It is like ‘judging a book by its cover’: An exploration of the lived experiences of Black African mental health nurses in England

The aim of this paper was to explore the experiences of perceived prejudices faced in England by Black African mental health nurses. Purposive sampling was used to identify five nurses from sub-Saharan Africa. They were interviewed using face- to-face semi-structured interviews. Data were analysed using interpretative phenomenological analysis (IPA). The findings were reported under two superordinate themes: Judging a book by its cover and opportunities. The findings showed that Black African nurses experience deep-rooted discrimination and marginalisation. Aside from that, because of their ethnicity and the fact that they speak English as a second language, they face discrimination and have difficulty achieving leadership roles. These findings provide key stakeholders, such as nursing trade unions and professional associations, as well as NHS employers, with the opportunity to act to counter hegemony in the NHS and recognise that discriminatory and racially related barriers hinder Black African nurses from reaching their full professional potential.


| INTRODUC TI ON
This article is part of a larger study addressing the marginalisation and prejudice faced by Black African mental health nurses (hereinafter Black African nurses) working in England.Although some scholars have argued that the National Health Service (NHS) has made considerable strides in valuing and embracing workplace diversity (Likupe & Archibong, 2013), the recent announcement that Black, Asian and Minority Ethnic (BAME) populations and healthcare staff in England experience disproportionate deaths from the coronavirus pandemic has caused widespread fear and anger (Royal College of Psychiatrists, 2020).Public Health England responded by setting up a commission of inquiry to investigate such disparities (Public Health England, 2020).What is unexpected from the conclusions of the Commission is the disclosure that long-standing racism and social disparities could have led to increased risks for BAME groups (BBC, 2020a;PHE, 2020).
Much has been said and written about the hostilities that BAME immigrants in the UK have endured.From the 1970s to the present, successive governments have gradually implemented selectively restrictive immigration policies (Lewis et al., 2017;Yuval-Davis et al., 2018).As a result, the UK was labelled as an immigrant-hostile nation (Bowling & Westenra, 2018;Webber, 2019).In the late 1990s, however, the Labour government, faced with a persistent shortage of nurses in the NHS, embarked on a massive international recruitment drive of nursing staff from all over the world, including those from sub-Saharan Africa.Not only did the strategy resolve the chronic shortage of nurses, but it also provided the NHS a more diverse and positive profile.Despite providing invaluable services to the NHS, many Black African nurses have experienced discrimination, prejudice and a lack of job opportunities during their careers in the UK (Likupe & Archibong, 2013).
The sense of discrimination, prejudice and institutional racism experienced by Black people in the UK was highlighted in the Macpherson Inquiry (1999) in the aftermath of the racially motivated murder of Stephen Lawrence, which ignited a national debate about racism and hostility towards Black people in the UK.Moreover, the recent Windrush scandal, which exposed the UK's profoundly flawed and racist immigration system against many Caribbean residents, could be seen as evidence of a failure to respect BAME people's contribution to the building and sustaining of the NHS (Williams, 2020).
Further to that, the unfolding disaster of coronavirus pandemic coinciding with the police murder of George Floyd in the United States, sparking a global uproar and anti-racism campaign and echoing demonstrations by the Black Lives Matter (BLM) movement seeking equality for Black people is an indicative of the negative experiences of Black people (BBC, 2020b).As a result, many public and private companies have been continually scrutinised for their diversity and inclusion activities (Palmer, 2020).The UK government, for example, has responded to the public uproar about its failure to follow equality law while enacting hostile immigration policies, and has recently passed legislation to ensure that the Windrush controversy does not happen again (The Guardian, 2021a).However, there is still a perception that the government's agenda is focused on malicious anti-immigrant sentiment (Webber, 2019).This point is supported by the government's rejection of systemic and institutional inequality in a recent landmark report on racial and ethnic disparities in the UK (Commission on Race & Ethnic Disparities, 2021).The government's unparalleled denial of racial and ethnic inequality has outraged equality activists (Marmot, 2021;Runnymede, 2021;The Guardian, 2021b).Besides that, the over-representation of Black nurses in Nursing & Midwifery Council (NMC) administrative and fitness-topractice proceedings, as well as the failure to correct organisational failures against BAME members of staff, are two examples of hostilities experienced by Black nurses (Archibong et al., 2019).All of these have increased the value of this paper, considering that the phenomenological meanings of discrimination faced by Black African nurses in England have not been treated in much depth by researchers.Kingma (1999) defines discrimination 'as a showing of partiality or prejudice in treatment, action, or policies directed against the welfare of minority groups' (p.87).Discriminatory practices can extremely affect their targets (European Union Agency for Fundamental Rights (FRA) (2010)).Discriminatory practices are ubiquitous in educational, social, political and healthcare environments where power imbalance is widespread (Cordon, 2013).Kingma (1999) points out that discrimination in the nursing profession is particularly troubling as it infringes on the core principles of care provision.Some scholars have argued that nursing discrimination manifests in the form of lower pay, intimidation, abuse and career development concerns (Kingma, 1999;Cordon, 2013).All these point to how the nursing profession should not be isolated from society's values and beliefs (Hall, 2014).Building on the work of FitzGerald and Hurst (2017), Iheduru-Anderson (2020a) argues that healthcare workers have the same degree of implicit bias as the public and that Black African nurses felt that their race and accent influenced their job opportunities.In the same context, research shows that the racism and negative feelings faced by Black African nurses in England are emblematic in contrast with their white counterparts (Likupe et al., 2014;Likupe & Archibong, 2013;Waters, 2011, and this can trigger the emotional reaction of otherness (Balibar, 2005;Brons, 2015;Crang, 1998;de Beauvoir, 1989;MacCallum, 2002).Despite this, little is known about discrimination experiences of Black African mental health nurses who are offering immeasurable contribution, strength and diversity to the NHS in England (Royal College of Psychiatrists, 2020).Thus, the aim of this article was to explore the experiences of discrimination of Black African nurses in England.

| The Concept of others
The concept of othering has been described as an essential category of human thinking that has existed since the beginning of time (de Beauvoir, 1989).The definition of others will be described for this study as 'a process (…) through which identities are set up in an unequal relationship' (Crang, 1998, p. 61).The concept of others can, therefore, be seen in the notion of superior and inferior (Brons, 2015), or as 'we' versus 'them' (e.g.Bauman, 1991;Heider, 1958;Mead, 1934;Tajfel & Turner, 1979).In addition, the concept of others was described by Balibar (2005) as relationships of power, culture, patriarchy, prejudice and exclusion.Little is known about how Black African nurses working in England are influenced by this.Thus, to narrow the knowledge gap, this empirical study is needed.

TUFFOUR
The participants were given full information about the study, and informed consent was sought from all of them.

| Research participants
Interpretative phenomenological analysis (IPA) does not insist on large sample size; instead, it uses a purposive and small number of participants who have all experienced similar phenomenon to optimise the research outcome (Eatough & Smith, 2017;Smith et al., 2009).Thus, five registered mental health nurses, one female and four males who self-identified as natives of sub-Saharan Africa, and actively practicing in England were deliberately selected.
Participants were chosen based on their availability and willingness to participate, and share their experiences and opinions in an articulate, expressive and reflective manner (Bernard, 2006;Spradley, 1979).Data were collected from the participants after the research information sheet was initially sent to key persons in two trusts in West Midlands and South Central region of England, who in turn introduced the study to prospective participants.
All participants came from countries in the former British colonies where British English is the official language.Three participants were originally from Zimbabwe and one each from Sierra Leone and South Africa.Except for the participant from South Africa who was trained in his native country, the rest had their nursing training in England.Their years of experience spanned from three to 20 years.Three participants were working within the mental health liaison team, one with the crisis resolution and home treatment team, and one with the psychological therapies.

| Data collection
Data were collected using face-to-face semi-structured interviews.
An interview schedule was used for flexibility to explore embryonic interesting ideas (Tuffour, 2020) or career?were asked to enable the participants' experiences to be explored in-depth.The interviews which lasted between 30 and 60 min were tape-recorded and transcribed verbatim.Pseudonyms were used to preserve anonymity.

| Reflexivity
In doing this research, I was able to assume a variety of positionalities.I took on insider or outsider (or somewhere in between) roles, which allowed me to generate synergetic and expanded understanding of the participants' perspectives (O'Boyle, 2017).While my role was to act as an architect to enable the participants to tell their experiences of discrimination as mental health nurses working in England, I concede that my shared identity as a Black African and a registered mental health nurse with the participants may have influenced some emotional connection (Tuffour, 2018;Tuffour et al., 2019), and compromised my role as an impartial and objective researcher.An example was when I spent time chatting with one of the participants, who was a former work colleague before and after the interview.However, it is important to emphasise that I showed self-awareness by documenting any issues of potential bias in my research journal and bracketed them off during the interviews and data analysis (Smith et al., 2009).
Researchers, on the other hand, have been encouraged to move away from a miserable confessional approach to researcher identity, which focuses on privileged self-examination and a routinised listing of their (researchers) identities, and to place a greater emphasis on unaccounted for experiences and research positionality (O'Boyle, 2017).Interpretation thus becomes crucial to the understanding process.Every encounter, according to Heidegger (1927Heidegger ( /1962)), requires an interpretation influenced by the person's background, history and values.
Therefore, my situatedness as a Black African and a mental health nurse influenced my reflexivity, critical thinking and sensitivity to the realities of the participants.Consequently, in this study, I used a more nuanced interpretive process, seeing not only from the participants' perspectives, but also through interpretation (O'Boyle, 2017).Rather than being a passive researcher, I took an active role in this study, attempting to interpret and appreciate the participants' experiences through the prism of personal and professional identities.This signals that my beliefs influenced the research process.

| Data analysis
In this study, the interview transcripts were analysed manually using the idiographic and iterative process of IPA that involves shifting from the particular to the shared, as well as eyeing for contrasting views across transcripts (Smith et al., 2009).To accomplish this, individual transcripts were pasted in the middle of a three-column table.Each transcript was read several times to identify developing themes.The themes were re-examined to ensure that they were anchored to the interview scripts.Emergent subordinate themes were subsequently clustered under superordinate themes (Table 1).
A detailed narrative interpretation of the participants' converging and diverging narrations backed with verbatim quotes formed the basis of the findings.Some selected quotes have been shortened using three dots (…) to increase coherency and readers' understanding (Smith et al., 2009).
Four superordinate themes with subset of subordinate themes were extracted from the analysis process.The participants' subjective memories of growing up in their home countries were the focus of the first theme.Their subjective experiences growing up, going to The 'Judging a book by its cover' superordinate theme includes the following three subordinate themes: discrimination and marginalisation, English language and accent, and 'snowy-peak syndrome.' The participants' vivid accounts of discriminatory treatment, and negative feelings, as well as issues with their accents and a lack of opportunities, are a common thread that emerged from these subordinate themes.The superordinate theme 'opportunities' has two subordinate themes: growing in my career and power of collective voice.
The participants' accounts of favourable situations aiding their work in England form a common thread in these subordinate themes.
The superordinate themes, as well as the subordinate themes that go with them, will now be fully presented.

| Discrimination and marginalisation
The participants gave vivid accounts of being victims of unfair recruitment processes, macroaggression and negative stereotypes from patients and colleagues alike who often perceived them as outsiders and incompetent.Such negative experiences triggered feelings of disempowerment and otherness.For example, one participant who has 20-year of mental health nursing experience narrated how his competency as a mental health team leader was repeatedly doubted: I have met from my colleagues and from patients.It is around competence.People will look at me and think I am not competent enough just by looking at me.But when they get to know me, become a bit different…in my earlier job when I was leading the team people will come … and will meet me sitting down and they will bypass me and go to white staff, who is really my subordinate and want to discuss issues…it is like they are not expecting the Black man to be the team lead… that is how I felt.So, they will then go to this white person who will say go to our team lead and only then will they come to me.So, for me it was those preconceived ideas that whoever a team lead is normally white person. [Joe] The narrative here suggests that his face did not fit for leading a team in the NHS, and he is regarded as not belonging to 'one of them'.
In addition, because of his appearance, he is made to feel like an inept practitioner who does not measure up, and such subtle negative experience triggers feelings of otherness and disempowerment.
Marginalisation, alienation and prejudice are the meanings of his experience.Similar unjustified attitude of being treated as the 'other' was echoed by Imani and Salim with three and 19 years of mental health nursing experience, respectively: Sometimes people just form an opinion because you are from a certain background…it is difficult to shift that prejudice most of the time.

[Imani]
It can be colleagues, it can be the clients, it can be relatives…I was the most senior person on the ward [Salim] The impression from these narratives is that negative treatment is continually faced by Black African nurses, and they need to prove their integrity and worth, and they often must censor or downplay their capabilities purposefully to do this.In addition, Amber, who has four years of mental health nursing experience, found experiences of discrimination and violence in patients' hands: Like when someone starts swearing at me …I could not handle those insults, calling me names yet I am caring for them…now I am used to it… But when I first came to this country, it was a bit difficult that the same person you are caring for is insulting you.
[Amber] Amber was visibly upset when narrating her story.It seemed alien and ironic to her that the people she is selflessly caring for, could also discriminate against her.But she seemed resigned to the fact that, regardless of her commitment and compassion, she was not appreciated by others.Ekon, an accomplished mental health nurse with 16 years of experience, spoke about how he suffered from marginalisation: I have made decisions as charge nurse and then they are reversed by certain people, and I have challenged that. [Ekon] Ekon resented efforts to undermine his authority as a senior nurse; however, unlike Amber, who lacked the confidence to speak out about the perceived injustice she endured, he was at least bold enough to challenge it: I did not make a mistake, but I just decided to omit medication to get some clarification and the manager blew it out of proportion.But I was right.And then my colleague who was white made a drug error and they did not say anything.So, I will be felt that it is because of who I am that's why things are happening like that…I felt unsupported then I left. [Amber] Out of fear of backlash, Amber did not speak up against prejudice, and her lived experience is characterised by isolation as she is not treated the same as her white counterparts.However, one participant was reflective, despite subtle prejudice, and showed that Black African nurses should investigate why they are being viewed negatively: The discriminations that I have suffered are subtle, they are not discriminations that are sort of out in the open…it may be difficult to challenge them and say, 'look, I've been discriminated against,' and people will look at it objectively and say really?But sometimes we are quick to jump to use the word discrimination.
But, when we take a step back, it could be because of certain skills or attributes that we do not hold that could make us feel discriminated against… I suppose it's always good to reflect to say, 'why is this happening?And trying to address those issues that could be contributing for you to feel that way. [Imani] The above narrative supplies informative guidance to Black African nurses to be considerate and to make a self-introspective evaluation of their pitfalls, even though it may be undeniable that many are directly or implicitly discriminated against.Salim could not resist recounting the unjust treatment he received after he was recruited from South Africa: [Salim] There is a sense that stemming from his formative years in his native country, Salim has internalised a sense of low self-esteem and disempowerment, which has had influence on him to stand up against the injustice and exploitation of his employers.He also made claims of unfair treatment, such as students he mentored are promoted over him, and to be line-managed by peers who were less qualified.He expressed resentment and remorse on reflection for not complaining to at least create awareness when he said: [Ekon] Here, there is a feeling that when he/she complains, the Black African nurse is showing weakness.Instead of exposing them, many are thus forced to internalise any unfair and discriminatory treatment.

| English language and accent
All participants expressed that fluency in English language and distinct accents were serving as barriers to effective communication with their patients and peers.This was clearly reticulated by Joe: No matter how educated you are or fluent you are in English, it is always a second language to you.
So, sometimes the nuances in English can give us a lot of problem of understanding.So, for me, I must bring the language … in my own language before I can interpret what it means…so that can be quite challenging. [Joe] One thing we can note from the above extract is that in the sense of the native language, a foreign language is partially acquired and cannot be completely understood as the native language.Obviously, this may create difficulties for Black African nurses in both peer relationships and therapeutic relationships.Imani also spoke about the challenges he was facing with his strong accent: Because of your strong accent a lot of people might find it difficult to understand you.And if you are in a therapeutic environment that of course could be quite distressing for the patient…meaning that the patient may find it difficult to understand the accent.
Somebody who is coming to seek support may find it distressing but it may be misconstrued as discrimination, the person can make racist comments or something like that, but it is because of they are finding it difficult to understand you. [Imani] What is ironic from this extract is the negative effect that strong accent can have on therapeutic relationships with patients.It also underlines the challenges in navigating through accusations of discrimination or prejudice in clinical practice.Moreover, these two narratives show that language discordance and ineffective communication skills may influence therapeutic relationships between Black African nurses and their patients.

| Snowy-peak syndrome
Participants took an absorbed look at why Black African nurses are not getting the opportunity to fulfil their potential to hold managerial roles even though they make up a considerable proportion of the workforce.This was clear when two participants analytically presented that people from BAME backgrounds are underrepresented in management roles: If you see people on the floor or junior staff, they are all Black people, they are all minority people.But as you go up, you will see most of them are white peo-ple…there is still that barrier. [Amber] If you look at the workforce of the Trust, the higher percentage will be what we call BAMEs, but then compare that to the Board of Executive, the percentage of the presentation does not correspond. [Salim] It is frustrating for these participants that even with the high proportion of BAME workers employed in the NHS, they are not rewarded with senior positions, compared to their white counterparts.Kline (2014) calls this phenomenon the 'snowy white peak'.The participants also said that, sadly, their career progression was sluggish and cited their identities as reasons for that: | 7 of 12 TUFFOUR I went for several posts, which I was overqualified, but I was not really given the job…it was because of who I am…my development was terribly slow compared to white counterparts…I can only conclude because of who I am. [Joe] Because of our background, we are already disadvantaged, and sometimes it feels daunting to make that first step.Imagine if you make the first step and it does not get you anywhere, it is easy for you to sort of just give up.But it is making people aware that as ethnic minorities you might need to try different avenues. [Imani] These narratives convey a feeling that Black African nurses face unfavourable conditions, and their backgrounds and identities obstruct their career advancement.Nevertheless, there is a feeling that Black African nurses are resilient and have desirable consistency to overcome any drawbacks when Imani states: 'as ethnic minorities you might need to try different avenues'.One participant, however, rationalised that, due to psychological reasons and lack of visibility, Black African mental health nurses do not get a management position: We already perceive ourselves that we do not go high up any way; what is the point of trying…there are no opportunities anyway.So that is from one side.But from the management side…when they create these little jobs to occupy us at the bottom, you hardly have opportunity to march up at the top because they will create quite a few…and more jobs at the bottom where you will be happily managing and there is no corresponding senior level of the kind. [Salim] There is a feeling in this narrative that not only are Black African nurses impeded by the glass ceiling, but they lack the enthusiasm to apply for management roles because they have been stereotyped to assume managerial positions at the lower and middle levels.It appears that an undiscovered obstacle to career advancement defines the experience of Black African nurses.But Amber had different views and described Black African nurses as not sufficiently ambitious when she said: Sometimes people from ethnic minority do not want to take a lot of responsibilities.They do not want the challenge. [Amber] The claim that Black African nurses avoid responsibility and accountability for leadership roles is incompatible with the rest of the participants who shared the difficulties they face in achieving managerial positions.Imani, on the other hand, believed that confusion and fear on the part of the white majority were the reasons for refusing management roles to Black African nurses: I think people do feel threatened by us.But sometimes we also need to understand their emotions to understand our moves…if somebody is feeling threatened, they might behave in a certain way, but it is about you understanding and saying, 'okay, how can I make this person understand that actually, I'm not here to take the cake, but I want us to share'. [Imani] A strong inference to be drawn from the above extract is that the alleged underrepresentation of Black African nurses in the management role is not due to discrimination, but because of the perceived white colleagues' deep sense of insecurity.Also, it is sensible to call on Black African nurses to display empathy to others and consider their viewpoints.In addition, participants framed their experiences in the sense of feeling stuck in a complicated NHS working world where they are deprived of opportunities to advance their careers.This became clear when Amber said: Sometimes because you are from the ethnic minority, you do not know the channels…the procedures, and if you are told things…you just keep quiet and just get on with it. [Amber] This extract reveals that the NHS can be a daunting place for Black African nurses to navigate, and for their voices to be heard, and often the only choice is for them to be quiet.As a Black African nurse with several years of experience working in England, I too am familiar with this feeling of being lost in the system.

| Growing in my career
Despite the above-mentioned negative and discriminatory encounters, the participants exemplified positive opportunities that are helping them to advance in their careers.Joe and Amber reported examples of this experience: Current place of work for me, is good…because I have been made a line manager…I am developing, I am growing in my job. [Joe] When I came last April, within four months, I got a frequent attendance nurse role which was a more senior post, and it was to utilise my skills…I felt really val-

ued…and now I am on another secondment as well…
There is support, the manager wants to see people progress.So, it is a good thing. [Amber] Joe and Amber found that their experience and abilities had been recognised and respected, which had aided their career advancement.
Salim, on the other hand, shared mixed feelings about the support he has got over the years: The support in this team I will say yes because the manager always looks to try and push us to do things but in the earlier settings, it was not possible.For eight years…there was nothing I ever did, except just doing the mandatory courses every year…but nobody wants you to advance in your career. [Salim] Salim's frustration at not being given the opportunity to upskill and advance in his career is raw and explicit.Having the possibility to take only mandatory courses is partly a pretext that gave the impression of equal opportunity, but this was not the case.and what is happening on the ground.I remember I went to supervision and said, this is what I would like to do, this is my career path…I was quickly shut down.They said look, we do not think this is something for you, we do not think you will be able to achieve things like that. [Imani] Imani claimed clearly that his experience as a Black African nurse [Imani] Imani responds to the unjust treatment in a dignified manner.As a Black African nurse, I recognise the unequal treatment, symbolic gestures and tokenism in each of the above extracts.

| Power of collective voice
Participants felt that the BAME support group appears to be assisting in the development of cohesion and influencing positive outcomes for Black African nurses.Amber, for example, shared a positive outlook on her future as a result of the support from such a group: Sometimes you feel you do not get supported.But ever since we had this BAME group, things are better, and I can see myself progressing with the support of that group. [Amber] Joe expressed a similar sentiment, stating that while he has struggled to adapt in teams, he has seen promising results from the BAME support group: When I started it was exceedingly difficult to adapt to any team, you had to struggle.But for now, there is lots of awareness.There is lots of work within this trust, there is a lot of work around BAME, this a group of us this, a whole movement within the Trust to make sure that people from ethnic minority background are encouraged and promoted. [Joe] Joe took advantage of the opportunity to eloquently advocate for Black African nurses' solidarity: We need to begin to appreciate ourselves, we need to acknowledge who we are, we need to begin to interact better, respect and support each other.We struggle a lot in isolation…we need to come together and begin to have a collective voice. [Joe] A main theme from the extract above is the need for Black African nurses to come together and share their experiences while also appreciating their own value.Solidarity among Black African nurses is vital because having a unified voice can help to better understand some of the issues mentioned above.However, for Black African nurses to have a common voice, they must be well organised.Even though Unison has a dedicated forum for Black members to advocate for workplace equality (Unison, 2021a), not all Black African nurses are Unison members.As a result, more self-organisation outside of self-help groups and union membership could be beneficial.This will take effort, but it is possible to achieve.

| DISCUSS ION
The aim of this paper was to explore the experiences of perceived prejudices Black African mental health nurses in England face.This section situates the findings to the existing literature.Consistent with the literature (Ford, 2019;Likupe & Archibong, 2013), the participants in this study revealed extensive, routine experiences of discrimination, marginalisation by colleagues, patients and their families.In addition, the disclosures from the participants that they experienced profound problems of inequality, alienation and career development concerns are consistent with Likupe et al.,'s. (2014) Anderson, 2020b;Iheduru-Anderson & Wahi, 2018;Likupe et al., 2014;Wood & Wybron, 2015).The results of this research are consistent with the 'snowy white peaks' phenomenon within the English NHS where there is a clear absence of ethnic diversity at the senior level; at the foundation, the workforce is diverse and vibrant, but at the top, white (Kline, 2014).This trend illustrates the discrimination faced by Black African nurses in leadership positions.In addition, a sense of disempowerment and feelings of otherness were created by the deep-rooted prejudice and microaggression experienced by the participants.These are consistent with several scholars who have shown that being distinct or the other has a negative connotation and can create power imbalance (Ballibar, 2005;Carabine, 1996;Roberts & Schiavenato, 2017).Furthermore, the participants' feelings of unpleasant and negative experiences, both subtle and overt, are consistent with Davis' (1989) concept of microaggression which he defines as stunning and automatic acts of disrespect arising from unconscious attitudes inflicted by the culturally dominant groups, and macroaggression, which is defined as overt structural racism, power imbalance and exclusion (Osanloo et al., 2016).
Furthermore, the participants' revelations that they purposely censor or downplay their capabilities or misgivings to feel welcomed by others are consistent with the literature that BAME workers indulge in self-censorship more than their white peers (CIPD, 2017).It has been suggested that ethnic minority nurses are unwilling to address their experiences of discrimination and unequal opportunities (Hall & Fields, 2013), because of fear of being accused of playing the 'race card' (Waite & Nardi, 2019;Yu, 2008).In addition, the informative admissions of the participants that they lacked the confidence to speak out against prejudice and unequal treatment because of fear of backlash and isolation are consistent with the study that systemic racism and intimidation at work prevented BAME employees' impact of speaking up (Ballibar, 2005;PHE, 2020).In addition, the explanation that some participants were discouraged by economic and financial gains to speak out against unequal treatment synchronises well with some authors, who claim that strong economic rewards may be a motivation against dissent from unfavourable working conditions (Kingma, 2007;O'Brien & Ackroyd, 2012;Tregunno et al., 2009).Despite the negative and discriminatory experiences, the participants believe that collective voice supplies strength and potential for positive change in the workplace is consistent with the literature that collective voice improves job satisfaction (Hoque et al., 2017).
Moreover, the participants showed that lack of command over speaking English has a profound impact on their careers, as well as interactions with their patients and colleagues.This is consistent with studies that have found that speaking English as a second language can impact on nursing career opportunities (Cantone et al., 2019;Iheduru-Anderson, 2020a;Lippi-Green, 1994), clinical performance and increase psychological stress for patients who are already anxious and insecure (Meuter et al., 2015).

| What the study adds to the existing evidence
The research offers insight into the reasons why Black African nurses choose to work in the NHS despite their career advancement being subjected to deep-rooted discrimination.The findings obtained here show that personal and professional development, selflessness and strong monetary interests are explanations for this (Kingma, 2007;O'Brien & Ackroyd, 2012;Tregunno et al., 2009).In addition, despite all the participants coming from former British colonies and being fluent English speakers, they felt that their accent impacted their opportunities for career development (Iheduru-Anderson, 2020a).
Different accents have been reported to interrupt understanding and trigger ethnic stereotypes (Cantone et al., 2019).Therefore, this study further raises awareness that accent and language differences can lead to feelings of stigmatisation, discrimination and ostracisation (Alexis, 2015;Ezeonwu, 2019;Iheduru-Anderson & Wahi, 2018;Jose, 2011;Wheeler et al., 2014).The suggestion that the participants felt that they experienced 'accent bias', which is said to take place when people are judged by how they sound rather than the quality of their expressions (Iheduru-Anderson, 2020a), helps make it clear that without the goodwill of the listener, the Black African nurses' ability in the English language, their degree of communicative ability and clinical skills are made meaningless (Lippi-Green, 1994).

| Implications and recommendations for practice and policy
One of the issues raised by these results is that, despite their selflessness and arduous work, Black African nurses face structural and institutionalised discrimination within the NHS.Employers must challenge the dominance and hegemony that exists within the NHS to ensure greater equality of all employees and understand that discriminatory and racially related barriers prevent Black African nurses from performing to their full professional potential and obstruct their professional growth (Iheduru-Anderson, 2020a).
Levelling up opportunities are therefore needed for Black African nurses to achieve their potential.In this regard, it is important to review recruitment, antidiscrimination, diversity and equality policies (Iheduru-Anderson, 2020a;O'Brien & Ackroyd, 2012).Also, the remedy could require the implementation of the ideals of social justice and ethics to mentor, sponsor and hire talented individuals from a variety of backgrounds to hold senior roles within organisations.
In addition, it should be encouraged to periodically report details on the diversity of senior management (CIPD, 2017).These should be applied to NHS trusts in England to improve fair and inclusive opposition in the workplace, because when employees believe that discriminatory obstacles, whether real, or perceived are obstructing their career advancement, it leads to work dissatisfaction and has consequences for the employer and the employee (Alexis, 2015).
For Black African nurses, discriminatory barriers pose psychological and emotional challenges.Therefore, it is critical to foster diverse workplaces free of prejudice, racial and accent stereotypes (Iheduru-Anderson, 2020a).The result from the present study grants key stakeholders, such as nursing trade unions and professional societies, as well as employers, the opportunity to act.In terms of racial inequalities and prejudice, the UK labour unions have a tumultuous background.In the 1960s and 1970s, they often entertained racial intolerance that targeted migrants and BAMEs.However, as their influence and status dwindled, they were forced to radicalise their policies and recognise the need for a more inclusive approach.The Trades Union Congress (TUC) started developing equal opportunity educational and training materials in the 1980s and worked with the Commission on Racial Equality (CRE) to develop a 'Code of Practice' that unions were expected to use (Connolly et al., 2012).Prejudice against ethnic minorities, however, continued, although in the form of unfair material advantage rather than official discrimination (Grint, 1998).
Unison's self-organised sectoral groups promoting inclusion and representation across all sections of its membership, such as a commitment to promote lesbian and gay workers' employment and human rights (Unison, 2017), equity and changes to women's rights (Unison, 2021b), and especially promotion of workplace equality, and fight against racism and discrimination (Unison, 2021a), are encouraging.However, it has been argued that trade unions such as Unison face many dilemmas in the context of immigration and migrant workers, as well as rising racism, nationalism and anti-migrant sentiment, including whether to oppose or comply with employers' attempts to recruit workers from abroad, or whether to include, exclude or partially exclude migrant workers from trade union regular membership (Marino et al., 2017;Penninx & Roosblad, 2000).
This study has shown that being less competent in English language and accents can cause Black African nurses to feel excluded, stigmatised and discriminated against, so it is a moral argument for NHS employers to enforce anti-discriminatory policies.It is undeniable that effective communication is critical for effective nursing practice.However, it poses both ethical and moral concerns when a person's accent is used to discriminate against him or her (Iheduru-Anderson, 2020a).When people reject an accent, they also reject the individual's identity, race and humanity (Lippi-Green, 1994), and this can have effect on practice and performance.A limitation of this research is that the experiences of a small number of Black African nurses have been explored.

| CON CLUS ION
The findings from this study have supplied a deeper insight into the deep-rooted discrimination and disadvantages that Black African nurses face.NHS employers must therefore take an introspective look at the discriminatory and racially biased concerns that prevent Black African nurses from working to their full professional potential to ensure greater equality for all employees.Black African mental health nurses need opportunities to step up to reach their potential.However, they face a daunting challenge, given a recent controversial claim that the UK does not have a systemic racism issue (Commission on Race & Ethnic Disparities, 2021).Findings from this study showed that English language complexities and accent pose significant problems for Black African mental health nurses in England.Further research is therefore necessary to understand how this impact working and therapeutic relationships.
school and working in Africa informed their stories.The participants' perspectives on working in England were the focus of the second theme.They provided a set of diverse and multidimensional comparative accounts of their experiences of bewilderment as they began their nursing careers in England.The third theme concentrated on the participants' beliefs of discrimination and negative experiences.The final theme explored the participants' beliefs of opportunities available to them.This paper focuses on two superordinate themes, 'Judging a book by its cover' and 'opportunities', to allow for in-depth analysis.The other two superordinate themes and their subordinate themes are to be published elsewhere.The two themes of 'Judging a book by its cover' and 'opportunities' have been chosen as the focus of this paper because they provide some valuable insights into Black African nurses' beliefs about discrimination and marginalisation, as well as what motivates them to remain committed to working in England, and what they believe are the right set of circumstances that encourage their practice in England.The paper also offers a significant opportunity to advance the awareness of biases in the NHS work environment.
was recruited by the Trust from South Africa when they were short of nurses and they recognised my qualifications…and yet when we came here, I was in the lower band [Band D].Whereas I had five years of my degree by that time I joined the team…but it was like they knew that now they have brought us here… it is either you go back, or you accept what is on the plate.I do not think it was fair, to be honest… my manager and deputy did not have a degree.[Salim] Despite the sense of being a victim of injustice, Salim felt that he lacked the courage to speak up due to fear of being victimised.Also, he emotionally narrated how perhaps, the experience of growing up in South Africa has affected his confidence to challenge any discriminatory treatment: If you challenge some things based on race or colour, we still think it is very much revolting thing than anything else.So, you really must have good facts because you do not want to fall into this category.So, I think the experience from back home that was like limiting us in that sense…it makes us take a long time to argue…it made me accept things that I should not have accepted in the first place.
Similar sentiment was echoed by Imani: It is mixed feelings I have.I have been in places where I have felt really inspired and empowered, where I felt valued…people recognised the talent in me.I have also had experiences where you feel…like chasing your tail, where you feel there is no career progression…you feel stuck…you find there is a lot of gaps in terms of what you know you signed up for has often been characterised by conflicting emotions.Despite this, he showed resiliency and self-reflection by saying: I suppose what I have learned from all that…trying to keep a positive mentality…looking at situations and looking at both pros and cons of being in that situation and trying to…focus on the positives and what I can achieve in that environment at a time… I have learned to deal with my emotions…being a more conscious and more of a reflective practitioner than anything else.

. The interview schedule included open-ended questions like: could you describe what it is like for
List of superordinate and subordinate themes apart from the ward manager and the deputy at the time.And a relative or somebody will come in asking for more information and when I give them the information, they will not take it and they will demand to see the person in charge and I will humbly go away and come back and say I am in charge, so what I am telling you is how it works.