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“I can't breathe”: A call for antiracist nursing practice

      Highlights

      • Nurses are positioned to respond to the epidemic of racism in our healthcare system and communities.
      • This call to action highlights ways that nurses can adopt antiracist practices.
      • Actions include recognition of personal biases, confronting systemic inequities, policy and political action, new approaches to research, and using antiracist pedagogy.

      Keywords

      In 2020, nurses are confronting emerging and persisting health crises that are propelled by systemic racism. Coronavirus disease 2019 (COVID-19), originally called the “great equalizer,” has ravaged the nation, but is disproportionately impacting Black Americans (
      Centers for Disease Control
      Hospitalization rates and characteristics of patients hospitalized with laboratory-confirmed Coronavirus Disease 2019 — COVID-NET, 14 States, March 1–30, 2020.
      ). Meanwhile, civil rights protests are underway after the killing of George Floyd, the latest extrajudicial killing of a Black American by the police. Police violence is a significant health issue. Negative experiences with police are associated with increased medical mistrust (
      • Alang S.
      • McAlpine D.D.
      • Hardeman R.
      Police brutality and mistrust in medical institutions.
      ). Police killings are a leading cause of death for young Black men and Black women are 1.4 times more likely to be killed by police than White women (
      • Edwards F.
      • Lee H.
      • Esposito M.
      Risk of being killed by police use of force in the United States by age, race–ethnicity, and sex.
      ). George Floyd's final words were, "I can't breathe." In a clinical context, when nurses hear a patient say, "I can't breathe," it is an immediate call to action. Protocols are followed, resources are gathered, and steps are taken to maintain the patient's airway. "I can't breathe" has become the rallying cry of a movement.  Whether from the disproportionate mortality from COVID-19, or police violence, when Black Americans call out, "I can't breathe," nurses must respond. In the International Year of the Nurse and Midwife it is critical that we advocate for justice for Black Americans with a unified and powerful voice.
      Racism exists in internalized, interpersonal, institutional, and structural forms, all of which nurses must recognize and name. Structural racism in particular impacts our patient's health, which is dependent on their living conditions and environment. For example, residential segregation, a product of structural racism from the 1930s to 1960s in the U.S. housing system (e.g., redlining), produced racially segregated hospitals and differences in hospital quality that persist today (
      • Sarrazin M.S.
      • Campbell M.E.
      • Richardson K.K.
      • Rosenthal G.E.
      Racial segregation and disparities in health care delivery: conceptual model and empirical assessment.
      ). These policies also perpetuated differences in opportunities for employment, socioeconomic status, and physical and social environments (
      • Williams D.R.
      • Lawrence J.A.
      • Davis B.A.
      Racism and health: Evidence and needed research.
      ). Structural racism is also contributing to the disproportionate racial impact of COVID-19. Economic disenfranchisement may make exposure more common for Black Americans working in essential jobs who are unable to self-isolate and racial residential segregation impacts differential access to high quality care (b). Racism, not race, is the critical distinction that we must address. As the writer, Ta Nehisi Coates writes, "Race is the child, not the father, of racism" (
      • Coates T.N.
      Between the world and me.
      , p. 7).
      We credit professional nursing to Florence Nightingale, who highlighted the importance of studying health disparities and their determinants. Nursing falls short as a profession if we are not actively and explicitly naming racism as a root cause of racial health disparities. Nurses value empathy and bearing witness to what is happening not only in our healthcare settings but also in our communities. The ANA Code of Ethics urges nurses to confront moral wrongs, promote, protect, and advocate for all patients and communities, and urges nurses to confront biases, protect human rights, and reduce disparities (
      American Nurses Association
      Code of ethics for nurses with interpretive statements.
      ). Nursing, public health, and medical organizations and professionals have previously released position statements addressing the impact of racism on health and healthcare (; ;
      ANA Center for Ethics and Human Rights
      ANA position statement: The nurse's role in addressing discrimination: Protecting and promoting inclusive strategies in practice settings, policy, and advocacy.
      ;
      • García J.J.L.
      • Sharif M.Z.
      Black lives matter: A commentary on racism and public health.
      ;
      • Hardeman R.R.
      • Medina E.M.
      • Kozhimannil K.B.
      Structural racism and supporting Black lives: The role of health professionals.
      ;
      • Trent M.
      • Dooley D.G.
      • Dougé J.
      The impact of racism on child and adolescent health.
      ). However, nursing must also develop antiracist practice, research, and education to begin to address racism. The status quo of race-neutral, race-blind, or culturally competent care will only strengthen existing disparities. We propose the following calls to action as a means to recommit our profession to naming and breaking racist structures and shifting towards an antiracist nursing practice.
      We call on nurses to commit to antiracism in their clinical practice. Nurses, nurse practitioners, and midwives have historically been committed to addressing health disparities and promoting justice, but we can lose sight of that when things become politicized. Being antiracist is not political rhetoric but is rather a moral imperative. It requires each nurse to engage in a daily practice of actively combating racist structures, institutions, and practices. We must combat racism within ourselves - no one is born racist or antiracist. We can do this by identifying our implicit and explicit biases. Tools such as the Implicit Association Test by Harvard's can highlight our biases and spur internal reflection on how these biases impact the care we give.  Nurses, particularly those in positions of privilege, must also use moral courage to speak up when witnessing discriminatory words or actions in practice. We must push healthcare and political institutions to transform structures that potentiate poor health outcomes through inaccessible and expensive care, and ensure they are accountable to the communities they serve.
      We call on nurse scientists to prioritize work that exposes inequities in care quality and health outcomes for Black Americans. The National Institute of Nursing Research strategic plan emphasizes the importance of using community partnerships with underrepresented and minority communities to study wellness strategies aimed at reducing health disparities (2016). While research with these populations is challenged by issues of trust related to historical grievances, newer methodologies that elevate the participant as the informant and that rely on partnerships, yield meaningful and helpful results while reestablishing trust in the ability for research to help their communities. The science examining racism and its effects on health is nascent. Rather than merely identifying relationships between race and health outcomes, nurse scientists should be developing and implementing new research methodologies that further our understanding of how racism drives inequitable health outcomes (
      • Mclemore M.R.
      • Asiodu I.
      • Crear-Perry J.
      • Davis D.A.
      • Drew M.
      • Hardeman R.R.
      • Scott K.A.
      Race, research, and women's health: Best practice guidelines for investigators.
      ;
      • Trent M.
      • Dooley D.G.
      • Dougé J.
      The impact of racism on child and adolescent health.
      ).
      We call on nurse educators to advance antiracist practice within nursing education. Increasing the diversity of the nursing workforce is an initial step. A diverse healthcare workforce is one way to improve access and quality of healthcare, and decrease health disparities (
      • Bouye K.E.
      • McCleary K.J.
      • Williams K.B.
      Increasing diversity in the health professions: Reflections on student pipeline programs.
      ;
      Institute of Medicine
      In the nation's compelling interest: Ensuring diversity in the health-care workforce.
      ). Faculty and academic institutions must provide financial and academic resources to optimize equity and maximize student support, retention, and success. To aid inclusivity, nursing programs should develop plans and accompanying supportive structures with ongoing evaluation to address the needs of students harmed by racism. Faculty must confront their own biases and incorporate antiracist pedagogy into their curriculum by encouraging reflexivity, reflective writing, and welcoming difficult conversations in the classroom (
      • Thurber A.
      • Harbin M.B.
      • Bandy J.
      Teaching race: Pedagogy and practice.
      ).  The application of critical antidiscriminatory pedagogy offers a path for reforming nursing education. Rooted in social justice to address health inequities, critical antidiscriminatory pedagogy builds the capacity of nurses to identify and counteract racism through an intersectional perspective and, through transformative learning, utilize this new perspective in antiracist practice (
      • Blanchet Garneau A.
      • Browne A.J.
      • Varcoe C.
      Drawing on antiracist approaches toward a critical antidiscriminatory pedagogy for nursing.
      ).
      Racism is an epidemic. COVID-19 and police violence are just two examples of how racism disproportionately harms Black Americans. Our call for antiracist nursing practice requires examining ourselves, the institutions where we work, and the racist policies that perpetuate health disparities and their social determinants. Rather than race neutral or culturally competent care, antiracist practice actively stands against racism. We must face the epidemic of racism head-on by applying rigorous changes to nursing practice, research, and education, and, as is always true with our profession, do this with empathy and respect.

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