The heroines of healthcare model: A framework for use in studies of Black women healthcare workers

Abstract

Black women healthcare workers serve as key drivers of health equity, providing quality care to a population that faces a gamut of concerns regarding (1) patient-provider interactions as well as (2) access to care. As such, it is vital to make sure healthcare is an inclusive field where Black women workers are not overly burdened, or uniquely susceptible to burnout. Here, we present the Heroines of Healthcare Model, which is a conceptual framework developed to better understand the well-being and lived experiences of Black women in healthcare professions. Drawing upon interdisciplinary literature, we combine sociological theory, Historical Womanism with social psychological framework, Superwoman Schema to contextualize Black women’s labor, and the overall burden of care work. The Heroines of Healthcare Model not only centers the voices of Black women, but also provides a tool for educators, practitioners, and researchers to develop more inclusive policies, curricula, and wellness strategies. By shifting the narrative from deficit to empowerment, the model affirms the value of Black women’s contributions and experiences within healthcare, ultimately promoting equity and systemic transformation.

Introduction

As literature on the social determinants of Black women’s health and wellness expands, it becomes clear that increased representation in healthcare is a key solution to addressing persistent health disparities. Patient-provider concordance refers to similarity across any set of traits. Race and gender concordance are well-established promoters of quality care and highly rated patient-provider interactions, particularly for patients from marginalized populations. Street et al. ¹ interviewed patients after their appointments with healthcare providers and found that shared personal beliefs, values, and styles of communication were key indicators of positive interactions with their providers. Additionally, Black women healthcare providers facilitate optimal patient-provider interactions. Black patients reported a strong rapport with their Black doctors, feeling a sense of pride from representation, and experiencing a sense of comfort that comes from belonging to a shared culture.^2–4 This is of note for Black women patients who, in many cases, experience medical racism ² and medical violence ³ from non-Black female providers. Townes et al. ⁵ found that Black women aged 18–35 reported that they had better experiences with sexual healthcare when their provider was the same gender or ethnicity. They also reported barriers related to inadequate communication with providers, perception of stigma, and fear of being judged by providers. These experiences negatively impacted their sexual healthcare experiences. Similarly, Thorpe et al., ⁶ in a study exploring Black women’s experiences with sexual pain found that having providers of the same demographic was preferred. The participants who experienced quality care noted that their providers had their preferred communication skills and characteristics. More specifically, the providers listened carefully and tried to understand the context of their sexual pain. The women who had negative experiences with providers reported experiences of being dismissed and expected to endure pain without complaining. Furthermore, Moore ⁴ claimed that when Black women are treated by Black women providers, the comfort that ensues “may allow us an opportunity to rebuild trust in the possible healthcare that can be attained.” Despite the push for a greater prevalence of Black women in healthcare, little scholarship considers the toll working in the field of health professions has on Black women.

The prevalence of Black women working in healthcare provides two other arguments for increasing targeted recruitment and retention efforts, as well as monitoring employee well-being. In terms of recruitment, there is a consistent dearth of Black women in highly skilled positions of authority in healthcare. Only 13% of Black women healthcare workers are registered nurses ⁷ and a minuscule 1%–2% are physicians and advanced practitioners. ⁸ This leaves a small group overburdened with care duties as they work to move Black Americans toward health equity. In terms of retention, there is an abundance of Black women healthcare professionals working as aides, technicians and providing long-term care, comprising 25%–30% of the field.^7,8 As vital frontline workers our society is dependent upon this group of Black women to keep healthcare accessible to the masses.

According to Black feminist thought, analyses of Black women’s work often focus on the (1) conditions of paid labor as racialized and sex specific spaces and (2) how Black women take on unpaid labor within the family to navigate oppression and limited resources. ⁹ The idea of unpaid labor within the family is corroborated and expanded by sociologist Shirley Hill, who notes that Black women have taken on a motherhood mandate (dating back to slavery), whereby they adopt a parenting/caregiving role in all spaces, not just within the family. ¹⁰ What this means is that healthcare work is a natural progression for Black women, which allows them to surpass their perceived “place” as low-wage workers, while also reproducing the motherhood mandate as they are now caretakers by trade. With this in mind, we present the questions: Who cares for the Black women who serve others? How do they manage the worries of healthcare and related disparities, while also facing the same daily stressors that put Black women’s health at risk? Specifically, how do they manage to provide equitable care, while also facing the daily stressors associated with racism and sexism that persist within the healthcare system?

Here, we present the Heroines of Healthcare Model, a framework designed for use in studies aimed at filling this important gap in the literature. This conceptual framework provides a theoretical lens for studies examining how the system of medicine is experienced by Black women healthcare workers and how it impacts their health and well-being. We use existing Black feminist perspectives, Superwoman Schema, and Historical Womanist Theory to inform this model, which focuses on race, gender, and the health-related implications of labor.

Conceptual framework: the heroines of healthcare model

Black women healthcare workers are in many ways deemed the keys to achieving health equity among Black Americans; as such, it is vital to monitor their well-being and the working conditions provided by the field of medicine. The conceptual framework we propose here does just that, using two Black feminist perspectives: Historical Womanist Theory and the Superwoman Schema. Reese ¹¹ provides a guide to use in the creation of conceptual frameworks. First, frameworks are a product of concept ideation, or the process of creating current ideas. One method of ideation he highlighted is the problem solver approach, which is what we use to address the growing need for Black women to navigate the field of healthcare as employees. We use multiple theoretical lenses to contextualize the experiences and well-being of Black women in healthcare. Reese ¹¹ goes on to argue that new conceptual frameworks must be distinct and not overlap with existing frameworks. Here, we use two perspectives: one based on Black women’s strength and related stress and coping, Superwoman Schema, ¹² and another based on Black women’s experiences as laborers, Historical Womanist Theory. ¹³ This method is novel and necessary as it allows scholars to consider the social constructions of race, class, and gender, their impact on health, and how these manifest in the context of healthcare work.

The Heroines of Healthcare Model, illustrated in Figure 1 below, uses key tenets of Black feminist thought and is guided by two other perspectives: (1) Historical Womanist Theory and (2) the Superwoman Schema. The key assumption of Black feminist theory is that Black women are members of multiple marginalized groups and that their experiences with racism and sexism are co-occurring. ⁹ This has been demonstrated in the paid labor force where Black female workers are often burdened with avoiding “being called out of their names” (gendered racism) or “asked out of their clothes” (sexual harassment). ⁹ As such, analyses of Black women must consider the interaction and cumulative effects of multiple forms of discrimination.

Figure 1.

Heroines of healthcare model.

It is important to note that the implications of the name “Heroines of Healthcare” can be detrimental to Black women healthcare workers. We acknowledge that this title can be perceived as the antithesis of what we want for Black women. It may reproduce the narrative that Black women are indeed superhuman, and thus capable of bearing the unbearable, both in life and in the workplace. We have committed to this name, however, for two reasons. Firstly, the definitions of heroine provided by Merriam Webster ¹⁴ speak to the lived experiences of Black women, the social construction of their gender expression and identity, and the reclaimed traits that are points of pride for Black women today. Specifically, heroines are described as legendary women of great strength and ability, who are admired or emulated for their achievements and qualities, and the central or principal character (or in this case, the principal laborer). And secondly, the title acknowledges the influence of the superwoman schema on the formation of this new framework. We do, however, want to make the case that even heroines need a manageable workload, work-life balance, opportunities for self-care, inclusivity in the workplace, and opportunities for professional growth and development.

Historical Womanist Theory addresses Black women’s role as laborers, using multiple theoretical frameworks. ¹³ First is historical materialism, which posits that social class shapes our place in society with two main classes: a ruling class and a working class. Second is womanism, which speaks to the racialized sexism that Black women experience and accounts for Black women’s historical inability to connect with Black men due to systems of oppression like slavery and mass incarceration. Third is material feminism, which speaks to the dual role of women laborers as both workers and literal laborers carrying future laborers through human reproduction. As a standalone framework, Historical Womanist Theory is rooted in several key assumptions. Specifically, our system of labor works to facilitate gendered racism, as most spaces were not designed with racial minorities or women workers in mind. Black women’s role as laborers is shaped by larger economic needs, beginning with slavery where they were used to build the country we know today. Black women healthcare workers face distinct experiences of gendered racism in the workplace based on social class. Those in the highly skilled positions, like physicians, face isolation, scrutiny, and tokenism—as they are often the only Black physician in each space. Black women, in low-wage positions face consistent micro aggressions from patients and providers and limited autonomy regarding working hours and conditions. ⁹ Labor is shaped by available tools and technology, which require education and access to master. This puts the countless Black women working as techs and aids at a disadvantage as they have little exposure to advanced tools and technological breakthroughs and limited time, money, and social support to pursue professional development and further education. Black women serve as a distinct laboring class who have a history of limited bodily autonomy. To free themselves from oppressive systems of labor, Black women workers must create a group-level consciousness and serve as activists and advocates. This has become more prominent recently as literature on sister circles highlights the ways in which Black women workers come together to create groups to vent and relate in the workplace. ¹⁵

According to historical womanist theory, Black women should be analyzed with consideration for the fact that they are of African descent in a racist society, women in a patriarchal society, and laborers in a capitalist society. ¹³ This triple minority status is rooted in historical events and policies like slavery, Jim Crow laws around “separate but equal” living conditions, the systematic exclusion of women from higher education and much of the paid labor force, as well as entering a capitalist society centuries after its inception, with no means of leveling the playing field. ¹³ They face economic hardship as Black women earn an average of $0.70 for every $1.00 earned by their White male counterparts. ¹⁶ Ly ¹⁷ indicated that only a 4% increase in the number of Black physicians was observed in over 120 years and that salary differences between Black and White physicians were significant, with White physicians earning higher pay.

Additionally, the potential social psychological toll of perpetual caring and navigating racism calls for further theoretical consideration from the Superwoman Schema. ¹² According to this schema, Black women who subscribe to the superwoman typology have an obligation to manifest strength, suppress their emotions, mask their vulnerability or dependence, display a determination to succeed despite limited resources, and help or care for others. This schema has been tested empirically and has negative implications for Black women’s health. ¹⁸ Recently, Kechi et al. ¹⁹ called for a reframing of the concept of strength among Black women nurses in response to the rampant burnout they noted. Specifically, they called for transitions like self-sacrificing to resting, emotional suppression to emotional intelligence, and unpaid labor for diversity work to be compensated as contributions. Here, we advance these existing theories by examining racialized and sex-specific aspects of mid-range and upper-level labor among Black women, test the historical womanist theory in the field of health and healthcare, and use the Superwoman Schema to explore the toll of medical labor/healthcare work on Black women’s well-being.

Black women in healthcare

Racism manifests itself in three key ways within healthcare—sex specific, medical, and vicarious. Firstly, Black women providers experience sex specific racism called gendered racism, or negative treatment based on their Black womanhood. Gendered racism comes from patients, colleagues, and other Black women, thus having a secondhand impact on Black women as witnesses. According to the work of Davis, ²⁰ Black women professionals have their intelligence questioned and are often silenced, undermined, demoted, and expected to fail, based on stereotypes attributed to their race and sex. Black women nurses reported having patients assume they were low-wage, entry-level technicians, janitors, or administrative assistants, and having patients defer to the White healthcare worker in the room regardless of who outranked whom. ²¹ Secondly, Black women providers experience medical racism or poor patient care based on race. ² Black women providers are also patients who navigate the healthcare system and may bring trauma to work based on their own experiences as patients. Thirdly, Black women providers experience vicarious racism or secondhand exposure to racial discrimination and/or prejudice directed at another individual. ²² This can manifest as Black women witnessing other medical professionals racially profile and misdiagnose their Black patients who come in for care. For example, a Black female physician who has a colleague who labels his or her Black female patients as “drug seeking” or “overly aggressive” when they request pain medicine may experience the physiological effects of vicarious racism.

When there is gender and racial concordance between the healthcare worker and patient, patients report having a better experience. ² However, provider well-being can have an impact on patients’ experiences, workforce engagement, and organizational outcomes regardless of the benefits of concordance. Therefore, it is important to increase workforce capacity for Black healthcare providers and women to promote employee well-being and health equity among Black women.

Burnout, defined by the World Health Organization as a syndrome, “resulting from chronic workplace stress that has not been successfully managed,” is a major concern for healthcare workers, given the nature of their work. ²³ In a systematic review examining burnout among healthcare assistants, Norful et al. ²⁴ reported that little was known because prior studies focused more on personal circumstances, such as financial, physical, and emotional stressors, and less on the organizational policies and structures that may contribute to burnout. This is of the utmost importance as we navigate the post-COVID era, which has exacerbated burnout in a field that was already rife with cases of burnout. In their large-scale study of healthcare worker well-being during the COVID-19 pandemic, Prasad et al. ²⁵ found that Black women’s risk for burnout illuminated quantitatively. They reported that Black female-dominated subfields, namely nursing and medical assistants, as well as social work, had the greatest rates of stress; plus, women were more stressed than men in healthcare, and Black workers were more stressed than White ones. Additionally, Thorpe et al. ²⁶ conducted a qualitative analysis of burnout among Black female pelvic floor therapists and reported several self-reported risk factors for that population. Risk factors included an unsupportive work environment and leadership, large patient load, unrealistic performance standards, patient and compassion fatigue, and instances of racism. Therefore, a better understanding of how various factors interact to impact the work-related well-being of Black women’s health professionals is needed to increase the prevalence of Black women in healthcare and improve their experiences as healthcare professionals.

Despite overall improvements in healthcare in recent decades, Black women’s experiences in healthcare institutions, whether as patients or healthcare providers, are shaped by socio-historical experiences and systemic racism that underlie significant disparities in health outcomes.^27,28 These experiences include barriers to career advancement, ²⁹ underrepresentation in medical research, ³⁰ and fewer opportunities for career advancement. ³¹ Advocates for more representation in the healthcare workforce have called for efforts to address disparities and improve workplace experiences for Black women. ³² Black women and other non-Black female allies in the field of healthcare have been advocating for culturally competent care, psychological safety, and improving access to care for underrepresented populations. ³²

In her study of Black healthcare workers, sociologist Adia Harvey Wingfield ³³ noted that Black healthcare workers were viewed by their colleagues as less prepared and were given fewer opportunities to gain experience and receive mentorship. She also noted sex differences where Black women noted the salience of their womanhood as a driver of stereotypes in interpersonal communications. Patients and colleagues would assume Black women doctors were nurses and that they required further coaching. She also quoted Black women physicians who discussed their colleagues’ expectations that they should be docile and subordinate, which aligns with traditional notions of White femininity, ³⁴ but not with the strong Black woman trope that Black women are raised to take on. ³⁵ This sexist expectation shows a lack of understanding around racialized sex socialization and creates a hostile environment for any female healthcare worker—whether they adopt traditional feminine traits or not. The Black women she interviewed also reported a need to tap into a more aggressive side of their personalities to be “seen” in the hospital settings. Unfortunately, because her analysis focused on race, but not sex, further work is needed to better understand the intersection of both, Black race, and female sex in healthcare work. Advocates for more representation in the healthcare workforce have called for efforts to address gaps in population health and improve workplace experiences for Black women. ³² Black women and other non-Black female allies in the field of healthcare have been advocating for culturally competent care, psychological safety, and improving access to care for underrepresented populations. ³²

In the meantime, experiences with discrimination and implicit bias impact the mental and physical well-being of Black women healthcare workers. In their study of well-being among healthcare workers during the COVID-19 pandemic, Hennein et al. ³⁶ found that reports of racial discrimination were related to anxiety, Post Traumatic Stress Disorder (PTSD), and depression and reports of gender discrimination were related to PTSD and burnout, putting Black women at risk for an array of mental health concerns as well as burnout. They may encounter doubts about their qualifications and a burden to prove their competence to coworkers and supervisors. To cope with the nature of their work environment, Black women healthcare workers have relied on what are called “sister circles,” or informal, organically occurring friend groups consisting of Black women colleagues, to cope during the pandemic. ³⁷ In a study by Cupid and Bogues, ³⁷ Black women who worked in hospitals, dental offices, and mental health offices reported that “sister circles” helped them cope with work and life demands. Most respondents shared that they felt unsafe and undervalued in their workplace due to treatment from their patients and colleagues. Apart from feeling undervalued, Black women often report subscribing to the Superwoman Schema, which emphasizes the detrimental impact of the perception that Black women should be strong helpers and be more productive with limited resources and under stressors from their personal and work environments.

Theoretical and methodological implications

This framework can be used in diverse studies of Black women healthcare workers’ well-being, for example (1) to explore Black women’s experiences with gendered racism from patients, colleagues, and as witnesses, to understand to what extent Black women act as buffers and create safe spaces within healthcare settings, (2) to examine the institutional environment of healthcare to investigate policies related collegiality, trainings addressing issues of sex (e.g., sexual harassment) and race (e.g., anti-racism), (3) the promotion of self-care and work-life balance, and (4) to assess how the healthcare system impacts the well-being of Black women medical professionals by assessing life satisfaction, burnout, stress, depression, and suicidality. Below, we detail the implications of this model for diverse approaches to research.

Qualitative research can help to further contextualize the lived experiences and well-being of Black women healthcare workers. As a profession, healthcare is consistently impacted by external forces like new viruses, changes in federally funded policies, and shifts in morbidity. As such, rich data is needed on a continuous basis to ensure the model still effectively frames studies of this field. Norms around race and gender are fluid as well. This means that qualitative research is also needed to understand the state of race and gender relations, policies in place to create safe spaces for minority workers, and the impact of scaling back DEI efforts on Black women healthcare workers, among other phenomena.

Quantitative approaches can systematically assess the prevalence and impact of workplace stressors on Black women healthcare providers. Surveys and longitudinal studies can measure levels of burnout, stress, job satisfaction, and mental health outcomes, comparing Black women’s experiences with those of other demographic groups, and conducting intragroup analyses that examine differences across education and professional positions. Experimental designs could assess the efficacy of interventions aimed at reducing gendered and racialized workplace stressors. Additionally, secondary data analysis of workforce statistics can help quantify disparities in hiring, retention, and promotion within healthcare institutions.

Mixed methods studies can bridge the gap between personal narratives and large-scale data trends. Integrating qualitative insights with quantitative measures allows for a more comprehensive exploration of Black women’s experiences in healthcare. For example, a mixed methods approach could combine in-depth interviews on gendered racism with survey data assessing psychological distress and workplace satisfaction. This approach ensures that research findings are both statistically rigorous and contextually rich, helping to inform policies that better support Black women healthcare professionals.

Finally, funding agencies should prioritize research that addresses the intersectionality of race, gender, and labor in healthcare. Grants should support studies investigating the mental and physical health consequences of the Heroines of Healthcare Model in medical professions, as well as initiatives aimed at creating culturally affirming work environments. Additionally, funding should be allocated to intervention programs that provide mentorship, wellness resources, and leadership development opportunities for Black women in healthcare.

Implications for practice and interventions

This framework also has implications for policy and practice. In terms of workplace policy, there has been a recent shift with many companies scaling back efforts to create psychosocially safe and equitable workspaces. Research generated from this model may serve to provide evidence needed to reinstate policies that inform recruiting strategies, hiring practices, and workplace inclusivity. Work generated from this model can also inform approaches to mental healthcare. Black women have been shown to use culture-specific practices like building Sister Circles, or organically formed friend groups, in the workplace to vent and share coping tools. ³⁷ Medical settings may need to help facilitate the formation of Sister Circles through affinity groups. This model can also be used to provide evidence needed to support the implementation of equity audits. This will allow medical facilities to audit existing policies (such as those related to professional appearance, personal leave, and professional development) to assess their impact on Black women, as well as other marginalized groups.

Limitations

While the proposed conceptual framework offers a valuable lens for examining the experiences of Black women healthcare workers, several limitations must be acknowledged. First, while this framework considers the intersection of race, gender, and labor, it does not fully explore other intersecting identities such as socioeconomic status, sexual orientation, disability, or immigration status, which may further shape Black women’s experiences in healthcare. Future studies should incorporate an even broader intersectional approach. Second, the constructs within this framework, such as sex-specific medical and vicarious racism, may be difficult to quantify in empirical studies. Researchers must develop reliable and valid measures to capture these complex psychosocial phenomena. And third, as with any conceptual model, it cannot be viewed as valid or dependable until it has undergone empirical testing. We urge qualitative scholars to aid in contextualizing the experiences and well-being of healthcare workers, and quantitative or mixed methodologists are needed to test the model on a large, generalizable scale.

Conclusions

Black women healthcare workers hold a vital yet underacknowledged role in advancing health outcomes, particularly for underserved communities. While their presence enhances patient care through racial and gender concordance, they often do so while navigating significant workplace challenges shaped by long-standing structural inequalities. The Heroines of Healthcare Model provides a timely and essential framework for understanding how these systemic pressures affect not only professional performance but also personal well-being. Grounded in Black feminist theories and foregrounding the lived experiences of Black women laborers, this framework encourages researchers, practitioners, and policymakers to recognize and address the systemic forces that undermine their well-being. Future research and interventions rooted in this model can support the development of more equitable, affirming, and sustainable work environments where Black women healthcare professionals are not only valued for the care they provide but also meaningfully cared for themselves.