Decolonizing Nursing

Series: Notable Works

As the year 2020 starts to unfold, along with escalating tensions world-wide related to power imbalances, inequities, and injustices, I am drawn to consider how our own endeavors related to the development of nursing knowledge intersect with these very large tensions that so directly shape the health of people worldwide.  I will not even attempt to present you with a “laundry list” of ways in which we could begin to tackle these issues as nursologists – the list alone would greatly exceed the boundaries of a reasonable blog post. Instead, I have decided to focus on one critical topic that repeatedly rises to the surface in many nursing discourses – the topic of racism.  Despite the fact that race and racism so repeatedly rise to the surface with a clear intent to address this issue, there is typically little or no substantive discussion that begins to reach deep down into explanations or understanding of what is really going on. Our efforts to  address the issues are sincere and well-intended but more often than not, end up being superficial “remedies” – often remedies that themselves have clear and undeniable racist dimensions. Seldom, if ever, is there a recognition or discussion of the ways in which nursing perspectives sustain the structures of racism. 

The nursing literature, over the past decade, has provided our discipline with a number of notable sources addressing race and racism, most prominently from an emancipatory, critical theory perspective (see Kagan et al., 2014).  But one notable work in particular is well worth our focus – titled “Toward decolonizing nursing: the colonization of nursing and strategies for increasing the counter-narrative” authored by Canadian and South African  authors Elizabeth McGibbon, Fhumulani M Mulaudzi, Paula Didham, Sylvia Bartond and Ann Sochane (McGibbon et al., 2014)

 The authors draw on Canadian experience, where culturally, there is very active, visible and dedicated progress toward truth and reconciliation addressing the injustices imposed by European settlers on native Indigenous peoples (see for example the excellent webinar on “Racism and Privilege in the Everyday”).  The United States in general is far behind Canada, South Africa and other colonized nations in openly and systematically embedding awareness of these injustices in public discourse. Unlike other colonized countries, the US has not yet established practices and programs that attempt to address the significant injustices that have seriously harmed those who have been historically disadvantaged, as well as the effects of these colonizing systems and practices on those who have inherited white settler privilege.  The truth is that each situation in which there is disadvantage for some and advantage for others has specific and unique characteristics, but the common threads that run through all such situations, particularly where race and skin color are concerned are significant. McGibbon and her colleagues have provided a cogent explanation that specifically addresses the realm of nursing theory, and ways in which colonization inhabits much of our nursing theorizing. This is not to say that certain nursing theories should be banned from our lexicon because of their colonized and colonizing characteristics.  Rather, examining nursing perspectives from this standpoint is a key that can begin to shift nursing into spaces, actions and ways of theorizing that hold potential to resist the harmful dynamics of colonization, specifically the dynamics of racism.

As Dr. McGibbon reiterated to me in a recent personal communication:

Colonization is a term that refers to the Eurocentric project of empire building that was motivated by the intent to “civilize” the rest of the world.

“Decolonization” is the process of exposing, resisting and transforming the continuing presence and influence of colonial practices and thought.

The project of colonization historically involved indiscriminate destruction of the ways of life, the cultural values, ways of being, spiritual traditions – the whole experience of people who were not European (read not white skinned) – in other words, people of dark skin.  In their article, McGibbon and colleagues provided a detailed and clear explanation of the nature of colonization, as well as the contributions of postcolonial scholars, particularly those of indigenous backgrounds, who have taken bold steps to reveal the devastation and painful struggle, as well as the courage and skills of survival for those who have been, and still are harmed by colonial practices and thought. 

Most significantly, McGibbon and colleagues provided several still-relevant clues where we can focus our attention in the quest to decolonize nursing.  The first challenge is raising awareness of ways in which colonization, and its racist underpinnings persist in nursing thought. They stated: 

Nursing has developed within all of the . . .  contexts of colonization, including the intersections of racism and sexism that inform the colonial project. Embedded beliefs and assumptions provide a foundation for the colonizing of intellectual development in nursing. Similarly, racism and white privilege play a central role in the continued colonization of the profession.” (p. 183)

First, they addressed the persistent belief that we have now moved beyond the “old” days when the white settlers arrived to inhabit, uninvited, the lands of indigenous people.  The same belief persists in the United States where we sustain the notion that we are beyond the slavery of African people that ended decades ago. Since those “days” are in the long-ago past, we tend to sustain the notion that we are now all equal – that we all inhabit the “same” world and that the cultural [read dominant white culture] norms are true for all.  We recognize that there are disparities, and acknowledge some of the disadvantages experienced by people of color, but fail to recognize, or acknowledge that white privilege remains as powerful a dynamic as it ever was. The languages of “diversity” and “multiculturalism” actually sustain this dynamic; when examined closely these perspectives in nursing treat cultures of color as “other” – as interesting curiosities.  Culture is seen as characteristics of any practices that are not white.  Notice that there are rare, if any discussions of white dietary practices, rituals, family relationships, religious practices. “White” experience is typically seen as diverse and individualized, as the “norm” against which other practices are judged or compared, whereas the experience of the “other,” of “people of color” are seen as essentialized markers of difference, with the “white” norms as the point of reference.

Another characteristic that reflects the effects of Euro-centric thought, and that persists as a pervasive characteristic in nursing thought, is the emphasis on empirics, and the presumption of “objectivity” in part because it is removed from the vicissitudes, the contamination, of everyday experience.  The gold standard of “evidence” presumes a certain “objectivity” that is apolitical and assumed to be universal to all human experience. The result is discourse that is largely grounded in white privilege, and its concurrent erasure of the experience of those with dark skin. When “race” is taken as a demographic variable, it tends to be treated, as in real life, as “different” and something other than what is presumed to be the “norm.” As McGibbon and colleagues pointed out, even when race and racism are brought into a conversation, the dominant impulse in relation to the nursing theoretical frameworks is to hide such dynamics in the larger metaparadigm concept of “environment.” 

Nursing’s search to become a credible science reflects this same dynamic of white privilege and unquestioned valuing of positivist values.  The focus of much of nursing’s theorizing is on the individual as a person with uninhibited free will, one who can care for oneself (with ample resources assumed to be available), with only a passing nod in the direction of the family and community (critical and central concerns for those who are not privileged).  The positivist assumption of the whole as the sum of the parts is reflected in just about all undergraduate nursing curricula, in the focus of our textbooks, and organization of hospitals, medical (and nursing) specialties – divided into children (under the medicalized label of pediatrics), various adult conditions (many of which have been transposed into major profit centers), mental health (again medicalized as “psychiatric”) etc.  To the extent that “family and community” is addressed, these vital, central dimensions of human experience are treated as separate and different from the individualized organizing concepts.

These dimensions of awareness are critical, but importantly, McGibbon and her colleagues devoted a significant focus on what this means for our current situation, and the future development of nursing knowledge.  They outline examples of everyday racism and the ways in which nurses of white privilege sustain racist practices, even when we wish not to do so and believe we do not. But as they correctly noted:

These experiences of ongoing racism form the fabric of everyday life for racialized nurses and are largely invisible for the perpetrators, be they in the individual, face-to-face realm, or at the level of governance and policy-making. (page 185)

They pointed to three significant steps that all nurses, and particularly white nurses and white nurse scholars, can take to begin to participate in the effort to decolonize nursing. These are  

  • Understanding racism and white privilege, and creating counternarratives that dismantle colonized thinking, in particular biomedical hegemony and other colonizing ideologies;
  • Committing to action based on social justice and human rights; and 
  • Sustaining attention to the structural determinants of health.

I would add one additional “goal” that deserves our particular attention as nursologist – the potential to completely re-vamp the organizing concepts and constructs of our discipline based on the insights from the three decolonizing projects that McGibbon and her colleagues outline.

The persistent question that always surfaces in these kinds of discussions (particularly among white people) is “What can I, as only one individual, do?”* In my view, the most important and fundamental step is to learn about and take to heart the ways in which our own actions and perspectives sustain racism in our everyday practices. For those of us who inherited white privilege, we have a particular responsibility to dedicate ourselves to our own self-awareness and commitment to change.  I have provided below a list of various resources that I have found invaluable in my own journey. Once we begin to explore our own experience, and understand the dynamics of colonization, we will begin to see a huge shift that will have great power in the direction of decolonizing nursing. 

Sources cited:

Kagan, P. N., Smith, M. C., & Chinn, P. L. (Eds.). (2014). Philosophies and Practices of Emancipatory Nursing: Social Justice as Praxis. Routledge.

McGibbon, E., Mulaudzi, F. M., Didham, P., Barton, S., & Sochan, A. (2014). Toward decolonizing nursing: the colonization of nursing and strategies for increasing the counter-narrative. Nursing Inquiry, 21(3), 179–191. https://doi.org/10.1111/nin.12042

Resources for self-awareness

Recommended reading, especially for white people, but also for people of color to gain understanding of the ways in which white privilege is sustained.

DiAngelo, R. (2018). White fragility: Why it’s so hard for white people to talk about racism. Beacon Press.

Two part blog posted on The Scholarly Kitchen relating the everyday experiences of people of color in the white-dominated publishing industry, 

On Being Excluded: Testimonies by People of Color in Scholarly Publishing (Part 1).

On Being Excluded: Testimonies by People of Color in Scholarly Publishing, Part II

 “Everyday Feminism” webinars (available for a modest fee)

Beyond Diversity: How to Build a Truly Anti-Racist Organization

So… You Have White Guilt. What Now?

Please also see the webinar series recommended to me by Dr. McGibbon – produced by the Indigenous Cultural Safety Collaborative Learning Series (ICS)

* Addendum 2020-02-01: I have been asked to also address ways nurses of color can address issues of racism.  First, I fundamentally believe that it is unacceptable to expect that our colleagues of color have any responsibility here.  Addressing this issue from the standpoint of someone who is racialized is exhausting, frustrating and disheartening – the effort and energy required to deal with the effects of everyday racism is more than many can bear.  And, as a white person, it is presumptuous of me to assume that my suggestions will have merit.  Understanding this, here are a few ideas that I have picked up from listening to women of color who are engaged in this work:

  • When you see an opportunity to speak your truth, find allies who will hear your words and feel your experience.
  • Develop spaces where you are nurtured, where you are truly “at home” – where you can relax, be yourself, and speak your truth.  This is likely to be a context in which there are no white people (yet) – but having this space will nurture your confidence to search for other allies.
  • Find others who are actively involved in anti-racism work in your community. These colleagues will help you develop a clear and unwavering dedication, and the strength, to face the challenges of everyday experience.

Notable Works on “Medicalization” by Beverly Hall and Janet Allan

Note:  we are delighted to introduce a new Nursology.net series featuring notable works exploring concepts and issues that are related to the development of nursing knowledge. As this series evolves, you can see the posts in the series “Notable Works” under the main menu “Series/Collections”

In 1988, Janet Allan and Beverly Hall, both prominent nursology scholars and leaders

Janet Allan

in the discipline, published an article titled “Challenging the focus on technology: A critique of the medical model in a changing health care system.” Drawing on a rich body of literature from nursing and other disciplines, and their own insights as nursing scholars, they called on nurses to examine and challenge the dominant model that derives from a model that views the body as a machine, one that needs to be “fixed” if something goes awry, and the process of disease as an evil force to be obliterated.  They called for nurses to question the reification of

Beverly Hall

this model, and to engage in dialogue to explore alternatives that are derived more directly from the values and goals of nursing. In particular, they pointed to the lack of established efficacy of the model (despite claims to the contrary), the serious unaddressed ethical and iatrogenic questions the model engenders, the harmful effects on health and well-being that derive from the model, and the economic consequences (Allan & Hall, 1988).

In 1996, Hall specifically addressed the challenges of medicalization in undermining nursing approaches to chronic mental illness. In her critique, she discussed the ways in which the disease framework of chronic mental illness creates barriers to understanding the person as a person, and creates an unequal power structure that draws attention away from the personhood of the patient and their experience. Stated succinctly, Hall noted: “Nursing, in its attempt to be scientific, has embraced objective theories and diagnostic schemes that are devoid of practical reasoning that has as its inherent focus humanistic values, personal meanings, and subjective language” (Hall, 1996, p. 24).

In 2003, Hall published another remarkable work that represented a departure from the purely “scientific” approach to show what can emerge from an approach that uses practical reasoning, humanistic values, personal meanings and subjective language in exploring what is recognized as the focus of the discipline of nursing- the human response, the human experience.  In this moving essay Hall draws on her own experience of having a life threatening diagnosis of breast cancer, reflecting on the effects of medicalization on her experience.  As she summarized in the abstract, these effects were “(a) giving useless treatments to keep the patient under medical care; (b) demeaning and undermining efforts at self-determination and self-care; and (c) keeping the patient’s life suspended by continual reminders that death is just around the corner, and that all time and energy left must be devoted to ferreting out and killing the disease” (Hall, 2003, p, 53).

Hall’s essay prompted three nurse scholars/practitioners, each with different experiences related to diagnosis and treatment in the current health care system, to respond to Hall’s call for ongoing dialogue.  Richard Cowling, Mona Shattell, and Marti Todd (2006)  added their own personal narrative to the dialogue — Richard as a person who experienced a mitral valve prolapse; Marti living through the experience of ovarian cancer, and Mona who has had very little experience as a patient, but wrote as a nurse and stated:

“Upon reflection on my personal experience with medicalization, I separate myself from my colleagues, to use Hall’s term, “not-yet-diagnosed, against the sick.” (Hall, 2003, p62). I am not conscious of this; however, it is a part of me. Even as I write about my support of Hall’s personal experience of medicalization, I am simultaneously betrothed, naively, to medicalization.

Naivety is not an excuse. In fact, it is what angers me most about medicalization—this overreaching power that silences me.” (Cowling, Shattell & Todd, 2006, p. 299).

Responding to Cowling, Shattell and Todd’s reflections, Hall affirmed their work, and stated: “As a reader, I feel privileged to be on an inside track with personal narrations that are conceived within such a sensitive context” (Hall,2006, p. 305).  She also observed that her own 2003 article, and in the Cowling, Shattell and Todd article, there could be a misunderstanding as to the nature of “medicalization” – that this dynamic is not about helpful or not helpful medical care.  Rather,

“medicalization is a form of organized and systemic oppression that is so culturally entrenched, powerful, and invisible, that everyone’s choices, including those practicing in the biomedical field are manipulated, and options are precluded with scant awareness on the part of any of the actors (Hall, 2006, p. 305.)

Medicalization is the exercise of a power dynamic that restricts the possibility to see any alternatives other than those prescribed by the “canon,” and that insists on excluding any other possibility.  From this frame of reference, western medicine is not the only source of “medicalization” – other forms that we sometimes call “alternatives” can be equally drawn in to the same type of power dynamic that uses the power of prescription to diminish human experience, and that destroys the possibility of an authentic human relationship that nurtures meaning and authenticity in the experience.

Parallel to the writing and deep thought that produced these notable articles, Hall was simultaneously engaged in her own nursing practice in the community, working with people who were experiencing life-threatening illness.  Drawing on her own experiences as a patient and as a nurse, she wrote and self-published a book that provides a glimpse into possibilities beyond the realms in which medicalization has taken hold.  The second edition of her book, published in 2008, explains three challenges of surviving and thriving after a life-threatening diagnosis – the challenge of preparing yourself mentally for surviving and thriving, the challenge of learning that help lies within you and all around you, and the challenge of focusing your attention on what your body needs to heal (Hall, 2008).  These challenges are relevant, as Bev shows, to anyone – whether they continue to live, or they move through dying.

I invite Nursology.net viewers to explore these notable works, and find ways to contribute to the ongoing dialogue that raises awareness of this dynamic, and in doing so explore pathways to shift our focus in the direction of nursing’s own perspectives.

Sources cited:

Allan, J. D., & Hall, B. A. (1988). Challenging the focus on technology: A critique of the medical model in a changing health care system. ANS. Advances in Nursing Science, 10, 22–34.

Cowling, W. R., 3rd, Shattell, M. M., & Todd, M. (2006). Hall’s authentic meaning of medicalization: An extended discourse. ANS. Advances in Nursing Science, 29(4), 291–304; discussion 305–7. https://www.ncbi.nlm.nih.gov/pubmed/17135798

Hall, B. A. (1996). The psychiatric model: A critical analysis of its undermining effects on nursing in chronic mental illness. ANS. Advances in Nursing Science, 18(3), 16–26.  https://www.ncbi.nlm.nih.gov/pubmed/8660009

Hall, B. A. (2003). An essay on an authentic meaning of medicalization: The patient’s perspective. ANS. Advances in Nursing Science, 26(1), 53–62. https://www.ncbi.nlm.nih.gov/pubmed/12611430

Hall, B. A. (2006). Author’s Response to “Hall’s Authentic Meaning of Medicalization: An Extended Discourse.” ANS. Advances in Nursing Science, 29(4), 305.

Hall, B. A.. (2008). Surviving and thriving after a life-threatening diagnosis. AuthorHouse.  https://market.android.com/details?id=book-giE2mx62bAwC . Also available here,