The courageous frontline work of nurses during the COVID-19 pandemic has brought new appreciation and visibility to their crucial roles. Perhaps inspired by nurses’ bravery and tenacity in the face of the pandemic, more than 250,000 students enrolled in US baccalaureate nursing programs in fall 2020, an increase of 5.6 percent over 2019, according to the American Association of Colleges of Nursing (AACN). Master’s and doctoral nursing programs also saw increases in enrollment, by 4.1 and 8.9 percent, respectively.
Although nursing students are more diverse than the current workforce, nursing leaders recognize that more needs to be done to recruit and retain nurses who will reflect the diversity of a nation where racially and ethnically minoritized groups will make up the majority of the population by 2043, according to US Census Bureau projections. Just over one-third of entry-level baccalaureate nursing students are students of color (compared with about one-fifth of registered nurses), and men make up around 13 percent of baccalaureate nursing students (compared with about 9 percent of registered nurses), according to recent surveys from AACN and the National Council of State Boards of Nursing. A diverse nursing workforce is needed to fill nursing shortages, provide quality care to all patients, and address the racial disparities in health care that COVID-19 has so clearly highlighted.
G. Rumay Alexander is a leader working to transform nursing education and address systemic racism within the nursing profession and the health care system more broadly. At the University of North Carolina (UNC) at Chapel Hill, Alexander serves as clinical professor at the School of Nursing and assistant dean for relational excellence at the Adams School of Dentistry. She was also formerly the university’s associate vice chancellor and chief diversity officer. On a national level, Alexander is a scholar-in-residence for the American Nurses Association (supporting the National Commission to Address Racism in Nursing) and immediate past president of the National League for Nursing. She spoke with Liberal Education about how COVID-19 has affected nurses and nursing students, how faculty and administrators can create equitable and inclusive environments that allow all students to thrive, how lessons learned from the pandemic might help transform nursing education, and how nurses can help lead us to a better future.
How would you describe the role nurses have played in responding to the COVID-19 pandemic?
The pandemic has highlighted nurses as the linchpin of the health care system. Without us, the system doesn’t work. I call us the surveillance system. We’re there 24/7, and we have the most patient encounters, so it’s usually our report that the rest of the health care team looks at to decide what they need to do.
Nurses are also the connector from an empathy standpoint. That’s why we’ve been the most trusted profession in this country for nineteen years in a row, according to Gallup polls. Nurses are connected to patients and their family members. It’s the nurses who are often with the patient during that last breath.
How has the pandemic affected the mental health and morale of nurses and nursing students?
Nurses are exhausted physically and mentally. They’re dealing with the stress and helplessness of not being able to make people better despite their most informed and best efforts. Prolonged stress attacks your immune system and makes you more susceptible not just to COVID-19 but to flu and other diseases.
We have stressed-out campuses on all sides: faculty, administration, staff, and students. Overnight, faculty had to change their most common modality of teaching and embrace new technology. Generationally, many faculty were not prepared for that.
Our students are wrestling with a lot. At UNC–Chapel Hill, we have students worried that they or their parents will be evicted or laid off. We have lots of students who go days without eating, so a lot of our departments have their own food pantries. We are seeing more and more students with conditions related to stress, like ulcers, gastrointestinal distress, or the inability to sleep or concentrate.
The need for mental health services far exceeds what we are equipped and staffed to provide. UNC–Chapel Hill is developing innovative responses such as the Carolina Collaborative for Resilience. The collaborative will use resilience coaches to provide timely, holistic, student-centered, culturally responsive, intersectional, and strengths-based support for students who are navigating challenges as a result of identity-based trauma.
How has the pandemic changed the way future nurses feel about entering the profession?
More people want to go into nursing. I think people genuinely want to help people. People like being the “sheroes” and heroes and delivering people from the agony and angst of illness or promoting well-being so that individuals don’t get sick in the first place.
Also, nurses are in demand. It brings a level of security in terms of always having a job. What a great combination when you can help people and have economic stability. Also, impressions of what nurses do are changing. Many patients now see nurse practitioners instead of physicians for routine medical visits.
A persistent issue in schools of nursing is a faculty shortage. At UNC–Chapel Hill, we turn away a lot of students because we don’t have capacity from a faculty standpoint. If we need to have enough nurses for the workforce, then we need to have enough qualified faculty who can teach them, and that means we need to pay faculty better. Nursing faculty are predominantly female. We need to deal with gender inequities—people’s lives depend on it.
“The pandemic has highlighted nurses as the linchpin of the health care system.”
How has COVID-19 raised awareness about racial disparities in health care?
It has heightened it considerably. Health care providers, educators, policymakers, and researchers are discussing social determinants of health (SDOH) and using them to determine accountability metrics. SDOH are the conditions in the places where people live or work that affect health outcomes. The system sometimes has created these conditions with intention but also by doing nothing. It may be lead in the drinking water in Flint, Michigan; unhealthy effects of climate change; gun violence; domestic violence; emerging diseases; or food deserts that affect people’s diets. The deeply rooted causes and power structures behind SDOH are sometimes called political determinants of health. We must reckon with these first and then talk about the outcomes.
I hear more and more people asking questions about SDOH now, and it’s not always people of color who are asking. That’s one of the good things that came out of the pandemic. You’re trying to make lemonade out of these lemons, right?
At the beginning of the pandemic, public health officials nationally and at the state level were not disaggregating data and looking at the demographics of who was affected by the virus. That was not an accident, in my opinion, but a way to avoid the obvious and manage perception. Now we know that Indigenous, Latinx, and African American people have had the highest rates of hospitalization and death from COVID-19 in the United States. When they disaggregated the data, injustices started showing up all over the place.
What role can nurses play in confronting vaccine hesitancy?
The COVID-19 vaccines are just amazing. What a wonderful time to see science help us with our lives and our ability to flourish. But some people are hesitant and downright frightened to take them, including underrepresented groups who have borne the brunt of experiments in America for years. These are the groups that are also the most vulnerable to the virus and have had the worst outcomes. A diverse workforce can help people trust the vaccine because someone just like them is telling them to take it. That’s not something you can manufacture.
Why is it important for nurses, nurse educators, and leadership to reflect the nation’s diversity?
We must recruit, train, nurture, and retain a diverse nursing workforce with demonstrated cultural competencies to care for an increasingly diverse population.
Concerted efforts to recruit and retain more male nurses must get moved to the top of the “to do” list for nursing. We need to address stereotyping, bias, and discriminatory treatment of men in both education programs and work settings.
We could also use a lot more diversity in the upper realms of nursing leadership—in our deans, associate deans, presidents, provosts, admissions officers, and leaders of major university committees—as well as in drug companies, Congress, the National Institutes of Health, and all the research institutions.
Lived experiences of difference matter. When experience shows up, it speaks, and when it speaks, it speaks loudly. The more you have people who can articulate those differences, the more possibilities you will need to consider as you come up with solutions. Studies have demonstrated that diverse groups make better decisions.
How do we educate all people in an equitable way? Talent doesn’t have a race, gender, age, sexuality, physical ability, or body size. One of the individuals who is different from others may have the answer to the next health care or environmental issue. When those possibilities get denied, our solutions to life get denied.
By including everyone, we reach our goals. By excluding people, we may get there, but it will take us much longer. We will have wasted time and energy, and some will die because of that.
How can administrators and faculty create inclusive, equitable, welcoming environments for all nursing students, in order to cultivate a diverse workforce?
My mother used to say to my sisters and me, “You can’t talk your way out of what you behaved your way into.” We do a lot of talking at colleges and universities, and we’ve got these wonderful diversity vision statements, but the behavior doesn’t match up. It’s got to move from rhetoric to reality. Diversity concepts must be infused throughout the curriculum and in awards criteria, course and faculty evaluations, and school celebrations.
We need to consider the dynamics that go into an inclusive classroom where all students feel they belong and everyone can flourish. True inclusion occurs when each individual is treated as an insider within the group (not as an outsider or “other”) and is encouraged to retain and use their uniqueness to better understand all of humanity.
In hiring, promotion, and tenure—wherever you’ve got those subjective choice points, implicit bias can creep in despite our best intentions. You don’t have to be racist to support racist systems. We all have implicit biases. One way to address them is to make sure every search process includes diverse candidates for consideration.
Also, language is so important. I find people using terms interchangeably that are not interchangeable, like diversity, equity, and inclusion. They are not the same things. Diversity is a fact. Equity is a practice. Inclusion is a goal.
What lessons have we learned from the pandemic that may lead to changes in nursing education?
The pandemic has shown the importance of skill sets like emotional intelligence, team science, and interprofessional skills.
Learning occurs with every encounter that we have with a teammate, colleague, student, or patient. Every encounter is a cultural encounter. Even if we look alike, there’s still a cultural dance between people, whether it’s because of ideology, religion, or sexuality. Even the professions are cultures. They socialize us in a certain way. Nurses are different from physicians, physical therapists, or pharmacists, so when you’ve got a team of health care professionals, that’s a cultural encounter. We’ve always had teams, but with COVID-19, it’s teamwork in an intense way. With changing dynamics with the patient, you need real trust between the professions.
One way to emphasize interpersonal skills in the classroom is to be intentional about mixing groups during group work, instead of allowing people to self-select. Learning occurs when we have exchanges among people who are different and have different perspectives.
Based on what we have learned from the pandemic, what changes do you hope to see in the curriculum of nursing programs?
Probably the biggest change needed is to integrate SDOH into every aspect of the curriculum—not just “whenever you can get to it.” If we’re going to help our nurses be the best they can be, then we have to teach them how to take a holistic view of the patient and the environment, including the conditions that patients live in and where they go for their spiritual or health needs. The pandemic has accelerated the surfacing of those kinds of topics. They’re basic to survival, and we need to make them explicit in our curriculum design.
We also need to be intentional about implicit bias education or unconscious bias education in the curriculum. I tell my students when you walk into a situation, maximize curiosity and minimize certainty. You maximize curiosity by asking questions. You minimize certainty by not making assumptions. Health care professionals at all levels have often looked at somebody and thought, “We know what you’re about,” when in fact we don’t verify that.
Labels put people on a path. Out of those labels come stereotypes, and stereotypes to me are a form of identity theft. Somebody’s treating you like the label they’ve placed on you, and that label may not be true at all.
Also, as nurses, if we say we are about caring for all individuals, then the curriculum ought to reflect those values, not cater to certain groups of people and not others. For example, why don’t we require some basic language other than English in the nursing education curriculum? Why don’t we teach nursing students medical Spanish at least? That would be a huge change to the curriculum, but it would reflect that we’re thinking about how to meet the needs of those who we’re caring for.
How should the syllabus reflect these values?
We need to include a variety of authors in the reading assignments. The syllabus also must include policies that walk the talk, like a disability clause and religious observance policies that reflect all religious beliefs.
We also need to put a “when life happens” clause in the syllabus, for example, when a student has a family member who is ill. I love faculty, but they can be very rigid at times. The pandemic is showing us that you’re going to have to adjust and be flexible. That “when life happens” clause says to the student, “I care enough about you that if you’ve got something tough going on, and it could affect your trajectory in the program or your ability to study for an exam, come talk to me, and we’ll work something out.” Students needed that before, and they really need it now.
Also, in the syllabus, you need rules of engagement—how we’re going to operate in this class, because it can quickly erode into a disrespectful, unsafe environment unless you set those kinds of parameters. That is not something faculty always had to do. We are microcosms of society. Whatever’s happening out there is happening in our classrooms. We’ve got “twindemics” going on. It’s not just the virus. It’s also the climate of the country.
What are some ways educators can create respectful classroom spaces for civil dialogue?
We’re in a discovery mode when we’re in class, so people may truly unintentionally say something that someone else finds to be offensive. How do you handle those situations, because we all do it?
First, we need to understand that we don’t get to define other people’s realities. When someone says that they have been disrespected or invalidated in some way, others might say they’re overly sensitive or dramatic or that it didn’t happen.
The fact of the matter is no one gets to define my reality for me. I am the expert on me. If I tell you something you said hurt, then it did. The questions are how did it manifest itself, and how do we minimize it?
Anger doesn’t help with that. Anger makes us self-focused, yet we know the future is in relationships and alliances. We’ve got to give each other grace and mercy. I call it “gracism.” We need to give people that latitude to be human and learn. The word that you hardly ever hear in these discussions is forgiveness.
How do we hold that courageous dialogue with each other? A good colleague will do that for another: “Can I talk to you for a minute? When that was said, this is how I heard it. Was that your intent?” I often talk about using “I” statements because “you” statements put people in the deep end.
Many people just avoid the conversation: “I don’t know what to say, but if I don’t say anything, then you can’t accuse me of saying anything bad.” But then there’s no conversation, and we never get anywhere. Educators need to teach people how to hold the conversation in a way that leads to discovery and curiosity, minimizes assumptions, and helps us begin to have an exchange that is authentic and honest and produces growth.
“Lived experiences of difference matter. Studies have demonstrated that diverse groups make better decisions.”
How can educators train future nurses to provide care that is culturally appropriate and that helps to reduce racial disparities and build trust with patients?
It has to be woven into every class. I am not a proponent of separate diversity courses. We don’t live our lives that way.
If we’re discussing the cardiovascular system, I expect people to talk about who is most likely to have hypertension. I don’t expect you to go through the whole cardiovascular lecture and then at the end say, “Oh by the way, African Americans have a higher incidence of high blood pressure than any other group,” as if they’re the outsider group or the deficit group.
For example, we might say a man would need 25 milligrams of a drug for it to be effective, and a woman typically would need 15 milligrams. Now we haven’t made it a deficit, we’ve just said there’s a difference in dosage. That’s the way we should be teaching about conditions and how they affect different populations.
To build trust with patients, we need the IQ, EQ, and DQ: the intelligence quotient, emotional quotient, and decency quotient. We need to put nursing students in real-life situations in all kinds of locations where health care is being delivered. We also need simulations where people have to think in the moment. Here’s where virtual reality could really play a significant role. Think about strapping on those goggles and interacting with someone in a virtual encounter.
What kind of influence do you think nurses can have on making positive changes in society?
Wherever nurses are, they change the game. We think about people who are suffering or vulnerable.
We’ve got to find our courage and our voice. We must have a presence in all the places where decisions are made, like in government and public policy. We need to lead research projects. That means a lot of firsts, which takes courage and energy.
The world is in need of some nurse-led innovations as we move forward.
Top image credit: Jeremy M. Lange