Racism, Implicit Bias, and Theory Failure in Nursing: How Cultural Competence Cloaks and Perpetuates Systemic Racism, Yielding Room for Improvement in Patient Outcomes and in the Profession

Submitted by Jennifer Papapavlou BSN RN CCRN

Tags: bias culture Systemic Racism theories

Racism, Implicit Bias, and Theory Failure in Nursing: How Cultural Competence Cloaks and Perpetuates Systemic Racism, Yielding Room for Improvement in Patient Outcomes and in the Profession

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Nursing practice of some form has been around for thousands of years, yet remains an emerging discipline; one in which theory is in its infancy, continuing to evolve. Of the more ‘forward thinking’ theories prevalent today in nursing is the Theory of Culture Care Diversity and Universality. Developed with the intention of promoting a culturally aware worldview from which the discipline of nursing could postulate queries, guide research, and enact practice norms, its emergence some 30 years ago renders it woefully out of date, creating a theory-research-practice gap that hinders real advances nursing is capable of attaining, both as discipline and as a practice, in providing competent and sensitive care to ethnic minorities and marginalized popula-tions. Nursing theory needs to evolve away from skirting the issues of racism, systemic racism/ marginalization, and inherent bias. Instead, it must address those issues head on in order to enact change and provide effective care to all patients. How has this continued use of an outdated theory impacted both research and practice?


Leininger’s Theory of Culture Care Diversity and Universality was first publicized in 1988, though her fundamental concepts had emerged well before that, born of her melding the disciplines of Nursing and Anthropology during her doctoral studies in the 1960s. In the dec-ades prior to her theory publication, she created the first nursing programs in transcultural nursing circa the 1970s (Alligood, 2018). Leininger synergized her studies from her Anthropology back-ground utilizing ethnographic methods to study other cultures, and her base in nursing to create from her own personal nursing theory what is now known as the middle-range theory entitled Theory of Culture Care Diversity and Universality (Leininger, 1988). This theory, widely popu-lar in nursing today, demands the nurse in their role as a practitioner, researcher, or within the discipline, to acknowledge that the culture of the patient/person should be understood, respected, and intertwined in the care relationship. That culture diversity care variables are differenced and acknowledged to be respected and understood, and the universality of culture allows for a com-monality in the care relationship to guide the health outcomes (Alligood, 2018). This was, at the time, a substantial paradigm shift from the typical Western Nursing viewpoint that had originated in white Eurocentric society. The intention was to guide nursing practice in ways that facilitated improved outcomes for patients and communities. Unfortunately, it was formed too close to the racial inequities systemically rampant in Western nursing to yield successful outcomes for mar-ginalized patients, failing to eliminate racial divides and barriers to holistic care.

Role Of the Theory

Leininger and her nursing counterparts of the Western healthcare system were born into, educat-ed, and worked in a racist society. Born in Nebraska in 1927 just 64 years after the Emancipa-tion Proclamation (of note, the Emancipation Proclamation happened three years after Florence Nightingale’s Notes on Nursing), she was educated in the Midwest, where she entered into nurs-ing prior to 1950, in a nursing school that was segregated. Prevalent in the era that Leininger was educated in trained in nursing was the segregation of white and black in healthcare. Fields et. al post that the 1896 Plessy vs Ferguson ruling which brought about racially segregated healthcare, furthering the disparities not only to ethnic minority patients, but further to the educational insti-tutions serving minorities. Only in 1954, after Leininger had received her first Masters, did the false practice of separate but equal get overturned in Brown v the Board of Education (2022).

Watson (2021) explores this history of segregation when examining the preventable harm of rac-ism prevalent in Western healthcare over the centuries, noting the continual abuse Black patients have experienced in healthcare, citing the Tuskegee Experiments (1932-1972), the segregation of a Black maternity ward in St. Louis, which was located right outside a morgue in the basement, whose sign hung for 54 years post integration until it was removed in 2018 (p. 303). For 30 years post the emergence of Leininger’s theory, a tribute to segregated, marginalized care of Black women hung in the halls of a major medical institution, and no one who worked there was ‘cul-turally competent’ enough to have cared about the weight that symbol conveyed to the Black or minority patients, or staff, that came across it. How can one say that is possible in 2018 if cultural competence works as the white woman who invented it intended? The cultural competency theo-ry places the nurses, majority white females perpetuating these disparities, at the center of the theory, and evaluates the practice and research from the vantage point of someone whose educa-tion and experiences shaping their worldview were buffered by an institution that neglected mi-norities since inception. Fields et.al (2022) note that currently over 80% of nurses are White fe-males, Black nurses constitute only 6%, and Hispanics 5.3%, where the US population of the same groups are 60%, 13%, and 18%, respectively. Iheduru-Anderson and Wahi (2022) note that this disparity in the nursing population provides a culture of racism in practice towards eth-nic minority nurses, the ‘cultural competence’ as a code phrase can pertain to skills used to deliv-er care but do not translate to measurable outcomes, and that the lack of direct language allows the prevalence of ‘whiteness’ to obscure the ability to educate about race, perpetuated by ‘white fragility’ leading to ‘white silence’. This in turn leads to the colorblind ideology where nurses can comfortably say that their practice is not based on the racial designation of their patient, but undermines the very real aspect that systemic racial bias, implicit bias, socioeconomic factors, and white privilege create inequities in nursing and practice. It is an easy premise for a white healthcare provider to attest that they “don’t see color”. The problem is that is not a solution. One cannot undo disparities by ignoring them, much like one cannot cover their eyes and assume if they can’t see people then people can’t see them. Not seeing color is tantamount to saying it doesn’t exist and therefore racism and bias does not exist, which is entirely a falsehood, and a dangerous one. To move past this false narrative and feedback loop, nurses must be able to view the whole of nursing, including research, practice, and as a disciple, be knowledgeable of ante-cedent occurrences to present day that continue to create inequities within the profession of nursing.

Theory Relationship

Theory is set to guide the practice of nursing, where day to day nursing practice should in turn drive research, and these identified areas of knowledge should form a cyclical connection back to yield theory reform (Smith, 2019). While cultural competent care at bedside serves to create a practice in which nurses provide care in which they recognize the differences in cultures of pa-tients, the translation into clearly improved outcomes has not been yielded as Leininger had hoped. Clear healthcare disparities exist regarding racism in nursing and outcomes of patients current day. Scott et. al (2021) reviewed the prevalence of the negative impacts structural racism has on Black nephrology patients, for one specific study. A devastating meta analysis of healthcare since the theory came into favor, coupled with the need for reform, has been identi-fied in all of the studies and reviews herein mentioned, not being an exhaustive list, yet the theo-ry remains, allowing refuge to these disparities which perpetuate. For example, Watson cited three evidence based practices proven to decrease harm related to racism in the healthcare setting that nurses could already incorporate into practice: awareness, training and application. These elements comprise the preventable harm bundle (2022). A simple model, consisting of three ele-ments each with two subcomponents, easily utilized for guiding the practice of a nurse to miti-gate the negative impact racism yields on healthcare outcomes. Yet, its implementation is not widespread. Acceptance of this in practice falls flat without theoretical support. In order to heal the cycle of theory-practice-research, all components must agree on the fundamentals.


With the movement of corporations to DEI based leadership, so too follows the leadership of healthcare. Fields et al identifies that The National League for Nursing published a Diversity and Inclusion Toolkit in 2017, along with recommendations for such reform by the AACN, National Academies of Sciences, Engineering, and Medicine, and the National Advisory Council on Nurse Education and Practice (2022). Independent research into this practice-outcome gap has increased, largely in part to the large scale initiatives of US governmental agen-cies and nursing organizations (Iheduru-Anderson and Wahi, 2022) and the rise of DEI practitioners in academic nursing (Fields, et. al, 2022).


As early as 1993, a study on racism in nursing showed that while the movement towards addressing racism was gaining traction nationally, the practice of nursing was hesitant to move towards this change. That the history of education gaps for Black nurses, the racial divide not surmountable by entering into a professional cohort, white denialism and ‘colorblindness’ created a stagnation, leading to a lack of black voices in research and education to drive change, and a silence among their white counterparts that stalled progress (Barbee, 1993).


Nursing can and should do better to promote equity for all; minorities and marginalized groups have suffered too long at the lack of truly competent care, and studies exist both quantitative and qualitative to espouse the negative outcomes attributable to this gap. Further, the continued di-minished capacity of minority and marginalized nurses within the discipline of nursing is not only incongruent to offer equitable representation, it perpetuates the cycle of disparities. Can we now, the profession of Nursing, honor the past of our founders like Leininger who saw a path ahead for equity when there was none prior, while also admit the absence of important voices of those she advocated for? It is time to hear their voices, to incorporate their focus. As a white nurse myself, I recognize my advantages. I recognize the education I received which focused on providing white cisgendered based care (please see staging pressure ulcers in any textbook for reference of white focused care). Let nurses focus on healing their profession and each other with this most important step. Theory is critical to the discipline of Nursing, and to the practice of nursing. Smith describes how solid theories guide and improve nursing practice, leading to improvement in quality of life of not just patients, but families and communities via a direct correlation between theory based thinking, which leads to decisions and actions, that enters into nursing practice providing models to be applied (2019). The discipline of Nursing as an emerging science needs to embrace the full onus of providing equitable care to the full populations it serves, from research to discharge, through community engagement and involvement, public policies and guidelines. In order to do so effectively, a shift in theory must occur to accurately account for the disparities which still exist, specifically in relation to minorities and marginalized individuals.


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