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White nurses, White spaces, and the role of White racial identity in the American nursing profession

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White nurses, White spaces, and the role of White racial identity in the American nursing profession

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White Nurses, White Spaces, and the Role of White Racial Identity in the American
Nursing Profession
by
Joanna Seltzer Uribe

Rossier School of Education
University of Southern California
A dissertation submitted to the faculty
in partial fulfillment of the requirements for the degree of
Doctor of Education

August 2022

ii

© Copyright by Joanna Seltzer Uribe 2022
All Rights Reserved

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The Committee for Joanna Seltzer Uribe certifies the approval of this Dissertation

Tanya Langtree
Paula Carbone
Cathy Krop

Rossier School of Education
University of Southern California
2022

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Abstract
This study uses a historical focus to analyze the context and spheres of influence on forming the
altruistic and caring identity of the nursing profession as exclusive to White, Anglo women. An
examination of the social construct of “White” as a race and the impact of White feminism and
western medicine as the basis for nursing knowledge are presented alongside strategies of
professional closure, which excluded men and nurses of color from both the professional
narrative and the workforce, since the origin of the profession. Together, the belief in the
“science” of White supremacy and the implementation of discriminatory strategies have led to
the formation of nursing as a White space. This finding exists in open contradiction to the
primary professional identity of altruism and caring and indicates that White racial identity is
relevant to understanding the nursing profession today. Original mixed method research was
used to explore the White racial identity of White nurses in the United States. The study findings
exhibit that nurses’ White racial identity begins in childhood and includes messages and
perceptions of White supremacy. Nursing school was broadly described as a setting where the
topic of race as a social construct or the impact of racism as a root of health disparities are not
explicitly addressed. The study found that White supremacy is not disrupted in the nursing
curriculum. White nurses in the study described needing to learn and evolve their perception of
White racial identity on their own without support from nursing curriculum or mainstream
professional nursing communities.
Keywords: Nurse, American nursing, White feminism, White space, White racial identity

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Dedication
To nurses: What we have inherited does not need to be our future. But we need to better
understand our inheritance. Thank you for showing up even when everything is crumbling; we
see you and validate you, although that should not be the status quo. Nurses deserve better health
systems, better technology, better leaders, better education, better professional structures and
organizations, better support, equitable health policies, transferable licensing, and less toxic
workplaces. We need to work in systems that value prevention over profit. Lord knows patients
deserve it, too. If we do not design and build it ourselves, someone else (corporations, insurance
companies, physicians, surgeons, politicians, administrators, and/or businesspeople) will. We
need to be at all the places where healthcare decisions are made, so let us rest and recharge to
have the energy needed to re-create the nursing profession and by extension, the healthcare of
humans for the next generation.
To my ride-or-die nursing crew for almost 2 decades: Ebony Barrett, Lisa Marcano, Dani
Monroe, Lisa Aponte, Jessica Brown, and Vanessa Cheng. A specific shout out to the steadfast
and inspiring Jessica Brown, RN, DNP who personally showed me it was possible to complete a
doctorate with two kids and a career. Between us we have been going back to school since 2009!
To Ravenne Aponte, Grateful for your validation of nursing history and cannot wait for your
PhD!
To Lara, Mateo, and Uber: Thank you for taking care of yourselves and each other while I
worked on my “book.”

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Acknowledgements
Writing this dissertation would not have been possible without the dedicated childcare
from my parents, our two baby-sitters Sanaa and Kelsey, my husband Uber, the Netflix and Hulu
kids’ streaming platforms, a host of after-school activities, and countless home cooked meals by
my mother. I started this degree when my youngest child was 3 years old. Next month, she will
be turning 6 and completing kindergarten.
The week I completed this work, a sitting U.S. congressmen described those who support
abortion rights as “over-educated and under-loved.” While a study on the White feminism of the
nursing profession has many overlaps with the strengthening or weakening of abortion rights that
could be discussed, it was not a direct focus of the last few months of work. That said, it is worth
noting the use of calling women “over-educated” as a derogatory statement occurred in our
country, in 2022. So, I would like to acknowledge that my maternal grandmother, Elvira Isaacs,
started college, but could not complete it after her father died. My paternal grandmother, Edith
Seltzer (who marched in the pro-choice movement), attended Queens Community College at the
age of 60 to complete her bachelor’s degree, and I also watched my mother attend evening
classes at Rutgers University when I was a child, so she could complete her master’s in library
science. Women and mothers in a state of learning and obtaining education is a powerful image
that children should see. Judging by my son’s Mother’s Day card this year, where he wrote
“smart, sweet, hardworking, kind, nurse, funny, and helpful, I love you, my mom,” I am grateful
that, at least in our family, being “over-educated” is not a criterion that makes one “under-
loved.”
To name just a few of the events from the background of the dissertation, this was written
during a pandemic, the 2020 presidential election, the January 6th insurrection at the Capitol, the

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establishment of the first-ever Commission on Racism in Nursing in 2021, the unprovoked
Russian war on Ukraine in 2022, the historic appointment of Justice Ketanji Brown Jackson, the
draft leak of the Supreme Court’s decision on Roe v. Wade, national baby formula shortages, and
this month alone, multiple mass shooting instances. I have found one of the hardest parts of this
process (besides securing enough childcare and consolidating a 100-page literature review closer
to 30 pages) is knowing when and how to stop with so many examples of how White feminism,
White supremacy, and the reaction to the perceived threat to White spaces continue to show up
in nursing, and in America, in real time, almost on a loop. There are articles I could always re-
read, book chapters to re-visit, concepts to re-phrase, more examples to include, or seeming
endless points and connections to make … and, so, it seems that arriving at the end of this
process is essentially defined by what can be done in the time I have to do it in, rather than any
finality in the work itself, which will be ongoing. To apply the title from the latest Pusha T
album co-produced by Kanye West and Pharrell: It ’s Almost Dry best captures the state of the
dissertation, which after so many countless revisions, can feel like it is never truly done.
Thank you to the architects of this organizational change EdD program, which satisfied
so much of what I was looking for as an adult learner: hybrid, interdisciplinary, peer learning,
and broadly applicable across industries. Thank you, as well, to my committee chair Dr. Cathy
Krop for always problem solving during this process. I also want to acknowledge the time of my
committee members, Dr. Paula Carbone, and Dr. Tanya Langtree. I could not be more grateful
for the support of Dr. Tanya Langtree, who worked around our time zones from Queensland,
Australia to help me re-work my literature review and each chapter of the project. Although Dr.
Langtree published her own 418-page dissertation in 2020, accompanied by multiple published
articles based on her research (Appendix P), she still had the mental and emotional capacity to

viii
craft a stunning, three-and-a-half-page acknowledgement section. I have returned to it more than
once to find strength to see this project to its end, and gain inspiration from how she wove
Beatles lyrics throughout her acknowledgements, and the touching way she acknowledged the
strain the doctoral process had on both her marriage and her brain.
Taking from Dr. Langtree’s cue, there were also Beatles influences in my own work,
albeit, more indirectly. Kanye West, who this year brilliantly sampled John Lennon’s “Jealous
Guy” and previously collaborated with Paul McCartney on one of my all-time favorite songs
“Only One,” provided an important soundtrack during this process. Although I mostly identify as
an agnostic, third generation Jewish American, I found writing a dissertation to be almost a faith-
based practice in believing my brain was capable of stringing together coherent thoughts within
the strict confines of academic writing. Tracks five through 11 on Jesus is King, from West’s
2019 gospel album, provided surprising and steady solace during the data analysis. I also
received fortitude from his unreleased 2013 song “Awesome,” and of course his 5-minute 2004
song “Hey Mama” where he promises his mother, Dr. Donda West, he will go back to school,
and later in the song rhymes “doctorate” with “chocolates.” In the well-known chorus he sings,
I wanna scream so loud for you
‘Cause I ’m so proud of you,
And, let me tell you what I ’m about to do (Hey Mama).
Dr. West received her EdD degree when Kanye was 3 years old. We all need mantras, anthems,
and a small cheerleading squad to get us through these processes, so I would be remiss not to
acknowledge Kanye’s musical influence on lifting me up and motivating me to the finish line.
Even though he has no idea that I exist, he served almost as a personal hype man, and I tangibly
felt that someone was really, truly proud of me, despite no one around me emphatically

ix
supporting the pursuit of my EdD 20 years into my nursing career as a mother of two children
under 5 years old.
It goes without saying that this is not an easy process. So, lastly, I would like to
acknowledge myself. I know that, even though I have myriad types of privilege to pursue the
opportunity of a terminal degree, this finished dissertation directly represents my time, effort,
research, thoughts, and above all, my own stamina to see it through. I was the one typing the
keys, threading concepts together, incorporating feedback, analyzing data, checking citations,
and pleading with my own mental capacity to stay on task in the final stretch. I believe the
articulation of these concepts is important for the profession, and it would not have happened
without my steadfast commitment to showing up every day and making it from Chapter One, to
Two, to Three, to Four, to Five, and the subsequent references and appendices that followed. I
acknowledge and appreciate the help and support I received, but of all the school and papers I
have written in my life so far, I am deeply proud of myself for not giving up on this one - even
(and especially) when the world seemed to be collapsing and crumbling around us. I was told in
2009, during the first semester of my graduate program in nursing informatics that I should earn
my doctorate. Two kids and 13 years later, I did. As they say at the University of Southern
California, “Fight On.”

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Table of Contents
Abstract .......................................................................................................................................... iv
Dedication ........................................................................................................................................v
Acknowledgements ........................................................................................................................ vi
List of Tables ............................................................................................................................... xiii
List of Figures ................................................................................................................................xv
Chapter One: Overview of the Study ...............................................................................................1
Background of the Problem .................................................................................................1
Purpose of the Study ............................................................................................................6
Questions Guiding the Study ...............................................................................................6
Relevance of the Study ........................................................................................................8
Theoretical Framework ......................................................................................................10
Methodology ......................................................................................................................11
Definitions..........................................................................................................................12
Organization of the Dissertation ........................................................................................13
Chapter Two: Literature Review ...................................................................................................14
Early Concepts of Race and Whiteness .............................................................................15
Early Structures and Culture of American Nursing ...........................................................22
The Role of White Feminism in Nursing ...........................................................................32
A Profession Pure and White .............................................................................................38
Nursing Literature at the Turn of the 21st Century: Silence and Whiteness .....................41
Theoretical Frameworks ....................................................................................................54
Summary ............................................................................................................................62

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Chapter Three: Methodology .........................................................................................................65
Research Questions ............................................................................................................65
Methodology Approach and Rationale ..............................................................................65
Population and Sample ......................................................................................................68
The Researcher...................................................................................................................69
Data Sources ......................................................................................................................70
Participant Recruitment Strategy and Rationale ................................................................72
Data Collection Procedures and Instrumentation ..............................................................74
Data Analysis and Integration ............................................................................................77
Mixed Methods Research: Rigor Qualifications................................................................78
Validity and Reliability ......................................................................................................80
Credibility and Dependability ............................................................................................80
Limitations and Delimitations ............................................................................................81
Chapter Four: Results ....................................................................................................................83
Participants .........................................................................................................................84
Results For Research Question 1 .......................................................................................90
Results For Research Question 2 .....................................................................................114
Summary ..........................................................................................................................139
Chapter Five: Discussion .............................................................................................................140
Findings............................................................................................................................140
Recommendations ............................................................................................................159
Limitations of the Study...................................................................................................169
Suggestions for Future Research .....................................................................................170
Conclusion .......................................................................................................................172
References ........................................................................................................................178

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Appendix A: Spanish Castas ........................................................................................................209
Appendix B: Institutional Racism and Structural Determinants of Health ..................................212
Appendix C: Influences on Professional Nursing Formation ......................................................213
Appendix D: Racial Hierarchies Within the Profession and Impact on Health Outcomes .........214
Appendix E: Expanded Nursing Timeline Before 1900 ..............................................................227
Appendix F: Nursing Journal Letters, 1963 and 2018 .................................................................229
Appendix G: White-Dominant Culture Values with Alternative Values Adjacent .....................232
Appendix H: White Space of Northern New Jersey Diploma Program 1912-1976 ....................237
Appendix I: Abbreviated List of International Citations on Whiteness in Nursing ....................242
2020–2022....................................................................................................................................242
Appendix J: Initial Survey Results from the Commission on Racism in Nursing.......................244
Appendix K: Schemas of White Racial Identity in Relation to Nursing Professional Identity ...246
Appendix L: Survey Protocol ......................................................................................................253
Appendix M: Semi-Structured Interview Protocol ......................................................................258
Appendix N: Online Survey Recruitment Graphic ......................................................................261
Appendix P: First Known Nursing Textbook, 1617 ....................................................................265

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List of Tables
Table 1: Variation of Nurse Participants by Survey Type 74
Table 2: Commonalities Between Quantitative and Qualitative Research 79
Table 3: Frequency Table of Characteristics of Survey Respondents 85
Table 4: Characteristics of Interview Participants 88
Table 5: Survey Finding: Family Influences on White Racial Identity 92
Table 6: Sub-themes: When White Nurses First Perceived Their White Identity 93
Table 7: Survey Findings Reflect Ways White Racial Identity Evolves Over Time 102
Table 8: Select Interview Responses to: What Does it Mean to be White? 107
Table 9: Survey Responses to Questions about White Privilege and White Fragility 109
Table 10: Survey Replies to Do You Perceive Being White Has Been a Barrier or Advantage
in Your Career? 112
Table 11: Survey Reponses to Question about Nursing School Preparation 120
Table 12: Survey Respondents Agreement of Racism as Root of Health Disparity, Need for
Diverse Workforce, Awareness of Men and Nurses of Color Excluded from the Workplace,
and Access to Safe/Brave Space for Candid Conversations Around Race 129
Table 13: Survey Respondents Level of Agreement on Actions or Responsibilities Towards
Decreasing Racism 132
Table 14: Treating Everyone Equally Statistical Correlations 134
Table 15: Learning to Live with Racism Statistical Correlations 135
Table 16: Agreement on Injustice Statistical Correlations 135
Table 17: Actively Wanting to Be a Better Ally for Health Equity Statistical Correlations 136
Table 18: Relationship Between Thematic Findings with Theoretical Framework and
Existing Literature 142
Table 19: Relationship between Thematic Findings with Theoretical Framework and
Existing Literature 151
Table 20: Terms Describing Harm Experienced by Nurses 156
Table 21: Overview of Study Findings and Recommendations 160

xiv
Table 22: Recommended Areas of Contextualize Nursing Curriculum 163
Table D1: Maternal Mortality per 10,000 Live Births in the Selected Cities of the United
States 1914–1930 217
Table D2: Assigned Responsibility for the 1,404 Preventable Deaths in New York City’s
Maternal Mortality Study, 1930–1932 218
Table E1: Nursing Timelines Before 1900 (Aponte & Seltzer-Uribe, 2022) 227
Table G1: White Dominant Culture Norms and Alternatives 232
Table K1: Schemas of White Racial Identity in Relation to Nursing Professional Identity 246
Table M1: Interview Protocol 259
Appendix O: Full Survey Replies Re: Ways White Racial Identity Evolves Over Time 262

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List of Figures
Figure 1: Bronfenbrenner’s Ecological Systems Theory 55
Figure 2: Graphical Depiction of Helms’s White Identity Development Model 58
Figure 3: Interaction Between Ecological Systems Theory and White Racial Identity
Developmental Model 61
Figure 4: Graphic Depiction of Explanatory Sequential Mixed Methods Design 66
Figure 5: Graphic Depiction of Validating Qualitative Data 81
Figure 6 Interaction Between Microsystem, Mesosystem, and Internalized Racism Phase of
White Id:entity 144
Figure 7: Image of Helms’s Evolving Non-Racist Identity Phase of White Racial Identity
(revised name) 146
Figure 8: Anthropological Diagram of Ways the Institution of Nursing Preserves White
Privilege 149
Figure 9: Aspects of White Supremacy Presented in Nursing Education 154
Figure 10: Memorial Statue of the “Nurse Section” at Arlington National Cemetery 173
Figure A1: Spanish Castas 209
Figure A2: Racial Hierarchy of Colonial Philippines 210
Figure B1: Relationship Between Institutional Racism and Health Outcomes 212
Figure C1: Influence on Professional Nursing Formation 213
Figure D1: History of Births Attended by Midwives Since 1900 220
Figure D2: Black Maternal Mortality over 100 Years 223
Figure F1: Editor and ANA Rebuked 229
Figure F2: Confronting Racism in Nursing Article 230
Figure H1: Graduate Photos 1912 through 1976 237
Figure J1: Initial Statistics from the Commission on Racism in Nursing 244
Figure N1: Recruitment Graphic 261
Figure P1: Instrucción de Enfermeros 265
1

Chapter One: Overview of the Study
Attend or observe any lecture in a United States nursing school program and you will
hear a myriad of information passed to students from anatomy to biology, pharmacology to
pathophysiology. Nursing students, sometimes in programs spanning less than 2 years, record
hundreds of hours of clinical experience alongside completing a western biomedical-based
science curriculum (Morris, 2021). This consumption of knowledge and clinical acquisition
occurs while needing to maintain at least a 3.5 GPA to graduate with sufficient preparation to
pass the National Council Licensure Examination-Registered Nurse (NCLEX-RN), ideally, on a
student’s first try.
Despite rigor and depth of content covered in American nursing schools, this study aims
to re-examine a content gap that is omnipresent in its absence in the nursing curriculum (Barbee,
1993; Iheduru-Anderson, 2021). This dissertation will examine the evolution of White as a
socially constructed racial category; the cultural influence of the Victorian, Antebellum, and
Postbellum Eras; White feminism; and White racial identity development of present-day White
nurses. American nursing is examined in the subsequent chapters to make plain the deliberate
construction of the profession as White space during the last century and a half and serves as a
starting point to level set the professional understanding of what is holding back nursing from
being a more diverse and inclusive professional space.
Background of the Problem
Nursing licensure exams have been used internationally to qualify nurses’ skill,
knowledge, and aptitude since 1901 and, following North Carolina’s lead, used in the United
States since 1903 (D’Antonio, 2010). Despite its independence from Britain in 1783, American
cultural and political institutions often remained close cousins to British standards and
2

expectations for subsequent centuries; in this path of influence, nursing was no exception
(Loudon, 2001). The nascent United States’ nursing structure of the turn of the century followed
the lead of the International Council of Nursing. The organization, founded in 1899 by British
nurses serving the United Kingdom, Germany, and the British colonies, held a meeting in 1901
to declare: “the duty of the nursing profession of every country [is] to work for suitable
legislative enactment of regulating the education of nurses, and protecting the interests of the
public by securing state examination and public registration, with the proper penalties for
enforcing the same” (Carney, 2019).
Well over a century later, the NCLEX-RN pass rates of nursing schools have become
ubiquitous markers towards colleges accreditation by nursing governing bodies, as well as for
schools’ competitive recruitment of students who want to ensure that their curriculum, education,
and temporal and financial investment will result in passing the test on their first try. The “first
pass rate” of a school also factors into nursing school rankings, which further impacts student
recruitment and school reputation (Taylor et al., 2014). This metric of success provides
transparency and accountability between the education nursing schools deliver and the ability for
students to obtain their professional nursing license. While obtaining a state-endorsed nursing
license to practice nursing following graduation is of undeniable value, since a nurse may not
work without one, high stakes testing has also been shown by many scholars to limit curriculum
as maximum attention becomes focused on “teaching to the test” (Jones et al., 2021). When the
entire undergraduate and graduate nursing programs in the country are winnowed together to
graduate students who can demonstrate aptitude by retrieving a specific knowledge set on their
first pass of the test, the ability to adapt, revise, or update curriculum in response to socio-
3

political, cultural, or student needs becomes harder for educators or leaders to justify when the
new knowledge is not included on the NCLEX-RN.
By definition, a multiple-choice test is limited to testing only distinct, tangible, and
answerable questions (Ashley, 1978). Scientific fact and processes and mathematical dosing
calculations lend themselves to multiple-choice formats while nursing theory, critical analysis of
systemic racism to reproduce health inequities, collaborative problem solving, the practice of
therapeutic communication, or the role and comprehension of history in forming the power (or
lack of power) that the nursing profession possesses today, are less test-able topics (Smith,
2020b). Even less quantifiable is internal work that reflects the way a nurse perceives or
understands their identity as a nurse. Nor are components of identity, such as a nurses’ racial
identity development, explored within the broader socio-cultural context where care is delivered
(Iheduru-Anderson, 2021). These less test-able topics are therefore less often covered, if not
omitted, from nursing curriculum and yet are increasingly argued as being as fundamental to
how nursing and nurses operate to shape the health of patients and communities as the
knowledge of basic medical science and pharmacology (Canty et al., 2022; Valderama-Wallace
& Apesoa-Varano, 2019a).
Implementing a topic such as nursing history into curriculum has been documented in the
nursing literature for over a century (Lewenson, 2004). Yet as nursing shortages in the decades
following World War II accelerated the need to abbreviate nursing curriculum in order to bring
more students to the bedside, nurse faculty were found to minimize or even omit historical
content as educators favored more exclusively on covering content that prepared students for
passing their licensing exam, a pattern that continues today (Schroeder & DiAngelo, 2010).
4

Even before school first pass rates were publicly available data points that reflected on
the worthiness of nursing schools, Ashley (1978) reported on the devaluation of nursing history
across the profession and educational landscape 4 decades ago. She stated:
Our identity has suffered greatly because we have not carefully incorporated our history
and incorporated historical knowledge into theoretical and clinical teachings. Without
this knowledge the foundation of nursing scholarship and practice have indeed been
shaky. Without knowing history, one cannot approach knowing the truth. Without
historical thinking science can all too easily become a fiction, an illusion, a social lie with
no regard for what is true. … Many of today’s problems have always existed. The crises
we hear so much about in healthcare are often repeats in history. (pp. 29–30).
Additional authors then, and in the following decades since, continued to call for history
to be included in the curriculum. Renowned historian Mary Elizabeth Carnegie found a further
deficit in studying a 25-year period from a prestigious research journal, where she found only 18
of over 1,000 articles published were on nursing history (Carnegie, 2005). This indicates a
cyclical impact that the lack of curricular history then mitigates scholarly work and subsequently
stagnates historical insight or contextual advances for the field. Training generations of nurses in
an ahistorical fashion has now become custom for over half a century (Davies, 2007). Whether
from willful ignorance or generations of both students and teachers who themselves lacked
understanding of professional nursing origination, the field at the turn of the 21st century has
become perfectly positioned to find itself as a professional White space (Flynn et al., 2021)
Current statistics on the demographics of the United States nursing workforce reveal that
nursing educators who identify as White women comprise 80% of the educational workforce and
nurses who identify as White women comprise 76% of the nursing workforce overall (American
5

Association of Colleges of Nursing, 2019a). To review these professional statistics in an
ahistorical fashion could lead to any number of conclusions; one might question the appeal or
desire of entering nursing as a male or student of color, or perhaps question if there are “enough”
interested males or students of color to recruit, train, or hire. These hypothetical conclusions
therefore dismiss the deliberate and intentional historical efforts of professional nursing leaders
to favor and advance careers of White women nurses while barring, discriminating, and
deliberately excluding nurses of color since the founding of nursing education in Britain when
the first Nightingale school opened to students of European descent in 1860 (Loudon, 2001).
Nurses of color were not the only ones impacted, or excluded, by the Nightingale training
model adopted by the United States. In 1900, men comprised 9% of nurses; today, over a century
later, they comprise 12% (D’Antonio & Whelan, 2009). As the Nightingale model of nursing
was the inception for modern nursing as we know it today and schools across continents were
established in its fashion, there is simply no coincidence that the demographic patterns of nursing
we see today are the result of intentional historical, and even present-day, actions nursing leaders
enacted since the very origin of the profession (Baly, 1995; D’Antonio, 2010; Dingwall et al.,
2002; Reddy, 2015; Reverby, 1987). In 2001, the University of Washington School of Nursing
became one of the first known schools to publicly apologize for “instances in which we failed to
support students adequately in their efforts to complete their education, observed the segregation
practices in area hospitals and residence halls, and engaged in everyday activities that neglected
to change the status quo in the broader society” (Schroeder & DiAngelo, 2010, p. 1). The
apology followed the publication of African American Registered Nurses in Seattle: The Struggle
for Opportunity and Success, a book by a University of Washington School of Nursing professor
which detailed the stories of 13 Black nurses who began work in the 40s and 50s and another 13
6

nurses who worked in the 1970s (Spratlen, 2001; Stefanik, 2001). In essence, without knowing
our history, we have been blind to identifying recurring intergenerational professional patterns
that only we can disrupt.
Purpose of the Study
This study seeks to truncate the distance between the nursing past and present by
contextualizing professional history as a lens through which White nurses’ perceptions of their
own racial identity development both impact, and are impacted by, our professional nursing
narrative. White female nurses dominate and occupy leadership positions across the professional
nursing industry, from research priorities and dissemination, professional ethics, and values,
awarding of professional recognition, accreditation criteria of nursing schools, licensure exam
content and preparation, and implementing nationwide curriculum standards that contribute to its
composition as a White space. Exploring their racial identity development aids, us in
understanding the otherwise intangible influence of racial identity that impacts and touches every
aspect of professional nursing today. Additionally, examining the responsiveness of White
members of the profession to incorporate societal changes that may not be covered as content on
a licensing exam, is fundamental to how nursing and nurses operate to shape the health of
patients and communities.
Questions Guiding the Study
Racial identity development has typically been addressed in literature regarding nurses of
color to understand and articulate the lived experience of Black nurses, Filipino nurses,
immigrant and foreign born nurses, Hispanic nurses or faculty of color (Wingfield & Chavez,
2020). For the decades of research describing racial identity and experience of non-White nurses,
rarely is racial identity development researched for White nurses (Hyett et al., 2019). It was not
7

until the 1970s that there was early nursing research on racism and the early 1990s that the topic
of Whiteness became more prominent in the nursing literature, well over a century after the
origin of the profession (Porter & Barbee, 2004; Schroeder & DiAngelo, 2010). The research
questions this project sought to answer are
1. In what ways does White nurse racial identity development impact their positionality?
2. In what ways do nurses perceive their Whiteness within healthcare and nursing
education?
Essentially, we ask the nurses in the study to address the question that is the title of
DiAngelo’s 2012 book: What does it mean to be White? (DiAngelo, 2012). And how does this
impact how nurses deliver healthcare? Psychologist Helms has described race as “a nice thing to
have,” to articulate the phenomena of the challenge for White people to define, describe, and
even to accept their Whiteness. In her book, subtitled A guide to being a White person or
understanding the White person in your life, she outlines how racism cannot disappear without
the development of psychologically healthy White people who are capable of consciously
dissociating their worth and identity from their privilege in a racial hierarchy and seeing past the
sincere fiction of America’s master cultural narrative which upholds it (Helms, 2020; Sue, 2004).
Research consistently demonstrates the persistence of health disparities and lack of
workforce diversity combined with the findings that the implicit bias of healthcare professionals
is no different than the public at large (FitzGerald & Hurst, 2017; Maina et al., 2018; Phillips &
Malone, 2014; Zimmerman & Anderson, 2019). Examining White nurses’ racial identity
development is the first step towards understanding a sample of nurses’ race consciousness and
what serves as a barrier or motivator to make sense of, or advance, their relationship with
Whiteness in a way that does not perpetuate racism or White supremacy.
8

Relevance of the Study
The National Healthcare Disparities Report mandated by Congress in 2003 created a
comprehensive national overview of disparities in access to and quality of health care among
racial, ethnic, and socioeconomic groups (Moy et al., 2005). This report demonstrated sustained
health disparities across historically marginalized non-White groups, unchanged for decades, and
led to increasing calls for health equity initiatives across health-serving entities. The lasting
impact of this report on healthcare providers, systems, and policymakers remain in place today
with advocacy organizations, healthcare providers, and lawmakers working collaboratively on
proposals such as the MOMNIBUS bill to reduce Black maternal health disparities that were
brought to attention by the data (Taylor et al., 2021). Seven years later the Institute of Medicine
and the Robert Wood Johnson Foundation (2011) published The Future of Nursing report. This
publication was a landmark report in its own right that outlined the evidence for ensuring nurses
practiced at the “top” of their license (as nurse practitioners or doctorally prepared), had access
to leadership roles, and suggested educational priorities such as informatics, quality
improvement, and collaborative team management. The report became not only the “north star”
of the nursing profession and education, but also the most downloaded document in the history
of the National Academy of Medicine’s entire library (Hassmiller, 2020). While its publication
was within a few years of the National Healthcare Disparities Report, health equity was
mentioned in the report a total of 10 times.
In 2015 the Code of Ethics published by the American Nurse Association obligated
nurses to “advance health, human rights, and reduce disparities” (Olson & Stokes, 2016, p. 49)
and subsequent nursing reports in the years since have begun to point towards the lack of
diversity in academia. In 2019, for instance, the American Association of Colleges of Nursing,
9

stated “the need to attract students from underrepresented groups in nursing is a high priority for
the nursing profession” (American Association of Colleges of Nursing, 2019b). A subsequent
Future of Nursing report, just published in 2021, called The Future of Nursing 2020 –2030, has
now declared the attention of the nursing profession towards health equity (health equity was
mentioned more than 1,000 times, compared to its first report a decade ago) which aligns the
profession with Healthy People 2030 (Pronk et al., 2021). The same year, the first-ever National
Commission to Address Racism in Nursing was launched by the American Nurses Association
and the National Coalition of Ethnic Minority Nurse Associations, among other leading nursing
groups (American Nurses Association, 2021).
While progress, research, funding, and publications on health equity and diversity in
nursing are worthwhile, a crucial time lag is evident that has real world implications as
workforce diversity and health equity have, for the majority of the history of the profession, been
both unaddressed and unprioritized. With over four million nurses nationwide, nurses comprise
the largest percentage of the healthcare workforce (American Association of Colleges of
Nursing, 2019a). Therefore, addressing diversity issues of retention, recruitment, and inclusion in
nursing today directly relates to reducing the known health disparities of tomorrow (Phillips &
Malone, 2014). Following the rise in anti-Asian hate starting in 2020 and the disproportionate
rate of COVID-19 deaths among Filipino nurses, Dr. Emerson Ea (Ea, 2021), himself a Filipino
nurse and faculty member from a top-ranked school of nursing stated,
The nursing profession is not immune to the effects of structure and a system that have
supported and perpetuated inequity, racism, and discrimination. These narratives exist in
the lived experiences of nurses belonging to minority groups, including immigrant
nurses. Nurses have also seen how system racism has contributed to poor health
10

outcomes and health inequities at the individual and community levels. If we are to truly
advance diversity, inclusivity, and belonging in nursing and to be the agents of social
change, the nursing profession and its leaders need to confront this ugly truth and take
decisive action to lead efforts towards a path of equity, diversity, belonging, and
inclusivity. (p. 15)
Historians explicitly point to Whiteness as “the thing behind the thing” (Flynn et al.,
2021, p. 1) that has informed the very epistemology, axiology, and ontology of nursing for over
150 years, as it was White female nurses who advanced in the profession, attained the highest
degrees, generated the essence of knowledge that was taught and disseminated, and themselves
wrote the rules of professional conduct and acceptance criteria for schools. One nursing scholar
more bluntly described a White/Black hierarchy that has institutionalized White supremacy but is
simultaneously obfuscated by the caring identity of nurses and their normalized dominance in the
field which makes “race ignorance possible” (Iheduru-Anderson, 2021, p. 2). In parallel to
research stating White supremacy is implicit in nursing, there have also been an increase in calls
to decolonize the profession over the last decades (Fontenot & McMurray, 2020; Kirkham &
Anderson, 2002). Colonization and Whiteness are linked in that colonial powers, and their
structural legacy, exist to protect and preserve the interests of White European and American
people. At the time of publication, no studies had been found describing the perception or
awareness of White identity by White nurses themselves.
Theoretical Framework
Two theoretical frameworks were used to guide this work from both a systems and
psychological perspective. The first framework was Helms’s (1990) White racial identity
development model which categorizes two phases and six schemas of White racial identity
11

development. A healthy White identity is described by the movement of psychological phases
where the initial phase is Internalizing Racism and the next is Evolving Non-Racist Identity. The
schemas are non-sequential and non-linear, and people may stay in one schema for a lifetime
(Helms, 2020). The second framework was Bronfenbrenner’s (1977) ecological system, which
describes a theory of influence on an individual’s identity composed of aspects of the
microsystem, the exosystem, the macrosystem, and the chronosystem. The mesosystem depicts
the interaction between the influence of a system and the individual’s beliefs by affirming or
contradicting values or messages that they receive. Upon entering nursing school, for example
students enter with the same influences on their identities as are present in the United States at
large, including internalizing racism as part of racial identity development. The culture of
nursing school, including its implicit and explicit hierarchies and dominant values, create an
additional microsystem influence that is generally consumed uncritically by the students and
faculty and further influence nurses’ racial identity development. Nurses can either accept, reject,
or be oblivious to the dominant values of the profession through their curriculum and education.
Methodology
The methodology used for this project was an exploratory sequential mixed method
research design. In the quantitative phase of data collection, 67 White nurses in the United States
completed a 15-question online survey using snowball sampling. Interested nurses from the
survey opted in for virtual interviews to discuss White racial identity for the qualitative phase of
data collection. This resulted in a series of 10 interviews which were transcribed and coded for
themes and sub-themes. The survey and interview data were then analyzed for triangulation,
illumination, and diversification, with the findings detailed in Chapter Four. Mixed methods
research, which integrates and combines both quantitative and qualitative approaches, led to a
12

comprehensive research design that may not otherwise be satisfied with one approach alone
(Billups, 2019).
Definitions
The key concepts that emerged in the literature review include
• White space: Embrick and Moore (2020) classified White space as the mechanism in
which “institutional spaces function tacitly and explicitly to reify White power and
privilege” (p. 1972). As described by Blayton (2015), a White space is one where
Black presence contradicts the idea of who belongs in which church, profession,
school, industry, park, museum, store, car, or neighborhood and, as such, creates
tension as People of Color enter and occupy these spaces.
• Whiteness: Frankenberg (1988) described Whiteness as the cumulative name
composed of three parts of lived White experience in America. The location of
structural advantage or privilege, a “standpoint” from which White people look at
“ourselves, at others, and society” (p. 1), and a set of cultural practices that are
usually “unmarked and unnamed” (p. 1). It is the Whiteness within the nursing
profession that this thesis will explore.
• White racial identity: Stages of racial identity developed as an extension of Erik
Erickson’s model of human development serve to illustrate the impact of race,
gender, and sexuality on racial identity. Helms (1990) popularized six schemas and
two phases of White racial identity for people who identify as White and is typically
measured with the White Racial Identity Attitudes Scale.
13

Organization of the Dissertation
This dissertation is organized in five chapters. The first chapter presents an introduction
to the study, including its purpose and relevance, guiding research questions, and methodology.
The second chapter presents a literature review grounded by the historical background of
professional nursing and development of its professional identity which is intended to dissociate
nursing’s image as objective and ahistorical. The review incorporates Whiteness as a socially
constructed racial category and the role of White feminism to protect a homogenous nursing
workforce as closed, professional White space. It also includes the theoretical framework guiding
the study. The third chapter details the mixed method research methodology and the rationale for
selecting the research design, participant selection strategy, data collection, and analysis. The
fourth chapter presents the data findings and results pertaining to the research questions, and the
fifth chapter will conclude a discussion of the findings, limitations of the study, areas of future
research, and recommendations.

14

Chapter Two: Literature Review
American professional nursing emerged in tandem with the nadir of American race
relations. The time period, coined by historian Rayford Logan, describes the decades between
1870–1940, when racism and White supremacy was the most pronounced it had been during any
other period in the nation’s history (New Jersey State Library, 2011). This chapter connects how
the nadir of American race relations informed the evolution of both White racial identity and
White feminism. Born from, and impacted by this history, the last 160 years of American
professional nursing used both de jure and de facto means to create a professional White space.
This chapter will describe how the social construct of Whiteness and the ideology of White
feminism collectively weaponized access to nursing education, licensure, leadership, and
employment opportunities, and by extension, resulted in the professional closure of nursing to
non-White nurses that has persisted through the present day.
Over the last century, concepts such as civilizing missions, abolition, de-colonization,
integration, civil rights, implicit bias, DEIB (diversity, equity, inclusion, and belonging), social
justice, anti-racism, cultural competence, and humility, and most recently, health equity, have
been presented informally in nurses’ discourse and formally in the nursing literature. The basis
of these collective terms is embedded in racism, of which White supremacy is the driver. This
review analyzes the last 3 decades of literature on Whiteness in nursing and examines how the
decisions by nurse leaders over time have served to define who was, or was not, a professional
nurse. By situating the profession within a historical context and describing the mechanisms
erected to create a profession, the ways nursing has perpetuated White supremacy then becomes
explicit.
15

Early Concepts of Race and Whiteness
The concept of race that has evolved over the last 500 years is a social and political
construct used for amassing and protecting resources and wealth (Aguilar, 2020). The cradle of
humankind region, as has been identified in Africa, has led archeologists to agree that as
Africans migrated north and were exposed to less sunlight, evolutionary biology gradually
produced less and less melanin, which impacted skin with less pigment and created lighter skin
colors over generation of homo sapiens who remained in the northern hemispheres (Nye, 2020).
Appendix A includes one of the earliest known systems of race, from the Spanish word “raza.”
This early caste system defined the way in which variations in skin color affected socio-political
status within Spanish society beginning in the 1400s. Known as Castas, the images and socio-
political hierarchy they illustrated was carried with Conquistadors to the New World and
imposed on the Spanish colonies (Aguilar, 2020).
Racist hierarchical ideas related to human worth were also disseminated by the mid-
1400s work of Gomes Eaenes de Zurara, who authored a hagiographic account of Portuguese
slave trading in Guinea (Reynolds & Kendi, 2020). Commissioned to glorify the Portuguese
monarchy, the Crónica dos feitos da Guiné (Chronicle of the Discovery and Conquest of Guinea
in its English translation) justified enslavement of Black Guineans with the Biblical curse of
Ham
1
(Eannes de Azurara, 1450/2011). The manuscript, which was translated into multiple
languages and published for centuries, circulated the ideological roots that historians and
scholars attribute to the justification of early modern slavery and what would become the
transatlantic slave trade (Wacks, 2020).

1
Ham cursed his son Canaan in Genesis ix, 25: “Cursed be Canaan: a servant of servants shall he be unto
his brethren.”
16

While early European imperialism and genocide had originally been done in the name of
Christianity, the rationalizing ideology during the “discovery” and colonization of the “New
World,” became increasingly based on skin color (Sue, 2015). White Europeans believed they
had the God-given right to dominate other lands and cultures because they perceived themselves
to be smarter, more civilized, more deserving, full-fledged human beings from the others, and
entitled to advance White civilization as rightful owners of the earth (Feagin, 2020).
Colloquially, and for subsequent centuries in print newspapers and popular media across the
British colonies of America, “British settlers reinforced the stereotypes of enslaved Africans as
“alien, lazy, or dangerous” and Native Americans as “savage” (Feagin, 2020, p. 47). While
notions of racial difference preceded the institution of slavery, it was the codified, legalized, and
invented concept of racial hierarchy built into Virginia Law in 1639
2
that formed the ideology to
support and rationalize centuries of the transatlantic trade of enslaved African people.
White Racial Identity: Who Is White and Who Is American?
The definition of American identity as synonymous and equal to White identity is present
from earliest days of exploration and colonization, in relation to racialized others, initially
towards Indigenous and enslaved Africans and later expanded to include Mexicans, Chinese,
Japanese, Italians, Irish, and Jews (Roediger, 2006). “The word “White” was mainly
conceptualized in contrast to the word “Black” - initially and most powerfully by those who
defined themselves “White” (Feagin, 2020, p. 60). Early colonial laws served to enshrine
supposed “racial” categories based on skin color and codified wealth or advantage to White slave
owners. The 1662 law passed by Virginia’s General Assembly departed from centuries of British

2
This was first law to exclude “Negroes” from normal protections by the government and was followed by
hundreds of laws across the colonies, including in 1691 which declared that any White man or woman who married
a “Negro, mulatto, or Indian” would be banished from the colony forever (Public Broadcasting Company, n.d.)
17

norms of inheritance by designating the status of a “mulatto” child as free or enslaved based on
the status of the child’s mother (Newman, 1999). This was replicated by all but one Southern
commonwealth and, in conjunction with widely used anti-miscegenation laws (which began in
1664 and pre-date the use of “White” in colonial law), effectively “commodified African
motherhood as capital” (Battalora, 2021 p. 13), while desexualizing and validating the protection
of White English motherhood.
Much like the foundation laid by the Spanish Castas of the 1400s (Appendix A), only the
“purity” of White womanhood was enforced by colonial law through their restriction to lawfully
marry White men and thus bear White children capable of inheritance (Battalora, 2021). By the
last decades of the 17th century, a shared White cultural heritage and identity was firmly rooted
within a racial hierarchy in support of preserving “White” familial lineage through the “purity”
of White motherhood. Historians and sociologists have observed the enormous amount of
intergenerational energy and commitment required over centuries to uphold this racialized
concept of White families as uniquely deserving of legal rights and protections (Newman, 1999).
Defined initially by colonial, and later American, law, these legal structures simultaneously
degraded and devalued the family unit for enslaved Africans and left Black women specifically
without protections from sexual violence by White men and post-partum exploitation by White
women, who relied on the practice of wet nursing throughout the Antebellum period (Jones-
Rogers, 2017).
The complicity in which White elites leveraged poor and middle-class Whites to enforce
racial hierarchy in Whites’ interests started in the early colonies and expanded to the laws and
political structures of America’s incipient social fabric following independence from British rule.
This is demonstrated by Congressional acts, such as the three-fifths compromise in 1787 and the
18

Fugitive Slave Act in 1793 (Reynolds & Kendi, 2020). Re-strengthened by Congress in 1850, the
Fugitive Slave Act made all citizens complicit in slavery, even in states where slavery had been
abolished, by mandating citizens’ assistance in apprehending enslaved runaways (Battalora,
2021). Another example was how the exercise of rights and liberty were initially preserved for
the White, male, land, and slave-owning colonial elite, but their reliance on White soldiers to
engage in battle to fight Indigenous and the British army expanded the definition of Whiteness to
include the working White male class as a means to reduce social class tension and potential
alliance of shared needs with People of Color (Feagin, 2020).
New European immigrants arriving between 1830s through the early 1900s were
informally taught the White racial frame in which Black Americans were portrayed as childlike,
dependent, and devious and White Americans were portrayed as intelligent and virtuous through
newspapers for the literate or via postcards, cartoons, and minstrel shows for the illiterate
(Feagin, 2020; Roediger, 2006). The reproduction of racism is illustrated by the way millions of
European immigrants were treated in comparison to Asian, Pacific Islander, and Mexican
immigrants during the same time (Choy, 2005; Gómez, 2020). By the turn of the 20th century,
following the sustained genocide of Native Americans, the Chinese Expulsion Act, the failure of
post-Civil War Reconstruction, and the lawful sanctioning of terrorism leveraged during the 80
years of Jim Crow to maintain racial caste, a shared White experience was essentially embedded
as the quintessential American identity. “White people are not united by a shared ethnicity: they
are united by access to institutional power … [which] elicits loyalty to the system and a
willingness to blame “outsiders” for their economic conditions” (Hamad, 2020, p. 191). Thus,
the assimilation and categorization of who is defined as White for purposes of gaining privilege,
suffrage, land rights, economic opportunity, and protection, evolved over centuries to encompass
19

all settlers and immigrants from Europe, regardless of region or nationality, whereby their
children (who became American-educated, native English speakers) could gain access to full
White American privilege within a single generation (Roediger, 2006; Sue, 2015).
Nursing as an Extension of Medical Racism
The constructed system of innate human inferiority has spanned law, politics, education,
economics, social norms, science and medicine, criminal and reproductive justice, and has even
informed the ideological and institutional precursors of what would become the Holocaust
(Aguilar, 2020; Wilkerson, 2020). Whiteness came to “represent institutional normality. White
people are taught to think of their lives as morally neutral, average, and ideal … the deception of
Whiteness as a universal identity has a monumental hidden meaning - that is, being a human
being is being White” (Sue, 2004, p. 37). The impact of socially constructed races as a way to
uphold White humanity thus forms the basis for much of what we now consider early western
medicine (Hogarth, 2017). Centuries-held American healing praxis in midwifery and
ethnobotany by Indigenous, Mexican, and Black healers did not comprise medical or nursing
curricula (Moss, 2015; Reddy, 2015; Smith & Willoughby, 2021). Rather, in America and the
British Empire, physicians dictated the first century of nursing education which led to a
curriculum strongly influenced by western biomedical axiology and epistemology (Melosh,
1982).
This reductionist biomedical model omits the holistic healing ideologies of Indigenous,
Latino, and African healing modalities. Practiced for millennia through mostly oral traditions,
these modalities broadly viewed disease as an imbalance, childbirth as sacred, food and plants as
endowed with healing properties, and human health as integrative between body, mind, spirit,
community, and the natural environment (Loudon, 2001). In time, western biomedicine, of which
20

nursing is an inextricable part, became a dominant global health care paradigm. This established a
paternalistic view of patients and communities and centered Whiteness by legitimizing the social
construct of race. This, in turn, re-created hierarchies of knowledge and expertise with elite,
educated White men establishing the epistemology, research, funding, professional structures, and
capitalistic-informed health care delivery models which were then supported and mirrored by the
first generation of professional nurses (Barbee, 1993; Jackson, 1993; Reddy, 2015; Wilson, 2012).
In America and the British Empire, western medical gynecology and the eugenics
movement rose in parallel with nursing education starting in the mid-1800s (Farber, 2008; Niles
& Drew, 2020). Both of these early biomedical paradigms demonstrate the ways the institution
of slavery and the social construct of race impacted early biomedical thought and practice. These
early decades of western medicine effectively merged the colloquial beliefs of non-White
inferiority with objective science and normalized the dehumanization and objectification of non-
White people for the benefit of advancing science (Bouche & Rivard, 2014; Farber, 2008;
Norrgard, 2008). This same deficit model of race, stemming from ideologies like the Spanish
Castas and the eugenics movement, has persisted throughout medical and nursing education for
over a century.
This enduring deficit-based model has kept the caste hierarchy intact within healthcare
culture, as it firmly established who should be cared for (White soldiers, White patients, or White
mothers) and who should provide care (White male doctors with White female nurses). This
deficit-based legacy has served to reify racial difference as biological and subsequently implies
to early professionals that health disparities are the fault of the individual while minimizing the
impact of colonization, structural racism, intergenerational trauma, environmental racism, the
possessive investment in White wealth accumulation and resource hoarding, and other social
21

determinants on health outcomes (Hyett et al., 2019; Scott et al., 2019). The last century of this
enduring deficit-based biomedical knowledge has, by extension, formed the basis of scientific
knowledge for nursing. This has created a century of students who obtain a professional license
and join a healthcare workforce, yet fundamentally lack the understanding to identify and assess
the root cause of health disparities in the context of a country founded on racist ideas of human
worth (Hyett et al., 2019; Iheduru-Anderson & Wahi, 2021). Appendix B provides a coherent
graphical depiction of how health disparities are indeed related to institutional racism and other
systemic oppressions but is frequently omitted as part of standard nursing curricula.
Whiteness as Full and Empty
To understand the full impacts of Whiteness in nursing, Whiteness is conceptually
considered to be full and empty, as well as multidimensional in nature. This includes race
privilege of structural advantage, a set of cultural practices that are unmarked and unnamed, and
a viewpoint from which White people perceive themselves, others, and society. As racism is
defined as “economic, political, social, and cultural structures, actions, and beliefs that
systematize and perpetuate unequal distribution of privileges, resources, and power between
White people and people of color” (Schroeder & DiAngelo, 2010, p. 245), Whiteness is defined
and inextricably linked to its primary utility of maintaining power dynamics, racial hierarchy,
and White supremacy. “In its most advanced forms [racism] is a nearly invisible, taken-for
granted, common-sense feature of everyday life and social structure” (Omi & Winant, 2014, p.
128). Whiteness is described as “full” in that it generates normative values, behaviors, and ways
of thinking and conceptualizing the world and others. However, it is also described as “empty” in
that it is so normalized in society that it remains unmarked and unidentified (Schroeder &
DiAngelo, 2010). Racism, then, becomes not just a structure and ideology, but created and
22

reinforced through everyday practices (Essed, 1991). In American nursing, this has been
achieved through collective denial, professing to be colorblind, and practicing aversive racism
(Barbee, 1993).
The impact of normality of Whiteness executed as a behavior becomes observed in the
ways that a homogenous nursing workforce, recruited from a homogenous student population,
thus creates a homogenous professional leadership as the desired status quo which serves to
protect their interests. As recently as 2014, a review of the U.S. National Nurse Workforce
1988–2013 reported “The gap in racial/ethnic minority representation between the RN workforce
and the population has been persistent and has widened over time … with the largest gaps
occurring for Hispanics in the South and West and for Blacks in the South” (Xue & Brewer,
2014, p. 102). Rather than diversify the student body, workforce, and leadership, over the last
century and a half of American nursing, maintenance, and protection of a century of
homogeneity through racial discrimination has served to “[deprive] the public of nursing care
and perpetuated injustices to minorities” (Barbee, 1993, p. 347).
Early Structures and Culture of American Nursing
The anti-Black frame was fully established by the circulated writings and cultural
discourse of European and American Enlightenment thinkers and scientists of the 18th century
(Feagin, 2020). Pre-dating the formation of American nursing by a century, the professional
culture and image of a nurse conjured in Britain was based on obedience, respectable character,
chastity, virtue, and Victorian-era ideals of womanhood and motherhood (Baly, 1995). This was
both practically and functionally incompatible with the crafted and reused tropes of Black people
who were consistently portrayed as “deviant, lacking moral character and unvirtuous,” Black
women specifically portrayed as “oversexed and dispensable,” and Native American as
23

“primitive” (Dingwall et al., 2002; Feagin, 2020, p. 78). Additional Victorian-era cultural
influences on the nascent nursing profession that continue to endure today can be found in
Appendix C.
Nightingale Narrative Informs Professional Identity
The exported British narrative of Florence Nightingale as an angelic, White-Anglo nurse
who professionalized and brought the altruism of nursing to the masses, complemented, and
aligned with the socio-cultural norms in America at that time. In the same way the narratives of
Columbus discovering America, pioneers settling and taming the West, Christians civilizing
heathens, and the founding fathers inventing democracy have served to inculcate White
supremacy, the Nightingale narrative has also stayed entrenched within the profession’s
collective memory far longer than has been useful (D’Antonio, 2022; Smith, 2020a; Sue, 2004).
Largely unexamined across Nightingale’s writings is a blatant Christian and colonial bias
informed by her trainings in European Sisterhoods where she learned that “cleanliness was a
synonym for purity, and the Victorian rituals attached to it came with a sense of godly
supremacy” (Stake-Doucet, 2020, Victorian “Cleanliness” section). Non-White, non-western
cultures deemed as filthy, dirty, or barbaristic in Nightingale’s worldview were in need of
civilizing, sanitation, or hygiene led by White professional nurses, and if that was not attainable,
then their decay or illness was seen as the inevitable result of disobeying a Christian God, from
which they could not, and should not, be saved (Stake-Doucet, 2020). Thus, western dominance,
homogeneity, and conformity to White, Anglo norms of health and wellbeing were more
consistent as nascent professional ideals than compassion for humanity or caring as a timeless
universal value (Foth et al., 2018).
24

Selections from Nightingale’s writings that referred to caring and her overall
contributions to launching the profession (such as securing funding the first hospital-based
training program in London) have continued to eclipse the writings, contribution, and inclusion
of other non-White, non-Anglophonic, and non-female nurses of the pre-professional era who
wrote on nursing and healing practices at the same time, or even centuries prior (Langtree, 2020;
Sleeth, 2018). The emphasis on written word within the emerging scientific community of the
turn of the 19th century
3
also served to omit practices and knowledge acquired over generations
from oral traditions. Healing practices on the American continent at the same time as
Nightingale’s work included, but are not limited to, Indigenous Mexican midwifery (practiced by
parterres) and healing traditions (Curanderismo), and West African midwifery and herbal
traditions practiced by enslaved women (Baptiste et al., 2021; Luna, 2003).
Notably, enslaved African women’s education and literacy was prohibited during the
Antebellum period, and in the Postbellum period, Black midwifery assistance in childbirth was
then regulated, effectively outlawed, and replaced by a (White) nurse midwifery model
(Bonaparte, 2007). The omission of men and non-White nurses from the earliest days of nursing
extends into an embedded cultural practice of overlooking the health needs and disparities of
non-White, non-Anglo populations (detailed in Appendix D). This was, and is, demonstrated by
the lack of adequate funding for research for illnesses or mortality more prevalent in non-White
populations, conflating health disparities with victim blaming, and contriving colonial missions,
settlement houses, or modern international philanthropic funding with the assimilation of western
medical models and measurements (Charbonneau-Dahlen & Crow, 2016; Jackson, 1993; Reddy,
2015; Scott et al., 2019).

3
Appendix F details the connection of the written word with White dominant culture.
25

An expanded timeline of significant pre and post Nightingale historic events serve to
ground nursing’s professional origin story in the context of American history and is provided in
Appendix E. Through the process of collective memory, groups construct versions of the past for
self-understanding and identity-making (Maza, 2017). Accurate timelines expand nursing’s
collective memory, which has essentially been reduced to a single historical moment of the mid-
1800s concerning Nightingale and the Crimean War. This has created a professional collective
memory that has passed over some of the most significant socio-cultural events of American
history, as if they have had no impact on the profession. Since the “remembered past is a much
larger category than the recorded past” (Horton & Horton, 2006, p.24), the collective memory of
nursing’s professional origin can be perceived as a modern instrument of power wherein
enduring myths that define cultural values (such as one woman from Britain “inventing” nursing)
thus formed the basis of nursing’s professional identity. It is this identity, and the historical
context around its formation, that aid an understanding of how the knowledge base of
“professional nursing” was derived, and how a “professional nurse” was defined, and by whom.
Who Is a Nurse?
Although President Lincoln’s Emancipation Proclamation was passed just a decade
before the first American nursing schools were founded, a praxis of abolition failed to translate
into the professionalization of nurses. Pre-professionalization, a nurse was simply a “woman who
happened to be nursing someone” (Ehrenreich & English, 2010, p. 25), whether a child, a
birthing person, or someone ill. This included nurses who were enslaved at the time of their
nursing, close or distant family relations, or White, poor, widowed, or older women who would
enter nursing at the end of their working lives, or for lack of other options (Baly, 1995; Choy,
2005). Though accepted for generations as nurses or healers within the domestic sphere, enlisting
26

the help of women in battlefield hospitals during the Civil War was resisted.
4
Despite joining
forces to serve the Union Army during the Civil War, enslaved and free Black women were
assigned to the most tedious and labor-intensive positions, such as cleaning bedpans, cooking, or
laundry; relegated to only caring for Black soldiers or fellow ill nurses; or enslavers hired out
their slaves to serve in Confederate hospitals (Backus, 2020). Black nurses were also assigned to
care for more contagious soldiers, such as those with smallpox.
5
While former enslaved people
serving the Union would gain freedom during the war as the Union took over Confederate
strongholds, most freed Black nurses served ad hoc contracts and were excluded from official
military nurse counts (National Institute of Health, 2013). This served to restrict their
documentation to be paid for their work or to receive military severance and benefits.
6

Thus, even pre-professionalization, the hierarchies of roles between White and Black
nurses that existed domestically and socio-culturally were replicated between White nurse
leaders, White nurses, and freed Black nurses when care was provided as a public good. While
an estimated 10% of the nurses who served in the war were Black nurses, the legacy of their
roles has been largely eclipsed by White nurses in the broader nursing narrative (Backus, 2020).
Both White and Black nurses who served in the Civil War “went bravely where few Victorian
women had dared tread” (U.S. Army & Heritage Education Center, n.d.) and their collective war

4
When the Civil War began, both the Confederate and Union medical departments preferred having men
rather than female nurses work in hospitals. Medical officers did not think that women had the constitution and
hardiness for hard work and were not willing to follow military etiquette. Logistically, officers did not want to
expend the effort to provide the separate accommodations that were thought necessary for women to stay at the
hospitals. Rather than include women, workforce shortages of male medical stewards were initially addressed by
ordering male soldiers recovering from a disease or minor injuries to assist their fellow patients (Backus, 2020)
5
A repeated pattern throughout American nursing i.e.: Black Angels, the Black nurses who cared for
tuberculosis patients when White nurses refused or assigning Filipino nurses to AIDS patients during the height of
the HIV epidemic (Aponte, 2021a; Aponte, 2021b).
6
The Black nurses who served include (but are not limited to) Harriet Tubman, Sojourner Truth, Ann
Bradford Stokes, and Susie Taylor King who authored the first Black American nurse autobiography Reminiscences
of My Life in Camp in 1902 (Carnegie, 1999; National Institute of Health, 2013)

27

experiences would thus serve to impact, whether collaboratively or antagonistically, their social
and political participation during the establishment of American nursing as a profession in the
subsequent decades. By the Reconstruction period, Black women sought to enter the emerging
profession of nursing with generations-old nursing skills, as many had attended births, provided
childcare, tended to the sick and dying, or served as nurses during the Civil War (Backus, 2020).
Abolition in Name Only
At the time the first nursing schools opened in the early 1870s in the Northeast, slavery
had been abolished nationally for a total of 7 years (and for over 60 years in the North), and
America was in the midst of the socio-political-cultural upheaval of the post-Civil War
Reconstruction period. Early nurse leaders at the turn of the 20th century sought “refined and
educated women, who have taken up the work not from necessity, but from choice” (Reverby,
1987, p. 87) as a deliberate strategy to distance professional nurses from domestic servants and
the working class. Though training schools were created to provide nursing students with the
necessary skills and knowledge to nurse, the governance structures used within many schools
imposed a hierarchy of control with strict admissions processes used to filter unsuitable
applicants. Controlling who enters training programs, in turn, controls who graduates as nurses
(Dingwall et al., 2002; Melosh, 1982). During this time, the implemented professional policies
by nurse leaders across the country were deliberately designed to exclude nurses based on race,
class, and gender. This served to support an idealized White, female profession, which has
defined at least the first hundred years of professional American nursing. Within these new
professional parameters, non-White nurses were
virtually excluded from the definition of who a nurse should be and were [routinely]
turned away from nursing schools. Whiteness is a theme that runs through nursing
28

history: White bibs and aprons, White caps, White staff uniforms, White as signifying
purity, hygiene, and science. … White nursing students transcended their bodies through
their performance of idealized femininity and through their use of their uniform as a
barrier. The pristine White bib and apron was constructed for White bodies, not non-
White bodies. There was no inherent definition of what a nurse should look like, but
nursing reform made White bodies normative and Black (or other non-White bodies)
alien to the profession. (Bates, 2012, pp. 113–114)
Most noteworthy to shaping the profession is that the founding of American nursing
occurred during the exact era of the nadir of American race relations. This time period between
1870–1940 followed Reconstruction
7
and saw the most blatant rise of eugenics, the KKK, and
xenophobia in the history of the culture (Connolly, 2021). This same time period is also defined
by the Allotment and Assimilation era of U.S. policies towards Native Americans, during which
reservations were established and a century of assimilation boarding schools would be funded
and supported (Dunbar-Ortiz, 2014). In 1872, one of the first of three founding U.S. nursing
schools, the New England Hospital for Women and Children, opened with a quota of “one Negro
and one Jew” in each class (Carnegie, 1999). However, it was not until 1879, for the first Black
nurse to graduate (Seltzer, 2021a). At this time, only eight percent (or a total of 14) of nursing
diploma schools permitted Black students (Carnegie, 1999). While Black women comprised 17%
to 24% of the female working population by the first decades of the 20th century, laws banning
midwifery and quotas at nursing schools resulted in less than 3% of Black women becoming
trained nurses during that time (D’Antonio, 2010; Niles & Drew, 2020; Reverby, 1987). Those
who could become nurses during this time were largely trained at historically Black colleges and

7
Reconstruction was the period following the Civil War between 1863 - 1877.
29

universities or through diploma schools associated with Black hospitals. These educational
programs were founded after Reconstruction, with the first school established in Atlanta, Georgia
at Spelman College in 1886 (Carnegie, 2005).
Over A Century of Marginalization
Discriminatory strategies varied regionally. The mechanisms of regional discrimination
included structural strategies such as restricting access to nursing education with the use of
quotas, preventing professional licensure, or restricting leadership and employment, as well as
documented treatment of horizontal and lateral violence from White nurses or educators
(Carnegie, 1999; D’Antonio, 2010; Hine, 1982). In the first half century of the profession, many
Black nurse graduates were largely relegated to staying in domestic roles, since they were not
permitted to join the American Nurses Association (a requirement for certain jobs), or work as
nurses with the Red Cross, the U.S. Army/Navy Nurse Corps, or at White hospitals (Melosh,
1982). Black women who did become professional nurses or formally trained midwives in the
first decades of the profession were largely trained from 11 Black nursing schools in five states,
but would then face discrimination in both licensing and employment, in addition to barriers in
gaining further educational opportunities past a nursing diploma degree (Carnegie, 1999).
8
While
the number of Black nursing school programs would grow to 91 across 20 states, subsequent
waves of Black nursing schools closures also left these programs vulnerable, with many open for
only several decades (Carnegie, 2005).
9

8
It would take until 1931 for the first Black nurse, Estelle Massey Osborne, to earn a master’s degree
(Seltzer, 2021b).
9
The first wave of closures in the 1920s - 1930s were a result of professional accreditation changes and the
impact of the Great Depression. By mid-century and after, a subsequent wave of closures was the result of Brown v.
Board of Education, the replacement of diploma schools with Associates degrees programs at community colleges
and increasing professional pressure to enter practice with a Bachelors (Carnegie, 1999; D’Antonio, 2010; Nelson,
2002).
30

Similar discriminatory patterns and restrictions existed for other nurses of color seeking
to enter nursing throughout the history of the profession. For Native Americans, who were not
granted U.S. citizenship until 1924, there was only a single, accredited, English-language
diploma nursing program established on an Arizona reservation between 1930 and 1950
(Kristofic, 2019). The small handful of early Native American students who were able to enter
nursing within the first 50 years of the profession were all alumni of U.S-backed boarding
schools designed to expedite assimilation (Charbonneau-Dahlen & Crow, 2016). The first
reservation-based baccalaureate program would not be established until 1996 (Kristofic, 2019).
These decades of systemic inaccessibility to the profession have resulted in a total of two dozen
Native American PhD-prepared nurses in the country as of 2020 (Moss, 2015).
On the American territory of Puerto Rico, Puerto Rican nurses at the turn of the 20th
century could only attend English-language nurse training programs on the island, and women
with paler-skin were largely recruited to the program (Hawkins & Sweet, 2014). Like Puerto
Rico, Filipino nurses had access to nurse training programs in the Philippines in American-
backed, English-language nursing programs since the turn of the 20th century, after America
claimed previously Spanish territories as a result of war, but despite their professional training in
the context of an American colony, nurses would not gain visas to immigrate as nurses until the
mid-20th century (Brice, 2019). Over decades of legal Filipino nurse migration, American
nursing organizations would engage in politics around limits, quotas, and credentialing logistics
designed to curb immigration and discredit Filipino nurses as less trustworthy or less competent
than White American nurses, and rarely promoted nurses to leadership positions (Choy, 2005).
Asians born in the United States were also prohibited from nursing programs until shortages of
31

nurses during World War II compelled select schools to train American-born, single Japanese
women who were being held in domestic internment camps (Seltzer, 2021e).
During the first century of American nursing, the profession largely mirrored the broader
American narrative from segregation to integration and from overt to covert racism. Four
decades of work by the National Association of Colored Graduate Nurses ultimately achieved
professional desegregation for Black nurses to join the U.S. Army Nurse Corps in 1945 and the
American Nurses Association in 1948 (Seltzer, 2021b; Threat, 2015). The impact of Brown v.
Board of Education in the 1950s; the Civil Rights Act, Immigration Act, and the emergence of
associate degree nursing programs in the 1960s; and the emergence of ethnic minority nurse
associations between the seventies through nineties, would seem to have created a political and
socio-cultural environment more in support of professional diversity. However, admission quotas
and other tactics of exclusion based on overt racism from the first century of professional nursing
evolved from one of strict segregation within nursing to more token compliance by the later 20th
century (McRae, 2018).
To illustrate the procession from overt to covert tactics on the profession, Appendix F
shows the letter of a nurse opposing the Civil Rights Act in 1963 next to a White nurse’s letter in
2018 reckoning with biased behavior exhibited towards a Black student that she could only
recognize retrospectively as racist, and as an extension of how her unconscious White identity
defined her understanding of professionalism. As noted by a Black nurse anthropologist:
“[Nurses] discriminate about Blacks but in ways that do not challenge their images of themselves
as non-prejudiced” (Barbee, 1993, p. 352). Based on the pace of diversity growth in the nursing
workforce since the Civil Rights Act, nursing educators and leaders have continued to exclude
groups of nurses who do not fit the White, Anglo, female nursing ideal. The lack of diversity in
32

the nursing workforce has been perpetuated in the 21st century by continuing to limit men and
nurses of color in school admissions, hiring, promotions, and implementing non-inclusive
policies that harm specific groups of nurses
10
while also claiming, and believing, to treat all
nurses and patients equally in spite of plain evidence (Barbee, 1993; Flynn et al., 2021).
The Role of White Feminism in Nursing
Florence Nightingale and her Victorian Era peers in Britain, and Clara Barton and her
Postbellum-Era peers in America have been the visual definition of what we think of when we
think of nurses for the last 160 years. Cast in sepia tones or Black and White photographs with
White caps and floor length skirted uniforms, these nurses have represented an enduring
archetype of an emerging professional independent woman living through the last era to precede
women’s suffrage. These early White nurses are represented as feminist pioneers who pursued
professionalization, paid occupations, and subsidized travel during which they established
Nightingale nursing schools internationally.
11
In remodeling women’s opportunities of their era
(while simultaneously conforming to the socio-cultural notions of femininity and White
womanhood), historians have linked the international nurse licensing movement in the early 20th
century with their subsequent suffrage efforts, as many nurses advocated for both (Baly, 1995).

10
Magnet designation status which began in 1983 by the American Nurses Association credentialing body,
compels hospitals to have a majority Baccalaureate-prepared nursing staff. This directly excludes Associates degree
nurses (ADN) from employment at 475 Magnet hospitals across the country. ADNs must pass the identical licensing
exam as Baccalaureate nurses and are consistently a more diverse group of graduates than Baccalaureate-prepared
nurses. This is one of numerous examples where a “race-neutral” policy, in fact, upholds racial homogeneity in the
profession. This policy has also impacted the culture of the profession which has used nursing literature to
stigmatize ADNs as fewer safe clinicians despite taking the exact same licensure test as BSN (McMurray, 2021).
11
Perhaps most radical, these new paths also created financial independence from a subservient role
raising children in a turn of the century marriage. Nightingale’s insistence to pursue nursing despite her family’s
objections and reject suitors for marriage has furthered her iconic status as a woman who eschewed status quo to
create a path less traveled for women of her generation. This decision has made her legacy seem more progressive
than her actual writings reveal, which upheld conservative Victorian-era and British imperial beliefs (Dingwall et
al., 2002).
33

Known as feminism’s first wave, American professional nursing emerged during the
same decades as women’s suffrage. But just as women’s rights advocates mirrored and
maintained racial hierarchies in their suffrage organizations, so, too, did the organizations of
professional nursing. “As White feminism … demonstrate[s], there is a marked difference
between thinking Black Americans should be free and believing they should have equal
opportunities to White people” (Beck, 2021, p. 26). This cultural through line of
disenfranchisement and marginalization of non-White nurses has recurred throughout the last
century and a half of the American nursing profession and affirms the way in which White
womanhood serves as “a corollary to toxic masculinity” (Hamad, 2020, p. 123) to maintain
access and control over White spaces. This section will detail how the role of White feminism in
nursing has been observed overtly, complicitly, or under the guise of professionalism.
Imperialism and White Feminist Nurses
White nurses at the turn of the 20th century traveled internationally to non-White
colonies of the American and British Empires to set up Nightingale schools, such as the
Philippines and Puerto Rico. These nurses were often funded by religious missions or Gilded
Age
12
philanthropists like Rockefeller or Carnegie, and their intermediary “role in the colonial
enterprise conferred real status and authority” (D’Antonio, 2022, p. 2) to shape public health
policy (Kristofic, 2019; Reddy, 2015). They were strategically deployed by organizations like
the Red Cross, which was founded in 1881 and did not accept a Black nurse until 1918, and the
International Council of Nurses, which was founded in 1899, and accepted membership by India
in 1912 as the first non-White member country only when their nursing chapter was led by a
White-Anglo nurse (Choy, 2005; Hawkins & Sweet, 2014; Reddy, 2015).

12
The Gilded Age is the era between 1870 - 1900 characterized by rapid economic growth for western,
White male titans of industry (Reddy, 2015).
34

White field nurses and matrons were also present following the formation of Native
American reservations to promote western medicine, nutrition, and childbirth practices
(Charbonneau-Dahlen & Crow, 2016). Through these envoys, nurses embodied the White
saviorism and the “ruthless individualism” of White feminism who “carry forward the racial
hierarchies and self-interested exploitation of the colonial era … bound White … feminism to …
nation building around the world, [and] convinced themselves of their own benevolence in
improving the lives of Native women” (Zakaria, 2021, pp. 86–87, 103). This is witnessed by the
implementation of professional nursing structures and promoting Anglo-American values as
supreme over Natives, who were not seen as capable or sophisticated to create either similar, or
better, models of care. It also exemplified that the highest value for women was to hold a job in
order to monetize her time and they alone deserved more freedom and higher status than colonial
or Native women (Zakaria, 2021), who themselves were subject to supervision by Anglo-
European nurses. Instead of working together as women to abolish patriarchal, colonial power, as
America did for itself in the late 1700s, early White nurse suffragettes of feminism’s first wave
benefitted from and served to support colonial and imperial expansion, including Nightingale
who wrote about nursing and sanitation in India, despite never having been there (Reddy, 2015).
Suffrage as a Mirror to Nursing ’s Segregation
The White women’s suffrage movement and the early licensing movement of
professional nursing were ideologically connected in their insular advocacy to legitimize White
women’s right to vote and for their entry into the healthcare workforce at the exclusion of other
disenfranchised voters and potential nurses (namely Black and Indigenous women). Both efforts
followed the landmark passing of the 14th and 15th amendments between 1868 and 1870 which
granted freed Black men legal citizenship and the right to vote after the Civil War (Newman,
35

1999). The political whiplash from this amendment left White women, for the first time in their
lives, in a less privileged position, despite generations of reinforced socio-cultural superiority.
Where White women of this period emphasized their gendered difference with White men, at the
same time, their identity included being similar and linked to White men in regard to their racial-
cultural privilege in America’s hierarchy (Beck, 2021). These decades of Reconstruction through
early Jim Crow also brought intense messages of White racial superiority in the form of minstrel
shows, fairs, and the revival of the KKK (Hamad, 2020). “Freedom became a zero-sum game,
[where] more for one group (White women) [is] only possible as the reinforcement of less for
another (non-White people)” (Zakaria, 2021, p. 80).
Thus between 1870 and 1920 the women’s movement was largely segregated and broadly
dismissed questions and issues of race, which was of high priority for Black women, as
irrelevant to their movement based solely on White gender equality (Newman, 1999). The
parallel dynamic is also observed within professional nursing. White nurses used the Red Cross,
International Council of Nurses, the U.S. Army Nurse Corps, and the American Nurse
Association as organizations to advance nurses’ roles and employment opportunities while
simultaneously using the same organizations to either prohibit or restrict admission of nurses of
color during the first decades of the profession (Aponte, 2022; D’Antonio, 2010).
White Feminist Power Structure of Nursing
White feminism not only erases and dismisses the valid issues of non-White women by
the insistence that White women alone represent and embody true womanhood (Sue, 2015), but
also places White men and their structures as the arbiter and validator of their goals rather than
create new, more egalitarian and liberatory spaces.
36

White women’s racial privilege is predicated on their acceptance of their role of virtue
and goodness, which is, ultimately powerlessness. It is this powerlessness - or this
appearance of powerlessness - that governs the nature of White Womanhood …
womanhood in general has been subordinated in patriarchal societies, but Whiteness has
positioned White Womanhood above other women … [and as] second-in-command to
White men, a role they know they hold and do not want to relinquish. … The
insidiousness of this strategic White Womanhood is that it masks power. It is power
pretending to be powerless. (Hamad, 2020, pp. 108–132)
Thus, the same strategies of attaining White male-adjacent power were strategically used
to establish nursing’s early infrastructure and are maintained today. Appendix D specifically
outlines the impact of this strategy on midwifery, which nursing adopted adjacent to the needs of
obstetric medicine, rather than the needs of peripartum women. In this case, the role of White
feminism does not serve as a benign ideology for the profession, but directly supports a
professional healthcare infrastructure that delivers suboptimal maternal health outcomes in
exchange for the approval and acceptance of the medical establishment (Merelli, 2021; Niles &
Drew, 2020). It is within this social-political environment that the White feminist aim was
established not to “dismantle this hierarchy, but to ensure White women join White men at its
helm by agitating only against those limitations imposed on their sex … and enforcing racial
hierarchy and purity” (Hamad, 2020, pp. 132–152). To gain professional status for nursing,
nurses mirrored the established systems of male-dominated western medicine: select admissions
recruitment, reliance on testing, state-based licensing, peer-reviewed journals, elite leadership
societies, deference to physicians, and adoption of a professional culture of eating their young, so
the weak among them would be weeded out of the profession (Baly, 1995). The American
37

medical establishments, notoriously racist and sexist, gave cover in some capacity for nurses to
appear more benevolent by being merely racist, but not also anti-female (Niles & Drew, 2020).
The appearance of benign powerlessness, paired with the calculated and destructive
nature of colonial force, was used extensively as a strategy to obfuscate imperial intentions. In
this way, the altruistic image of colonial nurses served to de-brutalize British imperialism as they
created hospitals and nursing schools in occupied territory, and the same strategy was used in
tandem in America: in the Philippines, Puerto Rico, and on Native American reservations (Choy,
2005; Hawkins & Sweet, 2014; Kristofic, 2019; Pollitt, 2016). This crafted benevolence explains
why the appearance of innocence and altruism, whether via uniform, illustrated imagery, or
photographs, became paramount in solidifying the profession’s reputation and was replicated
globally during the Golden Age of Postcards, from 1907 through 1920 (Mills, 2014). In the
Zwerdling Postcard Collection exhibit by the National Institute of Health in 2014, over 500 of
2,500 nursing postcards produced between 1893–2011 were digitized. The digitized collection
shows the stark absence of nurses of color in the postcard imagery, described as “scarce” by the
exhibit curators. Of the hundreds of digitized images, a total of five included Black nurses, of
which three images depict Black women as a mammy stereotype cradling a White baby, and a
single postcard image from India serves to reinforce the relationship of medical missions during
colonial rule, where the “civilization” of White nurses in white dresses are depicted in contrast to
Indian women in saris sitting on the ground (National Library of Medicine, 2014; Taylor, 1999).
This scarcity of imagery of nurses of color does not reflect their actual contributions to the
profession of nursing at that time, but rather the desire to omit their contributions and presence as
the identity of professional nursing was being established during the nadir of American race
relations.
38

A Profession Pure and White
Nurse leaders learned that gradual acquisition of their professional social capital within
the emerging White, male medical infrastructure was aided by a perception of beneficence and
could be replicated by feminine, white uniforms and a sustained professional image of nurses as
pure and caring (Bates, 2012). White nurses followed American physician’s political strategy to
leverage their newly found professional power to enact structures and systems as extensions of
colonialism and Whiteness, which kept themselves in power to gain economic and employment
opportunities in an increasingly corporatized healthcare industrial complex (Niles & Drew, 2020;
Waite & Nardi, 2019). Thus, the foundational roots of nursing and White feminism become
inextricably linked and obvious.
Nursing as a White Space
Despite recent rhetorical attempts towards improving workforce diversity, American
nursing has largely acted in parallel to the professionalization of medicine and in alignment with
the strategy of professional closure throughout the last century and a half. Whether leveraged to
exclude freed Black Americans and midwives, men, trained Philippino nurses, or non-native-
English native immigrant nurses, the politics of the nursing profession today claims itself free of
bias and discrimination via its codes of ethics while its statistics reveal a workforce that is 76%
White and 88% female and 80% White and 90% female in nursing academia (American
Association of Colleges of Nursing, 2019b). The enduring and resilient Whiteness of the nursing
workforce is of major significance in terms of professional power and advancement, nursing
epistemology, axiology, ideology, funding, research, and the capacity for nurses to improve
health outcomes for diverse patient populations. Appendix G details 22 values of White-
dominant culture which align with professional nursing culture in order to demonstrate the
39

impact of White-dominant professional values in contrast to alternative cultural values which
could directly impact health, wellbeing, equity, and power sharing.
White spaces are defined as a means of operationalizing and normalizing race and racism
within spaces that can be both physical and geographic, as well as ideological and cultural. They
work to reinforce behavioral patterns of White supremacy that normalize White resource
hoarding, racially oppressive hierarchies, and ensures Whites’ complete dominion of space and
place (Embrick & Moore, 2020). The very concept of institutional racism implies the existence
of White space, while at the same time Whites in control of spaces perceive, describe, and attest
to them as non-racialized and non-biased spaces. White spaces, or predominately White
institutions, are “organizations that are produced by and function to reproduce racialized social
institutions … mechanisms of White instructional space function tacitly and explicitly to reify
White power and privilege … and explicate how social spaces are organized such that the …
material and ideological resources flow disproportionately to Whites” (Embrick & Moore, 2020,
p. 14). This directly results in an unpaid, compulsory emotional and psychological labor and
burden to non-Whites as they navigate White spaces (Embrick & Moore, 2020).
White Space As Professional Closure
The research presented in this chapter clearly demonstrates how White nurse leaders used
nursing education and licensing structures to professionalize and legitimate nursing, while
establishing an exclusive occupational hierarchy to their benefit (Flynn et al., 2021). The same
profession often celebrated as liberating (White) women from domestic labor and advancing
(White) women’s access to economic independence, at the same time erected professional
closure strategies which restricted and marginalized men and non-White women from
professional participation.
40

Professionalization as a strategy of exclusionary closure … has specified the tactical
means employed as the use of legalistic tactics which entail seeking a legal monopoly
through licensure by the state, and credtialist tactics, which describe the use of
educational certificates and accreditation to monitor and restrict access to occupational
positions. (Witz, 1990, p. 676).
For over a century the nursing profession has justified the exclusion, marginalization, or
disposability of Black nursing schools, followed by diploma schools and Associates programs in
favor of baccalaureate programs (Carnegie, 1999). Nurse leaders have left a paucity of
infrastructure for Native Americans to access nursing education and questioned the credentials of
immigrant nurses in the name of professional standardization (Charbonneau-Dahlen & Crow,
2016; Choy, 2005; Kristofic, 2019; Nelson, 2002; Pollitt, 2016).
The caring identity and genuine desire of people who become nurses to be helpful
obfuscates the reality that nurses do not operate in their professional role in isolation of
their socialization, their socioeconomic and political contexts, not of their identities as
racialized or non-racialized beings. … This normalized dominance gives White nurses
the privilege of identifying with their professional role without necessarily
acknowledging their role in a racial hierarchy. This is to say that the normalization of a
White majority and White leadership makes race ignorance possible. Belonging to a
long-standing racial majority enables, but does not dictate, partial awareness of the racial
climate. (Bell, 2021, p. 2).
Appendix H details the graduating photos of a nursing diploma program in northern New
Jersey from 1912–1976 to illustrate the extent of nursing’s closure strategies in creating a White
space, which was replicated in nursing diploma programs across the country. The photo of this
41

specific academic White space extends to the professional workforce in the community overall
and spanned a nearly 60-year time period, or the entirety of the school’s existence. This period is
particularly noteworthy because of the role of this region during the Great Migration (one of the
largest movements of people in United States history with an estimated six million Black people
migrating from the American South to northern, midwestern, and western states between the
1910s until the 1970s), which was the largest haven for Black Southerners than any other
Northern state (Reynolds & Kendi, 2020). Although the Black population increased by 132% in
the first 2 decades of the Great Migration, it would not be apparent in the photos of the
graduating nursing classes (PBS Learning Media, 2020).
Nursing Literature at the Turn of the 21st Century: Silence and Whiteness
Due to the structured limitations for non-White nurses to access nursing during its first
century, professional nursing power in America remained, and continues to be, the reserve of
White women who not only set admissions criteria, program accreditation, licensing eligibility,
and examination content of the profession, but also set the professional priorities and
gatekeeping of mainstream nursing journals. With the nursing literature limited to perspectives
and priorities of predominately White nurses, non-White nurses in the early decades of the
profession were often relegated to publishing in their own journals, such as the Filipino Nurse
Journal established in the 1920s, the Journal of Chi Eta Phi Black nursing sorority founded in
1932, or in non-nursing journals, such as the Journal of Negro Education, if they were published
at all (Osborne, 1949). The purpose of this section is to provide the professional historical
context of the generation of nursing knowledge alongside a review of nursing literature from the
turn of the 21st century. It further demonstrates how the same professional structural restrictions
that limited non-White nurses from accessing nursing programs, attending an accredited school,
42

attaining a license, and accessing equal employment and leadership opportunities over the last
century, in the same way limited their participation and contribution to mainstream nursing
publications and, by extension, the generation of nursing knowledge.
Evolving Education, Organizations, and Publishing Options
As influenced by the World War II experience of the U.S. Army Nurse Corps integration,
Brown vs. Board of Education, and the Civil Rights Act, the foundations of nursing education
shifted by mid-century, and initiated the first significant change in the demographics of the
nursing workforce. The community college-based Associates nursing degree (ADN)
13
became
the first evidence-based nurse training program in the country to graduate registered nurses and
would go on to account for a 20% increase in nursing school admissions. The ADN program
attracted nurses who were typically ineligible for both baccalaureate and hospital programs,
which still required living at the hospital, or college, during training (D’Antonio, 2010). The
students were older, ethnically diverse, of modest financial means, and included men and
married women, the antithetical demographic from the original students recruited to nursing in
the preceding century. Between 1952 and 1980, “the proliferation of the associate’s degrees …
parallel[ed] the rapid growth of diploma schools in the first quarter of the century” (Christy,
1980, p 487) and would be the first step towards phasing out diploma education entirely in the
coming decades.
14
While in theory this change in nursing education could, and did, expand the
pool of diverse nurses who could be ultimately be eligible for access to leadership, research, and
faculty roles, the research in the first decades after civil rights points to a precipitous drop in

13
ADN programs were based on the success of the Cadet Nurse Corps administered by the U.S. Public
Health Service during World War II which sufficiently trained over 100,000 cadets in thirty months and was the first
evidence-based training program developed by a nurse (Nelson, 2002).
14
By 2006, associate programs would account for 58.9% of nursing programs, produce 63% of licensed
registered nurses, and today contribute over half of nurses enrolled in Baccalaureate programs (Leer, 2020; Nelson
2002).
43

Black nursing students enrolled in primarily White nursing schools, at the same time of a second
wave of Black nursing schools closure occurring nationally (Barbee, 1993).
The inability of nursing schools to support a diversifying student body was also observed
in nursing’s major professional organizations. It is during the early years of the success of the 2-
year ADN program that the American Nurses Association passed a 1965 resolution to make the
baccalaureate degree the minimum education to be eligible for a nursing license (Nelson, 2002).
Although decades of work by the organization followed to establish the baccalaureate minimum
by the turn of the 21st century, no state board of nursing ever adopted the resolution. Instead,
mainstream national and international nursing organizations internally created baccalaureate
educational minimums for membership, developed new accreditation criteria for hospitals with
majority baccalaureate-prepared nurses, and went on to build literature on the effectiveness of
baccalaureate nurses on quality and patient safety (Aiken, 2014; McMurray, 2021). Indeed, these
strategies of justifying exclusion based on scientific research and the creation of separate classes
of nurses have been part of the nursing profession since its earliest days (D’Antonio, 2010; Hine,
1982). These racialized strategies thus created a bifurcated nursing culture where the majority
nurse graduates of affordable ADN programs became professionally stigmatized as less educated
(despite passing the same licensing exam as baccalaureate nurses) and has become an entrenched
and normalized assumption in the professional culture. Appendix D demonstrates how this
pattern of stigma and delegitimization along racial lines has resulted in hierarchical nursing
classes within the profession and has detrimental impact on patient outcomes.
Non-White nurses would be most hurt by baccalaureate minimums for entry to practice,
so it is unsurprising to see the organizing tactic from the Civil Rights Movement used only a few
years later to reject the American Nurses Association’s agenda. By the 1970s, the National Black
44

Nurses Association, the first iteration of the first American Indian Nurses Association, and the
National Association of Hispanic Nurses would all be established to address unmet needs of their
communities and to mitigate the lack of non-White leadership representation by the American
Nurses Association and other national organizations (Aponte & Seltzer-Uribe, 2022). Reflecting
the impact of the 1964 Immigration Act on the nursing workforce, the Philippine Nurses
Association of America would be founded in 1979, followed by the first organized state chapter
of nurses from India in 1980 which would also become a national organization (Choy, 2005;
Reddy, 2015). By 1984, the Organization for Associate Degree Nursing was established and
created its own peer-reviewed journal to address the needs of the ADN community (Organization
for Associate Degree Nursing, 2021).
In the transition decades following the Immigration and Civil Rights Acts, these
organizations (which all continue to exist today) formed pipelines for non-White nurses to enter
national leadership roles, advocate for their communities, and created their own peer-reviewed
publications reflective of their membership. The first Black nurse-owned publishing company
15

was founded in 1987, which published three peer-reviewed journals (including the
interdisciplinary Journal of Cultural Diversity and Journal of the Association of Black Nurse
Faculty, which both exist today), as well as books on recruitment and retention of minority
nurses (Seltzer, 2021d). But the existence of these new nursing organizations during these
decades also represents the incapacity, reluctance, and even retaliative spirit, by newly
integrated, mainstream nursing organizations and mainstream nursing publications to extend

15
The journals from Tucker Publications are widely credited with the dissemination of hundreds of articles
that led to recognition, tenure, and promotional opportunities for minority academicians, as well as the
dissemination of literature on topics relevant to marginalized nurses and communities that were not accepted to
mainstream journals (Seltzer, 2021d)
45

space to the topics of concerns for non-White nurses and were not widely subscribed to by the
university libraries of most schools of nursing (Barbee, 1993).
The Nineties: If White Women Do Not Write About It, Does It Exist?
Four decades after nurses’ professional integration and 3 decades after civil rights, the
nursing workforce remained 89% White and Non-Hispanic by the turn of the 21st century
(Taylor, 1999). An American nursing literature search conducted from 1983 to 1991 uncovered a
total of 18 articles on racism in major nursing journals, of which only three dealt with some
aspect of racism within the profession, and the other sources examined racism as a problem of
patients (Barbee, 1993). This paucity of research demonstrates that the first full generation of
nurses post-civil rights entered a culture of colorblindness in the nineties that led to both
indifference and denial of racism (Iheduru-Anderson & Wahi, 2021). To review and publish on
racism in this environment, a nurse anthropologist observed, “how to write about a problem that,
at least according to the nursing literature, does not exist?” (Barbee, 1993, p. 347), while another
nurse asked, Is there really racism in nursing? (Vaughan, 1997).
In the same way early nurses published in non-nursing journals, seminal nineties
literature was published by two nurse anthropologists in Medical Anthropology Quarterly by the
American Anthropological Association to detail the impact of nursing as a White space and the
profession’s inability to recognize, mitigate, and dismantle racial bias within its field (Barbee,
1993; Jackson, 1993). Jackson’s work focused on how professional conformity results in the
“whiting-out difference” to White middle-class standards for feminine thought and behavior that
impacts unrecognized bias and research perspectives. This causes harm to non-White nurses who
cannot bring their contributions to the profession and to non-White patients whose needs, or even
existence, are unaddressed in nursing literature and research (Jackson, 1993). Barbee’s work
46

detailed the unwillingness of the profession to recognize racism as endemic in nursing and health
care and how a professional ethos emphasizing the individual over the structural impacts nurses’
preparation to provide safe and effective care to all people. “A recognition of racism in the
nursing profession would allow Euro-American nurses to redirect the energy they use in denying
racism toward forming alliances and organizational goals that could result in changing power
relations among women” (Barbee, 1993, p. 358).
The work to make the contribution of Black nurses visible in the broader nursing
narrative or explore why the needs of Black patients were invisible, were also evident during this
era. The work of Pitts Mosley (nurse EdD), Carnegie (nurse PhD), and Hine (historian)
published the histories of Black nurse professionalization in relation to overcoming barriers of
discrimination and further substantiated Black American nursing contributions in shaping the
modern-day profession (Carnegie, 1999; Hine, 1982; Mosley, 1994, 1995)
16
. Taylor (nurse PhD
and Gender, Women’s and Sexuality Studies and African American Studies professor), in
writing for Advances in Nursing Science, drew on the work of bell hooks and Audre Lorde in
seeking to examine how the invisibility of Black female patient needs are overshadowed by
colonizing images and stereotypes, which negatively impact their treatment in healthcare settings
and make it “exceptionally difficult to describe or comprehend the extent to which ethnocentrism
and White privilege have been woven into the fabric of our healthcare systems” (Taylor, 1999, p.
40).
Also in this era, to counteract the lack of capacity for mainstream nursing publications
and organizations to meet the needs of nurses and patients of color, the National Coalition of

16
By contributing to the Journal of Cultural Diversity and the Journal of the National Black Nursing
Association, as well as the Nursing History Review, and the Official Journal of the American Association for the
History of Nursing, Mosley’s work could influence both mainstream and marginalized nurses.
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Ethnic Minority Nurses Association was founded in 1997. The aim of the Coalition was to fulfill
this gap by uniting all of the minority nursing groups (National Coalition of Ethnic Minority
Nurses Association, 2021). Despite the establishment of such organizations, growing awareness
of multiculturalism, and increasing publications, the willingness to embrace cultural diversity in
nursing remained tokenistic and primarily the work of nurses of color in the subsequent decades.
Turn of the 21st Century: Seeing a Problem for the First Time
While the seventies through nineties saw the emergence of half a dozen minority nursing
organizations alongside new publications for dissemination of nursing knowledge, mainstream
nursing literature in the early 21st century found the members of the profession responding
slowly over the next 2 decades to health disparity trends and not yet able to fully reckon with
clear suggestions published in the literature by non-White nurses from the 1990s. Formative
healthcare reports at the turn of the century such as Unequal Treatment: Confronting Racial and
Ethnic Disparities in Health Care by the Institute of Medicine in 2002 and Missing Persons:
Minorities in the Health Professions by the Sullivan Commission in 2004 concluded the need to
address health inequities and improve workforce diversity (Institute of Medicine, 2002; Sullivan
Commission, 2004). When the Future of Nursing: 2010 –2020 was published, diversifying the
workforce was included as a sub-section among four main recommendations, but it was not until
the midst of a global pandemic that the Future of Nursing 2020 –2030: Charting a Path to
Achieve Health Equity called for nursing strategies to reduce health disparities as a professional
priority. Notably, the five-hundred-page report mentioned Whiteness a total of three times
(Institute of Medicine, 2021).

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The 2000s: Multiculturalism and Postcolonialism
Early 2000s literature expanded on efforts from the 1990s in crafting the nursing
narrative to include nurses of color and more plainly addressed the role of Whiteness in the
profession. George, Bradford, and Battle published a 7,000-word review designed to re-introduce
the discriminatory practices toward “Negro” nurses by the profession and highlighted the
isolation, stigmation, and injustice Black nurses needed to overcome (George et al., 2000). Allen,
publishing in Nursing Philosophy, and Puzan, publishing in Nursing Inquiry, explicitly
challenged the multicultural and culturally competent terminology of the profession as masking
the ways nursing participates in and reproduces the negative impact associated with White
cultural privilege (Allen, 2006; Puzan, 2003). Hassouneh-Phillips and Beckett highlighted the
need for faculty and students to critically reflect on their own racism in order to challenge the
status quo of racism in nursing education (Hassouneh-Phillips & Beckett, 2003).
University-based scholarly critiques during this time, such as postcolonialism and anti-
racism, served to apply relevant interdisciplinary frameworks to nursing issues. Kirkham and
Anderson called for using the postcolonial lens as a powerful analytic tool needed to advance
nursing scholarship and make power dynamics (racial, colonial, or otherwise) informing the
profession more visible, with the goal of research grounded in emancipation (Kirkham &
Anderson, 2002). Cortis and Law proposed expanding nursing curricula together with skills to
challenge racism as a pre-requisite for an anti-racist nurse education (Cortis & Law, 2005).
Works such as Racism Without Racists, published in 2003, provided a paradigm to challenge the
merits of colorblindness within academia at large, while Empire of Care, published in 2005,
integrated ethnic studies with nursing to make the decades-long migration and contributions of
Filipino nurses more visible within the professional narrative (Bonilla-Silva, 2006; Choy, 2005).
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The 2010s: From Research to Actions
Critiques of nursing’s leadership and intellectual development as fundamentally limited
by colonial thinking also began to grow in the 2010s. Nursing Inquiry published work analyzing
how the profession upholds racism and White privilege by suppressing counter-narratives
(McGibbon et al., 2014), and the Journal of Professional Nursing examined the role of nursing
colonialism on nursing leadership with five opportunities for de-colonizing actions the
profession can implement (Waite & Nardi, 2019). Editorials in Nursing and Health Sciences
outlined the consequences of racism and the complicity of the professional culture when nurses
stay silent, Valderama-Wallace and Apesoa-Varano published research on the challenge for
White nurse educators to integrate social justice into curriculum, and Bennett et al. (2019)
published research on how a historical lens could equip nursing students to learn about racial
inequality within the profession (Bennett et al., 2019; Stone & Ajayi, 2013; Valderama-Wallace
& Apesoa-Varano, 2019a, 2019b). Additionally, books during this era by historians on Native
American and Indian nurses, and colonial and postcolonial nursing practices have further added
to the literature and provided a broader understanding of nursing’s counter-narrative (Hawkins &
Sweet, 2014; Kristofic, 2019; Moss, 2015; Reddy, 2015).
The 2010s literature also brought early adopter organizations detailing their paths toward
improved equitable and anti-racist actions. The first nursing school to publish their experience on
addressing a climate of Whiteness was the University of Washington School of Nursing in 2010.
Their work to transform their school’s culture towards anti-racism was prompted by the
publication of a 2001 book African American Registered Nurses in Seattle: The Struggle for
Opportunity and Success which detailed the lived experience of Black nurses from the 1940-50s
(when there was a total of 13 Black registered nurses in the state) and prompted the dean of the
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School of Nursing to publicly apologize for the discrimination the nurses endured (Schroeder &
DiAngelo, 2010; Spratlen, 2001). Moreover, Hall and Fields implored nurses to examine the
difficulties of dismantling White privilege and confronting the propagation of subtle racism
within the profession by implementing more historical awareness and more open dialogue (Hall
& Fields, 2013).
In 2014, the Association of Public Health Nurses (APHN) became the first nursing
organization to issue a position paper tackling the upstream systemic and social determinants of
health impacting health outcomes. The organization called for centering the goals of health
equity and social justice with awareness, respect, and humility for the communities’ nurses serve
(APHN, 2015). The issuing of position statements for social justice and anti-racism by nursing
organizations would soon gain growing momentum in the face of the COVID-19 global
pandemic and the Summer 2020 mass social justice awareness, with calls to consider racism a
public health crisis across all health sectors and disciplines.
The 2020s: Whiteness Everywhere
While Whiteness in nursing “continues to be deeply rooted because of the uncritical
recognition of White racial domination” (Iheduru-Anderson & Waite, 2022, p. 1), 2020 through
2022 have so far initiated an early peak of Whiteness in the nursing literature, with the
publication of more articles and special issues devoted to de-colonizing, anti-racism, social
justice, and disrupting and dismantling White supremacy than surpassed the publication volume
from the previous years. Appendix I details an abbreviated citation list of over a dozen titles
from 2020 through the first quarter of 2022. International in scope, the list reflects the growing
global awareness of White colonial influence on nursing from Australia to Canada, and America
to Britain, and affirms that “to speak of Whiteness challenges White scholars’ state of racial
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unconsciousness” (Besson, 2021, p. 28). Thus, this pandemic period in nursing exemplifies an
expanding consciousness of Whiteness in the professional literature.
Nurses published articles on ways the COVID-19 pandemic, economic disruptions, social
justice protests, or police violence might serve as a positive catalyst to transform nursing
ideology from its White feminist colonial roots. Paynter et al. (2022) proposed the utility of
moving nursing towards a feminist abolitionist framework, while Dillard-Wright and Shields-
Haas (2021) advanced the need for radical imagination where nurses served as emancipatory
change agents to transform the healthcare system collaboratively with the community. Editorials
in Nursing Inquiry and Nursing Outlook also called on nurse leaders to make meaningful change.
Thorne (2020) conveyed how nurses continuing to hold or demonstrate biased and prejudiced
beliefs abjectly destroys the aims of the profession, while Villarruel and Broome (2020) asked
how to move beyond naming racism to dismantling it, as ingrained institutional practices make it
challenging to see the problems right in front nurse leaders. Flynn et al. (2021) named White
supremacy in education as the “thing behind the thing” holding the nursing profession back from
achieving diversity.
Organizations also participated in new ways. Grassroots nursing organizations like
Nursing Mutual Aid on Twitter, Nursology Theory Collective’s Equity, Diversity, Inclusion,
Justice and the Future of Nursing webinar, and NurseManifest’s Overdue Reckoning on Nursing
and White Nurses: It ’s On Us Zoom series created community cohesion, momentum, information
dissemination, and alternative spaces to advance conversations during a pandemic when virtual
activities were the only options and larger organizations were slower to react (Chinn, 2022;
Nursing Mutual Aid, 2020; Nursology Theory Collective, 2020). The NurseManifest year-long
zoom series for nurses of color resulted in the publication of 40 nurses’ interviews on the
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Reckoning with Racism in Nursing website in 2022 (Reckoning with Racism in Nursing
Committee, 2022). Mainstream organizations such as the American Association of Colleges of
Nursing presented its first-ever Diversity Symposium in 2020 to share best practices for
implementing DEI in nursing education, along with revisions to “actively combat structural
racism, discrimination, systemic inequity, exclusion, and bias” for accredited nursing curriculum
(Morris, 2021, p. 2). The first-ever Commission on Racism in Nursing, in partnership with the
National Coalition of Ethnic Minority Nurses Association, the American Nurses Association,
and over a dozen organizations led by nurses of color, was announced in 2021 (American Nurses
Association, 2021). Initial survey findings (included in Appendix J) and a total of five draft
reports on The History of Racism in Nursing, Systemic Racism in Contemporary Society, and
papers on racism across nursing education, nursing practice, research, and policy, were published
in January 2022, and open for public comment through February 2022.
For nursing education to become anti-racist, Bell (2021) outlined the need to deconstruct
White normativity, socialized White supremacy, and enactments of White privilege and Coleman
(2020) recommended for nursing to adopt a racial justice praxis. To address health equity,
Iheduru-Anderson (2020, 2021) outlined the way nursing education has successfully
institutionalized White supremacy and suggests the work of equity needs to be done first within
the profession before nurses can ethically serve patient populations, as well as detailing
evidence-based strategies to eliminate racism in the educational culture. Bonini and Matias
(2021) analyzed the lack of effectiveness in strategies to recruit and retain nurses of color as
endemic to the unaddressed culture of Whiteness that is pervasive in nursing education. Fontenot
and McMurray (2020) called for critical review of recruiting practices to schools of nursing to
un-do western colonial ideologies of superiority and privilege, while Zappas et al. (2021)
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outlined the lack of prepared faculty to facilitate discussions on power privilege, dominance, and
institutional racism as a reason for all schools of nursing to support the work of DEI committees
in order to better equip faculty and curriculum development.
Education is an extension of nursing’s professional values, and as faculty comprises the
Whitest (and oldest) members of the nursing workforce, numerous projects and articles
addressed areas of improvement grounded in addressing the knowledge deficit of the education
sphere. Examples include the development of distinct, online educational content series which
encourages nurses to think “Beyond Florence” (Smith, 2020a), reckon with Nightingale’s racist
legacy (Stake-Doucet, 2020), confront the ways White feminism severed generations of Black
midwives from their craft (Niles & Drew, 2020), and candidly face “history for the future of
nursing” (Smith, 2020b). The Nurses You Should Know project used social media to expand the
nursing narrative and narrow the representation gap for nurses of color (Seltzer, 2021a). The
American Academy of Nursing’s Institute for Nursing Leadership developed a multi-media
toolkit to facilitate critical conversations on health equity and racism, which included webinars,
resources, interviews, and articles on bystander training, anti-racist teaching, and the impact of
structural racism on health outcomes (American Academy of Nursing, 2020). As part of the work
of the Commission on Racism in Nursing, an eight-series, virtual cohort to educate nurses on
topics like bias, racism in academia, and allyship was also launched (American Nurses
Association, 2022a). The issues of racism and real commitments to diversity are only recently
being meaningfully acknowledged by White nursing leadership a century and a half since the
founding of the profession in America. Researchers in 2021 described White nurses as being
“completely ignorant when it comes to issues about racism” (Iheduru-Anderson, 2021 p. 418).
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This indicates that the increased literature observed in the last 2 years is likely to expand, as the
need for professional transformation to meet the needs of the post-pandemic era will only grow.
Theoretical Frameworks
This section outlines the theoretical frameworks used in this study and demonstrates why
research on the impact of White racial identity in nursing is a necessary starting point to advance
the field of nursing beyond its proclaimed colorblindness. If White nurses, as a profession,
perceive themselves to be fair and good, as consistent with phases of White racial identity and
linked with nursing identity, they lack urgency and capacity to analyze ways the expression of
their identity, consciously or unconsciously, may cause harm. Seeking to better understand the
White racial identity of White American nurses establishes a potential baseline through which to
view the lens of the most dominant and powerful nursing group in the country.
Bronfenbrenner ’s Ecological Systems Theory
Bronfenbrenner’s (1977) ecological systems model provides a framework for examining
the individual through the lens of societal influences. His model describes the micro, meso, exo,
macro, and chronosystems that work in synergy, and often invisibly, to form an individual’s
beliefs and perceptions of themselves and their relationship within their culture and community.
The microsystem influences include your family, household, school, church, and peers. The
exosystem describes the local economy, neighbors, social services, and mass media. The
mesosystem functions within and in relation to the influence of the micro and exosystems, as
beliefs and ideas from religion, school, or mass media can be condoned, dismissed, or challenged
by the individual. The macrosystem describes the broader economic, and wider societal influence
such as social norms and attitudes of the broader culture and national politics and policy. The
chronosystem (not pictured in the graphic below) refers to changes that accompany passage of
55

time, as social foundations from technology to the status quo evolve over decades and yet remain
informed by the past.

Figure 1
Bronfenbrenner ’s Ecological Systems Theory

Note. Theory visualization from “Bronfenbrenner’s Bioecological Theory Revision: Moving
Culture From the Macro Into the Micro,” by N. M. Vélez-Agosto, 2017,
Perspectives on Psychological Science, 12(5), p. 902
(https://journals.sagepub.com/doi/abs/10.1177/1745691617704397). Copyright 2017 by
Perspectives on Psychological Science.

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The model illustrates how nurses work both within society and are also a part of it. The
profession is, undeniably, a study of western biomedical science. Students spend years learning
the intricacies of how drugs, surgeries, and the body work and how to function in a healthcare
team. However, the broader context of how patients achieve health or how nurses work
effectively with each other or within organizations is clearly more interrelated with a study of
social science, American history, and self-examination. The level of Bronfenbrenner’s
microsystem is the sphere in which the concepts of nursing education, whether limiting or
expansive, thus informs the individual nurses’ professional identity. It is in this sphere that White
racial identity can be reinforced or disrupted, where outdated models of race and deficit-based
difference can be challenged or upheld, and where the power of the nursing narrative that is
passed down to new generations can be replicated or revised.
A nurse within the Bronfenbrenner conceptual framework illustrates that the mere
election of choosing an altruistic or beneficent profession does not sever an individual from the
spheres of cultural and community influences and, in fact, will also be influenced by the values,
culture, and narrative of nursing itself. Within the United States, nurses consciously or
unconsciously enter the profession from the lens of a White-centered, normative, and
supremacist cultural perspective. While in nursing school, this dominant cultural influence is not
made visible or examined, nor are the contributions of historically excluded nurses presented in
curriculum. These omissions, combined with the impact of systemic racism that impacts students
of color enrollment in college, creates a majority White workforce who are told that their
profession’s history and origin is to the credit of White women. This, in turn, creates a sense of
false dominion for White nurses to enter healthcare and academics in staff and leadership
positions with blind spots to how lack of diversity impacts patient care and can further perpetuate
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nursing as a White space. While nursing is a personal act of delivering clinical care, the nurse
themself is not perceived as a person in need of deeper awareness of their beliefs and biases to
enter the profession. Combined with the impact of deficit storytelling prior to and within nursing
education, Bronfenbrenner’s model demonstrates the dynamic influence between the spheres that
ultimately impact the way nurses deliver patient care.
Helms ’s White Racial Identity Development Model
One strategy to resist White supremacist ideology, as is omnipresent in the nursing
profession, is the ability to interrogate Whiteness and White racial identity in order to disrupt the
invisible “normativity of Whiteness” and more closely examine racial privilege and power in
shaping identity (Moffitt et al., 2021, p. 1). Helms’s landmark 1984 model on racial identity
explicitly named racism as impacting the identity development for both Black and White
Americans (Helms, 1990). Her work demonstrates that while Black Americans can both
internalize racism and inferiority, and still gain the capacity to feel proud and confident in their
Blackness, White Americans’ racial identity is conjoined with the normalcy of White supremacy
which simultaneously minimizes the importance of race itself (Helms, 2020). In essence, a
healthy White identity requires one to dissociate one’s value from their skin privileges.
Since White Americans are taught that racial identity is something related to people with
other skin colors, Helms’s model seeks to articulate that White people do not lack a racial
identity of their own; their full identity development is the psycho-social process of internalizing
their White supremacy faced with reconciling privilege and racism during their lifetime that
compose the basis of White’s racial identity development. Helms’s model has been continually
iterated over the decades with input from scholars since it was developed; the White racial
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identity development (WRID) is a reliable model to describe the two phases and six schemas of
WRID theorized by Helms since 1984 (Carter et al., 2004).

Figure 2
Graphical Depiction of Helms ’s White Identity Development Model

Note. Graphic from A Race is a Nice Thing to Have: A Guide to Being a White Person or
Understanding the White Persons in Your Life, by J. Helms, 2020, Cognella. Copyright 2020 by
Cognella.

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The current version of the model illustrates how racial identity development is not
logical, linear, nor sequential. In fact, White people (or White nurses) may “remain in a given
schema indefinitely, unless prompted by social events and/or interpersonal interactions to either
progress forward or regress to earlier schemas” (Moffitt et al., 2021, p. 3). The bi-directional
arrows between the internalizing racism and evolving non-racist identity phases indicate that
White people do not arrive in a static phase but can vacillate between both phases over their
lifetimes. The iterations to the model over time also accommodate for non-mutually exclusive
development, wherein a person may be in between, or may progress or regress depending on
external events or personal experiences (Moffitt et al., 2021). To avoid linear conceptualizations
of her model, Helms now includes the analogy of liquid in a container to conceptualize the
fluidity between schemas, with the most present or influential schema weighted to the bottom of
the container. As liquid naturally behaves, there are both micro and macro-movements that shift
contained liquid over time, in the same way White racial identity can develop gradually or
significantly over time.
The first phase of internalizing racism includes three schemas: Contact, Disintegration,
and Reintegration. The Contact schema is the willing or unintentional obliviousness to the role of
race and meaning of Whiteness. The Disintegration schema is the confused state of realizing
Whiteness exists and the personal and societal ramifications. The Reintegration schema is a
conscious return and acceptance of the White supremacist status quo. The next phase is
considered the phase of Evolving Non-Racist Identity and includes three schemas: Pseudo-
Independence, Immersion/Emersion, and Autonomy. The Pseudo-Independence schema begins
the process of recognizing racism and its benefit to White people, where the focus becomes
“saving” persons of color. The Immersion / Emersion schema is a more active exploration of
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racism as not just interpersonal, but also systemic and is characterized as an intellectualization
phase. The Autonomy schema is when a person attains comfort with their White identity and can
confront racism as a multi-layered system of intersectional oppression (Helms, 1990, 2020).
Appendix K includes the phases of WRID as they relate to the mainstream professional nursing
identity and the corresponding beliefs or actions by mainstream nursing organizations from each
schema.
The pivotal schema in the Internalizing Racism phase is that of Disintegration. It is
during this schema that one must reconcile the teaching that “all people are created equal” with
the reality that White people receive advantage and privilege across all aspects of U.S. society
based on their skin color. This can be accompanied by “overwhelming feelings of guilt, shame,
confusion, lack of group membership to which one feels kinship, and no socially approved
guidelines for resolving one’s internal turmoil” (Helms, 2020, p. 41). On one hand, this is a
positive schema as it initiates a change of perception about White racial identity from the naivete
of the Contact schema that can ultimately lead toward the phase of Evolving Non-Racist Identity.
However, it can also initiate regression to the Reintegration schema that is characterized by an
idealization of Whites and White culture and an unwillingness to engage with information that
does not support their beliefs, which is also the predominant schema of American society.
Frameworks in Combination
Figure 3 depicts the overlapping interaction between ecological systems theory and the
development of WRID, in which the influences from the ecosystems impact the associated
identity schema of WRID over time. The related identity schema of a nurse also interacts within
the mesosystem, which interacts between spheres of influence and could, in turn, serve to
influence a related ecosystem, such as within the interactions and messaging within their own
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home or within their broader workplace setting (microsystem) in a multi-directional capacity.
Examples could include a nurse in non-racist phase of identity who works to promote health
equity in a local clinic, or a nurse in the Internalized Racism phase who perpetuates stereotypes
at home to their children or family members or works to ban books at a local school or library.

Figure 3
Interaction Between Ecological Systems Theory and White Racial Identity Developmental Model

Note. Helms has since removed the numerical reference in her phases and replaced the phase
titled Challenging the Status Quo with Evolving Non-Racists Identity.

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The theoretical lens of Bronfenbrenner’s ecological systems theory in combination with
Helms’s WRID model provides a coherent framework for this dissertation study and aids the
understanding of the interplay between ecological systems and the evolution of White nurses’
racial identity development. Throughout their careers, nurses are influenced by both the
trajectory of their White racial identity of Helms’s WRID model and the micro, meso, exo,
macro, and chronosystems of Bronfenbrenner’s ecological systems theory. This interaction is
seen in the evolution of nursing’s professional culture from the past through the present day. The
combined frameworks serve to create a guidepost to identify in which ecosystem cultural
stagnation, regression, or progress is observed, and to ascertain which racial identity phases or
schemas stall or transform the professional nursing culture. White nurses in the Evolving Non-
Racist Identity Phase could impact professional organizational culture just as much as nurses in
the Internalized Racism phase. The professional organizational culture could either replicate and
reinforce schemas of internalized racism, or adequately engage and mitigate White nurses in the
Internalized Racism phase from perpetuating harm. The professional identity of nursing culture
more broadly can also be more clearly understood through Helms’s model. Used together, these
frameworks create a clarifying opportunity to dissect Whiteness from the nursing culture and
offer an opportunity for the profession itself to develop an evolving non-racist identity.
Summary
The significance of the turn of the 21st century is used here as a contextual portal to
understand the themes of the nursing literature in relation to Whiteness at a time of professed
equality and multiculturalism. This entry point best captures the profession’s perspectives in the
three decades preceding the present time, wherein racism has gone from being virtually ignored
in the mainstream nursing publications to an all-hands-on-deck effort with the establishment of
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the Commission on Racism in Nursing. Scholars and feminists of color argue that the
combination of White womanhood over the last century as exclusively tied with the feminist
agenda has limited the utility of feminism by prioritizing economic access, individualism,
proximity to male power, heterosexual motherhood, consumerism as activism, avoiding division
by maintaining an order of respectability, and replicating racial hierarchy and power structures
rather than working to dismantle them (Beck, 2021; Zakaria, 2021). This same criticism, directly
applicable to nursing, demonstrates the way White feminism is embedded within the very origin
of the profession and why it has taken so many decades to arrive at this point in the profession.
Racism in nursing has been obfuscated for over a century by the need to adhere to a
professional image of White altruism (Flynn et al., 2021). The professional image of nursing,
rather than the actual history of nursing, has impacted the nursing’s collective memory and its
professional identity, which is formed by the perceived, if inaccurate, understanding of its past
(Lewenson, 2004). Social dominance theorists’ term these “legitimizing myths” (Pratto &
Stewart, 2011, p. 2), which serve as vehicles that can disguise or make discrimination acceptable
within a group or society. Such myths have been identified across cultures, languages, and time
periods (Pratto & Stewart, 2011). The “legitimizing myth” of Victorian-era nurses as the
inventors of the profession through the omission of contributions by men and nurses of color has
served to reinforce a hierarchy-enhancing narrative whereby White, Anglo, Cis-Hetero, Women
become both pre-destined and entitled to represent and lead the profession (as they have for 160
years). The first step towards establishing a hierarchy-attenuating narrative that promotes a more
egalitarian culture is to affirm and disseminate the counter-narrative of all nurses (including, and
especially, those outside of the “legitimizing myth”) whose contributions have also shaped the
profession.
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This review intentionally included the historical influences on the field of nursing to
supplement the primary literature review, or, what the profession publishes about itself. How can
one review the literature without the context of who had the access and the control of what was
being published? As the profession often perceives itself to be ahistorical, it becomes necessary
to frame and reframe the profession within historical and socio-cultural context that has
undoubtedly informed the trajectory of the field. Whiteness is a residual social construct from the
eras of slavery, colonialism, and eugenics, yet the role of White feminism and White identity has
continued to exert a powerful, unnamed, and largely unexamined influence in the nursing
profession until the last decade. The length of tenure by White, female nurses to occupy every
position of professional leadership demonstrates the insidious strength of “legitimizing myths” as
a tool to maintain power. It is this myth that must be exhumed for the profession to move
forward. Indeed, American nursing is just that, inherently American, and with it, inherits the
same struggles around equity and equality that is found in the culture at large. Whereas in the
90s, researchers asked “Is there really racism in nursing?” the growing literature by 2020, in the
midst of a global pandemic and increased national awareness of social justice, answered
emphatically, yes, and to finally address it, please stop ignoring it.

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Chapter Three: Methodology
White female nurses dominate and occupy leadership positions across the professional
nursing ecosystem. The setting of research priorities, awarding of professional recognition,
accreditation criteria of nursing schools, licensure exam content and preparation, publishing and
editing of major nursing journals, authoring of textbooks, implementation of nationwide
licensure eligibility and setting curriculum standards by a homogenous group of nursing leaders,
have contributed to nursing’s composition as a professional White space (D’Antonio, 2010;
Flynn et al., 2021; Jackson, 1993). This study seeks to truncate the distance between the nursing
past and present by contextualizing professional history as a lens through which White nurses’
perceptions of their own racial identity development both impact and are impacted by the
professional nursing narrative. Exploring White nurses’ racial identity development aids in
understanding the otherwise intangible influence of racial identity that impacts and touches every
aspect of professional nursing today.
Research Questions
The research questions guiding this study sought to answer:
1. In what ways does White nurse racial identity development impact their positionality?
2. In what ways do nurses perceive their Whiteness within healthcare and nursing
education?
Methodology Approach and Rationale
The study used a two-phase explanatory sequential mixed method design to approach the
research questions. In this research methodology, the first data collection phase involved
soliciting quantitative data from a selected group. Based on the analyses, the second phase
followed sequentially to purposely identify a smaller subset of participants for further
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exploratory qualitative inquiry and interviews (Creswell & Creswell, 2018). In this approach, the
first phase informed the participants and question types for the second phase “with the purpose
of explaining the results or particular finding in more depth” (Merriam & Tisdell, 2016, p. 47).
Mixed methods research, such as illustrated by the explanatory sequential approach, integrates,
and combines both quantitative and qualitative design together for a comprehensive approach to
understanding a research question that may not otherwise be satisfied with one approach alone.
This approach, as seen in Figure 4, was selected to obtain insights drawn from both quantitative
and qualitative methods and mitigate the limitations of using only one methodology to explore
the complex notion of White racial identity.

Figure 4
Graphic Depiction of Explanatory Sequential Mixed Methods Design

Note. From “Mixed Methods Approaches in Family Science Research” by V. L. Plano Clark, C.
A. Huddleston-Casas, S. L. Churchill, D. O’Neil Green, A. L. & Garrett, 2008, Journal of
Family Issues, 29(11), p. 1551. In the public domain.

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The acceptance of mixed methods research has evolved over time, beginning with the
“formative period” (Merriam & Tisdell, 2016, p. 45) in the late sixties and early seventies when
interviews began to be used in combination with quantitative surveys. By the late seventies and
eighties, a period of “paradigm debate” (Merriam & Tisdell, 2016, p. 45) ensued among scholars
and researchers where it was questioned whether quantitative and qualitative designs could in
fact be used together, or if they were inherently incompatible based on antithetical
epistemological philosophies, with quantitative design representing a singular definition of
reality and qualitative design comprising constructed, perceived realities conceived differently
by groups and individuals. Procedural developments in the 1990s allowed for enhanced
clarification of how to approach mixed method research design, which has led to the “advocacy
and expansion period” (Merriam & Tisdell, 2016, p. 46) starting around 2000 through today and
gaining more widespread acceptance of the validity and reliability of the research method at
leading research organizations.
By beginning with a quantitative approach to collect data from White American nurses
via an online survey, the study focused on the desired population of interest and then narrowed
down to an interviewed subset of the sampled population to combine qualitative methods with
the research design. This design enabled me to collect a larger volume of data regarding nurses’
perception of White racial identity and explore any possible correlation with their length of
nursing practice, educational background, age, identified gender, or geographic region not
otherwise possible from qualitative interviews alone (as interviews are generally more limited in
scale and scope). During the first qualitative phase, select participants voluntarily opted in for
interview participation in the second phase. By initially inviting White American nurses to
participate in a quantitative survey regardless of age, gender, educational background, or work
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specialty, and then narrowing the nurses for interviews, there is a capacity to better understand
and describe how White nurses’ experience and perceive their WRID which builds upon and
furthers the findings from the first phase.
Semi-structured interviews were utilized during the second qualitative phase. This
technique leaves room for conversational dialogue, and a preconceived topical outline was
developed for the interview. This technique serves to flexibly guide the conversation in a semi-
structured capacity that allows for the development of a storyline and for the interviewer to adapt
to the conversation as it unfolds (Billups, 2019). Establishing a psychologically safe space for the
interview to be conducted was key for eliciting candid information in what is a potentially
uncomfortable conversation for White nurses to participate in. As video conferences offer “many
of the same benefits as in-person interviews” (Billups, 2019, p. 41), video interviews conducted
by me were used for transcription ease and logistical convenience of the interviewee. Interviews
were then coded and analyzed to best capture the essence of the interviewees’ experience and
perspective in aggregate (Saldaña, 2021). The coding process enhances the dependability of
qualitative results and the coding analyses into categories, themes, and theories strengthens the
authenticity and confirmability of the interview data. Member checking in the coding process
was also used to confirm data credibility (Billups, 2019).
Population and Sample
The sample included White American nurses of any age, gender, educational background,
or work specialty, who were working or retired. This approach comprises a more complete
survey strategy than recruiting White nurses from a single nursing organization or institution,
which would be limited in representing a cross-section of the nursing population. The sampling
approach used was “two tier sampling” (Merriam & Tisdell, 2016, p. 99), with the first tier
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including an anonymous online survey disseminated with snowball sampling. Follow-up
interviews, as the second tier, were conducted by surveyed nurses who voluntarily opted in for
online interviews (Merriam & Tisdell, p. 101). Up to 10 interviews were sought in order to
achieve either redundancy or data saturation of qualitative data. As the surveys are otherwise
anonymous, confidential, and de-identified, the nurses who opted in to participate in one hour
follow-up interviews, emailed me separately to keep their initial survey decoupled from their
identity.
The Researcher
Positionality refers to the assumption that power relations exist everywhere, including
within the research study itself. As such, examining how the power dynamic impacts and
influences myself as a researcher is needed to reflect upon and mitigate bias (Merriam & Tisdell,
2016). The act of talking about experiences related to race and identity can raise consciousness,
as well as cause emotional or psychological discomfort. Within the ethos of conducting “research
with people, not on people” (Merriam & Tisdell, 2016, p. 65), my status as a White American
nurse conducting research and interviews with select White American nurses means I am aware
of their role as an insider within the insider/outsider research paradigm. Acknowledging and
remaining conscious of their positionality as a White, heterosexual, able-bodied, American-born,
highly educated nurse enables a reflexive practice of how their identities influence the
interpretation of data collection. To best reflect the most authentic research findings as relevant
to the interviewees’ process of making meaning from their White racial identity, and not to
confirm bias, hypothesis, or my personal experience, I entered the process without preconceived
expectations of what they might find during the course of the research.
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Data Sources
I sourced data from the surveys and interviews, with both methods incorporating the two
research questions. This permitted a holistic data design strategy that accounted for combining
knowledge generated from quantitative surveys and qualitative interviews to more completely
understand WRID of White nurses without the limits of a single data source used on its own
(Billups, 2019). Surveying is effective and widely used in research as an opportunity to ask the
right questions in order to obtain truthful and accurate answers about what matters to participants
but can also be subject to survey fatigue and non-responsiveness, or questions left blank
(Robinson & Firth Leonard, 2018). For this reason, the survey was intentionally planned, pre-
drafted, tested, iterated, and kept to a maximum of 15 questions with user experience design in
mind to be respectful of nurses’ willingness to participate in the study (Robinson & Firth
Leonard, 2018). Interviewing is a reliable form of data collection but involves more time
commitment and is more labor intensive than surveying (Billups, 2019). Interviews are described
as purposeful conversations designed to elicit new knowledge and insight with “detail, depth,
and nuance” (Billups, 2019, p. 36) with an emphasis on the trustworthiness established in the
interaction between the interviewer and interviewee. As with the surveys, the interview questions
were also pre-tested and iterated before being finalized for live data collection.
Surveys
Anonymous surveys were conducted using snowball sampling and the Qualtrics online
survey platform. The survey contained seven close-ended questions; five open-ended questions;
one five-point Likert-scale section; and one section for respondents to select their level of
agreement using yes, no, or maybe. Seven closed questions established baseline demographic
information such as ethnicity, length of practice, age, level of nursing education, gender, and
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geographic upbringing. Five open-ended questions corresponded with research questions one and
two regarding nurses’ perception of White racial identity and their White racial identity in the
context of nursing and healthcare. The Likert-scale section and yes, no, or maybe section were
loosely adapted phrases from Helms’s White Racial Identity Attitude Scale (Helms, 1990) to
understand the level of agreement of White nurses to statements such as “I hardly think about my
race and has little to do with my identity” or “When you hear that the nursing workforce should
be “more diverse” is that a statement you agree with?” The use of “forgiving language”
(Robinson & Firth Leonard, 2018, p. 140) is a survey technique to minimize respondents’
discomfort to sensitive questions or questions perceived as a threat. As White nurses in a White-
dominant American culture, spaces for conversations about racial identity development are
limited and not part of the nursing curriculum. Appendix L includes the full survey protocol.
Interviews
Ten semi-structured interviews lasting approximately one hours were conducted by
myself via Google Meet to explore the perception of White American nurses. A list of guided
questions was used to ensure consistent information is elicited in each interview without
dictating the flow of the conversation or style of probing questions when needed (Creswell &
Creswell, 2018). The semi-structured interview approach is the most common method in
qualitative research and provides for the opportunity to ask more questions than non-structured
interviews, as well as flexibility for the interviewer to adapt in real time to the conversation
(Billups, 2019). This allowed for the interviewee’s verbal and non-verbal response to lead the
interviewer to follow-up questions or probes that culminated in a developed storyline of their
experience aligned with what the interviewer was aiming to learn. Approaches to establish trust
by the interviewer include genuine, non-judgmental listening, quiet patience, and appropriateness
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of response (Billups, 2019). The nurses’ consent and confidentiality were also ensured prior to
commencing and recording the interview to establish a trusting relationship between the
interviewee and interviewer. Appendix M includes the full interview protocol.
Participant Recruitment Strategy and Rationale
The following steps were deployed to recruit online survey participants during the first
phase of the exploratory sequential mixed methods study, which was conducted in the first 10
days of March 2022. The criteria on the recruitment messages were for White American nurses
of any educational background, in any specialty, and working full time or retired (Appendix N).
Snowball sampling using mostly email of known professional acquaintances was selected after
my doctoral colleagues found there to be invalid results when their survey links were broadly
disseminated across social media.
• Institutional research board (IRB) approval was obtained from the University of
Southern California.
• Once IRB approval was obtained, a link with the Qualtrics survey was sent using
snowball sampling via email and LinkedIn.
o The first email was sent to two dozen White American nursing colleagues with
diverse educational, clinical, age, and geographic backgrounds. The outreach
effort spanned known colleagues with overlapping work or academic history with
me, as well as informal professional acquaintances introduced via social media or
nursing networks. Nurses were asked to submit anonymous replies and continue
to forward the survey to other White American nursing colleagues.
o There were also two posts from the my LinkedIn at the beginning and end of the
survey response window with the link to the survey. This post was viewed 196
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times and received nine comments and 56 reactions. The post was also reshared
online by 11 nursing colleagues from their LinkedIn pages.
• The survey was open for a total of 10 days. This allowed for a follow-up round of
emails and a final LinkedIn post to be sent after one week, which still provided a final
72 hours for nurses to submit survey responses.
• The nurses who opted in for further interviews were provided an email to contact me.
• Data from the 67 respondents was collected and analyzed by me.
The second phase of the study, which included qualitative interviews, began once participants
from the first phase had been identified and occurred between March 10–17, 2022. The steps
included the following:
• The nurses who emailed me to opt in for interviews were scheduled according to the
convenience of their schedules.
• Thirteen nurses contacted me and a total of 10 nurses followed up with scheduling an
interview via Google Meet.
• Interviews lasted 60 minutes, with one interview lasting 90 minutes and one interview
lasting 120 minutes with transcription completed by Otter.AI.
• Data coding and analysis from the 10 interviews commenced following each
interview using ATLAS.ti, with additional rounds of coding repeated following the
final interview.
The use of an explanatory sequential mixed methods approach which combines a semi-structured
qualitative interview with quantitative survey data enabled me to access the illumination
(illuminates’ questions between the two methods) and diversification (uncover broader, more
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diverse set of findings than with one method alone) outcomes of mixed methods research
(Billups, 2019).
Data Collection Procedures and Instrumentation
Data collection in this study included two phases. This initial phase included an online
survey. Sixty-seven White, American nurses responded to the 15-item survey, which included a
Likert-scale section loosely adapted from Helms’s White Racial Identity Attitude Scale (Helms,
1990). To avoid “forcing” an inauthentic response, no questions were required on the anonymous
survey. For closed-ended questions, there was an observed drop-off of approximately 16
participants from the beginning to the end of the survey. Open-ended questions varied from a
minimum of 23 responses to a maximum of 47. Table 1 includes the variation of nurse
participants by survey question. There may have been a technical glitch on the free-text option to
enter gender identity or preferred pronouns, as it was never entered by any participants.

Table 1
Variation of Nurse Participants by Survey Type
Questions n
Questions 1–3 are closed demographic questions.
How many years have you been working as a nurse? 62
In which part of the U.S. were you primarily raised? 67
In which setting do you currently work? 67
Questions 4 and 5 are open-ended questions to prime nurses to think about their
White racial identity.

What age would you say you were when you realized you were “White”?
[Free Text]
64
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Questions n
Please describe any additional context or information about that experience. How
did it make you feel? Has it impacted how you’re thinking or perception about
Whiteness or what it means to be a White person? Has that experience been
solidified or challenged your identity as you grew older?
[Free Text]
47
Questions 6–9 are additional demographic and identity questions.
In which part of the United States do you currently reside? 65
How old are you? 64
Please list your gender identity or preferred pronouns.
[Free Text]
0
What is your highest level of education? 64
Question 10 is designed to understand the nurses’ current perception of their White
racial identity.

Please rate your level of agreement with the following statements. Users were given
a grid format displaying a Likert-scale 1–5.
51
Questions 11 and 12 are designed for more narrative opportunities, for nurses to
share stories or experiences that shape their identities.

If any of the statement above resonated, confused, or bothered you, please tell us
more. [Free Text]
26
Can you please describe a time when you became aware of your White identity
during a situation at work? Was this a positive, neutral, negative, or a learning
experience for you and how has it impacted future experiences? i.e., Do you
avoid similar situations, feel better able to handle them, or has it had no impact?
Please remember this is completely anonymous. [Free Text]
51
Question 13 is designed to understand nurses’ level of agreement to statements
about nursing education, workforce diversity, health disparities, racism, and
White privilege.

Please respond to the following statement with yes, maybe, or no. 51
Questions 14–15 allow nurses to provide further reflections on their White identity
within their nursing career.

Please tell us more about whether you perceive Whiteness as a barrier or advantage
in your career? Have you ever thought about your racial identity in terms of your
career? Have you ever considered nursing to be a professional “White space”?
Again, this is anonymous. [Free Text]
42
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Questions n
Please feel free to describe any other insights, questions, or comments that you may
have about your identity as a White nurse. Please remember this is completely
anonymous. [Free Text]
23
OPT-IN: This was a yes/no radio dial for nurses to select their interest in
participating in an interview. To keep the survey data de-identified, nurses were
an email to schedule an interview.
Yes = 24
No = 28

The survey included the ability to opt into a single follow-up interview, wherein the
nurses were provided my email in an otherwise anonymous survey. From the voluntary sample
of nurses who opted to be interviewed at the conclusion of Phase 1, 13 nurses emailed me. The
nurses were sent a self-scheduling link to find a convenient time slot and details of what to
expect and 10 nurses scheduled interviews. Interviews were conducted in English via Google
Meet between March 10–17, 2022 and transcribed using Otter.AI. Nurses had the ability to
reschedule up to two times should their schedule change, and a buffer week between March 17–
25, 2022 was allocated for nurses who require rescheduled interviews. Data remained
confidential and de-identified.
The interview commenced by building rapport with the nurses to establish trust. Types of
questions used during the interview included background, behavioral (what a person has done/is
doing), opinions/values (what a person thinks), and feelings (intuitive versus factual; Billups,
2019, p. 45). The sequence of the interview included four parts. The first is an explanation of
interview process, consent, and what to expect. The second consists of general questions to
warm-up and establish rapport, with questions such as their motivation to enter the nursing
profession. The third part entails core question sequence, with “saving challenging, sensitive, or
more complex questions” (Billups, 2019, p. 46) until the second half of the interview once
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rapport has been built. These included questions such as their first experience realizing they were
White, how Whiteness factors into their identity, perception of Whiteness as a barrier or
privilege in their career, and naming experiences of ways nursing education or the nursing
workforce has perpetuated or challenged White supremacy. During the interview, the use of
clarification, continuation, elaboration, attention, and steering probes were used as needed
(Billups, 2019). Fourth The concluding sequence finalized the interview process with an
opportunity for the nurse to debrief or offer any final thoughts or questions before ending the
interview.
During qualitative research design, the researcher becomes the instrument for data
collection where their capacity to induct, deduct, and ascertain meaning from participants
requires deep listening and engagement (Creswell & Creswell, 2018). Derived from the long-
standing work of anthropologists and sociologists conducted “in the field” to “giv[e] voice” and
describe the “intersection of social context and biography” (Merriam & Tisdell, 2016, pp. 6–7),
the use of interviewing spans both decades and disciplines. The use of semi-structured interviews
with White American nurses offers an opportunity to explore themes and trends, and also to
correlate any findings across the six schemas and two phases of Helms’s WRID model (Helms,
1990, 2020).
Data Analysis and Integration
Phase one quantitative survey data were analyzed for trends such as demographic patterns
and correlation between specific survey answers and nurses’ demographics or length of nursing
practice. Percentages and averages were aggregated based on survey responses to determine the
ratio and rate of the samples’ perception about their White racial identity. Phase two qualitative
interview data was analyzed separately but integrated with the aggregate representation of how
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White nurses in the survey responded. This involved a review of interviews transcriptions in
order to categorize and interpret interview data with my first-person insights conducting the
interview. The four phases of interview data analysis included (a) raw data management. (b) data
reduction (categorization), (c) data analysis and interpretation (reflecting the essence of the
interviewees’ perspective to tell the story), and (d) data representation (conceiving an organized
pattern for findings to be used as recommendations or conclusions; Billups, 2019, p.82-83).
Coding conducted during the data reduction phase has been used for over half a century
by qualitative researchers to thematically analyze interview findings as they relate to the research
questions (Saldaña, 2021). Coding using an iterative process was used for exploratory coding
methods which allowed for preliminary and tentative coding assigned to data as an initial review,
followed by a more specific first cycle or second coding cycle. In the second cycle, code
mapping, code landscaping, and code charting were applied for the best fit. The transition
between coding cycles allows the researcher to “strategically cycle forward” (Saldaña, 2021, p.
280) through the efforts from the first coding cycle. Representative coding was applied by
uploading de-identified transcripts to ATLAS.ti software. Coding interviews for meaning
requires the attributes of organization, perseverance, navigating ambiguity, flexibility, creativity,
rigorous ethics, and extensive vocabulary, which I strove to attain (Saldaña, 2021).
Mixed Methods Research: Rigor Qualifications
Effective mixed methods research entails ensuring methodological rigor for both
quantitative and qualitative methods used in the study. The rigor of the research is dependent
upon the finding’s credibility and dependability when using qualitative methods, and validity and
reliability when using quantitative methods. As such, this section will describe the strategies to
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ensure the findings from the mixed method study meets the standards for both research
methodologies. Table 2 details the bridge concepts applicable to mixed methods research.

Table 2
Commonalities Between Quantitative and Qualitative Research
Quantitative
lens
Qualitative
lens
Bridge Essential question
Validity Credibility Truth Are results believable? Do they appear
truthful?
Reliability Dependability Replicable Are results consistent over time?
Generalizability Transferability Applicable Are the results applicable to similar
settings?
Objectivity Confirmability Neutrality Corroborated through triangulation
Accuracy Authenticity Reality(ies) Are all “realities” represented?

Note. Table from Trustworthiness and the Quest for Rigor in Qualitative Research by F. D.
Billups, 2014, The NERA Researcher, 52, 10 (https://www.nera-
education.org/docs/TNR_Fall_2014_Color_Final.pdf). In the public domain.

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Validity and Reliability
Quantitative validity, or the trustworthiness of the study’s results, can be impacted by
internal and external threats, but are able to be mitigated by deliberate study design (Creswell &
Creswell, 2018). Threats to internal validity can impact the researcher’s ability to draw inference
from the data regarding their target population. I mitigated some selection threat by randomly
selecting nurses to participate in the survey instead of pre-selecting nurses who may complete the
survey in a specific or predicted way (Creswell & Creswell, 2018). Threats to external validity
occur when researchers draw incorrect inferences from their collected data. I mitigated this threat
by restricting generalizability of findings to groups outside those which participated (Creswell &
Creswell, 2018).
Credibility and Dependability
Qualitative validity indicates the research checks for accuracy of interview findings by
using certain procedures to ensure credible and trustworthy results. As such, validity strategies
were deployed in the study, such as member checking to confirm the findings resonate with their
experience, peer debriefing, and presenting negative or discrepant information (Creswell &
Creswell, 2018). Qualitative reliability means the researcher’s approach is consistent among
different researchers and different projects and confirms the consistency and dependability of the
study’s findings. This was accomplished through documenting procedures of data analysis and
confirming with participants that the conclusions were aligned with their lived experience when
needed. Figure 5 details the process of validating accuracy of qualitative analysis.

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Figure 5
Graphic Depiction of Validating Qualitative Data

Note. Graphic from Research design: Qualitative, quantitative, and mixed methods approaches
(3rd ed.), by J. Creswell, Sage (https://www.researchgate.net/figure/Data-analysis-in-qualitative-
research-Creswell-2009_fig1_269793586). In the public domain.

Limitations and Delimitations
A study limitation can be the use of surveys, which can be perceived as “inherently
imperfect and fraught with error” (Robinson & Firth Leonard, 2018, p. 5). As studies rely on
self-report, there is limited chance to assess non-verbal cues or the accuracy of the answers, as
well as risk of nonresponse. Should the surveys be answered incompletely or with social
desirability bias by the participants, the resulting findings will yield less validity. This is a
limitation within the use of survey deployment, though balanced in some ways by the
incorporation of mixed methodology which leverages the quantitative survey phase as a single,
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but not only, data source and used in service to identify a subset of the sample needed for the
qualitative research phase. A limitation of the qualitative interview phase is the reliance on
nurses to opt in which may, or may not, impact the interview results. Additionally, interview data
is subject to observer effects, the interviewer’s techniques, and the patience, engagement, and
truthfulness of the participant (Billups, 2019). With racial identity being an uncommon topic for
White nurses, there may be a reluctance to disclose true feelings. Ambiguity and lack of
vocabulary around how to describe their perception or experience was also observed. Known as
delimitations, researchers decide the study’s boundaries (such as time and sample) and what to
include or exclude for the study to be feasible (Creswell & Creswell, 2018). In this way, my
decision to interview no more than 10 nurses may or may not impact data saturation and study
findings.

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Chapter Four: Results
This chapter describes the mixed method study findings to explore White nurses’
perceptions of their racial identity. The American nursing profession has been a majority White
profession for a century and a half (D’Antonio & Whelan, 2009). Presently the workforce is over
75% White and 90% female, while the 2020 U.S. Census reports White, non-Hispanic
Americans comprise 57.6% of the population and women comprise 51.1% of the population
(American Association of Colleges of Nursing, 2019b; United States Census Bureau, 2021). This
research is relevant to understand the following research questions:
1. In what ways does White nurse racial identity development impact their positionality?
2. In what ways do nurses perceive their White racial identity within healthcare and
nursing education?
For generations, U.S.-based healthcare consistently delivers disparate outcomes across
racial and ethnic groups and calls to diversify nursing and healthcare professions have increased
over the last two decades as a solution towards achieving health equity (Institute of Medicine,
2002; Institute of Medicine, 2011; Institute of Medicine, 2021; Sullivan Commission, 2004).
Disparities in treatment within the nursing profession have also been documented. New findings
from the Commission on Racism in Nursing published in 2022 also reports that 6 out of 10
nurses of color report racism at work, while three out of 10 White nurses do (American Nurses
Association, 2022b). Less known is how White nurses perceive their White racial identity, if
their identity impacts their positionality, and how their identity intersects with healthcare and
nursing education. In a White-dominant profession, the lived experience of White nurses has
been less explored than marginalized nursing communities in the literature but is critical to
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understanding the intersection of identity and how White nurses navigate their careers in the
White space of nursing.
Participants
Quantitative sampling was conducted online between March 1–10, 2022. The primary
sampling technique used the snowball effect across professional circles via email and also two
posts at the beginning and end of the recruitment period on LinkedIn. To obtain a diverse cross-
section of nurse participants, I recruited American nurses who identify as White and are of any
gender, any age, any years of experience, practice in any nursing specialty in any work setting, or
are retired.
Survey Participants
The online Qualtrics survey link was administered by snowball email sampling to White
American nurses, with two posts on LinkedIn. The survey remained active for 10 days. A total of
77 began the survey, with 67 completing most closed questions. Between 51 to 23 nurses
responded to the open, free-text questions. The variation of respondents by question can be found
on Table 1 (in Chapter Three) and the survey questions can be found in Appendix L. The survey
contained 15 questions such as demographics, the age at which they first perceived their White
identity, a selection with Likert scales, a yes/no/maybe section, and free-text options to share
experiences in healthcare or nursing school related to their identity.
The surveyed nurses reported an average length of 26.37 years for their nursing careers,
with a minimum of 2 years and maximum of 50 years. The average age of surveyed nurses was
50.80 years old, with a minimum of 23 years old and maximum of 81 years old. In age and
length of career, this sample is representative of the current workforce overall. Twenty percent of
the respondents cited their current role as leadership positions, which reflects the longevity of
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career experience of the respondents. Geographically the sample was representative of the U.S.,
although more than half of respondents were raised (52%) and currently live (43%) in the
Northeast. Half of the respondents also held doctoral degrees. As less than 2% of nurses held
doctoral degrees as of 2018, this percentage of degree holders is over-representative for the
profession overall (American Association of Colleges of Nursing, 2019a). Table 3 is the
frequency table of survey respondents.

Table 3
Frequency Table of Characteristics of Survey Respondents
Survey characteristics Category n %
Years in nursing career
0 -9 3 4.93%
10–19 21 33.87%
20–29 11 17.75
30–39 14 22.58%
40–49 11 17.74%
50 or more 2 3.23%
Geographic upbringing
Midwest 15 22.39%
Northeast 35 52.24%
Southwest 0 0.00%
South 6 8.96%
Heartland 1 1.49%
West Coast / Hawaii 8 11.94%
Northwest / Alaska 2 2.99%
Not raised here 0 0.00%
Current workplace setting
Hospital 11 16.42%
Academic Faculty 15 22.39%
School (K - 12) 2 2.99%
Home Care 2 2.99%
86

Survey characteristics Category n %
Lab / Research 0 0.00%
Clinic / Medical Office 3 4.48%

Hospice / Long- or Short-term
Care 1 1.49%
Community / Public Health 4 5.97%

Administration or Leadership
(any setting) 14 20.90%
Retired 5 7.46%
Other 10 14.93%
Part of the United States you
currently reside
Midwest 12 18.46%
Northeast 28 43.08%
Southwest 3 4.62%
South 11 16.92%
Heartland 0 0.00%
West Coast/Hawaii 9 13.85%
Northwest/Alaska 1 1.54%
No longer live in U.S. 1 1.54%
Age
20–29 1 1.56%
30–39 13 20.32%
40–49 14 21.89%
50–59 16 25%
60–69 18 28.13%
70–79 1 1.56%
80 or older 1 1.56%
Highest level of education
LPN 0 0.00%
ADN 0 0.00%
BSN or other bachelor’s degree 6 9.38%
MSN or other master’s degree 26 40.63%
Doctorate (EdD, PhD, DNP) 32 50.00%

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Interview Participants
To retain survey anonymity, participants were asked to volunteer for an opt-in virtual
interview on White racial identity by emailing me directly. Twenty-four nurses stated interest on
the survey (replied “yes” to opting in for an interview), 13 nurses emailed me, and 10 nurses
scheduled and completed the interviews on Google Meet between March 10—March 17, 2022.
Interviews were transcribed using Otter.AI and lasted between 60 to 120 minutes. Participants’
length of their nursing careers ranged from 18 months to 50 years and represented different
practice areas (i.e., emergency room, intensive care, neonatal intensive care, detox, oncology,
home care, pediatrics, hospice, academia, national certification organization, and nursing
informatics) and different geographic locations (Northeast, Northwest, South, and Midwest). As
reflective of the over-representation of doctorally prepared nurses who responded to the survey
(50%), 50% of the interview participants were also doctorally prepared. Forty percent of
participants identified as queer or gay and 30% identified as Jewish, which are both over-
represented compared to the American nursing workforce. Names have been changed to ensure
anonymity of interview participants. Table 4 details the interviewed nurses’ characteristics.

88

Table 4
Characteristics of Interview Participants
Name Age
Gender/
sexual
identity
Upbringing Education
Current
residence
Work
experience
Daria 42 Queer
female
Raised in Born
Again
Christian
family from
Pennsylvania

Fourth-
generation
White
American
Second
degree
BSN
Wilmington,
DE
NICU lactation
consultant
School/camp
RN
Daniel 60 Gay male Raised in the
South Bronx
and Brooklyn

Second-
generation
Jewish
American
Diploma
nurse
master’s in
psych/ment
al health
DNP
Newark, NJ
Catskills,
NY
Oncology
Hospice
home care
Academia
Andy 52 Cisgender
male
Raised in a
Seventh Day
Adventist
family,
homeschooled
CNA
ADN
BSN
MS, PhD
Southeast
“Deep
South”
ICU
ED
Academia
Penelope 81 Cisgender
female
Raised in a strict
missionary
family in
Hawaii as one
of the few
White
children
BSN
Master’s in
child health
PhD
Oakland, CA Pediatric RN
Academia
Author
Mary 64 Cisgender
female
Raised briefly in
Puerto Rico
and mostly in
Michigan
BSN
Master of
Nursing
Education
PhD
Texas Case manager
Academia
CEO of
national
nursing
certification
organization
89

Name Age
Gender/
sexual
identity
Upbringing Education
Current
residence
Work
experience
Cait 44 Queer
cisgender
female
Raised in “the
Hills” of
Oakland, CA
identifies as
White and
Jewish
Second
degree
BSN,
Master of
Nursing
Education,
PhD
student
Buffalo, NY Abortion clinic
Med/Surg
oncology ED
Clinical
educator
Academia
Shelly 56 Cisgender
female
Raised in a
Zionist Jewish
family, briefly
in Florida and
mostly in New
York City
One of the
first direct
entry NP
programs,
recent DNP
graduate
Berkeley,
CA
HIV/AIDS RN
Academia
Declan 35 Cisgender
female
Raised on both
East and West
Coasts
BSN
Master’s
nursing
informatics
New York
City
Nursing
informatics
Alice 23 Queer
female
Raised in Seattle BSN Seattle Outpatient
detox
Jessica 62 Cisgender
female
Raised in
working class
Boston
suburb,
moved to rural
Connecticut
Hospital
house-
cleaner
CNA
BSN Master
of Nursing
Education
Boston Maternal health
Neonatology
labor &
delivery
Academia

The interview protocol is included in Appendix M. Interview transcripts were coded
using ATLAS.ti to find thematic patterns and corresponding coding. In reviewing the interviews
over several rounds, the codes were revised across all 10 interviews to reflect the most dominant
themes. Nurses were contacted via email during March to confirm demographic information and
to verify interpreted results.
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Results For Research Question 1
The following sections detail the findings derived from a synthesis of survey and
interview results. By capturing 10 in-depth conversations, the initial survey data is able to be
elaborated for meaning and interpretation. Each research question led to three unique findings,
which are described in detail, as well as summarized. The use of “Interview” or “Survey” sub-
headings indicate which data sets informed the findings, although the analysis was performed
holistically using both qualitative and qualitative data points to arrive at the finding results.
This question aims to understand the ways WRID impacts White nurses’ positionality.
Are nurses navigating White spaces prior to entering nursing school and how do White spaces
impact their level of consciousness of their racial identity? The findings indicate that (a) WRID
typically begins in childhood with primary influence from family; (b) White families generally
act to keep or seek majority White educational spaces; and (c) White racial identity changes over
time and nurses are active participants in learning on their own about how their identity
intersects with larger societal issues.
Finding 1: Messaging on Whiteness Typically Begins During Childhood From the Family
The nurses in both the surveys and interviews indicated that their family’s beliefs were a
primary influence of their first conceptualization of White identity. The majority of nurses in the
study sample first identified themselves as White by age 10. These messages were reinforced or
challenged by school or religious settings as they grew older.

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Survey Results
While a minority of respondents recalled no conversations about racial identity as a child
(i.e., null messages), others reported more explicit messaging from their parents and extended
family. Some nurses reported that they received positive messages, such as observing their
parents be kind to people that looked different from them as an early memory. Many nurses
reported receiving explicit messages from their families, often linked with religious beliefs, that
White people of Christian faith are “better”, or Jewish people are the “chosen ones.” Messages in
the form of approval or disapproval were also transmitted by multiple generations of family
members, typically by both parents and grandparents. Table 5 shows select survey results from
the question “How old were you when you first realized you were White?” which was
accompanied by a free text to elaborate on the experience. The table details the range of
responses (from null to mixed family messaging, and positive to negative family messaging) that
nurses received as children from their immediate family members, as representative of the range
of responses overall.

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Table 5
Survey Finding: Family Influences on White Racial Identity
Message category
Survey responses to describing the first time they realized they
were White
Null family message We never talked about being White or different growing up. I did
have friends from different religious or racial, ethnic
backgrounds
Mixed family message I was led to believe that though nobody is better than anyone else,
the only acceptable romantic relationships were those between a
male and a female of the same skin color.
Negative family message I was raised in a military family by parents who were 1950s
products of their time. I grew up in largely integrated housing
complexes with mixed families as my dad was a
noncommissioned officer. It was then that I saw the differences
in race and that I was forbidden to bring Black friends’ home,
but White friends were ok.
My mother brought home her new boyfriend; a Black man named
Sidney. Now even remembering his name tells me how much an
impression it made on me. Up until that point, I’d never
communicated with an adult person of a different race. He
seemed nice but uncomfortable. This was understandable, as my
grandparents, who were also there, were overtly racist. We never
saw Sidney again.
I don’t know that being White was anything special. I would hear
the adults talking about “coloreds” or “Jews.” We were Catholic,
so the fear of Jewish people was always a topic. Whiteness really
had no meaning at that point. As an adult, and with education
and exposure, I just think it is sad how racist and ignorant my
relatives were about what they believed and still believe. The
challenge for me is more with the White people I am surrounded
by who have no idea how their micro-aggressive behavior or
openly racist behavior is so offensive.
Positive family message I remember I was on a bus at Kennedy Space Center and a Black
family sat across from us and my mom was making small talk
with the family. It was nice, but I don’t remember ever realizing
before that time that I was White, and others were Black. I never
forgot that experience and I was so thankful to my mom for
being a decent human being and treating everyone with kindness
and respect.

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Further, over 60% of the survey respondents first perceived their White racial identity
between the ages of 0–10 years old, with the youngest perceiving their racial identity at age three
and the oldest at age 50 years old. The average age of reported racial identity awareness occurred
at age 10, with no correlating patterns found between the average age of White racial identity
awareness and a respondents’ geographic upbringing, current residence, current age, educational
level, or years of nursing experience. Within the survey data, nurses generally described their
first perceptions of White identity as being shaped by one of three sub-themes: the role of White
identity formation in specific contrast to Black or Non-White Americans, busing
17
to integrated
school settings, and White identity formation in relation to being a minority. Table 6 details these
three sub-themes from survey respondents to the question “How old were you when you first
realized you were White?” which was accompanied by a free text to elaborate on the experience.

Table 6
Sub-themes: When White Nurses First Perceived Their White Identity
Sub-theme Recalled memory of first perception of White identity
White identity in
contrast to
Black or non-
White
Americans
In elementary school our janitor was Black, and someone burned a cross in
his front yard and my parents had the conversation then.
I remember understanding that I was “not Black” rather than understanding
that I was White. Over time I’ve learned so much about Whiteness and
racial bias, especially what women of color face regularly in the
workplace.
I realized I was White when my best friend, who is not White was asked by
another child why her skin was dark.

17
The coordinated process of using bus routes to diversify a student body of a public school which started
in the 1950s and became briefly mandated between 1971 - 1990s. Some districts continue to use busing through the
present day, which districts, led by White parents, resisted at all costs (McRae, 2018).
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Sub-theme Recalled memory of first perception of White identity
1968 was a coming-of-age year for me. Dr. Martin Luther King and Bobby
Kennedy were murdered. I started to understand I lived in a world that
wouldn’t always value a person’s contributions but cared a lot about their
color and were willing to kill them for fighting for equality. I’m not sure I
developed an identity as a White person, so much as I began to see how
dangerous it could be if you were Black. My parents raised me to look at
people’s character first, not their ethnicity or their religion. Some of that
had to do with my father being an immigrant and being discriminated
against when he moved to this country. I gradually became aware of my
privilege.
I had a Black teacher in 2nd grade.
In middle school there was one African American in my school / class.
Role of busing I remember living in East NY Brooklyn during times when racial tensions
were high. My sister and I were assaulted by 4 ten-ish year old Black girls
in the neighborhood. We were in front of the apartment we lived in. We
moved to Staten Island to be in a safer neighborhood. In high school we
were picked on again by a group of Black girls being bused into our high
school from the Bronx. It’s more challenging to be White because it’s no
longer a color of acceptance. Even as a nurse I have been discriminated
against because of being White. A patient once told me they didn’t want
me caring for them because I was White.
1960: the New Orleans Four forced New Orleans public schools to integrate.
I was 4 and entered Kindergarten the next year but had 2 older sisters in
the house.
My awareness of my Whiteness at the time had more to do with NOT-
Blackness. I grew up in a somewhat racially mixed neighborhood in
Oakland, CA, and went to the neighborhood school which was
significantly more diverse due to busing. I remember realizing that I
would not likely have extensions in my hair, and that my parents did not
want me going to the mostly Black middle school for which I was
distracted, around age 9-10. I continued my education in progressively
Whiter environments, which made me uncomfortable and seemed strange
after my elementary school years.
Being a White
minority
My family moved to Hilo Hawaii when I was 7 years old, and I was one of
only two other White children in my grade. So, I was very aware of this
and assimilated as much as possible into the local multicultural, multi-
racial context.
I remember being aware that we were White in a community that was
almost all Black and Hispanic.
95

Sub-theme Recalled memory of first perception of White identity
I grew up in the “projects” as a minority White and experienced racism from
a very early age.
I grew up Eastern European Jewish 2nd generation American, it was clear
we were not part of the dominant culture, not White, flagrant anti-
Semitism. That started to schist in jr. high school (see the book when Jews
became White). I still struggle with White skin and the privilege it affords
while dealing with anti-Semitism in personal life and in the news. But it
does give me insights and I work in DEI spaces using my experiences and
my sense of allyship.

Interview Results
These findings and sub-themes were also consistent during the interviews, in which
nurses also described perceiving their White identity as children in elementary school. The
study’s interview findings showed the synergy between how White identities formed during
childhood or adolescence in combination with, or in opposition to, familial, religious, and school
influences. For Daria, she received consistent messaging between generations, as when both
parents and grandparents did not approve of Black friends they met at school. While Andy
shared how he received general support from his mother when he began dating a Black woman
as a teenager, though his grandfather disapproved, telling him that “back in my day we knew
where we belonged” (they later married). Jessica described her parents sending her to a Unitarian
church that promoted social justice, but then feeling that she was becoming “too open-minded,”
which grew in concern as she reached adolescence. When they moved to a Whiter neighborhood
in Connecticut as a teenager, she described how her parents’ use of the euphemism that the
“neighborhood was changing” blinded her to understanding that their move was motivated by
non-White neighbors moving in, which she learned later in her 20s.
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The interview data show how White nurses specifically received strong messages from
their parents around which spaces they belonged in as White Americans, especially as it related
to their education. A strong and recurrent interview finding found in five of 10 interviews was
the messages nurses received from their families around education and the subsequent actions
taken to physically relocate or insulate their children to Whiter schools or neighborhoods. Daniel
described receiving mixed messaging between generations of family members and of growing up
with overt phrases that implied everyone was created equal yet reading between the lines when
their parents decided to change their school or neighborhood. He described his Jewish
grandmother who worked with the NAACP and watching his mother cry over the assassination
of Martin Luther King, Jr. yet shortly after, having his family decide to move from the South
Bronx because the “n___ were burning it down.” Cait received messages that involved
celebration of the work of the local Black Panthers, but soon found that diversity was more
acceptable in elementary school before she was switched to a private middle and high school.
This experience left her to feel as though there was a predetermined path set for her. During the
interview she described how some initial ambivalence started when she was in high school:
I used to joke that I would attend DeVry Institute of Technology for college and the joke
of course (perhaps not funny looking back) is like, I’m a nice White kid from the hills,
like, of course I’m going to go to fancy liberal arts college. … Now I [realize] I was
really wrestling with the whole like “what life’s path am I being set up for in this in
environment?” as a White person and what if it was actually a better fit to find a different
path? I felt like I’m being sort of unwittingly sent down this funnel towards, you know,
privilege be-getting more privilege and I don’t know how to feel about it. But I did, in
fact, go to a fancy tiny liberal arts school. … I mean this is now 20 plus years ago and
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after I [met my White husband there, it’s like we have] sort of achieved our class destiny
by meeting each other at college and it feels like this is the funnel and I have, like, come
out the other end of the funnel.
Moving to more White environments during childhood or adolescence was a common
theme in the interviews and occurred across geographic regions of the country. Fifty percent
(five of 10) of the interviewed nurses spoke of their experience being moved to more
predominantly White neighborhoods or schools as a defining experience of their childhood or
adolescence. Although four of 10 nurses participating in the interviews were moved to more
White environments, Mary perceived her parents’ choice to move to more diverse neighborhoods
or school districts as their attempt to avoid racist messaging and a homogeneous upbringing. She
was born in Texas, spent some of her childhood in Puerto Rico, and then moved to Michigan.
When she reported to her mother, she didn’t want to befriend an elementary classmate because
“their skin was dark,” she described her parents’ efforts to intentionally move her to a more
diverse school district in Ann Arbor to subvert messages of White supremacy. Nurses also
reported they received external messaging about the value of White people within school
settings. This messaging tended to be secular and more implicit. For example, Penelope learned
that “only White history really matters” and shared how she experienced covert racial
segregation between classrooms based on “language proficiency” in elementary school. These
findings reflected how early conceptions of White racial identity are formed by the
interdependent influences between their family’s values and school social circumstances.
Finding 2: Perception of White Identity Evolved as Nurses Learn on Their Own
The interview and survey findings demonstrate how WRID was not stable over time.
Rather, nurses in the study described how their racial identity evolved and were shaped by socio-
98

cultural influence, lived experience, acquisition of new knowledge, and occurred at any age.
Nurses in the surveys and interviews, who ranged in age from 23–81, grew up and worked as
nurses during different eras, and era-specific socio-cultural influences were described as a
tangible factor impacting the development of their racial identity.
Interview Results
For nurses growing up in the 1960s and 1970s (four of 10 nurses), some experienced or
witnessed overt racism, antisemitism, homophobia, violence following Dr. Martin Luther King
Jr.’s death, or housing discrimination. For example, Penelope experienced housing
discrimination in the 1960s, when she and her Chinese husband were not shown a house for sale.
After nursing school, she found herself gravitating outside of professional nursing culture to
understand the social dynamics by joining a community bookstore to study Black feminist
thought. Nurses in the interviews reported ways they sought resources outside of nursing to
inform their practice. Jennifer began taking Speak Up
18
courses on bystander behavior because
she wanted to address passive racism during her academic career. Daniel frequently found his
non-White patients dismissed as “non-compliant” and sought skills from the discipline of holistic
nursing, which incorporated more spiritual aspects of patient care. The holistic practices and
integrative philosophies equipped him to better meet his patients’ psycho-emotional needs than
the clinical skill training (and stereotypes) he received in his diploma nursing school. These
insights from the interviews exemplify how nurses learn on their own to make sense of socio-
cultural influences of the time and sought ways to orient their care delivery or careers to be more
aligned with their values as their racial identity evolved.

18
Step Up Bystander courses are designed to help allies know how to respond when racism and
discrimination are observed at work, school, or in the community.
99

Interviewed nurses who grew up or worked by the 1980s and 1990s encountered less
overt racism and prejudices, but not the absence of them (eight of 10 nurses). Nurses described
incidences where nurses could be both challenged or oblivious when faced with external
influences or perpetuated stereotypes. For example, Jennifer was a labor and delivery nurse who
cared for a newborn who did not survive during her shift. The newborn was connected with the
Charles Stuart
19
debacle and she reflected how completely gullible she had been in believing a
Black man must have shot his pregnant wife (when, in fact, it had been a homicide committed by
Charles). Dani, on the other hand, shared how she attended film school at a state college in the
late 1980s and was required to take a social justice course to graduate. Twenty years later, she
described the impact of the course in permanently challenging the views from her sheltered and
religious upbringing and she frequently drew on the tenets of social justice when navigating her
first nursing role in an inner city neonatal intensive care unit (NICU), more so than what she
learned in her nursing curriculum.
Perception of White identity was not necessarily a clear-cut moment that they could
articulate or point to. Nurses who grew up in the 1990s showed how a culture of colorblindness
in part delayed their ability to see or recognize themselves as White, with two interview
participants describing a level of ambiguity in recognizing their racial identity. Cait described
how growing up during the “United Colors of Benetton”
20
era gave her the sense that race should
not be spoken of, in the name of everyone being “equal.” Yet despite messaging of equality, her
experience mirrored the book Why Are All the Black Kids Sitting Together in The Cafeteria
during middle school, with an increasingly segregated social circle that was never discussed. For

19
Charles Stuart was a White man who murdered his pregnant wife in 1989 and later died by suicide after
he was found to have lied that his wife had been shot by a Black man, he identified in a police line-up.
20
United Colors of Benetton was a popular clothing company who ubiquitously featured multi-racial
models in their campaigns during the 1990s.
100

Declan, she responded to the interview question of what it means to be White by wondering if
she was White and asking what specifically defined Whiteness or any other “race.” She
expressed a level of exacerbation in having her identity decided by society’s external meaning to
her complexion that did not personally resonate for her.
The participants also processed, or re-processed, their White identities as a result of both
personal and societal events. Three interviewed nurses reported feeling that they did not become
conscientious of their White identity until after the murder of George Floyd,
21
during which they
were already middle age, or older. Other nurses described active participation and effort to
educate themselves and other nurses which spanned decades and shared how they engaged in
ongoing reflexivity regarding both work and personal relationships. Shelly shared the moment
years ago when she recognized that
I always bring chicken soup, or “Jewish penicillin,” to friends when they are sick, but I
realized I was only bringing soup to my White friends. As soon as I recognized that, I
“caught myself.” Not only did I start bringing chicken soup to my friends of color, but
our friendships are deeper now because of it.
Rather than pat themselves on the back for being a “nurse who treats everyone equally,” the
interviewed nurses expressed both an ability and desire to examine and re-examine their own
behavior clearly, even when biased. They could also candidly admit to the interviewer the
potency and insidious nature of White-dominant culture (Appendix G), which required active
deconstruction of times they may have consciously or unconsciously engaged in prejudice or
stereotyping. Andy’s deeper examination of his White identity was prompted during his

21
George Floyd was murdered by a policeman who applied an 8 min 46 second chokehold in front of
witnesses in broad daylight in Minneapolis, MN and was later found guilty of manslaughter. His death sparked
nationwide protests across the world.
101

courtship and eventual marriage with a Black woman. He also spent time in his interview to
observe how the impact of the “post-racial” promise of Obama’s 2008 presidency provides his
colleagues with the perception that “racism is over because we’ve had a Black president,” and
that the same perception was shared widely by his nursing colleagues who believed that since the
American Nurses Association elected a Black male nurse president, “nurses can’t be racist.” His
personal relationship helped him understand how he operates differently in the world than his
spouse, while simultaneously navigating a White world that conceptually believes racism has
gone away.
Survey Results
Similar socio-cultural influences were also described by the survey respondents. The
selected quotes presented in Table 7 demonstrate how the survey respondents’ perception of their
White identity evolved over time. These surveyed nurses described how their White racial
identity evolved over time, often reflecting the schemas of Helms’s White racial identity
development model in which the Disintegration schema of the Internalized Racism phase
prompts the expansion of one’s sense of White identity towards the first schema of the Evolving
Non-Racist Identity Phase. For example, one nurse described their racial identity over time by
writing: they were “proud as a child, shameful as a teenager/early twenties, and feel I am
comfortable with who I am today.” The nurse entered their age at the time of the survey as 35
years old. The feeling of shame is part of the Disintegration schema. According to Helms’s
WRID, processed shame can transform into momentum towards the schemas of Evolving Non-
Racist Identity, as occurred for this nurse. However, when shame is unprocessed, the
Reintegration schema of realizing not “all people are treated equally” can compel someone to
102

instead idealize White culture and stay (sometimes permanently) in the Reintegration schema of
the Internalized Racism phase (Figure 2 in Chapter 2 lists the model).

Table 7
Survey Findings Reflect Ways White Racial Identity Evolves Over Time
Survey findings: Ways first perceptions of White racial identity evolves over time
I remember understanding that I was “not Black” rather than understanding that I was White.
Over time I’ve learned so much about Whiteness and racial bias, especially what women of
color face regularly in the workplace.
I realized I was White in kindergarten and as I’ve grown older, I realize I have an obligation to
use my privilege to help balance the scale. I need to recognize and check myself because our
system is broken.
I was raised to be “colorblind.” When I started working as a staff nurse, my colleagues, leaders,
and patients made it abundantly clear in many ways that your race defines you in many ways.
I have spent many years owning this awareness.
I experienced bullying from Black kids and was afraid of certain people and areas. As I grew
older, I challenged that fear.
Probably as my children were growing and heading off to college that I realized I was White
and needed to be more of an ally.
What does it even mean to be White, I think about this a lot. And I’m often ashamed of how
other White people behave.
I make it my responsibility to learn how to be better at being more inclusive to non-White
patients, coworkers, or students.
I honestly haven’t thought of being White as anything until the Black Lives Matter movement.
Now I am constantly seeing why that’s problematic, and how my Whiteness has and does
harm People of Color with the structures we live in at times.
At the time, I was concerned.” Reverse Racism” I realize it was not but an example of White
privilege.
I had many different feelings throughout my life. I was proud as a child, shameful as a
teenager/early twenties, and feel I am comfortable with who I am today.
I think I began having more of an awareness and experience of Whiteness as I’ve grown older,
I’ve been more aware of my Whiteness and how that influences how I move through life, as
well as the privileges I have and the challenges I need to make to myself and my beliefs to
challenge Whiteness and White supremacy. As a nurse, I’ve become more comfortable
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Survey findings: Ways first perceptions of White racial identity evolves over time
advocating for my patients but also understanding that I may not be the person they want to
receive care from if they are BIPOC, and that they deserve nurses and care teams that better
understand their experiences.
It made me curious about others, it made me more aware of how adults in my life perceived
Whiteness as a preferred identity. The experience helped me explore my own identity as I
grew and acted opposite to how I was raised. Exploring racial justice in college, I was able to
be honest about my growing up experience and it helped me understand how Whiteness as the
default in so many places really isn’t in our best interests.
I have become very aware of the privilege that comes with being a White woman and the
responsibility I have as a result of making sure inclusivity is practiced where I work, worship,
shop, play and live.
Did not really understand how non-White people were treated differently until in college
because I was fortunate to have grown up with friends of many races and cultures before
becoming a nurse. I was a theater and music student and worker. Working in healthcare and
seeing / hearing about discrimination was eye-opening.
I grew up in the same community that my dad was raised in. At age 15 our family moved to
rural Connecticut because my father felt like the town was “changing.” My parents never said
the words, but I understood it was because Black families were moving into the town. I didn’t
hear the term White flight till I was well into my 20’s.
I was 28 before I ever experienced being the only White person in a particular space. I was in
grad school on a bus, and it completely transformed how I view myself, my identity, and my
position in life. This happened WAY too late and gave me insight as to how the non-majority
may feel at any given time.
This is a space where I continue to learn and unlearn. I shudder when I think back on some of
the myriad ways in which I have failed to respond in such situations (like bystanderism)
and/or centered Whiteness and White feelings in the past, to the harm and exclusion of
racialized colleagues. I am trying to do better, and to build external accountability into my
actions and daily life. My practice continues to evolve, and I am sure I continue to make
many mistakes.

Surveyed nurses who used the free-text responses to describe the development of their
racial identity (n = 47), broadly described identity development towards the Evolving Non-Racist
Identity Phase, which occurred well into adulthood. Nurses used terms like “until only recently;”
“honestly haven’t thought of being White as anything until the Black Lives Matter movement;”
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“probably as my children were growing and heading off to college;” “well into my 20s;” “in
college;” since the “results from the recent national survey on racism in nursing,” were published
(in January 2022); and “once I was around more People of Color who experienced different
treatment because they weren’t White. I think as I’ve grown older, I’ve been more aware of my
Whiteness and how that influences how I move through life.” Several surveyed nurses also wrote
that they “continue to learn and unlearn.” The complete table is included in Appendix O.
These findings suggest the state of White racial identity is not one that ‘arrives’ in a static
place but seems to present itself as an ongoing inquiry across time, space, and situations. Over
time, nurses’ question both their own identity, and by extension, the identity, and values of the
profession itself. Wrote one surveyed nurse,
In the wake of the killing of George Floyd, nursing professional organizations all around
the United States released position statements about their commitments to “dismantling
structural racism.” In not one of these statements could I find a single mention of
Whiteness and how it operates to preserve a power status quo. Now every organization
has a “diversity committee”. I sometimes wonder what it would look like to rename these
committees: Instead of “diversity” what about the “decentering Whiteness and
redistributing power” committee? Would folks still be so enthusiastic? Would the labor
of such groups, perhaps, achieve more meaningful outcomes? I don’t know, but I do see a
whole diversity economy designed not to dismantle oppressions such as White
supremacy culture and structural racism but rather, to assuage White feelings by making
the issue all about the “diversity pipeline” not the inherent violence of Whiteness.
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Finding 3: White Racial Identity as a “Greased Wheel ”
Survey and interview data consistently described White identity in relation to privilege.
Every interviewed nurse connected their White racial identity with the privilege they are
afforded by American society. One interviewed nurse described their Whiteness as a “greased
wheel” that provided a certain ease and protection afforded by their skin color over their lifetime.
Nurses in the study sample reported their White identity providing an instant credibility and an
automatic sense of belonging in both American society and within healthcare and nursing spaces
and felt that they could apply to jobs without questioning if their experiences or names would be
negatively judged and advance in their careers without their authority being questioned. Even in
families that made exerted efforts to raise their children in diverse schools or neighborhoods to
promote an anti-racist upbringing, nurses reported that they continue live and experience their
privilege daily, whether not having to pay off substantial school debt, owning their home,
seamlessly being able to advance their careers or professional opportunities, or generally
avoiding microaggressions or feelings of being belittled.
Interview Results
Intersectional identities in relation to White identity were described by four of 10
interviewed nurses. Male nurses included male privilege along with their racial privilege. Other
nurses were able to see how even with experiences where they were marginalized by their
religion (specifically Judaism) or sexuality (nurses with queer or gay identity), they continued to
be afforded access and opportunities with their White privilege that they may not have had
otherwise. As shared by one Jewish nurse who was raised during the 1960s and 1970s, she
quickly acknowledged her privilege but also admitted,
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I don’t think I’ve ever felt 100% [White] … even in New York, Jews were decidedly not
White people when I grew up, and [when] you went to school, everything was about
Christmas. There was always this way that you were like, not invited to certain people’s
homes, people look at me and go, you have a really big nose and curly dark hair or ask if
I am related to Barbra Streisand. I wasn’t allowed to be with certain [White] friends from
[an early age in the] Girl Scouts. … [Jewish people] understand oppression, and Jews
also have a Democratic chop. In some ways, we really showed up for the civil rights
movement, and, but we also, enjoy our White privilege, too, so there are lots of dialogues
to have around this stuff. … I think my parents and upbringing sort of informed my
ability to be critical of nursing as a White space.
Privilege was also understood through seeing the lack of privilege in the struggles witnessed by
non-White students, peers, or fellow Americans. Alice shared a story of entering the nursing
profession at the same time as her peer, who was Iraqi-American. Alice witnessed first-hand
how, in addition to learning the ropes and being a novice in her profession, her peer was called a
“terrorist” and subjected to overt racial profiling. She admitted that own initiation into the first
year of the profession after graduation (when she was still “getting her sea legs”) was equally as
awkward as her friends’ in terms of them both being nursing novices. However, she recognized
that it was widely devoid of overt harassment or bias, with her Whiteness serving almost as a
protection in which she could just acclimate to gaining professional competence and not
simultaneously manage perceptions and judgments of her worth. As a new White nurse joining a
professional White space, she was aware that her Whiteness shielded her to some extent by
providing her with an extent of legitimacy she still “belonged” during a time when she otherwise
lacked a sense of competence, confidence, or professional power.
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Parenting and motherhood were also identified as a common shared humanity by some
participants. Although the nurses expressed an understanding of how their White privilege
functioned in American society as a protective factor, they desired a society in which all children
could thrive and feel safe and where all mothers could safely survive childbirth (alluding to
maternal health disparities among non-white Americans), regardless of skin color. Thus, these
participants could not only identify White privilege, but also understood that it was unearned.
Table 8 lists select responses by the interviewed nurses that described their association with
privilege and their White identity.

Table 8
Select Interview Responses to: What Does it Mean to be White?
Nurse Response to “What does it mean to be White?”
Daria Just a person in public sees me as a White 46-year-old woman with two blonde
children, you know, so I get all the advantages of that. I have that advantage
wherever we go. [In my career] there’s no question that I have that advantage. I’m
the person that is gonna [be accepted to] be the nurse and I’m [accepted as being] in
charge, and they [patients] kind of think that they should do what I say because [the
system is set up that] they want us to listen to the people that look like me and that
kind of stuff.
Andy I am the first person to acknowledge, and I don’t know why it’s so hard for White
males to do this. I’m the first person that I know of, to openly acknowledge that I
have privilege, that my life is not bad. I’m quite open about, you know, that, I
recognize my Whiteness, and I recognize my advantage and stuff like that, I tend to
avoid talking about White guilt. I don’t talk about White guilt. … I recognize that,
you know, mistakes have been made in the past, even I’ve made mistakes, everyone
has made mistakes, but I don’t dwell on that.... I am the complete opposite of what
most White men in this country, I am not afraid of questioning Whiteness.
Shelly I can [fit] easily in White spaces and people often perceive me as White and that does
make my life easier. … So much stuff comes with “White Cape.” I always had good
nutrition, I’ve gone to good schools, where I struggled, my parents paid for a tutor, I
learned to read The New York Times critically from a very young age to engage in
dialogue, so I can kind of go into any space and I might know how to come off
polished for an interview. I know about what a good cover letter is, a follow-up
thank you, how [to write a good] resume, so you know, I haven’t gotten every job
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I’ve wanted, but when I really wanted a job, I pretty much did get it.
Mary I would say that despite all that [my parents intentionally living in and sending me to
diverse schools], I very much grew up White privileged. My parents paid for my
education. I had to pay for my books and extra, I worked from I think 12 years old
on, with either a summer job or worked on the weekends, but I didn’t have to work.
I didn’t have to support anybody else. [As a White person] I’ve never felt like [my]
safety was threatened.
Alice I didn’t have any problems getting a job and I didn’t have any problems, you know,
being accepted as a nurse. I mean, there was, like some issues kind of just like,
lateral violence with like, being a new nurse, but I know that wasn’t because I was
White.
Jessica I think [being White has] made [it] pretty easy you know, made it very easy. You
know, go back historically. … my dad had a good job. He was a college teacher, it
got me free tuition to go to college. You know, I think being White totally, like,
greased the wheels. It made it pretty enjoyable and easy for me to have a career. I
feel like there seems to be a correlation between people that can recognize that and
not be fragile about it. Like, even if you refer to yourself and your colleagues [as
White and recognize] oh, we’re in a bubble, but there’s not a sense of like,
defensiveness. … I recognize my privilege. I mean, how can you not?

Survey Results
Survey data found in Table 9 also supported the perception of privilege afforded to White
Americans. Over three-quarters (76%, n = 39) of the respondents also reported that they were
aware of the concept of White fragility. This finding indicates a high level of awareness for such
a relatively new term in the American cultural lexicon. Data analysis found no statistically
significant different between awareness of White fragility with current geographic residence (p =
0.00001, Cramér’s V = 0.618), number of years working as a nurse (p = 0.185, Cohen’s f =
0.220), workplace setting (p = 0.000470, Cramér’s V = 0.632), respondents’ geographic
upbringing (p = 0.00001, Cramér’s = 0.718), age (p = 0.257, Cohen’s f = 0.168), or education
level (p = 0.00001, Cramér’s V = 0.626).

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Table 9
Survey Responses to Questions about White Privilege and White Fragility

Survey Question Survey Responses
Yes Maybe No
Percent n Percent n Percent n
Would you say that being
White has offered any
advantage for you in your
career?
68.63% 35 17.65% 9 13.73% 7
I am aware of the concept of
White fragility as the way
White people react to
conversations around race.
76.47% 39 15.69% 8 7.84% 4

The majority (69%, n = 35) of respondents indicated that being White has offered
advantages in their lives and nursing career. No statistically significant difference was found
between the responses to having advantages of being White in a nursing career and the current
number of years working as a nurse (p = 0.875, Cohen’s f = 0.0669), age (p = 0.907, Cohen’s f =
0.0589), education level (p = 0.00001, Cramér’s V = 0.622), geographic residence (p = 0.00001,
Cramér’s V = 0.646 ), workplace setting (p = 0.000108, Cremér’s Vb = 0.657), or respondents’
geographic upbringing (p = 0.00001,Cremér’s V= 0.638). Both survey and interview respondents
were asked if being White has been a barrier or advantage in their careers. While the interview
participants unanimously agreed being White was a career advantage, 13.73% (n = 7) of
surveyed respondents replied with ‘no’ and 17.65% (n = 9) replied with ‘maybe.
The findings of the nurses who chose to share their experience in the free-text option on
the survey about the role of Whiteness in their career revealed a sense that their Whiteness is
perceived as a barrier. Said one nurse, “At this stage of my career my race and age have become
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acute barriers.” Similarly, another said, “I have been explicitly excluded and harassed by Filipino
and Black colleagues for being “White.” Comments like, “Do you feel outnumbered as the only
White person?” “You think you’re so much smarter than us, don’t you, etc.” Another nurse
shared,
Being a White woman in nursing was and remains a safe space. One doesn’t really feel
different in this space. Increasingly though, being a White woman, and now an older
White woman, in nursing is viewed differently. There is more of a sense that being a
White woman in nursing makes you complicit to racist ideology and behavior.
Sentiments of Whiteness as a barrier to nursing was a minority finding in the survey (six
nurses of 42 free-text respondents). Broadly, nurses described ways being a White nurse was
beneficial. One nurse succinctly summarized her professional experience as, “It is an advantage
in the fact that it is never an obstacle.” Sharing that sentiment, three other surveyed nurses
described their lack of consideration to how their privilege functioned in their careers as
emblematic of the problem itself. Wrote one nurse, “I haven’t really considered my racial
identity in terms of my career, other than general White privilege which in my experience,
operates invisibly.” A second nurse wrote, “It is certainly an advantage from privilege. I have
worked with 98% only White colleagues, so it’s hard to think on, but clearly there’s a problem
with that statement alone.” A third nurse wrote,
This hasn’t ever been a thing for me. My feeling is that as long as I do excellent work and
hold myself to high professional and ethical standards, my skin color shouldn’t matter in
terms of professional advancement. However, I realize that shows my White privilege to
a certain extent so may not be helpful in this racially divided climate.
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For one nurse whose gender identification changed during their nursing career, they were able to
deconstruct Whiteness and the need to conform to Whiteness for career advancement as distinct
from gender norms:
I have at various times in the past used the hashtag #NursingSoWhite because while there
are absolutely amazing nurses of every background in the profession, the dominating
narratives, cultures, pedagogies and policies of the profession remain deeply grounded in
Whiteness and White feminism. When I was a newer nurse, and still coded as a White
woman, I am absolutely sure this rendered me all manner of privilege and unearned
power even insofar as I had to do less labor to interpret the culture around me and the
unspoken “rules” of it. Even now that I no longer identify as a woman, I know Whiteness
in nursing means that I as a White person get access to persons, conversations, power
spaces, social and professional networks, etc. that are systematically denied to persons
not read as White. Just look at the Academy; for generations it was basically an all-White
club, and even as that is slowly evolving the culture remains very much, at least to my
perception, dominated by Whiteness and White feminism.
Table 10 presents selected descriptions of how White nurses navigated their careers and
their level of consciousness around White privilege. The replies demonstrate that while the
majority (68.63%, n = 35) agreed it had been an advantage, some expressed sadness, reluctance,
or frustration when acknowledging an otherwise invisible structural benefit of their White
identity.

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Table 10
Survey Replies to Do You Perceive Being White Has Been a Barrier or Advantage in Your
Career?
Survey replies: Do you perceive being White has been a barrier or advantage in your career?
I work in nursing leadership. It is obvious in every setting I have worked in that being White is a
clear advantage to being hired and/or promoted into leadership roles. I have recently seen an
effort to promote POC but look in any boardroom or conference or leadership team and what
you see is White White White.
Whiteness has been an advantage. I cannot imagine the challenges and barriers I would have
faced as a Black man. Yes, frequently. Historically and more recently, the nursing profession
is a White space. Many nurses feel threatened and challenged when presented with this, but a
study of history reveals the reality of this. Only in the past several years do I feel progress to
challenge the White space has been made.
Totally agree nursing (especially nursing education) is a White space
There is no question in my mind that nursing is a “White space” and the lack of diversity in
nursing is due to this mindset.
Sadly, I know it’s an advantage, but I don’t want it to be
Nursing is a White female-dominated profession. There is no denying it. Therefore, it is safe to
say being a White female provides advantages.
Nursing is 100% a White space; I hate that it is and yet have benefitted from it.
Not sure. I think it would definitely be wrong to say that being White has not given me
advantages in all parts of my life. I have and did work very hard for my successes in nursing,
but I know non-White nurses have hard bigger obstacles and had to work harder for the same
thing.
My racial identity is frequently broached during my international work. My White racial
identity combined with United States citizenship have afforded me privilege in the ability to
work globally and to gain respect of global colleagues in a way that is different from my
colleagues of color.
I don’t worry that the people I am working with will ever have an issue because the majority are
White. I work in Houston, so I don’t know that nursing is so much a “White space” because
the nursing teams are usually a good mix of multi-cultures. I currently work as an interim
leader, and I do think that “Whiteness” is an advantage. I do not see very many interim
employees who are POC.
I perceive it as an advantage. I think the fact that I’m able to be a nurse, find a good job, and not
feel like I’m walking on eggshells at every turn is an advantage. My patients aren’t racist to
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Survey replies: Do you perceive being White has been a barrier or advantage in your career?
me, don’t second guess my thoughts based on my race, and I don’t face micro or
macroaggressions due to my race. I think nursing as it stands is a fairly White space and has a
lot of professionals that either don’t care about changing the space or actively appreciate how
they benefit from the systemic racism. There are so many changes that need to be made in
order to change the nursing space, and that starts with increasing diversity but also will come
from major systems changes.
I often am in exclusively White spaces or predominantly White spaces with People of Color
who conform or are forced to conform. I see both clinically and academically POC folks are
scrutinized in a way I rarely am.
When comparing experiences during the pandemic with a coworker of color; it has reminded me
yet again that we don’t all have the same experiences, even those of us in the same economic
strata.
I was most aware of my identity when caring for a young Black man with sickle cell whose pain
was not being treated appropriately and he was continually labeled the “frequent flyer with
sickle cell.” The combination of his racial identity, age, and illness led to care that I felt was
inappropriate and made me reflect on care I had received as a White, educated woman.
I consider my Whiteness a big advantage in my nursing career in two ways. The first, most
direct, is that I look (for the most part, I look “queer” I think) like what people generally
expect to see when they think of a nurse: i.e., a White cisgender woman. This is important
because the intersectionality of racialization and gender are so important to nursing. However,
I also consider my Whiteness an asset because of the work I do as a nurse educator and
scholar—anti-racism, deconstructing CIS heteropatriarchy—I am more likely to be
recognized and taken seriously as a novice nursing scholar because of being a White,
cisgender woman in nursing education/scholarship.

Summary of Findings for Research Question 1
On average White nurses, in both survey and interview findings, first perceived their
White racial identity as children between the ages of 3–10. Early influences for their identity
were their families’ values and were often informed by religion. This influence shaped children
at a young age whether they believed themselves to be “better” or “equal” to non-White
Americans and framed whether religious, ethnic, or cultural difference was affirmed or
“othered.” Ambiguity was also communicated whereby parents said one thing (“everyone is
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equal”) but did another (sending children to Whiter private schools). Across eras and geographic
locations, relocating or secluding children to White-majority school settings was also a
consistent sub-theme. At times, their experiences mirrored dominant thinking from cultural eras
(such as thinking colorblindness was effective or interracial marriage was wrong), but the
findings also showed how their racial identities evolve over time and could become more
informed and conscientious than what the average American media or society was modeling. The
majority of nurses who were surveyed and interviewed associated White identity with privilege
and societal advantages that were also identified when navigating a nursing career within a
professional White space, although several perceived their White identity as being a professional
barrier. Overall, White nurses largely navigated their understanding of their White racial identity
over their lifetimes without structured guidance and developed ways to learn independently apart
from formalized education. The survey and interview findings both indicated that a majority of
White nurses surveyed are open to learning about their racial identity in constructive ways and
desire understanding and skill building to be a positive and corrective force within a broken and
racially fraught cultural era.
Results For Research Question 2
The following sections detail the findings derived from a synthesis of survey and
interview results. The initial survey data is elaborated for meaning and interpretation in
aggregate, or in contrast, with the analysis of 10 in-depth conversations. Each research question
led to three unique findings, which are described in detail, as well as summarized. The first and
third findings include sub-headings for ‘Interview’ or ‘Survey’ results to distinguish the data set
which informed the finding, while the second finding comprises three sub-themes. The clinical
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and academic harm sub-themes were derived from the interview data and the harmful hiring
practices were derived from an aggregate of survey and interview data.
This section details how the study findings demonstrate the ways in which nurses’ White
racial identity intersects within the context of healthcare and nursing education. Does American
nursing education reinforce or challenge a White-dominant culture? How do White nurses
navigate workplaces which harm marginalized nurses, patients, and students? Have White nurses
developed the skill to leverage their privilege as an agent of change within their workplaces? The
findings across the surveyed and interviewed nurses reveal that nursing school experience across
generations has been and continues to be inadequate for challenging nursing as a White space
and has instead reinforced a White-dominant curriculum and matriculation agenda. Interviewed
White nurses also reported negative psycho-emotional impact as a “second victim,” across work
and school settings. The term second victim means that when observed harm is experienced by
marginalized patients, families, students, or fellow nurses, White nurses are also indirectly
impacted. Some instances of observed prejudice or discrimination that were shared in the
interviews had stayed with the nurses for years or decades. As White racial identity evolved
during their careers, White nurses also reported examples of using their privilege to serve as
advocates across workplace settings.
Finding 1: Nursing School Reinforces Stereotypes and Inflicts Harm
Although nursing school forms the basis of professional practice, surveyed, and
interviewed nurses described their nursing school experience as lacking in explicit preparation
and knowledge regarding health disparities and was largely observed as an educational setting
where stereotypes were reinforced. Interviewed nurses also shared how nursing school served as
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an initial setting of direct or indirect harm related to the treatment of marginalized students and
the carelessness or culpability of White faculty.
Interview Results
Interview participants corroborated the survey respondents’ experiences. These nurses
described the extent to which their nursing school experience perpetuated nursing as a White
space and centered the experience of White nurses and White patient populations. The ways in
which these White spaces were reinforced included having an all-White faculty; being in a
majority White nursing student body on a relatively diverse university campus; using White-
centered textbooks that “spoke to White learners” in othering ethnic and cultural differences, and
the frequently reported use of White manikins to learn nursing skills. Daniel described his
education from the vantage of being a “gay Jewish man at a pre-eminent Catholic nursing
school” in the 1980s and observed how little nursing education had changed over the decades.
He described his time as a student to his current role as a faculty in Northern New Jersey, where
he has faced “a lot of horizontal violence,” such as anti-Semitism and homophobia from faculty,
bullying of new faculty, and directly observed recurrent and explicit favoritism of White, female,
native English-speaking students. “Imagine the parents of the cast of the Jersey Shore,” he said,
“Now you can picture my fellow colleagues and faculty members.” He went on to explain that
the normalization of an individualistic culture minimized the role of collective culture which
encourages collaboration and working together. A byproduct he witnessed was that Hispanic or
Asian students were “instantly labeled as cheaters” when they were studying and working
together in order to support each other, while White students who were actually cheating would
get second chances.
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Other nurses were less attuned to racism in the moment during their education but
looking back could identify it more clearly. Cait attended an elite Northeast Coast school in 2005
and recalled how the curriculum made time to center issues affecting an individual White patient
(Terry Schiavo
22
life support case) but did not discuss the ethics related to the displaced Black
residents following Hurricane Katrina which had happened during the same semester. For
another nurse from a West Coast school, who graduated in 2020, she described how “there was
always this caution of like, we’ll talk about health disparities, but we’re not going to talk about
socioeconomics or politics, or gentrification, or like, racism, it was like, we’ll talk about it very,
very gently, so no one gets offended.”
There was agreement across interview participants that the nursing curriculum, in fact,
reinforced American gender, ethnic, cultural, and racial stereotypes although there was a
concurrent professional messaging to “treat patients equally.” This messaging was illustrated and
described by nursing students, as well as faculty. In the survey results, two anonymous replies
specifically articulate the cultural blind spots within nursing curriculum. One nurse wrote, “I
teach using the “equal treatment” fallacy all the time; nurses are inculcated with this idea that we
are TRAINED to treat everyone the same (or fairly, or justly, or whatever), but it is simply not
the case, and evidence of health inequity tells the story.” Another nurse wrote, “Recently I
realized all of the simulation manikin in our sim lab are White. It’s been over 2 years since we
purchased the equipment and I never noticed. It really hit me; I am still reflecting on it.”
Nursing school, for many interviewed, was also the first setting of experiencing or
witnessing harm. The stories shared by the interviewed nurses spanned eras from the 1960s

22
Terry Schiavo was a 41-year-old White woman who was kept in a persistent vegetative
state for 15 years and removed from life support in 2005.
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through to the present day. One nurse shared the experience of her mother who attended nursing
school during an era of separate cafeterias and drinking fountains. For a gay, Jewish, male in a
nursing diploma program in the 1980s, he struggled with a sense of belonging in a Catholic,
female-dominated culture and found that speaking up about discrimination during his career he
would often hear that “we are all children of God” as justification for why nurses would not, or
cannot, discriminate. For a White Jewish nurse in the 1990s, who attended a Southern nurse
practitioner program in the Bible Belt,
23
her personal marginalization within the program and
“whispering behind” her back combined with the bigotry of students around providing
cardiopulmonary resuscitation to patients with human immunodeficiency virus or their
unwillingness to deliver unbiased care around abortion, ultimately caused her to transfer nursing
schools. For another nurse, educated in 2010, she shared an experience, that although she had
been a teachers’ “pet,” she ultimately reported the faculty member for their bias against a trans
student. Students and faculty both reported and witnessed favoritism of White students and
harsher treatment for non-White or non-native English speakers. There was also a sense by
participants that there was no “litmus test” for the kinds of students or faculty that operated in the
educational space, with multiple nurses reporting tension or witnessing harm when faced with
both explicit and implicit bias of fellow students or faculty. For a nurse new to the profession,
she described her education as eye-opening,
It kind of made me realize, I think there’s this kind of celebrated image of nursing and,
you know, like nurses are great and angelic and they save people, but it also really, like,
wipes away any harm that they do a lot of the time.
Survey Results

23
Bible Belt refers to the Southern American states of the former confederacy.
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Twenty-two nurses (n = 15) of the surveyed sample listed their present work setting as
academic faculty and provided additional context that reflected their nursing school experiences
in the free-text responses and corroborated the harm described by the interviewed nurses. One
surveyed nurse wrote, “It breaks my heart how in nursing academia we hold the keys to who can
and cannot be a nurse. There is very little empathy, or diverse thinking,” while another nurse
expressed frustration with “nurses who refused to acknowledge Whiteness is a problem.”
As corroborated by the interviewed nurses, over 70% of survey respondents agreed with
the statement “In nursing school when we learn(ed) about health disparities we never talk(ed)
about the ways bias, racism, or structural or institutional racism impact poor outcomes” (Tavke
11). Data analysis found no statistically significant difference between not learning about bias,
racism, or structural or institutional racism in relation to health disparities with current nurses’
geographic residence (p = 0.00001, Cramér’s V = 0.632 ), number of years working as a nurse
(p = 0.136, Cohen’s f = 0.256), workplace setting (p = 0.000162, Cramér’s V = 0.651), nurses’
geographic upbringing (p = 0.00001, Cramér’s V = 0.654), Age (p = 0.287, Cohen’s f = 0.219),
or nurses’ education level (p = 0.00001, Cramér’s V = 0.591).

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Table 11
Survey Reponses to Question about Nursing School Preparation
Survey question Survey responses
Yes Maybe No
Percent n Percent n Percent n
In nursing school, when we learn(ed)
about health disparities we never
talk(ed) about the ways bias,
racism, or structural or institutional
racism* impact poor outcomes.
70.59% 36 11.76% 6 17.65% 9

*Defined as laws or policies that are based on racist beliefs designed to exclude groups of people

Since the average age of surveyed nurses was 50 years old and 50% of the surveyed
sample earned doctoral degrees, these findings reflected curriculum spanning the last several
decades across all degree program types (ADN, BSN, MSN, DNP, and PhD). Appendix B
depicts the connection between structural racism and disparate health outcomes. As school
curriculum encompasses social determinants of health without the context of systems of
oppression, nurses reported graduating with incomplete assumptions about root causes for health
disparities. Interviewed and surveyed nurses concurred that since the curriculum students receive
provides an incomplete understanding of how to address health disparities, nurses are essentially
trained to work within broken systems, but not to question them. The survey and interview
responses also indicated that nursing schools are sites where non-White, non-native English-
speaking students are not supported, which causes indirect harm to White students and White
faculty who observe maltreatment and may be powerless to remedy, prevent, or address it.
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Finding 2: White Nurses Witness Harm Across Settings
The first finding described nurses experiencing or witnessing harm that begins in nursing
school, and nurses also described ways they witnessed harm across workplace settings during
their resulting careers. Two nurses were visibly emotional during the interviews when describing
early nursing career experiences. One experience involved infants in the NICU and another with
pregnant patients in an outpatient detox unit. Harm was witnessed across clinical, academic, and
professional development settings, and was described as both horizontal and vertical. Harm was
directed towards patients, nurses, students, or faculty. Nurses described a range of reactions from
intervening, speaking up, involving leadership, staying silent, leaving their role or workplace, or
“still processing” the events, even years later. Jewish nurses also described explicit anti-Semitic
experiences that went unaddressed by their leadership, which reflects the intersectional nature of
White identity and how nurses can experience both privilege and discrimination and
marginalization. While the detailed findings of clinical and academic harm sub-themes were
largely drawn from the interviewed nurses, the sub-theme of harmful hiring was also
corroborated by surveyed nurses and served as the most emotionally charged free-text responses
on the survey.
Academic Harm
Within academia, interviewed nurses described the nursing school as a “hostile
environment” for non-White students who are then “judged based on the environment created.”
In looking through her school’s data, Shelly found that White students routinely had first choices
in preceptorship placement and “could do no wrong” during clinicals, whereas non-White
students would be “judged more harshly” as a result of stereotype confirmation, low
expectations, or overt racism during clinicals. This treatment resulted in non-White students
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trying to “fly under the radar” to not be noticed, which in turn meant that preceptors would know
less about their capabilities and potential and pass over them for harder assignments or
placement opportunities. In turn, these students would graduate with less experience in the
clinical areas they were most interested in pursuing such as the emergency room or a critical care
setting. White students were also made to feel “uncomfortable” having to witness implicit or
explicit bias from nursing faculty but were unsure how to intervene. In her role as a dean, she
went on to describe how she would generally look at negative behaviors by faculty as a
“teachable moment and moment for growth.” But in certain cases, the faculty would respond that
“they don’t see color” even though promising non-White students would be asked to leave the
program in their last semester because of 1 point off on an exam, or for having an outstanding
fee. This pattern was not observed for White nursing students (even with mediocre grades or
performance) who would “always” be given a second chance. Jessica, another interviewed nurse
in a faculty position, reported a story of her colleagues calling college security on two Black
male nursing students who fell asleep in the student lounge and disbelieved that they were
students when they did not have their badge. When she later tried to impress on them that if the
students had been “two White students with blonde ponytails,” the situation would not have
escalated to calling campus security, her colleagues confessed they could “not see the
difference.”
The interviewed nurses who work in academia agreed there was little to no organizational
reflection on the nursing culture or on faculty or leadership behaviors. They also reported disgust
at the performance of DEI and how the same schools that do not invest in helping non-White,
non-native English-speaking students succeed will then be the first to take photos of the students
as evidence of their diversity for brochures and websites or deal with discrimination lawsuits by
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using tokenism or having a “Black guy come for a mandatory talk once year” instead of actively
disrupting the White-majority culture by re-assessing tenure, recruitment, and retention of more
diverse faculty or students. Said one nurse faculty working in the South, who has chosen to focus
his energy on what is “fixable” in his institution: “If you don’t change the front end of the
pipeline, you’re not going to improve the backend of the pipeline, then you can’t change the
system.” Another nurse described the scandal on her campus when Black students wanted a safe
space to discuss George Floyd on their own and White nurses felt offended that they weren’t
invited. “It’s not easy to realize we [as White nurses] can be violent without intending to be, it’s
not an easy thing to cop to, but the way nursing is set up, it means that everything in nursing is
set up as if it is for us,” so we have fragility when it comes to exclusion, since we feel entitled to
everything within the professional space [the jobs, the promotions, the publications, the speaking
gigs, the tenure]. As a result, “we don’t know how to function when there is any space in which
we are not invited or don’t belong, which shows how much work we have to do.” Post-George-
Floyd, one new graduate nurse found moral courage to join a group that went to the dean to
report racist social media posts of a newly admitted student, but she admitted if she didn’t
“already have my diploma” she wasn’t sure if she would have felt empowered to participate.
Clinical Harm
Clinically, the White nurses interviewed also navigated the impact of White spaces and
both witnessed and internalized various types of harm. One nurse reported feeling caught in a
“system of harm” when working on a detox unit. After the adjacent birth center was closed
(“they used COVID as the excuse”), marginalized pregnant patients would need to go in and out
of the hospital for birth, without being able to consistently stay with their newborns while they
were in recovery from addiction. There were instances when children’s protective services (CPS)
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or police would need to be called and she questioned the merits of involving CPS or law
enforcement when there was a marginalized patient in active recovery. Additionally, she
witnessed mistreatment of Medicaid and “frequent flyer” patients with drug abuse histories when
they required medical transfers, sharing stories of a “pass the baton” attitude that delayed care,
worsened conditions, and left patients further reluctant to seek care in a timely fashion. As a 22-
year-old new graduate, she expressed a depth of emotional responses during the interview, which
she summarized by feeling powerless to dismantle a system which she knew was harmful and
that she was somehow contributing. Ultimately, she felt her only best option was to move to
another job where she didn’t feel she was contributing to harm. Even with more years of
experience, Daria also came to the same conclusion. After working towards a lactation
certification, she left a harmful neonatal ICU for a postpartum unit to support new mothers with
breastfeeding, but instead, she found a culture of fear that was not supportive of new mothers of
color or lactation work. She shared how the homogenous White, middle-aged staff was a
“boundaryless family” that “was not safe” for her or the patients. She ultimately let her lactation
certification expire and moved into per diem school nursing as a way to better discern which
school cultures were least harmful before signing onto a subsequent full-time position.
Nurses also reported the impact of White solidarity from White colleagues that left them
stunned, surprised, frustrated, or uncomfortable. White nurses describe how patient events could
reveal a nurses’ implicit or explicit bias. One nurse who had a diverse upbringing growing up,
realized through her clinical handoffs with other White nurses there was almost a coded
“warning” that she did not know to give about the race of the patients when she was giving a
report for change of shift. In the 1970s, she found herself being chastised by a coworker for not
informing the next shift that her patient was Black. Later on, a labor and delivery unit in the
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1980s, she was on the receiving end when a nurse described an interaction with a patient’s
family member. The White nurse told her,
Well, I went into the woman’s room after she had her baby and her big, Black husband
was naked in bed with her.” And I started laughing. And I said, Well, good for them.
They were all coddling the baby. But the way she said Black was really obvious. It was
like it was a problem that he was Black, and it was a problem that he was naked. And
probably there was a problem with the mixed baby. So, you know, I remember thinking
that and I said, “they’re bonding. They’re bonding as a family” and she looked at me like
I was an alien. But I remember thinking it was because he was not a White man with a
White mother and baby that there was even a story behind what was an otherwise normal
postpartum practice [to do skin-to-skin with your baby].
White nurses also reported how they navigated casual conversations where White
solidarity was conflated to a shared bias. Nurses report White colleagues downplayed race by
universalizing their White experiences (i.e., White nurses claimed to worry their sons “won’t
come home” to relate to the experience of Black mothers), engaged in victim blaming (i.e.,
blaming a teenager in a hoodie for not “respecting authority”) and poverty-shaming (i.e., blaming
poor patients for not affording a co-pay because they “have a cell phone”), or took “ownership”
of babies in the NICU which resulted in disempowering the parents. One nurse voiced her
frustration with presumed White solidarity: “people need to stop saying things out loud. Just
because you think I look like you, does not mean I agree with you,” yet expressing that she is
caught in a catch-22 about how to respond because “no one wants to admit they’ve done racist
things.” Some White nurses also reported being perceived as racist by White patients. Said one
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interviewed nurse, “I have had a lot of patients who are racist who assumed that I was too and
now I just cut them off when they started on a racist rant.”
Harmful Hiring
The lack of diversity in nursing leadership, as categorized as a nursing harm, was also
obvious to both interviewed and surveyed White nurses across workplace settings. One nurse
shared how “we are hurting a lot of people by creating this White space.” By not including the
right decision-makers in nursing leadership, she explained how there is a recurrent, negative
downstream effect that stubbornly resists dismantling at every level:
I have risen the ranks to nursing educational leadership, and I sit in some very big rooms,
and often I look around, and it’s like, everyone’s White, or I look around, and I’m like,
there’s one Black person. … So, we have to really be critical of how we look at things at
every level. “When I was dean, they were like, we need to diversify the students.” And I
was like, “Yeah, which means we have to diversify the faculty.” And they were like,
okay, and I’m a good recruiter, and I stay in touch with a lot of my students. So, I brought
in a lot of faculties of color to apply. And they set up my hiring committee that I have
nothing to do with, because it’s like, the president of, you know, the faculty. And my
hiring committee is all White. And I’m like, “wait a minute, like, how can you want me
to diversify, when here is a level that’s all White?” And people always [come up with the
most] ridiculous excuses [why their faculty aren’t diverse].
Witnessing harmful hiring practices was also corroborated by the survey respondents. Shared
another nurse,
I had an opportunity to be on a selection committee for staff instructors in a healthcare
organization. I proposed one candidate that was Black, one who was an Asian immigrant.
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I supported my decision by saying that both were highly qualified and would better
represent the population they were training. Neither were selected and all 10 final
candidates that were selected were White. I couldn’t believe it. It was a real eye opener.
The hiring practices that emerged from the survey data was one of the most contentious
and emotional areas of free-text responses. Replies revealed a range of emotions, from
frustration, to discomfort, to long-lingering confusion. One nurse shared a professionally
confusing hire involving a qualified Black candidate that had “stayed with her for 25 years,”
stating now they “would feel more confident in being able to have a conversation about it.”
Another nurse confessed that “when we interview a Black candidate, [I have the] feeling of not
knowing what to say, hard to relate to culture.” Other nurses shared the effort to diversify nurses
as being harmful to White candidates: “I have been passed over for jobs based on my
“Whiteness” because the organization wanted to hire other races to fill positions to look
“diverse.” Said another nurse, “Going for a position in upper management it has been made clear
that in order for the institution to make amends for structural racism and bias that the position
will not go to a White candidate.” Another nurse shared, “As a White nurse, it is the opposite
[from advantage]. Women dominate and exclude, bully us. Then I am passed over for promotion
because they want “diversity.” It’s a no win. Then we get subjected to trainings and BS surveys
like these discussing White fragility.”
Finding 3: Nurses Learn on Their Own to Leverage Privilege for Advocacy and Change
Despite not learning about the root causes of health disparities in nursing school (see
Finding 1 for Research Question 2), a majority of interviewed and surveyed nurses described an
ability to learn on their own about health disparities and issues of injustice in nursing. Agreement
scale responses from the survey largely demonstrated that the sampled nurses believed the lack
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of diversity in the nursing workforce was problematic, nurses should be allies for health equity
and advocate against injustice, and that racism impacted health outcomes (more than 60%
agreement across all statements). Although a majority of surveyed nurses described in free-text
responses how these issues required further learning, commitment, and action by White nurses to
be adequately addressed, a minority (n = 3) of surveyed nurses expressed opinions in their free-
text responses that indicated racism was overblown and nursing as a female-dominated
profession was a more pressing concern (of 67 total respondents, the agreement scales cited in
this finding section were completed by a total of 51 respondents and free-text replies were
answered by 23–47 respondents, depending on the question). On the other hand, interviewed
nurses unanimously shared examples and strategies of leveraging their privilege for advocacy
and working to enact change across a variety of workplace settings. Interviewed nurses described
examples of working towards addressing issues of equity or injustice within their professional
settings, leaving work settings that perpetuated them, or finding work settings that were more
committed to address them.
Survey Results
Table 12 shows that the majority of surveyed nurses agreed that racism was a real
problem that affected healthcare outcomes (65% of respondents, n = 33), that the nursing
workforce should be more diverse (88% of respondents, n = 45), and they were aware that non-
White American and non-female nurses were intentionally excluded from the profession (61% of
respondents, n = 31). However, there was widely shared agreement (76% of respondents, n = 42)
that their nursing careers would be improved by having a safe or brave space to have candid
conversations around race. This indicates that for the majority of White nurses surveyed, racial
literacy and understanding is an important aspect of delivering healthcare, but there are no spaces
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in which conversations can occur. This finding reinforces that for White nurses’ racial literacy
and WRID, they largely learn on their own, outside of formal relationships or access to
supportive structures.

Table 12
Survey Respondents Agreement of Racism as Root of Health Disparity, Need for Diverse
Workforce, Awareness of Men and Nurses of Color Excluded from the Workplace, and Access to
Safe/Brave Space for Candid Conversations Around Race
Survey question Survey responses
Yes Maybe No
Percent n Percent n Percent n
When you hear that the nursing
workforce should be “more
diverse,” is that a statement you
agree with?
88.24% 45 9.80% 5 1.96% 1
Racism is a real problem that affects
healthcare outcomes. We keep
funding studies to say what we
already know.
64.71% 33 21.57% 11 13.73% 7
Would you say your nursing career
would be improved by having a
safe or brave space to have candid
conversations around race?
76.36% 42 11.76% 6 5.88% 3
I am aware of the ways nursing has
intentionally excluded
immigrants, men, Asians, African
Americans, Hispanic, and Native
Americans from the profession
60.78% 31 21.57% 11 17.64% 9

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Free-text responses in the survey described how nurses were “continuing to learn,” that
their learning was “ongoing,” “worked on my beliefs about race all throughout my life,” or were
“doing more to support my non-White colleagues.” One nurse wrote how more equitable patient
care served as a motivation:
I have had some very candid conversations because I asked for honest dialogue. We need
more. We also need to create opportunities to flatten the race curve for health outcomes.
Our patients deserve to have ample opportunity to be cared for by competent nurses that
look, talk, and have similar lived experiences as them.
As seen in Table 12, the majority of surveyed nurses expressed agreement that health
equity and advocacy against injustice were shared beliefs that required deliberate action, rather
than passively “treating everyone equally” or “hoping it gets better for future generations.” The
majority (60% of respondents, n = 31) of surveyed White nurses also expressed a desire to
“actively be a better ally for health equity and to become more conscious of any bias that may
impact patient care or interactions” (31.37% agreed n = 16, and 29.41% strongly agreed n = 15)
and “even if I may be personally less affected by injustice or have a different lived experience as
a White American, it is still important to advocate for anyone based on human rights” (82%
strongly agreed, n = 41 and 6% somewhat agreed, n = 3). The majority (89% of respondents, n =
46) also disagreed that there was “nothing to be done about racism but hope it gets better for
future generations” (72.55% strongly disagreed, n = 37 and 17.65% somewhat disagreed, n = 9)
and that “racism could go away if we just treated everyone equally” (47.06% strongly disagreed,
n = 24 and 27.45% somewhat disagreed, n = 14).
Data analysis was conducted to identify any correlation with survey responses in Table
12 and nurses’ demographic variables. No patterns of statistically significant differences were
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found. For the survey responses if there was agreement that nursing should be more diverse,
there was no correlation with current geographic residence (p = 0.00001, Cramér’s V = 0.605),
number of years working as a nurse (p = 0.334, Cohen’s f = 0.183), workplace setting (p =
0.000217, Cramér’s V = 0.646), nurses’ geographic upbringing (p = 0.00001, Cramér’s V =
0.644), nurses’ age (p = 0.958, Cohen’s f = 0.0776), or nurses’ education level (p = 0.00001,
Cramér’s V = 0.599). For the survey responses if racism is a real problem that affects health
outcomes, there was no correlation with current geographic residence (p = 0.00001, Cramér’s V
= 0.686), number of years working as a nurse (p = 0.0950, Cohen’s f = 0.388), workplace setting
(p = 0.000111, Cramér’s V = 0.657), nurses’ geographic upbringing (p = 0.00001, Cramér’s V =
0.628), nurses’ age (p = 0.0822, Cohen’s f = 0.316), or nurses’ education level (p = 0.00001,
Cramér’s V = 0.601). For the survey responses if a safe/brave space would improve a nurse’s
career, there was no correlation with current geographic residence (p = 0.00001, Cramér’s V =
0.699), number of years working as a nurse (p = 0.0655, Cohen’s f = 0.315), workplace setting (p
= 0.00001, Cramér’s V = 0.706), nurses’ geographic upbringing (p = 0.00001, Cramér’s V =
0.648), nurses’ age (p = 0.215, Cohen’s f = 0.301), or nurses’ education level (p = 0.00001,
Cramér’s V = 0.645). For the survey responses if there was awareness of intentional exclusion
within the profession, there was no correlation with current geographic residence (p = 0.00001,
Cramér’s V = 0.660), number of years working as a nurse (p = 0.0331, Cohen’s f = 0.397),
workplace setting (p = 0.0000245, Cramér’s V = 0.680), respondents’ geographic upbringing
(p = 0.00001, Cramér’s V = 0.659), nurses’ age (p = 0.205, Cohen’s f = 0.237), or nurses’
education level (p = 0.00001, Cramér’s V = 0.621).

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Table 13
Survey Respondents Level of Agreement on Actions or Responsibilities Towards Decreasing
Racism
Survey question Survey responses
Question
Strongly
disagree
Somewhat
disagree
Neither
agree nor
disagree
Somewhat
agree
Strongly
agree
Percent n Percent n Percent n Percent n Percent n
I just treat everyone
equally. If we all did
that, racism could go
away.
47.06% 24 27.45% 14 3.92% 2 15.69% 8 5.88% 3
Racism is real for some
people, and that is such
a complex, enduring
societal problem there
is nothing we can even
do about it, but just
learn to live with it and
hope it gets better in
future generations.
72.55% 37 17.65% 9 1.96% 1 5.88% 3 1.96% 1
I don’t agree with
injustice for any group.
Even if I may be
personally less affected
by injustice or have a
different lived
experience as a White
American, it is still
important to advocate
for anyone based on
human rights.
6.00% 3 6.00% 3 0.00% 0 6.00% 3 82.00% 41
I actively want to be a
better ally for health
equity and to become
more conscious of any
bias that may impact
my patient care or
interactions with
coworkers, but I’m not
sure how to start.
7.84% 4 17.65% 9 13.73% 7 31.37% 16 29.41% 15
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Although the majority of respondents expressed agreement that nursing should be more
diverse, racism impacted health outcomes, and nurses should be allies for health equity and
advocate against injustice, there was not unanimous agreement among the surveyed sample of
White nurses as there was for interviewed nurses. Some surveyed nurses answered with a clear
stance, while others appeared to use their responses to work out and reconcile their bias and
opinions in real time. One surveyed nurse described White skin as “demonized” and nursing as
“hugely diverse” in their free-text response:
If you look at most hospitals there’s a huge Filipino contingent, throughout the U.S.
Appreciate it’s in vogue to demonize White skin, but it’s not reality. Hugely diverse and
with unions, not sure what structural racism means? Also, men make up less than 10% of
the workforce, why aren’t you addressing the major inequity in the workforce, over-
representation of women? If you want to truly improve the profession maybe start with an
actual disparity.
In response to the question at what age did they first realize they were White, this nurse
stated that they have “never realized” they were White. They responded “yes” that Whiteness
was a barrier to their career and replied “no” to being aware that the nursing profession
intentionally excluded immigrants, men, Asians, African Americans, Hispanic, and Native
Americans from the profession. Another surveyed nurse felt “rejected as a White supremasist
before I get a chance” and responded that “maybe” nursing should be “more diverse.” They
expressed that retirement had been a time of missing “interracial connections” and reflected, “I
had Black instructors and mentors and coworkers along the way, but at the end of the day, I
come home to a White culture.” They admitted that they “have a limited view of other worlds
outside my bubble. The best effort I can deliberately do is have more Black friends. Friendships
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teach tolerance.” A third surveyed respondent felt conflicted feelings that racism was overblown,
while recognizing groups that were vulnerable:
The more racism is shoved down people’s throats, the more they will rebel. There is a
clear division of us and them and that is a sad thing. In nursing, I view everyone the same
on the same level, while recognizing the vulnerabilities of certain races and classes and
socioeconomics.
These statements reflect the importance of anonymous surveys in contributing to candid
understandings of WRID, as they differed from the interview findings.
Survey data was also analyzed to identify any corresponding demographic attributes for
respondents’ level of agreement on actions or responsibilities towards decreasing racism. No
statistically significant differences between responses on treating everyone equally were found
with current geographic residence, number of years working as a nurse, workplace setting,
nurses’ age, or nurses’ education level (Table 14).
Table 14
Treating Everyone Equally Statistical Correlations
No statistically significant differences between
responses to treating everyone equally with:
p value Cramer/Cohen
Current geographic residence 0.000304 Cramér’s V = 0.496
Number of years working as a nurse 0.615 Cohen’s f = 0.283
Workplace setting 0.0000364 Cramér’s V = 0.620
Nurses’ age 0.939 Cohen’s f = 0.143
Nurses’ education level 0.00001 Cramér’s V = 0.610

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Table 15
Learning to Live with Racism Statistical Correlations
No statistically significant differences for
responses of learning to live with racism
with:
p value Cramer/Cohen
Current geographic residence 0.000434 Cramér’s V = 0.491
Number of years working as a nurse 0.692 Cohen’s f = 0.222
Workplace setting 0.0191 Cramér’s V = 0.529
Nurses’ geographic upbringing 0.00001 Cramér’s V = 0.578
Nurses’ age 0.832 Cohen’s f = 0.157
Nurses’ education level 0.0001 Cramér’s V = 0.627

No statistically significant differences between responses on learning to live with racism
were found with current geographic residence, number of years working as a nurse, workplace
setting, nurses’ age, or nurses’ education level (Table 15). No statistically significant differences
between responses on justice as a human right were found with current geographic residence,
number of years working as a nurse, workplace setting, nurses’ age, or nurses’ education level
(Table 16).

Table 16
Agreement on Injustice Statistical Correlations
No statistically significant differences on
responses to agreement on injustice with
p value Cramer/Cohen
Current geographic residence 0.00001 Cramér’s V = 0.571
Number of years working as a nurse 0.0161 Cohen’s f = 0.382
Workplace setting 0.000178 Cramér’s V = 0.590
Nurses’ geographic upbringing 0.00001 Cramér’s V = 0.597
Nurses’ age 0.206 Cohen’s f = 0.211
Nurses’ education level 0.00001 Cramér’s V = 0.622

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Table 17
Actively Wanting to Be a Better Ally for Health Equity Statistical Correlations
No statistically significant differences
between actively wanting to be a
better ally for health equity with
p value Cramer/Cohen
Current geographic residence 0.82 Cohen’s f = 0.182
Number of years working as a nurse
0.773 Pearson’s r = -0.0427, R-squared
linear regression = 0.00183
Workplace setting 0.29 Cohen’s f = 0.613
Nurses’ geographic upbringing 0.532 Cohen’s f = 0.253
Nurses’ age 0.0873 Cohen’s f = 0.354
Nurses’ education level 0.00001 Cramér’s V = 0.591

No statistically significant differences between responses of wanting to be a better health
equity ally were found with current geographic residence, number of years working as a nurse,
workplace setting, nurses’ age, or nurses’ education level (Table 17).

Interview Results
As reflective of the way nurses’ sense of their White identity evolved over their lifetime,
White nurses who were interviewed described ways they had learned, and continued to learn,
how to use their social capital, privilege, and voices across workplace settings to advocate for
more equitable treatment on behalf of marginalized peers, students, and patients. The
interviewed nurses expressed a responsibility to effectively dismantle the White space of nursing
and did not perceive increasing diversity as a threat related to “losing” personal racial privilege.
In fact, they deliberately sought ways to change systems or expand the pipeline for a more
diverse workforce, beginning in nursing school. All interviewed nurses described their work long
term commitment, not as something that was “done” or “over” after a single project.
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Nurses outside of academia described working in advocacy roles, such as reaching out to
coworkers, as Declan did when she saw non-native English speakers were struggling to have a
paper accepted for a conference and asked if they wanted help. Mary, who worked at a
certification organization, decided to form a partnership with marginalized nursing organizations
and together they waived the course review fee, certification, and re-testing exam fees, so cost
wouldn’t be a barrier for career advancement. She also offered certification starting with ADN
nurses, so they could access the benefits of certification. Several nurses in leadership roles also
discussed their work on boards at the national level and their advocacy to have more diverse
board members by calling out and addressing the limitation of all-White board membership.
For nurses in academia, there was considerable effort toward discerning between what
was “fixable” versus “unfixable.” David and Jennifer recommended and advocated for their
schools to hire non-White nurses when they held positions on hiring committees. Andy put his
time and energy into their classroom with their students and worked to ensure non-native English
speakers did not fall behind and could “see” themselves in nursing by presenting slides with
diverse nursing legends. Nurses like Shelly intentionally sought ways to use leadership roles in
academic spaces to address achievement gaps. She described herself as being “very mindful of
healthcare being extremely racist, and deliberately so” since she first started her career as an
LPN working with HIV/AIDS patients. After a promotion, she purposefully leveraged her role to
work on long term recruitment and retention strategies to counter the profession’s culture of
“weeding out” non-White students by providing marginalized or under-resourced students with
practical needs like textbook money or tutoring, as well as “TLC” to keep them encouraged
during times of family strife or instability. She described how she was able to support
marginalized students in navigating the hidden curricula and norms of academia so that they
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could enter the profession and was able to effectively close the racial achievement gap at her
California community college after her program was implemented and sustained. In fact, during
her program, the NCLEX pass rates and graduation rates improved for all students. Both David
and Shelly remained mentors to students long term and encouraged graduate school or other
opportunities to further their career. However, other nurses like Andy who didn’t hold a formal
leadership role expressed frustration that there was even more they could accomplish if there was
cultural alignment and committed leadership at their school to take responsibility for students’
success. David, Jennifer, and Shelly also learned when an institution was “unfixable” and found
they could be most helpful when leaving a toxic culture and finding a school that was more
amenable to supporting a more diverse faculty and student body.
Research Question 2 Summary
Nurses first become acculturated into the nursing profession through their experience in
nursing school. The shared experiences depict the way White nurses navigate a culture in which
marginalized students are always not given support, or students or faculty demonstrate bias.
Nurses’ school experience is also the first setting of ‘horizontal and vertical violence.’ Nurses
reported feeling a sense of powerlessness that begins during nursing school, of not knowing how
or who to report negative behaviors, or if they reported, if anything would change. Interviewed
nurses that did seek to report bias or discrimination found that little or nothing would change.
The majority of nurses did not receive information regarding the social construction of race
during school and found the textbooks and resources reinforce gender, ethnic, and cultural
stereotypes. After graduating to begin their careers, nurses are left to learn on their own the cause
of health disparities once they observe them in practice and how to best deliver care with diverse
patient populations. They again witness or experience harm from bias across work settings and
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learn to navigate on their own how to leverage their privilege in a way that can be constructive
for students, patients, and peers.
Summary
White American students enter nursing school with a variety of experiences that inform
their racial identity. Their earliest influences about racial identity come from family, religion,
and school, or the intersection of all three spheres of influence. The study findings demonstrated
that racial identity evolves over time and is not stagnant, which is also corroborated by Helms’s
research on Black and White racial identity (Helms, 1990, 2020). Entering nursing school is the
first experience witnessing harm within the nursing profession towards marginalized students or
patients, which continues through the nurses’ career across workplace settings. The White
American nurses interviewed and surveyed in this study were largely aware of their White
privilege and on their own, sought to make sense of health disparities and inequities during their
careers. Although some White nurses felt their racial identity was an increasing barrier in their
careers, the majority reported learning on their own about how to leverage their privilege in a
way that is more constructive to support the success of marginalized patients, peers, and students
and recognized that learning is a continuous process to which they feel committed.

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Chapter Five: Discussion
The nursing profession has been a majority White profession since its inception in 1860
and has been described by anthropologists as a professional White space (Barbee, 1994). The
goal of this study was to use mixed methods to understand the role of White racial identity for a
sample of American nurses. Qualitative interviews and survey data were used together to explore
the intersection between White racial identity and nursing. Chapter four provided findings
related to the following research questions:
1. In what ways does White nurse racial identity development impact their positionality?
2. In what ways do nurses perceive their White racial identity within healthcare and
nursing education?
Chapter five presents a discussion of the study’s findings and recommendations based on the
data analysis and available literature. The chapter concludes with limitations of the study and
areas of future research.
Findings
The thematic findings from the data correlate with the theoretical framework presented in
Chapter Two. Based on the findings, the two frameworks, Bronfenbrenner’s ecological systems
theory and Helms’s WRID model, intersect with each other in terms of how each ecosystem
influences nurses’ White racial identity. The nursing profession itself is directly influenced by all
systems of the ecological model and all phases and schemas of the White racial development
model. Just as with the ecological systems development of children, the nursing profession, as it
currently exists, is cross influenced by its history and past (chronosystem), attitudes and
ideologies of the dominant American culture (macrosystem), as well as systems like national and
international nursing organizations, the American healthcare system, capitalism, government,
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and the law (exosystem). The nursing profession is also composed of nurses who identify
themselves across the spectrum of schemas presented in Helms’s WRID model. The study
findings affirmed that some nurses are presently navigating an identity phase of internalized
racism while others are navigating an identity phase of challenging the status quo (also referred
to as “evolving a non-racist identity”). Both groups of nurses’ identities evolved based on
influences experienced throughout their ecosystems. The rate of change for the White-majority
nursing profession to move towards a less racist and more diverse workforce will largely occur
between the interaction of the pre-established professional norms, culture, rituals, and structures
(primarily represented within the microsystem and exosystem) and the individual nurses whose
evolving White identities correlate within one of Helms’s six schemas.
Research Question 1: In What Ways Does White Nurse Racial Identity Development
Impact Their Positionality?
As described by Helms’s WRID model, White racial identity develops over a lifetime and
is not linear or sequential, which was confirmed by the study’s findings. The associated schemas
of White racial identity may be progressive or regressive. Both societal and cultural influences,
as demonstrated by the ecological systems theory, as well as direct interpersonal relationships,
contribute to WRID and the positionality of White nurses. Table 18 summarizes the relationship
between the first research question, the thematic findings, the theoretical framework/existing
literature, and the related citations.

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Table 18
Relationship Between Thematic Findings with Theoretical Framework and Existing Literature
Research questions Themes
Theoretical framework /
existing literature
Citations
RQ1: In what ways
does White nurse
racial identity
development impact
their positionality?
Messaging on
Whiteness
typically
begins during
childhood
from the
family
Bronfenbrenner’s ecological
systems model incorporates the
spheres of influences from
family, school, peers,
workplaces, media, laws, and
government and Helms’s WRID
model affirms that White racial
identity exists in a state of non-
linear evolution during a
lifetime from schemas such as
obliviousness to entitlement of
privilege, to guilt, to adjustment
to accepting of White identity
while acting as an agent of
change.
Bronfenbrenner,
1977; Helms,
1990, 2020
Perception of
White identity
evolves as
nurses learn
on their own
White racial
identity as a
“greased
wheel”
Scholars confirm that in a White
supremacist society, White
people have privilege. In
Helms’s WRID model, half (3
of 6) of the schemas center how
White people reconcile their
privilege. These include
Reintegration (in which White
people express entitlement and
defense of their privilege as
being earned), Pseudo-
Independence (in which
privilege is mostly an
intellectual exercise), and
Immersion-Emersion (a seeking
to more deeply understand
privilege in regard to what it
means to be White) stages.
Jensen, 2005;
Helms, 1990,
2020;
Rothenberg,
2008;
Schroeder &
DiAngelo,
2010; Van
Herk et al.,
2011

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Finding 1: Messaging on Whiteness Typically Begins During Childhood From the Family
The study findings demonstrate that nurses themselves, as children, are primarily
influenced by their microsystem, which encompassed their family, school, peers, and religion.
There is also a secondary influence by the mesosystem, which is the interaction between the
microsystem and the child; does the family, school, and religion exist in harmony or are there
tensions, ambiguities, or counter-messages directed towards the child? It is during this phase of
childhood development that children enter what Helms describes as the first of two phases of
White racial identity: Internalizing Racism (note: recent modeling has removed numerical
reference of “Phase 1” to “Phase”). Figure 6 relates the interaction between the schema of the
internalizing racism phase and the dominant influence of the micro and mesosystems.

Figure 6
Interaction Between Microsystem, Mesosystem, and Internalized Racism Phase of White Identity

144
145

When nurses in the study described the role of busing in forming their first perception of
White identity, the interaction between ecosystems and the development of White racial identity
was apparent (demonstrated by the dotted and solid lines in the Figure 6). The chronosystem
influence of historical time frame, the macrosystem influence of cultural ideologies, and the
exosystem influence of government/laws impacted the microsystem of school with the
mesosystem of their parents’ subsequent response. In turn, this federal level policy directly
impacted personal WRID.
Finding 2: Perception of White Identity Evolved as Nurses Learn on Their Own
This second finding from the study also connects with the framework and model of
Bronfenbrenner and Helms, wherein influences from the ecosystems impacted the development
of White racial identity. For the majority of the nurses in the study and nearly all of the nurses
interviewed (nine of 10), this identity development turned towards the phase of challenging the
status quo (also referred to as evolving a non-racist identity). A sub-theme that emerged from
speaking with the interviewed nurses was the macrosystem influence of American culture post-
George Floyd, from which at least three of 10 nurses directly pointed towards contributing to
their WRID and shifting towards the White racial identity schema of pseudo-independence.
While some nurses could still be identified within the schema, others had shifted their identity
towards Immersion/Emersion or Autonomy. Figure 7 illustrates the schemas of White racial
identity as they correspond to this phase, affirmed in the study’s findings.

146

Figure 7
Image of Helms ’s Evolving Non-Racist Identity Phase of White Racial Identity (revised name)

Note. Helms has since removed the numerical inference for this and the primary phase of her
model and renamed this phase to Evolving Non-Racist Identity. From A Race is a Nice Thing to
Have: A Guide to Being a White Person or Understanding the White Persons in Your Life, by J.
Helms, 2020, Cognella. Copyright 2020 by Cognella.

Finding 3: White Racial Identity as a “Greased Wheel ”
In Helms’s WRID model, three of six schemas relate to perception of White privilege.
The schemas include a sense of entitlement of privileges (reintegration schema), a reckoning of
one’s privilege (Immersion/Emersion schema) and abandoning entitlement to leverage privilege
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as an agent of change (autonomy). The study findings show how White nurses’ identities range
across these three schemas.
Within America, many scholars widely agree that in a White supremacist society (a
society in which there is built in structural and institutional advantages based on White or light
skin color), White people will have privilege (Rothenberg, 2008). There is also agreement that
the social construct of Whiteness, in and of itself, does not require White people to have a self-
identity as any racial or ethnic identity, which results in having the privilege of not having to
reflect on your own identity (Van Herk et al., 2011). Helms subversively referenced this
phenomenon in the title of her most recent book, A Race Is a Nice Thing to Have (2020) and has
been notoriously described as an “invisible backpack” which White people must learn to unpack
(McIntosh, 1982). This phenomenon was demonstrated by two interviewed nurses who
questioned their White identity and were reluctant to identify as White and was also found in the
free-text survey responses. Said one survey participant, “I am not a White nurse; I am a
NURSE.”
Within nursing, anthropologists since the 1990s have demonstrated the ways the
profession preserves White professional privilege by valuing homogeneity of the workforce and
has resulted in professional closure (historically and presently), as depicted in Figure 8 (Barbee,
1994). Given the propensity of the profession to privilege Whiteness, the role of Whiteness in
nursing becomes normalized within nursing practice until it is “reinscribed ever more deeply”
(Schroeder & DiAngelo, 2010, p. 253). Normalization of Whiteness makes it harder to dissociate
“the hegemony of White, middle-class perspective that directs nursing research, practice, and
education” (Van Herk et al., 2011, p. 29) from the profession itself. This was confirmed by the
findings that the majority of nurses in the study described their White identity as an advantage
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within the profession, with some stating that they were “comfortable” and described a sense of
belonging in the profession. This is affirmed in the literature when scholars describe existing in a
White space with the phrasing “a membership has its privileges” (Rothenberg, 2008, p. 163).

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Figure 8
Anthropological Diagram of Ways the Institution of Nursing Preserves White Privilege

Note. Depiction of preserving White privilege graphic from “White Public Space and the
Construction of White Privilege in U.S. Health Care: Fresh Concepts and a New Model of
Analysis” by E. Barbee, 1994, Medical Anthropology Quarterly, 8(1), 109–116
(https://doi.org/10.1525/maq.1994.8.1.02a00120)

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Research Question 2: In What Ways Do Nurses Perceive Their White Racial Identity
Within the Context of Healthcare and Nursing Education?
Table 19 summarizes the relationship between the second research question and the
thematic and sub-thematic findings with the theoretical framework and existing literature (with
their relevant citations included).

151

Table 19
Relationship between Thematic Findings with Theoretical Framework and Existing Literature
Research
questions
Themes
Sub-
themes
Theoretical framework /
existing literature
Citations
RQ2: In what
ways do
nurses
perceive
their White
racial
identity
within
healthcare
and nursing
education?
Nursing
school as
initial
setting of
harm and
reinforces
stereotyp
es
Bronfenbrenner’s ecological
systems model describes the
influences of schooling or the
workplace (microsystem) in
relation with governing laws
(exosystem) and cultural attitudes
of the dominant culture
(macrosystem), which are also
influences within the profession
of nursing. Harm experienced by
nurses and nursing students
within the microsystem of the
school or workplace has been
described since the 1600s and is
presently conceptualized in the
literature with concepts such as
epistemic violence, moral injury,
second victim, horizontal
violence, and oppressed group
behaviors.
Banerjee et al.,
2015;
Bronfenbrenner,
1977; Bryant &
Murillo, 2022;
Canty et al.,
2022; Cox et al.,
2021a; Dancis &
Coleman, 2021;
Jeffries et al.,
2018; Jones &
Treiber, 2012;
Langtree et al.,
2020; Louie-
Poon et al.,
2022; McKenna
et al., 2003;
Roberts et al.,
2009; Rowlands,
2021; Scott et
al., 2019; Stake-
Doucet, 2020;
Villarruel &
Broome, 2020
White
nurses
witness
harm
across
settings
Academic
harm
Clinical
harm

Harmful
hiring
Nurses
learn on
their own
to
leverage
privilege
for
advocacy
and
change
As Helms’s WRID model suggests,
a healthy White identity can be
attained. Half of the schemas in
Helms’s model are categorized
under the phase of Evolving Non-
Racist Identity in which White
people begin to dissociate
entitlement from their identity
and serve as agents of change.
Bronfenbrenner,
1977; Helms,
1990, 2020;
Roberts, 2000

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Finding 1: Nursing School Reinforces Stereotypes and Inflicts Harm
It has been argued that nursing education, in the 21st century has “appeared to fully
commit to doing nothing at all about structural and systemic racism” (Darbyshire, 2022, p. 1).
The context of nursing education exists generally within Bronfenbrenner’s microsystem, while
also reflecting (or deflecting) the broader influences from the exosystem (healthcare system,
nursing organizations, government), macrosystem (attitudes and ideologies of American culture),
and chronosystem (influence of past and historical eras). These interlocking systems move
slowly and are challenged to respond in real time to calls for social justice or inclusion and
belonging, and largely operate in the background of students’ experience.
Over 70% of survey respondents agreed with the statement “In nursing school when we
learn(ed) about health disparities we never talk(ed) about the ways bias, racism, or structural or
institutional racism impact poor outcomes.” The absence of explicit instruction linking structural
racism with health disparities, means that stereotypes, cultural inferiority scripts, and victim
blaming can instead be replaced to justify poor health outcomes (Dancis & Coleman, 2021; Scott
et al., 2019). The roots of deficit thinking in nursing extend back to Nightingale, who blamed
Indigenous illnesses on their lack of hygiene and lack of obedience to a Christian God, rather
than the germs introduced by the British, the outlawing of Indigenous healing and sustenance
practices, destruction of families, or the economic marginalization related to the expansion of
colonial empire (Stake-Doucet, 2020). The absence of information which describes the role of
racism in causing health disparities thus leaves inequitable systems both de-identified and intact
(Appendix B). This lack of explicit curriculum has been described in the literature as “covert
mechanisms of racism” (Louie-Poon et al., 2022, p. 1), and as the “hidden curricula messages
within schools that speak to our students” (Villarruel & Broome, 2020, p. 375), which then leave
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nurses unprepared to practice in the context of inequitable systems, or left to feel that they did
not “have the best training or knowledge” (Morone, 2021, p. 2) as their career progresses.
The study findings, as illustrated in Figure 6, clearly indicate that students enter nursing
school with a phase of internalized racism that may or may not have been reconciled. Once in
nursing school, the nurses in the study described interactions with colleagues or professors who
themselves were in various stages of their own WRID and were witnesses to lateral and
horizontal violence and workplace bullying. This finding refutes the idea that has long been
accepted in nursing that, to some extent, nurses must be inherently good or virtuous (Nelson &
Gordon, 2012). As conformity and colorblindness (treating everyone the same) is part of the
microsystem of nursing education, WRID may progress, regress, or stay unchanged according to
the influences of the curriculum within the microsystem. Lack of non-White representation in
textbooks and in clinical simulation manikins were reported by the nurses and supported in the
literature (Canty et al., 2022).
Of particular concern in nursing education is the tendency to “reward those who guard
[the professional White space] with upward mobility” (Barbee, 1994, p. 112), which is seen
across macro disparities of retention and recruitment efforts of student and faculty, to micro
disparities of grading practices, hair discrimination, or lack of support for non-native English
speakers (Bryant & Murillo, 2022; Cox et al., 2021b; Prather et al., 2018). These findings were
largely validated by the nurses interviewed in descriptions of nurse educators and administrators
who acted punitively and without consequence. Figure 9 highlights in green the aspects of White
supremacy that were present in nursing education from the literature and study’s findings.

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Figure 9
Aspects of White Supremacy Presented in Nursing Education

Finding 2: White Nurses Witness Harm Across Settings
Interviewed nurses unanimously reported witnessing or experiencing harm which began
in nursing school and continued throughout their careers. This finding is a supported
phenomenon in nursing literature, both domestically and internationally. Nurses historically have
experienced psychological “suffering” as documented as early as 17th century nursing textbooks
when they could not provide an adequate level of patient care (Langtree et al., 2020). The study’s
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findings reiterate the extent to which a sample of White American nurses’ experience or witness
inequitable care or harm in the clinical, academic, and workplace settings that negatively affect
their peers, students, faculty, patients, or leaders and result in psychological distress. Nursing
researchers have continued to describe and articulate the concept of harm through the following
terms, listed in Table 20, which correspond with the stories shared by the interviewed nurses.

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Table 20
Terms Describing Harm Experienced by Nurses
Term Definition Citation
Epistemological
violence
Also known as slow violence. This four-fold violence is
associated as an extension of colonialism, ableism, and
sexism and includes violence against the subject of
knowledge, the object of knowledge, the beneficiary of
knowledge, and against knowledge itself which results
in dehumanizing experiences that threatens one’s
integrity. In healthcare this is seen by omitting
concepts/conceptions of “othered” peoples and
interpreting observed group differences to be caused by
inherent inferiorities of “othered” peoples.
Banerjee et al.,
2015; Shiva,
1988
Horizontal
violence
Also known as bullying or inter-group rivalry.
Interpersonal conflict which includes verbal abuse,
threats, intimidation, humiliation, excessive criticism,
innuendo, exclusion, denial of access to opportunities,
disinterest, discouragement, and withholding of
information and results in psychological distress.
McKenna et al.,
2003
Second victim Healthcare providers involved in unanticipated adverse
events, near-misses, or inadequate care and experience
trauma through primary or secondary interaction with
the event.
Jones & Treiber,
2012
Moral injury Derived from military terminology when there are ethical
challenges during armed conflict, moral injury is
experienced when a person perpetrates, witnesses, or
fails to prevent an act that conflicts with their moral
values and beliefs. Often synonymous with moral
distress.
Rowlands,
2021; Shay,
2014
Moral distress Defined in 1984 as (a) the psychological distress of (b)
being in a situation in which one is constrained from
acting (c) on what one knows to be right. Nursing
ethicists further include (a) distress from causing
intimate pain during care of the dying, (b) constraints
stemming from proximate and background challenges of
healthcare organizations, and (c) changing perspectives
on therapeutic technologies derived from global
environmental perspectives.
Jameton, 1984,
2017

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Starting in the 1980s, oppressed group behavior based on the work of Fanon, Freire, and
others has been applied by Roberts (1983) to explain nursing behaviors (such as nurses who
notoriously “eat their young”
24
) as predictive of the recurrent cultural violence that is contrary to
nursing’s professional image. Due to the lack of control nurses have in a hospital setting led by
administrators and a hierarchy of knowledge led by physicians (which results in epistemological
violence), nurses both benefit from being employed by healthcare systems, while being hurt by
it. This paradox results in a documented devaluation of nursing practice that can result in
powerlessness. In turn, this sense of powerlessness shows up as hostility towards other nurses or
becomes habituated as an aspect of nursing’s culture that nurses repeat when they enter
leadership or join academia (Roberts et al., 2009). The finding of hostile workplaces was
confirmed by the sampled nurses in this study.
Finding 3: Nurses Learn on Their Own to Leverage Privilege for Advocacy and Change
Interviewed and surveyed nurses expressed how their advocacy evolved in tandem with
their WRID, with four interview participants describing their full commitment to equity work as
their “life’s work.” The three schemas of the Evolving Non-Racist Identity Phase (shown in
Figure 7) include pseudo-independence (understanding that the world is unfair for non-White
Americans, can be accompanied by guilt and renewed desire to help others); immersion-
emersion (acknowledgement that stereotypes are inaccurate and White people are responsible to
dismantle White supremacy, will often seek other White people who feel similarly); and
autonomy (ability to be proud of being White, no longer having fear, intimidation, or discomfort
with non-White Americans, and will actively seek work towards repair and justice). Nurses in
this phase were largely comfortable in their identity, sought ways to examine if they had been

24
“Eat their young” is a colloquial phrase in nursing and medicine that refers to a cultural hazing of new
nurses or doctors to the profession to test their “toughness.”
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biased, and acknowledged inevitable errors with strong cultural humility. Nurses also expressed
how they functioned within Bronfenbrenner’s mesosystem by serving between and within toxic
settings or cultures. For example, faculty members protected and advocated for their students and
clinical nurses advocated on behalf of their patients. Nurses also worked to address systemic
inequities, such as hiring more diverse faculty or learning to speak up in meetings when there
were decisions being made with a potential harmful consequence. Over half of the interviewed
nurses also chose to leave toxic settings that were causing moral injury and psychological
distress to find other avenues where they could feel more constructive and helpful, instead of
feeling as though they were contributing to a harmful culture.
In parallel with Helms’s WRID phase of Evolving Non-Racist Identity, and in
corroboration with the study’s findings, Roberts (2000) also proposed a model in which nurses
could be “liberated from the oppressor within” (p. 71) by developing a healthier nursing identity
that was not tied to the internalization of nursing as an oppressed group. Roberts proposed that
nurses initially accept a subservient nursing role with an unquestioned belief in the power
structure that exists in health including the unspoken ideology that physicians should control “the
system.” Over time, this oppression can turn into an awareness of injustice and an overwhelming
sense of having been wronged. Nurses will then seek to affiliate themselves with other
empowered nurses and begin the process of synthesis where they see nursing in a positive light
and seek interdisciplinary problem solving. These actions and mindsets result in nurses’
commitment to political actions across a broad scope of activities that further social justice.
Both Helms and Roberts have complementary models that describe the evolution of the
sampled nurses’ identity development from oblivious and powerless, to aware and empowered,
which was also reflected in the interviewed nurses. The White nurses within the Evolving Non-
159

Racist Phase of identity largely shared how they found their voices and learned to find what was
“fixable” in an otherwise broken system by forging alliances with other nurses in order to enact
meaningful changes within and across institutions. They cited projects that helped marginalized
students pass their NCLEX and the enter nursing profession, work that amplified or supported
the work or research of marginalized nurses, diversifying boards and faculty positions, and
efforts to create increased racial awakening and inclusion in the profession, as strategies to
constructively leverage their privilege within their work settings. The nurses shared a sentiment
that there was always more to work on (personally and externally), but they conveyed a practical
confidence in which they felt able to tackle injustices and inequities within their settings of
professional practice.
Recommendations
This section includes recommendations based on the study’s findings and the literature
towards ways the nursing profession can address its homogenous workforce and develop a more
inclusive professional culture. The first recommendation details needed revisions to nursing
curricula and the second recommendation re-conceptualizes the role of nursing school to
dissociate nursing from educational harm. An interdisciplinary approach to literature was
referred to for this section, including, but not limited to, the fields of social science, nursing,
history, and innovation science.

160

Table 21
Overview of Study Findings and Recommendations
Research questions Themes Recommendations Citations
RQ1: In what ways
does White nurse
racial identity
development
impact their
positionality?
Messaging on
Whiteness
typically
begins
during
childhood
from the
family
Contextualized curriculum:
Current nursing curricula
does not frame healthcare
delivery in the context of
American history, and nurses
never learn about the history
of their profession or
science. Racial identity as it
relates to delivery of
equitable care is also not
addressed. These omissions
leave nurses with blind spots
about how the systems in
which they work operate.
Through contextualized
curriculum in nursing
education, nurses can better
understand themselves, their
profession, and the systems
which impact healthcare
delivery.
Baptiste et al., 2021;
Barbee, 1993;
Charbonneau-Dahlen
& Crow, 2016;
Dancis & Coleman,
2021; Davis, 1995;
D’Antonio, 2022;
FitzGerald & Hurst,
2017; Flynn et al.,
2021; Frankenberg,
1988; Helms, 2020;
Hogarth, 2017; Jones,
2021; Judd &
Sitzman, 2010;
Lewenson, 2004;
Matias, 2016;
Mkandawire-Valhmu,
et al., 2019; Moss,
2015; Smedley &
Smedley & Smedley,
2005; Taylor, 1999
Perception of
White
identity
evolves as
nurses learn
on their own
White racial
identity as a
“greased
wheel”
RQ2: In what ways
do nurses perceive
their White racial
identity within
healthcare and
nursing education?
Nursing school
as initial
setting of
harm and
reinforces
stereotypes
Incubator educational model:
Nursing school is the entry to
the profession and has an
outsized influence on
shaping professional norms.
The current model is based
on gatekeeping and a one-
size-fits-all Darwinian
philosophy that causes harm
and keeps nursing a White
space. An incubator model
better supports adult
learners, provides tailored
support, promotes diversity,
and properly invest in
students’ growth and
success.
Edmondson, 2018;
Emami & de Castro,
2021; Holland, 2015;
McAdam & Marlow,
2008; Morone, 2021;
Stokes-Parish et al.,
2020
White nurses
witness harm
across settings

Nurses learn on
their own to
leverage
privilege for
advocacy and
change.

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Recommendation 1: Contextualized Curriculum
Nursing education is a powerful setting to establish professional norms but has so far
failed to provide students with deep analysis of themselves, their racial identities, the partiality of
nursing science, the root cause of health inequities, or where they enter the field in the context of
their professional history. This means nurses remain under-prepared to understand how socio-
cultural, political, and historical legacy impact their work, profession, and delivery of healthcare
overall. The findings of this study, paired with the literature review, show that nursing education
has perpetuated harm to both students and faculty by continuing to uphold White spaces and
generating science which portrays a deficit model of race in comparison to a White ideal, rather
than as a social construct. The hyper-focus and prioritization of a school’s success based on their
students passing the licensure exam has led to a curriculum that has been decontextualized from
the structural settings where nurses actually deliver healthcare. Nursing curriculum has continued
to prioritize the role of an obedient nurse following orders to deliver one-to-one patient care in a
presumed neutral setting, rather than facilitating nurses as collaborative partners to repair
systems harmful to human health. Contextualizing nursing curriculum serves to ground nursing
education in transparency about what nurses and patients have inherited when they enter into
therapeutic relationships, and what agendas, power dynamics, and institutional legacies operate
invisibility when nurses deliver healthcare.
Re-contextualizing nursing curricula by examining racial identity of nursing students
(and faculty) and examining the (White) racial identity of nursing itself through a historical lens
of the profession, serves to identify the impact of White supremacy on both professional identity
and nurses’ psyches. In the settings where healthcare is delivered, identifiers such as race or
genders are in the foreground of interactions, not only for patients or nurses of color. Grounded
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in the relationship between the theoretical frameworks of Bronfenbrenner and Helms, re-
contextualizing professional identity and nurses’ identity together has the potential to result in a
synergistic and reinforcing effect on the longer term of the profession. Nursing curriculum needs
to prepare nurses for how to navigate and deliver care humanely in a broken system, understand
their role in advancing a profession to mitigate harm, and reimagine new systems for equitable
healthcare delivery.
Building curriculum with space to address nurses’ racial identity and knowing the full
truth of the profession that nurses represent are not arbitrary to clinical nursing practice, but are,
in fact, essential to the understanding of how nurses operate within healthcare systems and
professional structures (which can support or diminish patient care). Recent literature describes
both the utility and ethical responsibility of leveraging nursing school as a primary setting to
promote anti-racist practice by supporting transformative dissonant encounters. Such encounters
serve to disrupt White “epistemologies of ignorance” which combine the psychological
motivation to not appear racist with the socialized ignorance of the impact of the systemic racism
on health outcomes (Dancis & Coleman, 2021, p. 3). It is of paramount interest to nurses who
deliver healthcare to have a keen understanding of the way both nursing science and the systems
where care is delivered have been shaped by physician, corporate, White feminist, and capitalist
interests and should be plainly told to both disrupt ignorance, and as a means towards repair.
Continuing to educate nurses to pass the licensure exam without contextualizing curriculum to
examine racial identity, professional history, nursing science, or professional positionality
diminishes the potency of healthcare’s largest workforce. Leaving each school to arrive at these
conclusions may not be expedient or effective. Rather, accreditation bodies could consider
revised policies that expand the content nurses need beyond the limits of exam questions and
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encompass the context nurses should acquire by graduation so that they can serve as change
agents regardless of their settings of care. Table X details recommended areas for nursing
curriculum contextualization.

Table 22
Recommended Areas of Contextualize Nursing Curriculum
Five recommended areas to contextualize nursing curriculum
Contextualize
race, risk, and
racism
The social construct of “race” is routinely presented as a deficit and a direct
factor for poor health outcomes for non-White groups. The study found
that over 70% of survey respondents agreed with the statement “In
nursing school when we learn(ed) about health disparities we never
talk(ed) about the ways bias, racism, or structural or institutional racism
impact poor outcomes. Although the nursing school curriculum has begun
to integrate social determinants of health, there is minimal connection
between the impact of racist laws and policies or features of capitalism in
creating the social determinants for historically marginalized groups,
previously illustrated in Appendix B by McLemore (2021). Instead, the
current style of decontextualized curriculum reinforces the status quo that
western-based scientific studies published by a majority White nursing
profession “know” how patients of all cultural groups “should behave”
(Charbonneau-Dahlen & Crow, 2016).

In focusing on patient behavior decoupled from system design, mainstream
nursing uncritically accepts that the interlocking systems (such as law,
policy, and economics) which impact Americans’ health and wellbeing
are working just fine. A conceptualized curriculum in nursing school
would directly address the ways racism, not “race” itself, contributes to
inequitable care, instead of “tip-toeing around” (as described by an
interviewed nurse) or using social determinants of health as a euphemism
to avoid tackling historic and systemically perpetuated racial inequities
(Smedley & Smedley, 2005).

A contextualized curriculum would frame nursing research results more
critically to show how the embedded lineage of a deficit model based on
“race” is a centuries-old tradition in healthcare, if not a healthcare
obsession, rooted eugenics with the aim to quantify non-White group
differences by “race” to “account for” inferiority (Hogarth, 2017). This
ideology, decontextualized, has been used for centuries to justify the
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Five recommended areas to contextualize nursing curriculum
institution of slavery, the deprivation of protection and rights during 80
years of Jim Crow, and “replacement theory” fears seen today.
Contextualizing further, the solution patterns that emerge from these types
of common medical and nursing studies, could instead equip students to
learn how deficit research centers White outcomes (the privileged group
in White-dominant culture) as standard of care. This is a professional
pattern that traces directly to the role of White field nurses in colonized
territories or Indigenous reservations who know better and bring modern
medicine, hospital-based childbirth,
25
and principles of sanitation and
nutrition. This can also present an opportunity to introduce strength-based
research practices and researcher accountability so that colonial patterns
are not repeated throughout nursing’s epistemology (Moss, 2015).
Contextualize
racial identity
Remedying nursing education with a contextualized curriculum must also
include an understanding of who is providing care. Seventy-six percent of
survey respondents agreed a brave or safe space to have candid
conversation on race would benefit their nursing careers. The study and
literature support that both students and faculty have all been exposed to
the racism of American culture since childhood yet have no structures or
support to process or reconcile internalized racism in the scope of
becoming a professional nurse. The lack of analysis of internalized racism
means nurses graduate unprepared for the reality of American inequities
and can end up perpetuating them (FitzGerald & Hurst, 2017).

Helms’s racial identity development (which has been adapted for White,
Black, and Multi-Racial identities) offers a valid model nursing
curriculum that could be incorporated as a reflective tool during a
professional nursing course (Helms, 2020). Faculty could also benefit
from understanding their own schema of racial identity. It is directly
through the Disintegration schema of the Internalized Racism phase that
one can evolve their identity, so it would make sense for nursing schools
to be a site to support disintegration so that nurses could explore their
racial identities as a means to unlearn bias, stereotypes, and racist beliefs
they may have prior to licensure (Mkandawire-Valhmu, et al., 2019).
Contextualize
professional
identity
The origin story of professional nursing as told exclusively through the
Nightingale narrative has done a clear disservice to the collective memory
of the profession (D’Antonio, 2022). Whitewashed nursing history
textbooks exemplify the necessity for diversity among authors, nursing
faculty, researchers, and historians to more intentionally craft and
reproduce a more truthful, inclusive narrative to be consumed by the

25
On Native Americans reservations, midwifery practice, ethnobotany, and Indigenous medicine was
outlawed, and women were required by law to deliver babies on a reservation hospital controlled by Indian Affairs
(Theobald, 2020).
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Five recommended areas to contextualize nursing curriculum
nursing profession (Judd & Sitzman, 2010). The current resources and
tools to make this history accessible to nursing students and educators
will need accelerated development to fully integrate into nursing
curricula. Diversifying the direct care nursing workforce will not reach its
fullest, equitable potential if the identity of the nursing profession has of
itself remains rooted in the “great White women” narrative of the last
century and a half, wherein non-White nurses have been perceived and
cast(e) as anecdotal in their success, rather than as essential leaders,
contributors, and profoundly positive change-makers to the profession

To expand the nursing narrative, the history of professional nursing as an
extension of American history should be a core part of curricula (Davis,
1995; Lewenson, 2004). Examples of expanding the timeline of nursing
to before the Victorian Era, could include the original nursing textbook by
the Obregonian brotherhood of Madrid, Spain from 1617, as a founding
nursing text (included in Appendix P). It also means teaching about Mary
Seacole, a Jamaican nurse who served in the Crimean War, as an equal
peer of Nightingale and framing the profession in the context of American
history. Incorporating such content and understanding why non-White
nurses were excluded from the profession can also become a useful
opportunity to discuss the roots of derogatory colonizing and stereotypical
imaging that continue to pervade nurse to patient, and nurse to nurse
interactions today (Taylor, 1999).
Contextualize
nursing
knowledge
Healing traditions and practices, and robust theories of wellness and illness,
exist in every culture, but are not widely part of nursing knowledge, which
is informed by a White-dominant culture in Appendix G (Baptiste et al.,
2021; Charbonneau-Dahlen & Crow, 2016). Whiteness is not neutral
(Frankenberg, 1988). When non-Anglo, non-Western knowledge is omitted
from curricula, it results in epistemological violence, which deprives the
nursing profession (and patients) of incorporating the valuable insights and
knowledge from multiple, historically marginalized healing traditions and
cultures.

This becomes possible when only doctorally prepared nurses contribute to
nursing science, and the nurses who can access doctoral education for
decades are White. The first doctorally prepared Black male American
nurse earned their doctorate in 1987 and there were about a dozen Native
American PhD nurses by 2020. This scarcity of diverse doctoral nurses
directly limits nursing knowledge. Historians have long described the
generation of nursing knowledge as a “White racialized project:”

The only people who could move from “professed” nurse to trained
nurse to the status of professional nurse, and thus have permission to
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Five recommended areas to contextualize nursing curriculum
contribute to the science of nursing were primarily White women
who advanced through the educational hierarchy to attain the formal
educational credential of first BSN and eventually a doctorate …
engagement with nursing history reveals the way debates about
nursing knowledge and who gets to make it is an indelibly White
racialized project (Flynn et al., 2021, p. 1)

Contextualizing the epistemology of nursing science would acknowledge
that western biomedical, hospital-based healthcare delivery is but one
approach amidst other legitimate healing practices of all cultures and across
languages. Internationally, the core of nursing knowledge for a century and
a half has been based on the English language and predominantly developed
by White, privileged women. Nursing gained professional legitimacy by
following the reductionist and individualistic sick care models of medicine
which uses surgical and pharmacological interventions by licensed
providers, the very licenses which were designed to exclude or tokenize
non-White professionals from entering the profession. It is this body of
knowledge that nurses acquire which has not provided equitable healthcare
to Americans (Jones, 2021).
Contextualize
caring and
neutrality
Caring has a benign connotation, but is not a neutral act (Matias, 2016).
Caring can be directed towards some people or some groups and withheld
from others. The role of nursing as a caring profession has shielded nurses
from identifying or acknowledging when harm has occurred since the
profession perceives themselves to be colorblind. The emphasis on
colorblind caring has also resulted in professional silence and a tendency to
avoid conflict (Barbee, 1993). While nurses possess a certain political
power, White mainstream nursing routinely avoids contentious topics, as
seen in withdrawing from contentious presidential elections and topics such
as abortion, police violence, or restrictive LGBTQIA laws. The desire for
nursing to stay neutral is only possible because the White majority of the
profession themselves exist as the privileged class within the broader
society. Neutrality and avoiding conflict are signs of privilege that should be
contextualized within the nursing curriculum, so the next generation of
nurses understand what is gained or lost by not engaging with politics and
policies that directly impact healthcare delivery. Ultimately, the focus on
caring and conflict avoidance has limited the profession’s humanity because
it has imposed limits to the care the profession wants to provide.

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Recommendation 2: Incubator Model to Dismantle Nursing as a White Space
The study findings and literature document the extent of harm experienced by nurses
which begins in nursing school. The findings of the research make clear that nursing schools
cannot continue to assume, as an extension of Nightingale’s legacy, that students applying to
nursing school are “caring” by nature, beneficent, and innately nurturing as the primary
qualification of entering the profession, with no required further personal exploration. Current
educational models focus on empathy as an intrinsic quality, instead of a learned and practiced
skill, with curriculum focus on teaching how to pass the nursing licensing exam, administer
medications, and gain clinical competencies such as inserting an intravenous line, rather than
allocate time to deconstruct one’s bias as well (Stokes-Parish et al., 2020). Nurses, in fact, are
humans in America and have been subjected to decades of messaging around race and
marginalized populations before entering nursing school (Morone, 2021). Pretending to be
colorblind or treating everyone equally is a professional identity that masks the reality of
American racial ideology. To provide adequate preparation for nurses to provide unbiased care
and navigate diverse workplaces without inadvertently causing harm, curriculum can be designed
so that both students and educators plainly confront the racial realities where care is delivered.
This shift means approaching nursing school with an incubator model, instead of treating
nursing as a calling. To say nursing is a calling places humans who apply to nursing school as
morally above the actual messaging they receive in a racist, sexist, ableist, and homophobic
society (Holland, 2015). An incubator model is one in which people are recognized for emergent
ideas, but require support, skills, investment, and collaboration to manifest their idea in a broader
marketplace or ecosystem (McAdam & Marlow, 2008). By treating students as emerging
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professionals and not as those called to the profession who already have the emotional skills and
characteristics to deliver healthcare, schools can better support future generations of nurses.
By conceptualizing nursing school as an incubator, nursing school could be a place where
nurses are supported the way one would support someone with a new idea (McAdam & Marlow,
2008). Both innovators and nurses need educational environments that nurtures them towards
success, allows them to fail forward, provides them with tailored support, and introduces them to
a diversity of ideas (Edmondson, 2018). Some nurses may need rudimentary exam preparation
classes, while others need to deep dive into their White privilege to deliver non-judgmental
healthcare. Nursing has been a one-size-fits-all Darwinian educational model for a century and a
half and is designed for those who cannot hack it to not just leave the program, but to never enter
the educational pipeline (Fontenot & McMurray, 2020). When Mary Eliza Mahoney graduated
as the first Black American nurse in 1879, she was one of four graduates from a class of 42
(Seltzer, 2021a). A similar educational philosophy of ruthlessly trimming cohorts from
admissions to graduation continues in nursing today. Nursing education is traditionally used as
the first gatekeeper to the profession by preventing students from advancing to licensure and
reflects how a White space is one that perpetuates its homogeneity. Incubators, on the other
hand, seek diverse candidates to foster innovation within their cohort and see their role as a
launching point (not a stopping point) for an entrepreneur to grow.
An incubator model of nursing education would also allow for the lived experiences adult
learners bring to nursing to be celebrated rather than devalued. One interviewed nurse shared that
when she applied to a baccalaureate program after already working as an associate degree nurse,
the dean stated she “hated admitting nurses with experience” because she felt they had developed
“bad habits.” As a vast majority of nursing students are second-degree students, this thinking
169

limits students’ potential to combine their previous work experiences with nursing knowledge
and tilts the field towards younger applicants with less life experience, just the nurses
Nightingale proposed recruiting in the Victorian Era. In contrast, incubators largely operate to
upskill and invest in their cohorts while recognizing the skills they already bring to the table and
creating a learning environment to address knowledge gaps that impede their success.
Incubators also provide monetary funding to equalize the success of the idea being
launched, whereas nursing schools continue to become more and more expensive and saddle new
nurses with debt for the prestige of a “four-year degree.” One interviewed nurse detailed how she
stayed in her nursing degree program funded by her parents as a mediocre student towards the
bottom of her class, while a Black colleague she met later in her career shared how despite
having a high GPA, she had to leave at the same school over an unpaid $200 fee. Nursing
schools that continue to operate their model as gatekeepers who devalue adult learners, upcharge
the cost of education, create punitive academic policies for students that need educational
support, and believe that nursing is a calling and nurses cannot be racist will continue to cause
harm and perpetuate nursing school as a White space (Emami & de Castro, 2021). Further,
incubator models also have longitudinal networks that follow innovators during stages of growth,
which can be used so that nurses do not need to “learn on their own,” as the study found. There is
no more important space than nursing education to impact the next generation of the future
workforce and set the norms of an evolved professional culture. It is therefore imperative to
eliminate the harm that occurs during this formative time of a nurse’s career.
Limitations of the Study
Several limitations were present in this study. The sample population was mostly
recruited using the snowball effect by a researcher in the northeast United States. Although the
170

survey and interviews included nurses from all areas of the United States, the participants were
geographically concentrated in the northeastern United States (43%). Another sampling
limitation was found with the interview participants, who voluntarily opted in for interviews.
First, 30% of the participants identified themselves as Jewish or half Jewish, which is an over-
represented religious group compared to nursing overall. Second, 50% of the interviewed
participants and 50% of the survey respondents reported their terminal degree as doctorates. This
is vastly over-representative of the nursing workforce overall, of which less than 5% hold
doctoral degrees (Campaign for Action, 2021), and could have been related to my professional
network from my own doctoral work. Thirdly, as the participants voluntarily opted in for the
interviews, the findings suggest that the nurses who chose to engage in an hour-long
conversation on White racial identity were broadly comfortable with the topic and some had
spent their careers reconciling their White identity and sense of privilege. Nurses who were in
the White racial identity phase known as internalized racism largely did not participate in the
interviews, though some completed the anonymous survey. Lastly, certain survey questions
could have been clarified or re-phrased, or Helms’s White Racial Identity Attitude Scale could
have been used directly with a sample of White American nurses. However, permission to use
the survey was not granted prior to the survey launch.
Suggestions for Future Research
Helms’s phase of internalized racism encompasses three schemas which a minority of
nurses in survey, and the profession more broadly, have also expressed, such as being colorblind,
entitlement to White privilege, and a focus on victim blaming. As only a minority of nurses with
those White identity schemas participated in this study, future research can more directly reach
out to nurses in those schemas to understand ways their identity intersects with nursing practice
171

and their reluctance to speak about racial identity. Sixty percent of nurses in the study reported
wanting to work as an advocate for equity and 88% agreed that nursing should have a more
diverse workforce. As White racial identity is not a fixed state, this suggests that there is an
opportunity to address, challenge, or deconstruct previously held beliefs about White racial
identity during a nurses’ pre-professional education.
As pre-professional education is designed to produce nurses capable of delivering care to
all people during their careers, nursing school represents a setting in which students should be
supported to reflect on their racial identity. Future research could focus on measuring the
effectiveness of programs or curricula in nursing school, as well as how the phases of WRID
impact the receptiveness of such offerings. Helms and Bronfenbrenner are valuable frameworks
that are both aligned in the overall nursing curriculum, which often includes stages of
development or systemic theories. All nursing students (as well as faculty) could benefit from a
psychologically safe space to have conversations around race and racial identity. Research into
the ways these conversations can be effectively facilitated can help these future nurses feel less
alone in processing their clinical and academic experiences. Specifically in a country as racially
fraught and with as much racist history as the United States, there is a responsibility for
researchers to understand effective strategies in helping nurses to serve all populations and make
sense of their racial identities in the context of a professional culture that widely endorses
colorblindness and centers White lived experiences. Lastly, the unique intersection of Jewish
nurses’ lived experience and White racial identity within the nursing profession is under-reported
in the literature and could be a population for future inquiry.
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Conclusion
Stories and symbolism are the building blocks to crafting professional identity. Even in
death, American nurses continue to be enshrined in the contrived professional imagery of nurses
as White angels. This is evident by the monument for nurses at Arlington National Cemetery
(Figure 10), which was erected in 1938 to honor the burial site of nurses who died during their
Army or Navy service (Arlington National Cemetery, 2022). Despite Black nurses having served
during both the Spanish-American Civil Wars, the Army and Navy Nurse Corps were still closed
to non-White nurses in 1938 and would not formally desegregate until the close of World War II,
in 1945 (Carnegie, 1999). The American Nurses Association would not desegregate until 1948,
and until threatened with expulsion, it would take some states until 1961 to formally desegregate
(D’Antonio, 2010). By then, there had already been a century of enacted rules, credentialing,
licensing, marginalization, and educational and employment criteria designed to establish
nursing as a professional White space.

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Figure 10
Memorial Statue of the “Nurse Section ” at Arlington National Cemetery

Note. Image of nurses’ memorial statue from Nurses Memorial by Arlington National cemetery.
(https://www.arlingtoncemetery.mil/Explore/Monuments-and-Memorials/Nurses-Memorial). In
the public domain.

The statue at Arlington National Cemetery was rededicated in 1971, during a time of
significant demographic and cultural shifts in the profession. By that year, nursing education had
become more accessible to men and nurses of color with the establishment of the associate’s
degree at community colleges across the country, the Immigration Act of 1965 expanded
immigrant nurses’ entry into nursing practice, broader egalitarian fashion trends were beginning
174

to replace a century of dresses and skirts with pants to represent the modern nursing uniform, and
the National Black Nurses Association (NBNA) was also created that year in response to the
American Nurses Association’s apathetic response to desegregation (Arlington National
Cemetery, 2022; Bates, 2012; Nelson, 2002; Seltzer, 2021f). This act of White, mainstream
nursing doubling down on traditional nursing iconography in a time of changing professional
identity is not new. Indeed, the strategy has been replicated throughout the history of the
profession and reflects the tension explored throughout this study.
By examining the impact of uncritically subscribing to the ethos of past and present
nursing professional identity, the study demonstrated how confining a “professional” nurse as the
apex of White femininity and moral virtue has directly contributed to nursing as a White space
and, by extension, limited the scope of nursing knowledge to generations of homogenous
researchers. Even by the post-Civil Rights Era, during which the statue at Arlington National
Cemetery was rededicated, the literature review demonstrated how racist and discriminatory
actions were systemic and sustained yet remained invisible within nursing literature. This
prompted a nurse anthropologist to ask by the 1990s, “how to write about a problem that, at least
according to the nursing literature, does not exist?” (Barbee, 1993, p. 347).
The nursing profession has managed to adhere to professional traditions for a century and
a half which have not improved health equity, nor cultivated a workforce that reflects the
diversity of the American population. It has, however, kept up with performative actions which
continue to fortify nursing’s long-cultivated image as a trusted and caring profession. An image
based on religious iconography of ethereal and altruistic angels ultimately serves to dehumanize
nurses. This removes the necessity for the nursing curriculum to reckon with real human traits
that impact the delivery of care, such as bias, prejudice, White supremacy, and racism. It has also
175

contributed to generations of professional exploitation for all nurses, who, heralded as
superheroes in today’s vernacular, are seen as super-human and not possessing the human needs
of rest, support, personal protective equipment, fair wages, or safe staffing. In fact, it is
practically revolutionary that the opening sentence introducing the Foundational Report on
Racism in Nursing unequivocally states, “Nurses are human beings, so our personal experiences
and biases naturally influence our relationships and profession” (American Nurses Association,
2022b, para. 1.). Grounding the profession in its collective humanity thus serves to dismantle
Whiteness, whose “purity” is only achieved in settings of segregation and hierarchy where White
privilege is preserved. Understanding nursing as a profession of humans therefore liberates its
identity by recognizing both the humanity and fallibility of all nurses.
This study demonstrated how humans who work as nurses in America initially received
messaging on White identity that were aligned with both Bronfenbrenner’s ecological systems
and Helms’s WRID model. The findings affirmed that systems and individual racial identity
development influence each other. As described by Bronfenbrenner’s microsystem, their earliest
perceptions of White identity began in childhood as influenced by their families, schools, or
religions and according to Helms’s model, their initial phase of identity is that of Internalized
Racism. The findings also demonstrated from Helms’s model, that racial identity development
evolves over a lifetime, with some nurses entering the phase of Evolving Non-Racist Identity in
their twenties, and others in middle age. The study findings demonstrate that the role of nursing
school is underutilized in helping nurses understand the root causes of health disparities and
continues to preserve White privilege. Schools also serve as the first sites of professional harm.
All nurses interviewed in the study reported needing to learn on their own about health
disparities and reflected on their White identity in isolation. Seventy-six percent of surveyed
176

nurses agreed that a safe or brave space to have candid conversations about race could help their
careers. A majority of White nurses in this study expressed both awareness of their privilege, and
interviewed nurses shared active involvement in using their privilege to advocate for
marginalized students, patients, or nurses. While this sample as representative of the total
population within nursing is unknown, the foundational report by the Commission on Racism in
Nursing just published May 1, 2022, provides a professional blueprint for anti-racist momentum
to grow, starting with the current generation of nurses.
Nurses (and patients) are the first to see what is broken in healthcare delivery settings, but
the last to be included in remedying healthcare’s design. The recommendations included in this
study envision two approaches to re-conceptualize nursing education so that nurses are fully
informed, supported, and activated as agents of change. Current nursing curriculum is presented
to students as a set of neutral, timeless facts to remember, and clinical tasks and documentation
to complete within systems that are presumed to be largely rational, equitable, and even helpful.
Decontextualized curriculum like this means that nurses learn about “hospitals as total
institutions” (Jenkins et al., 2022, p. 1), rather than the totality of systems that are deeply rooted
in both history and politics, and directly influence the baseline of society’s health. Nursing
school curriculum could instead contextualize nursing care and knowledge, and race-based
health disparities as outcomes of history, politics, law, White supremacy, policy, and
corporatization. Education can also be delivered as an incubator model where there is direct
investment and customized learning designed to further the success of the nurse, rather than the
centuries-old culture of “weeding out” students, which was disclosed by the sampled nurses as a
de facto, present-day strategy to “weed out” nurses who do not conform with a homogeneous,
Victorian-era nursing ideal.
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White female nurses have, and continue to hold, professional power in nursing. To
meaningfully diversify the nursing profession and nursing knowledge, there needs to be a
systematic recognition, and subsequent dismantling, of the strategies used to create nursing as a
White space. For the profession to remain relevant and equitably meet the needs of diverse
Americans, there needs to be a reconciliation of the professional image of nursing with its
factual, historical past. Licensed nurses graduate with blind spots to identify the insidious impact
of White supremacy, White feminism, racism, or their personal schema of racial identity
development. This knowledge deficit, present for generations of nurses, diminishes the quality-
of-care nurses deliver and weakens the profession’s ability to advance equitable healthcare. To
change the future of the profession and disrupt the toxic traditions of the past, nurses must know
where they come from, both personally and professionally. The power of the past supports nurses
to understand the present. The grace of a professional nurse does not need to be calcified in
statues of moral virtue, but rather, should manifest through the habitual reflexivity of nurses to
treat themselves, and patients, as humans in an otherwise imperfect world.

178

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Appendix A: Spanish Castas
While caste systems pre-date the Spanish Castas, this was one of the earliest known and
documented systems using skin color as the basis of hierarchy. The word race as it relates to
physical characteristics of skin color is widely seen from the root of the Spanish word “raza”
(Aguilar, 2020). Spain’s early caste system defined the way in which variations in skin color
affected socio-political status within Spanish society beginning in the 1400s (Baker, 2017).
Figure A1
Spanish Castas

Note. Depiction of 16 categories of Castas from Mi casta es su casta: The casta system of racial
hierarchy in new Spain by J. Baker, 2017, East India Blogging Co.
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(https://eastindiabloggingco.com/2017/01/18/casta-system-new spain/). Copyright 2017 by East
India Blogging Co.
Privilege associated with lighter/whiter skin color became codified into American law by
the 1600s by White, male, slave owners who wrote and passed anti-miscegenation laws. The
basis of White privilege began in this era when the legal definitions of an heir in relation to
property, inheritance, and wealth was bestowed to lighter/White children - and a life of servitude
bestowed to darker/Black children (Battalora, 2021). This is reflective of the Spanish Castas,
which illustrated and denoted socio-political hierarchy and were carried by Conquistadors to the
New World and imposed on the Spanish colonies - such as the example below from the
Philippines, which Spain occupied for over 300 years (Frade, 2019).
Figure A2
Racial Hierarchy of Colonial Philippines

Note. Graphic from Day Five: Colonialism and Politics by S. Frade, 2019,
(https://slideplayer.com/slide/15198898/). In the public Domain.
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American professional nursing in the Philippines, which began at the turn of the 20th
century following the 1898 Spanish-American War, followed these imposed racial hierarchies
and sought lighter-skinned Filipinos from the middle and upper classes to apply to the English-
language nursing schools (Choy, 2005). The same pattern was also seen in the first American
nursing schools in the commonwealth of Puerto Rico and on Native reservations, where the most
assimilated Native Americans were recommended for nursing (Hawkins & Sweet, 2014;
Kristofic, 2019).

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Appendix B: Institutional Racism and Structural Determinants of Health
As described by Dr. Monica R. McLemore, PhD, MPH, RN, FAAN, “one of the few
nurse-scientists in the world with expertise in reproductive justice and family health equity
grounded in the principles of anti-racism and critical race praxis” (University of Washington,
2022), there is a direct connection between social determinants of health and systemic wealth
and power imbalances. Nursing school curriculum, however, routinely addresses social
determinants of health decoupled from the structural roots of U.S. inequality like racism, low
road capitalism, and oppression. This was confirmed in the study findings as an educational
deficit.
Figure B1
Relationship Between Institutional Racism and Health Outcomes

Note. Graphic from An update on reproductive health, rights, and justice – Implications for
nursing by M. McLemore, 2021, California Black Nurse’s Summit, adapted from Tackling
health inequities through public health practice by R. Hofrichter an R. Bhatia (Eds.), 2010,
Oxford University Press. Copyright 2010 by Oxford University Press. Used with permission.
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Appendix C: Influences on Professional Nursing Formation
Steadfast Victorian-era and turn of the 20th century influences present since the
formation of nursing have remained as part of its professional culture through today. To illustrate
these enduring influences, eight are detailed in the graphic below. These strong influences need
to be deconstructed, dismantled, and replaced with new professional values for the profession to
achieve genuine diversity, inclusion, equity, justice, and belonging.

Figure C1
Influence on Professional Nursing Formation

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Appendix D: Racial Hierarchies Within the Profession and Impact on Health Outcomes
The establishment of classes within the nursing profession has been used for over a
century to justify racial hierarchy and preserve the legitimacy of White female leadership. This is
seen in the present-day through the use of nearly endless educational credentials to distinguish
between the scope of practice of nursing aids, licensed practical nurses, registered nurses, and
advanced practice nurses - not to mention numerous and additional specialty-specific
certifications. After a full century of White hegemony of the “registered nurse” title, the
American Nurses Association proposed in 1965 (on the heels of the success of Associates degree
programs), to have the title of “RN” become exclusive to baccalaureate-prepared nurses, while a
new title “RAN” would indicate an Associates prepared nurse, despite them passing identical
licensure exams (Nelson, 2002). These strategies have recurred throughout nursing’s
professional history as an extension of eugenics roots of biomedicine which were embraced by
both western medicine and nursing (Farber, 2008). The ideology influenced the creation of
separate, racialized classes of nurses since the early 20th century, as demonstrated by the practice
of providing Black nursing students with certificates to become nursing attendants, rather than a
professional nursing license (Hine, 1982). Regardless of if Black and White nurses attended
accredited nursing schools or earning the same license or credentials, hierarchies within nursing
were also reinforced through the titles Black nurses could be addressed by (only White nurses
could be addressed by “Miss” in the South), to the very uniforms’ nurses wore (the use of
different uniforms for Black and White nurses was commonplace across the South for decades;
D’Antonio, 2010).
Since the beginning of the profession, trained Black nurses and nurses of color from the
British or American territories (including Native American reservations) were excluded from
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formal nurse leadership positions, which created additional classes within nursing - those in
leadership, and those on the front lines. This structure was intentional, as only “firm and
competent White direction” was perceived as being able to achieve the level of discipline needed
from emerging professional nurses, along with the inability for White women to accept direction
from “colored women” (Hine, 1982, p. 218). The classes established within the profession
essentially mimicked the same racial caste hierarchies of British and American empire and
chattel slavery - and continues to persist in nursing today. The lack of diverse nursing leadership
is acknowledged in the foundational report of the Commission on Racism in Nursing, just
published in 2022 (American Nurses Association, 2022b; Choy, 2005 Hawkins & Sweet, 2014;
Kim, 2019; Kristofic, 2019; Reddy, 2015). Rather than report gradual improvement in the
diversity of nursing leadership in the 6 decades post-civil rights, present-day scholars describe
the capacity of the profession to become diverse and inclusive as “an illusion” by pointing to the
“severe” lack of diversity in nursing leadership, which has so far only been remedied by
tokenism (Iheduru-Anderson et al., 2022, p. 1).
Besides establishing separate classes of licensure types and restriction of leadership roles,
certain nurse specialties and practice areas have used both de jure and de facto means to sustain
their own White-dominant sub-spaces and subcultures. For example, recent demographics from
the last 5 years show that critical care nurses were reported to be 70% White, certified registered
nurse anesthetists were reported to be 88% White, and nurse midwives were reported to be 90%
White (Campaign for Action, 2019; Wren Serbin & Donnelly, 2016; Zippia, 2022). These
White-dominant settings reveal the persistent role of racial hierarchy in organizing nursing
workplaces across the country. The trajectory of midwifery in the United States into a White
space of nursing uniquely exemplifies how White feminism functions in preserving White
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supremacist ideals under the guise of professionalization. Along with the emerging and White
male-dominated field of obstetrics, the medical and nursing professions collectively “established
themselves as the only legitimate purveyor of … health knowledge by masking the notion of the
white norm” (Besson, 2021, p. 2329), with devastating consequences to health outcomes that are
still seen today.
Following centuries of mostly unrestricted, apprentice-based practice dating to Biblical
times, midwifery in the United States became distinguished by the creation of nursing credentials
as an entry-to-practice requirement after the turn of the 20th century (D’Antonio & Tobbell,
2022; Ellerby-Brown et al., 2008). During this time, a nursing license became a requirement to
practice midwifery as a means of differentiating between (White) nurse midwives formally
trained in a school or diploma setting, and those who learned from oral traditions and
apprenticeship (Black, Mexican, and Native American women). This change was backed by both
scientific publications and federal regulation. The first issue of the Journal of Obstetrics and
Gynecology published in 1915 asserted that “uneducated” midwives were to blame for poor
maternal outcomes, which would be echoed by the American Medical Association in the
subsequent decades (Rooks, 2014). However, as illustrated in Table H20, poor outcomes were
contributed far less from the “uneducated” midwives than from the unsterile and unsafe surgical
techniques of surgeons (Dawley, 2003). The subsequent passage of the Sheppard-Towner Act in
1921 established a federal initiative for formal midwifery training to be part of nursing, since the
obstetric data indicated it was their practice which should be “improved” (Merelli, 2021;
Tobbell, 2021).
217

Table D1
Maternal Mortality per 10,000 Live Births in the Selected Cities of the United States 1914–1930
Physician Midwife
Deaths/10,000 live births Deaths/10,000 live births
Neward 1923 87 22
Philadelphia 1914–1930 74.6 8.5
Alabama, Kentucky, Virginia* 1927 111 51

*In Alabama, Kentucky, and Virginia, physicians were responsible for 32%, and midwives 62%
of births among African American women. From The Origins of Midwifery in the United States
and its Expansion in the 1940s, by K. Dawley, 2003,
https://www.sciencedirect.com/science/article/abs/pii/S1526952303000023. Copyright 2003 by
the American College of Nurse Midwives.

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Table D2
Assigned Responsibility for the 1,404 Preventable Deaths in New York City ’s Maternal Mortality
Study, 1930–1932
Physicians Midwives Patients
61.1% of deaths 2.2% of deaths 36.7% of deaths

Note. In NYC, midwives managed 5.4% of the births and physicians the rest. Total deaths during
the period were 2,041. Of these, 68.8%, or 1,404, deaths, were judged preventable if the patient
had received proper care. From The Origins of Midwifery in the United States and its Expansion
in the 1940s, by K. Dawley, 2003, American College of Nurse Midwives.
(https://www.sciencedirect.com/science/article/abs/pii/S1526952303000023). Copyright 2003 by
the American College of Nurse Midwives.

For context to the medical literature disseminated during this time, it is noteworthy to
mention the history of obstetrics medicine itself. Rooted in chattel slavery, during the decades
after the transatlantic slave trade was abolished when “Black women’s wombs [were] the
producers of their children’s subjugated condition” (Roberts, 2021 p. 50), obstetric medicine was
founded by slaveowner Dr. Marion J. Sims in the mid-1800s and based on unconsented
experiments on enslaved Black women (Holland, 2018). Thus, acquiescence of the body of
knowledge by Black female midwives was not compatible with the role of slave ownership in the
Antebellum Era, or the assertion of physician’s epistemological dominance in the Postbellum
Era. As generations of previously enslaved midwives had no access to even primary education,
professional closure from their own epistemological base of clinical, practice-based knowledge
occurred under the guise of literacy and licensure. The actions of federal regulation informed by
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pseudo-science and combined with the cooperation of White nursing leadership in the 1920s
served to de-legitimize, restrict, surveil, and ultimately outlaw, generations of midwifery work
by Indigenous and previously enslaved Black women,
26
while validating and elevating the role of
White nurse midwives as more “qualified” to assume the role of supporting hospital-based,
obstetric-directed childbirth (Niles & Drew, 2020). These actions formed dual classes of (non-
White) “lay” midwives and (White) “professional” nurse midwives, the latter of which
subsequently held the political, academic, and professional power for the next century and
attended to the maternity needs of the White middle class.
Since the nursing profession had already established academic White spaces with the
first nursing schools in the 1870s, a key to defining the training of midwifery with professional
nursing was the ability to control who entered midwifery programs (Carnegie, 1999; Merelli,
2021). While the access to gain professional qualification through attending a formal nurse
midwifery program was unrestricted for White women across the country, Black midwives
seeking a nursing credential to continue their existing practice would need to first apply to, and
graduate from an accredited nursing school, and then attend an additional postgraduate
midwifery program (Merelli, 2021). The scarcity of Black nurse midwifery programs in the
United States inevitably impacted the diversity of nurse midwifery and directly contributed to
professional closure of the nurse midwifery workforce. A decade after nursing became a
requirement to practice midwifery, the first program opened at Dillard University, a historically
Black college and university (HBCU) in Louisiana but closed within the first year due to lack of
funding (Merelli, 2021). The Tuskegee Nurse Midwifery program opened a decade later in
Alabama, but closed after 5 years, in 1946 (Carnegie, 1999). By 1945, only 15% of midwives

26
The same women had been entrusted throughout the Antebellum period to safely deliver White babies
and support White women during childbirth and postpartum (Ellerby-Brown et al., 2008).
220

attended births and the post-World War II boom in hospital construction would further move
childbirth into hospitals and into the hands of obstetric surgeons and White nurse midwives.
Black midwives, who had previously been in practice for decades, were denied admission to
nurse midwifery schools through the 1960s (Niles & Drew, 2020). Meharry Medical College
established a nurse midwifery program in Tennessee in 1973, which closed in 1982 (Carnegie,
1999). To this day, there are no operating nurse midwifery programs in any HBCU in the country
(Merelli, 2021).

Figure D1
History of Births Attended by Midwives Since 1900

Note. From U.S. Midwifery, by T. Livingston and J. Seltzer, 2021. New Jersey Department of
Consumer Affairs. Copyright 2021 by New Jersey Department of Consumer Affairs.

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Figure D1 shows the percentage of births attended by midwives in steady decline over a
115-year period. With additional barriers to educational access, the curve of midwifery attended
births is not likely to increase in an abbreviated time period. For the last several decades, current
nurse midwifery licensure has been predicated on master’s preparation, either following a
Bachelor’s in Nursing or from direct entry of another bachelor’s degree. Of 39 nurse midwifery
and certified midwifery (midwives without nursing degrees) graduate programs in the United
States, just two have Black program directors (Niles & Drew, 2020). While only 13% of the
nursing workforce have master’s degrees, it is increasingly becoming a trend for master’s level
nursing programs nationwide to transition to doctorate programs (American Association of
Colleges of Nursing, 2019a). Several states have already transitioned nurse midwifery master’s
programs to doctoral level programs, with some states now offering only the doctoral program
option to become a licensed nurse midwife (Rutgers University, 2022). Thus, the very structures
to licensure that White nurse midwifery has established, continues to create barriers of entry in
the 21st century and mirrors the same exclusionary strategies of medical training. Just as
physicians worked to abolish traditional midwifery practice, White feminist nurse midwives
achieved similar outcomes by securing nurse midwifery licensure in all 50 states while
supporting marginalization of the scope of practice for non-nurse midwives to homebirths and
limiting their licensure to only five states for certified midwives and 28 states for certified
professional midwives (Kennedy, et al, 2018). In 2022, there was one Black certified
professional midwife working in the state of Colorado (Beckman, 2022). Nationally, nurse
midwives attend 12% of American births, while a small class of non-nurse midwives attend 1%
of births (Birth by The Numbers, 2019). Reflective of the contentious relationship between nurse
(attend nursing school) and non-nurse (study through apprenticeship) midwives, the nationwide
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organizations representing nurse midwives and certified professional midwives, published a joint
consensus document for midwifery legislation and regulation for the first time, in 2015, which
seemed “impossible to navigate until now” and required “unprecedented bridging and collective
understanding” (Kennedy et al., 2018, p. 658).
Restrictive educational and credentialing pathways devised by White nurse midwives
have served to homogenize the midwifery workforce for a century and has subsequently led the
American Colleges of Nurse Midwifery (ACNM) to a truth and reconciliation apology and
resolution published in 2022. Their public apology acknowledges,
that it can no longer continue to attribute the White washing of midwifery to a lack of
qualifications or interest by Black and Indigenous people. This fails to acknowledge that
white supremacy acted as suppressor, then law enforcer and “teacher,” then eliminator
and replacer of Black and Indigenous traditional midwives with white midwives. ACNM
leadership acknowledges and apologizes for past and present harms to BIPOC midwives
and the organization’s role in perpetuating and maintaining systemic racism in midwifery
and healthcare. Historical facts clearly illustrate that the exclusion of Black and
Indigenous midwives was intentional and by design, with the resulting Whiteness of the
profession of midwifery as the intended outcome.
Systemic racism not only impacts the diversity of the midwifery workforce, but also maternal
and infant health outcomes (Prather et al., 2018). Systemic racism “refers to the totality of
constantly reconstituting and reinforcing social and political systems and their policies, practices,
and ideologies that engender inequities” (Alson et al, 2021, p. 50). From slavery through the
post-Civil Rights Era, systemic racism and discrimination at the individual level have
contributed to mostly preventable morbidity and mortality of Black women during childbirth and
223

the peripartum period (Prather et al., 2018; Taylor et al., 2022). Figure H16 depicts Black
maternal mortality for over a century, which has continued to rise for both Black and Hispanic
mothers post-pandemic (Declercq & Zephyrin, 2020).

Figure D2
Black Maternal Mortality over 100 Years

Note. Post-COVID and post-overturning of Roe v. Wade, these ratios have continued to increase.
Graph from Maternal Morality in the United States: A Primer by E. Declercq & L. Zephyrin,
2020, The Commonwealth Fund (https://www.commonwealthfund.org/publications/issue-brief-
report/2020/dec/maternal-mortality-united-states-primer). Copyright 2020 by The
Commonwealth Fund.

224

Part of the consequence of connecting a universal healthcare role such as midwifery with
White feminist ideology and structures, is the ability for the majority White nurse midwifery
profession to be complacent with inequitable birthing outcomes, so long as White women believe
they will be spared the costs.
Perhaps it makes sense, if you’ve spent a lifetime seeing yourself as the winner of a zero-
sum competition for status, that you would have learned along the way to accept
inequality as normal; that you’d come to attribute society’s wins and losses solely to the
players’ skill and merit. You might also learn that if there are problems, you and yours
are likely to be spared the costs (McGee, 2021, p. 205)
However, the healthcare system is not segregated enough to guarantee that White women will
not be harmed by the same broken systems or reproductive injustice (Declercq & Zephyrin,
2020). The American maternal mortality in aggregate, still ranks last in maternal mortality for an
industrialized country and demonstrates how the professional closure strategies which have
served to benefit White women’s occupational trajectories as nurse midwives have not resulted
in better maternal health outcomes for American women (Tikkanen, et al, 2020; Vedam et al.,
2018). The rate of White Americans’ maternal mortality, while lower than the rates for Black or
Hispanic women, is still more than twice the rates of other industrialized nations (Declercq &
Zephyrin, 2020). In conjunction with medical licensure, western healthcare strategies have
served to “impose perceived authority and dominance despite growing evidence of its failure to
provide increasing standards of service [or] increased states of health” (Wilson, 2012, p. 3).
Figure H17 shows the current maternal mortality rates among industrialized nations.

225

Figure D3
United States Maternal Mortality

Note. Graph from The Worsening U.S. Maternal Health Crisis in Three Graphs by J. Taylor, A.
Bernstein, T. Waldrop, & V. Smith-Ramakrishnan, The Century Foundation
(https://tcf.org/content/commentary/worsening-u-s-maternal-health-crisis-three-
graphs/?agreed=1). Copyright 2022 by The Century Foundation.

An evidence-based reason for the discrepant rates of maternal mortality between western
countries, is that during the same decades the United States regulated midwifery to the White
space of nursing, the racist fallacies being published about the poor outcomes of midwifery did
not take hold in other industrialized nations. Instead, a midwifery maternal healthcare model was
supported and funded by national healthcare in dozens of industrialized countries due to the
226

overwhelming positive evidence of midwifery on maternal and infant health outcomes (Tobbell
& D’Antonio, 2022). Meanwhile, in the United States, the American Medical Association
successfully lobbied to revoke the Sheppard-Towner Act by 1929 which had provided states with
federal funding for low-income mothers to receive midwifery-supported perinatal care. They
deemed the first federally funded program to improve maternal health to be anti-states’ rights,
too “socialistic,” and a “violation of the privacy of the parent-child relationship” (Lewis, 2019).
Obstetricians and nurse midwives had no interest in serving non-White poor communities, or
supporting childbirth at home, as had traditionally been done by Black and Indigenous midwives
(Morrison & Fee, 2010). The sustained delegitimization campaign against Black and Indigenous
midwives in combination with a hierarchical nurse-based midwifery has ultimately prioritized
the economic and professional interests of obstetricians and hospitals without improving
outcomes for American mothers on par with other industrialized nations (Niles & Drew, 2020;
Vedam et al., 2018).

227

Appendix E: Expanded Nursing Timeline Before 1900
Table E1
Nursing Timelines Before 1900 (Aponte & Seltzer-Uribe, 2022)
Nursing’s collective memory of
the profession
Historical events impacting professional nursing
1617: First nursing text published by Catholic
Brotherhood in Spain
Missing from nursing narrative: This text and the
contributions of non-English-speaking, non-female
early nurses
1619: First slave ship arrives in Virginia Colony
Missing from nursing narrative: African midwifery and
healing practices used for centuries in U.S.
1776–1804: Northern states abolish slavery
1821: Mexico gains independence from Spain
Missing from nursing narrative: Curanderismo
Indigenous Mexican healing practices, including
parteras (midwives)
1846–1848: Mexican American War results in Mexico
ceding 55% of its territory to the United States
1851: Congress passes the Indian Appropriations Act,
which created the Indian reservation system. White
field nurses and matrons are hired by the government
to promote Western medical practices.
Missing from nursing narrative: Extensive Indigenous
ethnobotany and healing practices, including birth
practices
1853–1855 Crimean War
1860: First Nightingale School
opens in London

1860: Marks the Beginning of the assimilation boarding
schools on Native American reservations. Female
graduates, who learned English in the schools would
become the first Native American professional nurses.
Missing from nursing narrative: Contributions of Native
American nurses to the profession
228

Nursing’s collective memory of
the profession
Historical events impacting professional nursing
1861–1865: Civil War
Missing from nursing narrative: Contributions of Black
nurses during Civil War and their role as abolitionists
1863–1877 Reconstruction Era
Missing from nursing narrative: Inability for the United
States to secure healthcare or lasting economic,
political, or educational opportunities for newly freed
Black Americans post-Civil War
1872: First U.S. Nightingale
Schools open in the Northeast

1881: Spelman opens as the First U.S. Black nursing
school in Georgia
Missing from nursing narrative: Contributions of Black
nursing schools to the profession
1887–1923: Nadir of American race relations
1898: Spanish-American War (Philippines and Puerto
Rico become American territories)
Missing from nursing narrative: Contributions of Filipino
and Puerto Rican nurses to the profession

229

Appendix F: Nursing Journal Letters, 1963 and 2018
In 1963, C. Howard Brittain wrote to the American Journal of Nursing to rebuke its
support of the Civil Rights Act (Figure F1).

Figure F1
Editor and ANA Rebuked

In 2018 the editor-in-chief of the Journal for Holistic Nursing reflected on her experience
handling the dismissal of a Black nursing student and acknowledged that, at the time, she had not
considered racism or White professionalism to have been relevant.

230

Figure F2
Confronting Racism in Nursing Article

231

232

Appendix G: White-Dominant Culture Values with Alternative Values Adjacent
Table G1 is adapted from the work of Partners for Collaborative Change (Okun & Jones,
2000) and retrieved from Government Alliance on Race and Equity (2022). The White-dominant
culture norms (left most column) are also observed in the nursing’s epistemology and
professional values. These norms have so far prevented nurses from diversifying the nursing
workforce or improving health equity.

Table G1
White-Dominant Culture Norms and Alternatives
White-dominant culture norms Cultural alternatives
Either/or thinking
Believing people are racist or not racist, good, or
bad. Seeing incidents of inequity as isolated
events.
Systems and complexity thinking
Understanding context and intersectionality.
Seeing patterns, holding contradictory
thoughts & feelings simultaneously.
Paternalism
No consultation or transparency in decision
making. Taking over campaigns, mediating and
facilitating others.
Partnership
Decision making is clear, affected parties are
consulted. Evaluations include staff at all
levels. Leadership of Frontline communities
is respected and nurtured.
Competition
Taking unearned credit for wins. Coopting local
organizing efforts, or the work of other staff.
Treating core campaign issues as more
important than issues that other people are
working on.
Collaboration
Taking time to build relationships based on
trust. Focus is on ‘building a bigger pie’
instead of fighting over a slice. Mutual
support and promotion of each other’s
campaigns and issues.
Power hoarding
Ideas from less senior people are treated as a
threat, information and decision making is
confidential. Holding on to resources, scarcity
mindset.
Power sharing
Ideas at all levels are valued for the positional
expertise they represent, ideas from others
are requested and space is made for them to
be heard. Budgets are made available for
viewing, providing input on, and resources
are shared equitably and appropriately.
233

White-dominant culture norms Cultural alternatives
Comfort with predominantly White leadership
Defaulting to all or mostly White leadership
using urgency and lack of available, qualified
People of Color as justifications for doing so.
Leadership representative of the communities
most affected by inequity
Take time to weave into the fabric of the
organization a critical mass of equity-‐
oriented People of Color in leadership and
on staff at large. Create inclusive culture.
With graceful awareness, acknowledge that
we’re all unconsciously socialized to see
physical features that are more White
European, including lighter skin, as ‘better’.
Be mindful of how norms of the White,
middle class can easily permeate the main
organizational culture.
Individualism & Separateness
Focus is on single charismatic leaders, Working in
isolation, from each other and from other
organizations.
Community & Collectivism
Working together, working from a movement
lens. Understanding that to change
everything it takes everyone. Understanding
interdependence of all social struggles.
Working for all who are impacted by
destruction and seizing of land, air, water,
and climate, especially those hit first and
worse.
Fear of open conflict
Right to comfort. Politeness is valued over
honesty. White fragility goes unchecked. Those
who bring up discomfort for others are
scapegoated. Useful feedback not given in
timely manner resulting in underperformance,
lack of growth and distorted sense of how one
is doing. Smaller problems left unattended
become bigger ones down the road.
Direct and constructive feedback/ Growth and
learning
Peers call each other in and continuously learn
from each other. Managers are skilled at
providing timely, supportive feedback in
culturally and individually responsive ways.
Superiority of the nonprofit written word
If it’s not written down, it is not valued. If it’s
written down in any way other than “Standard
American English”, it is seen as incorrect or
less intelligent. Superiors “correct”, edit and
change documents to reflect a particular
normalized language for that non- profit.
All forms of communication valued and taken
seriously
Communication is treated simply as
communication, stripped of “right” or
“wrong”, recognizing that an individual’s
use of language involves culture, power,
lived experience and geography. Editing
focuses solely on communicating more
clearly to a particular audience and done
with permission of the writer.
Appreciation for how in some communities,
info relayed effectively through relationship
networks and the spoken word, not just the
234

White-dominant culture norms Cultural alternatives
written word.
Comprehensiveness
Continual research and writing that leads
nowhere. Creating multiple reports, groups,
committees that are working in isolation and
don’t build on each other’s work. Vision,
values, and goals that no one can remember nor
easily refer to in a meeting.
Clarity & alignment for action
Simple, memoizable and repeatable shared
vision, values, and goals.
Transactional relationships
Detached “professional” communication, for the
purpose of completing a transaction and
efficiency. Reaching out or acknowledging
people only when you need something from
them.
Transformational relationships
Building relationships internally and
externally that are based on trust,
understanding and shared commitments.
Even in the simplest ways, taking time to
see, greet and acknowledge each other to
sustain caring connections, especially when
there’s ‘no time’ to do so. Space to
appropriately be in one’s majesty and share
in each other’s cultural bounty.
Transactional goals
Transactional deliverables / quantifiable are
ranked above meaningful engagement or
qualitative goals. Rushing to achieve numbers.
Transformational goals
Working towards meaningful engagement
with depth, quality; using qualitative goals
in addition to whatever deliverables a
foundation is asking for. The timeline for
the deliverables Includes enough time for
quality.
Progress is bigger, more
Focus on quantity; less focus is put on the cost of
growth on people, communities, and
relationships.
Progress is sustainability and quality
Cost/ benefit analysis includes all costs. Focus
is on sustainability.
Over- working as unstated norm
Encouraging people to work through weekends
and into the night (directly or passively by
setting up work plans that are unachievable in a
40-hr. week) -‐ ignoring how Black and Brown
people have been historically and systemically
requested to take on physically taxing work by
White bosses.
Self-Care/ Community Care
Actively encouraging a culture of self-‐care
and community care in which people care
about each other’s physical and emotional
wellbeing, support time boundaries and are
considerate of time zone difficulties,
parental needs or personal health issues.
Work plans include 20% of unscheduled
time to enable space for the inevitable
unpredictable tasks that emerge.
235

White-dominant culture norms Cultural alternatives
Perfectionism
Mistakes are seen as personal, reflect badly on the
person -‐ the person is seen as a mistake. Little
time for learning.
Appreciation
Mistakes are valued as opportunities for
learning. People verbally show their
appreciation for one another
Skeptical management
As new hires slowly learn their job, it is subtly or
directly communicated that they “must prove
themselves”, setting them up to hide mistakes
or face discipline.
Supportive management
As new hires slowly learn their job they are
supported, given freedom to make mistakes
and learn from them. Supportive feedback is
provided in real-‐time or soon thereafter.
White mediocrity
People of color given extra work and scrutinized
while White staff with more years and/or
formal credentials are given a pass or promoted.
Fair evaluations and just promotions
Based on a broader range of competencies
than what has been historically valued
(skills in the left column)
Equity washing
Signing on to big lofty values, but not enacting
them. Hiring People of Color but not supporting
a culture shift to retain them, focusing on
inclusion internally while the field work
perpetuates inequities.
Real equity
Focus on all dimensions of the organization
Official title outweighs experience
Regardless of someone’s broad skill and
experience base, they are treated as though they
only know how to do what is in their job
description, and their ideas are valued based on
organizational rank. When offering to do more
or different, are told to “stay in their lane”
Holistic view of people
People’s experience and skills are understood
to likely expand beyond what they have
been hired to do, and opportunities to
contribute more of who they are, are
offered.
Changing the subject away from the role of race
Limited understanding of how biases (preferences
and dislikes) based on race and culture interplay
with all aspects of our lives and systems. Seeing
difference as bad.
Perception that talking about biases is an attack on
White people or that White people can’t handle
the conversation.
Compassionate curiosity about how race,
cultural differences, racial bias may be at
play with 360-‐degree compassion, assume
there may be unconscious biases at work
with respect to race to some extent. Create
an environment that celebrates the courage
to explore racial bias in all its forms,
avoiding ‘gotcha’ and good person/bad
person dynamics and camps. Acknowledge
we all carry unconscious bias that is not
helpful, and each have a role in addressing
it. Focus on building stamina and healing
for self- reflection; focus on the
consciousness and behaviors, not on
shaming the person.
Narrow valuation of intelligence / performance
Assessing higher value to left column attributes
Broad appreciation of differences
Valuing attributes on the right column.
236

White-dominant culture norms Cultural alternatives
over right column attributes. Verbal/linguistic
and logical-‐mathematical intelligences treated
as superior
Including spaces for work that needs
musical-‐rhythmic, visual-‐spatial, bodily-
‐kinesthetic, interpersonal, intrapersonal,
and naturalistic intelligences.

237

Appendix H: White Space of Northern New Jersey Diploma Program 1912-1976
These are original graduating photos from a Northern New Jersey nursing diploma
program from 1912 to 1976 (Figure H1). The hospital-based diploma was founded in 1903 and
closed in 1977. Based on these photos, there were no men and virtually no students of color
found in the primary source photographs during the six decades the school existed. This
demonstrates the strength of nursing segregation even in a Northern state whose Black
population grew by 132% in the first decades of the Great Migration (PBS Learning Media,
2020).

Figure H1
Graduate Photos 1912 through 1976
1912

238

1932

1935

239

1938

1968

240

1971 (School’s catalog)

1971 (Last page of school catalog shows a Black female instructor using an instructional poster
with White breasts to explain breastfeeding)

1976
241

242

Appendix I: Abbreviated List of International Citations on Whiteness in Nursing
2020–2022
Allan, H. T. (2022). Reflections on Whiteness: Racialized identities in nursing. Nursing Inquiry,
29(1), Article e12467.
Bonini, S. M., & Matias, C. E. (2021). The impact of Whiteness on the education of nurses.
Journal of Professional Nursing: Official Journal of the American Association of
Colleges of Nursing, 37(3), 620–625.
Bell, B. (2021). White dominance in nursing education: A target for anti-racist efforts.
NursinInquiry, 28(1), Article e12379.
Besson, E. K. (2021). Confronting whiteness and decolonising global health institutions. The
Lancet, 397(10292), 2328–2329.
Canty, L., Nyirati, C., Taylor, V., & Chinn, P. L. (2022). An overdue reckoning on racism in
nursing. The American Journal of Nursing, 122(2), 26–34.
Cox, G., Sobrany, S., Jenkins, E., Musipa, C., & Darbyshire, P. (2021). Untangling the roots of
hair racism in the nursing profession. The British Journal of Nursing, 30(18), 1090–1092.
Dancis, J., & Coleman, B. R. (2021). Transformative dissonant encounters: Opportunities for
cultivating anti-racism in White nursing students. Nursing Inquiry, 29(1), e12447.
Flynn, K. C., Reverby, S. M., Smith, K. M., & Tobbell, D. (2021). “The thing behind the thing”:
White supremacy and interdisciplinary faculty in schools of nursing. Nursing Outlook.
https://doi.org/10.1016/j.outlook.2021.03.001
Iheduru-Anderson, K. C. (2021). The White/Black hierarchy institutionalizes White supremacy
in nursing and nursing leadership in the United States. Journal of Professional Nursing:
Official Journal of the American Association of Colleges of Nursing, 37(2), 411–421.
243

Iheduru-Anderson, K. C., & Wahi, M. M. (2021). Rejecting the myth of equal opportunity: an
agenda to eliminate racism in nursing education in the United States. BMC Nursing,
20(1), 30.
Iheduru-Anderson, K., & Waite, R. (2022). Illuminating antiracist pedagogy in nursing
education. Nursing Inquiry, e12494.
Lamberson, J., Pearson, P., Crooks, N., & Ricca, P. (2021). Examining Whiteness in obstetric
and pediatric simulations: A content analysis. The Journal of Nursing Education, 60(12),
690–696.
Louie-Poon, S., Hilario, C., Scott, S. D., & Olson, J. (2022). Toward a moral commitment:
Exposing the covert mechanisms of racism in the nursing discipline. Nursing Inquiry,
29(1), e12449.
Morone, J. (2021). Not just one bad apple: Calling out racism among nurses. Nursing Outlook,
69(4), 536–538.
Moorley, C., Darbyshire, P., Serrant, L., Mohamed, J., Ali, P., & De Souza, R. (2020).
Dismantling structural racism: Nursing must not be caught on the wrong side of history.
Journal of Advanced Nursing, 76(10), 2450–2453.
Valderama-Wallace, C. P., & Apesoa-Varano, E. C. (2020). “The problem of the color line”:
Faculty approaches to teaching social justice in baccalaureate nursing programs. Nursing
Inquiry, 27(3), Article e12349.
244

Appendix J: Initial Survey Results from the Commission on Racism in Nursing
Survey results of 5,600 U.S. nurses published in January 2022 by the Commission on
Racism in Nursing affirmed decades of literature by nurses of color that racism was a substantial
problem in the profession: Ninety-four percent of nurses report that there’s either “a lot” or
“some” racism in their profession (American Nurses Association, 2022b). These results were
published more than a century after the National Association of Colored Graduate Nurses was
founded in 1908 to improve education and employment opportunities for Black nurses. It also
marks the first-time work on racism has been supported by mainstream national nursing
organizations in collaboration with the National Council of Ethnic Minority Nurses Association
and a total of 20 nursing organizations, fellowships, and nurse sorority members representing
nurses of color.

Figure J1
Initial Statistics from the Commission on Racism in Nursing

245

Note. Graphics from Survey Shows Substantial Racism in Nursing by American Nurses
Association, 2022 (https://www.nursingworld.org/survey-on-
racism?_ga=2.140753271.477589000.1643214626-752314245.1642782897). In the public
domain.
246

Appendix K: Schemas of White Racial Identity in Relation to Nursing Professional Identity
Schemas of White racial identity in relation to nursing professional identity as adapted
from Helms WRID, 2020.

Table K1
Schemas of White Racial Identity in Relation to Nursing Professional Identity
WRID schema Related phases/examples
How this schema manifests in
nursing’s professional identity
Contact

Unconsciousness of
White identity
“I’m innocent”

“The only race that is
important is the human
race”

Avoids interracial contact to
continue to believe that the
world is safe and fair and
minimizes differences in
treatment due to race.

White worldviews are seen as
a universal and strong belief
that other groups want to
assimilate to White culture.
Mainstream White nursing
professes to be colorblind,
which is reinforced in school
(Barbee, 1993).

Mainstream White nursing has
also avoided contact with non-
White nurses through
segregation efforts in the past
and tokenizing in the present, as
well as keeping contrary facts
or criticism of the ‘innocent’
and ‘caring’ profession outside
of the professional narrative so
their worldview of nurses as
‘good’ can remain intact
(D’Antionio, 2010; Hine,
1982).

Whiteness as universal is also
seen through nursing textbooks
illustrations (even those used in
non-White-majority countries)
and the use of White manikins
for clinical skill demonstrations
(Canty et al., 2022).
Disintegration

Challenged to identify
and reconcile the
“How can I be White?”

Initial recognition that Whites
people receive benefit and
Mainstream White nursing has
used avoidance of interracial
interactions both internally
within the profession and with
247

WRID schema Related phases/examples
How this schema manifests in
nursing’s professional identity
meaning of White
identity
privilege in society but
causes confusion to
reconcile with belief that
“all people are created
equal.”

Can be feelings of shame,
guilt, and confusion around
one’s racial membership
with few outlets to resolve
inner reckoning or turmoil.

Often people will react in self-
protection by
Avoiding interracial
interactions
Directing anger towards
People of Color
Declaring their own
oppressed status
Staying silent as a means
of hiding.

non-White patients. With
patients, White nurses cared for
White patients at White
hospitals and White nurses
cared for White soldiers during
wars. Professionally, schools
had quotas to reduce the
admission of non-White
students and White faculty
hired other White faculty. The
national nursing organization
was also segregated until the
1960s (Carnegie, 1999;
D’Antonio, 2010; Hine, 1982).

Mainstream White nursing has
tended to blame marginalized
groups for their health
disparities or judge them
through stereotypes such as
“lazy” or “uneducated.” Black
nurses who speak up about
racism or unfair treatment as
judged as “problematic,”
“angry,” or “uppity” (Dancis &
Coleman, 2021; Iheduru et al.,
2022; Scott et al., 2019).

Mainstream White nursing has
been notoriously silent on
issues of critical importance to
non-White nurses and patients.
This is seen by the lack of
urgency around maternal health
disparities and racism in the
profession, and the national
nursing organization rescinding
their own presidential
endorsement policy as recently
as 2020 during a time when
non-White nurses were dying at
higher rates than White nurses
from the pandemic.
248

WRID schema Related phases/examples
How this schema manifests in
nursing’s professional identity
Reintegration

Idealization of Whites
and White culture
“We have the best because we
are the best”

“I’m not racist”

Belief that
Whites are no more racist
than other groups
Distortion of environmental
information to conform
White superiority
principle
Hostility and anger directed
towards People of Color.
Whites as standard for good,
moral, and socially
desirable
Denial of responsibility of
White people
Use of “politically correct”
as derogatory
Desire to enhance White
privilege
Achievement and
accomplishments of
People of Color are seen
as a threat
Mainstream White nursing was
founded on principles of
altruism, wherein nurses
“can’t” be racist.

White majority of nursing
workforce is perceived as
White nurses being the “best”
for the job and non-White
nurses not being “smart,”
“disciplined,” or “capable”
enough for the profession
(Choy, 2005; Hine, 1982;
Kristofic, 2019).

White mainstream nurses reacted
in shock and anger at
publications by a historian that
revealed racist writings by
Florence Nightingale in 2020.
Rather than accept the primary
source information, they
preferred ignorance than
revising their concept of
Nightingale. The historian was
harassed and bullied, as it
negated their beliefs of
Nightingale - and by extension,
themselves - as good and moral.
Similar patterns also occurred
in Britain in the last decade
(British Broadcasting
Corporation, 2014; Flynn et al.,
2021; Smith, 2021).

Nurses of color report being
tokenized, less likely to obtain
tenure, and less likely to be
promoted compared to White
colleagues, often with less
qualifications, experience, or
education (Iheduru et al., 2022).
White mainstream nursing has
249

WRID schema Related phases/examples
How this schema manifests in
nursing’s professional identity
also spent a century creating
racial hierarchies within the
profession or “raising the bar”
of educational minimums and
entry to practice that would
provide further advantages
directly to White nurses
(Nelson, 2002). This can be
seen in recent discussions for
nurse practitioners (which was
a master’s level since the
1960s) to become doctorally
prepared.
Pseudo-
Independence

First schema towards
development of a
positive non-racist
identity
“Let’s help them become more
like Whites”

Being perceived as a “good
White person” is central to a
person’s self-concept and
can view White people as
“good” or “bad.”
Understands White people
are responsible for racism
but is perceived as a sin of
the “bad” White people and
cannot take personal
responsibility.

Will engage in “thinking”
about racial issues rather
than “feeling” the pain of
them; is prone to
intellectualization.

Seeks to maintain racial
comfort. Wants to help
People of Color behave in a
way to be more accepted by
White society that can
continue helping the person
feel good about being
White. Instead of admitting
This schema is represented in
nursing through the way White
nurses were sent internationally
to teach western biomedical
nursing in colonial territories or
on Native American
reservations (Kristofic, 2019;
Sweet & Hawkins, 2014).

The cultivated professional image
of nurses as ‘good’ connects to
the founding influences on
nursing listed in Appendix C
and has led to a preoccupation
with the image of goodness
rather than actually being
equitable, fair, or just. Like in
policing, instances of racism by
nurses are treated as “bad
apples” rather than indicative of
entrenched thinking of the
nursing culture (Darbyshire,
2021; Moroe, 2021).

Nursing academics and
researchers in particular are
susceptible to conducting
research about marginalized
communities that are
250

WRID schema Related phases/examples
How this schema manifests in
nursing’s professional identity
racism, generically declares
“everyone’s racist.” Desires
fairness so long as there is
no immediate implication in
their life.

Can minimize, ignore, or
refuse to engage with ideas
that imply society is not fair
for People of Color and
point to token People of
Color who succeeded as
evidence things are “better.”

Engages in friendly
colorblindness where they
believe they are aware of
racial injustices but cannot
always see them when they
occur in front of them, or if
they recognize it, they do
nothing about it.

Views advantage gaps as
resolvable through the
improved efforts or People
of Color. Expresses desire to
help People of Color access
opportunities but may never
actually do anything.

disconnected from emotion,
empathy, or genuine care or
concern. Some have been
described as “health equity
tourists” for this reason (Lett et
al., 2022).

Seeking racial comfort is a theme
that has been reiterated in the
500-page Future of Nursing
2020 - 2030 report which
centers health equity as a goal
of nursing but mentions
Whiteness three times. Often
nursing education content about
racism focuses on
“microaggression” or
“unconscious bias” without
explicitly naming Whiteness or
racism directly. One nurse
started the hashtag
#dontupsetwhitenurses which
has been used on Twitter and in
online nursing conference chat
threads to capture the sentiment
of the need for racial comfort in
the profession.

This can be seen in nursing when
nurses point to the Black, male
nurse as president of the
national nursing organization to
imply nursing is becoming
more diverse and has less
barriers for advancement.

There has been a delay and inertia
within the nursing profession
that has resulted in a decades-
old gap between the
documentation of an issue like
racism or harm to patients of
color and a lack of actionable
251

WRID schema Related phases/examples
How this schema manifests in
nursing’s professional identity
steps or funding to address it.
This has led to what nurses of
color have described as “missed
opportunities” when White
nurses publish far-reaching
professional goals such as the
Future of Nursing 2010 - 2020
report, but do not prioritize
workforce diversity as much as
other goals (Fields, S, personal
communication, October 12,
2021).

Immersion/
emersion

Active attempt to re-
define the meaning of
Whiteness
“I’m White”

Search for other White people
who think about race in the
same way, and one feels a
personal responsibility for
racism and understanding
they may have (advertently
or inadvertently)
perpetuated it.

Consider themselves to be
more knowledgeable about
racial matters than most
White people and will either
actively criticize or try to
educate White people in
other schemas.

Seeks continuous education
and finds a way to be White
that “feel” more moral and
righteous, which can be
threatening to other White
people in other schemas -
there can also be anger or
embarrassment towards
Although this schema has been
less observed in White
mainstream nursing, White
nurses have self-organized in
grassroots groups to support
each other and their evolving
non-racist identities. Offerings
such as White Nurses: It ’s on
Us created by NurseManifest in
2022 was a series of virtual
conversations specifically for
White nurses to reconcile their
identities with their
responsibilities to not
perpetuate racism within the
nursing and healthcare
profession, and to hold each
other accountable (Nurse
Manifest, 2022).

Criticism of White nurses by
other White nurses is observed
in professional and social media
settings. White nurses in
leadership positions are called
out or called on for their
behaviors and opinions that
252

WRID schema Related phases/examples
How this schema manifests in
nursing’s professional identity
oneself or other White
people. They may also be
abandoned by previous
White social circles who are
in other schemas.

Seek brutal honesty with
themselves and facing
feelings of guilt, anger, or
anxiety that racism has
caused them. This can result
in self-liberation and an
ability to see humor in
White culture (as opposed to
reacting with fragility).

reinforce White-dominant
cultural values. These can
include nurses who challenge
instances when White nurses
are punitive to students, speak
on all-White panels, sustain the
Nightingale narrative, or
amplify unjust treatment for
White nurses more than nurses
of color.
Autonomy

Also called racial self-
actualization
“I see color - and I like it!”

Defined by ability to truly
value diversity and a
lifelong discovery and
recommitment.

Do not rely on People of Color
to validate them for their
non-racist actions or
behaviors.

Actively works toward
elimination of socio-
political oppression and is
more aware of the direct and
indirect ways in which
oppression exists that is also
harmful to dominant groups
and their own humanity.
While individual nurses can be
described by this schema, this
would be the goal for White
mainstream nursing to achieve
this level of investment in
diversifying the profession and
actively work towards health
equity and social justice.
253

Appendix L: Survey Protocol
This survey was available via mobile, tablet, laptop, or desktop using the survey Qualtrics
URL link.
This is an anonymous survey on White nurses’ racial identity development that takes
approximately 10 minutes. Your participation in this research is appreciated and voluntary. If
you have any questions regarding the survey items, please feel free to contact the researcher,
Joanna Seltzer Uribe, jrseltze@usc.edu.
By beginning the survey, you acknowledge that your participation in this study is
voluntary, you are 18 years of age or older, identify as a White, American registered nurse, and
you are aware that you may choose to terminate your participation at any time and for any
reason.

Questions 1-3 are closed demographic questions.
1. How many years have you been working as a nurse?
Nurses answered using numerical sliding function:

2. In which part of the U.S. were you primarily raised?
a. Midwest
b. Northeast
c. Southwest
d. South
e. Heartland
f. West Coast / Hawaii
g. Northwest / Alaska
h. Not raised here
254

3. In which setting do you currently work?
a. Hospital
b. Academic Faculty
c. School (K -12)
d. Home Care
e. Lab / Research
f. Clinic / Medical Office
g. Hospice / Long or Short TCare
h. Community / Public Health
i. Administration or Leadership (any setting)
j. Retired
k. Other
Questions 4 - 5 are open-ended questions to prime nurses to think about their White racial
identity.
4. What age would you say you were when you realized you were “White”?
[Free Text]
5. Please describe any additional context or information about that experience. How
did it make you feel? Has it impacted how your thinking or perception about
Whiteness or what it means to be a White person? Has that experience been
solidified or challenged your identity as you grew older?
[Free Text]
Questions 6 - 9 are additional demographic and identity questions.
6. In which part of the U.S. do you currently reside?
a. Midwest
b. Northeast
c. Southwest
d. South
e. Heartland
f. West Coast / Hawaii
g. Northwest / Alaska
h. No longer live in U.S.
7. How old are you?
Nurses answered using numerical sliding function:

8. Please list your gender identity or preferred pronouns.
255

[Free Text]
9. What is your highest level of education?
a. LPN
b. ADN
c. BSN or bachelor’s degree
d. MSN or Other Master’s Degree Associate
e. Doctorate (EdD, PhD, DNP)
Questions 10 is designed to understand the nurses’ current perception of their White racial
identity.
10. Please rate your level of agreement with the following statements.
Users were given a grid format displaying a Likert-scale 1 - 5
[1 = Strongly Disagree, 2 = Somewhat Disagree, 3 = Neither Agree nor Disagree, 4
=
Somewhat Agree, and 5= Strongly Agree]
a. I hardly think about my race and has little to do with my identity.
b. Racism is real for some people, and that is such a complex, enduring
societal problem there is nothing we can even do about it, but just learn to
live with it and hope it gets better in future generations.
c. For most of my life, I have not thought about racial issues or the impact of
structural or institutional racism (defined as racist beliefs that are
institutionalized and are designed to exclude groups of people)
d. In conversations around race, I prefer to stay neutral by staying quiet.
e. I don’t agree with injustice for any group. Even if I may be personally less
affected by injustice or have a different lives experience as a White
American, it is still important to advocate for anyone based on human
rights,
f. When I do need to think or talk about race, it makes me feel self-conscious
or uncomfortable.
g. As a White person, I lack guidance, skill, or understanding about how to
work in a way that is more inclusive to non-White health professional, non-
White students, or non-White patents.
h. I feel comfortable being White and using my privilege to dismantle racist
policies, laws, or unfair practices that impact non-White groups.
i. Many have said that, as race is a social construct, Whiteness is a lie we’ve
chosen to believe in. What does it even mean to be White? I’m not sure.
j. I actively want to be a better ally for health equity and to become more
conscious of any bias that may impact my patient care or interactions with
co-worked, but I’m not sure how to start.
k. I just treat everyone equally, if we all did that, racism could go away.
Questions 11 - 12 are designed for more narrative opportunities, for nurses to share stories
or experiences that shape their identities.
11. If any of the statement above resonated, confused, or bothered you, please tell us
256

more.
[Free Text]
12. Can you please describe a time when you became aware of your White identity
during
a situation at work? Was this a positive, neutral, negative, or a learning experience
for
you - and how has it impacted future experiences? i.e.: Do you avoid similar
situations,
feel better able to handle them, or has it had no impact? Please remember this is
completely anonymous.
[Free Text]
Question 13 is designed to understand nurses’ level of agreement to statements about
nursing education, workforce diversity, health disparities, racism, and White privilege.
13. Please respond to the following statement with yes, maybe, or no.
a. When you hear that the nursing workforce should be “more diverse” is that
a statement you agree with?
b. In nursing school, when we learned about health disparities we never
talk(ed) about the ways bias, racism, or structural or institutional racism
(defined as laws or policies that are based on racists beliefs designed to
exclude groups of people) impact poor outcomes.
c. At work, when we observe health disparities we never talk(ed) about the
ways bias, racism, or structural or institutional racism (defined as laws or
policies that are based on racists beliefs designed to exclude groups of
people) impact poor outcomes.
d. Would you say your nursing career would be improved by having safe or
brave spaces to have candida conversations around race?
e. Racism is a real problem that affects healthcare outcomes. We keep funding
studies to say what we already know.
f. Racism is a problem for some but is not so bad that it should be considered
a public health crisis.
g. Would you say that being White has offered any advantage for you in your
career?
h. Would you say that being White has offered any barriers for you in your
career?
i. I am aware of the concept of White fragility as the way White people react
to conversations around race.
j. I am aware of the ways nursing has intentionally excluded immigrants, men,
Asians, African Americans, Hispanics, and Native Americans from the
profession
Questions 14 - 15 allow nurses to provide further reflections on their White identity within
their nursing career.
257

14. Please tell us more about whether you perceive Whiteness as a barrier or advantage
in
your career? Have you ever thought about your racial identity in terms of your
career?
Have you ever considered nursing to be a professional “White space”? Again, this is
anonymous.
15. Please feel free to describe any other insights, questions, or comments that you may
have about your identity as a White nurse. Please remember this is completely
anonymous.
Nurses are provided instructions on how to opt in for an interview on the last survey page.
OPT IN:
To participate in a one-time interview on Google Meet about White racial identity
and nursing:
- select YES below
- then email jrseltze@usc.edu to receive open interview times
The interview is voluntary and will be 60 minutes max.
To maintain anonymity, these survey results will not be connected with your
interview.
This study has been reviewed and approved by USC’s institutional research board (IRB)
and will follow the protection and rights of study participants as established in the IRB
guidelines.
● Yes
● No

258

Appendix M: Semi-Structured Interview Protocol
Thank you for taking the time to chat with me today. I am conducting this interview as
part of my dissertation research with my doctoral program at the University of Southern
California. I am seeking your insight to understand the lived experience of White American
nurses and their White racial identity development. I anticipate this interview to take no more
than 60 minutes of your time.
Your participation is entirely voluntary. We can skip any question you want, and you
may stop the interview at any time for any reason. Any identifiable information obtained in
connection with this study will remain confidential. Your responses will be coded with a false
name (pseudonym) and maintained separately from your answers. Nothing said here will be
shared outside of myself and my dissertation committee and all answers are strictly confidential.
Your identity will remain anonymous.
I will not record this video, but I will record the audio in order for the transcription
service to record the conversation. There will only be transcription of this interview maintained
as an artifact and no video or audio files. By participating in this interview, your consent is
presumed, and you agree to be recorded for transcription purposes. May I have your permission
to transcribe this conversation?
Do you have any questions?
(Begin transcription)

259

Table M1
Interview Protocol
Interview questions RQ addressed Key concept addressed
What inspired you to become a
nurse?
n/a Warm-up, softball, trust
building
Where and how much nursing
school did you attend?
n/a Warm-up, softball, trust
building
How long have you been practicing?
Clinical background
n/a Warm-up, softball, trust
building
Begin to ask questions about White
identity … set stage about White
spaces
What is the demographic mix of
where you were raised, where you
attended nursing school, where
you work
1, 2 Awareness of White spaces

What age did you first conceptualize
being a White person?
1 White racial identity
development
Can you tell me about that
experience? How does Whiteness
factor into your identity?
1 White racial identity
development
What does it mean to be a White
person?
1 White racial identity
development
Has being White influenced your
career? Why/why not?
2 Impact of Whiteness at work
^ tweak based on answer to #8 …
Would you say that being a while
nurse provides any privilege or
power in your workspace? Why /
why not? What in your experience
makes you say this?
2 Impact of Whiteness at work
If something in nursing aims to
advance anti-racism or creates
more diversity, inclusion, or
belonging, do you perceive it as
being anti-White?
2 White racial identity
development in nursing
260

Interview questions RQ addressed Key concept addressed
Can you tell me more about that? 2 White racial identity
development in nursing
I will ask you three questions about
about your nursing school
experience:

Was there any content in nursing
school about race as a social
construct and its impact on health?
Do you feel nursing school
reinforced or challenged a White-
dominant culture?
Do you feel you were prepared in
nursing school to work in a
diverse setting or care for diverse
populations? HOW / instruction in
how to treat patients ethically,
equally, or equitably,
2 Awareness of White spaces
Did nursing school equip you to feel
capable to understand the factors
that led to health outcomes
disparities or does it seem
confusing or opaque why those
disparities exist today?
2 Impact of Whiteness at work
What would be your final thoughts
on the nursing profession
currently and ways the dominion
of nursing as a White space can be
addressed? Or any final comments
about Whiteness or White racial
identity in our profession?

2 Awareness of White spaces

261

Appendix N: Online Survey Recruitment Graphic
This was emailed to professional acquaintances on March 1st, 2022 and posted twice to
LinkedIn on March 1st and March 9th. Professional acquaintances were encouraged to forward
to colleagues and peers to leverage the snowball sampling technique.

Figure N1
Recruitment Graphic

262

Appendix O: Full Survey Replies Re: Ways White Racial Identity Evolves Over Time
Survey findings: Ways First Perceptions of White Racial Identity Evolves Over Time
I remember understanding that I was “not Black” rather than understanding that I was White.
Over time I’ve learned so much about Whiteness and racial bias, especially what women of
color face regularly in the workplace.
I realized I was White in kindergarten and as I’ve grown older, I realize I have an obligation to
use my privilege to help balance the scale. I need to recognize and check myself because our
system is broken.
I was raised to be “colorblind.” When I started working as a staff nurse, my colleagues, leaders,
and patients made it abundantly clear in many ways that your race defines you in many ways.
I have spent many years owning this awareness.
I experienced bullying from Black kids and was afraid of certain people and areas. As I grew
older, I challenged that fear.
Probably as my children were growing and heading off to college that I realized I was White
and needed to be more of an ally.
What does it even mean to be White, I think about this a lot? And I’m often ashamed of how
other White people behave.
I make it my responsibility to learn how to be better at being more inclusive to non-White
patients, coworkers, or students.
I discovered not everyone at my school had the same skin color (although our BIPOC students
were few); in my 20s I had exposure to an anti-racism group within the Mennonite Church
(30 years ago) -- that was when I first started grappling with the notion of White privilege.
I grew up in a rural community in the Midwest with no diversity (until I reached high school).
Growing up in such a homogenous culture made it difficult to see, recognize, and explore the
experiences of other racial identities. I have since found myself for opportunities to learn
more about other racial and ethnic identities through education, travel, and conversation
because it was missing most of my early life.
Definitely my level of reflexivity, awareness and criticality has evolved as I have grown older
and been exposed to more people, critical history, writings such as Black feminist
scholarship, and cultural contexts in which Whiteness manifests and/or in which I navigate
daily life with a certain awareness of my Whiteness and how racialization (or in my case,
being read as “White” by others especially other White people) renders unearned power and
privilege across myriad contexts.
I think I began having more of an awareness and experience of Whiteness once I was around
more People of Color who experienced different treatment because they weren’t White. I
think as I’ve grown older, I’ve been more aware of my Whiteness and how that influences
how I move through life, as well as the privileges I have and the challenges I need to make to
myself and my beliefs to challenge Whiteness and White supremacy. As a nurse, I’ve become
more comfortable advocating for my patients but also understanding that I may not be the
person they want to receive care from if they are BIPOC, and that they deserve nurses and
care teams that better understand their experiences.
It made me curious about others, it made me more aware of how adults in my life perceived
263

Whiteness as a preferred identity. The experience helped me explore my own identity as I
grew and acted opposite to how I was raised. Exploring racial justice in college, I was able to
be honest about my growing up experience and it helped me understand how Whiteness as the
default in so many places really isn’t in our best interests.
I had many different feelings throughout my life. I was proud as a child, shameful as a
teenager/early twenties, and feel I am comfortable with who I am today.
As a nursing manager I wanted to hire a diverse team of nurses that reflected our newly built
inner city children’s hospital. HR said it couldn’t be done because there were no eligible
people of color or bilingual members of the community that were qualified to be nurses. My
first experience with trying to recruit members of the community and hire PCAs and tech and
support school programs to go back to school for nursing while working at the hospital.
I have become very aware of the privilege that comes with being a White woman and the
responsibility I have as a result of making sure inclusivity is practiced where I work, worship,
shop, play and live.
Did not really understand how non-White people were treated differently until in college
because I was fortunate to have grown up with friends of many races and cultures before
becoming a nurse. I was a theater and music student and worker. Working in healthcare and
seeing / hearing about discrimination was eye-opening.
At the time, I was concerned.” Reverse Racism” I realize it was not but an example of White
privilege.
Reading about experiences of Black Americans and realizing I have White privilege.
Only recently have I fully realized that I was indoctrinated into a binary way of thinking; thus,
differences were cataloged as good or bad and “others” cataloged as “Other.”
Since I was a child, I realized I was White. The implications (privileges, societal norms) have
become more evident in the last 18 years.
I honestly haven’t thought of being White as anything until the Black Lives Matter movement.
Now I am constantly seeing why that’s problematic, and how my Whiteness has and does
harm People of Color with the structures we live in at times.
I grew up in the same community that my dad was raised in. At age 15 our family moved to
rural Connecticut because my father felt like the town was “changing.” My parents never said
the words, but I understood it was because black families were moving into the town. I didn’t
hear the term White flight till I was well into my 20’s.
I was 28 before I ever experienced being the only White person in a particular space. I was in
grad school on a bus, and it completely transformed how I view myself, my identity, and my
position in life. This happened WAY too late and gave me insight as to how the non-majority
may feel at any given time.
This is a space where I continue to learn and unlearn. I shudder when I think back on some of
the myriad ways in which I have failed to respond in such situations (like bystandrerism)
and/or centered Whiteness and White feelings in the past, to the harm and exclusion of
racialized colleagues. I am trying to do better, and to build external accountability into my
actions and daily life. My practice continues to evolve, and I am sure I continue to make
many mistakes.
264

Even given my experience growing up and being educated in Hawaii, once I was on the
mainland the totally White culture completely soaked in, and it took me a number of years to
realize the effect of this. Plus, my parents were from the south, so I also acquired a strong
tendency toward Black racism specifically.
Recently I wrote a test question that didn’t translate well regarding the race of a patient. Several
students were very vocal about how they interpreted the questions. At first, I was really upset
as I viewed them as calling me racist, but it was with them and talking about the question I
realized how the question was written. I asked for assistance in rewriting the question and
have since joined a University DEI committee.
I am looking forward to reading your results. I think that lack of understanding and awareness
of myself and our White colleagues has great impact on continuing systemic racism without
meaning to do so.
I feel rejected as a White supremacist before I get a chance. I have a limited view of other
worlds outside my bubble. The best effort I can deliberately do is have more black friends.
Friendships teach tolerance.
With results from the recent national survey on racism in nursing, it is incredibly important to
note that a majority of Black nurses say there is racism in our profession and a majority of
White nurses do not. How can we hope to address a problem where so many of the folks
upholding it don’t even know it’s a problem? The Whiteness in nursing is both personal and
structural.

265

Appendix P: First Known Nursing Textbook, 1617
Cover of the Instrucción de Enfermeros y Método de Aplicar los Remedios a Todo Tipo
de Enfermedades (Training Nurses and a Method for Applying Remedies to all Forms of Illness)
which was written by Catholic brotherhood in Madrid, Spain in 1617 and pre-dates Nightingale’s
work by over 200 years (Figure P1). The text, which was peer reviewed by Spanish physicians,
the monarchy, and the Church, had five editions over the course of a century, traveled with
Conquistadors to the New World, and was recently translated in English in the doctoral work of
Australian nursing scholar Dr. Tanya Langtree (Langtree, 2020). It is previously unknown to the
international nursing profession.

Figure P1
Instrucción de Enfermeros

Note. Image in the public domain.

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Asset Metadata

Creator Seltzer Uribe, Joanna Rachel (author)

Core Title White nurses, White spaces, and the role of White racial identity in the American nursing profession

School Rossier School of Education

Degree Doctor of Education

Degree Program Organizational Change and Leadership (On Line)

Degree Conferral Date 2022-08

Publication Date 08/05/2022

Defense Date 08/05/2022

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag American nursing,nurse,OAI-PMH Harvest,White feminism,White racial identity,White space

Format application/pdf (imt)

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Krop, Cathy (committee chair), Carbone, Paula (committee member), Langtree, Tanya (committee member)

Creator Email joannaseltzer@gmail.com,jrseltze@usc.edu

Permanent Link (DOI) https://doi.org/10.25549/usctheses-oUC111376219

Unique identifier UC111376219

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Rights Seltzer Uribe, Joanna Rachel

Type texts

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