One of the nursing staff’s favorite person to take care of was a kind Latina woman. While there was a language barrier between us and she was experiencing some severe health challenges, she was extremely thankful for our care. She had come from South America to visit her daughter and suddenly found herself in the hospital, newly diagnosed with hepatitis. She had initially presented with pneumonia and kidney failure. We were running continuous dialysis to help clear her body of toxins, but she would require a liver transplant to survive long-term. A coworker asked how she was doing.
“Oh, you know–she’s okay, but she’s not really going to get better unless she gets a transplant,” I responded.
“See, that makes me mad. She came to this country illegally, she’s not even a citizen–and she thinks she can get a transplant? It’s hard for even citizens of this country to get transplants, and illegal immigrants think they deserve one? You think if I went to Europe and I got sick, I’d get a transplant?”
“I don’t know, but you might, if it was an emergency and you’d die without one. Because, you know, they have real healthcare.” I was furious. This nurse had taken care of her sick patient and seen her only through a lens of nationalism, racism, and classist hatred. She didn’t acknowledge that throughout our hospital, patients from all over the world receive transplants funded by their governments. Are their lives more valid because their governments are friendly to the United States, or they are lighter-skinned and wealthier? Are their lives more valid because the artificial borders were crossed with the mobility granted by a passport stamp?
Judging from the way healthcare in the US functions, or fails to, the answer is yes.
Systemic oppressions are embedded in healthcare. As a nurse, while I may not view myself as the perpetrator of oppressive practices, I willingly reinforce a healthcare system that is inherently unjust. Ideally, I would love to work in a healthcare setting that fights inequality and oppression on a daily and systemic manner. In reality, I have never worked in that setting.
While working within a flawed system, how can nurses combat the latent racism, classism, homophobia, transphobia, ableism and sexism that exist at our jobs? Here are some concepts to consider when walking into work.
1. Acknowledge Our Power. At work, nurses are with patients more than anyone else. We admit and discharge, which involves asking questions about their past and present. We advocate for patients, which can be as small as tracking down a meal tray during shift change and as big as getting the Ethics Committee or Patient Advocate involved when the patient or family is unsatisfied with care. We answer call bells, helping patients find comfort in a foreign environment. We give medications, which are sometimes life-saving and sometimes pain-relieving. We assess patients from head-to-toe, which is often redundant but sometimes can help catch new stroke symptoms or prevent an impending decline. We have power.
2. Recognize that Within Healthcare, Patients Are Often Margnialized. We stick needles in them, we tie them to beds, we stick a tube in a penis without even telling the person our name. Our patients are people, and we often forget this. We also forget context. Many of the people who get sickest are the people who have been marginalized in multiple ways. Race, class, and gender presentation may mean that access to wellness promotion, risk reduction, and health education have been limited throughout their lives. When a child is diagnosed with diabetes, hopefully parents are around to check blood sugars and appropriately give insulin. What if the parent works multiple jobs or has an addiction they are trying to manage? As an adult, this patient comes in with “poorly controlled diabetes” with “multiple complications related to noncompliance.” These words ignore context. When a middle-aged Black man comes in with stroke symptoms and has undiagnosed hypertension, we blame the patient for not seeing a doctor in decades. What if there are no affordable clinics within a reasonable distance of where he lives?
Our patients’ health does not exist in a vacuum. They often come to us with multiple marginalized identities. When they enter the hospital, we marginalize them once more. Our license allows us to do what is medically necessary, regardless of whether the patient wants it. Legally, the patient can refuse. Realistically, if a patient is in kidney failure and we need to monitor urine output, but they don’t want a catheter, we are going to do what we deem medically necessary.
3. Know Your Role. Nurses are not only involved in power dynamics with patients and their families, but also with nurse managers, administrators, and most importantly, doctors. We have distinctly different roles from doctors which allow us to be more acutely aware of what a patient is going through on a human level. We spend time with our patients and sometimes even see them as people, struggling to survive, rather than as the other. The expected power dynamics between nurses and doctors often are similar to the traditional expected roles between women and men, regardless of the gender of those involved. The nurse is expected to be ignorant, unscientific in her explanations, and needs the doctors to fix difficult patient situations. The doctor swoops in and fixes everything quickly, then leaves the nurse to clean up his or her mess. Nurses are expected to obey instructions, carry out orders, and avoid confrontation or dissent. Notice my use of the word expected. This is what many doctors expect us to do, but then act surprised when we ask why, tell them to clean up their messes, or ask them to have a conversation with a patient. While doctors write orders, nurses need to know the ins and outs of why we are carrying out these orders and we need to believe the rationale behind them. We need to be sure that the doctors have considered everything that is going in with this person-including their family involvement and what the patient really wants. So, we ask a lot of questions and demand a lot from the physicians. We are advocates. Confronting power, or perceived power, is part of the job description.
Speaking truth to power is not easy but I am looking for ways to speak my truth within my job as much as I can. I cannot claim to do all of these things all of the time, but am trying to practice nursing with justice on my mind. I would love to hear suggestions from other folks working towards a more just world. In following posts, there will be more concrete ideas for how nursing practice can work towards justice. As this is coming from a Critical Care nurse, these concepts and ideas will be primarily centered around inpatient hospital care, but I would love to hear from nurses of all disciplines.
This post was born through conversations with rad nurses and came together with the encouragement and help of Carol Dreibelbis and Nwadiogo Ejiogu. Thanks for your editing skills and support!