S YS T E M AT I C R E V I E W P R O T O C O L

African Canadian nurses in the nursing profession in

Canada: a scoping review protocol
Keisha Jefferies 1  Ruth Martin-Misener 1  Gail Tomblin Murphy 2  Melissa Helwig 3  Wanda Thomas
Bernard 4,5  Jacqueline Gahagan 6
1
School of Nursing, Faculty of Health, Dalhousie University, Halifax, NS, Canada, 2Research and Innovation, Nova Scotia Health Authority, Halifax,
NS, Canada, 3W.K. Kellogg Health Sciences Library, Dalhousie University, Halifax, NS, Canada, 4Senate of Canada, Ottawa, Canada, 5School of
Social Work, Faculty of Health, Dalhousie University, Halifax, NS, Canada, and 6School of Health and Human Performance, Faculty of Health,
Dalhousie University, Halifax, NS, Canada

ABSTRACT

Objective: The objective of this review is to synthesize the evidence on African Canadian nurses in the nursing
profession in Canada.
Introduction: With approximately 1.2 million people of African descent, Canada has committed to addressing the
United Nations’ decade for people of African descent. Intergenerational racism continues to result in multisectoral
discrimination against African Canadians. Studies suggest that African Canadians are under-represented in nursing,
and encountering systemic barriers to entering and advancing in the profession. Additionally, African Canadian
nurses experience racism from patients and colleagues, as well as systemic racism through hiring and promotion.
Inclusion criteria: This review will consider sources that include African Canadian nurses who identify as Black or as
of African descent. All levels of professional nursing practice will be included (practical nurses, registered nurses, and
advanced practice nurses, including nurse practitioners and clinical nurse specialists). Qualitative, quantitative, and
mixed methods studies and gray literature will be searched.
Methods: This review will be conducted in accordance with the JBI methodology. Databases to be searched from
inception to the present include CINAHL, MEDLINE, Embase, Sociological Abstracts, Gender Studies Database,
America: History and Life, PsycINFO, Academic Search Premier, and Scopus. Studies published in English and French
will be included. A comprehensive search strategy developed with a librarian will be used to retrieve relevant sources.
Two independent screeners will screen titles and abstracts as well as full texts of relevant sources. Data will be
extracted by two independent extractors then presented narratively, using appropriate tables and figures.
Systematic review registration number: Open Science Framework Preregistration October 3, 2019. Open
Science Framework Link for Abstract https://osf.io/6a2fe/?view_only=57d86d5b7c1d464182692d0f4bb9b396
Keywords: African Canadian; Black Canadian; nurse; nursing; nursing profession
JBI Evid Synth 2021; 19(4):883–890.

Introduction England.2 Nursing has since transformed into a

ursing is a health profession that encompasses
N both an artistic and scientific approach to
care.1 Florence Nightingale, who was a British nurse,
social reformer, and statistician, is regarded as the
founding philosopher of modern nursing.2 In 1860,
Nightingale established the first scientifically based,
professional nursing school located in London,
Correspondence: Keisha Jefferies, Keisha.jefferies@dal.ca
The authors declare no conflicts of interest.
DOI: 10.11124/JBISRIR-D-19-00376
profession with influence in clinical practice, educa-
tion, research, and policy.1 In addition to changes
within the profession, nursing is undergoing an
image transformation.3,4 The image of nursing
reflects who is viewed as a nurse and who is able
to become a nurse.3,4 Historically, a nurse was
depicted as an image of purity, dignity, and gentle-
ness (ie, the Victorian ideals of ‘‘true womanhood’’),
which was associated with white women and not
with people of African descent.4 Within Canada, the
nursing profession is of interest because Canadian
nursing schools did not admit African Canadians

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SYSTEMATIC REVIEW PROTOCOL
into their programs until the late 1940s.4 Racism in
Canada prevented African Canadians from entering
nursing and practicing in a safe, inclusive environ-
ment, and this continues today.5-8
The legacy of African Canadian nurses illumi-
nates years of racism, discrimination, and struggle,
but also profound resilience and success.4,7 The
purpose of this scoping review is to synthesize the
existing evidence related to African Canadian nurses
practicing the nursing profession in Canada. By
definition, nursing encompass clinical care, policy,
education, administration, and research.9 This
review is both timely and necessary as diversity in
Canadian nursing is gaining national interest; there
is no published synthesis of this evidence; and there is
a need to determine the magnitude and type of
available evidence. Lastly, this review may hold
international relevance by offering insights for
racialized people in nursing while simultaneously
addressing the international call-to-action declared
by the United Nations (UN).
People of African descent in Canada
In 2014, the UN declared 2015–2024 as the Inter-
national Decade for People of African Descent in
order to address the ongoing human rights violations
and social injustices experienced by people of
African descent worldwide.10 The decade’s theme,
‘‘People of African Descent: Recognition, Justice and
Development,’’ has been recognized by several coun-
tries, including Canada.10 In addition to this inter-
national call-to-action, a 2017 UN report raised a
nationwide alarm in Canada, calling for immediate
action to improve the social welfare of African
Canadians by addressing the pervasive anti-Black
racism that is rampant across all sectors of Canadian
society.11
In Canada, there are approximately 1.2 million
people who identify as Black or of African descent.12
Throughout the literature and in everyday commu-
nication, several terms are used in reference to Afri-
can Canadians or people of African descent who
reside in Canada. Terms commonly used in research
include ‘‘Black,’’ ‘‘immigrant,’’ ‘‘African,’’ and ‘‘vis-
ible minority.’’13,14 The authors acknowledge that
African Canadians are not a monolith and that
there are differences that exist within this group.
However, to provide clarity for this review and to
facilitate understanding by an international audi-
ence, the term ‘‘African Canadian’’ will be used.14
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K. Jefferies et al.
African Canadians have a hidden history in
Canada, which dates back to their arrival as enslaved
or freed people in the 17th century.13,15 Jefferies
et al.14 provide a more comprehensive explanation
of the historical context surrounding African Cana-
dians, particularly involving the arrival of African
Canadians; their contributions in war efforts; as well
as health issues affecting this group, including high
rates of chronic illnesses, such as hypertension, dia-
betes, and mental illness.14,16 Additionally, Jefferies
et al.14 expand on the human rights violations and
social injustices that remain pervasive throughout
multiple sectors of society including, but not limited
to, housing, labor, education, and health.
Diversity in nursing
Within the nursing profession, diversity has a posi-
tive impact on patients and the function of the health
care system.17,18 Diversity is a term used in reference
to the biological, genetic, cultural, and sociological
variations of individuals and group.19 Specifically,
diversity is often thought of in terms of sex, race,
sexual orientation, and ability. Ensuring diversity
in nursing has numerous benefits, including a cul-
turally inclusive and competent approach to care,
the integration of experiential knowledge from
professionals, as well as a holistic understanding
of diverse individuals, families, and communi-
ties.17,18 There is a need to understand the multiple
and intersecting layers of diversity in nursing related
to race, sex, sexual orientation, ability, and class
while simultaneously understanding how each of
these components interacts with one another. The
authors recognize the need to examine multiple
facets of diversity in nursing. However, based
on national and international proclamations to
address human rights violations and discrimination
encountered by African Canadians,10,11 the authors
have prioritized synthesizing the evidence pertain-
ing to African Canadians in the nursing profession
in Canada.
African Canadian nurses in Canada
The first nursing school in Canada opened in 1874,
with the number of nursing schools increasing to 70
by 1909 and more than 200 by the 1920s.20 How-
ever, Canadian nursing schools did not admit Afri-
can Canadians until the late 1940s.4 Institutional
racial segregation displayed by nursing schools in
Canada is often contrasted to that of the United
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States, which admitted Black students to nursing
schools in the 1870s.4,21 Until the 1940s, African
Canadians interested in pursuing nursing were
instructed to travel to and train in the United States.4
At present, African Canadians continue to expe-
rience challenges entering the nursing profession.
For example, the under-representation of African
Canadian nurses has been linked to institutional
racism, which prevents African Canadians from
entering or advancing in nursing.7,22 Vukic et al.22
explained that despite initiatives put in place by
institutions, there are systemic barriers that impede
recruitment, admission, and retention of African
Canadians in nursing. When present, African Cana-
dian nurses are concentrated in entry-level and non-
specialty areas while being under-represented in
specialty areas, advanced practice positions, and
leadership roles.7,23 Lastly, African Canadian nurses
feel as though they are practicing on the margins of
the nursing profession due to racism perpetrated by
patients, colleagues, and superiors, as well as the
systemic hurdles.24
A preliminary search of PROSPERO, MEDLINE,
the Cochrane Database of Systematic Reviews,
and the JBI Database of Systematic Reviews and
Implementation Reports revealed no published or
in-progress systematic reviews on this topic.
To date, the only record of a synthesis of this
evidence is a literature review conducted by Etowa
et al.24 The review by Etowa et al.24 was published
as a section of a manuscript; however, i) it was a
literature review embedded within a manuscript and
thus was not published as a systematic review; ii) the
review was described as a literature review, which
did not describe a systematic process for searching,
screening, or analyzing the literature; and iii) at least
10 years have passed since this manuscript was
published. To this end, the authors deem it necessary
to build on the literature review by Etowa et al.24 by
conducting a scoping review to determine the extent
of available peer-reviewed and non-peer-reviewed
evidence regarding African Canadian nurses in the
nursing profession in Canada. Thus, the purpose of
this review is to synthesize the existing evidence by
illuminating areas that have been investigated as well
as describing ways in which African Canadian nurses
have been represented. Identifying and mapping all
existing evidence will inform knowledge gaps and
priorities for future research. Finally, this review
informs a larger qualitative study that examines
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K. Jefferies et al.
leadership in the nursing profession among a histor-
ically distinct group of African Canadian nurses.
Review question
What evidence exists regarding African Canadian
nurses in the nursing profession in Canada? Specifi-
cally to:
i) describe how African Canadian nurses have
been represented in the literature.
ii) map existing evidence to inform knowledge gaps
and priorities for future research.
Inclusion criteria
Participants
This scoping review includes sources focused on
African Canadian nurses, with African Canadians
encompassing various groups of people who identify
as Black or as being of African descent in
Canada.13,14 Literature about African Canadians
includes those who identify as African Canadian,
Black, immigrant, African Nova Scotian, or a new-
comer from continental Africa, the Caribbean, South
America, or the United States.13,14
Concept
The concept of interest is the nursing profession,
which encompasses five domains of nursing practice
including clinical care, education, administration,
policy, and research.9 All levels of professional nurs-
ing practice will be included, ranging from nurses
who received training at the diploma, baccalaureate,
or graduate level. Respectively, in Canada these
regulated roles refer to practical nurses, registered
nurses, and advanced practice nurses, including
nurse practitioners and clinical nurse specialists.9
Non-licensed, clinical practice roles, such as per-
sonal care workers and continuing care assistants,
will be excluded as these are unregulated, unlicensed
professions that are not classified as nursing in
Canada.9
Context
This review focuses exclusively on the Canadian
context. Despite similarities throughout the Black
experience that transcend international borders,
there are highly influential contextual elements,
including historical racism, segregation, and sociali-
zation, which result in stark differences between
Canada and other countries. These differences
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require a country-level examination prior to a global
comparison. The Canadian context is of particular
interest because African Canadians are identified as
a highly vulnerable group globally,10,11 yet literature
regarding this group remains hidden as Canada
continues to lag in collecting race-disaggregated
data.11
Types of sources
This scoping review will consider experimental and
quasi-experimental study designs including random-
ized controlled trials, non-randomized controlled
trials, before and after studies, and interrupted
time-series studies. In addition, analytical observa-
tional studies including prospective and retrospec-
tive cohort studies, case-control studies, and
analytical cross-sectional studies will be considered.
This review will also consider descriptive observa-
tional study designs including case series, individual
case reports, and descriptive cross-sectional studies
for inclusion. Qualitative study designs including,
but not limited to, phenomenological, grounded
theory, ethnographic, qualitative description, action
research, and feminist research will be considered.
Additionally, systematic reviews, dissertations, and
gray literature, as well as text and opinion papers,
will be considered for inclusion. Research that
includes a subgroup analysis, related to the context,
concept, or population, will also be considered
for inclusion.
Methods
This scoping review will be conducted in accordance
with JBI methodology.25
Search strategy
The search strategy was developed in collaboration
with a librarian, and the final search strategy will
undergo peer review by a second librarian. The
search aims to locate published studies and gray
literature. An initial limited search of CINAHL
(Appendix I) was undertaken to identify articles
on the topic. The words contained in the titles and
abstracts of relevant articles, and the index terms
used to describe the articles were used to develop a
full search strategy for CINAHL and MEDLINE.
The search strategy, including all identified key-
words and index terms, will be adapted for each
included information source. Search terms related
to the population of interest include ‘‘African
JBI Evidence Synthesis
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K. Jefferies et al.
Canadian,’’ ‘‘Black,’’ ‘‘African Nova Scotia,’’
‘‘immigrant,’’ and ‘‘minority,’’ as these terms are
used in Canada. Other keywords include ‘‘nurse’’
and ‘‘Canada.’’ Ancestry searching will be per-
formed to identify relevant sources. Literature pub-
lished in English and French will be included, and
databases will be searched from inception to present.
Information database sources include CINAHL
(EBSCO), MEDLINE (Ovid), Embase (Elsevier),
Sociological Abstracts (ProQuest), Gender Studies
Database (EBSCO), America: History and Life
(EBSCO), PsycINFO (EBSCO), Academic Search
Premier (EBSCO), and Scopus (Elsevier). Sources
of unpublished studies and gray literature to be
searched include Canadian Nurses Association, Reg-
istered Nurses Association of Ontario, College and
Association of Registered Nurses of Alberta, Nova
Scotia College of Nursing, and ProQuest Disserta-
tions and Theses Global (ProQuest).
Study selection
Following the search, all identified citations will
be collated and uploaded into Covidence (Veritas
Health Innovation, Melbourne, Australia) and
duplicates removed. Titles and abstracts will then
be screened by two independent reviewers against
the inclusion criteria for the review. Potentially
relevant studies will be retrieved in full and their
citation details imported into the JBI System for
the Unified Management, Assessment and Review
of Information (JBI SUMARI; JBI, Adelaide,
Australia). The full text of selected citations will
be assessed in detail against the inclusion criteria
by two independent reviewers. Reasons for exclu-
sion of full-text studies that do not meet the inclusion
criteria will be recorded and reported in the system-
atic review. Any disagreements that arise between
the reviewers at each stage of the study selection
process will be resolved through discussion or with a
third reviewer. The results of the search will be
reported in full in the final report and presented in
a Preferred Reporting Items for Systematic Reviews
and Meta-Analyses extension for scoping reviews
(PRISMA-ScR) flow diagram.26
Data extraction
Data will be extracted from included articles by two
independent reviewers using the data extraction tool
developed by JBI, which has been modified for a
scoping review by the reviewers.25 A preliminary
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customary data extraction tool has been included in
Appendix II. The tool will be tested with two
reviewers completing extractions independently fol-
lowed by comparisons before continuing with the
extraction process. The data to be extracted will
include details about the article, purpose of the
article, population, concept, context of the study,
study methods, and key findings relevant to the
review objective. A detailed description of the data
extraction process, the data extraction tool, and tool
modifications will be included in the full scoping
review report. Any disagreements that arise between
the reviewers will be resolved through discussion or
with a third reviewer. Authors of sources will be
contacted to request missing or additional data,
where required.
Data analysis and presentation
Data will be presented in diagrammatic or tabular
form in a manner that aligns with the objective of
this scoping review. A narrative summary will
accompany the tabulated or charted results to
describe the characteristics of the literature and
how the results relate to the objective and question.
The categories used for data presentation include
those within the extraction tool; however, these may
be modified based on the review findings.
Acknowledgments
Funding
KJ is supported by the MacEachen Institute for
Public Policy and Governance, Aligning Health
Needs and Evidence for Transformative Change
(AH-NET-C): A JBI Centre of Excellence, and the
Centre for Nursing and Transformative Health
Research.
KJ is funded by the Dalhousie University Faculty
of Graduate Studies, the School of Nursing and
Killam Trust. Additional funding sources include
Vanier Canada Graduate Scholarship, Johnson
Scholarship Foundation, Research Nova Scotia,
Nova Scotia Health Authority and Building
Research for Integrated Primary Healthcare Nova
Scotia (BRIC NS).
Co-author RM-M is director of the Dalhousie
School of Nursing, which provided funding to KJ,
for her doctoral studies. Such funding is provided to
all doctoral students. No other funders had a role in
content development.
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K. Jefferies et al.
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Appendix I: Search strategy

CINAHL (EBSCO)
Search conducted October 10, 2019

Records
Search Query retrieved
1 (MH ‘‘Blacks’’) 49,546
2 (MH ‘‘Nursesþ’’) 202,379
3 1 AND 2 1226
4 TI ((Black OR African OR Coloured) N4 (nurse OR nurses OR nursing)) OR AB ((Black OR 1391
African OR Coloured) N4 (nurse OR nurses OR nursing))
5 3 OR 4 2323
6 (MH ‘‘Canadaþ’’) 91,956

7 TI (Canad OR ‘‘British Columbia’’ OR Alberta OR Saskatchewan OR Manitoba OR Ontario 70,730
OR Quebec OR ‘‘New Brunswick’’ OR ‘‘Nova Scotia’’ or ‘‘Prince Edward Island’’ OR
Newfoundland OR Labrador OR ‘‘Northwest Territories’’ OR Yukon OR Nunavut) OR AB
(Canad OR ‘‘British Columbia’’ OR Alberta OR Saskatchewan OR Manitoba OR Ontario OR
Quebec OR ‘‘New Brunswick’’ OR ‘‘Nova Scotia’’ or ‘‘Prince Edward Island’’ OR Newfound-
land OR Labrador OR ‘‘Northwest Territories’’ OR Yukon OR Nunavut)
8 6 OR 7 120,516
9 5 AND 8 26

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SYSTEMATIC REVIEW PROTOCOL K. Jefferies et al.

Appendix II: Data extraction tool

Date:

Reviewer:

Extraction components Response

Article title:
Year of publication:
Authors:
Article citation:
Article type (research, policy, commentary):
Article aim/purpose:
Article questions/objectives:
Theoretical framework (if presented/applicable):
Study design (if presented/applicable):
Methods (data collection and analysis, if applicable):
Study population (including participant description eg, African Canadian, Black, African Nova
Scotian, immigrant) and sample size (if presented/applicable):
Context (including setting and location eg, province, city):
Concept (including type of nursing practice eg, clinical care, education, research, administration
and/or policy):
Results/key findings (if presented/applicable):
Sample demographics –
Themes/sub-themes –
Level of significant/confidence intervals –
Article recommendations/implications for nursing practice (policy, education, administration,
clinical care, and research):
Gaps identified by article:
Additional notes:

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