Abstract
This study investigated how social structures in the United States have influenced the leadership development of women of color in occupational therapy.
Leadership is a dynamic process that influences and transforms roles, relationships, and social structures making up complex networks of relationships, institutional norms, and roles organizing society (Ritchie, 2020; Wilson, 2023). These social structures include families, educational institutions, economic systems, and legal frameworks that shape individuals’ opportunities and experiences.
Leadership development involves coconstructing social identities, building networks, and learning to navigate social structures and established norms through education, mentorship, and professional experience (Nirmul et al., 2023; Roth, 2022). Formal leadership roles—such as those in academia, advocacy, policy-making, research, and management—illustrate the reciprocal relationship between leadership and the broader social structures that shape and are shaped by it (Roth, 2022; Wilson, 2023).
In the United States, social structures are deeply rooted in a history of Anglo-European colonization, which established and continues to sustain racial and ability hierarchies that favor White Europeans and uphold neoliberal norms (Spickard et al., 2022). As a result, White supremacist ideology—a belief system asserting the superiority of White people over other groups—has significantly shaped leadership development by reinforcing oppressive structures that perpetuate inequities and disadvantage marginalized communities (Skouteris et al., 2024; Verduzco-Gutierrez et al., 2022). These same dynamics have influenced the history and frameworks of occupational therapy, a field historically grounded in White colonial, Christian, and capitalist values. This foundation has often prioritized heteronormative, able-bodied male worldviews, further marginalizing diverse identities (Amorim et al., 2020; Beagan et al., 2023; Kronenberg, 2021; Lavalley & Johnson, 2022; Parkin & Johnson, 2024; Turcotte & Holmes, 2024).
Women and racialized minorities remain underrepresented in health care leadership, with women of color occupying only 6% of these roles (McKinsey & Company, 2022). In 2022, 81.6% of occupational therapists identified as White, highlighting the underrepresentation of racial and ethnic minority groups (Data USA, 2022). Despite women comprising 87.9% of the occupational therapy workforce, a significant wage gap persists between male and female therapists, reflecting systemic inequities (Data USA, 2022). In addition, public data lack comprehensive insights into the representation of occupational therapists of color in leadership roles, underscoring the need for better data and actionable strategies. The American Occupational Therapy Association’s (2019) Vision 2025 states that leaders are crucial in promoting diversity, equity, and inclusion (DEI). However, women of color in occupational therapy face unique challenges in navigating professional networks, mentorship opportunities, and organizational cultures that are often imbued with historical inequities (Nirmul et al., 2023).
Nirmul et al. (2023) investigated how intersecting patterns of social identity categories shaped the leadership development trajectories of eight women of color leaders in occupational therapy in the United States. The study analyzed the prevalent identity constructions, symbolic representations, and social structures. Four key social structures—mentorship, professional organizations, sponsorship, and organizational culture—shaped the women’s leadership development. Expanding on these findings from Nirmul et al. (2023), this secondary analysis aims to understand how social structures have shaped the leadership development of women of color in occupational therapy in the United States. It examines the associated social practices, structural power relations, prevailing norms and values, and their interrelations, highlighting the systemic barriers women of color may face in the profession. Specifically, this analysis seeks to answer the following research question: How have organizational culture, professional organizations, mentorship, and sponsorship shaped the leadership development of women of color in occupational therapy in the United States?
Method
Research Design
This secondary qualitative analysis revisits data from Nirmul et al. (2023) to explore social structures shaping leadership development among women of color in U.S. occupational therapy using Winker and Degele’s (2011) multilevel intersectional approach.
Ethical Procedures
The study was approved by Thomas Jefferson University’s institutional review board. We maintained relational ethics by acknowledging participants’ values, beliefs, unique context, and experiences through the interview process by reaffirming consent and allowing participants to adjust their involvement or withdraw at any time. We also shared our positionality as women of color to build trust. Confidentiality and privacy were ensured through password-protected data storage.
Guiding Theory
The study applied intersectionality theory to examine how intersecting social identities—such as gender, race, class, ethnicity, and occupation—interact with historical and geopolitical contexts to influence leadership acquisition for women of color (Cho et al., 2013). This approach highlighted the impact of power dynamics and workplace experiences on upward mobility, uncovering themes related to social realities and professional leadership development in occupational therapy. For more details, see Nirmul et al. (2023).
Participants
The study included eight women of color in occupational therapy leadership roles, recruited through purposive snowball sampling of multicultural and professional networks. Participants identified as African American, African Caribbean, Asian American, South Asian, Indigenous/White Hispanic, and Native American. Their ages ranged from 30 to 62 yr, with 3 to 40 yr of professional and leadership experience across academia, advocacy, research, and policy-making. A more detailed account of participant demographics is available in Nirmul et al. (2023).
Narrative Interviews
Based on Winker and Degele’s (2011) multilevel intersectional framework, narrative interviews explored participants’ leadership trajectories and how intersecting identities influenced their experiences. The development and content of the interview guide are available in Nirmul et al. (2023).
Data Collection
This secondary analysis did not collect further data from what was detailed in the published study by Nirmul et al. (2023), in which Nirmul conducted one-on-one interviews via Zoom between October 27 and November 17, 2021, lasting 60 to 90 min each. Transcripts were cataloged using NVivo 12 software, and their accuracy was verified by replaying the audio recordings.
Data Analysis
We conducted the secondary analysis following Steps 5 through 8 of Winker and Degele’s (2011) multilevel intersectional analysis framework, as outlined in Nirmul et al. (2023), and guided by Chatfield’s (2020) recommendations for secondary qualitative data analysis. We used NVivo 12 analytical software to initially code social structures and power relations. The steps included the following: Step 5: Participants’ narratives were compared and clustered to identify shared social practices within the social structures: mentorship, professional organizations, organizational culture, and sponsorship. Step 6: Structural power relations, including colonialism, classism, ableism, racism, and sexism, were identified in participants’ narratives. These power dynamics were analyzed for their influence on leadership development within the identified social structures. Step 7: Participants’ references to norms and values were coded to uncover their connections to U.S. historical and sociocultural contexts embedded in their narratives (e.g., Federal Indian Boarding School Initiative, Jim Crow laws). Step 8: A thematic analysis examined the interrelations among structural power relations, norms, and values across participants’ narratives, providing a nuanced understanding of how these factors collectively shape the leadership development trajectories of women of color.
To deepen the analysis, Nirmul used Taguette (https://www.taguette.org), a secure open-source computer-assisted qualitative data analysis software, to code references to U.S. historical markers, structural power relations, and prevailing norms and values. We engaged in an iterative process of discussion and debriefing to refine the coding and themes, culminating in a comprehensive synthesis presented in Table 1 and the results.
Data Analysis Sequence of the Most Prevalent Social Practices, Structural Power Relations, Norms, and Values Within the Historical and Sociocultural U.S. Context and Identified Interrelations From Which Central Themes Emerged Based on the Narrative Interviews
Note. Steps 5 to 8 are from Winker and Degele’s (2011) multilevel intersectional approach. DEI = diversity, equity, and inclusion; AOTA = American Occupational Therapy Association.
Results
How Have the Identified Social Structures Shaped the Leadership Development of Women of Color in Occupational Therapy in the United States?
As shown in Table 1, this secondary analysis of participants’ narratives revealed the pervasive influence of White supremacy across all the previously identified social structures (mentorship, sponsorship, organizational culture, and professional organizations). It manifested through social practices and structural power relations, significantly affecting the leadership trajectories of women of color through two central themes: (1) early exposure to social structures and (2) institutional barriers and discrimination in the U.S. context. We first describe the central themes and then the social practices and power relations prevalent in each of the social structures.
Central Themes
Early Exposure to Social Structures
Participants’ narratives revealed that early experiences with social structures profoundly influenced their professional and leadership trajectories, shaping their self-perceptions and aspirations. These experiences often involved cultural assimilation, racism, and the systemic undervaluation of certain social identities. For example, Participant 3 shared the story of her grandfather’s forced assimilation: My grandfather was taken to a [Native American] boarding school … run by the government and the Catholic churches … that were to kill the Indian and save the man. They were intentionally trying to strip away the culture and assimilate the people.
Participant 5 recounted the discouraging racialized messaging she received as a teenager: “A friend of mine, their parents said, ‘Well, you know you’re Mexican so that you may go to college, but you’ll never finish.’” Participant 6 described messaging about knowing one’s place and the systematic undervaluation of certain social identities under White normativity: I think it’s about being a woman, and I think it’s about being African American. It was how I was brought up. Both were going to be looked at as second-rate. So as a woman, I had to be better, and as an African American, I had to be better.
The narratives illustrated how early exposure to social structures shaped the participants’ understanding of social identities in a U.S. society dominated by racial hierarchies and the standard of Whiteness. The need to assimilate and “be better” profoundly influenced the participants’ leadership pathways within the profession by instilling an awareness of one’s place early on.
Institutional Barriers and Discrimination
The pervasive impact of institutional barriers and discrimination was present across the participants’ narratives, influencing their access to education and professional opportunities. These were often manifested as limited access to quality education, discriminatory practices in the workplace, and the marginalization of minoritized and racialized voices.
Regarding limited access to quality education, Participant 7 expressed, “I was fortunate to go to a private school … that was looking for diversity in the late ’60s and early ’70s … I was one of the first African Americans there.”
Participant 5 described discriminatory practice in the workplace. She shared how her workplace violated its dismissal practice of “last hired, first fired.” She recounted, “They were going to have a reduction in the workforce … and they laid me off, even though there were four White women that were hired after me.”
The marginalization of minoritized and racialized voices was explained by Participant 6: “It’s hard for me, sometimes, to take information from people who don’t even know what it is to be me, right? Moreover, the organization is just run from that one perspective. Their [White] perspective.”
Prevalent Social Practices and Power Relations
Table 1 and the participants’ narratives that follow describe the more prevalent social practices and power relations derived from the grandparent code of White supremacy in each of the social structures.
Organizational Culture
Organizational culture is a social structure that mediates participants’ leadership development and can also validate structural power relations such as racism and institutionalized patriarchy. Racism was a pervasive issue, as Participant 2 pointed out: “I think it just depends on the culture of the institution … with my last institution, … there was this preference for White colleagues, … if you weren’t White then you’re already a step behind.”
Anti-Blackness, a specific form of racism involving cultural disregard, systemic and individual violence, dehumanization, and the marginalization of people racialized as Black and their cultural practice (Dumas & Ross, 2016), was prevalent in the participants’ narratives, often manifesting as institutional barriers and discrimination. For instance, Participant 4 recounted applying to a university where she was the only one of three applicants accepted. The guidance counselor, addressing the college recruiter, remarked, “Nobody at the [high] school would be able to apply and get into [named university]. Most of our students graduate and go off to a trade.”
Institutionalized patriarchy was a significant issue for women of color in leadership roles, requiring them to prove themselves more than their male counterparts. Participant 6 emphasized this, stating, Being a woman in leadership is a whole different thing; being an African American in leadership is a whole different thing. You got problems with both. And so I think being a double minority, you fight against men in the academy.
The racialization of organizational culture was evident in the undervaluing and dismissal of the work of women of color. Participant 2 described, I was at [university] for 10 yr and never recognized for any of the things that I was doing … there were definitely opportunities to seek out more formal training, mentorship, … but the leadership at [university] it still is all White leadership, White women … even with that additional training they still didn’t see me as somebody with potential for leadership.
White solipsism, another recurring theme, was evident in the dominance of White cultural norms and efforts to erase cultural identities. Participant 5 shared an example: So we’re sitting at this faculty meeting … and we really are focusing on diversity … and the student’s response to me was, “Don’t forget the White people.” And the White male [faculty] sitting at the table responded to the whole group saying, “She’s right.”
Both tokenism—the superficial inclusion of individuals from underrepresented groups to create the appearance of diversity without addressing systemic inequities (Childress et al., 2024)—and the model minority myth—a stereotype portraying Asian Americans as uniformly successful and the “ideal” minority (Walton & Truong, 2023)—posed notable challenges. Participant 6 described the emotional toll of tokenism, stating, “Don’t just have me at the table, because I fulfill a number, and that fits that diversity part. Make me … feel like I belong, and then I can give and I can offer something.”
Similarly, Participant 2 highlighted the pressures of the model minority myth, explaining, “In the whole faculty meetings … I just would sit there and think, ‘Oh, okay, is that what everybody thinks about Asians?’ There were a lot of narratives around Asian students.” These insights underscore how both practices reinforce exclusionary dynamics and perpetuate harmful stereotypes, obstructing genuine inclusion and equity.
Professional Organizations
Professional organizations play a crucial role in representing the whole professional body and its interests and concerns, supporting leadership development, and setting the tone for intra- and interprofessional relationships. Participants recounted their experiences with lost-cause messaging from majority White, able-bodied, and middle-class professional organizations through performative DEI initiatives, which involve superficial gestures to appear diverse without meaningful systemic change (Roberson et al., 2024), and aversive racism, in which outward support for equality hides unconscious biases that exclude others (Pearson et al., 2009).
For example, Participant 3 noted, “A lot of the time around conference time we’re talking about the accessibility of the conference and the diversity of the conference sessions … And so [the organization] constantly says, ‘Oh yeah it’ll be accessible,’ but it’s not.” Participant 7 also recounted, “I did a diversity campaign for occupational therapy in 1986 with [organization] … and you could talk to people that were considering occupational therapy. But the money ran out, and that was that. Nobody even cared anymore.”
Participant 5 recalled exclusion from a majority White professional organization that affected her professional advancement: They [the professional organization] invited me … I went one time, I did one thing … and I said to them, “You don’t have a very diverse group here,” … and they never invited me down … they never called me back.
Mentorship
Mentorship is an accepted social practice for guiding, influencing, and supporting the leadership development of individuals. Participant 2 noted how racial hierarchies affected her mentorship experience: “They [White colleagues] establish social capital so effectively … they had mentors that were teaching them these things. I didn’t have the mentors to teach me those things.” Racial hierarchies within mentorship further complicated career advancement. Participant 3 noted, “I think mentorship is one of the biggest factors … having somebody who understands my lived experience … it definitely helps in terms of avoiding burnout, and just kind of moral support.”
Participant 6 talked about how she wanted to change the anti-Blackness narrative through intentional mentorship connections with students: I was teaching at a university as a special guest lecturer … and, at the end of the class three African American girls came up to me … and they had concerns, “What do you do when a patient doesn’t want to work with you because you’re Black?”
On the other hand, Participant 8 talked about the lack of mentorship and the frustration that came from that: “I made the choice to get more education so that I had all the skill set needed to be able to lead in the field. And I never found mentors in the field … I didn’t know that I could have a mentor.”
Racial hierarchies within mentorship further perpetuated inequalities. Participant 4 described how mentorship by someone who shared her lived experience helped her recognize her potential and described how her career stalled when the same mentorship disappeared: I stayed at [named academic institute] for 18 and a half years, … in that period … I found myself being very angry, … I saw my colleagues moving ahead, publishing, progressing, but I was still doing the same exact thing. … Because the woman that was there, the African American woman, had left.
Sponsorship
Sponsorship was a social structure prevalent among the participants’ leadership development, especially for securing the economic resources for professional opportunities. Underfunded neighborhoods and schools have limited educational opportunities. As expressed by Participant 5: I didn’t go to a phenomenal high school … so when I got there [university], that’s when I realized, “Oh, I don’t really know how to write scientifically.” So I learned a lot that summer … so I find it a big joke that now people will come to me for writing stuff.
Other participants spoke of the necessity to secure economic resources by assuming different roles early on, denoting the need for financial sponsorship to expand the development opportunities. As Participant 4 described, “When I was in college, I worked four jobs, going to school, because my mom didn’t have the means to send me to that school.”
Participant 1 further illustrated how lack of financial sponsorship can limit professional choices: “My first job after graduation, … even though I had the support of parents … I struggled financially through school. So for me, it was the first job I was offered.”
Monolingual and imperial language ideologies influenced the need for scholarships among minoritized students. Participant 3 explained, Now that I know more about the intentional policies to create that shame in my life, in my family … my grandfather was the one that was in the [Native American] boarding school. He never spoke our language after going to that school.
Participant 3 further recounted how racist and anti-Native educational policies are embedded into higher education: “At [higher education institution] there’s a large Native American community because of the background of the school being intended to educate Native youth but that was never actually realized because of … White people.”
Discussion
This study further illuminated the complex interplay, first documented in Nirmul et al. (2023), between historical and contemporary social practices and power relations in shaping the leadership trajectories of women of color in occupational therapy. Through a secondary analysis of narratives from these leaders in the United States, two main mechanisms of White supremacy were identified: early exposure to racialized social structures and institutional barriers and discrimination. This study also highlighted the widespread impact of White supremacy on various social structures, including organizational culture, professional organizations, mentorship, and sponsorship.
Our findings revealed that participants’ professional and leadership paths were significantly influenced by early experiences involving cultural assimilation, racism, and systemic undervaluation of certain social identities. Historical examples include the Assimilation Act of 1890, Black Codes, Jim Crow laws, and the Immigration Acts of 1917 and 1924, which restricted the expression of cultural traits and languages different from a White European-American standard (Roth, 2022; Spickard et al., 2022). These norms created barriers to leadership development (Roth, 2022). Participants recounted stories of forced assimilation in Native American boarding schools, segregated schools, underfunded schools and neighborhoods, and discouraging racialized messaging during their formative years, which highlighted the pervasive nature of White normativity, as documented in other fields (Austin & Anya, 2024; Iheduru-Anderson, 2021).
Furthermore, our findings indicated that institutional barriers and discriminatory workplace practices affected participants’ access to education and professional opportunities. Participants described being overlooked for promotions, facing layoffs despite seniority, and struggling against systemic racism within their organizations, which are consistent with other research (Skouteris et al., 2024).
Organizational culture in occupational therapy often perpetuates power dynamics such as racism and institutionalized patriarchy (Amorim et al., 2020; Parkin & Johnson, 2024). Participants in this study described experiencing microaggressions, institutional racism, and a lack of recognition for their contributions. Although professional organizations play a critical role in shaping the work environment, they often fail to address DEI at a systemic level (Black, 2002). Participants highlighted the prevalence of performative DEI efforts and subtle forms of racism. These issues harm the profession’s internal cohesion and hinder its ability to serve diverse communities effectively.
Mentorship and sponsorship are vital for career development and leadership advancement (Goertz et al., 2024; Verduzco-Gutierrez et al., 2022). Participants emphasized the importance of mentors understanding their lived experiences and providing moral support and guidance. However, racial hierarchies within mentorship complicate career advancement. Verduzco-Gutierrez et al. (2022) highlighted the need for mentorship programs for women faculty with intersectional identities. Goertz et al. (2024) critiqued traditional mentorship approaches, arguing that they socialize mentees to uphold Eurocentric values of individualism, competition, and meritocracy, thus reproducing oppressive structures within the profession. They advocated for a decolonial mentoring framework to challenge racialized ideologies and question how knowledge is produced and validated.
Limitations
This study included only U.S. historical markers, norms, and values referenced in the narrative interviews concerning the social structures (as shown in Table 1, Step 7), which may have left out other relevant social practices. The reliance on eight participants’ interviews and the specific interrelation of their social identities are not meant to be generalizable to all women of color in occupational therapy or other health care professions. However, it offers an important base for studying leadership development concerning the intersection of multiple social identities and social structures, helping us to understand and address systemic barriers in daily social practices and other forms of less evident racialization, such as socioeconomic status, disability, and sexual orientation. Thus, further research is warranted.
Implications for Occupational Therapy Practice
Although diversity, equity, inclusion, justice, accessibility, and belonging (DEIJAB) initiatives are essential, they are insufficient without systemic transformation. Our findings support previous research, with the following practice implications to foster antiracism within leadership development in occupational therapy: Equip the workforce to recognize, question, and address systemic inequities across education, research, and practice while dismantling biases to prevent unintentional othering and complicity in exclusionary practices. Advocate for and implement policies that promote inclusivity, accountability, and respect, ensuring that workplace environments actively counteract systemic racism. Nurture mentorship programs and networks that intentionally support underrepresented practitioners and students, enabling equitable access to professional growth opportunities. Hold organizations accountable for building antiracist values into their actions, advocacy, and community work.
Conclusion
This study highlights how systemic practices shape leadership for women of color in occupational therapy, underscoring the need for systemic change to create equitable pathways to leadership. Although DEIJAB initiatives are crucial, they must be accompanied by a commitment to dismantling structural power dynamics and fostering an inclusive and equitable professional environment. By addressing these systemic issues, the field of occupational therapy can move toward a more just and inclusive future in which all individuals can thrive and lead. This requires a multifaceted approach involving changes in organizational culture, mentorship practices, professional development, and education systems.
Footnotes
Acknowledgments
We acknowledge the use of artificial intelligence (AI) language models to assist in summarizing and editing the content of this article. We both reviewed the use of all AI-generated content. All original research, analysis, and conclusions presented in this article are our work.