Looking back at this post I was surprised that my intro didn't actually name one of the main things that I originally thought was valuable about the "practice narrative" I share: Erin is a white nurse(-ing student, now nurse) talking pretty candidly and eloquently about being a witness to anti-Black racism in health care.
This was something I was thinking about a lot at the time of posting. At the time I was also picking my way through this book about Black and other racialized nurses' experiences of racism in Canada, called: Real Nurses and Others: Racism in Nursing by Tania Das Gupta. I highly recommend anyone interested in any of these topics to check it out.
There you go. Institutional racism was (and is) on my mind. This is a post about that. And about nursing in Toronto. Read on and enjoy the pictures. --Nurse Peents---------------------------
This is Erin, pictured here in her graduation garb. The photos are of her mother and aunt -- also strong women and accomplished nurses.
I met Erin at a conference for health care workers against poverty that was held the same day as our nursing school's student-lead orientation. Erin was the only other person from our year who was more interested in talking about dismantling systemic oppression than in going to a major league baseball game (don't get me wrong - both activities have their particular appeal). I am unbelievably stoked that this person is becoming an RN.
I want to share a "reflective practice narrative" of hers that struck a chord with me. It was read aloud in one of our classes to frame a discussion around professional ethics, and I immediately wished more people could hear it. I think it demonstrates so many of the qualities I love about this person -- a woman with brains and a heart, who sure can write.
(If you want to read more about the social construction of pain, check out this piece by another person I respect and admire -- http://still.my.revolution.tao.ca/pain )
-----
It was my first adult acute care placement and I was on a general
medicine ward. I loved it. I loved the variety of clients, I loved the variety
of conditions, and I loved the constant buzz of activity as everyone ran around
trying to keep up with the needs of the clients and the management. I felt
really buoyed by the fact that I seemed to be able to meet the needs of the
patients. It’s always a secret personal goal of mine to connect with even
“challenging” patients. I take pride in the fact that the patients with whom I
work feel cared for. And everything was going swimmingly, until about halfway
through the rotation when I was assigned to a patient with sickle cell anemia.
She was a woman in her late thirties, married, with a teenaged son. And we hit
it off immediately. Despite being in constant, horrendous pain, Ms. S had a
very bright and compassionate character, and gave me the blessing of being very
open to my learning experience as a nursing student and educating me about her
illness and experience. I loved working with her.
But there was something that troubled me deeply and increasingly during the time that I worked with her. Ms. S was in pain. And her pain medication never changed. In fact, it decreased during the time that I worked with her, though her pain score had never dipped below an 8 out of 10. Why weren’t they increasing her pain medication? What was more troubling, no one seemed particularly concerned that she was in pain. The behaviors ranged from quite subtle, to egregious. On the one end of the spectrum, I noticed that the nurse would not prioritize Ms. S’s pain medication doses. In a list of patient needs, Ms. S’s pain medication always seemed to fall to the bottom of the list. On the other end of the spectrum, I heard more than one nurse use the term “frequent flyer” when referring to Ms. S and other patients with Sickle Cell Anemia. Somewhere in between, her chart was littered with notes such as “? Substance misuse”, “? Pain medication addiction.” There was also another woman on the unit who had been admitted for a Sickle Cell pain crisis. Over their time in the hospital, Ms. S and Ms. B had developed a friendship, and supported each other. Ms. B, who was able to walk on her own, would come to visit Ms. S often. They both shared their frustrations with me. They were aware that some thought of them as “frequent flyers”. They were sensitive to the fact that nurses sometimes only begrudgingly administered their pain medication, and the physicians were reluctant to increase their pain medications. They were acutely aware of the fact that they were sometimes perceived as being “drug seekers.” They told me that these were challenges that they faced through their entire adult lives.
But there was something that troubled me deeply and increasingly during the time that I worked with her. Ms. S was in pain. And her pain medication never changed. In fact, it decreased during the time that I worked with her, though her pain score had never dipped below an 8 out of 10. Why weren’t they increasing her pain medication? What was more troubling, no one seemed particularly concerned that she was in pain. The behaviors ranged from quite subtle, to egregious. On the one end of the spectrum, I noticed that the nurse would not prioritize Ms. S’s pain medication doses. In a list of patient needs, Ms. S’s pain medication always seemed to fall to the bottom of the list. On the other end of the spectrum, I heard more than one nurse use the term “frequent flyer” when referring to Ms. S and other patients with Sickle Cell Anemia. Somewhere in between, her chart was littered with notes such as “? Substance misuse”, “? Pain medication addiction.” There was also another woman on the unit who had been admitted for a Sickle Cell pain crisis. Over their time in the hospital, Ms. S and Ms. B had developed a friendship, and supported each other. Ms. B, who was able to walk on her own, would come to visit Ms. S often. They both shared their frustrations with me. They were aware that some thought of them as “frequent flyers”. They were sensitive to the fact that nurses sometimes only begrudgingly administered their pain medication, and the physicians were reluctant to increase their pain medications. They were acutely aware of the fact that they were sometimes perceived as being “drug seekers.” They told me that these were challenges that they faced through their entire adult lives.
In the research that I did to prepare for this client, I learned
that Sickle Cell Anemia is a disorder that predominantly affects Black men and
women. Both Ms. S and Ms. B were Black women of Jamaican descent. I couldn’t
help but wonder: was race a factor in Ms. S’s care?
I have been raised in a cultural milieu in which “racism is bad” is
a common refrain. I have encountered it at every level of my education.
However, like “Just say no to drugs”, I wonder if this is more public service
lip service than anything else. Racism, I believe, is far subtler than we have
been taught. It lurks in the shadows of structural powers and slight individual
gestures. It is not always obvious, but that does not lessen its harm.
At home one night, I typed “sickle cell racism” into Google. The
results were staggering. I found website after website, article after article,
detailing the ways in which racism has been identified as a factor in
inadequate care for individuals living with Sickle Cell Anemia. On the one
hand, I felt comforted by this knowledge. At least I wasn’t the only one having
this thought; I wasn’t crazy. On the other hand, I was enraged. Why, when there
is peer-reviewed empirical evidence that this problem exists, has it not been
addressed by the healthcare system? Why were these women in physical pain and
also experiencing racism in one of the top hospitals in Canada?
Yet, as a nursing student, I felt powerless. I could not change the
medication orders. I could not hang the pain medication on time on my own. And
I certainly could NOT, as a nursing student, just stand up and call “RACISM!” All
I could do was make sure that Ms. S had warm blankets and plenty of water at
all times. I felt so impotent; so
powerless. I remembered the posters in my elementary school saying “Stop
Racism!” I wish it were so simple. Nursing students, as it is, hold a marginal
and liminal space in the healthcare setting. Often, we are merely tolerated.
Sometimes, we are not even afforded that luxury. It’s hard enough, and taboo
enough, to call “Racism”, without also being in an unacceptable position to do
so. We have also created an environment in our society in which the word
“racism” is avoided like the plague, and there is almost no diplomatic way to
say, “Okay, I think we have some systemic racism going on here. What can we do
to ameliorate this situation?”
In the end, all I could do was ask “innocent” questions to the
nurses and physicians. I found an ally in one nurse. He was a Black man of St.
Lucian decent, who has a nephew with Sickle Cell Anemia. I also found an ally
in my Clinical Instructor, who helped me to arrange for both Ms. S and Ms. B to
be seen by the Acute Pain Team, which neither of them had, up to that point in
their care. But not all were supportive. I included this issue in the nursing care
plan that I created for my class assignment. The comments from the marker
indicated that this was “not a client-specific issue” and therefor not
“appropriate for the care plan.”
My father is a refugee. My mother is a second wave feminist and a
nurse. My whole life, they have endeavored to make me see the ways in which
discrimination is endemic in our society, and the ways in which it trickles
down from our very institutions. They
have also instilled in me the importance of equity and social justice. I carry
these concepts with me in my day-to-day life. These values are the main reason
that I wanted to go into nursing. People are often at their most vulnerable
when they are dealing with the healthcare system. I see nurses as the sacred
guardians of human rights, the very foot soldiers of social justice. And yet,
when caring for Ms. S, I felt utterly impotent. I try to carry this experience
in all of my patient interactions. I always ask myself, “What is the bigger
picture here? Is there something I’m seeing that others may have missed?” These
questions are simple. Their answers are complex. And the battle to resolve them
is long, arduous, and rife for the potential of unwanted consequences dealt
like blows by those who don’t appreciate people who “rock the boat.” But I have
promised myself that I will never stop asking these questions. I will never
stop seeking the answers. And I will never, ever, stop fighting for resolution.
After all, the optimal care of my patients depends on my strength and courage
to fight for justice. If I am not willing to take on this fight, then I have
certainly chosen the wrong profession.
