The issue of embittered race relationships in the United States has been on my mind since August 9, 2014, when a white police officer named Darren Wilson shot and killed Michael Brown, an unarmed black teenager, in Ferguson, Missouri. The violent protests that erupted after the shooting culminated in even more pronounced violent protests in the early morning hours of November 25, 2014, following the grand jury decision not to indict Officer Wilson for the fatal shooting of Brown.
Not being close to the case, or having examined the evidence upon which the decision not to indict was based, I wondered whether that decision was purely based on evidence, or whether historical and institutionalized racism, discrimination, and injustice against blacks in the United States played a role. While I have no answers to my question, I struggled to think about what we, as a nation, can learn from Michael Brown’s death that will help this nation heal.
I believe that each one of us in the United States needs to think long and hard about race relations in this country. I allowed my mind to wander as I took this journey myself. I thought about the Institute of Medicine report, Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. In this report, the committee—charged by Congress with identifying and recommending strategies to eliminate racial disparities in health care in the United States—chronicled the pervasiveness of poor health outcomes for minorities.
As a minority and an academic nurse researcher with a focus on health disparities in pain management, I thought about historical and institutionalized racism, discrimination, and injustice that contribute to poor pain management for patients with sickle cell disease—an inherited blood disorder suffered by an estimated 100,000 Americans, mostly of African descent—and for patients with other pain conditions. I thought about an article I had written for Minority Nurse back in 2003 titled “Mentorship in Black and White,” where I narrated my experience of being mentored by a white senior professor when I was a nursing student. This mentorship experience affirmed my belief that humanity is inherently good, but social constructions such as race taint our good nature. I thought about my current experience as an assistant professor of nursing in higher education and how I have reacted when I encountered interactions I felt were unjust. I wondered about how I have interacted with students in my capacity as a nursing faculty where I have the opportunity to teach and mentor both black and white students. I wonder if I have done everything humanly possible and within my power to pay forward the inherent human goodness to improve race relations with my students, colleagues, and friends.
I thought about the slave ship captain and later an abolitionist, John Newton, who, after his repentance, wrote the hymn “Amazing Grace.” This hymn is sung in Christian churches around the world by many Christians to confess and repent of sins and enlighten the spirit. The song has also become the mainstay of funeral services around the globe— a way to send the dead home believing they had the chance to repent of their sins at the time of death.
Now, in the United States, we must sing “Amazing Grace” in unison. Why is amazing grace important in this moment of pain and hurt, loss of faith in humanity, and lack of trust in race relations in the United States? The nurse in me feels that this nation needs healing. We must repent for whatever we might have done consciously or unconsciously, overtly or covertly, to contribute to racial unrest and the suffering of blacks and other minorities in the United States,. We will not stand and just sing the lyrics of the hymn paying lip service. We must be on our knees and feel the words break through our hearts, minds, and spirits. The words must purge us of the biases, injustices, discriminations, racism, sexism, ageism, and other “isms” that have deadened our spirits in this country. We have to let the spirit that connects us as humans and make us one with the universe—the trees, the oceans, the winds, and the animals—emerge to help us heal. We must let the light of our spirit unite us, and together we can outshine the darkness in our hearts and minds that we use to oppress others who look different than us.
We must heal our nation by checking our individual biases that encourage us to treat others unfairly. Like Newton, we must repent so that God and the universe will shower our spirits with the everlasting peace that comes with positive race relationships in the world full of turmoil and unrest. We must heal our nation, the United States of America.
Miriam O. Ezenwa, PhD, RN, is an assistant professor in the Department of Biobehavioral Health Science at the University of Illinois at Chicago, College of Nursing.
Have you ever been passed over for a promotion because of your race or ethnicity, even though you met all other qualifications for the job? Do you feel that nurses of color continue to face substantial personal and professional barriers to career advancement? In your opinion, do racial and ethnic minority patients receive lesser quality care than their white counterparts?
If you answered “yes” to any of these questions, you’re not alone. An important new study from the American Nurses Association (ANA), based on a national survey of more than 5,000 African-American, Hispanic, Asian/Pacific Islander, American Indian/Alaskan Native and Caucasian nurses, reveals that nearly half of the respondents (48%) believe there are barriers to their progress in nursing.
In addition, 59% of African-American respondents, 53% of Asian/Pacific Islander respondents and 46% of Hispanic respondents felt they had been denied a promotion because of their race or ethnicity. The survey also found evidence that nurses of color are more likely than their Caucasian colleagues to believe that minority patients do not receive the same quality of care as whites.
When asked to cite specific barriers to their career advancement, the majority of respondents (44%) felt they faced a combination of educational, institutional, personal and professional obstacles. However, white nurses were slightly more likely to list educational and institutional barriers while black nurses tended to mention only institutional barriers and Asian/Pacific Islander nurses were more likely to cite personal barriers.
The study, Minority Nurses in the New Century: Characteristics and Workforce Utilization Patterns–A Survey, was led by the distinguished African-American nursing scholar Hattie Bessent, RN, EdD, FAAN, who had previously authored a landmark 1997 study on the recruitment, retention and graduation of minorities in the nation’s nursing schools. In the New Century workforce survey, about half of the nurses sampled were African American and one-third were Caucasian.
Although the survey’s findings seem discouraging, the good news is that they grew into a unique one-year pilot project designed to help minority nurses learn to overcome overt and covert racism in the workplace, develop the leadership skills that can open doors to career mobility, and negotiate with their employers to achieve more equitable treatment. Based on the project’s successful results, Bessent has developed it into a model program that can be used by other nurse educators nationwide.
The Minority Nurses in the New Century study–which contains more information about the pilot project, as well as data on minority nurses’ educational background, certification status and employment profiles–can be purchased from the ANA’s publishing division for $29.95 ($23.95 for ANA members).
In a year when the Philippine Nurses Association of America is proudly celebrating its 30th anniversary as an important and highly respected presence in our nation’s nursing landscape (see Directing Our Destiny), it might seem strange that the immigration of Philippine nurses to the U.S. could still— after all these years—continue to be a source of controversy. But consider this email I recently received from a reader named Janet Christian:
“I have one important question on behalf of all nurses who graduated from American nursing schools by taking out lots of loans and making a significant difference in the U.S. economy,” she writes. “Why should they do so when hospitals want to hire or import nurses from [outside the U.S.]? Hospitals in the state of New York are filled with Philippine nurses. [People] who are stakeholders for NCSBN (the National Council of State Boards of Nursing) and CGFNS (the Commission on Graduates of Foreign Nursing Schools) have special interests, and hospitals have their own interests, but what about the future of our children, who want to be nurses but [can’t find jobs] because hospitals are looking for cheap labor from overseas?”
It would be easy to dismiss this as just the grumbling of one disgruntled nurse who may be having a tougher than usual time trying to compete in a recessionary job market. But some remarkably similar comments surfaced this past August during the National Black Nurses Association’s 2009 annual conference in Toronto, Canada—the first-ever NBNA convention to be held outside the U.S. After a presentation on international nurse migration and global health by CGFNS chief executive officer Barbara Nichols, someone in the audience who introduced herself as a faculty member at a nursing school in California complained that “foreign nurses are being hired for jobs that should be going to my BSN graduates.” Someone else pointed out that even President Obama has said he wants to reduce America’s dependence on foreign-educated nurses.
Nichols’ response to these comments was—as they say on the public radio quiz show “Whad’Ya Know?”—well-reasoned and insightful. (As the barrier-breaking first African American president of the American Nurses Association, Nichols knows a thing or two about territorial prejudices in nursing.) And since Janet Christian, as well as other nurses who share her sentiments, were presumably not there to hear it, Minority Nurse is happy to pass it along. First of all, Nichols argued compassionately, nurses in the U.S. must be careful not to scapegoat nurses from the Philippines, Africa, India and elsewhere who come to our country in search of a better way of life for themselves and their families. These nurses have every right to arrive here in pursuit of the American dream, just as so many previous generations of immigrants have done. The foreign nurses themselves are not the problem, Nichols emphasized; the real problem is that certain U.S. health care employers must stop hiring nurses from overseas simply because they can pay them less than American nurses.
There are other reasons why some hospitals in this country prefer to fill their staffing needs with foreign-educated nurses rather than U.S. nursing graduates, Nichols continued. Nurses from overseas are more likely to have BSN-level education than American nurses, as well as more work experience. Secondly, many of today’s newly graduated U.S. nurses are reluctant to pick up and move to where the jobs are—such as rural and underserved areas. And some hospitals have learned the hard way that many of these new grads— unlike “imported” nurses—tend to not stick around for more than a year or so once they’re hired.
These are all issues that nurses can work toward addressing, both collectively and individually. Through nursing unions, professional associations and political activism, nurses can try to influence health care employers to adopt fairer hiring practices. And some individual nurses may need to take an honest look at how they can increase their marketability to employers—e.g., by advancing their education. Together, nurses can find some viable answers to Ms. Christian’s “one important question.” But blaming foreign-educated nurses shouldn’t be one of them.
Successfully entering and completing a nursing program can be a daunting task for any student. But students of color often face additional challenges and barriers that white students do not—for example, lack of financial aid, inflexible admissions policies, a greater burden of family responsibilities and feelings of isolation.
While the obstacles experienced by students of color are well documented in the nursing literature, there is much less information available about the “survival skills” and strategies these students have used to successfully overcome those obstacles. Although the literature includes some older studies focusing on success strategies that American Indian and Latina nursing students found to be useful, there is very little currently being written about what today’s students of color can do to be successful as they plot a course through the process of obtaining their nursing education.
Why is so important for underrepresented students of color to not just get accepted into nursing programs but to succeed in them? The demographics of the United States are changing dramatically and rapidly. By the year 2050, 20% of the U.S. population will be foreign born, and Caucasians will no longer be the majority. As the country’s racial, ethnic and cultural demographics change, nursing has a responsibility to change with them so that the profession fully reflects the patient population it serves. Furthermore, if nursing is to retain its reputation as a profession that advocates for the underserved, then it must also advocate for the fair representation of people of color in the nursing workforce.
Latinos are the fastest-growing minority group in the U.S., yet they are severely underrepresented in the current RN population. What are the most significant institutional, personal and cultural obstacles Latino/a students face in nursing school? What assets and strategies can help them surmount these obstacles and complete their nursing programs? What can nursing school faculty and administrators do to create a more equitable educational experience for students of color and help ensure their success as they pursue their dreams of becoming registered nurses?
As a nurse researcher with a strong interest in exploring these questions, I conducted a study that used critical ethnography to examine how Latina students who were in their last year of an RN program or had recently graduated as RNs managed to successfully complete an associate degree or bachelor’s degree nursing program. Six nursing students and seven RN graduates from various schools participated in the study, which was conducted using open-ended interviews and focus groups. The participants were asked to describe their experiences in nursing school, focusing on obstacles, assets, coping strategies and how power was used in the nursing program they attended.
Encountering Racism
It is not surprising that the study participants cited many obstacles encountered while pursuing their nursing degrees. These included lack of multicultural understanding at the institutional level, hostility and lack of cultural awareness in nursing faculty, pressure to give up their Latino culture, inflexibility within the nursing program, unwritten “rules” of nursing education and a climate of competitiveness that was encouraged by the faculty.
The participants also talked about how family responsibilities created a dilemma for them. They had to push against the current of cultural expectations of women and deal with the day-to-day issues of childcare and other family obligations. This group of Latina students and RN graduates were not willing to abandon their families to get an education. Instead, they chose to find ways to maintain both family and school responsibilities, which was a difficult task to accomplish.
One of the most frequently mentioned obstacles was racism. This is noteworthy because racism in nursing school is rarely discussed or studied. It is widely perceived as a problem that existed in the past but has been eliminated today. Yet, racism—on the part of both classmates and faculty–was cited often in the interviews. For example, Latina students who spoke with accents commented that they felt they were being treated as less intelligent than other students. Many participants described being told by instructors that they were less capable than white students. As a system of advantage and disadvantage based on skin color and ethnicity, the effects of racism were felt by every participant in the study.
Perhaps even more insidious was the systemic racism they faced, which was evident in the number of blockades they experienced at the institutional level. Some of the Latina students reported being given different admissions information than that given to white students, and they were frequently encouraged by high school or college counselors to become nursing assistants rather than RNs.
While the participants had been able to develop strategies for overcoming a number of obstacles, they had difficulty naming specific strategies to deal with racism. They often described feeling that they should have responded more strongly to racist incidents or policies. Yet they feared that if they spoke out about racism they would be punished.
Cultural Assets
Sadly, when asked about assets that helped them overcome obstacles, the study participants were unable to cite many examples of institutional support from the nursing programs they attended. A few spoke of the “one” instructor who was supportive, but this was the exception rather than the norm for these students and RNs.
Therefore, they found support through other channels. Their own goals and dreams served as a compass that kept them on course as they headed toward their goal of becoming RNs. Interviewees also cited a desire to give back to their communities, and to help the Latino community to move ahead, as incentives that helped them persevere. Support from peers and being unified as a group were major assets the participants credited for their success.
Latino culture played a particularly important role in the coping strategies of these students and RNs. Every participant commented that they had to be a “cabezona”–meaning stubborn or determined–to make it through. They described this characteristic as a cultural asset that was a part of their Latino history and identity. They were proud to be Latina, proud of their heritage and they wanted to make their families and communities proud of them.
This cultural pride served as a powerful force that helped them swim against the tide of obstacles and racism they so often encountered. Perhaps because of their individual personalities, but most likely because of their culture, this group described how they actively resisted as a means of being successful. They resisted cultural norms that could hold them back. And by holding onto family ties and finding ways to integrate their Latino culture into their education, they resisted pressure to desert their cultural heritage.
Strategies for Students
Although all of the participants in this research study were Latinas, the findings revealed many strategies for success in nursing school that are applicable to all students of color. For example:
When you are applying to or entering a nursing program, identify students of color who are ahead of you in the program. Ask for their advice about what to watch for and how they navigated the program. These students can serve as cultural brokers and explain the expectations that nursing instructors may have.
Learn the unwritten “rules” of majority-dominated academia. This does not necessarily mean that you have to follow all of them, but awareness of these rules will help you decide when to resist and when to conform.
Form support groups. Study together, share information and stand up together against injustices.
Enlist additional support from family members. Maybe they are willing to baby-sit, cook some meals or help out in other ways so you can devote more time to your studies.
Tap into your cultural heritage. If stubbornness and determination are the norm in your culture, then don’t give up!
Acknowledge that racism exists, and that sometimes people who participate in it may not even realize they are doing so. This does not diminish the injustice, but as opportunities arise, educate your peers. Above all, do not let instances of racism define who you are. You have a great deal to offer the nursing profession!
How Faculty Can Help
Nursing educators who want to create a more equitable educational system for students of color must abandon the notion that treating all students the same or being “colorblind” is a solution to the problems of racism or student failure. As is true in the health care workplace, when failure occurs it is often the result of a system failure, not an individual one.
Based on the insights gained from the study participants, here are some additional recommendations for how faculty members can increase their understanding of the issues nursing students of color face and how they can partner with these students to help remove barriers to their success:
• Examine the curriculum to determine whether it is inclusive and relevant to all students or if it is centered on the care of white patients while excluding the needs of patients of color. It is imperative to bring racial, ethnic and cultural diversity into the nursing curriculum, such as teaching students about differences in skin, hair, dietary preferences, etc.
Rather than having a “culture day,” thread the concepts of cultural diversity and its importance in health care throughout the curriculum.
Encourage students of color to hold on to their cultures, both as assets for their own success and as assets that will enrich the nursing profession. Acknowledge, respect and build on these students’ cultural knowledge, beliefs and experiences.
Recognize that while curriculum content that includes information about cultural differences, health disparities and culturally sensitive health care is essential, students remain underserved if the curriculum delivery is not culturally sensitive as well.
Learn the personal stories of your students. Are there very young students? Older students? Students of color? Male students? Ask yourself: “What unique assets does this student bring to nursing?”
Be aware that students have different learning styles, based on factors such as age, culture and personality. Offer to help students. Often, students of color are reluctant to ask for help because they are uncertain about how others will perceive them, but they appreciate help when it is offered respectfully.
Flexibility is a must, both in the admissions process and in the classroom. Is your nursing program’s admissions policy based solely on GPA? Consider revising it to give more weight to students’ personal assets and experiences. Do your class times and days reflect a student-centered or a faculty-centered approach? Faculty and administrators must ask themselves who benefits from the policies and norms that are currently in place. Do they promote or inhibit student success?
Nursing programs are notorious for having a competitive atmosphere. But keep in mind that some students may come from cultures where working together for the benefit of the group—rather than striving for individual success—is the norm. These students will not thrive in a highly competitive environment. Furthermore, fostering an atmosphere of cooperation and collaboration in the classroom more closely reflects what will be required of RN graduates when they enter the workforce.
Mentor students and help them understand the unique culture that is nursing.
Learn to recognize how racism is manifested institutionally as well as individually. There are many anti-racism curricula that can be incorporated into nursing education. Be a role model by teaching white students to be anti-racism advocates and by speaking out against racism yourself. Never, ever tolerate negative comments about an individual’s race, ethnicity, gender, religion, sexual orientation, disability or any other characteristic that is not the majority. Learn to talk openly about discrimination and bias and how they affect health equity. Encourage all students to consider other viewpoints than their own.
Understand that many students may have strong family ties and responsibilities that they must balance with their academic responsibilities. Educators often argue that privacy laws make it impossible to engage with a student’s culture of family. Still, it is possible to find ways to include family in the nursing school experience. Invite family members to student presentations; include family in end-of-term celebrations. This sends a clear message that you value your students and acknowledge that they have their own lives outside the walls of the classroom, and that retaining these aspects of their lives is important.
In conclusion, there are many ways that students of color and faculty members, both individually and together, can employ strategies and engage resources to ensure that all students have an equal opportunity to successfully earn a nursing degree. Just imagine what could happen if every student of color was able to achieve his or her dream of becoming an RN. In today’s increasingly multicultural America, imagine what a difference this will make for the nursing profession, for health care and for improving the health of the medically underserved.
Transforming Nursing Education: The Culturally Inclusive Environment
By Susan Dandridge Bosher, PhD, MA, and Margaret Dexheimer Pharris, PhD, RN, MPH, FAAN (Editors)
Springer Publishing Company, 2009
$50 (paperback)
For years, the nursing profession has been grappling with the issue of how to recruit, educate and graduate more racially, ethnically and culturally diverse nursing students. Everyone seems to agree that there’s a critical need for nursing schools to create more culturally inclusive learning environments and curricula, develop more culturally sensitive teaching methods and eliminate cultural barriers that can create unfair disadvantages for minority students. But how exactly do you do that? How can schools of nursing move beyond theoretical discussions to start developing actual programs for accomplishing these goals?
Transforming Nursing Education: The Culturally Inclusive Environment provides some long overdue answers to these questions. But be warned: This book is only for those institutions and educators who are seriously committed to change. The word “transform” means to markedly alter the form or nature of something, and Bosher and Pharris argue in their introduction that creating a more culturally inclusive environment will require making dramatic changes to the traditional culture and structure of nursing education as we know it. And that means coming to grips with thorny, uncomfortable issues like institutionalized racism, discrimination and whitecenteredness in the educational system.
For those who are up to the challenge, Bosher and Pharris have put together an anthology of essays from more than 20 culturally diverse leaders in education and nursing to help nursing schools redesign their curricular, pedagogical and structural systems to better meet the needs of multicultural students. Through case studies, practical examples and in-depth analysis of successful programs, the book provides a roadmap for creating a more welcoming environment for minority students and faculty, revamping traditional teaching methods to accommodate diverse learning styles, developing and teaching a culturally competent nursing curriculum, and removing cultural and linguistic barriers to student success.
Transforming Nursing Education profiles many innovative programs that “model structural change,” including the Latino Nursing Career Opportunity Program at the Catholic University of America, the Recruitment/Retention of American Indians Into Nursing (RAIN) program at the University of North Dakota, the Students’ Test Anxiety Management Program (STAMP) at the College of St. Catherine and more. Each chapter concludes with specific recommendations for nursing educators and administrators.
Bosher and Pharris emphasize that Transforming Nursing Education is “not meant to be a cookbook approach to structural change but rather a stimulus for thought-provoking dialogue that will lead to concrete actions.” Because both that dialogue and those actions are so crucial to the future of the nursing in the 21st century, this landmark book is an invaluable resource and absolutely essential reading.
To order the book:Transforming Nursing Education: The Culturally Inclusive Environment can be ordered from Springer Publishing Company, 11 West 42nd Street, New York, NY 10036-8002, or online at www.springerpub.com.
Real Nurses and Others: Racism in Nursing
By Tania Das Gupta, PhD
Fernwood Publishing, 2009
$15.95 (paperback)
The quote from author Tania Das Gupta that adorns the back cover of Real Nurses and Others: Racism in Nursing pulls no punches about what readers will find inside. “Most nurses of color experience everyday forms of racism, including being infantilized and marginalized,” she writes. “Most [nurses interviewed for the book] reported being ‘put down,’ insulted or degraded because of [their] race/ethnicity/color. A significant proportion of nurses, non-white and white, report having witnessed an incident where a nurse was treated differently because of his/her race/ethnicity/color.”
Das Gupta is a Canadian sociologist and activist whose previous book, Racism and Paid Work, included a chapter on racial discrimination in Canada’s nursing workforce. Real Nurses and Others, which began as a study commissioned by the Ontario Nurses’ Association (ONA)’s Racially Diverse Caucus, expands on this earlier research to present a full-length examination of systemic racism in nursing, based in part on surveys and interviews with nearly 600 ONA members, both minority and majority.
Although the book focuses exclusively on Canada, American readers—including nursing staff, managers, administrators and hospital diversity directors—can also learn much from Das Gupta’s analysis of the many subtle and not-so-subtle ways racial/ethnic discrimination manifests itself in today’s nursing workplace. For example, the title Real Nurses and Others refers to a black interviewee’s comment that white patients and family members routinely treated her as if she was a nursing assistant or aide rather than a “real” (i.e., white) nurse—a situation that all too many American nurses of color can relate to.
Das Gupta presents what she calls an “intersectional analytical framework” for understanding how and why workplace racism can occur in health care institutions. But Real Nurses and Others really comes alive when it focuses on the case studies and personal testimonials of the many nurses who reported experiencing discrimination from colleagues, managers, patients, doctors and others because of their race/ ethnicity. The book documents many examples of “everyday racism”—e.g., targeting, scapegoating, excessive monitoring and blaming the victim—as well as “how fear, lack of support, management collaboration, coworker harassment and ineffective institutional responses make it difficult for victims of racism to fight back.”
The slim (128-page) book does have a few shortcomings. There is no research data on Aboriginal (First Nations) nurses, an admittedly small but still important part of Canada’s minority nursing workforce. And while Real Nurses and Others does an excellent job of discussing the problems of racism in nursing, I would have liked to see Das Gupta go one step further by proposing some recommendations and solutions. But all in all, this brave and provocative book makes fascinating reading—especially for those in the nursing profession who are not afraid to engage in honest dialogue about a serious issue that is all too often swept under the rug.
To order the book: Real Nurses and Others: Racism in Nursing can be ordered in the U.S. from Independent Publishers Group, 814 N. Franklin Street, Chicago, IL 60610, [email protected]. Canadian readers can order it directly from the publisher at www.fernwoodpublishing.ca.
