ARTÍCULO DE REVISIÓNARTÍCULO DE REVISIÓN

Escenarios y situaciones de racismo y clasismo durante el

cuidado de enfermería: Una revisión de la literatura

Scenarios and situations of racism and classism

in Nursing care: A literature review

Cenários e situações de racismo e classismo durante a

assistência de enfermagem: Uma revisão da literature

Erika Lozada Perezmitre1

http://orcid.org/0000-0002-0515-8662

Erick Landeros Olvera2

http://orcid.org/0000-0001-6270-1759

Rosa María Galicia Aguilar1

http://orcid.org/0000-0002-0933-124x

Charlene Esteban Ronquillo3

http://orcid.org/orcid.org/0000-0002-6520-1765

1Facultad de Enfermería Benemérita, Universi-

dad Autónoma de Puebla, Puebla. México

2Doctorado en Ciencias de Enfermería, Universi-

dad Autónoma de Puebla, Puebla. México

3School of Nursing, University of British Colum-

bia, Okanagan, Kelowna. Canada

Autor de Correspondencia:

Erika Lozada Perezmitre

Correo electrónico:

erika.lperezmitre@correo.buap.mx

Recibido: 25 noviembre 2023

Aceptado: 15 diciembre 2023

Publicado: 20 diciembre 2023

Resumen

Introducción: Una revisión sistemática

rápida que explora las interacciones del clasismo y

el racismo en la enfermería.

Objetivo: Comprender la discriminación ba-

sada en la clase y la raza en el sistema de salud de

América del Norte a través de un análisis de conteni-

do de la literatura.

Metodología: Los criterios de elegibilidad

para esta revisión fueron predeterminados según el

formato PICOT. Se incluyeron artículos publicados

entre 2016 y 2020 que describían al personal de en-

fermería como actor principal o secundario en situa-

ciones de racismo y clasismo dentro del cuidado de

enfermería.

Las publicaciones se limitaron a los idiomas

español, portugués e inglés. Los riesgos de sesgo

se mitigaron mediante un proceso de selección de

varios pasos y una herramienta de extracción de

datos adaptada de los criterios de revisión

ISSN: ISSN: 2954-44592954-4459

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sistemática COCHRANE. Se incluyeron un total de 1395 publicaciones, 46 que cum-

plían los criterios de análisis. Menos artículos en la búsqueda en inglés en comparación

con las búsquedas en español y portugués.

Resultados: Se sugiere una diferencia potencial en la atención prestada a la in-

tersección de clase y raza en diferentes regiones de las Américas. Se extrajeron ocho

temas: violencia, áreas de oportunidad, consecuencias, estrategias, eventos desenca-

denantes, barreras, sentimientos y acciones realizadas.

Discusión y Conclusiones: Es importante que la enfermería cuestione las con-

ceptualizaciones de los blancos norteamericanos sobre el clasismo y el racismo para

abordar de manera efectiva la discriminación en los sistemas de salud.

Palabras clave: Racismo, práctica de enfermería, inequidad en salud, desigual-

dades en salud, marginación

Abstract

Introduction: A rapid systematic review exploring interactions of classism

and racism in nursing.

Objective: To understand the class and race-based discrimination in the North

American health system through a content analysis of literature.

Methodology: Eligibility criteria for this review were pre-determined as per the

PICOT format. Articles published from 2016 to 2020 that described nursing staff as

the primary or secondary actors in situations of racism and classism within nursing

care were included. Publications were limited to the Spanish, Portuguese, and English

languages.

Risks of bias were mitigated through a multi-step screening process and data ex-

traction tool adapted from the COCHRANE systematic review criteria. A total of 1395

publications were included, 46 meeting analysis criteria. Fewer articles in the English

language search as compared to the Spanish and Portuguese language searches.

Results: This suggests a potential difference in the attention paid to the inter-

section of class and race in different regions of the Americas. Eight themes were ex-

tracted: violence, areas of opportunity, consequences, strategies, triggering events,

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barriers, feelings, and taken actions.

Discussion and Conclusions: Is important for nursing to challenge white North

American conceptualizations of classism and racism in order to effectively address

discrimination in health systems.

Keywords: Racism, nursing practice, health inequity, inequalities in health,

marginalization

Resumo

Introdução: Uma rápida revisão sistemática explorando as interações de

classismo e racismo na enfermagem.

Objetivo: Compreender a discriminação baseada em classe e raça no sistema

de saúde norte-americano por meio de uma análise de conteúdo da literatura.

Metodologia: Os critérios de elegibilidade para esta revisão foram pré-deter-

minados de acordo com o formato PICOT. Foram incluídos artigos publicados no pe-

ríodo de 2016 a 2020 que descreviam a equipe de enfermagem como atores primários

ou secundários em situações de racismo e classismo no cuidado de enfermagem.

As publicações foram limitadas aos idiomas espanhol, português e inglês. Os

riscos de viés foram mitigados por meio de um processo de triagem em várias etapas

e uma ferramenta de extração de dados adaptada dos critérios de revisão sistemáti-

ca da COCHRANE. Um total de 1.395 publicações foram incluídas, 46 atendendo aos

critérios de análise. Menos artigos na busca em inglês em comparação com as buscas

em espanhol e português.

Resultados: Sugere uma diferença potencial na atenção dada à interseção

de classe e raça em diferentes regiões das Américas. Foram extraídos oito temas:

violência, áreas de oportunidade, consequências, estratégias, eventos desencadean-

tes, barreiras, sentimentos e ações tomadas.

Discussão e Conclusão: É importante para a enfermagem desaar as con-

ceituações norte-americanas brancas de classismo e racismo, a m de abordar

efetivamente a discriminação nos sistemas de saúde.

Palavras-chave: Racismo, prática de enfermagem, iniquidade em saúde, desi-

gualdades em saúde, marginalização

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Introduction

Racial and social inequities have been brought starkly into the light by com-

bined events in 2020 of the disproportionate impact of the Covid-19 pandemic on

racialized communities1,2 and the deaths of Black and Indigenous peoples in North

America, that highlighted the ongoing problems and signicant effects of systemic

racism. A direct consequence is the reckoning of many North American professio-

nal groups with their own relationships with systemic structures of racism and

oppressions3,4,5,6.

While issues of racism in relation to nurses and nursing care are not new7,8,9,

events in 2020 have created a different climate of urgency for action, with nurses

seemingly positioned at a crossroads of how to move forward.

While some point to the crucial role of nurses as advocates and work towards

supporting nurse’s role in anti-racist efforts3, at the same time, recent events have

pointed to the complicity of nursing in perpetuating and enacting systemic racism1.

Within academic nursing, there is admirable work being conducted to address

issues of racism. However, much of the recent interest in engaging with racism in

nursing has been largely embedded in normative assumptions that is centers on

issues in white North America.

For example, the current outcry for action to address systemic racism in

health systems is largely in reaction to the high-prole incidents anti-Black and

anti-Indigenous racist treatment by nurses that have captured much of the attention

in North America in 2020. While we agree that these are most pressing issues, we ne-

vertheless highlight that even within anti-racist work in nursing, we maintain a view

that privileges and centers North American and western nursing issues, with limited

questioning of the extent to which our North American issues relating to racism are

also salient for the nursing profession elsewhere.

Background

Lived experiences of nursing academic scholars in Mexico have pointed to

issues of classism as deeply intertwined with racism. In this paper, we dene clas-

sism as discrimination and social divisions according to social and economic condi-

tions that are experienced by individuals with particular attention to issues of power

and determined by status, expectations, location, and access to resources10,11.

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The importance of considering race and ethnicity in relation to other social

determinants of health is emphasized by the Pan American Health Organization

(PAHO / WHO)12, highlighting the inextricable link between experiences of classism

and racism.

The intersecting nature of class and race is made apparent when looking to

the disproportionate impact of the Covid-19 pandemic on racialized communities

that are, often, also communities with lower socioeconomic status13. The increased

recognition of the role of systemic racism has demanded that scientists, healthcare

systems, and healthcare professionals use more critical lens in understanding the

pandemic’s impacts on racialized communities. Researchers have emphasized the

importance of developing more nuanced understandings of racialized communi-

ties that concurrently consider class and socioeconomic status, among other social

locations, to move explanations of the impacts of Covid-19 on racialized communities

that may be grounded in racial stereotypes14, 15.

One key barrier to understanding the nature and impact of the combined im-

pacts of class and race on nursing is the scarcity of published scientic literature

on this topic. The lack of published scientic articles on the topic perhaps reects

an underappreciation or lack of awareness of the complexity of intersecting social

locations and how these shape individual’s experiences of racism.

Another potential contributor is the dominance of authors from predominant-

ly white western nations academic nursing in the popular nursing journals, which

inadvertently reect the priorities of this region of the world, beyond others.

Underappreciated recognition of the role of class as it intersects with race

represents a substantial challenge in providing nursing care in our understanding

of, as has been only recently pointed out.

In contrast, anecdotes can be readily found among nursing educators and

clinicians that speak to how nursing care can be jeopardized because of discrimina-

tion of patients according to class, race, or both, in health systems.

There is limited understanding of nurse’s encounters with and responses to

instances where they may be faced with the intersecting effects of classism and

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racism on patients, despite nurses being important intermediaries, communicators,

and connectors in health systems16,17,18,19. Nurses potentially mediate power dynam-

ics within patient’s encounters and experiences within the healthcare system20.

To broaden our understanding of impacts of racism with a lens that extends

beyond issues in North America, attention must be paid to the intersection of rac-

ism with class discrimination: an issue of importance in Latin America. To address

this gap in the literature, we conducted a rapid review to generate evidence and

illuminate insights into the nature of the classism and racism intersection in health

systems, as they relate to nursing practice in the Americas.

Methodology

Established consensus and guidance of rapid review methodologies are emer-

gent and as such, there is currently variation on a formal denition of a rapid re-

view. To this study, we used the following working denition developed by Tricco and

colleagues25: “a rapid review is a type of knowledge synthesis in which components

of the systematic review process are simplied or omitted to produce information in

a short period of time.”

We conducted a rapid review of the literature informed by leading emergent

guidance on rapid review methodologies21,22,23,24,25. Reporting of results were informed

by established reporting guidelines to mitigate the signicant limitations of incon-

sistent reporting and transparency that has been found in many rapid reviews26.

Articles included in the rapid review were examined using content analysis,

which involved expert consensus to describe the scenarios and situations of racism

and classism during nursing care in America.

The protocol registration was completed by the Benemérita Universidad

Autónoma de Puebla, faculty of Nursing in Puebla, Mexico. Methods of the analysis

and inclusion criteria were specied in advance and documented in a protocol.

Eligibility Criteria

: A preliminary search of the literature initially limited to

Latin America was conducted using combinations of the keywords and their vari-

ants: “racism, classism, nursing, and discrimination.”

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Results from this preliminary search did not yield enough articles, suggest-

ing that relevant literature addressing the concepts of race and class in relation to

nursing practice would produce very few results. We therefore decided to broaden

the search to the Americas, include articles written in the English, Spanish, and

Portuguese languages (reecting language prociencies within our team), and add

the keyword “exclusion” in literature search.

The research question to guide the literature search asked: What is the nature

of instances of classism and racism encountered by nurses in their clinical practice?

This question was developed based on the PICOT format, in line with rapid review

methodology26; the question components are outlined in table No.1.

The Information Sources following databases were searched: PubMED,

COCHRANE Library, EBSCO, DIALNET, SCIENCE DIRECT, REDALyC, MEDLINE,

CINAHL, and Scielo. Articles published between the rst semestre of 2019 to the

second semester of 2022 were considered.

The search for articles was limited to Spanish, Portuguese, and English.

The key words in Spanish were: Racismo, Clasismo, Discriminación, Cuidado de

Enfermería. For the Portuguese language: Racismo, Discriminação, Cuidados de

Enfermagem. For the English language, key words were Racism, Classism, Discrimi-

nation, Nursing Care.

Study Selection taken inclusion criteria

: Articles that contain situations of

racism, classism in clinical settings or settings where nursing staff is involved as

primary or secondary actors.

Exclusion criteria

: Articles that contain situations of racism, classism in edu-

cational settings or other than the clinical setting. Elimination criteria: All articles

that do not contain enough information on the subject in the full text.

The strategy for the selection of articles were conducted in the following or-

der: 1) The identication of articles was carried out through the use of subject head-

ings that corresponded with the key words of interest, using the DeCS subject head-

ings for the Spanish and Portuguese language, and MeSH for the English language;

2) conducting the search using Boolean operators AND, OR and NOT, with the

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following structure: racism OR classism AND nursing OR care NOT medicine.

3) Screening of titles. 4) Screening and review of the abstract. 5) Full text analysis.

For the analysis of the articles, the authors designed a data extraction form

that was adapted from the COCHRANE systematic review criteria27 to describe the

scenarios and situations of racism and classism.

In the content analysis, the results yielded very few original research articles

which made conducting quality appraisals and evaluating publications according to

empirical research requirements an unsuitable approach. Therefore, to analyze the

results, the team conducted qualitative content analysis and considered the pub-

lished evidence as “academic products”23. After completing reading the selected ar-

ticles, the parts where racism, classism and exclusion were involved in nursing care

or health service situations were identied. In each scenario, similar or equivalent

concepts were identied and dened.

They were divided in eight groups: violence, opportunity areas, consequences,

strategies, triggering events, barriers, feelings and taken actions to analyze the di-

mensions that build up each concept and analyzed together to interrelate it. The con-

tent analysis indicated theoretical saturation before nalizing the complete review

of the academic products, which encouraged the researchers to close the evaluation

to present the concepts, categories, and their dimension.

Results

It is evident that 1395 academic products were initially identied, but were

subsequently excluded based on title or abstract, leaving 1225 full-text articles for

assessment against the inclusion criteria. Following a meticulous analysis, a total of

46 published products were included in the study. Subsequently, upon scrutinizing

the content of these academic products, an open coding approach was employed,

yielding eight distinct concepts. This coding process aimed to enhance clarity and

precision in elucidating the meaning of these concepts.

The content analysis resulted in the identication of 39 categories, from which

137 dimensions emerged. These dimensions are delineated as follows: [proceed with

the presentation of the 137 dimensions].

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Violence pertains to any nurse behavior that causes harm to the person re-

ceiving care, including both directly harmful actions and omission of action.

Areas of opportunity are dened as any situations or circumstances wherein

improvements to services and health care are necessary to mitigate the effects of

discrimination and exclusion. Six categories and 13 dimensions show the most com-

mon areas of opportunity in which nurses could be focusing to prevent racism and

classic.

Consequences include any unfavorable effects on the person receiving care

because of perceived classist or racist discrimination or exclusion. Four categories

and 12 dimensions were analyzed as the most common experienced by patient.

Strategies comprise of sets of actions that seek to improve health care condi-

tions against classism, racism, and exclusion in vulnerable groups. Five categories

and 35 dimensions were identied during the nursing care to improve health care

conditions.

Triggering Events are contextual situations or events that create an environ-

ment that favors classism, racism, discrimination, or exclusion within health care.

Five categories and 10 dimensions were obtained as the events favoring classism,

racism, or discrimination during care.

Barriers comprise of physical, cognitive, or perceived obstacles that disallow

the development of professional skills that mitigate situations of classism, racism,

discrimination, or exclusion in vulnerable groups in health care. Five categories and

10 dimensions were extracted as the obstacles to deliver health care without dis-

crimination.

Feelings refer specically to any positive or negative affective states expressed

by nurses facing events or circumstances of classism, racism, or exclusion in vulner-

able groups in health care. Three categories and 10 dimensions were obtained as the

most common feelings nurses presented. Taken Actions are specic actions carried

out by health professionals, aimed at avoiding classism, racism, or exclusion at the

point of care of vulnerable people. Six categories and 10 dimensions were obtained as

the specic actions done by nurses to avoiding classism, racism, or exclusion in care.

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Discussion

The objective of this study was to synthesize the available evidence to describe

the scenarios and situations of racism and classism in the context of nursing care

in the Americas with a rapid review of the literature. In accordance with the PICOT

question that guided this rapid review, situations of racism and classism in the con-

text of nursing were examined broadly and included examination across levels of

care (i.e., primary, secondary, and tertiary care), across racial groups, across ethnic

groups, and across service sectors (i.e., public or private health services).

While the involvement of nursing was a requirement for article inclusion,

not all the studies had a specic focus on nursing. Indeed, the majority of articles

included in the review were selected because they included nursing as one of the

key actors among other health professionals in health systems. Scrutiny of the

evidence showed that there most of the selected publications comprised academic

products that were other than original or research articles; few qualitative research

articles and even fewer quantitative research articles were found. Most publications

in this rapid review were editorials, case reports, news reports, life stories, magazine

articles that were mostly from the social sciences, rather than health sciences.

The lack of scientic articles denotes the importance of a research line to

gather evidence on racism and its implications in health services in most of Latin

America. Brazil is in Latin America, the country with the biggest contribution on

classism and racism nursing research, possibly due to the considerable number of

Indigenous and Afro-American groups in this society and where situations of racism

are perhaps more apparent.

In other countries, results of the review suggest that instances of clas-

sism over racism is more evident. The greater focus on classism in comparison to

racism seems to be the most common in Mexico. It might be that Mexicans have a

constitutional right to health regardless of socioeconomic class, skin color, or ethnic

group. However, private health services restrict access to certain population groups

and undermines rights to equal health services.

Regarding the scenarios where violence occurs, it is a concept permeating

across all scenarios of classism, racism, and exclusion where health service is

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involved. In most of the articles, situations of violence stood out from migrants and

indigenous groups, who did not receive equal treatment. Even if which, the profes-

sional did not deny the service, the attention was postponed. According to the litera-

ture, if the patient comes from an indigenous group, the risk of dying if higher than

other patients28. This is a clear violation committed against human rights. Given the

panorama, it can be concluded that violence could be considered a surrogate term

for racism.

Conclusions

Efforts aimed at addressing racism within the eld of nursing have garnered

signicant attention and momentum, particularly in response to the heightened in-

justices and disproportionate impact of the Covid-19 pandemic on racialized groups.

Progress towards fostering an anti-racist nursing environment necessitates a de-

liberate examination and rectication of our own professional blind spots. Notably,

prevailing normative assumptions regarding discourses on racism often derive

from issues predominantly centered in the white North American nursing context,

leading to the oversight of classism as an intricately interconnected challenge.

This oversight is particularly conspicuous in the Latin American context,

where classism is recognized as a signicant issue. This rapid review seeks to fur-

nish evidence underscoring the critical intersections of classism and racism in

nursing practice in Latin America, a perspective hitherto predominantly informed

by the lived experiences of Latin American nursing scholars. These insights into

classism and racism within the nursing profession are pertinent not only to scholars

but also to practitioners across the Americas. Future research endeavors should aim

to further elucidate these intersections.

Acts of racism, classism, and exclusion within health services, including

nursing, are responses to multifactorial situations encompassing systemic, educa-

tional, professional training, ethical, and unprojected values. Despite the existence

of testimonials documenting instances of racism and studies examining sociocultur-

al situations in vulnerable groups, efforts to mitigate these acts are apparent. This is

evident in the manifestation of values, legal initiatives aimed at policy modication,

and increased awareness.

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Health professionals, particularly those in the eld of nursing, express

concern, and endeavor to eradicate acts of racism, classism, and exclusion through

meticulous documentation and the provision of humane treatment to patients and

their families.

Funding

No funding was received for this study.

Conicts of Interest

The authors declare no conicts of interest.

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Annexes

Table No.1

PICOT Question

Source: Own, 2022

Figure 1

Flowchart of the article selection process

Source: Reporting Items for Systematic Review

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Figure 2

Concepts identied in the actions of Racism, classism, and discrimination in health care.

Source: Reporting Items for Systematic Review

Table No.2

Concept: Violence

Source: Content Analisys

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Table No.3

Concept: Areas of Opportunity

Source: Content Analisys. Note: EBE, Nursing Based on Evidence

Table No.4

Concept: Consequences

Source: Content Analisys

Table No.5

Concept: Strategies

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Table No.5 (Continuation)

Source: Content Analisys

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