Abstract
In the tumultuous year 2020, our journal's overarching theme was Seeing Beyond: Beyond Borders, Beyond Gender, Beyond Traditional Measurement, and Beyond Current Care. As we prepared each issue for publication and sent it out into the universe, events were unfolding around us that challenged our profession, our actions as citizens, and the lives and health of millions of people around the world. Our editorial board was inspired to change the more introspective theme we were working on for 2021, Identities and Intersectionality to an overarching In It Together (we chose those words before others made them more public), and to title our four issues as calls to action: Dismantling Systems of White Supremacy, Breaking New Ground for Leadership, Engaging the Public in Public Health, and Promoting Planetary Health.
These are word choices we have to make now—in the words of author James Burroughs II, Chief Equity and Inclusion Officer for Children's Minnesota, we are calling it what it is. Most of those word choices (many with far-reaching implications), we have left up to the individual authors: Capitalize Black and Brown and Indigenous? Capitalize White? Capitalize White people but not White supremacy? Use the acronym BIPOCs (Black, Indigenous, and People of Color) or spell it out each time? Use the nouns whites and Blacks, or always white people and Black people? Include or omit words that are neutral to some white people but deeply wounding to many people of color? The authors made those decisions.
Our authors hold us accountable for learning a vocabulary that is new to many of us: whiteness, white advantage, white privilege, and white fragility; anti-Black racism, racialization, and racial disparities; allies, collaborators, and co-conspirators; unconscious bias and systemic bias; microaggressions; tone policing; calling out and calling in. And words we thought we knew, used in new, challenging ways: bodies, intentional, epigenerics, othering, trauma, epidermal, underrepresented.
Then there is the question of how to describe absences—how to prove a negative. Colorblindness: What is the difference between the aspirational “I treat everyone equally.” and the dehumanizing “I don't see color.”? Or the difference between the active antiracism of confronting dehumanizing behavior in the moment, and the passive “I'm not racist—I grew up near a Reservation.”? How do we make overt the covert environment that surrounds us all—of white as the norm, the default, appearance; white history as the accurate history; and white values (whatever that is) as the only values that should guide us?
And finally, the overarching editorial decisions: How graphic can we get in calling out the horrific, dehumanizing actions of so many citizens, in the past and in the present? How completely can we stop the blaming of the victims of health disparities? And how strongly can we word the news that race is a social construct, with no basis in the science that nurses love to claim?
So nursing is where we start calling it what it is— we are a journal by, for, and about nurses and our colleagues in the health-care professions. The nursing profession has elements of its own history and current status to answer for. In this issue we talk about racism in our education, in the organizations and systems where we provide care, and in the way we treat each other. In “Sharing Our Stories and Holding Our Past to Task,” guest co-editor Tammy Sinkfield-Morey, nursing supervisor at Gillette Children's Specialty Healthcare in St. Paul, Minnesota, and the Minnesota Hospital Association's 2019 “Caregiver of the Year” for her work in Storying and in Diversity and Inclusion, shares the page with Teddie Potter, clinical professor, Director of Planetary Health, and specialty coordinator of the Doctor of Nursing Practice in Health
How strongly can we word the news that race is a social construct, with no basis in the science that nurses love to claim?
Dismantling Racism in Nursing Education
Our discussion begins with the entrenched white supremacy that maintains and reinforces the disparities between representation of white nurses and nurses of color in leadership positions in schools of nursing, as reported by guest co-editor Brigit Carter, associate professor and Associate Dean for Diversity and Inclusion at Duke University, and coauthor G. Rumay Alexander, nursing professor and former Chief Diversity Officer at the University of North Carolina, and past president of the National League for Nursing. They present statistics about these disparities within faculties, as well as data about the Browning and graying of America that make a diverse nursing workforce ever more crucial. But they also remind readers of the anecdotal disparities: the stories of white people in faculty leadership positions that contain the theme of being “chosen”—that “someone saw something in them,” in contrast to stories shared by faculty of color who feel the need to meet many requirements, earn countless certifications, and complete endless fellowships, to achieve the same positions as their white counterparts. “Where the implicit is not made explicit, injustices flourish.”
A companion article by Dr. Carter and coauthor Beth Cusatis Phillips, associate professor and Director of the Institute for Educational Excellence at Duke University School of Nursing, advocates for incorporating social determinants of health (SDH) throughout nursing curricula. “Teaching assessment of SDH creates an invaluable context for future nursing professionals to provide appropriate delivery of care, health education, and recommendations and longitudinal support to patients and families of various populations.” These authors remind us that “race and ethnicity are social constructs that artificially divide people into groups based on characteristics such as physical appearance, ancestral heritage, cultural affiliation, cultural history, ethnic classification, and the social, economic and political needs of a society at a given time.” [Emphasis mine].
Two nurse educators describe their everyday efforts to confront and eliminate racism in their respective schools of nursing. Amie Koch, assistant professor at Duke University School of Nursing and a family nurse practitioner in palliative care, advocates for openness: “Health-care professionals and health-care systems cannot embrace the values needed to reduce health disparities if they are governed by prohibitions against open and honest discourse …. Educators must make a commitment to learning and teaching the truth that racism, oppression, and white privilege have as great an impact on health as biology and genetics.” And Amy Harding, assistant professor in the College of Nursing and Health Sciences at Metropolitan State University in St. Paul, Minnesota, cites behavioral norms for students that are often disparately enforced: “Students of color risk being labeled as difficult, unprofessional, or as 'playing the race card ‘when pointing out inequities.”
Vernell DeWitty, Director for Diversity and Inclusion at the American Association of Colleges of Nursing, and David Byrd, Associate Dean for Admissions and Student Services in the School of Nursing at the University of Texas Health Science Center San Antonio, present creative strategies to foster diversity of applicants to schools of nursing: Categorize nursing as a Science, Technology, Engineering, and Mathematics (STEM) field grounded in science and evidence-based practice, spurring students interested in STEM to consider nursing as a career option and opening additional revenue streams. “Recruit for a diverse teaching force to enhance availability of nursing faculty who resemble the students they support.” Advertise community initiatives focused on social justice efforts; demonstrating “commitment to addressing health-care disparities can be particularly attractive to students who have lived with those inequities throughout their lives.”
Dismantling Racism in Health-Care Systems
In “Understanding Racism as a Historical Trauma that Remains Today: Implications for the Nursing Profession,” Roberta Waite, professor of nursing and Associate Dean of Community-Centered Health and Wellness & Academic Integration in the College of Nursing and Health Professions at Drexel University, and Deena Nardi, a psychotherapist in Chicago, Illinois, define the terms whiteness, white supremacy, racializarion, anti-Black racism, white privilege, and historical trauma. They remind us that “racial images influence the world and produce character assumptions; however, racializarion is rarely applied equitably to all humans,” and advocate that “Nurses who understand themselves as racial beings can better comprehend actions occurring in society and recognize the role of whiteness in our systems.”
James Burroughs II of Children's Minnesota, who contributed to the title of this editorial, advocates for structured, intentional diversity initiatives in organizations: “a team that is formalized, focused, and funded, actively seeking to improve the experience of the entire workforce through equity and inclusion …. We must intentionally put systems in place to recruit and retain a racially diverse group of employees and partners, so that our pool of qualified job applicants, our staff of caregivers, and the people who help build and maintain our infrastructure better reflect our patients and families.”
Our Voice of Patients and Families feature addresses disparities in maternal outcomes between white women and Black/African American women. Jacquelyn McMillian-Bohler and Angela Richard-Eaglin, assistant clinical professors at Duke University School of Nursing, state that “adverse maternal outcomes of Black and African American women occur when the effects of structural racism reverberate through the determinants of health.” The physiological impact of caregiver disregard, stereotyping, and microaggressions on health outcomes is magnified by the psychosocial impact: “Patients may feel reluctant to disclose critical health information or to follow medical advice if their provider appears to minimize or dismiss their concerns, or fails to respond to symptomatic complaints due to racism…. Moving nursing practice toward health equity requires intentionality, mutually beneficial collaboration with patients, and nursing practices that support the social, physiological, economic, and environmental determinants of health.”
Educators must make a commitment to learning and teaching the truth that racism, oppression, and white privilege have as great an impact on health as biology and genetics.
According to Pandora Goode, assistant professor of nursing at Winston-Salem State University in North Carolina, the primary care that people of color receive in their communities is often informed by venerable theoretical models such as the Health Belief Model, the Theory of Planned Behavior, and Bandura's Self-Efficacy Theory, whose relevance to the populations being served may be unclear. “Understanding historical and theoretical perspectives and assessing their appropriateness for an intervention are important to understanding how the knowledge generated by the theories is to be applied.”
Dismantling Racism in how We Treat Each Other
Erika Samman, a Texas nurse and medical writer with research interests in social science, population health, and disease management, traces the origins of uncivil social behavior within nursing to post-Civil War policies and organizations that involved the developing profession. The knowledge required to assume this new role was limited by race; “While the opportunity to work in a self-supporting occupation outside domestic service naturally attracted educated Black women, most of the nursing schools that came into existence after the 1870s excluded them …. As institutions that shaped racial interactions, military hospitals played a key role in advancing and reproducing the hierarchies of privilege and subjugation invisible to the Whites who made them.”
In “Moving from Allyship to Antiracism,” Rebecca Smith, writer and editor in Minnesota (and a member of Creative Nursing's editorial board), challenges her fellow white people (particularly white Americans) to admit that we live in a world that centers whiteness constantly, to use reflection to neutralize our defensiveness and understand our own motives, and to take responsibility for staying present even when our trauma has been triggered. She states, “If the truth is that the fates of all humans are inexorably intertwined, then the supposed supremacy of any person or group is a lie; in the case of white supremacy, it's a lie on which our entire American system is based.”
There are many resources to help us learn more about the unconscious biases we all carry. Nicholas Tangen, a community organizer and faith formation educator in the Evangelical Lutheran Church in America, reviews one of them, me and white supremacy: Combat Racism, Change the World, and Become a Good Ancestor, by Layla Saad. His familiarity with antiracist literature stems from a commitment to deconstructing racism and white supremacy as a personal and
Where the implicit is not made explicit, injustices flourish.
In assembling this issue, I searched our journal archive of all the articles we have published from 2008 to now, looking for articles about social justice, determinants of health, diversity, and inclusivity— the kinds of knowledge that inform the discussions in this issue. The result is a list of 78 articles containing these concepts in their titles. They range from broad calls to action (Jean Watson's “A Model of Caring Science as a Hopeful Paradigm for Moral Justice for Humanity”) to specific caveats (nursing professors Susan Lampe's and Bessie Tsaouse's “Linguistic Bias in Multiple-Choice Test Questions”), and from aiming for the best (nurse manager Mika Sunago's “Strategies for Nursing Leaders on Recruiting and Retaining a Diverse Workforce”) to recognizing crucial resources (reviews of Judy Pasternak's Yellow Dirt: A Poisoned Land and the Betrayal of the Navajos; Resmaa Menakhem's My Grandmother's Hands: Racialized Trauma and the Pathway to Mending our Hearts and Bodies; and Davey Shlasko's Trans Allyship Workbook). So with this theme issue, we are building on foundations laid by founding editor Marie Manthey, and our wonderful authors who challenge us to be our best selves.
Footnotes
Disclosure. The authors have no relevant financial interest or affiliations with any commercial interests related to the subjects discussed within this article.
Funding. The author(s) received no specific grant or financial support for the research, authorship, and/or publication of this article.
Marty Lewis-Hunstiger, BSN, RN, MA, is a retired pediatric nurse and preceptor, editor-in-chief of Creative Nursing, copy editor of the Interdisciplinary Journal of Partnership Studies, and an affiliate faculty member at the University of Minnesota School of Nursing in Minneapolis, Minnesota.