Implementing Accountability for Equity and Ending Racial Backlash in Nursing: Accountability for...

Implementing Accountability for Equity and Ending

Racial Backlash in Nursing:

Accountability for Systemic Racism Must Be Guaranteed to Uphold Equal Rights in Society and Promote Equity in Health.

Submitted by

Centre for Equity in Health and Society

Rebecca Hagey, Ph.D., Merle Jacobs, Ph.D., Jane Turrittin, Ph.D., Monica Purdy, M.N., Ruth Lee, Ph.D., Angela Cooper Brathwaite, Ph.D., Marianne Chandler, C.H.R.P.

With Pilot Survey by

Tania Das Gupta Ph.D

Published by

Canadian Race Relations Foundation

April 2005

Implementing Accountability for Equity and Ending Racial Backlash in Nursing

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Library and Archives Canada Cataloguing in Publication Implementing accountability for equity and ending racial backlash in nursing : accountability for systematic racism must be guaranteed to uphold equal rights in society and promote equity in health / submitted by Centre for Equity in Health and Society, Rebecca Hagey ... [et al.] ; with pilot survey by Tania Das Gupta. Includes bibliographical references. ISBN 1-894982-04-5 (set) 1. Nursing--Social aspects--Canada. 2. Equity--Canada. I. Das Gupta, Tania, 1957- II. Hagey, Rebecca, 1943- III. Canadian Race Relations Foundation IV. Centre for Equity in Health and Society RT83.3.I46 2005 610.73'089'00971 C2005-905019-5


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Table of Contents


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Table of Contents

Table of Contents............................................................................................................. i Acknowledgments ..........................................................................................................vii In Memoriam ...................................................................................................................xi Dedication ......................................................................................................................xii Ontario Human Rights Code ......................................................................................... xiii The Centre for Equity in Health and Society .................................................................xiv

CEHS Vision............................................................................................................................. xv CEHS Mission .......................................................................................................................... xv CEHS Rationale ........................................................................................................................ xv Contact Information .................................................................................................................. xv Centre for Equity in Health and Society Membership Form ................................................... xvi

Executive Summary ......................................................................................................xix

Backlash for Addressing Systemic Racism in Nursing ........................................................... xix Research Purposes .................................................................................................................... xx Resistance to Accountability for Equity in the Health Care System ........................................ xx Evidence of the Need for Accountability to Dismantle Systemic Racism .............................. xxi Evidence of Nurses Experiencing Racial Profiling ................................................................ xxii Summary of Tania Das Gupta’s Survey Conducted with Nurses from November 2001 – May 2002........................................................................................................................................ xxiv Set-up as a Strategic Practice of Systemic Racism................................................................ xxvi The Problem of Backlash for Seeking Accountability in Race Relations ........................... xxviii Employment Context of Backlash .......................................................................................... xxx Health Effects of Backlash...................................................................................................... xxx Building a Coalition to Construct Accountability Policy and Procedure: The Centre for Equity in Health and Society ............................................................................................................ xxxii

Selected CEHS Objectives................................................................................................ xxxv Recommendations to Achieve Accountability for Systemic Racism: The Romanow Commission’s Health Council of Canada............................................................................. xxxv

Recommendations for the Health Council of Canada...................................................... xxxvi Recommendations from Partisan Sectors of the CEHS Network....................................... xxxvii

1. An investigation by the Ontario Human Rights Commission ................................ xxxvii 2. Leadership Training and Anti-racism Education.................................................... xxxvii 3. Ontario Legislation ................................................................................................ xxxviii 4. Ontario Policy ........................................................................................................ xxxviii 5. National Accreditation ............................................................................................. xxxix 6. Voluntary Policy in Key Organizations......................................................................... xl

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Chapter 1 – Toward Accountability among All Stakeholders: Introduction and Overview1 Questions, Objectives, and Accountability Discourse Strategies ............................................... 2 Who Are the New Stakeholders?................................................................................................ 5 How Can New Stakeholders Gain Full Inclusion into Society’s Institutions? ........................... 7 Literature Pertaining to Set-up and Backlash among Particular Stakeholders ........................... 8 Background on Getting the Stakeholders Together .................................................................. 15 Leadership from the Powerful Stakeholders in Nursing is Appreciated................................... 17 Who Were the Stakeholders Participating in the PAR?............................................................ 18

Aboriginal Nurses Association of Canada (ANAC)............................................................. 18 Association of Black Health Care Providers (ABHCP) ....................................................... 19 The Barbados Nurses Association of Canada (Toronto Chapter)......................................... 20 The Centre for Equity in Health and Society........................................................................ 21 Coalition of Black Trade Unionists (CBTU), Ontario Chapter ............................................ 24 Culture Care Nursing Interest Group (CCNIG).................................................................... 24 The Filipino Nurses Association, Toronto Branch ............................................................... 25 The Grenada Nurses Association.......................................................................................... 25 Health Canada, Office of Nursing Policy ............................................................................. 26 International Nurses Interest Group (INIG), Registered Nurses Association of Ontario (RNAO)................................................................................................................................. 26 Joint Provincial Nursing Committee (JPNC)........................................................................ 27 Korean Nurses Association of Ontario (KNAO) .................................................................. 28 Rainbow Health Network (RHN) ......................................................................................... 28 Registered Nurses Association of Ontario (RNAO)............................................................. 29 The South Asian Nurses' Association of Canada.................................................................. 30 University Hospital of the West Indies Graduate Nurses' Association (UHWIGNA) ......... 30 Urban Alliance on Race Relations (UARR) ......................................................................... 31

Stakeholder Interpretation and Debate...................................................................................... 32 Participatory Action Research Methodology: Toward Consensus Building among Stakeholders................................................................................................................................................... 33

Sampling ............................................................................................................................... 34 Demographics ....................................................................................................................... 35 Issues of Validity and Generalization ................................................................................... 35 Suggested Strategies for Stakeholders to Work Productively Together............................... 35

Evidence of Stakeholder Resistance to Accountability Moves ................................................ 37 Canadian Nurses Association (CNA) ................................................................................... 37 Canadian Institute for Health Information (CIHI) ................................................................ 38 The Joint Provincial Nursing Committee ............................................................................. 39

Changing Discourse to Achieve Stakeholder Accountability................................................... 39 Chapter 2 – Evidence of the Need for Accountability: Presentation of findings............. 45

Some Effects on Nurses of Race, Colour, or Ethnicity: Summary of Das Gupta’s Survey of Nurses, November 2001 – May 2002 ....................................................................................... 46

Demographic breakdown of the respondents........................................................................ 47 Set-up: Racially organizing advantages and disadvantages during downsizing....................... 48

What is a Racial Set-up? ....................................................................................................... 48 What Happens if Accountability is Introduced?................................................................... 52

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Examples of Set-up in Nursing in an Environment Where Racial Profiling Is Not Held Accountable .......................................................................................................................... 53

1) Targeting the Individual............................................................................................ 54 2) Top-down Setting up of Racialized Informal Policies and Practices ....................... 56 3) Recruiting Compliant Peers who Support Targeting and Scape-goating ................. 58 4) Documentation for Pre-emptive or Reactive Defence of Set-ups............................. 58

Cautionary Summary ............................................................................................................ 60 Case Study – The Story of Nurse “A”: The Grievance Process as a Set-up for Backlash ...... 61

Preface................................................................................................................................... 61 Case Study ............................................................................................................................ 61

Benchmark 1 – The need for answers: Why did white management and staff discriminate against Nurse A? ............................................................................................................... 70 "Tit for tat, infernal trap” .................................................................................................. 70 Benchmarks 2 and 3 – The need for recognition that they have been wronged and the need for safety................................................................................................................... 75 Benchmark 4 – Restitution through healing processes that balance relationships and prevent further harm ......................................................................................................... 78 CEHS Benchmark – Lack of Accountability for breaching the grievance process.......... 79 Benchmark 5 – Significance or meaning .......................................................................... 83 Discussion......................................................................................................................... 83 Chronology of Nurse A’s grievances against OPH1 ........................................................ 85

Shifting Context: The declared shortage of nurses and union innovations for retention.......... 86 Health Outcomes of the Complainant in a Racial Dispute ....................................................... 90

Traumas Experienced While Objecting to Racial Discrimination........................................ 91 1. Feelings of exclusion, loss of belonging...................................................................... 91 2. Feeling humiliated, contained...................................................................................... 91 3. Intimidation, paranoia, isolation .................................................................................. 92 4. Loss of confidence and grief........................................................................................ 92 5. Depression, loss of focus, and memory loss ................................................................ 92 6. Distressing physical symptoms.................................................................................... 92 7. Death images................................................................................................................ 93 8. Sensations challenging integrity and wholeness.......................................................... 93 9. Positive awareness ....................................................................................................... 93 10. Less than optimal health basis for professional work................................................ 93 11.Long-term effects......................................................................................................... 93

Summation of Evidence............................................................................................................ 94 Chapter 3 – Accountability Informed by Transformative Justice: Discussion and recommendations.......................................................................................................... 95

Review and Introduction........................................................................................................... 96 The Vision of Transformative Justice....................................................................................... 98 Defining Accountability in the Context of Equity: What is institutionalized racism? Systemic racism? A racial encounter?...................................................................................................... 99

Race..................................................................................................................................... 101 Racialized People................................................................................................................ 101 Racialized Encounter .......................................................................................................... 101

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Race Consciousness ............................................................................................................ 102 Equity.................................................................................................................................. 102 Institutional Racism ............................................................................................................ 102 Systemic Racism................................................................................................................. 102 Discourse............................................................................................................................. 103 Discourses of Racism.......................................................................................................... 103 Anti-racist Discourse .......................................................................................................... 103

Is Accountability for Racism a Menace to Some People?...................................................... 104 Policy’s Role in Implementing Relationships of Accountability ........................................... 105 Conflicting Perspectives on Accountability for Systemic Racism ......................................... 106

Theoretical Perspectives on the Sanctity of Accountability Breaches................................ 108 Experience of Relational Elements Where Racial Profiling Is Unaccounted for and Unchecked................................................................................................................................................. 110 What Relationship Issues Arise with Particular Accountability Strategies? .......................... 113 How Do I Evaluate Alternative Discourse Strategies? ........................................................... 115 Anti-racism Grounded in Transformative Justice and Freedom Ideology.............................. 118 The State’s Weakened Role in Accountability for Systemic Racism: Policy and legislation are required to implement and integrate voluntary accountability ............................................... 119 Recommendations to Achieve Accountability for Systemic Racism: The Romanow Commission’s Health Council of Canada............................................................................... 121

Recommendations to the Health Council of Canada .......................................................... 122 Recommendations from Partisan Sectors of the CEHS Network....................................... 122

1. An investigation by the Ontario Human Rights Commission ................................ 123 2. Leadership Training and Anti-racism Education.................................................... 123 3. Ontario Legislation ................................................................................................. 124 4. Ontario Policy ......................................................................................................... 124 5. National Accreditation ............................................................................................ 125 6. Voluntary Policy in Key Organizations.................................................................. 125

Chapter 4 – Undoing the Catch-22 of Racism: Overview of Study Findings Intent on Integrating Accountability for Systemic Racism........................................................... 127

How Integrative Processes could be Used to Implement Accountability for Equity in Nursing and Health care ....................................................................................................................... 128 Toward an Accountability Discourse Model that can Deal with Racial Discrimination in Nursing.................................................................................................................................... 130 Initiating Accountability Policy that can Regulate Programs, Practices, and Procedures at Local, Provincial, and National Levels in Nursing................................................................. 134

Chapter 5 – Summary and Future Research............................................................... 137 Reference List ............................................................................................................. 141 Definitions ................................................................................................................... 153 Appendix A.................................................................................................................. 157

Table 1 - 1990s Immigrants by Source Country and Proportion Speaking a Non-Official Language................................................................................................................................. 157

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Table 2 – Proportion of Visible Minorities, Canada, Provinces and Territories, 1991, 1996, and 2001......................................................................................................................................... 157

Appendix B – Resolutions For Presentation To The CNA Annual Meeting ................. 159 Appendix C – Resolutions To The Registered Nurses Association Of Ontario (RNAO).................................................................................................................................... 162 Appendix D – Letter From Anne McLellan................................................................... 165 Appendix E – Letter to the Representatives of the Joint Provincial Nursing Committee (JPNC) and the Nursing Secretariat ............................................................................ 169 Appendix F – A Time For Change: Recommendations .............................................. 171 Appendix G – Role Playing Exercise and Case Studies to Learn about Backlash and Set-up Experientially ................................................................................................... 177

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Acknowledgments


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Acknowledgments

Of the numerous individuals who contributed to this participatory action research project, our

thanks go first of all to Rani Srivastava for introducing the concept of equity assurance programs

to nursing. We thank Professor Enid Collins at Ryerson University, Professor Ushi Choudhry at

Windsor University, Sepali Guruge, doctoral candidate at the University of Toronto, Celeste

Leano, and all the members of the Culture Care Nursing Interest Group who sustained the

Culture Care Nursing Research Council when it secured funds for this project to explore “how

to” gain accountability for equity in nursing. Thank you to Anna Mathai, President of the South

Asian Nurses’ Association, for supporting our proposal. We thank Agnes Calliste and Evelyn

Brody for giving momentum to research on the problems of backlash and set-up as mechanisms

in systemic racism. We dedicate the report to Claudine Charley whose victory in her grievance

against the Toronto Hospital marked the first public exposure of a racial set-up in nursing. We

honour Professor May Yoshida who advocated anti-racism curriculum for nursing nationally in

1994. Sadly, her work has gone unheeded to date.

The challenging process of building a coalition to promote accountability for anti-racism,

anti-discrimination, anti-harassment, employment equity, and ethnoracial competencies in

nursing through participatory action research has put us in contact with an ever-widening

network of dynamic nurse activists – leaders in their communities and/or nursing associations –

and members of the public. We thank you for coming forward and for your contributions,

including painful stories of discrimination and strategies for solutions. We thank Nurse A for her

willingness to share her experience publicly, for her patience in documenting it, and most

importantly, for her persistent quest to make employers and colleagues accountable for

Acknowledgments


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condoning systemic racism. We thank the members of the nursing associations (listed in section

on stakeholders) for their interest and support. We thank Dr. Tania Das Gupta for her

collaboration, including making it possible for think tank participants to join in her survey of

racism in nursing. Our thanks also to the individuals who worked on drafts of letters to the Joint

Provincial Nursing Committee, and on draft resolutions to the Canadian Nurses Association and

the Registered Nurses Association of Ontario (RNAO).

We acknowledge the chapters submitted for this report by Dr. Angela Chan, entitled

Longing for my Jade Bangle and by Sarah Egginton, entitled Coming to understand racism: one

nursing student’s journey and we are sorry these were not included for lack of space. They will,

however, be posted on our website, www.BeforeQuality.com.

We are grateful that Pam Chou, Ajamu Clarke, Gerald and Natashia Deer, and Prodip

Saha contributed their expertise and time to the development of our website, also noted as

www.BeForEquality.com.

Thanks to Rob Higgins for depicting Tania Das Gupta's findings. Leonardo Alfaro,

Gemma Baik, Agnes Card, Max and Marianne Chandler, Ruth Ann Cyr, Lorna Edwards, Valerie

Glascow, Carmen James Henry, Jackee Higgins, Bhandat Lurkhur, Monica Mitchell, Pauline

Palmer, Jean Pierre, Cynthia Reyes, Petal Samuels and Gloria Taylor-Boyce are especially

thanked for the time and effort they put into conceptualizing participatory events and sharing

critical analyses and ideas. We thank these and other courageous nurse activists, including

Dyanne Affonso, formerly dean at the Faculty of Nursing, University of Toronto, Joan Lesmond,

Doris Grinspun, Irmajean Banjok, and Mary Ferguson Pare who support CEHS's research and

consensus building in the nursing profession. Thanks also to Steve Bosanac and Trevor Smith

Acknowledgments


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for editorial suggestions and Yvonne Bobb-Smith and George Dei for support and

encouragement.

For providing space and/or hosting the think tanks, we thank Winston Clarke and the

Marcus Garvey Centre for Leadership and Enterprise, Toronto Public Health (Scarborough

Office), the Canadian Black Nurses' Association, the University of Toronto, RNAO, and York

University, Atkinson College. We thank the University Hospital Network for making it possible

for us to hold team meetings at Toronto Western Hospital. We thank the think tank speakers,

including Josephine Wong of Toronto Public Health, Nuzhat Jafri of the Bank of Montreal, Dr.

Lillian McGregor, Dr Souraya Sidani, and those who do not wish to be named, for voluntarily

sharing their expertise and experience with us. We thank the many individuals responsible for

various activities at each think tank, including giving the opening prayer, acting as moderator,

facilitating discussions and report back, and participating in the awards ceremony.

Additional thanks go to the following individuals who contributed their expertise to the

development of research proposals that focus on equity in nursing: Doctors Rose Baaba Folson,

Any Marie Gerard François, Diana Gustafson, and Lillie Lum, and to Kwasi Kafele, Marylin

Kanee, Anthony Mohamed, and Rhonda Williams for "Strategies and Models for Negotiating

Diversity: Anti-Discrimination Advocacy and Appreciative Inquiry in Selected GTA Hospitals."

Also, Kevin Armstrong, Bernice Downey, Margaret Horn, Peter Menzies, and Cynthia Wesley-

Esquimaux, as well as Dr’s. Diane Doran, Hyun Sil Kim, Deb McGregor, and Kris Sieciehowitz,

are thanked for "Guidelines for Nurses Working in Aboriginal Communities with Attention to

Traditional Knowledge." Further, we thank Angela Cooper Brathwaite, Madge Ellis, Doris

Grinspun, and Dr. Sheryl Nestel, for the RNAO questionnaires examining the curriculum content

in Ontario nursing schools. We regret that so few of the schools cooperated with your study.

Acknowledgments


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We thank Dr. Anne Moorehouse who, as chair of the curriculum committee, supported an

initiative on anti-racism and found it to be a career-limiting move.

The Centre for Equity in Health and Society (CEHS) and its companion website

www.BeForEquality.com are the fruits of our coalition building. We thank students Bridget

Liriano and Pam Sun for their commitment to the vision of the CEHS and to board member

Ishwar Persad for assistance with definitions. We regret that we cannot name numerous

individuals publicly in these acknowledgements because the fear of backlash continues. We

thank each of you for your contributions, energies, and clarity of vision. We are particularly

indebted to Sandra Carnegie-Douglas, Patrick Hunter, Anne Marrian, and Karen Mock at the

Canadian Race Relations Foundation for critical feedback and astute support of this endeavour.

In Memoriam


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In Memoriam

To the memory of Professor May Yoshida, who taught for many years at the Faculty of Nursing,

University of Toronto, for her tireless efforts to bring ethnoracial competencies to the forefront

of nursing practice by envisioning anti-racism content in nursing curricula and research across

Canada.

Dedication


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Dedication

To Evelyn Brody, and to the memory of Claudine Charley, who fought discrimination so that

every person in the nursing profession will be accountable for equity and every organization will

refuse to condone racial set-up and backlash.

Ontario Human Rights Code


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Ontario Human Rights Code

According to the Ontario Human Rights Code, you cannot be discriminated against because of

your: race, ancestry, place of origin, colour, ethnic origin, citizenship, creed, sex, sexual

orientation, disability, age, marital status, family status, same sex partnership status, record of

offences (in employment only), and receipt of public assistance (in housing only) (Author, 2003).

The Centre for Equity in Health and Society


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The Centre for Equity in Health and Society (CEHS) is a virtual centre that coordinates a

research network of interdisciplinary researchers and advocates for equal access and

participation in organizations responsible for health. We recognize that membership in a

marginalized group or category poses an additional risk for persons with respect to social

and healthy outcomes. Additionally, research suggests that risks increase for persons

with compounded risk factors such as race and gender, poverty and disability. We

recognize as well that the broad determinants of health (e.g., housing, employment, good

access to health services) have a significant impact on members of marginalized groups

or individuals of difference. Equity is a determinant of health. Moreover, the nature of

marginalization is that barriers exist so that voice, participation, and choice are restricted,

which impedes efforts to correct the effects of marginalization and the trauma it

produces. CEHS acknowledges the experience of reprisal for trying to counteract

marginalization. In collaboration with researchers at George Brown College, Ryerson

University, the University of Toronto, and York University, the CEHS research focus is

on transformative justice practices, ethnoracial competencies and critical structural

analysis for organizational change, and inter-sectoral collaboration. CEHS annually

awards leaders who have facilitated accountability for equal access and participation in

nursing. The Centre for Equity in Health and Society is an affiliate of the Urban Alliance

on Race Relations and consults with health services students, professionals and unions on

education, and career development.



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CEHS Vision Accountability for equal access and participation in organizations responsible for health.

CEHS Mission To promote policies and programs for accountability towards equal access and participation in

organizations responsible for health through research, advocacy, recognition, and leadership

development.

CEHS Rationale Research suggests that lack of accountability for racial discrimination results in health and

economic disparities among racialized people.

Contact Information [email protected]

www.BeforeQuality.com



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Centre for Equity in Health and Society Membership Form

178 Jarvis St., Suite 907, Toronto, ON, M5B 2K7.

Email: [email protected]

www.BeforeQuality.com

Name:

Address:

Permanent address if different from above:

Contact me by: Email:

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Current place(s) of employment/volunteering:

Areas of interest:

___ Research/writing (state area)

___ Political action on accountability for equal access and participation

___ Promoting CEHS membership/contacting members for events

___ Policy/legislation development

___ Internet and website

___ Mentoring/career mobility counseling



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___ Nursing education/curriculum

___ Advisor/negotiator for nurses experiencing work-related issues

___ Speaker/resource for anti-racism

Describe special interests:

Please state languages in which you are fluent:

Ethnoracial identification:

Gender:

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Age:

Union membership:

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$ 40 for Joint Membership with CEHS and the Urban Alliance on Race Relation

___checks ___cash

Thank you!


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Executive Summary


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Executive Summary

Rebecca Hagey

“Nursing, like a cappuccino – white on top, brown on the bottom –

requires stirring up.”

Excellence in race relations requires holding ourselves accountable for racial discrimination

and its effects. Backlash and resistance to accountability must end and new accountability

practices must be required throughout the health care system.

Backlash for Addressing Systemic Racism in Nursing

"Implementing Accountability for Equity and Ending Racial Backlash in Nursing" offers

evidence of the need for accountability to deter systemic racism and outlines initiatives study

participants have taken to advocate for accountability measures. The study uncovered a

generalized fear of backlash for raising issues concerning systemic racism.

The report documents how nurse and research activists used participatory action research

(PAR) to build a movement toward accountability for equal access and participation in health

care and toward freedom from racial harassment in nursing. It is intended as a resource for

advocates of equity and procedural justice in nursing who are interested in accountability,

transparency, and direct negotiation strategies to remove barriers and heal relationships.

Backlash for addressing systemic racism is predicted to diminish in everyday work life if

Executive Summary


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accountability is considered a privilege and a responsibility in all relationships – personal,

organizational, and public.

Research Purposes

1) To use PAR to investigate how integrative processes can be used to implement

accountability for equity in nursing and health care;

2) To develop an accountability discourse model that can deal with racial discrimination

in nursing, beginning with set-up and backlash against racialized nurses who presume

equality or exert expectations for equity; and

3) To initiate strategies toward developing accountability policy that would regulate

programs, practices, and procedures at local, provincial, and national levels in nursing

(for example in regulatory and professional bodies).

Resistance to Accountability for Equity in the Health Care System In the context of global migration, the ethnoracial diversity of the nursing profession in Canada

is greater today than ever before. The profession's resistance to ensuring equal access and

participation for all nurses has been compounded by sporadic under-funding of nursing care. An

emerging body of research shows that systemic racism is a serious problem in health care

delivery organizations. An anti-racism policy issued by the Joint Provincial Planning Committee

of the Ontario Hospital Association and the Ministry of Health (1996) was shelved following the

defeat of the New Democratic Party government in Ontario and the rescinding of the

Employment Equity Act by the Conservatives. A curriculum plan that Yoshida introduced in

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1994 at a prestigious nursing school to include anti-racism content in Canadian nursing

education has been steadfastly resisted (Hagey and MacKay, 2000).

We present evidence in this report that when accountability is demanded by nurses

experiencing systemic racism, the issue of racism is resisted systematically. This participatory

action research documents witnesses' accounts of resistance by decision-makers in privileged

positions within the health care system. For example, minutes show that in the Northwestern

General Hospital case, white nurses were asked what specialty they preferred when they applied,

whereas nurses of colour were told there were openings only in long-term care. The result of this

unwritten systemic racism policy was racial segregation. Most specialties were staffed by non-

racialized nurses, whereas long-term care was almost completely staffed by racialized nurses

(Calliste, 1996, 2000b; Ontario Human Rights Commission [OHRC], 1994).

Months after the OHRC awarded $320,000 to the complainants of harassment in this

case, some executives of that hospital were reported as excusing the events as a problem of

"reverse discrimination" instigated by the complainants themselves. This denial of the systemic

racism that was publicly exposed reveals persistent resistance to equal access and participation

and resistance to the accountability measures that the commission administered.

Evidence of the Need for Accountability to Dismantle Systemic Racism The accounts reported in our participatory action research are voluminous and continuing. Even

if space permitted exhaustive testimony, we would be bound by concerns for confidentiality and

the very real threat of backlash for accountability efforts. Our presentation of evidence is limited

to four pieces where we have been able to respect confidentiality and provide some detailed

Executive Summary


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perspectives for readers to understand that systemic racism persists because accountability for it

is systematically thwarted.

Acknowledging that accountability can occur at individual and organizational levels and

be public or private (Henry, Tator, Mattis, and Rees, 1995), we conceptualize accountability as

both a privilege and a responsibility that is fundamental in relationships at all levels. We

understand systemic racism as the privileges associated with not having to be accountable for

racial dominance. That is, racial oppression activates privileges. Through commission and

omission in race relations, privileges accrue to members of the dominant groups, and immunity

from accountability is upheld by group power. Instances of systemic racism in organizations can

be identified and rectified by self-monitoring, peer monitoring, stakeholder monitoring,

executive monitoring, and editorial monitoring.

Evidence of Nurses Experiencing Racial Profiling Evidence suggests that some nurses experience racial oppression. In other words, race, ethnicity,

and colour are felt to have an effect on relations in the workplace. We present previously

unpublished findings from a pilot survey that Tania Das Gupta conducted among some

participants in our larger study. Of the sixty-two persons who completed the questionnaire,

thirty-eight were Black/African Canadian, thirteen identified as Asian or South Asian Canadian,

five as White/European Canadian, four as Other, one as Central/South American Canadian and

one no response. There were fifty-seven females in the convenience sample, three males, and

two who did not specify gender.

Participants felt that race, ethnicity, and colour had an effect on relations with patients

(39/62); on the hiring of nurses (39/62); on relations with colleagues (38/62); on relations with

Executive Summary


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managers (37/62); on where they were assigned to work (33/62); on access to training (30/62);

on performance reviews (21/62); on the experience of being disciplined (15/62); on sick leaves

(12/62); and on access to accommodation for disability (3/62). Of the sixty-two nurses who

participated, fifty-six said they had been put down, insulted, or degraded as a nurse because of

their race, colour, or ethnicity. Of these, thirty-eight said that a patient put them down, thirty-

two said that another nurse had put them down, twenty-four said that a manager had put them

down, and nineteen said that a doctor had put them down. Some respondents mentioned more

than one offender.

Of the fifty-six who had been harassed, forty-seven said they were affected emotionally,

twenty-eight mentally, and eighteen physically. Several nurses noted more than one effect. Of

those who had been harassed, thirty-three said that they took some action. Of the thirty-three

who took action, sixteen had no results or negative results and thirteen had positive results,

whereas four had ongoing proceedings.

Although these findings were preliminary and their purpose was to assist Dr. Das Gupta

in developing her questionnaire for a larger study, we believe they provide evidence that nurses

are experiencing racial profiling that calls for accountability. We refer readers to the larger study

commissioned by the Ontario Nurses Association (Das Gupta, 2002) that shows that white nurses

of European ancestry experience far fewer negative effects of race, colour, or ethnicity than

nurses from groups subject to racial profiling.

Marshall's (1996) analysis of the 1991 Census data for the health care professions showed

that blacks are underrepresented in management positions. Nestel (2000) reported that the 1991

Census indicated that visible minority nurses in Ontario have half the chance of their white

counterparts to move into the managerial level. Hagey and MacKay (2000), who studied

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racialist discourse in a nursing school, found that students were fearful of discussing racism. For

example, one student said, "that person may perceive this as a threat and it will come back on

you in different ways…" (p. 53).

Summary of Tania Das Gupta’s Survey Conducted with Nurses from November 2001 – May 2002 Table 1: Demographic Overview of Survey Respondents (n = 62)

Ethnoracial Identity Number

Black/African Canadian 38

Asian or South Asian Canadian 13

Central/South American 1

White/European 5

Other 4

No response 1

Gender Identity Number

Female 57

Male 3

No response 2

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Table 2: Impact of Race, Colour, or Ethnicity in Employment (Reported by Nurses)

Type of Impact of Racial Domination in Employment Reported Number

Made to feel uncomfortable as a nurse because of race, colour, or ethnicity

54

Felt put-down, insulted, or degraded because of race, colour, or ethnicity 56

Area of Employment

Effect No Effect Don’t Know No Response

Hiring 30 25 2 5

Promotion 39 18 1 4

Relations with colleagues 38 17 0 7

Relations with management 37 17 1 7

Relations with patients 39 18 0 5

Assigned work location 33 14 0 15

Access to training 30 13 1 18

Response to disability 3 36 0 23*

Sick leave 12 40 0 10

Performance review 21 18 0 23*

Disciplinary review 15 34 0 13*

* Includes not applicable * Non-inclusive categories

By a doctor 19 By a patient 38

By manager 24 By another nurse 32

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Table 3: Nurses' Responses to Racial Discrimination in Employment Type of response reported (Non-exclusive categories)

Number

Emotionally affected 47 Physically affected 18 Mentally affected 28 Took some action: 13 had positive results 16 had no results or negative result 4 ongoing

33

Did not take action 22 No response 7

Set-up as a Strategic Practice of Systemic Racism Based on observations of problematic race relations reported by several nurses in this PAR, our

second piece of evidence concerns set-up as an aberration in accountability that privileges non-

racialized nurses at the expense of racialized nurses. Four types of set-up were reported:

• Targeting individuals;

• Top-down orchestration;

• Recruiting peers; and

• Pre-emptive or reactive documentation.

We also identify four respective counter-strategies that can be studied in future research

for their effectiveness in addressing each type of set-up:

• Identifying supporters;

• Gaining influence;

• Recruiting powerful allies; and

• Strategically using documents.

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The targeted nurses of colour are set up in such a way that focus is shifted from a clinical

or administrative problem onto the racialized nurse, who then becomes the problem. As Essed

(1991) defined it, racism has the effect of problematization. The rules of the set-up strategy

make the nurse who complains about this state of affairs a target so that accountability and

transparency are impeded. Benefits accrue to the nurses and administrators who collaborate in

the set-up. Racialized nurses are drawn into set-up activities with the effect of deflecting

attention from the racially-based strategy. This process makes accountability for set-up practices

highly improbable, especially in light of the potential for being targeted for complaining about

the problem in this strategic system.

The other accounts included in our report use conventional interpretive methods for

qualitative description to outline how set-up works as a main mechanism in the practices

associated with taking advantage on the basis of race during underfunding of nursing. Although

there is a scarcity of full-time jobs, currently there remains a shortage of nurses. Unions have

informed us that the number of complaints about such set-up practices has dropped due to a

feeling of security in the nursing shortage. We are concerned that set-up will be used again now

that nurses’ jobs are being eliminated under collaborative hospital and government policy that

attack nursing budgets. Systemic racism offers convenient advantages for members of the in-

group – including politicians – at the expense of selected racialized nurses, many of whom have

immigrated to Canada to practice nursing here. Calliste (2000a) argues that Canada has a racist

surplus labour strategy that exploits racialized nurses to stabilize the job market for non-

racialized nurses.

There remains the spectre that when jobs are cut, racialized nurses, en masse, will be set

up for job transfer and job loss during so-called restructuring that appears to be rationally

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managed according to criteria. Those who blow the whistle, resist, or protest will fall into the

category of the "problem nurse." Their assertive behaviours will be declared inappropriate and

provide justification for the racialization practices. As Head reported (1985), equity will no

longer be a relevant topic as it disappears from agendas during job scarcity.

Accountability and transparency are elements of procedural justice that can be introduced

to bring ethical standards to the workplace. They require compassionate exchanges, intentional

relationship building, forgiveness, and restitution. With peer pressure that is backed up by

human rights legislation to normalize accountability, unfair systems that result in racial

dominance can be transformed in personal, organizational, and public arenas. As Mandela

realized when setting up the Truth and Reconciliation Commission in South Africa, offending

strategic behaviours such as those we are describing as set-up and backlash can be based on

assumed privileges rather than incurable maliciousness (Hagey, 1999; Hagey et al., 2001c;

Llewellyn and Howse, 1999). However, maliciousness is evident against racialized nurses. The

diversity office in one large metropolitan hospital where racial complaints are filed reported

receiving threatening phone calls. An effigy doll with a noose around its neck was hung on the

office door conjuring the hateful racist lynching of people of colour. Hate messages are a

common reality for racialized nurses in Canada who are coming to question whether hate can be

cured.

The Problem of Backlash for Seeking Accountability in Race Relations Our third piece of evidence is a case overview of Nurse A's efforts to assert her right to call for

accountability for the systemic racism she experienced in the places where she worked. The

covert rule of not having to be accountable to a racialized nurse is played out in a total of twenty-

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three grievances in her twenty-one year career as a nurse in Toronto. Nurse A's experience with

retaliation and escalation in the dispute process is evaluated from the perspective of a model of

transformative justice developed by Ruth Morris (2000). Transformative justice calls for a

healing approach to racial offenders that assumes that shared strategies, not only participating

individuals, must be held accountable, and that the whole community must take responsibility for

the group-based privileges and advantages that result from discriminated activities.

Canadian human rights legislation does not stipulate that intent must be proven, allowing

that racial discrimination can occur without intent. Perhaps unintentional, backlash appears to be

built into the process of formal complaints and grievances. The effects of backlash include

marginalization, problematization, and containment, which Essed (1991) established to be the

effects of racism. We provide ample documentation that proceedings activated when filing a

union grievance or making a complaint to the OHRC contributed to Nurse A's being

marginalized, treated as the problem, and contained. Insufficient accountability within such

legal proceedings results in irregularities that cause damage to the racialized employee. One

systemic response to Nurse A’s accountability efforts was that potential employers were

evidently told that Nurse A was trouble. She can no longer find employment within the

profession. We were informed by union personnel that this type of treatment did not occur for

the white nurse who put Claudine Charley’s patient at risk in a plot to keep her job.

A recent report issued by the Canadian Nurses Association to the Canadian Council on

Health Services Accreditation listed unresolved grievances as one of eight key indicators that

impact on the quality of work-life and the future of nursing services in Canada (Lowe, 2002).

Yet the report does not mention the nature of the grievances or the prevalence of cases where

racial discrimination and harassment are issues. Nor does it mention the glass ceiling that exists

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for racialized nurses in all sectors of nursing. It fails to acknowledge the lack of accountability

for equity, one of nursing’s most fundamental problems. It also does not mention the impact that

unresolved grievances have on nurses' health, on absenteeism, on patient morbidity, or mortality

in workplaces poisoned by racist set-ups and backlash.

Employment Context of Backlash Employee surveys and exit interviews conducted by one of our participants, who is a semi-

retired human resource manager, indicated the following concerns of racialized nurses. Speaking

out in support of a colleague who had experienced unfair treatment because of race proves to be

a "career limiting move or CLM" (backlash). Moreover, racialized nurses reported differential

treatment and being "ear-marked" for more severe and unfair levels of work assignments and

discipline than were non-racialized nurses. Also, issues of racism directed by patients towards

nurses were considered to be "trivial" in nature and "par for the course." These root causes of

sickness and absenteeism were not identified or dealt with.

Health Effects of Backlash Social psychologists Dion and colleagues (1975, 1978, 1996) provide evidence that anxiety in

varying degrees is linked to the perception of discrimination. In a culture that invalidates the

appropriateness of accountability for discriminatory practices, one would predict anxiety to be

exacerbated when the social means for eliminating the source of the anxiety is blocked.

Restoration to a non-anxious state would be impeded. Backlash being unrestrained would

escalate and prolong anxiety and produce health effects over time.

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Health effects from backlash were reported by nurses who attempted to introduce

accountability for systemic racism by filing complaints or grievances that named racism as the

issue. Our evidence is drawn from earlier research funded by the Centre for Excellence in

Research on Immigration and Settlement (Collins, Calliste, Choudhry, Fudge, Hagey, Lee,

Turrittin, and Guruge, 1998). In this qualitative study of nine nurses who had formally charged

their employer with racism, all experienced retaliation for naming racism as the issue, even

though the Ontario Human Rights Code forbids backlash or reprisals for complaining of racism.

This aspect of the code was not effectively enforced for the nurses contributing to this study (See

recommendations for provincial legislation).

The health effects the nurses described included feelings of loss, humiliation,

intimidation, paranoia, and isolation. Some experienced depression, grief, loss of confidence,

loss of focus, and memory loss. Distressing physical symptoms, death images, and

overwhelming sensations, such as being invaded or torn apart, were reported as stress effects.

Although many of the nurses were able to focus on the positive in what they were doing for their

community, most confided that the negativity of the backlash had an impact on their families and

is with them long-term. In this light, the right to racial equality is a prescription for adverse

health effects when the accountability for systemic racism – set-up and backlash – is not a

guaranteed right.

While implementing accountability for racism we must also implement accountability for

backlash, which is an integral part of the system. The future of nursing requires a milieu of

openness and acceptance so that the character of systemic of racism can be discussed. The

problems racism engenders will need to be addressed locally, nationally, and internationally

since Canada competes locally and globally for an adequate supply of nurses.

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Building a Coalition to Construct Accountability Policy and Procedure: The Centre for Equity in Health and Society Diverse associations of nurses were unofficially associated with this participatory action research

that convened gatherings of local chapter members across the Greater Toronto Area (GTA). The

gatherings included members of the Aboriginal Nurses Association of Canada, nurses from

several African countries, various Caribbean associations including The Barbadian Nurses, The

Grenadian Nurses, The Trinidadian Nurses, the University Hospitals of the West Indies Graduate

Nurses and Associates (Kingston, Jamaica), the Chinese Canadian Nurses Association, the

Filipino Nurses Association, Hispanic nurses, Jewish nurses, the Korean Nurses Association of

Ontario, Muslim nurses, Persian nurses, the South Asian Nurses Association, the Culture Care

Nurses Interest Group, the International Nurses Interest Group, and additional nurses,

community activists, union leaders, and consumers who identified themselves as supporters.

Some interest came from various francophone nurses, including, for example, those tracing their

heritage to various African countries, or to Haiti, Lebanon, or Vietnam. Interest and support also

came from the Rainbow Nurses Coalition that champions issues and health concerns of gay,

lesbian, bi-sexual, and transsexual people. We consulted with individuals from the Ontario

Association of Black Trade Unionists, the Urban Alliance on Race Relations, the Registered

Nurses Association of Ontario, the National Office of Nursing Policy at Health Canada, and the

Joint Provincial Nursing Advisory Committee.

Given the fear of backlash for broaching the issue of racism, we found that not all group

members subject to racial profiling are in agreement about how to embrace an anti-racism

strategy that promotes accountability for systemic racism. We found much disagreement about

how accountability should be introduced. There appeared to be consensus that healing is

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required to build relationships of trust and that organized dialogue is necessary to develop

ground rules within the profession and beyond. The problem we encountered in this research

was that dialogue was not possible because few of the top decision-makers in the profession that

we invited actually attended our PAR think tanks, even though many verbalized the importance

of equity, diversity, and human rights issues. The nursing leadership in every sector across

Canada is perceived as predominantly white and silent about accountability for system racism.

Henry et al. (1995) outlined the phenomenon of democratic racism, in which values of

social justice and equity are verbalized but implementing anti-racism policy is resisted. Thus,

the practices of discrimination that create racial disparities and condone racial harassment are

sustained. One way to change this approach to the racial inequalities in our midst is to change

the cultural rule. This report calls for developing a ground-rule of accountability for equity. We

are appealing to all Canadians to be continuously committed to anti-racism, which means to

speak out against privileges owing to racial dominance and disadvantages owing to racial

oppression and systemic racism. On March 19, 2002, at the think tank held at the Registered

Nurses Association of Ontario (RNAO), it was declared that anti-racism is on the agenda in

nursing to benefit all nurses and the Canadian public.

The PAR think tanks culminated in an awards ceremony held on the opening day of the

Biennial Conference of the Canadian Nurses Association. The ceremony acknowledged the

efforts of many nurse leaders who, far from being recognized, were harassed for their work to

make reforms in nursing. A healing prayer was offered by Dr. Lillian McGregor, elder and nurse

at First Nations House, University of Toronto. The occasion of the ceremony was the

inauguration of the virtual centre linking the nurse researchers and advocates – The Centre for

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Equity in Health and Society (CEHS), which has since incorporated as a non-profit organization

in Ontario.

Following this ceremony, resolutions to the Canadian Nurses Association (CNA) were

drafted, which were formally submitted in November, 2002, on behalf of CEHS. Some of these

are still being negotiated, whereas others were passed at the Annual General Meeting of the

RNAO. Also in November 2002, the CEHS made a presentation in a session at a joint

conference of the RNAO and the Registered Practical Nurses Association of Ontario (RPNAO).

This was the first public forum in the history of Ontario nursing where the issue of racism

appeared in print on the program.

The coalition continues to learn how systemic discrimination is organized in nursing and

what strategies can establish equity assurance in nursing. The concept of equity assurance was

introduced into nursing in 1997 by Rani Srivastava, who is also the author of the RNAO's anti-

racism policy, issued in September, 2002. The network of study participants did not resolve

certain dilemmas, including whether to build associations internally, to work on coalition

building, or to join RNAO as individuals who could enhance their group’s engagement in

professional developments. Participants did, however, support staying in touch by telephone and

email to promote research and profession-wide policy dialogues on barriers and strategies.

CEHS is calling for dialogues on anti-racism throughout the Canadian nursing profession

to create effective accountability policies that will ensure that the work environment for nurses,

and, therefore, for patients, is caring rather than poisoned. Such policies, as they pertain to

systemic racism in nursing, would govern local, provincial, and national programs and practices.

They would ensure safety for racialized nurses, especially during periods of underfunding for

nursing that involve restructuring and downsizing.

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Selected CEHS Objectives

• Advocate for equal access and participation for nurses in the profession and for reducing

racial disparities in health and safety (Jacobs, 2002);

• Advocate for accountability to end racial domination and harassment in personal,

organizational, and public arenas of the health care system;

• Ensure representation of diverse cultural and language groups, including Aboriginal

people, in the education, practice, research, and governance of the health professions;

• Promote reform of health care curricula to include diversity content about anti-racism,

anti-discrimination, anti-harassment, employment equity, ethnoracial competencies,

negotiation, and consensus building; and

• Since one in every sixty-seven Canadian voters is a nurse, CEHS wants to convert nurses

to anti-racism theory and evidence-based practice to create a critical mass of advocates

for equity in health and society.

Recommendations to Achieve Accountability for Systemic Racism: The Romanow Commission’s Health Council of Canada We envisioned that, in addition to resolutions, recommendations, objective-setting, and

guidelines set forth by CEHS, the newly emerging Health Council of Canada (HCC) could play a

role in promoting accountability. The HCC could decrease the costs pertaining to systemic

racism in health care, such as the legal, insurance, and other costs including potential morbidity

and mortality for patient and the erosion of the supply for nurses.

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The Romanow Report did not address racial discrimination directly but denounced the

“big disconnect," by referring to health care for Aboriginal people and targeting the reduction of

morbidity and mortality due to barriers in access, primary prevention, and treatment. Lack of

accountability for racism, colonization, and poverty was not specifically targeted. Nor were

jurisdictional issues and actual funding commitments laid out (Koebel, 2003). Some Native

leaders are calling for a national Aboriginal Health Act to correct the racial disparities created by

The Indian Act.

The HCC could introduce accountability mechanisms to monitor the costs associated

with systemic racial disparities in health and health care and set guidelines for equity practices.

The Romanow Report’s Recommendation 3.2 states that “On an initial basis, the Health Council

of Canada should establish benchmarks, collect information and report publicly on efforts to

improve quality, access and outcomes in the health care system” (Romanow, 2002, p. 248).

Recommendations for the Health Council of Canada

• Monitor the racial disparities in health and health care and require interventions to correct

them;

• Require process and outcomes reports on equity programs for health care workers and

consumers;

• Monitor the number of health care dollars spent on defending discriminatory practices

and set mechanisms to ensure freedom from racial discrimination, harassment, set-up,

and backlash in organizations responsible for health; and

• Promote equal access and participation in organizations responsible for health, including

the provision of interpreter services and removal of barriers for racialized people and

invisible minorities.

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We thank Anne McLellan, former federal minister of health, for her encouraging response to

CEHS's suggestions about the future role of the Health Council of Canada.

Recommendations from Partisan Sectors of the CEHS Network Since there was no consensus about what recommendations should be included or excluded, our

report includes recommendations submitted from different sectors of the network. What follows

is a selection of some key recommendations that attempt to build accountability for systemic

racism impacting on nurses through changes in legislation and policy to build new structures,

procedures, and practices. Members of the CEHS network recommend:

1. An investigation by the Ontario Human Rights Commission

The Centre for Equity in Health and Society (CEHS) calls upon the Ontario Human Rights

Commission (OHRC) to initiate (under section 29(g) of the Code) an investigation into the

systemic discrimination against racialized nurses as well as all designated groups protected

under the code with respect to education and employment in the health care system. The

investigation should take account of discrimination, harassment, and procedures for

redressing grievances and complaints.

2. Leadership Training and Anti-racism Education The Centre for Equity in Health and Society (CEHS) would establish a leadership academy

that holds training workshops for negotiating the implementation of anti-racism

policy and practice in support of ethnoracial competencies. The Province of Ontario

should fund this academy to develop curricula and organize dialogues on changing the

culture of nursing to one that practices accountability for equal access and

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participation in all sectors and at all levels of the profession. The CEHS leadership

academy, in partnership with university research units, will evaluate curricula

and develop and disseminate new knowledge on ethnoracial competencies and

achieving diversity in leadership. The CEHS will collaborate with appropriate

professional and regulatory bodies to develop questions for registration and

licensure examinations pertaining to antiracism and racial dispute proceedings.

CEHS will also collaborate with unions that negotiate nurses' contracts to sponsor

conferences that discuss innovations addressing member-to-member racial disputes.

The CEHS leadership academy will convene dialogues in nursing on the overt

racism from patients, colleagues, and supervisors experienced by nurses of Asian

and Filipino descent during the outbreak of SARS and how to prevent such

behaviours in future.

3. Ontario Legislation

The Ontario Human Rights Commission be legislated to report directly to an all-party

committee of the Parliament instead of to the Attorney General.

4. Ontario Policy

1. The Ontario Human Rights Commission develop policy to:

• monitor workplace complaints proceedings for reprisals and step up investigations to

properly document reprisals and irregularities in procedure; and

• levy fines based on the degree of resistance to anti-racism procedure.

2. The Ontario Human Rights Commission report to the legislature, categories

of complaints and statistics on how they are dealt with. Private and union practitioners

adjudicating racial complaints report to the legislature similar data ensuring the

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confidentiality of complainants and respondents but listing the sector – for example,

health care – in which the complaint arose.

3. The Ontario Ministry of Health and Long Term Care require the Nursing Secretariat to

provide the opportunity for the inclusion of Aboriginal and visible and non-visible

minority member representatives in its proceedings in collaboration with the Joint

Provincial Nursing Committee.

4. The Ontario Ministry of Health and Long Term Care integrate anti-racism, anti-

discrimination, anti-harassment, employment equity assurance, and language and culture-

care agendas in the nursing and other relevant secretariats to carry forward the

requirement of ethnoracial competencies in a mission of diversity and equity in health

care.

5. The College of Nurses of Ontario introduce transformative justice proceedings to handle

allegations where a racial dispute is evident between a client and a nurse.

5. National Accreditation

1. The accreditation proceedings of hospitals and health agencies in cooperation with all

regulatory colleges implement equity assurance to augment their quality assurance

programs.

2. The accreditation arm of the Canadian Association of Schools of Nursing require:

• evidence of recruitment and strategies for retention of Aboriginal, visible minority,

and non-visible minority faculty and students;

• evidence of anti-racism curriculum; and

• evidence of requiring ethnoracial competencies among faculty, staff, and students.

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6. Voluntary Policy in Key Organizations 1. Provincial, regional, federal, and national bodies supporting and directing health services

research develop programs to obtain and publish data on health care workers in terms of

Aboriginal status, ethnicity, mother tongue, and visible minority identity.

2. The Ontario Hospital Association develop and promote best practice models of anti-

racism policy. Guiding policies should include Principles for Good Governance in the

21st Century and the United Nations Declaration of Human Rights – Legitimacy and

Voice, Equity, and the Rule of Law.

3. All regulatory and professional bodies introduce measures to address racial

discrimination and systemic racism in health care:

• Registration forms be changed to allow for self-identification of Aboriginal,

racialized, and non-visible minority status;

• Committees and panels be required to be diverse and inclusive so that they reflect the

diverse population of Canadians;

• Ethnoracial competencies be made a requirement for nurse registration and an

expectation for ongoing, self-reflective practice required for professional registration;

• Regular in-service education programs and human rights orientation to new staff at all

levels;

• Electronic monitoring using human rights software to track equity indicators; and

• Tools for employment systems review be adapted to identify set-up and backlash

experienced by racialized employees.

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We thank the Canadian Race Relations Foundation (CRRF) for supporting research on backlash

against accountability for equal access and participation in nursing.

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Toward Accountability among All Stakeholders: Introduction and Overview


1

Chapter 1 – Toward Accountability among All Stakeholders:

Introduction and Overview

Rebecca Hagey and Jane Turrittin



2

In this overview of the participatory action research (PAR), we invite all stakeholders in the

Canadian health care system to contribute towards solution of the problems presented in this

report. After reviewing selected stakeholder issues and PAR methods for building consensus, we

offer a brief account of the available literature on set-up and backlash and introduce the concept

of accountability discourse as a lead-in to the presentation of our evidence.

Questions, Objectives, and Accountability Discourse Strategies First, as a means of preparing for the participatory action phase of our research as well as to

develop accountability discourse theory, we reviewed interview data from our earlier research

and asked the following theoretical questions:

1. What are the key issues associated with accountability for racial discrimination?

2. What reactions and organized responses ensue from initiatives seeking accountability for

systemic racism?

3. What relationship implications are evident in initiatives seeking accountability for

systemic racism?

4. What irregularities and outcomes are evident with particular accountability strategies?

Our objective in addressing each of these questions was to develop a theoretical

understanding based on the interviews from earlier studies about how accountability for racial

discrimination is contested, challenged, or by-passed. We need this understanding to devise

ways and means to institute accountability for racial discrimination. We then formulated yet

another question, given the challenges to accountability – the discourse practices of set-up and

backlash – that we describe in our report.



3

5. By naming issues and specifying recommendations, will the CEHS be a) ignored,

marginalized, or excluded? b) problematized and punished? or c) contained? Or will the

report be taken seriously in nursing, health care, and Canadian society?

Another objective was to conduct participatory action research (PAR) with voluntary

associations of nurses to explore the feasibility of developing equity assurance programs aimed

at instituting accountability for racial equality and employment equity at all levels and in all

sectors in nursing. In keeping with PAR methodology, we identified evidence and the

participants themselves shaped what is presented. For purposes of confidentiality and brevity,

we have been highly selective of what we offer in this report. For various resources that expand

on what the participants deem may be useful for changing stated human rights into values that

are put into practice, we refer our readers to the CEHS website: www.BeforeQuality.com.

As our action research gained momentum, participants recognized that an equity

assurance program is feasible if – and only if – those who need it make it happen. A vision of a

Canada-wide program emerged that would use interest-based lobbying, negotiation, and political

action informed by research to hold all nurses and their employers accountable for systemic

discrimination in their organizations. To these ends, the Centre for Equity in Health and Society

became formalized, inspired by the statement in the Ottawa Charter (World Health Organization,

1986) that equity is a determinant of health (p. 1).

For policy development and implementation to occur, we believe that a widespread

collaboration on changing discourse is necessary. Our thesis is that all stakeholders will need to

change discourse strategies if accountability for racial discrimination is to become a shared

value. The theoretical understandings of discourse underlying our PAR are summarized in

Henry and Tator’s book, Discourses of Domination (2002). They implicitly advocated that



4

change in discourse (language and ideology) was the intervention that held the most promise for

shifting how determinations are made about who is denied privileges and on what basis. We

used discourse strategies to promote accountability for equal access and participation by

targeting (a) political discourse, (b) the locations of discourse, (c) discourse strategies in and

between organizations, (d) policy regulators of discourse, (e) personal discourse, (f) discourse

outcomes, and (g) research discourse. The theoretical development of our questions pertaining

to change through purposeful discourse will be addressed in future submissions to scholarly

journals.

The answers to our questions unfolded as our participatory research took shape.

1. We identified set-up and backlash as manifestations of the poor accountability for

racial dominance, as well as a number of other issues, which we discuss in our

chapter on accountability.

2. We gathered evidence of organized strategizing to take advantage of racialized nurses

in our description of set-up, as well as evidence of backlash to initiatives seeking

accountability for racial differences or domination.

3. We collected evidence of poor dispute resolution methods that are used in racial

disputes.

4. We gathered evidence of how the complainant is further subjected to racial

discrimination and domination through violation of the grievance process.

The CEHS thanks the reader for taking the time to read this report and asks for her/his

support in creating effective policies that will ensure that the work environment for nurses, and

therefore the care environment for patients, is caring rather than poisoned. You too are a

stakeholder.



5

Who Are the New Stakeholders? The term visible minority is used by Statistics Canada to define “persons other than Aboriginal

Peoples, who are non-Caucasian in race or non-white in colour” (Statistics Canada, 2003). In

addition to census questions about visible minority identification, immigration profiles emerge

from questions about country source, ethnic origin, place of birth, official language capacity, and

so on. The 1991 Census counted occupational groups such as nurses within these categories, but

we have not been able to retrieve such data for 1996 or 2001. Appendix A provides 2001 data

for immigrants by source country (top 10) and proportion speaking a non-official language, as

well as the proportion of visible minorities in Canada, the provinces, and territories for 1991,

1996, and 2001.

The total Canadian population in 2001 was 29,639,035, of which 5,448,480 or 18.4%

were immigrants. The total categorized as visible minorities (not including Aboriginal persons)

was 13.4%, which is a three-fold increase since 1981. With some variation among groups, three

in ten people from visible minorities were born in Canada.

Canada's new immigrants are coming increasingly from Asia and the Middle East.

Numbers have noticeably declined for those coming from Caribbean and Central American

countries. The twelve top places of birth in the decade of immigration to Canada from 1991 to

2001 are ranked as follows:

People’s Republic of China 197,355 India 156,120 Philippines 122,015 Hong Kong 118,385 Former Yugoslavia 67,750 Sri Lanka 62,750 Pakistan 57,990



6

Taiwan 53,750 United States 51,440 Iran 47,075 Poland 43,370 United Kingdom 42,645

Since 1991, all visible minority groups have grown in size, with Chinese, South Asians

and Blacks, respectively, making up the largest groups. In 2001, in Toronto, the total population

was 2,456,805. The percentage of visible minorities was 42.8%; 43.7% of these people were

foreign-born. Vancouver's population is now one-third Asian, and all urban areas in Canada are

receiving immigrants.

It can be assumed from these data that there is some consensus on keeping track of the

numbers who identify as “visible minorities.” But the fact that census respondents can declare

multiple ethnic origins makes interpreting contrasts in ethnic origin and visible minority status

difficult. For example, in 2001, 1,094,700 individuals identified themselves as having Chinese

ethnic origin, but only 1,029,395 (94%) identified themselves as a visible minority using the

Chinese category. Similarly, 327,550 individuals said they had Filipino ethnic origin, but only

308,575 used the Filipino category to declare their visible minority status. This contrast is most

dramatic for Aboriginal people where (excluding thirty reserves that did not report) the total

population who identified themselves as Aboriginal persons in Canada in 2001 was 976,305,

compared to the 1,000,890 who identified themselves as having North American Indian ethnic

origin, with an additional 307,845 who declared a Métis ethnic origin. One child in four is

Aboriginal in Manitoba and Saskatchewan. The territories and prairie provinces have the highest

shares of Aboriginal peoples in proportion to their total populations (Statistics Canada, 2003).



7

How Can New Stakeholders Gain Full Inclusion into Society’s Institutions? In our anti-racist advocacy, we have observed that the words 'whiteness' and 'anti-racism' are a

turn-off for numerous nurses. We were told that social work talks about racism but in nursing

we talk about cultural sensitivity. So our problem is, how do we call attention to the issue of

racism in nursing if we cannot use the "R" word? How can we advocate for equal access and

participation in nursing if the consensus of the leading nurses is that racial inequality is not their

problem?

A challenge we heard repeatedly from prominent nursing leaders can be paraphrased as,

"Why are they feeling disenfranchised? They should get involved with the provincial and

national associations and roll up their sleeves like we do to make things happen.” Notice the

we/they separation in identity. Also notice the lack of interest in making bridges or helping

inclusion along.

How would you penetrate the assumptions embedded in these responses to help leaders

empathize with nurses who feel marginalized? How can we all work together to include nurses

who feel trapped and hopeless about racial dominance in the activities and governance of our

discipline? If racial dominance is kept in place by discourse that keeps repeating old images and

using them to categorize people negatively to create barriers, then how do we change the

discourse? How do we contend with a backlash that disparagingly considers changing discourse

as having to be politically correct? How do we build a movement when those interested in

changing discourse are head-locked into disagreement about the strategies?



8

Literature Pertaining to Set-up and Backlash among Particular Stakeholders In an extensive international literature review using public and private search engines, we found

a paucity of work on racism and backlash. Tuen van Dijk (1993) discussed backlash as a normal

response to organized challenges against institutionalized European racism. In-group/out-group

process was subtly used in order to defend the privileges of elite decision-makers, thus

reinforcing their political and economic advantage. The NACLA Report on the Americas (1995)

issued a special issue on backlash, linking shifts in U.S. domestic and global economies with

vengeful strategies against immigrants in the U.S, such as California’s Proposition 187. Mills

and Simmons (1995), who outlined the history and barriers excluding minorities from full

participation in Canadian organizations, also described the contemporary backlash against

minority rights, which includes outright attacks on programs for equity.

Within nursing, no studies of racial backlash against employment equity were found, with

the exception of our own publication (Hagey et al., 2001b). Indeed, Canadian nursing research

journals are silent about the issue of racism. Calliste (1993) outlined the virtual colour bar that

existed in Canadian nursing until the 1950’s, when a shortage of nurses forced a challenge to

racist immigration laws that resulted in nurses coming in from the Caribbean. This colour bar

still exists in many domains of nursing.

One diagnosis offered for why diversity is such a challenge is that racism in nursing is

denied (Calliste, 1995; Head, 1985). So the refusal to use words like racism stems from the fact

that nurses in positions of power and influence do not believe that it exists. Yet, studies done in

Toronto report that in comparison to white nurses, racialized nurses are under-represented in

management positions and over-represented in the “lower paid, lower status jobs” (Collins, 2004;

Das Gupta, 1996; Marshall, 1996; Doris Marshall Institute and Minors, 1994; Head, 1985).



9

Although we found no empirical studies on practical strategies for combating backlash

against employment equity, Stith (1998), like Henry et al. (1995), offered well-reasoned

approaches to deal with institutional racism across a variety of professions and employment

areas. Backlash and reprisals are strictly forbidden under the Ontario Human Rights Code, but

we found that none of the offending employers were reprimanded by tribunals for engaging in

backlash. The testimony of many of the victims participating in our research was not admitted

into evidence. As Aylward (1999) pointed out, the legal system in Canada is itself riddled with

systemic racism. We found this to be true for nurses whose arbitrator refused to allow racial

differences as evidence at the hearing.

Stith (1998) argued that corporate leaders, executives, and senior management must

become educated about systemic racism. They must become directly involved in eliminating

racism and discrimination in the workplace and must encourage minorities and women and

support them in advanced positions. His recommendations include incentive and reward

programs to encourage equal access and participation and integrative anti-racist training. Other

strategies necessary to create confidence that complaints will be taken seriously and acted upon

include creating and supporting proactive intervention programs to deal with racism and sexism,

holding those who discriminate accountable, and protecting employees who make valid

complaints. Finally, he called for anti-discrimination employment laws that would include both

severe penalties and incentives not to discriminate to avoid the current unfair burden placed on

minorities to prove their cases in costly legal hearing. In Ontariom, the HR Code does not fine

the offender with penalties and awards modest accommodation to the victim whose case is

upheld.



10

Arguably, this weak accountability for racial justice in employment relations is condoned

by a Human Rights Commission that does not prosecute racial discrimination but only

conciliates. We find support for the contention that conciliation should not be used in human

rights cases:

There are public disputes that shouldn’t be mediated at all. I don’t think disputes concerning rights—constitutional rights, human rights, basic rights—should be mediated, even if you could meet the interests of all sides. We have certain basic constitutional, human rights that are decided and legislated in a different way. I don’t think that those ought to be compromised in any way by negotiations (Susskind, Harvard Law School, Program on Negotiation, as cited in Kolb, 1994, p. 353). With inadequate state enforcement of equity principles encoded in Human Rights

legislation, we believe the best available strategy is to build coalitions among the many

associations of racialized nurses who want accountability for employment practices in nursing.

The African Canadian Community Coalition against Racial Profiling (ACCCRP) is using this

strategy to make police who use racial profiling accountable (Smith 2004). A glimmer of

support for this idea is emerging in the research literature. In “Planning an Anti-Racism

Initiative,” Batten and Leiderman (2001) examined a program that Levi Strauss Foundation

developed to address racial prejudice and institutional racism in communities where Levi Strauss

and Co. had facilities. Working with multiracial coalitions in Albuquerque, El Paso, Valdosta,

and Knoxville, the Foundation and the Center for Assessment and Policy Development have

learned a number of lessons about starting a corporate-sponsored, community-driven, anti-racism

initiative.

Communities need to understand how difficult it is for multiracial groups to be inclusive

and to reach consensus in a timely and efficient way. Task forces require a variety of people and

a great deal of community support. A common approach will eventually emerge, and those who



11

stay involved will be able to adapt their own strategies. However, specialized training and

assistance are necessary to bring community representatives to that point. Corporate sponsors

need to understand that local task forces need time to develop strategies and engage participants.

An effective task force facilitates change. There is a role for outside assistance, but it is

important to promptly establish local ownership of the initiative where the community is in

charge.

Our participatory action research took a community development approach to prepare for

eventual dialogue between minority nurses and members of powerful decision-making

committees who steer the profession and exercise control over employment policy and practices.

If backlash is to be inhibited, leaders such as these will need the supports, knowledge, and policy

to implement programs of accountability for employment equity. To prohibit this institutional

backlash that minority nurses experience individually for objecting to exclusion, marginalization

or problematization (as Essed, 1991, defined racism), we need to embark collectively on policy

formation and developing new leadership.

In a speech on racism in nursing, June Veecock, an educator with the Ontario Federation

of Labour, described how this backlash is experienced by racialized nurses in Ontario:

When we remain silent, what in effect we are doing is contributing to our own oppression. And I know that once you begin to speak, you have to be prepared for what comes. People are accused of making false claims of racism. They are accused of being incompetent and of using racism as an excuse for their incompetence. So that immediately the focus is shifted. The accuser becomes the accused. The victim is then faced with the additional burden of not only having to prove that she is experiencing racism, that this is a racist environment, but also that she is competent. (Calliste, 1995, p. 60-61). The publication that reported this speech covered the proceedings of a conference

organized in 1995 to publicly address the problem of racism in nursing and the emotional trauma

that resulted from being targeted for “cutbacks” and having one’s expertise attacked to the point



12

of having to mount an expensive legal defense. The conference began a movement against

discrimination, harassment, and reprisals.

We found no other literature identifying reprisals as a key term but turned up an

interesting experimental study on retaliation by racists (Beal, O’Neal, Ong, and Ruscher, 2000).

The researchers tested the hypothesis that modern racists who demonstrated negative affect and

attitudes on a questionnaire would alter their behaviours to express their aggression covertly in a

competitive reaction-time test. Their motivation was presumed to be to avoid appearing

prejudiced. The sample was divided at the median into high modern racists and low modern

racists, and the hypothesis was tested comparing these two groups using measures of both overt

and covert aggression. The experiment went on to examine responses to provocation by whites

versus by African American test competitors, as well as the effects of light and heavy cognitive

load. Cognitive load was added by requiring participants to recall easy or difficult number

sequences. The purpose was to determine if cognitive load is associated with covert or overt

aggression to indicate whether or not the type of retaliation is strategically selected. The

presumption was that a high cognitive load could interfere with processing and selection. The

study findings follow:

• High modern racists were more overtly and covertly aggressive than low modern racists

regardless of the race of the competitor in the test;

• With provocation, high modern racists displayed increasing levels of covert aggression

toward African Americans (beeping noise for longer duration) in contrast to low modern

racists who inhibited retaliation even under high levels of provocation; and



13

• Evidence from the cognitive load experiment that required the participants to recall

numbers during the time-reaction test suggested that covert aggression is a strategic

process that is less likely to be used when cognitive capacity is overloaded.

The study is important for validating the description of modern racism as manifesting

discrimination in covert and indirect ways, thus reproducing the conflict between “law and

conscience on one side and with custom and prejudice on the other side” (Allport, 1989, p.57).

The finding that modern racists are more aggressive in general parallels studies of old-fashioned

racism that demonstrated associations between ethnocentrism and aggressive behaviour. For low

modern racists who more clearly fit the “modern” description, the suggestion that even they

require sufficient cognitive resources to maintain a non-aggressive approach is an important

finding.

These experiments raise compelling questions for nursing. Does nursing have in its ranks

high modern racists who express overt as well as covert aggression regardless of the

provocation? Is nursing in a stage of evolution called old-fashioned racism where it is

permissible to express racism overtly when provoked about the issue?

The latter possibility is plausible in light of findings by Turrittin, Hagey, Guruge, Collins

and Mitchell (2002). This qualitative interpretive study employed Marshall McLuhan’s (1964)

cultural categories of hot and cold reactions and Brian Turner’s (2000) adaptations of notions of

thick and thin solidarity. Nurse managers that participants viewed as racists were identified as

having “hot, angry reactions” and yet their support within the administrative network reflected

“thick solidarity.” By contrast, the visible minority nurses who were complaining of racism

displayed coolness and firmness about their legitimate rights but, unfortunately for them, the

support was very thin and solidarity was expressed only covertly. The prospect of thin and



14

covert solidarity raises the question of what resources racialized nurses can rely on to hold

superiors accountable for covert and overt racism.

After an extensive search of key words, we found no literature pertaining to set-ups.

However, Bakan and Kobayashi (2003) recently discussed set-up in employment in relation to

the continuing struggle for employment equity. They documented set-up as one of several types

of systemic discrimination that racialized workers encountered, and quoted an Aboriginal woman

who spoke in a public forum about her experience of being set-up by managers of the Canadian

Park Service. Our account of set-up points out that without any actual conspiracy, systemic

racist practices are highly organized, systematically accruing benefits to non-racialized persons

at the expense of racialized persons. We attribute the organizing principle to the underlying

racist ideology that accountability to racialized people is optional depending on the

contingencies.

In contrast to the sparse research documenting racial inequities in nursing, there is a

mature and sophisticated literature documenting racial disparities with respect to a myriad of

health indicators (Navarro and Muntaner, 2004). Nevertheless, Jackson (1993) discussed the

disinterest in racism among researchers in nursing, calling it “whiting out” knowledge and issues

that are important to Black nurses and Black families. In research designed to examine

collegiality among staff nurses, Jacobs (2002) found evidence of racism identified as a barrier to

collegiality.

A literature is emerging that documents the experiences of racialized immigrant nurses

from their own perspective (Collins, 2004; Dicicco-Bloom, 2004; see also Essed, 1990).

Dicicco-Bloom observed that "one of the challenges facing [the] health care system [in the

United States] is the social inequity within our society that impinges on the daily lives of



15

minority health care providers, including nurses" (p. 26).

Agocs and Harish (2001) provided encouraging new evidence on case review showing

that complainants of social inequity have more than a fifty percent chance of having their racism

complaint upheld at the Ontario Human Rights Commission. These strategies offer potential

currently for influencing positive change in the workplace and in general attitudes and

behaviours in society. Joan Anderson (2000) suggested that post-colonial feminism offers ways

for nursing to orient to the research agendas that are needed in this area. However, front line

nurses and other staff continue to be subject to abuse, as Cooper-Braithwaite’s studies have

revealed (1996), and that presents a stark reality context for shaping agendas and changing

everyday discourse.

This review of the literature suggests that the multigenerational legacy of the problem of

racism in Canadian nursing reflects that of the larger society, therefore any reforms must seek the

mechanisms of the larger society and the levers it can put in place to dismantle racism. We must

begin by addressing the professional implications of the racially based differences in our midst to

promote policy discussion and legislation as outlined in the recommendations contributed by our

stakeholders.

Background on Getting the Stakeholders Together In 1994, May Yoshida published a curriculum plan that included anti-racism content and

advocated for it to be adopted nationally (see also Gustafson, 2002). Building on her work, a

research approach to curriculum change was launched at the University of Toronto. It called for

faculty development and formal evaluation and led to the publication of a study identifying

racialist discourse in curriculum (Hagey and MacKay, 2000). Our shift to investigating



16

grievances, complaints, and backlash for naming racism began in 1996 when two nurses,

Claudine Charley and Evelyn Brody, came to the Faculty of Nursing at the University of Toronto

to ask that research be done on racial discrimination, harassment, and reprisals in nursing.

The two nurses were part of a movement lead by the Congress of Black Women of

Canada that was helping racialized nurses organize against systemic resistance, backlash, and

reprisals for challenging racial discrimination and disparities. Claudine Charley had received a

$250,000 settlement from the Toronto Hospital in her case. During the proceedings it was found

that a white nurse had set-up Claudine to get her into trouble during a period of job losses and

downsizing related to the underfunding of health care. The white nurse confessed to unplugging

a monitor without regard for the patient’s safety. The strategy of set-up was well known by

nurses of colour during this period. Black nurses especially got into trouble because of set-up.

When they reacted in an upset manner to being disciplined, they would be accused of having

"communication problems." Then, as a matter of course, escalating communication problems

between supervisor and nurse would result in termination of the racialized nurse.

To her credit, Claudine Charley garnered support among colleagues, won her case, and

was featured in a film called End the Silence on racism in nursing (1996) that was sponsored by

the RNAO and the Ontario Nurses Association (ONA). Neither of these organizations hosted a

viewing of the film or wrote about it. A copy of the film may be obtained at ZACfilm.

The strategies of set-up were more covert in Evelyn’s case. The remarkable aspects of

the dispute process for her were backlash, reprisal, and retaliation – in short, revenge, for having

expressed her concern that what she was experiencing was racial discrimination. Consequently,

it is these two phenomena – set-up and backlash – that we are beginning to describe and

challenge in this study.



17

Our biggest challenge remains how to bring to the table the factions composed of those

who do not want to talk about racism as well as those who are willing but fearful that the

discussion will erupt into negativity and be a waste of time. The CEHS has been successful in

bringing together small gatherings in various think tanks, research day, and graduate seminars, so

we are confident that our methods of inquiry are safe and productive.

Leadership from the Powerful Stakeholders in Nursing is Appreciated In addition to presenting evidence of systemic racism and resistance to racial equality in nursing,

we are building our participant action research on positive initiatives already embarked on by

leaders in nursing in Ontario. PAR requires taking stock of stakeholders and historical and

political realities in the planning stage.

It can be postulated that nursing organizations have not recognized systemic racism as an

issue because they have lacked the expertise and had no personal interest in learning about the

benefits to the whole profession from promoting health and anti-racism. To their credit, nursing

organizations have begun to seek expertise and develop policy. The RNAO issued a statement

on racism in the early 1990s and updated it in 2002. In 1995, the Joint Policy and Planning

Committee (JPPC) of the Ontario Hospital Association and the Ministry of Health released Anti-

racism Policy Guidelines. Rani Srivastava, who later introduced the term equity assurance,

drafted the Cultural Sensitivity Guidelines for the College of Nurses of Ontario (CNO) as well as

the RNAO statement on racism. She was also one of the leaders of this initiative and was a key

player on the JPPC.

Nursing organizations were not officially part of the JPPC process, although ONA, the

largest nurses' union in the province, did make two presentations to the committee. ONA



18

recently commissioned Tania Das Gupta's (2002) study of racism experienced by nurses. The

CNO has been developing a program that will support nurses newly immigrating to Canada to

obtain their registration.

Who Were the Stakeholders Participating in the PAR? The following diverse associations of nurses agreed to be listed in this resource. Over 200

nurses, some belonging to one or more of these associations or smaller groups of less formalized

associates, participated in the think tanks and the network continues to expand.

Aboriginal Nurses Association of Canada (ANAC) ANAC is a non-governmental, non-profit organization that was officially established in 1975 out

of the recognition that Aboriginal peoples' health needs can best be met and understood by health

professionals of a similar cultural background. The ANAC soon discovered that if their

association was to survive, grow, and successfully achieve their objectives, they would have to

become familiar with the culture of politics and bureaucracy and to develop new skills in the arts

of diplomacy and persuasion. The only Aboriginal professional nursing organization in Canada,

the ANAC is an affiliate group of the Canadian Nurses Association. ANAC objectives commit

its members to the following:

• To act as an agent in promoting and striving for better health for the Indian and Inuit

people, that is, for a state of complete physical, mental, social and spiritual well-

being;

• To conduct studies and maintain reporting, compiling, and publishing of material on

Aboriginal health, medicine, and culture;



19

• To encourage and facilitate Aboriginal control of Aboriginal health, as well as of

involvement and decision making on matters pertaining to health care services and

delivery;

• To offer assistance to government and private agencies in developing programs

designed to improve Aboriginal health;

• To maintain a consultative mechanism with the association, band government, and

other agencies concerned with Aboriginal health issues;

• To develop and encourage the inclusion of courses in the education system on

nursing, the health professions, Aboriginal health, and cross-cultural nursing;

• To develop general awareness in Aboriginal and non-Aboriginal communities of the

special health needs of Aboriginal people;

• To conduct research on cross-cultural medicine and develop and assemble material on

Aboriginal health; and

• To actively develop a means of recruiting more people of Aboriginal ancestry into the

medical field and health professions.

• To generally develop and maintain on an ongoing basis, a registry of Aboriginal

Registered Nurses.

Aboriginal Nurses Association of Canada 56 Sparks Street, Suite 502 Ottawa, Ontario K1P 5A9 Tel. (613) 724-4677 Fax: (613) 724-4718 www.anac.on.ca Association of Black Health Care Providers (ABHCP) ABHCP was formed in June 1995, following the conference, "End the Silence on Racism in

Nursing," sponsored by The Congress of Black Women of Canada. The Association's founding



20

members and the conference organizers were motivated to take action as a result of complaints

concerning racist attitudes from nurses at Northwestern General Hospital, Toronto. The creation

of ABHCP was newsworthy at the time because it demonstrated that women of colour could

organize and resist/challenge racism. No other Black social groups/organizations specifically

focused on health care providers at that time. The founding members included: Paula Stewart

(Chairperson), Monica Mitchell (Secretary), Olive Issacs (Vice Chair), Joan Bernard, Claudine

Charley, Valda Christian, Peter Cunningham, Ann Headley, and Monica Purdy. The

association's number one goal was to promote the development of creative and innovative

strategies to help its members deal effectively with racism and discriminatory practices in their

work environment. The ABHCP's main accomplishment was to create a forum where minority

nurses could come to have their issues validated. Many nurses had nowhere to go to speak

openly about their issues. There is always strength in numbers and issues of race and

discrimination are often denied by the dominant group. Association members provided support

to nurses whose complaints were heard at arbitrations and informally advised nurses about legal

aspects of the grievance/complaint process. There is no formal relationship between the former

ABHCP and the newly formed Canadian Black Nurses Association.

The Barbados Nurses Association of Canada (Toronto Chapter) The Barbados Nurses Association of Canada (Toronto Chapter), which was founded in 1990 by a

group of Barbadian Nurses, currently has a membership of forty. The Association was formed in

order to provide professional and social support to Barbadian nurses, to provide health education

and information to the community, and to support selected charities. Currently the Association

supports The Sickle Cell Association of Ontario, Doctors without Borders, and Sayes Court

Children's Home in Barbados. For the past three years, the Association has offered an annual



21

scholarship to students pursuing a career in the health care field. Members raise funds for these

activities through an annual variety show and dinner, bake and rummage sales, and walk-a-thons.

The Association also has adopted a group of seniors from the Baptist Methodist/Episcopal

Church in Toronto. Special events such as a picnic, attendance at the Stratford Festival and a

boat cruise are held throughout the year. Meetings are held on the first Tuesday of each month at

the Caribbean Catholic Church on College Street at 5:30 p.m.

The Centre for Equity in Health and Society The Centre for Equity in Health and Society (CEHS, pronounced “says”) is a virtual centre that

coordinates a research network of interdisciplinary researchers and advocates for equal access

and participation in organizations responsible for health. CEHS was formalized in June 2002 by

the nurses and others who participated in the action research and coalition building to promote

equity assurance policies and programs documented in the present report. CEHS undertakes

research-based advocacy promoting anti-racism, anti-discrimination, employment equity, and

ethnoracial competencies to improve access and participation in all levels and sectors in health

care. CEHS also studies what is effective for holding individuals and organizations accountable

for equal access and participation. CEHS calls for the creation of an equity assurance policy to

ensure that the work environment for nurses, and therefore for patients, is caring rather than

poisoned. For more information, contact CEHS through its website at: www.BeforeQuality.com.

The Canadian Black Nurses Association (CBNA) – Media Release

Historically, black nurses have been positive contributors to the Canadian Health Care System;

however, black nurses have been marginalized, silenced, and ultimately excluded from nursing

leadership roles in Canada. Therefore as a means of providing a forum to support, mentor, and

acknowledge their contributions, the first Canadian Black Nurses Association has been



22

established. CBNA was developed by a group of nurses from diverse nursing backgrounds in

response to the aforementioned statement. The association has been established in order to:

• Enhance the health status of black communities through role modeling, research, and

education;

• Develop strategies to engage with leaders in health organizations to

investigate and determine the necessary process to effect change; and

• Provide leadership through mentoring, while recognizing all nursing initiatives and

contributions made by black nurses.

CBNA is requesting the public’s assistance in promoting our association through sharing

information about CBNA, since CBNA is essential to addressing the needs of all black nurses

living in Canada, while improving the overall health status of individuals within the black

community. CBNA is currently recruiting nurses interested in working towards a healthier work

environment in Canada's health care system and in creating a health care system with transparent

processes that will truly represents all nurses and a health care system that will recognize black

nurses’ contributions and achievements, and provide equitable nursing opportunities for all black

nurses.

In the near future, CBNA will have a general membership meeting. Interested parties can

email the association at [email protected] with the following information:

Name E-mail address

Phone number Place of Employment

Home Address (optional) Professional Title



23

Chinese Canadian Nurses Association (CCNA), Ontario

The Chinese Canadian Nurses Association, Ontario was founded in 1986 in Toronto. Founding

members included public health nurses, hospital nurses, and nurses who were not practicing in

Ontario because of a lack of reciprocities with a license earned outside of Canada.

The mission of the CCNA is mainly to promote professional development for Chinese

nurses. It aims to provide a forum for networking and enhancing nursing services to the

community at large. Criteria for CCNA membership are to be trained as a nurse and to be of

Chinese origin. The category for associate members is open to anyone who supports the

CCNA's mission. Though there were about forty pioneer members in 1986, membership has

grown with the increase of Chinese immigrants to Canada.

A major accomplishment was to bring together Chinese nurses who were trained from all

corners of the world. The CCNA has assisted members in the registration process of the College

of Nurses of Ontario. It participated in community health activities in health promotion fairs and

workshops. Responding to members' concerns about workplace politics, the CCNA developed a

workshop series on Job Survival Skills. Experts on administration were invited to help members

understand the corporate culture that closely affects everyone's daily work. In addition to the

mandate to serve the public with expert skills in caring according to regulatory standards, the

association promotes adherence to a code of ethics for professional practice, which includes

social justice. The CCNA collaborates with various community groups in advocating for equity

issues and supports members of various minority groups in their struggle for fairness.



24

Coalition of Black Trade Unionists (CBTU), Ontario Chapter The Ontario Coalition of Black Trade Unionists was formed in 1987 to put issues of racism and

discrimination - in the workplace and unions - higher on labour's agenda. The CBTU has a

nursing division headed by Gloria Taylor-Boyce. With regard to nursing, the CBTU:

• Encourages and supports the full participation of black nurses and nurses of colour in

their unions;

• Promotes access and the opening of doors for Black nurses and nurses of color within the

labour movement; and

• Organizes to maximize nurses' political influence within the labour movement.

Contact the Coalition of Black Trade Unionists, Ontario Chapter at www.cbtu.ca.

Culture Care Nursing Interest Group (CCNIG) The Culture Care Nursing Interest Group (CCNIG), founded by Enid Collins, Margaret Hosang,

Rani Srivastava, and Kathy Wong, is a network of Toronto-based nurse-activists and other

professionals who developed the group in 1994 at Wellesley Hospital to ensure the advance of a

paradigm shift in nursing towards excellence in culture care. CCNIG members are nurses,

researchers, educators, administrators, and students who have a commitment and passion for

culture care. One of the CCNIG's purposes is to provide a forum for dialogue and networking on

issues relating to culture care. To this end, for two years (1998-2000) it published the CCNIG

Newsletter. CCNIG members advised the College of Nurses of Ontario on its "Guide for

Providing Culturally Sensitive Care," drafted by Rani Srivastava, a founding member of CCNIG.

Identifying racism in nursing as a research priority, the CCNIG's research council secured



25

funding from the Centre for Excellence in Immigration and Settlement (CERIS) to carry out

research to make racism "see-able" (see Collins et al., 1998), of which the participatory action

research described in this report is a direct descendant. In 2002, CCNIG was one of the

sponsoring organizations of the Annual Meetings of the Transcultural Nursing Association

(TCN) in Toronto. Many of CCNIG's activities are now being continued by the newly formed

Centre for Equity in Health and Society (CEHS).

The Filipino Nurses Association, Toronto Branch The Filipino Nurses Association, Toronto Branch, was formed in 1991 by Sally Quan, Irene

Turner, and others. By 1994, it had grown to about 500 members. With its sister associations in

Vancouver and other major Canadian cities, the Toronto Filipino Nurses Association works to

advance the full rights of Filipino health workers in Canada. It provides information on

accreditation and lobbies the government for change in immigration policy. In 1993, the Filipino

Nurses Association submitted a report of the Anti-Racism Strategy Project to the Federal

Ministry of Citizenship. The association worked very closely with the College of Nurses of

Ontario and other organizations such as Skills For Change to remove barriers and improve access

to the profession for Philippine-trained nurses.

For further information, contact Vicky Romero, President, at 416-636-5245.

The Grenada Nurses Association The Grenada Nurses Association was founded in January 2001 by a group of nurses who are

Grenadian nationals; the nurses came together as the need for a safe space where Grenadians

would be free to speak was identified. In this space, members provide counselling, support, and

mentorship, as well as share experiences in confidence. In addition, the Association assists



26

Grenadian nationals who do not have access to or who do not know how to navigate the services

in the health care system. Its objectives are as follows:

• To provide emotional and professional support for each other;

• To provide support, advocacy, and outreach to Grenadian Nationals;

• To share health information with other nursing associations/organizations;

• To actively participate in and assist with the interpretation of College of Nurses'

Standards to our members; and

• To form partnerships with other Nurses' Associations.

The Association’s work includes providing support services in the home to Grenadian

nationals who are unable to care for themselves, fundraising to assist with such services, and

advocating with health care providers on their behalf. It works in collaboration with the Grenada

Consulate; nationals needing assistance may contact the Association directly or through the

Consulate.

Health Canada, Office of Nursing Policy Housed in Health Canada's Health Policy and Communications Branch, the Office of Nursing

Policy takes a lead role in health policy, communications, and consultations with respect to

nursing and related professions, including registered practical nurses and nurse practitioners.

The Office of Nursing Policy works in close collaboration with provincial nursing organizations,

whose leaders collaborate with the work of specific task forces. Contact the Office at onp-

[email protected].

International Nurses Interest Group (INIG), Registered Nurses Association of Ontario (RNAO) INIG was established by a small group of nurses with international experience who wanted to

collaborate with nurses of similar experience and interest. In April 1997, one of these nurses



27

reviewed the RNAO membership list of nurses from different cultural backgrounds and sent

them an invitation letter with the aim of developing an international/global interest group of

RNAO. Twenty-four nurses indicated an interest in establishing such a group. Concurrently, the

President of the Global Health Interest Group from the Registered Nurses Association of British

Columbia was contacted about its formation, bylaws and affiliation. In April1998, the RNAO

Board approved INIG Associate Interest Group Status. The current membership is one hundred

fifty-one. Since 2000, INIG has been a full-fledged RNAO interest group. INIG publishes three

newsletters per year and holds a conference bi-annually. The last conference was held in

December 2003. INIG has critiqued and evaluated the Guide to Nurses for Providing Culturally

Sensitive Care, which was developed by the College of Nurses of Ontario (1999) and

participated in a Jurisdictional Workshop with the Canadian Nurses Association entitled,

"Nursing Partnership in a Globalized World: Building Bridges to Equity in Health". INIG

continues to participate on the Care for Nurses Advisory Committee, a project dedicated to

assisting internationally educated nurses in preparing for the College of Nurses of Ontario

examination. INIG continues to explore with colleges and universities their inclusion of cultural

diversity in their curriculum and how nurses are being educated about social difference.

For more information, see INIG at www.RNAO.org.

Joint Provincial Nursing Committee (JPNC) Reporting to the Ontario Ministry of Health and Long Term Care, the Joint Provincial Nursing

Committee (JPNC) is made up of the leaders of the major provincial government and non-

government nursing organizations. The JPNC undertakes research, policy, and planning for the

purpose of strengthening and stabilizing the nursing profession in the province. Thus, members

of the JPNC produced the Nursing Task Force strategy to ensure that Ontarians have access to



28

high quality nursing services when and where they are needed. Contact JPNC at

www.health.gov.on.ca.

Korean Nurses Association of Ontario (KNAO) The Korean Nurses Association of Ontario, established in Toronto in 1985, currently has about

160 members, of whom about twenty are active. KNAO sponsors seminars for newcomers,

provides information on job prospects to newly arrived or student status Korean nurses, and

telephone counselling for Korean Nurses. In 1985, as its first project, KNAO published 1500

copies of a Korean language handbook (English title: Health and I) written by Gemma Baik, first

President of the KNAO. Health and I quickly sold out to the benefit of both the community and

KNAO. More recently, KNAO has established a sub-section, The Korean Nurses' Interest Group

(KNIG).

In order to fulfill its mission to serve the Korean-Canadian community's health concerns,

KNIG organizes seminars, special health-related workshops, and undertakes community projects.

In 1994, for example, KNIG published a Korean language guidebook with English translations

(English title: Clinical Guide) to help non-English- speaking Koreans communicate with health-

care professionals. KNAO has sold approximately 10,000 copies of Clinical Guide.

For more information, please contact Gemma Baik at [email protected].

Rainbow Health Network (RHN) The Rainbow Health Network was initiated by the Coalition for Lesbian and Gay Rights in

Ontario (CLGRO) in 2001 on the recommendations of their 1997 report Systems Failure. Its

vision is the optimal health and wellness of Lesbian, Gay, Bisexual, Transsexual and

Transgendered people and communities. RHN’s mission is to be a catalyst and a resource for

LGBTT health and wellness activity, in Toronto and beyond. The Network strives to:



29

• Create and sustain a dynamic, accessible network of individuals and agencies committed

to promoting LGBTT health;

• Initiate, support and participate in specific LGBTT health and wellness initiatives,

including: public education, health professional education, advocacy, resource

development, program development, and fundraising;

• Act as a resource to health and social service providers, community groups, researchers,

and academics regarding the health and wellness needs, strengths, and priorities of

LGBTT people; and

• Create opportunities for collaboration among LGBTT health and wellness services.

For additional information, contact Rupert Raj at the Sherbourne Health Centre: 416-324-4174

or [email protected].

Registered Nurses Association of Ontario (RNAO) The Registered Nurses Association of Ontario (RNAO) was established in the first decade of the

20th century as a professional association to represent registered nurses in Ontario. Its vision as a

diverse, member-driven organization is to lead the nursing profession into full partnership in the

practice and shaping of health care in Ontario. Supported by over 20,000 members, RNAO

undertakes ongoing political activity:

• Lobbying the government on issues that impact registered nurses and health-care service;

• Lobbying CEOs and senior hospital and community administrators;

• Lobbying other decision-makers and organizations that affect nursing practice and health

care; and

• Working to enhance the position of registered nurses through proactive media and

lobbying campaigns.



30

RNAO seeks to promote excellence in nursing practice and to advocate for the role of

nursing by respecting the dignity and diversity of and empowering the people of Ontario to

achieve and maintain their optimal health and to provide membership-centred services. Contact

RNAO at 416-599-1925 or www.rnao.org.

The South Asian Nurses' Association of Canada The South Asian Nurses' Association of Canada is a non-profit professional organization

representing nurses from India, Sri Lanka, Pakistan, and Bangladesh and nurses of South Asian

origin. The association is the realization of a long-cherished desire of several South Asian nurses

who migrated to Canada. Its main goal is to stay unified as South Asian nurses to empower our

profession and our community within our own cultural context. The organization functions to:

• Provide a structure for South Asian nurses to work together as a unified force and to

provide opportunity to meet together to discuss and deal with our concerns and issues in a

cultural context;

• Provide a support system for meeting needs of immigrant nurses and practicing members

on an on-going basis;

• Promote professional advancement and leadership and networking for professionals; and

• Develop professional linkages with teaching institutions in South Asia.

For further information, contact Anna Mathai, President, at 905-897-6038.

University Hospital of the West Indies Graduate Nurses' Association (UHWIGNA) The University Hospital of the West Indies Graduate Nurses Association was founded in 1986 by

a group of graduate nurses working in Canada. Its main focus has been to provide financial

resources to support patient care and the education of nurses and health care in Jamaica. As of

2002, the association has raised $90,000 (Canadian), which it has sent to Jamaica for these



31

purposes. In addition, the UHWIGNA (a) provides financial support to nurses who achieve

excellence dispite difficult circumstances; (b) contributes financially to community organizations

such as The Herbie Fund, the Sickle Cell Association of Ontario, and the Jamaica-Canadian

Association; (c) recognizes and encourages individuals who have made outstanding contributions

to the Black community, such as Dr. Robert Taylor, Opthamologist, June Veecock, Human

Rights Educator at the Ontario Federation of Labour, and Bromley Armstrong, Human Rights

activist; and (d) heightens awareness of the contribution of our alumnae and associates and

encourages professionalism among our members and other Black nurses through organizing

conferences and seminars. Finally, the UHWIGNA provides support to its members and other

nurses as needed and gathers for annual social functions.

For further information, contact Monica Mitchell at 416-502-1834.

Urban Alliance on Race Relations (UARR) UARR is a non-profit charitable organization formed in 1975 by a group of concerned Toronto

citizens to promote a stable and healthy multiracial, multi-ethnic environment in the Metro

Toronto community. UARR works primarily in a proactive way with the community, public,

and private sectors to provide educational programs and research that are critical in addressing

racism in society to:

• Create awareness of issues that exist in a multiracial, multiethnic, multicultural urban

environment;

• Promote full and equal participation by all sectors of the community by dismantling

barriers to equal opportunity; and

• Assist public and private institutions to develop policies and practices that will ensure

equal access to jobs and services in Canada.



32

For more information, see the UARR publication, Currents: Readings in Race Relations or

contact the organization at 416-703-6607 or www.uarr.org.

Stakeholder Interpretation and Debate Interpretive theory and methods inform our insights into discourse for both our qualitative

research and the PAR. These methods are employed in ongoing, everyday analyses of power

relations with which many racialized people astutely engage. This process is reflected in self-

evaluative questions, for example, “What just happened?” or “Why am I feeling outdone?”

The discourse theories of Essed, Stuart Hall and van Dijk are well reviewed by Henry and

Tator (2002) and are used in an exemplary fashion in their analysis of ideologies intrinsic to

discourses of racial domination in news media in Canada. If we want to change ideologies about

employment equity, we can reach the public through other domains – work and family – to

change the interest in stereotypical racial images into a desire for realistic images that are more

positive, less segmentary, more inclusionary, less dominating, more informed, and less

ideological.

To create inclusive and participatory decision-making in workplaces, employers and

employees must be given tools of interpretation and analysis so that everyone can be aware of

how words segregate people, thus excluding them from information and opportunities for

problem solving. Being aware of racism and race consciousness is only the beginning of

developing a community that is equipped with critical, strategic, empathic, and ethical thinking

that is the basis of accountability for unspoken and unacknowledged racial dominance.

French and Albright (1998) outlined a “discourse ethics” that provides a framework for

conflict management by convening stakeholders in a variety of practical procedures guided by an



33

ethicist. The approach requires all those affected by decisions to be included in the discourse.

Kettner (1993) suggested that all stakeholders should be able to challenge one another’s

assertions. This process requires that power differentials are neutralized for the purposes of

debate. All parties are expected to own their own perceptions and be open about their interests

and motivations pertaining to the goals and/or issues under consideration. We see this report as a

gesture in being open and ask our colleagues, Canada-wide, to engage in debate on the issues we

raise here.

Participatory Action Research Methodology: Toward Consensus Building among Stakeholders In PAR, subjects become researchers in partnership with those involved in the project who have

specialized research training. Those with the specialized training adopt new epistemologies that

permit them to be committed learners in a process that leads to promoting change rather than

preserving a semblance of detachment and neutrality. See Oquist (1978) and Fals Borda (1979)

for elaborations on epistemology and methods for conducting PAR, for example, transforming

reality. Also see Stevens and Hall (1992) for references to the major critical theories informing

the philosophy and Hagey (1997) for abuses of the methodology. See Susskind, McKeaman, and

Thomas-Larmer in the Consensus Building Handbook (1999) for effective techniques in bringing

polarized groups to the table.

The concept of reflexivity invites the clarification of power relations through locating

oneself within relational hierarchies. PAR supports owning responsibilities and a reality

orientation that for example assists participants in identifying how we contribute to our own

oppression and to the oppression of others. These exercises form the base from which we can

support an empowerment process. The simple human interaction techniques employed in our



34

think tanks have helped to generate shared knowledge, understandings, and new relationships

and roles. Ethnically-based nursing associations have now a seat at the table with numerous

other associations. New relations and consensus about achieving accountability were developed.

According to PAR philosophy, rather than putting culture-based differences under a microscope

for examination, each party owns its preferences and communicates them to others in coming to

new understandings and a common agenda. The agenda has focussed on, for example, getting

visible minority nurses elected to key positions. Marcia Taylor was recently voted as a

counsellor at the College of Nurses of Ontario.

Sampling PAR typically is not concerned with sampling issues. Participation is purposefully organized but

can meet with resistance. Participants who identify with the concerns of the research self-select.

Others resist. In our research, participants self-selected by attending think tanks and invited

others to come. Participating nurses heard about the think tanks through word of mouth or

through advertisements in minority media as well as in "Hospital News," a national paper that is

distributed free in most hospitals.

The PAR research network purposely held one of the think tanks at a university research

day to garner participation from top decision-makers in nursing who represent a racially skewed

population. Other attempts included phoning selected leaders personally to invite them to events

and distributing an open letter to the Joint Provincial Nursing Committee at a conference of both

RNAO and RPNAO. Although we contracted to pay to have this letter distributed in the hand

outs the registrants would all receive at the conference, this privilege was denied (without our

being informed until the day of the conference), and we had to distribute our letter and other

materials by hand.



35

Demographics PAR usually is not concerned with demographic particulars either because of its reality

grounding in common interests for change and its more personal interests in the parties for the

sake of the common cause. However, the demographic breakdown of participants who

completed Das Gupta's survey between November, 2001, and May, 2002 (reported on pp. 10-12

and pp. 48-50), offers a rough reflection of the proportion of groups that participated. It should

also be noted that most of the participants had actively pursued advanced certification, and a

large number held advanced degrees. Furthermore, Aboriginal nurses eventually asked for a

category that would reflect their presence so they would not have to list themselves as "other."

Issues of Validity and Generalization In this participatory action study, we validated diverse meanings expressed by multiple actors.

Moreover, we advocated in our provincial and national resolutions to the RNAO and Canadian

Nurses Association respectively, for carefully planned forums and specific strategies for

implementing accountability for equity in nursing. The resolutions to the RNAO were passed so

have taken on validity, but not until they are translated into programs and practices, will their

everyday validity in the workplace be established and generalized.

In our case reports about set-up and backlash, we have not made claims about the

prevalence of reported incidents, but we are very concerned that patterns of targeting racialized

nurses will reappear whenever job scarcity occurs. These patterns should be followed up in

future research. The groundwork for research based monitoring of equity indicators should

begin immediately.

Suggested Strategies for Stakeholders to Work Productively Together



36

To build a social movement and bring programs and policies into being, we need to activate

various processes such as resolutions, lobbying, negotiation, strategic planning, and consensus

building. We explicitly developed ground rules for participation processes, both within our own

network and in reaching out to prominent leaders to stimulate policy discussions. Responsive

self-reflection and accountability in the relationship is anticipated to more effectively emancipate

nurses than resistance and counter-resistance among racialized and non-racialized nurses. But

first, working relationships among all nurses in the racially stratified hierarchies nurses speak of

will have to take shape.

To help establish working relations in our think tanks, the following guidelines were

circulated to all participants.

1. Our objectives include:

• Identifying supportive partners who will promote the agenda of accountability;

• Identifying ways of building positive relationships so that our perspectives will be

learned and appreciated; and

• Identifying language that can be heard and absorbed.

2. Our methods include:

• Identifying triggers that put us and others into automatic, unconscious, negative

communication;

• Being astute about areas conducive to common understanding and consensus building;

• Listening carefully to ourselves and others and slowing the communication down so

connections can occur; and

• Reaching out to the other with questions so that we can understand, clarify, and reconnect

after disconnects occur.



37

3. Our focus includes interdependence, respect, trust, and mutual problem solving.

4. Our process begins by saying what each of us wants and what we don’t like. All perceptions

are important and valid as perceptions. What we are building is a movement. We have the

freedom to speak up. We are holding everyone accountable for the negative images and

outcomes of systemic racism, set-up, and backlash.

5. Stakeholders negotiate how they want to engage with each other and what they want to

achieve. Building relationships across boundaries is necessary to engender responsibility

and collegiality and motivate those in positions of power to initiate inclusion practices and

incentive strategies so that everyone gains. Accountability requires implementing anti-

discrimination and anti-harassment programs and monitoring employment equity. Within

emerging relationships, strategies for implementing accountability for equality can be

clarified and negotiated. Accountability is the means to Equity.

Evidence of Stakeholder Resistance to Accountability Moves At the risk of sounding ungrateful, it must be pointed out that the initiatives to promote equity

taken so far have been perceived by many of the participants to be insufficient. Moreover, they

feel that some of the initiatives have actually set back the push for accountability for racial

discrimination because they "soft pedaled" around the real problem, making it appear that the

issue was addressed. Numerous examples of resistance to dealing with individual nurses who

experienced racism in their work life cannot be reported for fear of backlash. The following are

a few examples that have been publicly visible to the participants.

Canadian Nurses Association (CNA)



38

CEHS developed a set of resolutions concerning specific strategies to facilitate equity in nursing

on the understanding that they could be introduced for discussion by a voting delegate at the June

2002, CNA Biennial General Meeting. However, the CEHS negotiator was counselled by CNA

officials to submit the resolutions to the November 2002 resolutions meeting rather than have

controversial items "create a futile discussion and then get voted down." CEHS followed this

advice and worked with the CNA officials to hone the wording into the "diversity resolution"

that got slated first on the roster at the annual meeting the following year. However, the

negotiator failed to get a seat as a voting delegate and when the question was called to admit the

resolution onto the floor for discussion, every voting delegate across Canada voted against it.

See Appendix B for the resolution and backgrounders that were not discussed at the Canadian

Nurses Association Meeting June 12, 2003. One prominent nurse leader from Ontario who

champions human rights afterward said to the negotiator, "The resource implications were

overwhelming."

Resistance to accountability is a topic that ought to be discussed by all the stakeholders in

nursing if we are to move toward racial equality and employment equity in nursing in Canada.

As stakeholders we have the freedom to consider how resistance is a type of discourse (language

and ideology). Accountability too depends on language and ideology. We have the power to

change discourses, beginning with the social categories that give rise to racial profiling in our

profession. Nursing is at the crossroads. Racial subordination and segregation can continue or

they can be addressed and dismantled.

Canadian Institute for Health Information (CIHI) CIHI's recent report, Canada's Health Care Providers (2003, p. 85), must be seen as negligent.

Despite the Ottawa Charter's declaration that equity is a determinant of health, this report



39

identifying health risks makes no mention of equity issues in the provision of health care. More

alarming is the report’s reviews of what is known and not known. It makes no mention of what

is not known about variations in and between occupations by ethnicity, Aboriginal or visible

minority status, first language, place of birth, etc. Racial discrimination, racial disputes, and the

health problems among care providers that can ensue from them are not even on the radar screen.

The Joint Provincial Nursing Committee CEHS has called for representation of racialized nurses on this powerful body that informs the

nursing secretariat at the Ministry of Health and Long-Term Care. CEHS invited the erstwhile

chair to join CEHS or designate an affiliate, but she declined.

Changing Discourse to Achieve Stakeholder Accountability The accountability strategies we would like to see emerge would involve changing discourses

(ideology, language, practices) among all the stakeholders, employers, employees, unions, and

clients in the health care system.

Changing discourse requires a social movement and change of location. The term

“location” as in “content and location of discourse” is used metaphorically in this report to

connote the importance of positioning in power relations. We invited ethnically-based nursing

associations known to the researchers to a series of preparatory gatherings. It was discovered

that most of the members of these associations did not belong to RNAO, which was perceived by

some as the dominant ethnic group in control of access, agenda-setting, and programs for

professional nurses.

In the early meetings to strategize how to meet the study objectives, a strong fear was

expressed about employers finding out that participants were gathering to discuss their plight.



40

Consequently, we followed advice to proceed discreetly in advertising the study. It was decided

to hold a series of think tanks in strategic locations around the Greater Toronto Area so that

nurses in each area would not have too far to travel. The fear of backlash for meeting outside of

the official professional nursing association was resolved by the third think tank, which was held

at the Registered Nurses Association of Ontario (RNAO). On March 19th, 2002, the RNAO

boardroom was packed, and the issue of employment equity and the problem of racial

discrimination in nursing were declared to be on the agenda in nursing in Ontario:

We who have assembled at the RNAO Think Tank funded by the Canadian Race Relations Foundation invite all those in the nursing profession to study our recommendations for policy. Accountability for equal opportunity arising from the lived experience of racism is declared to be the agenda. The process that had been encumbered by isolation and the fear of backlash dissolved.

Indeed, the understanding of racial backlash that emerged was that isolation is a condition for

reprisals. Accordingly, building coalitions and organizing a research-based challenge to

resistance, retaliation, denial, and inertia became strategies for addressing the lurking problem of

racial backlash.

Five think tanks were held during the course of the research to identify barriers, concerns,

and specific strategies for accountability toward improving knowledge and practice in specific

contexts such as performance review, career development, nursing education, and using

technology to advance equity. The discourse generated by the think tanks addressed barriers,

concerns, and strategies in personal narratives and dialogue. A consensus emerged regarding the

existence of systemic racism and racial hierarchies that spawn disputes between individuals or

groups who are members of separate racial groupings. This includes the ubiquity of disputes

arising between members of racialized groups.



41

No consensus was reached on how to proceed collectively or whether collective strategies

were possible. While there was consensus that the profession as a whole must own the problem,

there was some resentment about only those with experiential knowledge of racism currently

owning the problem, and about those with "knowledge deficits" avoiding all opportunities

presented for gaining that knowledge. Very few white nurses, whether at staff, executive,

manager, or educator levels, attended any of the think tanks. Even the think tank that was

conveniently held in conjunction with a research day that was very well attended by nurse

leaders drew little interest from members of the "in-groups." With a couple of exceptions, a

number of VPs of nursing said they were coming but never actually attended or sent someone in

their stead.

Health problems that arose due to inequities were recognized in our awards and healing

ceremony held on the opening day of the biennial conference of the Canadian Nurses

Association at the Sheraton Hotel in Toronto on June 23, 2002. The event garnered considerable

media coverage in minority community television and newsprint and the ceremony was recorded

on video. The practice of healing relationships and building communitarian values is palpable in

this visual record of the heart of our study. It clearly details the power of public apology and

forgiveness to galvanize relationships.

This ceremony also represented the inauguration and consolidation of a research network

composed of nurse leaders from the numerous language and cultural minority communities in

Canada. Following the ceremony, resolutions to the Canadian Nurses Association were

developed by a group of those in attendance.

The CNA resolutions (see Appendix B) provide an example of how changing discourse

location can function as a power strategy. To mobilize accountability initiatives, it may be



42

necessary to go outside of organizations for external support. The resolutions were circulated to

the federal Minister of Health, the provincial Minister of Health, the provincial Attorney

General, the Association of Canadian Health and Human Resources (ACHHR), the Canadian

Federation of Nursing Unions, the Ontario Nurses Association, the Joint Provincial Nursing

Committee, and the national Office for Nursing Policy, Health Canada.

At the provincial level, we sent out invitational letters to the presidents of RNAO and

RPNAO and requested that copies go to members of the nursing provincial secretariat and the

Joint Provincial Nursing Committee (JPNC). We invited these organizations and the Canadian

Nurses Association to attend the November (2002) RPNAO/RNAO conference concurrent

session on “Racism and Responses.” Members of the Centre for Equity in Health and Society

participated in the round table on “Racism and Responses” at this conference on Healthy

Workplaces in Action and were credited with naming the theme of this concurrent session. It

was the first time the word racism had been officially used in a public forum sponsored by either

of these organizations.

The Centre for Equity in Health and Society solicited nurses to join the network at this

event. Electronic technology now permits such networks to function as virtual centres, and the

CEHS is now incorporated as a non-profit organization within the province of Ontario. One

CEHS mandate is to integrate the content of OHA/OMH JPPC 1995 anti-racism policy

throughout Canadian nursing. The four pillars of this policy are anti-racism, anti-discrimination,

employment equity, and culture care.

CEHS is hopeful that activities in participatory research, advocacy, and capacity-building

will lead to more racial integration and freedom to talk about issues. We predict change in

discourse practices. For example, it will become normal and acceptable to voice issues of set-up



43

and backlash and to organize to prevent and stop these unfair harassment activities. Attention

will have to be paid to levels of feeling, trust, and safety as we work towards inclusion in a

profession that is predominantly female and subject to what has been described as horizontal

violence – abuse by one nurse against another.

CEHS anticipates playing a major role in contributing to new regulators of discourse to

develop leadership that will help achieve an accountability for employment equity, as well as

access and participation in nursing, that is effective at reducing racial disparities. We envision

new policy that will guide programs and regulate outcomes by various means of accountability

for racial equality and employment equity in nursing.

One regulator of discourse already being studied in a downtown Toronto hospital that has

a nursing informatics department is the use of human rights software to monitor equity,

privileges, and the incidence of harassment in the employer organization. We refer the reader to

the recommendations in “A Time for Change” (Kohli and Thomas, 1995), that could form a

basis for interventions to address systemic discrimination (see Appendix F). Another Canadian

initiative that we found that addresses systemic discrimination in tool development was Carol

Agocs and Harish Jain's (2001) preliminary study, “Systemic Racism in Employment in Canada:

Diagnosing systemic racism in organizational culture.”

We advocate supporting the new personal discourse that is required for changing our

profession and the organizations we work in. We encourage all nurses and health care workers

to attend anti-racism workshops where exercises for engaging in deep self-reflection and healing

self-disclosures are facilitated.

Finally, we advocate moving to new and healthier outcomes of discourse strategies. In

our findings section, we present heart-rending metaphors that illustrate the serious trauma



44

suffered by nurses who had filed formal complaints or grievances charging their employers with

racism. Racial disputes that challenged racial targeting resulted in negative health outcomes for

these nurses during a period of restructuring.

By contrast, white nurses who were transferred or let go during the restructuring period

were reported to be approached in more caring ways and were often helped to find another

position. The outcomes, which were seen as very different by nurses who disputed racism,

involved racially based differences, set-up, and backlash for broaching accountability issues.

This report is intended to stimulate accountability for racial equality and employment

equity in Canada. Using participatory action research (PAR) to engage in transformational anti-

racism in nursing, we identified issues that represent the need for accountability for the

discourses of racial domination throughout the profession. We turn now to present the study

findings on racial set-up and backlash.

Undoing the Catch-22 of Racism: Overview of Study Findings


45

Chapter 2 – Evidence of the Need for Accountability:

Presentation of findings



46

Some Effects on Nurses of Race, Colour, or Ethnicity: Summary of Das Gupta’s Survey of Nurses, November 2001 – May 2002 As the tables depicted in our Executive Summary, of the sixty-two nurses who completed the

survey at think tanks:

• Fifty-four indicated that they had been made to feel uncomfortable as a nurse because of

their race, colour, or ethnicity.

• Fifty-six felt that they had been put-down, insulted, or degraded because of their colour,

race, or ethnicity. A break-down of the data follows:

Nineteen indicated that a doctor had put them down;

Twenty-four indicated that their manager had put them down;

Thirty-eight indicated that a patient had put them down; and

Thirty-two indicated that another nurse had put them down.

• Some mentioned that they had encountered more than one harasser.

• Thrity-three said that they took some action, whereas twenty-two did not take action;

seven did not respond.

• Of those who took some action, thirteen had positive results; sixteen had no results or a

negative result; four situations are ongoing.

• This experience affected forty-seven respondents emotionally, eighteen physically, and

twenty-eight mentally. Several respondents noted more than one effect.

• Thirty felt that their ethnicity/colour/race had an effect on their hiring; twenty-five felt it

had no effect; two did not know; and five did not respond.

• Thirty-nine felt that their ethnicity/colour/race had an effect on their promotion; eighteen

felt it had no effect; one did not know; and four did not respond.



47

• Thirty-eight felt that their ethnicity/colour/race had an effect on their relations with

colleagues; seventeen felt it had no effect; and seven did not respond.

• Thirty-seven felt that their ethnicity/colour/race had an effect on their relations with

managers; seventeen felt it had no effect; one did not know; and seven did not respond.

• Thirty-nine felt that their ethnicity/colour/race had an effect on their relations with

patients; eighteen felt it had no effect; and five did not respond.

• Thirty-three felt that their ethnicity/colour/race affected where they worked; fourteen felt

it had no effect; and fifteen did not respond.

• Thirty felt that their ethnicity/colour/race had an effect on access to training; thirteen felt

it had no effect; one did not know; and eighteen did not respond.

• Three felt that their ethnicity/colour/race had an effect on access to accommodation due

to disability; thirty-six felt it had no effect; and twenty-three did not respond/not

applicable.

• Twelve felt that their ethnicity/colour/race affected their sick leaves; forty felt it had no

effect; and ten did not respond.

• Twenty-one felt that their ethnicity/colour/race affected their performance reviews;

eighteen felt it had no effect; and twenty-three did not respond/not applicable.

• Fifteen felt that their ethnicity/colour/race affected their experience of being disciplined;

thirty-four felt it had no effect; and thirteen did not respond/not applicable.

Demographic breakdown of the respondents

• Thirty-eight Black/African Canadian

• Thirteen Asian/South Asian Canadian

• Five White/European



48

• Four Other

• One Central/South American

• One No response

---------------------------------------------------

• Fifty-seven Female

• Three Male

• Two No response

Set-up: Racially organizing advantages and disadvantages during downsizing

Merle Jacobs and Rebecca Hagey What is a Racial Set-up? As alluded to earlier, a classic example of a racial set-up came to light when Claudine Charley, a

nurse at the Toronto Hospital, discovered that a child's monitor had been unplugged without her

knowledge. Pursuing the problem in a tense environment that was undergoing restructuring, she

came to suspect that the monitor was unplugged on purpose so that she might be seen as

negligent. Her hypothesis, which she addressed with utmost diplomacy, was reacted to by

management and soon Claudine found herself being disciplined and having to defend herself in a

human rights complaint. Under oath, the nurse Claudine had suspected confessed to having

purposely unplugged the monitor in order to cast into doubt Claudine's competence.

Claudine who, though she was a victim of racial discrimination, felt she was treated as an

offender at her place of employment. She took a $50,000 reduction of her award of $300,000 in

order to have the right to let the public know about her set-up. Unfortunately for Claudine, she



49

experienced great disappointment and suffering over her portrayal in the mainstream media “not

as someone defending my rights but as someone who was paid off by the hospital to go away and

keep quiet about my questionable abilities as a nurse” (personal communication, 1996).

What follows is a preliminary exploration toward theoretical understandings of set-up as

a social phenomenon and as a set of interactional discourse strategies. The majority of nurses

whom researchers belonging to the CEHS network interviewed (N = forty) because they had

filed formal grievances or complaints, used the term set-up in describing what they experienced.

It can be noted in Claudine's case and numerous others that there was immediate denial

about participating in a set-up and that there was a closing of ranks against her, suggesting there

was a collective, and perhaps rather unconscious, shared group response to protect members of

the dominant groups and systematically disadvantage individuals like Claudine, racially

dominated in the process. The concept does not require us to contemplate the motivations of the

players involved. It is plausible indeed that the players are unaware of any purposeful

motivation. However, the timely effects of set-up – the social differences that are constructed

when a scarcity of jobs has emerged – reveal an organized process of racial domination that

begins with racial discrimination and results in less privilege for racialized nurses and more

privilege for non-racialized nurses in the responses to job scarcity.

This set-up of group control depends on a lack of transparency and accountability to

flourish, and results in creation of an in-group and an out-group or outcast individual. The fact

that accountability is conditional on transparency has hampered the efforts to integrate

accountability for systemic racism into clinical practices.

Secretive administrative decisions that elect to discipline racialized nurses rather than

expose strategies designed to benefit certain in-group members are hidden and the appearance is



50

created in the setting that what is going on is normal. This situation is problematic, but

“normal,” since it is normal to problematize racialized individuals in an institution that condones

racism.

Understanding set-up as an aspect of systemic racism can help us all begin to see the

process of racialization as a systematic way in which people in organizations can use racial

discrimination to advantage without necessarily being obvious or accountable. The extra benefit

of their being seen as upholding rational standards adds barriers to transparency, as does the fact

that decisions are made behind closed doors without representation or actual input from members

of the out-group or racialized persons.

Tokenism can also be a feature in a set-up. The small number of out-group members

who are let into the game are under the same bind as every member of the in-group. Anyone

who breaks the code will suffer backlash in some form such as being ignored or isolated, having

privileges removed, or being set-up for retaliation and serious harassment and punishment. The

same code is applied for members of the dominant group who do not go along with the game.

The fact that this type of anti-social treatment erodes persons’ self-confidence, re-

organizes their priorities, saps their energies, affects their personal and family lives, and so on,

works to perpetuate the system. Most people conform to the set-up as long as it is someone else

who is targeted. This response even applies to managers in positions of authority who join an

organization with an agenda to effect change but who are brought into conformity since they

need co-operation and since the in-group sticks together. Outsiders with influence can sabotage

their reform agenda.

That is, set-up is an aspect of social and political power that can be used to coerce people

because vulnerable people fear rejection, isolation, or expulsion. The strategy of set-up, then, is



51

not coincidental when one considers that the agenda of racialized peoples is equal inclusion and

participation. The strategy of set-up did not succeed altogether in Claudine Charley's case. She

chose to be included in the history of the fight for human rights rather than succumb to racial

domination as so many others had done at her hospital. The set-up did succeed in making her

life miserable for many months. It succeeded in motivating her to organize the presence of at

least forty nurses at each hearing, each with a daffodil signifying their fight against the cancer of

racism.

There are at least four types of set-up: (1) targeting individuals; (2) top-down

orchestration; (3) recruitment of peers; and (4) pre-emptive or reactive documentation that we

will be pursuing in this discussion. These different types of set-up all have certain functions in

common. The functions, apart from having “everyone really on their toes to do their bidding” as

one participant stated, include ferreting out opposition, capturing and securing advantage,

reinforcing the game plan, and fending off liability. This latter function is a sanctification

activity because, theoretically, under the law, employers are liable for discrimination practices.

All four of the types of set-up that we describe leave racialized nurses fundamentally

vulnerable and subject to racialization, which can be ongoing or intermittent. Their supporters

who have power can be coerced into abandoning them for fear of lack of group support. The

pervasive awareness of lack of accountability and lack of transparency is fundamentally

unnerving for those in the vulnerable position of being a potential target. Situations where

racializing can occur with impunity set up relationships of ready-to-distrust/not-being-perceived-

as-trustworthy, which is problematic for balance, reciprocity, and collaboration in working

relationships. Communication becomes defensive on both sides when the targeted nurse gives

any indication of objecting to the treatment. Reciprocal resistance begins. The targeted person’s



52

resistance becomes evidence to the in-group that the person does not really belong in the work

unit, and then the person is isolated. It is crucial to recognise the in-group’s set-up strategies that

marginalize, exclude, problematize, and contain and isolate along racial lines. Set-up is a

method for achieving outcomes of racial segmentation and segregation with impunity since

accountability is not in the picture. For example, one hospital with documented set-up practices

provided separation packages for white nurse managers but not for nurse managers of colour

following its lay-offs. Immunity, silence, and the advantages gained by being part of the set-up

rather than a target constitute a powerful incentive for onlookers to condone events rather than

challenge them, as this shocking example shows.

If we want to theoretically test the importance of lack of accountability to the

perpetuation of set-up, we can pose the question of what happens if accountability is introduced.

What Happens if Accountability is Introduced? We believe that accountability to prevent set-up from occurring would require a set of conditions

parallel to the types outlined previously that make set-up possible. The parallel types we pose,

respectively, are strategies used by Claudine Charley that relied on the Human Rights

Commission Policy at the time (which was then much stronger than it is now): (1) She gained the

presence of supportive individuals, but unfortunately most were from outside her work unit; (2)

She orchestrated activities toward inclusion by including herself in the duly constituted

complaints process available to her; (3) She recruited peers for support from key external sources

such as the Congress of Black Women of Canada; and (4) She strategically used documents to

establish the facts of her case. Each of these conditions can be seen as an intervention motivated

to bring balance to an out-of-balance set of relationships. We will come back to these strategies

later in our discussion to consider what might be the necessary structure to prevent out-of-



53

balance race relations from developing in the first place. Each of these parallel activities requires

leveraging social power for example, from a union or union installed diversity unit, from access

to an "old boys network" or from external media, or from community consensus building that

establishes a powerful advocacy group.

Even then, as we will show, these strategies are not yet a panacea for realizing racial

justice in nursing in Canada. It is important to recognize that particularly racist individuals can

have enough autonomy within an organization to harass with impunity since autonomy is a

fundamental value that overrides equity in our society. Colleagues would rather condone than

oppose. The mythologies about equal opportunity, merit, or individual responsibility that place

the onus on the racialized individual or group to "pull themselves up" are rooted in a lack of

acknowledgement of the anti-social workings of set-up and in-group/out-group politics.

Ideologies about freedom of choice, founded on individual liberties trumpeted in the legal

documents of society, are rather oblivious, not to mention non-compassionate, about restrictions

on choice when the sanctions are against a racialized person(s) being set-up in a negative bind

formation. The individual in a negative bind – damned if they do or damned if they don't – has

to decide whether to risk backlash for objecting to the treatment or risk allowing the set-up to

proceed with impunity. This is a bind that many racialized individuals understand, whereas non-

racialized individuals, without the experience of being targeted, apparently have difficulty

understanding what is going on. “Speak no racism, hear no racism, see no racism” appears to

cloud their observational capacities.

Examples of Set-up in Nursing in an Environment Where Racial Profiling Is Not Held Accountable We present four types of racializing set-up – forms of coercive control – that disadvantage and

thus racialize members of designated groups and marginalize any supporters they might have. In



54

these situations, nurses of colour have felt harassed, especially as the set-up intensifies and the

effects start taking their toll.

1) Targeting the Individual

This type of set-up is typical when an individual is targeted by another nurse who is at an

immediate level above her or him. Nurses reported, as an example of this behaviour, being given

heavy assignments from a charge nurse or unit manager and feeling set-up when problems occur.

One nurse reported that she had the heaviest load and could not give adequate care to all her

patients, while the rest of her peers had “normal work loads.” She was reprimanded for not

doing her work. Racialized nurses also reported that they are pulled aside and spoken to more

often than their white counterparts. One nurse told us how she perceived being set up:

I was in my office when the new director came in and introduced herself. She said that she would be working with me to help me develop, and that I had been working in the institution far too long, had I thought about moving to another hospital. I asked her how she knew this about me as this was her first day meeting me and new to the hospital. She informed me that she had heard that my unit was not up to the standards of how patient care should be delivered. There were no witnesses, but I knew I did not have the support of nor would I get the right direction from this new, white director when it came to doing my job. In fact, I felt that she was setting me up for failure.

This passage reveals that the new director had tipped off the nurse that she was not

welcome through comments such as “working in the institution too long” and that the “unit was

not up to the standards of how patient care should be delivered.” These signals alerted her to the

possibility of being set up. So when this nurse observed that her workload was heavier than

others and inquired about it, she was told it was “just her heavy day.” She came away thinking

that perhaps the supervisor was “parcelling out heavy days to everyone.” Then she began

worrying about the opening greetings the supervisor met her with, without getting to know her as

a person, as she saw her assignments were consistently heavier than the white nurses'. In a

while, she felt the set-up. She faced the dilemma of either repeating her question about the



55

perceived unfair workload or quietly submitting to the racialized assignment. It is this dilemma,

this being contained, that is an earmark of racialized set-up.

We conceptualized this situation as being racialized on two counts. We were suspicious

because the supervisor was white and the nurse was a racialized person. Furthermore, the

allegation was that the white nurses consistently had a lighter load and the nurse of colour a

heavier load. However, the clincher was the supervisor’s continuing distant approach, which

was laced with messages of veiled threats that anyone would perceive as unsettling, if not fear-

inducing. Opportunities to clear up any ambiguity regarding these innuendoes all confirmed the

consistency of the unspoken message: “You have good reason to be fearful. Do my bidding or

take the consequences,” or “you can try to placate me.”

Ambiguous messages that imply subtle coercion are cause for feeling psychologically

harassed. However, the spectre also looms of being disciplined for minor professional oversights

that white nurses are allowed to commit without fear of reprisal. This nurse felt that her

supervisor's set-up strategy had escalated to the realm of tripping her up on professional issues.

She had reluctantly opted to being saddled with an unreasonable and unfair workload, not being

able to gain support for her plight from those non-racialized nurses who had a lighter load and

who clearly did not want to jeopardize that privilege. This fear of professional slip-ups fed her

feeling of psychological dis-ease. Even though she was pressed for time, she felt compelled to

document defensively to protect herself. She then became aware that she, too, was being

documented.

The nurses we interviewed who resolved their set-up dilemma by acting on

documentation to complain or grieve, for example about their work load, found they immediately

“became” the problem, as noted in the literature (Veecock, as cited in Calliste, 1995; Essed,



56

1991; Smith, 1990). The supervisor’s task, then, under the set-up logic was to gather allies from

upper management, internally from staff, and externally from colleagues. With all bases

secured, the supervisor then could buy off the staff with special privileges and isolate the

problem nurse.

2) Top-down Setting up of Racialized Informal Policies and Practices Calliste (2000b) argues that the existence of dispute mechanisms that are controlling, coercive,

and racialized are manifestations of a surplus labour pool that is activated as necessary,

depending on demand. A vulnerable pool of racialized immigrants will stand in line for jobs that

are casual and temporary. Indeed, Head’s (1985) study suggesting that equity becomes popular

during periods of job surplus, but disappears during job scarcity, gives credence to this logic. It

is not surprising then that one form of set-up occurs when management seeks to re-organize

institutions. The set-up is accomplished through a "rationalization" of work, where opinions and

decisions are held to be objective. Any challenge about this fact of objectivity is dealt with

abruptly.

For example, when racialized managers in one hospital that was in the midst of

downsizing reviewed staff as they closed departments, they were critical of the method whereby

staff declared their first, second, and third choice of placement. They saw it as an imposition on

vulnerable staff members who had the onus placed on them to lay bare their perceptions of their

options. Their vulnerability, then, could be exploited. As an example, when senior management

knows what individuals want such as a certain speciality, they can put the racialized middle

manager on par with lower staff competing for a job, any job. The information is power. Senior

management can make an offer nobody would want to refuse. They can play one individual off

against another.



57

Indeed, it became apparent that this method resulted in assigning non-racialized staff to

preferred areas such as emergency or intensive care, while racialized staff were placed in heavy

medical units or in areas that were not one of their three choices. The racialized managers who

complained were targeted. Even though they had seniority, they were asked to step down and

work as staff nurses, while their white counterparts were given another unit to manage. The staff

who got the better jobs were set-up to win due to white management’s control of the positions

and activities that set up the racialized staff. The discourse of luck was used in face-to-face

situations to explain how some nurses were lucky to get their first choice, while racialized

managers who took staff nurse jobs were lucky to have a job at all. This discourse appears to

validate the surplus labour pool hypothesis (see Calliste, 2000b) that works on the axiom, “you

are lucky to have work at all.”

Another aspect of top-down orchestration of racialization is concerned with what

strategies are used to release information and to whom it is released. Typically, the set-up works

by providing information to non-racialized managers during social hours while not providing

racialized managers with the same information. As one racialized nurse manager stated:

I was not told to inform my staff that they had to bring in their registration or they would be docked a day’s wage. This was not policy and was not discussed in any meetings. However, when I did not dock the wages of my staff, I was told I did not know how to manage my unit. There were so many little things that they [other managers] would be told, and I would be looked at with a "so you don’t know again" type look, while all the time they withheld information from me for doing my job.

It is important to recognize that when there is laissez-faire for racial domination, that is

when there are no accountability mechanisms to curb its use in employer/employee and

employee/employee relations, then the much-touted strategy of building up relationships and

friendships is not of much use in single-handedly gaining transparency and/or accountability.

Moreover, discourse strategies that request clarification presenting a challenge are not really an



58

option. As this manager found out, racialized managers are kept out of the collaborative

decision-making loop:

Challenging this type of behaviour often triggers accusations that the individual is defensive for not doing her/his job, is not a team player, or is preoccupied with narrow issues relating to the area of management and not to the organization. ….Withholding information on how decisions are made is crucial for during work orientation and work socialization. So then you are in a bind of having insufficient knowledge to do your job versus triggering more barriers by even hinting that you are dissatisfied with the flow of information. 3) Recruiting Compliant Peers who Support Targeting and Scape-goating

This type of set-up operates when managers ask white nurses to provide them with information

about a racialized peer. The behaviour occurs at the management as well as at the staff nurse

level. The request itself sends the message that it is permissible to target racialized nurses. For

example, at the staff level, managers have been observed to recruit non-racialized peers to "tell

on" the racialized group or nurse. Nurses set-up their peer by looking for errors, missed charting,

or missed physicians’ orders. One nurse reported:

Complaints were made in writing about my missed work, while for the white nurses the excuse was, “Oh well, we have continuity over 24 hours…" Another way of setting me up was to have peers send patients not suited for the unit so that when a medical incident occurred, it was due to my incompetence and not that the patient should have been in an intensive care bed. In fact, when a patient had an arrest and died within 24 hours of the transfer, it was my fault even though I protested the decision to put this acutely ill person on a rehab unit…. and they upheld the decision of the white manager who sent the patient…As these incidents are par for the course, going on all the time, I may be unaware of what is occurring but I feel the stress of being over-monitored and not having support from my colleagues.

Some white nurses refuse to be recruited to participate in set-ups and, in fact, testify on

behalf of nurses of colour when the complaint goes forward to a grievance. Such support is

crucial for the complainant.

4) Documentation for Pre-emptive or Reactive Defence of Set-ups



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Racialized nurses and managers have reported that their human resource files include documents

that they were unaware of until they checked the file. This set-up is related to targeting but is not

visible or known by the individuals that are being set-up. For example, a manager expressed

anger when she looked at her file and found notes on her meetings, patient care decisions, and

reports from her staff. She reported:

They wrote notes on me when they spoke to me about anything or when they met with me to discuss staff-related issues. The notes were negative in that they always had a spin that I was not doing my job. As I did not know about this, I did not have a chance [to] refute the accusations. Once I knew and spoke to the HR manager, who did not see a problem with this behaviour, I added my side to the file. I felt that they were setting me up for dismissal and failure…Then my shortcomings were stated in terms of how they saw me measuring up to the guidelines and standards. The discussion was never about patient safety or how could this be organized to solve the problem. It was all a frame-up of me and my deficiencies.

As we have seen in Das Gupta’s (2002) study, these sorts of encounters are probably very

rare for non-racialized nurses. Only 1% of White/European nurses felt that their race, colour, or

ethnicity might be interfering with their performance review, whereas the percentage was up to

39% for racialized nurses. This finding raises the possibility that some racialized nurses could

feel vulnerable to a set-up regarding their performance review that would result in further

racializing them.

It is important to theorize about the organizational dynamics that can result when the

ruling in-group becomes defensive and controlling, such as when job scarcity precipitates

downsizing and transfers. Two main options appear to be available to those subject to racial

targeting: (1) buckling in and trying to survive being set-up, and navigating the unfairness and

oppression by hanging onto any good relationships in the work setting or (2) challenging the

unfairness and thus precipitating the consequences of set-up and opening up the possibility of

backlash. For example, it is not uncommon to have to demonstrate one’s innocence in the set-up



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and one’s general competency at the same time as having to show that racial discrimination was

taking place. The dispute process can drag on for months or years and be very destructive for the

nursing teams and the clients who are dependent on them.

Cautionary Summary These preliminary accounts on set-up supply examples of social and language practices that are

consistently reported among nurses who have filed complaints or grievances to describe what

they have experienced. The word “set-up” is used again and again in describing their story.

Ethnographic work would be required to more fully document these interactive discourse

practices. We have not been able to access the various persons who have participated in such

transactions since they have not been attracted to the study. Ethnography would call for

participant observation and interviews with all parties in a variety of settings in a number of

locations to develop a fuller picture of perceptions, stated rationales, motivations reported to

others, and so on. However, we are more interested in finding out how to break up such social

systems and have identified parallel positive strategies to each of the anti-social types of set-up,

as previously mentioned in the description of strategies used by Claudine Charley.

Such constructive strategies as identifying supportive individuals, orchestrating activities

to gain inclusion and influence (such as support under the Ontario Human Rights Code, when it

was accessible for use by unionized nurses), recruiting peers, and strategic use of documents,

could theoretically build up support against the negative set-up strategies of targeting

individuals, top-down orchestration, recruitment of peers, and pre-emptive or reactive

documentation, respectively. However, given the case examples we have been able to access in

this preliminary study, the success of these structural antidotes as interventions would depend on

racialized persons becoming organized. Relations of loyalty or solidarity would need to develop



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to erode the segmentation that divides racialized and non-racialized people and prevents equal

access and participation in the institution's discourses of power.

Case Study – The Story of Nurse “A”: The Grievance Process as a Set-up for Backlash

Jane Turrittin

Preface As an introduction to Nurse A's case, we call attention to the fact that the cappuccino principle

typifies the workplace hierarchy of most long-term care facilities in the GTA. Most staff are

racialized, and most patients, managers, and administrators are white with European ancestry.

That is, Nurse A worked in agencies that were rife with systemic racism and unaccustomed to

any accountability measures aimed at change.

Case Study In her effort to defend her human rights and expose racialization of staff as an impediment to the

delivery of quality care in the nursing homes at which she worked, Nurse A filed a total of

twenty-three grievances during her twenty-one year career in Toronto. This makes her the

champion of the participants in our "Making Racism See-able" research project (Collins et al.,

1998). She filed the first nine of these grievances at Old Person's Home 2 (OPH2) between 1980

and 1986 and the latter fourteen grievances at another nursing home, OPH1, her first employer in

Canada where she returned to work from 1990 to 1999. Twelve of these fourteen grievances

were filed between May 1996 and February 1999.

Nurse A also filed three complaints with the Ontario Human Rights Commission

(OHRC) and made submissions to other venues. Her insistence that her employers respect her

role as a nurse in mutual accountability for the treatment of both patients and staff has been a



62

core activity of her career as a nurse in Canada. We found Nurse A to be a lovely person,

extremely articulate with a droll sense of humour, but overladen with sadness.

For Nurse A, as for other nurses who have filed grievances, one of the costs of speaking

out is prolonged backlash. Employer backlash at OPH1 brought Nurse A into conflict with her

union, the Ontario Nurses Association (ONA). It profoundly affected her emotional and physical

health and continued even after Nurse A resigned. When Nurse A persisted in defending her

human rights and identified the conflict between herself and OPH1 management as one of racial

discrimination, OPH1 management problematized and harassed Nurse A using procedures to

marginalize and contain her. Management's retaliation activities thus escalated the dispute

process that was supposed to be the venue for problem solving and redress of grievances.

Nurse A's experience with discrimination and defense of her human rights in the 1980s

made her aware of the importance of documentation. When OPH1 management began to

discriminate against her in the early 1990s, she saved every scrap of evidence relating to her

case. Drawing upon this documentation, including legal documents, personal diaries, and letters,

as well as two interviews, we present here a highly selective version of Nurse A's experiences.

The story of Nurse A's efforts to make her union accountable on matters relating to racial

discrimination at work deserves far greater elaboration than we have been able to give in this

narrative. Nurse A is a union supporter and former union rep; she very much wants the ONA to

be accountable to its members on issues of racial discrimination.

Nurse A described a poisoned work environment that interfered with the delivery of

quality care at virtually every facility in which she worked. Moreover, the procedures available

to Nurse A and to management to deal with the racial disputes, such as the grievance process,

functioned primarily to escalate the conflict, thus compounding the traumatic quality of the lived



63

experience of racial discrimination. When Nurse A joined the participatory action research

effort, she volunteered to tell her story as a contribution toward equity assurance policies in

health care facilities that would render such trauma avoidable. We present Nurse A's case in

support of CEHS advocacy for the creation of equity assurance policies and procedures that

address victims' "core needs" in a dispute.

Ruth Morris, an expert on transformative justice, identified five "benchmarks" that

address victims' core needs: (1) the need for answers; (2) the need for recognition that they have

been wronged; (3) the need for safety; (4) the need for restitution and balance in workplace

relationships; and (5) the need to find significance or meaning from this assault on their human

rights (2000, p. 248). We use these benchmarks to evaluate Nurse A's experiences with

retaliation and escalation in the dispute process and the legal proceedings to which it gave rise.

Transformative justice defines racial discrimination as behaviour that harms not only

individuals and communities but social relationships. It therefore views racial conflict as an

opportunity for individuals and organizations to examine, reflect upon, and repair the

relationships that poison the workplace. Since the problem is a relational one, with a relationship

being out of balance, the goal is to get at the source of the problem and to change or transform

the relationship. Balance can be created and maintained by changing procedures that structure

relationships. Recognizing the importance of victims’ knowledge and experience as well as the

importance of community validation of this knowledge and experience, the restorative justice

model gives scope for the whole employment community to be involved in the healing process

(Law Commission of Canada, 1999, p. 23). It recognizes that the very proceedings that are

meant to help redress grievances are laden with denial and barriers that complicate the issues,

when what is needed is often apology for communications that marginalize, problematize, or



64

contain the complainant. This means that the organization employing nurses should practice

mutual accountability to prevent and deter racial discrimination to ensure due process for

handling complaints.

When Nurse A filed grievances and complaints charging OPH1 management with racial

discrimination, she wanted an opportunity to give her version of what had happened. She

wanted her employer and her union to recognize (public confirmation) that wrong (racial

discrimination) had occurred, and she hoped for no further harm to herself and others, and fair

(transparent) procedures. She wanted balance to be characteristic of relationships so that quality

care could be given in a work environment free from racial and other forms of discrimination.

She wanted all employees to be valued, and she wanted her experiences to have positive meaning

and significance through achievement of positive closure. We ask you to make use of the five

benchmarks to consider how effective the remedies available to Nurse A were with respect to

meeting her core needs.

Nurse A is Caribbean-born. She went to England for her nurses' training, taking a four-

year diploma course and a one-year program in midwifery. After living and working in England

for twenty-two years, she immigrated with her family to Canada in 1979. While preparing to

write her Ontario registration (licensing) exam, Nurse A worked part-time as a nurse’s aid at a

long-term nursing care facility, Old People's Home 1 (OPH1). Nurse A related how she became

quickly aware of the realities of racial stratification in the nursing profession in Canada.

During the early '80s, I worked at Toronto Western, at Northwestern, and I also started working at a nursing home in the Jane and Finch area…. I was encouraged to leave…the hospitals and come to long-term care because…nurses were dissatisfied with the treatment they were receiving and, having worked at Toronto Western and Northwestern, I was at the forefront of it too. I saw what there was.... I stood up to it, and had some repercussions but … I was fearless at the time and I tried to do some organizing of the nurses but it didn't work. In Northwestern, I can afford to tell you, discrimination – treating certain people –



65

was as plain as anybody's nose on their faces.... My colleagues on the unit, they just wanted to do what they had to do and …go home. And on a few occasions I said to them, "No, you can't just do what you have to do and leave. You can't. …There's a force here that doesn't give us any respect." And then that took a lot of my…. We started organizing so that we would get ONA in, and ONA did come in (personal communication, 2002).

When she got her license, Nurse A took a full-time job at OPH2, serving as union

representative.

I had about 9 grievances [that] were related to the Director of Care's (DOC) discriminatory behaviour, and the fact that the nurses were not getting what they were entitled to, and job satisfaction, and regarding job workload, and the …unsatisfactory and … obviously illegal ways that the staff in charge in the nursing office and administration behaved. We were supposed to get a pay rise. And the pay rise came, and we were all informed of what we would get. And…I disagreed and some of the other girls (all racialized)...disagreed because they realized that there was something wrong. I worked it out according to the schedule that we all worked and found out that, to the dollar… we were, all of us, every single night I worked on one person,… I made it a point of duty...And I…took the documents to [the nursing staff], told them to copy it,…and handed them to the office, and they [the administration] were…absolutely distressed and upset with me. I got my money. Besides, I took them to the Labour Board. I complained about [OPH2] not giving me my rightful amount of money. And the other nurses [also]. [Two of the 3 arbitrators were] Mr. Bromley Armstrong and Judge Rosalie Abella - she wasn't yet a judge at the time. [OPH2] had intended to keep this money…. (I)n the end after all the repercussions for me, I decided that I was going to leave (personal communication, 2002).

In her letter of resignation to the facility's administrator, Nurse A stated:

Non-staff recognition – poor support; uncaring attitude – creating unnecessary stress, has caused you to ignore your commitment to the residents. You have refused to explore any recommendations or solution to improve the morale of the staff through your bigotry. This organized and systematic flow of abnormal level of stress, this mental torture, this psychological warfare, is not good for anyone. I now find it difficult to function under the duress in this unstable environment (personal documents, August 21, 1986).

Shortly after Nurse A left, "Everybody was fired ... including (the DOC). They searched

and they found money staked away in the Coca Cola machine" (personal documents, August 21,



66

1986). Nurse A asked for and received a letter of reference. The envelope the letter was in also

contained a note of appreciation to her signed by the facility's administrator and a check for

$5,000, signed by the corporation's accountant. Was this check in compensation for her troubles,

in recognition of her whistle blowing, or both? The fact that management gave her this check is

in itself evidence of her integrity and their admission, perhaps, of the need for accountability.

Nurse A's experience with this employer shows that a lone individual exercising leadership can

have some success in making an employer accountable, if not for racialization of staff, at least

for failure to deliver quality care. But did anyone speak up after Nurse A left?

During the next four years, Nurse A worked at various nursing homes as well as through

an agency that sent her to work from time to time at OPH1, and she did not file any grievances.

In 1990, at the invitation of her old manager, a South Asian, as well as the Unit Manager at

OPH1, a white Canadian nurse, Nurse A began part-time work at OPH1. In 1992, she was given

a full-time position on the day shift.

OPH1 is a long-term care nursing home run by a religious organization whose faith Nurse

A shares. The administrative offices and the dining room are on the building's main floor and

250 to 300 residents are housed on the upper four floors. Cognitively impaired residents occupy

one of these floors, which is locked. Residents' needs for care have gradually increased over the

years. Nurse A dislikes talking about white people and black people but confirmed that the

administrative staff supervisors are white, while the staff (nurses, Registered Practical Nurses

[RPNs], and health care aides) are people of colour, with Blacks outnumbering those with

Filipino ancestry by more than two to one. All Unit Managers are white and identify with one of

the dominant ethnic groups in the Toronto area; those who are nurses graduated from nursing

school in the 1980s.



67

Cutbacks in health-care financing in the early 1990s brought about unnecessary stress and

low staff morale at OPH1, accompanied by a high turn-over among administrative staff, and job

insecurity for front-line staff. In September 1994, Nurse A received notice that her job had been

terminated, but was called back to work at the last minute, and in November, management told

her that she was being put on part-time work.

In this insecure work environment, Nurse A observed that standards of quality assurance

with respect to patient care were not being met and communicated her concerns to management.

We're [Nurse A and her Unit Manager] sitting in Quality Assurance [committee] meetings together. …(H)er behaviour was one thing and she was saying something else...[I was] trying to do my job (and) getting obstacles at every turn from the leaders themselves...[My] Unit Manager was ignoring me. (personal communication, 1998).

Nurse A expressed her frustration with management's efforts to marginalize her in

a diary entry:

For a very long time, I have not been able to maintain the quality of my work, as most of my efforts have been hindered and, as a result, I have suffered on-going frustration and unnecessary stress. I understand how much there is to be gained in a unified effort, to achieve a satisfactory level of care, and general all-round job fulfillment. I have always observed that important issues are ignored in the pursuit of trifles. The custom in which incidents and other issues are handled, unrealistic, non-communicative, exacts a toll, unknowing, on most workers' morale. As an RN, I am not recognized. Support is poor. Information continually ignored…my…experience is not valued. I feel there is no respect for my professional abilities (personal documents, October 1994).

In January 1995, Nurse A returned to full-time work but felt unsupported by her Unit

Manager. White staff got privileges such as six-week holidays that were granted only reluctantly

to Nurse A. When she received a second "Notice of termination" in May 1996, Nurse A filed her

first grievance against OPH1 stating that the lay-off violated the collective agreement. After a

series of meetings between ONA reps and OPH1 administration, Nurse A remained (except for a

two-week period) a full-time employee. The administrator wrote her a letter in which he



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apologized for any inconvenience and stated that the "action was without prejudice" (personal

documents, June 24, 1996).

In July, management changed her work shift, in violation of the collective agreement, and

Nurse A filed a second grievance. The matter was resolved to her satisfaction but in September,

when management found fault with her clinical practice and placed a letter of warning in her file,

Nurse A filed a third grievance. The matter was resolved at a meeting between Nurse A, her

Unit Manager, and her ONA representative. Management was instructed to remove the letter

from Nurse A's file. Nurse A filed a fourth grievance in October, demanding that monies owing

her be paid. In this grievance, Nurse A expressed:

…her growing frustration and unhappiness regarding her working environment at OPH1 [where] [s]he feels undervalued, and as a result has experienced both stress and anxiety. This grievance is an attempt to improve her working environment through better communications with the appropriate management personnel (October 23, 1996).

Was money owed Nurse A withheld simply because OPH1's accounting practices were

lax or did management deliberately try to withhold her money as a way of harassing Nurse A?

About this time, OPH1 hired a new DOC and Nurse A went to her, as well as to the

facility's administrator, for help:

…with documentation that I had written (about problems delivering quality care). …She asked me for certain copies which I gave to her (and)…she said,…"I can assure you that I will not be ignoring this," which is exactly what she did. She did nothing about it (personal communication, 1998). Nurse A's concerns were discussed at a meeting attended by all the Unit Managers, the

Administrator, the DOC, and two ONA reps. The meeting was amicable, but Nurse A was

further marginalized under this DOC who allied herself with Nurse A's Unit Manager. When

that DOC left, Nurse A felt that, under the supervision of the DOC hired to replace her, her Unit

Manager had even greater liberty to harrass and discriminate without sanction



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Nurse A began to work nights in March 1997. She was responsible for supervising a team

of RPNs and health care aids who delivered care to a minimum of 120 residents on two units,

including the unit for the cognitively impaired. They were frequently short-staffed. Nurse A

describes the poisoned work environment for racialized staff at OPH1 in the second complaint

she filed with the OHRC:

A staff member [names a white RPN] has been allowed and encouraged for many years to display racist behavior when I worked [names shift]. For several nights [this RPN] walked into the Unit, shouting the comments – "I am fed up of these immigrants and darkies," – while slamming her bag and chairs around, in the presence of all the evening staff. As well as racist comments, abusive/cursing language would be used also frequently: "Is this what this country fought a war for?" (I informed my manager of this RPN's behaviour and no action was taken.) In fact, a worker was removed from my shift. When the RPN informed her that she is happy to come on to see her own colour for a change, she even remarked this to [my manager] who again took no action...Serious medication (errors) made by nurses of a different (white) persuasion were constantly overlooked (gives 2 examples) (March 1998).

Out of concern that the continuous stress and racial harassment at work was having an

adverse effect on her health, Nurse A went to her doctor, who put her on medication for high

blood pressure.



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Benchmark 1 – The need for answers: Why did white management and staff discriminate against Nurse A? Why was nothing done about the racial discrimination that poisoned the work

environment at OPH1? Why did the employer not adopt the 1996 Anti-racism policy

put forth by the Joint Provincial Planning Committee of the Ministry of Health and the

Ontario Hospital Association? Why didn't OPH1 management make white staff who

expressed racial epithets toward Nurse A and other racialized individuals accountable

for this aspect of their behaviour?

"Tit for tat, infernal trap”

In July 1997, Nurse A's Unit Manager had wrongly accused her of refusing to attend a

mandatory in-service training session on "Classification Documentation Incidental Charting,"

charged Nurse A with "insubordination," and suspended her for one day without pay. In fact,

Nurse A did not refuse to attend the in-service. Rather, she requested that it be scheduled at a

time that was convenient for her and not on a morning following her night shift. According to

Nurse A:

…When I went on nights in March of 1997, I was expected to attend an in-service on communication after…I was finished working at 7:00. When I was finished working at 7:00, all I want to do is to come home, have a shower, have a hot drink of milk and go to bed, because that's all I'm sick for. I can't hear what you're saying; I can't talk to you. But I'm expected to stay…from 7 to 10 in an in-service (personal communication, 1998).

Management's scheduling of this in-service was the catalyst that led to escalation of their

conflict with Nurse A. Management's insistence on a time that disturbed Nurse A's sleep pattern

allowed them to project the problem onto Nurse A and then harass and discipline her.

The morning of Nurse A's first night back at work following her suspension, Nurse A:

requested a minute to speak with [my Unit Manager]. In her office, I told her that I am well aware of her harassment of me, which has been a gradual process for some length of time. I asked her to please stop or I would have to make complaints to the Human Rights



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Commission and the Board of Race Relations regarding her inappropriate behavior toward me (Hand written incident report, personal documents, no date).

A few days later, Nurse A filed grievance #5, stating that her one-day suspension was

without just cause. The following week, her Unit Manager called her at home several times

during the day, awoke her, and asked her in a very disagreeable manner to attend an in-service at

1400 (2 pm). Nurse A slept between 10 am and 4 pm and was not willing to interrupt her usual

sleeping pattern to attend an in-service scheduled at 1400; she declined to attend.

There were additional incidents symptomatic of the deepening rift between Nurse A and

management. Nurse A discovered, for example, that instead of categorizing her pay stub as

"suspension without pay", the accounting department categorized it as LOAWOP (Leave of

Absence Without Pay--Pay stub # 649-5th, SEQ 112 for pay period July 21-Aug. 3, 1997,

personal documents). Was this simply because of bureaucratic ineptitude or orchestrated

deliberately by management to harass Nurse A?

Over the years, several RPNs and health care aids had filed complaints about racial

harassment and working conditions at OPH1 with the Ontario Labour Relations Board and the

OHRC. An OHRC complaint filed by a Black health care aid whom Nurse A supervised was

settled in late 1997 or early 1998. The health care aid received a financial payment from OPH1

and Nurse A's Unit Manager was made to apologize to her.

Nurse A underwent a performance/documentation review. In mid-October, management

instructed her to "improve her communication skills both verbal and non-verbal...document in

accordance with CNO and OPH1 standards," attend the in-service, and "Submit a list of 10

charts and 10 care plans monthly…to the Unit Manager for mutual review" (October 30, 1997,

Letter from Unit Manager to Nurse A).

Nurse A recognized this as a set-up.



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To submit 10 charts/10 care plans monthly by Nov. 15th, Dec. 15th, Jan. 15th, 1998, I would have had to work from 7 am until (all hours of the night)…or go in on my nights off. (This is) simply unrealistic – (a) project to intimidate/belittle, to try to discredit me. …(M)y charting and documentation are well within the College of Nurses and [OPH1] standards…I have been on staff since 1990. Therefore, there is sufficient proof of my documentation (Submission to the OHRC, March 1998).

I'm there at work every night…and doing my work….why would I have to [do these care plans]?…Well, they knew it was an impossible task, so they decided…okay,…we do her with this…we have a reason…[to] give her the sack…(personal communication, 1998).

On 3 consecutive mornings, beginning October 28, 1997, Nurse A's Unit Manager

approached her:

at 7 o'clock …or just before 7, and told me that she wanted to talk to me…her approach was threatening… Well…I can't even talk because I'm so tired and sleepy. I'm up and down doing two floors all night long… I can't get my breaks at night. This is a Unit Manager, our leader, my leader, and when I said to her, No, I am not speaking to you…I feel threatened. … I can't speak to you now. This is [a] quarter past 7…in the morning;…I'm just …finishing up … my paperwork and all that, and she says that I'm insubordinate. This is …[the] Unit Manager, who was giving me all these letters and insubordinate and all these different accusations. I went in there, and do you know what, as I walked in…, "Oh you're late"… Late, I'm not late, I just finished doing my work upstairs. I'm not late but this is how they decided to attack me. Even I may have been …missing a few things, like putting in the amount of time spent with a resident. I didn't do it often. It was done because I didn't have the time…between…5 … and 7 in the morning to cram everything in. She was letting me have it, about…[how]…I'm not meeting their standards, and… have not attended that in-service, and I have to attend the in-service or else I'm going to be…suspended again … without pay. And they were threatening me…they're saying that I can't communicate and I can't document…I mean, all these years I've been passing (documents) on to them; they never had a problem with anything. At this meeting in the DOC's office when I was isolated that morning, their full intention was to…route my thoughts, to mortify me, to unravel me, to disorder my thoughts and my perception, to impair my memory and my judgment, to disorientate me, to impair my capacity to recognize reality so that I would exhibit even the faintest hint of a mental breakdown. To make me mentally unstable. That's what the meeting was all about. And when I realized this, when I had come to, I burst into tears. I'm not a crying person, but I broke down. I think I broke down too because it was 7:30 in the morning. I was tired, and when I realized what these women were trying to do to me to destroy my life in this way, I burst … into tears. And you know what, the two of them…leapt up from the chairs and one went to the door, and she stood in the door. She looked to see if anyone had shown up yet, from administration, …if anyone was over there listening or hearing me. But I was SO distraught, I thought I was going to die. I could feel my heart pounding through my ear at that very time. I'll



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never forget it. My heart pounding through my ear, and …I could I feel my chest was going to burst. And then I said, …when I realized that …they were upset too and they thought that somebody might be listening outside, then their attitude changed immediately. …Would you like a cup of coffee? Would you like… something. Oh no, and … I've just remembered, …you drink a lot of herbal teas, don't you? This is the Unit Manager who's known me for years, who pursued me relentlessly to join the staff years ago. She, I realized that they…got upset and were scared that somebody would be hearing all this, and um, so I… decided that, (says her own name), stop this. When they sat down, and I could …I was actually sitting there bringing myself, and I could feel my heart getting…um…less and less noisy. I brought myself back. I said, just sit here quietly and look. Observe these women, watch them very carefully (personal communication, 1998).

Nurse A and another staff member attended the in-service the following week and it was

not raised as an issue again. However, OPH1 management and the ONA could not agree on a

settlement for grievance #5, which was scheduled for arbitration in February 1999.

Viewing management's requests for care plans and charting as a set-up, Nurse A decided

to "leave it alone, and just continue doing my work" (personal communication, 1998). However,

a meeting between Nurse A and her supervisors to review her work was scheduled for November

18. Having been told by management that she could not bring her ONA rep, and not having

done the care plans/charting, Nurse A, who was not scheduled to work the night of November

18, 1997, "knew they were going to harass me.” She chose not to attend this meeting that had

been scheduled unilaterally. Her Unit Manager then phoned Nurse A at home to notify her that

she was suspended from work without pay until management "received a report from COSTI

(Catholic Organizations and Services to Immigrants – an agency that provides counselling and

other social services to immigrants) related to your ability to cope with the requirements of your

position.” This demand served to validate Nurse A's perception that what her Unit Manager and

the other two administrative staff were trying to do to her by wrongly accusing her of having a

communication problem and sub-standard documentation, by referring her to scrutiny by an

organization that serves immigrants, was to demean her and break her down psychologically.



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The suspension and events leading up to November 18th, 1997 prompted Nurse A to file

her first complaint on November 25th to the OHRC about racial discrimination at OPH1, which

was eventually shunted back to the union. However, on December 1, following the suspension,

she also filed union grievance #6 requesting that any mention of this suspension be removed

from her file. Management denied this request, stating that it was filed beyond the filing date

limit. The DOC then told the ONA rep to advise Nurse A to get a note from her physician

saying she was fit to work and to tell Nurse A that if she failed to bring the note in on a specific

date and time, she would be terminated. Nurse A questioned the logic of this advice – she had

been off work because of suspension, not because she was sick – but she did get a note from her

physician stating that she was fit to work. On December 11, seventeen days after being

suspended, Nurse A returned to work, even though she did not feel safe to do so.



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Benchmarks 2 and 3 – The need for recognition that they have been wronged and the need for safety Even prior to the three consecutive mornings when Nurse A's manager and two other

supervisors went after her in an isolated room when Nurse A was without support, the

work environment at OPH1 had not been one where racialized staff were granted

recognition that they had been wronged so they could resume feeling safe, nor was it

one where racialized staff were assured the community would do all it can to prevent

repetition. By requiring that Nurse A produce ten charts and ten care plans in each of

the following three months for their inspection, management set her up for duties that

had the appearance of rational care planning but were in fact make-work tasks in the

idiom of punishment for disobedience. On top of responsibility for delivering care to

120 residents each night, this was felt as an unreasonable demand, and perhaps unsafe.

But Nurse A herself had started to feel unsafe.

In interview, Nurse A said: "A lot of black nurses who are who are (whispering)

have low self-esteem. Everything is grinding down…down – they've lost a lot. Its

been taken away from them and they don't know which way to turn” (2002).

Grievance #7, which Nurse A filed in January 1998, was the first that cited

"discrimination" as an aspect of the conflict between Nurse A and OPH1 management. On her

behalf, the union requested that the employer cease discriminating against Nurse A, remove any

mention of the suspensions from her file and compensate her for damages.

About this time, Nurse A's doctor referred her to a psychiatrist, who wrote a note

attesting that she was fit to work. In March 1998 Nurse A filed a second complaint to OHRC

charging OPH1 with racial discrimination and harassment. In June, Nurse A found it necessary



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to file grievance #8 requesting that "the employer cease making libelous statements re: her role

in a medication incident and her role replacing sick staff."

In July 1998, the DOC was fired and for the next several months the facility was run by

the Unit Managers, some of whom were not nurses. During this period, management falsely

blamed Nurse A for a number of administrative problems, such as not covering for staff who

cancelled shifts and wrongly purging charts. Citing administrative errors which they said were

Nurse A's fault, management wrote a letter notifying Nurse A that she would be suspended for

four days at the end of the month and threatening her with termination if these problems

continued (personal documents, October 20, 1998).

In response to this letter, Nurse A filed two grievances on November 4, 1998 – grievance

#9 requested that references to her suspensions be removed from her file; grievance #10

requested that [OPH1] cease making libelous statements and compensate her for her damaged

emotional and physical state. Nurse A again consulted the psychiatrist in November 1998. A

few days before Christmas, management placed a letter of warning in Nurse A's file concerning

her handling of a clinical situation.

Other OPH1 staff members were experiencing workplace stress during this period. A

white ethnic LPN whom Nurse A supervised had had a nervous breakdown. When the LPN

returned to work after a six-weeks paid leave she was not well enough to work. Nurse A wrote a

letter to alert management to the situation, despite the fact that at the time she herself was

experiencing a great deal of stress from management's harassment:

I think it is time that you should be more aware and involved in [names LPN]'s problem, in order that her health would improve and not continue to deteriorate. The state of her health is affecting her ability to perform her job. At this time, I think she is using distorted reality to solve her problems that will certainly make them escalate. The truth is, it is obvious that she is unable to help herself. Please look into this (Letter to Unit Manager from Nurse A, personal files, December 17, 1998).



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In January 1999, management suspended Nurse A for four days without pay, wrongly

accusing her of not covering for a staff member who cancelled a shift, thus "compromising

resident care and safety," of failing to submit ten care plans, and other matters. Nurse A filed

grievance #11 in response requesting that all references to her suspensions (now totaling twenty-

six days) be removed from her files. This grievance was denied by OPH1 management and

grievances #9 and #10 remained outstanding.

In February, management informed Nurse A that her employment at OPH1 was

“terminated.” Nurse A filed grievance #12, stating that OPH1 management had terminated her

without just cause. The ONA then entered into negotiations with OPH1's management and

suggested that an independent mediator (Mediator A) be brought in to investigate the situation

and work out a settlement. Since the ONA had not been effective in deescalating the conflict

that resulted in Nurse A's "termination," Nurse A was skeptical that a mediator brought in by

ONA would genuinely represent her interests. She therefore hired her own mediator (Mediator

B), who entered into communication with the ONA and OPH1 management on her behalf.

About ten days after her "termination," Nurse A's former manager, who was not a nurse,

wrote a letter of complaint to the College of Nurses of Ontario (CNO) about Nurse A citing

eleven incidents. In the twenty years of Nurse A's work life in Toronto, this was the first time an

employer had complained about her nursing practice to the CNO. In her letter to the CNO, this

manager cited an incident that had taken place in September 1996 and been settled with the

condition that any correspondence relating to the incident be removed from Nurse A's file.

Nurse A filed grievance #13 to protest this former manager's unfair complaint to the CNO.

This former manager had neglected to inform her boss, the OPH1 administrator, that she

had written a letter of complaint to the CNO about Nurse A. When OPH1's administrator



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became aware of the existence of this letter, he immediately wrote the College stating that OPH1

did not wish to register a complaint about Nurse A. He did not want the letter of complaint to

the CNO to complicate settlement negotiations between OPH1, Nurse A, and the ONA.

Early in April 1999, Mediator A negotiated a settlement between Nurse A and OPH1.

Two of Nurse A's Black colleagues, each of whom wrote a letter to the CNO in support of Nurse

A and one of whom had received a settlement from the OHRC, were present at one of the

meetings leading up to the settlement to give Nurse A support. The Minutes of Settlement

instructed that: (1) OPH1 pay a substantial sum of money to Nurse A as compensation for the

years of racial harassment and discrimination she had endured; (2) Nurse A's "termination" be

rescinded and that Nurse A resign; (3) OPH1's administration remove any records pertaining to

Nurse A's "termination" from her file; and (4) OPH1 provide references for Nurse A. In early

April 1999, Nurse A submitted her letter of resignation to OPH1.

Benchmark 4 – Restitution through healing processes that balance relationships and prevent further harm There is no evidence that OPH1 management ever investigated systemic discrimination in the

facility or that there was ever any self-reflection or self-examination on the part of management

regarding the way in which Nurse A became problematized. No investigation has been made by

an outside body of conditions, including management practices, at OPH1.

The settlement and OPH1's administrator's letter to the CNO put the College of Nurses in

an awkward position. Instead of refusing to investigate the complaint, however, they chose to go

ahead, adopting unusual procedures by instructing the College's Executive Committee, which

does not have a mandate to discipline, since it is the Complaints' Committee that normally

carries out investigations. Note that all members of both committees are white.



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The ONA hired a well-known labour lawyer to represent Nurse A before the CNO. This

lawyer convinced the investigating committee to drop nine of the eleven incidents since they did

not relate to Nurse A's clinical practice but were rather expressions of management's

problematization of, discrimination toward, and harassment of Nurse A. Nurse A retained her

registration to practice nursing. However, the College wrote Nurse A a letter requesting that she

"reflect" upon her practice with respect to the two remaining incidents.

Nurse A appreciated the positive results her lawyer had gotten for her from the College's

Executive Committee. Nurse A's view, however, was that the fault lay with OPH1 management

and she felt strongly that the College should have investigated OPH1's organizational practices,

especially racialization of staff and the effect of racialization on patient care. Why should she be

reprimanded and OPH1 elude censure and be free to perpetrate further harm? Disheartened by

the fact that the College had not investigated practices at OPH1, Nurse A filed a third complaint

with the OHRC in December, in which she stated: "What was done to me at [OPH1] I consider

tantamount to lynching".

CEHS Benchmark – Lack of Accountability for breaching the grievance process OPH1 never admitted wrongdoing, even after they breached the Minutes of Settlement by

supplying erroneous information about Nurse A to potential employers who asked for

references. Nor did the CNO give any recognition to Nurse A that she had been wronged and

that OPH1's management practices made working conditions problematic with potentially

unsafe consequence for the residents under care.

The April 1999 Minutes of Settlement of the grievance between OPH1 and Nurse A

instructed OPH1 to inform potential employers to whom Nurse A had applied for jobs that Nurse

A had been employed as a RN at OPH1 between a certain date in 1990 and a certain date in



80

1999, and that she had performed her duties competently. Nurse A applied for and went to

several job interviews. When she did not get a job, she began to suspect that OPH1 was not

adhering to the terms of the settlement with respect to providing her reference. Nurse A

therefore asked a prospective employer what information they had been given about her by

OPH1 and learned that there was a discrepancy between the date she had given the employer as

her last day of employment and that given by OPH1. Aggrieved greatly by this "error," Nurse A

filed her fourteenth grievance against OPH1. The ONA put off meeting with her to discuss this

problem.

Shortly after Nurse A made a submission to the Ontario Labour Relations Board attesting

that the "ONA did not represent the applicant in a timely way" (No date, Form B 29, OLRB), the

ONA representatives agreed to meet with Nurse A. At this meeting, which took place a few days

before the scheduled OLRB hearing, the ONA agreed to set an arbitration date for grievance #14

(OPH1's breach of the Minutes of Settlement). Because Nurse A now had the hearing date she

requested, she withdrew her application to the OLRB. Less than twenty-four hours before the

scheduled arbitration hearing, the ONA Employment Relations Officer (ERO) phoned Nurse A

from an administrative office at OPH1 and informed her that a settlement had been reached, that

the hearing was cancelled. She told Nurse A that she would receive a letter by courier the next

day formally notifying her of these developments but this letter did not arrive until the very hour

of the day the hearing was scheduled. Lacking formal notification that the hearing was

cancelled, Nurse A went to the arbitration building where she was informed of the cancellation.

The ONA's handling of this matter reconfirmed Nurse A's belief that the union, just like the

employer, was unfettered by accountability for fair grievance proceedings.



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In the spring of 2000, Nurse A got a part-time job working nights at a nursing home

(OPH4) where management's bigotry toward staff made working conditions difficult. Short-

staffing necessitated that Nurse A put in an extra hour to complete her tasks each morning.

Nurse A's contract stipulated that she would receive a pay increase following successful

completion of a three-month probationary period. The increase was not forthcoming after the

three-month period, so Nurse A wrote management requesting the pay increase as well as

payment for the extra hours she routinely put in. About this time, a CUPE union steward (who

was a nurses' aid) hand-delivered a letter to Nurse A that contained erroneous information about

Nurse A's attendance record and requested that her to "improve" her attendance (October 12,

2000). Nurse A corrected the false information and requested that the letter be removed from her

file. On November 1, two young women who worked in the administrative office delivered an

envelope to Nurse A that contained a bonus check for $500 made out in her name. Nurse A was

given no explanation about why she had been given this check and Nurse A's letter to the

administration requesting monies owed was never answered.

In December, Nurse A fell on ice outside her home and sustained a lower-arm bone

(Colles) fracture. She immediately notified her employer that she would be unable to work and

requested a record of employment so that she could apply to Human Resources Development

Canada (HRDC) for medical unemployment insurance. When the accounting office of OPH4

failed to give her a record of employment after several requests, Nurse A contacted the

corporation's main office. A few days later she received the form. In early February 2001,

Nurse A got a letter from HRDC informing her that their records showed she had not declared

earnings for hours she had worked in January. Astounded, Nurse A checked her bank account,

which showed an unexpected surplus of $500. Investigating further, Nurse A learned that though



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she had not been working, money had been deposited in her bank account by her employer

because her time card at OPH4 had been punched the weekend of January 7, 8, 9. Was this

transpiring because of her demand that she be paid for overtime hours, or was it an innocent

error? Nurse A wrote a letter about the matter to OPH4's administrator and again contacted a

Senior Regional Director at the corporation's head office. Initially, the administrator responsible

for OPH4 told Nurse A that what happened was "an innocent error on the part of the Office

Manager controlling the payroll entry" (Letter from OPH4 administrator to Nurse A, March 12,

2001). Nurse A met with the Senior Regional Director at his invitation at the Corporate Head

Office. Following their meeting, Nurse A received an apology about the matter from OPH4's

administrator. The corporation has since closed OPH4.

After signing the settlement agreement with OPH1, in an effort to call attention to the

problem of racial discrimination in nursing homes and its impact on the delivery of quality care,

Nurse A undertook a letter-writing campaign. She wrote nursing leaders at ONA and the CNO,

the Law Society of Upper Canada, and the President of OPH1's Board of Governors about

conditions at OPH1. In her letter to this latter individual, a nurse, Nurse A stated:

Management premeditatedly embarked on a campaign of personal destruction against workers of colour. A mission statement, standards of employee conduct, Quality Assurance program, means nothing to management (June 2000).



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Benchmark 5 – Significance or meaning Nurse A undertook a letter writing campaign because of her strong belief that

individuals and institutions that discriminate on the basis of race (and other attributes)

should be made accountable. In a letter to the then head of the CNO (Ontario College

of Nurses), Nurse A wrote that racial discrimination impedes delivery of quality care:

Management create[s] many ethical dilemmas, causing working conditions to be unsafe frequently…On many occasions their behavior has caused professional services to be somewhat discontinued or poorly applied. Health and safety are quite often compromised. If this makes it unsafe for nurses, then it is unsafe for clients…I will continue to find the inner strength for justice. I am both a citizen and provider of high quality care. Should I be an advocate for the people I care for? I should be able to function without fear of reprisals. No nurse should be robbed of her right to pride of workmanship (April 2000).

Nurse A has undertaken the painful process of seeking meaning and closure with

respect to what she has experienced by making her story available to the public through

this research report. Nurse A's prayer is that inclusion of her case in this report will

contribute to bringing about a national racial equality and employment equity

accountability program that meets the needs of all nurses. Creation of equity assurance

monitoring procedures under the Health Council of Canada would bring about healing

and closure for Nurse A.

Nurse A has not returned to work since sustaining her Colles fracture. She feels that she

will never again be able to work as a nurse.

Discussion Nurse A experienced racial discrimination in every health care delivery facility at which she

worked past the probationary period. Nurses who have experienced racial discrimination at

work, or have witnessed the effects of such discrimination on colleagues, are calling for the



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creation of an equity assurance policy to ensure that the work environment for nurses, and

therefore for patients, is caring rather than poisoned.

In work settings where racism is an everyday practice, everyone has the choice to: (1)

perpetuate out of balance relationships that impact negatively on racialized individuals and

groups, or (2) promote equal opportunities and freedom of choice for all. Issues of competence

and responsibility are treated in the context of power relations in health delivery settings. For

this reason, it is difficult to separate race relations from power relations. Present structures for

dealing with racial conflict are inadequate because those who name racism risk triggering

reprisals and backlash.

In theory, hierarchies (the pecking order) remain intact because of discourses of

domination that systematically disadvantage on an in-group/out-group basis. As long as the

accountability is ineffective, the offender will repeat. Current procedures do not provide those

offended with equal opportunity for being heard in grievance proceedings. One of the benefits

accountability policies – equity assurance – can provide in terms of power relations, is that all

players can voice their concerns without reprisals.

Following her encounters with the three white supervisors who threatened her and

accused her of "insubordination" in July 1997, Nurse A sometimes "forgets" her words, finds it

difficult to sleep, and suffers from anxiety attacks whose severity sometimes prevent her from

driving her car. She says that "these women have destroyed me" and she is engaging in a

difficult daily struggle to regain her physical, emotional, and financial stability. The lengthy

conflict between Nurse A and OPH1 management did not result in balancing the relationship

between Nurse A and her employer. Rather, the conflict has made a profound impact on Nurse

A's physical, emotional, and financial well-being. Moreover, her case ripples out rancor to



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racialized and non-racialized communities alike that does not help in recruitment and retention of

nurses.

In reviewing Nurse A's experiences with retaliation or backlash that escalated the dispute,

we advocated for the introduction of transformative justice to deal with racial disputes and

pointed to Ruth Morris’s five "benchmarks" that address core needs. There is a need for

answers, for recognition that the nurses have been wronged, for safety, and for restitution and

balance in workplace relationships, as well as a need to find significance or meaning from the

violation of human rights (2000). These benchmarks can be used to evaluate any dispute process

or legal proceeding. If these needs would be addressed for example by unions or in-house

diversity representatives, we anticipate that complaints would be greatly satisfied and working

relations would be improved.

We turn now to consider the union’s roles in relation to the larger contexts of collective

bargaining, grievance arbitration, and hospitals taking on responsibility for monitoring racial

harassment and unchallenged systemic racial conflict.

Chronology of Nurse A’s grievances against OPH1

Date Grievance Filed Explanation

1996 May 8 Grv 1 1/96 Lay-Off Notice (union intervention – June 1996

Nurse A receives notice she will remain full-time) July 22 Grv 2 3/96 Protesting shift change in violation of collective

agreement September 2 Grv 3 7/96 Letter of warning in file regarding handling of

patient fall October 2 Grv 4 8/96 Payment for cancelled shifts, vacation pay – OPH

admits error and pays 1997 August 6 Grv 5 2/97 (ONA #970537) 1-day suspension without pay,

harassment November 25 1st complaint to OHRC December 1 Grv 6 3/97 Suspension without pay (denied – filed after limit) 1998 January 22 Grv 7 1/98 4-day suspension without just cause No Date Grv 8 2-98 26 night suspension (denied)



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No Date

Grv 8 3-98 Employer cease making libelous statements against Nurse A; Note regarding June 11 medication incident; Role regarding replacing sick staff

March 2nd complaint to OHRC November 4 Grv 9 4-98 Suspensions November 4 Grv 10 5-98 Libelous statement/suspensions/monies owed 1999 January 22 Grv 11 1-99 Employer cease libelous statements; compensation

for damaged emotional/physical state (denied) February 8 Nurse A receives letter from

Unit Manager notifying her that her employment at OPH1 has been "terminated"

February 17 Grv 12 1-99 Termination without just cause March Grv 13 (ONA #199019) Against OPH1 Unit Manager for filing complaint

with CNO December 3rd complaint to OHRC 2000 January 27 Grv 14 1-00 (ONA #200111) Breach of Minutes of Settlement by OPH1 May 10 Application to OLRB

requesting investigation of OPH1

May 18 Further papers filed regarding OLRB

June 16 Application to OLRB withdrawn

2001 February 20 Letter from HRDC to Nurse A

informing her that their information showed she had worked on 3 consecutive days in January and earned money that she had not declared

February 22 Letter from Nurse A to Senior Regional Director of OPH4 regarding payroll error

February 28 Arbitration hearing regarding Grv 14 (ONA #200111) cancelled

March 12 Letter from OPH4 administrator apologizing for the “miscommunication”

Shifting Context: The declared shortage of nurses and union innovations for retention

Marianne Chandler

In her submission to the Commission on the Future of Health Care in Canada headed by the

Honourable Roy Romanow, Kathleen Connors, President of the Canadian Federation of Nurses'



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Unions stated: "Canada...(is) experiencing a nursing shortage that, if not addressed quickly, will

become a nursing crisis by the decade's end. Canada is short about 20,000 nurses right now but

this will be five times worse by the end of the decade" (2001, p. 4).

In other words, Canada will be short some 113,000 nurses by the year 2011, unless

measures are taken to both retain and attract nurses. As of 2001, there were 252,913 nurses

employed in Canada in hospitals, public health agencies, homes for the aged, nursing homes,

industry and nursing agencies, and so on. Unions represent the majority of the nurses employed

in Ontario – 88,013 in 2001 – with the majority of those nurses represented by the ONA.

The history of central collective bargaining for nurses in Ontario has not always been a

happy one. Collective Agreements are rarely freely negotiated; arbitrated decisions leave a sense

of anger, concern, and low morale for nurses. With more and more cost-cutting measures being

implemented in health care settings across Ontario, there appeared to be little interest on the part

of the employers to agree to Quality of Work Life language in collective agreements. The

implementation of anti-racism, anti-harassment, and anti-discrimination policies and programs

did not appear to rate as essential to the workplace. Training for management on the

investigation of racism or harassment complaints in the workplace was not seen as a priority.

Employee surveys and exit interviews indicated that racialized nurses cited the following

issues and concerns:

• No opportunity for progression up the "career ladders;"

• Differential treatment and being "earmarked" for more severe and unfair levels of work

assignments and discipline than were non-racialized nurses; and



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• Speaking out in support of a colleague who had experienced unfair treatment because of

race proves to be a "career limiting move or CLM" (backlash).

From the early 1990s, hospitals continued in denial of the issues facing nurses in the

workplace; absenteeism increased to alarming figures as nurses attempted to survive in the

‘trenches’. Employee Assistance Programs (EAPs) were introduced, but were only seen as band-

aid solutions. Employee Satisfaction Surveys attempted to identify negative treatment issues in

the workplace in early 2000. Results of these surveys were rarely acted upon as clinical and

administrative managers struggled with greater workloads and reduced budgets. Quality of Life

Programs for patients were implemented, but issues of racism directed by patients towards

nurses were considered to be ‘trivial’ in nature and ‘par for the course’ if one worked in a

healthcare institution.

Nurses were losing interest and becoming cynical about any improvement in workplace

conditions. The root cause for the increased sickness and absenteeism was neither identified nor

addressed.

Mergers and hospital takeovers added a new negative dimension to workplace

relationships. The new hospital corporate culture was dominated by the organizational culture of

the most powerful member of the newly formed corporation. Supportive voices were stifled or

exited the healthcare sector.

The labour relations environment became more hostile as unions struggled to survive in

the restructured healthcare environment. Dealing with the malignancies of racism, harassment,

and discrimination became a secondary focus for unions. Membership declined for certain

unions at the same time that costs for mediation and arbitration under collective agreements were

skyrocketing. Private sector unions now obtained a foothold in healthcare and changed the face



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of relationships between employers and unions. Survival in this new healthcare environment

became the goal of several unions who traditionally represented healthcare workers.

Changes also occurred in the area of grievance arbitrations. Arbitrators were now finding

themselves faced with complex situations which would have been unimaginable twenty years

before. Arbitrators became "social engineers" (Swan, 1996). They required distinct skills in "the

contract-shaping function, the interpretative function and the public policy or community

conscience function" (Nolan and Abrams, 1985, p. 873). As Kenneth Swan writes:

[T]o whatever extent arbitrators are to play a greater role in the administration of human rights, they will need to develop increased sensitivity to the issues and a better understanding of the remedial tools that are available and appropriate. Unfortunately there is no mechanism for delivering continuing education to arbitrators unless they do it themselves, through their professional organizations. At this point in the development of arbitral authority, those organizations should be giving serious consideration to educating the profession in issues of systemic discrimination and equality rights, and in the social context in which arbitration decisions must be made, in much the same way as similar efforts have begun for members of the judiciary (Swan, 1996, non-paginated presentation). Swan also states “that for employees covered by a collective agreement,” arbitration is

now virtually the “supermarket of employment justice – one-stop shopping for legal remedies for

all complaints” (non-paginated presentation).

It is within this context that the ONA has negotiated innovative structures with selected

employers that were on their censure list for poor compliance with human rights legislation. One

hospital has a diversity practitioner who is a social worker by profession who, at arm’s length

hears, complaints of harassment and arranges contractual agreements between complainant and

employer. Her role also has a preventive focus aimed at changing the hospital culture through

special events that celebrate diversity and infuse the internal hospital media with inclusive

images. Another larger hospital has set up a workplace diversity unit with a lawyer and staff.

Initially, this unit was located next door to Human Resources, but has since moved to a nearby



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off-site location. This hospital has been on ONA’s censure list for ten years. With the help of a

cooperative CEO, the workplace diversity unit is being utilized to deal with complaints and to

work on clearing the backlog of 400 cases that had accumulated by the time it was implemented

four years ago. The unit has also been involved in developing new policies and negotiation

methods as well as various programs intended to work toward prevention of ongoing

marginalization practices among staff.

It is important to note that at least one major hospital is treating language as a factor in

the reduction of potential risk to patients (Mohamed, 2002) and a pathway to improved patient

safety and satisfaction as well as employee satisfaction.

Before applauding these new developments, it is important to recognize that the

underfunding of the OHRC and the rescinding of employment equity legislation have shifted the

financial drain owing to racial discrimination in health care workplaces from other jurisdictions

directly onto the budgets competing for health care dollars. CEHS is calling for research that

evaluates the extent to which proactive programs that effectively address racial profiling of

nurses may contribute to retention and future recruitment of nurses from diverse communities.

However, the health of nurses related to their workplace experiences will also have to be

addressed. Next, we briefly outline some health effects reported by nurses filing grievances or

complaints of racism.

Health Outcomes of the Complainant in a Racial Dispute

Ruth Lee, Rebecca Hagey, and Jane Turrittin

Social psychologists Dion and colleagues (1975, 1978, 1996) provide evidence that anxiety in

varying degrees is linked to the perception of discrimination. In a culture that invalidates the



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appropriateness of accountability for discriminatory practices, one would predict anxiety to be

exacerbated when the social means for eliminating the source of the anxiety is blocked.

Restoration to a non-anxious state would be impeded. Backlash being unrestrained would

escalate and prolong anxiety and produce negative health effects over time.

The following excerpts are as yet unpublished data from a CERIS-funded qualitative

study of nine nurses who grieved through their union or complained to the Ontario Human

Rights Commission against their employer on grounds of racial discrimination (Collins et al.,

1998). To maintain confidentiality for the nurses and their employers, identifying markers have

been removed. The nurses came from seven different countries, representing the current

diversity in the Toronto area.

Their experiences included physical, emotional, spiritual, and financial challenges to their

health. Grievances can consume an unforgivable expenditure of time, energy, and money, and

can lead to the loss of home, car, neighborhood, spouse, and dreams. We have identified themes

related to the emotional pain and somatic trauma that comprise the lived experience of objecting

to racial discrimination. In all cases, escalation of conflict accompanied naming the problem as

racism.

Traumas Experienced While Objecting to Racial Discrimination

1. Feelings of exclusion, loss of belonging

"Stressful knowing that you are...on the outside; stressful knowing that they don't want you there.

I really miss the belonging where I could call I belong to X hospital; this is my home (hushed

voice).”

2. Feeling humiliated, contained



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“The final taking away the…the job from…from me was so humiliating…I sort of felt boxed in a

corner and I really didn't have anyone to speak to how to get out of this. Humiliation...It is [an]

unbearable experience that I have. It really affects my health, affects my marriage (crying)…It

was the worst I ever had in my entire life.”

3. Intimidation, paranoia, isolation

“I felt...I don't know if it’s paranoia, but I felt that people were out to get me…People weren't

being fair with me. I felt like an easy walking target…intimidat[ion]...I felt isolated.”

4. Loss of confidence and grief

“My worst fears had come true…I just picked up a message and, you know, that

...premonition...and as soon as I listened to this morning, I figure, Oh my God, today is the

day…I had lost all confidence and all self-esteem…all day I cried…I just was so devastated

about the whole thing…grief” (about losing her job).

5. Depression, loss of focus, and memory loss

“It took me about 8 months to recover enough...I had gone through a major memory loss, my

depression had caught me. I couldn't study. I just stayed enclosed in my bedroom for months...”

6. Distressing physical symptoms

“I went into shock before I could even get to my car. I just started shaking...I never stopped

shaking for days, days...it was like a dagger...I could feel the pain in my heart...within a month I

became very sick. I went into a...state of shock. I just crashed. I got dizzy and [would] be

vomiting at four o'clock in the morning. Low energy and extreme fatigue. It was such an effort to

start a new day I was sick. I was vomiting. I was shaky...I was devastated. Pains in my

chest...pseudo-heart attack... My blood pressure went up to 180.”



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7. Death images

“I would pray that at least if I would die in my sleep, I wouldn't wake up. Each step I took, my

feet were heavier and heavier as if I was walking before the firing squad. I was so distraught – I

thought I was going to die.”

8. Sensations challenging integrity and wholeness

“I felt as if I was being invaded. I feel that my life has been tattered…that I'm not being

supported by my union...things that I found very easy for me to do before…I've just been

drained.”

9. Positive awareness

“At the time, I thought about [being documented] in terms of being a hard-boiled egg; the longer

you boil it, the harder it becomes.”

10. Less than optimal health basis for professional work

“I took time off work; the doctor gave it to me – stress leave. I was tensed, you know. I couldn't

do my job. When I look back, my brain probably was functioning at half a level. I was stressed. I

did a stress test after the fact...you know, they make you go back and I had 59 per cent; now it's

nine.”

11.Long-term effects

“It is a psycho-physiological...aspect to it...when you go under stress for almost 5, 6 years, my

serotonin is very depleted. Today, sometimes I'm speaking and I can't speak. I lose my words; I

forget things, which is not at all like me.”

As reported elsewhere (Hagey et al., 2001a), the nurses who shared these effects on their

health were able to turn their trauma into community contributions. They had the conviction that



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what they were doing was so that, in the future, nurses would not have to go through the same

ordeals, thus they continue to push for recommendations.

Summation of Evidence Our presentation of evidence was composed of: (1) a pilot survey on the effects of race, colour,

or ethnicity (i.e. racial profiling of nurses); 2) a description of set-up as a group-based practice

that targets racialized nurses during under-funding and cutbacks, so members of the dominant

groups can take unfair advantage during job transfer and job loss; (3) a case study and analysis of

how a racialized nurse encountered barriers to accountability involving irregularities of the

complaint process so that the proceedings fell far short of the ideals of transformative justice; (4)

a brief overview of unions' roles with respect to human rights protections in the employment of

nurses required for the future of nursing; and (5) an account of negative health effects

experienced by nurses who had charged their employers with racism.

The evidence we presented suggests that employers, employees, professional

organizations, and unions have reason to commit to a coordinated plan of accountability for

equity or an equity assurance program. Without any feasible recourse when nurses experience

racial profiling, set-up, backlash, and health effects, the participants in this study believed that

there is a generalized fear of backlash that prevents more nurses from complaining or pressing

forward with the normal accountability strategies expected in collaborative working

relationships. That is, the ever-present threat of racial backlash makes racialized nurses subject

to disconnection and exclusion in relations in nursing work that presents a potential threat to

patient safety. We turn now to explore issues associated with developing and integrating

accountability policies and practices in nursing.



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Chapter 3 – Accountability Informed by Transformative

Justice: Discussion and recommendations

Rebecca Hagey and Monica Purdy



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Review and Introduction One objective of this study was to conduct participatory action research (PAR) with voluntary

associations of nurses to explore the feasibility of instituting equity assurance programs aimed at

establishing accountability for racial equality and employment equity at all levels and in all

sectors in nursing. In keeping with PAR methodology, we identified evidence, and the

participants themselves shaped what is presented.

As our action research gained momentum, participants recognized that an equity

assurance program is feasible if – and only if – those who need it make it happen. A vision of a

Canada-wide program emerged that would use lobbying, negotiation, and political action

informed by research to hold all nurses and their employers accountable for systemic

discrimination in their organizations. To these ends, the Centre for Equity in Health and Society

(CEHS) became formalized as a research and advocacy organization.

For CEHS and others interested in equity, we believe that a widespread collaboration on

changing discourse is necessary to develop and implement policy. Our thesis is that all

stakeholders will need to change discourse strategies if accountability for racial discrimination

is to become a shared value. We used discourse strategies in this study to promote

accountability for equal access and participation targeting (a) political discourse; (b) the

locations of discourse; (c) discourse strategies in and between organizations; (d) policy

regulators of discourse; (e) personal discourse; (f) discourse outcomes; and (g) research

discourse. The theoretical development of our questions pertaining to purposeful discourse

change will be addressed in future submissions to scholarly journals.

Answers to our research questions have emerged from the evidence presented in the

previous chapter:



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1. Set-up and backlash are key manifestations of poor accountability procedures that are in

place to respond to racial dominance.

2. The organized practices that are associated with set-up and backlash are manifestations of

institutionalized racism – unchallenged discourse of racial dominance.

3. When racism is an issue among nurses, the process for addressing and resolving issues is

problematic.

4. Violations of the grievance process in racial disputes further subject the complainant to

racial dominance.

In light of these findings that argue for better accountability, we first consider issues

about defining accountability in the context of achieving equity through transformative justice

and providing definitions of institutionalized racism, racial encounters, and systemic racism. We

briefly consider the political landscape that currently condones discourses that effect racial

dominance. In this discourse milieu, we point out that there are fundamentally conflicting

convictions about how accountability for racial discrimination should be organized. We then

outline some benefits accountability would have on social relationships and advocate for anti-

racism as a relational perspective to be operationalized by the CEHS network. We briefly

summarize some anti-racism findings that will need conscious attention by health care leaders

intent on implementing accountability for equity.

We then we provide some policy and legislative recommendations submitted by diverse

sectors of the CEHS network. We include our recommendation to the Health Council of Canada

to function as one national accountability structure for regulating not only equal access to

universal health care but also for monitoring employment equity in health care because the latter

can impact on both patient and employee health and safety. Finally, we briefly summarize the



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study and invite researchers and colleagues to embark on participatory action research to see the

recommendations implemented and to use and hear the language in our glossary of definitions.

The Vision of Transformative Justice Transformative justice is a new approach advocated for dispute resolution in the civil justice

system, derived from the introduction of restorative justice – mediation, negotiation, settlement,

compensation, reparation – in the criminal system: “Transformative justice is a way of handling

conflict that recognizes and responds to the variety of harms caused by conflict …..and responds

….by bringing individuals together in a process that encourages healing and growth (Law

Commission of Canada, 1999, p. 43).

Restorative justice advocates a number of requirements. Those we have selected include:

(1) the complainant, respondent, and community being involved in a consensus building process;

(2) the inquiry process providing an opportunity for the person(s) involved in a breach to take

responsibility for the rupture in relationships; (3) the complainant, respondent, and community

identifying what standards are appropriate and how the breach will be compensated and

standards maintained; and (4) decisions about restoring parties to the community are made with

respect to the parties and their circumstances and ethical standards (Law Commission of Canada,

1999). All parties in conflict are assumed to have historical realities and ideologies that inform

their conflicting perspectives.

Our mission in this report, therefore, is to advocate for the normalizing of relationships

through garnering a collective commitment to problem-solving around systemic racism, which is

chronically conflictual. We wish to motivate all nurses to rectify institutionalized racism by

organizing and implementing multiple layers of accountability, including personal self-



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reflections and committee-based corrections, to organizational media, events, and reports that are

responsive to critique and feedback. Through relationships that collaboratively address

employment equity practices (see A Time for Change, Appendix F), we can correct racial

disparities, so that when racial disputes arise, they will be far more constructively handled than

reports from our participants would indicate. We can institute accountability for equal access

and participation in our profession. We can change the discourses of racial dominance to the

discourses of healthy collaboration.

Defining Accountability in the Context of Equity: What is institutionalized racism? Systemic racism? A racial encounter? According to the Canadian Oxford Dictionary (Barber, 1998), the term “accountability” first

appeared in the 1700s and referred to the idea that the state should be accountable to the people.

Slavery was widespread during this era, so what is hidden in the dictionary examples of

accountability is that racial status is a condition for the right of people to require answers and

remedies concerning their governance. Britain lost its American colony for not being responsive

or responsible to the colonized European people. France followed with a revolution too and,

under Napoleon Bonaparte, instituted centralized powers that became the template for the weak

notion of accountability in modern state structures. Following the U.S. civil war, the term

accountability became associated with corporate business concerns about profit, gain, or loss.

Accountability to the bottom line has become the popular meaning of the term.

Organizations understand accountability to be a process through which a person is

responsible to a designated group or body for his or her actions. This may involve reporting

relationships and roles of designated parties because everyone cannot be reporting to everyone

else all the time. Typically those lower in a hierarchy are more accountable to higher ups than



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vice versa. The presence of unions as parallel administrative structures is an organized attempt

to provide protection for those in lower positions of influence. In the discipline of ethics,

accountability is a type of procedural justice along with transparency (Hagey et al., 2001a).

One accountability problem associated with racial discrimination in nursing is that in-

group advantages and out-group losses are not made transparent owing to in-group power over

research. But the larger problem, we argue, is that accountability is missing in race relations, and

when disadvantaged parties try to introduce it, denial, resistance, reprisals, righteous indignation,

and so on, surface. Transparency and accountability are not on the agenda, and an inordinate

amount of monitoring and petitioning is required to get attention paid to equal rights supposedly

guaranteed by the state.

To remedy this, we are introducing a definition of accountability, informed by

transformative justice, that values relationship. Accountability can be seen as a feature of

relationship that holds individuals, groups, or offices responsible according to principles or

criteria befitting the relationship, for example, transparent communication, fairness, and

trustworthiness.

We are defining racism as an ideology built on the concept of race that is fundamentally a

relationship problem of accountability. Racism has different manifestations at individual levels

and between offices within organizations. We define race and racialized people accordingly in

this perspective that shows how accountability can address racism.



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Race A set of assumptions used in discrimination, creating racialized and non-racialized peoples.

Assumptions of race make a connection between European derived signifiers of race, such as

skin colour or heritage, so that accountability is not owed to the racialized person(s).

Racialized People People who experience social inequalities because of their race, colour, or ethnicity.

Manifestations of racism, such as racialized encounters, institutional racism, and systemic

racism, can be remedied, we argue, by participants engaging in accountability that is race

conscious and equity driven.

Where individuals in an organization can be exposed to racialized encounters:

Racialized Encounter An encounter where a racialized person(s) receives an intentional or unintentional

communication so that the sender accomplishes racial segmentation and domination in the

situation. “We” versus “they” is connoted where the “we” are non-racialized persons and “they”

are marginalized, racialized, and disadvantaged in comparison to the “we.” Racialized

encounters can occur interpersonally, publicly, or through media.

We suggest that race consciousness based on anti-racist principles is necessary to

accountability for this type of miscommunication. Consciousness is always required to make

amends for social breaches and miscommunication.



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Race Consciousness Race consciousness based on anti-racist principles is a strategy for racial equality that names and

questions discourses of domination and promotes equal access and participation in governance

among peers.

This sort of good governance among peers has to be supported by education about

fairness, trustworthiness, transparency, and accountability or what we are calling the proceedings

of social justice that are required to support equity.

Equity Standards of fairness achieved through social justice proceedings.

Where organizations are concerned, we have said that two main problems exist that

accountability, theoretically, can remedy: institutionlized racism and systemic racism.

Institutional Racism The lack of accountability for racial equality in society’s institutions, such as health care. Its

fundamental basis is the privilege – informed by ideology and group power – of not having to be

equally accountable to racialized people as to non-racialized group members.

Systemic Racism Policies, practices, and procedures that are considered normal, but can intentionally or

unintentionally discriminate against individuals and groups protected under the Code, thus

privileging non-racialized people. The privileges of systemic racism are upheld by discourse that

avoids accountability for racial domination.



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In this perspective, institutional and systemic racism can be dismantled by accountability

proceedings and accountability relies on race consciousness as well as equity committees,

policies, and programs. It is crucial to have paid, specialized, diversity practitioners who are

knowledgeable in anti-racism and informed by transformative justice so they can administer

social justice and achieve standards of equity. All employees must be required to learn anti-

racist discourse as opposed to discourse that condones or promotes racism.

Discourse Language-based expression (verbal, written, non-verbal,) that includes knowledge plus ideology,

or “the talk and the walk.” Discourse can be either a reflection of social structures or a

mechanism for restructuring relations.

Discourses of Racism Language-based expressions that structure relations of dominance, including marginalization,

exclusion, problematization, and containment of racialized people. These expressions can also

target supporters of racialized people.

Anti-racist Discourse The discourse of accountability for equity. It is conscious and relational. It is practiced.

Accountability practices pertaining to equity include:

• honesty and ownership of the impact of racial discrimination;

• informing persons of the perception of unfairness;

• providing an opportunity for persons to retract mistakes on their own recognizance along

with apology and accommodation; and

• informing persons what the community requires.



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What are the benefits of an anti-racism informed by transformative justice and skilled in

relational practices of accountability? Good accountability outcomes.

Accountability outcomes of a transformative justice hearing of a complaint:

• parties feel as whole persons;

• relationships feel in balance; and

• members of racialized groups feel safe (see Author, 1988).

Is Accountability for Racism a Menace to Some People? Calliste (1993) has shown that racist immigration policies have governed the relationship

between nurses from the Caribbean and the Canadian state. Glaessel-Brown (1998) illustrated

how immigration policy is explicitly used to manage nursing shortages. Calliste (2000a)

demonstrated how black nurses constitute a segregated, surplus labour pool in Canada.

Moreover, an ethnoracial hierarchy (Ornstein, 2000) exists in the Greater Toronto Area

according to employment, income, and education. Complaints of racism are often about other

racialized people not being accountable to people of colour. We argue that the hierarchy itself is

a self-reinforcing function of a system of discourse that regulates to whom one does, or does not,

have to be accountable. The nurses participating in our study were very conscious of the

hierarchy, and there was unanimous concession among various groups of nurses that Blacks were

the most vulnerable in this hierarchy in terms of being denied the privilege of accountability.

Institutionalized racism and systemic racism go unchallenged in organizations where

accountability for racism is resisted.



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Policy’s Role in Implementing Relationships of Accountability Despite the outpouring of anti-racism policy seen in the previous decade, accountability for

racial discrimination has not been achieved in nursing, including accountability for overt and

covert dominance and negative profiling of members of racialized groups (see Smith, 2004, for a

discussion of racial profiling). A continuum that ranges from breaches of simple forms of

etiquette to vicious indecencies toward racialized people exists within the health care system.

Yet, the following anti-racism policy accountability initiatives that some of our study

participants have worked on have not been implemented:

• Committee for Intercultural, Interracial Education in Professional Schools. (1993).

Consultation for Action Report. Submitted to the Department of Multiculturalism and

Citizenship Canada, Race Relations and Cross Cultural Understanding;

• Municipality of Metropolitan Toronto. (1993). Anti-racism Policy and Implementation

Strategy Discussion Paper;

• Ontario Ministry of Health. (1994). Strengthening voices: Anti-racism strategy.

• Ontario Hospital Association and the Ontario Ministry of Health, Joint Policy and

Programming Committee (1996). Anti-racism organizational change self-assessment

tool/anti-racism policy guidelines; and

• Kohli, R. and Thomas, B. (1995, October). A time for change: Anti-racism, employment

equity organizational change process. Final Report of the East York Health Unit

Employment Equity Coordinating Committee. Toronto: The Doris Marshall Institute for

Education and Action.



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Why have these policy documents been ignored? What damage has been done because

they have not been implemented? Why is anti-racism resisted despite formal policies that call

for an end to condoning or promoting racism?

The participants in this study expressed seriously conflicting convictions about anti-

racism as an organizing framework that could bring about accountability for racism.

Conflicting Perspectives on Accountability for Systemic Racism We found wide variation and disagreement between research participants on strategies for

introducing accountability in response to experiencing or observing racism. Some advocate

paying attention to racial differences and directly naming issues. Others advocate prohibiting the

word racism and avoiding accusatory tones in naming issues, while strengthening relationships

to build support in higher places. Some have strong convictions that race consciousness is the

remedy to foster discussion and problem solving. Others expressed equally strong convictions

that race consciousness itself is the epitome of racism.

We observed in this project that the extreme distaste for the word “racism” was centered

on assumptions and associations that were altered when we combined the understandings of

transformative justice with those of anti-racism. This synthesis offered potential for bringing

accountability into race relations and contractual arrangements with employers and unions.

However, we still have to contend with the legacy of misunderstandings of the ways and means

of anti-racism. We understand that:

1. The word “racism” triggers an accusatory, diagnosing, or branding effect that it is normal

to react against.



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But “transformative anti-racism” is interested in diagnosing problems, not people. The

normality of reacting against the word “racism” must be changed to a new accepting

normal if an open, problem-solving orientation is to be realized.

2. The word “racism” is interpreted as whining, as a type of “victimology” that nurses in

particular react to. Victimology is disdained in nursing as it has been well critiqued as

being detrimental to health.

Yet the concept of anti-racism that arises out of transformative justice is worlds apart

from victimology. It moves away from the concepts of victims and perpetrators. It is

about complainants in a contractual relationship (formal or informal) trying to make the

relationship safe and fair. In a democratic society, based on formal and informal

contractual relations, the privilege of accountability must be guaranteed and the

responsibilities of accountability must be reviewed and mutually monitored. We believe

a transformative type of anti-racism would uphold these social justice ideals. The

integration of accountability becomes possible through stakeholder dialogue,

participation, and the breaking down of social barriers to establish safety. When the R-

word can be used without reactivity and prohibition, discussion can be safely used for

problem solving.

3. The word “racism” is associated with hate crimes so, if someone is approached about

having offended somebody, the reaction is righteous indignation, and guilt is denied. Our

research suggests that this denial escalates the dispute and leads to fears of threat and

feelings of non-safety in all parties. The transformative justice approach to anti-racism is

mainly concerned with equal access and participation so that inequities in employment

and service do not result; so that processes of marginalization, problematization,



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containment, and/or exclusion are not used in negotiation with racialized peoples; and so

that the needs of the racialized person complaining are met in the proceedings of the

complaint. When there is a shift to self-monitoring and supportive equity monitoring

where issues are openly discussed in safe supportive environments, then feelings of threat

and non-safety can subside. If informal means of resolving issues are not effective, then

formal proceedings may be required.

A particular feature of organizations is that employee relations exist within hierarchies of

power. The nature of power hierarchies is that accountability and transparency involve top down

reporting relationships. However, we observe that even if accountability is supported from the

top down in an organization that is composed of people with divergent perspectives on how to

institute employment equity, instituting anti-racism principles will be difficult. Hence, we argue

that the main barrier to an accountability that could correct institutional racism is conflicting

views on how to achieve equity. The effect of this conflict is silence about racism so that racial

conflict continues relentlessly. Of course, other possible explanations for the perpetuation of

conflict include:

(a) influential people do not want equity instituted because they fear losing power, and

(b) influential people really do hold negative attitudes based on racial groupings and

want to retain the privilege of arbitrarily bestowing merit on exceptionally deserving

racialized individuals (See Calliste, 1993).

We prefer to take good will at its face value. Such a stance is consistent with

transformative justice, because it changes potential perpetrators into potential supporters and

gives the benefit of any doubt that they are not sincere in wanting equal access and participation.

Theoretical Perspectives on the Sanctity of Accountability Breaches



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Breaches of accountability result in proliferating accountability problems. It is not only racial

discrimination that produces racial disparities. Group-based refusal to be accountable also has

damaging effects on racialized persons, as well as on the system of governance. Lack of

accountability for racial discrimination may be linked to a lack of compelling or ethical interest

in being able to recognize discourses of domination, therefore precluding implementing effective

social justice programs that could improve race relations. Many of the effects, as well as the

causes, of systemic, organizational, or institutionalized racism, can be attributed to distortions of

accountability. But are these distortions due to unethical dispositions or virtuous missions such

as upholding standards?

Apart from segmentation and segregation that result from breaches in accountability

practices, serious disadvantaging games of set-up and backlash can emerge and we have shown

how disabling and distressing these can be. These instances of accountability gone awry

problematize racialized nurses who are set-up for discipline, job transfer, or job loss in uncaring

ways that conflict with nurses' identities. Nurses marginalize racialized nurses so that they are

already stressed about not being in relationships for collaborative decision-making, then they

contain and problematize colleagues who are courageous enough to object to unfair treatment

and they provide rationales for their decision-making.

As we saw from the aberrations in accountability practices described in Nurse A’s case,

various organizations engaged in practices that had the effect of containing – keeping Nurse A in

her place – and ultimately of closing ranks to exclude her participation in nursing employment,

presumably to keep bad apples out of the profession.

Accountability for distortions in accountability practices is precluded when organized,

group-based protection practices exist that are barely perceptible to nurses and others, including



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arbitrators and mediators, who are uninformed about contemporary manifestations of racism

such as set-up. Extreme amounts of energy go into documentation for hearings and large

amounts of money go into dispute proceedings. The benefit to non-racialized nurses is that the

system of merit for whiteness remains unchallenged. Can Canadians afford to keep paying for

this benefit, and what does it achieve? Are white nurses really the best educators, managers,

researchers, nurse practitioners, or program planners? As the popular saying goes, “Nursing is

white on top and brown on the bottom and it needs stirring.”

Experience of Relational Elements Where Racial Profiling Is Unaccounted for and Unchecked Evidence suggests that how relationships are managed when accountability is sought is quite

variable. This report provides evidence that relationships become extremely problematic as a

result of backlash when there are formal complaints or grievances. We have theorized elsewhere

about the relational elements in play because of the lack of accountability for systemic racial

discrimination and the low prevalence of courtesies such as apologies (Hagey et al., 2001b). The

range of relational problems runs the gamut from simple misunderstandings to gross violations

of relationship, including physical assault.

In an article entitled, “What is a racial dispute? How can we reach a level playing field?”

Hagey (2003) attempted to get a “buy-in” from nursing leaders to address the underlying issues

pertaining to systemic racial discrimination in Ontario. She defined the concept of agency as

participation capacity in recognition of external social realities such as systemic racism that

impact on decision-making capacity. Agency relies on accountability and transparency in

reciprocity as well as on voicing needs and realizing interests through decisions and actions.

Sadly, racialized nurses whose participation capacity has been ruptured are seen as “lacking



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internal capacities.” What is overlooked is that the nurse’s decision-making agency cannot be

normal, healthy, and collaborative when transparency and accountability are withheld in the

relationship.

Collaboration is a participatory process. If racial disparities regarding inclusion in

participation exist, collaboration will be impaired or aborted. When reviewing the contents of

the figure below, the reader is reminded that racialized persons can be selected into the non-

racialized in-group, although the motivation is not to include everyone, but to be seen to be

equitable.

Figure 1: Attributes of the Experiences of Non-racialized In-group and Racialized Out-

group Members

Non-racialized In-group Racialized Out-group

Oblivious (in denial) about

disrespecting the “other”

Perceives being disrespected

Ready to distrust Perceives not being trusted

Collaborates to sustain power Experiences barriers to collaboration

Takes agency for granted Agency is intermittently subordinated

This relationship model depicts the racialized nurse as perceiving that he or she is not

respected, whereas the non-racialized colleague or manager is oblivious about having shown any

disrespect. The racialized nurse perceives not being trusted, whereas the non-racialized nurse is

ever vigilant, ready to find a reason to distrust the racialized nurse. With this set of attitudinal

dynamics in play, the racialized nurse experiences barriers to collaboration, while nothing stands

in the way of collaborating to sustain power based on whiteness (defined as culturally sanctioned



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in-group dominance) for the non-racialized nurse who takes the privilege of agency for granted.

By contrast, the racialized nurse can have decision-making agency interrupted for a host of

reasons – lack of command of accountability, lack of participation, lack of information

transparency, outright subordination, patients demanding to have a white nurse, but most

importantly, activated fear of backlash and signs of set-up.

We assume (until research shows otherwise) that agency – equal access in participation –

is supported by transparency and accountability when the relational process is guided by nursing

leaders committed to anti-racism policy and astute to the discourses of domination. Regarding

policy that was issued by the Joint Provincial Planning Committee of the Ontario Hospital

Association and the Ministry of Health in 1995, the effect could have been the legitimization of

accountability to racialized people. Sustained expectations could have required working

relationships to be kept in balance so that collaboration among all colleagues would be realized,

free of racial profiling. Given that relationships have been a notable topic in nursing for years,

the denial response of “hear no racism, see no racism, speak no racism” is shocking to racialized

nurses, not to mention frustrating.

Building relationships between parties is problematic when agendas conflict and there is

an implicit agreement that it is safer not to communicate. Communication in nursing can begin

with orienting to the experiences of the person – the empathic approach – that can lead to making

accommodations when the ethics of restitution is used. Acknowledging the need for restitution

and apologizing to make up for omissions or commissions is a requirement for mutual

accountability in collaboration. Such amends are made routinely among in-group colleagues and

are especially important for the organization’s image in diverse communities, so why not extend

the amends to erode in-group/out-group boundaries.



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What Relationship Issues Arise with Particular Accountability Strategies? Removing the cloak of silence shrouding accountability for systemic discrimination puts

members of non-racialized groups and their supporters on the defensive. The sense of threat is

high. While nursing as a discipline in Canada has spent much of the last century contending with

diversity issues, it has never dealt with the labour dimensions related to experiencing diversity

(McPherson, 1996). For CEHS, it is important to put effort into sustaining relationships across

boundaries while maintaining honesty and clarity about any perceived problems. Clarity when

requesting to understand peoples’ perceptions can lead to mutual understanding. It is important

to maintain dialogue and learn what issues must be dealt with and set ground rules on how to

deal with them.

All those embarking on ways to implement strategies to achieve accountability for racial

equality and employment equity need support from a mentor and an organized support system.

We are all learning to take baby steps. We all need recognition and rewards and should be

having adventurous fun in this newly expanding personal growth area, be curious about where it

will lead, and pleasantly surprised with new mutuality. One goal for racialized and non-

racialized nurses seeking connection is mutual responsibility and reciprocity while becoming

astute to lurking forms of built-in advantage and disadvantage.

In this study, we found it energizing to talk about our perceptions and keep our

relationships in balance by resolving issues. Our think tanks demonstrated that collaboration

between racialized and informed non-racialized nurses is not only possible, but very fruitful,

suggesting that knowledge may be the key to dialogues on accountability policy. We believe

that the negotiation of equity in relationships requires convening racially integrated fora for



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dialogue. We have been instrumental in the passing of a resolution by the Registered Nurses

Association of Ontario to “devise a series of conferences to envision means of achieving racial

equality and employment equity….” (see Appendix C). CEHS is willing to collaborate on

devising this series of conferences.

Building interracial relationships across sectors and hierarchies is hard work.

Nevertheless, it is necessary to build responsibility and collegiality and motivate those who rule

– each one of us – to nurture inclusion programs and incentive strategies. Goals remain to

enhance the quality of ethnoracial interrelationships and realize employment equity. Many of us

come from several generations of fighting discrimination and have been reared to continue doing

so. Many racialized nurses have built exquisite legal expertise and extensive knowledge of

human rights legislation at provincial, national, and international levels and are aiming to meet

nursing leaders in all of these arenas. You could say we are highly motivated to pursue the

development of effective accountability strategies within the profession.

This goal requires building grass roots organizations representing nurses, holding public

dialogues and debates on the issues surrounding accountability, and making educational

materials accessible. In the current context of heightened war and conflict around the globe, it is

pertinent to point out that nursing of the European variety was born in the context of religious

wars in medieval times. Every nurse in the United States is automatically a member of the

armed forces. Nursing has never shed its hierarchical rituals born in its military period. Our

quest for accountability begins by critiquing the systemic pecking order that we perceive as

preserving privileges based on race. We ask you to please circulate for debate Peggy McIntosh’s

classic article “White privilege: Unpacking the invisible knapsack” (1990), available at:

http://www.utoronto.ca/acc/events/peggy1.htm.



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Also, the Centre for Social Justice has a valuable resource, Expanding the circle:

People who care about ending racism. We need your help (Curry-Stevens, 2005). This resource

is available at: http://www.socialjustice.org/pdfs/expandingthecircleEnglish.pdf. More and more

scholarly sources are appearing that are relevant locally. For example, the Fall 2004 issue of the

Association for Canadian Studies/ Association d’etudes canadienne publication Canadian

Diversity/Diversite canadienne centres on racial discrimination, racism, and human rights. See

also recent work that documents the impact of racism on health (Navarro and Montaner, 2004)

and mental health (Waldron, 2002).

We doubt that systemic racism is held in place by malicious hatred. We have learned,

however, that pointing out differences along racial lines can spark viciousness, which increases

tension and polarization and escalates problems because it complicates communication. When

this happens, we need each other’s support to clarify communication strategies.

How Do I Evaluate Alternative Discourse Strategies? Discourses of domination are played out socially to both marginalize racialized nurses and

contain them with stringent retaliation if they persist in "not knowing their place." For this

reason, it is important to be critical about the role we ourselves, as racialized nurses, play in

becoming ensnared in a set-up. The Jean Baker Miller Training Institute (JBMTI – see website

at: www.wellesley.edu/JBMTI), has been investigating the options that African-American and

other racialized women can generate with the coaching and support of therapists who are also

racialized women developing relational/cultural theory (RCT) (Walker, 2002). RCT

recommends analyzing situations inspired by questions like these:

• How can I build personal and political support in this situation?



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• How can I communicate from a relational self that stays in relation rather than getting

into the trap of distant and alienated disconnects where they have even less interest in me

as a person?

• How can I deal with this combative person’s perspective, fears, and wrong assumptions?

• What if I express my fears and legitimize my issues by being firm about who I am and

what I expect, and also attend to the other person’s fears so that I minimize the images of

threat that are conjured by racial stereotypes?

The JBMTI has not reported studies that empirically trace elements of situational

problem solving, or scientifically link certain strategies and outcomes. Nevertheless, it does

continue to advance the hypotheses that having sound working relationships is healthier for the

individuals involved and that sustaining relational (positive) connections with the individuals in

situations avoids the isolation they characterize as the "glue of oppression" (Jordon, 1999).

Our research network continues to expand to members who testify they were calm, firm,

and honest in situations where they were boxed in and then systematically isolated when they

broached the issue of racial difference or disparity. One nurse reported physical assault by a

manager who was apparently triggered by her calm, firm demeanor. The majority of these

reports come from community hospitals, health agencies, and continuing care facilities that

appear to be cut off from current knowledge, although there are some shocking exceptions.

Non-racialized, influential nurses do not come to the CEHS to report their woes about

difficult colleagues and experiences in racial disputes. They support each other in what Brian

Turner calls “thick solidarity,” which is eroding as a social form under the postmodern approach

to organizing relationships (2000). He argues thin solidarity is the mode for the new era of

fleeting connections that are tied to particular fleeting projects. Because of shared assumptions



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and strategies, dominant groups can work in concert without conspiracy. Actual conspiracy

requires time and opens up possibilities for disagreement and questions about who is going to get

the credit for what, and so is comparatively inefficient. As social capital theory stipulates –

“efficient systems compete better."

Racialized groups are at a distinct disadvantage in comparison to non-racialized groups

that share common goals and trust each other to act independently. Organizing to cut through in-

group barriers to power is a relatively uncharted journey in the empirical administrative sciences.

Moving from being a token to gaining a critical mass to become a part of central decision-

making is often pointed to as the trajectory (Collins, 2004; Dei, 1996). The importance of

having progressive leadership in an organization is always cited as crucial for emerging from the

chilly climate (Chilly Climate Collective, 1995). Moving in this direction is the leading edge

exception in nursing in Canada, according to observers in our networks (Villeneuve, 2002).

The main dilemmas that arose in our think tanks pertained directly to issues of gaining

ascendancy and emancipation. “Do I stay in my own nursing association and put my energies

there or should I join the RNAO?” “Given that the RNAO is so racially homogeneous, there is

little hope of the RNAO really dealing with the systemic racism issues we face everyday.” “Do I

put my energies into building coalitions that together can become the new official voice of

nurses in the province?” “What could be gained?” “How would disagreements be handled?”

“Wouldn’t nurses be a force to reckon with if we all united into a strong organization?” “What

are the forces that are impeding against that happening?”

The nurses explored these issues in connection with the question of the profession as a

whole working on developing policy and programs to address resistance and counter-resistance

that lies below the surface of people’s fears and attitudes. It is a reality that well-informed



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people can be offenders and repeat offenders because of widely differing views on what

constitutes racism and how it should be handled. The lack of language and etiquette in this type

of conflict leads to reactions and counter-reactions that escalate into a trap of resistance and

counter-resistance along lines of racial conflict. Avoiding problem-solving only increases

tensions and deters and delays any integrative movement.

Anti-racism Grounded in Transformative Justice and Freedom Ideology As an alternative, we offer anti-racism as a type of freedom ideology. Anti-racism encourages

people to freely choose to oppose, in principle, a set of practices that people are drawn into

without full cognizance. If racial domination and disparities are allowed to operate, the

advantaged and disadvantaged in the situation will be ensnared in resistance and counter-

resistance or tit-for-tat and everyone loses (See Fisher and Brown, 1988). Therefore, we

advocate anti-racism to nursing as a liberating opportunity that can further emancipate our

discipline.

For the same reason, it is important for us to share our discovery in this project that anti-

racism discussions can be conducted in scholarly, respectful ways. For example, our think tanks

invited knowledgeable, accomplished speakers who set the tone for excellence on so many

levels. Anti-racism can be fun, sensitive to people’s feelings, and consistent with health

promotion principles, not to mention the direct application of primary health care strategies of

participation and community ownership of problems to promote healthy ways of being.

We are calling for an end to the pattern of nurses being embarrassed, humiliated, or

threatened when broaching the issue of racial disparity. But these responses can only diminish if



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there is an end to reactivity and retaliation when someone broaches an issue. We appeal to all

parties to keep the relationship intact.

Knowing how deep-seated and unconscious dominance practices can be, we urge you to

support each other in expressing difficult feelings. Feelings of confusion and hopelessness are

common when one does not know how to intervene to prevent well-meaning, but nevertheless

offending and repeat-offending practices.

We ask you not to mistakenly claim that racialization of non-racialized people – so-

called reverse racism – is going on when efforts at equilibration are taking place. We ask you to

identify where feelings of racial domination come from and deal with them in therapy or anti-

racism role-playing seminars. We are asking all nurses, and ultimately all Canadians, to come

into the centre of the opposite poles and work out a system of balance among the so-called races

in the human race. We are looking to those in positions of leadership who have the power to

take the lead in promoting anti-racism and accountability for racial equality and employment

equity and to bring an end to racial disparities.

The State’s Weakened Role in Accountability for Systemic Racism: Policy and legislation are required to implement and integrate voluntary accountability Beck and others point out that federally, the Canadian Human Rights Act (CHRA) and

Employment Equity Act (EEA) were amended by legislation in 1996, with the effect of

terminating the potential for case hearings, and hence for remedies, that hold employers

accountable for systemic discrimination (Beck, Reitz, and Weiner, 2002). This can be seen as

but one indication that the role of the state in the enforcement of equity is weakening.



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In Ontario, Henry and Tator (2002, p. 95) point out that on 13 December, 1995, the

Harris government rescinded the 1993 employment equity legislation, the first in Canada to

address group-based advantages that are widespread, persistent, and systemic. They called their

act “Bill to Repeal Job Quotas,” to direct attention away from virtual job quotas enjoyed by in-

group members who are not subject to systemic discrimination. By calling the new legislation an

“Equal Opportunity Plan,” the privileges held by some who are "more equal" than others are now

protected in legislation.

Enforcement of the Provincial Human Rights Code is problematic in the absence of

effective employment equity legislation and proceedings. In the four-year period following the

act, in the GTA alone an estimated seven million health care dollars were paid in settlements for

discrimination cases filed by nurses, according to our informal sources. Some of these cases

included disability grievances, but the majority concerned racial discrimination. Most of these

settlements were concealed from the public because “gag orders” were stipulated in the

agreements. Taxpayers have the right to know that there is currently a jurisdictional contest

under way. Should health care dollars be spent to remedy deficiencies in employment equity

legislation? Alternatively, is it better to attempt to integrate human rights accountability

measures into the day-to-day proceedings of institutions such as health care?

This growing trend away from accountability for systemic racism makes employers,

union representatives, nurses, and colleagues we have talked with feel "backed into a corner,"

trying various means to deal with escalating conflicts or embarking on expensive grievance

arbitrations which neither employers, unions, nor the human rights tribunals can afford. Some

health agencies have contracted with unions to develop workplace diversity units that address

both prevention and dispute resolution with a variety of consequences we want to study in future



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research. Nurses participating in our study perceive accountability to be problematic and

extremely laborious for the individual experiencing the effects of racial discrimination or

harassment in employment. The following recommendations are made in the hope that

implementing accountability for institutional and systemic racism will bring about equity.

Recommendations to Achieve Accountability for Systemic Racism: The Romanow Commission’s Health Council of Canada In addition to promoting accountability through resolutions, recommendations, objective-setting

and guidelines set forth by the CEHS, a role for the newly emerging Health Council of Canada

(HCC) was envisioned. The HCC could decrease the number of health care dollars that are

currently being expended on problems pertaining to systemic racism in health care, such as

legally defending charges of discrimination. As mentioned above, unions in the GTA reported to

CEHS that in a four-year period, seven million health care dollars were spent settling

discrimination cases, the majority of which were racial.

The Romanow Report (2002) did not address racial discrimination directly, but

denounced the “big disconnect," referring to health care for Aboriginal people, and targeting the

reduction of morbidity and mortality due to barriers in access, primary prevention, and treatment.

Lack of accountability for racism, colonization, and poverty were not specifically targeted. Nor

were jurisdictional issues and actual funding commitments laid out (Koebel, 2003). Some

Native leaders are calling for a national Aboriginal Health Act to correct the racial disparities

created by The Indian Act.

The HCC could introduce accountability mechanisms to monitor the costs associated

with systemic racial disparities in health and health care and set guidelines for equity practices.

The Romanow Report Recommendation 3.2 states that “On an initial basis, the Health Council



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of Canada should establish benchmarks, collect information and report publicly on efforts to

improve quality, access and outcomes in the health care system” (2002, p. 248).

Recommendations to the Health Council of Canada

• Monitor the racial disparities in health and health care and require interventions to correct

them.

• Require process and outcomes reports on equity programs for health care workers and

consumers.

• Monitor the number of health care dollars spent on defending discriminatory practices

and set mechanisms to ensure freedom from racial discrimination, harasssment, set-up,

and backlash in organizations responsible for health.

• Promote equal access and participation in organizations responsible for health, including

the provision of interpreter services and removal of barriers for visible and invisible

minorities.

We thank Anne McLellan, former federal Minister of Health, for her encouraging letter

responding to the CEHS' suggestions about the future role of the Health Council of Canada

(Appendix D).

Recommendations from Partisan Sectors of the CEHS Network The recommendations below have not evolved out of consensus. The beauty of a network is that

despite differences in ideas and diversity of backgrounds, we are linked together in a common

vision. How that vision – equity in health and society – might be realized may be through

multiple, even conflicting, pathways. The recommendations are offered in the spirit of sharing

strategies that can be discussed and debated so that actions can be tried and demonstrated to

work or not. Changes can be undertaken until the vision is achieved. What follows is a selection



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of some key recommendations that attempt to build accountability for systemic racism through

changes in legislation and policy to build new organizational structures, procedures, and

practices in the nursing profession.

We have outlined the recommendations under six change categories: (1) An investigation

by the Ontario Human Rights Commission; (2) Leadership Training and Anti-racism Education;

(3) Ontario Legislation; (4) Ontario Policy; (5) National Accreditation; and (6) Voluntary Policy

in Key Organizations.

1. An investigation by the Ontario Human Rights Commission The Ontario Human Rights Commission (OHRC) initiate (under section 29 [g]) of the Code) an

investigation into the systemic discrimination against racialized nurses as well as all designated

groups protected under the code with respect to education and employment in the health care

system. The investigation should take account of discrimination, harassment, and procedures for

redressing grievances and complaints.

2. Leadership Training and Anti-racism Education

The Centre for Equity in Health and Society (CEHS) establish a leadership academy that holds

training workshops for negotiating the implementation of anti-racism policy and practice in

support of ethnoracial competencies. The Province of Ontario fund this academy to develop

curricula and organize dialogues on changing the culture of nursing to one that practices

accountability for equal access and participation in all sectors and at all levels of the profession.

The CEHS leadership academy, in partnership with university research units, will evaluate

curricula and develop and disseminate new knowledge on ethnoracial competencies and

achieving diversity in leadership. The CEHS will collaborate with appropriate professional and

regulatory bodies to develop questions for registration and licensure examinations pertaining to



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antiracism and racial dispute proceedings. CEHS will also collaborate with unions that negotiate

nurses' contracts to sponsor conferences that discuss innovations addressing member-to-member

racial disputes. The CEHS leadership academy will convene dialogues in nursing on the overt

racism from patients, colleagues, and supervisors experienced by nurses of Asian and Filipino

descent during the outbreak of SARS and how to prevent such behaviours in future.

3. Ontario Legislation

The Ontario Human Rights Commission be legislated to report directly to an all-party committee

of the Parliament instead of to the Attorney General.

4. Ontario Policy

The Ontario Human Rights Commission develop policy to:

• Monitor workplace complaints proceedings for reprisals and step up investigations to

properly document reprisals and irregularities in procedure.

• Levy fines based on the degree of resistance to anti-racism procedures in the complaints

process.

• The Ontario Human Rights Commission report to the legislature, categories

of complaints and statistics on how they are dealt with. Private and union practitioners

adjudicating racial complaints report to the legislature similar data ensuring the

confidentiality of complainants and respondents but listing the sector – for example,

health care – in which the complaint arose.

• The Ontario Ministry of Health and Long Term Care require the Nursing Secretariat to

provide the opportunity for the inclusion of Aboriginal and visible and non-visible

minority member representatives in its proceedings in collaboration with the Joint

Provincial Nursing Committee.



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• The Ontario Ministry of Health and Long Term Care integrate anti-racism, anti-

discrimination, anti-harassment, employment equity assurance, and language and culture-

care agendas in the nursing and other relevant secretariats to carry forward the

requirement of ethnoracial competencies in a mission of diversity and equity in health

care.

• The College of Nurses of Ontario introduce transformative justice proceedings to handle

allegations where a racial dispute is evident between a client and a nurse.

5. National Accreditation

1) The accreditation proceedings of hospitals and health agencies, in cooperation with all

regulatory colleges, implement equity assurance to augment their quality assurance

programs.

2) The accreditation arm of the Canadian Association of Schools of Nursing require:

• evidence of recruitment and strategies for retention of Aboriginal, racialized, and non-

visible minority faculty and students;

• evidence of anti-racism curriculum;

• evidence of requiring ethnoracial competencies among faculty, staff, and students.

6. Voluntary Policy in Key Organizations

1) Provincial, regional, federal, and national bodies supporting and directing health

services research develop programs to obtain and publish data on health care workers in

terms of Aboriginal status, ethnicity, mother tongue, and visible minority identity.

2) The Ontario Hospital Association develop and promote best practice models of anti-racism

policy. Guiding policies should include Principles for Good Governance in the 21st Century



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and the United Nations Declaration of Human Rights – Legitimacy and Voice, Equity, and

the Rule of Law.

3) All regulatory and professional bodies introduce measures to address racial discrimination

and systemic racism in health care:

• Registration forms be changed to allow for self-identification of Aboriginal, racialized,

and non-visible minority status.

• Committees and panels be required to be diverse and inclusive so that they reflect the

diverse population of Canadians.

• Ethnoracial competencies be made a requirement for nurse registration and an

expectation for ongoing, self-reflective practice for registration in self-reflecting

professions.

• Regular in-service education programs and human rights orientation to new staff at all

levels.

• Electronic monitoring using human rights software to track equity indicators.

• Tools for employment systems review be adapted to identify set-up and backlash

experienced by racialized employees.



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Chapter 4 – Undoing the Catch-22 of Racism: Overview of

Study Findings Intent on Integrating Accountability for

Systemic Racism



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How Integrative Processes could be Used to Implement Accountability for Equity in Nursing and Health care 1) Any plan to integrate accountability has to address the resistance to accountability for equity

among leaders in the health care system. This resistance is manifested in denial of inequities,

prohibition on the use of the term racism, “white-out” on research on racial differences in

quality of work life and healthy environment research that has been heavily funded in

nursing, and targeting of individuals who break the silence on racism in nursing. Moreover,

the gridlock resistance to accountability means that redress of grievances is extremely

problematic. The out-of-control patterns of set-up and backlash were perceived by

participants in this study to impact on racialized nurses, negatively affecting their resources

for health, making the workplace unhealthy and potentially a risk to patient safety.

2) Racialized nurses perceive that race, colour, or ethnicity impacts on relationships with

colleagues, patients, doctors, and supervisors. A study by Das Gupta (2002) shows that few

white nurses of European background perceive this. This disparity in impact of race, colour,

or ethnicity has implications not only for patient care but for the quality of work life, career

mobility, and leadership opportunities for racialized nurses. Racialized nurses report that

they are excluded from collaboration, which is a key task of the health care professional.

Racism’s power is in its catch-22: It’s bad if we do not talk about it; it’s worse if we talk

about it. To change this, we must create safe opportunities in nursing for discussing racial

disconnects and disparities and what we can collectively do about them.

3) The 1991 Census indicated that visible minority nurses in Ontario have half the chance of

their non-racialized counterparts to move into the managerial level, yet there has been no

profession-wide discussion about barriers and accountability for removing barriers and

building bridges. This report calls for updating the census statistics on ethnicity, visible



129

minority, and Aboriginal status in relation to occupation and career mobility. Without

current statistics, it is difficult to strategically plan.

4) Evidence exists that students in a nursing school were fearful of discussing racism. For

example, one student said, "that person may perceive this as a threat and it will come back on

you in different ways.” The accreditation tool of the Canadian Association of Nursing

Schools is silent about problems of racism in nursing education, health care, and society.

Moreover, participants in this study perceive that faculty who break the silence on racism in

nursing continue to be marginalized, problematized, and contained or excluded (i.e.

ostracized as “others”). Any plan for integrating accountability should consider how to use

accreditation to require nursing schools to conform with anti-racism curriculum, staffing, and

recruitment and retention of students, as called for by the Aboriginal Nurses Association of

Canada and others (Author, 2002).

5) Racialized nurses reported differential treatment and being "ear-marked" for more severe and

unfair levels of work assignments and discipline than were non-racialized nurses. Also,

issues of racism directed by patients towards nurses were considered to be "trivial" in nature

and "par for the course." These root causes of sickness and absenteeism were not identified

or dealt with by administration. Any plan for implementing accountability should require

human resource departments to enforce anti-racism standards of work allocation. Client-

centred care policies and practices should acknowledge the inappropriateness of any client’s

racist behaviour and should retain the facility’s right to allocate staff free of demands by

clients using prohibited grounds under the Code. Staff experiencing workplace racism

should be granted compensation time and pay.



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Toward an Accountability Discourse Model that can Deal with Racial Discrimination in Nursing 6) Due to the findings of the present study, an accountability discourse model should begin by

addressing set-up and backlash against racialized nurses who presume equality or exert

expectations for equity.

7) New language is required so everyone working in health care can recognize systemic racism

and cooperate fairly in the redress of grievances. New language is required that permits free

discussion of racism so that repeat offending is less likely. The report invites recognition of

set-up as a type of systemic discrimination that disadvantages racialized nurses, especially

during times of downsizing, so that preferential treatment is given to non-racialized nurses

making them prone to condone the set-up. No health care workplace orientation programs or

policies exist that could aid in the recognition and prohibition of this human rights offense.

8) Backlash is a term universally understood by the nurses participating in this study. We are

asking for compassion from our colleagues so they understand that to be racially different

means having fear of backlash for being racially different. Moreover, we ask that it should

be legitimate in our profession to complain about a problem, and racism is a problem. We

ask for an end to backlash in the procedures for handling racial disputes. The widespread

practice of backlash impacts on long term relationships with our communities and it is a

source of rancor.

9) When accounting for the costs of racism, we must account for the costs to health. The health

effects described by the nurses who charged their employers with racism included feelings of

loss, including loss of confidence, loss of focus, and memory loss. They reported

experiencing humiliation, intimidation, paranoia, and isolation. Depression, grief, distressing



131

physical symptoms, death images, and overwhelming sensations, such as being invaded or

torn apart, were reported as health effects.

10) The discourse of accountability for racism should acknowledge that set-up is an everyday

possibility for racialized nurses who experience racism from their colleagues and patients.

For example, delicate tasks can have potentially problematic power dynamics, such as when

a female nurse has to insert a catheter into a male patient. Requiring a black female to

catheterize a white openly racist male can be seen as a potential set-up. Problems of racism

should be discussed, taking into consideration the energies of the care provider when making

and revising care plans.

11) The discourse of accountability for racism should be developed by the regulatory bodies,

such as the College of Nurses of Ontario, which is accountable for protecting the public

through standards of practice. The report strongly suggests that such bodies retain personnel

who are knowledgeable about racism in the health care system. Review panels should be

constituted by racialized members who are knowledgeable about racism and the culture,

language, and communities under review. Racialized nurses perceive being much more

vulnerable than their counterparts to being reported to the College of Nurses of Ontario.

Racial domination and backlash by colleagues is implicated in setting nurses up for being a

scapegoat, as we have witnessed in proceedings disclosed in confidence. Scapegoating

should be acknowledged as an effect of set-up and should be prohibited by local policies that

adopt the discourse of accountability for racism.

12) Racialized nurse managers reported experiencing more vulnerability than their counterparts,

were more often exposed to bullying, and more subject to behind-the-back complaints from

colleagues or underlings who can be supported by management from above. They perceive



132

being more likely to fall out of favour with superiors without explanation. This report is

calling for supervisors to be astute to the tactics of racism that sabotage racialized leaders

with the effect of advancing white leadership.

13) Cultural dominance is being used to discipline racialized nurses. One nurse reported, “I was

called in after I met a former client in the hallway and gave him and his child a “high five” to

say hello. The nursing manager said that the high five greeting is unprofessional behaviour,

and I was threatened that this incident would go on my record as being unprofessional. I

thought I was being culturally sensitive, but they have a very skewed and uninformed idea of

cultural sensitivity, and I have no way of holding them accountable for it.”

14) Racial Harassment has a presence throughout the health care system:

• One nurse reported: “when I went to pick up my mail there was a cup with images of

black people in my mail box. It had water in it so when I took it out to look at it, water

spilled all over my mail.”

• Another nurse reported: ”you begin to understand that there is a segment of the Canadian

population that really hates visible minorities when you look at the graffiti on postings.

My picture was put up in the lobby with twenty or so others for our outstanding service.

Mine was the only black one and the only picture that was mutilated”.

• Another reported: “Graffiti appeared on the flyers that we put up to advertise the think

tank today. This one from the elevator says, “piss on it.” The others are here, but I do

not want to say the words in polite company. Where are the people who did this? How

do we hold them accountable for their behaviors?”

• The diversity office in one large metropolitan hospital where racial complaints are filed

reported receiving threatening phone calls. An effigy doll with a noose around its neck



133

was hung on the office door conjuring the hateful racist lynching of people of colour.

Hate messages are a common reality for racialized nurses in Canada, who are coming to

question whether hate can be cured.

15) Equity disappears from the dominant discourse during job scarcity. Moreover, it is perceived

that non-racialized nurses who lose jobs during periods of under-funding of nursing have a

qualitatively different experience in how they are let go. In contrast to the hostile targeting

experienced by racialized nurses, non-racialized nurses are consoled and assisted with

finding another job.

16) Because accountability for discriminatory practices is considered not to be a valid,

appropriate response, those who are subject to racism experience anxiety. This anxiety is

exacerbated when the social means for addressing the problem and removing the source of

the anxiety is blocked. Blocking paths to accountability produces frustration and can lead to

illnesses that are triggered by anxiety. Racialized people in Canada have higher rates of

mental illness, chronic illness, injuries, and accidents and use more health care dollars per

capita. Increasing accountability for racism is a rational intervention targeted at lowering

these rates.

17) Given the fear of backlash for broaching the issue of racism, we found that not all group

members subject to racial profiling are in agreement about how to embrace an anti-racism

strategy that promotes accountability for systemic racism. We found much disagreement

about how accountability should be introduced. There appeared to be consensus that healing

is required to build relationships of trust and that organized dialogue is necessary to develop

ground rules within the profession and beyond.



134

Initiating Accountability Policy that can Regulate Programs, Practices, and Procedures at Local, Provincial, and National Levels in Nursing These policies should be instituted in workplaces, and in professional and regulatory bodies,

where applicable.

18) Effective accountability proceedings for racism are the exception. For example, only two

hospitals in Ontario have trained staff to address racial harassment before a dispute escalates

into a union grievance or a complaint to the Ontario Human Rights Commission (OHRC).

There is a need to normalize accountability and accommodation for systemic racism in both

informal and formal contractual relations, in both interpersonal and organizational culture

and in governmental relations.

19) Ruth Morris, an expert on transformative justice, identified five "benchmarks" that address

victims' core needs: (1) the need for answers; (2) the need for recognition that they have been

wronged; (3) the need for safety; (4) the need for restitution and balance in [workplace]

relationships; and (5) the need to find significance or meaning from the assault on their

human rights (2000, p. 248). We used these benchmarks to evaluate Nurse A's experiences

with retaliation and escalation in her dispute process and legal proceedings. We found that

none of these needs of the complainant, Nurse A, were properly met. Racial conflict can be

viewed as an opportunity for individuals and organizations to examine, reflect upon, and

repair the relationships that poison the workplace. Health care settings should offer respite to

racialized workers and supports for them to grieve and process the ongoing assaults on

dignity and the lack of accountability that are anxiety producing.

20) Evidence exists that making a complaint of racism to the human rights commission or filing

a union grievance contributes to being expelled, marginalized, treated as the problem,

contained, punished, or scapegoated. Evidence also exists that an investigation of racism



135

feels to the respondent like “being guilty until proven innocent” and insufficient

accountability within such legal proceedings results in irregularities, including backlash.

Policies have yet to be established that hold employers accountable for backlash, even though

the Ontario Human Rights Code forbids it.

21) Speaking out in support of a colleague who experienced unfair treatment because of race was

perceived to be a "career limiting move or CLM" (backlash). Moreover, in a pilot study of

nine nurses who charged their employer with racism, only those who had a non-racialized

person testifying for them were successful in their proceedings. One person from the Ontario

Human Rights Commission witnessed that race cases that were granted hearings had the

support of a white person.

22)This report calls for developing ground-rules of accountability for equity and developing

capacities among all nurses for recognizing andresponding ethically when equity is being

challenged. Moreover, we are appealing to all Canadians to be continuously committed to

anti-racism, which means to speak out against privileges owing to racial dominance and

disadvantages owing to systemic racism and racial disparities in resources for health. We

invite you to support our strategic resolutions and recommendations designed to help us all

learn accountability for systemic racism. You can be part of the solution by developing

ethnoracial competencies. We thank you for your interest in these issues.



136

Summary and Future Research


137

Chapter 5 – Summary and Future Research



138

Through the use of PAR, we have engaged in integrative processes by reaching out to

stakeholders to address accountability procedures in response to systemic racial discrimination.

We have begun to expose discourses associated with set-up and backlash in our case studies. We

suggested that backlash, set-up, and scapegoating are indicative of the ideological coordination

of organized practices consistent with institutionalized racism. That is, they are normalized and

institutionalized due to the systematic lack of accountability for racial discrimination. We

discussed strategies and issued resolutions and recommendations toward accountability policy

that can begin to regulate programs and practices at local, provincial, and national levels in

nursing organizations through self-monitoring, peer monitoring, stakeholder monitoring,

executive monitoring, and editorial monitoring. Organizations can normalize talking about

racism breaches, including harassment, and institute clear policy and procedures for solving

problems, repairing relationships, and promoting equity throughout health care education,

employment, and service.

We discussed some relationship implications that arise when individuals or groups seek

accountability for systemic racism. Specifically, when racism is an issue among nurses, clear

procedures are needed for addressing and resolving issues. We are calling for a shift to

transformative justice approaches in the grievance processes of racial disputes so that

complainants, plaintiffs, and others in the workplace are not traumatized by the very proceedings

that are supposed to bring about resolution. In racial disputes, parties need answers to deeply

personal and political questions. They need recognition that they have been wronged. They

need safety. There is a great need for restitution and balance in workplace relationships, and a

need to find significance or meaning from any breach of human rights (Morris, 2000, p. 248).



139

We are inviting profession-wide problem solving to correct the irregularities in

transactions, outcomes, and interpretation of events that are evident with particular

accountability strategies. For example, it should not be a career-limiting move to speak out in

support of a colleague who has experienced unfair treatment because of race, or to call for

accountability on the anti-racism agenda in organizations. We outlined how anti-racism is

consistent with health promotion and excellence in healthy workplace environments.

Accountability is an anti-racism strategy to dismantle institutional racism and build instead a

healthy organization that rewards the practices of excellence in race relations and equity

monitoring.

We are seeking funding – and encourage colleagues to do so – to employ the

participatory action research model in a wider circle of nursing colleagues and other stakeholders

in health care. We see PAR as potentially effective for implementing and evaluating the

recommendations of this study and for generating deeper understanding of the issues and

potential strategies for institutionalizing accountability through equity assurance in nursing. In

our coalition-building, we advocate the support of individuals to assist them to orchestrate anti-

racism activities to gain inclusion and influence, recruit peers, and carry out the strategic use of

documents such as this report which we hope will receive wide attention.

The Centre for Equity in Health and Society intends to carry forward its research and

advocacy agenda. We thank the Canadian Race Relations Foundation (CRRF) for supporting

research on backlash against accountability for equal access and participation in nursing.



140

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Definitions


153

Definitions

Aboriginal peoples: A term referring to First Nations, Inuit, Metis, non-Status, or Status Indians. The latter designation is defined in different ways under the 1876 Indian Act. Accountability: A feature of relationship that holds individuals, groups, or offices responsible according to principles or criteria befitting the relationship, for example, transparent communication, fairness, and trustworthiness. Accountability practices pertaining to equity include:

• honesty and ownership of the impact of racial discrimination; • informing persons of the perception of unfairness; • providing an opportunity for persons to retract mistakes on their own recognizance along

with apology and accommodation; and • informing persons what the community requires.

Accountability outcomes of a transformative justice hearing of a complaint: • parties feel like whole persons; • relationships feel in balance; and • members of racialized groups feel safe (see Author, 1988).

Individual Accountability refers to the assignment of responsibility for a specific set of actions for which non-compliance may result in specific sanctions.

Public Accountability entails community participation in, and control of, the decision-making processes of public institutions (Henry et al., 1995).

Agency: A term referring to participation capacity, such as voicing needs and realizing interests through decisions and actions. Agency is equal when there is equal access and participation. Anti-racism: Refers to a health promotion agenda that calls for an end to condoning and promoting racism by advocating for accountability in relationships irrespective of race, colour, or ethnicity. Avoiding accountability for racial equality: A condoned practice permitted among all members of a society where racial discrimination, racialization, racial dominance, racial disparities, and racial segregation are not necessarily held accountable. Backlash: Striking out in reaction to a perceived threat (Archaic use refers to the slave lashing back at the master). Discourse: Language-based expression (verbal, written, non-verbal) that includes knowledge plus ideology or “the talk and the walk.” Discourse can be either a reflection of social structures or a mechanism for restructuring relations.

Definitions


154

Discourses of racial discrimination: Language-based expressions that structure relations of dominance including marginalization, exclusion, problematization, and containment of racialized people. These expressions can target racialized persons’ supporters. Employment Equity: Refers to a set of standards of fairness and equality achieved throughout employment by the administration of equilibration practices designed in policy and legislation to protect all workers. Equity: Standards of fairness achieved through social justice proceedings. Ethnocentrism: Refers to an ubiquitous tendency to view all peoples and cultures in terms of one's own cultural standards and values. Ethnoracial competencies: Skills manifested by healthy discourse practices that integrate anti-racism principles and strategies in decisions and relationships. The term can also refer to broad based people skills that transact equity pertaining to age, class, disability, gender, race, sexual diversity, and so on (Meeks, 2003). Institutional racism: The lack of accountability for racial equality in society’s institutions, such as health care. Its fundamental basis is the privilege – informed by ideology and group power – of not having to be equally accountable to racialized people as to non-racialized group members. Invisible minorities: People who experience social inequalities because of traits that are not visible, for example, cognitive capacities, sexual diversity, or age. Non-racialized people: Members of dominant groups who enjoy white privilege because of their race, colour, or ethnicity (see “Racialized people,” below). The Ontario Human Rights Code protects non-racialized people who experience racial discrimination by association with racialized people or anti-racist agendas. Otherness: A situation in which one is being undervalued or discounted because of race, colour, or ethnicity, for example, being subjected to difference, marginalization, subordination, disadvantaging, restriction, being silenced, lacking in information or cooperation for control, events being in chaos, and/or lacking information about the correct means and channels for decision-making (Hagey and MacKay, 2000). Non-racialized people who champion anti-racism can experience otherness in their workplace. Race: A set of assumptions used in discrimination, creating racialized and non-racialized peoples. Assumptions of race make a connection between European derived signifiers of race, such as skin colour or heritage, so that accountability is not owed to the racialized person(s). Race consciousness based on anti-racist principles: A strategy for racial equality that names and questions discourses of domination and promotes equal access and participation in governance, media, education, research, corporations, health care, policing, child welfare, politics, justice, and so on.

Definitions


155

Racial backlash: Negative reaction or repercussion when a racialized person assumes a privilege that is deemed suitable for whites only; also pertains to reprisal for complaining of racism (see “Reprisal,” below). Racial discrimination: Policy and practices characterized by avoidance of a relation of accountability for equity with racialized people, who consequently experience social domination and differences. Racial disparities: Inequalities in health, employment, income, education, social justice, and other societal benefits, that impact negatively on racialized people. Racial profiling: Intentional or unintentional discrimination of personal attributes consistent with the European derived ideologies around race, white privilege, and racial superiority. Accountability for racial profiling requires race consciousness. Racialization: A social segmentation and control process that relies on discourse practices of discrimination, dominance, and difference in treatment that are based on the assumption that in a racist society, one is permitted not to be equally accountable to racialized people as to non-racialized people.

Racialization is denied and behaviours are rationalized even when non-racialized people challenge racialization processes. Accountability for racialization requires race consciousness. Racialized encounter: A racialized person(s) receives an intentional or unintentional communication so that the sender accomplishes racial segmentation and control (i.e. marginalization, problematization, containment and/or exclusion of the racialized person(s)). Accountability for perpetrating racialized encounters and their effects requires race consciousness. Racialized people: People who experience social inequalities because of their race, colour, or ethnicity. Reprisals: Denotes retaliation for making a complaint. Reprisals are prohibited under the Ontario Human Rights Code. Resilience: Individual strengths based on coordinating supports and influence to achieve social goals and objectives. Restitution: Differences including accommodation required in order to achieve equity outcomes. Set-up: The unfair manipulation of people and the organization of events toward desired inequitable outcomes. For example, racialized nurses experience set-up that puts them in a bind so that they (and not their non-racialized counterparts) must choose between one disadvantage and another.

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156

Systemic racism: Policies, practices, and procedures that are considered normal, but can intentionally or unintentionally discriminate against individuals and groups protected under the Code, thus privileging non-racialized people. The privileges of systemic racism are upheld by discourse that avoids accountability for racial domination. Tit for tat: Backlash and counter backlash, or resistance and counter resistance typical of dispute escalation. (See Fisher and Brown, 1988) Transparency: A principle of procedural justice upholding ethical practices, such as informed consent and equal access to information, participation, and decision-making channels. Visible minorities: Statistics Canada allows Canadian residents other than Aboriginal peoples to self-identify their visible minority status when completing forms. Identification usually refers to race or colour. Whiteness: In-group credits enjoyed on the basis of the freedom of not being liable for one’s race, colour, or ethnicity and on immunity from having to be accountable to out-group members (see “Otherness”). Privileges include normality, authority, dominance, freedoms for flexibility, capacity for voicing and likelihood of being heard, opportunity for being in control, events being orderly, and having information and access to the correct means and channels of decision-making (Hagey and MacKay, 2000). In workplaces that uphold institutional racism, in order to sustain the privileges of whiteness, racialized people and non-racialized people collaborate to oppose anti-racism.

“Nursing is like a cappuccino – white on top, brown on the bottom – and it needs stirring up.”

“Stir it up” – Bob Marley Please visit our website www.BeforeQuality.com.

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Appendix A

Table 1 - 1990s Immigrants by Source Country and Proportion Speaking a Non-Official Language

Country of birth (top ten listed)

Number Percentage speaking non-official language

most often at home

Percentage with no knowledge of the official languages

China, People's Republic of

193,355 88.4 29.1

India 156,120 70.6 14.7 Philippines 122,015 46.8 1.1 Hong Kong, Special Administrative Region

118,385 87.9 7.7

Sri Lanka 62,590 73.4 7.3 Pakistan 57,990 67.7 6.2 Taiwan 53,750 86.8 12.7 United States 51,440 9.7 1.2 Iran 47,075 76.0 6.8 Poland 43,370 73.1 7.3 Other countries 920,590 50.9 6.4 Total 1990s immigrants

1,830,680 61.1 9.4

Source: Statistics Canada, 2003 Table 2 – Proportion of Visible Minorities, Canada, Provinces and Territories, 1991, 1996, and 2001

Province/Territory 1991 1996 2001 Newfoundland and Labrador

0.8 0.7 0.8

Prince Edward Island

1.0 1.1 0.9

Nova Scotia 3.4 3.5 3.8 New Brunswick 1.2 1.1 1.3 Quebec 5.6 6.2 7.0 Ontario 13.0 15.8 19.1 Manitoba 6.9 7.0 7.9 Saskatchewan 2.6 2.8 2.9 Alberta 9.4 10.1 11.2 British Columbia 14.2 17.9 21.6

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Yukon Territory 2.7 3.3 3.6 Nunavut 0.9 0.6 0.8 Northwest Territories 3.5 3.8 4.2 Canada 9.4 11.2 13.4 Source: Statistics Canada, 2003

Appendix B


159

Appendix B – Resolutions For Presentation To The CNA

Annual Meeting

June 2003

RESOLUTION 1 DIVERSITY 1. BE IT RESOLVED THAT CNA develop an initiative to address cultural competencies.

Initially these should include anti-racism, anti-harassment, anti-discrimination (sexual diversity and disability), employment equity and negotiation practices known as ethnoracial competencies.

2. BE IT FURTHER RESOLVED THAT CNA involve various nursing associations in the

development of its programs to ensure they are inclusive and pertinent to nursing for all Canadians.

3. BE IT FURTHER RESOLVED THAT CNA take actions to encourage nursing organizations

to ensure their leadership, governance, decision-making, and recruitment processes reflect the diversity of the Canadian population.

4. BE IT FURTHER RESOLVED THAT CNA meet with representatives from various nursing

associations to strengthen and diversify nursing leadership. 5. BE IT FURTHER RESOLVED THAT CNA promote research and education for the practice

of Primary Health Care in terms of the integration of language and culture-based nursing knowledge and research into the planning and delivery of health services.

Background • In 1996, the Ministry of Health and Ontario Hospital Association joint provincial planning

committee (JPPC) released a policy report and a video to all hospitals. The goal of the recommendations was “diversity,” conceived as a desired state where currently marginalized groups would have equal access and participation at all levels of decision-making (Ontario Hospital Association and the Ontario Ministry of Health, Joint Policy and Programming Committee, 1996).

• Our research has identified only sporadic implementation of this Ontario Hospital Association/Ontario Ministry of Health 1996 Antiracism Policy. We have recommended that nursing locally, provincially/territorially, and nationally should organize consensus building forums to develop policy and accountability structures to take leadership on implementing equal access and participation in the health care system (Hagey and Turrittin, 2003).

• Ornstein’s (2000) study of the 1996 census confirms that there is ethnoracial stratification by employment, income, and education in the Greater Toronto Area (GTA), suggesting the goal

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of diversity may be long way off unless explicit leadership development strategies are initiated.

• The CNA report to the Canadian Council on Health Services Accreditation on Quality of Worklife for Nurses in Canada, July 2002, identifies grievances and unresolved grievances as one of eight major indicators of worklife challenges in nursing in Canada.

• Our research program has documented millions of health care dollars being spent on grievances and complaints charging employers with discrimination or harassment. We reported racial tension, poor handling of disputes, and a reduction in diversity during times of under-funding and down sizing (Hagey, Lum, MacKay, Turrittin and Brody, 2001b).

• The rescinding of the Employment Equity Act in Ontario and the weakening of federal legislation to address systemic discrimination (see Hagey and Turrittin, 2003) has put the onus on representatives of employers, including nurses, to enforce standards of fairness and handle conflicts that erupt when fairness is in question.

• We have completed two case studies that identify racial harassment and backlash implicating nurses in the reinforcement of the perceived racial hierarchy in nursing. The dispute process in racial disputes appears to be informed by retributive justice – enforcing obedience through punishment – rather than by negotiation, restitution, transformative, and restorative justice (see Hagey et al., 2001a).

• Nestel (2000) has identified that according to the 1991 Census visible minority nurses in Ontario had only half the chance of becoming a manager as did nurses who do not have visible minority status (self identified).

• The Report by Rita Kholi and Barb Thomas entitled “A Time for Change” identifies forty-four recommendations for combating racism in one community health unit where diversity was reduced among nursing staff during a period of downsizing due to underfunding. Systemic racism is acknowledged as a barrier to inclusive practices.

• Major Human Resource challenges arise from these issues including recruitment and retention of nurses for the future. Moreover, the 2001 Census documents the growing number of Canadians who speak neither official language (see Appendix A). Language diversity makes communication between staff and patients very complex to the point where patient safety may be in jeopardy. The word “diversity” has proliferated to denote new social forms such as “diversity practitioners” and “diversity workplace units” that are being funded in a growing number of health service agencies to address a broad range of diversity issues. Both the Kirby Report (2002) and the Romanow Report (2002) make specific recommendations pertaining to Aboriginal health.

• Our research report argues that nurse managers require a knowledge base to be developed that can inform the promotion of leadership opportunities for all nurses (Hagey and Turrittin, 2003). Our report was a result of participatory action research unofficially involving the following groups who shared their perceptions of barriers to leadership in nursing: The Aboriginal Nurses Association of Canada, the African Nurses Network, various Caribbean associations including the The Barbadian Nurses, The Grenadian Nurses Association, The Trinidadian Nurses, and the University Hospitals of the West Indies Alumnae and Associates (Jamaica) have participated. Also included were the Canadian Black Nurses Association, the Chinese Nurses Association (Cantonese and Mandarin speakers), the Filipino Nurses Association, Hispanic, Portugese and Central and Latin American Nurses and Muslim Nurses, the Korean Nurses Association of Ontario, the South Asian Nurses Association, the Culture Care Nurses Interest Group, the International Nurses Interest Group, and individual

Appendix B


161

nurses, community activists, union leaders, and consumers identified barriers to leadership influence. So did the Ontario Association of Black Trade Unionists and the Urban Alliance on Race Relations and also spokespersons for the RNAO and the National Nursing Policy Office.

• In a recent study of staff nurses by Professor Tania Das Gupta, 39% of Black nurses, 22% of South Asian nurses, 20% of Asian nurses and only 1% of white nurses thought that their performance review was influenced by their race, ethnicity or colour (Das Gupta, 2002).

• 55% of Black nurses and 47% of Asian nurses and 44% of South Asian nurses and 27% of Central and South American nurses and 6% of European/White nurses felt their relationship with their manager was affected by their race, ethnicity or colour.

• The nurses reporting harassment in this Das Gupta study identified colleagues, patients, supervisors and physicians (in that order) as a source of harassment.

• Our recent study identified “set-up” as a method employed to exclude racialized nurse managers from decision (Hagey and Turrittin, 2003).

• A recent report issued by the City of Toronto Department of Public Health, entitled Access and Equity: A Case Study of Toronto Public Health’s Current Practices and Organizational Needs (2002), identifies a paucity of nurse leaders and managers from minoritized communities.

• Nursing Informatics technology is advancing that could develop a research-based infrastructure to track diversity issues and how well policies are working to ensure employment equity and standards of fairness.

• The Dorothy Wylie Institute for Nursing Leadership could play a role in proliferating a research-based infrastructure to track diversity issues and how well policies are working to ensure equity and standards of fairness.

• Also, the Centre for Equity in Health and Society coordinates a network of interdisciplinary researchers and nurses who advocate for equity in health and organizations responsible for health care. CEHS invites nurses to participate in learning more about racial disparities and social inequalities and their impact on health. We are using a research base to advocate for anti-racism, anti-discrimination, employment equity, and intercultural competencies becoming integrated into the knowledge and practice in all levels and sectors in nursing. We are studying what is effective for holding individuals and organizations accountable for equity in health care and society. CEHS asks you to support nurses who have experienced racial discrimination at work themselves, or have witnessed the effects of such discrimination on colleagues and their families and communities. CEHS is calling for the creation of a nursing-wide equity assurance policy to ensure that the work environment for nurses, and therefore for patients, is caring rather than poisoned. This policy and the research that supports it could inform local, provincial, and national Racial Equality and Employment Equity Assurance Programs (REEEAP) in nursing. Soon to come: www.StirItUp.ca.

Submitted by Rebecca Hagey, member, Registered Nurses Association of Ontario

Appendix C


162

Appendix C – Resolutions To The Registered Nurses

Association Of Ontario (RNAO)

Submitted for the April 11, 2003 AGM at the Hilton in Markham RESOLUTION # 4 SUBMITTED BY REBECCA HAGEY, PhD, RNAO REGION 6 MEMBER

BE IT RESOLVED THAT RNAO devise a series of conferences to envision means of

achieving racial equality and employment equity.

BE IT FURTHER RESOLVED THAT RNAO will embark on coordinated planning

to develop policy with its nursing and community stakeholders to develop and promote

local and provincial employment equity program initiatives.

Background Information Resolution # 4 • CEHS has documented millions of health care dollars being spent on grievances and

complaints charging employers with discrimination or harassment. We reported racial tension, poor handling of disputes, and a reduction in diversity during times of under-funding and down sizing (Hagey, Lum, MacKay, Turrittin and Brody, 2001b).

• The CNA report to the Canadian Council on Health Services Accreditation on Quality of

Worklife for Nurses in Canada July 2002 identifies grievances and unresolved grievances as one of eight major indicators of worklife challenges in nursing in Canada.

• CEHS has identified barriers to career mobility for racialized nurses based on the statistical proportion that reaches managerial levels.

• Major human resource challenges arise from lack of equity and systemic racism, including

recruitment and retention of nurses for the future. • The rescinding of the Employment Equity Act by the Conservative government in 1996 has

put the onus on representatives of employers, including nurses, to enforce standards of fairness and handle conflicts that erupt in agencies that employ nurses when fairness is in question.

Appendix C


163

• CEHS has identified only sporadic implementation of the Joint Provincial Planning

Committee 1996 Antiracism Policy Framework. • The Romanow Commission has identified “The Big Disconnect” with respect to health care

to Aboriginal Communities. The Aboriginal Nurses Association of Canada is well positioned to provide leadership and invites the support of colleagues to help sustain the association’s vision and mission.

• Nursing Informatics technology is advancing that could develop a research-based

infrastructure to track diversity issues and how well policies are working to ensure employment equity and standards of fairness.

• A recent study by Tania Das Gupta (2002) has found that nurses experience racial

harassment from other nurses, from patients, managers and doctors. RESOLUTION # 5 SUBMITTED BY REBECCA HAGEY, PhD, RNAO REGION 6 MEMBER

BE IT RESOLVED THAT the RNAO identify management competencies pertaining

to systemic anti-racism, anti-harassment, anti-discrimination, employment equity, and

culture care.

Background Information Resolution # 5 • In 1996, the Ministry of Health and Ontario Hospital Association joint provincial planning

committee released a policy report and video to all hospitals. The goal of the recommendations was “diversity” conceived as a desired state where currently marginalized groups would have equal access and participation at all levels of decision making (Ontario Hospital Association and the Ontario Ministry of Health, Joint Policy and Programming Committee, 1996). The four pillars of this policy are anti-racism, anti-discrimination, employment equity, and culture care.

• In a recent study of staff nurses by Professor Tania Das Gupta, 39% of Black nurses, 22% of

South Asian nurses, 20% of Asian nurses, and only 1% of white nurses thought that their performance review was influenced by their race, ethnicity, or colour.

Appendix C


164

• 55% of Black nurses and 47% of Asian nurses and 44% of South Asian nurses and 27% of Central and South American nurses and 6% of European/White nurses felt their relationship with their manager was affected by their race, ethnicity, or colour.

• The nurses reporting harassment in this Das Gupta study identified their manager as a source

of harassment. • A study recently completed by CEHS, identified “set-up” as a method reported to

marginalize or exclude minority group nurse managers from decision making (Centre for Equity in Health and Society, 2003).

• Two case studies completed by CEHS identify harassment and backlash employed by nurses

that can be seen as contributing to reinforcement of the perceived racial hierarchy in nursing. These strategies are informed by retributive justice, obedience, and punishment rather than by negotiation, restitution, transformative, and restorative justice (see Hagey et al., 2001a and Centre for Equity in Health and Society, 2003).

• Nurse managers require a knowledge base to be developed that can inform the promotion of

leadership opportunities for all nurses.

• The Aboriginal Nurses Association of Canada is well positioned to provide leadership and invites the support of colleagues to help sustain the association’s vision and mission.

• Nursing Informatics technology is advancing that could develop a research-based

infrastructure to track diversity issues and how well policies are working to ensure employment equity and standards of fairness.

• A recent study by Tania Das Gupta (2002) has found that nurses experience racial

harassment from other nurses, from patients, managers, and doctors.

Appendix D


165

Appendix D – Letter From Anne McLellan

Appendix D


166

Appendix D


167

Appendix D


168

Appendix E


169

Appendix E – Letter to the Representatives of the Joint Provincial Nursing Committee (JPNC) and the Nursing

Secretariat

Accountability for Equal Opportunities in Nursing c/o Canadian Centre for Equity in Health and Society

November, 2002 Joint Provincial Nursing Committee Hepburn Block 11th Floor 80 Grosvenor St Toronto, ON M7A 1R3 To: Adeline Raphael-Falk (RNAO) and Gabrielle Bridle (RPNAO) On behalf of the Accountability for Equal Opportunities in Nursing, Research Team at the Centre for Equity in Health and Society, I am personally inviting you to a dialogue that I am participating in at the round table discussion on racism in nursing to be held at the upcoming RNAO/RPNAO conference on Healthy Workplaces. We congratulate RNAO/RPNAO for breaking the silence on racism in Nursing at this session being held on Nov 22 11am-1pm (at the Holiday Inn on King Street in Toronto) to strategically promote inclusion practices in nursing. The research program findings at the CEHS strongly support the need for the development and implementation of an accountability tool for use in nursing employment and we are asking to dialogue with Canadian nurse leaders on this agenda. Perceptions and questions arising from this program of research requiring attention include: • Is there a commitment to change organizational culture to promote inclusion at all levels in

nursing? • Is there a willingness among key stakeholders in the nursing profession to dialogue and

engage in problem solving on the problems of racialization? • Is there resistance among administrators and human resource personnel toward implementing

the 1995 JPPC (OHA and OMH) Anti-racism Policy framework that includes anti-racism, anti-discrimination, employment equity and culture care?

The research findings to date strongly indicate: • A call from prospective nurses for faculties and student bodies to address admissions,

curriculum and mentoring to achieve equity.

Appendix E


170

• A call from front line nurses for assistance on racial abuse and inequality issues. We hope to gain from you, specific strategies for promoting accountability for equity and procedural justice in restructuring race relations in nursing education, administration, professional, union, and regulatory bodies for equal access, participation and representation in nursing. We believe these strategies to be fundamental and crucial to recruitment and retention in our profession. Through our future collaborations, strategies in overcoming the historical and systemic barriers identified by racialized nurses can be successful. Recent studies link disparities due to racial discrimination and systemic lack of inclusion to detrimental health effects. Equity is a determinant of health for nurses and non-nurses alike. Either as preliminary to or follow-up to the round table discussions on November 22, we would appreciate meeting with each one of the Joint Provincial Nursing Committee members on an individual basis for more of an in-depth understanding of your thoughts and recommendations along with other leaders in health care and professional education. My CEHS associate Marianne Chandler (416-363-4546) <[email protected]> awaits hearing about what possible times would be suitable for each of you to have a brainstorming session on the issue of a profession-wide Employment Equity Program in Nursing in Canada. Please see attached our recent petition to the resolutions committee of the Canadian Nurses Association. Respectfully submitted, Rebecca Hagey, PhD. Acting Co-Director, CEHS research program .

Appendix F


171

Appendix F – A Time For Change: Recommendations

By Rita Kohli and Barb Thomas

Anti-Racism, Employment Equity Organizational Change Process East York Health Unit

Final Report of the Employment Equity Coordinating Committee (EECC)

The Doris Marshall Institute for Education and Action

October 1995

Part VI: Summary of the Recommendations (pp. 62 – 69) What Needs to be Done: Recruitment and Selection: 1. The EECC examine the language of a cross-section of job postings for adverse impact on

Aboriginal Peoples, Racial Minorities and People with Disabilities.

2. The EECC, in consultation with designated group members, establish a database of comparable ethno-racial, Aboriginal and disabled peoples networks for the distribution of job postings and employment opportunities.

3. The Board, in consultation with the EECC, develop an Anti-Racist Employment Equity Policy and ensure that all job postings and hiring practices comply.

Interviewing Process: 4. The EECC identify and eliminate any real or perceived barriers/adverse impact to Racial

Minorities, Aboriginal Peoples, Peoples with Disabilities in the following components of the interviewing process: - The current screening and short-listing criteria for application; - Response rating criteria for weighing or ranking interviewee responses; - The interviewer’s guide.

5. The EECC monitor all hiring over the next year to ensure that the process complies with the new employment equity policy and procedures of the organization, and that implementation results in increased numbers of people of colour, Aboriginal People, and people with disabilities employed in the organization.

6. Management/EECC, establish policies and guidelines to ensure equity in representation on selection panels; that all selection panels comprise at least 2 people – 1 from management

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and 1 from the constituency being hired (management, administration, etc.) and that at least 1 selection panel to racial minority, and/or person with disability.

Job Descriptions: 7. The EECC identify expedient ways to validate job descriptions and ensure all new staff see

their job description by commencement of work. Accommodation: 8. The Board in conjunction with the Borough, plan to conduct a physical demands analysis to

determine the capacity of the EYHU to accommodate peoples with a wide range of impairments and disabilities; that in the meantime, EYHU accommodate needs as identified.

9. Spectrum conduct employee awareness workshops on disabilities in the workplace, in conjunction with community based Disability Advocacy Networks.

10. The Board and EECC ensure that an anti-harassment and anti-discrimination policy is developed and endorsed throughout the organization, with clearly defined procedures for redress.

Credentials and Related Competencies: 11. The EECC, in their review of job descriptions and personnel policy, identify competencies

related to work with diverse communities for inclusion in job descriptions and interview questions. Performance appraisals include measures to assess the effective use of these skills.

12. Teams, in implementing the Equal Access Program standards, consider ways to maximize the use of these skills among their current members. Teams to set clear, measurable indicators of equal access to the designated groups, and racial minorities within these groups, in all areas of programming.

Orientation and Training: 13. The EECC review existing orientation and training policies and procedures for adverse

impact, particularly on persons with disabilities, with a view to ensuring a consistent practice for all employees.

Probation: 14. The EECC review the criteria, guidelines and processes for probation setting, termination and

the processes of communicating same to employees. Performance Appraisals:

Appendix F


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15. The EECC, in its ongoing document review, examine Performance Appraisal criteria and

procedures to eliminate the inconsistencies in the annual frequency of appraisals and the noticeable level of dissatisfaction, particularly in the management group. This to be done in consultation with management and staff.

Supervision: 16. EECC in consultation with the Borough, organize training sessions for managers and

supervisors to further enhance effective supervision and appraisal skills in the context of an anticipated changing and diverse workforce.

Bridging/Developmental/Secondments: 17. The EECC examine ways to expand bridging, developmental and secondment opportunities

as a strategy for staff development, and for extending the presence of designated group members in the organization.

18. The EECC establish processes for the uniform announcements of these positions. Flexible Working Conditions: 19. CUPE representatives ensure that flex time is negotiated in the next collective bargaining. Complaints: 20. The EECC examine the complaints systems for adverse impact, and revise with attention to

protection against reprisals.

21. Spectrum continue to host educational sessions on discrimination and build a resource list of external supports for staff to use in the current working environment.

22. The board and management develop and implement an anti-racism and an anti-harassment and anti-discrimination policy.

23. The board and management revisit the Vision, Mission and Mandate Statement of the EYHU and revise them to reflect principles of zero tolerance for racism and all forms of discrimination and harassment in the workplace.

24. The EECC ensure consistent inclusion in job descriptions and interview questions, knowledge and skills in addressing discrimination as essential skills to do any job at EYHU.

Rewards:

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25. The EECC in the course of the document review examine systems of rewards and recognition for adverse impact.

26. All levels of the EYHU become less reticent about praising and rewarding excellence where due.

Organizational Culture and Climate: 27. The EECC in conjunction with the Borough host a series of seminars for all employees on

recognizing racism in the workplace: What constitutes a grievance based on race? Discipline: 28. The EECC ensure that its current document review result in clear policies and procedures for

discipline.

29. The EECC ensure that all employees are informed of discipline policies and procedures, and that this is a routine part of orientation for new staff.

30. Spectrum identify external and internal supports to assist employees coping with the impact of disciplinary action.

Lay-Offs and Termination: 31. The EECC examine the lay off, termination, resignation and retirement policies for adverse

impact, and revise as necessary to ensure employment equity principles are upheld in these policies and practices.

Exit Interviews: 32. The EECC review the exit interview process and develop, in consultation with management

and staff, a simple procedure and guidelines for consistent practice.

33. The EECC ensure a mechanism whereby information provided by exiting personnel gets integrated into the ongoing organizational development process.

Document Review: 34. The EECC continue its own training on document review, involving managers where

appropriate and possible, to enhance their ability to recognize barriers in policies and procedures, and engage them with the committee, in assessing and revising personnel policies and procedures.

35. The EECC solicit input, as appropriate, from managers, community-based staff and administrative staff into its review and revision of personnel policies and complete the document review and revisions of policy.

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Who Should Do What in the Change Process?: EECC: 36. The EECC develop a work plan for July 1995 to June 1996. The work plan should specify

how it will:

• Communicate the findings of this report to the rest of the organization; • Complete the document review and revisions to policy; • Incorporate employee input into the policy review; • Involve managers in the process of analysis and revision; and • Develop a realistic plan for the next three years to achieve more equity in who is

present in the organization, and in how issues of racism and discrimination are addressed in the workplace.

37. The EECC establish a database and information system for all employees to ensure accurate

tracking of the Employment Equity program.

38. The EECC procure up-to-date external data, as available, to inform its Employment Equity Plan.

39. The EECC seek management team approval to build in education, support and a budget for itself over the next year to:

• Consult expertise from community organizations, on disability, on racism, on

heterosexism; • Work directly with SPECTRUM where appropriate; and • Selectively use community consultants for process help.

SPECTRUM: 40. The MOH ensure that Spectrum has a budget for its educational activities.

41. Spectrum research and begin to work jointly with community resource people and activists in

East York on issues of discrimination.

42. Spectrum meet with the EECC to discuss the work of each group over the coming year, and:

• Clarify areas of separate and possible joint work; and • Agree on how to communicate their separate and connected roles to the organization.

Board:

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43. The board organize training for itself, utilizing the resources of the EECC and Spectrum as appropriate, to identify more specifically, how to play its role of representing community concerns effectively to the organization.

44. The board set its own goals and develops a plan for increasing representation from the communities of racial minorities, Aboriginal Peoples and peoples with disabilities.

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Appendix G – Role Playing Exercise and Case Studies to Learn about Backlash and Set-up Experientially

Angela Cooper Brathwaite, RN, BScN, MN, PhD

Introduction – There are 3 parts to this role playing exercise. Part I presents a case study of a Nurse Manager's experience of systemic and individual racism in a health care facility. The case study is presented in narrative form as a letter from the Nurse Manager to a friend. Part II uses role play to sensitize individuals who are not ordinarily aware of systemic and individual racism to how these forms of racism work and the effect they have on those who experience them. Part II includes an introduction in which the concepts of transparency and accountability are defined, as well as role play instructions, and an actual role-playing script based on the Nurse Manager's letter. Part III presents procedural and policy strategies based on principles of transformative justice to indicate how equity could be achieved in Nurse D's institution. While the exercise is designed to involve participants, we suggest it could also be effectively used as theatre to instruct larger audiences. We suggest that required reading for conducting this role playing exercise is on our website at www.BeforEquality.com. See especially the Discursive Framework in the report to the Law Commission of Canada submitted by Hagey, R., Lum, L., MacKay, R., Turrittin, J., and Brody, E. See also Nurse X’s Story. Part I: Institutional Relations: A Nursing Manager’s Lived Experience

May 26, 2001

Dear Jane: I would like to share with you another true story. This story is about a nurse

manager (a Black nurse with Caribbean heritage) with a culturally diverse staff (the majority of whom were White Canadians). For purposes of this letter, I will call this manager D. She has 30 years of nursing experience and has been Director of the Family Life Centre for ten years. D is a certified midwife in England and Wales and holds a Bachelor of Nursing Degree from the University of Manitoba. She has worked for the same employer for over 24 years (14 years as a clinical nurse and 10 years as a Director) in Maternal and Child Nursing.

About a year and a half ago, a small group of white nurses complained to the CEO of the hospital that they were very dissatisfied with D’s leadership and management abilities. These nurses did not report their dissatisfaction to the VP of Nursing (D’s supervisor) but colluded with the Chief of Obstetrics in their complaint to the CEO against D. The CEO met with all the staff nurses and the Chief of Obstetrics on three occasions to discuss D’s leadership and management abilities. The VP of Nursing, the Nurse Educator and the manager were excluded from these meetings.

As a result of these meetings, the CEO developed an Action Plan and completed a performance appraisal of D. The nursing staff gave positive and negative feedback to the CEO but he documented only negative comments in the performance review. Up until

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this time, D had received positive performance appraisals. She was accused of practicing favouritism, having poor communication skills, failing to follow up with staff on staff education, and contributing to low morale in the program. The Action Plan outlined the objectives she was expected to meet in six months. She was responsible for: 1) Improving communication with staff; 2) Resolving conflicts on the units; 3) Providing consistency in approach to all staff; and 4) Improving staff’s morale. This action plan was discussed with D in the presence of her supervisor and a hard copy was given to her for her signature.

She was expected to sign an agreement stating that she was responsible for the aforementioned problems and will resolve them in six months. The documents were given to her on a Wednesday and she was expected to return them on Monday (the following week).

D read the documents at home and realized the implications behind the accusations. Thus, she called me and read the documents over the phone. She also asked my opinion about these documents and I told her that she was being set up for failure, since it was impossible to accomplish those objectives on her own. I told her those objectives and problems belonged to the group and not one person; that the problems constituted management-staff relations and required staff collaboration and willingness to work through the conflicts with her. I also suggested that she consult her lawyer and discuss her situation with him because the CEO had a hidden agenda. I questioned why the CEO, (the most powerful person in the hospital) had not included the VP of Nursing in dealing with this situation.

I also asked D what her staff meant by favouritism? She said that favouritism consisted of: 1) Hiring a (qualified) non-white nurse; 2) approving vacation for staff who were from a minority group (based on seniority), and 3) not granting time off after the schedule was posted, if staffing levels were inadequate to meet patients’ needs and the minimum requirements for the program. Five white nurses with junior seniority lodged the complaint, apparently retaliating for the change in practice represented in the fact that D hired nurses with midwifery experience from a minority group. These white nurses made remarks about the newly hired nurses of colour such as: “they are taking over the unit and white nurses will not get the vacant positions". Also, they said that "the newly hired nurses were D’s friends", evidently because she hired them. D did not know the nurses she hired since they were new to the province. The hiring practices included panel interview for all applicants with the same scoring tool to rate each applicant. The person with the highest score won the competition. The white nurses also told the CEO that one thing he could do for the hospital was replace D as director of the program.

Jane, I am making the claim that the hospital where D worked was an “ideological organization” which perpetuated systemic racism by upholding policies and practices to deal with manager-staff relations. Further, there was a disjuncture in D's experience at the hospital. In other words, there was disparity between how D experienced conflicts with her staff and how these were represented in documents. I base these claims on arguments provided in subsequent paragraphs.

My argument is based on the premise that Canada is a sexist-racist state with colonial ideology, i.e. Whiteness and European heritage are widely and implicitly held to be superior to non-white groups or heritage (Bannerji, 2000). Another premise is that racism is so pervasive and subtle in Canada that it forms the background or environment,

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which influences ones thinking, discourse, decision making, practices and social relations (Smith, 1990). Thus, people unknowingly perpetuate the colonial ideology through media, the school system, state regulations, policies and social organizations.

Firstly, I will discuss the ideological organization followed by the disjuncture in D’s experience. According to Smith (1990), an ideology is a method of superseding, substituting, and suppressing the accounts that people create out of the recollection of experience with the accounts of professional discourse. Thus, an ideological organization is an agency that has institutionalized racism through its racialist discourse practices (suppressing and omitting information, not honouring and respecting people of colour) and policies. Additionally, these practices occur in the background without being stated. They are systemic and perpetuate the system because there are no accountability mechanisms to challenge these practices. In D's case, the ideological practice was evident as the CEO did not hold himself responsible and accountable to a person of colour. He overlooked her enormous contributions and apparently perceived D as an easily dispensable person because she was Black.

In D’s case, the CEO suppressed all the positive information about her performance and managerial expertise and reinterpreted D’s actual experience, based on his ideological interpretations, experience and practice, in order to form an account of the situation. For example, a number of staff nurses reported in the meeting with the CEO that D was one of the first managers to implement single room maternity nursing in the province. This type of nursing supported continuity and consistency of patient care by admitting patients in the same room, where they went through childbirth, and post-partum care until discharged. Thus, patients received care from the same nurses from admission to discharge. Additionally, they pointed out that she maintained a positive variance in the budget, hired qualified competent nurses who were able to care for any maternity patient. Therefore, they said, D was effective in reducing the risk of lawsuits in this program and enhanced patients’ satisfaction with nursing care.

However, the CEO highlighted the negative criticisms and misperceptions of a few junior (white) nurses to support his objectification of the information being documented. In other words, the situation was rationalized, justified and reported based on the CEO's and junior staff’s perspectives. Thus, an account of D’s experience (social relations with staff) was reproduced consisting of only the negative particulars. A hidden negative value accompanied the transfer of D’s information in the documents. Therefore, what actually happened in D’s experience, and what was reported, was influenced by the interpretation (“interpretive schema”) and knowledge of the CEO producing the documentation. The CEO used the performance appraisal tool, job description, and human resource policies as documents to propagate his agenda. Moreover, the CEO never questioned the nurses’ comments such as, "they are taking over the unit" and "no white nurse will get the vacant position". He expected D to sign the agreement and action plan, so that he would hold her responsible and accountable for all the problems in the program. However, when he received her lawyer’s response to those documents, he changed his tone and attitude as well as modified the action plan.

D immediately consulted the lawyer who informed the CEO that D had retained him to respond to the Action Plan and performance appraisal and she was not prepared to sign those documents. She acknowledged that there are problems on the unit with a few nurses who would like her replaced. The CEO had over emphasized the negative

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comments of these junior nurses and eliminated the positive comments by the majority of the staff. The lawyer believed it was the responsibility of all the staff to work with D to bring about a resolution to the problems. He felt it was unlikely that her six months evaluation will be impartial, since D was being evaluated by the same group of nurses who wanted her dismissed from her position. The lawyer also stated in his letter that a wrongful dismissal suit was looming over the situation, which will ensure legal counsel; that the tone of the Action Plan indicated that D was not welcome to work in that organization. Thus, he recommended a buyout of employment with full benefits until her magic 80 commenced in two years (based on her benefit plan) since a legal suite would be expensive for the organization.

As a result of the lawyers’ letter, the CEO modified the action plan and sent a copy of it with a letter to D’s lawyer. In the letter, he stated that there was a misunderstanding and he was not assuming any blame to D. He was willing to work with D because of her long-term employment with the hospital and her ten years management experience in the present position. Changes to the action plan included the following actions:

The manager will hold monthly meetings with the staff to develop a cohesive nursing team (the supervisor was present for these meetings); • Staff will discuss evidence of favouritism at staff meetings and D will be expected to

give an explanation of her actions. • The manager will discuss staff performance issues in the presence of the Human

Resources Director and VP of Nursing. • Staff, manager and senior administrative team will collaborate to achieve the action

plan. • The manager will develop an educational plan to address knowledge deficits in staff. • The CEO will conduct a formal evaluation of the action plan at three and six months. • The CEO will complete a follow up performance appraisal of the manager in six

months to validate whether changes have occurred. At the end of six months, the CEO surveyed 65 staff to receive feedback on the

manager’s performance to ascertain whether the action plan was effective in meeting its objectives. Only five staff completed the survey and the feedback was positive. The CEO met with the staff to review the action plan and completed a positive performance review for D. However, he did not place her on the new salary scale with all the other managers. This salary scale was the result of a job evaluation for the management staff, which was conducted prior to D’s problems with the staff.

If one applies the Transformative Principles for Racial Justice (TPRJ) Assessment Tool (see the tool in Hagey et al., 2001b) to this case, one will notice that D was the victim of racial discrimination. She had become the problem in the system. Transparency and accountability issues were prevalent in this case. For example, all the meetings between the CEO and staff were held in the absence of the manager and the VP of Nursing and there was omission of pertinent positive information of D’s management style and performance. Also, no one named the issue as “racial discrimination” although it was present in this situation. Additionally, transformative justice had not occurred at this time, since neither the hospital nor the community took responsibility for changing organizational rules and practices to prevent future discrimination practices in the

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program. The employer did not assume responsibility for ensuring the ethno-racial safety of the manager or other minority staff in this program.

Pertaining to the disjuncture in D’s experience, I am proposing that there is disparity between how discrimination is experienced by D and how it is represented. If one explores the contrasts between the ideological practices of social relations of ruling and the everyday experience in which the events as told in D’s story, one will notice the disparities in this case. For example, the CEO’s selection, assembling, rearranging and interpretation of the information to develop a strong case against D are contrasted against his failure to acknowledge D’s positive contribution to the program and the feelings this failure provoked in her. He omitted segments of her experience that reproduced a negative image of her. Furthermore, he did not increase her salary on the new pay scale although she received a positive performance appraisal from him.

In order to receive the pay increase as per the new salary scale for all mangers, D wrote the Director of Human Resources explaining her situation. Due to D’s actions, the CEO and VP of Nursing decided to place D at level two on the new pay scale when she was at level five on the old pay scale. She declined their offer and stated that she will not accept anything less than level four or five on the new salary scale. Finally, they placed her at level five on the new pay scale.

I asked D how she felt during this experience. She said that she felt unsupported, misunderstood, helpless and victimized. She did not trust anyone including her supervisor. She became angry when she was not offered level five on the new salary scale, even though she had received a positive performance review and the problems in the program were resolved. D acknowledged that her faith in God, and the support of friends gave her the strength to endure this experience. Also, she had legal representation to help her through the process.

Today, the four nurses who accused D of favouritism are no longer in the program and organisation. The human resources director disciplined two of these nurses for injecting themselves and peers with drugs on the unit and they resigned their positions. Another nurse who gave a mother the wrong baby to breast feed, resigned her position rather than face disciplinary action, while the other nurse made major medication errors and left the institution. Similarly, the Chief of Obstetrics was not reinstated in his position and has retired. Also, the VP of Nursing has recently retired. D is still working as Director of the program and is enjoying a positive experience with her present staff. She has a cordial working relationship with the CEO.

At present, one can say some aspects of transformative justice have occurred in D’s situation. She has kept her former position as Director of Family Life Program and received fair compensation for her work (similar to her peers). Also, recently the CEO thanked and commended her for a presentation she gave to the senior team and her peers. This letter of commendation stated how proud he was of her knowledge, presentation skills and professionalism.

Part II: Transparency and Accountability: Re-framing Practices Pertaining to Race Differences Introduction

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Institutions are composed of individuals who have a degree of dependency on others within them and dependency on the institutions for financial, emotional, social, or occupational status/needs. For example, a student in an academic institution is dependent on a teacher to facilitate and foster increased knowledge and intellectual growth. Similarly, an employee is dependent on his employer for financial and career advancement. Regardless of the institution, its members are influenced by the policies and ways of working of that institution in many ways and in various degrees, depending on the positions they occupy, the power they can leverage and their own particular agendas. Each person within an institution brings a particular background, values and beliefs. Additionally, each institution has its own culture (values, practices, beliefs etc) which impacts upon the individuals who attend or work in them. Canadian institutions are influenced by racial ideologies. Today we would like to demonstrate (using two case studies) how racism is practiced in two Canadian institutions: A hospital and an academic setting. Institutional (Systemic) Racism Institutional Racism is described as “systemic inequality which results from institutional processes, which are racially discriminating" (Ben-Tovim, Gabriel, Law, and Stredder, 1986). Institutional Racism is the collective failure of an organization to provide appropriate and professional service to people because of their colour, culture or ethnic origin. It is seen or detected in processes, attitudes and behaviour which amounts to discrimination through unwitting prejudice, ignorance, thoughtlessness, and stereotyping which disadvantages minority ethnic people (McPherson, 1996). Purpose of our Presentation The purposes of this presentation are to use role play: To critically examine the concepts of transparency and accountability as they relate to practices that produce racial disparities. To examine institutional racism. 3) To apply the Transformative Principles for Racial Justice (TPRJ) Assessment Tool to two case studies. 4) To experience racism in a workplace situation in which the CEO uses power, texts (language in documentation) and discrimination against a Black nurse manager. Role Play Facilitator’s Role: Assigns the different roles to each person in the class and conducts debriefing after the role play. Hands each participant a card, e.g. Nurse Manager D, CEO, junior nurse complainant 1,2,3,4, or 5, staff nurse A, B, C, VP Nursing, Director, Human Resources, Chief of Obstretics. The number of staff nurses can expand to accommodate all participants in your class.

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Plan Time requirement is 20-30 minutes Resources: 7 volunteers, plus flip chart, paper, pens, overhead transparencies/ power point. Description of the rules for role play Activity: Participants must take a role and cannot be an observer. Debriefing/discussion period. Rules Each role must be taken seriously. Once the role play begins, it should be played seriously so that participants get immersed into his/her character. No discussion should be entertained during the role play and the rules should be strictly adhered to. All participants should participate in the debriefing session following the role play. Debriefing This stage could be called a follow-up discussion period. Debriefing is a time to reflect on and discover what happened during the role play and what it means. Debriefing an experience with participants is necessary in order to identify the issues and how they relate to the learning objectives (Majumdar, 1996). This process provides participants with an opportunity to reflect on their emotions, thoughts, and feelings. Debriefing encourages and allows participants to verbalize thoughts and feelings that occurred as a result of the learning experience. Through the identification of thoughts, feelings and issues, debriefing assists in bringing the experience into a “real life” context, applicable to daily life. I - Facilitator’s Guide Explain that participants need to explore their feelings before an analysis of the role play can occur. Questions to facilitate this process are: What did you think when the CEO gave you that performance appraisal? How did you feel when you (staff C) heard how your peers described the manager’s performance to the CEO? How did you feel when you heard staff A and B describe the manager negatively to the CEO? How did you respond to the Chief of Obstetric's comments on staff morale? What would you do if you were the nurse manager? How did you feel about other members of the group and their roles? II - Reviewing and Describing What Took Place

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This step assists participants in gathering data and ordering their thoughts. It helps them examine the experience from a different perspective, thus creating new insights. Questions to facilitate this process are: What happened in this situation? What were the challenges? Were you successful? What interactions took place? What events took place? What outcomes or decisions were made? What led to these results? Could anything have been prevented? III - Analysis of the Experience This step helps to establish meaning and identify connections between issues. Questions to facilitate this process are: What were some of the issues at play during the role play? What other real life situation(s) does this situation remind you of? Now that you have this new insight, do you think or feel differently? How can you use this new information in day to day life? How does this affect your view of racial issues in your workplace? Evidence of Racism From the Case Study Case Study #1 of Nurse Manager D's experience: Unrealistic goals "Fix it now" mentality (6 months to turn the situation around). Suppression and omitting of information: all the positive things Nurse D had accomplished were omitted from the performance review Not honouring and respecting Nurse D because she is a Black nurse. Racism was never mentioned. It was subtle or systemic. The CEO perceived D as easily dispensable. She had worked 24 years for this institution with 10 years administrative experience as Manager of the Family Health Centre. Accusation of favouritism when Nurse D hired qualified nurses from minority groups even though a panel conducted the interviews. SCRIPT FOR ROLE PLAY SCENE I: Opens with the CEO, Chief of Obstetrics, 5 to 6 staff seated around a table. CEO: “I am having these forums with you to gather information on what is occurring in the Family Life Centre. I must assure you that all information discussed here is confidential and no names would be identified with any comments made during this forum. I would like to know what are the problems in the program and how these problems are addressed. Also, I would like

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to know how nurse D is dealing with these issues and concerns and how she contributes to them?” Staff C concludes her statement: “…she likes to have a mixture of experienced and junior staff work together …vacations are granted based on seniority.” CEO continues: “ What has D done in the past few years that resulted in staff dissatisfaction?” Staff B concludes her speech: “…who she grants special requests” CEO continues: “I will meet again with you next week to get more input from other staff who are absent today. I assure you that your concerns and issues will not go unattended. I will personally address them with nurse D. Thank you for your input. I will be in touch with you as soon as possible.” Staff A: “ Ray, do you really want to know what is happening on the unit? I am so glad you have taken the time to meet with us. Staff morale is low because D practices favouritism with some of her staff. She grants certain staff time off and vacations and denies others the same requests. I am not able to exchange shifts with another nurse, especially when the time schedule is posted. She never grants me vacation requests when I need them.” Staff C completes her input: “She holds monthly staff meetings and keeps us up to date on program issues.” Staff A continues: “Nurse D might have done those things but staff morale is low because she practices favouritism with her friends on the unit. Some of us do not like her management style.” Staff A completes her input: “ I am not granted my vacation requests.” Staff B: “D never communicates with us about activities on the unit. If you ask for a request, she denies it without any explanation. Also, she fills the vacancies with nurses who are midwives from other countries. Canadian nurses will never get the opportunity to fill a vacancy because of her hiring practices.” Staff C: “Ray, Manager D supports shift exchanges if two nurses have similar years of experience. She ensures that there is a balance between experienced nurses and nurses with little experience in maternal child nursing. Sometimes she denies shift exchanges if staffing level is not adequate or if the exchange would result in too many junior nurses working the same shift. Also vacation requests are granted based on seniority.” CEO concludes his response: "These past few years have resulted in staff dissatisfaction.” Staff C continues her response: “D has done many positive things for the unit during the past few years. She has implemented single room maternity, which results in continuity and consistency of care for patients. She hires qualified competent nurses, which enhances patients’ satisfaction with nursing care and no law suites. Also, she includes the nurse educator and a senior clinical

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nurse on all the panel interviews. Staff hires are based on a scoring tool and the applicant with the highest score gets the position. Additionally, she holds monthly meetings to keep us abreast of issues and changes in the program and hospital.” Chief of Obstetrics:“ I have been practicing obstetrics for many years at this hospital, but have never seen staff morale as low as it is now. The nurses are very unhappy with D’s leadership. If we don’t resolve the problems on the unit, patient care would suffer. I personally don’t have a problem with D but I am concerned about the nurses’ well being.” Staff B, “ The people who are satisfied with D are her friends, because she grants them special requests.” SCENE II - Scene II opens with the CEO, VP of Nursing and Manager D. In this scene, the CEO gives D her performance appraisal. Both the CEO and The VP of Nursing promise to work with D on the issues in the program and encourage her to sign the performance appraisal and return it on Monday. CEO: “D, over the last few months we have been reviewing with you staff concerns regarding management of the Family Life Centre (FLC). Additional concerns were identified in three staff forums I conducted in October of 1999. Most recently, FLC staff has responded with critical comments in the nursing questionnaire survey regarding your management performance. The VP of Nursing shared these comments with you yesterday (current date). In considering the staff comments and the criticisms, and recognizing the scope, volume and consistency of them, we have grave concerns that these management issues must be addressed. We believe that failure to resolve these issues will result in further erosion of morale on the FLC, a deterioration of public relations that could ultimately result in failure of the Program and increase difficulty in retention and recruitment of staff. In recognition of your years of service to the (name relevant) Hospital as well as 10 years as Manager of FLC, senior management is willing to work with you to resolve the serious management concerns identified by FLC staff. This commitment to resolve concerns must be mutual with you and must include the following elements: Acknowledgement by you that these management concerns are legitimate and must be addressed. Commitment to implement an action plan that will resolve communication issues, real/perceived favouritism and management approach. The action plan must resolve the following issues: • Consistency in addressing issues on the unit. • Involvement of the HR in HR issues such as disciplinary matters with staff and conflict

resolution. • Flexible scheduling for staff, that is, shift swaps and self-scheduling. • An improved process for scheduling staff with HR. • Improved quality of communication on the unit. • Improved staff morale; and

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• Development of an education plan for staff which reflects staff input. Your signature to this performance review would indicate your commitment to continue as Program Manager of Women’s Health under these conditions. By (date in 3 months) we will conduct an interim review to determine how the action plan is proceeding. By (date in 6 months), we will conduct a formal evaluation including receiving staff input on your management performance. We are willing to work with you D, in successfully meeting these challenges. The success though will be largely dependent on a renewed enthusiasm from you as Program Manager for Women’s Health. Once you have had an opportunity to review this letter, I would appreciate receiving from you a formal commitment to work with Senior Management and proceed with the action plan elements as indicated in this letter. Sincerely, RJ, President and CEO D’s response to this letter and performance review: “I will review this letter and performance appraisal at home and will return it next Monday.” CEO echoed by VP of Nursing response: “We expect your response by Monday of next week. We would like to address the concerns in the program as soon as possible.” D’s response to the CEO and VP of Nursing: “Thank you.” D leaves the room followed by her supervisor. **End of role play** Facilitator conducts the debriefing. Part III: Case Study #2 -- Application of Transformative Justice Principles Constructive Approaches to Institutional Racism • Acknowledge racism exists • Adopt anti-racism strategies to ensure fairness and equity as outcomes • Provide diversity training and race relations workshops for staff and employees. • Develop and implement anti-racism policies. • Include a statement on anti-racism in the mission and vision statements of the institutions. • Establish an employment equity committee for the institution. • Develop a monitoring system to assess changes in the institution. • Develop a complaint mechanism to deal with racism and harassment. • Develop a program and contingency plan to overcome systemic racism in the institution. • Management demonstrate and state its commitment to both the process and content of anti-

racism changes i.e., make individuals and institutions accountable for racialized discourse practices.

Conclusion

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Today we have discussed institutional (systemic) racism and focused on how it affected two individuals. We have applied the Principles of Transformative Justice to a case study and showed how this framework identified transparency and accountability issues. There are three types of accountability: Individual, institutional and public. Our case demonstrated both individual and institutional racism. Thank you so much for your participation. Types of Accountability Individual Accountability refers to the assignment of responsibility for a specific set of actions for which non-compliance may result in specific sanctions. Organization or Institutional Accountability Refers to an assignment of responsibility for practices and policies that govern institutions, which are bureaucratized, specialized and isolated from the public and each other. They often operate in isolation (separate and distinct), far removed from society and the concerns of issues of people of colour. These organizations are administered by bureaucrats whose roles, functions and responsibilities appear to be largely unaffected by racism. Judgments and ideology of senior bureaucrats dictate what is fair, reasonable and achievable in the organization. As a group, they are the least accountable of all public servants but the most trusted. (Henry, Tator, Mattis and Rees, 1995) Public Accountability entails community participation in and control of the decision-making processes of public institutions (Henry et al., 1995). References: Bannerji, H. (2000). The Dark Side of the Nation: Essays on Multiculturalism, Nationalism and

Gender. Toronto: Canadian Scholars' Press. Ben-Tovim, G., Gabriel, J., Law, I., and Stredder, K. (1986). The local politics of race. London:

Macmillan. City of Toronto, Department of Public Health. (2002). Access and Equity: A case study of

Toronto Public Health’s current practices and organizational needs. Toronto: Department of Public Health.

Hagey, R., Lum, L., MacKay, R.,Turrittin, J., and Brody, E. (2001). Exploring transformative

justice in the employment of nurses: Toward reconstructing race relations and the dispute process (Unpublished Report to the Law Commission of Canada).

Henry, F., Tator, C., Mattis, W. and Rees, T. (1995). The colour of democracy: Racism in

Canadian society. Toronto: Harcourt Brace, Canada. Kirby Report. (2002). The Health of Canadians: The federal role. Final Report. The Standing

Senate Committee on Social Affairs, Science, and Technology. Retrieved Retrieved

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January 23, 2003, from www.parl.gc.ca/37/2/parlbus/commbus/senate/ Com-e/SOCI-E/rep-e/repoct02vol6-e.htm.

Majumdar, B. (1996). Culture and Health: Culture-sensitive training manual for the health care

provider, 5th ed. Hamilton, ON: McMaster University Faculty of Health Sciences, School of Nursing.

McPherson, K. (1996). Bedside matters: The transformation of Canadian nursing 1900-1990.

Don Mills, ON: Oxford University Press. Meeks, D. (2003). Deconstructing Romanow. Concurrent Session at the Canadian Race

Relations Foundation Award of Excellence Symposium, entitled Racism: Breaking Through the Denial. March 28, Sheraton Hotel, Toronto, Ontario.

Smith, D. (1990). The conceptual practice of power: A feminist sociology of knowledge.

Toronto: University of Toronto Press.

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Evaluation of the Presentation-- Please tell us how helpful this role play has been. 1) Content is useful 1 2 3 4 5 not useful very useful 2) Process is informative 1 2 3 4 5 not informative informative 3) Material is organized 1 2 3 4 5 not organized organized 4) Topics are in sequential order 1 2 3 4 5 not ordered ordered 5) Resources are useful 1 2 3 4 5 not useful useful 6) List two things you liked most: a) b) 7) List two things you liked least: a) b) 8) Other comments:

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