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Racism in nursing: a critical realist approach

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VOL: 97, ISSUE: 32, PAGE NO: 40

Barbara Condliffe, BA, Cert Ed, RGN, RM, RCNT, DN, is senior lecturer in adult nursing, Buckinghamshire Chilterns University College

Shaha (1998) says that nursing as a profession seems to avoid considering the problem of racism. In the UK, the need for debate and analysis of the issue became obvious in 1999, when members of the RCN rejected a resolution to increase the involvement of ethnic minorities in the work of the college (Nursing Times, 1999). It was ironic that the congress which led to this vote had opened with a pledge to stamp out racism but ended with the RCN general secretary admitting that the organisation was ‘institutionally racist’ (Waters, 1999).

Spratlen (1998) defines racism as the pattern and practice of systematic oppression and exploitation of one racial group by another, which can occur at both an individual and institutional level. The Macpherson report into the role of the police in the investigation of murdered black teenager Stephen Lawrence described institutional racism as the collective failure of an organisation to provide an appropriate and professional service to people because of their colour, culture or ethnic origin (Warden, 1999). The then home secretary, Jack Straw, accepted the issues raised by the Macpherson report and extended the powers of the Race Relations Act 1976 to cover all public services, including the NHS, from April 2000. By this date, all NHS employers had to have established mechanisms to deal with racial harassment, whether committed by staff or patients.

Critical realism

Racism can be explored in many ways, but one method is an approach called critical realism, which is concerned with building theories that account for events in the real world (Wainwright, 1997). Doyal (1993) discusses his everyday experience of growing up in Atlanta in the USA in the 1940s. He says it was taken for granted that black people would have worse health and housing because they were seen by the local white population as being inherently less intelligent and lacking in drive and ambition compared with whites. The socialisation of children reinforced the view that blacks were inferior; if any of them did anything exceptional it was put down to ‘white genes’. The structural processes that caused blacks to live in poor circumstances, and the ideology that caused whites to see them as inferior, was never questioned.

A critical realist approach does not suggest that when structures exist they automatically cause things to happen in the real world. For example, although Doyal grew up in a racially prejudiced world, he developed a close friendship with a black boy, despite his parents’ opposition. Rather, critical realists believe that structural mechanisms should be seen as tendencies, operating in an open system, where other competing tendencies may be more influential in determining what occurs.

Critical realism and nursing

There is a critical realist study in relation to racism in nursing by Porter (1998), who notes that nurses in an A&E department seemed to make more overtly racist comments about non-white doctors than nurses in an intensive care unit (ICU). He identified two structural mechanisms operating at the same time: racism and professional ideology. The A&E nurses’ open criticisms of the doctors were rationalised by claiming that the junior doctors were professionally inept. Where doctors were highly skilled, as in the ICU, the nurses’ opportunities to make racist remarks were curtailed. Their racism, while still evident in private discussions, was not openly expressed because they could not find a professionally acceptable reason to criticise the doctors.

Eliason (1998) conducted an interesting study with 116 nursing students in a Midwest American university. Its aim was to discover whether exposure to racial and sexual minorities led to a lessening of racism and homophobia. The grouping of sex with race in her study was based on previous research she cited which suggested that students who were racist were also likely to be homophobic. She found that nursing students had more positive attitudes about people from racial minorities than about people from sexual minorities. However, she says this may have represented a false sense of security about race, as most respondents had low levels of racial awareness.

The experiences of black nurses who came over on the SS Empire Windrush - the first ship to bring people seeking jobs from Jamaica to the UK in 1948 - demonstrate the low levels of racial awareness in the UK at that time. Some of these nurses reported that English children thought they were covered in coal dust or chocolate, and one sister asked a black nurse on her ward to take a plate out of the oven without an oven glove because, coming from a hot climate, she would not feel the temperature (Inman, 1998). One could theorise, as Eliason did, that given time and exposure to a multicultural community, racism would lessen, but Koh (1999) confirms from his experience of nursing in the UK that although people may believe they are culturally aware, prejudice is common. He states that racism is confirmed in small ways, in so-called ‘harmless’ jokes and raised eyebrows.

Both Koh (1999) and Eliason (1998) suggest that racism is no longer overt because of legislation such as the 1976 Race Relations Act, which has had the effect of driving racial hostility underground. Koh says that naked prejudice is easier to confront than prejudice clothed in the language of equality. Koh’s experiences are not unique. Scott (2000) reports on a study into racism in the NHS. Ethnic minority nurses and other staff listed their experiences of racism, which included being ‘talked down to’, colleagues laughing off incidents of racial abuse and being reprimanded for a minor misdemeanour that would be ignored if made by a white member of staff. Pfeffer (1998) comments that ‘white’ is never seen as an identity by white people: white ethnicity is invisible because it is set up as a standard against which all others are measured.

Taylor (1999) discusses oppressive mechanisms that work to undermine black African American women’s health. She found that both the general public and health care professionals used labelling, stereotyping and categorising when referring to these women. Negative images such as ‘the mammy’, and ‘the black lady over-achiever’ were applied to these women, affecting not only their self-image but also the health care they received. For example, health care professionals caring for a well-educated, middle-class black woman often had inappropriately high expectations of her ability to know about medical terminology and self-care, on the basis that she was ‘an over-achiever who knew everything about everything’. Critical realist approaches could explore how these labels arise and how they are used to shape behaviour.

Racism and nursing

It is important that racism is eliminated from nursing. Moral and ethical reasons apart, helping people from under-represented ethnic minority groups feel that nursing is an occupation into which they will be welcomed and supported could reduce the current recruitment crisis. Department of Health figures show that 8.7% of nurses, midwives and health visitors aged over 55 are Afro-Caribbean, but only 0.8% of nurses under 25 are black. If the proportion of black nurses employed at all levels in the NHS was 8.7%, there would be an additional 17,000 nurses. A two-year research study by Aliya Darr for the University of Bradford found that racism in the NHS was not an issue for Asian sixth-formers but that once they began working in the health service, Asian nursing students experienced racist attitudes among patients and colleagues. The students also doubted the ability of the school of health studies to tackle racist behaviour (Darr, 1999).

Racism and nurse education

Nurse educators have a major role to play in eliminating racism from nursing. Baxter (1998) evaluated current practice regarding the promotion of race equality in the nurse education curriculum. Four main themes emerged: the need for appropriate teacher preparation; the role and function of black and ethnic minority staff; a theory/practice gap; and the predominance of a culturalist approach to the subject of race equality. This meant that where race issues were addressed, it was done in a way that perpetuated stereotypes of the ‘Muslims do this and Hindus do that’ variety.

Hagey and MacKay (2000) found a great deal of discomfort in nursing faculties when issues of racism were investigated. The curriculum they reviewed did not support either discussion of theory about racial phenomena or discussion of clinical issues that could arise. Although conducted in Canada, Baxter’s study suggests such findings would be equally true in the UK.

The critical realism framework has much to offer nurse educators because it is a means of exploring the causal mechanisms of racism in nursing that goes beyond the immediately apparent and observable. Examining the ways in which student nurses are socialised into the profession, where white ethnicity is used as the basis from which everything is taught, is one way. Another is to explore the labels, images and stereotypes used in teaching as a means of characterising the ‘otherness’ of ethnic minority groups. Nurse educators should review what they are teaching and check whether it is being taught from a white ethnocentric perspective. Providing a supportive classroom environment that encourages students to challenge racist stereotypes or remarks is also important.

According to critical realists, once openness, research and reflection make structuralised racism visible, then oppression of racial minorities may be reduced. However, as Baehr (1990) points out, oppression is embodied through patterns of learning which, through repetition and habit, become a part of human nature. Nurse educators need to examine the ways in which their own actions and values reflect racism. Only once this painful process has been undertaken will they be able identify and challenge the structures that make racism an inevitable part of the nursing curriculum.

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Readers' comments (1)

  • very good issue. its what i was looking for. can you please supply the references?

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