June 24, 2020

Daihnia Dunkley, an RN and professor at Farmingdale State College, recently interviewed Black women who are current or former CNOs and found the obstacles they've faced in their roles hit three major themes. Here's what she found—and recommendations for how organizations can better support Black nurses.

July 1 webinar: How to build a more racially diverse health care workforce

Health care industry lacks racial diversity among leaders—particularly among CNOs

According to HealthLeaders Media, a 2015 study by the Institute for Diversity and Health Equity found that racial minorities represented 32% of patients in hospitals that participated in the study, but similar representation wasn't found among the health care leadership. According to the study, 19% of first- and mid-level management positions, 14% of hospital board membership positions, and 11% of executive leadership positions were held by racial minorities.

Dunkley told HealthLeaders Media that while information regarding the number of Black women in those roles is largely unavailable, she believes Black nurse leaders are even less common. "I have been fortunate to work with several Black nurse leaders, but then as I started to climb the [career] ladder, I realized how rare it was to actually work with a Black CNO," she said.

Dunkley said that realization led her to focus on the lack of racial diversity in hospital leadership—specifically the lack of Black women among CNOs—for her PhD dissertation. Dunkley interviewed 10 Black women who were current or former CNOs about their experiences in the position and the challenges they had to overcome to acquire the positions. "I wanted to know what that process looks like," Dunkley said.

3 themes that captures Black women's experiences as CNOs

Ultimately, the interviews led Dunkley to identify three themes regarding the Black CNOs' experiences:

1. The women felt as though they needed to live in a 'constant state of readiness'

Dunkley said one theme that really "stood out" to her was that the women felt they needed to live in a "constant state of readiness," which "embodied all the different things that the participants felt they needed so they could be prepared at all times" to advance in their careers—and even be "a step ahead" of their counterparts "by having several certifications" that "their counterparts weren't required to have."

For example, Dunkley said one of the women told her that, although the woman had years of experience for a leadership role, it was clear the person interviewing her "already knew who they wanted to hire." That person turned out to be "somebody with much less experience than [the woman] and no certifications, but one of the differences was that person was white," Dunkley said.

Because of instances like that, a lot of the women participated in what Dunkley described as "armoring," or bolstering their qualifications for their current and future roles by "getting all these advanced degrees and certifications and always being ready," she said. "It's putting on the heavy suit or layer of protection because being Black and female put them at a disadvantage."

2. The women felt they needed to embrace responsibilities beyond their job descriptions

While the CNO role typically "comes with its own specific job description and performance requirements," many of the women Dunkley interviewed said they felt that, because they were the first Black woman to fill the role, they "had this weight of their community on their shoulders and felt that they couldn't mess up or make a mistake," Dunkley said. "They didn't have … space to fail because everybody was looking at them as a representative for success."

However, Dunkley said the women viewed the responsibility they felt as both a "blessing and a burden," because while being the first Black women to serve in their CNO roles carried extra weight, it also allowed them to "open doors" for themselves and other Black women with similar goals. "They also felt it necessary to do a lot of community outreach to mentor others inside and outside of the organization," she said.

3. Overcoming challenges

Dunkley said the women also had to overcome many challenges to progress and be successful in their careers, including obstacles related to discrimination, sabotage, and censorship.

And that didn't end once they worked their way into leadership roles, Dunkley said, noting that some of the women said they faced even more challenges after they got promoted. "For example," Dunkley said, "when you're at the same level as your colleagues, you're kind of all in the same struggle. Then suddenly you get a promotion and they did not. That can cause a little bit of friction."

The women also said they also experienced a greater deal of gender discrimination after being promoted to an executive-level role. Although nursing is a predominantly female profession, "once [the women] got to the C-suite, they saw more gender discrimination since the other executive titles were mostly male," Dunkley said.

The women also told Dunkley that their title as "nurse executive" often wasn't respected. Dunkley said the women wondered whether they weren't being respected because they were nurses, because they were "not suited to be an executive, or … because nurses are mostly women and [some of their colleagues thought that] women are not suited to be executives."

But Dunkley said the woman pushed through those challenges using "internal and external motivation."

"Internally, these nurses were extremely resilient," and "[w]hat helped them overcome internally was their own fortitude, their own sense of self," she said. For instance, Dunkley said that "[m]any of [the women] mentioned they didn't wake up thinking, 'I'm a Black woman. This is what I have to do today.'" Instead, they viewed themselves as "people in careers, trying to do their best. They pulled from their faith" and "use[d] their families as their support system to pull through." Most of the women also suggested having a mentor could help to motivate Black women in executive positions.

However, one mechanism that Dunkley said "was not healthy" was that the women sometimes weren't "their authentic sel[ves]" while at work. Many of the women said they changed their personas "depending on who was in the room," Dunkley said. "They felt like sometimes they had to look the part or speak the part or dress the part because they wouldn't be accepted otherwise."

How organizations can support Black nurses

Dunkley said health care organizations now "know about the underrepresentation" of racial minorities and "gender disparities" in their workforces, as well as "the discrimination and the obstacles that Black nurses face, whether they're at the bedside or trying to pursue [a] leadership position."

Unfortunately, Dunkley said, there currently isn't "sufficient career or leadership development for Black nurses going beyond the bedside," so Black nurses must "take the horse by the reins and spirit it in the way that you'd like it to go."

For health care organizations, "a lot of the onus is on them to support and invest in the growth and development of their employees" in order to develop a more diverse workforce, Dunkley said. Organizations need to "provide the resources that these nurses will need so it's not another story about how those within [the] organization weren't supportive or there's no diversity within [the] executive leadership team" (Thew, HealthLeaders Media, 6/19).

July 1 webinar: How to build a more racially diverse health care workforce

A more racially diverse health care workforce can better serve the needs of increasingly diverse patient populations. But biases can prevent organizations from hiring more diverse candidates. And even when people of color are hired, they may not reach the top of the organization—recent Advisory Board data shows 34% of frontline staff are people of color, while only 10% of senior leaders are.

In this webinar, we’ll discuss how health care employers can build a more racially diverse workforce at all levels.

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