“No filters needed . . .”: A qualitative study exploring sister circles and workplace messages for Black women healthcare professionals during the double pandemic

Abstract

Objectives:

To explore the experiences of Black women healthcare professionals during the pandemic in the United States, with a particular focus on those in sister circles.

Design:

This is qualitative research with data from online survey results.

Methods:

A qualitative survey was distributed through listservs and via social media from December 2021–April 2022. The qualitative data were analyzed using a thematic analysis to extract the themes.

Results:

There were 69 respondents, primarily represented in hospitals, dentist offices, and mental health offices. The majority of respondents stated that they had one to three sister circles, with them primarily being formed online. The themes that arose from the meanings of membership in sister circles during the pandemic were (1) sister circles offered them a space to be sane and safe, (2) members received access to professional support, and (3) they are needed. As Black women healthcare professionals, the workplace messages they received were (1) either their workplace provided them with solidarity or (2) made them feel unsafe and undervalued.

Conclusion:

Sister circles provided these Black women healthcare professionals with a space of coping during the pandemic, as well as a site to respond to their workplace burnout.

Introduction

The COVID-19 pandemic highlighted the impacts of inequitable systems on Black and Brown communities.^1,2 Many have noted that we are living in a double pandemic, one due to COVID-19 and the other due to structural racism.^3–6 During this era, it is pertinent to address the experiences and needs of those who lie at the intersection of this double pandemic, such as Black women healthcare professionals. Their professional identity places them in positions of authority and responsibility over their patients, whereas due to their race and gender, systemic inequities often present challenges and barriers. Within their community, they often are viewed as caretakers and uphold a value in uplifting and supporting members. ⁷ Within healthcare, they are underrepresented in higher wage roles such as physicians ⁸ and research scientists, ⁹ and overrepresented in lower wage roles such as behavioral health workers and technicians, ¹⁰ and often perceived as less competent. ¹¹ Their position is a vital area to explore as many institutions have announced their commitment to diversity, equity, and inclusion.

Although the research on these professionals during the pandemic is scant, studies have found that nurses engage in motherwork to better care for Black patients, ¹² and mental health practitioners experience vicarious trauma and burnout, and practice advocacy for their patients.^13–15 Given the rise in attention and activities within the Black Lives Matter movement amid the global pandemic in 2020, elevating Black women healthcare professionals’ experiences offer insight into how they navigated the pandemics, how health institutions responded to their employees, and possible modifications to ensure culturally competent efforts and strategies are implemented. To explore these professionals during this era, a practice to examine is sister circles. Sister circles are informal or formal “support groups that build upon existing friendships, fictive kin networks, and the sense of community found among Black women” ¹⁶ within a particular setting, such as educational institutions, professional organizations, and religious institutions, with the overall goal of Black women’s advancement. ¹⁷ Members refer to each other as sister or sis as a term of endearment. ¹⁶ Sister circles have been found to create a sense of belonging, lower anxiety, and provide mentorship in the areas of higher education, psychology, and teacher training.^16,18–21 From historical to contemporary times, sister circles are activist spaces where Black women theorize and strategize ways to address Black womanhood, family, and community upliftment.^22,23 The aim of this qualitative study was to identify the meanings of sister circles for Black women healthcare professionals and the informal workplace messages they received during the double pandemic.

Methods

To capture the experiences of Black women healthcare professionals during the pandemic, an online survey was created by the first author in Qualtrics. The survey contained three sections: demographics, sister circle experiences, and workplace experiences. The “Methods” and “Data analysis” sections contained both closed-ended and open-ended questions. For example, closed-ended questions captured their demographics such as their personal income, state of employment, and profession. The open-ended questions sought to understand their lived experiences, such as, what has it meant for you to be a part of a sister circle during the pandemic. Respondents were encouraged to answer the question in a few sentences. Following institutional review board approval, the survey was distributed via listservs, social media, and newsletters from December 2021 to April 2022. Due to the population and scope of the study, the minimum desired sample size was mid-range, 60–99 respondents. ²⁴ To complete the survey, respondents consented to the inclusion criteria, they self-identified as a Black woman, were 18 years of age or older, and a practicing medical or health professional within the United States and its territories. After the survey closed, the data were cleaned to remove respondents who did not meet the inclusion criteria, specifically respondents who did not identify as a Black woman and/or a practicing medical or health professionals were excluded from the data. A total of 69 respondents met the inclusion criteria.

Data analysis

The open-ended questions were analyzed using Braun and Clarke’s six-phase approach to thematic analysis.^25,26 Each researcher manually and independently coded the surveys using an inductive, data-centered approach in Excel. After coding the surveys, the researchers met to discuss their codes and any points of differences to arrive at a consensus of the codes. Inter-coder reliability was established using Cofie and colleagues’ eight guidelines, which is commonly used in qualitative research to ensure accuracy and consistency in coding. ²⁷ There was a total of two coders, one of which was removed from the data collection process to reduce bias. Once data were collected, the two coders held a dialogue to discuss the codes. This was an integral step in establishing inter-coder reliability, as it allowed the coders to compare their codes and come to a consensus on how data should be categorized. After the codes were solidified, researchers used the codes to establish and define the themes. The threshold for determining a theme was if six or more participants mentioned it. The researchers conducted a thorough analysis of the data and determined that thematic saturation had been reached, indicating that the themes emerged from the data were comprehensive and representative of the participants’ responses. ²⁸

Results

Sixty-nine participants were included in this survey and sociodemographic data for the survey respondents are presented in Table 1. Most reported having primary caretaker roles (n = 44), with some having multiple roles, such as children and spouses. Respondents were generally located in the South, followed by the West, Northeast, and Midwest, respectively, and the majority worked in hospitals, dentist offices, and as health practitioners (see Table 1). Most respondents had one to three sister circles, with these sister circles being both formal and informal (Table 2). Also, most were formed online, at work, and school, respectively, with a few being formed at religious or social organizations and at social outings. The number of participants who answered each question varied due to some participants not providing responses. As a result, the n for each question may differ.

Table 1.

Socioeconomic demographics.

Characteristic	Survey respondents (n = 69)	Survey respondents (%)
Age range (years)
18–29	21	30
30–39	23	33
40–49	13	19
50–59	8	12
60–69	4	6
Personal income last year ($)
1–9999	11	16
10,000–24,999	3	4
25,000–49,999	8	12
50,000–74,999	11	16
75,000–99,999	12	17
100,000–149,999	6	9
150,000 and greater	12	17
Prefer not to answer	6	9
Region of employment a
Northeast	12	15
Midwest	4	5
South	39	48
West	26	32
Field of representation
Ambulatory services	1	2
Dentists offices	16	23
Health practitioners	16	23
Home healthcare	3	4
Hospitals	17	25
Medical and diagnostic laboratories	5	7
Nursing and residential care facilities	11	16
Outpatient care centers	0	0
Physicians’ offices	0	0
Work mode during COVID-19
Telework or hybrid	50	73
In-person	19	27
Primary caretaker roles b	Survey respondents (n = 44)	Survey respondents (%)
Children	29	45
Extended family members (i.e. nieces, nephews, cousins)	11	17
Grandchildren	5	8
Parents	12	18
Partner/spouse	8	12

^aSix survey respondents are employed in two or more states.

^bThirteen respondents have multiple caretaker responsibilities.

Table 2.

Sister circle demographics.

Characteristic	Survey respondents (n = 52)	Survey respondents (%)
Number of sister circles
0	5	10
1	12	23
2	12	23
3	12	23
4	3	6
5 or more	8	15
Type of sister circle	Survey respondents (n = 29)	Survey respondents (%)
Informal	8	28
Formal	8	28
Both	13	44
Length of time in sister circle (years)
0–5	18	62
6–10	7	24
11–15	2	6
16–20	1	4
21–25	0	0
26–30	0	0
31–35	0	0
36–40	1	4
Gathering mode	Survey respondents (n = 61)	Survey respondents (%)
In-person	7	12
Virtual	21	34
Both	33	54
Sister circle(s) formed a	Survey respondents (n = 64)	Survey respondents (%)
Online	33	34
Work	30	31
School	24	25
Professional organization	4	4
Religious organization	3	3
Social outing	3	3
Forms of communication b	Survey respondents (n = 61)	Survey respondents (%)
Group texts (e.g., text messages, WhatsApp, GroupMe, etc.)	42	28
Video conferences (FaceTime, Google Duo, Zoom, etc.)	35	23
In-person communication	28	19
Phone calls	23	16
Emails	21	14
Communication frequency	Survey respondents (n = 29)	Survey respondents (%)
Daily	4	14
Several times a week	11	38
Biweekly	3	10
Monthly	8	28
A few times throughout the year	3	10

N varies due to some participants not answering certain questions. The number of participants who answered each question is shown in the table above.

^aTwenty-one respondents formed sister circles in multiple places.

^bForty respondents use two or more forms of communication.

The meanings of sister circles

When respondents reflected on the meaning of being a part of a sister circle during the pandemic, three themes emerged: (1) sister circles offered them a space to be sane and safe, (2) members received access to professional support, and (3) they are needed.

Sane and safe

The pandemic brought upon many stressors for healthcare professionals. For many respondents, being a part of a sister circle during the pandemic meant they had a space to help maintain their mental health. For example, Respondent 1, a registered nurse (RN) in Florida, stated,

They keep me sane and offer me a safe place to be me. No filters needed and I can take off my mask.

Having a space where she could take her mask off meant that she could be her authentic self. Relatedly, Respondent 8, an RN in Maryland, shared,

Being able to speak to other women who look like me and have similar experiences has been helpful with navigating the struggles of working in health care during the pandemic. Black people in general, and especially Black women, are disrespected and not well supported within health care. Having a sister circle of Black women, I went to nursing school with has been very helpful in maintaining my sanity within this profession.

For this RN, she describes how she has been a part of her sister circle since nursing school, and it is built a shared experience. Membership within a sister circle from student to professional has been beneficial to her career. Moreover, she provides contextual information that Black people and Black women are mistreated within healthcare; thus, her circle became a buffer during the pandemic. In addition, sister circles provide them with a space to show emotions and vent. For example, Respondent 53, a mental health practitioner in Kentucky, expressed,

It has helped to sustain my mental health and provided emotional support during the pandemic. While in the heart of the racial injustice movement in Louisville KY, my sister circles created a virtual safety-net and space for me to be authentic. While having difficulty finding an appropriate mental health professional, my sister circle brought me solace.

This respondent further explained, “Mental health professionals played a vital role (and saw a dramatic increase in client needs) during the pandemic.” Thus, this mental health practitioner revealed the challenge of finding mental health services during the pandemic, while being in greater demand. Although she had to navigate finding professional help, her sister circle was able to provide her a space to cope with the racial climate. Ultimately, for these respondents, having a sister circle meant they had a space where they could be themselves, which validated their experiences as Black women healthcare professionals and aided in their overall socioemotional well-being.

Professional support

An added benefit of being a part of a sister circle was the professional support they received. As Respondent 42, a home health/personal care aide in Maryland, shared,

We support each other by talking about experiences and how to best navigate the challenges we face on the job. Best practices the do’s and don’ts pros and cons etc.

For this home health/personal care aide, her sister circle became a space to exchange information and offer advice. Some respondents also spoke about the importance of mentorship. Respondent 60, a physician/surgeon in Massachusetts, offered,

It is an important source in finding mentees and helping younger doctors navigate the challenges of being Black in medicine.

In addition, she characterized sisters circles as “invaluable for coping with change related to COVID and also with culture of racism in medicine.” Sister circles provide a space for culturally specific mentorship for Black women in healthcare. Even further, Respondent 63, a physician/surgeon in Massachusetts, echoed a connected sentiment:

As a late career physician, it added to my overall sense of mentoring and safety. Being able to share wisdom and insights about navigating the system of medicine has meant a lot.

Thus, for some respondents, sister circles resulted in professional growth, as they were able to strategize how to confront challenges, and offer insights, such as promotion recommendations.

Needed

Six respondents stated that sister circles were needed in the health professions during the pandemic. As stated in the definition, they can be informal or formal; however, Respondent 43 believes that formalizing a sister circle would allow for more professionals to be served.

I think they are vital to the success of practicing health and medical professionals. I would love to be a part of a formal association to make sure than every Black woman who needs a sister circle in the field has one, no matter where they are. (Respondent 43, a health psychologist in Georgia)

African Americans within any profession need safe spaces to express their concerns, to discuss ideas, and collaborate with one another. (Respondent 41, a disease research scientist in Kentucky)

Comfort and sisterhood is always needed. (Respondent 9, a dental hygienist in Illinois)

Respondent 9 speaks to the overall need for them, whereas Respondent 41 highlighted the professional need. Even respondents who were not a part of a sister circle shared that they would like to receive more information about joining them because they would bring professional development and support. Thus, some respondents recognized an area of professional concern and offered a solution.

Workplace messages

In order to understand their experiences as Black women healthcare workers during the double pandemic, respondents also shared the informal messages they received from their workplace. There were two contrasting themes that emerged, either their workplace provided them with solidarity or made them feel unsafe and undervalued.

Solidarity

Four respondents stated that they worked predominantly in Black or minority-owned workplaces. These respondents shared positive workplace experiences. For example, Respondent 33, a medical social worker in Louisiana, explained,

So far, the messages have been positive and supportive as my workplace is 90% African American women.

Similarly, Respondent 58, a birth and postpartum doula in California, described her work environment as follows:

Even before the pandemic our mission was to provide culturally congruent and equitable doula care to women of color all over the San Francisco Bay Area. I think the pandemic just made us double down on our mission.

Respondent 58 shares the women of color centered mission for their patients is also evident for its workers:

Even though this is not our reality right now, all Black women deserve to have equitable, culturally competent and dignified care. That the high maternal mortality rate in the US among Black women is 100% preventable and it starts with healthcare providers having open and honest conversations with their patients and community workers.

As evident in this quote, her workplace understands the importance of transparency from healthcare providers and that eliminating maternal mortality rate among Black women is achievable. Moreover, Respondent 43, a health psychologist, in Georgia described a positive work environment:

I receive that my work and worth are valuable and necessary. That I am an integral part of the success of the organization.

These responses revealed that when workplaces demonstrate a need for their employees, they receive the messaging that they understand the current cultural moment and that they are essential within their organizations.

Unsafe and undervalued

Most respondents shared that they felt unsafe and undervalued in their workplace due to treatment from their patients and colleagues. The treatment they received as Black women was subpar compared to their colleagues. Respondent 68, a physician/surgeon in Texas, highlights the burden that is placed on them:

Message 1: please do the DEI work free of charge.

Message 2: You all are magic and we don’t want to lose you so let’s make you visible everywhere.

The first message they receive reveals that there is an expectation to overwork without proper compensation. Furthermore, the expectation for a physician/surgeon to engage in DEI (Diversity, Equity & Inclusion) may be outside of her job requirements. Thus, an assumption is that one’s marginalized identity grants them the ability or desire to execute diversity, equity, and inclusion work, which could be nonfactual and undesired. The second message alludes to the strong Black woman stereotype, which presents the notion that they are invincible and capable of accomplishing inhuman feats despite sometimes living in detrimental circumstances. This stereotype can lead to Black women becoming hyper-visible within the workplace, again without their request. Woods-Giscombé’s work on the “Superwoman Schema” emphasized the detrimental impact it can have on Black women’s mental and physical health, as it creates unrealistic expectations and denies them the space to express vulnerability and seek support. ²⁹ In addition, this stereotype can perpetuate systemic racism and gender inequality, due to it reinforcing the idea that Black women should work harder and do more than that of their counterparts, while not receiving the recognition or compensation that they deserve.

Respondent 53, a mental health practitioner in Kentucky, also expressed,

I felt unheard, unseen, and unappreciated in my workplace. The pandemic caused me to reconsider my job choice, ultimately shifting me into becoming a full-time student again and focusing on building my practice.

Her experience with feeling invisible indicates a lack of belonging that led to her departure from her workplace. Her workplace dissatisfaction is a cause for concern in the field of healthcare, especially during a time when the demand for mental health professionals has increased. While she intends to return to the field, her withdrawal still presents a challenge for healthcare to meet the needs of current patients.

Unfortunately, Respondent 24, a nursing assistant/orderly in Florida, states her “Especially racist, not to touch them, since I’m a Black race” as the informal message they receive in the workplace. This workplace creates an unhealthy and troubling environment where Black professionals are deemed untouchable. This message likely produces high-stress, especially considering her patient-facing position. Finally, Respondent 8, a RN in Maryland, critiqued the healthcare system:

I’m not valued or safe. This is conveyed through how we are treated as workers and patients. We are upholding a system that was built and maintained on causing us harm.

This RN works in a fraught space. The mission of the healthcare system is to improve patients’ health and provide care, but on the contrary, it has detrimental outcomes for key members. Based on the messaging that these respondents receive, it is evident that their workplaces create unhealthy environments, which some may deem as toxic.

Discussion

This survey reviews perspectives of Black women working in healthcare settings during the pandemic. Since most of the respondents worked in the South region, the findings may not be generalizable to other women. When respondents were asked what informal messages they believed they were receiving from their workplace, many women reported that they received messages that made them feel undervalued and unsafe. According to the Centers for Disease Control and Prevention (CDC), Social Determinants of Health (SDOH) are “conditions in the places where people live, learn, work, and play that affect a wide range of health and quality-of life-risks and outcomes.” ³⁰ One key area of SDOH includes social and community context. Social and community context can be defined as “the connection between characteristics of the contexts within which people live, learn, work, and play, and their health and wellbeing. This includes topics like cohesion within a community, civic participation, discrimination, conditions in the workplace, and incarceration.” ³⁰ Feeling unsafe due to racial and gender bias and discrimination is a stressor for Black women that can lead to a deterioration in their health and well-being. ³¹ The literature informs that while Black women have higher employment rates than other groups of women in healthcare, they still suffer from higher rates of poverty and adverse health outcomes compared to their White counterparts. ³² In addition to this, Black women also suffer from a multitude of inequities in their places of business. ³² The inequities that these women experience, “have been indicated as barriers to advancement, a detriment to their personal and professional identities, and a sense of self-efficacy.” ³²

Moreover, respondents spoke to the minority tax they experienced; they were expected to contribute to diversity efforts without proper recognition and compensation for this work.^14,33 This uneven burden coupled with experiences of invisibility devalued them as professionals. Hence their workplaces added to the racial fatigue and trauma, which was already at an increased level for Black women during the pandemic. ¹⁴ In particular, therapists had to respond to the vicarious trauma as secondhand witnesses to their patients’ experiences, which often resulted in them privileging their patients over addressing their needs to cope.^13,14 Thus, the expectation for Black women to perform as superwomen without responding to their racial trauma contributed to feelings of burnout. ¹¹ Within their work environments, respondents wore a mask as a protective factor to prevent colleagues from witnessing the challenges they were navigating.^14,34

Fortunately, the respondents in this study have cited sister circles as a means to cope with what they are experiencing daily. Within their circles, they remove their masks to reveal their authentic selves while addressing the oppressive environments in which they must survive. Having positive interactions and relationships with women who face similar experiences help them deal with and process what they go through. Hence, sister circles for healthcare professionals become a counterspace for Black women to respond to unsafe workplaces and center their mental health and holistic well-being. In addition, they receive professional support and counsel, which is beneficial due to the lack of mentorship throughout their career course.^9,14,35 These findings are consistent with the literature on sister circles in education and psychology;^{18,20,36–38} sister circles offer members a safe space because they gain a sense of belonging and empowerment which is often negated in non-Black settings.

This study is significant because it is the first to investigate the meanings of sister circles for Black women healthcare workers during the pandemic in the United States. In response to their workplace and societal dissatisfaction and discrimination, sister circles are needed to honor their humanity and recognize their expertise. Although this population experiences challenges and barriers within their fields, our findings indicate the mental health and professional benefits of belonging to sister circles. ¹⁶ Sister circles are an essential part of ensuring that these women are able to share their experiences as Black women in these particular spaces, not only allowing them to address the stressors of working in healthcare, but also those that come with being a Black woman in America. Due to their inclusion in sister circles, they maintain a wellness practice that adjusts to societal transitions. The sense of community from a place of mutual understanding encourages them to bring their personal and professional selves into the space. Respondents tending to their mental health needs revealed that they confront their challenges, to buffer against hinderances to their well-being. Hence, sister circles during the pandemic ensured that sisters remained connected with the ever-present reminder of their wholeness.

Limitations and future research

The recruitment approach consisted of requesting national health organizations within specific fields and professions to add the announcement to their listservs with the goal of getting across fields and geography. Although a wide range of organizations was contacted, including dentistry, nursing, cardiology, psychology, physicians, and podiatry, only two organizations responded and shared within their network. Therefore, these fields may have been more represented in the data, due to the recruitment announcement coming from their organization. Moreover, the fields of outpatient care centers and physicians’ offices were not represented in the data. Since the professions were aggregated into fields of representation, in order to capture a more dynamic picture, the survey could have included both professions and field of representation. Regarding geographical representation, since the lead researcher was located within the South region at the time of data collection, those recruited through her networks may have been within this region.

Although, this project sought to capture representation of the professional fields, and geographically, future research can have a narrower focus. First, the researchers can partner with a hospital to conduct a case study on how sister circles are functioning within their organization. A case study approach will allow for a more in-depth analysis of how Black women healthcare professions are navigating a particular setting. This case study can be used to help human resource professionals in implementing change and providing services and benefits to employees. Second, the researchers can partner with a national health organization in particular fields, such as nurses, physicians, and psychologists, to investigate how the overall field can improve the experiences and training for Black women. A national health organization may also be able to see how geographical differences impact their experiences and use this knowledge to offer additional recommendations. Finally, a longitudinal quantitative analysis may highlight unique and distinct patterns regarding the protective role of sister circles on Black women healthcare professionals’ work satisfaction and wellness outcomes over time.

Conclusion

Sister circles are like a life intervention for Black women who must live through the tumultuous double pandemic, especially for healthcare professionals. Since they are in the helping professions, they often have to carry the weight of secondhand pain and trauma experienced by their patients, as well as being primary caretakers for their family members and juggle difficult work environments. COVID-19 magnified how structural racism has detrimental effects on the SDOH for minoritized folx. Moreover, this study revealed a good portion of healthcare workers do not feel safe and appreciated within their workplaces. Although there has been a heightened focus to diversity, equity, and inclusion, Black women should not have to balance the undue burden of educating a system of its shortcomings, without added benefits that address both their financial and socioemotional well-being. Since the healthcare industry is witnessing both employee burnout and departure, healthcare leaders need to address and reform healthcare so that minoritized professionals are safe and rewarded for their contributions. Creating and sustaining a healthy work environment is not only beneficial for professionals, but for patients, and the overall system. Hopefully, healthcare leaders heed the urgent call of this double pandemic and vigorously participate in transformative change and reform.