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Abstract

Despite nursing's stated mandate of health equity and social justice, concrete steps to address racism and anti-Black racism in the profession and nursing education remain mainly non-significant and are often seen as performative. It is crucial to implement tangible measures to dismantle racism and anti-Black racism in nursing education to address racial health disparities. Throughout history, nursing education has been shaped by colonial and Eurocentric ideologies, leading to the silencing and erasure of the knowledge, culture, perspectives, and ways of knowing of Black and other racialized communities. Consequently, urgent action is required to dismantle embedded racism and anti-Black racism in the nursing profession. Drawing on anti-racist philosophies, we argue that dismantling racism in nursing education goes beyond superficial discussions of equity, diversity, and inclusion. Instead, it demands a proactive approach to tackle the underlying causes of racial inequities. In this article, we propose several recommendations and implications for nursing educators, researchers, policymakers, and educational institutions to eliminate racism and anti-Black racism in both nursing education and practice. These recommendations include acknowledging the historical and contemporary impacts of racism and anti-Black racism on the health and well-being of Black individuals, engaging in critical self-reflexivity, integrating and prioritizing Black knowledge and perspectives in nursing education, practice, and research, and intentionally adopting anti-racist pedagogy.

Keywords

Anti-racism anti-Black racism racism nursing education nursing students

Conversations about racial inequities in Canada and within the nursing profession are of continued relevance, as we see direct connections between racism, underrepresentation of Black people and other racialized groups, quality of care, and health outcomes (Cooper Brathwaite et al., 2022a, 2022b; Onagbeboma, 2020; Ramsoondar et al., 2023). This paper discusses the historical and contemporary discourses of racism on Black students’ experiences in nursing education in Canada and the implications of achieving nursing's health equity mandates of social justice. As Daly et al. (2020) assert, “knowing where we have been, to understand where we are, and where we should be going is surely the legacy that nursing's rich history can give us” (p. 1). Nursing education plays a critical role in shaping the future of healthcare, not only by equipping students with theoretical and clinical knowledge but also by preparing them to provide culturally responsive care (Tobbell & D’Antonio, 2022). Addressing racism and anti-Black racism within nursing education is, therefore, crucial not only to improve the experiences of racialized students but also to ensure that future nurses are prepared to care for diverse populations in ways that acknowledge and dismantle systemic inequities, leading to better healthcare outcomes for these groups (Cooper Brathwaite et al., 2022a, 2022b; Garland & Batty, 2021). Due to the limited number of papers that explicitly address racism within the Canadian context, we will explore both Canadian and international literature. Through the use of several databases, such as CINAHL, Medline, and Google Scholar, our focus was to contextualize and better understand the discourses of racism in nursing education, especially as it influences Black nursing students in Canada.

Racism is a pervasive and historical system of oppression that upholds white supremacy and encompasses a range of discriminatory practices and beliefs affecting various racial and ethnic groups, perpetuating inequities, stereotypes, and exclusionary practices across various social institutions, including healthcare and education (Beagan et al., 2023; Cooper Brathwaite et al., 2022a, 2022b). Anti-Black racism, while part of this broader system of racism and white supremacy, is characterized by unique patterns of discrimination and marginalization that specifically target Black individuals. However, it is essential to recognize that anti-Black racism does not exist in isolation but is intertwined with the broader systems of racism and white supremacy (Black Health Alliance, 2018; Cooper Brathwaite et al., 2022a, 2022b; Prendergast et al., 2024).

Racism impacts racialized populations’ quality of life, health, and well-being. It is associated with higher rates of chronic diseases, trauma, and early death in patients due to the onset of severe illness and violence that are linked to societal and health inequities (Coleman, 2020; Salami et al., 2022; Stanley et al., 2019). Racism can lead to stress, anxiety, depression, burnout, and trauma for nurses and nursing students who are racialized, affecting their mental and emotional well-being (Cooper Brathwaite et al., 2022a, 2022b; Iheduru-Anderson, 2021; RNAO, 2022). As such, racism has been identified as a global, national, and local public health issue (Canadian Nurses Association, 2020, 2021; Toronto Board of Health, 2020; World Health Organization, 2020). Consequently, this is of utmost importance to the nursing profession. In Canada, the profession's moral and ethical commitments to social justice, human rights, and “do no harm” are guided by the Canadian Nurses Association (CNA) Code of Ethics for Registered Nurses (CNA, 2017). To maintain these moral commitments, nurses must consistently practice with moral integrity by questioning racist discourses, standing up against racism and other forms of discrimination, being aware of how health inequities impact health and well-being, and advocating for improvements in the profession and the development of nursing knowledge (CNA, 2017; Coleman, 2020; Louie-Poon et al., 2022). Within nursing education, racism and anti-Black racism manifest in various ways, including biased curricula, discriminatory hiring practices, lack of promotion, and a lack of representation among Black students, faculty and leadership, contributing to an exclusionary and hostile environment for this population (Cooper Brathwaite et al., 2022a, 2022b; Jefferies et al., 2018). Though research has increasingly explored the impacts of racism on healthcare outcomes (Coleman, 2020; Salami et al., 2022; Stanley et al., 2019), literature specific to anti-Black racism in nursing education remains limited.

While the focus of this paper will be on anti-Black racism, as it helps us understand Black nursing students’ experiences in Canada, of equal importance is the reckoning with the legacy of anti-Indigenous racism within Canada (Blanchet Garneau et al., 2018; McGibbon et al., 2014). Anti-Black racism and anti-Indigenous racism are two distinct forms of discrimination and prejudice, each rooted in its own historical and socio-cultural context. However, they often intersect and reinforce each other in various ways, creating a complex web of systemic oppression. Anti-Black and anti-Indigenous racism have their origins in European colonialism through the enslavement of Africans and the displacement and marginalization of Indigenous peoples (Haeny et al., 2021; Malawa et al., 2021; Williams et al., 2022). These systems of oppression perpetuate economic, social, and political inequities among Black and Indigenous communities, resulting in higher levels of racism and discrimination compared to other racialized groups in Canada (Canadian Race Relations Foundation, 2023; Malawa et al., 2021; Statistics Canada, 2019). Recognizing the shared historical experiences of colonialism is essential for understanding the complexities of the challenges faced by Black and Indigenous communities. Colonialism has had profound and far-reaching consequences, creating racial hierarchies with Black and Indigenous communities at the bottom (Malawa et al., 2021). The ideology of racial superiority was used to justify oppression, marginalization, and the dehumanization of these communities, resulting in the suppression and erasure of cultural identities, languages, and traditions (Haeny et al., 2021). The legacy of colonialism continues to shape the socioeconomic and political realities of Black and Indigenous communities today as they grapple with the ongoing impacts of displacement, oppression, discrimination, and racism (Williams et al., 2022).

Concrete steps to address racial health inequities and enact social justice in nursing remain mainly non-significant and are often seen as performative despite recent calls to prioritize equity, diversity, and inclusion (EDI). This gap between stated ideals and practice suggests that the commitment to EDI is performative rather than real. Bell (2021) contends, “This heightened moment of racial awareness is the opportunity for nursing organizations to move beyond the performativity of issuing statements, especially those that sanitize the nursing profession as if it were free from racial injustice” (p. 1). For example, actions or statements laden with symbolic gestures of diversity, such as diversity and inclusion statements, offering cultural competency training, and featuring nurses from diverse groups in marketing and recruitment materials, but do not explicitly challenge systemic racism, may be viewed as superficial and performative (Bell, 2021).

The prevalence of performative gestures in higher education instead of substantive structural changes contributes to a lack of representation of Black people and other racialized groups within the nursing profession. This lack of representation is seeped into the historical legacy of racism, colonialism, systemic barriers, and discriminatory practices (Jefferies et al., 2018; Waite & Nardi, 2021), which has affected Black individuals and other racialized communities in accessing nursing education and employment opportunities, and have influenced hiring practices, promotions, and career progression for individuals from these communities (Cooper Brathwaite et al., 2022a, 2022b; Jefferies et al., 2018). Furthermore, a lack of movement to address racism constrains the development of knowledge, practice and policy solutions that can best respond to the needs of Black communities and other racialized populations. Thus, nurse educators and administrators are responsible not only for developing strategies for better representation of Black scholars and trainees but also for fostering a transformative culture that consistently challenges systemic racism. By being critically engaged and committed to anti-racism, nursing in Canada can actively contribute to dismantling racism, disrupting discriminatory hiring practices, and promoting equitable, inclusive, and culturally safe care. Anti-racism work requires continuous effort, accountability, and an ongoing commitment to challenging systemic barriers that create lasting change that improves health equity and social justice for all communities. This paper provides an overview of key terms: race, racism, whiteness, a brief overview of racism in nursing education, and anti-Black racism. Next, we situate the erasure of Black nursing leadership and the historical political context of nursing education in Canada to highlight how historical discourses impact contemporary nursing practice. We then discuss the contemporary experiences of Black students in nursing education in Canada. Lastly, we offer recommendations and implications for nursing education, practice, research, and policy.

Key terms, context, and anti-Black racism

Race

The concept of race, a social construct, stems from the seventeenth century as a way of justifying the enslavement of Black people, portraying and essentializing differences between groups of people, promoting the narrative that Black and other racialized people are inferior, and assigning “whiteness” as the “gold standard” (Bell, 2021; Brawley, 2021; Bryant et al., 2022; Hantke et al., 2022; Smedley & Smedley, 2005). Despite evidence that race is not reliably measured or biologically relevant, researchers, clinicians, and educators continue to use race to inaccurately explain differences in health outcomes (Bryant et al., 2022; Dordunoo et al., 2022; Ibrahim et al., 2022). This has been ongoing in nursing education and reinforces racism through deficit thinking about the “Other.” In education, deficit thinking blames students from historically racialized populations for their challenges and inequities and fails to place responsibility on oppressive structures, policies, and practices within educational settings (Bell, 2021; Patton Davis & Museus, 2019). Materials commonly used in nursing curricula have a long-standing legacy of disseminating race as a biological concept or inherent trait (Dordunoo et al., 2022; Gustafson, 2005). This has implications for the nursing profession by contributing to the narratives of racism and ignoring the history of how ‘race’ was constructed to essentialize, stereotype, and dehumanize others in society (Ibrahim et al., 2022; Lawrence & Keleher, 2004).

Racism

Racism is the ideology and practice of upholding and supporting differences that result in inequitable distribution and access to resources and the justification of practices that benefit one group over another based on the social construction of race (Bakan & Dua, 2014). It results in racialized people being othered and excluded because of their race. Kendi (2023) states, “Racism is a powerful collection of policies that lead to racial inequity and injustice and that are substantiated by ideas of racial hierarchy” (p. 26). Racism is instituted on a belief that the dominant group is superior and “Others” are inferior. Such a belief system imbues institutions with the power to demean, disempower, and limit the allocation of resources, including adequate housing, equitable healthcare, safe living environments, and opportunities to groups deemed inferior. Its construction is engrained in whiteness and white supremacy (McGibbon et al., 2014; Louie-Poon et al., 2022; Waite & Nardi, 2021; Williams et al., 2019). Racism at the individual, institutional, systemic, and structural levels (re)produces discriminatory practices that cause violence, leading to disability and early death in Black people and other racialized groups (Poteat et al., 2020).

Systemic and structural racism are “forms of racism that are pervasively and deeply embedded in systems, laws, written or unwritten policies, and entrenched practices and beliefs that produce, condone, and perpetuate widespread unfair treatment and oppression of people of colour, with adverse health consequences” (Braveman et al., 2022, p. 171). These forms of racism are often rendered invisible by the dominant group, are upheld in Canada, and are legitimized by the dominance of whiteness and white supremacy (Hardeman & Karbeah, 2020; Iheduru-Anderson, 2021; McGibbon et al., 2014; Thorne, 2020). Braveman et al. (2022) state that although systemic and structural racism are usually used interchangeably, their emphasis differs. The authors define systemic racism as “the involvement of whole systems, and often all systems – for example, political, legal, economic, health care, school, and criminal justice systems – including the structures that uphold the systems” and structural racism as “the role of the structures (laws, policies, institutional practices, and entrenched norms) that are the systems’ scaffolding.” (Braveman et al., 2022, p. 172). On the other hand, institutionalized racism refers to the unfair policies and discriminatory practices that occur within and across institutions (for example, schools, workplaces, and mass media) that routinely produce racially inequitable outcomes for people of colour and advantages for white people (Iheduru-Anderson & Waite, 2022; Williams et al., 2019).

In Canada, racism continues to gain momentum because of a reluctance in society, such as governments, policymakers, and electorates, to recognize and acknowledge that racism is entrenched within our so-called multicultural community. Gulliver (2018) contends that although Canada erroneously claims to be a welcoming multicultural society, the notion of “multiculturalism” reinforces racism by encouraging the acceptance of institutional structures that deny that racism exists in Canadian discourses and education. This notion of multiculturalism fosters a culture of denial by being euphemistic and not acknowledging that racism exists. Using euphemistic language when discussing race-related issues contributes to the avoidance of critical conversations about racism in nursing and healthcare settings (Bell, 2021). Discourses that champion Canada as a multicultural society ensure that racism remains invisible and “proactively rejects that Canadians could be racist” (Gulliver, 2018, p. 75). As such, this notion of multiculturalism leads to many Canadians accepting the narrative that racism does not exist in Canada and only exists in our neighbouring country, south of the border. In addition, scholars argue that multiculturalism facilitates the maintenance of dominance and white privilege by masking the reality of racial inequities in Canada and in nursing specifically, even to this day (Clark & Saleh, 2019; Dryden & Nnorom, 2021; Hilario et al., 2018). In nursing, instances of racism may go unrecognized, unacknowledged, or addressed using euphemistic language such as diversity or cultural competence. This failure to confront racism directly can result in disparities in patient care and perpetuate inequalities within the healthcare system (Bell, 2021).

Additionally, an emphasis on culture puts the onus on racialized communities by suggesting that differences stem from inherent cultural traits or behaviours within these groups. This emphasis tends to attribute disparities and opportunities solely to cultural factors, overlooking the broader socio-economic and structural issues contributing to health inequities (Bell, 2021). In nursing, emphasizing cultural differences without addressing broader systemic issues perpetuates a practice of denial regarding the impact of racism on health outcomes. In addition, some nursing practices may adopt a colorblind perspective, claiming to treat everyone equally and overlooking the unique challenges faced by different racial groups (Bell, 2021; Iheduru-Anderson & Waite, 2022). Furthermore, emphasizing culture can essentialize and inferiorize racialized populations. This essentialization can lead to harmful generalizations about racialized groups, suggesting their culture is monolithic and unchanging and assuming that they all share the same beliefs, behaviours, or health practices. This dismisses and overlooks the unique needs of racial or ethnic groups, contributing to them feeling misunderstood or marginalized and reinforcing inequitable power structures (Iheduru-Anderson & Wahi, 2021; Kishimoto, 2018).

Whiteness

To understand the historical and social construction of race and racism, it is crucial also to acknowledge the construction of whiteness. Whiteness entails the historical and social construction of being White, including social status, privilege, and power that is connected to being White (Beckles-Raymond, 2020; Lamberson et al., 2021) and represents White norms and values as the ideal standard of which all “Others” are compared to and seen as deficient, inferior, or less than (Bell, 2021; Louie-Poon et al., 2022; Puzan, 2003; Racine, 2021). Whiteness is linked to ongoing oppressive practices because of the enslavement of Black people, the colonization of Indigenous peoples, and the continuous racial domination and discrimination we see today (Waite & Nardi, 2021). As a significant instrument of oppression, whiteness plays a critical role in white supremacy by supporting and maintaining social injustices and racial hierarchy and disregarding ethical and moral obligations in nursing and health care (Noe, 2020). Integral to the hierarchical power structures of colonization and white supremacy, the nursing profession is overwhelmingly dominated by whiteness (Bell, 2021; Puzan, 2003). Whiteness permeates and informs contemporary nursing education, research, practice, and policy. For example, in terms of nursing curricula, whiteness influences how the nursing curriculum is developed and taught. Many of the textbooks used in nursing education are written by White scholars, contain images that exemplify the White identity, and often portray Black people and other racialized populations through a deficit lens (Bell, 2021; Jefferies et al., 2018). This greatly impacts how nursing care is provided, research is conducted, and nurses engage in political discourses (Holland, 2015; Puzan, 2003).

White supremacy and white privilege are inherently linked to whiteness. Caswell (2017) classifies white supremacy as a “political, economic, and cultural system in which Whites overwhelmingly control power and material resources, conscious and unconscious ideas of white superiority and entitlement are widespread … and non-white subordination are daily re-enacted across a broad array of institutions and social settings” (p. 224). On the other hand, white privilege is seen as an invisible, unearned advantage enjoyed by all white people in society, whether they actively choose such an advantage or not (Caswell, 2017; Waite & Nardi, 2021). White privilege fundamentally reinforces racism in nursing at the systemic, structural, or institutional levels. This is often seen when Black people and other racialized nursing students are not provided with the same support and acknowledgment throughout their nursing education (McGibbon et al., 2014). Additionally, the curriculum, nursing textbooks, case studies, and other educational materials often reflect the experiences and perspectives of White individuals, reinforcing the idea that White experiences are the norm while others are deviations, which further reinforces racial bias (Besa et al., 2022). Furthermore, the faculty in nursing schools are disproportionately White, creating an environment where Black and other racialized students may face challenges related to mentorship and role modelling. This lack of representation perpetuates the idea that White individuals are the primary authority figures in the field (Jefferies et al., 2018; Vukic et al., 2016). Thus, the historical, social constructions of whiteness have been perpetuated across generations and in nursing education and practice to marginalize, alienate, and create inequities for racialized groups.

Racism in nursing education

The nursing profession and academia have been shaped by white, colonial legacies that have marginalized and racialized Black and other underrepresented communities (Hamzavi & Brown, 2023; Swartz et al., 2024). In nursing education, racism takes many forms. It is operationalized as disparities in access to nursing education, unequal treatment, microaggressions, and being disrespected, stigmatized, or degraded because of race, ethnicity, or skin colour (Das Gupta, 2009; Nardi et al., 2020; Roy et al., 2022). Racism can manifest as a lack of support from teachers, colleagues and administrators and disrespect from patients and staff. Racialized students often report feeling invisible or hypervisible amidst stereotypes of incompetence, overwork, and an absence of diversity in nurses and leaders (Beagan et al., 2023). Black and other racialized students often encounter overt or covert acts of racism, such as being overlooked for leadership roles or receiving differential feedback and evaluation than White peers (Cooper Brathwaite et al., 2022a, 2022b). These differential treatments create hostile learning environments, undermine student well-being, and contribute to disparities in academic achievement and success (Gona et al., 2023).

Racism in nursing education contributes to the unequal representation of Black and other racialized students, faculty, and nurse leaders within the profession. This underrepresentation is a result of the historical and continued othering and exclusion of racialized communities in nursing education, resulting from the impact of whiteness and white supremacy (Nye et al., 2023; Swartz et al., 2024). Racism can deter racialized students from pursuing careers in nursing and contributes to high attrition rates among students (Roy et al., 2022). This leads to a lack of representation in nursing, undermining efforts to create inclusive environments and hindering the profession's ability to cultivate a diverse workforce that reflects its communities (Jefferies et al., 2018). Structural barriers within educational institutions, such as discriminatory admissions practices, financial barriers, limited support for students from racialized backgrounds, and unequal access to resources, hinder their success and perpetuate the lack of diversity within the profession (Bonini & Matias, 2021; Swartz et al., 2024). Black and other racialized nursing students report feelings of being entrenched in white academic nursing spaces, experiencing the erasure of their identities and a lack of a sense of belonging (Bonini & Matias, 2021; Hamzavi & Brown, 2023).

Additionally, the underrepresentation of racialized faculty members in academia can lead to the absence of supportive networks and mentorship opportunities for racialized students. This further contributes to feelings of isolation, alienation, and powerlessness, creating an unwelcoming and non-supportive environment that hinders students’ retention and advancement within nursing programs (Beagan et al., 2023; Bell, 2021; Gona et al., 2023; Iheduru-Anderson et al., 2021). Moreover, the absence of diverse perspectives in leadership positions hampers decision-making processes and perpetuates institutionalized biases, as well as the dominance of Eurocentric and Western knowledge in nursing education, research, and healthcare practices (Beagan et al., 2023; Hamzavi & Brown, 2023; Iheduru-Anderson & Waite, 2022)). This overwhelming whiteness of the nursing culture often perpetuates blindness toward racism (Iheduru-Anderson et al., 2021).

The nursing curriculum and pedagogy often fail to adequately incorporate diverse perspectives, experiences, and culturally relevant materials, limiting students’ understanding of the complexities of healthcare delivery in diverse communities (Pusey-Reid et al., 2023). The omission of diverse voices within nursing education speaks volumes about the ‘hidden curriculum’ and what faculty considers important for learners (Roy et al., 2022; Villarruel & Broome, 2020). Additionally, the lack of diverse representation in course materials further marginalizes Black and other racialized students by reinforcing White culture's dominance and Eurocentric healthcare approaches and perpetuating anti-Black racism (Bonini & Matias, 2021; Pusey-Reid et al., 2023). It is critical for nursing education to address racism and anti-Black racism and to be aware of its impact on the profession.

Anti-Black racism

The term anti-Black was first coined by the academic professor Dr. Akua Benjamin to capture the unique nature of systemic racism that is rooted in the historical legacies of slavery and colonization targeted against Black people in Canada (Black Health Alliance, 2018; Cooper Brathwaite et al., 2022a, 2022b; City of Toronto, 2017; Dryden & Nnorom, 2021)). Anti-Black racism entails discrimination, prejudices, beliefs, practices, and policies that directly or indirectly racialize Black people as inferior to other racial groups. Anti-Black racism manifests at interpersonal, institutional, and systemic levels and operates through white supremacy (Cooper Brathwaite et al., 2022a, 2022b; Noe, 2020; Waite & Nardi, 2021).

In 2017, the United Nations Working Group of Experts of People of African Descent, on its mission to Canada, expressed grave concern at the sheer prevalence of structural racism in many Canadian institutions and the ongoing systemic anti-Black racism that continues to impact the human rights of Black Canadians negatively. The historical legacies of anti-Black racism dating back to the enslavement of Black people, enacted through societal practices and the judiciary system, are so deeply ingrained in our institutions, policies, and practices that they are seen as normal and invisible to the dominant group. The United Nations Working Group emphasized that although Black people face health inequities and discrimination continuously, Canada has yet to implement specific actions that address anti-Black racism, which has dramatically impacted their overall health and well-being. Historical and ongoing barriers such as access to health care, legacies of systemic racism, low socioeconomic status, absence of culturally responsive care in health education, and the underrepresentation of Black health professionals contribute to health disparities and poorer health outcomes for the Black population (The United Nations Human Rights Council, 2017). In 2020, the Canadian Nursing Association (CNA) condemned all forms of racism and discrimination within the nursing profession. The CNA Code of Ethics states, “We uphold principles of justice by safeguarding human rights, equity, and fairness. We have rested too comfortably for too long on a myth that anti-Black racism is not systemic in Canada, but the reality has been harshly exposed”.

Likewise, Landry (2020), Chief Commissioner of the Canadian Human Rights Commission, contends that “the roots of anti-Black racism and systemic discrimination in Canada run deep … are historically embedded in our society, in our culture, in our laws, and our attitudes. They are built into our institutions and perpetuate the social and economic disparities that exist in everything from education to healthcare …”. More recently, the RNAO Black Nurses Task Force (2022) reported that anti-Black racism is deeply entrenched within our Canadian healthcare system and structures, including work environments, academic institutions, and professional associations. Black nurses continue to face microaggressions, discrimination, and racism, significantly impacting their mental health, such as experiencing increased stress, depression, and anxiety. Thus, nationwide strategies are needed to address the harmful impact of anti-Black racism, discrimination, and microaggression on Black people's lives and to interrogate the impact and legacies of whiteness in society.

The Erasure of Black nursing leadership in historical nursing discourse

Highlighting the contributions of historical Black nursing leaders in nursing education curricula enriches the learning experience for nursing students as it provides a more comprehensive understanding of nursing history, inspiring future generations of students. Addressing racism and anti-Black racism within nursing education must also acknowledge the wider historical discourses in nursing and the broader society. The history of the modernization of nursing dates to the nineteenth century and answers the issues of nursing diversity that we see today in the profession. As Foth et al. (2018) contend, “understanding that broad historical factors have shaped not only the way health care is provided, but the way we understand “health” itself, is essential to a social justice agenda in nursing” (p. 2). Florence Nightingale is revered worldwide as the historical representation of nursing and the pioneer of modernizing nursing (Hamzavi & Brown, 2023). While Nightingale has been heralded as the pioneer of modern nursing, it is necessary to ask the questions: How did this influential and revered leader shape the nursing profession and nursing education regarding equity, diversity, and inclusion (EDI), and racism in nursing, and how has this impacted the nursing profession today? We would argue, along with other scholars, that the lack of racial and ethnic diversity within nursing today stems from the historical legacies of Florence Nightingale's era, where the “ideal type,” the “right type,” “respectable,” White middle-class women, were recruited to enter the nursing profession (Best, 2021; Cooper Brathwaite et al., 2022a, 2022b; Prendergast, 2014). Today, we see this legacy played out in the underrepresentation of Black people and other racialized groups in nursing education and the nursing profession.

It is important to note that racism, patriarchy, classism, whiteness, and social hierarchies were embedded in the modernization of nursing, where “uneducated lower-class women” did not meet the requirements to provide nursing care. Nursing education targeted White middle-class women who dominated the profession, and nursing was inaccessible for Black people and other racialized groups. Until the late 1940s, Black individuals and other racialized groups were excluded from attending nursing schools as they did not fit the “ideal type” required for the nursing profession. Florence Nightingale's refusal to work with Mary Seacole, a Black British-Jamaican nurse, during the Crimean War, despite Seacole being a qualified nurse, demonstrates a preference to train and only work with middle-class, White women (Houlahan et al., 2022; Tobbell & D’Antonio, 2022). Mary Seacole worked as a nurse during the Crimean War, providing care and support to wounded British soldiers despite facing discrimination and racism throughout her career. Seacole was a skilled and dedicated nurse who earned the respect of her patients and colleagues. She established a hospital, provided care to wounded soldiers, and was known for using herbal remedies and other non-traditional treatments. She also trained other nurses and pioneered nursing education (Hamzavi & Brown, 2023; Jefferies et al., 2018; Rappaport, 2022; Staring-Derks et al., 2015). During the 1960s and 1970s, countries such as England and Canada experienced a nursing shortage, resulting in the loosening of exclusionary and restrictive policies regarding who could enter the profession. This presented an opportunity for Black students who were needed during this crisis to care for the failing health of the Black population.

Nightingale is celebrated for her work in modernizing the nursing profession. In 2020, the World Health Organization, in honouring Florence Nightingale's 200th birthday, proclaimed it the International Year of the Nurse and Midwife. However, the contributions of notable Black leaders such as Mary Seacole, Harriet Tubman, Sojourner Truth, and Mary Eliza Mahoney, to name a few, are often excluded from recognition, forgotten, remain invisible, and are not celebrated in many nursing scholarships, and discourses. This is primarily due to systemic racism and discrimination in the healthcare system (Donnelly, 2016; Jefferies, 2020; Jefferies et al., 2018; McGibbon et al., 2014; Staring-Derks et al., 2015).

There are many examples of historical figures whose link to nursing has been erased. Harriet Tubman, often called the mother of the Underground Railroad, was known primarily for her work as an abolitionist and conductor. She served as a nurse and cook for Union troops during the Civil War and was known for her ability to diagnose and treat illnesses. Tubman's experiences as a nurse and her knowledge of herbal remedies and other natural treatments were instrumental in her efforts to care for sick and injured soldiers. She was later appointed as a matron of nursing at a hospital at Fort Monroe in Virginia ((Donnelly, 2016; Jefferies et al., 2018). Sojourner Truth was well-known as a women's rights activist who advocated for the abolition of slavery and worked as a nurse during the Civil War. She worked in a hospital in Washington, D.C., providing care to sick and wounded soldiers. Truth was known for her compassion and dedication to her patients, and she was widely respected for her nursing skills. Later, after achieving freedom, she advocated for formal nursing education and training programs for other freed Black women (National Women's History Museum, n.d.). Mary Eliza Mahoney was the first Black woman to earn a nursing degree in the United States. She was admitted to the New England Hospital for Women and Children Training School for Nurses in 1878 and graduated in 1879. Mahoney became a pioneering nurse, advocating for the rights of Black nurses and working to improve the quality of care for African-American patients. She was also a founding member of the National Association of Colored Graduate Nurses, which worked to promote the professional development of Black nurses (Darraj, 2009; Eke et al., 2021).

This lack of representation of Black nursing pioneers in historical nursing discourses continues to pervade contemporary discourses in the nursing profession. Highlighting these notable Black women's contributions is imperative for nurses to understand their significant contributions to the modernization of the nursing profession and helps to reiterate the importance of diversity and inclusivity within the profession. These women persevered and showed resilience despite facing racism and discrimination. These were trailblazers in nursing, breaking down barriers and paving the way for future generations of Black nurses. Their nursing contributions improved patient care quality, helped advance the profession, and promoted greater diversity and inclusivity in the healthcare industry (Hamzavi & Brown, 2023; Jefferies et al., 2022; Staring-Derks et al., 2015).

The historical political context of nursing education in Canada

The history of nursing education in Canada brings to light the ways that the discipline was founded explicitly on structural racism and, therefore, not designed to educate and support Black students, ultimately impacting diversity within the profession as a whole. Canadian nursing schools are embedded in racist ideologies imported through the principles of Florence Nightingale that excluded Black students from being trained as nurses, fearing that White patients would not want Black nurses to be their healthcare providers (Flynn, 2009, 2011). As a result, Black students interested in becoming nurses had to attend nursing schools in the United States but found that when they returned to Canada, the hospitals would not hire them (Calliste, 1993; Flynn, 2011). Bernice Redmond, a Canadian by birth, is believed to be the first Black registered nurse in Canada. Even though she had Canadian citizenship by birth, she was not allowed to study nursing in Canada. She had to complete her nursing education in the United States at the St. Phillip Hospital School in Richmond, Virginia, where she earned her nursing diploma in 1944 and a graduate diploma in public health nursing in 1945. Despite excelling in nursing school and registering with the Registered Nurses Association (RNA), she had to seek legal help to practice nursing in Canada. She successfully obtained employment first with the Nova Scotia Department of Health in Sydney and subsequently with Mount Sinai Hospital and the Victoria Order of Nurses in Toronto, Ontario (Calliste, 1993).

Consequently, with much political advocacy, such as public speaking campaigns, pressure from Canada's Black community, and help from trade unions and church groups, nursing schools accepted two Black students, Ruth Bailey from Toronto and Gwen Barton from Halifax (Calliste, 1993). Subsequently, students from the Caribbean were admitted on the basis that they would return to their own countries after graduating (Calliste, 1993). As previously mentioned, in the 1960s and 1970s, Canada experienced nursing shortages similar to those in other parts of the world. To alleviate this shortage, the government provided funding to recruit nursing students. However, despite the nursing shortage and the Canadian Nurses Association's declaration to end racial discrimination and exclusion in Canadian Schools of Nursing, not many Black people were allowed to enter nursing schools (Calliste, 1993; Flynn, 2011).

Between 1948 and 1961, only 13 Black nurses graduated from nursing programs in Ontario, Canada. Furthermore, the few Black women admitted into nursing schools faced racism, discrimination, microaggression, stereotypes, and a lack of belonging (Flynn, 2011). Black nurses reported experiences of racism and discrimination during their nursing education in Canada between 1940–1970. This is significant because the challenges encountered by Black students after first entering nursing schools in the late 1940s continue to persist in present-day nursing. These challenges included being constantly watched regarding any deviation from “appropriate behaviour,” being reprimanded for disobedience, being humiliated, and being othered (Calliste, 1996; Flynn, 2009; Jefferies et al., 2018). In the following section, the contemporary experiences of Black students in nursing schools are discussed in more detail. Furthermore, we can see linkages between nursing schools being the gatekeepers of the nursing profession, the underrepresentation of Black students in nursing education, and the underrepresentation of Black nurses and nurse leaders in the workforce. This underrepresentation of Black students, Black nurses, and Black leaders retains dominant ways of nursing practice, impacting culturally responsive care, cultural safety, and overall patient satisfaction and may lead to adverse outcomes for the Black community (Jefferies et al., 2018; Onagbeboma, 2020).

Contemporary perspectives of racism among Black nursing students

As the sections above suggest, racism in nursing education and practice has a long and problematic history dating back to the modernization of the nursing profession, which is still present in nursing today. Canadian nursing schools have a lengthy history of excluding Black students from nursing education, and even today, adequate representation of Black students and other racialized groups in nursing education remains dismal (Jefferies et al., 2018; Onagbeboma, 2020; Sensoy & DiAngelo, 2017). In the current Canadian context, there is a sparse amount of literature specific to the experiences of Black students in nursing education. Jefferies et al. (2018) argue that the historical difficulties associated with gaining admission to nursing programs and the rigidity of the nursing curriculum directly connect to the obscurity and suppression of Black nursing leaders. This is partly a result of the insufficient presence of Black students in nursing education. Likewise, Vukic et al. (2016) contend that the inadequate presence of Black students in nursing, both in the past and present, can be attributed to societal factors and inadequate efforts to recruit and retain Black students. The authors also maintain that the exclusionary admission policies in nursing's history have lasting repercussions, discouraging Black students from considering nursing as a career choice today. Although race and ethnic identities are not collected in Canadian universities, the student population remains overwhelmingly White, which is a direct result of centuries of power and privilege, which has contributed to racial inequities for Black people and other racialized students (Onagbeboma, 2020; Sensoy & DiAngelo, 2017).

In the current nursing context, Black students continue to experience racism and discrimination, impacting their mental health, grades, and career path in nursing. They experience increased stress in the clinical setting, increased anxiety, and depression, which impacts their overall success (RNAO Black Nurses Task Force, 2022). In addition, Onagbeboma (2020) found that Black nursing students experience isolation, micro-aggression, biases, stereotypes, and racism and are often left to navigate these challenges alone. Some may overcome these negative experiences, whereas others leave the program altogether.

Zanchetta et al. (2021) found that racism is so normalized in the classroom and practice environments that some nursing students cannot recognize racially motivated violence. Black nursing students reported fear of speaking out about racism in nursing for fear of being labelled as “overly sensitive, a troublemaker or problematic” (Zanchetta et al., 2021, p. 472). Furthermore, to exacerbate this issue, there is a lack of inclusive learning resources, such as textbooks and mannequins, for “darker skin” students and a lack of visibility and influence of Black, Indigenous, and People of Colour (BIPOC) faculty in nursing academia and leadership (Besa et al., 2022). When people of colour are not represented, racism remains unchallenged and is not seen as an issue (Onagbeboma (2020). As such, dismantling and eradicating racism from nursing education is not a quick-fix solution and will require ongoing commitment from the nursing profession. Below, we provide some recommendations and implications for the nursing profession.

Moving forward: recommendations and implications

Self-awareness and self-reflexivity

Undeniably, the time to act is now. To address this complex issue, we propose a critical first step for the nursing profession to engage in reflexivity on its impact on society. This requires genuine assessment, interrogation, and introspection in identifying the discipline's and one's individual “subconscious racial superiority” and expanding knowledge of how racism, anti-Black racism, and whiteness impact nursing care (Bailey et al., 2021; Bell, 2021; Lamberson et al., 2021; Waite & Nardi, 2021). This type of engaged work is foundational for sustained long-term anti-racism work that can propel action. Anti-racism work is a lifelong journey that requires challenging and questioning ourselves and the systems and structures that we work in (Kendi, 2023; Moorley et al., 2020). It is essential to actively participate in open discussions and conversations about race and racism. Remaining passive, staying silent, and neglecting the topics of racism, anti-Black racism, and whiteness can perpetuate white supremacy and the current racial situation. This is a risk that nurses should avoid for the betterment of the nursing profession (Bell, 2021). Dismantling racism and anti-Black racism necessitates a long-term commitment to achieving nursing's health equity mandate of social justice for the nursing profession, patients, and the communities we serve (Waite & Nardi, 2021). Considering this, a few concrete implications for nursing education, practice, research, and policy are highlighted below.

Implications for nursing education and practice

Professional development

If nurse educators are to teach about race and racism and do so effectively, then there is a critical need for professional development on the topics of race, racism, anti-Black racism, and whiteness in understanding its impact on health inequities for Black people (Waite & Nardi, 2021). It is the responsibility of faculty and staff to increase their theoretical knowledge about race and racism, as well as how to navigate challenging conversations that they are not comfortable having (Bell, 2021; Holland, 2015). Nurses in practice settings must also educate themselves to understand racism, anti-Black racism, racial violence, trauma, and their role in healthcare inequity and health disparities (Waite & Nardi, 2021). Commitment from healthcare organizations is crucial to normalize and support this shift in individual practice and address racism within the nursing profession. Organizations are responsible for creating inclusive and equitable environments that actively work to eliminate systemic racism and promote anti-racist practices (Nardi et al., 2020). Black nurse educators may require unique resources, support, and protection to ensure they are not uniquely burdened or tokenized when carrying out such initiatives (Cleveland et al., 2018; Shavers et al., 2014).

Nursing program admissions and student supports

Addressing the underrepresentation of Black students in nursing schools cannot be overemphasized. As we have seen in past and current discourses, the underrepresentation of Black people in the nursing profession is the result of nursing's historical exclusionary admission policies, a lack of sense of belonging, inadequate recruitment and retention, insufficient academic support, financial barriers, and inadequate or absence of Black nurse educators to serve as mentors and role models (Etowa et al., 2005; Jefferies et al., 2018; RNAO Black Nurses Task Force, 2022; Strayhorn, 2019; Vukic et al., 2016). Black nurse educators who can provide more nuanced education about the societal issues that cause health inequities within the Black community are needed. Considering this, nursing schools must create a culture of belonging, adopt and implement targeted recruitment and retention strategies, employ anti-racist policies and programs, and engage in education and employment equity to counteract the underrepresentation of Black people in nursing. Schools and nursing bodies should also provide support and resources to Black nursing students, including mentorship programs and scholarships, to address barriers to entry and advancement in the profession (Jefferies et al., 2018; RNAO Black Nurses Task Force, 2022; Strayhorn, 2019). Establishing mentorship programs that connect Black nursing students with experienced nurses and faculty can provide guidance, support, and encouragement throughout their education and early careers (Beagan et al., 2023; Hamzavi & Brown, 2023). Providing targeted scholarships and financial aid to Black students can help reduce financial barriers to entering and completing their nursing programs (Iheduru-Anderson et al., 2020). Additionally, creating safe spaces and support groups for Black nursing students can offer a sense of community and belonging, helping them navigate challenges and succeed academically and professionally (Iheduru-Anderson & Waite, 2022; Morgan et al., 2020). The profession requires a workforce that can address the unique needs of the Black population while delivering culturally safe care through cultural humility, reducing health inequities, and actioning nursing's health equity mandate (Jefferies et al., 2018; Waite & Nardi, 2021). The profession can no longer deny or ignore that the historical legacies of racism and anti-Black racism have led to an underrepresentation of Black people in the nursing profession today.

Curricular revisions and required courses

Historically, nursing education has been shaped by colonial and Eurocentric ideologies, resulting in the marginalization and erasure of Black people's knowledge, culture, and ways of knowing (Iheduru-Anderson & Waite, 2022). Anti-racism education is critically needed at all levels of nursing for nursing students, educators, clinicians, administrators, researchers, and regulators. Nursing faculty must engage in curricular revisions that include explicit language about race, racism, and anti-Black racism and explicitly teach about power, privilege, and systemic manifestations of racism. A comprehensive education on the impact of racism in healthcare, the history of racial discrimination, the history of Black nurses, and strategies for promoting anti-racism are needed (Bell, 2021; Holland, 2015). Integrating content reflecting Black individuals’ experiences and contributions to nursing can provide a more comprehensive and inclusive education (Jefferies et al., 2022). Adopting and integrating anti-racist philosophies and critical theories to challenge inequities and explicitly address racism and anti-Black racism in education is needed. Anti-racism as a philosophical way of life requires White discomfort and a commitment to integrating anti-racist truth (Noe, 2020). Critical theories, with a focus on anti-racism, such as critical race theory, critical race feminism, intersectionality, post-colonialism, and critical counter stories, to name a few, can assist in examining the structures of racism and anti-Black racism within the profession (Bell, 2021; Clark & Saleh, 2019; Coleman, 2020; Collins & Bilge, 2020; Crenshaw, 1989; Louie-Poon et al., 2022). Conversely, culturalist theories or accommodation theories that are often used euphemistically and do not directly focus on anti-racism are inadequate in addressing systems of racism, anti-Black racism, white supremacy, and white privilege (Louie-Poon et al., 2022; Waite & Nardi, 2021).

Academic regulation

It is vital that nursing regulatory and accreditation bodies actively seek to address racism and anti-Black racism in nursing education and practice and undertake definitive action to ensure transformative education to serve our nursing students and patient population better. As such, entry-to-practice competencies, code of ethics principles, program approvals, and accreditation standards should explicitly include clear language related to race, racism, and anti-Black racism. Nursing regulatory bodies must recognize its unique positionality within institutions of power and integrate a critical approach to racism and anti-Black racism to achieve and maintain nursing's mandate of health equity for social justice in Canada (Garland & Batty, 2021; RNAO Black Nurses Task Force, 2022). Nursing schools and nursing bodies must also be involved in reparation and reconciliation efforts by taking steps to acknowledge historical injustices and actively work towards rectifying them. Nurses’ mandate should evolve to consider investments in kindergarten through higher education for all children of Black, African, and Caribbean descent, as well as general engagement in such communities (Braveman et al., 2022).

Implications for nursing research and scholarship

There remains a critical need for greater inclusion of Black people in academic research to bring about more diversity of thought and knowledge development. Despite the history of racism and anti-Black racism, empirical research continues to have a limited number of publications that explicitly name racism or investigate the impact of anti-Black racism on health outcomes (Thurman et al., 2019). Waite and Nardi (2021) encourage nurse scientists to identify when there is an absence of diversity of standpoints in nursing science and knowledge development and to invite scholars with an anti-racist lens to be part of research design, implementation, and dissemination. In addition, the notion of race as a biological construct in research has added to the continuance of negative stereotypes and stigmatization of racialized groups. Therefore, careful consideration must be made when interpreting research data and how misunderstanding research findings leads to ongoing oppression and racism. Thus, the idea of race as a biological construct must be dismantled within nursing research (Bryant et al., 2022; Dordunoo et al., 2022). The profession of nursing, which is rooted in colonialism and dominated by Eurocentric worldviews, continues to disproportionately marginalize the Black population and limit what is accepted as legitimate knowledge (Beavis et al., 2015; Iheduru-Anderson & Waite, 2022; McGibbon & Lukeman, 2019). Such practices must be disrupted. Strategies may include clear ethical standards implemented in research design and publication protocols. Nursing scientists conducting research with the Black population could be required to learn about the social and political oppressive origins of the construction of race as a biological category before initiating research with these populations (Bryant et al., 2022).

Implications for policy development

Racism continues to shape current educational and healthcare policies by allocating resources that advantage the White population and disadvantage the Black population, resulting in inequitable access to quality education and healthcare services. Attempts to remedy this issue have stagnated because dismantling structural racism has not been a priority (Yearby et al., 2022). To achieve meaningful change, nursing education and the healthcare system need to transform. Kendi (2023) states that anti-racism is a powerful collection of policies that lead to racial equity and justice that are substantiated by ideas of racial equality” (p. 26). As such, policies and guidelines must be revised to denounce racism, anti-Black racism, and discrimination in nursing education and practice. This includes addressing systemic racism embedded in policies, practices, and funding structures. Establishing funding structures focusing on health disparities affecting the Black population can contribute to a deeper understanding of these issues and inform better healthcare practices and policies (Figueroa et al., 2023). This process can be further actioned by explicitly aligning policies with anti-racist objectives in nursing education and practice. Provincial regulatory bodies and nursing accreditation organizations can take steps to examine their policies and procedures to ensure they are fair, unbiased, and free from discriminatory practices. Regular review of licensing processes, licensure exams, and disciplinary actions should be conducted to identify and correct any discriminatory obstacles (Cooper Brathwaite et al., 2022a, 2022b; Garland & Batty, 2021; Houlahan et al., 2022). Additionally, healthcare employers have a crucial role in how nurses and nursing students are socialized to the healthcare environment and in providing strong ethical guidance. An inclusive workplace culture that promotes respect, equity, diversity, belonging, and anti-racism should be fostered. Policies that address racial discrimination and provide transparent reporting mechanisms for racial incidents, offering support to those who experience anti-Black racism and discrimination, should be a priority (Cooper Brathwaite et al., 2022a, 2022b; Iheduru-Anderson et al., 2020). Furthermore, developing positive relationships with Black communities promotes trust and collaboration. Healthcare institutions should actively engage with Black communities to understand their healthcare needs, concerns, and experiences. This can be achieved by involving the Black community in healthcare policy development and decision-making processes, engaging in community outreach programs, and establishing advisory boards with community representatives (Cooper Brathwaite et al., 2022a, 2022b). Healthcare institutions can better address Black communities’ unique challenges by actively seeking input and incorporating community perspectives. Furthermore, higher education institutions, schools of nursing, healthcare organizations, and policymakers should promote diversity in healthcare leadership positions, ensuring representation and decision-making power for individuals from the Black community (Jefferies et al., 2018). This can lead to more inclusive policies and strategies addressing racial disparities. As we have seen, combating racism and anti-Black racism in nursing requires a comprehensive, multifaceted approach involving licensing, regulatory and accreditation bodies, employers, schools of nursing, healthcare institutions, and policymakers. By implementing anti-racist policies that foster inclusive learning environments and workplace cultures, the healthcare system can move towards greater equity, inclusivity, and improved healthcare outcomes for all individuals (Cooper Brathwaite et al., 2022a, 2022b; Garland & Batty, 2021).

Conclusion

In this paper, we discussed the historical and contemporary discourses of racism on Black students’ experiences within nursing education in the Canadian context. The nursing profession in Canada was built upon a foundation of exclusion and racism, and today, these issues persist in preserving the status quo of racist ideologies and discourses to create disparities and inequities for Black communities. Nursing has a critical role within the Canadian healthcare system and has the opportunity and responsibility to contribute to dismantling racism, anti-Black racism, and inequities in healthcare. Despite the efforts of the Canadian nursing discipline to uphold moral commitments in nursing science and knowledge development, it continues to perpetuate racism and inequities. This is partly due to the covert forms of racism in Canada and nursing's hesitancy to uncover and dismantle the pervasiveness of racism. We find ourselves at a crucial point where nursing cannot delay action, expecting the next generation to be the ones to eradicate racism from our educational and healthcare systems. Deliberately overlooking and ignoring the presence of racism and anti-Black racism and its impact on the health of Black people can no longer continue. It is time for nursing, a profession grounded in moral and ethical obligations, to take bold steps toward dismantling racism and anti-Black racism within its structures. More importantly, with nursing education being the gateway into the profession, a purposeful focus on dismantling racism and anti-Black racism is essential to advancing health equity and student success, fostering a sense of belonging, improving health and well-being, and providing quality patient-centred care for all.

Footnotes

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The first author disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported in part by the Social Sciences and Humanities Research Council Doctoral Scholarship, the Ontario Graduate Scholarship, and the University of Western Ontario Graduate Award.

ORCID iDs

Janet Montague

C. Susana Caxaj

Author Biographies

Janet Montague, RN, MN, PhD Candidate, is a nursing professor in the School of Community and Health Studies at Centennial College and a PhD Candidate in the School of Nursing at Western University. Her doctoral research explores Black students’ experiences of belonging in nursing education through the lens of Critical Race Theory and Intersectionality.

C. Susana Caxaj, RN, PhD, is an Associate Professor in the School of Nursing at Western University. Her research interests include migrant workers’ housing, health, and service navigation, as well as capacity-building for anti-racism practices and policies.

Fiona Webster, PhD, is a critical sociologist, Professor and Associate Director Nursing Research in the Labatt Family School of Nursing at Western University. She holds a cross-appointment with Social and Behavioral Health Sciences, Dalla Lana School of Public Health, University of Toronto, where she is also an Academic Fellow with the Centre for Critical Qualitative Health Research (CQ). She has successfully led many Tri-Council funded, interdisciplinary research teams with a particular focus on applying sociological approaches to understanding and improving care, with a particular focus on chronic pain and marginalization.

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Call to Action: Integrating Anti-racist Philosophies in Dismantling Racism and Anti-Black Racism in Nursing Education in Canada

Abstract

Keywords

Key terms, context, and anti-Black racism

Race

Racism

Whiteness

Racism in nursing education

Anti-Black racism

The Erasure of Black nursing leadership in historical nursing discourse

The historical political context of nursing education in Canada

Contemporary perspectives of racism among Black nursing students

Moving forward: recommendations and implications

Self-awareness and self-reflexivity

Implications for nursing education and practice

Professional development

Nursing program admissions and student supports

Curricular revisions and required courses

Academic regulation

Implications for nursing research and scholarship

Implications for policy development

Conclusion

Footnotes

Declaration of conflicting interests

Funding

ORCID iDs

Author Biographies

References