A Review of Nursing Position Statements on Racism Following the Murder of George Floyd and Other Black Americans

Abstract

National outrage over the killings of George Floyd and other Black Americans in the United States prompted public outcry against police brutality and racism in law enforcement and drew national attention to systemic racism as a public health crisis. In response, during the summer of 2020 many health organizations issued position statements in response to the murders. This paper examines such statements issued by three prominent nursing organizations and 18 schools of nursing. Thematic analysis revealed six themes in the statements of the professional organizations, and a content analysis revealed that the statements of the schools of nursing were generally aligned with these themes. Such position statements can provide a viable approach to the public commitment to anti-racist reforms, but it is unclear if such statements can promote meaningful and measurable change.

Between February 23 and May 25, 2020, three unarmed Black Americans were killed during responses to alleged criminal activity. On February 23, Ahmaud Arbery was jogging when he was shot and killed by two white men who suspected he was responsible for a series of break-ins in the neighborhood in which he was jogging. His murder was captured on video and released several weeks after the incident. Two men suspected of shooting him were ultimately arrested. On March 13, Breonna Taylor, an emergency medical technician, was shot and killed by police serving a warrant to search her home. Ms. Taylor received no medical treatment for more than 20 minutes after she was shot and subsequently died at the scene. On May 25, George Floyd was arrested for alleged use of a counterfeit $20 bill. Mr. Floyd’s arrest was captured on video showing a Minneapolis police officer kneeling on his neck for more than 8 minutes, while he cried out that he could not breathe. Mr. Floyd became unresponsive and subsequently died at the scene of his arrest.

These three events prompted a national outcry against racism and police brutality. Between May 26 and June 27, 2020, it is estimated that between 15 to 26 million Americans participated in nationwide protests (Buchanan et al., 2020). The protests were in large part supported by and aligned with the Black Lives Matter social movement founded in 2013 after the acquittal of George Zimmerman—a neighborhood watch captain who murdered Trayvon Martin, an unarmed 17-year-old teenager walking home from a convenience store (Alvarez, 2012; Black Lives Matter: Herstory). The 2020 anti-racism protests flourished into one of the largest social movements in U.S. history (Buchanan et. al., 2020).

Black Lives Matter is a Black liberation movement with a global network of over 40 chapters. The movement has been described as “an ideological and political intervention in a world where Black lives are systematically and intentionally targeted for demise. It is an affirmation of Black folks’ humanity, our contributions to this society, and our resilience in the face of deadly oppression” (Black Lives Matter: Herstory). In addition to calls for major policing and justice reform, the Black Lives Matter Movement has focused national attention on systemic racism as a public health crisis. Research on racism and health and calls for health equity have proliferated in the last 2 decades (Krieger, 2012), but the Black Lives Matter movement created an urgency for widespread concerted initiatives to address racism in health care. In response, public health organizations, schools of medicine, major nursing organizations, and schools of nursing in the United States (US) have put forth position statements on racism and health.

Although such statements are usually welcomed as an indication of an institutional commitment to confronting racism, the role they play in promoting lasting social change is unclear. For example, Kiang and Tsai (2020) examined statements issued by top-ranked schools of medicine after George Floyd’s death and found a minority of schools acknowledged the role of police in Floyd’s killing and most failed to acknowledge White supremacy. While this review is informative and identified opportunities for schools of medicine to play a larger role in anti-racist efforts, a similar review focusing on schools of nursing is needed because nursing as a distinct discipline has a unique set of practice issues related to racism and healthcare. Professional nursing organizations issue position statements to guide nursing practice, which in turn, should guide the education and training of new nurses. Therefore, it is important to examine statements issued by national professional nursing organizations and schools of nursing.

The purpose of this article is to describe the key ideas contained in position statements issued by three prominent national professional nursing organizations and 32 top-rated schools of nursing (defined under sampling and inclusion criteria, below) in the US in response to the murder of George Floyd and other Black Americans due to police brutality and vigilantism. Specifically, we (a) discuss the impact of racism on health, (b) discuss the use of organizational and academic position statements in nursing, (c) identify common themes in position statements issued by three national professional nursing organizations, (d) determine if position statements were issued by 32 top-rated schools of nursing, and (e) determine whether the schools’ position statements align with those of the organizations. Describing the ways in which position statements issued by nursing organizations and academic programs express support for anti-racist actions can lead to a better understanding of the role these statements might play in influencing nursing practice and policy.

Racism and Health

Defining Racism

Ibram X. Kendi (2019), in his book How to Be an Antiracist, states that racism is “a marriage of racist policies and ideas that produces and normalizes racist inequities” (p. 20). This definition is multi-layered and can be used to identify the professional spaces in which racism is manifest. Kendi (2019) notes in recent history the term “racist” has taken on a pejorative meaning that implies endorsement of racial violence or overt prejudicial treatment and leaves us scrambling to declare we are “not racist.” Because denying racism and racist policies allows them to persist, identifying and acknowledging them is critical to dismantling them.

Examining How Racism Affects Health: Ecosocial Theory

Although a number of theories have been proposed to provide a foundation for research on the effects of discrimination on health, Kreiger’s (2012) ecosocial theory provides perhaps the most comprehensive framework for understanding racism as a multi-layered public health issue. The theory describes the role of structural racism on health using four core constructs: (a) embodiment (i.e., incorporation of the social and material world), (b) pathways to embodiment (i.e., mechanisms by which adverse exposures lead to embodiment), (c) cumulative interplay of embodied exposures throughout the lifespan, and (d) accountability and agency for social disparities in health (Krieger, 2012). The pathways of embodiment of racism have particular health care implications and include social trauma, economic deprivation, limited access to health care, and environmental degradation.

The social trauma of racial and ethnic discrimination begins at an early age. Marcelo and Yates (2019) examined experiences of discrimination among young children aged 7 to 8 years and found the majority of children of color reported experiencing one or more forms of racial and ethnic discrimination. The three most frequently endorsed forms of discrimination were (a) someone refused to be their friend (25%), (b) someone was rude to them (23%), and (c) someone at school accused them of something they did not do (17%). The authors found these experiences predicted behavioral problems in the children at follow-up. Experiences of racial discrimination continue throughout adolescence and adulthood. More than 75% of Black American adults report they have experienced racial discrimination (Pew Research Center, 2019).

In addition to experiencing racial discrimination in daily life, Black Americans experience the collective social trauma of police brutality and disproportionate incarceration. Police brutality is likely underreported due to bias in law enforcement administrative records (Peeples, 2020). However, recent research indicates Black men are 3.2 to 3.5 times more likely to be killed by the police than White men, with significant variation in risk by urbanity and region (Edwards et al., 2019). Moreover, in the US approximately 33% of prisoners are Black and 23% are Latinx, although these two groups comprise 12% and 16% of the general U.S. population, respectively (Gramlich, 2019). These national statistics mask stark racial disparities by state. In 12 states, more than half of state prisoners are Black, and in 11 states one in 20 adult Black men is incarcerated (Nellis, 2016). Incarceration exacerbates the chronic health problems with which many incarcerated persons enter prison (Binswanger et al., 2009; Prins, 2014) and contributes to increased morbidity and mortality (Brinkley-Rubinstein & Cloud, 2020; Massoglia & Remster, 2019).

Economic deprivation has a profound effect on the health of Black Americans. Approximately half of Black American adults indicate their race has prevented them from getting ahead in life (Pew Research Center, 2019), and data support this perspective. A number of policies have prevented Black families from accumulating wealth at the same pace as White families. Slavery clearly deprived Black Americans of accumulating wealth of any kind but, even after emancipation, Jim Crow laws continued to prevent the accumulation of wealth and movement to the middle class. Discriminatory hiring practices prevented Black Americans from gainful employment. The practice of redlining prevented the accumulation of wealth through property ownership, which is the mechanism by which the majority of Americans build financial reserves and family wealth. Relatedly, property values drive property taxes, which are a significant source of funding for public schools. Redlining and discriminatory lending practices ultimately affect educational and employment opportunities and lead to income inequality for Black Americans, which in turn contributes to health inequities (Bailey et al., 2017; Chetty et al., 2016).

Limited access to health care for Black Americans is a pathway that contributes significantly to health disparities. Compared to White Americans, Black Americans are more likely to be uninsured or underinsured, which restricts their access to health care services (Artiga et al., 2020). When they do access care, many experience racial bias from their health care providers. For example, 20% of Black Americans surveyed by the Kaiser Family Foundation reported being treated unfairly based on their race while seeking health care for themselves or a family member in the last year (Hamel et al., 2020). Racially biased views are endorsed by medical students and nursing students. Hoffman et al. (2016) studied White medical students’ and residents’ beliefs about racial differences in skin thickness, nerve sensitivity, brain size, and likelihood of contracting certain illness. They report 40% of first- and second-year medical students and 25% of medical residents endorse the false belief that Black men and women have thicker skin than whites. Greater endorsement of false beliefs was significantly associated with greater racial bias in pain assessment and less accuracy in prescribed pain treatment (Hoffman et al., 2016).

Racism in health care is also exemplified by the high rate of maternal and infant mortality among Black Americans compared to White Americans. Black women have 2.5 times the maternal mortality of non-Hispanic White women (Petersen et al., 2019), and Black infants have 2.3 times the infant mortality rate of non-Hispanic White infants (Ely & Driscoll, 2019). Black Americans are less likely than Whites to be recommended for chronic disease management programs and invasive procedures (Gianfrancesco et al., 2018; Schulman et al., 1999). All these instances of racism in health care contribute to poor health outcomes and lower life expectancy for Black Americans.

Systemic racism contributes to environmental degradation that in turn harms health among Black Americans. Schell et al. (2020) offer a robust and expansive review of the effects of systemic racism on urban ecosystems. They note most research on environmental degradation examines the relationship between wealth and ecology, particularly in urban environments. However, such studies are limited in explanatory value because they seldom explore the social structures that affect wealth accumulation. Intersectional research on wealth and race indicate neighborhood and regional racial composition is a more significant predictor of exposure to environmental toxins than wealth. For example, persons of color are 21% to 52% more likely to live in neighborhoods with higher surface temperatures, making them more vulnerable to heat-related illnesses compared to White Americans (Jesdale et al., 2013).

Waterways and their pollution are another example of racial disparities in environmental health hazards, as evidenced by the water crisis in the predominately Black city of Flint, Michigan. In an effort to cut costs, the city sourced water from the Flint River, which had demonstrably high levels of Escherichia coli and total coliform bacteria, total trihalomethanes (which are carcinogenic), and lead contamination (Hanna-Attisha et al., 2016). The change in water source resulted in a significant increase in the percentage of children with an elevated blood lead level (from 2.4% to 4.9%), with the greatest impact in low-income and minority neighborhoods (Hanna-Attisha et al., 2016). Elevated blood lead levels in childhood have lifelong effects on the individual as well as epigenetic impacts on multiple generations following in utero exposure (Sen et al., 2015). Other examples of environmental degradation and subsequent health effects in communities of color include closer proximity to polluting industries and greater exposure to atmospheric particulate matter, both of which affect human health (Schell et al., 2020).

Professional Response: Nursing Position Statements

Position Statements From National Professional Nursing Organizations

In response to strong evidence of the impact of racism on health and spurred by the murders of George Floyd and other Black Americans, many national professional nursing organizations issued position statements in the summer of 2020. Position statements are public endorsements of an organizational commitment related to an issue of concern to the organization. For example, the American Nurses Association (ANA) states:

The American Nurses Association (ANA) develops positions relevant to nursing practice, health policy, and social concerns impacting the health of patients and families. Position statements guide the profession, amplify the views of nursing, and educate consumers and decision makers.

Such position statements can influence practice and policy. For example, between 2008 and 2019, eight states and the District of Columbia passed Death with Dignity laws that allowed medical aid in dying. In 2013, the ANA put forth a position statement titled The Nurse’s Role When A Patient Requests Medical Aid in Dying. The position statement was revised in 2019 toclarify nurses’ roles and ethical duties when providing care for persons considering or choosing medical aid in dying. Other ANA position statements have addressed issues such as global volunteerism, care for persons with intellectual and developmental disabilities, managing pain and suffering, and nursing advocacy for lesbian, gay, bisexual, transgender and queer (or questioning) and others (LGBTQ+) populations (American Nurses Association).

As seen in Table 1, position statements issued by three prominent national professional nursing organizations in the summer of 2020 included the following: Resolution on Racial Justice for Communities of Color (ANA), Racism Affects Health and Wellness and It Must Be Addressed (American Academy of Nursing [AAN]), and Statement on Academic Nursing’s Call for Liberty and Justice for All (American Association of Colleges of Nursing [AACN]).

Table 1.

Position Statements by Three Prominent National Professional Nursing Organizations

	Key Role in Profession	Date Statement Issued	Links to Statement
American Academy of Nursing (AAN)	National organization whose goal is to advance the profession by knowledge and policy-related initiatives to influence health policy, practice, and science	6/1/20	Racism Affects Health and Wellness and It Must Be Addressed.
American Association of Colleges of Nursing (AACN)	National association that establishes quality standards for nursing education, assists schools to implement those standards, promotes public support for professional nursing education, research and practice	6/2/20	Statement on Academic Nursing’s Call for Liberty and Justice for All
American Nurses Association (ANA)	Professional organization that represents the 4 million registered nurses in the United States	6/20/20	Resolution on Racial Justice for Communities of Color

Position Statements From Schools of Nursing

In the summer of 2020, many schools of nursing in the US also issued position statements related to racism and health in response to the murder of George Floyd and other Black Americans. As schools of nursing play a pivotal role in developing a nursing workforce, these statements reflect important commitments to combatting racism in academic institutions and more specifically among nursing students. By teaching the next generation to recognize racism and take action to address it, schools of nursing can contribute significantly to initiatives to diminish racism in nursing practice.

Methods

To describe ways in which position statements issued by nursing organizations and academic programs express support for anti-racist actions, we conducted two qualitative analyses. First, we conducted a thematic analysis (Braun & Clarke, 2006) of the position statements issue by the AAN, AACN, and ANA in response to the murder of George Floyd and other Black Americans (hereafter referred to as national position statements) to identify common ideas included in the statements. Second, we conducted a directed content analysis (Hsieh & Shannon, 2005) of position statements issue by highly ranked schools of nursing in response to these murders (hereafter referred to as school position statements) to determine the extent to which these statements aligned with the national position statements. The thematic analysis and the directed content analysis are described below.

Methods for Thematic Analysis of the National Position Statements

Documents

The national position statements were downloaded and placed in the team’s file sharing and storage platform. The statements were all four paragraphs long. One was signed by the President of the Organization (AAN), and one was signed by Chair of the Board of Directors and the President/Chief Executive Officer (AACN). The hyperlinks to these three statements appear in Table 1.

Analysis

Thematic analysis as described by Braun and Clarke (Braun & Clarke, 2006) was conducted on the three statements. Thematic analysis is a method for identifying, interpreting, naming, and describing recurring patterns in a narrative data. We used an inductive approach so the analysis would be data-driven and independent of a priori theoretical commitment. We searched for semantic themes reflecting the explicit content of the position statements rather than latent themes reflecting underlying meanings or conceptualizations. Thematic analysis was used as we wished to identify broad common themes across the three documents.

We analyzed the documents in five phases (Braun & Clarke, 2006). First, the first and last author read the statements multiple times to understand the overarching tenor of each statement. Second, the first author conducted initial coding on the policy statements by providing a label to capture the essence of each comment. Third, the first author grouped similar codes and suggested potential or “candidate” themes. Fourth, the candidate themes were reviewed and discussed with the last author and, through discussion and consensus, the final themes were identified. Fifth, the first author proposed a definition and name for each theme that were discussed with and agreed upon by the last author.

Identified Themes

The themes are (1) condemnation of police brutality, (2) acknowledgment of the effect of racism on health, (3) calls to combat racism, (4) calls to end structural, systemic, or institutional racism, (5) calls to stand by or support those working against racism, and (6) calls to promote respect for all persons.

Theme 1: Condemnation of Police Brutality.

The national policy statements all condemned murders of George Floyd and other Black Americans by police and vigilantes and stressed that such acts cannot be tolerated. Examples of comments reflecting this theme include the following:

Continued acts of aggression and excessive force against African American communities, as a result of unjust systemic inequities these communities face, cannot be tolerated. (AAN)

The American Nurses Association (ANA) 2020 Membership Assembly condemns the brutal death of George Floyd and the many other Black, Indigenous, and People of Color who have been unjustly killed by individuals within law enforcement. (ANA)

As the nation struggles to come to terms with the senseless, tragic killing of George Floyd, and those before him, the time has come to send a clear message that injustice and racism will no longer be tolerated. (AACN)

Theme 2: Acknowledgment of the Effects of Racism on Health

The statements also affirmed the profound influence of racism on health. They emphasized that racism was a social determinant of health, led to health disparities, and contributed to poor health outcomes. Examples of comments reflecting this theme include the following:

Violence, discrimination, and racism have a direct impact on determinants of health, exacerbate health inequities, and can lead to long-term trauma. (AAN)

Racism is a public health crisis that impacts the mental, spiritual, and physical health of all people. (ANA)

Theme 3: Calls to Combat Racism

The statements included appeals for members and others to combat racism. Some of these remarks were in the form of overarching appeals to no longer tolerate and take action against racism. Examples of comments reflecting this theme include the following:

ANA, along with the Constituent/State Nurses Associations and the ANA individual Member Division, pledges to: Oppose and address all forms of racism and discrimination. (ANA)

The time has come to send a clear message that injustice and racism will no longer be tolerated. (AACN)

Theme 4: Calls to End Systemic Racism

The statements included calls for members and other nurses to confront systemic racism that exists at institutional or societal levels. These appeals differed from the general calls to actions to fight racism in that they specifically addressed racism embedded in social structures rather than person biases. Examples of comments reflecting this theme include the following:

We must not only work to eliminate systemic and institutional racism, personal racism, and unconscious bias, but we must also work to increase the diversity within our profession and not succumb to the institutional structures and processes that can block openness and prevent change. (AAN)

ANA, along with the Constituent/State Nurses Associations and the ANA individual Member Division, pledges to: In partnership with nurses everywhere educate, advocate, and collaborate to end systemic racism, particularly within nursing. (ANA)

Theme 5: Calls to Stand By or Support Those Working Against Racism or Discrimination

The statements included assertions that the organizations support or stand in solidarity with others who are working to end racism. Examples of comments reflecting this theme include the following:

The American Academy of Nursing mourns the death of George Floyd and stands with those across the country calling for action to change structures and policies that have enabled and permitted senseless violence of occur. (AAN)

Archbishop Desmond Tutu said that to remain neutral in situations of injustice is to have taken the side of the oppressor. (AACN)

Theme 6: Calls for Respect for All Persons

The statements included comments that did not mention racism per se but rather called for members, and nurses more broadly, to embrace values that promote respect for the dignity and worth of all persons including inclusivity, equity, dialogue, and compassion. Examples of comments reflecting this theme include the following:

Nursing places at the center of our care the highest commitment to achieving health equity, reducing disparities, and fully respecting human dignity. (AAN)

Collectively, we must emerge from silence and speak with one strong voice as leaders and role models of compassion and empathy for our patients, families, communities and most importantly towards one another. (ANA)

AACN stands ready to help nurses lead in advancing human rights and reducing health inequities by developing a nursing workforce that is compassionate and respectful of the inherent dignity, worth, and uniqueness of every individual. (AACN)

Methods for Directed Content Analysis of School of Nursing Position Statements

Sampling and Inclusion Criteria

There are more than 800 schools of nursing in the US. To narrow the sample of schools, we used two criteria. First, we used Schnall’s (2020) report of funding patterns among schools of nursing, in which she identifies the 15 schools that were top-ranked for National Institutes of Health (NIH) funding in fiscal years 2014 to 2018. We began with this criterion to identify the schools with strong programs of research that not only produce cutting edge scientific knowledge but also train future nurses, nurse leaders, and nurse scientists. Next, we sampled schools from the U.S. News and World Report ranking of top master’s level nursing programs (U.S. News and World Report, 2020). We selected schools in rank order until the sample included all 15 of the top-funded schools from Schnall’s (2020) report, which resulted in a final sample of 32 schools (Table 2).

Table 2.

Sampled Schools, Their Rankings, and Position Statements Issued

	U.S. News & World Report Rank	Top-Ranked for NIH Funding?	Link to Statement Meeting Inclusion Criteria
Boston College	27	No	Statement issued by Dean Susan Gennaro
Case Western Reserve University	11	Yes	No
Columbia University	11	Yes	Dean Frazier’s message denouncing racism
Duke University	2	Yes	Dean Broome’s message to alumni Dean Broome’s message to the school of nursing
Emory University	5	Yes	No
Johns Hopkins University	1	Yes	No
New York University	17	Yes	Dean Sullivan-Marx’s statement on recent events
Ohio State University	6	No	Message from Dean Melnyk
Rush University	24	No	No
Rutgers University	17	No	Message from Dean Flynn (1) Message from Dean Flynn (2) Rutgers School of Nursing statement of solidarity
The Pennsylvania State University - University Park	30	No	No
University Maryland, Baltimore	22	Yes	No
University of Alabama at Birmingham	15	No	No
University of California, Los Angeles	20	Yes	Dean Sarna’s letter to school of nursing community
University of California, San Francisco	11	Yes	Statement of commitment to solidarity with communities of color
University of Illinois at Chicago	19	Yes	Message from Dean Weaver Official statement on equity and inclusion
University of Iowa	21	No	University of Iowa homepage statement of solidarity with Black Lives Matter
University of Miami	27	No	No
University of North Carolina at Chapel Hill	3	No	No
University of Pittsburgh	6	Yes	No
University of Rochester	26	No	No
University of Tennessee, Knoxville	25	No	No
University of Texas at Austin	22	No	UT at Austin DEI statement of solidarity
University of Texas Health Sciences Center at Houston	27	No	No
University of Utah	30	Yes	Dean Wilson’s message
University of Virginia	15	No	Associate Dean Kool’s message to students Associate Dean Kool’s essay
University of Washington (UW)	6	Yes	UW School of Nursing statement of solidarity
University of Michigan	9	Yes	Dean Hurn’s message Statement on diversity equity and inclusion a Q & A with Dean Hurn
University of Pennsylvania	3	Yes	Statement on the killing of George Floyd
Vanderbilt University	9	No	Notification of support for Day of Remembrance
Yale University	14	No	Commitment to antiracism Statement of solidarity

Note. DEI = diversity, equity, and inclusion.

^aUpdated in summer 2020 to include support for student engagement in lawful protests against racism.

To be included in the analysis, the statements had to meet the following criteria: (a) issued after the death of George Floyd (May 25, 2020), (b) reflected an official school position on the murder of George Floyd and other Black Americans, (c) written by an administrative official such as a school dean or dean of diversity, and (c) presented the school’s position on racism.

Documents

Of the 32 school websites we searched, 18 had position statements that met our criteria (Table 2). These statements were downloaded and placed in the team’s file storage and sharing platform. Most of the statements were direct messages from the deans of the schools of nursing, and some were from other administrative personnel such as associate deans of diversity. The statements varied in length from several paragraphs to several pages. Some schools issued more than one statement over the course of the summer.

The team noted that the majority of the schools had posted a number of documents on their websites that were not in direct response to the murder of George Floyd and other Black Americans but did reflect a commitment to diversity, equity, and inclusion (DEI). These documents often outlined plans to increase the diversity of faculty, staff, and students; to create inclusive classroom and school environments; and to combat injustices, including racism. These documents were presented in a variety of formats (e.g., newsletters, blog posts). Although the documents reflect schools’ commitments to DEI, they were not included in the analysis discussed in the following section as we focused specifically on position statements posted in the summer/early fall of 2020 in direct response to the murder of George Floyd and other Black Americans.

Analysis

In order to determine if the information contained in each school position statement aligned with the themes from the national position statements, a panel of raters was assembled, and a directed content analysis was conducted on the statements. In a directed content analysis, data are coded to pre-existing structures (Hsieh & Shannon, 2005), which in this instance were the six themes we drew from the national position statements.

The raters included three nurse scientists (first, fourth, and last authors), a nursing doctoral student (fifth author), and two social scientists (second and third authors). The raters were assigned a set of schools and provided with a data display sheet for each assigned school that listed each of the six themes and definitions. The raters were instructed to read the school position statements and indicate on each sheet whether the statements contained comments that aligned with each theme. If they felt the school position statements did contain such comments, they were instructed to copy and paste at least one comment from the statements in a text box next to the name of each theme. If there were comments in the school position statements that were not reflected in one of the themes, the raters were directed to place those comments in a text box at the end of the sheet. Each school’s statement was independently reviewed by two raters.

The first and last author met to review the team’s ratings. If there were any disagreements between the raters as to whether a school position statement had remarks that aligned with one of the themes, they returned to the statements of the schools in question and, through discussion and consensus, resolved the discrepancy. Because the ratings were straightforward and did not require a high level of interpretation, the raters typically agreed about whether the comments in the statements aligned with the themes. The ratings were then tallied to determine how many schools had comments in their position statements that aligned with the themes from the national position statements. The comments provided as examples of each theme by the raters were summarized, as were the comments provided by the raters as not aligning with one of the themes.

Results

Most of the 18 school position statements addressed a number of themes from the national position statements (Table 3). The number of themes reflected in the school position statements ranged from two to six (mean = 5, median = 6). Ten of the 18 schools addressed all six themes. Several of the statements referred to or provided links to the national position statements. The ways in which the school position statements reflected each of the national position statements are described in the following section.

Table 3.

Presence of Six Themes in Position Statements Issued by 18 Schools of Nursing

	Themesa From Position Statements of National Nursing Organizations
	1	2	3	4	5	6	Number of Themes Represented in Position Statements
Boston College	0	1	1	1	0	1	4
Columbia University	1	1	1	1	0	1	5
Duke University	1	0	1	1	0	1	4
New York University	1	1	1	1	1	1	6
Ohio State University	0	0	0	1	0	1	2
Rutgers University	1	1	1	1	0	1	5
University of California, San Francisco	1	1	1	1	1	1	6
University of California, Los Angeles	1	1	1	1	1	1	6
University of Illinois at Chicago	1	1	1	1	1	1	6
University of Iowa	0	1	1	1	1	1	5
University of Michigan	1	1	1	1	1	1	6
University of Pennsylvania	1	1	1	1	1	1	6
University of Texas at Austin	1	1	1	1	1	1	6
University of Utah	1	0	0	0	0	1	2
University of Virginia	1	1	1	1	1	1	6
University of Washington	1	1	1	1	1	1	6
Vanderbilt University	1	0	1	0	1	0	3
Yale University	1	1	1	1	1	1	6
Number of Schools With Content	15	14	16	16	12	17

^aTheme 1: Condemnation of police brutality; Theme 2: Acknowledgment of the effects of racism on health; Theme 3: Calls to combat racism; Theme 4: Calls to end systemic racism; Theme 5: Calls to stand by or support those working against racism or discrimination; Theme 6: Calls for respect for all persons.

Theme 1. Condemnation of Police Brutality

Fifteen school position statements included comments that were consistent with theme 1. Most of the statements specifically named George Floyd and condemned his death, and several also named and condemned the deaths of Breonna Taylor and Ahmaud Arbery. One school (University of Texas, Austin) also named and condemned the deaths of Mike Ramos, Philando Castile, Trayvon Martin, Sandra Bland, and Tamir Rice. These comments were often extended to a broader group of Black Americans or, in some instances, persons of colors more generally who had been killed by law enforcement or vigilantes.

Although the deaths were typically referred to as “horrendous,” “tragic,” and “senseless,” not all statements used terms that directly tied the killings to police brutality or overuse of force. For example, one statement (University of Washington) proclaimed, “There is pain, there is anguish, there is an accumulated burden of injustice and inequity. And there is the loss of George Floyd’s life and the lives of far too many others whose only crime was the color of their skin.” In contrast, a few statements emphasized that the killings were due to police violence. For example, one statement (University of Illinois, Chicago) described, “Here, we often talk about the community, but it is also important to talk about the individuals that bring a face and name to community: Breonna Taylor, Ahmaud Arbery and George Floyd, to name just a few. In the past three months, these individuals have lost their lives to the most pernicious of the social determinants of health: racism and police brutality.” Another statement (University of California, San Francisco) asserted, “We the students, faculty, and staff of the UCSF School of Nursing stand in solidarity with those impacted by the senseless racialized violence at the hand of law enforcement, most recently the killing of George Floyd, as well as countless other Black and Brown individuals killed by the police and/or other white vigilantes.”

Theme 2. Acknowledgment of the Effects of Racism on Health

Fourteen school position statements included comments that were consistent with theme 2. Many of the statements discussed the role of racism as a social determinant of health and a major contributor to health disparities. A few stressed that racism should be viewed as an urgent public health crisis. Some statements acknowledged the unequal treatment of Black Americans in the health care system. For example, one statement (University of Michigan) claimed, “We … have decades of data and experiences from African Americans who have engaged with care providers and demonstrated that the health care system doesn’t fully work for them, and they don’t receive the quality and quantity of care that all Americans expect. We need to be hypervigilant in our advocacy for African American patients.” Several statements pointed to the disproportionate impact of coronavirus disease 2019 (COVID-19) and other health threats (e.g., maternal and infant mortality) on Black Americans and other communities of color. A few statements made a direct connection between police brutality and health. One statement (University of Illinois at Chicago) asserted, “We know from research that has taken place right here at UIC that violent encounters with the police have profound direct and indirect effects on the health, neighborhoods and life chances of individuals living in segregated communities of color.”

One statement in particular (University of California San Francisco) placed the impact of racism on health in an historical context: “The legacy of America’s racism and the oppression of people of color casts a long shadow in modern health care…. We acknowledge the horrific historical influence of racism in health care and nursing, including the exploitation of enslaved persons to develop medical treatments and technologies…”

Theme 3. Calls to Combat Racism

Sixteen school position statements included comments that were consistent with theme 3. These statements denounced racism generally and call for actions to combat it. One statement (University of Washington) proclaimed, “The School of Nursing is wholeheartedly committed to taking actions to combat racism at all levels.” Some statements focused on combating racism within the school or institution by which the statement was issued. Several of these statements acknowledged the effects of racism on members of the school’s community. One statement (University of California at San Francisco) declared, “We acknowledge all forms of racism, from everyday bias and micro-aggressions to racialized violence, create an undue weight on the daily lives of our faculty, staff and students of color.” Some statements included a commitment to begin new programs to combat racism and others announced events that supported anti-racist initiatives. For example, one statement (University of Virginia) announced a newly launched anti-racism study group and plans for faculty and staff to attend a Racial Equity Institute. Only a few statements directly called for confronting White supremacy or White privilege in the fight against racism. One statement (Yale) declared, “To achieve better health for all people, we acknowledge White supremacy as an insidious, toxic, and expansive system that must be renounced, including within our own school.”

Theme 4. Calls to Action to End Systemic Racism

Sixteen school position statements included comments that were consistent with theme 4. Unlike the comments supporting theme 3 that spoke to racism generally, these statements situated racism in social structures and called for an end to systemic or institutional racism. For example, one statement (University of Virginia) asserted, “Systemic racism is at the root of both of these life-limiting circumstances [racism, poverty]. Until we understand and actively address systemic racism, we are destined to return to the way things have always been.” Some statements appealed for actions to combat systemic racism existing within the schools from which the statements were issued, and others revealed actions that had been taken or were being planned to confront institutional racism. One statement (Boston College) avowed, “…. In this unprecedented historical time, we reaffirm our commitment to confronting and dismantling systemic racism and oppression. Our community has taken steps to cultivate a more inclusive educational setting through our teaching, research, and practice.” Several of the statements identified social structures steeped in systemic racism. One statement (New York University) outlined a number of such structures:

It is a political system that suppresses voting rights. A housing system that implicitly promotes segregation. An economic system that routinely sees Black unemployment twice as high as white unemployment. A prison complex that sends five times the number of Black Americans to jail than whites… [These outcomes] are the result of 100 million little individual actions and decisions that intersect and interlock to create the scaffolding for structural racism.

A number of statements not only identified roots of systematic racism but included recommendations to dismantle racist structures. One statement (University of Texas, Austin) appealed to others to seek knowledge about current anti-racist movements and the history of systemic racism, empower anti-racist advocacy, make donations to organizations doing anti-racism work, and to vote.

Theme 5: Calls to Stand With or Support Those Working Against Racism

Twelve school position statements included comments that were consistent with theme 5. These statements included commitments to “stand in solidarity” with others who were actively doing anti-racist work or who were speaking out for anti-racist causes. Several statements expressly indicated support for the Black Lives Matter movement. One statement (University of Chicago, Illinois) asserted, “The UIC College of Nursing stands in solidarity with the efforts of Black Lives Matter to eliminate structural and anti-Black racism and to create a more just and equal society for all.” Other statements indicated that the school supported Black students who were speaking out or taking part in protests. Several statements rejected “silence” and “inaction” as a response to racism in its various forms.

Theme 6: Calls for Respect for All Persons

Seventeen school position statements included comments that were consistent with theme 6. These comments did not address racism directly but rather appealed for actions in which all persons are respected. These comments often were related to nursing values of compassion, equity, justice, inclusivity, and civil discourse. Some of the statements focused on providing nursing care based on these values. One statement (Rutgers) proclaimed, “Woven into the DNA of our profession is the call to provide compassionate and competent care without discrimination. We do this with the utmost excellence, and without bias. A nurse is, as the Nightingale Pledge recited by nurses everywhere affirms, a ‘missioner of health,’ dedicated to ‘devoted service to human welfare.’” Other statements focused on enacting these values in nursing education and included comments that focused on creating inclusive and welcoming learning environments. One statement (Columbia University) appealed:

“All of you receiving this message have chosen nursing—or the support of nursing—as your life’s work. It thus falls to each and every one of us to help heal these injuries. To care. To treat every person with dignity and respect, no matter their race or ethnicity, religion, socioeconomic status, gender, age, sexual orientation or gender identity, mental health, or cognitive, sensory, or physical disabilities…”

Additional Comments

The statements contained very few comments that were not related in some way to any of the themes. The comments that could not be coded to a particular theme were primarily school-specific announcements that were included in the statements. For example, some schools in their statements offered sympathy to students who were particularly affected by the events of the summer and listed resources for those that were distressed. Some of the statements offered an apology by the school official (e.g., dean) for “not doing enough” to combat racism and vowing to do better, and other statements included announcements of DEI or anti-racist programs that were offered by the schools or universities.

Discussion

Over the course of the last 2 decades, researchers have developed a strong body of empirical evidence on the effects of racism on health. Racism affects health over the course of the lifespan through multiple pathways and has been shown to have a cumulative and multi-generational impact (Krieger, 2012). The recent killings of George Floyd and other Black Americans, and demands for significant reform spearheaded by the Black Lives Matter movement, shed a glaring light on the criminal justice system as a racist structure. This movement also provided a call to action to dismantle other racist structures, including those that permeate health care.

Historically, position statements issued by the national professional nursing organizations have had a significant influence over nursing practice and health policies. Our review of the position statements issued in June of 2020 by the ANA, AAN, and AACN revealed that these national bodies responded in a timely and consistent manner to the public outcry over the killings of George Floyd and other Black Americans. These position statements provided direction for a unified response from the nursing profession, articulated clear messages that police brutality will not be tolerated, highlighted the effects of racism on health, and called for actions to end to personal and systemic racism, including standing in solidarity with those actively engaged in anti-racist initiatives, including Black Lives Matter. The statements were consistent with the Code of Ethics for Nursing (American Nurses Association, 2015), which calls for the respect of the dignity and worth of all persons.

Our review also revealed that many schools of nursing across the country responded with position statements of their own. Position statements in direct response to the killing of George Floyd and other Black Americans were posted on 18 of the 32 school websites we examined. These statements provided a public means by which schools announced their commitment to anti-racist action. In contrast, we did not find school position statements meeting our criteria on 14 of the 32 websites we examined. As all schools in our sample were top-ranked schools of nursing, it is unclear why some schools did not provide a clear anti-racist statement in response to the events unfolding during the summer/early fall of 2020.

Our content analysis of the school position statements suggested that the majority of position statements issued by the 18 schools were well aligned with the national position statements, and many contained similar assertions and appeals. The statements addressed from two to six of the themes that we identified in the national position statements. Despite this, we noted variations among the statements in several regards. For example, some statements were limited to general declarations regarding the school’s commitment to an anti-racist agenda, whereas others included specific announcements or pledges of new initiatives. Although most of the statements addressed systemic racism, several were void of comments that might be considered controversial, such as references to White supremacy as the foundation of racism, support for the street protests of the Black Lives Matter movement, and pointed calls for substantial policing reforms. Other statements included such comments despite the potential for political ire or backlash.

Our conclusions should be considered in light of several limitations of this project. First, we limited our sample to highly ranked schools of nursing and therefore cannot make broad claims about the percentage of schools in the US that issued position statements or the nature of those statements. Second, our search was limited to the summer of 2020, and schools may have issued statements since that time that are not reflected here. Third, our review of the school websites revealed many schools posted articles, lists of resources, announcements of events, commentaries, committee descriptions, and blogs related to their DEI agendas. We did not include these documents in our analysis as they did not meet our criteria of position statements issued specifically in response to the murder of George Floyd and other Black Americans. We therefore cannot make claims about overall diversity and inclusion efforts, including anti-racist initiatives, of any of the schools. Finally, our project only analyzed the content of the official position statements, which may not reflect the experiences of faculty, staff, and students of color at the institutions represented here.

Our findings suggest that while position statements are a viable approach to the public assertion of commitment to anti-racist reforms by schools of nursing, it remains unclear if and how such statements can promote meaningful and measurable changes. Experts have pointed out that such statements need corresponding institutional commitment and financing for evidence-based training, policies, and other programs to address intersectional stigma and discrimination for faculty, students, and staff (Turan et al., 2019). Moreover, Gutierrez (2020) warns that position statements and associated trainings may ultimately detract from real and sustainable change to institutional racism and argues that schools must expand beyond statements to hire and support faculty of color, sustain programs of research that address racism, and support faculty, staff, and students who report experiencing racism in their institutions (Gutierrez, 2020).

One strategy by which schools of nursing may enact the changes promoted in their position statements is to offer or develop evidence-based programs to address structural racism within their schools. For example, Schroeder & DiAngelo (2010) describe a project designed to address the climate of whiteness in the University of Washington School of Nursing. Their project included (a) formal workshops attended by a small group of competitively selected faculty and staff; (b) a year-long educational curriculum on white beliefs, norms, and behaviors; and (c) development of action plans to improve antiracism efforts at the school. The action plans included incorporating antiracism agenda items at each standing meeting, eliminating the Graduate Record Examination from admission requirements due to its bias against under-represented groups, and attaching antiracist journal articles to school-wide emails. Participant outcomes included a deepened understanding of racism, increased awareness of enacting white privilege, and increased countering of racist comments from others.

A program initiated at a school of medicine offers another example of an intervention to combat structural racism in an academic healthcare setting. Woodruff et al. (2020) describe an institutional intervention to promote inclusive learning environments and professional development. The program was initiated after medical students expressed interest in addressing issues of identity and inclusion as the Black Lives Matter movement gained momentum. The features of the intervention included (a) establishment of an identity and inclusion steering committee with representation of all stakeholder groups (students, faculty, administrative staff), (b) regular communication, including open forums, climate surveys, and annual town hall meetings, and (c) programming to support identified needs, including opportunities to develop competence with debate, civil discourse sessions which are facilitated by faculty, and self-expression through art. These efforts were measured with climate surveys, each of which indicated graduating students were felt their school prepared them for working with individuals of different backgrounds and identities.

The impact of antiracist position statements on the climate of schools of nursing is unknown and it is important to explore associations between the issuance of position statements, the specific content of the statements, and the long-term impact of the statements on faculty, staff, and students. However, it is reasonable to assume that evidence-based institutional interventions will be required to create real change. Schools of nursing are responsible for the education and training of the largest body of health care workers in the US. As a profession, we have espoused a commitment to ensuring health equity for all communities. As such, nurses bear a significant responsibility for dismantling the structures of racism in order to improve the health of Black Americans. This work will be buoyed by passioned calls for anti-racist health care reforms and clear calls to action by our professional organizations and educational institutions. However, these calls must be accompanied by efforts that support lasting reform. Nonetheless, the use of position statements offers one means by which schools of nursing can align with national professional nursing organizations in efforts to train the next generation of nurses to combat the toxic effects of racism in health care.

Key Considerations.

• Racism affects health through multiple pathways of embodiment—social trauma, economic deprivation, limited access to health care, and environmental degradation—over the course of a lifetime.

• The murders of three Black Americans in 2020 galvanized national support for the Black Lives Matter movement and intensified efforts by the nursing profession to respond to racism as a public health crisis.

• Position statements from national professional nursing organizations and schools of nursing assert an organizational or institutional commitment to confronting racism and provide direction for nurses to engage in anti-racist actions.