By Nora Beebe ’26

Majors: Philosophy and Political Science; Minor: Religious Studies

Brief Description: This piece discusses the virtues needed by both patients and nurses when patients lack the ability for full cognitive function. This paper focus on African American female nurses and Alzheimer patients in order to emphasize how the intersectionality between race and gender are prevalent issues within the caregiving environment.

Contributor Biography: Nora is a student of Philosophy and Political Science at Washington College. Her interest in the ethics of caregiving was fostered by her own experiences caregiving for a family member as well as spending the last three summers working at a wound care manufacturing facility that served nursing homes throughout the United States.

The following was written for PHL 325: Biomedical Ethics

Introduction

Case study

Susan L is a 35-year-old nurse that works in freelance health care. Susan is an African American woman and has been practicing medicine for many years. Due to her experience, she was hired by a family to take care of Mark B. Mark B is an 85-year-old man diagnosed with Alzheimer’s disease which causes a progressive decrease in memory and mental functions. At first, the nurse is met with small comments about her disparaging intellect, the type of comments that every black female has heard before. As she is taking care of him and the days progress, his comments escalate. He asks for coffee “the color of her skin” and constantly asks her to bend over and pick objects up for him. The nurse continues for the next several weeks to take care of this man but is met with a worsening of his actions as his dementia progresses. She does not know who to go to since the patient lacks the mental facilities to understand the implications of his actions and being in freelance home healthcare means she does not have a human resources department.^[1]

Thesis

On a whole, nursing occurs in a racialized and gendered context. This causes black female nurses to be faced with harassment and discrimination by patients who regard them as merely “dark eye-candy,” especially by patients who have Alzheimer’s and fail to recognize the impacts of their words and actions. This brings me to my question: what kind of values and practices are required to keep the patient-nurse relationship healthy while navigating a highly racialized and gendered society? I plan to examine the virtues of compassion and respect in order to explore how they differ depending on who is the recipient and who is practicing the virtue.     

Justification

            This question is extremely important to all nurses and the medical industry in general, especially in regard to the national nursing shortage. It is important to find out how to navigate the issue of keeping the patient-nurse relationship healthy in order to keep nurses and not have them retire or quit because of the day-to-day abuse and harassment that some face. This is especially essential when considering that some patients grew up in times when sexual harassment was viewed as “cute behavior” and the antiquated notion that racism was acceptable. In situations where patients regress back to their adolescent or teenage self and exhibit these racist and intolerable notions, it is paramount that there is a way to address those issues for nurses, especially when the nurse is the primary caretaker of the patient and is stuck in this constant cycle of abuse.

            Racial and sexual injustice has been a cornerstone in American culture since the beginning of American society. I intend to focus on the black female nurse experience and how to keep the patient-nurse relationship healthy especially considering patient mental conditions like Alzheimer’s. Most studies that I found focus only on the black female nurse experience and lack ideas of sexual and racial assault and the added complexity of the mental conditions of patients. I intend on addressing this gap within my research paper, considering the fact that patients can lash out in stressful situations while also balancing the fact that black female nurses deserve to be treated with the utmost care and respect. I will only be covering the black female experience in this paper and not the genderqueer experience, which brings along its own set of challenges. 

Background

Critical Race Theory

 To be a black woman is to be thrust into a subordinate role in a society of power hierarchies. Critical race theory is the idea that there is a history of oppression of black people and that that history still causes them to be oppressed to this day. Critical Race Theory focuses on how laws, media, and in general the American perception of people of color are formed by social concepts of race. Critical Race Theory is founded on the idea that the laws of the United States carry within them racist principles that unjustly affect people of color. Typically, Critical Race Theory is used by theorists to eliminate unjust racial hierarchies. Critical Race Theory is especially important in the hospital environment, as there are already multiple power hierarchies, including the hierarchy of the nurse and the patient. Typically, it is seeing that the nurse will do whatever the patient will want, and black nurses are treated much worse than white nurses because of that idea. Furthermore, black nurses are typically met with reduced pay and reduced opportunities because of this inherently racist environment that they are subjected to when working at a hospital. This fact is seen in Women’s Lives Into Printwhere a black nurse, known as G, experiences the racial hierarchy that is found within hospitals.

G worked as a sister on a gynaecological ward for twelve years, and is now having a rest from the NHS [National Health Service], which she thinks has become a deeply racist institution… G was the senior Sister on her ward by many years, but she was given a lower grading (and hence a lower salary) than her white co-worker. Her tribunal appeal was never heard… She can provide numerous examples of the poor treatment black nursing staff received during regrading at her hospital and the preferential treatment shown to whites^[2]

The hospital itself may not realize these racist practices, but Critical Race Theory implies that they are there inherently within the practices of the hospital, as well as the National Health Service.

Ideals and Stereotypes of Black Female Nurses

Nurses are forced to deal with the stereotypes placed on them by patients in their care. There are a lot of assumptions associated with nursing: there is the idea that a “good nurse” is female, white, blonde, attractive, and angelic. That is the nurse that is portrayed throughout the media and throughout the American consciousness. Constantly seen in movies, jokes, and television shows is a degradation of this sacred profession. Even decorating people’s skin are pin-up tattoos of nurses. A study done by Beatrice J. Kalisch, Philip A. Kalisch, and Mary L. McHugh found that “73% of the motion picture nurses”^[3] were portrayed as sex objects. However, the stereotype of nurses as female, white, blonde, attractive, and angelic is only the reality for a small percentage of nurses in America. Many nurses do not fit these stereotypes and are oftentimes women of color who face backlash due to their race. The stereotypes that nurses face seem to compound when they are African American. Within the last century, black women have been stereotyped as being

sexually promiscuous… The myth of the lascivious Black woman was systematically perpetuated after slavery ended. While white women were placed on moral pedestals, ‘[e]very black woman was, by definition, a slut according to this racist mythology,’ writes historian Gerda Lerner.^[4]

This causes a lot of older white men to see African American females as subordinate to them as that was the common view during the time they grew up. This causes them to believe that it is okay to make racist remarks as it was deemed “normal behavior” during that time; this is further considering patients with Alzheimer’s who say hateful things because they are unable to express the problems they are facing, such as an unfamiliar environment and pain.

Virtues

The Virtues Necessary for a Healthy Patient-Nurse Relationship

Respect and Compassion are essential to promoting a healthy patient-nurse relationship. Acknowledging a person’s autonomy and allowing it to flourish means adhering to these virtues.

Worsening someone’s mental and physical health violates their autonomy by impacting their ability to function fully. The study Sexual harassment against female nurses: a systematic review found that “35% of the female nurses (ranged 21.1 to 46.6%) [were] faced with verbal sexual harassment [from their patients]” and “In respect of the physical sexual harassment type, 31% of participants (ranged 11.64 to 59.7%) were harassed physically.” The study also found that nurses who experience sexual and verbal harassment were left with mental and physical problems. Nurses were found to have “mental health consequences [such] as anxiety, depression and stress” and physical health consequences such as “headache, exhaustion and for gastrointestinal disturbances gastritis, nausea or vomiting, weight gain or weight loss, neuromuscular problems such as muscle pain or convulsion and dizziness.”^[5] All of these issues impact their ability to live their day-to-day lives and to care for their own patients. 

It is critical that in this time of nursing shortages, hospitals focus on practices that keep nurses in their field and make them feel respected. The main problem is the verbal and sexual harassment, but also hospitals’ unwillingness to address it. Nurses are faced with a duty to give care to every patient, but are also faced with a duty to themselves to be treated fairly. No nurse should ever be scared to go to work for fear of being groped and called racial slurs. 

Critique

Patient’s Need For Compassion

However, some would point out that sexual assault when caused by older patients is sometimes caused by loneliness as well as stress. Patients are prone to lash out due to the stressful and unfamiliar nature of the hospital environment. The article The gray zone of patient‐nurse communication: Inappropriate sexual behavior found that especially in older adults,

ISB may arise as a means of attracting attention and meeting the need for intimacy and closeness because older people need as much intimacy and closeness as younger people… In addition, elderly people, especially those with cognitive impairment, experience multiple losses and the condition can be extremely stressful for them. At this point, the need for closeness exhibited by the patient may arise due to efforts spent on coping with stress.^[6]

This behavior, even though explainable, is not acceptable. Just because a patient is experiencing high levels of stress does not mean that they can sexually or verbally assault a nurse. It is important that when a patient is experiencing these problems, they speak about it with a nurse or a counselor instead of violating the autonomy of another person. By treating nurses with respect and compassion, issues like these can be avoided. Furthermore, by nurses treating their patients with those same virtues, the stressful effects of a hospital environment can be limited. Things like keeping personal belongings with a patient, as well as maintaining a level of privacy, allow for a patient to better adjust to their new situation. Even small things, like the nurse knocking on the door before entering the room, allow the patient to feel respected in an environment that they feel powerless in.

Patients with Alzheimer’s

            What about patients with mental conditions who do not have full control over their brain? Is it fair to hold them to the same moral standard as older patients when they lack the mental facilities to make moral decisions? The article The gray zone of patient‐nurse communication: Inappropriate sexual behavior found that with patients with Alzheimer’s, inappropriate sexual behavior (ISB) can be caused

due to physical changes in the brain structure stemming from dementia and problems related to memory loss, impaired judgment, and lack of impulse control. The frontal lobe function is often impaired in dementia and may trigger inappropriate behavior. As a result, the ISB exhibited by the patient may not arise as a direct expression of sexuality or as an attempt to satisfy sexual needs; rather, it may be the result of the improper management of unmet needs.^[7]

Since these patients lack the ability to make rational moral decisions, it is even more crucial to use respect and compassion. Perhaps not from the patients to the nurses, but from the nurses to the patients. It is important that nurses understand that sometimes when a patient does or says certain things, they are simply lashing out because of a bigger issue. There is also respect and compassion needed on the part of the hospital. When a nurse expresses a great amount of discomfort after dealing with a patient with Alzheimer’s who is racially and sexually abusive, it is important that the hospital listen to their nurses. Sometimes it is paramount that a nurse stop working with that patient in order to prevent the nurse from being in a long-term unhealthy environment. A healthy line of hospital-nurse communication is essential to fixing the patient-nurse relationship.

Nurses Sexually Assault Patients

            In some cases, nurses are the ones who take advantage of vulnerable patients. These nurses take advantage of the position of power they have over their patients. Patients often believe that they cannot report when a nurse is abusing them because then they will not be provided the same level of care. Nurses often abuse patients with Alzheimer’s who do not have the mental facilities to refuse and/or report them. Within nursing homes, especially, this type of abuse is prevalent. A press release from the New York State Office of the Attorney General titled Attorney General James Announces Conviction of Former Nursing Home Employee for Raping a Resident Suffering from Dementia, 

New York Attorney General Letitia James today announced that Khadka Pradhan, 52, of Rochester was found guilty of raping and otherwise sexually assaulting an 81-year-old resident suffering from dementia at the Shore Winds Nursing Home in Rochester, where he worked as a housekeeper in September 2021. “Khadka Pradhan hideously violated an elderly woman with dementia in her home, where her loved ones trusted she would be cared for and protected,” said Attorney General James. “Pradhan abused and took advantage of our most vulnerable, and today, the jury convicted him of these heinous and reprehensible crimes.”^[8]

In cases where nurses abuse their patients, respect and compassion are needed from other members of the hospital environment in order to make sure that every patient has a voice and can speak up without fear when they are being abused. Respect is required in instances when it is a he said, she said situation and the patient has Alzheimer’s. Just because they have a disease that impacts their mental functions does not mean that their accusations should not be taken seriously. Other nurses need to side in favor of what a patient is saying over a colleague in instances like these. Moreover, compassion is of the utmost necessity when it comes to aiding a patient who is a victim of verbal or sexual assault. It is important to realize that they will not trust the hospital staff and be wary of them. By taking more time when interacting with these patients to make sure that there is no unnecessary stress added, that will help the patient remain as calm as possible. 

Concluding Thoughts

            In every society, compassion and respect should be the foundation of how humans interact with one another. In a hospital environment, this becomes increasingly essential. When humans are faced with high stress situations, they tend to lash out.  This is not just limited to patients, but to nurses as well. Compassion and respect allow stress caused by environments to lessen. Sometimes it really is the little things, like saying “please” and “thank you,” that make a big difference, as well as making sure that patients have their personal items with them at all times. The virtues can limit the causes by which harassment occurs in a hospital setting, and will allow it to be healthier for every single person involved. Respect and compassion need to go both ways in order to make this relationship healthy. Autonomy, above all else, is facilitated by respect and compassion. Compassion must be utilized by both nurses and patients to allow for mercy and grace within the stressful hospital environment. Both respect and compassion involve looking past race and gender and acknowledging that we are all human beings living on the same planet deserving of an equality of treatment based on the principle of personhood. 

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^[1]I’m grateful to the help of ….  Whose insights helped me make this case more powerful.

^[2] Pauline Polkey and Hallam Julia, “Self-Image and Occupational Identity: Barbadian Nurses in Post-War Britain,” in Womens Lives into Print: The Theory Practice and Writing of Feminist Auto/Biography (New York, NY: Macmillan, 1999), pp. 131-151, 146.

^[3] Beatrice J. Kalisch, Philip A. Kalisch, and Mary L. McHugh, “The Nurse as a Sex Object in Motion Pictures, 1930 to 1980,” Research in Nursing &Amp; Health 5, no. 3 (1982): pp. 147-154, https://doi.org/10.1002/nur.4770050306, 151.

^[4] Dorothy E. Roberts, Killing the Black Body: Race, Reproduction, and the Meaning of Liberty (New York, NY: Vintage, 1999), 11.

^[5] M Hasanpour et al., “Sexual Harassment against Female Nurses: A Systematic Review,” BMC nursing (U.S. National Library of Medicine, 2020), https://pubmed.ncbi.nlm.nih.gov/32612455/.

^[6] Buldukoglu K and Uslu E, “The Gray Zone of Patient-Nurse Communication: Inappropriate Sexual Behavior,” Perspectives in psychiatric care (U.S. National Library of Medicine, 2021), https://pubmed.ncbi.nlm.nih.gov/32730666/.

^[7] Ibid.

^[8] “Attorney General James Announces Conviction of Former Nursing Home Employee for Raping a Resident Suffering from Dementia.” New York State Office of the Attorney General. New York State Attorney General, 2022. https://ag.ny.gov/press-release/2022/attorney-general-james-announces-conviction-former-nursing-home-employee-raping.