African Nova Scotian nurses’ perceptions and experiences of leadership: a qualitative study informed by Black feminist theory

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.

Table 1:

Three-dimensional framework of critical discourse analysis^27–29

Level	Description
1 — Discourse structures	Identify and examine talk and text: language and words used by participants.
2 — Social structures	Identify and examine social, institutional and systemic processes, policies or practices identified by participants.
3 — Cognitive structures	Regarded as the interface between the discourse and social structures. Identify and examine the perception and meaning ascribed to the experience or phenomena by participants.

Table 2:

Trustworthiness of findings^26,30

Component	Description of component	Strategy performed by researcher
Credibility	The degree of confidence in the truthfulness of findings.	Peer-debriefing: weekly supervisory meetings, monthly expert committee meetings, consultation with African Nova Scotian health advisory group. Reflective journaling.
Confirmability	The degree of neutrality of the study’s findings. Findings are based on participant data and not the bias or motivation of the researcher.	Provision of an audit trail detailing the process of analysis. Reflective journaling.
Dependability	The extent to which the study can be repeated by other researchers to achieve similar findings.	Inquiry audit: involves an external review and examination of the research process, specifically the analysis.
Transferability	The ability of the research findings to be applied to similar groups or populations in other contexts.	Thick, detailed and rich description of methods, which permits readers to determine whether findings are transferrable to their problem.

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.

Table 3:

Overview of study findings

Area	Theme and subthemes
African Nova Scotians as a distinct people	Situating African Nova Scotian identity The power of socialization: setting the foundation “We are not homogeneous”: a place that feels like home Navigating social constructs
	The leaky pipeline in education Early education: from colourblind to invisibility Transitioning to postsecondary: patching the leaky pipe Fitting a mould: a nontraditional student in a traditional institution
	An ethic of care “Caring is in my blood”: an intergenerational tradition of care “My duty to educate”: leaning in and taking the lead Caring for the self: on mental, emotional and spiritual well-being
Institutions of care	“Black tax” in nursing Nursing as a service: the blending of art and science Nursing politics: navigating intraprofessional tensions Nursing education: primed for praxis Invite only!: gatekeepers, policies and structural design
	Nova Scotia health care as an archaic institution Who is at the table?: inclusion beyond tokenism Competency gaps: mistrust, discrimination and patient harm Community-oriented care within a medical-based model: providing the best care
Leadership philosophy and practice	Leadership reimagined: lifting as we climb “It’s part of your job”: leadership as integral to nursing Along the pathway to success: climbing the professional ladder Black feminist leadership: a practice and philosophy rooted in community-oriented care

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.

Table 4:

Illustrative quotes for African Nova Scotians as a distinct people

Theme	Subtheme	Illustrative quote
Situating ANS identity	The power of socialization: setting the foundation	Well… I grew up in a rural community… in a town as the only biracial family at the time. There’s a lot of challenges, let me tell you. I went to an all-white school. You know, you get the name calling. I was the kid that wore the braids … that stuff. (R#12) I grew up in Nova Scotia. And we know the battles that we faced … in a rural town. And nobody understands the struggle like we understand the struggle. Actually, when you try to express your struggle to … someone that’s not lived the Black experience, they’re totally oblivious, and [that] actually is quite invalidating. They actually discount how you feel and tell you how you shouldn’t feel that way because, “Oh, we just don’t see colour and we accept everybody for who they are.” It’s like, oh, I’m glad that’s your experience but that has not been my lived experience. (R#3)
	“We are not homogeneous”: a place that feels like home	We’re not at all homogeneous. And Nova Scotia’s Black community is changing very quickly because in the 80s and the early 90s, we had such a huge migration of our Black community to Ontario. All of my ancestors, from like 300 years back, have all been from here. … You definitely see that difference of experience when you have blending of other parts of our diaspora that are coming into Nova Scotia. And you have this wonderful diversity that’s growing. But you also have a lot of people who don’t understand the experience of Black Nova Scotians. (R#13) I remember saying to my mom when I had finished nursing, … “You know, I wonder if I should come home. I wouldn’t mind trying to live in Halifax and nurse there.” And she said, “Don’t come home, child, they don’t make the same money there as they make everywhere else. So just stay behind where you are.” I still remember that. (R#4)
	Navigating social constructs	Lately I’ve seen these little comments on Instagram, on Haligonia.ca, “Oh, all that stuff that’s happening in the States, it doesn’t affect us here.” Like if you’re Black, it’s going to affect you … . Saturday was a sad day for me. … every time I was on Facebook or Instagram, just seeing all this stuff, and I’m like I need to take a break because I can’t take this. And I don’t even think I’d go to a march because I’d start crying because it’s like this is what I have to do because I’m Black, just to be Black? (R#16) When I speak up, there’s the stereotype of a Black woman who’s angry. So I have to kind of tone-police myself sometimes because I know how I will sound. You have to think about your career. And you don’t want to sound like the angry Black woman. Not that you should have to police that, because anybody else could say the same thing you did in the exact same tone, and it will be interpreted as, wow, what an assertive person. (R#13) I think I’ve just become … I don’t want to say harder, but I have just learned to kind of not take it personal. Because I know that there are a lot of people out there who are ignorant to different cultures. They don’t see the minority as being people who can do this kind of stuff. … Like be nurses and doctors … Because they come from a different time. I make a joke out of it sometimes. Other times I won’t even really acknowledge it. I guess it just really depends on my mood for the day. (R#7)
The leaky pipeline in education	Early education: from colour-blind to invisible	I went to a local high school. And over there they weren’t really focused on certain people’s career paths. I don’t want to say they weren’t looking at the Black folks, but they weren’t. (R#15) No one in my family had gone to university. I’ve never had a university experience to draw upon. And that’s something that I think is huge. Because I didn’t have that background to know what university would be like to even know that it might be a possibility. So that really targeted me toward going to college because that just … seemed like an easier flow or way to get into a program. I had no idea about university at all. And I didn’t have the support there. And even through school, I didn’t have the guidance counsellors or anybody saying, “Why aren’t you going to university?” Which in hindsight is crazy because I was on student council, I had good grades, I was involved in different extracurricular activities. There was no way that I wouldn’t be able to manage university. But it was just never a conversation that was ever had. (R#9)
	Transitioning to postsecondary: patching the leaky pipe	When I was younger, I went to a nursing camp for Black students. So that also helped me to say, okay, this is what I really want to do. We did things that nurses do. Like doing needles and like putting on little finger casts and stuff like that. So now, they have a camp in the summer which was similar to the camp that I attended when I was younger. Strictly for Black students in junior high school, just trying to get them introduced to health care. So whether it be nursing or medicine or physio … So they start them off earlier, in junior high. So that when they get to high school, they can pick the right courses … their sciences and their math. (R#7) So what I loved is that camp that I was a part of when I was a nursing student. And it got students … in grade 8 or grade 9. Because the goal was before they went into high school, and having an idea of what courses they would need to be able to set themselves up to be successful to get into a nursing program. Now, that was just at a local level of Halifax. Which I guess is where the biggest population of ANS students would be. But I know I would have valued an experience like that when I was in junior high. I did have the opportunity to go to science camp in a rural community. And again, I was the only ANS student. So I just think having specific opportunities for ANS students, whether it’s nursing or health professions, I think experiences for learning in youth are huge. (R#11) That’s when I heard about TYP. I filled out the application forms, applied. And I’ll never forget the day I saw the letter. And the letter said “you’re accepted.” And that day I was like my life is just going to be changed. (R#16)
	Fitting a mould: a nontraditional student in a traditional institution	We talked to the young people, young women who were pregnant. Your life is not over. It’s harder. Because I went back to school. I did all my education except my high school education as a married woman, with children. And if you really want to do it, it takes a lot out of you, but you can do it. If you’re a mother and you’re a wife, and you’ve got responsibilities, it’s harder to do it. But it’s still attainable … you can do it if you want to do it. (R#2) Me and my sibling were the first in the family to go to university … I didn’t really have anyone to look to in the health care profession. I didn’t really know many nurses or doctors because there ain’t none of that down here. (R#15) I was self-motivated because I thought about what an opportunity for me … And my dad always was like education is so important. Because my dad’s parents, who are both ANS, they were denied those opportunities. So, for me, it was always about valuing this as an opportunity that I’ve been given and not to waste it. Not everyone is going to think like that. That’s just my experience of what kept me moving forward. My grandfather couldn’t read. He was illiterate. I’ve been very, very blessed to have a plethora of education opportunities that have set me up so that I can have the job that I want and live a comfortable life. And that’s not lost on me, that that’s from the sacrifice of others in my family history. (R#11)
An ethic of care	“Caring is in my blood”: an inter-generational tradition of care	I didn’t have big encouragement, other than from my grandmother. Going to my grandmother’s house, I’d always seen her in white uniform coming home at 3:00. I can remember her saying, “Come over and visit me.” And I always remember hanging out the line of clothes, the uniforms and looking at them. And seeing her taking safety pins out of her pockets and nail clippers. … And then my mom always had me ironing her white uniforms growing up. … It started off with going, as a child, in and out of nursing homes. That’s where it started. I’d visit my grandmother and go to my mother’s work. (R#12) When I was young, my grandmother had Alzheimer’s. So me and my cousins would take care of her a lot. And they always knew that I wanted to do something in health care. So whether it be nursing or medicine or something along those lines, I always knew I want to do something that way. (R#7)
	“My duty to educate”: leaning in and taking the lead	You have your patients that are prejudiced or racist. But I always go back to thinking, okay, well, that’s the area where they’re coming from. However, it’s my duty to educate them. (R#8) Personally, it gets exhausting because it shouldn’t be my job to have to explain these things to people. But if I don’t then nobody else is. And I see other colleagues, other Black colleagues who struggle with it because they’re either Black and new to Nova Scotia and dealing with sort of that silent racism that we see far too often, or they’re from the Black community here but haven’t taken on that responsibility within a leadership role and feel like they don’t have a place to say it. (R#13)
	Caring for the self: on mental, emotional and spiritual well-being	I have better coping than I did back then. And the type of work that I do is extremely helpful for that. So I don’t get stuck. I don’t get stuck with it like I used to get stuck. Yeah, it still happens. And then when you confront people, they’re less likely to come back at you. And that’s why I find my courage, it’s like if I deal with this now then they’re not going to come at me that way as much. … If I show them my comfort with my Blackness then they can’t use my Blackness as a weapon against me. (R#3) I say my little prayer on my way to work every day. Lord, let my hand do your work and your work only. (R#18) Don’t do what I did and play yourself down. Be proud of who you are and let that emanate from who you are. (R#4)

Note: ANS = African Nova Scotian, TYP = transition year program.

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.

Table 5:

Illustrative quotes for institutions of care

Theme	Subtheme	Illustrative quote
“Black tax” in nursing	Nursing as a service: the blending of art and science	I think sometimes people have to remember that we’re there to care for the patient. So any of our own personal feelings need to be left at home. (R#18) I mean it’s a good profession. It pays well. But you’ve got to be in it because you love it. And sometimes you can even say to staff members — “Well, why are you even in nursing if you hate it so much?” (R#12) Then it would come to, “Is [participant] on today? I don’t want you. I want [participant] to come in.” It is because I would take the time, right. Then you would have family members say, “Oh, my gosh, [participant], you stand out above everybody else. It doesn’t matter if they need to use the bathroom. You’re only supposed to be doing medication. But you have no issue taking them to the bathroom or changing them.” And I would tell them, well, I’m here to care for them so it really doesn’t matter what they need, that’s what I’m here for … I’m treating them like humans. (R#8)
	Nursing politics: navigating intraprofessional tensions	I felt like I was never going to fit in. I felt like I would get common ground in a conversation where like I had children, and a lot of these nurses had children. So, I would say, “Oh, how are your kids? Where do your kids go to school?” But I very much felt left out in those conversations … I thought maybe it was me, maybe I was aggressive, maybe I came off too harshly. But I don’t think so because I always knew what I wanted to be taught. So I can’t really say that there’s a nurse that sticks out in my mind as someone who took me under their wing and mentored me. And I think that’s what led me to always strive to make sure that that never happened to somebody else. And that’s why I have such a strong sense of mentorship today with the nurses. (R#4) They should be helping me out. But these were older people that have been doing this for 5 million years. They’re jaded. They’re on their way out the door. They’re ready to retire. They’re sick of the place. They’re sick of the politics. They’re like in their 70s. Which not all of them are like that. It just so happens that people that unfortunately I was around, that’s how they were acting. (R#16) I mean it’s sad to say that because there aren’t enough of us … I feel I always have a different experience than somebody else. I always feel like I have to do things 100% right because if I don’t then the next nurse will come on, and the patient will be like, “Well, it was the Black one,” and everybody knows who it is. So I found that it kind of made me work harder and want to be better for myself and for my patients. Always keeping my head high and owning up to everything that I do as a nurse, making sure that my assessments are good, and just being a great leader for the patient and for the interdisciplinary team. (R#7)
	Nursing education: primer for praxis	In my nursing class, it was me and another Black girl in our whole like class of like 180 or 160 students. So as a student, when I would go in our clinical group, I always felt like I stood out. (R#7) We’re like taught from a white perspective, a European perspective. I found that in classes they would teach things that weren’t true. We did the Tina simulation where you talked to Tina on the computer. You had to like interact with her and try to give her. … You had to be good at asking questions so you could get the actual answer. So they were saying that there were all these things wrong with Tina. And some of them were true. But there was 1 thing that they commented on, which was the darkness around her neck and how that was a health issue. And it can be, but lots of people who are darker complexion just naturally have that discolouration around their neck. But they were putting it in all my classmates’ head that that’s just automatically wrong. So I’m like, you’re going to go into the workplace and you’re going to offend someone who’s Black. And guess what, you’ve just ruined that relationship. So I felt like they were just giving false information. Also when they would cover a topic of anyone who wasn’t white, they would just be like, “Oh, you’ll see something different.” But they never told you what you would see that was different. They’d be like, “Oh, you’re looking at oral mucosa. And for someone who is white, it will be pink. And for someone who is like black, it’ll be a different colour.” But then the next topic just starts. And you’re like, well, what colour is it going to be? Like how am I going to save lives if I don’t even know what’s going on? (R#14) There were some heated topics. I remember it was just me and 1 other ANS student in this class because we always tried to stay in the same classes together just for support. … And I remember there were some heated topics about employment equity and affirmative action. And, of course being a predominantly white class, there were some people who would say “I don’t believe in affirmative action.” And I was like, wait a minute, like, no, no, no … I hate to bring up history, and the social determinants of health, and how we have systemically been oppressed. And I hate to bring up the Black card, as people say. But … we are in the condition we are based on systemic issues, historical issues. Like there’s nothing we can do change that. But I feel that white people just don’t understand that. And I felt like at that point, from a leadership perspective, I was advocating for my population and my community. That was big in a nursing school from a nursing student perspective. (R#10)
	Invite only!: Gatekeepers, standards and structural design	It’s at the School of Nursing. When you go there and you fill out your application forms. She was showing me the papers. And I’m looking at the courses. I was like oh, I can’t wait to take this course, I can’t wait to take this class. And she’s like, “Well, you’ve got to make sure you get in first.” And I was like, oh, I’m pretty sure I’m going to get it … I’m like no, I know I’m going to get in. And she’s like, “Well, don’t start picking things now. You better get in first.” (R#16) If I had walked away upset and not spoke with anybody, that would have changed my whole life. It was potentially life changing… because I wasn’t accepted into any other program. I didn’t apply for any other programs. So that was my first experience with the School of Nursing. (R#3) I feel very much that if I was Caucasian, I would have been further ahead than what I am now … it feels like the old boys club or the old girls club. And, it sparked me into almost writing a book called “If only they could see me” or “If they could see me.” I’d write the story about my life and what it’s like. But I really do think that my race has a lot to play with the fact that I haven’t been in leadership positions. … And, I guess one has to sort of resign themselves to the fact that it is what it is. But I really do feel that if I was born a different colour, I would be a lot further ahead with the experience that I have. (R#4)
Nova Scotia health care as an archaic institution	Who is at the table?: Inclusion beyond tokenism	I’m a big advocate for Black people in the health care field because I feel it’s needed and it’s important, especially in Nova Scotia, because we have such big Black communities. And like I said, for them to feel represented in the health care field. When they see you, it’s amazing. It’s a good feeling … I am a big advocate for nursing and trying to get more Black nurses in the hospitals because I know the way the Black community feels when they see a Black person. It’s like I’m the best thing in the world. It doesn’t matter who I am, any of that stuff. (R#7) Patients have stated how good it is when they come into this place and they see that there are Black nurses here that understand what they’re going through, who may have been in the same shoes that they’ve been, who have dealt with racism at the workplace, who have dealt with racism and classism, in Nova Scotia. They feel great about having someone that understands and that knows. They don’t have to explain everything because we understand. So that’s one reason why I think we need Black nurses — because we need to mirror our community … why shouldn’t we have Black nurses? Why shouldn’t we have Asian nurses? Why shouldn’t we have people that represent this community? But Black nurses are crucial, right. In this space where I’m working, we need to have Black nurses. (R#6) We should have a voice at the table. And any programs that they’re setting up should involve us. We should be involved. For example, I’m feeling really proud that yes, we have a person who is the ANS health consultant. However, for 10 or 15 years, we’ve had the gay, lesbians; we’ve had the Acadians. So why are we always just an add-on? … I think that it should be automatic when you’re setting up a program of any sort … you should cover everybody, not just be an add-on, and not be told that your numbers are small. (R#5)
	Competency gaps: mistrust, discrimination and patient harm	We’ve been a marginalized population in Canada, let alone Nova Scotia. You have some patient advocates, like Aboriginal patient navigators. Do you have any Black patient navigators? You know, there’s nothing like that. So one of the things I see is we’ve certainly not done ourselves any favours with bringing up anything to do with Black people. (R#4) I had a patient from our community. And they were brushing her hair. And I said, ‘whoa, she needs oils in her hair, she needs grease.’ And they’re looking at me like I’m crazy. And I’m saying she needs lotion on her skin. Put some cream on her. … Our skin needs that daily. (R#8) Even as far as when Black newborn babies are born, they have Mongolian spots. Well, I think everybody knows what they are now, hopefully. But, I recall a woman who came to the Black health program, she said that they called community services on her when she brought her baby in for a check-up. Community services was called. She was put in one room, her baby was put in another room because her baby had bruises on his back. And it was Mongolian spots … I guess the other reason is so we can add to the knowledge about our race, about Black people, you know. … There just needs to be more information. Not only just understand things that are physical, like sickle cell anemia, like Mongolian spots, but also to understand the history. What has that person encountered in their life? What have they dealt with before they come into a clinic or before they can go into a hospital, and they’re upset and they’re angry because you said something? Can we just bring another perspective? Can you have somebody who understands, who can shed a little light on that situation? (R#6)
	Community-oriented care within a medical-based system: providing the best care	I think working in acute care and seeing the lack of representation from the ANS community accessing services. Not having that representation and not having that reflected within the workforce. Because I was the only Black nurse. There were some other allied health workers. But not having that representation … I think how important it is to have professionals that are representative of the patients you want to see in these programs … I know there are youth out there that could benefit from these programs and services. … The structure of how some services are set up create barriers to access. It’s how the programs are structured, the staff, and some of the expectations around the programs that don’t take into consideration aspects of how to best engage with people. (R#9) More Black people are staying home and being looked after at home. I find it’s rare to have an Indigenous or a Black person on our unit. They’re staying home longer, and being looked after at home. And it’s not usually the diagnosis of caregiver burnout either. A lot of times when it’s caregiver burnout, it’s like they’re just dropped off. “I had enough. It’s like I’ve had enough. I can’t do it anymore.” But you don’t see that so much with the Black population or the Indigenous population. (R#12) Which is why we’ve got to take care of ourselves, mentally and physically before you try to go through a system that isn’t designed for you to be taken care of. You can’t rely on that. You have to be the one that you rely on. Then when the time comes, let’s hope we have some diversity in the field. That’s the last boat you want to have. You want to take care of yourself is what I was trying to say. (R#15)

Note: ANS = African Nova Scotian.

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.

Table 6:

Illustrative quotes for leadership philosophy and practice

Theme	Subtheme	Illustrative quote
Leadership reimagined: lifting as we climb	“It’s part of your job”: leadership as integral to nursing	Well, that’s part of your job. No, but it’s part of your job. When you apply for your nursing license, part of it is how much professional development did you do? … I didn’t even think of that as leadership. What I thought was what’s good for the community, what’s good for my people. (R#2) I was just doing my job. Personally, I felt like I was just doing what I do. I just encourage people. I just want to see people excel and do well in their lives, and to feel that they have some control, and not feel that they don’t have skills. (R#6) I like to think of nursing leadership as roles in which nurses are able to advance their profession. And I’m being a bit vague about what type of person that could be because I think any nurse can be a part of nurse leadership. And I think every nurse has a responsibility to be a part of leadership. I try to harp on that with nurses that I work with. Some certainly don’t have the same value as I do on the input into leadership. But I think that all nurses have that responsibility in some way. We’re a regulated profession with a certain amount of ethics and accountability to the public. And I think that part of that is taking on leadership in whatever way you can. (R#13)
	Along the pathway to success: climbing the professional ladder	I always wanted to pursue my master’s and be a nurse practitioner. So I’m trying to keep my goals in mind. I don’t want to get too comfortable. I always had that goal in mind. I’m like master’s, master’s, master’s. (R#10) I have noticed there’s a disproportionate amount of males in leadership roles versus the amount of males in nursing overall. … Which makes me wonder the reasons behind that. Like are women not ambitious for those roles or are men more ambitious. I think there’s probably something to be said about they’re more favoured, they’re chosen more often. And from what I’ve seen in nursing school, professors like them. It’s more effortless. Their journey throughout nursing school and through their practice. Patients, coworkers, doctors give them a benefit without having to prove themselves. (R#1) I would love to see more involvement like tying education and health care professions together. My local tutoring group asked me to come in and talk to kids. Because … if they’re not seeing health care professionals who look like them, it’s not going to be something they think they can do. If all they’re seeing when they go into the hospital, from the Black community, are aides and housekeepers. … And not that those jobs aren’t valuable and meaningful. But if that’s what they’re seeing, that’s all they will pursue. (R#13)
	Black feminist leadership: a practice and philosophy rooted in community-oriented care	When I think about nursing and leadership, I think about being in the community, assisting people, whether it be in school, whether it be … people in their own residence, assisting people to educate them, but also assisting them to take care of and be advocates for themselves. When I think of leadership, I think of advocacy. And I think of sharing what your community is saying, sharing what the residents in your community consider important health concerns for them, and working diligently to try to meet those needs. I’m very community-minded. … Not just nursing and being a manager or being in an administrative position in your workplace but being a leader in the community and being a champion to the community for people to be whole and to be healthy. (R#6) But the people in the community, when someone was sick, the women of the community got together, whether it was cleaning the house, cooking food, or making pads. I remember my grandmother making quilting pads for incontinence pads. So that tradition was there too for community. And when I went into nursing, I never thought of leadership. What I thought was, oh my God, people in the community don’t know about this. What can I do? I’m here. (R#2) I think that the concepts of nursing leadership is part of our scope and a part of our ethics. And I think that scope and ethics need to be incorporated into every single class. Because if you’re going to say that we want to foster a culture of diversity then you need to include diversity everywhere. You need to do the same thing with encouraging nursing leadership. So you have to kind of foster that along every step of the way, through every sort of course. And then among the Black community, with Black nurses. I think when you have an opportunity to have groups together, whether it’s associations … when you can have groups get together, then within that you can say we want to foster leadership among ourselves. How are we going to do that? And have something that is grown from within the community rather than pushed upon the community. I look at a lot of good models within the US [United States] because they have such a large Black population compared with us. (R#13)

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.