Beyond the naming: Institutional racism in nursing

In these past few weeks, we have seen and witnessed two symptoms of the same disease—the killing of George Floyd by a policeman and the disproportionate impact of COVID-19 on communities of color. Both are stark examples of the effects of structural racism, which refers to a system in which public policies, institutional practices, and other norms perpetuate racial group inequities, and is a feature of the social, economic, and political systems in which we live (Aspen Institute, 2016). Injustices in law enforcement and health inequities are not new occurrences – nor are they rare.

Whether it be the proximity of these events to each other, the fact that we all, at some level, are being affected by COVID-19, or the inhumanity we have borne witness to in recent months – we can no longer be silent. There have been countless statements from every corner of our nation and the world naming these incidents for what they are – the results of structural racism. Make no mistake, this is a watershed moment. So many people across the country are standing up to call out these injustices, and it has been a long time coming.

Nurses, like so many others, have joined the chorus of people decrying police brutality. We have also been on the frontlines in health care systems and seen first-hand the disproportionate impact of COVID-19 on communities of color. Historically, nursing has been at the forefront of advocacy, and there are many examples of how nurses have addressed, and are addressing, inequities in many aspects of our teaching, research, scholarship, and practice. Yet, there remain too many examples of structural racism throughout nursing and we must be open to continuing to examine, identify, and change these within our own profession.

Almost 20 years ago, a major finding from the landmark IOM report Unequal Treatment (2003) affirmed:

“Racial and ethnic disparities in healthcare exist and, because they are associated with worse outcomes in many cases, are unacceptable (pg 6).”

While today this seems like an understatement, nearly 20 years ago this was profound. It was notable that there were very few, if any, studies conducted with and by nurses in which health care disparities were examined, and this is still true today. There are, however, efforts to address the role of nurses in dismantling structural racism in practice. Scott, Britton, & McLemore (2019) provide tools to address adverse pregnancy outcomes in Black families. Guided by an ethical framework, strategies are presented to move from “mother blame” narratives to addressing social determinants of health through a life-course approach and eliminating disparities in health outcomes.

As similar work addressing structural racism are disseminated, we must also examine how nursing journals and other vehicles support or impede dissemination. Over the past year there have been several posts in The Scholarly Kitchen asking about what inclusive scholarship means. This same t applies to manuscripts from underrepresented minorities. Although no formal studies have been done in nursing journals, as an editor, I am much more aware of how challenging it is to find enough reviewers for some papers about racism in the US. Sometimes silence ‘yells’ the loudest. Conversely, I (Broome) have also read how reviewers who do accept the review are more thoughtful in their critiques of those papers. This careful approach allows the author to hear what they are saying, and, in the majority of cases, resubmit a revision that any journal would be proud to publish. But are there papers, or authors, who are not being given the same consideration in Nursing Outlook? This fall, the editorial board will be discussing at our next meeting the extent to how our practices can support racial justice.

There has also been increased attention to diversity and inclusion within education and nursing. Efforts to recruit and retain underrepresented minority students and faculty are a part of many institutions’ goals. But as Zambrana (2018) asks, does inserting diversity into every discourse and discipline significantly change the social fabric of institutional policies and practices? In a comprehensive study of Black, Mexican American, Puerto Rican and American Indian/Alaska Natives tenure track or tenured assistant and associate professors at Carnegie-defined research institutions in the United States, discrimination and daily microagressions and their adverse physical and mental health were documented. As Deans we have heard similar experiences from our faculty of color, and felt their pain. The pervasiveness of these findings across elite institutions calls attention to the systems that continue to perpetuate discriminatory behavior towards faculty of color, and limits access to decision-making and resources. Zambrana's research was the basis for the landmark summit, Changing the National Conversation: Inclusion and Equity (Zambrana, Allen, Higginbottom, Mitchell, Perez, & Villarruel (2020)), in which over 100 college and university presidents and provosts attended, resulting in the identification of institutional transformation strategies to promote a more diverse and inclusive environment.

Another important question for nursing education is what are the hidden curricula messages within our schools that speak to our students—both those of color and those who are not? What weight, and how much, we give to certain content and clinical experiences speaks volumes of what faculty consider really important. What are the processes within our curricula that reinforce racism, or discounts racism and structural racism as an important factor in how they and their patients are treated? What messages are we giving them about the responsibility of nurses to actively engage in dismantling racism within our own profession?

Next steps

Calling out racism is an important step, but it is not enough—there is much more work to be done. How do we each lead within our own organizations to examine, call out, and change policies, practices, and traditions that disadvantage and diminish people of color in our schools of nursing, our professional organizations, and our health systems? How willing and able are we to move from naming racism to dismantling racism? Many times, institutional practices have been so ingrained in the tradition and fabric of our organizations that it is extremely challenging to see the problems that are, and have been, right in front of us. And these examinations can't be done by one person, nor by a “Diversity and Inclusion Committee.” People throughout the organization at all levels must be involved, which can lead to uncomfortable conversations, but ones that we must have. It is time to get comfortable with being uncomfortable. And how will any efforts we invest in now be different from the past, in which leaders focused on these injustices, and then soon moved the issues to the back burner as they kept up with the work of their busy day jobs.

If it is to be different, it is time to act. Get past the statements, the walks and marches, and the assignments of one more task force (Banks & Harvey, 2020). Actions, if inclusive and well thought out, can be the medium to bring people together to make a real difference—especially the younger students and faculty who we so often ‘protect’ from that work. They are the ones who will inherit the future, so they must be part of envisioning and crafting it.

The big question moving forward for leaders of nursing is: How do we each lead within our own organizations to dismantle structural racism? Can we critically examine how current policies and ways of doing work maintain or reinforce structural and institutional racism? One framework that can be helpful in guiding our thinking AND action about ‘what's next’ is:

• 1.Honoring the Voices, Listening to Understand
• 2.Applying the Lessons Learned
• 3.Moving Forward in a Sustainable Way (Brandon, 2020).

This framework clearly values the honoring of all voices and listening, but suggests those voices must also be ‘at the table’ to craft the approaches that will actually change the culture. Lastly, and perhaps most importantly, it speaks to the importance of planning for sustainability of any efforts to address racial inequities and injustices.

So where do we start? It is important that our first step be to listen and hear. We must then engage those who are committed to investing the time to examine practices, collect the evidence, and plan the change. Sustainability requires evaluation of these plans—if we don't evaluate what we change, we run the risk of institutionalizing new practices that don't get us where we need to be.

We know so many of you reading this are grappling with these questions. Please send your thoughts (and actions) about what you are doing moving forward in examining and dismantling racism so we can share with others.