Is there Caste in Nursing? Owning Our History and Reconnecting the Disconnect

Contributor: Mary Elaine Southard DNP, RN, MSN, APHN-BC,

What led to the writing of this post was the reading and reflection on Isabel Wilkerson’s book Caste: The Origins of Our Discontent and Brene Brown’s Dare to Lead. I wondered how the messages in both books related to nursing in today’s healthcare environment. My lived experience in the discipline I have dedicated 44 years to has been a wonderful, painful, juxtaposition. Could nursing be a caste system, I pondered? I began to read with a new eye.

As Wilkerson states, “It turns out that the greatest threat to a caste system is not lower caste failure, which in a caste system is expected, and perhaps even counted upon, but lower caste success, which is not. Achievement by marginalized people who step outside the roles expected of them puts things out of order and triggers primeval and often violent backlash.”

Nineteen years ago, I made the decision to go against the script. I had spent over 20 years in traditional health care, working in staff, administrative, and academic positions. I had been working as an Oncology CNS for many years and loved the role and the constant learning that is required in a specialty like Oncology. I could see the missteps of not treating the whole person and how symptom management was not healthy, healing or caring. While mitigating symptoms is important, there are efficacious non-traditional interventions that can also be used. Assessing the causative factor of a symptom may be multi-factorial and offering alternative treatment options may be the “gain of function” that is needed.

I was fortunate that I was supported by hospital administration and was given a dedicated Healing Touch room and consulted to provide pre-op, intra-op, and post-op energy sessions. I also facilitated a cancer support group for over 10 years and the conversations/questions centered around integrative therapies and evidence-based interventions. The hospice unit now offered aromatherapy diffusers and energy therapy at end of life.

I adhered to Myra Levine’s theory of Conservation of Energy (Levine, 1996) since this is vital to guide a practice in Oncology, yet my personal philosophy aligned more with a Rogerian holistic worldview  (Rogers, 1992). Viewing nursing as a science and an art to promote health and wellbeing requires a broader view and synthesis of the environment, evidence, facts, and spirituality.

At the time, CNS positions were becoming extinct as more NP programs came to the forefront and, as with other colleagues, my position as a CNS was eliminated. Researching doctoral programs at the time, I was drawn to a holistic Post Master’s Certificate NP program that would incorporate both the NP role and holistic modalities to offer mind-body-spirit care more fully.

Unfortunately, being ahead of the curve proved to be a boomerang affect. In my quest to provide evidence-based holistic care, I was denied CRNP status in the state in which I reside, although was approved in the state where the university was located. Following an intuitive GPS is probably like following our vehicle GPS. You never really know if the directions are correct, but not knowing leads to greater knowing in the long run.

 Holistic nursing was considered an affront to the national bio-medical education and policies and even today there is that misrepresentation and bias. Keeping with healthcare societal norms that nurses who dared to risk being visionary (or whoo whoo) were not to be commended, lest the plan to have consensus be delayed, there was a position to “keep people in their place”. Know your place, don’t think of yourself as equal to other NP’s, don’t have the audacity to threaten the paradigm.

While I am resilient and resourceful (and had been told by others to just ‘shake it off’), it certainly has taken a toll professionally and personally. Choosing highly respected academic preparation was of little consequence and the financial burden was also a hardship on my family. But as Brene Brown indicates, ‘What stands in the way, becomes the way”.

Imagine decades later, how powerful this would have been in the American press if the word got out that holistic nurse practitioners existed and cared for the whole person-body-mind and spirit. Today, continued resistance remains from regulatory agencies and outdated legislative scope of practice language and hierarchical leadership. Caste obstructions exist and comes at a price that marginalizes holistic nurse practitioners that need to be able to practice as APRN’s.

As Wilkerson writes, “If one of the requirements of a hierarchy is that the lowest caste must remain the scapegoat on the bottom, the culture works to keep it that way by playing up the stereotypes that affirm their lowliness and minimize indications to the contrary. The investment in the established hierarchy runs sufficiently deep to keep their fruits of citizenship within their own caste. As a caste system shapeshifts and protects its beneficiaries, a workaround emerges,

Embracing language such as self-care and resilience without confronting the tectonic shift of the iceberg requires daring leaders that go beyond language. Being able to live values and choose courage over comfort is empathy in practice. Leadership research is about the timing of teaching skills for rising or resilience. As the most trusted profession, nursing needs to be able to identify exactly where the breech lies and then speak to it. Own it. And show a greater sense of joint responsibility. Supporting real change is continued dialogue, scholarly endeavors, and commitment to a shared purpose. Once awakened, we then have a choice, sharpening our creativity, powers of discernment and adding our true strengths to humanity. Living holistic values and following an internal compass is, as Janet Quinn once said, “not for the faint of heart.” Passion for truth, social justice, fairness and equality in practice, education, research and policy will shape the nurse of tomorrow.


Levine, M. E. (1996). The conservation principles: A retrospective. Nursing Science Quarterly9(1), 38-41.

Quinn, J. F. (2000). The self as healer: reflections from a nurse’s journey. AACN Advanced Critical Care11(1), 17-26.

Rogers, M. E. (1992). Nursing science and the space age. Nursing science quarterly5(1), 27-34.

About Mary Elaine Southard

Mary Elaine Southard

Mary Elaine Southard is a national/international educator, author, clinician and leader in Holistic Nursing and Integrative Health. Her diverse career experience encompasses chronic care case management, insurance.oncology, adult health, and primary care. She has worked as an Oncology Clinical Nurse Specialist, a Holistic Nurse Practitioner, Clinical Homeopath- Source Resonance Practitioner and is Board Certified as an Advanced Practice Holistic Nurse & Health and Wellness Nurse Coach. Her research focuses on using the Omaha System in Nurse Coaching as a key to practice, documentation, and information management. She is co-author of The Art and Science of Nurse Coaching: A Provider’s Guide to Scope and Competencies (2nd Ed) published this year by the ANA. She is also a Founding Member of the Global Academy of Holistic Nursing and a member of the American Holistic Nursing Association.

She has a private consulting and coaching practice, Integrative Health Consulting and Coaching, in Scranton, PA.

3 thoughts on “Is there Caste in Nursing? Owning Our History and Reconnecting the Disconnect

  1. I had to laugh when seeing all of the initials designating degrees, memberships, etc after the author’s and other team members’ names. Caste is clearly delineated by all of these initials. What is it about us that makes RN insufficient? Do we need to declare how insecure we are by listing all of these that are superfluous to why we became nurses to begin with? Yes, we did work hard to become who we are but seeing them in the discussion of Caste is exemplary of what caste is all about.

  2. Well written Dr. Southard! You provided a concise example of how advanced integrative nurses are disenfranchised by aggregates within our own profession. Display your credentials proudly; you earned each and every one! Those who have walked in a similar path would not dare suggest any insecurity by documenting your achievements in nursing.

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