This article highlights a growing gap in the Canadian nursing workforce, specifically in nursing leadership. Black nurses are significantly underrepresented in nursing and even more so as nurse leaders. This commentary will provide a brief background related to Black nurses in healthcare, a description of nursing leadership, the significance of having Black nurses in leadership positions and finally how to move towards increasing the representation and visibility of Black nurse leaders. This commentary is timely and necessary, as it will describe how Black nurse leaders can enrich the nursing profession as well as the lives of Black individuals, families and communities.

Black Nurses and Leadership in Canadian Healthcare

Black nurse leaders are nurses of African descent who embody nursing leadership competencies and practice in formal and informal leadership roles. In Canada, individuals of African descent typically include those who have ancestral linkages to continental Africa but may have immigrated to Canada by way of the Caribbean, Africa or the United States (Maddalena et al. 2013; Pachai 1997). Several terms are used to describe Black people in Canada such as African, Black or Caribbean Canadian; however, this discussion will use the term Black in reference to individuals who identify as such. The common African origin has resulted in Black people sharing similarities in culture, practice, belief and way of life. However, the manner, time and circumstances of the arrival of Black people in North America (i.e., transatlantic slave trade from the fourteenth to nineteenth centuries) have resulted in stark differences among Black people (Pachai 1997). As a result, the experience of Blackness can be similar yet vary greatly within the Black community.

Nursing leadership is required for and integral to health policy, practice and system reform (Downey et al. 2011; Ferguson 2015; Huston 2008). Nursing leadership encompasses the formal and informal leadership roles in nursing, which are practiced by licensed practical nurses, registered nurses as well as advanced practice nurses (CNA 2009; Downey et al. 2011; Ferguson 2015; Huston 2008). Examples of formal leadership roles include managers and charge nurses, whereas informal roles include coaching and mentoring (Downey et al. 2011). Each level of nursing has a distinct scope, which influences opportunities for how, where and when nursing leadership is practiced (CNA 2009; CLPNNS 2013). In addition, as nursing leadership competencies are embedded within nursing programs, all nurses upon graduation have the foundation required to serve as formal and informal leaders (CNA 2009; CLPNNS 2013). Similarly, many nurses have access to training throughout their career, which aims to enhance leadership competencies, including conflict management and team building. Yet, to truly address gaps in care provision and offer services that are relevant and inclusive of diverse needs, nursing leadership must also develop and support Black nurse leaders who reflect the values of the Black community.

Visibility and Representation of Black Nurse Leaders

A multitude of factors acting as barriers has resulted in a lack of visibility and the underrepresentation of Black nurse leaders in the Canadian healthcare system (Jefferies et al. 2018a). Visibility refers to recognizing and acknowledging Black nurses in practice whereas representation refers to the number of Black nurses in practice in relation to the population of Black people in Canada. Unfortunately, Black nurses encounter numerous barriers along their journey to becoming a nurse as well as in the workforce (Etowa et al. 2009; Vukic et al. 2016). Examples of barriers include the historical admission restriction of Black students to nursing schools and the contemporary policies and structures that were developed during a time when racism and segregation were acceptable (Flynn 2009). The impact of these substantial barriers perpetuates an oppressive system that favours the advancement of White nurses while simultaneously restricting the progression of Black nurses (Flynn 2009). Thus, supporting Black nurse leaders goes beyond maintaining a diversity quota and having a token Black nurse as part of the care team (Vukic et al. 2012). Intentional action on an individual, team, organizational and systemic level must be used to achieve representation and visibility (Vukic et al. 2012; Jefferies et al. 2018b). The underrepresentation of Black nurse leaders can be linked directly to the underrepresentation of Black students in nursing programs (Etowa et al. 2005; Vukic et al. 2016). Although more Black students are gaining admission to the nursing program, particularly beyond the baccalaureate level, the rates of attrition among Black students remains high, as traditional recruitment and retention initiatives have been unsuccessful in considerably increasing enrolment and promoting retention within programs (Vukic et al. 2016).

Black nurses are overrepresented in entry-level and non-specialty areas such as continuing care assistants and underrepresented in specialty, advanced practice and upper-level roles such as intensive care units and managers (Calliste 1996; Flynn 2009; Hagey et al. 2001; Premji & Etowa 2014; Vukic et al. 2016). Moreover, systemic barriers and ideologies make transitioning to advanced practice roles and specialty areas, such as nurse practitioners, managers and intensive care units, difficult for Black nurses (Calliste 1996; Flynn 2009; Hagey et al. 2001; Premji & Etowa 2014). Moreover, the underrepresentation and invisibility of Black nurse leaders is compounded by the dearth of race-based consideration found within traditional leadership models, theories and frameworks (McLane-Davison 2015). As a result, influential Black nurse leaders are often omitted from discussions in nursing (Jefferies et al. 2018). This is problematic, as the theories and frameworks developed to be used with diverse groups of people are not developed in an inclusive manner. This lack of racial consideration in leadership has led to Black scholars and allies exploring and developing more Africana approaches to leadership (McLane-Davison 2015; Shockley 2008). Thus, as society continues to diversify in relation to patient populations, work environments and colleagues, Black nurse leaders are pivotal in ensuring that Black voices are heard and included in decision-making.

Significance of Black Nurse Leaders in Canada

Phillips and Malone (2014) explain that increasing diversity in nursing has significant implications for addressing the health disparities experienced by non-White communities. Canada is in dire need for Black nurses to be visible and represented in leadership to address the unique and diverse health needs within the Black community. There are approximately 1.2 million Black people in Canada, which accounts for approximately 3.5% of the Canadian population (Statistics Canada 2018). Black communities across Canada experience health issues at higher rates than the general Canadian population. For instance, Kisely et al. (2008) found that African Nova Scotians experience high blood pressure, diabetes and mental illness at a rate of 13–45% higher than non-Black Nova Scotians. Evidence also shows that Black people often receive a later disease diagnosis and worse disease prognosis. This later disease diagnosis is particularly concerning in the case of prostate cancer, which is shown to be higher among Black men (Prostate Cancer Canada 2018).

Black patients describe ease and reassurance when they see and receive care from a nurse who looks like them (Etowa et al. 2007). This is due in part to the fact that there is a plethora of nuances that practitioners are unaware of, which result in misunderstandings and insensitive care. An example of this is related to the maintenance required for Black skin and hair. These misunderstandings then lead to a lack of trust in the healthcare system and the providers, which reduces the inclination to seek care (Etowa et al. 2007). Too often, stereotypes, assumptions, unconscious bias and ignorance cloud the ability of practitioners to provide competent care to Black patients (Edge 2010). Edge (2010) found that harmful stereotypes held by practitioners affected the manner in which they provided care to Black patients. Edge (2010) also found that practitioners would adopt a "colour-blind" approach, stating that they did not take a patient's race into consideration. Despite this being a common traditional approach to working with patients of a different race or ethnicity, evidence shows that the "colour-blind" approach is more detrimental to a patient, as they are not regarded as an individual and their unique circumstance is not considered (Bonilla-Silva 2014).

Race is listed as a social determinant of health, which significantly influences health service utilization and access (Maddalena et al. 2013). Race is also just one of the many factors that severely impact the health of the Black community. Many Black people in Canada experience the pressures of multiple social determinants of health, such as unemployment, inadequate housing, food insecurity and hazardous/harmful environments (UN Report 2017). Moreover, within the Black community, there are hyper-marginalized individuals who experience social constructs or multiple factors impacting and influencing their health status resulting in profound inequities (Collins 2000; Crenshaw 1991). Black women and Black trans folks are examples of groups who experience hyper-marginalization. Not only do Black women experience oppression in the form of racism because of their Black identity, but they also experience oppression as the result of sexism from their female identification (Collins 2000; Crenshaw 1991).

Black nurse leaders are essential in addressing the unique needs of the Black community in multiple ways. These include informing policies impacting the health of Black individuals, families and communities; addressing harmful stereotypes rampant in healthcare; informing culturally competent care; and fostering an inviting and safe work environment. Black nurse leaders are needed to facilitate this process to incorporate key considerations from their lived experience. Without incorporating this perspective, the gap in service provision will continue to grow and the Black community will continue to be underserved and suffer injustices (UN Report 2017).

Facilitating Black Nurse Leaders in Practice

To address the absence and invisibility of Black nurse leaders, it is necessary to be intentional in supporting Black nurses throughout their nursing journey. Black nurse leaders are essential to ensuring relevant care provision to the Black community and ultimately improving their health outcomes. Thus, supporting Black nurse leaders in education and the workforce is vital (Jefferies et al. 2018). As described, Black students encounter increased challenges and barriers when applying to nursing programs. Therefore, examining the admission process is an essential initial step (Vukic et al. 2012). In addition, the nursing education curriculum must be inclusive, relevant and reflective of Black values and experiences (Jefferies et al. 2018). Finally, recruitment and retention initiatives need to be redesigned in a manner that dismantles hegemonic and narrow views of what nursing entails and who is able to be a nurse (Price & McGillis Hall 2014; Vukic et al. 2016). An example of a progressive initiative is seen with the recently launched initiative in the School of Nursing at Dalhousie University. This initiative, which was conceptualized by the first author and colleagues, offers peer-mentoring for Black students in the nursing program at Dalhousie. The Community of Black Students in Nursing is designed to provide guidance navigating the undergraduate and graduate programs, expose students to research, offer opportunities for community engagement and provide a safe space to share and discuss experiences as a Black student nurse.

Addressing the drawbacks of nursing education must happen in unison with addressing drawbacks and gaps in the nursing workforce. Empowering Black nurse leaders cannot be achieved in a system that holds on to oppressive, hegemonic ideologies. The nursing workforce and health systems must review, amend and create policies in collaboration with Black nurses to ensure that their voices are heard and included (Etowa et al. 2011; Vukic et al. 2012). There are several jurisdictions across Canada, which have initiated progressive approaches to nursing diversity and inclusion through their strategic plans and guidelines. Finally, prioritizing the collection of race-based data is necessary to adequately assess and address health issues in the Black community. Without race-based data, there is inadequate understanding of the current issues and ways to move forward.

Conclusion

Representation and visibility of Black nurses is necessary if health policies and practices are intended to serve all Canadians from diverse communities. Black nurse leaders are capable of using their experiential knowledge and training to inform their practice when working with patients from culturally and racially diverse backgrounds. Specifically, Black nurse leaders are able to use their subjectivity and lived experience to address the challenges of race, class and gender as well as the profound influence of race on health. Drawing on their experiential knowledge, Black nurse leaders are able to assist in the development of policies, practice standards and health system reform to better serve the Black community. Without the insider perspective of Black nurses, it becomes increasingly difficult to recognize and challenge the oppressive privilege within the Canadian healthcare system. Thus, this commentary is calling for a paradigm shift across practice areas and at multiple levels to improve the health outcomes of the Black community and to strengthen the reputation of nursing leadership in Canadian healthcare by truly being inclusive.

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