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London Metropolitan University
• To enhance your understanding of intersectionality and its relevance to healthcare staff, including nurses
• To recognise the intersecting factors that may contribute to the disproportionate effects of coronavirus disease 2019 (COVID-19) among nurses from ethnic minority backgrounds
• To consider how an intersectional approach could be implemented in your area of practice
People from ethnic minority backgrounds in the UK have been disproportionately affected by coronavirus disease 2019 (COVID-19), with higher death rates and suboptimal health outcomes compared with those from white ethnic backgrounds. This trend is reflected in healthcare staff from ethnic minority backgrounds, including nurses, who are disproportionately affected by COVID-19 and have higher death rates from the disease. The theory of intersectionality contends that social categorisations such as gender, race and class can contribute to discrimination and result in disadvantages. In this article, the authors outline several intersecting factors that could be contributing to the disproportionate effects of COVID-19 among nurses from ethnic minority backgrounds, as well as making recommendations for further research in this area.
Nursing Standard. doi: 10.7748/ns.2021.e11645Peer review
This article has been subject to external double-blind peer review and checked for plagiarism using automated software
Qureshi I, Garcia R, Ali N et al (2021) Understanding the disproportionate effects of COVID-19 on nurses from ethnic minority backgrounds. Nursing Standard. doi: 10.7748/ns.2021.e11645
Published online: 12 July 2021
It has been identified that healthcare staff in the UK, including nurses, are at significant risk of contracting coronavirus disease 2019 (COVID-19), and people from ethnic minority backgrounds are disproportionately affected by the disease, with higher death rates and suboptimal health outcomes compared with people from white ethnic groups (Intensive Care National Audit and Research Centre (ICNARC) 2020, Lan et al 2020).
People from ethnic minority groups comprise around 20% of the UK population (Office for National Statistics 2019), but represent 34% of COVID-19 cases admitted to critical care (Razaq et al 2020). This over-representation of people with COVID-19 from ethnic minority backgrounds applies to both the general population and the healthcare workforce (Khunti et al 2020).
The higher risk of infection and harm from COVID-19 among nurses may have resulted from several complex and interrelated factors such as age, sex and ethnicity. Therefore, the authors of this article propose that healthcare policymakers, employers and researchers adopt an intersectional approach when attempting to identify contributory factors in the COVID-19-related deaths of people from ethnic minority backgrounds (Crenshaw 1991). This article defines intersectionality and outlines the intersecting factors that may contribute to the disproportionate effects of COVID-19 among nurses from ethnic minority backgrounds.
• Healthcare staff in the UK, including nurses, are at significant risk of contracting coronavirus disease 2019 (COVID-19), and people from ethnic minority backgrounds are disproportionately affected by the disease
• Intersectionality considers the relationship between power, subjectivity and social systems, and how these factors can result in discrimination
• Intersecting factors that may contribute to the disproportionate effects of COVID-19 among nurses from ethnic minority backgrounds include lower pay scale banding, bullying and prejudicial redeployment, and the availability of personal protective equipment
• An intersectional framework should be used to review the effects of COVID-19 on health outcomes of nurses from ethnic minority backgrounds
Intersectionality considers the relationship between power, subjectivity and social systems and how these elements can result in discrimination (van Mens-Verhulst and Radtke 2011, Walby et al 2012). Unlike other theoretical positions in healthcare research – such as the social determinants of health, which uses an additive perspective to suggest that a person’s health is influenced by the cumulative effect of risk factors – intersectionality takes a multiplicative approach to risk factors, as well as considering the effects of power imbalances (Hankivsky and Christoffersen 2008, Dutta 2015). For example, an additive approach would emphasise individual risk factors such as hypertension, obesity and hyperlipidaemia and how the aggregation of these factors makes a cumulative contribution to the development of cardiovascular disease; whereas, an intersectional approach would consider how these factors interacted or intersected with each other to cause cardiovascular disease.
The intersectionality framework approach was developed in the late 1980s by Kimberlé Crenshaw to analyse the position of women from ethnic minority backgrounds in the US. Intersectionality acknowledges that multiple factors – including ethnicity and gender at an individual level, and power dynamics at a systemic level – influence an individual’s experience of society and their personal relationships (Crenshaw 1991, Ucock 2020).
Several authors have asserted that healthcare researchers and policies in the UK continually fail to recognise the critical intersection of various social identities among healthcare staff, for example being female and from ethnic minority backgrounds, and therefore fail to identify how individuals may experience disadvantages in healthcare services at a structural level (Bagilhole 2010). By analysing nurses’ experience of working in areas where patients with COVID-19 are being treated using intersecting factors such as age, sex and ethnicity, researchers can begin to identify similarities and differences that may or may not influence the effects of COVID-19 on nurses.
Furthermore, as well as being marginalised or disempowered, nurses from ethnic minority backgrounds may have underlying conditions such as type 2 diabetes that can be exacerbated when they are exposed to COVID-19. Thereby, nurses from ethnic minority backgrounds may be disadvantaged without this being understood or acknowledged by healthcare policymakers and those within positions of power (Hankivsky and Christoffersen 2008). Until researchers explore the specific circumstances of such groups, any disadvantages that affect them cannot be identified and assessed.
It is also important to note that while intersectionality developed from analysis of the specific position of black women in US society in the 1980s, the concept has been used to analyse the position of minority groups in other contexts such as the health outcomes of immigrant populations (Viruell-Fuentes et al 2012).
One in every five nurses, midwives and health visitors in the NHS is from an ethnic minority background (NHS 2021), and the evidence shows that healthcare staff from ethnic minority backgrounds are disproportionally represented in death rate statistics, with 63% of all COVID-19-related deaths in healthcare staff being experienced by this group (Razaq et al 2020).
One suggested explanation for the over-representation of healthcare staff from ethnic minority backgrounds in COVID-19 death rate statistics has been their frontline exposure to viral load, which, in the case of COVID-19, is considered a significant factor in the deaths of healthcare staff (Zhao et al 2020). The viral load is a measure of the total number of viral particles inside an individual (in this case, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus that causes COVID-19); exposure to higher amounts of the virus, in turn, leads to higher viral loads, and therefore more severe effects. Other intersecting factors that may contribute to the disproportionate effects of COVID-19 among healthcare staff from ethnic minority backgrounds include:
• Lower pay scale banding and a lack of specialist status and/or management positions.
• Bullying and prejudicial redeployment.
• Regional variations.
• Use and availability of personal protective equipment (PPE).
• Genetic predispositions and underlying health conditions.
• Social factors.
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).
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.
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.
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).
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’.
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.
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.
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.
Because SARS-CoV-2 is a novel virus, the evidence base is still developing and there are few studies that consider the specific implications of COVID-19 for nurses from ethnic minority backgrounds. However, emerging data has identified the disproportionate effects of COVID-19 on ethnic minority populations, including those who are part of the nursing workforce (Khunti et al 2020).
Various authors have supported the use of intersectionality as a framework for healthcare policies and research (Viruell-Fuentes et al 2012), stating that the focus of research has too often been on singular constructs; for example, a focus on men versus women in gender-based research, or people from ethnic minority backgrounds versus people from non-ethnic minority backgrounds in race-related research. This singular approach in research can obscure issues among disadvantaged populations, for example the lack of acknowledgment of differences between various South Asian ethnic groups (McGibbon and McPherson 2011). In addition, if intersectionality is viewed as a framework for identifying power imbalances, nurses from ethnic minority backgrounds can be regarded as an appropriate group for research due to their marginalised position in the nursing workforce and wider society (Collins 2012).
It is important to acknowledge that the use of intersectionality in health research and policy is a relatively new approach and several criticisms of it have been raised, including the lack of clearly defined terms and an agreed definition (Nash 2008). Nash (2008) also observed that although intersectionality has been promoted as having the capacity to expand beyond the use of single-axis analysis – for example, a focus on race or gender only – it often reverts to using black women as quintessential subjects of study. Another criticism of intersectionality is that there is a lack of scholarly consensus on which method to use when applying an intersectional approach (van Mens-Verhulst and Radtke 2011).
Despite these criticisms of intersectionality, it is still possible that the factors detailed in this article – such as age, social factors and the use and availability of PPE – have intersected with the experiences of individual nurses from ethnic minority backgrounds during the COVID-19 pandemic. In addition, demographic and environmental factors such as poverty, access to healthcare services, education level and immigration status may also have affected the health beliefs and behavioural outcomes of people from ethnic minority backgrounds, including those who are nurses. For example, this has been demonstrated in the lower uptake of the COVID-19 vaccine among people from ethnic minority backgrounds compared with those from a white background (Razai et al 2021).
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:
• Educational and healthcare organisations should undertake any research activities using an intersectional framework.
• Healthcare organisations and leaders should adopt an intersectional framework when conducting internal NHS reviews of nurse deaths.
• Educational and healthcare organisations should share any findings on COVID-19 deaths among people from ethnic minority backgrounds to support a broader understanding of commonly occurring themes.
• Healthcare organisations should undertake COVID-19 risk assessments for individual staff from ethnic minority backgrounds. Employers have a legal duty of care to protect their employees from harm, illness or injury, and as such they are required to undertake risk assessments and make appropriate interventions to reduce any identified risks (NHS Employers 2021).
Intersectionality is a concept that considers the relationship between power, subjectivity and social systems. This concept could be used to investigate and address the disproportionate effects of COVID-19 on nurses from ethnic minority backgrounds, particularly in terms of understanding potential intersecting factors such as age, sex and ethnicity. It may be beneficial for healthcare organisations to use an intersectional framework when reviewing nurse deaths from COVID-19 and when conducting research activities.
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