Reckoning With Racism in Nursing: Towards Structural Transformation and Epistemic Justice

Despite longstanding rhetorical commitments to diversity, equity and inclusion, racism remains a pervasive and a systemic force within the nursing profession, shaping experiences of both the workforce and the populations they serve. A recent UK survey found that 75% of nurses from ethnic minority backgrounds reported experiencing racial discrimination from colleagues or patients, resulting in stress, burnout and a heightened intention to leave the profession (Royal College of Nursing [RCN] 2024; Kapadia et al. 2022). In the UK, Black and racially minoritised staff experienced more harassment, bullying and abuse from patients, their relatives, and staff when compared to white staff in the English National Health Service (NHS) (NHS England 2023). However, focusing solely on interpersonal or overt forms of racism risks obscuring the more insidious manifestations embedded within the structural and epistemological foundations of nursing. Structural racism in nursing is not simply a reflection of individual prejudice but is reproduced through institutional policies, curricula, leadership pipelines and regulatory frameworks that perpetuate racial hierarchies (American Nurses Association [ANA] 2025; Moorley et al. 2025; Robinson-Lane and Patel 2022). These structures systematically marginalise racialized nurses through inequitable access to mentorship, promotion opportunities and decision-making power, often under the guise of ‘neutral’ meritocratic standards. In Australia, the UK and Canada Black and other racialized nurses are significantly underrepresented in senior clinical and academic leadership roles despite comparable or higher levels of education and experience. These disparities are not coincidental but stem from historical legacies of colonialism and whiteness as normative within the education and professional identity of nursing (Jackson 2023). Although most nurses may be aware of structural and systemic racism, they may know less of epistemic racism. Structural racism in nursing is upheld by institutional systems i.e., policies, curricula, leadership pathways and regulation that systematically disadvantage racially minoritised staff (American Nurses Association 2025; Robinson-Lane and Patel 2022). Beyond structural exclusion, epistemic racism further entrenches inequality by devaluing the knowledge, experiences, and ways of knowing of Black, Indigenous and other racialized nurses. We believe that the dominant nursing epistemologies, largely shaped by Eurocentric, biomedical and positivist paradigms, often fail to recognise or validate knowledge systems and knowers grounded in community, relationality or lived experience. This epistemic injustice operates not only through curriculum design and research agendas but also through peer review, editorial bias and the privileging of Western frameworks in nursing scholarship. The result is a profession that not only marginalises racialized nurses but also fails to reflect the diverse worldviews necessary for truly equitable racial care. To move towards structural transformation and epistemic justice, nursing must go beyond tokenistic inclusion and engage in a deep reckoning with its own complicity in maintaining racial inequity. This includes reimagining leadership development, embedding anti-racist pedagogy in nursing education, decolonising research methodologies and nursing care and amplifying the voices and scholarship of marginalised nurses. It also requires a critical interrogation of how power operates within professional organisations, accreditation bodies and healthcare systems to perpetuate white normativity. We believe that transformation will not occur through diversity initiatives alone but through sustained collective action aimed at dismantling oppressive structures and reconstituting nursing as a truly just and pluralistic profession. Structural racism in nursing manifests through persistent patterns of exclusion, marginalisation and inequality embedded in institutional policies, professional norms and educational systems. There is a chronic underrepresentation of Black, Indigenous and People of Colour (BIPOC) in nursing leadership, research and scholarship, alongside inequities in career advancement, mentorship and access to high-status roles. Internationally educated nurses (IENs), particularly those from the Global South, also encounter systemic barriers, such as biased credentialing, discriminatory regulatory processes and devaluation of prior experience, which impede their professional mobility and reinforce racialized hierarchies. In countries with colonial legacies like South Africa, Australia, Canada, New Zealand and the UK where most colonisers originated, nursing education systems have historically privileged Eurocentric biomedical paradigms, often at the expense of local or Indigenous knowledge traditions. As Mulaudzi et al. (2020) argue, ‘the exclusion of African Traditional Indigenous Knowledge (ATIK) perpetuates epistemic injustice, undermining both the legitimacy of African knowledge systems and the cultural safety of patients and practitioners’ (p. 5). This epistemic marginalisation is not a neutral omission but a form of violence that delegitimizes alternative worldviews and constrains the possibilities of culturally responsive care. African and decolonial scholars have forcefully argued that racism in nursing education is not simply about gaps in content but about deeper issues of power, voice, whiteness as gold standard and legitimacy. The erasure of Black and BIPOC voices from the curriculum reflects the dominance of whiteness in authority and legitimacy. This reinforces colonial epistemologies under the guise of professionalisation. We view the coloniality of knowledge as a process through which Eurocentric ways of knowing are accepted as universal gold standards, whereas others are dismissed as anecdotal, emotional, or non-scientific. Within this framework, the nursing canon itself becomes a site of epistemic domination, one that upholds whiteness as the normative centre of knowledge production and ethical practice. These dynamics have material consequences. BIPOC students and professionals are often subjected to microaggressions, tokenism and surveillance in academic and clinical settings, creating hostile learning and working environments that hinder retention and well-being. Moreover, the absence of culturally relevant curricula and diverse faculty undermines the profession's capacity to meet the health needs of racialized communities, which can further exacerbate existing health inequities. To address structural and epistemic racism, nursing must move beyond superficial commitments to diversity and instead engage in critical self-examination of its foundational assumptions, institutional practices and knowledge hierarchies. This includes incorporating anti-racist pedagogies, valuing Indigenous and community-based epistemologies and redistributing power within professional structures to ensure that historically marginalised voices shape the future of nursing education and practice. Only by addressing these layered forms of injustice can nursing begin to fulfil its ethical commitment to equity, justice, and holistic care. Clinical racism undermines therapeutic relationships, compromises care quality, and exacerbates health disparities leading to inequity. Discriminatory practices, such as racial stereotyping, communication exclusion and patient mistrust, persist in Australian healthcare settings, particularly affecting nurses of African and Asian descent (Dywili et al. 2021). For racialized patients, such experiences can have life-threatening consequences. Racial bias has been shown to influence pain management decisions, diagnostic accuracy and triage protocols (RACGP 2025). Racism impacts patient outcomes through creating inequitable environments that foster distrust, disparities and diminished access to care (AHRC 2025). Global nursing shortages exacerbated by aging populations, underinvestment in health systems and pandemic-induced burnout have intensified aggressive recruitment campaigns by high-income countries (HICs), many of which disproportionately target nations in the Global South. Countries like the United Kingdom, the United States of America, Canada, New Zealand and Australia have increasingly relied on the migration of nurses from countries such as Ghana, Nigeria, Kenya, the Caribbean, Zambia, India and the Philippines to sustain their healthcare systems. The UK's continued recruitment of nurses from sub-Saharan Africa, despite World Health Organization (WHO) guidelines discouraging active recruitment from nations with critical health workforce shortages, has sparked renewed critiques of neo-colonial labour extraction. The President of the National Association of Gambia Nurses and Midwives warned that their health systems are vulnerable and fragile because of the loss of experienced skilled healthcare workforce to western countries. This pattern reflects a broader global political economy of care in which human resources from the Global South are routinely extracted to meet the care deficits of the Global North, a dynamic that can be described as ‘care drain’. These practices reproduce neocolonial hierarchies in which the South continues to subsidise the North through the loss of skilled labour, with little regard for the sustainability of health systems in sending countries. Such forms of migration are often framed through a liberal discourse of opportunity and mobility, but this obscures the structural inequalities and policy failures that compel nurses to migrate, including low wages, lack of career progression and political instability at home. Once they are in HICs workforce, African and other internationally educated nurses (IENs) frequently encounter racialized forms of devaluation. Research documents widespread deskilling, where experienced nurses are either relegated to lower-status roles or required to repeat qualifications to be deemed ‘competent’ by local regulatory bodies (Bayuo et al. 2023; Mapedzahama et al. 2018). Their linguistic fluency is often questioned, with accent discrimination emerging as a persistent barrier to career advancement and social integration (Gnevsheva 2025). These forms of epistemic injustice suggest not merely an issue of regulatory mismatch but a deeper denial of the legitimacy and value of non-Western expertise within global nursing practice. Critically, the transnational recruitment of nurses must be understood within a matrix of intersecting racial, economic and geopolitical inequalities. Global care chains are structured by the uneven legacies of colonialism and capitalist accumulation, wherein the bodies of racialised women from the Global South are mobilised to uphold health systems in the Global North. The ethical implications extend beyond questions of fairness and consent to the very foundations of global health governance and labour justice. Calls for ‘ethical recruitment’ often fall short when they fail to address the asymmetrical power relations and histories of extraction that underpin global health labour flows. To move towards a more equitable global health system, there is a pressing need for policy frameworks that prioritise health system strengthening in source countries, ensure fair credential recognition and uphold the dignity and rights of migrant nurses. More fundamentally, this requires challenging the racialised and gendered logics that treat care work and those who perform it as endlessly mobile and expendable. We believe that while the concept of cultural competence has become a staple in nursing education and practice, its widespread adoption has done little to disrupt the deep-seated structures of racism embedded in healthcare systems. Rooted in the liberal multicultural ideal of understanding and respecting ‘difference’, cultural competence tends to frame racism as a problem of individual ignorance or interpersonal misunderstanding, rather than as a product of institutional power relations and historical injustice. Cultural competence frameworks often sanitise the realities of racial oppression by focusing on static cultural traits, thereby individualising racism and deflecting attention from the broader structural conditions that sustain it. The limitations of cultural competence are compounded by its tendency to reinforce white normativity as the baseline against which ‘other’ cultures are measured. In this model, whiteness remains invisible, unexamined and structurally privileged, whereas racially minoritised individuals are positioned as “diverse” subjects whose cultures require translation, tolerance, or management. Consequently, cultural competence often becomes a managerial tool aimed at improving communication or patient satisfaction rather than a transformative ethic that interrogates systemic power imbalances in healthcare and education. In contrast, anti-racist frameworks call for a fundamental reorientation of nursing's epistemological, pedagogical, and institutional foundations (Tembo 2024). Anti-racism demands more than symbolism and gestures, it requires confronting uncomfortable truths including nursing's continued ties to colonial legacies of exclusion. This confrontation necessitates a shift from inclusion to justice: moving beyond representational diversity to the redistribution of power, resources and voice in decision-making and knowledge production. Anti-racism in nursing thus involves not only naming racism but actively working to dismantle the systems that reproduce it through policy reform, leadership diversification and curriculum decolonisation. At the heart of this project is the call to de-centre whiteness as the normative epistemic frame in nursing. This includes critically examining who is considered a knowledge-holder, whose research is funded and published, and whose histories are taught as part of the nursing canon. Anti-racist and decolonial approaches must also attend to epistemic justice i.e., the right of racialized communities to be recognised as legitimate producers of knowledge. This means not merely adding ‘diverse’ perspectives to an otherwise unchanged curriculum but rethinking the very structures and logics that have historically excluded them. Moreover, anti-racist nursing practice must be underpinned by critical consciousness, which is the ability to perceive social, political and economic oppression and to act against the oppressive elements of reality. In this context, nurses and educators are called to move from passive awareness to active resistance: to challenge racist practices in clinical care, speak out against discriminatory policies and advocate for institutional accountability. This orientation positions anti-racism not as a supplementary competence but as a professional and ethical imperative central to the integrity of nursing itself. Racism in nursing is not an aberration but a reflection of broader societal and historical injustices. It manifests in who becomes a nurse, who leads, whose knowledge counts and who thrives. More importantly, it stipulates who validates race knowledge and claims and these are usually white people. Addressing racism requires not only cultural sensitivity but also calls for structural change leading to epistemic justice. To tackle racism and make healthcare equitable and fair for everyone, we need to change the way nurses are taught, decide what constitutes knowledge claims and how they work and experience the profession in its entirety. Nursing, as a profession of care, must now also become a profession of social and epistemic justice. Open access publishing facilitated by The University of Sydney, as part of the Wiley - The University of Sydney agreement via the Council of Australian University Librarians. The authors declare no conflicts of interest. The authors have nothing to report.

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