Rooting out Racial Bias in Nursing: Hope and Grace

Dr. Susan Moore died of complications related to COVID-19. Prior to her death, she detailed what she felt was racial bias in her care. This article explores our own responses and how we can find the hope and grace to keep moving forward in a positive direction.

Dr. Susan Moore, 52, died of complications related to COVID-19 in St. Vincent Carmel Hospital in Carmel, Indiana. A Black physician, she posted on social media about her treatment in and discharge from another area hospital. Her post describes what she felt was “racist” treatment by her medical team and her attempts at self-advocacy in the midst of her severe disease.

Racial and Ethnic Minority Group Disparity

Her course of treatment and subsequent death highlight the disparities some persons of color face in their care. The disparities have become more visible during 2020 with the coronavirus pandemic. The inequities in health care may have been in the background all along, but they have begun to stand out starkly in the past few months as Blacks and persons of color suffer and die disproportionately.

Long-standing systemic health and social inequities have put many people from racial and ethnic minority groups at increased risk of getting sick and dying from COVID-19. The term “racial and ethnic minority groups” includes people of color with various backgrounds and experiences. But some experiences are common to many people within these groups, and social determinate of health have historically prevented them from having fair opportunities for economic, physical, and emotional health (CDC.gov).

"If I Were White"

Dr. Moore posted several times to social media during her course of treatment. She described, with the knowledge of a physician, her plan of care, and necessary actions. She was diagnosed with COVID-19 on November 29 and was hospitalized for treatment of respiratory symptoms. During that hospital stay, she reported her symptoms, treatment, and concerns that she was being treated differently because of her skin color. She said, “I put forth, and I maintain, if I were white, I wouldn’t have to go through that.”

While the particulars of her case are difficult to ascertain, the CDC and the U.S. Department of Health and Human Services have determined significant disparities in the Social Determinates of Care and access to related to ethnicity, poverty,  discrimination, and access to care (healthypeople.gov).

As professional nurses, we are part of the access and delivery of treatment outside the hospital and at the point of care. What is our role in identifying discrimination and inequities and addressing those?

Surely we would never discriminate against a patient because of the color of their skin. Would we? Not on purpose, anyway. The problem of possible racism and inequality of treatment based on skin color is impossible to deny and monumental to address.

What Can We Do in Our Day-to-Day Practice that Makes a Difference?

Assess

While we may not feel we are racist in any way, studies and our own experience show us that we all have a racial bias. Often it is hard for us to see and acknowledge racist attitudes in ourselves. Still, it is a first step in addressing the problem, especially as it relates to our professional behavior. Attending training, reading, watching movies, educating ourselves can all be steps to help us, but in the end, we must sit with the fact that we all have work to do as humans. None of us is exempt. But there is hope. With grace, compassion, and love we can come together to see the problem and do something about it. Grace and love are the only actions that can truly change racism. Everything else just points a finger at it and stirs it around.

Acknowledge

Acknowledge that the change begins with me. As Mahatma Gandhi said, “If we could change ourselves, the tendencies in the world would also change. As a man changes his own nature, so does the attitude of the world change toward him.” It is always easier to point fingers and shame/blame others for their bad behavior. But for racism and racial bias and discrimination to stop, we must come together to identify the problem and pull it out by its roots—every day. This is not a training session that we can attend to fix what is wrong—this is an attitude of the heart.

Advocate

When you hear labels being tossed about—“ drug addict” or “difficult patient” or “trouble maker”—be aware and alert to your own feelings and the possible need to speak out. Advocacy is not mean, and it doesn’t employ shame. It simply provides a human perspective. People who are hurting need care—even if they aren’t nice or thankful or kind themselves. While we all know this and practice it every day, we all need encouragement to stay the course. It can be wearing to care for someone who doesn’t reciprocate with appreciation. A friend once said, “Hurt people, hurt people.” We don’t know what our patients are going through and what their lives are like outside of their illness. When they lash out, we cannot strike back. We provide care. Excellent care. Every time and to every patient.

Appreciate

As nurses, we get tired. We have bad days, too. As we walk through difficult days, we want to continue to help each other be our best selves. This begins by not denigrating other staff or talking negatively about our patients in the lounge's privacy. Negativity breeds negativity, and soon the contagion overwhelms the unit with discouragement. Be aware of co-workers who have a tendency toward negativity and work to maintain a positive balance. While we don’t want to be always countering with “the bright side,” we also don’t have to enter into the negativity. We can stay the course, remaining neutral. If we are in a leadership position, we help set the tone: finding ways to express appreciation and allowing nurses to vent when they need to in appropriate and supportive ways.

Hope and Grace

Dr. Susan Moore was a Jamaican-born immigrant who graduated from the University of Michigan Medical School. According to Alicia Sanders, who has established a GoFundMe account, “Susan was a phenomenal doctor. She loved practicing medicine, she loved being a member of Delta Sigma Theta Sorority, Inc, she loved helping people, and she was unapologetic about it.” May she rest in peace, and may her self-advocacy propel us forward on our journey toward more compassionate care.

7 minutes ago, cynical-RN said:

If you tell me your pain is 9/10 after I have given you fentanyl and hydromorphone while still insisting that you need more narcotics, other factors have to be considered like your respiratory status and potential for abuse of narcotics. I am not giving you another 50 mcg of fentanyl when your RR is 8. You've got people who have had regional blocks and can't move an extremity yet complaining of 9/10 pain in that extremity or feel a cold wet chlorohexedine wipe. Make that make sense to me physiologically. Again, what you report is considered and respected, but it is not going to dictate my interventions. What your teachers taught you might be outdated. It might be time to brush up on recent scientific literature. 

Adequate pain management is a human right and moral imperative for all patients, but especially for the older adults considering the prevalence and evidence showing significant under-assessment

42 minutes ago, Kooky Korky said:

If you look for trouble (bias), you will always find it.  Whether it's there or not.

I'm not certain that bias was there or was not there in the cases mentioned so far in this thread.  I believe it could have been, but there is no way to know for sure, unless someone out and out said, "You &(%(**@ N word" or whatever race word applies. 

We can't just assume that people who have complexions different than our own are prejudiced against us.   Also, we can't assume that their bias is worse than our own bias against them.

Assuming bias/prejudice exists in others is a good way to learn to hate everyone different than you.  It teaches them to have prejudice if they didn't already.

Again there are facts and there are anecdotes. The facts indicate that there are inequalities in the provision of care, especially relative to black people (POC is too wide of a brush). These facts have been established in multiple studies. My response was to an anecdotal comment about all people being treated poorly. Whereas it might be true, it detracts/subtracts validity from the context of the subject in the OP. It is akin to observing a burning house in the neighborhood, then one person comments that all houses in that neighborhood are decrepit. It is the same argument that the sentiment (not movement/organization) 'black lives matters' gets detracted by those who counter by all lives matters. Both could be true, but some offer the counterproductive retort to subtract validity from the message being portrayed. I heard somewhere that if America catches the cold, Black America catches Ebola or something to that effect. Not literally, but figuratively. I hope that clears the smoke for you. 

2 minutes ago, Karmat said:

Adequate pain management is a human right and moral imperative for all patients, but especially for the older adults considering the prevalence and evidence showing significant under-assessment

Could you have offered more than this platitude of a retort? Read my response again, and make it make sense physiologically.  

52 minutes ago, cynical-RN said:

Again there are facts and there are anecdotes. The facts indicate that there are inequalities in the provision of care, especially relative to black people (POC is too wide of brush). These facts have been established in multiple studies. My response was to an anecdotal comment about all people being treated poorly. Whereas it might be true, it detracts/subtracts validity from the context of the subject in the OP. It is akin to observing a burning house in neighborhood, then one person comments that all the houses in that neighborhood are decrepit. It is the same argument that the sentiment (not movement/organization) 'black lives matters' gets detracted by those who counter by all lives matters. Both could be true, but some offer the counterproductive retort to subtract validity from the message being portrayed. I heard somewhere that if America catches the cold, Black America catches ebola or something to that effect. Not literally, but figuratively. I hope that clears the smoke for you. 

Unfortunately, I live in the real world and have experienced the kind of racism experienced by the doctor.  What I experienced was validated by staff in certain situations. It's odd that you would mention BLM but you do you. For me, pain is what the patient says it is and for me to think otherwise would be a disservice to my patients and their recovery. Again, I find it interesting that you reference Black America catching Ebola and that speaks volumes about how you think. You can argue all you want with a patient about what their pain is but in the end if you don't treat their pain to their satisfaction they will go to your supervisor, the house supervisor, or the Director of Nursing. If enough of these instances take place you will have to explain your thought process and the patient will get the pain medication to cover their pain as they indicated if within reason.

20 minutes ago, Karmat said:

Unfortunately, I live in the real world and have experienced the kind of racism experienced by the doctor.  What I experienced was validated by staff in certain situations. It's odd that you would mention BLM but you do you. For me, pain is what the patient says it is and for me to think otherwise would be a disservice to my patients and their recovery. Again, I find it interesting that you reference Black America catching Ebola and that speaks volumes about how you think. You can argue all you want with a patient about what their pain is but in the end if you don't treat their pain to their satisfaction they will go to your supervisor, the house supervisor, or the Director of Nursing. If enough of these instances take place you will have to explain your thought process and the patient will get the pain medication to cover their pain as they indicated if within reason.

What is odd about my reference of BLM and the Ebola analogy? Do you understand how pain is transmitted physiologically? In the previous example, if your patient had an interscalene regional block with loss of sensation and mobility to the upper extremity, then they continuously report a pain level of 9/10 post-op on said extremity, and you choose to give them dilaudid, fentanyl et al repeatedly because of you want to treat their pain to their satisfaction, despite RR <10, you are in for a rude awakening. Context and safety matters in addition to a solid understanding of pain pathways and receptors. I asked you to provide your rationale physiologically or even on a pathophysiological aspect, but you have failed to do so thus far. I treat patients' pain with safety as a priority. I have been fooled once or twice and had to use Narcan, so I am not coming from a sanctimonious POV. If you practice with fear of DON and managers, rather than your understanding of pharmacology and physiology, then that is a disservice to your patients as summarized by the convictions you have written thus far. 

4 minutes ago, cynical-RN said:

 

 

4 hours ago, cynical-RN said:

What is odd about my reference of BLM and the Ebola analogy? Do you understand how pain is transmitted physiologically? In the previous example, if your patient had an interscalene regional block with loss of sensation and mobility to the upper extremity, then they continuously report a pain level of 9/10 post-op on said extremity, and you choose to give them dilaudid, fentanyl et al repeatedly because of you want to treat their pain to their satisfaction, despite RR <10, you are in for a rude awakening. Context and safety matters in addition to a solid understanding of pain pathways and receptors. I asked you to provide your rationale physiologically or even on a pathophysiological aspect, but you have failed to do so thus far. I treat patients' pain with safety as a priority. I have been fooled once or twice and had to use Narcan, so I am not coming from a sanctimonious POV. If you practice with fear of DON and managers, rather than your understanding of pharmacology and physiology, then that is a disservice to your patients as summarized by the convictions you have written thus far. 

I took the same nursing classes and NCLEX that you did and understand the issue of pain as you do only I don't need to flaunt my education from top-rated schools so chill on the superior attitude. As I said before when you discount what your patient is telling you, you do them a disservice with regard to managing their pain. If you choose to practice that way then have at it and suffer the consequences when you don't manage it correctly. Luckily, I have never had to use Narcan on a patient due to the pain medication that I have given. I talk to the patient and work in conjunction with the patient to make sure that they are comfortable as they recover from various surgeries they may have had. I don't discount what they are telling me and assume that I know what they are feeling because I have been that patient on that operating table, that patient who had gas leak into a shoulder, and that patient trying to recover from surgery.

With regard to the comments regarding Black Americans catching Ebola, why wouldn't they catch a cold like everyone else, why did it have to be Ebola?

With regard to BLM it was a movement started because of the many responses by police departments all over the country that resulted in Black Americans being killed by overly aggressive officers and a lack of accountability and consequences.

20 minutes ago, Karmat said:

With regard to the comments regarding Black Americans catching Ebola, why wouldn't they catch a cold like everyone else, why did it have to be Ebola?

With regard to BLM it was a movement started because of the many responses by police departments all over the country that resulted in Black Americans being killed by overly aggressive officers and a lack of accountability and consequences.

Read the comment again. It was highlighting the severity of things in this society. Look at how COVID19 has disproportionately affected the black community. I even went a step ahead and said it was not literal but rather figurative analogy because I knew that someone will cherry pick it because some people are hellbent on seeing racism that they cannot even comprehend when someone is agreeing or supporting their premise. It irks me to state the obvious. I am a black man. There was nothing odd about the analogy. It highlights inherent inequalities within the systems in the U.S. Read the comment once again. Nonetheless, I understand your misunderstanding. 

6 hours ago, Karmat said:

I took the same nursing classes and NCLEX that you did and understand the issue of pain as you do only I don't need to flaunt my education from top-rated schools so chill on the superior attitude. As I said before when you discount what your patient is telling you, you do them a disservice with regard to managing their pain. If you choose to practice that way then have at it and suffer the consequences when you don't manage it correctly. Luckily, I have never had to use Narcan on a patient due to the pain medication that I have given. I talk to the patient and work in conjunction with the patient to make sure that they are comfortable as they recover from various surgeries they may have had. I don't discount what they are telling me and assume that I know what they are feeling because I have been that patient on that operating table, that patient who had gas leak into a shoulder, and that patient trying to recover from surgery.

I respectfully disagree. We do not understand the phenomenon of pain the same way. You just could not back your platitudes with scientific facts and resorted to trite platitudes. I do not discount what the patient says. I said it is considered and respected; however, other variables are taken into account as well. I think some of those teachers who taught you rudimentary nursing emphasized ABCs as well. RR of 8 and the patient has had multiple narcotics and a block, but you are still arguing for more narcotics? Perhaps we did not take the same undergraduate classes. Moreover, NCLEX is a minimum competency test. 

Specializes in Hospice, Geri, Psych and SA,.
12 hours ago, Karmat said:

When I went through nursing school my instructors repeatedly said that "pain is what the patient says it is". Who are we to decide for a patient that the pain that they are feeling is not what they are feeling? If I'm in pain and I tell you my pain is at 9 then my pain is at 9. You can't look at me and tell me my pain is not a 9 it's a 5. What other reasonable factors need to be addressed in order for my pain to be addressed in a timely manner? You are not in the patient's body and you are not clairvoyant. When a VIP shows up at the hospital and says that his pain is a 9 do you think anybody disputes what his pain is? Why should it be any different for anybody else?

I think what you and Cynical are pointing out is how complex pain management is nowadays and even more so when race is involved. I was trained that pain is the 5th vital sign, and pain must be managed aggressively. And now we know this drivel was being driven by Purdue as they insidiously wrapped their influence on how pain management is conducted by physicians and nurses. Now, the literature is saying that we are overtreating chronic pain and that acute pain must be managed on an individualized basis and not with a one size fits all algorhythm. 

I do think that acute pain should be managed aggressively in the acute setting, but there patient should also be given reasonable expectations of treatment depending on their condition. You're going to have pain with pancreatitis even with the pain meds, etc. I think if patients know that some pain is normal for their condition it is less distressing and even more tolerable.

In the difficult cases where there is a suspicion of med seeking behavior, my personal opinion is if the patient is hemodynamically stable a short course of time limited medication is appropriate just in case if the patient is having pain. The nice thing is that there are several medications that can be used that are non-narcotic and proven to be very effective in managing a wide spectrum of causes of pain. IV Acetaminophen, Toradol, lidocaine, etc.

Another thing I educate patients on is that opioid can have a paradoxical effect especially with frequent use or high dosing where pain actually gets worse instead of better. 

Specializes in Critical Care.

Before starting another racist article did you actually do any “nursing research “ to assess how Dr Moore’s treatment was different compared to white privileged patients? Maybe there is a educational opportunity to assess own bias towards non colored individuals?