What It's Like to Be a Black Woman and CNO.

Daihnia Dunkley, RN, interviewed black women about their experiences as CNOs. Here's what healthcare organizations need to do to support these executives.

It's no secret that healthcare executive teams often do not reflect the communities they serve.

According to the Institute for Diversity and Health Equity's 2015 benchmarking study, Diversity and Disparities: A Benchmarking Study of U.S. Hospitals in 2015, "minorities represent 32% of patients in hospitals that responded to the survey."

However, that same representation is lacking in healthcare leadership. The same report found "minorities comprise only 14% of hospital board members, 11% of executive leadership positions, and 19% of first- and mid-level managers."

As Daihnia Dunkley, PhD, RN, professor at Farmingdale State College in Farmingdale, New York, points out, data specific to the number of black women in chief nursing officer roles is lacking, but their representation is likely even lower than the aforementioned numbers.

"I have been fortunate to work with several black nurse leaders, but then as I started to climb the [career] ladder, I realized how rare it was to actually work with a black CNO," she says.

This rarity of black CNOs was the inspiration for Dunkley's PhD dissertation, "The Lived Experience of Being Black and Female When Becoming a Nurse Executive."

"I thought [becoming a CNO] is something that's along my career aspirations. Why don't I study who I'm aspiring to become?" she says.  

Rather than strictly studying the obstacles black women faced in becoming CNOs, Dunkley interviewed 10 black women who were working or had worked as CNOs in New York, New Jersey, and Connecticut, about their experiences becoming and leading as CNOs.

"I wanted the 'cheat codes,' " she says.

She recalls what she said to the woman she interviewed: " 'How did you do this? I already know that there are so few of you and I'm pretty sure you had challenges thrown at you, but you still did it.' I wanted to know what that process looks like."

Dunkley recently spoke with me about her study findings, common themes among the CNOs' experiences, and how healthcare organizations can support this group of leaders.

The following is a lightly edited transcript of our conversation.

HealthLeaders: What were the findings of your research? I know you were able to identify many themes and subthemes regarding your participants' experiences.

Daihnia Dunkley: I came up with three essential themes: Living in a Constant State of Readiness, Embracing the Responsibility Beyond the Job Description, and Overcoming, and several subthemes.  The first theme, Living in a Constant State of Readiness, stood out to me and really captured a lot of what these nurses went through. That embodied all the different things that the participants felt they needed so they could be prepared at all times. So, whether that was educationally or in their actual role, they [felt] the need to be a step ahead by having several certifications, even though their counterparts weren't required to have the same.

For example, one study participant mentioned she'd had all these years of experience and she applied to a leadership role that she saw. The person who interviewed her was somewhat dismissive, and [it became clear] that they already knew who they wanted to hire. It was somebody with much less experience than [the participant] and no certifications, but one of the differences was that person was white.

That feeling of needing to be prepared was a pattern that came up over and over in their stories and was a subtheme [I categorized it as 'I want to be ready"].

Another thing that stood out was this whole notion of armoring. Armoring was the term used to describe the things I just mentioned—getting all these advanced degrees and certifications and always being ready. It's putting on the heavy suit or layer of protection because being black and female put them at a disadvantage.

HL: Can you tell me about the second theme you identified?

Dunkley: The second major theme was embracing the responsibility beyond the job description. Yes, being a nurse executive comes with its own specific job description and performance requirements but many of the participants mentioned that because they were the first of their race to achieve this honor, they felt like they had this weight of their community on their shoulders and felt that they couldn't mess up or make a mistake.

It was described to me as a blessing and a burden to be in their position. They didn't have that same space to fail because everybody was looking at them as a representative for success. Even though that is sort of a burden, it was also a blessing because they were the first in the position and they thought it was an opportunity to open doors and then pull others along who had the same aspirations. They also felt it necessary to do a lot of community outreach to mentor others inside and outside of the organization.

Another subtheme—the names of all my subthemes are the titles or lyrics from Negro spirituals—was "The whole world in her hands." This is how the participants felt because they were juggling the job description and the tremendous burden of being the first or only black woman who accomplished this level of achievement.

HL: And last, but not least, your third theme?

Dunkley: So, the last theme was overcoming. This was [about] the challenges that they faced and the different ways in which they overcame obstacles to attain their success and progress in their careers. One of the subthemes that fit here was "The trouble I've seen."

Basically, this is where the participants expressed the challenges they had and some of the things that they went through, like discrimination, oppression in terms of dealing with censorship, or being sabotaged or experiencing mistrust from their counterparts. For example, when you're at the same level as your colleagues, you're kind of all in the same struggle. Then suddenly you get a promotion and they did not. That can cause a little bit of friction.

There were challenges inflicted by their white or male counterparts, including sexism. That was an interesting piece because nursing is a majority female profession, so once they got to the C-suite, they saw more gender discrimination since the other executive titles were mostly male.

There was mention of the boys' club, but then it was also mentioned that even the title of nurse executive wasn't respected. My analysis of that and trying to capture what they were feeling was, "Is it because I'm a nurse that I'm not suited to be an executive, or is it because nurses are mostly women and women are not suited to be executives?"

HL: You mentioned that your last subtheme focused on how the CNOs dealt with these obstacles. Can you tell me about that?

Dunkley: My last subtheme was "How I got over," which is how the participants overcame these struggles. I categorized this with internal and external motivation. Internally, these nurses were extremely resilient. What helped them overcome internally was their own fortitude, their own sense of self. Many of them mentioned they didn't wake up thinking, "I'm a black woman. This is what I have to do today." They were people in careers, trying to do their best. They pulled from their faith. They were very spiritually driven women. They use their families as their support system to pull through.

As for the external motivation, the majority of the participants said they definitely would recommend having a mentor.

One internal motivation that was not healthy was code switching or not being able to show up to work as their authentic self. A lot of them admitted that depending on who was in the room, "I became that person." They felt like sometimes they had to look the part or speak the part or dress the part because they wouldn't be accepted otherwise.

HL: What are the implications of your findings based on knowing all this information?

Dunkley: At the end of the study, I realized that now we've got lots of data. We know about the underrepresentation. We know there are racial and gender disparities. We know about the discrimination and the obstacles that black nurses face, whether they're at the bedside or trying to pursue leadership position. The implications for nursing is there isn't sufficient career or leadership development for black nurses going beyond the bedside. The nurse executives had to take it into their own hands. You have to take the horse by the reins and spirit it in the way that you'd like it to go. However, if healthcare organizations truly want a diverse workforce, a lot of the onus is on them to support and invest in the growth and development of their employees. We know there's going to be difficulties, so why not get ahead of that and provide the resources that these nurses will need so it's not another story about how those within my organization weren't supportive or there's no diversity within your executive leadership team. Slogans and statements [about diversity and inclusion] are great, but what does your organization look like?