Lower pay scale banding and a lack of specialist status and/or management positions

Figures have demonstrated that nurses from ethnic minority backgrounds are over-represented in the lower Agenda for Change pay scale bands; for example, in 2018, 26% of nurses from ethnic minority backgrounds were on band 5 (the lowest band for registered nurses) – more than on each of the other nursing grades (NHS Improvement and NHS England 2019). Less than 2% of nurses from ethnic minority backgrounds were in the top five pay bands. Similarly, nurses from ethnic minority backgrounds have been historically underrepresented in senior or managerial posts (Public World 2013).

These factors not only lead to nurses from ethnic minority backgrounds being paid less and having perceived lower status than their white colleagues, but also diminishes their power and agency (Johnson et al 2019). Consequently, nurses from ethnic minority backgrounds may not be as autonomous as their predominantly white, senior managerial nurse colleagues. This lack of seniority, perceived lower status and consequent lack of autonomy may increase the likelihood that nurses from ethnic minority backgrounds may be redeployed from their usual clinical area to an emergency COVID-19 ward (Ford 2020).

Bullying and prejudicial redeployment

Since nurses from ethnic minority backgrounds are often positioned at the lower end of the nursing pay scale, and are less likely to occupy senior or managerial positions, they may experience unconscious bias, racial harassment and bullying from senior colleagues (Johnson et al 2019). The national Workforce Race Equality Standard (WRES) survey of more than 220 NHS trusts identified a consistent pattern of NHS staff from ethnic minority backgrounds experiencing higher levels of workplace harassment, bullying or abuse from other staff, patients and members of the public than their white colleagues, regardless of trust type or geographical region (NHS Equality and Diversity Council 2016).

Reports have suggested that one manifestation of bullying or prejudicial behaviour that has occurred during the COVID-19 pandemic is that managers are more likely to redeploy nurses from ethnic minority backgrounds to COVID-19-specific wards, thereby increasing their risk of exposure to COVID-19 compared with white nurses (Ford 2020). In a survey on discrimination during the COVID-19 pandemic, which included more than 2,000 NHS staff from ethnic minority backgrounds, some of them reported feeling concerned at being placed in at-risk front-line roles, that they were being unfairly deployed, and were at an increased risk of COVID-19 (Morgan 2020). The researchers found that 50% of respondents felt discriminatory behaviour contributed to the disproportionate death rate of NHS staff from ethnic minority backgrounds compared with white NHS staff.

Regional variations

The NHS in England has an average nursing vacancy rate of 12% (National Audit Office 2020), although there is regional variation in vacancies between NHS trusts (Glasper 2016). If an NHS trust is experiencing significant vacancy rates, with higher-than-usual demand on services due to the COVID-19 pandemic, the nurses working in that trust may experience increased workloads and suboptimal working conditions, for example being less able to take breaks and experiencing lower staff-to-patient ratios (Evans 2018). At the time of writing, the area of the UK recording the highest number of COVID-19 infections was London (Statista 2021), an area with a high proportion of healthcare staff from ethnic minority backgrounds, including nurses. Therefore, nurses from ethnic minority backgrounds are more likely to be working in healthcare organisations with a high COVID-19 infection rate.

Use and availability of personal protective equipment

PPE is routinely used to protect staff and patients from infectious diseases such as COVID-19. However, a Royal College of Nursing (RCN) (2020) survey of 1,465 members practising in Scotland found that 69% of nurses had raised concerns over inadequate PPE provision during the pandemic. Furthermore, approximately half (46%) of respondents stated that they had felt pressured to care for patients with COVID-19 without appropriate PPE.

There have been reports that one consequence of institutional racism has been inequitable access to appropriate PPE for nurses from ethnic minority backgrounds (Kituno 2020). Furthermore, when nurses from ethnic minority backgrounds do have access to PPE, design faults such as respiratory masks that do not accurately fit the physiological structure of some nurses from ethnic minority backgrounds’ faces have further increased their risk of exposure to COVID-19 infection (Kituno 2020).

Genetic predispositions and underlying health conditions

Research has shown that certain ethnic minority groups have genetic predispositions which mean they are increasingly likely to experience some diseases. For example, while the aetiology is unknown, people of South Asian origin are particularly susceptible to type 2 diabetes and cardiovascular disease (Joshi et al 2012), whereas people from a black African or Caribbean background are more likely to experience hypertension, thalassemia (an inherited blood disorder that affects haemoglobin production), sickle cell disease and lupus (Phillips and Malone 2014).

One Chinese study suggested that COVID-19 appears to be particularly damaging to the kidneys (Cheng et al 2020), which would mean that people with ineffectively managed type 2 diabetes who contract COVID-19 are at increased risk of suboptimal health outcomes, due to damage to the small vessels in the kidneys. Considering the high prevalence of type 2 diabetes among people from a South Asian background, this population could be disproportionally affected by type 2 diabetes and COVID-19. Guidance from the Faculty of Occupational Medicine emphasises the importance of considering underlying health conditions as well as the ethnicity of healthcare staff when assessing their risk of COVID-19 (Khunti et al 2021).

Researchers have investigated the role of vitamin D deficiency in the health of some ethnic minority groups and its possible effect on the prevalence of COVID-19 (National Institute for Health and Care Excellence (NICE) 2020). NICE (2020) stated that vitamin D supplements can have some beneficial effects on respiratory conditions and are recommended in certain groups, including people of African, African-Caribbean or South Asian family origin. However, the evidence for the use of vitamin D supplements to mitigate against COVID-19 is inconclusive, suggesting that further research is warranted (Vimaleswaran et al 2021).

With regards to nurses, a position statement from the RCN (2021) outlined employers’ responsibilities for the health of staff from ethnic minority backgrounds during the COVID-19 pandemic, for example stating that ‘managers should be encouraged to have supportive and confidential conversations with [ethnic minority] staff about any underlying health conditions’.

Age

Since the onset of the COVID-19 pandemic in early 2020, figures have consistently demonstrated that people aged over 65 years are at higher risk of dying from the disease than younger people (Byrne 2020). Moreover, as people age, their risk of developing underlying conditions increases and age may not just constitute a contributory factor in their development of COVID-19, but may also act as a confounder. In this scenario, the person’s older age status obscures the fact that it is their underlying health condition that increases the likelihood of them developing COVID-19. For example, in an older patient with COVID-19 and comorbid cardiovascular disease or type 2 diabetes – conditions that disproportionately affect people from ethnic minority backgrounds (Joshi et al 2012) – the underlying comorbid condition may be the main contributory factor in the person’s development of COVID-19, rather than age alone (Khunti et al 2020).

These findings suggest that people from ethnic minority backgrounds may be at increased risk of COVID-19 if they are of older age and have underlying health conditions such as type 2 diabetes. Additional research is required to examine this complex area further.

Sex

At the time of writing, statistics demonstrated that men have been disproportionately affected by COVID-19, although men comprise only around 11% of the nursing workforce (Clifton et al 2020, Dehingia and Raj 2021). Therefore, an examination of the number of deaths from COVID-19 among male nurses may provide an understanding of whether being male is a significant risk factor.

Social factors

People from ethnic minority backgrounds often follow culturally specific practices such as intergenerational living, where members of the extended family live together in one shared home. For example, one report from the Equality and Human Rights Commission (2016) found that in England in 2012-13, 31% of Pakistani and Bangladeshi children and 27% of black children were living in overcrowded conditions, compared with 8% of white children. While there are advantages and disadvantages to intergenerational living, in terms of COVID-19, the more cross-generational family members that live in the same home, the higher the risk of the disease spreading. This risk is further increased if members of the family are key workers and continue to attend work during lockdown restrictions (Scientific Advisory Group for Emergencies 2020).

The Equality and Human Rights Commission (2016) report identified that 36% of people from ethnic minority backgrounds were living in poverty, compared with 17% of white people. However, data on ethnic minority groups are often homogenised; for example, people from Indian, Pakistani and Bangladeshi backgrounds are typically considered together as being from a South Asian background (Garcia et al 2015). This means that the subtle differences between ethnic minority communities might not be identified and the various challenges they experience are often overlooked. For example, people from a Pakistani or Bangladeshi background are more likely to live in overcrowded housing than other groups (Equality and Human Rights Commission 2016), thereby increasing their risk of COVID-19 infection.

Recommendations for future research

The COVID-19 pandemic presents an opportunity to incorporate intersectionality within healthcare research (Springer et al 2012), particularly since there is an established evidence base on racism within the NHS, whereby the position of nurses from ethnic minority backgrounds can be linked to issues regarding power and disadvantage (Qureshi et al 2020). In addition, Collins (2012) stated that intersectionality is a politically engaged theoretical approach that is concerned with challenging social injustice.

The authors of this article suggest that an intersectional framework should be used to review the effects of COVID-19 on the health outcomes of nurses from ethnic minority backgrounds so that any intersecting factors such as age, sex and ethnicity can be identified. For example, additional research is required on the age profile of the nurses from ethnic minority backgrounds who have died due to COVID-19 to determine whether age was a significant contributory factor.

Another potential area for intersectional research could be to determine how many of the nurses from ethnic minority backgrounds who have died from COVID-19 were also experiencing comorbidities, and whether there are patterns in relation to these comorbidities within ethnic minority populations.

Based on the evidence presented in this article, the authors make the following recommendations: