The Impact of Racist Patients

The Impact of Racist Patients

When sick and injured patients arrive at hospitals for treatment, they also bring with them their unhealthy prejudices and biases. On the frontline of health care and healing, nurses may find themselves dealing with patients who prefer a caregiver who is of the same race. Patients—or their loved ones—may express their racial preference with negative comments and intolerant behavior, or directly voice their desire for another nurse. In a perfect world, hospital management would not cater to racially biased requests or demands. But real life is imperfect.

One blatantly racist incident involving an African American nurse made national headlines in 2012 when a white, swastika-tattooed father demanded that no black nurse care for his sick baby at a Michigan hospital. That case served as a springboard for several lawsuits and as a template for health care providers of exactly what not to do. Tonya Battle, a 25-year nurse at Flint’s Hurley Medical Center, worked in the neonatal intensive care unit when she met the white parent. After introducing herself, she was told by him to get her supervisor. The father relayed his racial preference to the supervisor, who reassigned Battle.

According to the Lansing State Journal, Battle said that a note was posted on the assignment clipboard reading: “No African American nurse to take care of baby.” Hospital officials removed the sign from the assignment chart after a short time. Still, black nurses were not assigned to care for the infant for about a month “because of their race,” according to the lawsuit. Battle’s case has since been settled.

While such overt incidents are isolated, no one should be shocked by racist patients, says Roberta Waite, EdD, APRN, CNS-BC, FAAN, associate professor of nursing and assistant dean of academic integration and evaluation of community programs at Drexel University’s College of Nursing and Health Professions.

“Racism is prevalent within our society. At times it’s been more covert and other times it has been more overt. It’s much more covert now,” says Waite, although it depends on geographical areas. “The more shocking component is: what do we do about it? How do we talk about it? How do we work with our students if we work with them at all? And how do we have these discussions amongst our colleagues?”

Whatever the solutions may be for patients who discriminate against nurses based on race, physicians need them, too. A 2010 survey of emergency room doctors found that patients often reject the physician assigned to them and request a doctor of the same race, gender, or religion. Their requests are routinely accommodated. If the patient request came from someone who was female, non-white, or Muslim, it was more likely to be granted.

“It’s medicine’s open secret,” Kimani Paul-Emile, an associate professor of law at Fordham University, told The New York Times. Paul-Emile did not respond to Minority Nurse’s requests for an interview but has written extensively on the topic. “The medical profession knows this happens but doesn’t want to talk about it,” she wrote in an article in the UCLA Law Review titled “Patients’ Racial Preferences and the Medical Culture of Accommodation.”

So, how do nurses of color handle patient encounters they believe stem from bigotry?

For Stephanie Stith, RN, a travel nurse for the past 10 years of her 15-year career, staying calm is a coping strategy. “I just mainly look [at them]. I give myself some time, because it’s not worth losing a job for.” She recalled one experience involving a patient who told her he was a member of the white supremacist Aryan Nation. “He looked at me and said, ‘I hate niggers.’ I said, ‘Good, so do I.’”

No other nurse was available to treat him, so she assumed her medical duties. As she worked, he continued his racist rant until she reminded him it was not smart to deride the person helping him stay alive. “I wanted him to know that I have the power over your life, and you are calling me names? Not that I was going to do anything; I just wanted him to think,” explains Stith, who says she deals more with slights than outright racism. For example, patients sometimes assume she is a medical tech instead of a registered nurse because she is black.

Stith also refrains from becoming emotional when responding to racist patients. “I need a paycheck. It doesn’t benefit me to get indignant. You can call me ‘nigger’ and say whatever you want, but at the end of the week I cash my paycheck. I am contracted to perform a service. I can’t change anybody’s mind or attitude. All I can do is be the best I can.”

Retired nurse Dinah Penaflorida, RN, MPH, MSN, agrees. Her advice for new nurses dealing with such requests is to remember that “the patient’s comfort and trust comes first. It is more important to be patient-centered in the care than to take the patient’s request personally. When the patient is in pain and suffering, it is not the time to talk about race and discrimination.”

Penaflorida was born and raised in the Philippines. At 16, she received an American Field Service Scholarship to spend a year in Hutchinson, Kansas. As a staff nurse at Kansas University Medical Center in the 1980s, she encountered a few patients who requested a Caucasian nurse instead of her. When it occurred, she went to the charge nurse to comply with the request to “create a more comfortable environment for the patient to heal.”  She left those experiences behind her when she moved to the West Coast. “Working in California was different. I did not experience that,” says Penaflorida.

Focusing on caregiving instead of the patient’s name-calling or other forms of intolerance is the best strategy, nurses say. “l always keep in the back of my mind that I had the best training going because I am a nurse of color,” says Deborah Bowser, RN, who has a master’s degree in health services administration and is a practice administrator in Richmond. “Most of my instructors were nurses of color and they dealt with worse situations than I have. They always instilled in us that ‘you will be judged by the color of your skin and it will be assumed you are not a RN, and you do not have the experience.’ They took no slack from us. We were the best of the best.”

Bowser recalled being rebuffed by two white patients during her 43-year career. Both incidents happened in New York during her night shift. Each time, her supervisor told the patient she was one of the best nurses. “One patient decided they did not want to be treated by me because I was black, so I informed my supervisor. The patient was extremely ill, so I said, ‘You have a choice; let your prejudices go by the side and let me take care of you. I know what I am doing.’ In one incident the patient said ‘yes,’ and in another the patient said ‘no’ and did not get care for a very long time because there was no other nurse who was Caucasian who could care for that patient.”

Bowser says she would like to think in this day and age that race-based requests would be nonexistent, “but you are going to have people who do not want people of color touching them” regardless of their expertise. For any young nurse of color who encounters such patients, “carry yourself with pride and get a mentor to help you,” she advises.

Racist patients can overwhelm young nurses, says LaDonna Northington, DNS, RN, BC, professor of nursing and director of traditional undergraduate studies at the University of Mississippi Medical Center (UMMC) School of Nursing. “A young nurse would probably be intimidated and wouldn’t know what to do but leave out of the room, so they have to find a mentor to help them… problem solve through a situation like that. A seasoned nurse is able to take a high road. If you try to take care of the patient, they can call it assault,” so a nurse must learn how to accommodate a patient from a legal standpoint, she explains.

“For a young nurse, they should get their charge nurse or head nurse to intervene. It’s a tough call,” says Northington, who has not dealt with a racist patient during her 35-year career.

“I can’t recall an incident when I was on the floor taking care of patients where I felt like a patient did not want me to take care of them because I was black…and you would think if it was anywhere blatant, it would be in the South where we are. I haven’t heard the students talk about it. It could be in pockets [of communities] or people deal with it in a different way.” The UMMC School of Nursing addresses sensitivity and cultural awareness and understanding, she says, adding it’s possible that black patients may reject white nurses. “An elderly black person who has never trusted white people because of Tuskegee and those kinds of things and Mississippi history” may request a black nurse.

Discussing race makes many people uncomfortable, but nurses say it’s part of the solution. “When you are talking about the elephants in the room, we talk more openly about religious differences… and gender or sexual orientation, but when you get to race, there is so much more hostility and changing the subject,” says Waite. “It’s not talked about openly… oftentimes not at all. I’m not shocked that those incidents occur; I am actually surprised it doesn’t occur more often.”

Waite uses a social justice framework to talk about such topics as power, privilege, oppression, “and every ism” in a leadership course she teaches all undergraduate health profession students, including nurses. “I explicitly talk about it. However, most often within nursing clinical courses the topic is called ‘cultural competence.’ That’s the catch-all phrase that overlays issues of culture and diversity. That phrase is probably in everybody’s syllabus; however, how each person operationalizes what they do in teaching their students will vary,” she says. It will come down to how comfortable that faculty member is in guiding or leading or discussing issues regarding race, she adds.

At the University of Texas-Pan American nursing department, the curriculum emphasizes culture and cultural differences among people, says Carolina G. Huerta, EdD, RN, FAAN, nursing department professor and chair. In one required course, undergraduate students spend at least two weeks listening to lectures and discussing the impact of culture on nursing care, with particular attention paid to debunking stereotypes and focusing primarily on each person’s uniqueness. The course aims to sensitize students to issues related to racism and stereotyping.

“Once admitted to our program, every student must address cultural implications of their nursing care following each of their clinicals,” explains Huerta. “There is a section on their assigned clinical paperwork that must be turned in that deals strictly with cultural implications of care. The students are asked to reflect on the patient that they cared for and address any cultural implications, whether these deal with the foods the patient ate, religious affiliations, overt or covert racism, family issues, et cetera.”

While some patients will always express a racial preference for nurses, what matters most is how the institution and administration respond to such requests. “If you cater and say ‘no black people will work with you,’ that’s the problem,” Waite argues. “A patient has the right to decide who will care for them, but they can’t do it in a discriminatory manner. Instead, the response could be ‘Everyone here is competent to take care of you. If you choose to [reject care from a specific nurse] that is fine, you can go to another hospital.’”

Most of the hospitals that have been in the news “gave in” to racial preferences, Waite notes. Hopefully, most hospitals have a statement within their policy on how to engage and work with clients if anything like this surfaces. Talking about these issues is key, she adds.

“I think oftentimes today, people think either you are racist or not. It’s not that you are racist or not; racism is a spectrum,” says Waite. “All of us continuously struggle to deal with prejudice and bias because no one is perfect. When trying to understand where these thoughts come from and not feed into it, we move society forward. And it’s going to move forward as we are able to have these open and authentic conversations with one another.”

Robin Farmer covers health, business, and education as a freelance journalist. Based in Virginia, she contributes frequently to Minority Nurse magazine and website. Visit her at


Are Health Centers the Future?

Are Health Centers the Future?

As millions of uninsured people get coverage under the Affordable Care Act (ACA), job opportunities for registered nurses could open up in the nation’s community health centers because many of the newly insured are expected to go there for care. These facilities, also known as federally qualified health centers (FQHCs), provide primary care in medically underserved areas, regardless of patients’ ability to pay. Teams of physicians, nurse practitioners, registered nurses, and other health care workers treat mostly Medicaid patients and the uninsured.

FQHCs, the mainstay of the nation’s health care safety net, have been growing by leaps and bounds in the past decade, posting an 80% increase in new jobs. Now a new wave of patients is expected, fueled by the Medicaid expansion and the new health insurance exchanges, where premiums for low-income people are subsidized.

Planners of the expansion predicted that since many physician practices have limited capacity for new patients, many of these patients would go to FQHCs. Therefore, the ACA set aside billions of dollars in construction funding to help FQHCs expand their facilities so they could handle an onrush of patients.

No one knows, however, how many new patients will come, and the centers, operating under tight budgets, have been holding off on hiring until they get a better idea.

Also, while FQHCs employ a significant number of RNs, these facilities may not appeal to everyone. Salary levels vary widely, with some facilities paying less than hospitals, and many FQHCs are more interested in health care workers with less training, like licensed practical nurses.

What FQHCs Want

Community health centers are looking for nurses who are committed to serving low-income people, usually minorities, says Gary Wiltz, MD, chair of the National Association of Community Health Centers.

“The work should be viewed as a calling,” he says. When Wiltz interviews job applicants for his own FQHC, the Teche Action Clinic in southern Louisiana, he says he wants to see compassion. “The patients are disenfranchised, but many of them have jobs and are working very hard,” he notes. “As a provider, you have to be aware of what they are going through.”

Jennifer Fabre, RN, a nurse practitioner at Teche Action, says nurses are paid less than those who work in hospitals or nursing homes. But Community Health Services, an FQHC in Hartford, Connecticut, pays them comparable rates, according to Valerie Tyson, RN, a nurse at the Connecticut facility.

Tyson says working in a FQHC is very different from the hospital med-surg unit where she used to work. “The hospital has people who are very sick, but here the patients have an acute illness or need follow-up care for a chronic illness,” she says. “This is their primary care stop.”

A big part of the job, she explains, is teaching patients to manage chronic conditions. The RNs also take patients’ calls, routing some of them to doctors or nurse practitioners but taking care of most of them, she adds.

The Connecticut FQHC serves inner-city patients who are mostly Hispanic and black, some sharing Tyson’s roots in Jamaica. Unlike in the hospital, “you get to know these patients over time,” she says. “You develop a relationship with them.”

Fabre added that nurses have to understand their patients’ needs. “You do whatever you need to do to help the patient,” she says. “It doesn’t do patients any good if you prescribe a medication for them and they can’t pay for it.”

Roots in the Civil Rights Era 

FQHCs have a rich history of community service, going back to the Civil Rights era. The oldest rural FQHC, the Delta Health Center, was founded in 1967 in Mound Bayou, Mississippi—the oldest predominantly black settlement in America.

This little village is in the heart of the Mississippi Delta, a land of cotton fields that gave birth to the blues. The health center sits on land once owned by the brother of Confederate president Jefferson Davis, Joseph E. Davis, who encouraged “self-leadership” among his slaves, letting them build a “model community.”

After emancipation, Joseph E. Davis’ former slaves spent two decades earning enough money to purchase the land, founding the village in 1887. Today, Mound Bayou has 687 households and is still almost entirely black. The town came into prominence again in the Civil Rights era of the 1960s, when it caught the eye of H. Jack Geiger, MD, an idealistic Massachusetts physician who wanted to create a new type of health care facility for the poor.

In the 1964 Economic Opportunity Act, the cornerstone of President Lyndon Johnson’s “War on Poverty,” Geiger persuaded President Johnson to include $1.2 million for test sites at Mound Bayou and Boston. Envisioning a self-sustaining community, Geiger and his followers not only built a clinic in Mound Bayou but also dug wells and helped residents improve farming methods.

FQHCs have enjoyed a renaissance in the new century, starting with a wave of new federal funding under President George W. Bush. Patient volume grew by 50%, reaching the 15 million mark in 2006. Under President Obama, the Recovery Act set aside $2 billion in extra funding for FQHCs in 2009, and patient volume then reached 20 million.

The ACA set aside $11 billion for the centers, mostly for construction, to help them build capacity to meet the coverage expansion. The Delta Health Center received $5 million of this funding, allowing for its first significant expansion since it opened 47 years ago.

The new building will open in February. “We’re going to have brand-new rooms and new equipment,” says Neuaviska Stidhum, RN, the chief operating officer at Delta. “It means we’ll be able to see more patients.”

Centers Holding off on Hiring 

But even as Delta and many other FQHCs expand, they are holding off on hiring more staff and even, in some cases, opening some of their new projects. Facilities have to be careful about hiring because the new federal funding does not cover operational expenses. Teche Action Clinic, Wiltz’s FQHC in Louisiana, renovated two new sites using federal money, but it doesn’t have the funds to open them.

Moreover, there are signs that the anticipated onrush of new patients may not be as large as expected. Half of the states, including Mississippi and Louisiana, aren’t participating in the Medicaid expansion. Technical problems with exchange websites are dissuading some people from signing up, and the fine for not obtaining coverage may initially be too low to force some people to buy insurance.

Stidhum adds that many doctors’ offices in the Delta region still have a lot of capacity, so there would be less reason for the newly insured patients to use her FQHC. “We don’t know what we’ll do yet, “said Stidhum when asked about hiring. “Maybe we’ll need more staff, or maybe we’ll just need to shift their duties around.”

The story is different in Connecticut, which has joined the Medicaid expansion and has a very active insurance exchange. Tyson says her Hartford FQHC has put off hiring, but she is optimistic about hiring in the future. “The center is really busy,” she says. “If there are more patients, we would have to hire more nurses.”