Keywords

African Canadian, Black Canadian, nurse, nursing, nursing profession

 

Authors

  1. Jefferies, Keisha

ABSTRACT

Objective: The objective of this review is to synthesize the evidence on African Canadian nurses in the nursing profession in Canada.

 

Introduction: With approximately 1.2 million people of African descent, Canada has committed to addressing the United Nations' decade for people of African descent. Intergenerational racism continues to result in multisectoral discrimination against African Canadians. Studies suggest that African Canadians are under-represented in nursing, and encountering systemic barriers to entering and advancing in the profession. Additionally, African Canadian nurses experience racism from patients and colleagues, as well as systemic racism through hiring and promotion.

 

Inclusion criteria: This review will consider sources that include African Canadian nurses who identify as Black or as of African descent. All levels of professional nursing practice will be included (practical nurses, registered nurses, and advanced practice nurses, including nurse practitioners and clinical nurse specialists). Qualitative, quantitative, and mixed methods studies and gray literature will be searched.

 

Methods: This review will be conducted in accordance with the JBI methodology. Databases to be searched from inception to the present include CINAHL, MEDLINE, Embase, Sociological Abstracts, Gender Studies Database, America: History and Life, PsycINFO, Academic Search Premier, and Scopus. Studies published in English and French will be included. A comprehensive search strategy developed with a librarian will be used to retrieve relevant sources. Two independent screeners will screen titles and abstracts as well as full texts of relevant sources. Data will be extracted by two independent extractors then presented narratively, using appropriate tables and figures.

 

Systematic review registration number: Open Science Framework Preregistration October 3, 2019. Open Science Framework Link for Abstract https://osf.io/6a2fe/?view_only=57d86d5b7c1d464182692d0f4bb9b396

 

Article Content

Introduction

Nursing is a health profession that encompasses both an artistic and scientific approach to care.1 Florence Nightingale, who was a British nurse, social reformer, and statistician, is regarded as the founding philosopher of modern nursing.2 In 1860, Nightingale established the first scientifically based, professional nursing school located in London, England.2 Nursing has since transformed into a profession with influence in clinical practice, education, research, and policy.1 In addition to changes within the profession, nursing is undergoing an image transformation.3,4 The image of nursing reflects who is viewed as a nurse and who is able to become a nurse.3,4 Historically, a nurse was depicted as an image of purity, dignity, and gentleness (ie, the Victorian ideals of "true womanhood"), which was associated with white women and not with people of African descent.4 Within Canada, the nursing profession is of interest because Canadian nursing schools did not admit African Canadians into their programs until the late 1940s.4 Racism in Canada prevented African Canadians from entering nursing and practicing in a safe, inclusive environment, and this continues today.5-8

 

The legacy of African Canadian nurses illuminates years of racism, discrimination, and struggle, but also profound resilience and success.4,7 The purpose of this scoping review is to synthesize the existing evidence related to African Canadian nurses practicing the nursing profession in Canada. By definition, nursing encompass clinical care, policy, education, administration, and research.9 This review is both timely and necessary as diversity in Canadian nursing is gaining national interest; there is no published synthesis of this evidence; and there is a need to determine the magnitude and type of available evidence. Lastly, this review may hold international relevance by offering insights for racialized people in nursing while simultaneously addressing the international call-to-action declared by the United Nations (UN).

 

People of African descent in Canada

In 2014, the UN declared 2015-2024 as the International Decade for People of African Descent in order to address the ongoing human rights violations and social injustices experienced by people of African descent worldwide.10 The decade's theme, "People of African Descent: Recognition, Justice and Development," has been recognized by several countries, including Canada.10 In addition to this international call-to-action, a 2017 UN report raised a nationwide alarm in Canada, calling for immediate action to improve the social welfare of African Canadians by addressing the pervasive anti-Black racism that is rampant across all sectors of Canadian society.11

 

In Canada, there are approximately 1.2 million people who identify as Black or of African descent.12 Throughout the literature and in everyday communication, several terms are used in reference to African Canadians or people of African descent who reside in Canada. Terms commonly used in research include "Black," "immigrant," "African," and "visible minority."13,14 The authors acknowledge that African Canadians are not a monolith and that there are differences that exist within this group. However, to provide clarity for this review and to facilitate understanding by an international audience, the term "African Canadian" will be used.14

 

African Canadians have a hidden history in Canada, which dates back to their arrival as enslaved or freed people in the 17th century.13,15 Jefferies et al.14 provide a more comprehensive explanation of the historical context surrounding African Canadians, particularly involving the arrival of African Canadians; their contributions in war efforts; as well as health issues affecting this group, including high rates of chronic illnesses, such as hypertension, diabetes, and mental illness.14,16 Additionally, Jefferies et al.14 expand on the human rights violations and social injustices that remain pervasive throughout multiple sectors of society including, but not limited to, housing, labor, education, and health.

 

Diversity in nursing

Within the nursing profession, diversity has a positive impact on patients and the function of the health care system.17,18 Diversity is a term used in reference to the biological, genetic, cultural, and sociological variations of individuals and group.19 Specifically, diversity is often thought of in terms of sex, race, sexual orientation, and ability. Ensuring diversity in nursing has numerous benefits, including a culturally inclusive and competent approach to care, the integration of experiential knowledge from professionals, as well as a holistic understanding of diverse individuals, families, and communities.17,18 There is a need to understand the multiple and intersecting layers of diversity in nursing related to race, sex, sexual orientation, ability, and class while simultaneously understanding how each of these components interacts with one another. The authors recognize the need to examine multiple facets of diversity in nursing. However, based on national and international proclamations to address human rights violations and discrimination encountered by African Canadians,10,11 the authors have prioritized synthesizing the evidence pertaining to African Canadians in the nursing profession in Canada.

 

African Canadian nurses in Canada

The first nursing school in Canada opened in 1874, with the number of nursing schools increasing to 70 by 1909 and more than 200 by the 1920s.20 However, Canadian nursing schools did not admit African Canadians until the late 1940s.4 Institutional racial segregation displayed by nursing schools in Canada is often contrasted to that of the United States, which admitted Black students to nursing schools in the 1870s.4,21 Until the 1940s, African Canadians interested in pursuing nursing were instructed to travel to and train in the United States.4

 

At present, African Canadians continue to experience challenges entering the nursing profession. For example, the under-representation of African Canadian nurses has been linked to institutional racism, which prevents African Canadians from entering or advancing in nursing.7,22 Vukic et al.22 explained that despite initiatives put in place by institutions, there are systemic barriers that impede recruitment, admission, and retention of African Canadians in nursing. When present, African Canadian nurses are concentrated in entry-level and non-specialty areas while being under-represented in specialty areas, advanced practice positions, and leadership roles.7,23 Lastly, African Canadian nurses feel as though they are practicing on the margins of the nursing profession due to racism perpetrated by patients, colleagues, and superiors, as well as the systemic hurdles.24

 

A preliminary search of PROSPERO, MEDLINE, the Cochrane Database of Systematic Reviews, and the JBI Database of Systematic Reviews and Implementation Reports revealed no published or in-progress systematic reviews on this topic.

 

To date, the only record of a synthesis of this evidence is a literature review conducted by Etowa et al.24 The review by Etowa et al.24 was published as a section of a manuscript; however, i) it was a literature review embedded within a manuscript and thus was not published as a systematic review; ii) the review was described as a literature review, which did not describe a systematic process for searching, screening, or analyzing the literature; and iii) at least 10 years have passed since this manuscript was published. To this end, the authors deem it necessary to build on the literature review by Etowa et al.24 by conducting a scoping review to determine the extent of available peer-reviewed and non-peer-reviewed evidence regarding African Canadian nurses in the nursing profession in Canada. Thus, the purpose of this review is to synthesize the existing evidence by illuminating areas that have been investigated as well as describing ways in which African Canadian nurses have been represented. Identifying and mapping all existing evidence will inform knowledge gaps and priorities for future research. Finally, this review informs a larger qualitative study that examines leadership in the nursing profession among a historically distinct group of African Canadian nurses.

 

Review question

What evidence exists regarding African Canadian nurses in the nursing profession in Canada? Specifically to:

 

i. describe how African Canadian nurses have been represented in the literature.

 

ii. map existing evidence to inform knowledge gaps and priorities for future research.

 

 

Inclusion criteria

Participants

This scoping review includes sources focused on African Canadian nurses, with African Canadians encompassing various groups of people who identify as Black or as being of African descent in Canada.13,14 Literature about African Canadians includes those who identify as African Canadian, Black, immigrant, African Nova Scotian, or a newcomer from continental Africa, the Caribbean, South America, or the United States.13,14

 

Concept

The concept of interest is the nursing profession, which encompasses five domains of nursing practice including clinical care, education, administration, policy, and research.9 All levels of professional nursing practice will be included, ranging from nurses who received training at the diploma, baccalaureate, or graduate level. Respectively, in Canada these regulated roles refer to practical nurses, registered nurses, and advanced practice nurses, including nurse practitioners and clinical nurse specialists.9 Non-licensed, clinical practice roles, such as personal care workers and continuing care assistants, will be excluded as these are unregulated, unlicensed professions that are not classified as nursing in Canada.9

 

Context

This review focuses exclusively on the Canadian context. Despite similarities throughout the Black experience that transcend international borders, there are highly influential contextual elements, including historical racism, segregation, and socialization, which result in stark differences between Canada and other countries. These differences require a country-level examination prior to a global comparison. The Canadian context is of particular interest because African Canadians are identified as a highly vulnerable group globally,10,11 yet literature regarding this group remains hidden as Canada continues to lag in collecting race-disaggregated data.11

 

Types of sources

This scoping review will consider experimental and quasi-experimental study designs including randomized controlled trials, non-randomized controlled trials, before and after studies, and interrupted time-series studies. In addition, analytical observational studies including prospective and retrospective cohort studies, case-control studies, and analytical cross-sectional studies will be considered. This review will also consider descriptive observational study designs including case series, individual case reports, and descriptive cross-sectional studies for inclusion. Qualitative study designs including, but not limited to, phenomenological, grounded theory, ethnographic, qualitative description, action research, and feminist research will be considered. Additionally, systematic reviews, dissertations, and gray literature, as well as text and opinion papers, will be considered for inclusion. Research that includes a subgroup analysis, related to the context, concept, or population, will also be considered for inclusion.

 

Methods

This scoping review will be conducted in accordance with JBI methodology.25

 

Search strategy

The search strategy was developed in collaboration with a librarian, and the final search strategy will undergo peer review by a second librarian. The search aims to locate published studies and gray literature. An initial limited search of CINAHL (Appendix I) was undertaken to identify articles on the topic. The words contained in the titles and abstracts of relevant articles, and the index terms used to describe the articles were used to develop a full search strategy for CINAHL and MEDLINE. The search strategy, including all identified keywords and index terms, will be adapted for each included information source. Search terms related to the population of interest include "African Canadian," "Black," "African Nova Scotia," "immigrant," and "minority," as these terms are used in Canada. Other keywords include "nurse" and "Canada." Ancestry searching will be performed to identify relevant sources. Literature published in English and French will be included, and databases will be searched from inception to present.

 

Information database sources include CINAHL (EBSCO), MEDLINE (Ovid), Embase (Elsevier), Sociological Abstracts (ProQuest), Gender Studies Database (EBSCO), America: History and Life (EBSCO), PsycINFO (EBSCO), Academic Search Premier (EBSCO), and Scopus (Elsevier). Sources of unpublished studies and gray literature to be searched include Canadian Nurses Association, Registered Nurses Association of Ontario, College and Association of Registered Nurses of Alberta, Nova Scotia College of Nursing, and ProQuest Dissertations and Theses Global (ProQuest).

 

Study selection

Following the search, all identified citations will be collated and uploaded into Covidence (Veritas Health Innovation, Melbourne, Australia) and duplicates removed. Titles and abstracts will then be screened by two independent reviewers against the inclusion criteria for the review. Potentially relevant studies will be retrieved in full and their citation details imported into the JBI System for the Unified Management, Assessment and Review of Information (JBI SUMARI; JBI, Adelaide, Australia). The full text of selected citations will be assessed in detail against the inclusion criteria by two independent reviewers. Reasons for exclusion of full-text studies that do not meet the inclusion criteria will be recorded and reported in the systematic review. Any disagreements that arise between the reviewers at each stage of the study selection process will be resolved through discussion or with a third reviewer. The results of the search will be reported in full in the final report and presented in a Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews (PRISMA-ScR) flow diagram.26

 

Data extraction

Data will be extracted from included articles by two independent reviewers using the data extraction tool developed by JBI, which has been modified for a scoping review by the reviewers.25 A preliminary customary data extraction tool has been included in Appendix II. The tool will be tested with two reviewers completing extractions independently followed by comparisons before continuing with the extraction process. The data to be extracted will include details about the article, purpose of the article, population, concept, context of the study, study methods, and key findings relevant to the review objective. A detailed description of the data extraction process, the data extraction tool, and tool modifications will be included in the full scoping review report. Any disagreements that arise between the reviewers will be resolved through discussion or with a third reviewer. Authors of sources will be contacted to request missing or additional data, where required.

 

Data analysis and presentation

Data will be presented in diagrammatic or tabular form in a manner that aligns with the objective of this scoping review. A narrative summary will accompany the tabulated or charted results to describe the characteristics of the literature and how the results relate to the objective and question. The categories used for data presentation include those within the extraction tool; however, these may be modified based on the review findings.

 

Acknowledgments

Funding

KJ is supported by the MacEachen Institute for Public Policy and Governance, Aligning Health Needs and Evidence for Transformative Change (AH-NET-C): A JBI Centre of Excellence, and the Centre for Nursing and Transformative Health Research.

 

KJ is funded by the Dalhousie University Faculty of Graduate Studies, the School of Nursing and Killam Trust. Additional funding sources include Vanier Canada Graduate Scholarship, Johnson Scholarship Foundation, Research Nova Scotia, Nova Scotia Health Authority and Building Research for Integrated Primary Healthcare Nova Scotia (BRIC NS).

 

Co-author RM-M is director of the Dalhousie School of Nursing, which provided funding to KJ, for her doctoral studies. Such funding is provided to all doctoral students. No other funders had a role in content development.

 

Appendix I: Search strategy

CINAHL (EBSCO)

Search conducted October 10, 2019

 

Appendix II: Data extraction tool

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