“To tell you the truth Im tired”: a qualitative exploration of the experiences of ethnically diverse NHS staff

Summary of findings

The study provides an in-depth insight into the difficulties experienced by ethnically diverse staff within the NHS, particularly during the COVID-19 pandemic. Participants shared experiences of indifferent treatment from senior team members, and how there was limited sensitivity towards and knowledge of their cultural differences. Specifically, during the pandemic, ongoing conversations around racism and discrimination left participants feeling trapped and unable to escape these conversations. Participants also discussed the difficulties they had in speaking up against discriminatory behaviours as they recalled previous negative experiences, which further deterred them from saying anything. Participants voiced a strong passion for their jobs and how this superseded their negative experiences as well as drawing on their spirituality to cope. While many negative experiences were highlighted, participants also described positive experiences with colleagues, as well as beginning to see more representation of ethnically diverse leadership. Participants described how through the establishment of Trust BAME networks staff were able to connect and create safe spaces to talk to one another about problems. Staff reiterated the need for diverse leadership, but also compassionate leadership where senior staff are comfortable with having difficult conversations around racism and discrimination. There was a genuine need for a protective space, as well as support to speak up and feel heard, highlighting that the NHS still has much work to do in order to support its ethnically diverse staff.

Consistency of findings with the wider literature

There have been a large number of qualitative studies published since 2021 describing healthcare workers’ experience during the COVID-19 pandemic, including studies from India,26 Malawi,27 South Africa,28 Puerto Rico,29 the USA,30 the UK,31 Canada32 and Singapore.33 Most of these studies describe high levels of stress and trauma among healthcare workers, which was exacerbated if there was a perceived lack of resources and operational efficiency within their respective healthcare organisations. This study focuses on the experiences of ethnically diverse healthcare workers in a predominantly white British healthcare system and society, which arguably have usually been harder. The often negative experiences described by participants reflects other qualitative literature on pandemic-related experiences of ethnically diverse healthcare staff, with one UK study highlighting how participants did not feel adequately supported by their employer and their manager during the pandemic, feeling particularly unsupported when their supervisor was from a white British background.34 The same study indicated how some staff members felt risk assessment exercises had not been treated seriously by their managers and organisations.34 Another qualitative UK study highlighted four key areas of racialised discrimination that put the lives of ethnically diverse staff more at risk of serious injury and death: work allocation, PPE provision, risk assessment provision and a culture of neglect.35 This same study noted that ‘these experiences should be seen as a continuation of prepandemic experiences resulting from a systemic culture of racism’.35

The wider international literature identifies similar themes: in the USA, there is limited ethnic diversity among nursing staff36 and qualitative exploration of the experiences of black nurses working within hospitals highlights feeling a need to work harder than their white counterparts to earn the same recognition, and feeling despondent when failing to see people in leadership positions that ‘looked like them’.37

In medicine, quantitative evidence from a recent UK cross-sectional study involving 2030 respondents (doctors and medical students) identified that over three-quarters (75.6%) of respondents had experienced racism at least once in the past 2 years, and 17.4% experienced racism regularly. More than 70% of doctors who had experienced racism at work did not report it because they had no confidence that the incident would be dealt with, or they feared that they would be labelled a troublemaker.38 A UK qualitative study reported respondents describing difficulties in challenging or reporting adverse experiences due to concerns about the impact on their career progression, fears of upsetting team dynamics, ‘rocking the boat’, and of being labelled a ‘snitch’ or ‘troublemaker’.20 This further supports the credibility of our findings regarding barriers to speaking up.

The findings of our study can be further understood through a lens of critical race theory (CRT): CRT argues how societal racism operates in favour of the dominant racial group in power; such perceptions were expressed by participants within our study. When describing being overlooked for promotions, or meeting backlash when speaking up, this supports the tenet that describes the permanence of racism, in this case how structural racism can promote silencing and fear of speaking up so to not be seen as disruptive. This can further exhaust ethnically diverse individuals and cause them to feel racism will not be eradicated. When considering solutions, there needs to be promotion of systems change with senior-level buy-in and accountability to deliver.39 40 However, the risk of retraumatisation when involving ethnic minority groups to codesign strategies requires serious consideration. As shown across our data, participants, in particular following the killing of George Floyd, expressed significant exhaustion when having to recount or defend the existence of racism and the impact of their lived experience. This aligns with the colour blindness tenet of CRT that has been observed in other studies20 41 adding credibility to our findings.

The findings call for greater diversity in healthcare leadership which is a well-known issue within the NHS,42 43 highlighted by the 2014 ‘Snowy White Peaks of the NHS’ report.44 This further reflects an international issue where a lack of diversity in healthcare leadership is dramatic, for example, in the USA 98% of senior management in healthcare organisations are white.45 Similarly, across Canada, individuals from non-white backgrounds occupied only 7 out of 118 highest-level hospital roles.46 This same paper argues that racial diversity in healthcare services leadership needs to increase, as racially diverse leaders are more likely to promote culturally sensitive care, address discriminatory policies, create inclusive spaces and use their own insights to improve staff experiences.46 However, it has also been highlighted that although increasing diverse representation in management positions is a critical step, this alone cannot eradicate the culture of racism: black managers have highlighted how they are not always fully involved in decision-making processes or are isolated, leading to the reproduction of discrimination and the failure to address racism even by racialised minorities in management.35 It can be argued that until the inherent institutional structures that prop-up racism and white privilege47 are dismantled, most of these efforts become tokenistic without real change in clinical practice. Inequalities will continue and arguably at the benefit of the dominant group in the organisation.

For ethnically white line managers, the study findings provide some suggestions as to the most effective ways for them to support ethnically diverse team members. Many white line managers may have good intentions but little understanding of cultural sensitivities and may therefore treat all ethnically diverse colleagues ‘the same’ as white staff members, or the same as each other, overlooking difference or individuality. One reason for this limited understanding may be that people are reluctant to discuss such topics, finding them uncomfortable; this is something that was highlighted in our findings.

It is crucially important that healthcare organisations take steps to become more culturally aware and sensitive to the needs of the individuals within their organisations. However, care must be taken to ensure that the need to respect each other’s cultural and ethnic viewpoints does not stymie discussion and close down any open questioning relating to these issues. The current EDI agenda that is increasingly prominent across healthcare organisations sets out to ensure that staff are treated fairly in relation to this premise. However, it is important that the differences that set people apart are not silenced in the drive for equality, as this may serve to create more tensions and divisions than it solves, as mutual understanding and shared support mechanisms are eroded. There is therefore an urging to ‘have the awkward conversations’ and improve understanding and hence staff well-being. Much evidence shows that supportive managers are strongly linked to improved mental health at work48 49 and changes in awareness and communication techniques could have widespread implications for the well-being, recruitment and retention of staff.

Not all participants’ experiences in our study were negative and evidence from another qualitative study suggests that participants who felt they had organisational support experienced improvements to their well-being, which may have mitigated against the effects of any racial injustices they were increasingly aware of and subjected to during the pandemic.34

While many of the studies highlighting the negative experiences of ethnically diverse staff indicate how staff are leaving or considering leaving their roles,50 the participants in this study mostly indicated that despite the challenges and experiences of discrimination, working for the NHS was part of a larger purpose made clear to them through their spirituality. Participants also expressed how their passion for their work provided them with a drive to continue in their roles.

The value of BAME networks to support ethnically diverse staff, and psychologically safe routes for raising concerns was highlighted by our findings. These ideas link to some extent with suggestions in the Kings Fund (2020) report ‘Workforce Race Inequalities and Inclusion in NHS Providers’.1 There are also practical ideas for tackling racism at work in recent guidance around combatting racial discrimination against minority ethnic nurses, midwives and nursing associates51 and the ‘Anti-Racist Health Service Manifesto for Change’ published by the Anti-Racism Research Group at the Centre for Culture Media and Society at Sheffield Hallam University.35

However, in the UK, despite the implementation in recent years of measures to tackle racialised inequities in the health services such as the NHS WRES,6 little progress has been made20 35 and in fact, in some areas discrimination and harassment has increased.52 Interventions tackling discrimination among healthcare staff have been reviewed,40 53 finding little evidence that initiatives such as cultural competency and unconscious bias training are effective in reducing discrimination. It is therefore suggested that ‘a radical shift in the institutional approach is needed to change the underlying narratives and to help dismantle the racialised structures that create an environment and tolerance for racialised inequalities which cause both physical and psychological harm’.35

One study, drawing on qualitative interviews with 48 healthcare staff in London (UK), identified how microlevel bullying, prejudice, discrimination and harassment behaviours, independently and in combination, exploited and maintained organisational-level racialised hierarchies.20 As a result, there was a call to reduce disparities via structural and systemic-level shifts in organisational culture, via instilling a promotion of work/life balance, proactively fostering inclusion by equitably valuing and esteeming differences in roles, attributes, knowledge and perspectives; and proactively levelling-up opportunities for career progression. It was stated that these actions were structurally key for staff retention and improved health outcomes for staff (and ultimately patients).20 Future research is needed to test implementation of these wider structural actions and their effectiveness.

Strengths and limitations

This was a qualitative study exploring the experiences of ethnically diverse NHS staff, to provide a rich, narrative dimension to complement the many quantitative studies in this area. This qualitative perspective can highlight subtle processes and experiences that may otherwise go undetected by outside observers.

Of the six research team members, three were from ethnically diverse backgrounds and three were of white British ethnicity. The research team had regular meetings to discuss the data analysis and identify themes, giving a broad range of views and perspectives, personal lived experiences and academic understanding to the topic.

The participants were a diverse sample from a broad range of religious affiliations, ethnicities, ages, professions and seniority levels.

A study limitation is that only people with ready access to computers and online working were able to participate. This is likely to have excluded staff such as porters, cleaners and staff needed intensively on hospital wards. This is a possible gap in the findings as it may be that general medical hospital staff, such as those working on COVID-19 wards, in intensive care units or in emergency departments experienced the highest levels of post-traumatic stress; the current literature suggests that although levels of trauma were high in all healthcare workers during the pandemic, most studies do not draw a distinction between different healthcare professions or specialties.54 There is very little literature about the role of cleaners (and seemingly none about porters) to the point that they are ‘an invisible workforce’,55 and yet they have often been exposed to high levels of risk from COVID-19 and are instrumental in infection control measures.55 56 They are also likely to be from ethnically diverse groups, although precise figures on this are difficult to obtain.

Another limitation is that the use of remote focus groups appeared to make discussions slightly less fluid than if they had been face to face, with participants waiting their turn to speak, which may have limited natural conversational flow and meant there was less direct interaction between the participants and few opportunities to observe participants concurring with or challenging each other. Although it was felt that most participants appeared to speak openly and passionately, this may have moderately limited the richness of some of the data. Some participants expressed reservations about being funded by NHS England, but we assured them that all discussion would remain anonymous, and NHS England, although reviewing and approving the final draft of the paper, would not be permitted to compromise the ethical and scientific integrity of the study.

There was no formal patient and public involvement (PPI), although we did present several webinars where some of the themes from the focus groups were discussed, which can be accessed online.57 Using a formal PPI process may have improved the design of the study and its relevance to participants.

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