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"Making sense of difference" : the social organization of intergroup relations in health care provision Reimer Kirkham, Sheryl Marie 2000

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"MAKING SENSE OF DIFFERENCE":  T H E SOCIAL ORGANIZATION  I N T E R G R O U P R E L A T I O N S IN H E A L T H C A R E P R O V I S I O N  Sheryl Marie Reimer Kirkham R.N., Grace General Hospital, Winnipeg, 1979 B.S.N. University of Victoria, 1988 M.S.N. University of British Columbia, 1995  A THESIS SUBMITTED IN PARTIAL F U L F I L L M E N T OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY in THE F A C U L T Y OF G R A D U A T E STUDIES School of Nursing  We a^ceg^this thesis as conforming to the required standard  THE UNIVERSITY OF BRITISH C O L U M B I A March, 2000 © Sheryl Marie Reimer Kirkham, 2000  OF  In presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of British Columbia, I agree that the Library shall make it freely available for reference and study. 1 further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the head of my department  or  by  his or  her  representatives.  It  is  understood that  copying or  publication of this thesis for financial gain shall not be allowed without my written permission.  Department of frAu f'5i r»<^ The University of British Columbia Vancouver, Canada Date  DE-6 (2/88)  f*W  ICO  Abstract "MAKING SENSE OF DIFFERENCE": T H E SOCIAL ORGANIZATION OF INTERGROUP RELATIONS IN H E A L T H CARE PROVISION Despite growing evidence of racialized health care experiences and inequitable health outcomes for patients of Colour, theoretical and practice responses have not typically addressed these concerns. This ethnographic study approached this problem by examining the social organization of intergroup relations in health care provision, beginning with the standpoints of nurses and patients. Over one year, the investigator conducted 220 hours of field work and interviews with 30 health care providers and five patients on three surgical units in two hospitals. Through this process of research, intergroup relations in health care provision were revealed as more complicated than commonly represented. Under ideal conditions, intergroup provider-recipient encounters illustrated "connected care", marked by respectful interpersonal connections, an understanding of the illness experience from the patient's perspective, and a holistic grasp of the patient's health care needs. Interpretive lenses were employed by nurses to make sense of "difference" and influenced how they provided intergroup care. However, various factors negatively influenced the provision of connected care. Depending on their interpretive lenses, individual nurses might participate in racialized discourses and practices. Recent trends brought about by health care reform, along with longstanding issues such as functional approaches, the immediate nature of nurses' work, and biomedical dominance, came together in particular ways to constitute nurses' work as disjunctured and "heavy", and mitigated connected care, especially to patients who did not speak English. Institutional and community contexts, shaped by professional and  Ill  public discourses, also mediated intergroup relations in significant ways. The social i  construct of race was mobilized in health care settings in subtle but damaging ways as common applications of the construct of culture and interpretations of "difference" often drew on colonial notions of race, thereby reinforcing longstanding patterns of domination and inequities. In light of these findings, re-conceptualized theoretical approaches are recommended for more realistic and nuanced understandings of intergroup relations and transformative health care practices. Critical consciousness must be fostered among nurses in order to facilitate connected intergroup care, challenge existing work environments, and confront racializing discourses and practices.  iv Table of Contents Page ABSTRACT  ii  TABLE OF CONTENTS  iv  ACKNOWLEDGEMENTS  ix  CHAPTER ONE: Introduction  1  Background to the Problem The Problem Purpose of the Study The Research Questions Organization of the Thesis  1 5 6 7 8  CHAPTER TWO: Review of State of Knowledge  10  Introduction Theoretical Perspectives Regarding Race and Culture Constructing Race Race as Biologically Determined Racisms Racism: One or Many? Racisms: Structural or Personal? Racisms: Power and Exclusions Cultural Racisms Race as Socially Constructed Constructing Culture Racialization and Representation The Contingent Nature of Racialization The Dialectic Nature of Racialization The Construction of Whiteness Race, Class, and Gender: Intersecting Oppressions Summary of Race-related Knowledge Nursing Theory and Research: Culturalist Approaches Nursing Theory Leininger's Culture Care Diversity and Universality Theory Cultural Assessment Negotiation and Cultural Brokerage Cultural Competence and Cultural Sensitivity Cultural Safety Nursing Research  10 11 13 14 15 16 17 19 22 24 27 31 32 33 35 40 42 44 46 46 48 48 50 51 53  V  The Canadian Context: A Pluralistic Society The Health Care Context: Rhetoric and Reality Intergroup Relations in Health Care Health Outcomes Health Care Experiences The Institutional Context Inadequate and Inappropriate Services Racialized Provider-Recipient Encounters The Standpoints of Nurses Summary of State of Knowledge  55 62 69 69 75 75 77 79 81 83  CHAPTER THREE: Theoretical and Methodological Framework  86  Introduction Theoretical Lens: Analyzing Social Relations Postcolonialism Feminisms Intergroup Relations Standpoint Theory Summary Methodological Matters: Power, Knowledge, and Praxis Attending to Relations of Power Accounting for Intersubjectivity in the Construction of Knowledge Orienting toward Praxis Summary  86 87 88 89 89 91 94 95 96 103 108 111  CHAPTER FOUR: Research Design and Implementation  113  Introduction Selecting a Design: Institutional Ethnography The Process of Research: Constructing the Data The "Artful Work" of Fieldwork Negotiating Access: Sites, Entry, and Sampling Site Selection Gaining Entry The Sample Engaging in Participant Observation Conducting Interviews Writing Field Notes Reviewing Texts Managing Data Constructing Meaning and Knowledge: Data Analysis Data Preparation Data Analysis  113 113 115 116 119 120 121 122 125 129 131 134 13 5 135 136 136  vi Data Interpretation Ensuring Scientific Quality Construct Validity Catalytic Validity Triangulation Reflexivity Rapport Voice Considering Ethics Summary  137 139 141 141 142 142 143 143 144 148  CHAPTER FIVE: Intergroup Relations in Health Care Provision: Nurse-Patient Encounters  149  Introduction An Entry Point: Standpoints of Nurses Descriptions of Intergroup Care Concerns Regarding Quality of Care Making Sense of Intergroup Encounters Sense-Making Strategies Understanding "Difference" Through Interpretive Lenses Influences on Interpretive Lenses Negotiating Intergroup Relations Seeking Points of Connection Working Through Language Differences "Muddling Through" Seeking Interpretation Accommodating "Difference" The Process of Accommodation The Negotiation of Contested Terrain Acknowledging the Experiences of Nurses of Colour Racialized Encounters The Racialized Workplace Reframing and Resisting Summary  149 151 152 154 157 157 163 166 173 174 177 181 183 186 190 197 203 204 213 215 220  CHAPTER SIX: The Context of Nurses'Work  222  Introduction The Context of Nurses' Work Disjunctured Care The Substance of Surgical Nursing The Delivery of Nurses'Work. Biomedical Influence: Absent Presence, Present Absence  222 223 225 225 227 232  vii Increasing Workload The Nature of Nurses' Work The Nature of Patients The Nature of Priorities The Nature of Resources Outcomes: Quality of Life, Quality of Care Quality of Life for Nurses: Dissatisfaction Quality of Care for Patients Summary: Agency and the Context of Nurses'Work  238 239 244 246 248 255 255 261 264  CHAPTER SEVEN: The Organizational and Community Contexts of Intergroup Health Care Relations  267  Introduction The Organizational Context Administrative Structures Institutional Practices Organizational Philosophies and Policies A Policy-Practice Gap Time, Coordination, and Energy Staff Education and Awareness The Institutions' Commitment: Resource Allocation Competing Priorities Resistances Summary: Understanding Organizational Contexts Community Contexts . Summary: Understanding Community Contexts  267 267 269 273 276 278 279 280 283 286 287 290 292 301  CHAPTER EIGHT: Discussion: The Complexities of Constructing and Negotiating "Difference"  303  Introduction Explicating the Social Organization of Intergroup Relations Nurse-Patient Encounters: The Intricacies of Connected Care Interpretive Lenses: Social Identity(ies) and Making Sense of "Difference" The Contexts of Intergroup Relations and the Influences of Health Care Reform The Shaping of Intergroup Relations by Discourses and Ideologies The Macrosocial Context: Capitalist Agendas, Eurocentric Assumptions  303 303 304 313 320 330 334  viii  CHAPTER NINE: A Way Forward: Conclusions and Recommendations  344  Introduction Conclusions Implications Theorizing Culture, Race, and Intergroup Relations in Health Care Provision Re-thinking Intergroup Relations Re-thinkng Culture Considering Research Fostering Critical Consciousness Facilitating Connected Care Challenging Work Environments Confronting Racializing Practices and Discourses  344 345 347 348 349 351 359 363 371 375 379  REFERENCES  382  APPENDICES  413  N  Appendix A: Definition of Key Terms Appendix B: Design: The Social Organization of Intergroup Relations Appendix C: Letter of Information to Agency Appendix D: Letter of Information to Nurses Appendix E: Demographic Profile of Participants Appendix F: Research Timeline Appendix G: Interview Guide Appendix H: Biographic Forms Appendix I: Consent Forms Appendix J: Transcriptionist's Consent Form  413 416 418 420 423 426 427 429 432 439  IX  ACKNOWLEDGEMENTS  The process of completing this dissertation and my doctoral studies has been a remarkable experience. I am most grateful to the many supporters I have had throughout the process. I am indebted to the health care professionals who participated in this study. You inspired me with your commitment, vision, and persistence in what are often very difficult circumstances. Thank-you to my supervisory committee who provided invaluable guidance. I am grateful to my research supervisor, Dr. Joan Anderson, for holding out an ideal for me, demonstrating how to achieve such an end, and providing kind support along the way. Thank you also to Dr. Sally Thorne for your commitment to excellent nursing scholarship and your unflagging enthusiasm; to Dr. Barbara Paterson for your thoughtful comments and questions, and your good-hearted way of championing me; and to Dr. Isabel Dyck for your important scholarly contributions. I am also grateful to my fellow colleagues in the doctoral program who have provided inspiration, support, and good times through the years. We do not undertake this journey alone! My friends and family have found many thoughtful and creative ways to encourage me through these years, both in person and across the miles - loving childcare, encouraging phone calls, computer consultations, a firm belief that I could meet the challenges, prayers, and the list goes on. Rebecca, our "Ph.D. baby", has been a wonderful grounding point for me, offering me perspective, love, and so much joy. I hope for a better world for her and her soon-toarrive sibling - one that is marked by more acceptance, respect, and equity. And to Rob - we did it!! You have been incredible, a true partner in the process, deserving of an honorary spousal degree. I would not, could not have done it without you. Finally, an acknowledgement to the foundational belief that drives me in my life's work: "There is neither Jew nor Greek, slave nor free, male nor female, for you are all one... " (Galations 3:28).  1 CHAPTER ONE: T H E INTRODUCTION Background to the Problem Despite a long history of ethnic and cultural diversity, Canada continues to be constructed as a White nation, both historically and presently. Early European colonists and settlers are depicted as "true" Canadians while Blacks, Chinese, Japanese, and South East Asians who arrived as early as the 1600s and on through the nineteenth century are represented as foreigners or Other. The "imagined identity" of Canadians was and is as White. Carol Schick explains, In the Canadian context,...the white body is a culturally organized site of nationalism which has come to represent what it is to be defined as Canadian. The white body is read as the semiotic for nationality; it is the white body that, along with some concessions to Native people and some slights of memory, has "always been here". (1996, p. 4) The deeply-rooted caricature of Canada as a White nation of "two founding peoples" ignores the original presence of Native peoples and the long-standing contributions of people of Colour in 1  Canada. This historical and current misrepresentation of Canada as a White nation has been challenged by the more recent increase of immigration from non-European sources and, as a 2  result, the fallacy of asserting Canada as a White nation is becoming more and more apparent.  In this current project, I chose to refer to non-European clients as people of Colour, following Carry's (1991) usage of the term. The capitalization of Colour reflects ethnic differences and denotes more than shades of skin colour. Used in this way, the term denotes a common context of struggle based on shared systemic discrimination in the Canadian social and political context. 1  54% of Canadian population reported themselves as non-French, non-British ethnic origin in the 1991 census, compared to 37.5% in the 1986 census. While earlier immigrants came primarily from Europe, by the mid 1990s, 78.5% of immigrants to Canada came from non-European origins such as South and Southeast Asia, Central and South America, Africa, and China. Most immigrants to British Columbia come from Hong Kong, Taiwan, India, the Philippines, and China (Statistics Canada, 1997). Demographic trends are discussed in more detail later in the proposal. 2  2 The heterogeneity of Canada's population is reflected in the health care system. Intergroup relations in health care provision have taken on new forms with shifting 3  demographic trends. Where health care providers, recipients, and institutions used to be predominantly White, there are now many providers and recipients of Colour. In response to these changes, intergroup health care provision has received increased attention as health care providers and institutions have sought to meet the needs of clients of Colour. Discourses regarding diversity in health care and the need for "cultural sensitivity" are widespread. Hospitals and health care agencies have joined together to evaluate the degree to which they are culturally sensitive (e.g., the 22 hospitals involved in the Multicultural Change in Health Services Delivery Project in British Columbia's Lower Mainland) and the majority of schools of nursing include multicultural content in their curricula (Toumishey, 1991). These are 4  encouraging signs of a general will to provide health care that is culturally relevant. Yet, although intergroup care is commonplace in most Canadian centers, there is mounting evidence of inequities in both health outcomes and health care experiences that fall along lines of race , class, and gender. People of Colour tend to suffer poorer health outcomes 5  than White people (Ahmad, 1993; Frideres, 1994; Krieger, Rowley, Herman, Avery, & Philips, 1993; Nazroo, 1998; Rootman, 1988; Shah & Dubeski, 1993). Both structural forces (e.g., higher incidence of poverty among people of Colour; exposure to dangerous working conditions;  Although "intergroup relations" might also refer to interactions between groups based on membership criteria such as class, gender, sexual orientation, or age, I limited my focus for this study primarily to relations between people of Colour and White people. In 1991, a questionnaire was sent to the deans and directors of schools of nursing across Canada to identify the multicultural content and teaching methods currently used. Despite the low response rate (39%), it was discovered that most programs include multicultural content in their curricula (Toumishey, 1991). While this report is encouraging, one wonders if the 61% who did not respond represent schools in which cultural content is not as valued. Race is italicized throughout this dissertation as a reminder of its socially constructed nature. As will be explained, it is my stance that while race does not exist as a biological reality, it does carry considerable social implications. 3  4  5  3 inappropriate or inaccessible health care) and individual actions (e.g., racism by health care professionals prescribing treatment) contribute to these outcomes (LaVeist, 1996). People of Colour seeking health care services describe marginalizing and racialized health care encounters (British Columbia, 1991; Browne, 1995; Chugh, Dillmann, Kurtz, Lockyer, and Parboosing, 1993; Henry, Tator, Mattis, & Rees, 1995; O'Neill, 1989). They may be excluded from negotiation with health care providers regarding their health care management, resulting in a prescription of treatment that is inappropriate or inaccessible (Anderson, 1986, 1991a; Anderson, Blue, & Lau, 1991), or may be the recipients of more blatant discriminatory actions and attitudes (Browne, 1995; Reimer, 1995; Reimer Kirkham, 1998). Such evidence suggests that the ideal of culturally relevant care has not been achieved, despite signs of a general will to provide such care and discourses in health care regarding "cultural sensitivity". With few exceptions, health care and nursing literature, particularly in Canada, is strangely silent on matters such as inequities in health, marginalizing health care practices, racialization, and racism. Instead there has been a pervasive tendency to focus on culture as an influence (or barrier) to health and illness in an effort to account for differences in health outcomes. Differences are mistakenly attributed to cultural lifestyles (e.g., claims that Blacks have higher infant mortality rates because they do not have "proper" nutrition) or supposed inherent biological weaknesses (e.g., suggestions that Native Indians have a natural propensity to alcoholism). To credit these disparities to cultural or biological differences paints a veneer over mediating structural constraints. I concur with Lock (1993) who observes that culture is in danger of being seized as a panacea, as the key which will open the  4 door to a trouble free health care system, while once again the deeper more persistent problems which lie at the root of so much ill health, most particularly poverty, exploitation, and discrimination, remain unexamined, (p. 145) In the case of racialized and marginalizing health care encounters, much nursing and health care literature explains these as an issue of individual intolerance (Culley, 1996). Within multicultural discourses, intolerance is conceptualized as a matter of attitudes, namely prejudice. In turn, prejudice is largely seen as the result of ignorance. The assumption follows that education is needed to dispel prejudice and thereby eliminate intolerance. Attention to prejudices is undoubtedly important, especially through anti-racist education. However, interpretations of discriminatory and marginalizing practices within health care as matters to be dealt with at the individual level disregard the ways in which intergroup health care provision extends beyond the interpersonal level to be influenced by a complex combination of social, ideological, historical, economic, and political forces. Heightened awareness by health care providers of cultural differences alone will not be sufficient to address power imbalances between dominant and subordinated groups. Thus, scholarship that typically focuses on culture and diversity may well be masking, albeit unintentionally, racialized health care experiences characterized by marginalization and exclusionary practices and serious inequities in health care outcomes that fall along the lines of race, class, and gender. Many studies in the area of health and race fail to uncover inequities in health outcomes and health care experiences because of short-sighted focus on the individual level, and conflation of culture with race, resulting in a general under-theorization of the ways in which health care is socially organized. The connection between the provision of care to patients of Colour at the level of the nurse-patient encounter and the larger context shaping that care has received little attention to-  5 date. Historical, economic, social, political and ideological structures and processes play a profound role in shaping all social institutions. For example, the social construction of Canada as a White nation continues to shape the social institutions of this nation in profound ways. Although the need to recognize different groups is acknowledged, the fundamental structures of society have not changed to be inclusive and representative of the groups that make up Canada. Institutions such as health care services remain Eurocentric and classist. Equity and equal access to health care are cornerstones of health legislation in Canada, yet closer examination reveals that these health care services are, at the core, monocultural, designed for middle-class Canadians fluent in English, and from Euro-Canadian backgrounds (Anderson & Reimer Kirkham, 1998; Henry et. al., 1995). Exclusionary practices are evident in the stratified and racialized structuring of the health care system, in which people of Colour are prominent in nonprofessional jobs (e.g., cleaning, food preparation) but noticeably absent from positions of leadership (Anderson & Reimer Kirkham; Das Gupta, 1996a; Sherwin, 1992). Ideologies employed by dominant groups are evident within health care. Biomedicine's emphasis on cure and the individual, and movements within health care reform toward self-care and deinstitutionalization all reflect ideologies of individualism and egalitarianism. Furthermore, health care priorities, policies and practices in Canada, while not as immediately apparent as in the United States, are economically driven and firmly grounded in liberal, capitalist society and ultimately serve to maintain the privilege of the dominant (Navarro, 1986). The Problem In light of these racialized health care experiences and inequitable outcomes for patients of Colour, the central problematic addressed in this study was the nature of the social organization of intergroup health care provision. A related observation of concern was that  6 traditional research approaches have not accounted for the larger social structures and processes that shape intergroup health care encounters. This study built on my Master's thesis in which I examined nurses' experiences in caring for culturally diverse clients . The complexities of 6  intergroup health care quickly became evident in this qualitative study. Revealing its influence on both health care providers and recipients, the social construct of race repeatedly entered into the interviews with nurses as they recounted stories of racism and unequal relations within health care. As a result, the inadequacy of research focused simply on cultural differences and culturally sensitive care became visible. Purpose of the Study The purpose of this study was to uncover the social practices and processes that structure intergroup relations in health care provision. To address this problem, an institutional ethnography (Smith, 1987) was conducted, with the standpoints of nurses and patients in the dayto-day provision of intergroup health care as the entry point into this problematic. From these standpoints, local social relations were analyzed in order to understand how they are mediated by social processes and practices happening beyond these immediate experiences. It was anticipated that such a critical inquiry would uncover processes and consequences of exclusion and inclusion, both of which are structured by relations of power operating through everyday social and institutional practices. (See Appendix A for definitions of key terms).  The term culturally diverse clients was used in my master's thesis to refer to clients who have ethnic and social origins and cultural values and practices other than those of the Canadian majority (i.e., European descent). I have since become uncomfortable with this term because of the way in which it positions White Canadians in a dominant position and in turn represents people of Colour as Other. 6  7 The Research Questions The overall research question driving this study was: What is the social organization of intergroup relations in the provision of health care? Subsumed under this umbrella question were several questions reflecting the multi-layered analysis required to understand the social organization of intergroup relations. The inquiry began at the micro level, uncovering the nature of intergroup encounters between nurses and patients. From this vantage point, I considered the meso level in order to understand the institutional setting as the everyday world of these intergroup encounters. Moving to the macro level, my goal was to explore how nurses' work processes and social practices are embedded in the social relations of extended social, economic, and political processes and are maintained in taken-for-granted ways by ideologies. Therefore, while the beginning point of this study was the everyday realities of intergroup relations in health care provision, based on the standpoints of providers and recipients, the substantive focus took into account the social organization of day-to-day health care provision at institutional and societal levels. My aim was to show the connections that exist between the micro, meso, and macro levels of health care provision. Providing guidance in operationalizing the overall research question were the following sub-questions: Micro Level  7  •  What are intergroup patient-provider encounters like in institutional health care settings?  •  How are providers and recipients positioned in social and material relations? How do they participate in these relations?  Although I organize these questions into micro, meso, and macro categories, I recognize this division as somewhat artificial. Institutional and societal influences inevitably invade and mediate patient-provider encounters. For example, while I list the question "How is race operationalized in health care provision?" as a micro level question, race is most likely operationalized across micro, meso, and macro levels. 7  8  •  How is race operationalized in health care provision?  •  How are racialized identities constructed in health care? What are the consequences of these constructions?  Meso Level •  What is the character of the everyday world in which nurses provide intergroup care?  •  What institutional policies, procedures, and structures shape intergroup encounters between nurses and patients?  Macro Level •  How do race, class, and gender intersect in health care provision?  •  What social, economic, and political processes mediate intergroup relations in health care? How do ideologies and social constructions shape the provision of health care?  •  How are society's relations of ruling mirrored in health care?  •  Given the context of intergroup relations in health care, what should the goals of health care be? What policies, structures, interventions, and social changes will support these goals?  Organization of the Thesis Having provided an introduction to the study in this first chapter, I turn to a detailed review of existing theoretical and research knowledge in Chapter Two. In Chapter Three, I delineate the interpretive lens brought to the study, informed by a particular theoretical and methodological framework, as well as my own social positioning. I present the research design and implementation, and discuss considerations for ensuring scientific quality and attending to ethics in Chapter Four. Chapters Five, Six, Seven, and Eight form the core of this report with presentation and discussion of research findings. Specifically, Chapter Five begins from the  9  standpoints of nurses in a discussion of intergroup nurse-patient encounters. Chapter Six situates these encounters in the context of nurses' work with a discussion of the implications of health care restructuring. Chapter Seven extends the analysis by locating intergroup relations in organizational and community contexts. In Chapter Eight, I offer a theoretical synthesis of the key findings of the study in an effort to extend our understanding of intergroup relations in health care provision. Chapter Nine concludes the thesis with a summary of the study, a presentation of key conclusions, and a discussion of further implications for practice, education, administration, research, and policy.  10  CHAPTER TWO: REVIEW OF STATE OF KNOWLEDGE The research problem directed me to explore a range of theoretical and empirical literature related to the social organization of intergroup relations in the provision of health care. Selecting literature for review has been no easy task, partly because the term "intergroup relations" is not commonly used within health care and nursing literature. Neither is the phenomenon represented by intergroup relations, that of individuals interacting as members of their ethnocultural communities and in the larger sociopolitical context, typically discussed. Instead, scholars tend to address a specific aspect of the general phenomenon (e.g., providerrecipient interactions). Literature presented from a culturalist perspective is also of limited relevance because its essentialist tendencies and infrequent acknowledgement of the relations of power that structure health care experiences. Because of the historical and societal specificity of issues such as marginalization and racialization stemming from the social construction of race, I have been most interested in Canadian scholarship. I have been, therefore, faced with at least two predicaments: ( 1 ) that of little literature dealing directly with intergroup relations in health care provision in Canada; and ( 2 ) that of a myriad of related literature regarding cross-cultural nursing, diversity in health care, and cultural differences. As a result, this review is both selective in emphasizing Canadian literature that relates most closely to the phenomenon under investigation, and broad in attempting to highlight key literature that relates directly to this study. Notably, I am applying "intergroup relations" in a particular fashion, employing the term as a conceptual device to focus this study on the relationships negotiated between individuals acting in certain social contexts. Intergroup relations is generally used to refer to individual behaviours within the contexts of groups based on social categories such social class, gender,  11 sexual orientation, ethnicity, or labour movements. This broad center allowed me to focus on my specific interest, that of how culture and race contribute to the social organization of health care provision, while also attending to the intersection of gender, class, and other signifying categories with culture and race. In keeping with this approach to the research topic, I begin with a review of theoretical perspectives related to race and culture and draw on this theoretical foundation in the remainder of the study. In particular, I draw on contemporary critical theories that have not traditionally been incorporated into health care and nursing scholarship. Next, I include a critique of nursing theory and research to illustrate how common theoretical approaches to issues of culture and race may, in fact, obscure inequitable processes of inclusion and exclusion. I then present further background information providing context to the study, as I summarize the changing demographics, history, and multicultural policies of Canada, and examine the shifting and restructured health care context as the site of intergroup relations. Finally, I focus more specifically on intergroup relations in the provision of health care with a study of the disturbing evidence of inequities in health care experiences and outcomes. Theoretical Perspectives Regarding Race and Culture Considerable theoretical challenges exist inherently in the concepts currently used to categorize and signify "difference". Race, culture, and ethnicity are frequently used, sometimes interchangeably, to denote "difference" (and often inferiority), with little consistency in when any one of these terms is applied. Constructions of race have shifted through time and across social spaces. Originally carrying a meaning that referred to biological origin and physical appearance, race is now understood to be a social construction manipulated to define, structure, and organize relations between dominant and subordinate groups (Henry, Tator, Mattis, & Rees, 1995). Scholars using the concept of race, including those grounded in critical or social  12 constructivist traditions, face the real danger of reifying race, inadvertently reinforcing the very notions they are attempting to deconstruct. In an effort to side step this risk, the concepts of ethnicity and culture have been widely used. Again, both of these concepts are not easily defined and, in the end, there is considerable slippage between these concepts. While conceptual clarity is an obvious concern with such conflation, a greater issue is the ways in which colonial legacies of race and racism are typically left unexamined by the constructs of ethnicity and culture, and how racialized discussions of "cultural difference" draw upon these historically grounded notions of race to make sense of "difference". Health care literature has drawn upon the concept of culture in particular. Often applied in a culturalist sense, culture tends to be portrayed as a relatively static set of beliefs, values, norms, and practices attached to a discrete group sharing a common ethnic background. While presented in a neutral fashion, these constructions of culture often draw on colonial images of race in representing "difference" and thereby re-inscribe longstanding patterns of exclusion and inclusion. Moreover, because they proceed from an apparently race-neutral account (i.e., without overt references to race), bias is typically masked rather than removed (Sherwin, 1992). Recently, the efforts of postcolonial scholars have disrupted mainstream theorizing regarding race and culture by pointing to the politics of race, particularly in sustaining colonizing relationships. Other theoretical traditions also enrich our understandings of race and culture. Feminist scholarship, especially the work of feminists of Colour, has drawn our attention to intersections between race, class, and gender, and poststructural/postmodern perspectives alert us to relations of power embodied in the discourses of the day. In this section, I highlight new ways of conceptualizing race and culture brought about by the influences of these bodies of scholarship, and apply these insights to the rest of the literature review. In order  13 to do so, I survey various definitions and conceptualizations of the core concepts of race, racisms, culture, racialization and representation, construction of White identity, intersectionality, and power. My review of theoretical perspectives begins at a somewhat rudimentary level; yet, because of the paucity of careful theoretical development of concepts such as race, culture, and power within the health sciences literature, this elementary starting point seems justified and ultimately serves as an important foundation for the study. Constructing Race Race does not have a single-agreed upon definition. This is due, in part, to the shifting understanding of race through time and across social spaces. Originally carrying a meaning that referred to biological origin and physical appearance, race was an inclusive concept, embracing a number of ethnic groups within a given racial category. Over time, race shifted from this biological meaning to a social meaning in which biological differences have become markers for assignment of status. Further evolution of such assignment of status has included complex social structures promoting power differentials between Whites and various people of Colour (Pinderhughes, 1989). Along with these shifting meanings, there are considerable gaps between theoretical understandings and practical outcomes. For example, although any biological component of race has been disproved, people continue to be grouped according to what are considered physical racial attributes. Despite these varying understandings of race, it continues as a central aspect of everyday life. "Race is a constitutive element of our common sense and thus is a key component of our 'taken-for^granted valid reference schema' through which we get on in the world" (Outlaw, 1990, p. 59). In the following section, I outline some of the significant constructions of race that represent a range of historical and ideological stances.  14 Race as Biologically Determined The notion of race has a long history, first emerging in the English language in the early sixteenth century to explain European history and nation formation (Miles, 1989). With increased migration and contact between populations, representations of Other as different, often on the basis of physical attributes such as hair, skin colour, and stature, grew in salience. Race took on a more specific meaning in the late eighteenth century, referring to distinct biological groupings of people. The growing field of science claimed to demonstrate the characteristics of races and also asserted hierarchical relationships between races. David Goldberg (1993) notes that "race is one of the central conceptual inventions of modernity" (p. 3). Enlightenment presented social subjects as abstract, universal, divorced from the contingencies of historicity, and driven by rationality. In this context, race pretended to universality, bringing individuals to a cohesive identity across space and time. Liberalism, another product of modernity with claims to individualism and equality, paradoxically confirmed the ahistorical and ultimately irrelevant place of race while its emphasis on rationality and science made room for a biological interpretation of race. The basic human condition, including economic, political, scientific, and cultural positions, was taken to be race determined. Europeans were judged to be the master race, all others were subject races. Dogmas about the natural, biological basis ofraceflourished during the colonial expansion era. By dismissing indigenous populations as inferior or subhuman, Europeans could exploit and oppress without remorse, guilt, or responsibility (Elliott & Fleras, 1992). By the later part of the nineteenth century, Social Darwinism, fostering the idea of "survival of the fittest" on a global basis as groups struggled over scarce and valuable resources, evolved to become a widely accepted doctrine of racial superiority that reinforced the colonialist project. Unilinear  15 evolution proposed that populations evolved through predetermined and progressive stages of savagery, barbarism, and civilization. Those with superior biological stock progressed to the pinnacle of the evolutionary ladder; others were left behind in the competitive struggle. As noted by Elliott and Fleras, "racial ideologies not only explained European superiority and justified outgroup exploitation, they also celebrated the virtues of capitalism and imperialism as integral to human progress and social enlightenment" (p. 39). The conceptualization of race as biologically determined continued into the twentieth century with the so-called scientific field of eugenics for the improvement of the human species by purging it of unwanted specimens. Large families were encouraged among the "civilized" while "defectives" such as Blacks and disabled were sterilized. The peak of the eugenics movement occurred under the Nazi regime with compulsory sterilization and mass murders. With the development of genetics in the 1930s, the racial categorization on the basis of physical appearance was thrown into question and finally disrepute. Scientists uncovered the enormous genetic variation among individuals and pointed to more intragroup than intergroup variation. Despite the clear evidence pointing to the error of race as a biological entity, variations of this earlier conceptualization of race still exist today, including within the health care arena (Ahmad, 1993; Krieger & Bassett, 1986). Kay Anderson (1991) observes that race also continues to be used and promoted by many lay people, policy-makers, and journalists as a concept with scientific value. Racisms Perhaps the most notable, tangible outcome of a biological construction of race is the matter of racism. Racism is a more recent term coined during the rise of Nazism in Germany. It wasfirstintroduced by Ruth Benedict in her book Race and Racism that defined racism as "the  16 dogma that one ethnic group is condemned by nature to congenital inferiority and another group is destined to congenital superiority" (cited in Solomos & Back, 1996, p. 4). Since this early definition, racism has taken on various meanings. As with other concepts presented here, racism does not carry a commonly shared definition. Yet, the theoretical grounding and definition of such a concept is critical. When viewed in a reductionistic, narrow way, racism becomes only the problem of certain groups (e.g., non-mainstream groups) and particular individuals. On the other hand, when stretched to include multi-faceted phenomena, the need for more discriminating forms of analysis is avoided (Donald & Rattansi, 1992). The lack of a clear "common sense" understanding of what racism means has, according to Omi and Winant (1994), become a considerable obstacle to efforts aimed at challenging it. Similarly, Miles (1994) observes that a concern to name racism tends to displace the concern to explain racism. As a result, anti-racist strategies are based on inadequate understandings of racism that are often ineffective. At a praxis level (i.e., transformative knowledge), then, clearer conceptualizations of racism are needed in order to bring about social change. In an effort to bring some clarity to this discussion of racism, I highlight some key theoretical positions put forward. Racism: One or Many? Until not so long ago, racism was seen as a singular monolithic, repeating itself across history and setting. Racism was also naturalized as a series of events waiting to be triggered. Solomos and Back (1996) conclude that one of the key lessons gleaned from an analysis of the changing forms of racial ideas and practices over the past two centuries is that a singular understanding of racism, unchanged by history and circumstances, is impossible. Today the notion of a single racism has been replaced by the idea of multifarious racisms, transformed from one period to another. Thus, racisms are always historically specific, though they may draw on  17 cultural traces deposited by previous historical phases. "Racism...arises out of present ~ not past — conditions. Its effects are specific to the present organizations of society, to the present unfolding of its dynamic political and cultural processes ~ not simply to its repressed past" (Hall, cited in Gilroy, 1990, p. 265). Racisms: Structural or Personal? Studies of racism have tended to divide methodologically between those assuming an individual orientation (i.e., racism viewed as personal prejudice ) and those accepting a structural 8  approach (i.e., racism viewed as embedded in, determined by, or emanating directly from prevailing constitution of social formation) (Goldberg, 1993). There are clear implications to taking either a micro or macro perspective. When viewed as a personal problem, prejudice is too commonly represented as being held consistently and expressed in a systematic and uncontradictory manner. The personal approach to racism also assumes that prejudice is primarily caused by ignorance and therefore education about other "cultures" will solve the problem. Rattansi (1994) points to the essentialism and falsity of such assumptions, citing the complex, contextual, and contradictory nature of racisms. Moreover, the final end is a pathologization of the individual who supposedly carries unhealthy neuroses and personality traits. A structural understanding of racism typically focuses on institutional practices of racism as well as ideologies sustaining such practices. Structural racism is thus entrenched within the structure, function, and process of social institutions. As such, the life chances of minority groups are restricted as a result of seemingly normal and neutral rules, regulations, and  There is a large body of literature, much within social psychology, that views racism as personal prejudice (Allport, 1954; Maluso, 1995). Racism is then seen as having affective (i.e., prejudice), cognitive (i.e., stereotyping), and behavioral (i.e., discrimination) components. 8  18 procedures (Elliott & Fleras, 1992). Robert Miles (1989) propounds a particular version of structural racism that limits the concept to refer exclusively to an ideological phenomenon. "Racism is...a representational form which, by designating discrete human collectivities, necessarily functions as an ideology of inclusion and exclusion....' presupposing' an explicitly negative evaluative component" (p. 79). Miles' definition has been critiqued for various reasons. Anthias and Yuval-Davis disagree with Miles' narrow view of ideology that assumes distortion: "although Miles is at pains to argue that racism is often used to provide meaning to the real conditions and experience of working-class actors, he is by default restricting it to socially determined attitudes that are false, but seized upon by individuals for functional purposes" (1992, p. 14). While many theorists agree on the pivotal role of ideology in sustaining racism, Miles' delineation of practices as falling outside of racism is less agreed upon. Racism has commonly been categorized as individual, institutional, and systemic in order to reflect the different levels at which it is enacted. Essed (1991) explains the problem of depicting individual and institutional racism as two distinct types. A false dichotomy is created, placing "the individual outside the institutional forms of racism, thereby severing rules, regulations, and procedures from people who make and enact them, as if it concerned qualitatively different racism rather than different positions and relations through which racism operates" (p. 36). Nonetheless, as a conceptual tool, there is some merit to differentiating between individuals who discriminate or are promotive of racial inequality and racial stratification resulting from structural barriers and processes (King, 1996). Notably, racisms do not require intentionality - any acts, policies, or structures, whether intended or unintended, that result in negative or unfavorable consequences for recipients from racially dominated groups are considered racist (Essed).  19 Bearing these varying theoretical perspectives in mind, what might be an ideal model for conceptualizing racisms? I agree with Essed (1991) who argues that any definition of racism must take into account both macro properties and micro inequities perpetuating a system of domination. The constraining impact of entrenched ideas and practices on human agency must be taken into account along with the system that continually invades everyday life. There is a need to develop a model for conceptualizing racisms that is (i) sensitive to local and contextual manifestations of racisms and (ii) able to connect local manifestations with wider or national public discourses (Solomos & Back, 1996). Within such a model, racisms must first be situated in their specific context before moving toward a more general account. Racisms: Power and Exclusion Whereas past racist forms defined and fueled colonialist expansions with insistence on racial inferiority, racisms today are visible in isolationist images of nation, in cultural differentiations, and in exclusionary or anti-immigration policies. Goldberg (1990, p. xiv) reflects on this current characteristic of racisms, "at the most abstract of theoretical levels, all forms of racism may be linked in terms of their exclusionary or inclusionary undertakings". Such undertakings constitute a special case of power. This power has been theorized in different ways: as belonging to individuals; groups; or to dominant society. Some theorists have drawn on the concepts of ideology and hegemony in explaining the power to enact exclusionary and inclusionary practices. Others have taken a Foucauldian approach to the micro-politics of power in which power is seen as diffuse and not located only in central apparatuses such as social institutions. Because of the centrality of power in understanding concepts such as race, racism, and racialization (discussed in more detail later in this chapter), further attention is given here to the  20 key conceptualizations of power that inform theorization in the area of race. Race theorists have often drawn on the notions of ideology and hegemony in explicating how power is operationalized through constructions of race. Ideology, for example, is understood as a political instrument in sustaining racist domination. Broadly defined, ideology is "a set of beliefs, perceptions, assumptions, and values that provide members of a group with an understanding and an explanation of their world" (Henry et al., 1995, p. 13). Terry Eagleton (1991) maps various interpretations of ideology including disputations about whether ideology (a) is primarily a feature of the dominant social power, (b) inherently suggests distorted beliefs or false consciousness, and (c) reflects not only distorted beliefs but unconsciously held beliefs. Most commonly, race theorists draw on an Althusserian view of ideology in which ideology thrives beneath consciousness at a level of "normal common sense" (Hebdige, 1979). Within our complex society, multiple ideologies may co-exist but those representing the groups in power are most likely to prevail. Thus, ideologies become less neutral when one considers how some gain dominance and others remain marginal. Hebdige draws on the Gramscian notion of hegemony in explaining how dominance is maintained within society. Hegemony refers to a situation in which a "provisional alliance of certain social groups can exert total social authority over other subordinate groups, not simply by coercion or by the direct imposition of ruling ideas, but by winning and shaping consent so that the power of the dominant classes appears both legitimate and natural" (Hebdige, 1979, p. 15). Thus, in keeping with Gramsci's conceptualization, hegemony is always composed of a mix of coercion and consent. Although rule can be obtained by force, it cannot be secured and maintained without the element of consent (Omi & Winant, 1994). Ideology plays a key role in maintaining such consent through a popular system of ideas and practices within the realm of  21 ''common sense". People come to interpret their own interests and consciousness of themselves in light of this "common-sense" ideology and ultimately in a unifying discourse supporting hegemonic rule. Kay Anderson (1991) perceives this interplay between ideology and hegemony in sustaining racist practices in British Columbia: Race has been a most effective unifying concept in the making and extension of European global hegemony. With more or less force in different colonial settings, racial ideology was adopted by white communities, whose members from all classes indulged it (often in contradictory ways) for the definition and privilege it afforded them as insiders. The race paradigm gave white groups the power of definition in cultural and ideological terms, as well as more instrumental power in the hands of politicians, bureaucrats, owners of capital, labour unions, judges, police, and other influential members of the ruling sector, (p. 25) According to common conceptualizations, ideology and hegemony, then, are modes through which power operates, with power centralized within those representing dominant interests. While such traditional theories of power have assumed that power is possessed (e.g., by a class or group of people, by the state), flows from a centralized source from top to bottom, and is primarily repressive, Foucault proposes that we think about power outside the confines of state, law, or class. Sawicki (1991) observes that Foucault does not deny such a traditional model of power (referred to as a juridico-discursive model of power), but that he "merely thinks that it does not capture those forms of power that make centralized, repressive forms of power possible, namely, the myriad of power relations at the microlevel of society" (p. 20). She goes on to explain that Foucault's theory of power differs from the traditional model in three basic ways: Power is exercised rather than possessed; power is not primarily repressive, but productive; and  22 power is analyzed as coming from the bottom up. Drawing on detailed analyses of the "genealogies" or historical accounts of various institutional and social discursive practices (e.g., mental hospitals, prisons, the process through which the modern individual has come to see himself/herself as a sexual subject), Foucault develops the notion of disciplinary power, exercised on the body and soul of individuals rendering them docile. However, in his more recent writings he expands on this notion of docility by defining power as dependent on resistance: ".. .as soon as there's a relation of power there's a possibility of resistance. We're never trapped by power: it's always possible to modify its hold, in determined conditions and following a precise strategy" (Foucault, cited in Sawtcki, p. 25). An understanding of the micropolitics of power allows for more nuanced interpretations of how race operates and accounts for shifting patterns of domination and oppression. Cultural Racisms Influenced by the work of scholars at the Centre for Contemporary Cultural Studies, University of Birmingham, and others such as Stuart Hall, theorists have distinguished new types of racisms that have emerged over the last decade. In Britain and Europe, these racisms are referred to as cultural or "new" racism; in the United States, as aversive racism; and in Canada as democratic racism. Generally, such racisms are based not on biological differences, but on the supposed incompatibility of cultural traditions. As Torres, Miron, and Inda put it, "This new cultural racism, rather than asserting different natural endowments of human races, notions which have generally lost credibility, emphasize differences of cultural heritage and their incommensurability" (1999, p. 8). Culturalism forms the basis of these racisms, along with a definition of race as a matter of difference rather than a question of hierarchy. Goldberg (1993) notes that these racisms are rooted in liberal traditions that emphasize individualism and  23 autonomy. Therefore, they are described as more subtle, silently sophisticated, and "contradictorily celebrated as multicultural diversity just as it (they) rationalize(s) hegemonic control of difference, access and prevailing power" (Goldberg, p. 8). The subtleties of these racisms are demonstrated in discourses "coded" to circumvent accusations of racism (Solomos & Back, 1996). However subtle these discourses, closer examination reveals the assumption of binary opposites, in which the national or citizen is on one side, and the alien, foreigner, immigrant or "other" is in opposition. The supposed shared unity of the nation is threatened by the presence of "other" and therefore they are relegated to the margins of society and blamed for many social and economic ills (Torres, Miron, and Inda). Within the Canadian context, Henry et al. (1995) characterize democratic racism as an ideology based on two conflicting sets of values made to be congruent with each other. "Commitments to democratic principles such as justice, equality, and fairness conflict but coexist with attitudes and behaviors that include negative feelings about minority groups and differential treatment of and discrimination against them" (Henry et al., p. 21). Democratic racisms, thus, are less likely to be challenged as they continue in a more silent manner, often under the guise of celebrating diversity. They call attention again to the shifting nature of racism and the need for specific, contextual responses for each form of racism. This brief overview of cultural racisms points to a shift from biological constructions of race to a social constructivist position, and also suggests a displacement of race as a neutral biological "fact" to race as a subtheme within discourses of culture. These shifts are the subject of the next section.  24 Race as Socially Constructed Influenced by postcolonial scholarship, social scientists have incorporated race into their theorizing with a new understanding of the concept emerging, that of race as a social construct. By this understanding, race is a socially constructed category used to "classify humankind according to common ancestry and reliant on differentiation by such physical characteristics as colour of skin, hair texture, stature, and facial characteristics" (Henry et. al., 1995, p. 328). As such, race exists as a social construction that is manipulated to define, structure, and organize relations between dominant and subordinate groups. Just what is meant by "socially constructed" requires further explication. Peter Berger and Thomas Luckman in their now classic book The Social Construction of Reality: A Treatise in the Sociology of Knowledge (1967) contend that sociology must focus on its proper object of inquiry, namely, "society as part of a human world, made by men (sic), inhabited by men (sic), and, in turn, making men (sic), in an ongoing historical process" (p. 189). They focus on the everyday life as it is experienced and interpreted as meaningful by people. This everyday life is "not only taken for granted as reality by the ordinary members of society in the subjectively meaningful conduct of their lives. It is a world that originates in their thoughts and actions and is maintained as real by these" (p. 19). In essence, Berger and Luckman challenge us to an ontological shift from a stance of realism to a stance of historical constructivism . Race as a 9  social construct, then, exists only as it is shaped or imagined through relationships. As explained by Solomos and Back (1996), "race can be seen as a discursive category through which differences are accorded social significance. But it is also more than just a discursive category  I am drawing on Guba and Lincoln's (1994) taxonomy that contrasts the paradigms of positivism, postpositivism, critical theories, and constructivism. While they categorize the ontology of constructivism as relativism with local and specific constructed realities, I contend that Berger and Luckmann's ontology is more of a historical 9  25  since it carries with it material consequences for those who are included within, or excluded from, a particular racial identity" (p. xiv). Under the general rubric of conceptualizing race as a social construct, various positions or debates can be identified. Howard Winant asserts that the main task facing racial theory today...is no longer to critique the seemingly "natural" or "commonsense" concept of race — although that effort has not by any means been entirely completed. Rather, the central task is to focus attention on the continuing significance and changing meaning of race. (1994a, p. 14) One of these variations regarding the meaning of race involves whether or not it solely is an ideological construct. Philomena Essed (1991), for example, contends that race is more than a social construction because it has never existed outside of a framework of group interest and is therefore best understood as an ideological construct. Robert Miles, a leading scholar in the field, posits that any reference to race necessarily rests upon a biological reference lacking all objectivity and theoretical content and so race ought to be analyzed as nothing more than an ideological construct (cited in Goldberg, 1993). On the other hand, Winant (1994a) argues against the assertion that race is an ideological construct in the sense of a false consciousness that explains other material relationships in a distorted fashion. According to Winant, viewing race as an ideological construct overlooks the salience developed by the construct over the years and the very real everyday experience of race as part of our identities. Another area of debate involves the "death" of the construct race. Some theorists argue that the concept should not longer be acknowledged for to do so simply reifies something that is not. Robert Miles argues that "race is an idea that should be explicitly and consistently confined  constructivism that takes into account the historical influence of social, political, cultural, economic, ethnic and gender values over time. Thus, while meaning is local, it is shaped by larger historical forces.  26 to the dustbin of analytically useless terms" (cited in Solomos & Back, 1996, p. 72). He puts forth racialization as a replacement concept. Perhaps the more concerning argument for the death of race comes from neoconservative camps who maintain that the concept no longer has relevance in a society that has overcome racism. Such a stance leads to "colour-blind" racial politics and a "hands-off policy orientation (Omi & Winant, 1994). A further trend in approaching race is assigning objectivity to the concept (Winant, 1994a). Whilefirmlyopposed to a biological interpretation of race, an unproblematic objectivism occurs in many arenas. In such cases, the shifting nature of race is not acknowledged; "in this logic there is no reconceptualization of group identities, of the constantly shifting parameters through which race is thought about, group interests are assigned, statuses are ascribed, agency is attained, and roles are performed" (Winant, p. 17). Although theoretically recognized to be a sociohistorical construct, race in practice is often treated as an objective fact. One simply is one's race. Race serves to naturalize the groupings it identifies in its own name (Goldberg, 1993). People are viewed as belonging to one of several races (e.g., white, black, brown) without recognition of the reductionist and essentialist nature of such 10  ascription. Many people do not fit easily into such categories. Neither does the objectivist approach account for the negotiation of incoherent and conflictual racial meanings and identities in everyday life. A related matter of disagreement involves the replacement of race with other supposedly more objective categories like ethnicity", nationality , culture, or class . Each of these efforts 12  13  A common use of this categorization is the assignment to racial groups common in many censuses and other surveys in the United States. 1 0  Ethnicity is a closely related concept to race. It refers to a sense of identity and belonging among those who share an identification or affiliation with a common set of symbols pertaining to birthright, homeland, language, culture, and heritage (Elliott & Fleras, 1992). It generally is construed as a more positive concept than race and is therefore often used interchangeably. Racial formations are then reduced to ethnicity while ignoring the specific 1 1  27 represents the tendency to reduce race to a mere manifestation of other supposedly more fundamental social and political relationships. Such reductionism fails to grasp the uniqueness of race, its historical flexibility and immediacy in everyday experience and social conflict (Omi & Winant, 1994, p. 2). As will become increasingly obvious, the case of culture replacing race is most salient to a critique of nursing literature. In the past several decades, the cultural conception of race has tended to eclipse all other conflations of race (Goldberg, 1993). A culturalist perspective directs attention to cultural differences while ignoring the materialist effects of the underlying notions of race. When race is identified with identity and culture, careful language enables people to "speak about race without mentioning the word" (Gilroy, cited in Henry et. al, 1995, p. 18). In the next section, I extend this discussion of the conflation of culture and race by examining theoretical constructions of culture in more depth. Constructing Culture As with race, the construct of culture carries a range of meanings, to the extent that Raymond Williams has observed that culture is one of the two or three most complicated words in the English language (cited in Lock, 1993). A recent burgeoning in the study of culture in virtually all fields of human science (e.g., as "cultural studies") has resulted in extensions to commonly held understandings of culture. Lock explains that early meanings conveyed "the idea of a process, and in particular with the tending of something, usually crops or animals" (p.  experiences of racially defined groups (e.g., such as a history of colonization, slavery, exploitation) (Goldberg, 1993; Winant, 1994a). Further, ethnic identity is almost uniformly viewed as relevant only to minority groups, leaving majority identities unexplored (Solomos & Back, 1996). Goldberg (1993) notes that while there is some tendency to conflate nation with race, they are better understood as intersecting discourses, both "largely empty receptacles through and in the names of which populations groups may be invented, interpreted, and imagined as communities or societies" (p. 79). Anthias and Yuval-Davis (1992) note that one of the most important debates within theoretical work on race addresses the connection between race and class. The traditions of critical theory have in particular privileged class over race (Outlaw, 1990). Although there are many different positions regarding the connections between race and class, I agree with Anthias and Yuval-Davis who conclude that racism cannot on its own be an adequate explanation for economic position and that race is an epiphenomenon of class. 1 2  1 3  28 144). This was followed in the 18 and 19 centuries by the idea of civility, distinguishing th  th  "educated people who were cultured and enlightened from 'uncivilized' peasants...." (p. 144). The evolutionary meaning of culture effectively distinguishes between "us" and "them", representing "ethnic minorities" and "immigrants" as on the whole irrational, unscientific, and hence childlike and primitive (Lock, p. 145). While these earlier meanings are still held within the notion of culture, today culture is commonly understood as a template or blueprint for human behavior, grounded in the "values, beliefs, norms and practices of a particular group that are learned and shared" (Giger & Davidhizar, 1991, p. 4). In practice, this interpretation most often translates into culture being understood as identification with a particular ethnic or religious background. This widespread understanding of culture derives from the social theory of cultural pluralism (also known as multiculturalism) informing much policy development today. At its core, cultural pluralism holds to the ideal of the harmonious coexistence of differing cultural or ethnic groups in a pluralistic society (Cashmore, 1996). Built on the notions of unity-withindiversity, cultural relativism, and often drawing on folkloric traditions, multiculturalism has been put forward as official state policy in several countries (e.g., Canada, Australia). However, there has been a range of critique directed toward multiculturalism, most of which centers on the ways in which multiculturalism addresses ethnic and racial difference as a question of 'identity' rather than of history and politics, and translates difference as an intrinsic property of 'cultures' and as a value to be 'represented' as such (Bennett, 1998). Donald and Rattansi (1992) offer a summarizing critique of multiculturalism and the culturalist perspective: By focusing on the superficial manifestations of culture, multiculturalism failed to address the continuing hierarchies of power and legitimacy that still existed among these  29 different centers of cultural authority. By exoticizing them, it even colluded in their further disenfranchisement. Despite its apparent relativism, in practice it defined alternative centers of cultural authority primarily in terms of their difference from the norm of English culture, not in their uniqueness and their discontinuities, (p. 2) Notably, cultures within this perspective have been portrayed as static and passed down through generations with the resultant possibility of developing tidy taxonomies of cultural beliefs and practices. Culture becomes afixedproperty of social groups rather than a relationalfieldin which they live in relationship. Despite such critiques, the culturalist perspective with its underlying liberal ideologies of individualism and egalitarianism still carries considerable influence within health care and nursing circles. More recently, there has been a shift within certain schools of thought to a more constructivist and political view of culture. For example, postcolonial scholars such as Stuart Hall (1986/1997) and Homi Bhabha (1990, 1994, 1998) have provided us with more nuanced conceptions of culture. Hall points to the personal and structural aspects of culture: I learned about culture,first,as something which is deeply subjective and personal, and at the same moment, as a structure you live....I could never understand why people thought these structural questions were not connected with the psychic - with emotions and identifications and feelings because, for me, those structures are things you live. I don't just mean they are personal, they are, but they are also institutional, they have real structural properties, they break you, destroy you", (cited in Chen, 1997, p. 488) This dual nature of culture offers important clarification, uncovering the societal structures that silently operate to disadvantage on the basis of culture. Hall also understands culture as carrying an ideological or "common-sense" component that leaves these structures unexamined. "By  30 culture here, I mean the actual, grounded terrain of practices, representations, languages and customs of any specific historical society. I also mean the contradictory forms of 'common sense' which have taken root in and helped to shape popular life" (Hall, 1986/1997, p. 439). Homi Bhabha, bringing together postcolonialism, postmodern, and psychoanalytic genres, integrates themes such as contingency, partiality, and indeterminancy into the discussion of culture. For example, he extends the thinking around culture as he points to the partiality of culture with the notion of hybridity, which brings about a "third space" by drawing on what he refers to as "incommensurable" forms of culture to bring about something "new and unrecognisable" (1990, p. 211). Further, ... .Hybrid agencies.. ..deploy the partial culture from which they emerge to construct visions of community, and versions of historic memory, that give narrative form to the minority positions they occupy: the outside of the inside: the part of the whole. (Bhabha, 1998, p. 34) Bhabha here is representing culture not only as negotiable, but also as positionality mobilized by resistive agents. His reference to "partial culture" suggests that cultures are less epistemological sureties than they are places of enunciation and negotiation. Throughout his work, Bhabha also emphasizes the importance of seeing culture as linked to colonial histories. We seen then that culture, as race, is also a disputed concept, to the extent that AbuLughod (1991) suggests that the notion of culture, despite it a long usefulness, may now be something anthropologists would want to work against in their theories, practice, and writing (p. 138). She comments that If "culture", shadowed by coherence, timelessness, and discreteness, is the prime anthropological tool for making "other," and difference....tends to be a relationship of  31 power, then perhaps anthropologists should consider strategies for writing against culture. (P-147) Perhaps her commentary here is less of a disavowal of the notion of culture per se than it is a warning against the historical tendency to essentialize and signify with the concept of culture. In this sense, Abu-Lughod echoes Hall's explication of culture as " institutional" with "real structural properties" (cited in Chen, 1997, p. 488) resulting in the material effects of othering, oppressing, and disadvantaging. Thus, we see that the influence of critical theories has shifted discourses on culture from those grounded in cultural pluralism theory to reflect culture as constructed, shifting and contextual. In summary, the concept of culture, though often used as a more neutral way of discussing "difference", is also a term that requires problematization. When race is recognized as a subtheme in culture discourses, we are alerted to potential problems in the application of this concept. In the review of nursing theory and research that follows later in this chapter, the limitations of a culturalist approach will be revisited. The remainder of this overview of race theory will consider the applications of race through the processes of racialization and representation. Racialization and Representation Race has fashioned and continues to mold personal and social identity, the bounds of who one is and can be, of where one chooses to be or is placed, what social and private spaces one can and dare not enter or penetrate....The history of racialized expression has served to fix social subjects in place and time, no matter their spatial location, to delimit privilege and possibilities, to open opportunities to some while excluding the range of racialized Others. And in so fixing, these imposed and imagined  32 h i s t o r i e s f r e e z e n o t o n l y the r a c i a l O t h e r b u t a l s o t h o s e so p r i v i l e g e d i n t o g i v e n identities, p e r s p e c t i v e s , a n d d i s p o s i t i o n s . ( G o l d b e r g , 1993, p. 2 0 6 ) B e c a u s e race is n o t a n a t u r a l attribute but r a t h e r a s o c i a l l y a n d h i s t o r i c a l l y c o n s t r u c t e d one, the a n a l y s i s o f h o w r a c i a l m e a n i n g s are f o r m e d a n d r a c i a l identities a s s i g n e d b e c o m e s i m p o r t a n t ( W i n a n t , 1994a). A s h i g h l i g h t e d b y G o l d b e r g i n the p r e c e d i n g quote, race p e r v a d e s e v e r y a s p e c t o f l i f e , at b o t h m a c r o a n d m i c r o l e v e l s . I n d i v i d u a l p s y c h e s a n d r e l a t i o n s h i p s a m o n g i n d i v i d u a l s are s h a p e d b y race; c o l l e c t i v e identities a n d s o c i a l structures are r a c i a l l y c o n s t i t u t e d . T h e t e r m r a c i a l i z a t i o n w a s first c o i n e d b y F r a n t z F a n o n a n d a d o p t e d b y R o b e r t M i l e s to c a p t u r e the i d e a o f the r e p r e s e n t a t i o n a l p r o c e s s w h e r e b y s o c i a l s i g n i f i c a n c e is a t t a c h e d to c e r t a i n b i o l o g i c a l features f o r the p u r p o s e o f c a t e g o r i z a t i o n i n t o s o c i a l c o l l e c t i v i t i e s ( M i l e s , 1989). 14  M i l e s d e f i n e s r a c i a l i z a t i o n as "a p r o c e s s o f d e l i n e a t i o n o f g r o u p b o u n d a r i e s a n d o f a l l o c a t i o n o f p e r s o n s w i t h i n t h o s e b o u n d a r i e s b y p r i m a r y r e f e r e n c e to ( s u p p o s e d l y ) i n h e r e n t and/or b i o l o g i c a l ( u s u a l l y p h e n o t y p i c ) characteristics. It i s t h e r e f o r e a n i d e o l o g i c a l p r o c e s s " (p. 74). R a c i a l i z a t i o n , i n effect, s u g g e s t s that a p a r t i c u l a r p o p u l a t i o n c a n o n l y be u n d e r s t o o d as a s u p p o s e d l y b i o l o g i c a l entity ( C a s h m o r e , 1996) a n d t h e r e f o r e t a k e s p l a c e w i t h i n the r e a l m o f c o n c e p t i o n s o f c u l t u r e s as static a n d h o m o g e n o u s a n d h a v i n g a b i o l o g i c a l basis. T h i s i s t h e n e x t e n d e d to n o t i o n s o f c u l t u r e s h a v i n g d i r e c t r e l a t i o n s h i p to attitudes, e x p e c t a t i o n s , a n d b e h a v i o r ( A h m a d , 1993). T h e p r o c e s s e s o f r a c i a l i z a t i o n are c h a r a c t e r i z e d b y t h e i r c o n t i n g e n t a n d d i a l e c t i c natures. The  Contingent Nature of Racialization  B e c a u s e o f the s o c i a l a n d h i s t o r i c a l nature o f race, t h e resultant s o c i a l structures, identities, a n d s i g n i f i c a t i o n s y s t e m s (i.e., r a c i a l i z a t i o n ) m u s t b e u n d e r s t o o d as f l e x i b l e a n d  14  Howard Winant (1994a) uses the term "racial formation" to portray a very similar process of social signification.  33  contested (Winant, 1994a). Particular racial meanings and social structures are always contextspecific. For example, the racialization process of assigning Aboriginals to reserve lands has been relatively fixed over the last century in Canada; the ensuing racial order is "naturalized" and publicly unproblematized. Yet, when this order is resisted and violently threatened (as in the Oka crisis and the Gustafson Lake stand-off), there is possibility for a shift in the established patterns of racialization. In another historical Canadian example, Irish immigrants were racialized as a distinct and inferior group in the 19th century. More recently, with the increase in non-White immigrants, the Irish are easily integrated as "mainstream" Canadians. Similar shifts have occurred for Eastern European immigrants (e.g., Ukrainians, Mennonites). Racialization is particularly contingent upon class and gender. People of Colour in upper classes may be categorized and signified in different ways than those in lower classes. To illustrate, business-class immigrants from Hong Kong may be highly regarded for their business acumen, but may still be categorized as Other and demeaned in everyday life or excluded from certain social privileges. Likewise, men and women with similar ethnocultural backgrounds may be racialized in different ways. The Dialectic Nature of Racialization Miles (1989) observes that racialization is a representational process of defining an Other (usually, but not exclusively) somatically. Through racialization (i.e., defining Other), self is defined by the same criteria. This process of representation has a long standing history within the Western world about populations elsewhere. European explorers, merchants, and missionaries represented those they came in contact with according to perceived physical and cultural norms, using their own sense of "normal" to identify abnormal characteristics in others. The period of colonization saw an intensification of representations, sometimes consisting of  34 positively evaluated elements (e.g., the "noble savage") and sometimes consisting of negatively evaluated elements (e.g., heathen, cannibals). As Miles (1989) suggests, representations of Other became increasingly interwoven with justifications for the exploitation of the colonies. For example, representations of Other as inferior were central to the enslavement of the African in America. Said (1978) makes a similar point in his widely read book, Orientalism, arguing that "European culture gained in strength and identity by setting itself off against the Orient as a sort of surrogate and even underground self (p.3). Other postcolonial writers such as Frantz Fanon also speak powerfully of the dialectic nature of racialization and constructing Other. Fanon, in Black Skin, White Mask (1967), convincingly argues that the black man is the symbol of Evil. In contrast, white is the symbol of goodness, purity, and light. The torturer is the black man, Satan is black, one talks of shadows, when one is dirty one is black — whether one is thinking of physical or of moral dirtiness.... Blackness, darkness, shadow, shades, night, the labyrinths of the earth, abysmal depths, blacken someone's reputation; and on the other side, the bright look of innocence, the white dove of peace, magical, heavenly light. A magnificent blond child — how much peace there is in that phrase, how much joy, and above all how much hope! (p. 189) Through the dialectic process of racialization, Other may adopt the content of the racialized discourse to identify itself as Self, essentially internalizing the representation. This may be either positive or negative. Winant (1994a) observes that the dynamics of racial signification are necessarily relational and questions how much autonomy an individual has to choose her/his racial location. Himani Bannerji (1995) speaks eloquently to this area known as identity politics and notes the power of self-naming.  35  When I looked to Black history, to history of Indigenous people of the Americas, and re-read the anti-colonial struggles, I took strength from an identification with Vietnam, Cuba, and subsequently from the African and Central American revolutionary movements. The word "Black", then a political metaphor rather than a territorial politics, filled me with a sense of pride and dignity, spelling a shared culture and politics of resistance. Those who dismiss so disdainfully all projects of self-naming and self-empowerment as "identity politics" have not needed to affirm themselves through the creative strength that comes from finding missing parts of one's self in experiences and histories similar to others, (p. 9) Read in isolation, this selection from Bannerji may leave the impression that the dialectic nature of racialization can easily be turned into a positive exercise of self-naming and agency by Other. However, the growing body of colonial discourse analysis by scholars such as Homi Bhabha (1994, 1998) and Gayatri Chakravorty Spivak (1988) belies such a simple conclusion. Spivak's interrogation of the question "can the subaltern speak?" uncovers the networks of imperial and indigenous class and patriarchal power that silence the voice and agency of Other. The Construction of Whiteness Notably, but often overlooked, racial signification includes the construction of White racial identity. There is now a growing group of scholars who are exploring the politics of Whiteness and an increasing awareness of the importance of such an enterprise. "The power, 15  Fishkin (1995) notes that with the publication of Playing in the Dark: Whiteness and the Literary Imagination, Toni Morrison launched an eloquent and provocative challenge to the privileged, naturalized whiteness of American literature. In this book, Morrison (1992) probed the influence of Afro-Americans on American literature and challenged scholars to examine Whiteness as an imaginative, social, and literary construction. In keeping with this challenge, an interrogation of Whiteness has begun in disciplines such as literary criticism (e.g., Shelley Fisher 1 5  Fishkin's Was Huck Black? Mark Twain and African-American Voices), history (e.g., David Roediger's The Wages of Whiteness: Race and the Making of the American Working Class 1991; Vron Ware's Beyond the Pale: White z  Women, Racism, and History, 1992), cultural studies (e.g., bell hooks Outlaw Culture, 1994), anthropology (e.g., Beth Ellis's thesis Representation of Race and Gender: The Social Construction of "White" and "Black" in Early  36 valorization and experience of 'whiteness' as a form of contemporary ethnicity needs serious theoretical and critical attention" (Williams & Chrisman, 1994, p. 17). Solomos and Back (1996) assert that "clearly there is a need for a research agenda which looks at the way white subjectivities are racialized, and how 'whiteness' is manifested in discourse, communication, and culture" (p. 23). They go on to point out that one of the central criticisms of studies in race and ethnic relations is that the focus has too often been on the victims rather than the perpetrators of racism. Likewise, Toni Morrison in her analysis of Whiteness in American novels comments, "My project is an effort to avert the critical gaze from the racialized object to the racial subject; from the described and imagined to the describers and imaginers; from the serving to the served" (1992, p. 90). Including Whiteness as an area of critical inquiry has the potential to shift the gaze from minority communities to ideologies and structures that often go unnoticed. Michelle Fine (1997) explains the importance of such endeavors, "whiteness and 'colour' are...not merely created in parallel, but are fundamentally relational arid need to be studied as a system; they might, in statistical terms, be considered 'nested' rather than coherent or independent variables" (p. 58). Deconstructing the meanings of Whiteness is a beginning step in challenging the silence and "naturalness" of Whiteness and has the potential to yield fruitful investigation into 16  everyday racial inequities. However, there are also some inherent pitfalls in such a project. There is the danger of bringing Whiteness into the center of all discourse and thereby continuing  British Columbian Historical Discourses. 1858 - 1900, 1996) and education (e.g., Christine Sleeter's essay, How White Teachers Construct Race, 1993; Leslie Roman's essay, White is a Colour! White defensiveness, postmodernism, and anti-racist pedagogy, 1993a). Recently, Michelle Fine, Lois Weis, Linda Powell, and L. Mun Wong (1997) have edited a collection of essays by educators and psychologists deconstructing "Whiteness", entitled Off white: Readings on race, power, and society.  This project of deconstructing Whiteness is essentially a Western one. Because of the contingent and shifting nature of racial identity, my discussion here applies to the Western world in which Whiteness has maintained hegemony. 1 6  37 the long-standing pattern of relegating contributions of non-Whites to the margins. In the process of such analysis, there is also the danger of reifying Whiteness as a fixed, singular 17  category (Fine et. al., 1997; Solomos & Back, 1996). In order to avoid this reification, any discussion of Whiteness must be carefully located in a specific historical, political, and social context. Further, Whiteness cannot be explored outside of the ways in which it is classed and gendered (Spelman, 1988; Ware, 1992). Solomos and Back's instruction regarding any efforts at deconstructing Whiteness serve as useful summary: "The need to comprehend the social construction of whiteness as a form of identity and a political discourse must (i) focus on decolonising the definition of'normal', and (ii) simultaneously prohibit the reification of whiteness as a social identity" (p. 24). Whiteness has been constructed as natural or the norm in the Western world, carrying with it notions of purity and multiple privileges. Ruth Frankenberg (1993), in her much cited book White Women, Race Matters: The Social Construction of Whiteness based on in-depth interviews with White women, argues that race shapes White women's lives. She presents a set of linked dimensions that reflect the privileged and social construction of Whiteness as a standpoint of structural advantage and set of cultural practices that are typically unmarked and unnamed. When Whiteness is understood as this privileged social construction, the locations, discourses, and material relations (often relations of domination) shaping Whiteness are acknowledged. Elizabeth Spelman (1988) notes that, generally, the self-esteem of White people is deeply influenced by their difference from and supposed superiority to Black people. While many White people do not consider themselves as racist, their self-esteem is propped up by a  This danger of reifying Whiteness could be compared to the reification of culture that has also been critiqued (e.g., Allen 1996a; Whittaker 1992). 1 7  38 sense of self based on the racism (e.g., systemic) that unfairly distributes benefits and burdens to Whites and Blacks. From this position of superiority, Whites can choose to acknowledge or overlook racism. Jennifer Simpson, in her essay entitled "Easy Talk, White Talk, Back Talk: Some Reflections on the Meanings of Our Words" (1996), makes the point that Whites do not have to monitor their speech but can engage in selective hearing, creative interpreting, and complicitous hearing; "talk we rarely notice or respond to, talk that occasionally gives us a strange feeling ('Was what I just said offensive?'), talk that most often simply slips through the conversation, not noticed, not even forgotten because it was never remembered" (p. 378). Peggy Mcintosh (1995) expands on this notion of White privilege by listing a concrete inventory of privileges she enjoys as on a daily basis as a White person. She notes "I have come to see white privilege as an invisible package of unearned assets that I can count on cashing in each day, but about which I was 'meant' to remain oblivious" (p. 76). The theme of the privilege of Whiteness is the most prominent and frequently presented theme in the discussion of the construction of Whiteness and certainly carries far-reaching implications for both everyday life and theoretical endeavors. Yet, while the privilege and purity of Whiteness is prominent, Whiteness is also constructed as terrorizing by people of Colour. Scholars such as Frantz Fanon (1967), bell hooks (1992), and Himani Bannerji (1995) provide graphic accounts of the terror instilled in them by White people, bell hooks, in her landmark essay entitled "Representations of Whiteness in the Black Imagination" (1992), describes the "special" knowledge of Whiteness gleaned by black folks from a shared fascination with difference and close scrutiny of White people: Collectively Black people remain rather silent about representations of Whiteness many of us pretend to be comfortable in the face of Whiteness only to turn our  ' 39 backs and give expression to intense levels of discomfort. Especially talked about is the representation of Whiteness as terrorizing....This representation of Whiteness as terrorizing emerges as a response to the traumatic pain and anguish that remains a consequence of White racist domination, a psychic state that informs and shapes the way black folks "see" Whiteness, (p. 169) Himani Bannerji (1995) similarly testifies to her terror as a recently arrived immigrant in Canada. My experiences very often spoke of violence and violation. They consisted of humiliation in the institution called the university...fear of the state at visa offices, borders and at home, of being judged an unfit parent. There were fears in the street for clothes I wore, the body I carried with me, for my child in her present and future, and a continual sense of non-belonging.... (p. 7) These representations of Whiteness as terror are likely not incorporated into the selfimage of most Whites, bell hooks (1992) recounts the disbelief, shock, and rage of White students when they listen to Black students talk about Whiteness. "In White supremacist society, White people can safely imagine that they are invisible to Black people since the power they have historically asserted, and even now collectively assert over Black people, accorded them the right to control the Black gaze" (p. 168). The theme of the representation of Whiteness as terrorizing adds another important dimension to the construction of Whiteness. The privilege of Whiteness, rampant in both health care theory and practice, has not yet been interrogated to any degree. Health care systems remain embedded in the ideologies and practices of White dominant society, reinforced by the legitimizing individualistic and "scientific" hegemony of biomedicine. Deconstruction of Whiteness in Canadian health care  40 theory and practice is urgently needed as a strategy against the subtle and not-so-subtle racism exercised in health care settings. Furthermore, the reality of the embodiment of racial identity requires exploration, particularly in light of the terrorizing effect of Whiteness on people of Colour. Fanon (1967) reminds us that in the White world the man of color encounters difficulties in the development of his bodily schema. Consciousness of the body is solely a negating activity. It is a third-person consciousness. The body is surrounded by an atmosphere of certain uncertainty.... (p. 110) This carries particular salience within thefieldsof health care that are so focused on the body. Race, Class, and Gender: Intersecting Oppressions In an effort to understand oppression, I briefly review two main theoretical positions, that of neo-Marxists who tend toward economic determinism in their theorizing, and that of Black feminists who emphasize the intersectionality of multiple oppressions. Both of these camps build on the basic Webster's (1994) definition of oppression as the burdensome and unjust use of power. Oppression may operate in subtle, taken-for-granted ways when the structuring of societal norms, laws, and other assumptions routinely disadvantage certain groups. Oppression thus becomes a consequence both of the manner in which society is structured and also of the fact that this structure is not questioned (Northway, 1997). Bolaria and Li (1988) note that oppression implies that the dominant group has the power to oppress and the subordinate group has fewer resources to resist the oppression. They exemplify the neo-Marxist tradition in their description of racial oppression: Racial oppression has a number of dimensions, ranging from physical coercion to ideological control. These levels of oppression are means to control the subordinate  41 group, with the ultimate purpose being to exploit its labour power, or to remove its sovereigntyfromland and resources", (p. 23: italics mine) Bolaria and L i go on to observe that while racist ideologies are rooted in the process of material production, they are supported by other social institutions such as inferior education, residential segregation, and poor health care. Although scholars like Bolaria and L i tend to reduce racial oppression to a matter of economics, they have brought balance to the more orthodox literature on race and ethnic studies that stresses culture and confines itself to issues such as adjustment, adaptation, and assimilation. There are, however, problems in reducing race to a matter of class (or gender). Analyses that do not consider the intersectionality of these concepts are more likely to present incomplete pictures of processes of domination and exclusion. Black feminists such as Rose Brewer, Hazel Carby, Patricia Hill Collins, bell hooks, and Himani Bannerji have been particularly instrumental in drawing attention to the error of privileging gender or class over race. Collins (1993) emphasizes that intersectionality is not about additive analyses of oppressions but rather about seeing the oppressions df racism, classism, and sexism as interlocking categories of analyses. She (Collins, 1990, p. 6) expands the conceptualization of oppression to include three interdependent dimensions: 1. Economic — the ghettoization of Black women into service occupations; 2. Political ~ the denial of rights and privileges routinely extended to White male citizens (e.g., vote, public office, education); and 3. Ideological — the process by which certain assumed qualities are attached to Black women and how those qualities are used to justify oppression (e.g., Jezebel, welfare moms).  42 The matrix of domination in economic, political, and ideological spheres is a complex one that cannot be reduced to either/or dichotomies. Collins insightfully observes that depending on the context, an individual may be an oppressor and an oppressed simultaneously (e.g., a white woman may be penalized by gender but privileged by race). Similarly, Rose Brewer (1993) argues that race, class, and gender cannot be understood apart from each other; each are embedded in the contexts of the others. Acknowledging the interrelatedness of race, class, and gender provides important insight for this study and guards against incomplete and simplistic analyses. Summary of /?acg-related Knowledge In sum, race provides the categorization for the process of exclusion (i.e., marginalization) and inclusion (i.e., privilege) of individuals on the basis of what are seen to be immutable biological or physiological differences that may be expressed through culture and life-style (Anthias & Yuval-Davis, 1992). The shifting nature of race through time demonstrates the remarkable resilience of the concept, adapting to various contexts to serve particular ends. "...Race is a fluid, transforming, historically specific concept parasitic on theoretic and social discourses for the meaning it assumes at any historical moment" (Goldberg, 1993, p. 74). While race is clearly not a biological entity, it denotes a particular way in which communal differences come to be constructed and therefore it remains as an important concept. Winant (1994b) speaks to the paradoxical nature of race, "at once evanescent and ferocious, ephemeral and intense, conspicuous and unspecifiable, race is a fascinating and terrible problem precisely because of its slippery and contradictory character. It is nothing but a contradiction, an absent presence, a present absence" (p. 267).  43  In an effort to summarize therace-relatedtheory reviewed, I conclude this section with what I consider the key points. •  Race is a social construct with ideological and material components for the process of exclusion and inclusion of individuals on the basis of supposed physical or cultural differences. It carries significant implications in everyday life.  •  The importance of an explication of race lies in the material practices that result when race is enacted as a category. These material practices vary in keeping with how race is conceptualized. To illustrate, race as biologically determined led to extreme practices such as the eugenics movement and less extreme but still false notions of IQ today. Race as culture results in the denial of disadvantage on the basis of racism, focusing instead on disadvantage as an outcome of cultural differences.  • •  Race is often mobilized as a concept to sustain dominant group relations. Although widely acknowledged as a social construct, race continues to be objectified as a real entity.  •  The culturalist approach to race is a primary and often unrecognized mode of maintaining dominant group hegemony. The risks of the culturalist approach include essentializing culture, abstracting culture away from its social, political, and economic contexts, and conflating race with culture.  •  Racialization, the signification process of assigning individuals to racial groups on the basis of physical or cultural attributes, is contingent and dialectic in nature.  •  Racism is the ideologies, structures, and practices by which exclusions are enacted on the basis of race. The exercise of power is a key component of racism.  44  •  The oppressions of racism often intersect with the oppressions of sexism and classism and should therefore not be viewed in isolation from each other.  These summarizing points served as guiding premises in the data generating and analysis phases of this study and thus contributed substantially to its theoretical foundation. Drawing on this review of race-related scholarship, I turn now to an analysis that uncovers how intergroup relations are typically represented within nursing literature. Nursing Theory and Research: Culturalist Approaches The culturalist perspective, with its emphasis on culture as a neutral system of shared beliefs, meanings, and practices, has had a pervasive influence on nursing theory and research. This reliance, however, needs to be understood within a historical context in which notions of culture were not typically integrated into nursing scholarship until the 1960s and 70s. Initially, anthropological theories were predominantly drawn upon, and it is only recently that more critical and/or constructivist traditions have begun to be incorporated. In this way, the trajectory of theorizing and research in nursing is not all that much different than that of other health care and social sciences. Therefore, despite its limitations, the interpretive framework of culturalism should be understood as a sincere attempt to replace earlier approaches to race. Stubbs, in his discussion of various models for health research, remarks that the "ethnic sensitivity" and "antiracist" frameworks attempt to "replace crude 'colour-blind' or 'assimilationist' models through which black and ethnic minority populations were either ignored or seen as 'integrating' into the supposed norms of the 'host society'" (1993, p. 38). Yet, several clear limitations of the culturalist perspective can be identified. Nursing has widely defined culture as static and deterministic, and thereby the relational aspects of culture tend to be overlooked. With this static view bf culture, cultural groups have been easily defined and associated health care beliefs and  45 practices have often been organized into neat taxonomies, leading to generalizations and stereotypes. Much greater attention has been devoted to developing nursing cultural awareness than to the social and economic contexts in which minority patients live and, as a result, individualistic and interventive practice has been promoted that helps clients adapt to oppressive environments. Self-awareness, when addressed, has focused on individual level prejudice rather than any significant locating of the nurse within larger societal ideologies and structures. Structural issues have been either neglected or intentionally ignored under the guise of cultural relativism (Meleis, 1996). Moreover, several ideologies (individualism, egalitarianism, and caring) are firmly embedded in the culture of nursing and, though often invisible or taken-for-granted, exercise considerable influence over the provision of intergroup care. First, the ideology of individualism is pervasive throughout nursing. Nursing, as biomedicine, has traditionally taken a micro focus, considering the health and illness of the individual apart from the larger environment in which they occur (Anderson, 1996; Chopoorian, 1986; Kleffel, 1991; Stevens, 1989). Chopoorian points to a sharp discrepancy between nursing practice and theory: although nurses continually witness the human responses to the underlying social dynamics of poverty, unemployment, undernutrition, isolation and alienation precipitated through the structures of society, nursing theory does not generally encompass a perception of environment as intolerable circumstances for large numbers of society. Second, a related ideology, that of egalitarianism, purports nurses as unbiased and aspiring toward the ideal that "everyone should be treated the same way". This egalitarian ideal, underscored by a concern to avoid favoritism, is often accompanied by the expectation of efficient care (Majumdar & Hezekiah, 1990). This ideology fits with the "colourblind" stance in which it is assumed that everyone has equal opportunities and should be treated  46 the same, regardless of race, and therefore fails to account for individual and structural disadvantages that influence health. Finally, caring has been widely espoused as the essence of nursing (e.g., Bevis & Watson, 1989). Deeply rooted in humanist traditions, the caring ideology puts forth the ideals of respect and tolerance for others and, in the process, undermines the irrationality of prejudices and racisms. Mulholland (1995) argues that, in effect, the caring ideology encourages inattention to a critical analysis of social realities. Caring ideology, then, falls neatly into the culturalist approach to race, emphasizing an appreciation of diversity and tolerance for others. The following discussion of nursing theory and research is located within this conceptualization of the historical evolution of the concept of culture within nursing science and the key ideologies that operate within the profession. Nursing Theory Stemming from a widely shared desire to provide culturally appropriate care in the face of increasingly diverse societies, much of nursing's approach to issues of "difference" currently tends to be "constructed as centring on the discourse of 'culture' and the distinct ethnicities of different groups" (Culley, 1996, p. 565). Here I outline some of the most dominant theories pertaining to culture and health that have been developed within nursing and have been drawn upon extensively. Leininger's Culture Care Diversity and Universality Theory Nursing's reliance on the concept of culture has evolved over the years, drawing heavily on anthropological perspectives integrated into nursing. Madeleine Leininger began incorporating cultural perspectives into nursing theory and practice as early as the mid 1950s. The goal of her theory, coined as "culture care" (also widely referred to as transcultural nursing), is to "provide culturally congruent nursing care in order to improve or offer a different kind of  47 nursing care service to people of diverse or similar cultures" (Leininger, 1996, p. 72). The Culture Care Theory emphasizes the use of three culture-related nursing care actions: cultural care preservation/maintenance, cultural care accommodation/negotiation, and cultural care repatterning/restructuring. Caring is described as the essence of nursing and culture as the "blueprint for determining human decision making and actions" (Leininger, 1984, p. 42). Therefore, cultural factors need to be considered in order to give even the most basic care to clients. With this theory, Leininger has drawn attention to the importance of integrating cultural care into day-to-day nursing care at a time when society has become increasingly ethnically diverse and when assimilationist policies are being questioned. A n impressive body of nursing theory has resulted from this early attention to the ways in which nurses provide care to diverse populations. Despite its widespread adoption, there is a growing critique of transcultural theory that follows along the lines of the critiques against culturalism already presented in this chapter (see pages 28 and 59). Concerns have been raised regarding how culture is conceptualized as stable and pre-existing within this theory (Mason, 1990; Meleis, 1996), and as abstracted away from social, economic, historical, and political variables (Bruni, 1988; Swendson & Windsor, 1996). Moreover, Mulholland (1995) notes the inadequate theorization of power within the transcultural nursing model, and a hegemonic and assimilationist stance in which nurses are implicitly assumed to be White, requiring education to deal with "different" cultures has also been noted (Bruni, 1988; Mulholland, 1995). Nonetheless, despite these limitations, the work of Leininger has been pivotal in drawing attention to the importance of culture in the realm of health and health care.  48 Cultural Assessment Among the mid-range theories developed to provide guidance to nurses when caring for clients from various ethnic groups, several assessment models have been developed (e.g., Giger & Davidhizar, 1990, 1991; Tripp-Reimer, 1984; Tripp-Reimer & Brink, 1985). Giger and Davidhizar (1991) present an assessment model for the evaluation of six essential cultural phenomena evidenced among all cultural groups: communication, space, social organization, time, environmental control, and biological variation. Once again, this particular cultural assessment model is based on a static and deterministic conceptualization of culture. Culture is defined as "a patterned behavioral response that develops over time as a result of imprinting the mind through social and religious structures and intellectual and artistic manifestations....Culture guides our thinking, doing, and being and becomes patterned expressions of who we are" (Giger & Davidhizar, p. 3). With such a portrayal of culture, any critical analysis of the historical nature and material consequences of race is unlikely. Yet, while there are significant limitations in the theoretical underpinnings of these assessment models, it must be noted that they alert nurses to the variations within client experience and therefore preclude a singular (i.e., colour blind) approach to all clients, regardless of ethnicity. Negotiation and Cultural Brokerage Mid-range theory has also been developed to address the "how-to" of interactions between nurses and clients. Negotiation is a common theme in such models and is often derived from the work of Arthur Kleinman (1978). A central critique brought against Kleinman's work 18  Kleinman (1978) maintains that most health care systems contain the three social arenas of popular (the family context of sickness and care along with the social network and community activities), folk (non-professional healing specialists), and professional (Western medicine and professionalized indigenous healing traditions). In each of these three arenas, explanatory models can be elicitedfrompractitioners, clients, and family members regarding etiology, onset of symptoms, pathophysiology, course of sickness, and appropriate treatment. Once the explanatory models have been clearly expressed by both client and practitioner, the practitioner actively negotiates with the 1 8  49 is that it carries an emphasis on explanatory models without analysis of relations of power, and thus assumes that health care providers and recipients negotiate from similar positions (Lazarus, 1988; Pappas, 1990). As Lazarus (1988) notes, "Explanatory models writers cannot arrive at a clinical praxis when they study only beliefs that are brought to the clinical interaction and do not include the behavior of both clients and clinicians" (p. 44). Further criticism is that Kleinman's work does not explore those factors underlying supposed cultural differences; that is, through a focus on negotiating cultural differences, the emphasis is on the differences rather than on the structures that create and maintain such differences. However, drawing on more recent work by Kleinman, Tang and Anderson (1999) offer a counter interpretation, suggesting that Kleinman did "in fact, recognize the importance of structure and the interrelation between structure and agency in the complex intersection of multiple clinical realities" (p. 85). Nursing scholars have applied Kleinman's explanatory model in various ways. The early work of Tripp-Reimer and Brink (1985) on cultural brokerage suggests that noncompliance by the client with medical protocol often alerts the nurse to the need for negotiation. The reference to noncompliance carries a strong message of the need to assimilate to the dominant health care system and overlooks any dynamics of power at work. However, Jezewski (1990, 1993) in her work on cultural brokerage acknowledges the power of the health care system and the integral role of policies and marginalization (e.g., through economic disadvantage). Her work, then, is an  client, as a therapeutic ally, about treatment and expected outcomes. Kleinman, Eisenberg, and Good (1978, p. 256) suggest the following questions in exploring the explanatory model of the client: 1. What do you think has caused your problem? 2. Why do you think it started when it did? 3. What do you think your sickness does to you? How does it work? 4. How severe is your sickness? Will it have a short or long course? 5. What kind of treatment do you think you should receive? 6. What are the most important results you hope to receive from this treatment? 7. What are the chief problems your sickness has caused for you? 8. What do you fear most about your sickness?  50 example of critical perspectives gaining entry into nursing literature and moving the focus from the micro to the macro level. Likewise, the nurse-client negotiation model (Anderson, 1987, 1990) draws attention to the context of health care by examining the three structural domains of the professional sector, the popular sector, and the folk sector. West (1993) has developed the cultural bridge model that emphasizes bridging between interacting groups of people through assimilation, integration, education, and tolerance. The model is based on mutual respect and the goal of maintaining cultural differences and uniqueness while having meaningful relationships. The model, then, offers the nurse several strategies whereby to "bridge" cultural differences. In essence, the model places the responsibility for culturally sensitive care on the nurse and does not acknowledge the many other complicating influences inherent in a complex health care system. Cultural Competence and Cultural Sensitivity Another area of mid-range theory involves the skills or qualities of the nurse involved in intercultural care. Cultural sensitivity and cultural competence are two terms used widely in nursing literature to refer to this area. Both terms generally refer to the components of attitude, knowledge, and skill (Campinha-Bacote, 1994, 1995; Capers, 1994; Majumdar, 1996). Cultural competence as portrayed in the nursing literature has been heavily influenced by the multicultural competence movement in counseling psychology (e.g., the work of Derald Wing Sue, Gargi Sodowsky, Thomas Ottavi, and Donald Pope-Davis). The concepts of cultural sensitivity and cultural competence are grounded in the cultural pluralism ideology that affirms diversity. In keeping with this perspective, "nurses are required to be more culturally aware, knowledgeable, and skilled at working with culturally diverse individuals" (Pope-Davis, Eliason, & Ottavi, 1994, p. 31). Mid-range nursing theories regarding cultural competence/sensitivity, by  51 their micro focus, tend to