Yvonne Coghill (@yvonnecoghill1) is the former Director of the Workforce Race Equality Standard in NHS London, and the former Deputy President of the Royal College of Nursing. Amelia Swift (@nurseswift) was an Associate Editor of Evidence Based Nursing and is a Senior Lecturer in Nursing at the University of Birmingham. They met to discuss race inequality in the NHS, and specifically in nursing. This blog is the result of that interview.
The unlawful death of George Floyd at the hands of the police force of Minneapolis in the United States of America was a watershed moment in the continued efforts of people of colour to gain equality. Across the world people of different races, ethnicities and colours have come together to denounce the lack of fair treatment based in the colour of a person’s skin and to declare their allegiance to that cause. At the same time, we have seen that people of colour are disproportionately affected by coronavirus disease, which has similarly led to increased awareness of inequality and injustice. But George Floyd and coronoavirus disease are the events of 2020. The history of inequality is long and shameful. Perhaps the mirror that these events holds up to our society can finally do some good.
What is the ‘correct’ vocabulary to use when we discuss issues related to race?
We have become very used to grouping everyone with darker skin together using the term Black and Minority Ethnic (BaME), or Black Asian and Minority Ethnic (BAME). Yvonne prefers the term people of colour or non-white groups.
We all have different amounts of melanin in our skin. If you have more melanin in your skin you stand out, and the more melanin you have the poorer treatment you get from society in general. YC July 2020
Putting people into different groups creates divisions and can feed hierarchies. While some do not like the term people of colour, it is probably the better term for the time being. One of the things we must do is talk about the issues. Being anxious about what the correct terms might be, which will depend on personal preference to a large degree, stifles the discussion. It is better to talk than to say nothing, and it is necessary to talk to be an ally.
Can we talk about race?
Having a conversation about issues to do with race can take courage. Many of us run the risk of exposing our ignorance, offending someone with a prejudicial attitude, or demonstrating a racist attitude. We tend to avoid the potential to expose ourselves in this way because racism is considered irrational, immoral, mean and bad 1.
The staff of the National Health Service are a microcosm of society. It is inevitable that our collective attitudes will range across that same normal distribution, including the extremes at either end. However, while surfacing racism and having the conversation is important, it is equally important for the individual to protect themselves. Apply your energy to changing the rhetoric and challenging inequality where it is most likely to have an effect, with those who have an open mind and are willing to have a conversation.
What is white privilege?
The term white privilege has become almost ubiquitous but can be unhelpful in promoting dialogue. The term social capital may convey the principle in a less divisive way. All else being equal, being born white confers an advantage – this is inarguable but uncomfortable to accept. Using the term white privilege can provoke defensiveness, and for many the need to point out their own disadvantage. We see this in the arguments provoked by the phrase Black Lives Matter. To some this is inflammatory because they feel that by making this statement what is implied is that black lives matter more – or that while we pay attention to this issue we will not be able to continue to pay attention to your unmet needs and grievances.
Renni Eddo-Lodge described the way that white people’s ‘eyes shut down and harden’ when a person of colour articulates their experience2. The reasons for this are many and varied but one is the position that white people occupy in society. Robin DiAngelo describes the way that white people are ‘insulated from racial stress’. Having never seen themselves in terms of race leads to perplexity when others describe their experiences in such terms. Racism is seen as deeply immoral and so we tend to deny that we have racist thoughts or attitudes. When we become aware that what we have said, done, or thought is racist we can learn and change. Instead we can react defensively, falling back to an individualistic perspective 1
I am not a racist, I am White Italian and I have experienced racism, I have Black friends therefore I am not racist. 1
This prevents the person from exploring and accepting the general and pervasive racism that is present in our society.
Is there really a problem in the health service?
No matter the colour of a person’s skin, the goals of nursing are the same and fair treatment and the absence of discrimination will allow all nurses to work towards those goals.
If you have a valued, appreciated, motivated workforce, you get better patient care, patient safety and patient satisfaction. YC July 2020
However, there is an obvious and persistent inequality. People of colour are more likely to face disciplinary action. The biggest disparity is seen in London where BME staff are 1.77 times more likely to face disciplinary action than their white colleagues 3. According to reports they are also slightly more likely to suffer from bullying and harassment from both patients and staff 4. In the 2019 NHS Staff Survey just over 30% of staff from BME backgrounds reported to having experienced bullying and harassment from patients, and 28% from managers and other colleagues 5.
About 20% of staff in the NHS are from ethic groups other than white but they represent less than 8% of those in senior and very senior management positions 4 6. Interview panels are dominated by white people, and black candidates may seem like more of a risk to them than the person who looks like they do. This is born out in the statistics with white candidates being 1.57 times more likely to get shortlisted for senior grade interviews. Only 8% of those in band 8c, and 6.7% of those in very senior management posts are from BAME backgrounds 4.
It is more difficult to reach a senior position, and then it is more difficult to operate in that senior position. As the only black person at a senior level you are more visible than your white colleagues. Your mistakes will reinforce any doubts your employer might have, and there is a strong likelihood that your deficiencies will be applied to the whole of your race rather than you as an individual.
So, what can NHS organisations do?
It is important that organisationally and individually we are allies. At an organisational level both in the NHS and in education we need to make sure that people of colour are not disadvantaged by the recruitment process. The data suggest that people of colour are successful in gaining entry to many universities and at getting entry level jobs, but it is after this point that the inequalities become glaringly apparent. There is an attainment gap in university education in terms of retention, degree classification and graduate employment. Universities must work hard to understand the reasons for these disparities and address them. This requires long-term strategies including increasing the number of people of colour employed as teaching and research staff. The number reaching senior levels needs to be increased. The Race Equality Charter 7 aims to improve the representation, progression and success of both staff and students of colour in higher education. Institutions start at Bronze level and work to Gold. There are currently 15 universities in the UK that have achieved a Bronze award since the scheme started in 2015. To achieve this award the university must
- Demonstrate their understanding of how race equality is perceived in the institution
- Acknowledge issues that exist for minority ethnic staff and students
- Have a comprehensive evidence-based action plan to address the organisations priorities and aims
- Have an institution wide senior and middle management commitment to advancing race equality
The NHS Workforce Race Equality Standard (WRES) was mandated in 2015 and is a component of the NHS standard contract and requires NHS organisations to report on the WRES indicators annually. This makes the employment and progression of a diverse workforce transparent and in turn generates a focus for discussion and development of a senior workforce that represents the whole.
And what about me? What can I do?
Perhaps the first thing we can do as individuals is to acknowledge that we live in a racist society, and respect the stories of those who experience it on a daily basis. Accept that racism hurts people as well as preventing them achieving their potential in a multitude of insidious as well as obvious ways. As DiAngelo said, it is difficult for a white person to consider racism because many white people do not live in a world where race is a dominant concept, certainly not on a personal level. Although there may be as many problems with the term unconscious bias as there are with much of the vocabulary in this area, it is nevertheless important to make an ongoing effort to be aware of our bias’.
Confronting racism is uncomfortable, but discomfort can lead to growth and to change. Be open to feedback and squash your natural urge to be defensive. Acknowledging intersectionality and your own disadvantages can be done without diminishing someone else’s experiences.
Senior nurses of colour perform an important role in the NHS. Being visible to others gives permission for others to aspire to the roles. Similarly, education needs to help student nurses of colour to believe that they belong in that world. Students and junior nurses find it difficult to see themselves in leadership positions and need role models to show them what is possible and to act as mentors. It is important to actively support nurses of colour to attain senior roles in the NHS and education, and once there we need to support them, as individuals rather than ambassadors. If we help a person do their job well, they can take care of the rest.
Listen, look, talk. To be an ally you need to have an open mind and an open heart.
- DiAngelo R. White fragility: why it is so hard to white people to talk about racism: Penguin 2019.
- Eddo-Lodge R. Why I am no longer talking to white people about race. London: Bloomsbury Publishing 2017.
- NHS England NI. A fair experience for all: closing the ethnicity gap in rates of disciplinary action across the NHS workforce. London: NHSE and I, 2019.
- NHS Equality and Diversity Council. NHS Workforce race equality standard: NHS UK; 2017 [Available from: https://www.england.nhs.uk/wp-content/uploads/2017/03/workforce-race-equality-standard-data-report-2016.pdf2020.
- National Health Service. NHS Staff Survey London: DHSC; 2019 [Available from: http://www.nhsstaffsurveyresults.com/.
- NHS Digital. NHS Workforce: Ethnicity facts and figures London: NHS Digital; 2020 [Available from: https://www.ethnicity-facts-figures.service.gov.uk/workforce-and-business/workforce-diversity/nhs-workforce/latest.
- AdvanceHE. Equality Challenge Unit: Race Equality Charter 2020 [Available from: https://www.ecu.ac.uk/equality-charters/race-equality-charter/ accessed 08/07/2020 2020.