Leadership Development of Women of Color in Occupational Therapy: A Qualitative Intersectional Analysis

Occupational therapy leaders are those who hold positions of power that influence the profession via advocacy, policy development, education, and research to ensure clients have equitable access to occupational therapy services (Lapointe et al., 2013). Their leadership development is a social process that supports them in acquiring leadership skills (Moorosi, 2014). Historically, leadership theories in occupational therapy, the main driver of leadership development, have aligned with White, Eurocentric, middle-class cultural values, beliefs, and assumptions (Hammell, 2011), and the U.S. occupational therapy professional workforce has been predominantly (87%) White non-Hispanic. This mirrors U.S. health care leadership trends (U.S. Bureau of Labor Statistics, 2021).

Forming a personal identity as a leader is a complex social process that meshes multiple subjective and socially constructed social categories. Women of color occupy social positions and group member identification that differ from those of White women, which changes their leadership acquisition experience (Key et al., 2012). The literature has shown that class and race are imbued with the social structure of power and dominance, often placing women of color on unequal footing with White women (McKinsey & Company, 2022; Windsong, 2016).

The leadership pathways of women of color in occupational therapy have yet to be specifically and fully explored from an intersectional perspective. Therefore, in this study we aimed to understand which intersecting patterns of social identity categories have been prevalent in the leadership development trajectories of women of color leaders in occupational therapy in the United States and how these intersecting patterns have shaped their leadership development. Studying intersecting patterns of social identity categories is crucial if we are to gain an understanding of leadership development as a social process and recognizing the complexity of interactions between multiple categories (Moorosi, 2014, p. 796).

In this qualitative research study, we followed Winker and Degele’s (2011) multilevel intersectional approach to analyze narrative interviews and relevant documents according to the central research questions. This approach considers how people are simultaneously positioned by individual, symbolic, and structural levels of social identity through social practices, such as leadership development.

The study was approved by Thomas Jefferson University’s institutional review board. We maintained relational ethics by acknowledging the participants’ values and beliefs. We ensured participants’ confidentiality, anonymity, identity, and privacy by cataloging all data in password-protected electronic formats.

All three of us identify as women of color. Ushentha Nirmul and Pamela Talero Cabrejo are immigrants to the United States. Nirmul is culturally Indian but was born and lived in South Africa when apartheid (a system of historical segregation governed by laws based on race) was fully enforced. Her exposure to social injustice and racism in South Africa heightens her awareness of discriminatory practices and drives her interest in understanding and ameliorating inequity. Talero Cabrejo is a mestiza (person of Latin American mixed-race identity) from Colombia. Growing up in a country of profound social inequalities and palpable colonial history, she strives for a critical, in-depth understanding of the world. Cristina Reyes Smith was born in the United States to a family of military veterans from Puerto Rico and has lived in a historic city in the southeastern United States since early childhood. Inspired by the resilience and unity of the community there in the aftermath of natural disasters and community violence, she endeavors to facilitate meaningful collaboration among culturally diverse groups while promoting access to care for the underserved.

Intersectionality theory premises that people live in multiple layered identities derived from social relations, history, and structured power operations (Moorosi, 2014). It further recognizes that gender, race, class, and ethnicity define women of color’s world experiences (Cho et al., 2013), overlaid with interactions specific to occupation, geopolitical location, and historical period, among others (Kim, 2020; Moorosi et al., 2018). Thus, the effect of intersectionality on leadership acquisition for women of color requires a careful examination of the historical context, the daily workplace experience, and how this affects upward mobility. Intersectionality as a methodological approach can identify themes related to social realities and professional power dynamics that shape leadership development for women of color in occupational therapy.

Participants were recruited by means of a purposive, snowball sampling of occupational therapy practitioners who met the following inclusion criteria: living in the United States, speaking English, being a woman of color, and being a leader as defined at the outset of this article. Participants were pre-identified through professional multicultural networks and our own professional networks. Twenty-three prospective participants were sent invitation emails. Ten responded, but 2 were unavailable for an interview within the timeline for data collection. Clarification of the participant’s social identity as a woman of color and leader was sought by means of a narrative interview. As shown in Table 1, the sample included 8 participants who self-identified as women of color: Two identified as African American, 2 as African Caribbean, 1 as Asian American, 1 as South Asian, 1 as Indigenous/White Hispanic, and 1 as Native American. The participants represented multiple U.S. regions and ranged in age from 30 to 62 yr. The number of years they had been practicing occupational therapists and number of years in occupational therapy leadership ranged from 3 to 40.

Narrative interviews were the primary method used to explore the research questions. Nirmul and Talero Cabrejo developed the interview guide following suggestions by Anderson and Kirkpatrick (2016) and the leaders’ guidelines suggested by the OT Leaders & Legacies Society (n.d.). Interview questions sought information about participants’ backgrounds as leaders, their leadership experience, what had shaped their leadership experience, and what had shaped their leadership development in occupational therapy. As shown in Table 2, the interview guide included subquestions that explored social identity categories within each level of analysis, consistent with Winker and Degele’s (2011) multilevel intersectional approach. Nirmul piloted the interview guide and transcription process with two occupational therapists who met the criteria of women of color leaders in occupational therapy but whose interviews were not included in the study. Before achieving verbal consent to proceed with the interview, Nirmul shared her social identity as a researcher with each participant.

Interviews were scheduled via email and conducted through a virtual technology platform. Nirmul interviewed all participants separately via Zoom once between October 27, 2021, and November 17, 2021. Each interview lasted between 60 and 90 min. Nirmul cataloged all transcripts with NVivo (Version 12) conversation analytic software. She replayed all the interviews to confirm the accuracy of the transcripts.

Winker and Degele’s (2011) eight-step multilevel intersectional approach was used to analyze the data and identify intersecting patterns of socially defined categories in the participants’ narratives of leadership development, as shown in Figure 1. Multilevel analysis was achieved by exploring the three interrelated levels: (1) identity constructions (how participants identified themselves through the narrative interviews), (2) symbolic representations (the predominant influencing norms, ideologies, and representations present in their narratives about their leadership development), and (3) social structures (references in the participants’ narratives to social institutions, organizations, laws, and other social practices that have shaped their leadership development).

The order of these steps was not prescriptive; however, all were needed to provide a complete picture of the interactions of social identity categories at the three levels. Nirmul and Dr. Maria Belen Montealegre, an occupational therapist and self-identified woman of color with more than 20 yr of clinical practice and experience in qualitative research, coded all interviews independently (Steps 1–4).

In Steps 5, 6, and 7, Nirmul and Talero Cabrejo compared and clustered interrelations, identified structural power relations present, and noted prevailing norms and values in occupational therapy that influenced the participants’ leadership development in each narrative interview. In Step 8, they analyzed themes of the clustered interrelations at the three levels in all narrative interviews.

As depicted in Figure 2, intersecting patterns of social identity categories at play in the leadership development trajectories of women of color leaders in occupational therapy in the United States were identified at the three levels of analysis.

The most recurrent identity constructions in the participants’ leadership development were race/ethnicity, citizenship status, professional role, and social connections ascribed by gender. Participants’ identity constructions demonstrated how social identities go beyond simple categories of difference to interrelated descriptions of who one is. Participant 1 stated, “I describe myself as a female. I am also an immigrant of Caribbean descent. I am an American citizen, but again I do recognize my Caribbean heritage,” which shows the intersection of social connections, citizenship status, and race/ethnicity.

Identity constructions also shaped how participants engaged in leadership and the perspectives from which they understand the world around them. Participant 6 explained, “Definitely being African American, being a female, are one of the top two when I think about anything in terms of how I engaged in occupation, as I looked at leadership roles.”

For many participants, identity constructions were not only a description of who one is but also a process of reclaiming oneself. Participant 3 expressed, “I like to introduce myself in my Native language. I need to introduce myself that way because my ancestors were not allowed to.”

Participants attributed their leadership trajectory to key symbolic representations of social capital, feeling like the other, and working harder (see Figure 2).

Social capital was a symbolic representation linking social interactions to leadership development, usually ignited by someone in a position of power, such as a supervisor or a mentor. Participant 4 stated, “I got in by doing this grant and then having someone who was interested in mentoring me say, ‘I can help her to move to the next level.’”

Feeling like the other was a symbolic representation of not belonging. Participant 2 explained, “I just didn’t feel like I really belonged in those roles [academia], like those roles were for White women. And I didn’t see myself reflected in the leadership of our profession.”

Finally, working harder meant that, even with the same amount of qualifications as their colleagues, or more than them, participants worked significantly harder to break through heavily gendered and racialized experiences. Participant 6 described the emotional tax of feeling like the other and working harder by saying, “I think it’s about being a woman, and I think it's about being African American. . . . I had to be better at both. Because both were going to be looked at as second rate.”

As shown in Figure 2, professional organizations, mentorship, organizational culture, and sponsorship were identified as the main social structures that have shaped the participants’ leadership trajectories.

Most participants reported active roles in occupational therapy professional organizations; however, most of them felt that even when they had a role in a professional organization they did not always feel represented or supported. Although position statements are made and networks are created, at a systemic level the power relations are different for women of color in the profession. Participant 8 expressed,

Mentorship was perceived and experienced as one of the biggest factors in leadership development. For Participant 7, mentorship happened at different points of her professional career, shaping her leadership trajectory: “I probably have had a lot of mentors. Different mentors for seasons of my life.” However, the narratives denote a need for mentorship models in occupational therapy. Participant 8 expressed, “I don’t think we have a mentorship model. That’s the main challenge. People don’t know they can seek mentors or be mentors.”

In addition, organizational culture was perceived to validate structural power relations such as racism and sexism. Participant 2 expressed, “I think it just depends on the culture of the institution. With my last institution, because there was this preference for White colleagues, that if you weren’t White then you’re already a step behind.”

Finally, the narratives discussed sponsorship in two ways. First, participants stressed the importance of receiving financial sponsorship through scholarships, grants, and funding, especially earlier in their careers. Participant 3 said, “It’s hard to think about where I would be if I had not had any of the scholarship funds. I believe I definitely would not have pursued a graduate degree.” Second, lack of personal sponsorship was attributed to organizational and structural power relations that fractured the participants’ leadership development. Participant 5 explained, “You say, ‘I have this idea,’ and nobody seems to hear it. Then another White male in the room has the exact same idea 30 minutes later, and I sit there and say, ‘Okay, it’s your idea now.’”

As shown in Figure 2, four central themes emerged from the intersecting patterns of social identity categories: (1) early leadership development does not happen without access to opportunities, (2) sponsorship and mentorship have implications beyond one’s leadership development, (3) being seen is essential for leadership development, and (4) persevering is a constant state of struggle.

All participants’ narratives referenced how they were exposed at a younger age to the profession, were driven to take on responsibilities within the social groups to which they belonged, and how interdependent systems of power granted them access to opportunities. Participant 2 stated, “Like starting even in junior high, I was a leader at my church group. In high school, I was in an [assembly of student delegates] position. And in college, I had similar types of positions.” Participant 7’s narrative illustrated how race, class, and gender as systems of power intersect and play a critical role in accessing opportunities that led them to the profession:

Sponsorship and mentorship played a significant role in the participants’ leadership development, with implications beyond their own leadership development. Participant 1 described how having social connections (identity construction) allowed her to cultivate social capital (symbolic representation) through mentorship and sponsorship (social structures) with a rippled effect for other professionals to develop as leaders:

Similarly, Participant 4 described how mentorship helped her recognize her potential:

All participants described how being seen shaped their leadership development. Being seen goes beyond noticing someone’s presence to fully recognizing their humanity and the complexities of power relations that allow them to be seen and included for who they truly are. For example, Participant 6 spoke of being seen as including not only physically sitting at the table but also having her ideas welcomed: “And when I say ‘invited to the table,’ it’s really being seen and being heard when you’re at the table. So don’t just have me at the table because I fulfill a number.”

Participants’ narratives also showed how power relations have shaped being seen as allowing an authentic inclusion, that is, to have a real and tangible influence from a leadership position. For example, Participant 4 talked about recognizing the implicit bias that prohibits a professional body from considering racial and ethnic diversity among other forms of diversity to secure access for people of color:

Finally, all participants expressed how perseverance played a significant role in their leadership development. Perseverance meant standing up to the power relations of racism, colorism, and ableism and working around microaggressions. Participant 2 described her experience in an academic setting:

Participant 8 explained how persevering meant that even after attaining the necessary qualifications to enact change, further effort was required to attain a position from which she could effect it:

Our findings support the results of other intersectional studies of women of color in leadership in health care and education (Jean-Marie et al., 2009; Moorosi et al., 2018) as well as studies in occupational therapy (Ford et al., 2021; Salvant et al., 2021) where the intersection of gender, race, and class have heavily influenced the professional trajectories of people of color. These studies also recount barriers to leadership achievement, such as minimal to no mentorship opportunities, racism, sexism, and minimal recognition of professional achievement. As Hill-Collins (2019) explained, “Intersecting power relations produce complex social inequalities” (p. 49). Therefore, recognizing the histories that have shaped women of color and the history of occupational therapy is paramount for creating structural and social change to build a cohesive profession (Beagan et al., 2022; Lavalley & Johnson, 2020).

Participants in our study described access to affirmative action opportunities through educational sponsorship. However, these were conditional not only on their academic standing but also on the sponsors’ symbolic representations of their identity constructions. The funds for which they qualified were tied to profound social inequalities previously documented elsewhere (Findling et al., 2022; Hahn, 2022; Stewart-Ambo, 2021). The household socioeconomic conditions of people of color in the United States are tied to historical, social, economic, political, and educational disparities that still prevail. For example, American Indian/Alaska Native nations still experience the most severe socioeconomic inequalities compared with any other racialized group in the United States (Stewart-Ambo, 2021). Thus, efforts to remediate historical inequity, such as sponsorship, though reconstructive, can become a gatekeeping mechanism for achieving educational scholarship. This restricts the participation of people of color in educational pursuits because it supports only a small percentage of individuals in racialized groups, perpetuating racial inequality in education and negatively affecting their leadership development (Hahn, 2022; Stewart-Ambo, 2021).

The present reality of women of color who want to advance into leadership positions comprises barriers to overcome (Biu, 2019; Lavalley & Johnson, 2020). Participants’ narratives elucidated that even when opportunities for leadership development arise, pervasive “othering” for women of color within the profession remains. “Feeling like the other” symbolizes how one feels different and how one is separated from the essential power structure of the group. This separation hurts the profession because it perpetuates social practices that undermine the experiences of people of color. Thus, systemic changes supporting women of color’s access to occupational therapy as a career and leadership roles are required. Efforts should include an inclusive curriculum in occupational therapy; models and frameworks that support marginalized students; access to scholarships, peer group support, and mentorship networks; and action by all occupational therapy practitioners to recognize their role in transforming structural and social inequity (Beagan et al., 2022; Ford et al., 2021; Sterman & Njelesani, 2021).

One of the strengths of this study is that a previously established process for intersectional analysis was rigorously followed (Winker & Degele, 2011). Study limitations include a small sample size (n = 8) that might limit the generalizability of the results and the potential for personal bias. We are aware that our lived experiences as women of color and leaders in occupational therapy may have influenced the interpretation of the participants’ narratives. Despite these limitations, these findings offer important implications for occupational therapy practice.

This intersectional study contributes to the literature on occupational therapy by elucidating how the intersection of social identities of women of color leaders has shaped their leadership development in the profession in the United States. Paramount to facilitating equity, inclusion, and diversity in occupational therapy leadership is the creation of sponsorship and mentorship opportunities for women of color that begin with attracting them to the profession and then supporting their development throughout their careers. Moreover, in order to dismantle structural racism and social inequity present in the profession, efforts must be made toward reframing theories, models, pedagogies, and programs that have historically shaped the profession to include perspectives of marginalized populations.

In this qualitative study, we explored the intersectional experience of eight women of color leaders in occupational therapy, discussing how their overlapping social identities affected their leadership development. Our findings raise awareness of the dynamics among identity constructions, symbolic representations, and the social structures of the occupational therapy profession in the United States. Four central themes illustrate how leadership development for women of color in occupational therapy rests at the intersection of scholarship, mentorship, and authentic inclusion. Additional research exploring the impact of the intersecting patterns of social identities on leadership development for men, nonbinary, neurodivergent, and persons of color with disabilities in occupational therapy also warrants inquiry to understand what actions will support professional and leadership development for all.

Future action in occupational therapy must include mentorship and sponsorship models and programs to support professionals of color in occupational therapy. Further research is also needed to measure the effectiveness of formalized mentoring programs for marginalized students and professionals.

We acknowledge the role and contributions of Dr. Maria Belen Montealegrec, Occupational Therapy Supervisor, Inpatient Rehabilitation, at Hackensack Meridian JFK Johnson Rehabilitation Institute for her expertise and support in qualitative coding. This study was conducted in partial fulfillment of Dr. Nirmul’s postprofessional doctorate in occupational therapy at Thomas Jefferson University. No extramural funding was received for this study.