A family nurse practitioner in New York City, Jose M. Maria has come to expect overt racism from patients. “I’ve been called the N-word, I’ve been called, you name it,” he said. A triple minority in nursing — Black, Latino, and male — he often gets mistaken for a janitor. More subtle racist behavior has come from supervisors and fellow nurses in past jobs, too — uncomfortable looks in the break room, extra questioning from supervisors over narcotics errors he’s responsibly reported and been cleared for. “I’ve felt I’ve had a target on my back.”

But he’s never reported a single racist incident to his employers. Partly that’s because he’s accustomed to such behavior; he grew up during New York City’s “stop and frisk” era and was himself targeted by police who could search anyone they deemed suspicious. But he’s also been afraid of repercussions and thinks nothing would be done anyway. “Forget about it. They will just fire you,” he said.

In this, Maria is like a majority of nurses, according to a survey of 900 nurses — RNs, NPs, and LVNs — released Wednesday by the Robert Wood Johnson Foundation: While 80% of the respondents said they have seen or experienced racism from patients, and 60% from colleagues, the survey found that fewer than 1 in 4 nurses reported the incidents. In interviews with pollsters, nurses said they felt human resources employees, administrators, and even their union leaders would do little to help, and more than half of those who did report what happened said their relationships with supervisors and fellow nurses suffered as a result.

“People don’t do anything because no one is going to do a damned thing,” Maria told STAT. “It’s an extension of society — plain and simple.” He was one of a number of nurses of different racial and ethnic backgrounds interviewed by STAT about their experiences with racism, how to make nursing more inclusive, and whether they think change is possible.

The nationwide survey, conducted in March and April 2022, as well as another survey of 5,600 nurses that came out last year, suggest there has been little progress in making nursing more inclusive — 81% of registered nurses are white — despite a stream of pronouncements against discrimination made by nursing organizations and schools since 2020. And a paper out this month that includes 15 in-depth interviews with RNs who recounted widespread racism due to their race, ethnicity, religion, or country of origin underscores the mental health toll that may be forcing some nurses from the profession.

Nurses working in residential care facilities, home health, and hospital settings were more likely to say they experienced racism than those working in doctor’s offices. These incidents were most common for Black nurses, of which 88% reported seeing or experiencing racism from patients and 72% from colleagues, and Asian nurses, of which 86% reported such behavior from patients and 65% from colleagues. (The survey, conducted for the foundation by NORC, did not break out data for Indigenous nurses, who make up 0.5% of the nation’s RNs.)

Experts say both surveys reveal a disturbing and deeply entrenched culture of racism and white supremacy in nursing that stretches back to the field’s iconic founding heroine: Florence Nightingale. A British nurse, she played a major role in promoting both colonial violence and exclusionary Victorian ideals that only upper-class white Christian women would make good nurses, scholars say, and she instilled in nursing a white-centered cultural norm that many say persists to this day.

The centering of Nightingale’s work has eclipsed the stories of other nursing leaders such as Mary Seacole, a mixed-race Jamaican woman who saved countless lives treating trauma in the Crimean War and battling cholera outbreaks; Edith Monture, an Indigenous nurse from Canada who was barred from Canadian nursing school but was educated in the United States and became a WWI nurse; and Emma Goldman, a Jewish nurse, activist, and midwife who treated prisoners, low-income people, and working-class immigrants in New York City around the early 1900s.

It is not only history books that exclude certain nurses. From 1916-1964, the American Nurses Association “purposefully, systemically and systematically excluded Black nurses,” according to the ANA, because membership came through state- and district-based associations, some of which barred Black nurses. This exclusion is detailed in a reckoning statement released by the ANA in June 2022 that called such decisions “a failure of ANA leaders” and admitted, as the recent surveys suggest, “the full inclusion of Black nurses within ANA leadership and decision-making remains unrealized and elusive for all nurses of color.”

The profession is trying to do better. In 2021, leading nursing organizations came together to form the National Commission to Address Racism in Nursing, a racially and ethnically diverse group working to help nursing confront and end systemic racism in its ranks.

It’s not easy. Some nurses have faulted a number of recent, large-scale efforts to confront racism within their profession as bumbling, superficial, and insufficient to bring about change.

For example, updated materials addressing health equity produced by the American Association of Colleges of Nursing — which calls itself the national voice for academic nursing — are seen as ineffectual by some because they sidestep the root causes of discrimination and ignore the power dynamics in nursing that uphold the field’s status quo.

“We can’t address racism just by adjusting our curricula,” said Claire Valderama-Wallace, a Filipino nurse and associate professor of nursing at California State University, East Bay, who has extensively researched challenges faced by nurses trying to disrupt racism. “If it’s not critiquing and acting to change the pillars of power, it’s not going far enough.”

Another missed opportunity, say critics, was a nearly 500-page Future of Nursing report, subtitled “Charting a Path to Achieve Health Equity,” released with much fanfare in 2021 by the National Academies of Sciences, Engineering, and Medicine. It failed to cite the pivotal work of Black women, did not center Black justice, and was too timid to challenge the power structures within health care that allow racism to persist, said Monica McLemore, a professor and the interim director for the Manning Price Spratlen Center for Anti-Racism and Equity in Nursing at the University of Washington.

One of the report’s committee members took the unusual step of writing a critique that was included as an appendix. The report underplayed the role of racism and was not bold enough to lead and inspire change, wrote William Sage, a white physician and professor of law at Texas A&M University. While it used the right vocabulary, “talking the talk without walking the walk does not shorten the journey, much less reach the destination,” he wrote.

Consequential change won’t occur, many STAT spoke with say, until the leadership of nursing becomes more diverse and allows in the voices of a more diverse and younger generation. Many currently in power, those pushing for change say, either deny that racism is a major problem, are deeply uncomfortable discussing it honestly, or simply have no idea what to do about it.

Leaders from the American Nurses Association told STAT they hear the criticism and are trying to do better in their efforts to end racism. “We ourselves acknowledge that we have been part of the problem and now want to be part of the solution,” said Cheryl Peterson, a white nurse who serves as the organization’s vice president for nursing programs. She cited the ANA’s own 2021 survey on racism and support it’s providing the commission now addressing racism in nursing.

Peterson said her organization could never move fast enough for some members, and was moving far too fast for many the ANA “needs to bring along” through education and dialogue. “We have a sense of urgency. We want to work fast but be intentional so we don’t cause more harm with a misstep,” she said.

The ANA’s work is starting with discussions with those who have been harmed, to create trust, said G. Rumay Alexander, a Black scholar-in-residence at the ANA and a professor of nursing at the University of North Carolina at Chapel Hill. “The work starts with those conversations, that courageous dialogue — not workshops,” she said. “Conversations where tears are shed and feelings are made known.”

Beth Toner gets the criticism. A white woman, Toner has worked as a nurse for 13 years at a free clinic in Pennsylvania and is also part of the group that commissioned the new survey at the Robert Wood Johnson Foundation, where she works in communication. She has seen much unacceptable behavior — white nurses wanting to touch the hair of Black colleagues, white nurses not drawing nurses of color into conversations about issues in which their lived experiences would be extremely valuable, and nurses of color being more likely to be disciplined for not being professional. “Looking professional is sometimes code for looking white,” Toner said.

And she regrets she sometimes stood by silently. “So often in nursing, we don’t speak up because we think someone else will,” she said. “And let me own my own behavior. I have frozen upon a number of occasions, walked away and then said, ‘Oh, I should have done better.’”

White nurses can do better, she said, “in ways that are helpful, and not white savior-y.” For starters, they can make an effort to get to know their colleagues who are not white. (If they can: Many white nurses in the survey said they did not attend school, and do not work, with nurses who are not white.)

White nurses, Toner said, need to be open to having hard conversations with those colleagues, and accepting feedback when their co-workers feel they can do better. “I know the pushback is there to not talk about this, but we really have to,” she said. “A lot of it is working our muscles, doing our homework,” she said. “Know who on your floor wants to disrupt racism and work with them. Let’s use our power for good.”

For many nurses, racism starts early, in school. A nursing textbook put out as recently as 2014 by the major book publisher Pearson included racist depictions of various ethnic and racial groups, including: Jewish patients are vocal and demanding; Filipino patients refuse medication because they see pain as the will of God; Native Americans may choose sacred numbers when rating their pain; and Black patients report higher pain intensity. “That’s not too far from ‘don’t believe Black patients when they say they’re in pain,’” Valderama-Wallace said.

The publisher apologized and revised the book, but other forms of racism are harder to address. In the new survey, more than 40% said racism was part of their nursing school’s culture, with more than 70% of Black and Asian nurses and more than 60% of Hispanic nurses saying they believed they were held to a higher standard of performance. A majority said they received minimal training on discrimination and disparities while at nursing school.

Valderama-Wallace said nursing has a “hidden curriculum” that maintains inequality through a focus on acute care and symptom management rather than root causes of health disparities. Discussions of equity in work settings and nursing schools, she said, are often perfunctory, don’t address racism head-on, and are too limited in scope.

California, for example, in 2021 started requiring all nursing graduates to have implicit bias training. While the rule was seen as groundbreaking in some quarters, the superficiality of the actual requirement makes Valderama-Wallace laugh out loud. “It required an hour of training,” she said. “One hour.”

In the survey, many nurses said they believed they received lower evaluations or were denied training opportunities during nursing school. That was true for Whitney Fear, a Lakota nurse now working as a psychiatric-mental health nurse practitioner in Fargo, N.D.

Fear’s path to nursing has been difficult, and expensive. She grew up on the Pine Ridge Reservation in South Dakota, and stumbled during high school as she dealt with her mother’s cancer and other issues. But once Fear got serious about school in her final year, she spent 12 hours a day there, taking both high school and community college classes, all while working 20 hours a week.

But those early problems — along with attending a reservation school that didn’t offer classes like chemistry and upper-level math — made it hard to gain entry into more reasonably priced state nursing programs. Instead, she attended a private for-profit nursing college with steep tuition. More than a decade after graduation, she is still paying off student loans despite working full-time throughout nursing school.

Once in school, Fear faced intolerance from some faculty, and felt great support from others. She told STAT she was hounded to cut her hair, even though in Lakota culture, that’s something she would only do in mourning. And, until she appealed to the dean, her family members weren’t going to be allowed to celebrate her by placing an eagle feather in her hair during the school’s pinning ceremony.

She said she got lower grades, harsher treatment, and had her commitment questioned despite feeling that she worked as hard, or harder, than white students. “They kept asking, ‘Do you really want to be an RN?’” Fear said. She was put on probation for having a flat affect.

She was graded poorly on her preceptorship despite being offered a permanent job at the facility where she was placed. (She said she was told her 55-page writeup of her experience wasn’t thorough enough.) But she graduated, and went on to receive not only her bachelor’s of nursing, but also a master’s of nursing, and certification as a psychiatric-mental health nurse practitioner.

Fear has become an outspoken leader on mental health, addiction, and tribal issues, and her achievements were chronicled in a documentary. But Fear still feels shut out. She said she’s been rebuffed in efforts to work on equity issues through national nursing organizations. “It’s definitely gatekeeping,” she said.

When she recently heard about a proposal to boost diversity by offering loan repayments to nurses from underrepresented racial and ethnic groups who have Ph.D.s, she had to scoff. “There are like eight of us with Ph.D.s,” she said. “How is that helping?” Instead, she said, the field should make it easier for marginalized students like her to attend nursing school.

“We need to take a long, hard look at how nursing is elitist,” she said. “There’s a lot of us that can take really good care of people.”

The racism nurses reported experiencing in the new survey doesn’t always come from patients; many said they experienced such behavior from co-workers, supervisors, senior health leaders, and human resources personnel, including being called slurs, being harassed, and being humiliated in front of others. Many nurses said any discussion of racism or discrimination in their workplace was “non-existent.” And some said the microaggressions they endure at work are almost constant. Just ask Hershaw Davis Jr.

Davis, an African American critical care nurse and clinical faculty member at the University of Maryland, Baltimore, has an undergraduate degree in biology with a minor in chemistry. He attended a top nursing school — the University of Maryland — and trained at a top hospital — Johns Hopkins. He also has a master’s in nursing and is pursuing a doctorate.

He’s encountered numerous patients and colleagues who assume he’s not as well trained or educated as he is, and are even shocked when they find out. When it happens, he has a reflexive internal monologue at the ready. “OK. We’re going to do this now?” he asks himself. He gets it — as an African American male from East Baltimore, he’s defied the narrative often told about men who look like him. “If it was somebody else, you’d be singing their praises,” he said, adding that he was speaking for himself and not on behalf of his university. “I know, I have to be better.”

He’s now teaching — serving as an important role model to students who might follow in his footsteps. He’s frustrated that the U.S. has not found a way to fix the pipeline that produces nurses. He believes increasing diversity among nurses and those who educate them could help ease the current nursing shortage. “Unless we come back to teach and serve as an example to the next generation, how are we going to change things?” he asked.

He feels supported by his current dean, but isolated in the larger world of academic nursing. “When I go to conferences, sometimes I’m the only one that looks like me,” he said. The discussions around racism in nursing have been far too timid for his taste. “It’s uncomfortable — no one wants to have that conversation. And nurses don’t like to cause trouble,” he said. “Nursing still has a long way to go.”

In the new survey, many nurses reported witnessing colleagues laughing at the names of patients from different ethnic or racial backgrounds or acting biased toward patients based on their race or income status.

Davis said he has seen the costs of the lack of nursing diversity: His own 93-year-old grandmother is afraid to enter a hospital because she thinks she’ll be experimented on; a patient who came to his emergency department after losing a toe to a lawn mower jumped off a gurney in anger and disbelief when the doctor treating him said he was surprised to learn Black neighborhoods in Baltimore had any grass; and an elderly Black couple were too timid to ask their white physician questions during discharge.

“I told them, ‘Go ahead, ask your questions, the doctor has time for you,’” Davis said. “They told me they had never seen an African American male nurse in the hospital before.”

What will it take to change? Anna Valdez, who chairs the nursing department at Sonoma State University in California, was in nursing school 33 years ago, and said there were discussions about diversity and health disparities then. Yet there’s been little meaningful progress.

“What’s really become clear to me in the last few years is the major problem we have in addressing racism in nursing is denial,” she said.

Valdez, who serves as a commissioner on the National Commission to Address Racism in Nursing, has come to believe that change will not occur until nurses in leadership — who are predominantly white — start sharing power. “A lot of people who are white have blind spots,” she said. “Folks that are not experiencing this don’t realize they have privilege,” said Valdez, who is mixed race and grew up with a Black mother. “To me, it was in my face.”

Reluctance to give up their authority may be one reason many leaders do not want to acknowledge, as the new surveys show, that a massive amount of racism exists within nursing, said Valdez. Nurses, after all, have a legal and moral obligation to fix any problems that are harming patients. “Maybe they don’t want to know, because then they have to do something about it,” she said.

She’s come to think that mandates from regulatory bodies or accrediting institutions will be the only way real change occurs. “If we rely on nurses or physicians to do it because it’s the right thing to do, it’s clearly not going to happen,” Valdez said.

McLemore of the University of Washington said it’s time to stop measuring and discussing racism in nursing and start ending it.

She’s been working on a set of recommendations for how that can happen, including insisting diversity, equity, and inclusion officers have the budget and power to actually effect change; having repercussions, including firing, for people who repeatedly engage in racist behavior; and training other nurses to intervene when they see racist behavior. Many nurses in the survey said more training was needed on DEI issues and 80% thought a zero-tolerance policy with clear consequences for racist behavior would help retain more nurses.

McLemore thinks nurses are uniquely positioned to disrupt racism in health care because their roles range from patient bedside to leadership, because of the trust they engender, and because their fundamental job is to help people manage major life transitions. “I believe,” she said, “nurses can change the world.”

This is part of a series of articles exploring racism in health and medicine that is funded by a grant from the Commonwealth Fund.

(This story originally appeared in Statnews.)