Qualitative analysis through the lens of minority nurses.
- Diversity in nursing and healthcare is necessary to combat health disparities and achieve health equity.
- Semi-structured interviews with Black/African American nurses who provide care to Black/African American patients and families with serious illnesses and at the end of life aimed to understand their perception care.
- Secondarily, the interviews uncovered information about nurses’ experiences.
Many argue that experiences of discrimination, racism, and microaggression (intentional or unintentional) serve as key barriers to the recruitment and retention of diverse nurses. Iheduru-Anderson, who interviewed 30 Black nurses, noted that despite an increase in the number of Black nurses in the U.S. workforce over time, they remain significantly underrepresented in leadership and faculty positions. The study identified several themes that contribute to lack of advancement, including maintaining White comfort, distrust, lack of role models and representation, expectations about leadership roles, and the ineffectiveness of advanced degrees in securing advancement. (See Nurse stats.)
Nurse stats
Nurses comprise the largest percentage of the U.S. healthcare workforce. According to the American Association of Colleges of Nurses, approximately 5.2 million RNs work in the United States, with 89% employed in healthcare settings. Although large in number, the nursing profession continues to grapple with a lack of diversity.
In 2022, according to Martin and colleagues, most U.S. nurses (81%) identified as White females; Asians, Blacks, and Hispanics accounted for 7.4%, 6.3%, and 5.6% of all RNs, respectively. Of significance, both Native Americans or Alaska Natives and Native Hawaiians or other Pacific Islanders accounted for only 0.4% of U.S. nurses. With regard to gender, 9.4% of U.S. nurses identified as male in 2022 (an increase of 0.3% since 2017).
We know that diversity in nursing and healthcare helps to combat health disparities and achieve health equity, which improves the health and well-being of all populations. Phillips and Malone describe this as a top public health priority.
The U.S. Census Bureau projects that as U.S. demographics shift, minorities will comprise more than half of the population. Data from several reports have documented the influence of discrimination and structural racism and its impact on inequitable risk exposures, access to healthcare and resources, and quality care. These inequities lead to cumulative and chronic adverse outcomes and higher rates of morbidity and mortality among minority groups.
What the literature says
The National Sample Survey of Registered Nurses 2024 nursing workforce data indicate that 67% of RNs are White, 11% Black, 9% Asian, 9% Hispanic, 4% Pacific Islander or multiple races, and less than 1% American Indian or Alaskan Native nurses. Although these numbers continue to grow, few minority nurses hold mid to high level positions, even though more minority nurses are likely to hold a bachelor’s or graduate degree. According to the American Association of Colleges of Nursing, 69.5% of White nurses hold degrees beyond associates, 73.9% of Hispanic nurses do, 75.6% of Black nurses do, 84% Native Hawaiian or Pacific Islanders hold degrees beyond associates, and 87.6% of Asian nurses do.
A nationwide survey by the Robert Wood Johnson Foundation, conducted with 980 nurses from diverse demographics and workplace settings, found that Asian, Black, and Latino/Hispanic nurses are the most likely to experience microaggressions from patients. Findings showed that 44% of respondents reported a culture of racism in nursing school, with 60% of Black respondents experiencing racism or discrimination and almost 80% advocating for more diversity, equity, and inclusion training.
An American Nurses Association survey with over 5,600 nurses found that 63% of nurse participants have encountered racism at work, primarily from peers, patients, and supervisors. Despite 57% of nurses reporting these incidents or taking action against them, more than half observed no improvement. Furthermore, over half of the respondents reported that workplace racism adversely affected their professional well-being, resulting in stress, anxiety, and depression. In light of the difficult past and turbulent present regarding racism, the association commenced a journey of racial reckoning and acknowledged a long history of unresponsiveness to the needs of nurses of color.
Combatting the problem
Amid this significant lack of diversity, nursing leaders and scholars have taken new and accelerated approaches to combat health disparities and promote health equity. Efforts should always begin by understanding the underrepresentation and experience of all minorities within nursing.
Our study focused specifically on the experiences of Black nurses who provide end-of-life care to Black patients and families. We also looked at the impact of racism, representation, disenfranchisement, scrutiny, and trust, as well as the lingering moral distress that permeates the nurses’ professional lives.
During the social justice movement in 2020 (due to the convergence of the stark disparities accentuated during the COVID-19 pandemic and the murder of George Floyd), many nursing leaders, universities, and associations attempted to tackle the longstanding issue of racial inequities, social injustice, and health disparities by issuing organizational position statements. The analysis of the statements demonstrated varying degrees of acknowledgement and themes. However, they don’t address how the organizations will address ongoing structural racism.
Honoring these position statements requires a commitment to abolishing structural inequities. Speaking freely about discrimination serves as an important driver in bringing the profession to a true understanding of the issue. Speaking directly to nurses of color about how their experiences have impacted their professional lives and well-being offers a good starting point.
Our study
This descriptive, qualitative study used semi-structured interviews developed by an advisory team and research staff. A PhD nurse practitioner conducted the interviews using the HIPAA-encrypted Zoom platform. Each interview lasted 60 to 120 minutes.
We framed interview questions to understand the experience of Black nurses who provide care to Black patients at the end of life and their families. Initially, we aimed to understand their perception of the treatment that patients and caregivers experience. We didn’t originally intend to uncover nurses’ experiences; this was a secondary finding. (See Interview Questions)
Interview questions
We asked participating nurses the following questions:
- What is your role in the healthcare system?
- How long have you been in this role?
- What setting do you work in?
- What populations do you work with?
- What is your experience with grief, death, and dying?
- Have you noticed any differences in treatment between races or ethnicities?
- Have you noticed any differences in treatment preferences between races and ethnicities?
- Have you noticed things that have worked or not worked by means of connecting with individuals of color?
- Have you witnessed people getting treated differently due to their insurance?
- What racial disparities have you noticed in your practice?
- What have you personally done to address these disparities?
- What has been the impact of these disparities?
- Have you noticed any disparities at the end of life?
- What have you done to address this?
- Anything you wish you could have done differently?
- What works and does not work when it comes to connecting with minority patients and their caregivers?
- What can we do as a whole to make healthcare more beneficial to Black Americans?
- Anything else you would like to tell me?
Who and where
We used convenience, purposeful sampling in participant recruitment. In addition to word of mouth, we placed calls for participants on social media platforms, posted flyers on college campuses, and advertised in community newsletters and newspapers. We sought nurses who self-identified as Black and had at least 1 year of experience providing care for Black adult patients at the end of life and their families within the past 5 years.
Individuals who expressed interest completed a prescreening form in REDCap (a secure web application designed for building online surveys and databases). After we established the individual nurse’s eligibility, we sent a consent form via email. We provided physical forms upon request.
After obtaining consent, we asked nurse participants to complete a demographic survey and then scheduled a semi-structured interview. We required the participants to use a telephone or electronic device to participate in the interview.
We screened 21 Black RNs for the study and enrolled 16. Ultimately, 13 nurses completed the study. The sample predominantly consisted of women over the age of 30, all holding at least a bachelor’s of science in nursing.
Ethical considerations
The study protocols received human subject approval from the Social and Behavioral Institutional Review Board at Case Western Reserve University (Protocol # STUDY20221370). Once enrolled, participants received a unique study number to maintain confidentiality. We collected all data using the transcription feature of the encrypted Zoom application and retained it in REDCap.
Next, we uploaded transcripts to NVIVO 14 for data analysis, which we conducted on a dual-password-protected computer and stored in a locked file cabinet in a locked office. Participants received an e-commerce gift card for their time.
Data analysis
We used a phenomenological approach to understand the experiences of nurses providing end-of-life care. Through these stories, the lived experience of racism experienced by these nurses in their daily roles emerged. Little research exists to understand the unique experiences of Black nurses. Examining qualitative data using a phenomenological approach empowers the research team to validate and interpret data from an individual’s perspective.
To ensure the trustworthiness of the qualitative data, we took several steps to ensure rigor. First, we identified the research problem and then developed structured questions based on relevant data gathered during an extensive literature search. Next, our team reviewed the research questions to arrive at those that would best capture the experience.
We used Colaizzi’s method for data analysis, first reading and re-reading interview transcripts and then identifying the significant statements. This method allowed us to formulate meaning from significant statements and categorize them into themes. Based on an exhaustive description of the nurses’ experiences, we formulated the fundamental structures of their experiences. Interviewees had the opportunity to recheck the integrated description by verifying the statements. Member checking helped validate the data findings and remain true to the shared phenomenon.
What we learned
Study findings highlight the lived experience of the nurse participants and emphasize the importance of representation and support for minority staff to address systemic racial disparities in healthcare. (See In nurses’ own words.)
In nurses’ own words
Following are quotes from interviews with Black nurses regarding their experiences of racism in the workplace.
Racism experienced
- “In my position, I feel like information is not shared with me. Sometimes I have to get it from somebody else. In many instances, I don’t feel comfortable…asking for help or asking for the information that I don’t know.”
- “They would accept your knowledge and allow you to show them things. They wanted to take credit for whatever you were showing them. Or if you knew something, they would use you for knowledge so they can learn, and in the meantime…still not like you because of your race…”
Shared experiences
- “Even as healthcare professionals of color, we have not always had opportunities ourselves. Sometimes we have family members, or before we became healthcare professionals, we encountered the same barriers…to healthcare. So, I think just being able to reach into that human level and have a connection unlike other healthcare professionals definitely makes a difference.”
- “I understand how patients feel because it’s written all over the person’s face. You can just tell. You can pick up on it.”
Racism experienced with patient encounters
- “A television celebrity, about 96 years old, so she was set in her ways already. I went to give her a bath along with a nursing assistant. She said some bad things to us…and I just brushed it off and told her we’re here to help. But I didn’t get angry. I observed it and I noticed it, but I didn’t angry…because I know sometimes it’s just instilled in some patients.”
- “The racism is out there. It’s been times where I would come in the room and I would have my ID badge on and the patient would still ask who I am, [what] position I hold. Or they will automatically say, ‘Are you housekeeping?’ It’s definitely out there. So out of all these years, I had to learn how to handle it because it is something that comes with the territory.”
Representation matters
- “I think [representation is] almost the most important solution and not only just minorities and being of color, but also gender…And this is so important because when our patients see a healthcare professional that looks like them, it just breaks down so many barriers right from the start.”
- “I’m the only African American in our management team. I often step in to assist healthcare professionals or case managers when they struggle to get results, especially with minority patients. I support staff members in their interactions with patients, believing that my presence and communication style can be more effective, particularly with patients of color.”
Increased scrutiny
- “I’ve interviewed so many times, I can walk into an interview and pick up on the vibe. I walked into an interview once. I could tell that they wanted me, but when I went to the interview, the lady who was interviewing me…was so focused on my color.”
- “One of the ways leadership may say things or just some of their actions. Yeah, this doesn’t make you feel empowered or even adequate.”
Moral distress
- “We’re next to a totally different department that has nothing to do with our department, but there are minorities in that department and they literally encourage me. I know where I can go to…physically…get encouragement. They see it, too. It’s…just so obvious. I have to be strong. And I pray that I deal with it in a dignified and professional manner.”
- “We have to be on our toes all the time because it’s…always that percentage and that chance of someone not liking us because of the color of our skin as opposed to our performance.”
Roadblocks
- “I found this term ‘symbolic racism,’ and I really like it because it’s no longer the overt racism. You’re not hanging from a tree, but you’re just not going to makes it as easy for me to accomplish any goal that may surpass you. You’re just going to throw whatever curves and whatever roadblocks in the way.”
- “If you speak up about anything, then it’s maybe…you, you know. I don’t know. Maybe you’re not working hard enough or you’re not doing something.”
Lack of support
- “If a person of color or minority goes to their nurse manager a lot of times, they feel like they can’t go to the manager if the manager is White. They feel like they’re going to side with the person they’re complaining about.”
- “I’m just trying to get the courage to send a letter to HR about my current work situation. Because I am giving voice to something I feel people don’t want to talk about; like it looks like we’re doing it. We have an equity, inclusion, and diversity department. We’re doing all these things, but we’re really not doing anything.”
Steps forward
- “So, if we can start being honest and having that conversation. That’s a good way to start…I know people have already acknowledged that there’s a racial issue in healthcare.”
- “The only way that we’re going to be able to attack this or the healthcare systems is going to be able to teach and educate and do courses on cultural diversity.”
Racism experienced
Nurses highlighted experiences of racism in their professional settings based on skin color. They expressed challenges in accessing information and encountering lies intended to create trouble, raising concerns about racial motivations. Some nurses shared experiences of remaining professional in the face of racism and disrespectful treatment in patient encounters. The stories emphasized representation for patients and colleagues as a crucial solution to breaking down barriers.
Participants underscored the need for diversity, not only in terms of race but also gender. One nurse in a management position discussed the significance of supporting staff members in interactions with minority patients, recognizing the potential for more effective communication in such circumstances. These narratives shed light on the pervasive racial challenges nurses face in their workplace.
Disenfranchisement
Nurses conveyed feelings of marginalization in their professional roles, and expressed struggles with a sense of inadequacy due to leadership actions and statements that undermined their authority. Some participants felt at risk of jeopardizing their positions when enforcing the rules, attributing these challenges to their skin color. Scrutiny emerged as a common theme, with individuals experiencing scrutiny when speaking about practices or pursuing promotions. These experiences underscore the challenges that nurses face in the workplace, contributing to feelings of inadequacy and the need to work harder under constant scrutiny.
Moral distress
Participants expressed moral distress in their workplaces due to various instances of racial discrimination. Nurses shared their experiences of being judged solely based on skin color and the assertiveness required to navigate through such situations. Moral distress extended to advocating for patients of color, where their concerns frequently were ignored or not taken seriously.
A lack of support in filing grievances appeared as a common theme, with some participants feeling unsupported and hesitant to approach White nurse managers. The participants expressed the overall sentiment that addressing racial disparities in healthcare requires not only open conversations but also systemic changes and support mechanisms to ensure a more inclusive and equitable work environment.
Steps forward
Taking a step forward to address racial issues in the workplace requires honest conversations about the experiences of people of color. Participants noted that acknowledging and discussing problems without pointing fingers serves as a positive starting point.
Participants also emphasized the importance of diversity education to support a cultural shift in healthcare. Joining minority nursing organizations offers a valuable platform for support, networking, and advocacy for Black nurses. In addition, the participants noted that advancing the representation of nurses of color offers a crucial step in fostering diversity, ensuring equitable care, and inspiring future generations. The overarching themes expressed in the interviews include the need for open dialogue, education, support networks, and increased representation to address and overcome racial disparities in healthcare.
Calls to action
This study yielded three main findings. First, representation and advocacy are important. Minority nurses experienced challenges with inclusion, support, and racism from both colleagues and patients. Advancing minority representation offers a crucial opportunity not only to support colleagues and the recruitment and retention of minority nurses but also to foster inclusivity in healthcare settings. Inclusion and representation enable better patient care and help break down barriers that hinder equal treatment.
Disenfranchisement and scrutiny remain prevalent in healthcare organizations. Nurses of color frequently experience feelings of inadequacy, moral distress, and scrutiny in their roles because of systemic racism. They encounter barriers when advocating for patients, experience professional judgment, and feel unsupported when raising concerns or grievances.
The path forward involves initiating honest conversations about racial issues in the workplace. Steps include implementing diversity education to promote understanding and cultural competency, as well as supporting initiatives that empower and amplify the voices of underrepresented nurses through organizations, mentorship, and leadership advancement.
The Institute of Medicine report Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care highlighted the underlying root causes and patterns of substandard care in people of color, which contribute to health disparities. The report concluded with recommendations to increase education, training, and diversity of the workforce. Efforts by professional nursing organizations have targeted increasing awareness and reform at all levels of education and practice. Implications for practice, research, and policy should work toward implementing a comprehensive approach to confront and eliminate racial and ethnic disparities in the healthcare system.
A resounding call
This collective perspective serves as a poignant reflection of the multifaceted challenges encountered by Black nurses and other healthcare professionals grappling with racism and discrimination within their workplaces. Their narratives vividly portray the pervasive nature of these issues, highlighting the critical importance of representation in the healthcare workforce to foster improved patient care and break down systemic barriers.
These accounts underscore the urgent need for genuine efforts in education, open dialogue, and systemic change to effectively combat racial bias in healthcare. Ultimately, these voices echo a resounding call for a more inclusive and equitable healthcare environment where diversity isn’t just embraced but also celebrated, fostering a space where both professionals and patients can thrive irrespective of their backgrounds.
Acknowledgment
Funding for this work was made possible by the Rita and Alex Hillman and the Arthur Vining Davis Foundations.
The authors work in the Frances Payne Bolton School of Nursing at Case Western Reserve University in Cleveland, Ohio. Siobhan Aaron is an assistant professor. Sonya Moore is the director of the nurse anesthesia program and assistant professor. Carolyn Still is an associate professor.
American Nurse Journal. 2025; 20(3). Doi: 10.51256/ANJ032518
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