In 2022, for the 20th consecutive year, the American public ranked nurses as the most trusted, ethical, and honest profession among a host of notable others, including physicians, pharmacists, and clergy members.1 Few people would disagree with this ranking, and reverence for nursing helps to explain the continued demand for qualified nurses on the health care team. Professional nursing is widely known for honesty, advocacy, empathy, compassion, acceptance, adaptability, and, most importantly, the art of caring. However, despite external perceptions of nursing's high moral and ethical standards, a report from the National Commission to Address Racism in Nursing noted that 94% of nurses reported racism in the profession.2 Nurses reported acts of racism from peers (66%), patients (63%), and supervisors (60%).3 These findings are a grim reminder that racism is pervasive in all care delivery settings and at all professional levels. The report creates a conundrum within health care that negatively affects morale within the workplace and the delivery of equitable patient care.
Since its conception, the nursing discipline has emphasized the importance of inclusion and the influence of the cultural dimension of care on patient outcomes.4 The U.S. Department of Housing and Urban Development defines inclusion as the "recognition, appreciation, and use of the talents and skills of employees of all backgrounds."5 A sense of belonging describes the "feeling of security and support" experienced when individuals perceive acceptance, inclusion, and community and is a step toward establishing a healthy workplace environment.6 Unfortunately, the culture of institutional racism in health care contributes to the normative standard of a racially homogeneous nursing workforce and preserves significant barriers to inclusion and belonging. The pervasive Eurocentric historical perspective of nursing emphasizes the contributions of White women like Florence Nightingale, but often neglects to acknowledge the notable contributions of nurses of color. Other consequences of the barriers to inclusion and belonging include the false belief that minoritized students are academically inferior,7 highly restrictive admissions and punitive progression policies,8 explicit exclusion of Black students from nursing programs,8 and poor representation of racial and ethnic minority nursing faculty and administrators.7
Given this historical context, it is important to maintain the inclusion, diversity, and cultural humility that undergirds nursing, especially concerning the care of diverse, underserved patient populations. However, according to the 2020 National Nursing Workforce Survey, only 19% of nurses identify as belonging to an underrepresented racial or ethnic group, compared with 28% of the general population.9 There is a critical need for the nursing profession to develop a culturally diverse workforce equipped to provide high-quality care to patients with a wide range of needs and preferences. Patients from various cultural, religious, ethnic, socioeconomic, and educational backgrounds rely on nurses to coordinate safe, quality, and competent care. An inclusive health care environment supports patient-centered decision-making and greater patient satisfaction. Finally, nurses can avoid stereotyping, miscommunication, and unnecessary delays in patient care when they work to mitigate the biases and prejudices that create barriers to optimal care.
An inclusive work environment, which results when the diversity of nurses' backgrounds, perspectives, and values is respected, contributes to a positive sense of belonging and improves nurse retention.10 However, the prevalence of racism and incivility toward nurses exacerbates the occupational stress of working in a complex health care system. Nurse victims of work-related uncivil behaviors often report undesirable psychological and psychosomatic symptoms.11 Moreover, negative attitudes and passive-aggressive behaviors associated with person-related discrimination toward nurses from underrepresented racial and ethnic groups are perceived by these nurses to interfere with career advancement.12 Compared with their fellow health care professionals, nurses more readily seek to understand and value patient beliefs and preferences. This value system needs transformation. Inevitably, the entire health care system benefits when inclusion and belonging coexist within the nursing profession.
The COVID-19 pandemic has reaffirmed that bedside nurses are the crux of nursing and health care systems. Nurses must continue to embrace and facilitate inclusivity among each other as well as among those seeking health care. While this can be challenging in a polarized society, bedside nurses have demonstrated that it can be accomplished. Inclusivity at the bedside means building rapport and relationships within a reality where patients' values may be juxtaposed with nurses' personal ones. Nurses must continue to navigate these situations cautiously and attentively to achieve better health outcomes. Nurses must consciously promote inclusion and a sense of belonging while also promoting and maintaining nursing as the most trusted profession.
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