Contributors: Jennifer Weitzel, Jeneile Luebke,
Linda Wesp, Maria Del Carmen Graf, Ashley Ruiz,
Anne Dressel, & Lucy Mkandawire-Valhmu

The murder of George Floyd and Breonna Taylor has prompted a wake-up call to reflect on the pervasive issue of structural racism.  As a nation created through histories of colonization and slavery, these murders—among countless others—have acted as a catalyst for American society to recognize and act to disrupt continued legacies of racism embedded into the fabric of American society¹.  As nurses, as a part of this society (and thus a reflection of society) it is incumbent upon the nursing profession to take a stark look at the ways in which the legacy of structural racism has continued to inform nursing practice, education, and research.  Doing so speaks towards the nursing professions commitment towards supporting best health outcomes for everyone.  As the most trusted profession, and largest healthcare profession, such allyship not only recognizes this issue, but acts to decolonize discourses, and provides explicit attention to the impact that racism holds on health outcomes.  Such measures call to realize the reality that racism is a health issue, that must no longer remain on the periphery of nursing education, research, and practice in the U.S. (see https://nursology.net/2020/01/14/decolonizing-nursing/ ) .

Nursing as a science, has historically been constructed from a positivist and Eurocentric framework that serves to sustain the domination of “whiteness as a form of disciplinary power.”^2(p.196)  Cultural competence is often the primary concept used to guide the nursing profession in addressing the needs of diverse populations locally and globally.³ The principles of cultural competence are heavily influenced by the social and political history of the U.S.⁴ Practicing with cultural competence is tainted with the effects of racial bias, as this concept fails to recognize how perceived “cultural differences” are code for modern-day racist ideologies dating back to colonialism.⁶ Therefore, what is often believed to be cultural knowledge is rooted in White, European worldviews and codified into healthcare practices based on faulty interpretations and observations of “Othering”. 

Calls have been put forth for nursing to transform these harmful approaches to cultural competency using emancipatory knowledge development and critical theory. Although nursing has been heavily impacted by the hegemonic ideologies of the biomedical model, we have also pioneered ways of knowing that disrupt oppressive knowledge paradigms.   The very institutionalization of competence within the medical field was one way for healthcare providers to establish a standard of expertise. This was key to the professionalization of many disciplines informed by the biomedical model, which focuses primarily on biological factors of health and excludes psychological, environmental, and social influences.⁴  Because of the societal value placed on our education and our expertise (cultural competence), nurses enjoy a position of power in Western models of health care. Operating blindly within the hierarchies of power existent in the Western, biomedical model of health leads to running the risk of de-contextualizing the care we provide. For example, Ilowite, Cronin, Kang, and Mack found that parents of children with cancer, regardless of race and ethnicity, wanted detailed information regarding their child’s prognosis.⁷ However, the researchers also found that physicians provided less information to Black and Hispanic parents than to White parents. This is an example of how healthcare providers exert power by deciding what information to share with patients based on perceived cultural norms and implicit bias.

Most individuals entering the healthcare field espouse a belief that they need to deliver care with impartiality.  However, without a sufficient understanding of the machinations of racism in everyday society, the ways in which racism are perpetuated in the healthcare system will remain a blind spot.⁶ In attempting to provide care regardless of race or ethnic background, we might overcompensate (“I don’t see color”) and subsequently fail to see how social determinants of health, including racism, affect our patient’s opportunities to achieve and maintain optimal health. ⁶

Practicing with cultural competence is predicated on the nurse’s ability to learn and understand cultures other than their own  to predict health behaviors and ultimately health outcomes.⁷ When these predictions drive how care is delivered, the complexities of how individuals, families, and communities make decisions about life, illness, and death become reduced to single narratives and stereotypes.⁹ By many of our textbooks and NCLEX review materials still provide content based on assumptions and broad categorizations. These assumptions often boil down to ideas such as the belief that because of their race or ethnicity, people share static traits, values, and beliefs, racial categories are legitimized as objective truths, when in reality, these categories are social constructions shaped by history and politics.

It is fundamentally impossible for nurses to provide culturally competent care under the premise that knowledge is based on these singular narratives, beliefs, and stereotypes. We must be open to the use of new frameworks that underpin the delivery of nursing care to meet the needs of diverse populations.  These frameworks derive from epistemologies that challenge Western hegemonic knowledge, how it is produced and who produces it.  For example, cultural safety is a concept originating from indigenous Maori New Zealanders that calls on nurses to engage in ongoing self-reflection about issues of power and privilege. Intersectionality theory, rooted in Black feminist thought, requires an understanding that people identify in a myriad of ways that are fluid and interactive.  These identities, some of which are self-ascribed, and others are socially ascribed, form matrices that confer or deny power. Legal scholars introduced Critical Race Theory (CRT) drawing from critical legal and civil rights scholarship.  CRT is underpinned by the following assumptions:

1.  Race is a social construct with no basis in science.

2. White supremacy does not exist on the fringes of society but is embedded in the everyday order of U.S. life.

3.  The voices of those experiencing racism are essential to knowledge development.

4.  The notion of ‘colorblindness’ is a detour that allows White people to absolve themselves of racial biases and deny the oppressive realities of structural racism.

These are a few of the concepts and frameworks that could inform nursing science and ultimately our practice. Why are we interested in theories from other disciplines? How might we develop nursology discipline specific knowledge that addresses the issues?  In the midst of the world witnessing the murder of George Floyd by police officers, the COVID-19 pandemic continues unabated with its current epicenter in the U.S.  In urban metropolitan areas, we have watched how centuries of disinvestment in Black and Brown communities and systematic oppression has led to health disparities that are also manifesting clearly in this pandemic in disproportionate morbidity and mortality of Black and Brown peoples.  Ethnic minority populations are at greater risk for contracting Covid-19, or experiencing severe COVID related illnesses.¹⁰  According to the CDC’s report on COVID-19 in the Racial and Ethnic Minority Groups, cases of COVID-19 are highest among American Indian persons, and hospitalization rates for COVID-19 related illness are highest among Latinos, American Indians, followed by Black persons.¹⁰  Since Covid-19 was first reported on the Navajo Nation in mid-March, infection rates per capita have soared to the highest in the country compared with any individual state.¹¹   The COVID-19 pandemic thus only exacerbates the challenges that ethnic minority communities already face, particularly American Indians who already experience disproportionate disparities in health outcomes.

The time for nurses to act is now, not just in the care of people and communities that are most marginalized, but to address the very root of marginalization and oppression through a practice of critical reflection on our own profession: which of our theories need to be contested because they are rooted in colonist and white supremacist ideologies?  How can we embrace of innovative ways of theorizing, through meaningful and intentional care that results from a critical and reflective analysis of the realities going on around us and our role as a profession in fostering lasting change? We leave you with these questions and call upon you as fellow allies and advocates on the path towards health equity and social justice.  When we discuss racism, should we not include all races and ethnicities?

Sources

1. Paradies Y. Colonisation, racism and indigenous health. J.Popul. Res. 2016; 33(1):83-96.
2. Puzan E. The unbearable whiteness of being (in nursing). Nurs Inq. 2003; 10(3):193-200.
3. Rajaram SS. Bockrath S. Cultural competence: New conceptual insights into its limits and potential for addressing health disparities. J Health Dispar Res Prac. 2014; 7(5):82-89.
4. Kirmayer LJ. Rethinking cultural competence. Transcult Psychiatry. 2012; 49(2). 149-164. doi.org/10.1177/1363461512444673
5. Wesp, L. M., Scheer, V., Ruiz, A., Walker, K., Weitzel, J., Shaw, L., . . . Mkandawire-Valhmu, L. An Emancipatory Approach to Cultural Competency: The Application of Critical Race, Postcolonial, and Intersectionality Theories. Advances in Nursing Science, ePub Ahead of Print. 2018.  doi:10.1097/ans.0000000000000230
6. Hester, RJ. The promise and paradox of cultural competence. HEC forum. 2012;24(4):279-291. doi.org/10.1007/s10730-012-9200-2.
7. Ilowite MF. Cronin AM. Kang TI. & Mack JW. Disparities in prognosis communication among parents of children with cancer: The impact of race and ethnicity. Cancer. 2017; 123(20): 3995-4003.
8. Brascoupé S. Waters C. Cultural safety: Exploring the applicability of the concept of cultural safety to Aboriginal health and community wellness. Int J Indig Health; 2009; 5(2):6-41.
9. Carter C. Lapum J. Lavallée L. Schindel ML & Restoule JP (2017). Urban First Nations Men: Narratives of Positive Identity and Implications for Culturally Safe Care. J Transcult Nurs. 2017; 28(5):445-454.
10. Centers for Disease Control (CDC).  COVID-19 Racial and Ethnic Health Disparities. 10 December 20.  Retrieved from: https://www.cdc.gov/coronavirus/2019-ncov/community/health-equity/racial-ethnic-disparities/increased-risk-illness.html
11. Cheetham, J. Navajo Nation: The people battling America’s worst coronavirus outbreak.  BBC News.  15 June 2020.  Retrieved from: https://www.bbc.com/news/world-us-canada-52941984

Note: this post is based on the ANS article published in the spring of 2020 – Weitzel, J., Luebke, J., Wesp, L., Graf, M. D. C., Ruiz, A., Dressel, A., & Mkandawire-Valhmu, L. (2020). The Role of Nurses as Allies Against Racism and Discrimination: An Analysis of Key Resistance Movements of Our Time. ANS. Advances in Nursing Science, 43(2), 102–113. https://doi.org/10.1097/ANS.0000000000000290

Jennifer Weitzel, MS, RN is a doctoral student and public health nurse with Public Health Madison & Dane County. Her research examines the use of cultural safety in the delivery of humanitarian nursing in Haiti

Jeneile Luebke, PhD, RN is a post-doctoral nurse research fellow at University of Wisconsin-Madison. Her area of research and expertise include violence in the lives of American Indian women and girls, and utilization and application of postcolonial and indigenous feminist methodologies.

Linda Wesp, PhD, FNP, APNP, RN is a Clinical Assistant Professor at University of Wisconsin-Milwaukee in the College of Nursing and Zilber School of Public Health, with a focus on health equity, participatory research, and critical theories. She also works as a family nurse practitioner and HIV Specialist at Health Connections, Inc. in Glendale, WI

Maria del Carmen Graf, MSN, RN, CTN-A, is a PhD candidate at UW-Milwaukee. Her research area includes studying the mental health needs within vulnerable populations with an emphasis on the Latina population and women of color in the US using a Postcolonial Feminist approach.

Ashley Ruiz RN, BSN, is a doctoral nursing student and clinical instructor at the University of Wisconsin-Milwaukee, as well as a Sexual Assault Nurse Examiner (SANE). Her current work focuses on advancing feminist theory in nursing science for the purposes of providing a theoretical foundation for addressing the problem of violence against women. Such advances inform Ashley’s research, which seeks to identify and develop nursing interventions that are tailored towards the unique needs of Black women that disclose sexual assault and seek healthcare services

Anne Dressel, PhD, CFPH, MLIS, MA, is an Assistant Professor in the College of Nursing at the University of Wisconsin-Milwaukee, where she also serves as Director of the Center for Global Health Equity

Lucy Mkandawire-Valhmu, PhD, RN is Associate Professor in the College of Nursing at University of Wisconsin-Milwaukee (UWM). Her research focuses on violence in the lives of Black and American Indian women. As a feminist scholar, she seeks to creatively identify interdisciplinary interventions and to inform policy that centers the voices of women in addressing gender-based violence. Dr. Mkandawire-Valhmu also seeks to contribute to the development of feminist theory that would help to advance nursing science.