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Key Words: Diversity, nursing education,racism, essay

American nursing has been and continuesto be a predominantly white, female profes-sion that does not reflect the diversity of thepopulation. Racial disparity in the profes-sion is also projected to increase, asethnic/racial minority groups will represent50% of the population by the middle of thiscentury. Recruiting and retaining minoritystudents in schools of nursing has become atopic of much discussion, yet students con-tinue to be predominantly young, whitewomen. The United States nursing educa-tion system has been viewed by some as aculture that reflects white, middle-class val-ues, which creates barriers for minority stu-dents (Sullivan Commission, 2004). It issuggested by dissenting voices in the pro-fession that subtle forms of racism existamong predominantly white faculty andstudents that make the educational experi-ence particularly difficult for underrepre-sented students (Allen, 2006;Hassouneh-Phillips & Beckett, 2003;Puzan, 2003). This essay explores some ofthe issues with race in nursing education.

Emphasis on cultural competence innursing education is evident when onelooks at the literature of the last fewdecades. Such competence has been de-scribed as the ability to care competentlyfor patients or clients from cultures otherthan one’s own. “Transcultural nursing” isconsidered essential in nursing curriculumto eliminate the shadow of racism in whichone culture is cast as the norm from whichothers differ. Leininger (1995) suggested,“some of the most significant changes innursing are related to learning, teaching,

and applying transcultural nursing knowl-edge” and that using transcultural nursingknowledge “is leading to different ways ofpracticing nursing” (p. 10). Emphasis ismost often placed on preparing nurses toprovide culturally specific care for a diversepopulation. Yet there is little emphasis onthe need for schools to respond to the needsof culturally diverse students. American ed-ucational institution culture is most oftenframed from a Eurocentric worldview andhas the potential to create conflicts for stu-dents with differing cultural perspectives.While recruitment efforts have led to in-creased enrollment of minority students, at-trition rates of non-white students fromschools of nursing continue to increase.Some scholars suggest that this may be at-tributed in part to curricula that do not re-flect the cultural perspectives ofnon-majority students.

The profession has done little to examineits own practices for inclusion of racial, cul-tural, and ethnic differences within the edu-cational system. De Leon Siantz (2008)noted that the need for changing nursing ed-ucational environments is imminent.Calling for change at the highest levels ofeducational institutions, she suggested thatrisk taking is necessary to transform nursingeducation for the future. It is acknowledgedthat the concepts of race, ethnicity, and cul-ture are socially constructed and not shapedby biology (Nairn, Hardy, Parumal, &Williams, 2004), however we continue tostruggle with the conflicts that such con-cepts have created in the world around us. Itis critical that nurse educators and othermembers of the nursing profession addressthe issues that encumber efforts to form aprofession that reflects diversity. These is-

sues include racism, heterosexism, ethno-centrism, stereotyping, and lack of culturalunderstanding (Sutherland, 2002).

The word “nurse” provokes a variety ofimages, for some it is the feeding and nur-turing of an infant or small child, but formost Americans it is a figure, most often fe-male, of Western European descent, dressedin white, administering to the sick. Theimage provokes thoughts of the aseptic hos-pital environment. While the population ofthe United States has changed, reflecting aculturally diverse population, the image ofthe nurse has remained essentially un-changed. The white uniform may be out-dated, but the white woman is still theprominent figure in professional nursing(Figures 1, 2, & 3). Traditional nursingleaders are women of middle- and upper-class white families. Their perspectives onorder, behavior, and professionalism haveshaped the profession for over a century.The single woman in the starched collarwith uniform pressed and spotless was theepitome of the ideal nurse until the mid-20th century (Figures 4 & 5). Female stu-dents remained unable to marry until the1960s. White typically connotes purity andinnocence; however, in the setting of nurs-ing education white has come to imply therigid, Eurocentric culture that is dominantin nursing education. Few images of womenof color, who were also pioneers in the pro-fession, are as readily available (Figures 6& 7). Although considered a neutral color inthe world of art, white is far from neutralwhen considering issues of power in therealm of nursing. Puzan (2003) demon-strated that the terms white and non-whitenot only represent categories of skin color,but also categories of domination andpower. Fox (1994) discussed Korzbski’sstudies of general semantics in which herecognized a relationship between lan-guage, behavior, and reality. In general se-mantics, words are not the same asexperience; the word is not always the same

When the World is White

Mary L. Wilby, MSN, RN, CRNP, PhD(c)La Salle University

Abstract

This essay offers insights into racial disparities in the nursing profession and nursingeducation. Perspectives are offered on cultural competency and a Eurocentric world-view. Historical antecedents of whiteness are discussed and the links between race andstatus are noted.

58 International Journal for Human Caring

as the thing that is being symbolized. It isimportant to remember that the experienceof images may outweigh what the written orspoken word portrays. Images of theSuperintendents of the Army demonstratethis clearly (Figures 3 & 8). Puzan de-scribed whiteness as an “unexamined sub-strate upon which all life is sustained...Those who are racially designated are mea-sured against mostly implicit standards ofwhiteness and, whether they are willing orunwilling, able or unable to meet those stan-dards, find themselves deficient or subordi-nate” (p. 194). Whiteness is equated withprivilege and advantage over those whonon-white (Allen, 2006). Those who arewhite get to make and validate the rules.Whiteness determines who belongs andwho does not. White and non-white arelinked with socially valued and negative at-tributes. White often becomes synonymous

with racist. Consider the character of NurseRatched (Figure 4) in One Flew Over theCuckoo’s Nest. Her character is synony-mous with rigidity and intolerance.Ironically, white light is comprised of allcolors of the light spectrum, while white inthis instance is reflective of the absence ofdiversity. When we consider culture innursing we generally speak of culture that isoutside the boundaries of a white, middle-class female-dominated world (Figure 5).

Transcultural nursing refers to the studyand practice of nursing that focuses in dif-ferences and similarities among cultureswith respect to health and nursing care. Weseldom consider the need for transculturalnursing education, which would focus onthe need to provide educational experienceswithin the boundaries of diverse cultural be-liefs and practices of students. Culturalcompetence is sometimes defined as the

ability to provide effective clinical care fora particular ethnic or racial group and is sel-dom seen as the ability to reach a culturallydiverse student population with varyingperspectives on health and illness and fe-male roles. There is so much dialogue aboutcultural diversity as the differences in thosewho are non-white that we fail to recognizeand discuss the attributes of whiteness.Attrition of students of color is often associ-ated with the absence of social connections,including role models who are people ofcolor, financial supports, and commitmentand support from predominantly white fac-ulty (Hassouneh-Phillips & Beckett, 2003).

Puzan (2003) suggested that there is anentrenchment of whiteness in nursing, evi-dent in practice, and where nursing educa-tion takes place. When we are white, we areneutral and those who are not are viewed asdistinctly different. White is representativeof the dominant Eurocentric culture. Peopleof color continually examine their statuswith relationship to prejudice in the every-day world, while whites are typically un-aware of the meaning of their race as acomponent of status, power, and authority.Among non-whites, white is synonymouswith the status and privilege of the domi-nant culture. Whiteness for whites is takenfor granted. For students and nurses ofcolor, “acting white” is often a way to blendinto the nursing establishment. This may re-quire embracing certain behaviors, commu-nication patterns, and practices from thedominant culture to gain acceptance. Whilethis may be useful in working in the whitehealthcare establishment, it is often a causeof personal and interpersonal conflict.Professional survival often requires submit-ting to the rules of established white author-ity while incurring loss of personal andcultural identity. For nurses of color, “wear-ing the whites” is distinctly more thandressing for work.

It is imperative that nursing faculty con-duct research with students of color to ex-plore, describe, and understand theirperceptions of education in a predominantlywhite nursing education culture. Through

When the World is White

Figure 1. Florence Nightingale.

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When the World is White

Figure 2. M. Adelaide Nutting

Figure 3. Jane Delano, Second Superintendent, ArmyNurse Corps.

Figure 4. Nurse Ratched, One Flew Over the Cuckoo’s Nest.

Figure 5. Class of 1941, Johns Hopkins University Hospital School of Nursing.

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Figure 7. Mary Seacole.Figure 7. Mary Seacole. Figure 8. Julia Flikke, Sixth Superintendent, Army NurseCorps

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such research, faculty may be able to linktheories of culture with theories of caring.They might ultimately identify teachingstrategies sensitized by the many experi-ences that diverse students bring to educa-tional and clinical environments.

References

Allen, D.G. (2006). Whiteness and differ-ence in nursing. Nursing Philosophy, 7,65-78.

De Leon Siantz, M.L. (2008). Leadingchange in diversity and cultural compe-tence. Journal of Professional Nursing,24(3), 167-171.

Fox, R. (1994). Image studies: An interdis-ciplinary view. In R. Fox (Ed.), Images inlanguage, media and mind. Urbana, IL:National Council of Teachers of English.

Hassouneh-Phillips, D., & Beckett, A.(2003). An education in racism. Journalof Nursing Education, 42(6), 258-265

Leininger, M. (1995). Teaching transcul-tural nursing in undergraduate and gradu-ate nursing programs. Journal ofTranscultural Nursing, 6(2), 10-26.

Nairn, S., Hardy, C., Parumal, L., &Williams, G.A. (2004). Multicultural oranti-racist teaching in nurse education: Acritical appraisal. Nurse Education Today,24, 188-195.

Puzan, E. (2003). The unbearable whitenessof being (in nursing). Nursing Inquiry,10(3), 193-200.

Sullivan Commission. (2004). Missing per-sons: Minorities in the healthcare profes-sions. W.K. Kellogg Foundation.Retrieved from http://www.aacn.nche.edu/Media/pdf/SullivanReport.pdf

Sutherland, L.L. (2002). Ethnocentrism in apluralistic society: A concept analysis.Journal of Transcultural Nursing, 13(4),274-281.

Author Note

Mary L.Wilby, Assistant Professor, La Salle University, School of Nursing, Philadelphia, Pennsylvania.Correspondence concerning this article should be sent through electronic mail via Internet to wilby@lasalle.edu

When the World is White