Notable works

Hall, J. M., & Fields, B. (2012). Race and microaggression in nursing knowledge development. ANS. Advances in Nursing Science, 35(1), 25–38. https://doi.org/10.1097/ANS.0b013e3182433b70

Exactly ten years ago, in the January-March 2012 issue of Advances in Nursing Science, an article appeared titled “Race and microaggression in nursing knowledge development” authored by Joanne Hall and Becky Fields (Hall and Fields 2012).  At the time there was a general awareness of racism in nursing, but it was hardly ever discussed in the open, and most people had not become aware of the concept of “critical race theory.” I recall a couple of white pundits on the U.S. national cable news starting to either explain the idea of  “microaggressions” to the general public, or refer to this idea with more than a bit of scorn.  Nevertheless, the conversation had begun, but was in its infancy in nursing.  Today, with the widespread awakening after the brutal killing of George Floyd, we can now read this article with a new appreciation and awareness.  Add to this the current uproar in some circles about critical race theory – and the Hall and Fields article is now a “must-read”! 

Hall and Fields open by explaining the tension between a “post-racial” discourse and critical race theory.  A post-racial discourse emphasizes the important gains that people of color have made in U.S. society since the civil rights movement, with some pointing to the election of Barack Obama as evidence that race is no longer a barrier to achieving greatness in American society.  By contrast, critical race theory focuses on the many obvious and subtle ways that race continues to be a dynamic that creates disadvantage for people of color and that sustain privilege for white people.  Hall and Fields acknowledge that critical race theory (CRT) originated in legal studies, but that it has emerged to characterize transdisciplinary, race-equity approaches that are grounded in social justice, that promote human liberation and expose systems of domination and oppression. 

As the title of this article indicates, Hall and Fields focus on indicators that confirm that race is a factor in nursing knowledge development – despite the fact that race is rarely mentioned, much less discussed.  They note how racial categories are used in research, yet the meaning of these categories, the rationale for using these categories at all, and adequate interpretation of findings based on these categories is gravely lacking.  This situation continues to exist today, and in fact led to my initiative to provide specific guidance on race and racism for authors who contribute their work to Advances in Nursing Science (detailed later in this blog).  Hall & Fields also show how people of color, and African Americans in particular, tend to be pathologized through the construction of data gathering tools, by misguided assumptions that white people are the “norm”, and by erroneous assumptions of the deficient nature of people of color.  

Hall and Fields provide a roadmap for examining nursing theory in relation to race and racism – an examination that can lead to new theories and to revisions of existing theories.  Here are common explicit and implicit theoretical constructions that they identify:

• Conceptualizations of the person do not incorporate the reality of race, suggesting that nursing theory assumes the person to be white, and to be the “norm”.  This is rendered explicit when the author talks about “people” or “clients” or “patients,” and then in the course of the narrative adds qualifiers referring to people or clients or patients of color. People of color are implicitly denied their humanity since race is so fundamentally essential in conceptualizing existence for people of color, but is ignored as a feature of being human, of being a person.
• Culturally based theories, or theories that incorporate culture, do not address race or racism and the historically political realities or power dynamics that shape the human health experience for people of color.  For the most part, these theories tend to (wrongly) attribute static essentialist characteristics to people of color, while people who are white are not characterized as having a common “culture” but rather enjoy the privilege of individual diversity, freedom of choice, and access to resources.
• The dominant focus on individual, one-to-one relationships typically excludes the realities of economic constraints, ignores the effect of historical trauma, and neglects the social contexts in which individuals live, thrive, and seek to survive. 

While many nurses do not give explicit thought to these theoretical ideas, these ideas and the social structures that sustain them continue to shape our actions in both explicit and subtle forms, giving rise to what is now termed “implicit bias” and microaggressions – patterns of interaction that are characterized by verbal, behavioral and environmental indignities.  White people typically do not recognize these; if they do they have made a conscious effort to learn how to “see” these things when they happen.  People of color recognize microaggressions immediately, experiencing them as a personal assault – yet another reminder of their invisibility, lack of worth, lack of humanity in a sea of whiteness. To highlight this critical difference, nurse scholar Kechi Iheduru-Anderson notes that she is now using the term “racial assault” (conversation in a recent”Overdue Reckoning on Racism in Nursing” discussion – see references to two of her important works below). In fact the term “racial assault” aptly emphasizes how damaging these dynamics are. All of the related terms – implicit bias, microaggression, etc. – simply do not convey the reality of dehumanizing harm that they cause. The typical terms used to describe this dynamic center on the person who is acting, the person with power (typically white), making it possible to ignore the fact that someone else is in the picture who is harmed. “Racial assault” implicates the perpetrator (rightfully) – it also points to the fact that there is a person who is harmed.

As Hall and Fields state:

“White people may view their comments as innocuous, and aversive body language as minor, but as experienced by [people of color], these aspects of interaction are perceived as part of a daily pattern of slights and have negative consequences that stem from, and contribute to, marginalization.” (p, 31)

If we translate this insight to the narrative of nursing theory, we can identify theoretical microaggressions – racial assaults – that have serious and real-world negative consequences.  A critical reading would reveal these types of assaults:

• Phrases and terms that reveal the assumption that “persons” conceptualized in the theory are white, and defacto “the norm.” Not only are white people the norm, but implicitly people of color do not exist or are considered only as an after-thought.
• Failure to take into account variables of race and long-standing racism that shapes everyday experience for both people of color and for white people, as if these phenomena simply do not exist.
• Assumptions about what is “good” and “healthy” that are grounded in white Eurocentric traditions, typically Judeo-Christian ideals, typically heteronormative relationships and nuclear families (cis-gender father, mother and their children) – with rare, if any acknowledgement of grandparents, other significant daily essential social ties, the vast variability of complex intimate relationships, or the vast variability in who constitutes a household and why they are there – as well as crucial social ties in the community (churches, clubs, other types of ties that are part of everyday shared experience).
• Neglect of unequal access to education, resources, health care, adequate nutrition, safe environments, environments free from exposure to toxins – all of the politically and socially determined factors that influence health and well-being.  In essence, most nursing theories assume that the people nurses care for have reasonable educational, material, or economic resources, free from many of the social and politically determined influences that have a negative impact on health.
• The theoretical impulse to make broad generalizations; in fact the theoretical ideal of “parsimony” requires making the broadest generalizations in the simplest of terms.  There are a host of problems with this notion in the humanities and social sciences, but in the context of microaggressions based on race – racial assaults – this is probably among the most egregious.  If the consumer of a theory is part of the large (and in fact culturally diverse) population known as white, this problem goes unnoticed.  For someone who has been racialized, these broad theoretical generalizations are untenable.

Nursing’s grand and middle-range theories have formed a valuable and  important foundation for our discipline. But their value will actually increase if they serve to prompt critical thought and discourse that moves our discipline to the future.  By recognizing the limitations of existing theories as well as their strengths, our capabilities as relevant healthcare providers will become a strong force for change. 

In my chapter that appears in the text edited by Eun-Ok Im and Afaf Meleis titled “Situation Specific Theories: Development, Utilization, and Evaluation in Nursing” I addressed the equity and social justice potential that situation-specific theory holds for the future of nursing theory.  The shifts that are possible include:

• A shift away from the individual as an autonomous, free-willed person to recognize the centrality of relationships and context, as well as the social and political structures that shape the reality of health experience.
• Recognition of the diversity that exists within all groups, rendering broad generalizations moot.  
• Shifting toward recognition of personal knowing and moral belief systems as vital forms of knowledge, and abandoning the primacy of empirics,

Situation-specific theories accomplish just what the term implies – they take into account a particular situation and only “theorize” relative to that situation. This can be a powerful approach in our quest to abandon both theoretic, experiential and personal practices that can render great harm. 

Additional sources  

Iheduru-Anderson, K. C. (2021). The White/Black hierarchy institutionalizes White supremacy in nursing and nursing leadership in the United States. Journal of Professional Nursing: Official Journal of the American Association of Colleges of Nursing, 37(2), 411–421. https://doi.org/10.1016/j.profnurs.2020.05.005

Iheduru-Anderson, K., Okoro, F. O., & Moore, S. S. (2022). Diversity and Inclusion or Tokens? A Qualitative Study of Black Women Academic Nurse Leaders in the United States. Global Qualitative Nursing Research, 9, 23333936211073116. https://doi.org/10.1177/23333936211073116

Postscript

Earlier in this post I mentioned the guidance we now provide in the Author Guidelines for Advances in Nursing Science. I am including these guidelines here – they apply in so many contexts related to our thoughts, actions and attitudes toward race, racism and racial justice.

Specific Guidelines Related to Racism

From ANS Information for Authors

The ANS leadership – editor, advisory board members, peer reviewers and publisher recognize that published scholarly works are vehicles that can challenge systemic racism and intersecting forms of power inequities.  ANS expects an explicit antiracist stance as a means to provide scholarly resources to support antiracism in research, practice, education, administration, and policymaking. To this end, we offer the following guidelines:

• Remain mindful of the many ways in which white privilege is embedded in scholarly writing, and engage in careful rereading of your work to shift away from these explicit and implied messages.  As an example, general “norms” are typically taken to reflect white experience only; this is revealed when the experience of people of color are taken to be “other” or “unusual” or worse yet “unhealthy”
• When race is included as a research variable or a theoretical concept, racism  must be named and integrated with other intersecting forms of oppression such as gender, sexuality, income, and religion.
• If your work does include race,
  • Provide a rationale that clearly supports an antiracist stance.
  • Be careful not to explicitly or implicitly suggest a genetic interpretation.
  • Explicitly state the benefit that your work contributes on behalf of people of color.
• Refrain from any content that explicitly or implicitly blames the victim or that stereotypes groups of people; situate health inequities clearly in the context of systemic processes that disadvantage people of color.
• Focus on unveiling dynamics that sustain harmful and discriminatory systems and beliefs, and on actions that can interrupt these structural dynamics.

* Peggy’s Positionality Statement

I am a white, cisgender, lesbian woman, soon to turn 81 years old. I grew up in Hilo, Hawaii, earned my BS in Nursing at the University of Hawaii Manoa, and married (briefly) into a Chinese-Hawaiian family (all of whom I still love and remain distantly connected to). My family core consists of my partner Karen and my mixed-race son and grandchildren. I have been an “activist” of sorts since childhood, culminating in my early adult life identified as a radical feminist. In nursing, this earned me a reputation as rebel on the radical fringe. Fortunately, many of my colleagues also recognized my potential as a writer, scholar and educator, and graciously provided contexts in which I was able to contribute to the development of our discipline while expressing my passion for feminist thought and action. For most of my adult life I have engaged in reading, group discussion and projects that address racism, but only since the summer of 2020 have I taken personal initiative to engage in anti-racist activism, specifically within nursing. Currently I am a co-leader of the “Overdue Reckoning on Racism in Nursing,” a project featured in the American Journal of Nursing, February, 2022