While COVID-19 has ravaged the health-care industry, a Ryerson nursing student says it has simultaneously created an opportunity to think differently about how to provide better care to diverse communities.
With visible minorities disproportionately affected by vaccine hesitation throughout the course of the pandemic, Octavia Bullen says more representative leadership in the nursing profession may help combat this effect.
“If there were more Black nurses, particularly in leadership positions, this would enable nurses to advocate for more health teaching and understanding about COVID-19 within Black communities,” said Bullen, a fifth-year Ryerson nursing student and the official delegate for the Canadian Nursing Students’ Association (CNSA).
“[This will] open a conversation about the need to get vaccinated in order to protect the ones they love, but others as well.”
Bullen says this positive influence will not only inspire Black nurses to pursue leadership roles more frequently, but may create an opportunity to provide better relational care to Black communities.
Susan Bookey-Bassett, assistant professor and researcher at Ryerson’s School of Nursing, says relational care is a clinical approach that aims to ensure quality of care. She is currently leading new research into the role that equity, diversity, and relational care play in patient outcomes.
“You really get to know people more on an individual level, and you’re able to provide more concentrated, individualized, patient-centred care which is based on relationships,” she said, highlighting that trust between patients and care-givers will usually result in better patient outcomes.
“Patients will comply because they trust their health-care providers,” she said.
Nancy Purdy, a Ryerson researcher and nursing expert who works alongside Bookey-Bassett, says having more Black nurses in leadership can improve relational care by creating better opportunities to understand their lived experiences and unique patient needs.
“Black nurses can help their colleagues understand the nuances of what it’s like to be a Black patient, and they can help advocate for changes in practice that address Black-specific issues,” said Purdy, whose research is focused on enhancing nursing leadership and improving patient outcomes.
This is reinforced in a study published in the Canadian Journal of Nursing Research, which revealed that marginalized communities are particularly under-represented in leadership roles. In the nursing labour force, eight per cent of managing positions were occupied by visible minorities, while nine per cent were head nurses. Peer-reviewed analysis of the study concluded that an increase in racial, ethnic and cultural representation is required in the Canadian nursing profession in order to provide “culturally appropriate” care to patients, families and communities.
Bullen says this is why there’s a lack of trust in the health-care system amongst Black Canadians — they don’t feel like their lived experiences are truly understood.
“It’s hard to navigate when you don’t see leaders like you,” she explained.
A survey released on Nov. 2 by the Angus Reid Institute found that vaccine hesitation in Canada was highest amongst Indigenous communities and visible minorities.
86 per cent of participants agreed that “vaccine passports [are an] example of government overreach,” with the largest portion of respondents citing both personal freedom and health concerns as the biggest reasons they were not getting vaccinated.
Experts say vaccine hesitation amongst these communities is born from generations of mistreatment at the hands of the government, such as colonization, displacement and slavery.
“People are being asked to trust government recommendations from a government that has not earned their trust in the past,” said Shannon MacDonald, a vaccine and nursing expert at the University of Alberta’s School of Public Health. “For sure, there’s going to be challenges.”
A report released by Canada’s chief public health officer detailing the public health approach to COVID-19 cited that health is inequitable amongst marginalized populations — specifically Black, African, Caribbean and Indigenous communities. It revealed that Canada’s history of residential school systems, colonization, displacement and slavery has enforced discriminatory socio-economic structures, leaving people of colour at a higher risk of contracting COVID-19 due to a lack of trust in government policies and institutions.
Bullen, previously the director of diversity for the CNSA, says the government’s involvement in the vaccine mandate is the reason why there has been a recent surge of pushback and protests outside hospitals. She says people are not protesting the vaccine, but rather, protesting government control, which has resulted in unfavourable outcomes for communities of colour throughout the pandemic.
“Vaccine hesitation led to a lot of Black patients being admitted into hospitals, then regretting not getting vaccinated,” Bullen said.
As of July 21, 2021, data collected for the City of Toronto revealed an overrepresentation of racialized groups in hospitals with COVID-19 (74 per cent), which included people who were Black, Arab, South Asian, southeast Asian, and Latin American.
MacDonald says this has highlighted the need for better communication techniques within the health-care system, specifically towards diverse communities.
“If there’s anything we’ve learned from this pandemic, it’s that one approach does not work for everybody,” MacDonald said, noting that more effective leadership is necessary to advocate for these communities.
“For folks where trust is an issue, they need to hear the message from somebody they trust, so it’s not just the government saying they should get vaccinated, it’s leaders within their community.”
Based on the research that’s been done on vaccine hesitancy, MacDonald says the biggest influence on changing somebody’s mind about a vaccine is a trusting relationship with their health-care provider.
“That’s not something you get by telling somebody what to do, that’s something that develops over time, and it involves listening, patience and compassion.”
In response to these findings, designated clinics have opened across Canada for Indigenous communities to get vaccinated in a culturally-safe space. At these clinics, elders greet community members at the door, vaccines are administered by Indigenous health workers, and smudging ceremonies are performed.
“There needs to be leadership at the local level when implementing vaccination programs for Indigenous communities,” says Simon Brascoupé, a member of the Kitigan Zibi Anishinabeg First Nation in Maniwaki, Quebec, and adjunct research professor in the Department of Sociology and Anthropology at Carleton University.
“There is historical trauma that has resulted from residential schools, colonial policies, and control over First Nation and Indigenous decision-making at the local level,” he explains.
“This indicates that communities who have control over their governance and programs are healthier than those that don’t.”
Brascoupé, previously the chief executive officer of the National Aboriginal Health Organization, published a paper in the International Journal of Indigenous Health titled Cultural Safety, where he explored how culturally appropriate care for Indigenous communities can be institutionally implemented to ignite genuine and lasting change. One of his recommendations was to increase the uptake of Indigenous students in post-secondary schools in order to create more representation in health-care jobs and positions of leadership.
“There’s been an effort to increase the number of Indigenous doctors, nurses, and health practitioners, because the research that’s being done is saying that if an Indigenous person has another Indigenous person as a health-care worker, that will improve things like communication, language barriers, and trust,” he says.
“The end result is improved health and wellness outcomes for Indigenous communities.”
While Brascoupé says that Indigenous representation in the health-care system is important, he says cultural safety and knowledge translation must be co-developed at the policy level as well.
“Governments need to have more flexible policies that enable Indigenous communities to develop their own culturally-appropriate approaches,” he says, highlighting that if society is not understanding of culture or actively creating relationships with Indigenous populations, then they are unknowingly doing harm. Without co-developed policy, structural inequity will continue, and Indigenous communities will suffer, he says.
In September, CBC published a story revealing that Indigenous Services Canada (ISC) accidentally administered expired COVID-19 vaccines to the Saugeen First Nation community in Ontario for a month. The organization said, after an investigation, that the federal nurses who administered the doses did not realize the vaccines had not been refrigerated and therefore expired. ISC wrote in a letter to the community that “the department sincerely apologizes for the vaccine error and the concern that it may cause for the members of the Saugeen First Nation.” They emphasized that no health risks are associated with getting an expired vaccine, but recommended re-vaccination.
“It’s situations like this that damages trust, and situations that people will remember,” MacDonald said.
As a nursing student and member of the Black community, Bullen says many people in her life had vaccine hesitation and turned to her for advice because they trusted her. She says with time and education, they decided to get it on their own accord. This is why Bullen believes it’s essential for nurses to work with diverse communities to provide them with the information and care they need to build trust and make an informed decision on their own; she believes this would be more effective than enforcing a mandate or suggesting they don’t deserve access to health-care if they don’t otherwise conform, which directly plays into their insecurities and fears.
This is something Bullen has noticed first-hand in her clinical placement. She recounts a time when she overheard a frustrated nurse tell an unvaccinated patient in the ICU that they didn’t deserve a bed, or care altogether.
“I was so shocked and lost for words when she said that,” Bullen said.
“That’s a lack of empathy right there.”
According to MacDonald, what Bullen observed in her placement was not common, but certainly problematic. She says nurses have an ethical duty to take care of their patients regardless of the circumstances.
“We care for alcoholics with liver disease, we care for people with substance use disorders — we don’t refuse care for them because they’ve made a poor life choice,” she said.
“If you’re making ultimatums about what kinds of patients you’re prepared to care for, then that’s not a good fit for the nursing profession.”
While having more diverse representation in the health-care system may help provide better relational care to diverse communities, Bookey-Bassett and Purdy both warn about the implications of ultimatums in health-care. They say the idea that only racialized nurses should care for racialized patients is potentially harmful and defeats the purpose of relational care; rather, they highlight the importance of understanding a patient’s history and unique needs— regardless of who you are.
“What we’re trying to do in the nursing profession is value everyone, it shouldn’t matter what colour I am or what age or gender I am,” Purdy explained.
“I should be able to use different communication techniques to really understand where a patient is coming from — and that’s the holistic approach we’ve always subscribed to in nursing.”
Correction: This story has been revised to include a voice that was unintentionally omitted in the original.