Abstract
Background: People of African Nova Scotian (ANS) ancestry are a culturally distinct group who experience numerous socioeconomic inequities and health disparities, secondary to structural and social determinants of health. Understanding the experiences of ANS health practitioners is important in addressing anti-Black racism in health care. We sought to critically examine the leadership experiences of ANS nurses in health care practice.
Methods: We used Black feminist theory to guide this qualitative study. We conducted 1-on-1 semistructured telephone interviews with ANS nurses and analyzed interview transcripts using Critical Discourse Analysis.
Results: We interviewed 18 nurses of ANS ancestry. We conceptualized study findings in 3 overarching areas: People of ANS ancestry as a distinct people, institution of care, and leadership philosophy and practice. Each area, and its corresponding themes and subthemes, illustrated an emergent understanding of factors that influence leadership among ANS nurses, such as socialization, early exposure to care and diversity in health care. Participants perceived and practised leadership in a manner that transcended formal titles or designations.
Interpretation: African Nova Scotian ancestry is implicated in the perception and practice of leadership among ANS nurses, who considered leadership to be a fundamental component of nursing practice that was grounded in community-oriented care. This study provides new insights that could inform recruitment, retention and representation of ANS people in nursing and other health professions.
People of African Nova Scotian (ANS) ancestry constitute a culturally distinct group within the larger Black population in Nova Scotia, Canada. This ancestry dates back to the 1600s, when Black people arrived in Nova Scotia as enslaved, fleeing or “freed.”1–3 People of ANS ancestry are historically one of the largest congregations of Black people in Canada (currently 22 000 people, constituting an estimated 2.4% of the Nova Scotian population,1 72% of whom identify as third generation or greater), which has resulted in a particular socialization and social context.1–4 People of ANS ancestry represent one of the largest racially visible groups in Nova Scotia.1 More than 50 ANS communities are located across the province, including in historic settlement sites.1–3 High rates of chronic disease, such as high blood pressure, diabetes and mental illness, have contributed to substantially worse health for ANS people than for the general population of Nova Scotia.4,5 Social and structural determinants of health have been implicated in the disproportionate rates of chronic illness experienced by ANS people.5,6
In 2017, the United Nations concluded that racism in Canada, particularly in Nova Scotia, exacerbated disparities and inequities across sectors including education, health and employment.4 Anti-Black racism — which permeates policy, practice, decisions and systemic processes — results in discriminatory treatment that compromises health.7 Addressing anti-Black racism in health care requires practitioners who are competent, invested in change and in positions to instigate reform.8 Leadership, which is a standard of practice and basic entry-level competency in nursing, encompasses formal and informal roles that contribute to enhanced health.9–11 Nurse leaders challenge health inequities and disparities through their knowledge and skills, by influencing health policy, shifting practices and contributing to the transformation of the larger health care system.8–10 Archival data reveal a legacy of segregation and exclusion of Black people in nursing, which contributes to issues of recruitment, retention and representation of ANS people in the nursing profession and in positions of leadership.12–15
Existing Canadian literature focuses largely on the experiences of Black immigrant nurses in larger, more diverse metropolitan regions such as Ontario, Canada. Therefore, we sought to critically examine the leadership experiences of ANS nurses in health care systems and how they perceive leadership, to inform health care policies such as recruitment and retention strategies to facilitate the entry of ANS practitioners into health care.
Methods
Study design and population
We conducted a qualitative study among ANS nurses in Nova Scotia, guided by Black feminist theory from question development to analysis. Black feminist theory is a critical social methodology that centres the experiences, ideas and interpretations of Black women. It is relevant and appropriate for research involving historically marginalized groups as it facilitates knowledge generation and utilization through the examination of social constructs such as race, class and gender.16–21
Demographic data on the nursing workforce are disaggregated according to age and gender; however, key indicators including race and ethnicity are not available. No national or provincial disaggregated data regarding race are available for nurses.22,23 Therefore, it is not possible to approximate the size of the population of ANS nurses in Nova Scotia; the province has roughly 15 000 nurses in total.24
Practising or retired nurses who identified as being of ANS ancestry, with at least 1 Black parent who was born and raised in Nova Scotia, were eligible to participate. We included nurses if they practised in any of the following recognized profession designations: licensed practical nurses (or registered practical nurses), registered psychiatric nurses, registered nurses and nurse practitioners. Gender-diverse, nonbinary and cisgender ANS nurses were eligible to participate.
Recruitment
We used purposive sampling to recruit and select participants who met the eligibility criteria and were able to offer meaningful insight into leadership experiences as ANS nurses in the health care system.25 Specifically, we used snowball sampling, which involved the identification of new participants by existing participants, along with email correspondence through personal and professional networks and social media (Twitter and Facebook). 26 Recruitment and data collection occurred concurrently from January 2020 to June 2020, using an email script (Appendix 1, available at www.cmaj.ca/lookup/doi/10.1503/cmaj.220019/tab-related-content) and flyer (Appendix 2, available at www.cmaj.ca/lookup/doi/10.1503/cmaj.220019/tab-related-content).
Data collection
We collected data through 1-on-1 telephone interviews using a semistructured interview guide (Appendix 3, available at www.cmaj.ca/lookup/doi/10.1503/cmaj.220019/tab-related-content) that was reviewed and approved by the research ethics boards and a committee of experts. Interviews centred mainly on eliciting nurses’ understanding and experiences of leadership, including both positive and negative aspects of experiences with mentorship, workplace support, educational opportunities and the perceived relationship between nurses’ ANS identity and their experience of leadership. One author (K.J.) conducted interviews, which lasted 30–90 minutes in duration, were audio-recorded and transcribed verbatim by a professional transcriptionist. The same author reviewed, cleaned and organized interview transcripts. Each participant was offered a $30 electronic money transfer for their participation.
Data analysis
Through a process of reading and rereading interview transcripts, data analysis involved an iterative process of organizing data, classifying data into overarching conceptual categories and then generating themes and subthemes. One author (K.J.) performed the analysis, with guidance, critical feedback and peer debriefing (through a series of weekly and monthly consultations) provided by 3 authors (R.M.-M., G.T.M. and W.T.B.). Together, the authors have extensive experience in the areas of the nursing workforce and profession, health policy, health care systems; ANS and Black populations in Nova Scotia and Canada, and qualitative and mixed methods research. Box 1 depicts the 6 actions of qualitative analysis employed in this study.26 Together, Black feminist theory and critical discourse analysis facilitated the interrogation of social constructs and 3 distinct, yet interconnected, structural levels.27–29 Similar to Black feminist theory, critical discourse analysis is a critical social approach to research that seeks to interrogate the manner in which language — in the form of talk and text — is used in the production and reproduction of power, particularly in social and institutional structures.27–29 The words and phrases (level 1 — discourse structures), used by participants, were examined to interrogate the identified institutions (nursing and health care) (level 2 — social structures). Further, examining words and phrases elucidated the perception and meaning (level 3 — cognitive structures) ascribed to leadership by ANS nurses. Table 1 outlines a succinct visual of the 3 structural levels. Finally, trustworthiness was established by attending to credibility, confirmability, dependability and transferability.26,30 Particular strategies used to address the components of trustworthiness are outlined in Table 2.
Box 1: Actions to guide qualitative data analysis26
Organize and prepare data.
Conduct a preliminary read of all transcripts.
Read and reread transcripts to generate categories according to analytical framework.
Organize themes and subthemes.
Represent data according to research purpose and questions.
Formulate interpretation of data.
Ethics approval
Ethics approval for this study was obtained from the Nova Scotia Health and IWK Health Centre research ethics boards.
Results
Eighteen ANS nurses participated in this study. Participants were raised in various communities across Nova Scotia. Participants had varying years of nursing experience, spanning from recent graduate to retiree. Clinical practice ranged from community to acute care, including patients across the lifespan. Given the small size of the population of interest, demographic data are not reported to protect the privacy of study participants. It is common for only 1 ANS nurse to work in any given department or unit. Therefore, identifying the unit, department, care facility or career stage of a participant, for example, would greatly increase the risk of breeching confidentiality and participant privacy.
We conceptualized the findings of this study into 3 main areas that provide an understanding of the perception and practice of leadership by ANS nurses (Table 3). The first area includes findings regarding people of ANS ancestry as a distinct people, encompassing aspects of identity, education and care. The second area includes the analysis of 2 institutions — nursing and health care — including issues of diversity, community-oriented care and practice competency. The third area presents a formulation of leadership as perceived and practised by ANS nurses, revealing the belief that leadership is rooted in community-oriented care and is a core component of nursing.
Overview of study findings
African Nova Scotians as a distinct people
African Nova Scotians as a distinct people explores how being born and raised in Nova Scotia constituted a particular experience of Blackness. Table 1 displays the 3 themes and associated subthemes in this section. The theme of situating ANS identity shows the complexity of socialization in a predominantly white society, with participants sharing how not seeing themselves positively represented across multiple sectors of society had a direct impact on self-determination, confidence and career aspirations. Further, Nova Scotia was viewed as a province that has deeply ingrained racism, which contributed to an exodus of people of ANS ancestry over a series of decades. The complexity of ANS identity forced nurses to constantly and strategically navigate social and professional settings. The positionality of being part of a historically marginalized community in Nova Scotia enabled nurses to critically examine this situation and develop relevant and appropriate ways to address issues; thereby informing their perception and practice of leadership.
The theme of the leaky pipeline in education captured how self-determination was shaped, influenced and formed by early childhood educational experiences and the obstacles that were overcome to pursue postsecondary education and a career in nursing. Feelings of invisibility and a lack of career guidance were particularly pronounced in the period of early education. Yet, participants described that targeted programs and initiatives served to address some of these gaps, by facilitating their entry and success in postsecondary education. Reflecting on gaps and challenges in education contributed to a greater understanding of opportunities to address these issues. Equipped with the knowledge of both the importance of education, as well as how the education system underserves people of ANS ancestry, nurses drew on their professional and experiential knowledge to advance the community through education and advocacy.
The final theme, an ethic of care, provided critical insight into the development of approaches to care. Despite a lack of formally trained, Black, nurse role models, participants described vivid memories of early exposure to caregiving, provided by women in their family. Early exposure to care paired with the pressure to “be the spokesperson” on the experience of Blackness, had profound influence on nursing practice and perceptions attached to leadership. Table 4 includes a series of illustrative quotations that support these findings.
Illustrative quotes for African Nova Scotians as a distinct people
Institutions of care
“Institutions of care” includes 2 themes that examine 2 interconnected institutions. The first institution, illustrated in Table 3, is the nursing profession. The theme, “Black tax” in nursing, describes the process of negotiating intraprofessional tension and legacy beliefs within nursing while simultaneously navigating the profession as a Black person. The Black tax involves the additional physical, mental, emotional and spiritual strain experienced by Black people as they navigate spaces where racial hierarchies exist, such as nursing and the health care system. The Black tax is an omnipresent, insidious notion that is affected by other social constructs including gender, class, sexual orientation and disability. Participants described the Black tax as becoming most apparent while they navigated intraprofessional relationships, in addition to attempting to ascend the professional ladder. Specifically, attempts to integrate into the nursing profession were made increasingly difficult by a reinforcing network of gatekeepers and institutional or organizational policies, as well as the physical, structural and ideological design of institutions, which effectively limited access and entry into nursing. Table 5 includes quotations that illustrate these points.
Illustrative quotes for institutions of care
The second theme, Nova Scotia health care as an archaic institution, is depicted in Table 3. Several participants had practised in other jurisdictions, including different provinces and countries. These participants viewed the health systems in other provinces and countries as more progressive and advanced than Nova Scotia in terms of patient care, diversity and concepts regarding personhood. A lack of diverse practitioners and ideas was viewed as contributing to a broken, paternalistic system that did not empower patients nor promote health. The drawbacks of the Nova Scotia health care system were echoed by participants who practised in Nova Scotia only. Building on this, absent or inaccurate content in nursing education raised questions regarding practice competency. Participants expressed concerns about nursing education, including its reinforcement of negative stereotypes that fuelled mistrust and increased the likelihood of patient harm. Further, participants expressed internal conflict with care delivery in the medical-based health system. To compensate for these drawbacks and system gaps, participants believed that a shift away from a medical-based approach toward a more community-oriented practice was necessary to both promote and sustain health. Table 5 includes a series of quotations that capture each of these themes.
Leadership philosophy and practice
Table 3 illustrates the final area, with 1 theme, leadership reimagined: lifting as we climb, which describes the philosophy and practice of leadership by ANS nurses. Participants were explicit in their belief that leadership is not separate from nursing, but rather is an integral component of nursing practice. Moreover, participants identified themselves as leaders, whether or not they held a formal leadership title. Expanding on this notion, the philosophy and practice of leadership centred around a strong connection to community — including the intentional integration of advocacy into care. In addition, the attainment of leadership, as defined by participants, was made possible by internal drivers and external facilitators including mentors and allies who shared opportunities, provided encouragement and supported the personal, educational and professional endeavours of participants. Illustrative quotations to support these findings are located in Table 6.
Illustrative quotes for leadership philosophy and practice
The illustrative quotations show how the leadership of ANS nurses was informed and shaped by their experiences as people of ANS ancestry, as well as experiences in the institutions of nursing and health care.
Interpretation
Our findings provide an initial understanding and conceptualization of leadership as perceived and practised by ANS nurses. Specifically, they show how ANS nurses possess a leadership philosophy that is community-oriented. The study findings were divided into 3 overarching areas that, together, depict the development of an intrinsic, community-oriented philosophy and practice of leadership for ANS nurses. Leadership was understood to be an integral component of nursing practice, drawing on knowledge and abilities rather than a formal title, which encompassed a deep-seated commitment to community-oriented care.
The findings of this study align with the existing body of knowledge related to Black nurses in Canada. A scoping review described 5 primary areas of focus within the literature on Black nurses in Canada: historical situatedness, immigration, racism and discrimination, leadership and career progression, and diversity in the workforce.31,32 We found similar themes related to leadership, diversity and racism in nursing.31,32 In addition, our findings align with the landmark studies of Flynn,14 Etowa and colleagues13 and Keddy,33 which examined historical and contemporary experiences of Black nurses in Nova Scotia. Although not focused exclusively on ANS nurses, these studies included people of ANS ancestry in their sample.13,14,33 Etowa and colleagues13 found that Black nurses perceived themselves as practising on the margins of the nursing profession. Flynn14 identified historical evidence of how Black women were actively denied admission to nursing training facilities in Nova Scotia and across Canada until the 1940s. The findings also corroborate the larger body of knowledge pertaining to the experiences of Black nurses (including Black immigrant nurses) and leadership in Canada.34–41 These studies described issues of representation of Black nurses in leadership, as well as the myriad challenges encountered with career progression and advancement within the profession. The heterogeneity of Blackness warrants the examination of differences in experience among Black people in Canada. To this end, we focused explicitly on the importance of ANS ancestry in relation to nursing and leadership.
Our research supports action in 4 critical areas in nursing. The first is education, which relates to curricula and underscores the need to examine institutional processes regarding recruitment and retention of people of ANS ancestry into nursing, including at the graduate level. Shifts in institutional policy in this direction have already begun at Dalhousie University.42 The second and third areas are policy and practice, which involve informing and enhancing professional development opportunities and career advancement. The fourth area is research, which warrants mixed-methods investigations to address gaps in national data of the nursing workforce. Research that examines the role of nurses in community practice, particularly their work with marginalized populations, would offer direction for improving access to care by addressing social and structural determinants of health.
The implications of these findings extend to ANS physicians and allied health professionals. With intentional structural efforts by institutions such as Dalhousie University, which has established pathways to facilitate the entry of people of ANS ancestry into medicine,43 it would be beneficial to examine the perceptions and experiences of ANS physicians to determine implications for interprofessional education and insight related to practice.
Limitations
Limitations in this study include the operational definition of ANS heritage, which did not adhere to the recently developed description from the ANS Advisory Council that ANS people (who also self-identify as Indigenous Black, Africadian, Afri-Scotian or Scotian) are descendants of free and enslaved Black loyalists, Black refugees, maroons and other Black people who were settled across 52 indigenous (original) land-based Black communities. 44 Moreover, eligibility relied on self-reporting of nurse status and ANS ancestry. We used telephone interviews (as opposed to in-person interviews) during the initial wave of the COVID-19 pandemic and the interview guide was not pilot tested. Other techniques, such as member-checking or triangulation (including participant observation), which may have enhanced trustworthiness of findings, were not performed. Finally, we did not collect any demographic data such as marital status, income or sexual orientation.
Conclusion
This qualitative study clarifies how ANS ancestry is implicated in the perception and practice of leadership for ANS nurses. Nurses of ANS ancestry determined leadership to be a fundamental, integral component to nursing practice, grounded in community-oriented care. This study provides new insights that could inform existing strategies related to the recruitment, retention and representation of people of ANS ancestry in nursing and other health professions, including medicine.
Footnotes
Competing interests: Keisha Jefferies is a member of the Registered Nurses’ Association of Ontario’s Black Nurses’ Task Force. No other competing interests were declared.
This article has been peer reviewed.
Contributors: All of the authors contributed to the conception and design of the work. Keisha Jefferies acquired, analyzed and interpreted the data, with guidance of the other authors. Keisha Jefferies drafted the manuscript. All of the authors revised it critically for important intellectual content, gave final approval of the version to be published and agreed to be accountable for all aspects of the work.
Funding: The doctoral research of Keisha Jefferies was funded by a Vanier Canada Graduate Scholarship, the Johnson Scholarship Foundation, the Killam Trust Foundation, a Scotia Scholars Award through Research Nova Scotia, Dalhousie University School of Nursing, Nova Scotia Health and Building Research for Integrated Primary Healthcare Nova Scotia (BRIC NS).
Data sharing: Data are not available on any public database, platform or repository.
- Accepted July 22, 2022.
This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY-NC-ND 4.0) licence, which permits use, distribution and reproduction in any medium, provided that the original publication is properly cited, the use is noncommercial (i.e., research or educational use), and no modifications or adaptations are made. See: https://creativecommons.org/licenses/by-nc-nd/4.0/
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