A Public Health Crisis: Unpacking Racial Biases in the Canadian Nursing Profession

When we speak we are afraid our words will not be heard or welcomed. But when we are silent, we are still afraid. So it is better to speak. – Audre Lorde

The death of George Floyd on 25 May 2020 sparked international outrage. What, many agree, should have been a suspect’s standard detainment and arrest turned into a preventable homicide: a life cut short due to the excessive force used by one of the white police officers. The global outrage that ensued following the viral video that showed a police officer kneeling on Floyd’s neck for 8 minutes and 46 seconds not only called for an examination of the anti-Black racism in policing but also every institution across every industry.

In Canada, the healthcare system in general, and the nursing profession, in particular, has acknowledged that racism toward Blacks is pervasive and in need of great reform. The Canadian Nursing Association’s (CNA) CEO issued the following statement: “CNA condemns all forms of racism and discrimination. The CNA Code of Ethics demands that we uphold principles of justice by safeguarding human rights, equity, and fairness. We have rested too comfortably for too long on a myth that anti-Black racism is not systemic in Canada, but the reality has been harshly exposed.”[1]

As a Black Canadian nurse, my own story of struggle is one of many in the profession. In this article, I use a reflective practice framework to explore my career’s trajectory from nursing student to a nursing leader and discuss the systemic factors that precipitated and maintained the challenges I experienced.

Reflective practice according to Oleofsen can be defined as the process of making sense of events that transpire in the workplace.[2] Several models of reflective practice are available for nurses to adopt.[3] Most of these fundamentally inspire nurses to participate in a process similar to the one summarized by Gibbs below:[4]

• Identifying your feelings
• Evaluating the experience
• Analyzing the experience
• Concluding, including alternative actions, that you could have taken
• Drawing up an action plan for the future

I conclude by discussing the importance of acknowledging, challenging, and dismantling anti-Black racist systems. I also speak of the efforts that I am leading with the Canadian Black Nurses Alliance (CBNA) to help create a culture, where every Canadian regardless of race, gender, or creed will be able to thrive.

Nursing School

Nursing is an esteemed profession in many parts of the world and this is no different in Canada. There are 114 nursing programs in the country, and 39 in Ontario. I was accepted into one of the first collaborative degree nursing programs between Humber College and the University of New Brunswick in Toronto. Every year, approximately 195 students are admitted and although race and ethnicity data is not collected in Canada, anecdotally, approximately 70 percent of admitted students are white.

A review of the nursing faculty indicates that while racial diversity among students has increased, faculty diversity has not.[5] Sensoy and Diangelo state that “despite two-plus decades of equity policies, the Canadian university professoriate remains overwhelmingly White (81 percent) and male (66 percent)” in their literature report.[6] The numbers are even bleaker as one looks up the ladder of university leadership: 73 percent of universities have all-white leadership teams, and “in 2016, not a single university had a visible minority woman or Aboriginal man or woman on their presidential leadership teams.”[7]

This combination of white teaching staff and leadership with a growing racialized nursing student population is a manifestation of centuries of power, privilege, and advantage, contributing to a system of structural disadvantage for said students. Substantively, this structure perpetuates an ideology that white leadership is normative and the status quo and “others”, namely, black students, are not welcomed. The literature describes an oppressive educational climate for non-white identifying people.[8] Also, when there are no people of  color present, race remains unnamed and is not presumed to be an organizing institutional factor.[9]

As a second-generation registered nurse, I never once received a cautionary warning from my parents or mother in particular about the racism I may encounter as a student or that my skin color could delay, or be a deterrent to, my success.

Notwithstanding, the evidence suggests that there have been historical challenges with admissions into nursing programs for Black nurses. Additionally, the nursing curriculum also tends to be “oppressive and restrictive.”[10]

Following reflective practice, my academic journey was typical until year three, when I had my first encounter with covert racism. With covert racism being hard to identify, I was unsuspecting.

[Ovie’s Reflections: I am a nursing student]

Undergraduate school had its challenges but that wasn’t my experience, I was excelling in all my courses and academic life was great. This bliss came to a sudden halt with the introduction of one particular professor, a caucasian female, pretentious and poised. Her reputation for clinically failing black students was known, but I ignored a warning from my classmate to “switch professors.” Big mistake. I was confident in my academic skills and delivered hard work which brought success. However, to my surprise, I was receiving D’s in all my written work despite seeking help from editors and putting forward my best efforts. I challenged my grade throughout the course sensing a great inequality in my experience. The final test for the course was my last chance to avoid failing. An open book final test seemed like a breeze. I ensured, all application and knowledge of the course learnings were cemented in my head, to secure at this point a passing grade. However, my overall final mark was even lower than before. I had received a letter grade of “F”, I was floored, and asked to formally review my final test with the professor. I was bewildered by the revelations of her systemic beliefs.  

During my review, I listened to Dr.W’s rationale for giving me little to no credit for correctly answering many questions. I received marks 2/10 or 3/20 despite it being very obvious that my answers were correct. Challenging this and requesting a second reviewer, Dr. W began listing her credentials (“I have a Ph.D.”) and stating that she was highly respected in many nursing boards across Canada and “no one would believe” me. I walked away feeling that I had enough information to escalate the matter as there were a few others who suffered Dr.W’s fate. However, we were not supported by the school with pleas to escalate our concerns. It is worth noting that those who failed that year were not all Black or visible minorities as there were several white immigrants from Poland and Russia who also failed her class.

The advice from the program director was to repeat the course as escalating the matter would be a “long proceeding.” Defeated and not equipped with the due process for raising a complaint beyond the program director, I and others repeated the course.

My last year of nursing school (in 2007) brought better success as I ensured a different professor for my repeated course. That year another Black student persistently forwarded a formal complaint against Dr.W for several biases and strong racially inappropriate comments in the classroom, notably, “who let the monkeys in the program.” Dr.W had to resign as the complaints became undeniable.

As I reflect on my year with Dr.W, several questions come to mind. I wonder what would've happened if I had pursued my advocacy and escalated my complaints to this highest level possible. Would she have resigned as she did? Would I have been vindicated? I often think about the role of clinicians we play in calling out “bad apples”, ensuring that patients and colleagues alike are given the best opportunity to thrive. I know that my experience with Dr.W is one that many Black nursing students can relate to. I am compelled to speak up about such matters knowing that silence perpetuates the status quo and that Black nursing students deserve better.    

White nursing professors and faculty members within the dominant mainstream majority have the power to influence the curriculum, grades, and academic experience. My experience over 13 years ago remains similar to the experiences Black nursing students today face, as they frequently report experiences of isolation, underrepresentation, and a curriculum that does not share any examples of the Black pioneers in nursing such as Mary Seacole.

It was suggested that a lack of support in the form of academic, financial, and/or other barriers, combined with the lack or even absence of Black faculty to serve as mentors and role models, exacerbate this phenomenon.[11]

Black nursing students are left to navigate these challenges, either surviving the experience or leaving the program completely. Tilki et al.[12] note that the nursing curriculum neglects racism, and although it is not unique to healthcare education, anti-racist strategies have been largely ignored in the education of nurses and healthcare professionals. 

Professional Life: A Harrowing Experience

As stated earlier, the invisibility of Black nursing leaders is evident in the current absence of teachings on the impact of influential Black nurses throughout history, Jefferies et al. particularly point out Harriet Tubman, Mary Seacole, and Sojourner Truth.[13] Moreover, the invisibility of Black nurses in leadership is a consequence of the significant underrepresentation of Black students in nursing programs.[14]

Substantively, Black nurses are largely absent from leadership positions and specialty practice areas such as intensive care. Instead, Black nurses are often streamlined into areas that are more physically demanding, task driven, and strenuous. At the same time, Black people are concentrated in entry-level positions, non-specialty roles, or in non-licensed clinical roles such as personal care workers.[15]

Given the aforementioned, it was a great achievement for me to secure a critical care nurse role in the Medical-Surgical Intensive Care Unit (MSICU) at one of Toronto’s world-renowned hospitals upon graduating from nursing school. In this role, I grew exponentially as a nurse delivering excellent evidence-based patient care. I increased my ability to think critically and was empowered by my professional team through autonomy and effective communication. These characteristics atop of a natural desire to lead qualified me to become a Patient Care Coordinator (PCC) in the Coronary Intensive Care Unit (CICU) within the same hospital. The PCC is a nonunion supervisory role that prepares a nurse leader for the typical next step—to be a nurse manager. This was a big achievement and a natural progression for my nursing trajectory. The organization has four centers and, working at the headquarters, it was visibly evident that Black representation within the managerial and senior-level positions was scarce.

[Ovie’s Reflections: I am a nursing leader]

As a PCC, my role consisted of supervising the frontline staff, ensuring safety as well as quality within the unit, and achieving financial objectives through appropriate staffing ratios to name a few duties. I prided myself on being able to effectively apply evidence-based care and working with others to do the same. After 11 months in the role, it became evident that my teammates and nursing unit manager were scrutinizing and undermining the work I was doing and the authority that I held. Uncomfortable with making it about race, I chalked it up to growing pains and filed the experience as leadership challenges. 

Several thoughts came to mind and many posed by external mentors such as am I being oppressed? Is this racism? Why isn’t respect and civility being emphasized? Why is my voice not being taken seriously by human resources and the senior leader? Why did white nurse L.C ask my supervisor and HR if I have the “right to supervise her performance” when the PCC role and job description had been in the organization for over 10 years with no modification? Did the title and job description have a different meaning for my colleague who was white?

I often ruminated about how things would've been had I not accepted this new position. I was excluded and my leadership exposure within the organization such as attending operational, managerial, and union workload meetings was limited. Jefferies et al. share that challenges have become normalized beyond detection, a sentiment that my lived experience echoes.[16]

After twelve months of internal and external struggle as a PCC, I decided to seek mentorship from my previous manager. This outreach was discouraged and frowned on by my supervisor, leaving me isolated from seeking trusted guidance within the organization. Notwithstanding, there was a lack of accountability from the HR lead, leaving me vulnerable and placing me in the crosshairs of either quitting or waiting to be terminated. Coincidentally, after 12 years of managing the unit, the supervisor was moved to take a position directing the ambulatory clinic and the unit educator became the new unit manager. I was hopeful that my experience in the unit would change but unfortunately, that was not the case. The continuation of the harassment, bullying, and insubordination from subordinates once my nursing unit manager was replaced by another white woman was indicative of the strength of the system.

What I learned from that experience was that pervasiveness of anti-Black racism, insubordination toward Black leadership, and the perpetuation of white leadership are powerful forces that are maintained by those in power and their beneficiaries.

Finally, to no surprise of my own I was the only nurse in my unit to be let go in January 2020, which was cited as “budget cuts and restructuring.” I do believe I was signalled out for reasons other than my professionalism. My conviction was reinforced when not eliciting a call back for the “all hands on deck” plea from the Ontario Premier was absent in midst of the coronavirus pandemic.

The challenges I faced in my role as a PCC (i.e., insubordination, challenges of my authority, scrutiny of my job description, and lack of peer and leadership support) are central themes in the discourse of Black nursing leadership in literature as well as the lived experience of many of my friends and colleagues. Calliste notes[17] that Black nurses are disproportionately concentrated at lower levels in the profession and are subjected to the racialization of surveillance in practice, which involves being over-supervised, disciplined, and terminated more often than non-Black nurses.

Das Gupta posits that disciplinary measures against Black nurses are taken in non-standard ways and are therefore prone to supervisory biases.[18] Harassment of outspoken nurses of color in the form of work discipline seems to be a common experience in some healthcare organizations. This often comes as negative documentation being solicited on nurses of color from direct supervisors and colleagues. Information is accumulated to be used for discipline.

As with my experience as a student nurse, my experience as a rising nursing leader has been colored and shaped by a system that doubts my merit and subjects me to a different set of standards than my white counterparts. While some may argue that nursing has come a long way in Canada given the rising numbers of visible minorities in the field, it is evident that the profession still has a long way to go in creating inclusive opportunities and spaces, especially in the leadership ranks. 

Addressing Anti-Black Racism: Reimagining a New System as an Activist

Anti-Black racism in nursing is detrimental to Black nurses and the health of all Canadians. Evidence indicates that Black people suffer from high rates of chronic illnesses including diabetes, high blood pressure, and mental illness. Accordingly, systems that do not value Black lives are apt to misdiagnose or undertreat certain conditions, furthering health inequities as a consequence of maltreatment and premature morbidity.

Although there are situations where my potential has been supported and recognized reflecting on my journey from student to a leader, it has become clear that I must play a greater role as a change agent in the system, particularly for Black nurses. With time to reflect during my career transition, I birthed my vision and founded a not-for-profit: The Canadian Black Nurses Alliance (CBNA).

In partnership with four other Black Canadian nurse leaders, CBNA’s mission is the advancement of Canadian Black nurses through empowerment, mentorship, and advocacy. The Canadian Black Nurses Alliance will also engage in research and outreach to black youths in post-secondary schools, and promote nursing as a profession and ensure interested students no longer are streamlined out of choosing the profession.    

CBNA Nursing Reform Recommendations

1.    Profound Listening
Engage in profound listening to unpack biases, enhance support for capacity building, and promote dialogue around ethnic inequalities in nursing.

2.    Disaggregated Race Data and Evidence
Collect and share disaggregated race data in all areas of nursing from academic to professional.

3.    Uncover Systemic and Institutional Racism
Facilitate fair representation by conducting yearly audits at all levels of nursing.

4.    Social Participation
Provide authentic social participation that promotes retention of skilled Black nursing practitioners at all levels that creates a psychological and professionally safe corporate culture.

5.   Bold Initiatives
Promote and increase the use of Black nursing representatives at university fairs and all media
campaigns for nursing recruitment.

6.    Entrance Scholarships for Black Students
Ensure equity in opportunity for all to participate in scholarship applications; promote these scholarships through the CBNA and other black empowerment hubs and organizations.

The tides have shifted in organizations with the recognition of the importance of Black representation.  We are optimistic that with the surge of healthcare organizations, academic institutions, nursing professional regulatory boards, and associations expressing commitment to racial equity, that the nursing profession stands to see similar changes.

The problem alarms louder when a health industry that is heavily based on data collection, facts, and evidence does not collect or perhaps is not transparent with disaggregated race data to refute or even substantiate the literature while making evidence-based changes. This is a call to action to improve the visibility and increase the support for Canadian Black nurses.