Welcome to the Nursing Outlook Blog – “3 Questions” – Timely Interviews with Thought Leaders in Nursing and Health Care Policy Issues of the Day

The conversation on racism in health care is largely quiet – and rarely reaches an opennes of other important issues of the day. Are nurses and health professionals engaged in the dialogue about the unspoken questions of racism while talking aloud and frequently about health care disparities? Does our research focus on questions of concerned for all races and do we educate our future nurses to understand the sources of race-based inequities?

A new article in Nursing Outlook (May/June 2013) by Joanne Hall and Becky Fields takes a close look at how structural and interpersonal racism, in general, and in nursing encounters, specifically, may marginalize patients of color. And well-intentioned White nurses may not even realize it!

These are among the hot topics of the day. All the critical issues that are important to nursing warrant rapid dialogue among informed readers and traditional modes of publishing cannot keep up with the pace of information available. “Agility” is needed to deliver contemporary arguments electronically for persuasive commentary for building consensus that is timely, substantive and prepared for discourse. Blogging and blogs are increasingly providing a paperless platform for professionals to present and debate ideas in the socially connected evolving web. Nursing Outlook is now hosting an online environment – “3 Questions” – to engage nurses with nursing leaders in discussions around focused topics that are important for the profession. Interviews will be routinely edited and posted for readers to learn from thought leaders of the American Academy of Nursing and a variety of other nursing and health care megastars.

The authors’ intent is to show the need for White-to-White conversation. We invite commentary that is thoughtful and provocative! Join the online dialogue!

Veronica D. Feeg, PhD, RN, FAAN


Joanne M. Hall, PhD, RN, FAAN


University of Tennessee College of Nursing

Knoxville, Tennessee



Becky Fields PhotoBecky Fields, PhD, RN

Associate Dean

South College, Knoxville, Tennessee



Question 1. Dr. Fields: Looking at the recent history of the U.S., do you really think the problem of racism is still that serious? What precipitated the writing of this article at this time?

That’s a very interesting question. I do believe that as we look at the history of this country, it is far time for us to really think about the conversations that we have in general and for me in particular as a nurse, for our discipline. As I think about that question – “do you really think the problem of racism is still that serious?” – I have to say it is probably more serious. For far too long, there have been many conversations, but they have not been mainstream conversations surrounding race, in general in this country, and in particular in our discipline in nursing. As I am a nurse, I’m certainly concerned about that. In order for us to be real self-actualized as a nation, as a group of people, we really have to think about the health of everyone. As nurses, being apolitical surrounding the idea of universal health care, without talking about the issue of race and racism, then we devalue or we treat as unimportant the whole issue of health in this country. For persons of color, racism is still very serious, and perhaps even more so. Because the fact that we have a person of color as our President, really highlights the fact that – yes – socially, we have really made some strides, perhaps politically we have, but we continue to have health disparities in this country. Primarily African Americans – even in the midst of the increase in the Hispanic population – African Americans still maintain worst health in this country. And that’s of concern to me and to many nurses. Part of it, we think, has to be surrounding racism in this country and the ill health effects of racism. We have spent thousands, millions of dollars, both in advertising and creating interventions – things we have tried to address disparities in this country. Even around something as simple as infant mortality – we still are far below other countries in the world in terms of infant mortality for persons of color in this country. That’s concerning – that shouldn’t be! So, do I think the problem is serious? Absolutely, I do.

Now in terms of what precipitated this particular article, Dr. Hall and I have been colleagues for several years. I was educated at the university where Dr. Hall is a professor. Later on, I came to teach there, so we have had a very interesting relationship both as colleagues, mentors and now as friends and collaborators in terms of our research. She has been a leader in the field in terms of talking about marginalization of people. My research has stemmed around vulnerability in individuals, particularly looking at older adults and minorities and women. So race and gender have been very important to me. We had a natural collaboration in terms of talking about the issues that affect people who are marginalized, people who are on the edge – trying to figure out what we can do as nurses in terms of creating knowledge and generating knowledge that would help and be instrumental in providing better care, and decreasing the gaps that we have surrounding health disparities. And so, it was a natural next step in terms of the discussions, the conversations that Dr. Hall and I have had to look at who else needs to be in this conversation? Who else needs to be talking? So we talked about how the burden of looking at health disparities really has been carried quite a bit on nurses of color – we’ve talked about it – both professionally, in the classroom, in the clinical area, in our homes, in our churches, in our neighborhoods. But we don’t see, at least, where the conversation has happened between White nurses, in particular around how does White privilege – how does the dominant culture in terms of White privilege – how does it impact individuals of color and then how does that affect health?


Question 2. Dr. Hall: What is it that White nurses need to talk about with each other? Aren’t nurses doing more than many others about unfairness and health disparities? Nurses have a history of including culture in our scholarship, and a commitment to vulnerable populations. What would this conversation accomplish?

Well first of all, I think if nursing kind of looks in the mirror and we can see the level of our diversity has just not changed in step with the history of other health professions or just professions in general. So I think it’s cause for concern that if it continues to be the same and I’m not sure we’re investigating heavily enough scholarship wise, and finding out first of all, why that’s the case and then to really understand the implications of that lack of diversity. We may have some illusions about just how culturally open we are as a collective. And when I say “we,” I am talking to White nurses myself right now as a White nurse, that we present, I think, sometimes to ourselves and to each other and to the public a kind of essentialist view of the nurse. We hear educators talking together about the qualities of a “good nurse” as though that’s kind of monolithic. I think some of those frozen ideas that we have about who’s a good nurse, perhaps we are working in unconscious ways to exclude people who don’t fit that mold for cultural reasons. And then, I think also, we’ve perhaps looked at culture, and not really race, very seriously, because we’re maybe content to acknowledge that there is a lot of diversity – that many cultures have different beliefs, values, etc.  – and we can appreciate that. But we don’t go that other step to say that the differences between the groups that we are pointing out don’t take into account often the power dynamics, and the fact that these groups are marginalized. If the cross cultural, or trans-cultural, or culturally competent – we’ve used so many phrases for this – but I don’t know if we’ve made appreciable dents in the perceptions that our patients of color might have about nurses. Have we looked at it? So, I guess I would just raise that question. If not, why not?

Nurses maybe console ourselves with that we repeatedly are considered the most trusted profession, and, I’m not exactly sure what that means. What do people trust us with? Are we content with that just as a comparison to what is the standard that the public is expecting? Maybe we’re the most trustworthy, but that doesn’t really include all the things that we sort of have a social contract with the public about. Certainly to make services accessible, to decrease health disparities, I think there are a lot of unturned stones that we could look to. We could do research in the area, for example, taught in our school of nursing what’s the curriculum around race, racism, race relationships, and the real harm I think that is caused in these daily micro-traumatic interactions that people of color are telling us happen with White people. I think that White people need to talk with each other because people of color have been giving us this message all along. And, I’m not excluding people from that conversation, but sometimes I think that similar groups need to kind of withdraw, look at themselves, and hold each other accountable. In the narrative interviews that Dr. Fields and myself are doing currently about these daily, we call them racial micro-aggressions: First of all that they will laugh in the interview because these are so commonplace to them and indeed do happen on a daily basis. I think White people in general are not mainly conscious about the ways we behave towards African Americans. For example, that they’re perceiving as derogatory, little insults, slights, being ignored, being followed in a store. What’s the accumulated stress? Can nursing be the profession that becomes, not only good at taking care of patients of color, but we should be an expert on these possible connections with daily micro-stress, if you will, possibly these huge health disparities that we make goals about every season, and they’re still there. We have not resolved all the aspects that we could be investigating about health disparities.

I think the key concern of nurses is the health care encounter itself. How much damage there would be if these small aggressions are inadvertently transmitted in the health care encounter? We’d have even more distrust by minorities of the health care system. We would be just throwing everything a step backwards, and I think, contributing to health disparities. This looks to me like a fertile area for nursing scholarship.

Question 3. Dr. Fields: Nurses consistently are considered the most trusted profession. We care for everyone, and value cultural competency and advocacy. Aren’t you talking to the wrong people?

No, I’m talking to the right people – the people who can hear it. Because nurses are in the front line of talking to people, people listen to them. Nurses do care about people. And, really when you think about it, [we should be] having conversations between White nurses. As a Black nurse myself – my mother is a retired diploma nurse – so nursing is rich in my family. I’ve listened to nurses talk, growing up. I’ve listened to wide varieties of nurses growing up. Being a nurse myself for over 20 something years, I know nurses. What I do know about nurses is that nurses do not intentionally do things that bring harm to other people. It is not their intent. People are drawn to nursing because they care about people. As a nursing professor, as I’m reading letters or things that our students write about why they want to be a nurse, caring always comes up. And, if you think about nursing, nursing is equated with care. And if you ask people what do nurses do? – Nurses care.

So, nurses are the ones who really need to have serious conversations, to really take the shades off – take the blinders off – to have true conversations about the things that nurses can do. In particular, [what] White nurses do unintentionally that really add to the aggressions and micro-aggressions, the perceived discriminatory treatment that persons of colors have. Nurses are not doing these things intentionally. But the fact that they are not talking about them from the perspective of persons of color is detrimental to all of us in nursing – not just White nurses – to all of us who call ourselves or wear the hat of nursing. If we don’t talk about the issues, having true conversations about race, racism, racialization, aggression, discrimination – if we don’t talk about those things, then we truly, truly, truly aren’t taking care of all of the patients or all of the people that nurses touch every day. We absolutely have to have this conversation – because we haven’t had it – in the way in which we need to have it.