The Evolution of Inclusion

Although Gallup polls have deemed nursing the nation’s most esteemed profession for the past 17 years, that wasn’t always the case. In the mid-19th century, when Florence Nightingale was inventing the field as we now know it, the guardians of he status quo resisted her efforts at every turn. But Nightingale clearly triumphed. Among her enduring legacies has been the embrace by nursing of an evolving culture of inclusion—of increasingly diverse patients, nurses, and teachers of nurses.

This is an apt moment to celebrate that evolution—and to examine how far it still has to go. The World Health Organization has designated 2020 as the International Year of the Nurse and the Midwife, in honor of the 200th anniversary of Nightingale’s birth. At the same time, this year has seen an unprecedented explosion in public awareness of the impact of racism—and demands for its rectification—sparked by the brutal death of George Floyd, yet another Black life lost to police violence, and by a pandemic that has killed people of color at more than twice the rate of whites.

“Society as a whole has reached a time of reckoning,” says Vivian Taylor, EdD, Columbia Nursing’s associate dean for diversity and cultural affairs. “And because racism and other forms of injustice have an enormous impact on public health, the nursing field has a special duty to grapple with these issues. At Columbia Nursing, we take that responsibility very seriously. It means acknowledging our shortcomings as well as our strengths and always looking for ways to do better.”

Roots of the Current Reckoning

The school’s social-justice journey has its roots in Nightingale’s own radicalism. However straitlaced her Victorian mannerisms now appear, the “lady with the lamp” was in many ways an iconoclast. Her first heresy was to declare that women could benefit from having a career outside the home—and that society could benefit from their skills and dedication. “Passion, intellect, moral activity,” she wrote, “have never been satisfied in a woman.” Through nursing, she proclaimed, those drives could be fulfilled in service to the wider world.

Even more shockingly for her time, Nightingale also contended that everyone—not just a privileged few—had a right to quality health care. When she began her work, only the wealthy had access to physicians, and they were treated in the comfort of their own homes. Less affluent patients were tended by family members when they fell ill; if none were available, many landed in filthy almshouses, often staffed by vagrants or ex-convicts with no medical skills. Conditions at the few public hospitals were little better. Only a handful of church-run institutions offered care by trained nurses, typically nuns or deaconesses.

Nightingale began crusading against such inequities. In 1853, when she became superintendent of the Institute for the Care of Sick Gentlewomen in London, she threatened to resign unless the hospital committee abolished a rule excluding Catholic patients. She insisted on admitting Jews and Muslims, too.

A year later, when Britain entered the Crimean War, Nightingale led a squad of 38 volunteer nurses to work at a military hospital in Turkey. There, she found that the high command’s contempt for common soldiers contributed to staggering death rates among the wounded. Inadequately fed and clothed on wintry battlefields, then warehoused in crowded, vermin-infested hospitals, soldiers were perishing in vast numbers. After a successful campaign to improve conditions there, Nightingale championed sanitary reforms—and the creation of a skilled nursing workforce—in medi-cal facilities around the world. She went on to fight for other measures aimed at uplifting the downtrodden, including improved housing, clean water, the repeal of harsh prostitution laws, and famine relief in India.

Reform-Minded Principles

Nursing thus carries a set of reform-minded principles in its DNA. From the start, the idea that the profession should serve patients at every level of society has been entwined with the notion that nurses from marginalized populations—beginning with women, who could neither vote nor hold office in Nightingale’s day—bring special strengths to the field.

Those precepts have also long informed the mission of the Columbia University School of Nursing. Yet, as with all genetic material, their expression has evolved over time. 

Presbyterian Hospital in New York City, established in 1868, was among the first hospitals in America founded on a vision as inclusive as Nightingale’s. A tablet by the entrance read, “For the Poor of New York Without Regard to Race, Creed or Color.” The facility was also among the first to adopt Nightingale’s model of nursing, which emphasized cleanliness, order, careful clinical observation, and a sympathetic attentiveness to patients’ needs.

Twenty years later, when Presbyterian launched its Training School for Nurses (as Columbia Nursing was initially known), the trustees recruited one of the era’s foremost nurse educators as the school’s first dean: Anna Maxwell, who had built similar programs at three other major hospitals. A dynamic innovator, Maxwell was determined to modernize the field, while fostering “that true love of humanity, which makes the helpful and successful nurse.” Indeed, Maxwell has been called “the American Florence Nightingale.” She insisted that students master the latest technologies—stethoscopes, hypodermics, thermometers, anesthetics—as well as studying topics ranging from anatomy and bacteriology to obstetrics and surgery.

Having proven that women could handle such challenges, Maxwell then pushed to expand their sphere of action. When the Spanish-American War erupted in 1898, she helped spearhead a campaign to send units of trained nurses—under their own command, not that of doctors—to field hospitals. Maxwell herself led a contingent of 200 nurses to Camp Thomas in Georgia, where they treated nearly 1,000 sick and wounded troops. Soon afterward, she and her allies persuaded Congress to create the U.S. Army Nurse Corps.

Back at Presbyterian, Maxwell mobilized an army of nurses clad in gingham uniforms to care for ailing New Yorkers in their homes. Established in 1904, the Department of Visiting Nursing and Social Service sent nurses throughout much of the city, providing their services to the neediest New Yorkers free of charge.

Over the following decades, the school continued to offer women a path to professional fulfillment when few other such options existed. At the same time, its students and graduates served patients at every sociocultural level. Yet as America’s population became increasingly diverse, the school’s own makeup didn’t reflect those changes.

Indeed, discrimination remained the norm in U.S. health care generally, even at Columbia-Presbyterian (as the hospital was renamed after affiliating in 1928 with the university). Despite the openminded plaque at its entrance, the institution long declined to hire Black doctors or nurses and denied private rooms to Black patients. Although those policies ended after World War II, the nursing school didn’t graduate its first Black student until 1958. And four years passed before another one enrolled.

Rekindling a Crusading Spirit

The political upheavals of the 1960s, however, brought a return of the crusading Nightingalian spirit to Columbia Nursing. Many students marched for the causes of the time—and called for their school to diversify. In 1970, the Black Caucus of Columbia-Presbyterian wrote to Dean Mary Crawford, decrying the paucity of nonwhite student nurses. Soon afterward, Crawford created the post of Recruiter of Minority Group Students. Gradually, probationers’ faces became less monochromatic. 

Another transformation began in 1970, when the school—responding to the era’s changing perception of gender roles—enrolled its first two men. One was Ramón Lavandero, BS ’72, MS, a physician’s grandson from Puerto Rico who’d discovered a passion for patient care while volunteering at a local clinic in high school. After starting college at the University of Miami, Lavandero transferred to Columbia Nursing’s BS program on the advice of a family friend who’d become medical director of New York’s Beth Israel Hospital. 

Lavandero was also one of the school’s first Latino students, but his gender is what set him apart—quite literally. He was assigned a room on the second floor of Maxwell Hall, in a wing sealed off by a fire door, where men from other schools would stay while doing rotations at Columbia-Presbyterian. (Fellow pioneer John Mladinich, BS ’72, lived at home with his parents.) In those days, nonfemale visitors to the dorm were strictly monitored; when a woman brought one upstairs, she had to call out, “Man on the floor!” Even Lavandero was required to announce himself whenever he ventured beyond his corridor. “As a joke,” he recalls, “I posted a sign on my hall door: ‘Reverse Isolation Unit.’”

Nonetheless, he managed to bond with many female classmates and in his senior year was voted student body president. Though some male physicians bristled at his presence (particularly in the delivery room), most nurs-ing faculty members were friendly and supportive. “They treated me like someone who was going to become their colleague,” recalls Lavandero, who did exactly that—eventually becoming a senior nursing administrator, an adjunct faculty member at Yale, and an executive with the American Association of Critical-Care Nurses.

Stressing Cultural Competency

By the 1980s, Columbia Nursing’s student body was relatively heterogeneous. Yet the faculty remained overwhelmingly white, in part because of the shortage of minority candidates with advanced degrees. One exception was Betty Watts Carrington, MS ’71,  EdD ’86, an alumna of the nurse-midwifery program who became its director in 1986. Nearly three decades earlier, Carrington had been the only Black student in her BSN class at the University of Michigan. “Back then, a lot of doctors didn’t want me touching their white patients,” she recalls. “And that remained the case when I began practice as a certified nurse-midwife in the early ’70s. I was hired to care for clinic patients who were all Black or Latino. The white doctors wouldn’t let me or my nurse-midwife colleagues provide services to their private patients.”

When Carrington started her new position at Columbia, she says, “there had not been a person of color in charge of a graduate nursing program. It was like walking the plank.” One of her primary missions was to increase nurse-midwives’ sensitivity toward African-American and Caribbean patients. To do that, she developed an affiliation between the school and Harlem Hospital, where she supervised students. She brought students to the Abyssinian Baptist Church, the Schomburg Center for Research in Black Culture, and Sylvia’s Restaurant—a local temple of soul food. She also taught a course on how to help minority patients eat healthily within their own culinary traditions.

“I really stressed cultural competency,” explains Carrington, who was among the earliest advocates of that concept. “I wanted students to realize that as a nurse-midwife, you are a change agent. You need to open your eyes and try to understand the women you care for. I wanted them to know not everybody eats eggs and bacon.”

By the end of the decade, such lessons were widely seen as central to improving nursing practice. Learning how to tailor health care programs to meet the needs of diverse populations became a key goal of Columbia Nursing’s research programs. Administrators were also coming to realize that recruiting minority students wasn’t enough; they needed to provide support so they could flourish. 

In 1990, the school launched its first such effort: the Office of Multicultural Affairs, which offered services ranging from open-agenda group meetings to seminars on study skills, time management, and writing. The students, in turn, brought new energy and purpose to the school, as well as skills and perceptions that strengthened nursing as a whole. 

One alumna has a special perspective on those contributions: Sharon Robinson, MS ’76, whose father, the legendary Jackie Robinson, integrated Major League Baseball (MLB) in 1947. The younger Robinson returned to Columbia Nursing as a faculty member in 1979, three years after graduating from the nurse-midwifery program. She later taught at other universities, practiced at several hospitals, ran an MLB children’s essay program, served as vice chair of the Jackie Robinson Foundation, and wrote memoirs and children’s books. Perhaps unsurprisingly, she uses a sports analogy to describe the impact of students of color on her chosen field. 

“Besides breaking the color barrier in baseball, my dad changed people’s perceptions of the game,” Robinson explains. “He brought a new style of play that he’d learned in the Negro Leagues and made baseball more interesting as a sport. Diversity doesn’t just contribute to equity and justice; it helps us function as a more holistic society—whether in baseball or midwifery practice.”

In the LGBTQ Vanguard

In recent years, as the concept of diversity has come to include sexual orientation and gender identity, Columbia Nursing has remained in the vanguard. PhD candidates who wish to focus on LGBTQ issues receive expert mentoring and institutional support. Those topics are also discussed in a growing range of core and specialty courses, as well as in extracurricular presentations and seminars. The school co-leads the groundbreaking Program for the Study of LGBT Health (a collaboration with the Columbia University Department of Psychiatry and the New York State Psychiatric Institute), whose mission is to promote the health and wellness of lesbian, gay, bisexual, and transgender people through research, clinical practice, education, and training—and to influence public policy in the United States and beyond. The Washington Heights practice of the ColumbiaDoctors Primary Care Nurse Practitioner Group, the school’s faculty practice, was the first in Upper Manhattan to offer a full range of LGBTQ-specific services. 

And in November 2019, the school hosted the first National Nursing LGBTQ Health Summit. The conference, which focused on advancing nursing’s progress in addressing LGBTQ health issues, drew deans and other leaders from nursing schools across the country, as well as representatives of the American Academy of Nursing, the American Association of Colleges of Nursing, and the National Institutes of Health. Participants brainstormed strategies for raising awareness of LGBTQ health around nursing education, research, and practice—with the ultimate goal of creating a national health action plan to achieve those goals. 

“Columbia Nursing is probably unparalleled among schools that do work in this area,” says Tonda Hughes, PhD, RN, associate dean of global health, who led the summit. “I don’t think there’s any other place like it in terms of its rich resources. It’s a really exciting place to be.”

A Never-Ending Quest

Today, the profession of nursing reflects the demographics of the U.S. population far better than it did in Florence Nightingale’s day. At Columbia Nursing, underrepresented minorities make up 54 percent of the student body, compared to 40 percent of the nation at large. (And the faculty, at 28 percent, is catching up.) Still, the pursuit of equity and justice in health care—the cause that drove Nightingale more than any other—is a neverending quest.

The school has redoubled its focus on diversity since the appointment of Dean Lorraine Frazier, PhD, in the fall of 2018. In part, this reflects the dean’s personal knowledge of what it means to be marginalized. Born in Northern Ireland to a Catholic father and a Protestant mother, she immigrated to Houston with her family at age eight to escape sectarian strife. Like many immigrant families, hers struggled to adjust to their adopted country. “We came from a small, rural community, and my father didn’t drive,” she recalls. “I remember a time when he took three buses to get to work.” The family’s troubles intensified after her father developed glomerulonephritis as a result of an untreated strep throat. “We didn’t know the health-care system. It was a challenge for us in ways that you really have to go through to understand.”

Having a daughter with disabilities adds to Dean Frazier’s insights. “I know what it’s like to go into nice restaurants and never be ‘seen,’” she says. “We make people uncomfortable, so they look away.” These experiences fuel her passion for improving society’s sensitivity toward differences—particularly within health care—and for ensuring that Columbia takes a leading role in that cause.

In May 2019, Columbia Nursing held a day-long retreat to ponder fresh approaches to such issues. The result was a campaign called the Social Justice and Health Equity Commitment, whose statement of principles declares that the school opposes social forces that “harm people, groups, and communities through marginalization, exclusion, exploitation, and voicelessness” and supports the elimination of barriers to health based on “race or ethnicity; religion; socioeconomic status; gender; age; mental health; cognitive, sensory, or physical disabilities; sexual orientation or gender identity; geographic location; or other characteristics.”

That commitment quickly led to a variety of initiatives. The school established a social justice/health equity assessment as part of the faculty and staff annual review process, with all employees asked to participate in at least two consciousness-raising activities related to issues of bias, diversity, and inclusion. The Office of Diversity and Cultural Affairs (ODCA), directed by Associate Dean Taylor, launched a series of workshops, films, and discussions aimed at building diversity aware-ness. The ODCA also established a new Subcommit-tee on Fostering an Inclusive Environment and began taking other steps to increase community engagement, promote recruitment of minority faculty, and support curricular content that boosts cultural competence and sensitivity toward health disparities. In March 2020, Jacquelyn Taylor, PhD, RN—nationally recog-nized for her research on minority health (but no relation to Associate Dean Tay-lor)—was named the Helen F. Pettit Professor of Nursing and director of the new Center for Research on People of Color.

A Whole New Level

And then, after the horrifying video of a white officer kneeling on George Floyd’s neck went viral, the school was swept up in the wave of protest that spread across the nation and the world. “We’ve never seen such a diverse and sustained movement to dismantle racism and white supremacy,” observes Associate Dean Taylor. “White people, particularly, are talking about these things at a whole new level.”

Many members of the Columbia Nursing community joined marches and rallies, with the administration’s support; a team led by MDE student Shayna Feuer distributed masks for COVID-19 protection to protestors. Meanwhile, Columbia University Irving Medical Center formed six campus-wide task forces to address structural racism—focusing on education, training, and curriculum; clinical care; community and public programs; population and implementation sciences; faculty recruitment and retention; and civility—each of which includes a faculty representative from the School of Nursing. In addition, the school has launched its own task force to disseminate anti-racism resources for students, faculty, and staff. 

More such projects are in the pipeline, and still more have yet to be imagined. “There’s a lot of great work to be done,” Dean Frazier says. “And this is the perfect time for us to be doing it.” 

This article originally appeared in the Fall 2020 issue of Columbia Nursing magazine.