Racism persists within the NHS and there is significant evidence that racial discrimination has negative consequences for those who experience it (Bheenuck et al, 2007; McChesney, 2015; Burnett et al, 2020). Krieger (2014) determined a direct relationship between racial discrimination and hypertension, premature labour and low birthweight, as well as other significant health conditions. In 2010, the World Health Organization explicitly identified racism as a social determinant of health (WHO, 2013).
Despite decades of research on the deleterious impact of racism on health, nurse educators rarely examine racism in healthcare. In fact, racism is often demonstrated and reinforced by health professionals and educators themselves (Burnett et al, 2020; Schmunk, 2020).
Nursing is a particular challenge because the profession is viewed as inherently non-judgemental, with a long-held commitment to the individual (Thorne, 2020). This presents as a barrier to critical scrutiny. Furthermore, while many nurses may practise anti-racist care, the nursing profession as a collective has upheld a culture of denial, silence and reluctance to address the issue of racism that pervades in healthcare education and practice (Hall and Fields, 2012; Bell, 2021).
This is an important time of reckoning for institutional racism in the UK as racial awareness has become heightened in recent years. This is in part because of the murder of George Floyd and the highly publicised demonstrations led by the Black Lives Matter movement (Moorley et al, 2020). This time of greater awareness provides an opportunity for nurse educators to understand the startling racial climate of the profession.
Background
In 1950, UNESCO published a controversial Statement on Race, which declared that there was no such thing as biological race. This is supported by Golash-Boza (2016), who described ‘race’ as a social construct. Yet the impacts of racism on health are far reaching. Zappas et al (2021) stated that racial discrimination contributes to biological changes such as higher levels of cortisol (a hormone that is linked to post-traumatic stress disorder), anxiety, depression and gastrointestinal and cardiovascular disease. Stress related to racism can also affect future generations as Nowak et al (2020) found from their systematic review of 25 studies linking maternal stress with epigenetic modifications to offspring DNA.
Furthermore, The MBRRACE-UK (2020) confidential enquiry into maternal deaths and morbidity for 2016-2018 revealed that Black women were four times more likely to die than White women during pregnancy and childbirth. Singhal et al (2016) revealed that Black patients were almost half as likely as White patients to be given analgesia in emergency departments when presenting with the same conditions.
Perhaps most alarming is research demonstrating that medical professionals believe things such as ‘Black people age more slowly than White people’, ‘Black people have thicker skin than White people’ and that Black patients are seen as ‘drug seekers, and over-exaggerators’ (Hoffman et al, 2016).
The reasons for health professionals harbouring such beliefs about Black patients may be multifactorial – including workplace and employer culture—but this also raises serious concerns about practitioner education and underscores the need for nurse educators to address racism in the classroom and in practice. Given the threat of racism to health as described above, anti-racist education should hold equal importance as the technical skills taught to nurses such as basic life support, venepuncture and cannulation.
In 2005, Cortis and Law (2005: 207) asserted that there was an ‘immediate need for nursing education to address the issue of racism in healthcare and higher education institutions’. Why has silence prevailed? It may be because nurse educators feel ill prepared to facilitate discussions on racism, White privilege and White supremacy (Zappas et al, 2021).
Therefore, this review analyses literature about anti-racism and nursing education in order to collate and produce the most effective strategies for the design and delivery of anti-racist undergraduate nursing education.
A note on terminologies
Language changes and evolves but terminology is always important in terms of intention and direction: for a comprehensive analysis of the politics, construction, application and efficacy of ethnic categorisation, see DaCosta et al (2021).
‘Black’ with a capital ‘B’ is used here as an alternative to BAME to articulate respect for people(s) who experience racism today. Black has been used routinely in anti-racist campaigns since the 1970s and, in this article, using Black is about creating unity in the fight against deep-rooted racism that sees Black people disadvantaged in housing, education, employment and the criminal justice and health systems (Unison, 2023).
Anti-racism is about moving beyond tokenistic gestures (such as merely including Black authors in reading lists or producing statements about anti-racism) towards concrete action.
Methods
The databases searched included CINAHL Plus, British Nursing Database (ProQuest) and MEDLINE. Limits set included papers that explicitly referenced anti-racism or decolonisation in the title and/or abstract. However, these initial searches yielded very few results, so the term ‘diversity’ was included to broaden the search.
It was identified in the review and from the authors' experiences that nursing education typically addresses difference from a culturalist perspective. Bell (2021:3) argues that the dominant culturalist approach to nursing misunderstands the true complexity of culture and frames difference in an othering process whereby ‘nurses learn about other people who have something called culture’. This is a superficial and outdated approach to understanding difference. Tengelin and Dahlborg-Lyckhage (2017) and Thorne (2017) contended that this approach ignores the influence and impacts of racism and oppression on social and health disparities.
Therefore, this review did not include the search terms ‘cultural competence’ or ‘cultural sensitivity’ to reflect the understanding that the culturalist approach does not adequately address the issue of racism. Other limits included the date range—from 2001 to 2022 to highlight the trajectory of anti-racism in nursing education—and language (English).
Initial searches yielded 182 results, and further relevant literature was found from reading the abstracts. Greenhalgh and Peacock (2005) suggested using many approaches to literature searching, including snowball sampling, where further papers are identified from reference lists. Just 10 papers were included in the final review as they were deemed appropriate in answering the research question.
Findings and discussion
Three themes and six subthemes were identified from analysing the selected papers.
Theme 1. Role of nurse educators
Seven of the 10 papers reviewed highlighted aspects of the nurse educator's role in the design and delivery of anti-racist education (Nairn et al, 2012; McGibbon et al, 2014; Blanchet Garneau et al, 2018; Coleman, 2020; Bell, 2021; Godbold and Brathwaite, 2021; Zappas et al, 2021).
The suggestions for nurse educators are explored here within two subthemes:
- Moving beyond denial and comfort
- Understanding white privilege.
Moving beyond denial and comfort
Denying or ignoring skin colour is criticised heavily in the literature reviewed here, which states that a colour-blind ideology sits within nurses' assertion that they treat everyone the same. Therefore, colour-blindness serves to erase the real impacts of racism and White supremacy on individuals and in society (McGibbon et al, 2014; Thorne, 2017; Coleman 2020; Bell, 2021).
Nurse educators in Nairn et al's (2012) study do not deny racism but are reluctant to address it, as encapsulated by the following quote:
‘I rarely raise the issue [of racism] myself because I'm very uncomfortable, self-conscious and embarrassed. I don't quite know how to raise it. What is the politically correct way to do this? There's all that and sometimes it feels sort of repressing to me.’
This perspective permeates the nursing profession. Prominent Black feminist and academic bell hooks (sic) noted in 2003 that teachers were often the most reluctant group of people to raise the issue of racism. In seminars on anti-racism, a great deal of time is spent ‘breaking through the denial that leads many… people… to pretend that racist and white supremacist… action are no longer pervasive in our culture’ (Hooks, 2003:25). In CP's experience, colleagues and students have exclaimed ‘I'm not racist, I don't see colour’ and ‘racism doesn't happen any more’.
Assertions like these are detrimental to Black students and staff because they are a denial of a fundamental aspect of life experience in that ‘a [Black] student cannot not see their race’ (Ferlazzo, 2020).
The work associated with anti-racism is uncomfortable but, as argued by Zappas et al (2021), the discussion of race must be continued with humility. Denial and defensiveness perpetuate White supremacy and we need to move beyond this to deliver effective anti-racist nursing education.
Understanding White privilege
Coleman (2020: 643) articulated the urgent need to move away from viewing Whiteness as invisible or neutral towards a critical awareness of its association with ‘unearned privileges and unaddressed racism’. The majority of the papers reviewed here call for the use of explicit and direct language to engage in discussions about racism, White privilege and White supremacy in order to change the culture in nursing education (Cortis and Law, 2005; McGibbon et al, 2014; Blanchet Garneau et al, 2018; Coleman, 2020; Bell, 2021; Garland and Batty, 2021; Zappas et al, 2021).
The work involved in understanding racism and White privilege is uncomfortable and challenging. Most nurse educators are extremely busy, in jobs that demand a great deal of time, attention and energy. Understanding the concepts raised here may seem daunting and overwhelming but this should not be a barrier to doing this work. Bell (2021: 8) contended that, where educators lack authentic expertise, it is important to model ‘humble, reflexive and accountable engagement’ with anti-racist pedagogies.
Furthermore, Godbold and Brathwaite (2021) identified that students want to see White educators taking responsibility for addressing racism that should not be left to the Black community to fix. Coleman (2020: 643) agreed, stating that ‘the burden of racial justice work [often] falls onto those who suffer the most from racism and consequently feel most compelled to act. This work goes largely unpaid and underappreciated’.
In response to this, White nurse educators have a responsibility to develop racial literacy. In other words, they should seek out and read literature authored by Black nurses—as well as literature from other disciplines—and include this in teaching and reading lists (Chinn, 2020; Coleman, 2020; Zappas et al, 2021). Further to this, there is a need to use White privilege to promote and uplift the work done by Black people, invite anti-racist scholars and activists into the classroom and provide spaces for Black voices to be shared and listened to.
The discomfort and the aversion to engaging with anti-racism are not unique to White people. Hooks (2003) acknowledged that any person who is born into a racialised society will be impacted by White supremacist ideology, regardless of their skin colour and, as such, there is a need to understand how Whiteness is a privilege.
Peterson (2020) produced a table to illustrate what is meant by ‘privilege’ in this context (Table 1). Any person who has a social privilege listed in the left column will not experience the social burdens associated with not having this privilege. So, in the same way that an able-bodied person does not experience disability discrimination, a White person will never experience systemic racism. Furthermore, according to Jones et al (2008: 496) ‘being classified by others as white is associated with large and statistically significant advantages in health status, no matter how one self-identifies’. Therefore, Whiteness needs to be examined and critiqued by nurse educators by exploring how being White has and continues to benefit White individuals. This will help to open up conversations about racism and move away from the denial that pervades nurse education.
Table 1. Social privileges and resultant burdens
| Social privileges | Social burdens |
|---|---|
| White privilege | Systemic racism |
| Male privilege | Misogyny |
| Cis or hetero privilege | Transphobia and homophobia |
| Class privilege | Class discrimination |
| Health and ability | Stigma, ableism, disability discrimination |
| Religious privilege | Anti-Semitism, Islamophobia |
In critiquing Whiteness in the classroom, intersectionality is an approach or a lens through which to educate and is explored later.
Theme 2. Nursing curricula
Eight of the 10 papers reviewed included suggestions for the incorporation of anti-racism into nursing curricula (McGibbon et al, 2014; Blanchet Garneau et al, 2018; Coleman 2020; Bell, 2021; Garland and Batty, 2021; Godbold and Brathwaite, 2021; Van Bewer et al, 2021; Zappas et al, 2021). Thematic analysis of the papers revealed two further subthemes:
- Social determinants of health
- Incorporation of diverse teaching resources and non-traditional teaching methods.
Social determinants of health
Integration of teaching on the social determinants of health provides students with a critical understanding of how racism in society impacts health (WHO, 2010; Marmot and Allen, 2014; McGibbon et al, 2014; Blanchet Garneau et al, 2018; Coleman 2020; Bell, 2021; Zappas et al, 2021). Zappas et al (2021) claimed that race is still taught as a risk factor or even causal of disease. Nurses are one of the largest groups in healthcare who meet people at every stage of life, so they are able to influence health disparities relating to the social determinants of health (Zappas et al, 2021). It is therefore crucial that nurses understand the root causes of disease.
For example, diabetes and COVID-19 disproportionately affect Black patients (Williamson et al, 2020). In nurse education, it is important to explore why this is the case, drawing attention to the role of poverty, racial discrimination, geography, food security and gender inequities (Coleman, 2020). With a broader intersectional understanding, students are better equipped to support and manage patients at greatest risk of diabetes and COVID-19, as well as other health issues (Spanakis and Golden, 2013; Coleman 2020; Garland and Batty, 2021). As Coleman (2020: 644) highlights:
‘Intersectionality was born from Black feminism to critique the tendency of social justice movements to separate out targets of oppression, such as gender and race, leaving out Black women.’
This approach would help nurse education move away from the culturalist perspective, enabling a more critical understanding of racism and White supremacy. Kumanyika and Jones (2015) offered suggestions for how to move towards a more intersectional approach to understanding the impact racism has on health: first, to explicitly name racism as a social determinant of health; second, to discuss how racism manifests within our practices, norms and values; and, finally, to work with community organisations to address the structural factors that shape discrimination and inequity in society.
Racism in society needs to be recognised as equally harmful as any other form of harm and Bell (2021) suggested that an intersectional risk assessment could become another nursing observation or vital sign alongside blood pressure and temperature assessments. Developing such a tool presents an opportunity for further research.
Incorporation of diverse teaching resources and non-traditional teaching and learning methods
Eight of the 10 papers reviewed indicated that nurse educators must develop resources that include Black people to articulate the similarities and differences in assessment, diagnosis and treatment (McGibbon et al, 2014; Blanchet Garneau et al, 2018; Coleman, 2020; Bell 2021; Garland and Batty 2021; Godbold and Brathwaite, 2021; Van Bewer et al, 2021; Zappas et al, 2021).
Key differences in skin assessment are rarely addressed in teaching or training. Despite the higher number of Black people affected by COVID-19, research conducted by Lester et al (2020) found that of 120 images published that showed skin manifestations of COVID-19, only seven were of darker skin. It is a vital skill for nurses to be able to assess for jaundice, cyanosis, soft-tissue injury, pressure injury and labial abrasions following sexual assault, all of which are different in Black and White skin (Sommers, 2011)
In clinical simulation in the UK, 94% of manikins and body parts are White (Foronda et al, 2017). There is an urgent need to better equip our students by using clinical scenarios in our teaching that reflect the diversity of the population as well as diversifying our simulation equipment. Mukwende et al (2020) produced a handbook of clinical signs in Black and Brown skin, which could be used to teach student nurses about skin assessment.
Often within nursing education, there is a false impression that Black nurses did not contribute to the evolution of the profession (Zappas et al, 2021). Nurse educators therefore need to understand and uphold the legacy of important Black nurses in our history such as Mary Seacole and Annie Brewster, as well as contemporary Black nurses such as Elizabeth Anionwu, the UK's first sickle cell and thalassaemia nurse specialist (Mistlin, 2020).
The importance of ensuring a safe environment for anti-racist education is paramount and has been highlighted in much of the literature on this subject (McGibbon et al, 2014; Hollinrake et al, 2019; Coleman, 2020; Bell, 2021; Garland and Batty, 2021; Godbold and Brathwaite, 2021; Van Bewer et al, 2021; Zappas et al, 2021). As well as demonstrating the open, reflexive and critical stance of individual nurse educators, some of the studies reviewed here suggest they use non-traditional approaches to teaching. Van Bewer et al (2021: 70) reported on a workshop informed by an indigenous and arts-influenced framework for anti-racist practice in nursing education. They found the following:
‘By exploring racism and oppression in healthcare and nursing through group images, participants experienced exclusion and marginalization viscerally and sensorially … it … allowed for communication without the constraints of the verbal language and without interruption.’
As well as images, it could be pertinent to use narratives and storytelling with students to enable a deeper understanding of the issues of racism and White supremacy (Hollinrake et al, 2019). In addition, Zappas et al (2021) stated that the use of blended learning and the flipped classroom are beneficial for Black students as these approaches facilitate increased interaction and discussion time with educators. Non-traditional approaches to teaching about racism in the classroom warrant further consideration.
Theme 3. Institutional responsibilities
Bell (2021: 9) stated that in tackling racism in nurse education ‘classroom strategies alone are not sufficient… when fundamental [social and institutional] ideologies are the culprits’. Seven of the 10 papers reviewed discussed institutional responsibilities in the provision of anti-racist nurse education (Cortis and Law, 2005; McGibbon et al, 2014; Blanchet Garneau et al, 2018; Coleman 2020; Bell, 2021; Garland and Batty, 2021; Godbold and Brathwaite, 2021). Synthesis of these papers generated two subthemes:
- Retention and support
- Training.
Retention and support
Retention of nursing students is a primary focus for many higher education institutions (HEIs) because there is a chronic shortage of nurses in the UK; before the coronavirus pandemic, there was a shortage of approximately 40 000 nurses (Buchan and Stockton, 2021; Zappas et al, 2021). According to the Office for Students (2019) more Black students discontinued their studies than any other ethnic group and, in 2017–2018, the degree-awarding gap between White and Black students receiving a 1st/2:1 degree in UK HEIs was 24%.
It is vital, therefore, that institutions address issues of recruitment and retention of Black students, as well as the stark degree-awarding gap. Zappas et al (2021) called for all institutions, specifically nursing schools, to form equality, diversity and inclusion committees, and Coleman (2020) contended that nursing programmes need to review and evaluate their diversity statements and policies, scrutinising the actual work being done. Godbold and Brathwaite (2021) highlighted the importance of removing the ‘deficit model’ where students who may more confidently speak and write in languages other than English are considered somehow lacking in ability. The ability to speak, read and write in more than one language should be celebrated by educators, acknowledging the hard work that is required to do this.
It is also vital that HEIs have robust and transparent policies and procedures for investigating incidents of racism and, importantly, to take action when required (Cortis and Law, 2005). According to a 2019 inquiry by the Equality and Human Rights Commission (EHRC) on racial harassment in universities, around a quarter of students from an ethnic minority background (24%) said they had experienced racial harassment since starting their course, with 56% of them having to deal with racist name-calling, insults and jokes; one in five of these students had been physically attacked. The EHRC (2019) therefore called for the introduction of effective reporting systems in universities to address these shocking findings.
Training
Based on the literature, there is a clear need for institutions to provide nurse educators with the skills and tools to make sense of racism and White supremacy to feel more confident in managing discussions on these issues in the classroom (Baxter, 1998; Cortis and Law, 2005; Nairn et al, 2012; Coleman, 2020; Bell, 2021).
One step towards moving away from colour-blind teaching is to uncover unconscious biases: beliefs and views people hold about others that may be unreasonable and untrue (Lokugamage 2019). Project Implicit provides online tests to uncover unconscious biases at https://implicit.harvard.edu/implicit/takeatest.html. However, unconscious bias training alone – for which attendance is mandatory in some HEIs – is unlikely to help dismantle racism (Noon 2018).
Cortis and Law (2005), Coleman (2020) and Bell (2021) argued that short training sessions to appease an organisation do more harm than good and that effective, evidence-based anti-racist training should be integral to an institution's operations. Babla et al (2022) highlighted the importance of allyship in healthcare and explore solutions to address racism and discrimination. For example, Coghill's (2020) 7As of Authentic Allyship is a model that could serve as a useful tool in framing anti-racist training for nurse educators.
Conclusion
The strategies for the design and delivery of anti-racist undergraduate nursing education presented across the literature expose key themes for further research and action. First, nurse educators are implored to move beyond denial and comfort, and to develop racial literacy and become accountable by approaching the issue of racism with commitment and humility.
Second, there is a need to examine nursing curricula carefully, ensuring students are taught the causes of racial health disparities by focusing on racism as a social determinant of health. Intersectionality is a useful concept for nurse educators to explore to move away from the traditional culturalist perspective of nursing education. Nurse educators also need to ensure that the resources used in the classroom are diverse, by not just upholding Black-authored literature but also adopting non-traditional teaching methods such as the flipped classroom, imagery, narratives and storytelling.
Finally, institutions are obliged to address the retention of Black students and staff, to provide effective support to empower Black students, moving away from the deficit model and to implement evidence-based anti-racist training for staff. Without the commitment from HEIs to take this obligation seriously, there is little that nurse educators can do alone to change the pervasive culture of racism in nurse education.
KEY POINTS
- Nurse educators have a responsibility to understand the impact of racism on health and to develop racial literacy
- Nurses are in a unique position to address the social determinants of health so need to understand the root causes of health disparities. Nursing curricula should therefore include racism as a social determinant of health
- Schools and departments of nursing should form equality, diversity and inclusion committees responsible for auditing policies and procedures relating to these issues specifically in nursing education
- Institutions need to commit to addressing issues of retention of Black students and staff, to ensure robust reporting systems are in place and to provide effective anti-racist training to all staff and students
CPD reflective questions
- What privileges do I benefit from and how do these benefit me?
- What is my role in addressing racism in nursing education and/or practice?
- How could I use an intersectional approach to teach someone about the racial health disparities related to COVID-19?