Highlights•

Race-related stress is well-studied in Sociology and Psychology, but not in Nursing.

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Distress caused by racial bias is actually racism-related rather than race-related.

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Racism-related stress can affect nurses’ engagement, performance and practice.

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Psychological resilience is vital for nurses’ health and well-being.

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Healthcare organizations must recognize racism-related stress and support resilience.

AbstractBackground

Studies have found race-related stress psychologically and physiologically harms members of stigmatized racial groups. However, the stressor is racism, not race.

Purpose

This study examined the relationship between racism-related stress and psychological resilience in Black/African American nurses.

Method

This study used a cross-sectional, quantitative, correlational design with two instruments, an investigator-developed demographic questionnaire and a convenience sample.

Findings

Participants perceived they have low psychological resilience in stressful situations. With racism-related stress, in particular, participants perceived they are affected by both lived and vicarious racism – ruminating over past occurrences, and expecting/worrying that racism will happen to them or other Black/African American people. There was a significant positive correlation between participants’ perceived psychological resilience, their ability to assess the nature of the racism-related stressor and their ability to mitigate its harmful effects by identifying and utilizing their coping resources. There was a negative correlation between racism-related stress and psychological resilience.

Discussion

There is a need for continued research on racism-related stress among Black/African American nurses. Further, healthcare organizations, advisably through their diversity, equity and inclusion (DEI) programs, must develop systemic approaches to meeting the unique needs of the Black/African American workforce.

KeywordsIntroductionIn her 2015 viral video “Call-In Black,” journalist and social media satirist, Evelyn Ngugi, asked viewers, “Have you ever just wanted to call-in Black to work?” Ngugi described a range of thoughts that flooded her mind after learning of another harming or death of a Black/African American person. Ngugi was likely referring to the widespread, frequent violence against members of the Black community at the hands of police officers, especially traumatic events recent to the making of her video. In addition to conveying her pain, Ngugi expressed frustration. She knew, or at least expected, that racism fueled the killings she alluded to and that justice would not be served. Ngugi then shared her realization that the feelings of hopelessness, confusion, fury and recklessness were facets of one complex emotion: Grief. This emotional toll caused withdrawal; and Ngugi decided to “call-in Black”, to stay home from work and “affirm (her) humanity to (her)self” ().Ngugi's video raises serious concern about the health, well-being, engagement and subsequent job performance of Black/African American employees. Specific to the healthcare industry, the relationship between human factors in healthcare workers and patient safety has been well-established by agencies such as the Institute of Medicine 2000Institute of Medicine (US) Committee on Quality of Health Care in America
To Err is Human: Building a Safer Health System.. Two human factors with the most impact are fatigue and stress; and if not prevented or ameliorated, these factors contribute to acute or chronic psychological and physiological impairments, like mental and physical exhaustion, illness, depression, and anxiety. These altered states can have a deleterious effect on employees’ job performance, productivity, decision quality and overall error management; and patient safety can be compromised (Jeanguenat and Dror, 2018Jeanguenat A.M. Dror I.E. Human factors affecting forensic decision making: workplace stress and well-being.).In Nursing, specifically, occupational stress, and subsequent compassion fatigue, moral distress and ultimately burnout, are topics that have been widely studied. For Black/African American nurses, racism is a unique social stressor that can compound and complicate the common occupational stressors experienced by nurses of any race. Studies on racism-related stress in nurses were not found in published Nursing research, but are well-studied in the fields of Psychology and Sociology. For example, in a 2009 study of sociodemographic variations in self-reported racism by Black/African American and Latinx persons, Brondolo et al., 2009Brondolo E. Beatty D.L. Cubbin C. Pencille M. Saegert S. Wellington R. Tobin J. Cassells A. Schwartz J. Sociodemographic variations in self-reported racism in a community sample of Blacks and Latino(a)s. found that participants experienced repeated exposure to racism, as often as a weekly. Additionally, the study showed that participants experienced racism regardless of socioeconomic status, which supports the assertion that professionals/persons with higher education (e.g., nurses) are not exempt from exposure to racism. The study also found that Black/African American participants experienced more lifetime, i.e. chronic, exposure to racism than did Latinx participants.The wealth of studies on racism-related stress and coping in Psychology and Sociology lend to the assumption that Black/African Americans nurses, like many Black/African Americans in general, experience various manifestations of racism and associated social stress. In consideration of this issue, this preliminary study examines the relationship between racism-related stress in Black/African American nurses and their psychological resilience. Three research questions were addressed:1.

What is the level of racism-related stress among Black/African American nurses?

2.

What is Black/African American nurses’ perception of their psychological resilience?

3.

For Black/African American nurses, is there a relationship between psychological resilience and racism-related stress?

BackgroundAn important development in examining the discriminatory treatment and disparate experiences of Black/African American people is the concept of “racism, not race.” Regarding terms such as race-related, race-based, and race-induced, scholars like Dr. Camara Jones, 2000Levels of racism: A theoretic framework and a gardener's tale., posit that these terms imply or assert that race is a risk factor when, in actuality, racism is the risk factor, if not the root cause (Krieger et al., 1993Krieger N. Rowley D.L. Herman A.A. Avery B. Phillips M.T. Racism, sexism, and social class: Implications for studies of health, disease, and well-being.;Williams et al., 2019Williams D.R. Lawrence J.A. Davis B.A. Vu C. Understanding how discrimination can affect health.). Given this important clarification by scholars of critical race theory, the term racism-related is intentionally used in this article. However, race-related is used when referencing works where the researcher(s)/author(s) specifically used that verbiage in their studies. StressStress is defined as a “constraining force or influence, such as a physical, chemical, or emotional factor that causes bodily or mental tension and may be a factor in disease causation” (). In the workplace, mitigating stress as a human factor improves job performance, decision quality, productivity and overall error management. When stress is repeated or looming, therefore chronic, performance and productivity tend to suffer. Resultant psychological and physiological phenomena include mental and physical exhaustion, illness, depression, and anxiety (Harrell, 2000A multidimensional conceptualization of racism-related stress: implications for the well-being of people of color.; Jeanguenat and Dror, 2018Jeanguenat A.M. Dror I.E. Human factors affecting forensic decision making: workplace stress and well-being.). RacismRacism is the belief that race is the primary determinant of human traits and capacities, and that racial differences produce an inherent superiority of a particular race (). According to Perry et al., 2013Perry B.L. Harp K.L. Oser C.B. Racial and gender discrimination in the stress process: Implications for African American women's health and well-being. sociological perspective: official publication of the., racism exists in different forms: individual, interpersonal (e.g., macroaggressions and microaggressions), institutional (e.g., workplace culture) and structural (i.e., ingrained in systems). For Black/African American people, experiencing racism can be a source of chronic psychological and physiological distress. Racism-Related StressRacism-related stress is the psychological distress that results from both direct and indirect experiences of racism. Similar terms include, but are not limited to, social stress, race-based stress and minority stress (Harrell, 2000A multidimensional conceptualization of racism-related stress: implications for the well-being of people of color.; Perry et al., 2013Perry B.L. Harp K.L. Oser C.B. Racial and gender discrimination in the stress process: Implications for African American women's health and well-being. sociological perspective: official publication of the.).According to the American Psychological Association's (APA) Office of Ethnic Minority Affairs, the pervasive and persistent exposure to racism and discrimination creates an additional daily stressor for Black/African American people, and can acutely or chronically affect their psychological and/or physiological health. At least three sources of racism-related stress have been identified: (a) acute, episodic stress from infrequent, contained experiences of racial discrimination; (b) daily stress of racial microaggressions, which are subtle, intentional or unintentional degradations and exclusions that may be imperceptible to others; and (c) chronic stress that can include the previous types but is also related to the inequities in resource allocation, access, and acquisition that impact the lives and livelihoods of Black/African American people. Emotional responses include anger, anxiety, fear, frustration, depression, helplessness, hopelessness, isolation, paranoia, resentment, sadness, shame, self-blame, and self-doubt. (APA, 2018; Brondolo et al., 2016Brondolo E. Ng W. Pierre K.-L.J. Lane R. Racism and mental health: Examining the link between racism and depression from a social cognitive perspective.; Harrell, 2000A multidimensional conceptualization of racism-related stress: implications for the well-being of people of color.; Perry et al., 2013Perry B.L. Harp K.L. Oser C.B. Racial and gender discrimination in the stress process: Implications for African American women's health and well-being. sociological perspective: official publication of the.).Inadequate intervention and support, combined with ineffective coping strategies, can lead to avoidance and withdrawal; and there can be somatization of this unique stressor manifesting as muscle tension, pain processes, hypertension, heart disease and forms of addiction (Brondolo et al., 2016Brondolo E. Ng W. Pierre K.-L.J. Lane R. Racism and mental health: Examining the link between racism and depression from a social cognitive perspective.; Greer, 2011Coping strategies as moderators of the relation between individual race-related stress and mental health symptoms for African American women.; Harrell, 2000A multidimensional conceptualization of racism-related stress: implications for the well-being of people of color.; Outlaw, 1993Stress and coping: The influence of racism on the cognitive appraisal processing of African-Americans.; Perry et al., 2013Perry B.L. Harp K.L. Oser C.B. Racial and gender discrimination in the stress process: Implications for African American women's health and well-being. sociological perspective: official publication of the.; Williams et al., 2019Williams D.R. Lawrence J.A. Davis B.A. Vu C. Understanding how discrimination can affect health.).Since 2000, there has been considerable research on racism-related stress and health outcomes of various groups, including Black/African American people. Two studies are particularly relevant to this present study. In 2011, Greer studied race-related stress among 128 Black/African American women and found that women trying to cope with or shield themselves from racism-related stress may unintentionally use strategies that actually increase, rather than prevent or alleviate, psychological distress (Greer, 2011Coping strategies as moderators of the relation between individual race-related stress and mental health symptoms for African American women.). Additionally, in a recent qualitative study undertaken in New York City with 22 Black men and 52 Black women, the researchers found that participants used a wide range of coping strategies when confronted with racism-related stress (). Racism-Related Stress in Black/African American Nurses: A PhenomenonIn 2017, the American Nurses Association (ANA) declared the “Year of the Healthy Nurse.” During that year of monthly observances and activities, April was dubbed the month for “Combatting Stress”, May brought the launch of the Healthy Nurse, Healthy Nation Grand Challenge wherein Quality of Life and Safety are two of the five domains, and October was slated for awareness about “Moral Resilience/Moral Distress” (). Black/African American nurses experience the common occupational stressors the ANA keenly identified. In addition, however, Black/African American nurses experience a unique social stressor that is superimposed on common occupational, even personal, stressors. While studies on the specific phenomenon of racism-related stress in nurses were not found in published Nursing research, it could be surmised that Black/African American nurses experience the myriad manifestations of racism, based on the many studies by other disciplines on racism-related stress. Moreover, most Black/African American nurses are members of at least one additional federally protected, sociocultural minority class. For example, women are a protected class; and ninety-one percent (91%) of nurses are women. Additionally, women 40 years or older are in a protected class; and the average age of nurses is 51 years (; ). Intersectionality, a socio-political framework developed by Kimberlé Williams Crenshaw, professor at The University of California, Los Angeles and Columbia Law School and Civil Rights scholar, describes the complex oppressive systems that affect people who have a combination of minority identities, e.g. a Black woman in her 50’s (). Psychological ResilienceResilience is the process of effectively coping with adversity, trauma, tragedy, threats or other significant sources of stress – the ability to bounce back (APA, 2016). Moreover, resilience is highly dependent on the constructs that exist in various aspects and layers of society. In their studies, Carter and colleagues found that participants were most likely to seek support and assistance from friends, family members, and spouses who have experienced, and perceive they have recovered from, the pain of racism-related occurrences (; Carter et al., 2017Carter R.T. Johnson V.E. Roberson K. Mazzula S.L. Kirkinis K. Sant-Barket S. Race-based traumatic stress, racial identity statuses, and psychological functioning: An exploratory investigation.).

Although there are a number of studies of psychological resilience among nurses, there were no studies found linking resilience to racism-related stress in nurses.

Conceptual FrameworkIn 2003, Dr. Ilan Meyer developed the Minority Stress Model to depict stress processes experienced by members of the LGTBTQ+ community who are affected by homophobia, transphobia, and other discrimination related to their sexual orientation and gender expression. The basis for minority stress theory is that there are social stressors specific to the minority group, and these stressors are above and beyond the stress experienced by those who are not socially stigmatized, i.e. cisgender and heterosexual. Meyer asserts, “If LGB[TQ+] people are indeed at risk for excess mental distress and disorders due to social stress, it is important to understand this risk, as well as factors that ameliorate stress and contribute to mental health.” Within the Minority Stress Model, distal/external stigma-specific stress factors lead to the subsequent development of proximal/internal stress factors in stigmatized persons. The presence or absence of mitigating factors such as community support and psychological resilience may lead to positive or negative outcomes, respectively (Holman, 2018Theoretical extensions of minority stress theory for sexual minority individuals in the workplace: a cross-contextual understanding of minority stress processes.; Meyer, 2003Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: conceptual issues and research evidence.; Testa et al., 2015Testa R.J. Habarth J. Peta J. Balsam K. Bockting W. Development of the gender minority stress and resilience measure.).

While created to illustrate experiences and needs in the LGBTQ+ community, the Minority Stress Model is apt for and generalizable to other socially stigmatized groups. For the present study, the model was reconceptualized with Black/African American people as the stigmatized population, and racism as the stressor. The present study is the first application of this conceptual model to the understanding of minority stress – specifically, racism-related stress – and psychological resilience in nurses.

Review of LiteratureAn important consideration regarding racism-related stress, or any form of discrimination, is as follows: “An event or enduring condition can be experienced as stressful or traumatic by one person, whereas another person undergoing the same or similar experience may not feel the same way. In order to assess whether an encounter with racism resulted in race-based trauma, it would be necessary to know if the person exposed was able to appraise the incident as being race-related” (Carter et al., 2017Carter R.T. Johnson V.E. Roberson K. Mazzula S.L. Kirkinis K. Sant-Barket S. Race-based traumatic stress, racial identity statuses, and psychological functioning: An exploratory investigation.). This is key in not assuming that everyone in a historically marginalized group perceives themselves as marginalized, or perceives undesirable situations that occur to be related to discrimination. However, the negative effects of discrimination are a reality for many; and, in 2015, the APA and Harris Poll conducted their annual Stress in America report with a focus on the Impact of Discrimination. The purpose was to measure the attitudes and perceptions of stress among the general public. The survey focused on the stress induced by major forms of discrimination and day-to-day discrimination with the goal of identifying the leading sources of that stress, its impact on daily life and common behaviors used to manage it. Of a probability sample, the survey respondents consisted of 3, 361 adults from various marginalized groups and segments of American life that included race, ethnicity, generation, gender, poverty level, region, urbanicity, emotional support, disability and LGBTQ+ orientation/identification. Survey included questions adapted from The Everyday Discrimination Scale and Major Experiences of Discrimination Scale. Key to this topic were the findings that racism-related stress lasted up to a year after the occurrence. Feeling disrespected and angry were the most frequent reactions, followed by feeling insulted, disappointed, frustrated, outraged, hurt and shocked. Survey respondents believed emotional support could reduce stress; and those who receive emotional support report lower levels of stress than those who do not receive emotional support ().Consistent with the 2015 Stress in America findings, a study of emerging adults (18–29 years old) who are minorities and have experienced racism, showed that this population may be more vulnerable to dissociative symptoms; the relationship was not explained by exposure to other traumatic life events. This is supported by another study that found the indirect effects of racism-related microaggressions and traumatic stress symptoms were the most robust with low self-efficacy. However, while racism-related stress was associated with feelings of hopelessness, those emotions were ameliorated, to some degree, by social support. This showed that the risk for dissociation may be impacted by presence/absence of effective coping strategies. Understanding this, it is important to note from the 2015 Stress in America study, that while all participants dealing with racism-related stress were most likely to seek support from spouses, family and friends, Black and biracial participants were the least likely to seek professional mental support, compared to the Latino and Asian study participants (; Odafe et al., 2017Odafe M.O. Salami T.K. Walker R.L. Race-related stress and hopelessness in community-based African American adults: Moderating role of social support.).Specific to nurses in the workplace, a 2015 study of racial and ethnic minority nurses’ job satisfaction in the U.S. was conducted to determine minority nurses' job satisfaction across racial and ethnic groups compared to White nurses. A retrospective cross-sectional analysis was conducted using the 2008 National Sample Survey of a representative sample of Registered Nurses; and at 28, 554 respondents the sample size was substantial. Though the majority of nurses were satisfied with their job, notable differences in job satisfaction were observed across racial and ethnic groups. Adjusting for individual and job-related characteristics, findings indicated the potential for lower job satisfaction among Black nurses compared to White nurses. The researcher posited, “More research is needed to understand factors underlying these differences, so that Nursing and hospital administrators can develop effective strategies to improve job satisfaction and retain minority nurses” (Xue, 2015Racial and ethnic minority nurses' job satisfaction in the U.S.).

What is known from the literature reviewed is that stress related to discrimination, in general, and racism, in particular, is a real phenomenon that can have deleterious psychological and physiological effects on those subjected to it. What is also known is that community support structures are integral to one's ability to “bounce back” from a stressor, that Blacks and African-Americans are less likely than their counterparts to seek professional help for stress and that healthcare leaders must explore reasons why Black/African American nurses experience less job satisfaction.

Racism-related stress and psychological resilience, and their synonymous and related concepts, are examined in various studies – both separately and together – but none of the studies found have a target population of Black/African American nurses. Therefore, what is not yet known is whether there is an association between the two phenomena and whether a correlation, if established, could lead to the discovery of a causal relationship.

Methods Design

This research was a preliminary study using a quantitative correlational descriptive design.

 Sample

The National Black Nurses Association (NBNA) was asked to recruit participants from its membership of approximately 150,000 Black/African American Nursing professionals (2020). In particular, the Greater New York City chapter of the NBNA amplified the study and survey. Inclusion criteria were age 18 or older, currently licensed as a Registered Nurse (RN) or Advanced Practice Registered Nurse (APRN), working in any Nursing role, and who identifies as Black/African American (non-Hispanic origin).

 Instruments

Three instruments were used: The Brief Resilience Scale (BRS), the Prolonged Activation and Anticipatory Race-Related Stress Scale (PARS), and an investigator-developed demographic questionnaire.

BRS. The BRS was used to measure the self-perceptions of Black/African American nurses regarding their resilience in general, not necessarily in response to racism. The BRS has six items, some positively worded and others negatively worded. The individual rates their responses on a Likert scale ranging from 1, or “Strongly disagree” to 5, “Strongly agree,” with three reverse-scored items. The BRS score is calculated as an average and interpreted as follows: 1.00 to 2.99 is low resilience, 3.00 to 4.30 is normal resilience and 4.31 to 5.00 is high resilience. The Cronbach's alpha ranged from .80 to .91 (Smith et al., 2008Smith B.W. Dalen J. Wiggins K. Tooley E. Christopher P. Bernard J. The brief resilience scale: Assessing the ability to bounce back.). In the present study the Cronbach's alpha for the BRS was .84.PARS. The PARS was used to evaluate the experience of racism-related stress in Black/African American nurses. The PARS is a 17-item, four-subscale instrument designed to examine the participant's self-perceived stress responses to a singular, specific encounter with racism, whether lived/direct or vicarious/indirect. The instrument's four subscales are: Perseverative Cognition, Anticipatory Race-Related Stress, Anticipatory Bodily Alarm, and Secondary Appraisal; and the development of the instrument was influenced by the seminal research of () on stress, appraisal and coping.Perseverative cognition is the persistent, vivid memory of a stressor which occupies one's thoughts and sustains negative psychological and/or physiological response(s) to the stressor (Utsey et al., 2012Utsey S.O. Belvet B. Hubbard R.R. Fischer N.L. Opare-Henaku A. Gladney L.L. Development and validation of the prolonged activation and anticipatory race-related stress scale.). This focus on a past event can yield anxiety about the potential for a future event. With the five-item Perseverative Cognition subscale, the individual rates their responses on a scale of 1/“In the days/weeks since I experienced racism, I did not think about racism at all” to 7/“I thought about it more than 3 times/day” (Utsey et al., 2012Utsey S.O. Belvet B. Hubbard R.R. Fischer N.L. Opare-Henaku A. Gladney L.L. Development and validation of the prolonged activation and anticipatory race-related stress scale.).Hypervigilance, or anticipatory stress is the expectation of a stressor as a result of a previous direct or indirect negative experience. With the four-item Anticipatory Race-Related Stress subscale, the individual rates their responses on a scale of 1 to 7, indicating the extent to which the individual believes they will experience racism in the future (Utsey et al., 2012Utsey S.O. Belvet B. Hubbard R.R. Fischer N.L. Opare-Henaku A. Gladney L.L. Development and validation of the prolonged activation and anticipatory race-related stress scale.).An anticipatory body alarm response in one wherein the person who is expecting a racism-related event experiences somatic symptoms. With the four-item Anticipatory Bodily Alarm Response subscale, the individual rates their responses on a scale of 1 to 7, indicating the extent to which the individual experienced bodily changes, e.g., hands shaking, whenever they think they are about to experience racism (Utsey et al., 2012Utsey S.O. Belvet B. Hubbard R.R. Fischer N.L. Opare-Henaku A. Gladney L.L. Development and validation of the prolonged activation and anticipatory race-related stress scale.).Lastly, and in contrast to the previously mentioned anticipatory stress, secondary appraisal is a self-evaluative process that assesses the stressor, one's response to the stressor and one's available coping mechanisms and readily accessible resources. The coping mechanisms and resources are foundational to psychological resilience. With the four-item Secondary Appraisal subscale, the individual rates their responses on a scale of 1 to 7, indicating the extent to which they felt prepared to deal with the experience of racism (Smith et al., 2008Smith B.W. Dalen J. Wiggins K. Tooley E. Christopher P. Bernard J. The brief resilience scale: Assessing the ability to bounce back.; Bonanno et al., 2015Bonanno G.A. Romero S.A. Klein S.I. The temporal elements of psychological resilience: An integrative framework for the study of individuals, families, and communities.; Utsey et al., 2012Utsey S.O. Belvet B. Hubbard R.R. Fischer N.L. Opare-Henaku A. Gladney L.L. Development and validation of the prolonged activation and anticipatory race-related stress scale.).For the first three subscales – Perseverative Cognition, Anticipatory Race-Related Stress, and Anticipatory Bodily Alarm Response – the higher the rating, the greater the degree of racism-related stress. For the final subscale, Secondary Appraisal, the higher the rating, the greater confidence in one's coping resources (Utsey et al., 2012Utsey S.O. Belvet B. Hubbard R.R. Fischer N.L. Opare-Henaku A. Gladney L.L. Development and validation of the prolonged activation and anticipatory race-related stress scale.).The originators of the PARS instrument reported a Cronbach's alpha for the total scale of α = .76, and for the subscales as follows: Perseverative Cognition, α = .83; Anticipatory Race-Related Stress, α = .70; Anticipatory Bodily Alarm Response, α = .83; and Secondary Appraisal, α = .78 (Utsey et al., 2012Utsey S.O. Belvet B. Hubbard R.R. Fischer N.L. Opare-Henaku A. Gladney L.L. Development and validation of the prolonged activation and anticipatory race-related stress scale.). In the present study, the Cronbach's alpha for the overall PARS instrument was 0.70, and for the individual components: Perseverative Cognition subscale = .80; Anticipatory Race-Related Stress subscale = .66; the Anticipatory Bodily Alarm subscale = .87; and the Secondary Appraisal subscale = .91. Scoring for each subscale is the average of the responses, ranging from 1 to 7 (Utsey et al., 2012Utsey S.O. Belvet B. Hubbard R.R. Fischer N.L. Opare-Henaku A. Gladney L.L. Development and validation of the prolonged activation and anticipatory race-related stress scale.). Investigator-Developed Demographic QuestionnaireThe investigator-developed demographic questionnaire included age (generation was subsequently determined by the investigators), genderidentity, education level, state of residence, state where employed, and Nursing role category (e.g., clinical or supervisory), and media sources by which participants learn about racism-related occurrences. Identifying as a member of the Black/African American race was an inclusion criterion; and this study did not further explore cultural background by including the variable of ethnicity. Racism is superficial in nature; and the color of one's skin, i.e. being perceived as a minority, makes one vulnerable to racism regardless of ethnicity (). ProcedureThe survey period spanned approximately four weeks, during March to early April 2020. During this time period, the NBNA Research Committee initially distributed the survey via email, and issued two reminders: one via email, and the other via the NBNA's official Facebook page (National Black Nurses Association 2020

National Black Nurses Association (2020, March 20). NBNA announces survey on Black/African American nurses. Retrieved from <iframe src="https://www.facebook.com/plugins/post.php?href=https%3A%2F%2Fwww.facebook.com%2Fpermalink.php%3Fstory_fbid%3D10158263915499736%26id%3D201829639735&width=500" width="500" height="5