters, and detention centers, which again presents a challenge for social distancing as they engage in activities of daily living in group settings.
Certain work conditions and policies also put workers at an increased risk of being infected with COVID-19. Certain minorities are more likely to work under such conditions. Being an essential worker in essential industries like health care, meat-packing, grocery stores, and factories put minorities at risk. This is because they are required to still work despite outbreaks occurring in their communities and some may need to work such jobs due to economic circumstances. They also may not have sick leave so such workers are more likely to work despite being sick. Income, education levels, and unemployment are other factors that must be considered. When considering the average earning of minorities compared to non-Hispanic whites, minorities earn less, possess less accumulated wealth, have lower levels of education, and higher rates of unemployment. All such factors contribute to the social and physical conditions of minorities which also affect health outcomes.
Lastly, the health circumstances of minorities play a major role in their being at increased risk of COVID-19. The issue of being uninsured is one of the highest concerns. Hispanics are about 3 times more likely to be uninsured than non-Hispanic whites. Whereas, non-Hispanic blacks are about twice as likely to be uninsured when compared to non-Hispanic whites. Minorities report cost as a barrier to seeing a doctor as well as distrust of the health care system, language differences, and losing wages due to missing work. Minorities also suffer from certain health conditions at higher rates than non-Hispanic whites. Black have higher rates of chronic conditions and at earlier ages with higher death rates than non-Hispanic whites. Non-Hispanic American Indian and Alaska Native adults are reportedly experiencing higher rates of obesity hypertension, and smoking then non-Hispanic white adults. Such health conditions put minorities at increased risk of severe illness. Racism, stigma, and systemic inequalities also contribute to health circumstances that increase the risk of COVID-19 in minorities. Such factors undercut prevention and increase the levels of stress in such communities, therefore, continuing health and healthcare disparities.
What can we do as health care providers and organizations?
As health care providers we must first understand this novel virus and how to best prevent, intervene, and treat it. However, in order to combat the health disparities in minorities, health care systems should offer providers training on how to identify their implicit biases. Providers must understand how implicit bias affects the way they communicate with their patients and how their patients will react to such communication. They also should be trained on how bias can affect their decision-making. Medical interpreters should be available in health care systems. Health care systems should work on community outreach projects in an effort to reduce the cultural barriers to care. As providers, we need to connect our patients with community resources that can help them manage underlying conditions. We should encourage our patients of all backgrounds to ask questions and promote a trusting relationship. All of these strategies could combat the distrust minorities may experience of health care in general. The starting point for all these forms of action is to learn more about the socioeconomic conditions that put certain patients at risk for getting sick with COVID-19. It is my hope that this essay is only the starting point for all health care providers and administrators who read it to aggressively protect the lives of racial and ethnic minority groups during this grueling pandemic.
In this essay, I present my firsthand account of my experience as an African American nursing student in a predominantly nonminority nursing program as well as my perceptions and interactions with fellow students. As an autoethnographer, I sought to answer the following question: What is the African American student nurse’s experience of education in a predominantly nonminority school of nursing and university, and how does that experience affect her as an individual?
Pre-Nursing School: Being “White”
In high school, I was called “white” by the majority of the few African American students in a high school of nearly 500 students in the Northeast. Initially, when they said this to me I was shocked. I had been on the receiving end of racially charged comments by white peers, and now I had to deal with this from my own race and ethnicity, too? I wondered why I could not catch a break. I remained confused but focused on my schoolwork. Since being a freshman, I was in honors classes, those with the maximum rigor in the entire school. It was viewed as if only the elite were in these classes, but I surely did not feel like the elite. My white peers in those classes assumed I came from the ghetto and asked me to teach them Ebonics and about rap music (which I did not listen to). I was isolated in those classes because of such stereotypical comments and the competition to be number one of the entire graduating class, but mainly because I was the only African American student in such classes. The comments from my African American peers only intensified as I was enrolled in both cosmetology in vocational school and Advanced Placement courses (which could alleviate me from taking college courses, once enrolled).
One of my African American acquaintances, who I thought seemed amicable, approached me purposefully one day in the hall. She looked like she was on a mission to find me as I put my things in my locker. I met her with a kind hello—I did not have many friends in school. I blamed myself for that, being so quiet. She stated loudly with a greeting, “Do you think you are better than us?” I said, totally confused, “Us? Better than who?” She quipped, “You know exactly who I mean, the few blacks in this school.” My face must have looked blank. I just stared at her with curiosity due to the fact that, besides the “white” comments, there was never an extended conversation or association besides my distant friendship with several other minorities. She continued to badger me, “You know you think you are better than us since you are in those special classes. Who do you think you are?” I simply responded, “Nothing.” At the time, my self-esteem was low; I had become tired of my lack of association. She was not buying it. “You know what? It must be true that you are white because you even talk like them,” she said. “Don’t ever think you are better than us. We are just as smart, although we may not be in the AP classes.” Taken aback, I explained, “I never said you weren’t. You should talk to your advisor about enrolling in one of the classes.” Without acknowledging my reply, she stormed away, saying, “Wow, you are white.” As she walked away, I blinked at her and said to the dust trailing behind her, “It is funny because my skin is black like yours.” I went on to finish my day; however, the episode never stopped playing in my head, even after I became a nursing student.
Katie Love, PhD, APRN, BC, AHN-C, wrote about the lived experience of African American nursing students in a predominantly white university in a 2010 article published in the Journal of Transcultural Nursing. One of the themes of her phenomenological study was that of fitting in and “talking white.” She reports about a study participant who had grown up in a predominantly white secondary school and had become accustomed to experiences with white students. African American nursing students who did not have such an experience described some African American students as being “Oreos…Black on the outside and white on the inside.” Such “Oreos” are described as African American students who are black but “act White, socialize, and talk like White people.” One of the participants of the study shared the following observation: “To me it’s kinda a funny thing that it’s such a problem in the Black community that you could not talk in a certain way…but if you start talking slang, then to them you’re trying.”
I could identify with Love’s study as my isolation from peers—from within my own race and from without—began in high school. In high school, I was excluded by white students because of the color of my skin and, at the same time, excluded by my African American peers because of the way I carried myself and spoke. In nursing school, my isolation continued. It would eventually lead to my depression.
Nursing School: Feeling Isolated and Excluded
Fast forward to nursing school. The faculty and advisors began our edification with a talk about the rigor of the courses. I remember a gentleman announcing, “Look around the room. See everyone here? Not all of you will be here in four years. The truth is, nearly half of you may not make it to graduation.” I remember sitting in the warm amphitheater and feeling intimidated by his words. When I looked around, as instructed, I noticed the class was made up of only three African Americans. The largest minority group were of Hispanic background.
The first few semesters were full of straight science courses, which translated into nonstop studying. I spent my days in the library enjoying my books and learning. The days went so fast, when all I did was read and study the day away. In the blink of an eye, the end of the first year arrived. All of the Hispanic students were eliminated either by not meeting academic requirements or by choosing to leave the program. I was afraid that I would be next. My classmates were mostly white students. At times, I felt I did not belong. None of my professors looked like me. The nonminority students studied together and did not invite me, much less speak to me.
I remember our professor addressing the class during our sophomore year. She advised everyone in our small section to avoid driving alone to a distant clinical site and to carpool instead. I looked around the room attempting to make eye contact but did not receive any response. My nonminority peers turned around in their seats and, within minutes, had arranged themselves into two car groups, which left me out. I told myself, “You really thought it would be different, huh?” I laughed to myself and stopped looking for a group. That experience solidified the divide for me.
In 2004, Nancey France, PhD, RN, and her colleagues at Murray State University published a pilot study in Visions: The Journal of Rogerian Nursing Science that examined the lived experiences of black nursing students and found many reported feeling isolated and discounted. One of the themes of the data was “You’re just shoved to the corner.” One African American student nurse clarified, “You may get one or two that wants to include you…You may go up to them, you’ll risk to say ‘are you going to study?’ If you think that you know them and everything’s o.k., you’ll say, ‘are you all going to have a study group this weekend?’ And they’ll say ‘yeh’. But, when the time comes…you can’t get in.” Another student reported, “I’m the only black, in all my classes I’ve been the only black. It’s hard because…you got to prove yourself. If you don’t do as well as the other students they just single you out. That’s why I have to strive to do the best I can.”
Black students also reported feeling they were only admitted to schools of nursing to meet a quota. They described the increased pressure exerted on them when minority attrition rates were high in their class. As a result, they experienced emotions such as self-doubt, fear, lack of confidence, and diminished self-esteem before attending class. Many students reported these feelings pushed them “even harder to prove they could be successful.” There seemed to be a consensus that there was an unspoken expectation of African American students to fail, which propelled these students to greater levels of determination to prove that “they were as smart as anyone else.”
Moving Up: The Benefits of Exclusion
During my third semester in nursing school, I became tired of sitting in the back of the classroom. What had once seemed comfortable became an annoyance to me. The students who supposedly knew all the answers sat in the front, always the first ones to raise their hands. However, their answers were the same as mine—always. They weren’t any better than I was. I decided to beat the caste system within my own classroom. I felt my sitting in the back row was perhaps contributing to my isolation and depression that had begun to develop. Humans are not meant to be excluded—we need contact. As a result, I started moving forward, slowly but purposefully, to avoid and overcome my feelings of exclusion.
I remember deciding I would not allow myself to sit in the back anymore. I felt like Rosa Parks as I migrated up to the middle rows of the classroom. I began to raise my hand more. I found that studying alone was beneficial to me, as I knew the full answers to questions that other students merely answered in a general way. As a result, I started raising my hand and answered insightfully each time.
I wasn’t sure of myself until my anatomy and physiology professor approached me and asked if I wanted to become a physician. He tried to convince me to enter the premedical program. I was flattered and taken aback, but I knew it was not what I wanted. I had fallen in love with the few nursing courses we were allowed to take. I could not betray my passion for nursing and really “being” with the people. However, he had not approached anyone else in the class with this offer.
It was after that discussion that I moved up and became the snob who raised her hand to answer every question, at every opportunity. It was not until then that I had my first contact with nonminority students, other than a glance. They soon began asking how well I did on my exams. When interrogated, I replied without emotion, saying I did “okay” when I knew I got an A. They soon lost interest in me again. They did not know that their exclusion of me in their study groups was paying off greatly for me. I had become an independent and successful learner.
As the years progressed, I think they began to suspect I was doing better than just “okay” as I began to earn scholarships and recognition from my professors in class. It was unwanted attention for me because I wanted to keep my head low. What began as a business venture to simply gain a skill that would sustain me as an adult turned into a love for the profession of nursing. I had not expected that—it just happened. As my love grew, I began to excel. As I excelled, I felt the isolation increase. I had become used to it; it didn’t really bother me on the surface. It seemed other students were in school to make lifelong friends and to have a good time. I was in nursing school solely to earn my degree, focusing intently and singularly on my studies; so, most nursing students tended to avoid most nursing students avoided me.
I soon began to wonder if I had isolated myself, but then I noticed in my junior year that professors began to assign more group assignments. In those voluntary group assignments, I observed minority students chose to work together in the same groups, while nonminority students chose to work together in their own groups. I wondered if the professors noticed the same thing I did. It went on like this until the end of the nursing program.
A 2015 integrative review published in Nursing Education Perspectives reaffirmed that there are several studies where African American nursing students reported feeling “voiceless, not part of the important conversations, left outside of the cliques, alienated and insignificant.” Many minority students coped with these conditions by forming their own network among other minorities and “sticking together.” Additionally, Love noted in her study that African American students familiar with “being left out” from high school experience were better able to accept exclusion and move beyond the experience.
All that studying and exclusion seemed to work better for me. It worked out because I graduated. During graduation, I knew a select few would earn special acknowledgement for their achievements. I was sure it would not be me. I was so focused on getting out of there. I had the chance to extern on a unit in a teaching hospital where nonminority staff embraced me as if I was family. I just wanted out of nursing school. At the end of four years, it felt like prison only being able to talk to and connect with six minorities who made it to the end of the program. Now, I was free to explore the world as an adult with a real job—not just a student building up debt.
These were my thoughts as I was called up to shake hands with all of my professors. I was so focused on receiving my degree that the moment when they called my name seemed only a second. When they began to announce the special recognition awards for academic and clinical excellence, I kept looking back at my family and realized I was one of the few students wearing a purple tassel, which meant we were part of a special group: the Honor Society of Nursing, Sigma Theta Tau. We had high GPAs.
Then I heard one of my professors say my name. I looked around and those around me whispered, “That’s you! Get up! They called you!” I had earned the award for clinical excellence. I was speechless and nearly stumbled up to the stage. I thought my professors were not interested in me, but they had nominated me for this award (and I assume they voted that I receive it). I was flabbergasted but filled with pride because I—the quiet African American student nurse—had earned this great honor. I thought I had not deserved it, because there were so many things I did not yet know, and I knew I was not the perfect student. I critiqued myself for those few senseless Bs I had earned. It was not until I returned to my seat the second time that I realized maybe I did deserve this award. Just maybe, I had worked hard enough in that I enjoyed putting the entire patient picture together—staying in their rooms, discussing how they felt about their illnesses while taking it all in, and figuring out how I could use my knowledge to prevent one less complication. I was more than a student nurse in those moments with my patients; I assumed the role of nurse and took such opportunities with the utmost seriousness. I remember a great exhalation as everyone threw their caps to the roof of the auditorium. I was deserving.
Soon after graduation, I passed my licensing exam on the first try and began working on a medical-surgical floor at a teaching hospital. My work was challenging and kept my attention, but I soon began to crave schooling. I decided to enroll in an online program. The main reason for doing so was so no one could see my face and perhaps I could fit in for once. And I did. I felt since no one could see the color of my skin or the youth of my face there would be no divisions. It proved true. I enjoyed my online schooling and soon pursued a doctorate program online after completing my master’s in nursing education.
In a 1998 study published in the Journal of Nursing Education, author Mary Lee Kirkland, EdD, RN, concluded that the most successful coping strategies of female African American nursing students are active coping and social support. She explains that “although they may have faced times of discouragement or despair, they did not waver in their pursuit of their goals. They relied on their inner strength to take the action needed to conquer their stressors and move on successfully.” I had a support system of my spirituality, my family at home, and my friends of the same faith that kept me strong. They probably were unaware how they were the one thread that held me together through emotional turmoil and numbness.
Enlightenment Upon a Return to the University: Six Years Postgraduation
Aside from the anatomy and physiology professor, who was from the biology school, I was never sure how the true nursing faculty viewed me. It was not until I returned six years later as a clinical nurse specialist to become a mentor for nursing students like I had been—of the minority. I was also pursuing a scholarship for my doctoral education with a focus on nursing education.
When I met with one of the professors, I was sure she had forgotten me by the e-mail she had sent back when I asked for a letter of reference and to meet to discuss a mentorship program for minority nursing students. However, when I walked in the door in my professional attire, she told me, “Wow, I remember you. I wasn’t completely sure in your e-mail, but now I know who you are exactly…You were always so bright. I knew it then, and look at you now and all you have accomplished. You have your master’s and are a clinical nurse specialist….[Another professor] and I are rooting for you to get this scholarship.” Our conversation ran long before a student showed up for her advisement. The professor told me warmly, “Keep in touch. We are so proud of what you will become and have become already!” She had written my letter of recommendation. However, the recognition she provided in those moments proved to me I did not know myself those years as well as I did right then.
I had not been invisible, after all, and the award I received upon graduation was not for show, but because my professors saw such great potential in me. I had become visible to myself and the world. My confidence soared as I left the campus. I had driven in, but I seemed to fly home, alongside the clouds.
My mother always encouraged me to play with dolls of a variety of shades. She particularly would always want me to play with dolls that had the same complexion as myself. I never quite understood this until recently.
I remember waiting for my women’s health professor to arrive. I expected her to be an older woman and not a minority as most of my other professors were. When she showed up, I only recognized she may be our professor because she wore a white jacket. Then she walked up to us and introduced herself as our professor. She was younger than I expected and of the same ethnicity as myself. For some reason, until then, I had never seen myself as being a nurse educator. But, seeing her standing there and doing such a good job teaching my classmates and I, I suddenly considered nursing education as a route I may take.
When working among a diverse nursing faculty as I do, I hope that we can do the same for our students from diverse backgrounds. Perhaps by seeing someone who looks like themselves, maybe we can inspire our students to go beyond what they ever imagined. I had only thought I would graduate and be a nurse, but this young woman I mentioned was a nurse practitioner and an educator. She made me think suddenly that I could aspire to a similar career.
I wish I could see her today to tell her that her work with me inspired me to be the woman I am today: a minority nurse educator!
I fondly remember sitting in the waiting room for a scholarship that was offered to African American students to be of use for academic endeavors. I was waiting to be interviewed. However, I remember not feeling nervous and feeling confident that I would be able to answer any questions they may have for me. This surprised me then and surprises me now as an adult. At the aforementioned time, I was only 17 years of age and a senior in high school. There was one question, though, that I did not anticipate as I sat in a room of nurse leaders.
They asked me, “As a young African American like yourself, what do you see as the barriers to your success?”
I just looked one of the interviewers square in the eye and stated, “There are no barriers, from my point of view.”
I’ll never forget the interviewers being so shell-shocked. I do not think they expected this answer.
I explained, “Barriers are what we perceive them to be. If I do not perceive any, they simply do not exist.”
Now, as an African American nurse who has attained her baccalaureate and master’s degrees and is currently working on her doctorate, I see the importance of this idea in my life. The brain can perceive many things, and they may not necessarily be real. This has been proven true again and again in the perception of illusions, or tricks of the eye. The same proves true in the outlook of minority nursing students today. Merriam Webster confirms that constructs are the things created by the mind or the product of ideology, history, or social circumstances. You must remember that barriers to success are simply constructs, only true if you choose to accept them into your reality. Such barriers may come in the form of racism, a challenging nursing course, financial troubles, or other adversities. There may be difficulties, but there are always ways to overcome these difficulties as one strives to complete an entry-level nursing program or pursue an advanced degree in nursing.
I was awarded that scholarship. And to think, it was attributed to a positive idea that my mind constructed. As a result of this positive idea, I was able to have a generous contribution made toward my baccalaureate degree. Yes, my positivity was a source of success and continues to propel me forward in this great profession. Do not let constructs of the mind hold you back in achieving your own elaborate dream of success.
A patient calls you a racial slur.
A coworker makes a racially charged statement.
A family member makes a racial joke and anticipates you will laugh with them.
How would you respond to such hurtful comments? Do you respond by confronting them verbally? Do you scold them? Or do you contemplate responding to them in a physical manner? All these thoughts may race through your head, running through your synapses. But what is it that is released by your body? An action or a word? Or do you say nothing and keep such pain within? What is the best course of action of the nurse?
One of the highest tenets of nursing is caring. How do you find it within yourself to care for individuals who verbally express racial hatred? Have you ever utilized self-awareness or mindfulness to combat such behavior? This means being aware of yourself, others, and the environment surrounding you. This also translates into one being keenly mindful of their emotions. Although such behavior may cause feelings of anger or sadness, one can begin to understand the cause of emotions and how one’s outer and inner circumstances triggered the emotion and may lead to the amplification of it.
Instead of going along with an overpowering emotion, we need to seek higher ground from which to look upon that feeling. This does not mean flattening our emotions or being emotionally numb. Brooding exploits one’s previous feelings, only illuminating hatred. On the other hand, analyzing the source objectively allows one to take such energy as they run out before us like ‘scouts,’ simply telling us about the world instead of dictating one’s behavior. Instead, you become like an artist who is keenly aware of their emotions yet can share their emotions through their art. Therefore, life becomes a work of art.
Arthur Zajonc, author of Meditation as Contemplative Inquiry: When Knowing Becomes Love, talks about great individuals who learned to practice such self-awareness. He explains of Mandela and the Dalai Lama being able to “carry not only their trials but also the burden of those under their care…with grace and lightness that belies the fullness of their heavy hearts…because they discovered the secret of empathetic knowing and equanimity when confronted with suffering.”
Once during a reception, a reporter pressured the Dalai Lama to comment regarding his opinion of those who had killed monks and nuns and destroyed monasteries during an invasion of Tibet. Instead of speaking out in anger he admitted that the loss of Tibetan autonomy was a tragedy. He then spoke of how the loss and suffering of his kinsmen were painful and should be stopped. He concluded that he would do all within his power to regain the self-rule of his nation. The Dalai Lama describes a contemplative exercise where he pictures the suffering of his people at the hand of Chinese offenders but also sought to look at the viewpoint of these Chinese soldiers as they saw themselves. They felt they were liberating the Tibetans from a religious tyrant. They believed the Tibetans to be ignorant in their belief of a god-king, the Dalai Lama. Therefore, he did not view the soldiers as evil despite their actions being violent and hateful. The Dalai Lama did not respond to the reporter without rage but instead provided a lesson in seeing through to the possibility of good in one’s tormentor.
Likewise, Nelson Mandela, after 20 years of incarceration, did not seek out revenge against those who imprisoned him. Rather, he effaced ethnic strife and Black Nationalism to affirm the humanity in everyone of every color. He did this with the goal of having the white minority have equal opportunity in government, the security, and the rights to land as the oppressed black South African majority. He displayed faith in the whites and blacks of South Africa and did not seek retribution. Rather, he saw the highest in those who oppressed him so that he worked with the government to create laws of inclusion and reconciliation, rather than exclusion and revenge.
Zajonc concludes that “in every situation, there is something worthy of the human being.” The self-aware nurse can acknowledge the negative, but not the negative alone. Therefore, the negative and unjust act is not allowed to blind the nurse who practices self-awareness. That nurse is still able to see the hidden good within each and every individual by upholding the ‘noble dimension’ of the individual who makes a racist comment or act. This is described as displaying faithfulness to the humanity of every individual.
The next time you are confronted with a discriminatory comment or behavior, consider practicing mindfulness. It is an evidence-based practice proven to raise one’s awareness of one’s emotions and sensations in a situation. Experiencing discrimination is associated with increased incidence of depression. However, according to a 2014 study published in Personality and Individual Differences, adults experiencing discrimination who reported high levels of mindfulness had fewer symptoms of depression. Mindfulness is thought to enable individuals to separate experiences from a sense of self-worth.
A decade of research has found mindfulness to be associated with regulation of emotional responses, reduction of anxiety, increased empathy and perspective-taking, and increased gratitude and well-being. As a result, perhaps we can conquer a similar perception to Nelson Mandela and the Dalai Lama. By practicing mindfulness, one can maintain peace of mind and with those who may make unwholesome comments of any nature.