Ensuring diversity among community nursing leaders

When Laura Serrant trained in the early 1980s, she heard that some patients did not want to be touched by ‘that black nurse’. Here, she asks how much things have changed.

When Laura Serrant trained in the early 1980s, she heard that some patients did not want to be touched by ‘that black nurse’. Here, she asks how much things have changed.

In today’s increasingly diverse society, healthcare leaders and their teams try to provide high quality care to patients while recognising cultural differences. Planning such service provision can be complicated by the need to manage competing interests. Diversity is a personal and professional issue, and community leaders must try to shape the diversity agenda rather than simply respond to society’s social, political and strategic drivers.

This means nursing must make a decision to change. But how? This article seeks to answer the question.

Advances in science, medicine and technology are making the 21st century an exciting time. Our understanding of the human condition has given us greater insight into the workings of the human body and our relationship with the world than ever before. More important than the scientific knowledge we have at our fingertips, however, is a greater appreciation that what makes us infinitely more interesting are the nuances and differences between us.

As healthcare professionals we are privileged, more than any other profession, to witness and experience the impact of our differences every day. Wherever we carry out our professional practice, we cannot avoid it: patients, families, students and peers are all ‘different’ to us, they have differing frames of reference, life experience, values and behaviours. This is even more important in community settings where the range of communities, social contexts and their impact on health and wellbeing cannot be masked by the uniformed ‘sanitisation’ of a hospital ward, where all beds are the same and life chances can appear to be ‘equal’.

The rich diversity of society challenges healthcare leadership at all levels to enable teams to provide high quality care ‘in the light of’ our differences, rather than ‘in spite of them’. This may sometimes be easier said than done.

Taking action on diversity leadership and enabling others to do the same brings with it challenges arising from fear or tension about the consequences of highlighting issues. For example, healthcare practitioners may ask ‘How do I do this?’, social groups may ask ‘Why pick this group but not another?’, and society as a whole may ask ‘Should we do anything about this?’.

Action planning and service provision may be complicated further by historical, political and linguistic issues, particularly at times of economic difficulties when service provision is being reduced. As a consequence, there are times when managing diversity in health care appears too ‘difficult’, therefore taking action is avoided or ‘sanitised’ by focusing on compliance issues relating to policy and documentation.

Improving diversity in practice means moving from managing compliance with laws to promoting and valuing difference. This means recognising individual needs and ensuring those involved feel equally valued throughout their care experiences. Effective leadership includes recognising and reflecting diversity in the workforce and in the care provided in different environments to different service users.

Not attending to the differing needs of the workforce and service users can be a personal and professional issue. As a young, black nursing student in the early 1980s, I lived with the constant experience of what I call ‘insider out’. Diversity was not a core part of my training so, although I was part of the family of nursing, all the ‘essential’ information and guidance I received was ‘blind’ to my difference from my all-white peers and most of the patients I cared for.

One of the consequences for me was learning to accept that some patients did not want to be touched by ‘that black nurse’. It also meant dealing with my managers’ and placement supervisors’ response that I should simply ‘ignore it and go to another patient’ rather than challenge the patients about their views. This was not an issue only for me. I often wondered how my white peers learned to identify clinical signs in black skins when the only examples any of us were given to observe in our training had white skin. This omission from education could have had life-threatening consequences for me, my family or community.

Preparing for diversity

Transcultural issues in undergraduate training remain problematic. The ability of students to be fully prepared to care for the diversity of the population depends on individual tutor expertise and interest in the subject, rather than on a professional recognition that it is an essential part of clinical practice and standardised clinical competencies. I note with dismay that preparing students to care for a diverse population is a recommendation rather than a compulsory directive in the Nursing and Midwifery Council’s standards for clinical skills.

There is robust evidence that valuing diversity and challenging racism are crucial to ensure high quality services, yet these areas are insufficiently addressed by healthcare leaders. In his Snowy White Peaks report, for example, Kline (2014) demonstrates that attitudes about diversity among many in the senior echelons of the NHS are a mixture of indifference and denial.

Research also suggests that the experience of black and minority ethnic (BME) NHS staff is a good barometer of the climate of respect and care for all in the NHS. In essence, how staff at the highest levels acknowledge the value of a diverse workforce is a reflection of the healthcare system we have developed and the care we provide.

West et al (2012) state that, if BME staff are engaged, motivated and valued, and feel a sense of belonging, patients are more likely to be satisfied with the service they receive.

Kline (2014) did much to shine a light on the lack of diversity in NHS leadership. This issue concerns all leaders, not just those in the health service but all senior staff in health and social care economies.

From my experiences as a nursing student to the accounts of BME staff, the personal is almost always revealed as the political. An awareness of diversity is a starting point, but taking action is the main challenge for healthcare leaders.

In 2004, during my PhD studies, I developed a concept called ‘screaming silences’ to describe experiences that are historically or politically undervalued in, or absent from, policies and practice (Serrant-Green 2010). These screaming silences will remain until we address the personal and political consequences of diverse experiences and their impact on health, wellbeing and, ultimately, life chances.

We must acknowledge that how we learn, experience and respond to health issues personally and professionally shapes the workforce we produce and the communities in which we live. This is particularly pertinent to community practice, where we engage every day, every hour and every moment with the rich diversity that is 21st century society. Consequently, we must continue to find ways to negotiate difference and integrate competing cultural values and expectations into our clinical advice.

Community leadership, and practice leadership as a whole, must start shaping the diversity agenda at local, regional and national levels, rather than responding to social, political and strategic drivers in society. This means assessing the diversity of our own leadership. Does it truly reflect the communities of the UK? How do we ensure the professionals working in community settings feel as valued as those accessing services? How do we instil respect and professional accountability for diversity in our teams? Answering these questions will involve more than simply considering ‘colour’ or status when making clinical decisions or building teams.

Equality, valuing diversity and ensuring quality through leadership in health care are inextricably linked. Diversity and its consequences permeate all the contexts in which we live, personally and professionally. Active leadership focuses on safeguarding the diversity of our community workforce while recognising our responsibility to ourselves and each other. This requires action to safeguard our futures and the safety of our patients and communities.

Professions are constituted through their specific ways of engaging with knowledge, or how we know what we know and how we use our knowledge (Jensen et al 2012). We are fortunate to know the importance of valuing workforce diversity in ensuring high quality healthcare services, but a silence remains about how we use our knowledge to make a sustainable change.

In the drive to reduce unwarranted variations in experience in community practice, we have an opportunity to address the screaming silences. The nursing profession must decide to change, and work to realise the changes it makes. The power is with us to ensure that we:

  • Have diverse leaders who reflect our communities, and are confident and competent in their leadership approach to care and care delivery.
  • Contribute to creating and drawing on evidence that is sufficiently ‘diverse aware’ to inform practice in a diverse society.
  • Champion the art and science of care, and unite the personal, clinical and political, to ensure high quality care for all and equity of experiences.
  • Get diversity issues ‘right’ for our workforce as well as for service delivery.
  • Prepare community practitioners to celebrate difference in and outside our profession.

We know the issues. What happens next is down to us all. Leadership at personal and professional levels is needed to move from aspiration to action.


I conclude with a promise from the notebook of that young, black nursing student in 1982. I repeated these words like a mantra to get me through training, while my peers, leaders and what seemed occasionally to be the entire profession failed to support me in ‘managing my difference’: ‘It won’t be easy, few things worth pursuing are. But it will be worth it.’

About the author

Laura Serrant is professor of community and public health nursing at the University of Wolverhampton.


Jensen K, Lahn LC, Nerland M (Eds) (2012) Professional Learning in the Knowledge Society: Volume 6. Springer Science & Business Media, Berlin.

Kline R (2014) The Snowy White Peaks of the NHS: A Survey of Discrimination in Governance and Leadership and the Potential Impact on Patient Care in London and England. (Last accessed: March 17 2016.)

Serrant-Green L (2010) The sound of ‘silence’: a framework for researching sensitive issues or marginalised perspectives in health. Journal of Research in Nursing. (Last accessed: March 17 2016.)

West M, Dawson J, Admasachew L, Topakas A (2012) NHS Staff Management and Health Service Quality Results from the NHS Staff Survey and Related Data. (Last accessed: March 17 2016.)

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