Racism in Clinical Nursing Practice: A Qualitative Study

Racism in Clinical Nursing Practice: A Qualitative Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Racism in Clinical Nursing Practice: A Qualitative Study Nichole Crenshaw, LaToya Lewis, Cynthia Foronda This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4934771/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 28 Jan, 2025 Read the published version in BMC Nursing → Version 1 posted 10 You are reading this latest preprint version Abstract Background Racism in healthcare has led to disparate health outcomes amongst people of color. The construct of racism may be misunderstood, and research is lacking about the actions nurses can in the clinical setting take to reduce racism. The purpose of the study was to determine behaviors demonstrative of racism in nursing care and behaviors that are demonstrative of cultural humble nursing care to develop an awareness of racial bias in nursing to inform future educational practices. Methods A qualitative, descriptive design was used with 10 doctoral-prepared nurses of color with expertise in diversity, equity, inclusion, and social determinants of health. Findings Three overarching themes emerged: 1) Experience of Racism as a Nurse of Color (with subthemes of False Negative Assumptions/Stereotyping, Discrediting/Unheard, and Rejection), 2) Experience of Racism as a Patient of Color (with subthemes of False Negative Assumptions/Stereotyping, Inequitable Treatment/ Lack of Care, and Dismissing/Ignoring or Not Believing), and 3) Culturally Humble Care (with subthemes of Asking, Active Listening, Caring Body Language, Individualized Care, and Respect). Conclusions Study findings may be used to inform and improve nursing practice to reduce racism and decrease health disparities. racism nursing education clinical practice bias Introduction Race has been used for over four centuries to marginalize and dominate certain populations while at the same time conferring privilege to others. Long-standing systemic racism has led to significant disparities in health treatment and patient outcomes. Race is highly relevant to healthcare because it directly influences health outcomes, access to care, and the quality of care that is delivered (Hamed et al, 2022; James-Conterelli, 2023) 1 , 2 . Different groups of patients experience the healthcare system in distinct ways and the literature shows, it is to the detriment of racial and ethnic minorities. As an example, Black patients experience disproportionately higher rates of chronic diseases, increased mortality, and lower life expectancy when compared to their white counterparts (KFF, 2023) 3 . Racial biases among healthcare staff, impact the quality of care provided by undermining the patient’s trust in their providers. Racially and ethnically diverse individuals are more likely to mistrust the healthcare system which effects patient-clinician relationships. With mistrust, there is a breakdown in communication and information sharing that may lead to the patient not following through with the treatment plan. Such factors may contribute to poor health care outcomes for these populations (Bazargan, et al., 2021) 4 . The existing literature offers limited understanding of racism in nursing practice, however, the American Nurses Association, in collaboration with several leading organizations that have advocated against racism in nursing, established The National Commission to Address Racism in Nursing. This group produced a comprehensive report that explored racism in nursing and particularly, how racism manifests in nursing practice. The report found that chronic health conditions like hypertension, asthma, diabetes, heart failure and kidney disease are experienced more frequently with patients of color. These health issue tend to begin earlier, be treated later, and result in poorer outcomes that when compared to their white counterpart (American Nurses Association, n.d.) 5 . Hamed et al. (2022) acknowledges that the research in this area is steadily growing 1 . The body of evidence indicates that healthcare uses who have experience with racism, are less likely to trust their providers, and are less satisfied with their care. Healthcare staff have also been examined as a root cause for this mistrust as implicit racial bias influences their interactions with patients leading to disparities in the quality of care that is given to racial and ethnic minority groups (Hamed, 2022) 1 . This manuscript will add to the body of knowledge around behaviors demonstrative of racism in nursing practice and culturally humble nursing practice. Nurses are uniquely equipped to address the widespread issues of racism and their consequences in the healthcare system. During their academic/clinical and theoretical coursework, students can be taught to recognize and respond to behaviors that demonstrate racism in either fellow nursing or patient interactions. This work has the potential to improve patient experiences and outcomes, while supporting the nursing workforce by promoting a more inclusive and supportive work environment. Although much is known about the existence of racism and disparities in healthcare, evidence is scant regarding the specific behaviors exhibited by nurses or patients that may either convey racism or demonstrate culturally humble nursing care in the United States. The primary aim of this study was to identify behaviors indicative of racism in nursing practice alongside those that reflect culturally humble nursing practice with the goal of raising awareness about racial bias in nursing. This awareness aims to inform future educational practices and foster efforts to eliminate racism in healthcare. To explore these aims in detail, the study addressed the following research questions: 1) What behaviors are demonstrative of racism in nursing practice, and 2) What behaviors are demonstrative of culturally humble nursing care? Methods This study involved a qualitative, descriptive design. Purposive sampling was used to identify doctoral-prepared nurses of color who possessed expertise in diversity, equity, and inclusion (DEI) or social determinants of health (SDOH). Most of the participants worked in academic or practice settings. Two researchers who identified as Black conducted interviews via Zoom (Zoom Video Communications, Inc). The interviews were audio-recorded and lasted approximately 30 minutes. Zoom captured the interviews and provided the automatic transcripts. The researchers developed and utilized semi-structured interview questions (Table 1 ) to guide the interviews for this study. All participants verbally consented to participate prior to the interviews. The study protocol #20211018 was approved by the University of [Blinded] Institutional Review Board. Table 1 Structured Questionnaire What behaviors or actions demonstrate racism in the context of nursing practice? How is racism in nursing practice exhibited in terms of verbal communication? How is racism in nursing practice exhibited in terms of touch? How is racism in nursing practice exhibited in terms of body language (non-verbal communication)? What experiences have you had related to racism in nursing practice? On the contrary, what does culturally competent or culturally humble nursing care look like? What behaviors or actions demonstrate culturally competent or culturally humble nursing care? How is culturally competent or culturally humble nursing care exhibited in terms of verbal communication? How is culturally competent or culturally humble nursing care exhibited in terms of touch? How is culturally competent or culturally humble nursing care exhibited in terms of body language (non- verbal communication)? What experiences have you had related to culturally competent or culturally humble nursing care? Is there anything else you would like to discuss? To analyze the data, we applied qualitative, content analysis as described by Sandelowski (2000) 6 . Transcripts were read multiple times by all three researchers (initials blinded). Data were analyzed and independently coded by the researchers with preliminary themes developed by each researcher. Discussion ensued to establish consensus on the major themes. All researchers cut and paste supportive quotes under each theme. Once data saturation was achieved, through an iterative process, overarching themes and subthemes emerged that were agreed upon by all. Behaviors of racism as well as cultural humility in nursing practice were individually extracted and placed in tables. To establish trustworthiness of the data, we used Lincoln and Guba’s (1985) evaluative criteria 7 . To establish credibility, we conducted frequent peer debriefing sessions. To allow for transferability, we provided thick description using quotes from participants. To attend to confirmability, the researchers documented self-reflections after analyzing each interview and created an audit trail. Findings Participants included 10 doctoral-prepared nurses of color who currently worked in academic and practice settings. All participants verified that they have produced scholarship or research in the field of DEI or SDOH. Three overarching themes emerged: 1) Experience of Racism as a Nurse of Color, 2) Experience of Racism as a Patient of Color, and 3) Culturally Humble Care with various subthemes occurring under each theme. The specific behaviors of racism (Table 2 ) and cultural humility (Table 3 ) in clinical nursing practice were extracted from the interviews. Table 2 Behaviors of Racism in Clinical Nursing Practice Poor Eye Contact Presents One’s Back to Patient When Speaking Stands Over the Patient Avoids Touch or is Rough, Wears Gloves When Not Procedurally Necessary Makes Angry or Confused Facial Expressions / Rolls Eyes Upward / Negative Tone Rushes / Distances Ignores, Omits, or Dismisses Disrespects Does Not Listen or Take the Patient at Their Word Neglects Social Determinants of Health Avoids questions/ Makes Negative False Assumptions- Underestimates Patient / Is Closed Inequitably Treats the Patient/ Withholds or Omits Treatment Stereotypes Needs of a Population Fears Differences Is Silent or Poor Communicator Table 3. Behaviors of Cultural Humility in Clinical Nursing Practice Makes Eye Contact (when culturally congruent) Faces the Patient When Speaking Sits Next to the Patient at Same Level Gentle, Genuine, Appropriate Touch (if ok with the patient) Smiles / Positive Tone Spends Time / Presence Cares and Advocates Respects Listens, Hears, and Believes Addresses Social Determinant of Health Asks/ Does Not Assume/ Is Open and Curious Appropriately, Thoroughly, and Equitably Treats the Patient Individualizes Care Appreciates Differences Communicates in an Understandable Way Experience of Racism as a Nurse of Color False Negative Assumptions/Stereotyping Participants shared a variety of stories and experiences with the commonality of having been underestimated in terms of their training or qualifications. When they entered a patient care encounter, they were assumed to be the housekeeper, maid, patient care technician, nursing assistant, or secretary. In situations of crisis, individuals would look to the White providers for direction instead of the participant who was the most qualified who happened to be Black. Participant 1 described how when she introduced herself to patients as their nurse, they would ask her about her training and ask, “how do you get this job?” There were common experiences of being falsely assumed by others to have lower intelligence or educational level. Participant 2 indicated, “I distinctly remember going downstairs to human resources and I was new, and I wanted to find out about my benefits. And as soon as I opened the door, she pointed to the benefits for housekeeping. Her assumption was that I wasn’t a nurse.” Participant 9 mentioned, It still happens to me all the time that you know. I'll be talking to someone. And then one of my students or somebody will know me, and they’ll happen to say oh, Dr. [Name Blinded]. And the look that the person gets on their face is like, oh, you're a doctor, like as if they heard the most shocking thing in the world. Participants also expressed that because they were consistently perceived as underqualified or not good enough to be the nurse, there was an extra pressure to be perfect. Participant 3 described how “they did not really want black nurses in the intensive care unit” due to the false assumption they could not aptly provide this level of care. “So, it was like, I always had to be the best...more than the best, in order to be accepted.” Participant 1 shared, “I had to prove to them that I was qualified to be their nurse and that was exhausting.” Participants noted feeling subtle or covert microaggressions and feeling like they were always being judged. Participant 1 described, “...and then there’s also the sweet old ladies [who say] ‘you’re so pretty for a Black girl.’ Subsequently, a consequence of resilience was expressed by participants because of this constant extra pressure. Participant 10 explained, “we get thick skin...we repress the stuff that doesn’t make us feel good”. Participant 3 said she tried not to let those experiences bother her. She would “push it off [her] shoulder...I’m not small. I’m strong. I’m big. Yeah, I deserve to be here.” Discrediting/Unheard Participants expressed the notion that as a nurse, they weren’t taken seriously or seen as a reputable source of information. Participant 7 indicated, “Yeah, they look to someone else for the answer. They don't want the answer from me as if I know it. It kind of discredits me.” Participant 9 shared a story about her working as a nurse practitioner at an athletic event when she assessed a man presenting with symptoms of an acute myocardial infarction (AMI). She had called for help, but no one was responding. I'm like, hey, I've been waiting for like 10 minutes. I have a guy with chest pain and arrhythmia. And they were like, oh, no, yeah. So, they came eventually. So, they came, and it was me, another nurse that was Black and an older nurse that was a White lady, White nurse. And I, you know, I don't even pay attention to that, but it is very pertinent for, based on my experience as far as racism, so the rescue people got there, and they were asking, you know, questions about the patient, and I was telling them, you know, I think he's having an arrhythmia. Maybe a-fib. His rate is really irregular, but it's fast and they all kinda like looked at me, but nobody really like said anything. And then, they were putting the patient on the vitals machine, the little portable the pulse ox thing, and one of the rescue guys said to...it was me, the other 2 nurses here, he said to the lady, oh, so I was the one, pretty much giving all the medical information. I'm like, I think he has this...[arrythmia/possible AMI]. The other 2 would just kind of stand there, and he looks at the lady, the older white lady nurse, and he says, oh, are you the doctor here? Because and she's like no, actually I'm not- she is. And she pointed to me. Who's the one that's been talking to them and giving them all the patient’s medical information, and like in medical terms...And he looked at me and I say, yeah, you never thought I could be the doctor, huh? And I'm like, in spite of the fact that I'm the one that's been giving you all the medical information.... Participants mentioned how leaders, those at the table so to speak, who make the decisions were mostly White. Participant 3 said, “as far as people who are really making the decisions, we’re still in a very, very minority of that...” Participant 2 shared, “I’m not seen as someone who has something significant to contribute to the conversation as the same people just monopolize the conversation.” Rejection This theme of rejection emerged as nurse participants described being rejected by their patients in terms of them not wanting a Black nurse to care for them. Participant 8 shared her experience with racist patients, “There’s another Black nurse. They find another reason to say they don’t want this nurse either without saying that I don’t want any Black nurses, but they just seem to have a problem with all the colored nurses...We actually support that when we change the assignments. That seems to be something that is still happening today.” Two participants mentioned being initially rejected in the context of being a home health nurse when first arriving to a White patient’s home. Participant 5 stated, “So, I specialize in home based primary care. So, I’ve been thrown into a patient’s house, and I had a patient. ‘Tell me before...you can’t come to my house because you’re Black...’ Participant 10 shared her experience, I was doing home health nursing, and I went to this home in Illinois and the folks won’t let me in the house. They were like, ‘is there another nurse?’ So, what do you mean, is there another nurse? And I said no, I'm it. I’m the nurse on call and they were like, well, you know, hold on. I said they won't be another nurse till Monday. It was Friday evening, and their loved one had passed away. So, I was there as the hospice nurse. Participant 1 expressed a story when working in an acute care facility. I worked in this very affluent hospital he was an elected city of as a county official and he was like a judge, and he said, ‘what are you doing here’... he was like, ‘I don't want you in here. He said, ‘they can stay, but you have to leave,’ and I said, well why, you know, I said, why would you like me to leave? I said, I'm here to help you. And he was like, ‘yeah because I don't even understand why they would hire you to teach them anything.’...I'll never forget that because I said these are the people that are making decisions for our county, the county which I lived in, which is which also had a pretty big Black population, you know, working class, middle class Black neighborhood, but Black and White neighborhood, but enough diversity, and I said wow this is not just about healthcare, but this is a social issue, too. These are the people, you know, sometimes we are you know, we're taking care of people who are making big decisions, not just for us, but like for our entire healthcare systems, and so if we're working within racist systems, racist counties, and zip codes and things like that, of course it's going to trickle into the hospital. Participants expressed a notion of rejection from patients as well as being ostracized as a nurse colleague or co-worker on the healthcare team. They noted feeling a lack of inclusion or acceptance in their work setting. Experience of Racism as a Patient of Color False Negative Assumptions/Stereotyping Nurse participants expressed their perceptions of behaviors experienced by Black patients. Again, the theme of false negative assumptions/stereotyping emerged. Patients were automatically assumed to be of lower socioeconomic status or of a lower level. They were frequently underestimated. Participant 1 said, “we’re also often perceived as poor and that’s not always the case....and non-compliant and uneducated and low health literacy...” Participant 8 reiterated, “I was told that, oh, she’s non- compliant...it’s not because she’s not compliant.” Participant 1 shared her personal experience of being a patient as a nurse, herself, when she was in pain and the provider was administering medications. “...it's just a cocktail, four meds we give everybody. And I said, which meds? Yeah, and I'm a nurse, like I know that. I was like please, you know, please always and I told her that, please always explain to your patients which medications and sure enough one of the meds was Toradol and I had just gotten Toradol two hours before in the ambulance, so it wasn't on the hospital record. I had a back injury in 2022 and so he's not giving me a dose of Toradol two hours after the Toradol [I had just received that is] toxic to the [kidney]. Yeah, that's no good, you know, this is not work. So, it's things like that you know, and I noticed that's how they treat Black patients. In this example, the provider demonstrates false assumptions and a lack of consideration. He had assumed the participant was just another patient. It turns out that if asked, he would have found out that she was a nurse, had a history of a back injury, and that it was too early for her to receive that “cocktail”. His mindset could have caused injury to the participant had she not prevented it. Inequitable Treatment/ Lack of Care All participants described that racism in clinical practice manifests as inequitable treatment or a lack in care. Examples included omission of information, giving a one-size-fits-all approach, not providing enough pain medication, not giving the correct medication or treatment, not referring a patient to the appropriate specialist, and not spending time or giving their full attention to the patient. Health disparities and disparate outcomes were attributed to the lack of proper care or treatment. Participant 1 explained, American Heart Association states that if somebody comes in with chest pain, they should get an EKG within the first 10 minutes so that we can meet that 90-minute benchmark if they're having a STEMI heart attack, but what we're finding is that Black people are waiting 33 minutes longer than their white counterparts to get an EKG which we know could be a life-saving diagnostic. Participant 2 offered that racism is displayed when the provider is “not really taking the time out to provide the same level of patient education that would be given to other white patients; not offering the same treatment options – cardiac catheterization to organ transplantation to expensive medication regiments such as substance use disorder. We get substandard care.” Participant 5 described that racist behaviors are when providers “just put Black people all completed under this umbrella, because I think you can tolerate the pain more so. I’m not going to give you a pain medication or send you to the pain management specialist.” Participant 7 stated that behaviors of racism include “giving differential treatment to their patients and families.” Dismissing/Ignoring or Not Believing Another behavior of racism in clinical practice that was elicited was the action of dismissing, ignoring, or not believing patients of color. Often, the participant’s stories relayed a life-or-death situation and the lack of urgent response to addressing the patient’s condition. Participant 2 shared a story about her friend’s daughter’s perinatal experience. On every visit was like, the baby’s not growing, the baby’s not growing, but then she said, I’m not feeling the baby move as much. And it was just blown off and ignored. And fortunately, at 37 weeks, I got the call to come to the hospital because I was there For her still birth delivery. It was devastating...they put her in a waiting room with a bunch of expecting moms all excited to give birth. Participant 1 shared a poignant story, A dear friend of mine who I went to nursing school with actually high school and nursing school, her sister was is a 61-year-old black female who came in with atypical coronary heart symptoms which we know is like heartburn, shoulder pain, and the physician tried to send her home on a muscle relaxer and said it was just your shoulder. They didn't do any EKG, didn't do labs or anything, and when her brother, who's an orthopedic surgeon- which we all don't have a brother who's an orthopedic surgeon, she's quite lucky her brother who's an orthopedic surgeon- called the emergency department and said ‘do a cardiac work up on my sister’ and apparently, she actually was having STEMI and she had to get a cardiac catheterization within 24 hours. She did get it done within 24 hours after he did that, but the moral of the story is that she was about to be sent home, and she could have died and this happened. This is not an uncommon story and again this, you know, this goes back to stereotypes...she was being dismissed. She was not being believed about her symptoms because she didn't have a history of any coronary heart disease but that doesn't matter, the point is you know anybody is at risk for heart attack...so really the main three things are you know implicit bias to being dismissed and just simply not believing our patients- not listening to them. On the other hand, there were general behaviors described that could occur in non-urgent situations. Participant 1 described how providers rush when speaking and start to walk away from the patient while speaking. Providers may avoid touch, distance themselves, be silent, or ignore the patient when the patient is talking. Additional behaviors noted were not taking the patient at their word, not communicating in an understandable way, and neglecting SDOH. Body language including rolling one’s eyes at the patient, making confused facial expressions at the patient by squinting eyes, and using a negative tone when speaking to the patient. Culturally Humble Care On the contrary, participants were asked about what behaviors demonstrate culturally humble care. While individually extracted behaviors were illustrated on Table 3 , the following five sub-themes emerged: 1) Asking, 2) Active Listening, 3) Caring Body Language, 4) Individualized Care, and 5) Respect. Asking Multiple participants indicated that culturally humble care started by asking patients about their culture and their healthcare preferences. Participants indicated that it was important to ask about one’s culture, religion, support their cultural needs, explain, and ask permission prior to touching the patient. Participants indicated that nurses need to be open and accepting. Participant 2 said, “Stop being scared and let’s ask people, what are your beliefs? What are the foods you like to eat? What’s going to help you feel better, to help you in your healing process?” Participant 10 shared, “For a nurse to have desire, there’s also an opportunity like within the experience so if you’re having an experience with the patient that’s your opportunity to be culturally sensitive or humble. So, I think what is culturally humble...would look like a nurse, where here she comes in, with open eyes, I know this person is different and even people have the same ethnicity, have to realize that everybody has a different story, right?” In reference to conversing with a patient, participant 7 stated that nurses should ask, What is your cultural background? I’m not sure if that’s a standard question, but I think it deserves to be...are there any cultural considerations that I should be aware of, so that I can better take care of you? So, getting to know who they are...getting at the intersectionality even beyond race...you can’t treat people as a monolith. You have to take into consideration all aspects of who they are. Participant 5 stated it was important to “ask inclusive questions about stress levels, living conditions...” Participants acknowledged that the nurse doesn’t have to know everything about the patient’s culture, but they should have the desire, be curious, and ask. Active Listening Participants indicated that in culturally humble care, patients need to feel heard. It was clear through the interviews that the nurse needs not only to communicate, but to truly listen. Additional descriptions included having open conversations, establishing trust, and creating transparency. Participant 5 shared a story about a low-income patient whose motorized scooter was broken. He said, “I understand that if I'm going to increase your happiness right, which will then also have positive health outcomes, I need to be able to get you back on the street. I need to be able to right like get you around so you can go see family members, right? And when I talk to her in that way, she was just happy, ‘cause she felt heard, and she felt seen.” Participant 7 shared “just more conversations about beyond just the health of our patients, but their background.” Participant 10 shared to “face the individual, not turning your back to them when you’re talking. Let them know that you see them, validating them in terms of looking in their face, looking in their eyes, I think those are all good ways to go. Participant 5 said, Explaining...and even as I’m touching them, still talking to them through it...you have my full attention, so I’m looking at you. My body is positioned toward you right? My shoulders is back, my head is up, meaning that I’m openly and actively listening to you right, instead of having my arms crossed or my legs folded. Participant 7 mentioned her position working with veterans. She said, “Spend time getting to know them. Like, I worked with vets...so they love talking to me about their experiences as Vets.” There was significant overlap amongst the subthemes about how to demonstrate active listening through body language. Caring Body Language Various illustrations of body language and behaviors emerged from the participants’ stories. Descriptions included eye-contact, smiling, giving genuine touch, facing the patient, sitting, giving one’s time and attention, and caring. Participant 1 indicated, “pull up a chair and become our level with the patient which I think is, you know, what we learned...like that’s the best way to communicate...lay your hand on somebody’s shoulder...provide that same caring touch to patients who don’t look like them.” Participant 2 shared, “I guess having eye contact is a basic think I think of that shows that you have a true interest in what your patient is saying in a connection to your patient. Being aware of people’s cues.” Participant 5 mentioned, “gentle [touch]...maintain eye contact and body posture towards the actual patient.” Participant 6 indicated, Establishing rapport...So, in terms of touch I think it’s putting your hand on their shoulder if you’re having a difficult moment. If you’re giving a bath, you know, give them a foot rub. Wash their hair if they’ve been there for days and their hair is magic. Touch them outside of just when it’s procedurally required. Smile.” Participant 7 added, “One of the cornerstones of nursing is touch. Touch is healing...finding appropriate ways to do that.” Participant 10 suggested, “Make your care that much better, more improved is simply just meeting a person, where they are talking to them, smiling at them, not giving them the stiff awkward looks and silence...yeah, just being human. Good grief! Just being human.” Individualized Care In addition to caring body language, an idea that was repeated amongst participants was the importance of providing individualized care. Nurses were to acknowledge and appreciate differences, recognize one’s intersectionality, accept people for who they are, involve them in their care, and not to force one’s opinions on them. Participant 8 stated, “I think that we just need to include them in what we're doing so that they can help us drive the whatever is the best thing for them as our patients. I think they need to be included in in their care.” Participant 6 answered, Seeing the person as an individual. Including their perspectives and their norms. And not trying to sway or convince them, giving them advice and care from the true medical aspect, but also considering how their way of being is impacting their decision-making. I think it's just acknowledging that the individual is different from you, okay, and our brains are wired to be comfortable with that, so we don't see lots of culturally humble care happening unless it's been taught... Truly getting to know that person as an individual and how their way of being has led them to be at the bedside with you. Additionally, several participants brought up the significance of addressing SDOH as part of the individualized care. Participant 5 described talking with patients in the context of community health after receiving vaccinations. “We can talk to them about food security, about money issues, social work. Right? So that was an all-in-one, all-inclusive, culturally competent clinic.” Participant 7 mentioned, Acknowledging our differences. I'm not sure if we really even call out health disparities in nursing, or even think about those larger social determinants that affect especially black and other people of color. Yeah, I don't think we do a good job of calling that out... be more intentional about the effects of culture on the health of our patients, and being more blatant about the role of race in health. And then also thinking about those larger social determinants. You know. What neighborhood did you grow up in? Do you have a place to walk? Personalized care to whatever the patient deems is appropriate. Participant 5 shared one of his favorite sayings from a movie called Patch Adams. He said, If you treat a disease, you win or you win or you lose. But if you teach, treat a patient, you win every time right, and that's how I feel right like because if you treat a patient instead of the disease, you have to treat them culturally. You have to treat them about their beliefs, what they go through, things that they like, things that's affecting them. And when you take your time to understand that and to address those things, it improves your patient's overall well-being. Respect The theme of respect was evident through many of the participants’ interviews in response to how to provide culturally humble care. Respect could be demonstrated by supporting patients’ cultural needs. Participant 5 said “you can have conversations and be respectful.” Participant 6 suggested to “have genuine curiosity and mutual respect.” Participant 1 shared, You want to recognize what group they represent. You want to respect the customs and the culture that they recommend that they identify with but treat them as a human being and take care of them as a whole person not the disease, not what they look like, not what their skin tone looks like, or what their hair looks like, and things like that. So, it's really about treating the whole person as a human being. But, also, not putting in that terminology of like I don’t see color. No, you need to see color. You want to recognize people for how they identify right...I think the main part is just treating the whole person applying those concepts of cultural humility of being egoless, selfless, and also reflection on what we say...and if we slip up, go back and apologize and learn with that patient and say, you know, I’m so sorry, I didn’t mean to say that. I have to admit that I was giving into a negative stereotype, but I would love to learn more about you as a person. Participant 4 explained, “Respect their dignity, making sure that you walk in their shoes...What are they feeling? What are they thinking? You know, listening. Not making judgments, it’s just being kind...you know what is acceptable to somebody else may not be acceptable to you, but it doesn’t mean it’s right or wrong, and not everybody has to think like you. Not everyone has to be like you.” Participant 9 mentioned the concept of respect multiple times. She said, “I try to speak to everyone at the same level, I guess, and not assume that they know more than you, you know, but not assume that they know less, either, you know, and with respect, and just when you bend down to like speaking to someone that's older, you know, saying, sir, ma'am....” She elaborated to speak to patients “in a tone of respect...that you respect their opinion and see them as an equal and not less than you.” Discussion This study sheds light on the behaviors of both racism as well as cultural humility in nursing practice from the unique perspective of expert Black nurses. With this new information, nurses can be more cognizant of what behaviors to avoid as well as utilize to combat racism and confront health disparities. Although the ANA recently provided insight about the purposeful exclusion in the nursing organization, this study delves deeper into the keen examples experienced by nurses of color working in healthcare organizations. Not only was the experience of the Black patient revealed, the experience of being a Black nurse was shown. While there are more obvious and tangible forms of racism, there are also subtleties and microaggressions. This study illuminates some of the common racist behaviors that occur in clinical nursing practice. Additionally, this study provides concrete examples to help those who wish to better connect with their Black nurse colleagues, Black patients, and provides examples on how to better demonstrate culturally humble care. This information could benefit nurses in practice as well as inform curriculum in early nursing education. Nurses of color experienced or witnessed behaviors of stereotyping, being discredited or unheard, and being rejected by their colleagues and patients. The reality of constantly being pressured to be perfect or held to a different standard was insightful. It was troubling that multiple nurses currently had patients refuse them as their caregivers because of the color of their skin. An unfortunate commonality amongst the interviews was that racism is still rampant at an individual level and systems level. Additionally, the experiences of Black patients that the nurse participants described was also illuminating. Again, patients were stereotyped, received inequitable treatment and were dismissed, ignored, or not believed. This study only affirms what the literature has demonstrated in terms of health disparities. On a positive note, the study elucidated the behaviors of a culturally humble nurse. The subthemes of Asking, Active Listening, Caring Body Language, Individualized Care, and Respect are helpful. As the construct of racism can be quite nebulous – as well as it’s antithesis of culturally humility – we now have distinct actions and behaviors to draw from to teach nurses on what to do and what not to do. Of course, some of these actions vary by culture and setting, and cannot be generalized. Patients should be asked about their individual culture and preferences. On the other hand, these behaviors are an evidence-based starting point from which to better understand the experience of the Black nurse and Black patient in the context of clinical nursing practice. Of note, two of the nurse researchers identified as Black and one researcher as White. We felt this was a strength as multiple perspectives were applied to analyze the data. While our primary aim was to uncover behaviors of racism against patients in clinical practice, the nurse participants also shared their own experiences of facing racism as nurses, faculty members, and students. As the focus of this study was to examine racism in the context of clinical practice, we will present the results of racism in nursing education – as a faculty member and as a student – in a subsequent manuscript. Comparison to previous research Study findings align with previous research supporting the need to address racism in various facets of healthcare that involves racist behaviors towards nurses and patients of color. Racism is a multi-faceted challenge in the healthcare environment with influences on providers and patients (Hamed et al, 2022) 1 as well as other aspects of healthcare delivery and access (James-Conterreli, et al., 2023) 2 . Furthermore, the participants descriptions of biases and racist behaviors in various healthcare settings provided increased awareness and knowledge about the obvious elements of discrimination, exclusion, and marginalization. There were significant findings in this study that aligned with the concise report in the ANA (n.d.) racial reckoning statements acknowledging the embedded structural racism in the foundation of different healthcare organizations 8 . Limitations This study was limited in several ways. First, the interviews were conducted via Zoom instead of in-person. While this increased feasibility and enabled reach across the country, we acknowledge that the sense of presence and ability to convey information through facial expressions and eye contact was not the same as a face-to-face interview. Second, all the participants were doctoral prepared nurses. It is possible that they may not have had experiences of racism or culturally humility to the same extent as someone who was not well-educated. However, the expertise of the participants was helpful in articulating their experiences, recognizing the terms for certain phenomena experienced to help us better understand. Further, the study and participants all lived in the United States. As cultures certainly vary outside of the United States, the transferability of the study is limited. Conclusion Nurses and patients of color experience many forms of racial inequities that impact the healthcare profession. Through delving deeper into the inequitable racist verbal, nonverbal, and exclusion practices experienced, healthcare organizations and the community will be able to recognize and identify the inappropriate practices faced by this underrepresented population. The study findings can be used to inform future initiatives to eliminate inequalities in patients and nurses of color. Declarations Ethics approval and consent to participate We have obtained ethical approval from the University of Miami Institutional Review Board and informed contest to participate was obtained from each participant. Consent for publication All authors consent the manuscript for publication. Competing Interests The author declare that they have no competing interests. Funding There is no funding to declare. Author Contribution N.C. and C.F. conceptualized the study idea and design. N.C. and L.L. conducted data collection. N.C., L.L., and C.F. interpreted qualitative data. All authors contributed to the writing of the manuscript. All authors read and approved the final manuscript. Acknowledgement We wish to acknowledge the participants who generously donated their time, stories, and spirit with the intent of improving the profession and the world. Data Availability This study's data and materials are available upon request. To protect participant confidentiality, personal identifiers have been replaced with participant numbers (e.g., Participant 1, Participant 2). We maintain a secure list that links the numbers to the participants identities. References Hamed S, Bradby H, Ahlberg BM, et al. Racism in healthcare: a scoping review. BMC Public Health. 2022;22:988. https://doi.org/10.1186/s12889-022-13122-y . James-Conterelli S, Dunkley D, McIntosh JT, Jullien T, Nelson MD, Richard-Eaglin A. The impact of systemic racism on health outcomes among Black women: Recommendations for change. The Nurse Practitioner. 2023. https://doi.org/10.1097/01.NPR.0000000000000001 . Hill L, Artiga S. (2023, May 23). What is driving widening racial disparities in life expectancy? Kaiser Family Foundation. https://www.kff.org/racial-equity-and-health-policy/issue-brief/what-is-driving-widening-racial-disparities-in-life-expectancy/ Bazargan M, Cobb S, Assari S. Discrimination and medical mistrust in a racially and ethnically diverse sample of California adults. Ann Fam Med. 2021;19(1):4–15. https://doi.org/10.1370/afm.2632 . American Nurses Association. (n.d.). Commission’s Foundational Report on Racism in Nursing. https://www.nursingworld.org/~49b97e/globalassets/practiceandpolicy/workforce/commission-to-address-racism/5racisminnursingpractice.pdf Sandelowski M. Whatever happened to qualitative description? Res Nurs Health. 2000;23(4):334–40. 10.1002/1098-240x(200008)23:43.0.co;2-g . Lincoln Y, Guba EG. Naturalistic inquiry. Newbury Park, CA: Sage; 1985. American Nurses Association. (n.d.). National Commission to Address Racism in Nursing. https://www.nursingworld.org/practice-policy/workforce/racism-in-nursing/national-commission-to-address-racism-in-nursing/ Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 28 Jan, 2025 Read the published version in BMC Nursing → Version 1 posted Editorial decision: Revision requested 22 Oct, 2024 Reviews received at journal 21 Oct, 2024 Reviews received at journal 08 Oct, 2024 Reviewers agreed at journal 04 Oct, 2024 Reviewers agreed at journal 01 Oct, 2024 Reviewers agreed at journal 01 Sep, 2024 Reviewers invited by journal 29 Aug, 2024 Editor assigned by journal 27 Aug, 2024 Submission checks completed at journal 27 Aug, 2024 First submitted to journal 18 Aug, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4934771","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":356933974,"identity":"d5fc160d-fded-4c20-9cf4-6cc1689f318b","order_by":0,"name":"Nichole Crenshaw","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA1klEQVRIiWNgGAWjYBCDBAYG5gMgkgfIMSBWC1sCyVp44CrxazFnYH724eOOujz+GTlfNzyo2SbDwN68TQKfFssGNuOZM88cLpa4kbvtRsKx2zwMPMfK8GoxOMDDzMzbdiCx4TZICxtQi0SOGWEtf9vqEuffznl2I+EfUIv8GyK0MLYxJ264ncN2I7ENZAsPAS2H2YwZe9sOJ268/8zsRmLfbR42nrRiC7xajjc/ZvgJdNi8M4ef3fzx7bY9P/vhjTfwaWFgRhdgw6t8FIyCUTAKRgFRAADbjksdb9thDAAAAABJRU5ErkJggg==","orcid":"","institution":"University of Miami School of Nursing and Health Studies","correspondingAuthor":true,"prefix":"","firstName":"Nichole","middleName":"","lastName":"Crenshaw","suffix":""},{"id":356933976,"identity":"ebd01e5b-8542-419e-871f-b1c8c3dab672","order_by":1,"name":"LaToya Lewis","email":"","orcid":"","institution":"University of Miami School of Nursing and Health Studies","correspondingAuthor":false,"prefix":"","firstName":"LaToya","middleName":"","lastName":"Lewis","suffix":""},{"id":356933978,"identity":"b2d0874d-d579-42b3-928f-e422349d3b40","order_by":2,"name":"Cynthia Foronda","email":"","orcid":"","institution":"University of Miami School of Nursing and Health Studies","correspondingAuthor":false,"prefix":"","firstName":"Cynthia","middleName":"","lastName":"Foronda","suffix":""}],"badges":[],"createdAt":"2024-08-18 21:02:08","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4934771/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4934771/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12912-024-02521-8","type":"published","date":"2025-01-28T15:56:52+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":75351102,"identity":"d4660422-6f9e-4a06-b92d-60d1c3034f0c","added_by":"auto","created_at":"2025-02-03 16:02:29","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":651029,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4934771/v1/ee030f03-139b-4d64-86d6-e6d12c64f9ff.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eRacism in Clinical Nursing Practice: A Qualitative Study\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eRace has been used for over four centuries to marginalize and dominate certain populations while at the same time conferring privilege to others. Long-standing systemic racism has led to significant disparities in health treatment and patient outcomes. Race is highly relevant to healthcare because it directly influences health outcomes, access to care, and the quality of care that is delivered (Hamed et al, 2022; James-Conterelli, 2023) \u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e. Different groups of patients experience the healthcare system in distinct ways and the literature shows, it is to the detriment of racial and ethnic minorities. As an example, Black patients experience disproportionately higher rates of chronic diseases, increased mortality, and lower life expectancy when compared to their white counterparts (KFF, 2023) \u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eRacial biases among healthcare staff, impact the quality of care provided by undermining the patient\u0026rsquo;s trust in their providers. Racially and ethnically diverse individuals are more likely to mistrust the healthcare system which effects patient-clinician relationships. With mistrust, there is a breakdown in communication and information sharing that may lead to the patient not following through with the treatment plan. Such factors may contribute to poor health care outcomes for these populations (Bazargan, et al., 2021) \u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThe existing literature offers limited understanding of racism in nursing practice, however, the American Nurses Association, in collaboration with several leading organizations that have advocated against racism in nursing, established The National Commission to Address Racism in Nursing. This group produced a comprehensive report that explored racism in nursing and particularly, how racism manifests in nursing practice. The report found that chronic health conditions like hypertension, asthma, diabetes, heart failure and kidney disease are experienced more frequently with patients of color. These health issue tend to begin earlier, be treated later, and result in poorer outcomes that when compared to their white counterpart (American Nurses Association, n.d.) \u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eHamed et al. (2022) acknowledges that the research in this area is steadily growing \u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThe body of evidence indicates that healthcare uses who have experience with racism, are less likely to trust their providers, and are less satisfied with their care. Healthcare staff have also been examined as a root cause for this mistrust as implicit racial bias influences their interactions with patients leading to disparities in the quality of care that is given to racial and ethnic minority groups (Hamed, 2022) \u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThis manuscript will add to the body of knowledge around behaviors demonstrative of racism in nursing practice and culturally humble nursing practice. Nurses are uniquely equipped to address the widespread issues of racism and their consequences in the healthcare system. During their academic/clinical and theoretical coursework, students can be taught to recognize and respond to behaviors that demonstrate racism in either fellow nursing or patient interactions. This work has the potential to improve patient experiences and outcomes, while supporting the nursing workforce by promoting a more inclusive and supportive work environment.\u003c/p\u003e \u003cp\u003eAlthough much is known about the existence of racism and disparities in healthcare, evidence is scant regarding the specific behaviors exhibited by nurses or patients that may either convey racism or demonstrate culturally humble nursing care in the United States. The primary aim of this study was to identify behaviors indicative of racism in nursing practice alongside those that reflect culturally humble nursing practice with the goal of raising awareness about racial bias in nursing. This awareness aims to inform future educational practices and foster efforts to eliminate racism in healthcare. To explore these aims in detail, the study addressed the following research questions: 1) What behaviors are demonstrative of racism in nursing practice, and 2) What behaviors are demonstrative of culturally humble nursing care?\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThis study involved a qualitative, descriptive design. Purposive sampling was used to identify doctoral-prepared nurses of color who possessed expertise in diversity, equity, and inclusion (DEI) or social determinants of health (SDOH). Most of the participants worked in academic or practice settings. Two researchers who identified as Black conducted interviews via Zoom (Zoom Video Communications, Inc). The interviews were audio-recorded and lasted approximately 30 minutes. Zoom captured the interviews and provided the automatic transcripts. The researchers developed and utilized semi-structured interview questions (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) to guide the interviews for this study. All participants verbally consented to participate prior to the interviews. The study protocol #20211018 was approved by the University of [Blinded] Institutional Review Board.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eStructured Questionnaire\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"1\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWhat behaviors or actions demonstrate racism in the context of nursing practice?\u003c/p\u003e \u003cp\u003eHow is racism in nursing practice exhibited in terms of verbal communication?\u003c/p\u003e \u003cp\u003eHow is racism in nursing practice exhibited in terms of touch?\u003c/p\u003e \u003cp\u003eHow is racism in nursing practice exhibited in terms of body language (non-verbal communication)?\u003c/p\u003e \u003cp\u003eWhat experiences have you had related to racism in nursing practice?\u003c/p\u003e \u003cp\u003eOn the contrary, what does culturally competent or culturally humble nursing care look like?\u003c/p\u003e \u003cp\u003eWhat behaviors or actions demonstrate culturally competent or culturally humble nursing care?\u003c/p\u003e \u003cp\u003eHow is culturally competent or culturally humble nursing care exhibited in terms of verbal communication?\u003c/p\u003e \u003cp\u003eHow is culturally competent or culturally humble nursing care exhibited in terms of touch?\u003c/p\u003e \u003cp\u003eHow is culturally competent or culturally humble nursing care exhibited in terms of body language (non- verbal communication)?\u003c/p\u003e \u003cp\u003eWhat experiences have you had related to culturally competent or culturally humble nursing care?\u003c/p\u003e \u003cp\u003eIs there anything else you would like to discuss?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTo analyze the data, we applied qualitative, content analysis as described by Sandelowski (2000) \u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e. Transcripts were read multiple times by all three researchers (initials blinded). Data were analyzed and independently coded by the researchers with preliminary themes developed by each researcher. Discussion ensued to establish consensus on the major themes. All researchers cut and paste supportive quotes under each theme. Once data saturation was achieved, through an iterative process, overarching themes and subthemes emerged that were agreed upon by all. Behaviors of racism as well as cultural humility in nursing practice were individually extracted and placed in tables. To establish trustworthiness of the data, we used Lincoln and Guba\u0026rsquo;s (1985) evaluative criteria \u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e. To establish credibility, we conducted frequent peer debriefing sessions. To allow for transferability, we provided thick description using quotes from participants. To attend to confirmability, the researchers documented self-reflections after analyzing each interview and created an audit trail.\u003c/p\u003e"},{"header":"Findings","content":"\u003cp\u003eParticipants included 10 doctoral-prepared nurses of color who currently worked in academic and practice settings. All participants verified that they have produced scholarship or research in the field of DEI or SDOH. Three overarching themes emerged: 1) Experience of Racism as a Nurse of Color, 2) Experience of Racism as a Patient of Color, and 3) Culturally Humble Care with various subthemes occurring under each theme. The specific behaviors of racism (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e) and cultural humility (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e) in clinical nursing practice were extracted from the interviews.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBehaviors of Racism in Clinical Nursing Practice\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"1\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePoor Eye Contact\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePresents One\u0026rsquo;s Back to Patient When Speaking\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStands Over the Patient\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAvoids Touch or is Rough, Wears Gloves When Not Procedurally Necessary\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMakes Angry or Confused Facial Expressions / Rolls Eyes Upward / Negative Tone\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRushes / Distances\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIgnores, Omits, or Dismisses\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDisrespects\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDoes Not Listen or Take the Patient at Their Word\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNeglects Social Determinants of Health\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAvoids questions/ Makes Negative False Assumptions- Underestimates Patient / Is Closed\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInequitably Treats the Patient/ Withholds or Omits Treatment\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStereotypes Needs of a Population\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFears Differences\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIs Silent or Poor Communicator\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e\u003cstrong\u003eTable 3.\u003c/strong\u003e Behaviors of Cultural Humility in Clinical Nursing Practice\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 100%;\"\u003e\n \u003cp\u003eMakes Eye Contact (when culturally congruent)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 100%;\"\u003e\n \u003cp\u003eFaces the Patient When Speaking\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 100%;\"\u003e\n \u003cp\u003eSits Next to the Patient at Same Level\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 100%;\"\u003e\n \u003cp\u003eGentle, Genuine, Appropriate Touch (if ok with the patient)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 100%;\"\u003e\n \u003cp\u003eSmiles / Positive Tone\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 100%;\"\u003e\n \u003cp\u003eSpends Time / Presence\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 100%;\"\u003e\n \u003cp\u003eCares and Advocates\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 100%;\"\u003e\n \u003cp\u003eRespects\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 100%;\"\u003e\n \u003cp\u003eListens, Hears, and Believes\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 100%;\"\u003e\n \u003cp\u003eAddresses Social Determinant of Health\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 100%;\"\u003e\n \u003cp\u003eAsks/ Does Not Assume/ Is Open and Curious\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 100%;\"\u003e\n \u003cp\u003eAppropriately, Thoroughly, and Equitably Treats the Patient\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 100%;\"\u003e\n \u003cp\u003eIndividualizes Care\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 100%;\"\u003e\n \u003cp\u003eAppreciates Differences\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 100%;\"\u003e\n \u003cp\u003eCommunicates in an Understandable Way\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003ch3\u003eExperience of Racism as a Nurse of Color\u003c/h3\u003e\n\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eFalse Negative Assumptions/Stereotyping\u003c/h2\u003e \u003cp\u003eParticipants shared a variety of stories and experiences with the commonality of having been underestimated in terms of their training or qualifications. When they entered a patient care encounter, they were assumed to be the housekeeper, maid, patient care technician, nursing assistant, or secretary. In situations of crisis, individuals would look to the White providers for direction instead of the participant who was the most qualified who happened to be Black. Participant 1 described how when she introduced herself to patients as their nurse, they would ask her about her training and ask, \u0026ldquo;how do \u003cem\u003eyou\u003c/em\u003e get this job?\u0026rdquo; There were common experiences of being falsely assumed by others to have lower intelligence or educational level. Participant 2 indicated, \u0026ldquo;I distinctly remember going downstairs to human resources and I was new, and I wanted to find out about my benefits. And as soon as I opened the door, she pointed to the benefits for housekeeping. Her assumption was that I wasn\u0026rsquo;t a nurse.\u0026rdquo; Participant 9 mentioned,\u003c/p\u003e \u003cp\u003eIt still happens to me all the time that you know. I'll be talking to someone. And then one of my students or somebody will know me, and they\u0026rsquo;ll happen to say oh, Dr. [Name Blinded]. And the look that the person gets on their face is like, oh, you're a doctor,\u003c/p\u003e \u003cp\u003elike as if they heard the most shocking thing in the world.\u003c/p\u003e \u003cp\u003eParticipants also expressed that because they were consistently perceived as underqualified or not good enough to be the nurse, there was an extra pressure to be perfect. Participant 3 described how \u0026ldquo;they did not really want black nurses in the intensive care unit\u0026rdquo; due to the false assumption they could not aptly provide this level of care. \u0026ldquo;So, it was like, I always had to be the best...more than the best, in order to be accepted.\u0026rdquo; Participant 1 shared, \u0026ldquo;I had to prove to them that I was qualified to be their nurse and that was exhausting.\u0026rdquo; Participants noted feeling subtle or covert microaggressions and feeling like they were always being judged. Participant 1 described, \u0026ldquo;...and then there\u0026rsquo;s also the sweet old ladies [who say] \u0026lsquo;you\u0026rsquo;re so pretty for a Black girl.\u0026rsquo; Subsequently, a consequence of resilience was expressed by participants because of this constant extra pressure. Participant 10 explained, \u0026ldquo;we get thick skin...we repress the stuff that doesn\u0026rsquo;t make us feel good\u0026rdquo;. Participant 3 said she tried not to let those experiences bother her. She would \u0026ldquo;push it off [her] shoulder...I\u0026rsquo;m not small. I\u0026rsquo;m strong. I\u0026rsquo;m big. Yeah, I deserve to be here.\u0026rdquo;\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eDiscrediting/Unheard\u003c/h2\u003e \u003cp\u003eParticipants expressed the notion that as a nurse, they weren\u0026rsquo;t taken seriously or seen as a reputable source of information. Participant 7 indicated, \u0026ldquo;Yeah, they look to someone else for the answer. They don't want the answer from me as if I know it. It kind of discredits me.\u0026rdquo; Participant 9 shared a story about her working as a nurse practitioner at an athletic event when she assessed a man presenting with symptoms of an acute myocardial infarction (AMI). She had called for help, but no one was responding.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eI'm like, hey, I've been waiting for like 10 minutes. I have a guy with chest pain and arrhythmia. And they were like, oh, no, yeah. So, they came eventually. So, they came, and it was me, another nurse that was Black and an older nurse that was a White lady, White nurse. And I, you know, I don't even pay attention to that, but it is very pertinent for, based on my experience as far as racism, so the rescue people got there, and they were asking, you know, questions about the patient, and I was telling them, you know, I think he's having an arrhythmia. Maybe a-fib. His rate is really irregular, but it's fast and they all kinda like looked at me, but nobody really like said anything. And then, they were putting the patient on the vitals machine, the little portable the pulse ox thing, and one of the rescue guys said to...it was me, the other 2 nurses here, he said to the lady, oh, so I was the one, pretty much giving all the medical information. I'm like, I think he has this...[arrythmia/possible AMI]. The other 2 would just kind of stand there, and he looks at the lady, the older white lady nurse, and he says, oh, are you the doctor here? Because and she's like no, actually I'm not- she is. And she pointed to me. Who's the one that's been talking to them and giving them all the patient\u0026rsquo;s medical information, and like in medical terms...And he looked at me and I say, yeah, you never thought I could be the doctor, huh? And I'm like, in spite of the fact that I'm the one that's been giving you all the medical information....\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eParticipants mentioned how leaders, those at the table so to speak, who make the decisions were mostly White. Participant 3 said, \u0026ldquo;as far as people who are really making the decisions, we\u0026rsquo;re still in a very, very minority of that...\u0026rdquo; Participant 2 shared, \u0026ldquo;I\u0026rsquo;m not seen as someone who has something significant to contribute to the conversation as the same people just monopolize the conversation.\u0026rdquo;\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eRejection\u003c/h2\u003e \u003cp\u003e This theme of rejection emerged as nurse participants described being rejected by their patients in terms of them not wanting a Black nurse to care for them. Participant 8 shared her experience with racist patients, \u0026ldquo;There\u0026rsquo;s another Black nurse. They find another reason to say they don\u0026rsquo;t want this nurse either without saying that I don\u0026rsquo;t want any Black nurses, but they just seem to have a problem with all the colored nurses...We actually support that when we change the assignments. That seems to be something that is still happening today.\u0026rdquo; Two participants mentioned being initially rejected in the context of being a home health nurse when first arriving to a White patient\u0026rsquo;s home. Participant 5 stated, \u0026ldquo;So, I specialize in home based primary care. So, I\u0026rsquo;ve been thrown into a patient\u0026rsquo;s house, and I had a patient. \u0026lsquo;Tell me before...you can\u0026rsquo;t come to my house because you\u0026rsquo;re Black...\u0026rsquo; Participant 10 shared her experience,\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eI was doing home health nursing, and I went to this home in Illinois and the folks won\u0026rsquo;t let me in the house. They were like, \u0026lsquo;is there another nurse?\u0026rsquo; So, what do you mean, is there another nurse? And I said no, I'm it. I\u0026rsquo;m the nurse on call and they were like, well, you know, hold on. I said they won't be another nurse till Monday. It was Friday evening, and their loved one had passed away. So, I was there as the hospice nurse.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eParticipant 1 expressed a story when working in an acute care facility.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eI worked in this very affluent hospital he was an elected city of as a county official and he was like a judge, and he said, \u0026lsquo;what are you doing here\u0026rsquo;... he was like, \u0026lsquo;I don't want you in here. He said, \u0026lsquo;they can stay, but you have to leave,\u0026rsquo; and I said, well why, you know, I said, why would you like me to leave? I said, I'm here to help you. And he was like, \u0026lsquo;yeah because I don't even understand why they would hire you to teach them anything.\u0026rsquo;...I'll never forget that because I said these are the people that are making decisions for our county, the county which I lived in, which is which also had a pretty big Black population, you know, working class, middle class Black neighborhood, but Black and White neighborhood, but enough diversity, and I said wow this is not just about healthcare, but this is a social issue, too. These are the people, you know, sometimes we are you know, we're taking care of people who are making big decisions, not just for us, but like for our entire healthcare systems, and so if we're working within racist systems, racist counties, and zip codes and things like that, of course it's going to trickle into the hospital.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e Participants expressed a notion of rejection from patients as well as being ostracized as a nurse colleague or co-worker on the healthcare team. They noted feeling a lack of inclusion or acceptance in their work setting.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eExperience of Racism as a Patient of Color\u003c/h2\u003e \u003cdiv id=\"Sec9\" class=\"Section3\"\u003e \u003ch2\u003eFalse Negative Assumptions/Stereotyping\u003c/h2\u003e \u003cp\u003e Nurse participants expressed their perceptions of behaviors experienced by Black patients. Again, the theme of false negative assumptions/stereotyping emerged. Patients were automatically assumed to be of lower socioeconomic status or of a lower level. They were frequently underestimated. Participant 1 said, \u0026ldquo;we\u0026rsquo;re also often perceived as poor and that\u0026rsquo;s not always the case....and non-compliant and uneducated and low health literacy...\u0026rdquo; Participant 8 reiterated, \u0026ldquo;I was told that, oh, she\u0026rsquo;s non- compliant...it\u0026rsquo;s not because she\u0026rsquo;s not compliant.\u0026rdquo; Participant 1 shared her personal experience of being a patient as a nurse, herself, when she was in pain and the provider was administering medications.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;...it's just a cocktail, four meds we give everybody. And I said, which meds? Yeah, and I'm a nurse, like I know that. I was like please, you know, please always and I told her that, please always explain to your patients which medications and sure enough one of the meds was Toradol and I had just gotten Toradol two hours before in the ambulance, so it wasn't on the hospital record. I had a back injury in 2022 and so he's not giving me a dose of Toradol two hours after the Toradol [I had just received that is] toxic to the [kidney]. Yeah, that's no good, you know, this is not work. So, it's things like that you know, and I noticed that's how they treat Black patients.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eIn this example, the provider demonstrates false assumptions and a lack of consideration. He had assumed the participant was just another patient. It turns out that if asked, he would have found out that she was a nurse, had a history of a back injury, and that it was too early for her to receive that \u0026ldquo;cocktail\u0026rdquo;. His mindset could have caused injury to the participant had she not prevented it.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section3\"\u003e \u003ch2\u003eInequitable Treatment/ Lack of Care\u003c/h2\u003e \u003cp\u003eAll participants described that racism in clinical practice manifests as inequitable treatment or a lack in care. Examples included omission of information, giving a one-size-fits-all approach, not providing enough pain medication, not giving the correct medication or treatment, not referring a patient to the appropriate specialist, and not spending time or giving their full attention to the patient. Health disparities and disparate outcomes were attributed to the lack of proper care or treatment. Participant 1 explained,\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eAmerican Heart Association states that if somebody comes in with chest pain, they should get an EKG within the first 10 minutes so that we can meet that 90-minute benchmark if they're having a STEMI heart attack, but what we're finding is that Black people are waiting 33 minutes longer than their white counterparts to get an EKG which we know could be a life-saving diagnostic.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eParticipant 2 offered that racism is displayed when the provider is \u0026ldquo;not really taking the time out to provide the same level of patient education that would be given to other white patients; not offering the same treatment options \u0026ndash; cardiac catheterization to organ transplantation to expensive medication regiments such as substance use disorder. We get substandard care.\u0026rdquo; Participant 5 described that racist behaviors are when providers \u0026ldquo;just put Black people all completed under this umbrella, because I think you can tolerate the pain more so. I\u0026rsquo;m not going to give you a pain medication or send you to the pain management specialist.\u0026rdquo; Participant 7 stated that behaviors of racism include \u0026ldquo;giving differential treatment to their patients and families.\u0026rdquo;\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eDismissing/Ignoring or Not Believing\u003c/h2\u003e \u003cp\u003eAnother behavior of racism in clinical practice that was elicited was the action of dismissing, ignoring, or not believing patients of color. Often, the participant\u0026rsquo;s stories relayed a life-or-death situation and the lack of urgent response to addressing the patient\u0026rsquo;s condition. Participant 2 shared a story about her friend\u0026rsquo;s daughter\u0026rsquo;s perinatal experience.\u003c/p\u003e \u003cp\u003eOn every visit was like, the baby\u0026rsquo;s not growing, the baby\u0026rsquo;s not growing, but then she said, I\u0026rsquo;m not feeling the baby move as much. And it was just blown off and ignored. And fortunately, at 37 weeks, I got the call to come to the hospital because I was there\u003c/p\u003e \u003cp\u003eFor her still birth delivery. It was devastating...they put her in a waiting room with a\u003c/p\u003e \u003cp\u003ebunch of expecting moms all excited to give birth.\u003c/p\u003e \u003cp\u003eParticipant 1 shared a poignant story,\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eA dear friend of mine who I went to nursing school with actually high school and nursing school, her sister was is a 61-year-old black female who came in with atypical coronary heart symptoms which we know is like heartburn, shoulder pain, and the physician tried to send her home on a muscle relaxer and said it was just your shoulder. They didn't do any EKG, didn't do labs or anything, and when her brother, who's an orthopedic surgeon- which we all don't have a brother who's an orthopedic surgeon, she's quite lucky her brother who's an orthopedic surgeon- called the emergency department and said \u0026lsquo;do a cardiac work up on my sister\u0026rsquo; and apparently, she actually was having STEMI and she had to get a cardiac catheterization within 24 hours. She did get it done within 24 hours after he did that, but the moral of the story is that she was about to be sent home, and she could have died and this happened. This is not an uncommon story and again this, you know, this goes back to stereotypes...she was being dismissed. She was not being believed about her symptoms because she didn't have a history of any coronary heart disease but that doesn't matter, the point is you know anybody is at risk for heart attack...so really the main three things are you know implicit bias to being dismissed and just simply not believing our patients- not listening to them.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eOn the other hand, there were general behaviors described that could occur in non-urgent situations. Participant 1 described how providers rush when speaking and start to walk away from the patient while speaking. Providers may avoid touch, distance themselves, be silent, or ignore the patient when the patient is talking. Additional behaviors noted were not taking the patient at their word, not communicating in an understandable way, and neglecting SDOH. Body language including rolling one\u0026rsquo;s eyes at the patient, making confused facial expressions at the patient by squinting eyes, and using a negative tone when speaking to the patient.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eCulturally Humble Care\u003c/h2\u003e \u003cp\u003e On the contrary, participants were asked about what behaviors demonstrate culturally humble care. While individually extracted behaviors were illustrated on Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e, the following five sub-themes emerged: 1) Asking, 2) Active Listening, 3) Caring Body Language, 4) Individualized Care, and 5) Respect.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eAsking\u003c/h2\u003e \u003cp\u003eMultiple participants indicated that culturally humble care started by asking patients about their culture and their healthcare preferences. Participants indicated that it was important to ask about one\u0026rsquo;s culture, religion, support their cultural needs, explain, and ask permission prior to touching the patient. Participants indicated that nurses need to be open and accepting. Participant 2 said, \u0026ldquo;Stop being scared and let\u0026rsquo;s ask people, what are your beliefs? What are the foods you like to eat? What\u0026rsquo;s going to help you feel better, to help you in your healing process?\u0026rdquo; Participant 10 shared, \u0026ldquo;For a nurse to have desire, there\u0026rsquo;s also an opportunity like within the experience so if you\u0026rsquo;re having an experience with the patient that\u0026rsquo;s your opportunity to be culturally sensitive or humble. So, I think what is culturally humble...would look like a nurse, where here she comes in, with open eyes, I know this person is different and even people have the same ethnicity, have to realize that everybody has a different story, right?\u0026rdquo; In reference to conversing with a patient, participant 7 stated that nurses should ask,\u003c/p\u003e \u003cp\u003eWhat is your cultural background? I\u0026rsquo;m not sure if that\u0026rsquo;s a standard question, but I think it deserves to be...are there any cultural considerations that I should be aware of, so that I can better take care of you? So, getting to know who they are...getting at the\u003c/p\u003e \u003cp\u003eintersectionality even beyond race...you can\u0026rsquo;t treat people as a monolith. You have to\u003c/p\u003e \u003cp\u003etake into consideration all aspects of who they are.\u003c/p\u003e \u003cp\u003e Participant 5 stated it was important to \u0026ldquo;ask inclusive questions about stress levels, living conditions...\u0026rdquo; Participants acknowledged that the nurse doesn\u0026rsquo;t have to know everything about the patient\u0026rsquo;s culture, but they should have the desire, be curious, and ask.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eActive Listening\u003c/h2\u003e \u003cp\u003e Participants indicated that in culturally humble care, patients need to feel heard. It was clear through the interviews that the nurse needs not only to communicate, but to truly listen. Additional descriptions included having open conversations, establishing trust, and creating transparency. Participant 5 shared a story about a low-income patient whose motorized scooter was broken. He said, \u0026ldquo;I understand that if I'm going to increase your happiness right, which will then also have positive health outcomes, I need to be able to get you back on the street. I need to be able to right like get you around so you can go see family members, right? And when I talk to her in that way, she was just happy, \u0026lsquo;cause she felt heard, and she felt seen.\u0026rdquo; Participant 7 shared \u0026ldquo;just more conversations about beyond just the health of our patients, but their background.\u0026rdquo; Participant 10 shared to \u0026ldquo;face the individual, not turning your back to them when you\u0026rsquo;re talking. Let them know that you see them, validating them in terms of looking in their face, looking in their eyes, I think those are all good ways to go. Participant 5 said,\u003c/p\u003e \u003cp\u003eExplaining...and even as I\u0026rsquo;m touching them, still talking to them through it...you have my full attention, so I\u0026rsquo;m looking at you. My body is positioned toward you right? My\u003c/p\u003e \u003cp\u003eshoulders is back, my head is up, meaning that I\u0026rsquo;m openly and actively listening to you right, instead of having my arms crossed or my legs folded.\u003c/p\u003e \u003cp\u003eParticipant 7 mentioned her position working with veterans. She said, \u0026ldquo;Spend time getting to\u003c/p\u003e \u003cp\u003eknow them. Like, I worked with vets...so they love talking to me about their experiences as\u003c/p\u003e \u003cp\u003eVets.\u0026rdquo; There was significant overlap amongst the subthemes about how to demonstrate active\u003c/p\u003e \u003cp\u003elistening through body language.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eCaring Body Language\u003c/h2\u003e \u003cp\u003eVarious illustrations of body language and behaviors emerged from the participants\u0026rsquo; stories. Descriptions included eye-contact, smiling, giving genuine touch, facing the patient, sitting, giving one\u0026rsquo;s time and attention, and caring. Participant 1 indicated, \u0026ldquo;pull up a chair and become our level with the patient which I think is, you know, what we learned...like that\u0026rsquo;s the best way to communicate...lay your hand on somebody\u0026rsquo;s shoulder...provide that same caring touch to patients who don\u0026rsquo;t look like them.\u0026rdquo; Participant 2 shared, \u0026ldquo;I guess having eye contact is a basic think I think of that shows that you have a true interest in what your patient is saying in a connection to your patient. Being aware of people\u0026rsquo;s cues.\u0026rdquo; Participant 5 mentioned, \u0026ldquo;gentle [touch]...maintain eye contact and body posture towards the actual patient.\u0026rdquo; Participant 6 indicated,\u003c/p\u003e \u003cp\u003eEstablishing rapport...So, in terms of touch I think it\u0026rsquo;s putting your hand on their\u003c/p\u003e \u003cp\u003eshoulder if you\u0026rsquo;re having a difficult moment. If you\u0026rsquo;re giving a bath, you know, give\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003ethem a foot rub. Wash their hair if they\u0026rsquo;ve been there for days and their hair is magic. Touch them outside of just when it\u0026rsquo;s procedurally required. Smile.\u0026rdquo;\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eParticipant 7 added, \u0026ldquo;One of the cornerstones of nursing is touch. Touch is healing...finding appropriate ways to do that.\u0026rdquo; Participant 10 suggested, \u0026ldquo;Make your care that much better, more improved is simply just meeting a person, where they are talking to them, smiling at them, not giving them the stiff awkward looks and silence...yeah, just being human. Good grief! Just being human.\u0026rdquo;\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eIndividualized Care\u003c/h2\u003e \u003cp\u003e In addition to caring body language, an idea that was repeated amongst participants was the importance of providing individualized care. Nurses were to acknowledge and appreciate differences, recognize one\u0026rsquo;s intersectionality, accept people for who they are, involve them in their care, and not to force one\u0026rsquo;s opinions on them. Participant 8 stated, \u0026ldquo;I think that we just need to include them in what we're doing so that they can help us drive the whatever is the best thing for them as our patients. I think they need to be included in in their care.\u0026rdquo; Participant 6 answered,\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eSeeing the person as an individual. Including their perspectives and their norms. And not trying to sway or convince them, giving them advice and care from the true medical aspect, but also considering how their way of being is impacting their decision-making. I think it's just acknowledging that the individual is different from you, okay, and our brains are wired to be comfortable with that, so we don't see lots of culturally humble care happening unless it's been taught... Truly getting to know that person as an individual and how their way of being has led them to be at the bedside with you.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e Additionally, several participants brought up the significance of addressing SDOH as part of the individualized care. Participant 5 described talking with patients in the context of community health after receiving vaccinations. \u0026ldquo;We can talk to them about food security, about money issues, social work. Right? So that was an all-in-one, all-inclusive, culturally competent clinic.\u0026rdquo; Participant 7 mentioned,\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eAcknowledging our differences. I'm not sure if we really even call out health disparities in nursing, or even think about those larger social determinants that affect especially black and other people of color. Yeah, I don't think we do a good job of calling that out... be more intentional about the effects of culture on the health of our patients, and being more blatant about the role of race in health. And then also thinking about those larger social determinants. You know. What neighborhood did you grow up in? Do you have a place to walk? Personalized care to whatever the patient deems is appropriate.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e Participant 5 shared one of his favorite sayings from a movie called Patch Adams. He said,\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eIf you treat a disease, you win or you win or you lose. But if you teach, treat a patient, you win every time right, and that's how I feel right like because if you treat a patient instead of the disease, you have to treat them culturally. You have to treat them about their beliefs, what they go through, things that they like, things that's affecting them. And when you take your time to understand that and to address those things, it improves your patient's overall well-being.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eRespect\u003c/h2\u003e \u003cp\u003e The theme of respect was evident through many of the participants\u0026rsquo; interviews in response to how to provide culturally humble care. Respect could be demonstrated by supporting patients\u0026rsquo; cultural needs. Participant 5 said \u0026ldquo;you can have conversations and be respectful.\u0026rdquo; Participant 6 suggested to \u0026ldquo;have genuine curiosity and mutual respect.\u0026rdquo; Participant 1 shared,\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eYou want to recognize what group they represent. You want to respect the customs and the culture that they recommend that they identify with but treat them as a human being and take care of them as a whole person not the disease, not what they look like, not what their skin tone looks like, or what their hair looks like, and things like that. So, it's really about treating the whole person as a human being. But, also, not putting in that terminology of like I don\u0026rsquo;t see color. No, you need to see color. You want to recognize people for how they identify right...I think the main part is just treating the whole person applying those concepts of cultural humility of being egoless, selfless, and also reflection on what we say...and if we slip up, go back and apologize and learn with that patient and say, you know, I\u0026rsquo;m so sorry, I didn\u0026rsquo;t mean to say that. I have to admit that I was giving into a negative stereotype, but I would love to learn more about you as a person.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e Participant 4 explained, \u0026ldquo;Respect their dignity, making sure that you walk in their shoes...What are they feeling? What are they thinking? You know, listening. Not making judgments, it\u0026rsquo;s just being kind...you know what is acceptable to somebody else may not be acceptable to you, but it doesn\u0026rsquo;t mean it\u0026rsquo;s right or wrong, and not everybody has to think like you. Not everyone has to be like you.\u0026rdquo;\u003c/p\u003e \u003cp\u003e Participant 9 mentioned the concept of respect multiple times. She said, \u0026ldquo;I try to speak to everyone at the same level, I guess, and not assume that they know more than you, you know, but not assume that they know less, either, you know, and with respect, and just when you bend down to like speaking to someone that's older, you know, saying, sir, ma'am....\u0026rdquo;\u003c/p\u003e \u003cp\u003eShe elaborated to speak to patients \u0026ldquo;in a tone of respect...that you respect their opinion and see them as an equal and not less than you.\u0026rdquo;\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study sheds light on the behaviors of both racism as well as cultural humility in nursing practice from the unique perspective of expert Black nurses. With this new information, nurses can be more cognizant of what behaviors to avoid as well as utilize to combat racism and confront health disparities. Although the ANA recently provided insight about the purposeful exclusion in the nursing organization, this study delves deeper into the keen examples experienced by nurses of color working in healthcare organizations. Not only was the experience of the Black patient revealed, the experience of being a Black nurse was shown. While there are more obvious and tangible forms of racism, there are also subtleties and microaggressions. This study illuminates some of the common racist behaviors that occur in clinical nursing practice. Additionally, this study provides concrete examples to help those who wish to better connect with their Black nurse colleagues, Black patients, and provides examples on how to better demonstrate culturally humble care. This information could benefit nurses in practice as well as inform curriculum in early nursing education.\u003c/p\u003e \u003cp\u003eNurses of color experienced or witnessed behaviors of stereotyping, being discredited or unheard, and being rejected by their colleagues and patients. The reality of constantly being pressured to be perfect or held to a different standard was insightful. It was troubling that multiple nurses currently had patients refuse them as their caregivers because of the color of their skin. An unfortunate commonality amongst the interviews was that racism is still rampant at an individual level and systems level. Additionally, the experiences of Black patients that the nurse participants described was also illuminating. Again, patients were stereotyped, received inequitable treatment and were dismissed, ignored, or not believed. This study only affirms what the literature has demonstrated in terms of health disparities.\u003c/p\u003e \u003cp\u003eOn a positive note, the study elucidated the behaviors of a culturally humble nurse. The subthemes of Asking, Active Listening, Caring Body Language, Individualized Care, and Respect are helpful. As the construct of racism can be quite nebulous \u0026ndash; as well as it\u0026rsquo;s antithesis of culturally humility \u0026ndash; we now have distinct actions and behaviors to draw from to teach nurses on what to do and what not to do. Of course, some of these actions vary by culture and setting, and cannot be generalized. Patients should be asked about their individual culture and preferences. On the other hand, these behaviors are an evidence-based starting point from which to better understand the experience of the Black nurse and Black patient in the context of clinical nursing practice.\u003c/p\u003e \u003cp\u003eOf note, two of the nurse researchers identified as Black and one researcher as White. We felt this was a strength as multiple perspectives were applied to analyze the data. While our primary aim was to uncover behaviors of racism against patients in clinical practice, the nurse participants also shared their own experiences of facing racism as nurses, faculty members, and students. As the focus of this study was to examine racism in the context of clinical practice, we will present the results of racism in nursing education \u0026ndash; as a faculty member and as a student \u0026ndash; in a subsequent manuscript.\u003c/p\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eComparison to previous research\u003c/h2\u003e \u003cp\u003eStudy findings align with previous research supporting the need to address racism in various facets of healthcare that involves racist behaviors towards nurses and patients of color.\u003c/p\u003e \u003cp\u003eRacism is a multi-faceted challenge in the healthcare environment with influences on providers and patients (Hamed et al, 2022) \u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e as well as other aspects of healthcare delivery and access (James-Conterreli, et al., 2023) \u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e. Furthermore, the participants descriptions of biases and racist behaviors in various healthcare settings provided increased awareness and knowledge about the obvious elements of discrimination, exclusion, and marginalization. There were significant findings in this study that aligned with the concise report in the ANA (n.d.) racial reckoning statements acknowledging the embedded structural racism in the foundation of different healthcare organizations \u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eThis study was limited in several ways. First, the interviews were conducted via Zoom instead of in-person. While this increased feasibility and enabled reach across the country, we acknowledge that the sense of presence and ability to convey information through facial expressions and eye contact was not the same as a face-to-face interview. Second, all the participants were doctoral prepared nurses. It is possible that they may not have had experiences of racism or culturally humility to the same extent as someone who was not well-educated. However, the expertise of the participants was helpful in articulating their experiences, recognizing the terms for certain phenomena experienced to help us better understand. Further, the study and participants all lived in the United States. As cultures certainly vary outside of the United States, the transferability of the study is limited.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eNurses and patients of color experience many forms of racial inequities that impact the healthcare profession. Through delving deeper into the inequitable racist verbal, nonverbal, and exclusion practices experienced, healthcare organizations and the community will be able to recognize and identify the inappropriate practices faced by this underrepresented population. The study findings can be used to inform future initiatives to eliminate inequalities in patients and nurses of color.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e \u003cp\u003e We have obtained ethical approval from the University of Miami Institutional Review Board and informed contest to participate was obtained from each participant.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent for publication\u003c/strong\u003e \u003cp\u003e All authors consent the manuscript for publication.\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eCompeting Interests\u003c/h2\u003e \u003cp\u003eThe author declare that they have no competing interests.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eThere is no funding to declare.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eN.C. and C.F. conceptualized the study idea and design. N.C. and L.L. conducted data collection. N.C., L.L., and C.F. interpreted qualitative data. All authors contributed to the writing of the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eWe wish to acknowledge the participants who generously donated their time, stories, and spirit with the intent of improving the profession and the world.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThis study's data and materials are available upon request. To protect participant confidentiality, personal identifiers have been replaced with participant numbers (e.g., Participant 1, Participant 2). We maintain a secure list that links the numbers to the participants identities.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eHamed S, Bradby H, Ahlberg BM, et al. Racism in healthcare: a scoping review. BMC Public Health. 2022;22:988. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s12889-022-13122-y\u003c/span\u003e\u003cspan address=\"10.1186/s12889-022-13122-y\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJames-Conterelli S, Dunkley D, McIntosh JT, Jullien T, Nelson MD, Richard-Eaglin A. The impact of systemic racism on health outcomes among Black women: Recommendations for change. The Nurse Practitioner. 2023. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1097/01.NPR.0000000000000001\u003c/span\u003e\u003cspan address=\"10.1097/01.NPR.0000000000000001\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHill L, Artiga S. (2023, May 23). What is driving widening racial disparities in life expectancy? \u003cem\u003eKaiser Family Foundation.\u003c/em\u003e \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.kff.org/racial-equity-and-health-policy/issue-brief/what-is-driving-widening-racial-disparities-in-life-expectancy/\u003c/span\u003e\u003cspan address=\"https://www.kff.org/racial-equity-and-health-policy/issue-brief/what-is-driving-widening-racial-disparities-in-life-expectancy/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBazargan M, Cobb S, Assari S. Discrimination and medical mistrust in a racially and ethnically diverse sample of California adults. Ann Fam Med. 2021;19(1):4\u0026ndash;15. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1370/afm.2632\u003c/span\u003e\u003cspan address=\"10.1370/afm.2632\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAmerican Nurses Association. (n.d.). \u003cem\u003eCommission\u0026rsquo;s Foundational Report on Racism in Nursing.\u003c/em\u003e \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.nursingworld.org/~49b97e/globalassets/practiceandpolicy/workforce/commission-to-address-racism/5racisminnursingpractice.pdf\u003c/span\u003e\u003cspan address=\"https://www.nursingworld.org/~49b97e/globalassets/practiceandpolicy/workforce/commission-to-address-racism/5racisminnursingpractice.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSandelowski M. Whatever happened to qualitative description? Res Nurs Health. 2000;23(4):334\u0026ndash;40. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1002/1098-240x(200008)23:4\u0026lt;334::aid-nur9\u0026gt;3.0.co;2-g\u003c/span\u003e\u003cspan address=\"10.1002/1098-240x(200008)23:4%3C334::aid-nur9%3E3.0.co;2-g\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLincoln Y, Guba EG. Naturalistic inquiry. Newbury Park, CA: Sage; 1985.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAmerican Nurses Association. (n.d.). \u003cem\u003eNational Commission to Address Racism in Nursing.\u003c/em\u003e \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.nursingworld.org/practice-policy/workforce/racism-in-nursing/national-commission-to-address-racism-in-nursing/\u003c/span\u003e\u003cspan address=\"https://www.nursingworld.org/practice-policy/workforce/racism-in-nursing/national-commission-to-address-racism-in-nursing/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-nursing","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurs","sideBox":"Learn more about [BMC Nursing](http://bmcnurs.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurs/default.aspx","title":"BMC Nursing","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"racism, nursing, education, clinical, practice, bias","lastPublishedDoi":"10.21203/rs.3.rs-4934771/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4934771/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eRacism in healthcare has led to disparate health outcomes amongst people of color. The construct of racism may be misunderstood, and research is lacking about the actions nurses can in the clinical setting take to reduce racism. The purpose of the study was to determine behaviors demonstrative of racism in nursing care and behaviors that are demonstrative of cultural humble nursing care to develop an awareness of racial bias in nursing to inform future educational practices.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA qualitative, descriptive design was used with 10 doctoral-prepared nurses of color with expertise in diversity, equity, inclusion, and social determinants of health.\u003c/p\u003e\u003ch2\u003eFindings\u003c/h2\u003e \u003cp\u003eThree overarching themes emerged: 1) Experience of Racism as a Nurse of Color (with subthemes of False Negative Assumptions/Stereotyping, Discrediting/Unheard, and Rejection), 2) Experience of Racism as a Patient of Color (with subthemes of False Negative Assumptions/Stereotyping, Inequitable Treatment/ Lack of Care, and Dismissing/Ignoring or Not Believing), and 3) Culturally Humble Care (with subthemes of Asking, Active Listening, Caring Body Language, Individualized Care, and Respect).\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eStudy findings may be used to inform and improve nursing practice to reduce racism and decrease health disparities.\u003c/p\u003e","manuscriptTitle":"Racism in Clinical Nursing Practice: A Qualitative Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-09-26 10:13:28","doi":"10.21203/rs.3.rs-4934771/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-10-22T06:09:42+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-10-21T15:11:02+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-10-09T01:49:32+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"235781943539821866796819235697776650850","date":"2024-10-04T21:23:53+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"88343736726565482725067785281456750159","date":"2024-10-01T07:39:17+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"319331417700770628665547328511072916837","date":"2024-09-01T15:29:53+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-08-29T13:01:23+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-08-27T12:52:40+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-08-27T12:28:20+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Nursing","date":"2024-08-18T21:00:39+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-nursing","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurs","sideBox":"Learn more about [BMC Nursing](http://bmcnurs.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurs/default.aspx","title":"BMC Nursing","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"4868781f-f7c8-4aee-b5f8-f697478cc7c7","owner":[],"postedDate":"September 26th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-02-03T15:58:31+00:00","versionOfRecord":{"articleIdentity":"rs-4934771","link":"https://doi.org/10.1186/s12912-024-02521-8","journal":{"identity":"bmc-nursing","isVorOnly":false,"title":"BMC Nursing"},"publishedOn":"2025-01-28 15:56:52","publishedOnDateReadable":"January 28th, 2025"},"versionCreatedAt":"2024-09-26 10:13:28","video":"","vorDoi":"10.1186/s12912-024-02521-8","vorDoiUrl":"https://doi.org/10.1186/s12912-024-02521-8","workflowStages":[]},"version":"v1","identity":"rs-4934771","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4934771","identity":"rs-4934771","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}