By Don Sadler
Despite recent progress in equity hiring, representation of Black and Indigenous People of Color (BIPOC) nurses still lags in the health care industry. This is especially true in the operating room.
“The nursing profession overall is lacking in racial diversity, which is also reflected in the OR,” says Katie Boston-Leary, Ph.D., MBA, RN, NEA-BC, the Director of Nursing Programs and Healthy Nurse, Healthy Nation for the American Nurses Association. “Having said that, many nurses and nurse leaders are moving from lack of awareness or acceptance of the status quo to action.”
“The biggest question,” Boston-Leary asks, “is what impactful steps need to be taken now to swing the pendulum further versus small measurements of success?”
Change Happens Gradually
Renae Wright, DNP, RN, CNOR, perioperative practice specialist with the Association of periOperative Registered Nurses (AORN), believes that underrepresentation of BIPOC nurses in the OR is like evidence-based practice. “The knowledge of what needs to be done is there, but it takes longer for us to actually see it in practice,” she says.
“I believe that most organizations intend to improve representation of BIPOC nurses,” says Wright. “Indeed, they are publicly articulating this in their mission, vision and values statements, and marketing campaigns. Many organizations are working hard to make it happen, but these changes don’t happen overnight.”
Boston-Leary has seen the underrepresentation of BIPOC perioperative nurses throughout her career at conferences, in the C-suite and boardrooms and also as a CNO and nurse leader.
“I’ve had people assume less of me despite my educational background and clinical competency,” she says.
“I’ve also experienced racially insensitive remarks from colleagues and managers that I would strategically ignore. And I’ve witnessed people genuinely be surprised when I would produce at a high level throughout most of my career.”
Diversified Candidates Are Lacking
According to Keeli Stith, MSN, RN, NEA-BC, associate director, UH Perioperative at the Ohio State University, Wexner Medical Center, OR departments continue to see a lack of diversified candidates – despite internal and external recruitment efforts.
“Human resources continues to forward resumes over to managers, but if nursing leaders do not challenge HR recruiters to be more intentional in reaching BIPOC nurses, we will continue to see the unbalanced scale of majority white nurses in the operating room,” Smith says.“In my personal experience as a BIPOC nurse in perioperative services, I was always in the minority,” says Edna Gilliam, DNP, MBA, RN, CNOR, senior director of perioperative services and SPD, DV at Nemours Children’s Hospital, Delaware. “As I progressed into management, there were more times than I can count where I was the only BIPOC leader in the room.” Boston-Leary concurs.
“Underrepresentation of BIPOC perioperative nurses is even worse in leadership,” she says.
According to the Institute for Diversity in Health Management, an affiliate of the American Hospital Association, the percentage of minorities in health care executive positions is currently 11% and the percentage of minorities in first and mid-level management positions is currently 19%.
“As I’ve spoken at numerous events or engaged with perioperative leaders, I’ve found that the majority of those in leadership roles are individuals from our majority ethnic group: Caucasian,” says Brian Dawson, MSN, RN, CNOR, CSSM, system vice president, perioperative services, patient care services at CommonSpirit Health in Denver, Colorado.
Dawson attributes this to two main factors. The first is that organizations are hiring individuals who they feel comfortable with and are among their same ethnic group. “I believe this is not a conscious choice, but an unconscious bias,” he says.
The second reason is more nuanced.
“I think when you don’t see yourself in a leadership role, you’re hesitant to aspire to become a leader,” says Dawson. “As our young nurses mature into perioperative leaders, if they don’t see themselves represented in a leadership role, they have a tendency not to strive for those types of positions.”
How Stereotyping is Manifest in the OR
Racial stereotyping can manifest itself in the operating room in subtle and not-so-subtle ways. Stith says she has seen it manifest as “bullying” and “tough preceptor.”
“I have witnessed nurse managers working through a complaint issue from an African American staff member and the issue was first addressed as the preceptor was bullying the staff member,” says Stith. “When I sat with the staff member to further investigate, the issue was really racism.”
Boston-Leary says that implicit biases, which we all have, could impact how assignments are made in the OR, the specialty teams BIPOC nurses are placed on and whether BIPOC nurses get considered for leadership roles. “A surgeon or team member may not like you based on their biases and suddenly assignments are switched without a sensible explanation,” she says.
Sometimes culturally insensitive comments are made during a procedure, says Boston-Leary, “and you have decide whether you should confront it or assume risk. I’ve actually received a posting request for a patient who did not want any black nurses or staff taking care of her because she was allergic to what black people put in their hair.”
In her experience as a Korean-American transracial adoptee, Wright says it was not uncommon for racism and racial stereotyping to manifest in the OR in the form of microaggressions. She says she has heard comments such as “Where are you from?”, “Where are you really from?”, “Your name doesn’t sound Asian” and “Wow, you don’t have an accent.”
Challenges Faced by BIPOC Nurses
BIPOC candidates face a number of unique challenges when it comes to breaking into perioperative nursing and nursing leadership.
“The first is whether you get the interview because of your name possibly reflecting your ethnic background,” says Boston-Leary. “Many of us have had to Europeanize our names for this reason.”
“Then, you hope you are given an opportunity because of who you are and how you show up in person or over the phone,” says Boston-Leary. “Of course, professional dress or scrub attire is the standard, but anything that reflects my ethnicity could jeopardize my chances. There are numerous ideological gates to walk through well before competency and expertise are assessed to determine whether you are selected for the position.”
Gilliam says that for many minority OR nursing candidates, the challenge starts with their name.
“Many of us have names that are associated with people of color so there is a fear that our names alone will exclude us as a potential candidate,” she says.
“There is also a concern about how much of our authentic selves we can express during the interview process,” says Gilliam. “For example, is it acceptable to wear our hair in certain styles like braids or dreadlocks? How relatable will we be to the individual or panel of individuals interviewing us?”
Meanwhile, Wright says there are often limited opportunities for coaching to increase a BIPOC nurse’s marketability as a leader within an organization. “There are few mentors who are people of color at all levels of leadership, from the executive team all the way down to frontline leaders, and fewer still who are in perioperative services,” she says.
Creating a Diverse Perioperative Team
Boston-Leary says the first step in creating a more diverse perioperative team is to make doing so a strategic imperative.
“Once this is formally declared, one of the tactics should entail collecting data on diversity at numerous levels and positions within the organization, including entry, mid and senior level and the C-suite,” she says.
“Nurse and nurse leader diversity should be measured separately from other groups since they are the largest workforce in the organization and tend to have the most interactions with patients,” says Boston-Leary. “Determine the hot spots and gaps and craft two- to three-year plans to close the gaps that exist.”
Gilliam also stresses the importance of making diversity hiring a priority. “Department leaders should be aware of their staff demographics and accountable to build diverse teams,” she says. “And there should be specific metrics and standard requirements for performance management.”
James Fly, RN, MSN, MBA, CLSSBB, the director of surgical services for LMH Health in Lawrence, Kansas, has seen the percentage of his workforce that’s BIPOC nearly doubled since he joined in 2018. He offers a number of suggestions for creating a culture of inclusion among all members of the perioperative team:
Treat all employees the same, regardless of their race.
Use data to advocate for diversity.
Mandate Inclusion, Diversity and Equity (IDE) and sensitivity training for all staff.
Strive to create a “broad tent.”
Organize team-building activities outside of work.
“A lack of diversity is tied to negative health outcomes in BIPOC patients and may reflect negatively on the organization,” says Fly. “It’s important that patients have caregivers who reflect them and the community at large.”
Fly says he’s encouraged about the Executive Order on Diversity, Equity, Inclusion and Accessibility in the Federal Workforce signed last year and its potential impact on BIPOC hiring in the private sector as well. The purpose of the order is to strengthen the federal workforce by promoting diversity, equity, inclusion and accessibility.
“Evidence-based research tells us that we should be attracting BIPOC employees at a younger age and not waiting until they are in college,” says Fly. “For example, I’m part of the Big Brothers Big Sisters program and I recently brought my ‘little,’ who is Hispanic, to spend the day in surgery with me.”
Dawson stresses the importance of making sure your organization has a diverse and inclusive selection panel. “I also think it behooves nurses like myself to reach out and mentor others who look like we do and make sure they understand that the opportunities to succeed are there if they want to take advantage of them.”
Wright encourages hospitals to refer to benchmarks for more diverse hiring practices and then set incremental goals that are achievable over time. “Change on this scale does not happen overnight,” she says. “So, it’s important to make sure that your goals are achievable.”
Hospitals should also create or find IDE education that is engaging and meaningful. “This education should be mandatory for all staff and providers, from the C-suite to basement,” she says.
“I recommend that OR managers get to know what their BIPOC staff would like to see in the department to make it more inclusive,” says Stith. “Attending workshops and networking with other OR managers who don’t look like them is a good place to start. “
Build a Culture of Inclusion
Gilliam says that diversity is “the easy part. Building a culture of inclusion for all team members is the challenging part.
“I think we all as perioperative leaders need to get comfortable with being uncomfortable,” says Gilliam. “Give your team the necessary tools and training to support them. The more you talk about diversity, the less scary the conversations become for everyone. Ignoring diversity-related issues only leads to bigger conflicts down the road.”