Health professionals across the globe must be commended for their commitment and outstanding bravery in their responses to the COVID-19 pandemic. Notwithstanding the limited resources available and the unprecedented high volume of critically ill patients often exceeding capacity, many lives have been saved. However, healthcare services need to remain vigilant for racial inequalities and disparities, as wider societal fears regarding COVID-19 are escalating, fuelling xenophobic and racist ideologies (Coates, 2020; Smith et al, 2020). Inevitably individual countries are taking measures to protect the wellbeing, safety and identity of their citizens, such as closing borders to some countries. However, this is escalating fears, introducing a culture of blame and contributing to an increase in stigmatising minority groups. For example, a rise in anti-Asian statements in political and media coverage of the pandemic (Gee et al, 2020) and accusations that Roma recently returned from other countries were spreading COVID-19 (Matache and Bhabha, 2020). The rise in health and social inequalities (Coates, 2020) and the increasing statistical trends showing that people from minority communities are disproportionately affected by COVID-19, are also growing concerns (Chowkwanyun and Reed, 2020; Devakumar et al, 2020). The risks associated with COVID-19, in terms of infection rates, recovery periods and mortality rates, are not equal across all members of society (Smith et al, 2020). For example, the mounting evidence highlighting that black people, Asian people, and people from minority ethnic communities are dying in disproportionately high numbers (Kirby, 2020), raises further questions about causes of such inequalities.
Although racism and xenophobia are often discussed as distinct phenomena, Rzepnikowska (2019) has highlighted the need to understand both constructs together, as one influences the other. Xenophobia is a term used to describe fear or dislike of people who are significantly different from oneself, as a means of protecting ones' own identity and ‘way of life’ (McCorkle, 2018). Unaddressed xenophobic ideologies can fuel tensions, which can result in prejudice, discrimination, or antagonism directed against people from diverse backgrounds (Fanning, 2012). Although the recent global pandemic brings a new wave of xenophobia and racism in healthcare, racism has pervaded healthcare organisations for decades (Markey et al, 2012; Rivenbark and Ichou, 2020). The widespread evidence of discrimination of nurses from minority backgrounds (Pendleton, 2017; Brathwaite, 2018) and health disparities and discriminatory behaviour towards people from minority communities (Hall et al, 2015; Markey et al, 2019; Kendall et al, 2020), continues to grow. Shepherd et al (2019) reported that although nurses understand the importance of providing culturally sensitive care, recognising and addressing biases, discrimination and racism are not seen as significant. Nurses must understand the complex and multifaceted nature of racism, its predisposing factors and the subtlety with which it is expressed, if they are to influence changes to practice. This will be particularly paramount in the recovery of COVID-19.
This discussion draws on a review of literature providing a broad overview of a wide range of published literature. A variety of searching techniques were used to locate papers and existing evidence on racism to locate both academic and grey literature on the area. The aim is to provide an overview and synopsis of publications reviewed, with a focus on proposing practical and sustainable approaches for understanding and operationalising anti-racist attitudes and behaviours.
Demystifying racism
There is a reluctance to explore racism, or the conflicts, perceptions and experiences contributing to and reinforcing tensions in healthcare (Cortis and Law, 2005; Markey et al., 2012). Consequently, racist practice quite often goes undetected or unchallenged due to the sensitivity associated with it and a lack of understanding of its complexity (Ben et al, 2017). The impact of deeply engrained stereotypes, biases and prejudices that occur unconsciously and can directly or indirectly impact approaches to care delivery, are difficult to recognise. For example, making inappropriate assumptions about patients' cultural norms or care needs and preferences, arises out of this kind of stereotyping. Over-focusing on cultural differences and ‘othering’ patients from cultural and ethnic diverse backgrounds can reinforce stereotypes and have a negative impact on cross-cultural encounters (Johnson et al, 2004). The need for openness to discuss similarities and differences in cultural norms, health beliefs and experiences of healthcare can support the acknowledgement and respect for cultural difference required. The subtlety with which discriminatory practice is operationalised is also difficult to authenticate. Markey et al (2019) highlighted how nurses use a range of disengagement strategies, including avoiding or minimising contact with patients from diverse cultural and ethnic backgrounds, which goes unnoticed.
Grant and Guerin (2018) drew attention to the limited research exploring health professionals' understanding of racism in healthcare, and how they manage it in practice. Nurses need to review how they conceptualise racism in a way that informs attitudes and behaviours that address racial inequalities and disparities. However, racism is often euphemised, denied or neglected in nursing discourse (Culley, 2006), creating a false illusion that racism is not an issue for nursing practice. Although the psycho-emotional aspects associated with exploring racism are invariably underestimated (Markey and Tilki, 2007), unless feelings, misunderstandings and narrow perceptions of racism are explored, it is difficult to find solutions or prevent escalation of tensions. There is a need for a more open and non-judgemental discourse around interpretations of racism and its predisposing factors as a means of combating the growing number of reports.
Racism is a complex and sensitive issue that engenders anxiety, evokes blame and incurs feelings of anger or guilt. Unaddressed stereotypes, biases, ethnocentric and xenophobic ideologies can result in discriminatory behaviour, albeit as a result of thoughtlessness and ignorance. Racism can occur in a variety of forms. It can be direct or indirect (Krieger, 1999) and blatant or subtle (Harrell, 2000), contributing to the challenges with acknowledging and addressing racist practice. Nurses need to appreciate that racist attitudes and practices can be intentional or unintentional and can be the result of action or inaction (Paradies, 2006). However, Pease (2010) drew attention to the complex wider social context in which discrimination takes place, such as behaviours that are socially reinforced and normalised. Nurses need to critically review their own attitudes and behaviours, but also develop awareness of social norms that render racist attitudes and behaviours acceptable. Johnstone and Kanitsaki (2009) referred to this as new racism, which is contextualised as subtle discrimination that occurs in ‘everyday talk’, but is not recognised as racism. Racism has been defined during the Lawrence inquiry as:
‘The collective failure of an organisation to provide an appropriate and professional service to people because of their colour, culture, or ethnic origin. It can be seen or detected in processes, attitudes and behaviour that amount to discrimination through prejudice, ignorance, thoughtlessness and racist stereotyping which disadvantage minority ethnic people.’
As with any definition, there are those who feel this definition remains superficial (Phillips, 2011). However, this inquiry added to previous definitions of institutional racism and differentiated between individual and institutional racism, highlighting the unconscious, deeply rooted and socially constructed beliefs which inform prejudices and stereotypes. Jones' (2000) definition describes three levels of racism: institutionalised racism, personally-mediated racism and internalised racism. The following outlines how this framework can be used as a structure to support nurses to critically review attitudes, practices and behaviours that can lead to racial inequalities and disparities.
Internalised racism: increasing self-awareness and respect for cultural difference
Jones (2000) described personally mediated racism as racial prejudices and discrimination that can be intentional or unintentional and can include acts of commission or omission. Nurses need to appreciate the importance of developing self-awareness of values and beliefs that inform perceptions of cultural difference, stereotypes and biases, as the cornerstone for addressing racist behaviour. This requires critically reflecting on attitudes, practices and behaviours as well as what informs them, when caring for patients from diverse cultural and ethnic backgrounds. For example, making pre-conceived judgements about patients based on their nationality, cultural norms or ethnic origin. It also requires a critical review of non-verbal behaviour during cross-cultural encounters (Levine and Ambady, 2013). However, exploring prejudices and biases can cause personal discomfort, as it can expose imperfections or racist attitudes and as such threaten personal images of the caring professional self. Subsequently, fear, guilt and uncertainty lead to avoidance and denial of practices that are discriminatory in nature. Nurses need to appreciate the importance of recognising how unaddressed stereotypes and unconscious biases can present as barriers to well-intended care (Almutairi et al, 2017; Shepherd et al, 2019). The term ‘implicit bias’ (FitzGerald and Hurst, 2017) or ‘unconscious bias’ (Marcelin et al, 2019) are terms more recently used to describe stereotypes and biases that are often subconsciously developed and underpin racist behaviour. By becoming aware of our own biases and actively resisting them, we can avoid perpetuating harmful racist stereotypes and prejudices. Developing positive attitudes and behaviours relating to cultural difference is core to developing anti-racist attitudes and behaviours. Encouraging nurses to explore similarities, while respecting differences in cultural norms, traditions and healthcare needs can help nurture such positive perceptions of cultural differences.
Nurses do not work in a vacuum and perceptions of cultural difference can be informed by wider social attitudes towards minority ethnic groups. FitzGerald and Hurst (2017) reported how health professionals exhibit the same levels of racial biases as the wider population, further reiterating the need to develop self-awareness. The importance of reviewing how nurses conceptualise cultural difference is paramount as it can affect how people view patients from different cultural and ethnic backgrounds (Kaihlanen et al, 2019). There is always the risk of viewing one's own cultural norms, traditions and beliefs as being superior to others, therefore viewing other cultures as inferior. This makes them guilty of being ethnocentric. Nurses need encouragement to question and challenge what they view as ‘normal’ or ‘acceptable’ and develop an awareness of habituated ways of thinking and working that sustain discrimination. Training activities and team discussions that encourage nurses to critically reflect on their own cultural values and beliefs and consider how they affect their perceptions of cultural difference, are recommended. However, Culley (2006) warned about the complexity of racism, suggesting that it does not only arise from ethnocentrism. Similarly, Fanning (2012) argued that the reality of racism that too often cloaks itself in the rhetoric of national identity and xenophobia contributes to a narrow interpretation of racism that allows it to go unnoticed.
Institutionalised racism: developing courage and confidence to challenge self and others
Jones (2000) defined institutional racism as structural barriers and societal norms that result in inaction or discriminatory actions. Although the complexity associated with personal attitudes and behaviours that inform discriminatory practices are evident, the culture of the organisation can facilitate and amplify discriminatory behaviours (Holdaway and O'Neill, 2006). Drawing on a theory of resigned indifference helps explain how collective ethnocentric practices of nurses become normalised to the point they go unnoticed and discriminatory care is perpetuated, albeit unintentionally (Markey et al, 2019; Markey et al, 2020a). Markey et al (2020a) highlighted how collectively nurses became content with providing substandard care to culturally diverse patients and even oblivious to the consequences of the standards of care provided. The complacency and general acceptance of less-than-perfect care for patients from different cultural and ethnic backgrounds was perpetuated by an organisational culture that had minimal repercussions for discriminatory behaviour (Markey et al, 2019; Markey et al, 2020a). These findings mirror Husbands' (2010) description of ‘moral professional complacency’ and the account by Horsburgh and Ross' (2013) of ‘institutionalised negativity’. Consequently, nurses are at risk of experiencing ‘emotional numbing’, which affects their ability to provide compassionate care (Dominguez-Gomez and Rutledge, 2009). Nurses need to develop courage, commitment and confidence to ask questions, discuss tensions and challenge threats to patient safety. Nurses have been reported to feel ill prepared and experience uncertainty when caring for patients from diverse cultural and ethnic backgrounds (Hart and Moreno, 2016; Markey et al, 2018). Developing the curiosity and motivation to proactively seek answers, solutions and resources when they are unsure of any elements of nursing care requirements is paramount. They need to feel confident to admit what they don't know, take risks rather than avoiding situations, and ask patients or families for information when they are unsure. Developing the courage and confidence to challenge discriminatory practices both within themselves and others is a necessity. Focusing on self-examination, assertiveness to question others and contextualising knowledge to different caring circumstances can help with this.
Nurses have a critical role in cultivating supportive working environments while remaining vigilant in maintaining ethical standards of their own and others' practice. This requires incorporating ‘ethical leadership’ in actively promoting moral behaviour (Barkhordari-Sharifabad et al, 2018) and revisiting the core values underpinning culturally sensitive care (Markey and Okantey, 2019). It also requires role modelling anti-racist behaviours and practices, motivating and empowering colleagues. Everyone has a role to play in creating an environment of trust where critical reflection occurs, openness to discussing racism as a means of addressing it and blame is avoided. Having open and transparent communication challenges with all members of the nursing team (Labrague et al, 2019) and regularly discussing cultural diversity issues (Shepherd et al, 2019) can create an environment where nurses feel comfortable to explore attitudes and behaviours informing discriminatory practices. Engaging in personal and professional development opportunities such as clinical supervision (Markey et al, 2020b) and anti-racism and cultural competence education and training (Almutairi et al, 2017; Shepherd et al, 2019), are also paramount. The importance of such education and training is well recognised in the literature (Harkess and Kaddoura, 2016; Grant and Guerin, 2018), but often poorly operationalised in practice.
Internalised racism: nurturing commitment to equality
Jones (2000: 1213) defined internalised racism as ‘acceptance by members of the stigmatised races of negative messages about their own abilities and intrinsic worth’. Essed (1991) described how socialised attitudes and behaviours, which are enacted as systematic, familiar and recurring practices, contribute to internalised racism. This can result in ‘resigned indifference’ (Markey et al, 2020b) or being ‘relatively impervious’ (Jantzen, 2019), which all describe how substandard nursing attitudes and behaviours are normalised, sustained and subsequently perpetuated. Nurses need to collectively learn to reject what is seen as normal and challenge unacceptable attitudes, practices and behaviour. They need support in developing the confidence to do the right thing even if it is not the popular course of action. Opportunities to think about their actions and omissions and reflect on approaches to care delivery, in a supportive and non-judgemental environment can help with this. The importance of considering power and its relationship to privilege/oppression when exploring racism is paramount (Paradies, 2006; Pease, 2010). Socially reinforced and normalised behaviour and attitudes must be explored and challenged if nurses are to understand privilege and the potential for oppression. The Council of Europe (2008), International Council of Nurses (2013) and the World Health Organization (2009) have all made explicit the global perspective regarding nurses' obligations from a human rights perspective. Despite such positive developments and directives, racism in health care continues operating in subtle ways (Kendall et al, 2020; Rivenbark and Ichou, 2020). Ultimately the responsibility for the introduction of policies to tackle racism lies with the institution, but the actual implementation of them in daily practice relies on the actions and attitudes of the individual staff members, highlighting the importance of nurturing commitment. Nurturing professional values-driven behaviour is essential, as it can inform caring behaviours and quality standards of care for all patients (Labrague et al, 2019). Providing education and training opportunities on ethics, creates a greater awareness of ethical considerations and supports the application of professional values in daily practice (Poorchangizi et al, 2019).
Although some racism is manifested in a fairly overt way, it is more likely to occur as a result of thoughtlessness and ignorance. There is a need to address the lack of awareness of unintended discrimination, which occurs as a result of thoughtlessness, ignorance (Lyons et al, 2008) or unwitting prejudice (Paradies, 2006). Becoming self-aware of one's culture, traits, perceptions and biases is a necessity, as this enables nurses to be sensitive and appreciate other identities and cultural differences (Markey and Okantey, 2019). Nurses who are knowledgeable of their patient's cultural and religious practices are empowered to give quality care for better patient outcomes (Almutairi, 2015). Although cultural knowledge and understanding the unique characteristics of diverse cultural groupings is important, in isolation it will not dispel stereotyping, biases and ethnocentricity (Markey et al, 2012; Almutairi et al, 2017). Nurses need to explore their own cultural identity while recognising the importance of exploring health beliefs, cultural norms and practices that influence care preferences for culturally diverse patients. Healthcare organisations need to emphasise the importance of this through mandating education and training in cultural competence development.
Conclusions
Responses to the COVID-19 crisis have highlighted historical injustices, racial inequalities and disparities, which are at risk of becoming a routine concern rather than a marginal issue. Tackling racism presents a diverse set of challenges for individuals, groups, institutions and society. Unless racist values, views and practices are discussed and challenged, the harmful effects in healthcare domains will remain hidden and will continue operating in subtle and powerful ways. Having explored the complexity of racism, practising nurses should better understand the importance of critical self-awareness, self-inquiry and the courage, confidence and commitment to challenge self and others as the cornerstone for transforming ethnocentric and racist attitudes and practices.