Dear Nursing Education, If We Can’t Even Acknowledge the Institutional Racism Apparent in Our Policies…How Will We Do the Harder Work?
In recent weeks, professional nursing organizations such as ANA, AACN, Sigma Nursing, ONS, AAN, APHA and NLN released statements of solidarity voicing an “[end] hatred, discrimination, and racism in every form.”
Some of these organizational statements were more direct than others. Practically none but the Nursology Theory Collective provided a description of specific resource investments or other steps being taken towards greater accountability to Black communities and commitment to active, on-going anti-racist nursing praxis. Notably, ANA’s statement from Dr. Ernest Grant spoke from his own first-person perspective, as a nurse leader and Black man in America who [has] “not been exempt from negative experiences with racism and discrimination.” ANA’s member assembly subsequently adopted a “Resolution on Racial Justice for Communities of Color” on June 20, 2020.
Almost none of the statements by major professional nursing organizations acknowledged nursing’s long history and on-going complicity in upholding structural racism and white supremacy. In fact, many statements from nursing institutions were almost completely ahistorical, as if the centuries-old emergency of racial injustice and other oppressions in the United States and beyond had only just arrived on the scene.
It was in this context that I, a white, non-disabled, tenured, employed, non-binary and Queer professor of nursing, entered into a conversation on an online nursing discussion board regarding a request for input on revisions to dress code policies for nursing students.
I am only 6 years into my journey as a nurse faculty member but that is long enough to know that the “dress code issue” is a now decades-old, perennial discussion that many educators in our profession would prefer to stay out of as folks presumably have better places to spend their time than rehashing tired debates. I know this because the topic also came up at the most recent AACN Doctoral Education in Nursing conference in Florida in January 2020 where multiple speakers, some on the speakers’ platform, some in the audience, asked aloud whether as a profession we were finally ready to move beyond “academic navel-gazing” about whether visible tattoos or blue hair is ‘acceptable’ in the workplace to tackle broader issues in the profession. So while the thread from the AACN online message board kept showing up in daily email summaries sent to my inbox, and as colleagues asked if I would weigh in, I held off, worried that adding my two cents to the mix would only distract from other important discussions where new energy was vitally needed to move the needle towards a more equitable and just future.
But eventually, as entries authored by extremely well-intentioned, clinically-experienced, and almost exclusively white women nurses with phrases from institutional dress code policies like “natural hair color” “piercings” “tattoos” and “fake eyelashes” … “ARE NOT ALLOWED” justified with words like “research” and “patient safety” and “infection risk” piled up, I couldn’t ignore it any longer. The situation was rapidly becoming bystanderism.
Bystanderism is a phenomenon, first coined by psychologists in the 1960s, that describes situations in which an individual witnesses another person or being who is in the process of being harmed or in need of their help, and does nothing. Bystanderism happens a lot in nursing, a profession wherein hierarchies of leadership continue to be dominated by white nurses (like me!), wherein a policy, curriculum, or other structure that is actively causing harm to some students, colleagues or community members is allowed to live on and even expand in the name of tradition and an unacknowledged but nonetheless ever-present normative whiteness which is not only upheld by those in power but effectively required to enter the profession in the first place.
Websites like Showing Up for Racial Justice have posted numerous resources, such as the workbook by Kenneth Jones and Tima Okun (2001), detailing characteristics of such institutionalized whiteness. These include, among others: perfectionism, defensiveness, paternalism, either/or thinking, power hoarding, fear of open conflict, and the “the belief that those with power have a right to emotional and psychological comfort”.
So I decided to add my thoughts to the online discussion thread, excerpted below:
“…we know that most health happens *outside* of hospitals and other clinical spaces. I hope, eventually, our curricula might reflect that. And those places have no such rules about uniforms, tattoos, piercings etc. If anything, our communities are anything *but* uniform.
As folx reflect on recent events, and the on-going, centuries old emergency that is white supremacy culture and institutionalized racism within the United States, I think we may want to reflect on the myriad ways in which phenomena such as universal ‘dress codes’ and other policies codify a certain hidden curriculum in nursing that communicates to students — especially, gender non-conforming and non-binary, trans, disabled, Black, Indigenous and students of color — that their value and acceptability — both as clinicians and as human beings — is wrapped up in their capacity to mimic (or hide) approved and non-approved symbols such as dress, hairstyle & hair color, piercings, tattoos or scars, and other externally visible features.
Sociologists and education researchers have established large bodies of research that indicate most ‘dress codes’ are grounded in a certain whiteness and assumption of institutional control. And frequently, the dress codes developed, revised, and passed down in nursing institutions have been largely codified by rather homogeneous groups of cis white women as this has been the norm in many American nursing leadership circles for decades. To be clear — there’s nothing intrinsically nothing wrong with white cis women (or persons of any identity/background), with good intentions, offering an expert opinion, but when that is the only opinion or the dominant opinion, harm and exclusion (quite often unintended harm & exclusion) can result. And this applies to all kinds of policies implemented in the name of good intentions such as promoting patient safety, or respect for the profession, etc.
Often, justifications for dress code exclusions (no visible tattoos, no piercings, etc.) are wrapped up in a sort of biological/infectious disease argument although the citations for this research are rarely given (if ever) and even when present, don’t necessarily grapple with the realities of the larger power dynamics at play. Dr. Ruha Benjamin and other sociologists with strong foundations in Black feminism have given us incredible tools with which to examine ways in which, even inadvertently, scientific evidence is used to other and to exclude. She quotes, in the opening of her book, “People’s Science” scholar-activist Patricia Berne, who said, “Before we start designing ways to get to the moon, can we just make sure everybody on my block can get to work?”
Here during the pandemic, we’ve seen a movement towards universal precautions such as mask-wearing. Suddenly something that was considered anti-social or ‘unprofessional’ in many circles moved to a heroic act once the health and well-being of folx who make the rules was threatened. So, if anything externally visible about a nursing student truly poses some kind of infectious disease ‘threat’ to patient safety or others (though I have yet, myself, to read compelling scientific evidence of this), should we not consider whether an exclusionary dress code policy is not so much a successful policy, but rather, a failure of a more inclusive moral and collective imagination?
And what is the ultimate intention of these dress codes? If it is patient safety, aren’t there exponential other ways in which we could better invest our collective energies, including but not limited to strengthening anti-racist nursing praxis, education about histories of nursing and the embeddedness of institutional racism and ways in which (we hope) nursing students and nurse educators will work to dismantle and transform this world to — in the words of Dr. Monica McLemore — #MakeThisALLDifferent?
ANA, AAN, AACN, NLN, and myriad other professional nursing organizations have all recently committed to ‘fighting’ racism and other interconnected -isms that persist within higher education, health care, and STEAMM. Wouldn’t abolition of universal dress codes be a step towards greater justice within our profession? What if we trusted nursing students’ own imaginations and the wisdom of their own lived experiences to develop proposals for how each individual could best *show up* for themselves, their classmates, and the folx we serve? What if nursing students, themselves, and especially those who’ve often been pushed to the margins within nursing and writ large, lead us to innovate something even better than what we have right now?]”
Of course, the discussion didn’t end there. By the next morning, my inbox had exploded with messages — some public, some private — mostly from seemingly well-intentioned, white nurse educators who expressed their hope that I would seek to understand how important the dress code policies they’d instituted or maintained were for clinical education, for patient safety, and for “evidence-based practice.”
And to be honest, while the volume of responses was somewhat overwhelming, I was heartened to see the depth of thought that respondents had put into their messages. One queried something to the effect of, “Shouldn’t we also ask patients what they would prefer?”. And indeed, some hospitals have done just that.
I considered these perspectives, then replied (excerpted below):
“…while consultation with patients can, and should, guide many design and policy decisions, we must remain aware of the fact that patients too are likely to reify [many] forms of oppression.
Patients can be racist. Patients can be transphobic. And no nurse should have to endure that type of violence, unchecked. If we ask nursing students, who are already in a vulnerable position, to bend to the whims of anyone who seeks to other them, we are teaching them their humanity does not matter and reifying the same sorts of biases in the system. Eventually, this will come back to hurt patients and families as well….”
Meanwhile, the Direct Messages (DMs) on social media platforms such as Twitter from nurses, nursing students, and former nurses and nursing students started coming. DMs arrived from Queer, trans, non-binary and gender non-conforming, Black, Indigenous and disabled colleagues who had experienced the other end of these policies, either as students or new nurses. I will not disclose who wrote to me or what they wrote, but I’d like to paint a picture of some of what they said (with some details retracted or generalized to protect their identities):
● A Black nursing student who was told by a white nurse educator that their natural hair was unprofessional and forced to physically change it.
● A nursing student who was publicly body-shamed by a nurse instructor because the combination of their body shape and the school’s required translucent white nursing uniform allowed a seam of undergarment lines to be semi-visible through the uniform. They were sent home from clinical.
● A gender-non-conforming nursing student who was publicly and repeatedly verbally assaulted by multiple nurse supervisors for a semi-visible tattoo, until they were eventually forced out of their nursing program.
And I could go on. These were not isolated incidents, rather, they described a systematic pattern of harm that — based on the ratio of messages from (mostly, perhaps entirely?) white nurse educators justifying dress codes to messages with examples of harm from current and former nurses and nursing students — disproportionately impacted Black and brown, Indigenous, Queer, trans, non-binary and gender non-conforming individuals within nursing.
And yet, the conversation on the online discussion board continued, as did the private messages from fellow nurse educators who wished me to know all the reasons why the dress codes they had instituted were necessary.
I replied to one such email from an educator who’d written me to explain their fear that without a dress code, clinical sites might not allow their program’s nursing students to train there (excerpted here):
“…If lack of a dress code threatens one’s ability to practice/learn at a particular site — Why not include an assignment like looking up and reviewing a particular facility’s policy (when/if it might apply) in advance, and [trust] students to show up prepared/oriented, rather than [invent] an unnecessary universal policy that only serves to perpetuate the hidden curriculum of nursing? And perhaps someday these nursing students will be empowered to challenge racist/transphobic/ableist policies in their own workplaces because there was an honest discussion at the beginning of their clinical regarding how the policies of certain facilities diminish their humanity. Even that acknowledgement might be a first step towards a transformed future….”
This series of online exchanges has left me with several unanswered questions:
If we as nurse educators know something we’re doing, that costs us nothing, is actively harming members of our community and profession…why would we keep doing it?
Who are these institutional policies, such as dress codes, designed to serve and who decides whether they are functioning as intended?
And finally, at an important and painful moment of national and global reckoning regarding the long and bloody history of racial violence, anti-Blackness, and oppression in the United States and beyond: If nursing education can’t acknowledge the institutional racism and other forms of oppression apparent in policies such as universal dress codes….how will we — particularly, white nurse educators who continue to dominate positionalities of power within academic nursing — engage in the even harder, messier, uncomfortable and necessary work of listening deeply to and believing those who’ve been harmed and othered, acknowledging ways in which both we as individuals and our institutions remain complicit in perpetuating oppression, and then dismantling and transforming these structures to, in the words of Dr. Monica McLemore, #MakeThisALLDifferent?
Who among us is ready to commit to co-creating new futures?
-Rachel K. Walker, PhD, RN
This post was written with the support and reflection of accountability partners in the work of Nursing Mutual Aid, co-signed below. I thank them for their on-going and relentless efforts to create new futures for nursing.
Anna Valdez, PhD, RN, CEN, CNE, CFRN, FAEN, FAADN
Jessica Dillard-Wright, MA, MSN, CNM, RN
Monica McLemore, PhD, MPH, RN, FAAN
Wanda Montalvo, PhD, RN, FAAN
Em Rabelais, PhD, MBE, MS, MA, RN
[This post was originally drafted in early June, 2020; revised June 24, 2020; published here on July 23, 2020.]
