When Elsie Chin Yuen Seetoo was born on September 14, 1918, in Stockton, California, no one could imagine that by the time she was 30 she would work in a hospital under attack by the Japanese Army; escape occupied Hong Kong disguised as a Chinese servant; travel by boat, truck and foot across 700 miles of war-torn China; become the first Chinese-American nurse to join the US Army Nurse Corps; and then graduate from Women’s College in Greensboro, North Carolina, with a Bachelor of Science in Nursing degree. Her unique and harrowing tale begins decades before her birth.
Seetoo’s father, along with thousands of other Chinese men, came to California seeking jobs and opportunities unavailable to them in their homeland. When he arrived, Mr. Chin first worked as a laborer and then as a cook for a private family. He saved enough money to open an import-export grocery store business in Stockton. He became a merchant because it provided the legal status he needed in order to bring his Chinese wife and son to the United States. After settling in Stockton as a family, the Chins had two daughters. Although she was the only Chinese student in her public-school classroom. she remembers her childhood fondly. The Chin children attended Chinese school from 5-9 pm, in Stockton’s small Chinatown, here they learned to read and write Chinese characters. In addition to her schooling, she was an active Camp Fire Girl (Lee, 2019)
In 1930 the United States was in the middle of the Great Depression. The family business was failing, so the Chins decided to return to China. Because Seetoo and her younger sister were born in California, they were United States citizens. After completing high school in China, she wanted to further her education. However, in the 1930s, Japan invaded China and controlled most of coastal and eastern China where the major cities and universities were located. Many Chinese universities closed during the Japanese invasion and occupation. In any event, the Chin family did not have enough money to help Seetoo with college expenses. So, in October 1938 she began her studies at the English language Queen Mary Hospital School of Nursing in the British Colony of Hong Kong (Moy, 2014).
Student Nurse Days
On December 7, 1941, the Japanese attacked Pearl Harbor, bringing the United States into World War II. That same day Japan also attacked the Philippines, Hong Kong, Burma and other Asian countries. Seetoo recalled:
“… it was the morning of December the eighth, when we were greeted by Japanese bombs and shelling. Of course, we were placed on a wartime footing right away … All patients that could go home were sent home, and then we were taking in battle casualties that very first morning … after two weeks Hong Kong surrendered … we knew after that the Japanese are going to want the hospitals … the British sisters [nursing faculty] had the foresight to know that they were going to be interned, so they gave us our temporary certificates, RN certificates. (Trojanowski, 2005).”
On December 10, 1941 during the Battle of Hong Kong, nursing school administrators issued each third-year student a Certificate of Training from the Medical Department of the Government of Hong Kong. These certificates were on par with diplomas and conferred the title Registered Nurse (Chung, Ching & Wong, 2011). Chinese, British, Indian and Canadian forces defended Hong Kong during two weeks of fierce fighting. Facing overwhelming Japanese forces, the allies surrendered on Christmas Day, 1941. By then, Queen Mary Hospital was full of casualties. Seetoo, alongside hospital staff and fellow student nurses, worked tirelessly caring for the wounded soldiers. On December 26, 1941, Japanese Army troops entered the hospital, interned the foreign patients and staff, and turned the hospital into a Japanese Military Hospital (Copp, 2001). Seetoo was 23 years old, a Registered Nurse and living under Japanese rule in occupied Hong Kong. In an oral history interview she remembered:
“A few days after the surrender we saw some Japanese officers come to inspect the hospital … as soon as we saw them, we were kind of on edge, because you’d hear all these stories about rape, and rape of Nanking, and the Japanese had been very bad about commandeering women to be part of their—they called it comfort women, which is actually making sex slaves of them. Anyway, we had heard stories of that, so naturally we were very, very concerned.” (Trojanowski, 2005).
Rita Wong, one of Seetoo’s classmates, remembered the early days after the Japanese invasion,
“All foreigners working at the hospital were sent to a concentration camp, and the Chinese were gathered at a hospital where they had nothing to do but wait for their meager food rations. The Japanese made it a rule that no doctors or nurses were to leave Hong Kong, and those who were caught doing so would be killed.” (Macfie, 2007, p.1)
Escaping Hong Kong
Despite this Japanese edict, Seetoo and several of her Chinese classmates, including Rita Wong, Rebecca Chan Chung, Daisy Pui-Ying Chan, Cynthia Chan and Irene Yu, were determined to help their country and its American and British allies. They knew they had to make their way to Free China, which was in southwestern China and unoccupied by the Japanese. Individually and in small groups, these nurses disguised themselves as peasants and slipped past Japanese guards as they escaped from Hong Kong, making the 700-mile journey inland towards Kunming, the capital of Free China (Chung, Chung & Wong, 2012).
Seetoo, her brother and three of her classmates began the journey together. They traveled to Macao by boat, then hitched a ride with a truck driver to the Chin family home in Xinhui. After a short visit, the group walked four hours to Shuiko where they boarded a ferry. On the ferry was a classmate of Seetoo’s brother, Mr. Liao. She recalled their encounter:
“[Mr. Liao said] I’m going to write a letter to the pastor of the Baptist Church at your next stop, Gaoyao, and ask him to let you folks sleep in the church sanctuary – and to provide whatever assistance you need. And when you leave for the next stop, ask him to write a letter to the Baptist preacher there in Wuzhou asking for the same favor … That was how we finally got to Guiyang – by stopping at various churches along the way.” (Trojanowski, 2005).
In April 1942 they reached Guiyang, headquarters of the Chinese Red Cross Medical Relief Corps (CRCMRC). There she met Dr. Robert Lim, the director of the organization, who offered her a position in the operating room of the Red Cross sponsored hospital in the city. Seetoo accepted the offer and went to work.
Diversity, equity, and inclusion (DEI) are hot topics in the healthcare world, but including a DEI module in our yearly education isn’t enough to address these issues. Policy is a valuable tool, but actual change needs to come from a more personal level, from each and every staff member.
Before we can have a meaningful conversation about DEI that might lead us toward significant change, we need to understand the meaning of diversity, equity, and inclusion and why it is important in healthcare.
First, the issues often relate to our biases, especially those so deeply ingrained in our life circumstances that we aren’t aware of them. We can’t advocate for what we don’t understand, and if we don’t advocate for change, we will stay in our “safe” silos, which only strengthens the idea that we are separate and different.
Understanding that we are separate and different and what that means is the first step in making diversity, equity, and inclusion a part of our workspace and nurse recruitment.
Diversity is simply including people with different backgrounds. For example, when healthcare systems conduct nurse staffing while considering different cultural, gender, religious, sexual orientation, and socioeconomic backgrounds, the staff benefits from exposure to differences among coworkers, and patients feel more comfortable knowing they aren’t alone.
Our healthcare system has been lacking in diversity from the beginning, and although we’ve seen a lot of progress since the days when only white males could practice medicine, we are far from diverse.
In one study, over 56% of physicians identified as White and 64% as male, according to the Association of American Medical Colleges (AAMC). According to Minority Nurse, about 75% of RNs identify as White, and 91% are female. So if most doctors and nurses are white, most doctors are male, and most nurses are female, who are we really serving?
When we don’t have a common background, it’s easy to make the mistake of seeing the patient through our own lens instead of their reality. Our lenses place them where we want them to be—fully able and capable of taking the steps we want them to take for their health. The outcomes we desire assume the tools, processes, and understanding are within their reach and that they have the same goals we do.
Textbook knowledge can never make up for the lack of diversity in our own lives. And our lack of understanding of our patients’ reality can lead to misunderstanding or errors in care, creating inequity. Hiring a diverse workforce promotes understanding and creates a more comfortable environment for patients and coworkers alike.
Equity is a concept that often gets confused with equality. In healthcare, equality means giving everybody the same resource or opportunity to achieve their health goals. Equity is recognizing that each person has different circumstances and honoring that by allocating opportunities and resources to allow them to reach an equal outcome.
Simply giving someone an opportunity isn’t enough if they don’t have the means to use it. Equity can only be achieved when nobody is allowed to be disadvantaged due to age, race, ethnicity, nationality, gender identity, sexual orientation, geographical background, or socioeconomic status.
Access to life-saving medication is an example of inequity we see every day. A medication that costs hundreds of dollars every month may not be out of reach for someone with superb insurance coverage and a large bank account. For someone whose job doesn’t offer prescription coverage or who doesn’t make a living wage, that life-saving medication is technically available but far out of their reach. Far too many patients fail to fill the prescriptions they need for this reason.
Healthcare policy can promote equity, but we can also change how we treat and educate patients. In our medication example, we could address a patient’s ability to obtain a prescription before they leave the office or hospital. No patient should walk out the door with a prescription they can’t fill.
Inclusion is about deliberately creating a respectful and safe environment for all staff and patients. Inclusion means giving patients and staff a voice in giving and receiving care and encouraging diversity. Healthcare isn’t the place for a one-size-fits-all approach. We must all strive to embrace diversity and promote equity.
Nurses Are Uniquely Positioned to Champion DEI
Nurses may have little say in enacting policy within their healthcare systems but are very likely the first and last staff member a patient sees and the role they interact with most frequently. That close relationship with our patients makes nurses the most important role to champion diversity, equity, and inclusion with our patients, in nursing education, and within our own workspaces.
One of the most essential directives we learned in nursing school may have been to meet patients where they’re at. Let’s add and coworkers to that and, together, we can create a more effective healthcare system that serves all people.
When he is not treating kids as a pediatric Transitional Care Unit (TCU) nurse at VCU Health in Richmond, VA, Ren Capucao, MSN traces the rich heritage of Filipino nurses in the US.
As a nurse historian (Capucao’s first article was published in 2019 in the Nursing History Review), he focuses on studying the fascinating story of Filipino American nurses. Capucao is working toward a PhD at the University of Virginia School of Nursing, and his scholarship has shown so much promise that he has been named a Fulbright Scholar for 2022-23 and will be a Fellow at the University of the Philippines, Manila.
“Seeing through my mother’s lens as a nurse,” Capucao says, brought home to him “the sacrifices she made to care for her loved ones. For all the trailblazing nurses that immigrated to the U.S., I can only imagine the struggles they faced on top of caring for patients often culturally dissimilar, so I am humbled to have these nurses invite me into their homes and openly share their memories.”
Capucao will use the Fulbright grant to travel to the Philippines during the 2022-23 academic year to continue his investigations into Filipino nurses’ histories, conducting interviews, collecting oral histories, and diving into historical archives. He is also an editor for the nursing and medical history blog Nursing Clio, and his dissertation study “Pressed into Starched Whites: Nursing Identity in Filipino American History” has already earned him grants and accolades from the Virginia Humanities, the Philippine Nurses Association of America, the Bjoring Center for Nursing Historical Inquiry and the Barbara Bates Center for the Studying of the History of Nursing.
In this video, “A Culture to Care,” Ren shares some background on the history of Filipino nurses in the US and his own very personal links to nursing and the tradition of nursing among Filipinos.
In percentage terms, Asian Americans are the fastest-growing U.S. racial group for the past three censuses, yet data aggregation obscure distinctions within subgroups of the more than 24 million Asians living in the United States. The JNCI commentary illustrates the harmful impacts this is having on Asian American communities.
Chen said the neglect of Asian American cancer inequities stems from multiple factors. They include historical prejudices against Asian Americans and the myth of Asian Americans as the model healthy minority, compounded by language and cultural barriers as well as racism.
“Asian Americans are unique as the first U.S. population to experience cancer as the leading cause of death,” said Chen. “Bigotry against Asian Americans, pervasive since the 19th century, but especially during the COVID-19 pandemic, is only exacerbating the cancer disparities that are costing Asian Americans their lives.”
High rates of certain cancers in Asian Americans
The authors cite a disproportionate rate of certain cancers affecting Asian Americans including:
Cancers due to infectious origin such as the human papillomavirus (HPV). For example, Vietnamese American women experience the highest U.S rates of cervical cancer.
High rates of liver cancer caused by chronic hepatitis B virus (HBV) infection rates in Asian and Southeast Asian Americans, including Hmong Americans.
Nasopharyngeal cancers, occurring in the upper part of the throat behind the nose, affecting Chinese Americans at high rates.
Stomach cancers, which have the highest rates among Korean Americans.
Lung cancer among never-smokers that disproportionately affects Asian American women at a rate of more than twice that of non-Hispanic white women.
The authors note an “infinitesimal proportion” of the National Institutes of Health (NIH) budget funds Asian American research even though the population is experiencing the highest percentage increases of any U.S. racial population for the past three decades. Between 1992 and 2018, only 0.17% of the total budget of the NIH funded research on Asian Americans. A portfolio analysis of grants funded by the National Cancer Institute’s Division of Cancer Control and Population Sciences showed a very limited number of studies focused on Asian Americans, with none at the time addressing the causes of cancer.
Asian Americans are also underrepresented in clinical trials. According to the commentary, only 1% of clinical trials emphasize racial and ethnic minority participation as a primary focus. Only 5 such trials focus on Asian Americans as compared with 83 for African Americans and 32 for Hispanics.
“Classifying Black Americans and Hispanic Americans as underrepresented minorities in clinical trials is helpful, but it is regrettable that our national policy excludes designating Asian Americans as underrepresented minorities, as documented by data in this commentary,” said Chen. “There is a myth that Asian Americans don’t get cancer, but that is far from the truth.”
What needs to happen to equalize cancer inequities
To rectify inequities, the authors recommend a call to action:
Disaggregate data for Asian American subgroups (Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippines, Thailand, and Vietnam). The commentary calls for a separate focus on Native Hawaiians and other Pacific Islanders.
Assess the impact of lived experiences and historical trauma. The authors state that culturally competent oncology care is required to improve access to health insurance/health care. They assert it is also needed to address language and cultural barriers that prevent Asian Americans from getting the medical help they need.
Listen to community voices. Rich diversity and unique experiences within Asian American communities are best understood and appreciated by listening to and partnering with patients and community advocates. Research must ensure community representation, buy-in and engagement.
“It is also important to focus on the impact of racism on cancer disparities and prioritize funding resources. Otherwise, we will not take the necessary steps forward for achieving health equity for Asian Americans,” Chen added.
Nurses inevitably encounter situations that cause moral distress. At the height of the Covid-19 pandemic, though—when there was no vaccine, and it was still assumed that for at least two years there would be no protection beyond masking and social distancing—moral distress became a daily ordeal for many frontline nurses.
Among those hardest hit by moral distress were the nurses of color working through a pandemic that exacted a disproportionate toll on Black, Filipino, Latino, and Native American minorities. Their experiences during the early days of Covid are at the core of a new study from researchers at DePaul University’s School of Nursing. In interviews with a diverse group of nurses located across the US, investigators found that moral distress was an almost inevitable affliction when lack of support made it impossible for nurses to provide high-quality care based on their training.
Nurses on the frontlines faced unrivaled psychological and physical demands during the pandemic, noted researchers. Voices of nurses from this moment in history could help inform policies and laws to improve retention and reduce burnout among nurses in the U.S. “People need to listen to nurses more, and nurses need to feel empowered to share their experiences at every level of leadership,” said principal investigator Shannon Simonovich, PhD, RN, an assistant professor of nursing at DePaul.
“Diverse nurses caring for a diverse patient population”
In 2020, many news stories about health care heroes featured white, female nurses, Simonovich said. In reality, nurses from many personal, ethnic and geographic backgrounds with a varying levels of education were caring for COVID-19 patients.
Simonovich recruited a diverse group of DePaul nurse researchers to conduct the study, which in turn helped recruit a diverse group of 100 nurses to be interviewed, according to assistant professor and coauthor Kashica Webber-Ritchey. “We captured the voices of diverse nurses caring for a diverse patient population that was being disproportionately impacted by COVID-19,” Webber-Ritchey said. In the DePaul sample, 65% of the nurses identified as a member of a racial, ethnic, or gender minority group.
Many nurses from these represented populations have lost their lives to COVID-19. Researchers at DePaul cite a tally that more than 3,300 U.S. nurses, doctors, social workers and physical therapists died of COVID-19 between February 2020 and February 2021.
DePaul researchers conducted interviews between May and September 2020, asking nurses to describe their emotions. Nurses reported moral distress related to knowing how to treat patients and protect themselves, but not having the staff, equipment or information they needed. As a result, they reported feeling fear, frustration, powerlessness and guilt.
The toll of frustration, stress, and guilt
This qualitative study is believed to be the largest of its kind from this period—a time of great uncertainty about the virus that causes COVID-19 before the development of vaccines. Highlights include:
Study participants described many forms of frustration while providing patient care, including frustration with healthcare leadership being out of touch with those on the frontlines.
Nurses felt powerless to protect themselves and others from contracting COVID-19.
Nurses described being placed in difficult patient care experiences that resulted in guilt around letting down patients and their families, as well as fellow members of the healthcare team.
““We are a largely female profession, and we don’t complain enough when things are tough.”
The burden nurses have shouldered during the COVID-19 global pandemic calls for research that describes and examines the emotional well-being of nurses during this unprecedented time in contemporary history, write the researchers. As the media coverage of nurse heroes fades, the narratives in this study should be a call to action, says Kim Amer, an associate professor with 40 years of nursing experience.
“Nurses need to come together as a profession and make our standards and our demands clear,” Amer said. “We are a largely female profession, and we don’t complain enough when things are tough. As a faculty member, we teach students that it’s OK to refuse an assignment if it’s not safe. We need to stand by that.”
The DePaul research team calls for clear, safe standards for nurses that will be legally binding and hold hospitals and health care agencies accountable. “We go into nursing with the intention of saving lives and helping people to be healthy,” said Simonovich. “Ultimately, nurses want to feel good about the work they do for individuals, families and communities.”
Investments by healthcare organizations and policymakers in mental health resources could help promote psychological resilience in nurses, noted Webber-Ritchey. “Taking time to speak to nurses to understand their needs and provide support would help with addressing moral distress,” she said.
Two recent papers by UIC College of Nursing faculty found that microaggressions – common, subtle indignities – can be just as harmful as a major discriminatory event, contributing to negative mental and physical health outcomes in bisexual women.
Bostwick is principal investigator on a National Institute on Minority Health and Health Disparities grant which funded the Women’s Daily Experience Study, one of the first ever to focus on bi-identified women and mental health. Participants completed a baseline survey, followed by 28 days of e-diaries to capture microaggressions that they may have experienced during the previous 24 hours.
“The old saying goes, ‘sticks and stones may break your bones, but words can never hurt you,” Smith says. “But you look at the data and realize that’s simply not true. Microaggressions that someone has experienced over a lifetime are correlated with mental and physical ailments they experience even today.”
The researchers looked at microaggressions related to sexual orientation, race and gender. Microaggressions could include denying a person’s bisexuality—suggesting it’s “just a phase”—or a rude or insulting comment about lesbian or gay individuals. A comment minimizing or denying the existence of racial discrimination is an example of a racial microaggression.
Participants reported an average of eight microaggressions of any type in the previous month, with almost all women—97%—reporting at least one microaggression throughout the duration of the study.
Gender-based microaggressions were reported the most frequently. Women reported being sexually objectified on more than 15% of the days recorded.
The papers also found microaggressions were associated with poor mental health and binge drinking, smoking and marijuana use. The most consistent finding was an association between microaggressions and anxiety.
“Our findings suggest that for bisexual women, the weight of denigrating comments about their sexual identity, gender and race can contribute to poor health outcomes—whether such comments happened last year or yesterday,” Bostwick says. “Of course, these comments are situated in a larger context of systemic inequities, which may render bisexual women with fewer resources to cope when confronted with dismissive and disparaging comments about core aspects of who they are and their own lived experiences.”
Bisexual women of color were a majority in the study—57%—a group that is notably absent in the literature, the researchers say. Latina bisexual women reported worse health outcomes than Black and White bisexual women in their daily diaries. Smith says the impact of microaggressions on bisexual women of color is an area where further research is needed.
“So often we focus on the large discriminatory events, like being denied housing or being fired from a job,” Smith says. “These subtle comments and slights can be just as harmful. That’s why it’s important to address it through education – understanding and recognizing what a microaggression is and then adapting policies to raise awareness.”
Co-authors included UIC Nursing visiting research specialist Larisa Burke, MPH, Amy L. Hequembourg, Alecia Santuzzi and UIC Nursing professor emerita Tonda Hughes, PhD ’89, RN, FAAN.