Diversity, equity, and inclusion can’t be authentically incorporated into curricula when faculty assign textbooks that harm those whose health they seek to protect.

For instance, nursing textbooks can present race as a biological risk factor in disease instead of recognizing racism, historical injustice, and social determinants of health as drivers of illness. Additionally, textbooks often depict pregnancy as an experience restricted to cisgender women. These descriptions result in a greater likelihood that our future patients will experience medical bias and mistreatment, which may lead to poor health outcomes. What’s more, it invalidates and stigmatizes the lived experiences of students from underrepresented backgrounds.

That’s why Workgroup Two: Assessing Teaching and Learning Processes and Practices of the Johns Hopkins School of Nursing’s Committee on Teaching and Learning as Pathway to Diversity, Equity, and Inclusion is working hard on a textbook review to improve curricula related to diversity, equity, and inclusion. The Committee’s mission includes efforts to “intentionally incorporate cultural inclusion into Johns Hopkins School of Nursing pedagogy to improve all students’ success.”

As such, the group is systematically evaluating how the Johns Hopkins School of Nursing’s Master of Science in Nursing (MSN) Entry into Nursing program’s required textbooks present and rationalize the health of underrepresented racial, ethnic, and LGBTQI+ groups.

Approaching the textbook review

Workgroup Two is systematically evaluating how the MSN (Entry into Nursing) program’s required textbooks present and rationalize the health of underrepresented racial, ethnic, and LGBTQI+ groups—groups that historically have been marginalized in nursing education. Postdoctoral research fellow Ruth-Alma Turkson-Ocran serves on a team examining textbook portrayals of race and ethnicity, and MSN (Entry Into Nursing) Angie Deng serves on a team reviewing the same of LGBTQI+ people.

The Race and Ethnicity team has tallied textbook terminology related to race and ethnicity (e.g., Black, White, Indigenous, Immigrant) and will examine how racial and ethnic health disparities are rationalized by authors. Similarly, the LGBTQI+ team has tallied textbook terminology related to LGBTQI+ identities (e.g., gay, transgender, intersex, gender-affirming) and will examine how LGBTQI+ health disparities are rationalized. The two teams have collaborated to identify the overarching themes and outcomes described below.

So far the review has shown:

• Most authors omit discussions regarding relationships between racism, discrimination, and health—even when they describe disparities.
• None of the textbooks have substantial information on caring for LGBTQI+ patients, despite many of these books having sections on “male” health, “female” health, and culturally informed nursing care.
• Many texts conflate or misrepresent terms such as “race” and “ethnicity;” or “transgender” and “transsexual.”
• A prominent theme across textbooks includes the portrayal of a default patient who is White, straight, and cisgender.

Harmful and offensive language

The workgroup tallied harmful and offensive language used to refer to underrepresented populations as well. For example, the LGBTQI+ team has recorded an instance of “gender confusion” being described as an adverse symptom of mental illness. Nurses should not be taught to view a patient questioning their gender or having a non-traditional gender identity as pathological issue.

The Race and Ethnicity team noted passages expecting students to identify African Americans as the racial group “who most likely will have HIV” or iron deficiency anemia, and claim that being African American is a risk factor for hypertension, osteoarthritis, HIV, and substance use disorders—all without citation or rationale. Racial health disparities do exist and should be recognized in textbooks. However, they should be presented with context, including how historical and ongoing inequities contribute to them. They should also be cited to help ensure that the information is factual. Unfortunately, our diverse teams have been exposed to textbook claims that directly marginalize ourselves or our community peers.

An effort championed by student volunteers

Concern for biased textbooks was initially raised by faculty, however students partnered with them in the budding Workgroup Two to propose, design, and implement the project. Now, all reviewers in both teams are student volunteers, with representatives that range from the pre-licensure MSN (Entry Into Nursing) program to postdoctoral fellows. As students, we are aware of the urgent and intense interest among our peers for our curricula to better prepare us for anti-racist and LGBTQI-affirming practice. Our work is slow, but we are committed to leveraging it for meaningful, structural change.

Our ultimate goal is for all textbooks—especially those used in Johns Hopkins’ programs—to accurately represent historically marginalized groups. We aim to publicize our findings in academic journals, letters to textbook editors and publishers, and communications with Johns Hopkins School of Nursing faculty, administrators, staff, and students to drive curricular change. We have already shared our preliminary findings with some faculty to help improve their lecture content, and we will present our work at the national Association of Community Health Nursing Educators Institute conference this summer. Additionally, the Race and Ethnicity group has contributed the chapter “Strategies for implementing antiracist frameworks and critical reflection in teaching materials for health professions” to Antiracist Helping Professionals: Research, Pedagogy, and Practice, a book focused on an anti-racist pedagogy (i.e., teaching and education that overtly oppose racism).

The issues we have identified aren’t specific to one program or one school, but represent a broader challenge in health professions. Short-term, we hope to support and hold our own institution accountable for change. Long-term, we hope to contribute to a national and global cultural shift toward preparing nurses to see strengths in their patients, while recognizing and addressing deficiencies in systems, policies, structures, and culture that impact health.

Angie Deng will graduate from the MSN (Entry Into Nursing) program in May 2021. She is the student lead for the JHSON LGBTQI+ Health Initiative, a student organization aiming to improve nursing education in LGBTQI+ health, and will present at the Association of Community Health Nursing Educators conference in June 2021. Angie earned her Bachelor’s of Arts in Neuroscience from Vanderbilt University in 2019.

Ruth-Alma Turkson-Ocran, PhD, MPH, RN, FNP-BC is an American Heart Association Strategically Focused Obesity Research Network postdoctoral research fellow at the Johns Hopkins School of Medicine. She is also a board-certified Family Nurse Practitioner. Prior to receiving a PhD from the Johns Hopkins School of Nursing, she received a Master’s in Nursing (MSN) and Master’s in Public Health (MPH) in Health Promotion/Behavioral Sciences at The University of Texas Health Science Center at Houston (UTHealth). She is also a graduate of Lincoln University in Jefferson City, MO where she obtained her Associate and Bachelor of Science degrees in Nursing. She is a member of the Sigma Nursing, the Preventative Cardiovascular Nurses Association (PCNA), and the American Heart Association (AHA).