essay on discrimination in nursing

Recognizing history of Black nurses a first step to addressing racism and discrimination in nursing

PhD Candidate, Nursing, Dalhousie University

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Keisha Jefferies receives funding from Vanier Canada Graduate Scholarship, Killam Trust, Research Nova Scotia, Johnson Scholarship Foundation and Dalhousie University.

Dalhousie University provides funding as a founding partner of The Conversation CA.

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During the coronavirus pandemic, nurses are among the nation’s front-line workers. Over the years and to this day, the contributions of Black nurses are hard-fought, unrecognized and under-appreciated.

Nurses are essential in care delivery, policy directives and in shaping the health-care system. The year 2020 is the year of the nurse and midwife . Yet, Canada’s history of racism and segregation has contributed to residual anti-Black racism that remains present in Canadian nursing.

Nursing, as a profession, was established on Victorian ideals of “true womanhood” , including notions of dignity, purity, morality and virtue . Think: white caps and pristine white smocks.

Historically, people who did not meet these “ideals” were prevented from practising nursing. It was believed that Black women did not possess these ideals of “true womanhood” and in turn, were prevented from pursuing nursing as a career . Many of these unconscious biases and stereotypes about nursing are still believed today, with evidence showing that the exclusion of Black folks and anti-Black practices persist in nursing.

Beginning with oppression

In Canada, the first nursing training facility opened in 1874 in Ontario. The first baccalaureate nursing program started in 1919 at the University of British Columbia .

Moving Beyond Borders , Karen Flynn’s 2011 account of the racial segregation in Canadian nursing, vividly describes the experiences of Canada’s earliest Black nurses.

As Flynn notes, Black folks were not permitted to attend nursing programs. Instead, prospective Black nurses in Canada were told to go to the United States . American schools began allowing Black folks into nursing in the 1870s while Canada continued to restrict admissions to Black folks until the 1940s, granting admission only after pressure from community groups and organizations.

Ruth Bailey and Gwennyth Barton were the first Black nurses to earn a nursing diploma in Canada from the Grace Maternity School of Nursing in Halifax, graduating in 1948 — almost three-quarters of a century after the first school opened .

Black nurses in Canada

Overall, Black nurses are largely absent from leadership positions and specialty practice areas such as intensive care. Instead, Black nurses are often streamlined into areas that are more physically demanding and strenuous . At the same time, Black people are concentrated in entry-level positions, non-specialty roles or in non-licensed clinical roles such as personal care workers .

Beyond physical challenges and visibility , Black nurses are subjected to micro-agressions and racism from patients, colleagues and superiors.

Gender and class have a substantial impact on Black women nurses with the nursing profession having successfully racialized gender and class discrimination . Men who enter nursing usually ride the glass escalator: leadership, higher wages and other substantial advantages .

It’s a marked contrast to Black women who do not encounter a glass ceiling but rather they hit a concrete wall from simultaneous racism and sexism; their existence is invisible, yet their mistakes and flaws are amplified .

Racism reinforced through nursing education

In 2013, I proudly graduated from a nursing program with more than 10 Black soon-to-be nurses. At that time, there were designated seats for qualified Black applicants resulting in a 100 per cent increase in enrolment for Black students .

After the removal of these designated seats, the program now graduates far fewer Black nurses each year. I hear similar findings from nursing graduates at other universities. Yet, despite evidence regarding inequity amongst faculty appointments in universities, most Canadian institutions do not collect nor publish race-disaggregated data related to the student population .

Multiple barriers limit access to post-secondary education for Black students. However, issues within nursing education go beyond admissions.

Considering what is taught in nursing school, we see stark examples of anti-Black racism embedded within a curriculum that not only reinforces the invisibility of Black nurses but also exacerbates health inequities.

What is taught is largely void of the contributions to nursing made by Black pioneers. For example, nurses are not taught about Bernice Redmon, who was refused admissions to Canadian nursing programs, trained in Virginia before returning to Canada in 1945. Redmon became the first Black nurse appointed to the Victorian Order of Nurses in Canada .

The nursing curriculum continues to be riddled with colonial, anti-Black, heteronormative and hegemonic content . For most of nursing’s history, aspiring nurses have been taught how to care for white, straight and gender-binary patients. If this is not you, even a routine hair, skin or health history assessment can pose a challenge .

Anti-Black racism in nursing is detrimental to Black nurses and to the health of all Canadians, especially since Black folks suffer from high rates of chronic illnesses including diabetes, high blood pressure and mental illness . These health inequities are worsened by an undertone of mistrust towards a health-care system that does not have health-care workers who look like you nor who understand your health needs — leading to misdiagnosed or undertreated conditions .

Read more: Study: Racism shortens lives and hurts health of blacks by promoting genes that lead to inflammation and illness

Towards an anti-racist profession

There are successful initiatives in place. The Faculty of Medicine at the University of Toronto has made great strides in combating anti-Black racism through the Black applicant stream and the collection of race-disaggregated data.

At the Dalhousie Schulich School of Law , a successful program established in 1989 has increase the representation of indigenous Black and Mi’kmaq students in the legal profession. Select universities, like Dalhousie, offer entrance scholarships for Black students as a means to alleviate financial barriers.

Nursing can learn from these bold, innovative ideas and work towards adopting anti-racist frameworks in education and practice. This begins by actively recognizing, appreciating and celebrating Black nurses and their contributions in nursing.

Despite the persistence of anti-Blackness in society, nursing education and health care, Black nurses continue to provide care. Now, more than ever, we must recognize and celebrate their contributions.

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How Nurse Leaders Can Address Discrimination in Nursing

February 22, 2021

View all blog posts under Articles | View all blog posts under MSN Post-Master's Certificates

A nurse is measuring a man’s blood pressure.

Just how prevalent is the problem? In a recent PLOS One study, 40 percent of nurses who responded reported experiencing discrimination in healthcare settings.

Discrimination in nursing not only affects the ability of healthcare facilities to provide optimal patient care. It also perpetuates health disparities. For this reason, nurse leaders need to develop and promote strategies that combat discrimination in healthcare settings. Programs, such as online post-master’s nursing certificates , offer nurse leaders opportunities to build the expertise needed to tackle discrimination and other issues that exacerbate inequalities in healthcare.

What Are Examples of Discrimination in Nursing?

Discrimination in nursing involves unfair or unjustified treatment that can harm individuals’ careers and their health. It can occur at the institutional level, when a healthcare organization’s policies curtail opportunities or adversely impact the well-being of certain groups. It can also occur among individuals, such as when negative interactions between nurses and patients are based on gender or racial stereotypes.

Regardless of intention, and whether perceived or not by individuals, discrimination in nursing carries a host of unwelcome consequences. Nurse leaders may observe several types of discrimination in health settings, including the following:

Gender discrimination
LGBTQIA discrimination.

Discrimination Among Nurses

Discrimination exists among nursing peers. Nurses may experience acts of discrimination from other nurses who hold ignorant or prejudiced attitudes and beliefs about one or several of their personal characteristics. They may make injurious assumptions about their skill level or knowledge as a nurse based on factors such as their age, country of origin, or gender.

Discrimination between nurses can manifest in the form of overt bigoted behavior, such as the use of racial slurs, or it can be expressed more subtly through microaggressions. Microaggressions — actions and comments that communicate a bias against a marginalized group — demean, invalidate and slight their targets. Examples of microaggressions include a nurse telling a nonwhite, U.S.-born colleague, “You speak English very well,” or a nurse ignoring the opinions and comments of nurses from particular backgrounds.

Discrimination creates a hostile environment that jeopardizes cooperation between healthcare professionals and diminishes trust and communication among the staff. Such things interfere with the delivery of quality patient care. For example, nurses with biases may ignore or fail to effectively communicate with other nurses, leading to preventable and sometimes critical errors in care.

Discrimination Involving Nurses and Patients

Discrimination also occurs between nurses and patients. Nurses may hold stereotypes about patients that impact the care they deliver, while patients may hold prejudicial views about nurses that cause them to mistreat those charged with their care.

The Impact of Implicit Bias on Patient Care

Implicit biases in nursing can lead to a host of unfortunate outcomes for patients such as the following:

Insufficient patient assessments
Incorrect diagnoses
Inappropriate treatment decisions
Decreased time spent inpatient care
Inadequate patient follow-up after discharge

Additionally, numerous studies have found that patients who perceive discrimination in their treatment often disengage from healthcare and treatment in some of the following ways:

They delay getting prescriptions or medical care.
They are less likely to adhere to medical recommendations.
They use preventive services less.
They miss more appointments.

Patient Discrimination Against Nurses

Nurses can experience overt discrimination by patients such as an outright refusal of any care from them because of their backgrounds. More subtle discriminatory experiences might involve patients assuming registered nurses are medical technicians because of their ethnicity, race, religion or other characteristics.

These experiences do emotional harm to nurses and add stress to an already challenging job. Excessive stress can lead to health issues including hypertension and depression. Such experiences also create ethical conflicts for nurses who have a responsibility to care for patients but also have a duty to not give treatment against a patient’s will.

Racism in Nursing

Racism has a profound effect on nursing care. While nurses have a history of advocating to redress inequities in practice, teaching and research, racism nevertheless persists and demands attention on both an individual and systemic level.

Systemic Racism in Nursing

Many ingrained policies and practices in healthcare organizations put people of color at a disadvantage. Some norms and ways of conducting business perpetuate inequalities between racial groups and give privileges and access based on race to some individuals while denying them to others.

A recent study published in the journal Science found racial bias in an algorithm widely used by healthcare systems. The algorithm, which is used to make decisions about patient care, significantly underestimates the needs of sick and chronically ill Black patients, while giving preferential treatment to the needs of white patients.

Dismantling structural biases first requires identifying them. This demands critically evaluating the ways in which healthcare organizations operate, and initiating inclusive conversations throughout an organization to weed out practices that perpetuate racial bias.

Discussions should explore the many ways healthcare professionals are prevented from delivering equitable care to patients of color. They also need to address the structures in place that act as barriers to nurses of color trying to advance their careers.

The Impact of Systemic Racism in Nursing and Healthcare

The health disparities between white and nonwhite patients speak to the profound impact of systemic racism in healthcare. One notable example involves infant mortality. According to the Office of Minority Health, Black babies die at twice the rate of white babies.

Moreover, adjusting for socioeconomic factors does not eliminate this gap in infant mortality. Numerous studies have shown that the infant mortality rate of Black babies born to educated black mothers from middle-class backgrounds is markedly higher than that of white babies born to white mothers who haven’t graduated from high school.

Historically, Black patients have received inequitable medical care and lacked access to the best healthcare facilities. This problem persists. A recent study in the International Journal of Health Services found that healthcare facilities serving mostly people of color receive about half the funding for new equipment and updates compared to hospitals mostly serving white patients. As a result, patients of color often have limited access to the latest technologies and treatment methods.

The Impact of Systemic Racism on Nurses of Color

The dearth of people of color in leadership roles in nursing attests to ongoing systemic racism in nursing.

According to the most recent study by the American Hospital Association’s Institute for Diversity and Health Equity, people of color hold only a small percentage of healthcare leadership positions:

9 percent of healthcare CEO positions
11 percent of executive healthcare positions
19 percent of first level and midlevel healthcare management positions

The study also found that Black and Latinx individuals earned less than their white counterparts.

Clearly, structural racism significantly impacts the earning power and career opportunities of nurses of color.

Racist Attitudes from Nurses and Patients

Beyond dealing with structures that exclude them from advancing in their careers, nurses of color routinely confront racism from their peers and patients.

Colleagues and patients doubt their competency, devalue their opinions and actively mistreat them. Experiencing such treatment can chip away at a person’s well-being and harm patient care.

Ageism in Nursing

According to a 2018 national survey conducted by the Health Resources and Services Administration almost half of nurses are over age 50. Despite making up a critical part of the workforce, however, these nurses often face discrimination based on their age.

Unfounded assumptions about their cognitive abilities and stamina have led many to undervalue and underestimate the contributions of older nurses. Additionally, as healthcare facilities try to maximize profits and cut costs, they often view older nurses as an unnecessary expense. As such, many older nurses are unwillingly pushed into early retirement.

Conversely, recent graduates from nursing programs may also face age discrimination, with peers and supervisors holding biased views about their readiness and ability to confront the job’s challenges.

Whether directed at the young or old, ageism has no place in nursing. Not only does it harm individual nurses, it also damages the nursing profession as a whole. Undervaluing and underestimating nurses because of their age undermines the healthcare delivery process and compromises patient care.

Examples of ageism in nursing include the following:

Pay discrimination
Assumptions that older nurses cannot keep up with changes in technology or medications
Perceptions that older nurses are too frail to safely handle patients

The Impact of Ageism on Nurses

Ageism has serious consequences for nurses as it affects their financial security, career growth and self-esteem.

Age discrimination in nursing often results in the denial of job opportunities to qualified candidates. Though it’s illegal, proving ageism is difficult and may occur before nurses are hired. When reviewing résumés, healthcare organizations can use graduation dates to decide who gets interviewed. This prevents both younger and older nurses from securing work and higher pay. It also creates career stagnation.

The discriminatory practice of pushing older nurses into early retirement can hurt them financially. It may leave them with no other choice but to draw on their Social Security early if they have no other means of income. However, collecting Social Security before full retirement age means permanently reduced benefits, up to 30 percent less.

Finally, for nurses who have devoted their lives to caring for patients, age discrimination is a painful blow. Being cast aside can leave older nurses feeling depressed and abused. Additionally, treating nurses with a lifetime of experience as mere financial burdens or second-guessing their professional competency robs them of their dignity and disrespects their contributions.

The Impact of Ageism on Nursing Care

Age discrimination not only hurts nurses. It hurts patients. Ageism against nurses impedes a healthcare organization’s ability to deliver quality care, while ageism against older patients can easily interfere with the ability to deliver proper patient care and assessments.

Ageism Against Older Nurses Compromises Patient Care

Older nurses play a vital role in healthcare delivery. In fact, their knowledge and experience often mean they have superior judgment when it comes to patient care.

Having nurses of diverse ages allows for the formation of critical mentoring relationships. Older nurses help teach less experienced nurses the ins and outs of the job and train them invaluable skills that benefit patients.

Too much responsibility on the shoulders of novice nurses not only creates burnout; it results in preventable mistakes. The collective knowledge and support of older nurses helps provide invaluable guidance. It also maintains balance in the work environment.

Ageist Attitudes Impede Quality Care

Ageist attitudes and stereotypes can affect both the quality and quantity of care older patients receive, which can negatively impact their health.

Evidence suggests that many clinical decisions made about older patients are biased. For example, studies have found older patients are less likely to get the same care as younger patients in areas that include the following:

Getting referred for surgery (even in cases when recovery outcomes aren’t age-dependent)
Being treated according to treatment guidelines
Receiving standard diagnostics

Ageist attitudes not only affect treatment decisions, they also influence how nurses communicate with older patients. When nurses hold ageist attitudes, they tend to do the following:

Relate to patients with more detachment
Use a patronizing tone with patients
Forego patient consultations
Have low expectations for patient rehabilitation

Gender Discrimination in Nursing

Society has ingrained gender stereotypes that have affected and continue to affect the professions people enter. Attributing self-confidence, strength and rational thinking to males has pushed men into leadership positions. Perceptions of females as nurturers and caretakers has relegated women to less prestigious work.

Since modern nursing began, women have dominated the profession. That’s partly because historically people have thought of nursing as almost an extension of domestic work, viewing nurses as little more than doctors’ assistants. To many, these implied women were best suited for the job.

Gender bias and other stereotypes — including the notions that men don’t possess caring or nurturing traits and women belong in subservient positions — have distorted perceptions of the profession and who can be a nurse.

Today’s nurses are a far cry from doctors’ helpers. With specialized knowledge based on extensive training, nurses have many duties independent of physicians and perform tasks that require advanced medical expertise. Nevertheless, gender stereotypes and misconceptions about the nature of nursing persist, perpetuating the problem of gender discrimination in nursing.

The Impact of Gender Discrimination in Nursing

Gender discrimination in nursing manifests in several ways. First, it unfairly excludes and marginalizes people. Though the number of nurses who are male has increased significantly in recent years, women still greatly outnumber men in the profession.

According to the U.S. Bureau of Labor Statistics, in 2019 men accounted for a small percentage of nurses:

11 percent of registered nurses
12 percent of nurse practitioners

Men who enter nursing training programs and secure nursing jobs may experience gender-biased comments or find their sexuality or masculinity questioned. Additionally, nurses who are male may feel discouraged from pursuing subspecialties in nursing that are thought of as less technical, and therefore less masculine.

Such gender biases have consequences for nurses who are female as well. They can easily result in supervisors overlooking women for leadership positions and assigning women to positions less likely to result in promotions.

Among the most unfortunate consequences of gender bias is the compromise of the nursing profession as a whole. By associating nursing with femininity, it wrongly links gender to the work. This perpetuates misconceptions regarding the level of professionalism among nurses and diminishes its value.

Historically, professions dominated by women have received less respect, lower salaries, and less authority than other professions. Perpetuating gender biases in nursing fuels outdated perceptions that nursing is little more than a subservient role, requiring only soft skills and compassionate nature. In fact, nurses are highly skilled professionals with in-depth clinical knowledge who perform vital, lifesaving work.

Ultimately, preconceptions about nursing roles and duties undermine the authority of nurses and inhibit their ability to pursue leadership and autonomous roles.

How to Combat Gender Discrimination in Nursing

Nurse leaders have a responsibility to combat gender discrimination in nursing. By exercising their leadership and interpersonal skills, they can help minimize gender discrimination among nursing staff.

First, nurse leaders need to learn to recognize their own potential gender biases. They can do this by reflecting on the experiences of nurses who are male, transgender and binary to become more sensitized to the incidents of gender bias they may encounter. They can also analyze their expectations of nurses who are female. Perhaps they will discover they expect more caring and collaborative behavior from them compared to nurses who are male.

Beyond increasing their own awareness, nurse leaders should initiate conversations with their staff about gender discrimination in nursing, discussing how it presents in both subtle and overt ways and using specific examples. This makes identifying bias, a first step to eliminating it, easier for nurses.

Strategies to Tackle Gender Discrimination in Nursing

Nurse leaders must set the right tone to tackle gender discrimination in nursing. This requires prioritizing gender equality and acting decisively in response to gender discrimination when it appears.

For example, nurse leaders need to address microaggressions, ignored opinions and inappropriate comments when they happen. Though such conversations can be uncomfortable, they offer everyone a chance to develop awareness and learn. They also make it cear that gender discrimination will not be tolerated.

Because words have power, careful use of language is an important tool for dismantling gender discrimination. By eliminating gender-biased terms, such as “male nurse,” nurse leaders help discourage people from associating gender with the profession.

Rebranding nursing as gender-neutral lends legitimacy to the profession and discourages discrimination by expelling gender-driven assumptions about nurses.

The Importance of Diversity in Nursing Leadership

Patient populations represent a wide assortment of ethnicities, nationalities, sexual orientations and religions. Having nurse leaders who reflect that diversity plays an important role in combating discrimination in nursing and providing the highest quality care to every patient.

The contributions of nurse leaders enrich discussions and lead to more deliberate strategies and thoughtful decisions. With a diverse spectrum of races, ages and genders in nurse leadership professions, a healthcare facility broadens its perspective on patient care, clinical operations and community outreach.

Diversity in Nursing Leadership Promotes Cultural Competence

To meet the needs of diverse patients, healthcare facilities must build cultural competence — the ability to interact respectfully and effectively with people from different backgrounds. Cultivating competence improves the quality of care nurses deliver and helps to alleviate health disparities.

Diverse nurse leaders are well-positioned to promote cultural competence within their staff. They have deeper insights into the beliefs, values and perceptions of diverse patient populations. This enhanced understanding equips them to provide valuable guidance and understanding to other nurses, allowing them to develop their cultural competence.

Acknowledging and appreciating the differences between patients regarding their priorities in healthcare helps eliminate miscommunications and heightens the collaborative effort with patients. While improving patient care, this also helps prepare nurses to respond to potentially hostile situations with patients who discriminate against them because of their race or gender.

Additionally, the improved communication that diversity in nursing leadership fosters offers a more welcoming environment to patients. Approaches to care that take into account the differences between patients allow for smoother interactions between patients and providers. For example, having practices in place that deal with diversity in language or religion helps patients feel more comfortable and gives them a greater sense of belonging.

Diversity in Nursing Leadership Breaks Down Stereotypes

Promoting diversity in nursing leadership can play an important role in breaking down barriers such as gender biases and discrimination in nursing.

Nurse leaders from diverse backgrounds can help their staff identify their biases and change bad behaviors. They can also help their staff become more attuned to the needs of various populations, more effectively listen to their concerns and make better suggestions about their care as a result.

Additionally, patients from diverse backgrounds with histories of discrimination in healthcare may feel reassured when they see people who look like them in leadership positions. Improved trust between patients and providers can have a meaningful impact on health outcomes and help lessen health disparities.

Unified Care for the Future

Nurse leaders strive to meet the needs of all patients. Cultivating diverse nursing staffs and minimizing biases and discrimination in nursing play an instrumental role in meeting patients’ needs. With the right education and expertise, nurse leaders can strategically tackle one of healthcare’s greatest obstacles.

Discover how Duquesne University’s online post-master’s nursing certificates prepare nurse leaders to reach their professional goals and combat health disparities.

Nursing students’ experiences of educational discrimination: a qualitative study

Zahra Hadian Jazi 1 ,
Kazzem Gheybi 2 ,
Zahra Zare 3 &
Hooman Shahsavari 4

BMC Nursing volume 21 , Article number: 156 ( 2022 ) Cite this article

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Metrics details

Although the need for justice and the elimination of injustice (or discrimination) is now a universally accepted principle, discrimination is still an unpleasant experience for many nursing students. This study aimed to explain the experiences of nursing students of educational discrimination and find out the main factors that cause this feeling.

This is a qualitative study conducted in the nursing faculty of Shahr-e-Kord and the Iran university of medical science (IUMS) in Iran. Twelve nursing students were selected by purposeful sampling method and data were collected through face-to-face and in-depth interviews with semi-structured questions. All interviews were analyzed according to the content analysis method.

Three main themes and ten subcategories appeared. Extracted themes include: "inappropriate behavior of nursing professors (or instructors) " with 3 subcategories (1- discriminatory behavior by nursing professors (or instructors), 2- lack of sufficient self-confidence in nursing professors and transferring it to the student, and 3- the educator role in motivating or eliminating motivation); "Strict rules" with 3 subcategories (1- inequality in implementation of rights and rules among students of different disciplines, 2- differences in compliance with laws and regulations, and 3- nurses are being strictly monitored), and " Lack of nursing professional independence " with 4 subcategories (1- lack of authority, 2- lack of supportive organizations for nurses, 3- lack of proper social status of nursing in society, and 4- the high authority and power of physicians over other disciplines).

Conclusions

In our study, it was shown that nursing students feel the most discrimination in front of medical students. Feelings of discrimination reduce self-confidence in nursing students. Therefore, nursing educators and professors must think of a solution, or at least they should not cause this feeling in them through inappropriate behavior and discriminatory speech and words.

Peer Review reports

Achieving professional values of nursing is a prerequisite for resolving conflicts, improving the quality of nursing care services, and increasing nurses' job satisfaction [ 1 ]. The core values accepted and endorsed by the American College of Nursing Associations (AACN) (1998) include human dignity, honesty, autonomy, altruism, and social justice, with social justice gaining so much attention in recent years. AACN defines social justice as fair treatment regardless of economic status, race, ethnicity, age, nationality, disability, or sexual orientation [ 2 ]. In fact, social justice, equitable distribution, facilities and resources for all people in a society is an abstract ideal that widely uses the concept of justice. But social injustice, is an incompatibility between what is and what should be. Edmond Cahn (1949) describes this concept as an emotionally charged structure that evokes anger, panic, shock and resentment .It prepares the humans or animals to resist attack. Social injustice, aroused by emotions arising from ethical cognitions about right and wrong, can motivate individuals, groups, and nations to take action, including violence and war, to correct perceived mistakes. [ 3 ].

Unfortunately, the issue of injustice or discrimination between the nursing and medical professions has always been accompanied by serious doubts and concerns [ 4 ]. The response of nurses to injustice is not always appreciated [ 5 ]. Indeed, physicians and nurses are considered the cornerstone of the healthcare system and their capabilities have a profound and important impact on the quality and efficiency of the medical system. Fair and non-discriminatory behaviors between physicians and nurses can increase job motivation, quality and satisfaction, and ultimately improve patient care [ 6 ]. Although in recent decades several quantitative and qualitative studies have been conducted to establish the concept of social justice among nursing graduates [7-10], it seems that academic nursing education has not been successful in this issue as Hosseinzadegan et al., (2021) in his studies indicates that lots of nursing students (in Iran) feel discrimination in both theoretical and practical courses [ 11 ].

Proper education plays a major role in educating justice-seeking nurses. Social justice and its importance in health care are among the nurses' curricula. Further attention to this issue in the practical and objective fields of education by educators can affect the thoughts, attitudes, and behaviors of students to pursue justice in health systems. However, unfortunately, the Iranian education system has failed to promote justice due to insufficient educational content, limited qualifications of nursing educators, and inappropriate educational approaches [ 11 ]. Given the importance of this issue, a qualitative approach was done to adopt a deep understanding of nursing students' experiences of educational discrimination. Therefore, the purpose of this study was to explain the perception and experiences of nursing students of educational discrimination and finding out the main factors that cause this feeling in nursing students in Iran.

Because the concept of discrimination in nursing students is an unknown subject with different dimensions and causes, a descriptive and qualitative method was chosen to gain knowledge on participants' perceptions of the experience of discrimination. Therefore, qualitative methodology and content analysis method were used to better answer the question. Qualitative content analysis is a suitable method for analyzing written, verbal or visual messages that, among other qualitative methods, is not dependent on a specific philosophical point of view and therefore helps the researcher with sufficient flexibility in advancing their study [ 12 ].

Participants were selected by purposive sampling [ 13 , 14 ] and those who could best enhance researchers' understanding of the phenomenon were employed. Inclusion criteria were: 1- Being nursing students (because the purpose of the study was to examine the experience of discrimination among nursing students); 2- Being the second to fourth year of bachelor, because in the first year they may have less experience of discrimination. It should be noted that Shahr-e-kord School of nursing had only a bachelor's degree at the time of the study; And 3- After explaining the purpose of the study, have informed consent to participate in the study. Researchers contacted students interested in participating in the study and made arrangements the time and place of the interviews with them, and if a student was reluctant to conduct the interview despite the previous announcement or did not wish to his information and experiences were mentioned in the study was excluded at any time of study.

Due to the qualitative nature of this study, the sample size was not determined before data collection. Therefore, the number of participants was decided based on the information collected. The end point or data saturation came when the new interviews did not provide additional information to the concept of purpose in the study. The analysis was performed simultaneously with data collection.

Participants included 12 undergraduate nursing students studying at Shahr-e-kord and Iran universities (in order to observe maximum diversity in the selection of participants).

Participants were first contacted and after explaining the purpose of the study, the date of the interview was determined. Data were collected through face-to-face and in-depth interviews with semi-structured questions at participants' favorite locations. Notes and field observations complemented the interviews. At the beginning of the interview, the interviewer asked a few introductory questions, followed by more specialized questions about the experience of discrimination. The interviews lasted about 40 min to an hour by one of the authors (ZH).

In this type of research, the text of the interviews is reviewed several times to be broken down into the smallest constituent and meaningful units (theme). After making a list of themes, and reviewing these words to clarify the similarities in their concept in order to place them in a subcategory based on the axis found between the themes, the same subtraction and inductive flow of the subclasses continued. These reviews, the sliding of the layers on top of each other, and the merging between the initial writings and the final classifications are repeated several times that the researchers eventually reach an acceptable stability between the data and a sense of satisfaction about the classes and subclasses [ 13 ]. Before the interviews, the participants were informed of the purpose and method of study, and researchers gained written informed consent from each participant and also researchers assured the participants that their personal information would be kept private.

In this study, Lincoln and Guba (1994) trustworthiness criteria was used [ 14 , 15 ]. Therefore, in order to ensure the validity and scientific accuracy of the data, we used more than one method to collect data (such as field notes and interviews). Maximum diversity sampling (selection of participants from 3rd to 8th semester undergraduate students from Iran and Shahr-e-kord universities) was also applied. Long-term engagement with participants and reviewing interviews before analyzing them, reviewing and modifying the codes several times, reviewing the codes with all members of the research team, and with the participants. The recorded interviews were analyzed by the researchers (ZH and HSH) according to the qualitative content analysis method and using the MAXQDA version 10.

Twelve undergraduate nursing students participated in this study. The mean age of participants was 21 years (19 to 24 years). Sixty-six percent of the participants were girls and 34% were boys. Seventeen percent of the students were second-year (semesters 3 or 4), 58% were third-year (semesters 5 or 6) and 25% were fourth-year (semesters 7 or 8). Because the main interviewer of this study was in the Shahr-e-kord university, 65% of the participants were selected from Shahr-e-kord university and 35% from the university of Iran.

Participants in this study shared their experiences of educational discrimination. During data analysis, three themes and 10 subcategories appeared. The extracted themes and classes focus on the reasons that are caused nursing students to feel discrimination, which is described below (Table 1 ).

Theme 1: inappropriate role of nursing professors (or instructors)

Discriminatory behavior by nursing professors (or instructors).

In this regard, many students considered the reason for the feeling of discrimination is the behavior of their professors with students who are all on the same level in terms of seniority (both in the field of teaching theory and in the field of clinical education in the hospital). Regarding this theme expressed one of the participants:

“At the beginning of the classes, after entering to the nursing faculty, the professor said: You had a very bad last year and you were not successful at all, and it made you come to a field (nursing) that is not a good job for your future at all …". Because one of his own children is studying medicine. (Participant two).

Some students believed that the behavior of professors in the theoretical and clinical classes was different and sometimes even contradictory. For example, a student said, "it is written in nursing textbooks that a nurse should first, have a strong relationship with the patient so that he or she is comfortable. So, the lessons and rules give us that authority. but I personally went up to one of the patients and greeted him warmly. Then the professor came and said why did you become intimate with the patient? … Go very formally, ask questions and come back …." (Participant two).

Lack of sufficient self-confidence in nursing professors and its transfer to the student

Many students believed that their instructors do not have enough self-confidence and authority in the internship environments and show weakness in the face of medical students and their professors, which cause others to dare to discriminate between nursing students and other disciplines. In this regard, a student said:

" If a fellowship comes in the patient’s room with their students, our instructors tell us -in front of the medical students- to go out and we will come back later. They tell us not to argue, the room is for them (medical students) (Participant eight).

Another student said:” It is upsetting that if while we’re using a classroom and medical students also want to use the room, they have the authority to make us leave the class, and our instructor is not so confident to not let this happen! “(Participant seven).

The educator role in motivating or eliminating motivation

Students stated that instructors have an important role in motivating students and make them to work and study more enthusiastically, but unfortunately in many cases they are being compared with medical students and this causes them to lose motivation and self-confidence to continue their education and feel ashamed of being a nurse.

In this regard, a student said: "We were in the second semester … Our professor told us, what field would you like to learn more about? Ask me some questions about it. Some students said that we would like to know more about pharmacology, so that if a doctor ordered a medication, and we thought that the medication interfered with another or it was not appropriate, we could mention it to them or we would like to be so good to know what is good for the patient now and to do it ... The instructor said: you never can do that... (Participant seven).

In addition, another student said, "One of the professors said: each of you who does not like nursing has to go and study medicine. I think medicine is much better!' (Participant five )

Theme 2: Strict rules

Inequality in supervising and implementation of rules among students of different disciplines.

Violation of the rules by medical students and failure to deal with them, lack of supervision of medical students, excessive supervision of nursing students, failure to comply with the rules in the field of medicine, etc. were cited by many students as a source of discrimination. For example, a student described his experience of discrimination in this regard: "There is no rule for medical students. There may be rules, but there is no supervision on them. They go to the hospital anyway they want. Sometimes they do not even wear a uniform"(Participant five).

Differences in compliance with laws and regulations

The participating students believed that the level of compliance with university rules and regulations and the clinical environment of hospitals were not the same simply because the disciplines were different. A student considered the extent of compliance with hospital rules and regulations not only in their dressing code, but also in the hospital's clinical regulations and communication with the patient, saying: "For example, a medical student can talk to patients in any way they want and they have the right to treat the patient as they wish, but if nursing student greet warmly with patients, they will face punishments from their staff and trainers" (Participant two).

Nurses are being strictly monitored

The students stated that so many rules and regulations for nurses and nursing students have been defined in detail and that non-observance of them has bad consequences that it seems that this group is under a microscope! One student described his experience as "from the very beginning there are certain rules for nursing that do not exist for any other field. For example, the length of the uniform should be that inches below the knee or be so loose; pants should not be jeans at all; the fabric of the pants should be either black or blue, etc.… Everybody can understand from the student's appearance what field they are, nursing or medical?! "(Participant two).

Another student said, "Doctors are not strict at all, and that in itself is discrimination" (Participant six).

Theme 3: lack of nursing professional independence

Lack of authority.

Doctors' interference in nurses' affairs and nurses' non-objection, being dependent on the doctor, reducing the quality of nursing care due to the nurse's unquestioning obedience to the doctors, etc., were all points that student mentioned and will eventually lead to feelings of discrimination.

One student said: "if nurses object to the doctors, in many cases, it has very bad consequences for them, so look, we do whatever they say... and whatever the doctor orders, we do... and what does this mean? It means that the genius of the nurse goes blind "(Participant seven).

Lack of supportive organizations for nurses

The students said that another factor that causes nursing to lack a proper professional independence and as a result suffer a lot of discrimination from others, are their lack of support for each other.

In this regard, it can be attributed to factors such as the feeling of futility of nursing liability insurance, lack of defense support for the nurse, consider a low worth of the nurse's work even in the nursing system, different behavior of even nursing staff with nursing students in front of medical students, not appreciating the work of nursing students, etc.

A student complained about the behavior of nursing staff towards nursing students, saying, "Even nursing staff do not respect us, they don’t consider us as their future coworkers" (Participant four).

Lack of proper social status of nursing in society

Students consider that one of the things that causes discrimination is the lack of a proper social position for nursing in society and the view of all people. Regarding the role of the media in creating a negative attitude towards the nursing profession, one student said: "In TV movies, nurses are always changing sheets, or saying yes to doctors’ orders...! Or even in the novels I read the doctor is always in a superior position, but the nurse always is insulted! these things change the people’s attitudes towards nursing” (Participant nine).

The same student commented about the negative attitude of people in the community, including patients, towards nurses: "It means that when you tell patients that I am a nursing student, they will not answer you anymore ... but if a doctor comes, everyone will respect them" (Participation nine).

The high authority and power of physicians over other disciplines

Another factor that has reduced the authority and professional independence of nurses is the high authority of medical practitioners in the Iranian society, which has led to a sense of superiority over other disciplines. A student said: “I heard it myself that a nursing supervisor objected to an intern medical student. But what happened eventually?... The nursing supervisor went to the head of the hospital and apologized" (Participant seven).

Or another student said: "A nurse in the hospital cannot show genius and creativity in any way; even if it is true, the head nurse or the supervisor says: how dare you to interfere in the treatment of the patient?" (Participant fifteen). " But in other countries, multidisciplinary teams are gathered including a nurse and decide for the treatment of a patient”,", he added "Such things will not happen in our society (Iran) for another thousand years! Because there is only a medical commission and they do not consider the nurse, even if she has a lot of knowledge" (participant seven)

The aim of this study was to explain the perception and experiences of nursing students of educational discrimination and finding out the main factors that cause this feeling in nursing students in Iran.

Three main themes and ten subcategories appeared. Extracted themes include: inappropriate behavior of nursing professors (or instructors), Strict rules and lack of nursing professional independence which some of more important findings are discussed in details.

,In this study, it was found that one of the factors that instigates a sense of discrimination in nursing students was the inappropriate behavior of educators and clinical instructors in the university educational environment and then in the hospital. The students stated that from the very first semesters, their professors cause nursing students to lose their motivation by comparing the field of nursing with medicine and makes them become disenchanted with their profession. In addition, many students feel insignificant in compared with medical students after entering the clinical environment. because nursing instructors discriminated against them or they were supported in front of the hospital staff. In fact, the attitudes and behavior of the instructor can play a great role in motivating a student to work in clinic setting or turn them away from their field, which in itself is closely related to the instructor's vision of nursing. Certainly, a nursing educator who believes in his profession and is passionate about nursing will also indoctrinate this interest to his students. In fact, student support by the instructor increases students' confidence and motivation, learning, professional development, and positive outcomes [ 16 ]. Therefore, according to the findings of this study, it is suggested that nursing school authorities be more careful in selecting nursing instructors and professors, and hire people who not only are impeccable academics, but are also passionate with the field. Consistent with our results, other studies showed that effective educators are important as a key strategy as well as a facilitator of education in empowering and supporting nursing students" [ 17 18 ]. In a study by Witzel et al. (2008), it was found that the support of the faculty and instructors were the most important source of support for nursing students during their studies [ 19 ]. Therefore, officials should not ignore the importance of selecting efficient, effective, and experienced nursing and instructors.

In this study, another factor that created a sense of discrimination among students was the existence of very detailed and strict rules for nursing students that made them feel that their behavior and even their physical presence were under constant control. This feeling was intensified when they saw the lack of attention and supervision on other students (especially medicine). We believe that the reason for this is the atmosphere in Iran hospitals where there is a superiority of medical practitioners. In fact, medical practitioner has a dominance in Iran healthcare system in terms of income and authority compared to other professions [ 6 ]. This monopoly, may cause many staff, especially nurses, to feel incompetent and it might affect the quality of their performance. In this regard, the study of Aiken et al. showed how the idea of being under the control of physicians has affected job satisfaction and professional identity of nurses and reduced the quality of patient care [ 20 ]. Roxburgh and his Colleagues also reported that nursing students need to feel empowered in order to efficiently study, and function in a clinical environment. This feeling is formed in an environment which the student feels belonged and supported by other nurse’s health care staff and not that only nurses have to enforce the rules and there are no rules for the rest [ 21 ]. Unfortunately, few studies have been done to compare compliance with laws and regulations between different disciplines, so this study may be a good start to address this issue.

Another issue mentioned was the lack of professional independence in the field of nursing which may instigate much of the discrimination feeling. The results of our study suggest an unconscious lack of self-confidence in nursing professors towards medical professors and students. The existence of facilities and educational classrooms available in the hospitals exclusive to medical students, involvement of physicians in matters related to nursing and even ordering and forbidding them in some issues, the lack of a proper professional position in society and among patients and other issues, all of which indicate the lack of independence and professional identity of nursing. Quoting du Toit, stated that having independence in the clinical activities of leadership and management power in the health care system, skills, critical thinking and commitment to the profession is important for the formation of a professional identity in nursing [ 22 ].

Impaired professional independence can affect the learning process of nursing students. But having a positive professional identity and independence can increase nurses' confidence in quality nursing care. However, this picture contrasts with what nurses see in practice. Nursing students often encounter professional identity problems in their own learning process. Students who do not experience a positive professional identity will experience lower self-esteem, weakened clinical reasoning skills, experienced many problems in interpersonal communication, and a sense of belonging to the nursing profession [ 23 ]. This will lead to less flexibility and efficiency when facing healthcare challenges, and being aware of these challenges and problems will be important for students' ability to learn and perform care tasks [ 23 , 24 ]. Hovere et al., Stated that the nature of nursing has not always been clear and that nurses continue to suffer from stereotyped statements about nursing. These public stereotypes can create a stressful environment in health care systems [ 25 ]. Therefore, nurses and nursing students should do a high-quality care work to improve the negative image of the profession, increase public awareness about their various roles and advanced nursing positions, and to be better seen, they can use their power through the media [ 26 ].

Implications for research/practice

The issue of justice and in contrast to injustice is a very important issue in education. This study tried to depict a corner of the feelings of nursing students who had experienced discrimination in the educational environment and its effect on self-confidence, job satisfaction, motivation and ultimately the quality of patient care. The findings of this study can be used extensively by nursing professors and educators to at least not cause this feeling in their students and avoid instigating the feelings of humiliation and frustration of nursing students in the future. In addition, professors of other disciplines and anyone involved in education can put the findings of this study at the forefront of their work and remember that all their actions, behaviors and words during theoretical and clinical teaching are carefully analyzed by students and can increase motivation and job satisfaction in the future or, conversely, cause frustration and despair.

Limitations of study

One of limitations of this study- like all qualitative studies- was the consideration of the two nursing faculties (Shahr-e-Kord nursing faculty and Iran Nursing faculty in Tehran) and two teaching hospitals in Iran. As such, it may not be a representative of the experiences of all the nursing profession members in Iran. In addition, it is highlighted that this study is based on qualitative data and thus the aim was in-depth understanding rather than reaching statistical generalization. Limitations of our study proposed the need for conducting further studies with larger and mixed groups and in different cultures.

In our study, it was shown that nursing students feel discrimination in many cases, and because most of the groups that cooperates and interacts with nurses are doctors and medical students, the feeling of discrimination particularly stems from medical practitioners and students. Feelings of discrimination in many cases cause a lack of interest and motivation to choose nursing or reduce self-confidence in students. This can negatively affect training of efficient and professional nurses for the future and cause problems for the health and treatment system. Therefore, it is necessary for nursing educators and professors to avoid causing the feeling of discrimination by inappropriate attitudes towards nursing students. More studies are required to elucidate the reasons of injustice in clinical education environment and finding a solution to this issue.

Availability of data and materials

We do confirm that all data generated or analyzed during this study are included in this published article.

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Acknowledgements

The authors of this article consider it necessary to express their gratitude and thanks to the students participating in this study who shared their experiences with us.

This study was funded by the Department of Research, Shahr-e-Kord University of Medical Sciences, Shahr-e-Kord, Iran.

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Department of Operating Room, School of Allied Medical Sciences, Tehran University of Medical Sciences, Tehran, Iran

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Contributions

Zahra Hadian Jazi: Conduct interviews with participants, Conceptualization, Methodology, Writing- Reviewing and Editing, Formal analysis. Kazzem Gheybi: Reviewing and Editing in terms of clinical aspects. Zahra Zare: Conceptualization, Reviewing and Editing, Formal analysis. Hooman Shahsavari: Conceptualization, Reviewing and Editing, Formal analysis, Supervision. The author(s) approved the final manuscript. The authors read and approved the final manuscript.

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Hadian Jazi, Z., Gheybi, K., Zare, Z. et al. Nursing students’ experiences of educational discrimination: a qualitative study. BMC Nurs 21 , 156 (2022). https://doi.org/10.1186/s12912-022-00925-y

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Thomas Kearns , executive director 1 ,
Paul Mahon , operational lead 2
1 Faculty of Nursing and Midwifery, Royal College of Surgeons in Ireland, Dublin, Ireland
2 Centre for Nursing and Midwifery Advancement, Faculty of Nursing and Midwifery, Royal College of Surgeons in Ireland, Dublin, Ireland
Correspondence to: P Mahon pmahon{at}rcsi.ie

Tackling stereotypes and assumptions that deter men from nursing is essential to meet the growing shortage of nurses and improve diversity, say Thomas Kearns and Paul Mahon

The covid-19 pandemic shows that where, when, how, and to whom care is delivered has never been more diverse. In today’s healthcare, the people delivering care must be similarly diverse, for the benefit of the profession, its practitioners, and patients. 1 2 3 Yet around 90% of the world’s nurses are women. 4 Calls are being made, as they have before, to examine ways to promote the profession among men to tackle this imbalance. 1 5

Nursing is an inherently human experience: it is done for humans, by humans, and as humans, and in human experience no one gender claims primacy. Men have had, and continue to have, a valuable contribution to make to nursing, not simply because they are male but because they are human. Men enter the profession for the same reason as women—to care for people.

Huge shortage

Nurses are often the first, and sometimes the only, healthcare provider that a patient sees, 6 making them well positioned to respond to healthcare challenges at every level. One of the key challenges affecting the achievement of the sustainable development goals of health and wellbeing, 7 is the worldwide shortage of nurses. Recruiting more men is essential to tackle this shortage.

The world faces a deficit of 13.5 million nurses in the next decade. 4 8 In its first report on the state of the world’s nursing, 6 the World Health Organization estimated that an additional six million nurses will be needed by 2030. This is a 20% increase from the current total global nursing stock of 27.9 million. In addition, the burden of anticipated retirement over the next decade means that 4.7 million new nurses must be recruited just to maintain current staffing levels. 4 It is too early to say what effect the covid-19 pandemic will have on intention to join the profession, but initial estimates are that at least a further 10% will leave. 9 Data to monitor the effect of covid-19 on recruitment and retention of nurses will be vital.

Recent changes in society, healthcare globally, and nursing have seen more men entering the profession. In general, their number varies across regions ( table 1 ) and remains stubbornly low in some countries and clinical specialties such as obstetrics. 10 The reasons for this are unclear but may include cultural perceptions of the role of men and women in society, the status of nursing itself, or the pay and conditions of nurses. For example, a higher proportion of male nurses in some countries may reflect societal perceptions of the role of women, and vice versa. Further research into this area may provide useful insights into gender equity for all.

Percentage of male nurses worldwide*

View inline

Why are men under-represented?

Contrary to the common perception that male nurses are a relatively recent phenomenon, men in nursing can be traced to 1600BC ( box 1 ). 16 History speaks of military and religious orders such as the Parabalani (“those who disregard their lives”)—a group of men who cared for people with leprosy in Alexandria in AD416, or St Camillus de Lellis, who in AD1535 vowed to care for sick and dying people. 5 12 The Maltese cross, a symbol of humanitarianism worn by the Knights Hospitaller in 1099, was subsequently adopted by the Nightingale School of Nursing in London. 14

Brief history of men in nursing

250BC: First nursing school in the world started in India. Only men were considered “pure” enough to become nurses 11 12

AD416-18: The Theodosian codes refer to the Parabolani—a group of 500 poor men who cared for the lepers of Alexandria 5 12

1095: Order of the Brothers of St Anthony founded (merged with the Knights of Malta in 1775) to care for people inflicted with the medieval disease of St Anthony’s fire 13 14 15

1099: Knight Hospitallers of St John of Jerusalem founded to care for sick and injured pilgrims en route to and from the Holy Land 13 15

1119: Order of Saint Lazarus of Jerusalem founded

1180: Order of the Hospitallers of the Holy Spirit and the Brotherhood of the Holy Spirit founded

1192: Order of Brothers of the German House of Saint Mary in Jerusalem, or the Teutonic Knights, founded

1334: The Beghards (renamed Alexian Brothers after Saint Alexis in 1469) cared for the poor, the lepers, and the “morons and lunatics” of Europe 5 14 16

1535: St John of God began studying under the monks of St Jerome and cared for the ill and mistreated

1585: St Camillus de Lellis became a priest and established a religious order, vowing to care for the sick and dying even with danger to his own life

1600s–1700s: Protestant reformation led to the closure of monasteries and convents across Europe resulting in a loss of records of organized nursing activity 14 16

1780s: Nurse James Durham (or Derham) became the first African American in the United States to practise medicine 12

1850–1950s : War began to alter nursing, and the role of men within it

1859: Florence Nightingale publishes Notes on Nursing , suggesting “every woman is a nurse”

1861–65: American civil war: more women became nurses in civilian life 12

1877: St John Ambulance Association founded (derived from the Knight Hospitallers )

1884: The Male Nurses (Temperance) Cooperation founded

1892: The Male Nurses Mutual Benefit Association founded

1888−1914: Alexian Brothers and other orders built hospitals throughout Chicago, Connecticut, Massachusetts, Missouri, New York, and Pennsylvania. Increasingly, men became nurses at their own social peril, experiencing discrimination, pay inequality, role erosion, and exclusion from formal nurse education 2 17

1914–18: American men were prohibited from practising in the US Army Nursing Corps

1919: The Nurses Act in England barred men from entering the general register. 5 11 14 15 Internationally, men found it difficult to access formal training and where they did, their training was shorter and lacked the curricular content of their female counterparts 5 15

1937: Society of Registered Male Nurses founded

1950s: Men begin to be recognized in nursing in the US, Czechoslovakia, the UK, 2 14 and towards the 1970s, in Denmark and Sweden 15

1971: American Assembly for Men in Nursing founded

By the mid-1800s as men fought and died during the Crimean, American civil, and other wars, more women became nurses. In the years after the introduction of the epochal Nightingale reforms, men were increasingly excluded from formal nurse education and eventually were barred from the English general register. 2 5 11 14 15 17

Combined with the gender based division of labor, and Victorian righteousness regarding the place of women in society, 14 15 16 18 the feminization of caring within the hierarchical male dominated medical model meant men wishing to do the dirty “women’s work” were classified as deviant, undesirable, or unable to get a “real man’s” job. As caring became devalued, more men were forced to find occupations with better pay so they could provide for their families. 16

The decline of the male nurse is a complex product of cultural, historical, economic, and political factors. In modern times, the move from the hospital based apprenticeship model of education to the tertiary setting has helped establish nursing as a profession. But rising entry requirements have not been accompanied by a corresponding increase in remuneration, making nursing a less attractive career option for men and women. In addition, gendered and inaccurate representations of nursing and male nurses limit the public’s perception and affect the recruitment and retention of men. 3 19

Men in the profession have also experienced stigmatization and have been disparately positioned as being both dominant and dominated, victimized and valorized, and of benefiting from the hidden advantages of status shield and status bonus that their gender affords. 20 21

Studies show that adverse stereotypes affect male nurses’ physical and emotional wellbeing, resulting in depression, demotivation, and in some cases their exit from the profession. 19 The perpetuation of such stereotypes and gender based labels injures the profession, preserves segregation, and stifles the pursuance of gender equality for all. 1 6 22 Moreover, they compound the shortage of nurses, limit diversity in the workplace, and deny patients of both genders a holistic caring environment. 1 5 23

What can be done?

Increasing the number of men in nursing is seen as difficult because of the erroneous perception that nursing is a female-only profession, sexist stereotypes of the male nurse being less masculine, 11 13 16 and nurses’ undervalued status and pay. Solutions are as complex as the genesis of the 200 year decline of men in nursing. There is no quick fix, and change requires political, sociocultural, and professional action. Although some solutions will be universal, ultimately each country and culture will have to determine what works best for them. Nurse leaders and politicians should offer long term, strategic solutions beyond mere marketing campaigns. 3

Better public understanding

That is not to say that marketing is not needed. Indeed, given the publicity afforded to the profession during the pandemic, now is an ideal time to set aside the nostalgic view of nursing 3 and capitalize on a contemporary civic conception of caring, competence, and capability throughout clinical settings from community to critical care.

The public has seen nurses caring for ventilated patients, using tablet computers so that family members could say goodbye to loved ones, leading covid testing centres, and innovating in practice. We have heard stories of nurses’ adaptability, resilience, determination, camaraderie, and composure. We have seen them hold patients’ hands and hold governments to account while fighting for proper personal protective equipment. This has given the public a better insight into the art and science of caring in modern healthcare, which we can build on to attract more men, and women, to the profession.

Neither patients nor the public fully understand the complexity of nurses’ work. 3 Highlighting nurses’ roles across domains of practice, registration status, and stage of career could promote a more realistic understanding, not just of men in nursing but of nursing itself. 24 Campaigns such as Nursing Now have raised the status and profile of nursing, and this momentum must be maintained. As part of this, we must de-gender and revalue caring 1 by attaining a gender balance and by continuing to advocate for better pay and conditions for nurses. 25

Better recruitment

Men enter and stay in nursing for many of the same reasons as women, and ultimately, they do so to care for patients. 24 Therefore, recruitment strategies that dispel the myths surrounding the male nurse while promoting the inherent values of nursing are needed. 10 We can look to countries with higher percentages of male nurses for direction.

For men becoming nurses mid-career, graduate entry should be an option—not just in terms of access to a place on the program but also with financial support to facilitate the uptake of that place. As countries seek to increase the number of nursing graduates, consideration could also be given to a specific allocation of places to male applicants to show that men are both missing and needed in nursing. 17 Many male nurse societies were established in the mid-1800s, and such social supports, including the provision of male role models, will help retain men in the profession.

More financial investment

WHO recommends that nursing education be considered a science subject. 6 Therefore, nursing should be afforded the status, pay, and benefits of other science and technology professions. For example, a senior staff nurse (a nurse with over 20 years’ experience) in Ireland earns just under €50 000 (£43 000; $61 000) in base pay a year whereas a pharmacist earns the same after seven years and up to €67 000 after 13 years. 26

Adequate pay and acceptable working conditions, 6 mobility, and opportunity for personal and professional advancement must underpin and be highlighted in recruitment and retention initiatives.

Confrontation of stereotypes

Stereotypical assumptions must be challenged at school and societal level in careers guidance, mainstream and social media, and popular culture so that boys know that nursing is a valid career option. 3 19 27 28 29 This will require greater intersectoral and cross government collaboration from the early years to higher education levels, 6 and for broadcasters to consider how their programming may negatively portray nursing and male nurses. We must robustly voice our objection to any outdated overtures that disenfranchise the profession and the people within it.

We must also promote professional acceptance and challenge stereotypes and assumptions in the profession itself—such as those in relation to male nurses’ sexuality, ability to care, or reasons for entering the profession. For example, the literature often refers to the “hidden advantage” of male nurses and the over-representation of men in leadership positions without examining broadly why this is so.

Although there may be many individual and institutional reasons for this “glass elevator,” including conscious and unconscious bias, hegemonic masculinity, explicit or tacit discrimination, continuity of employment, organizational gendering practices, or the personal and professional characteristics of the individual nurse, 17 30 31 such discussion conflates the problem of attracting men to the profession with the career progression of all nurses. Indeed, examining ways to empower all nurses thorough initiatives such as the International Council of Nurses’ global nurse consultants initiative will help improve health, promote gender equality, and support economic growth. 32

Continuing men’s long history in nursing

Men have a rich and varied history in nursing, a history that is somewhat lost to the last 200 years and the often misquoted preface of Florence Nightingale’s Notes on Nursing that “every woman is a nurse.” Less well quoted, however, is her full contention that “While it has been said and written scores of times, that every woman makes a good nurse I believe, on the contrary, that the very elements of nursing are all but unknown.”

The consequences of the lack of men in nursing can be considered in terms of the effect on male nurses themselves, the profession as a whole, and on the patients that nurses serve.

To increase the number of men in nursing, it is important to highlight to men their historical past and their potential future in a rewarding, contemporary career with myriad clinical, academic, and professional development opportunities. The profession must continue to lobby governments to move beyond mere platitudes and actually provide parity of pay and esteem. We must portray to the public the true scope and complexity of our professional practice, 3 and we must build a profession for all through robust policy that focuses on education, jobs, practice, and leadership.

Competing interests: We have read and understood BMJ policy on declaration of interests and declare that we have no competing interests.

Provenance and peer review: Commissioned; externally peer reviewed.

This article is part of a series commissioned by The BMJ for the World Innovation Summit for Health (WISH). The BMJ peer reviewed, edited, and made the decision to publish. The series, including open access fees, is funded by WISH.

This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/ .

Philipsen N
Jackson D ,
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World Health Organization
↵ International Council of Nurses. Mass trauma experienced by the global nursing workforce. ICN Covid update 13 Jan 2021. https://www.icn.ch/sites/default/files/inline-files/ICN%20COVID19%20update%20report%20FINAL.pdf
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↵ All Party Parliamentary Group on Global Health. Triple impact: how developing nursing will improve health, promote gender equality and support economic growth. All Party Parliamentary Group on Global Health, 2016.
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↵ International Council of Nurses. ICN says nurses’ pay and safety are gender issues at the United Nations Commission on the Status of Women (CSW65) virtual event. Press release, 22 Mar 2021. https://www.icn.ch/sites/default/files/inline-files/WS_09_CSW65_final_FINAL.pdf
↵ Health Service Executive. Health sector consolidated salary scales in accordance with FEMPI 2015 and the public service stability agreements 2013-2020 (The Lansdowne Road Agreements). 2020. https://healthservice.hse.ie/filelibrary/staff/october-2020-consolidated-pay-scales.pdf
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Research article
Open access
Published: 09 January 2020

Discrimination in healthcare as a barrier to care: experiences of socially disadvantaged populations in France from a nationally representative survey

Joshua G. Rivenbark ORCID: orcid.org/0000-0002-7120-6677 1 , 2 &
Mathieu Ichou 3

BMC Public Health volume 20 , Article number: 31 ( 2020 ) Cite this article

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People in socially disadvantaged groups face a myriad of challenges to their health. Discrimination, based on group status such as gender, immigration generation, race/ethnicity, or religion, are a well-documented health challenge. However, less is known about experiences of discrimination specifically within healthcare settings, and how it may act as a barrier to healthcare.

Using data from a nationally representative survey of France ( N = 21,761) with an oversample of immigrants, we examine rates of reported discrimination in healthcare settings, rates of foregoing healthcare, and whether discrimination could explain disparities in foregoing care across social groups.

Rates of both reporting discrimination within healthcare and reporting foregone care in the past 12 months were generally highest among women, immigrants from Africa or Overseas France, and Muslims. For all of these groups, experiences of discrimination potentially explained significant proportions of their disparity in foregone care (Percent disparity in foregone care explained for: women = 17%, second-generation immigrants = 8%, Overseas France = 13%, North Africa = 22%, Sub-Saharan Africa = 32%, Muslims = 26%). Rates of foregone care were also higher for those of mixed origin and people who reported “Other Religion”, but foregone healthcare was not associated with discrimination for those groups.

Conclusions

Experiences of discrimination within the healthcare setting may present a barrier to healthcare for people that are socially disadvantaged due to gender, immigration, race/ethnicity, or religion. Researchers and policymakers should consider barriers to healthcare that lie within the healthcare experience itself as potential intervention targets.

Peer Review reports

People within minority or otherwise socially disadvantaged groups are confronted with a multilevel web of challenges that negatively impact their health and wellbeing [ 1 , 2 , 3 ]. Among these numerous factors, research has increasingly focused on experiences of discrimination and how they may relate to individuals’ health [ 4 , 5 ]. In addition to a direct influence on health via physiologic stress pathways, experiences of discrimination are also thought to influence health indirectly via behavioral responses [ 6 , 7 ]. Indeed, a meta-analysis reported a significant association between perceptions of discrimination and health-related behaviors such as diet, exercise, sleep, or substance use [ 8 ]. However, one health-related behavior that has received comparatively less attention in its association with discrimination is the utilization of healthcare.

Individuals who have experienced discrimination in the past may be more reluctant to seek health care, as they may perceive it as a setting of increased risk for discrimination (i.e., refusal of service or lower quality of care). This may be especially true for those who have experienced discrimination within the health care setting itself. Prior work has hypothesized that experiences of discrimination within the healthcare setting may have a negative effect on individuals’ trust in and satisfaction with the healthcare system, increasing the likelihood of delaying or foregoing seeking care [ 9 , 10 , 11 , 12 ]. Further, individuals who interact with the healthcare system most often may, simply by greater exposure to the setting, be more likely to experience discrimination in healthcare, and consequently delay or forego future care [ 13 ].

Research from the United States (USA) has documented disparities in rates of discrimination in healthcare settings across race/ethnicity, immigrant status, language proficiency, and insurance status [ 14 , 15 ]. Further research has investigated possible links between discrimination within healthcare and utilization, with mixed findings [ 9 , 10 , 11 , 12 , 13 , 16 ]. A large-scale survey conducted in New Zealand documented an association between experiences of racial discrimination within healthcare and lower rates of preventive care use [ 12 ], whereas a separate large-scale survey in the USA found that nearly all significant unadjusted associations between discrimination and preventive services were no longer significant once sociodemographic characteristics were controlled for [ 16 ]. A number of studies have documented an association between experiences of discrimination within the healthcare setting and delayed or foregone care, both in the USA [ 9 , 10 , 17 ] and in Europe [ 18 ]. However, a nationally representative sample of USA women found that discrimination was linked with more frequent healthcare visits, though the authors note that this may not relate to foregone or delayed care [ 13 ]. Parallel evidence comes from research among people living with human immunodeficiency virus (HIV), which has consistently shown that higher perceptions of HIV-related discrimination and stigma within care settings is associated with lower retention in care [ 19 , 20 ].

In addition to the mixed findings above, the existing literature is limited by studies often focusing on a single dimension of social stratification (e.g., disparities in discrimination by race or gender). Research with large-scale nationallyrepresentative samples remains relatively rare [ 10 , 12 ], making the generalizability of findings to a population level more difficult. Further, the USA remains the site of most existing research on discrimination within healthcare and healthcare utilization, with a small number of studies outside the USA [ 12 , 18 ]. Finally, although some prior research has tackled the issue of statistical association between discrimination in healthcare settings and healthcare utilization, we know of only one study [ 16 ] (and none outside of the USA) that investigates the extent to which discrimination in healthcare can account for gaps in foregone care between groups.

France has a number of distinguishing characteristics that make it an important place for the study of discrimination in healthcare settings and its consequences. France has long been a country of immigration, as significant immigration flows began well before the Second World War [ 21 ], and the immigrant population in contemporary France is both numerous and diverse. Among all European countries, France has the second largest population of immigrants born outside the European Union (EU) after Germany, reaching 6 million in 2017 (approximately 9% of the total population) [ 22 ]. The largest immigrant groups come from North Africa (Algeria, Morocco, and Tunisia), Southern Europe (especially Portugal), Sub-Saharan Africa, Turkey, Southeast Asia (Vietnam, Cambodia, and Laos) and, more recently, China [ 23 ].

France also has a distinct political model of immigrant assimilation and ethnic diversity management, known as the French republican model [ 24 ]. Ethnic and racial distinctions are not recognized by the state; as a result ethnic statistics are not collected for official purposes, and ethnic minorities are not considered as targets of social policies [ 25 ]. Data and knowledge of discrimination on the basis of ethnicity or migration status are thus extremely scarce, despite the potential insight they could provide on the lived experience of minority groups in France.

Finally, the French healthcare system provides high levels of quality and access to care [ 26 ]. It is largely funded by public spending; more than three quarters of total health expenditures are publicly financed. Health insurance has a compulsory and universal coverage [ 27 ], and it includes state-funded health services for undocumented immigrants residing in France. This national context, in which the entire population should have access to healthcare, offers a valuable setting for analyzing foregone care and its potential explanatory factors.

In this study, we use data from a nationally representative study in France – with an oversampling of immigrant households – to examine social disparities in discrimination within healthcare, foregone healthcare, and how they are related. These data are of particular interest both for their large-scale, representative nature, and for the demographic diversity of the sample. We leverage these sample strengths and build on prior research by documenting population disparities, both in terms of discrimination and foregone care, across numerous demographic characteristics, including gender, immigrant status, country of origin, and religion. We also explicitly examine the extent to which discrimination in healthcare settings could explain any disparities in foregone healthcare between groups.

Data come from the Trajectories and Origins (TeO) study [ 23 ], a large-scale, nationally representative cross-sectional survey of France. The survey was conducted from 2008 to 2009 with in-person home interviews across France. The sample consisted of 21,761 individuals aged 18 to 59, with oversamples of immigrants and individuals born to at least one immigrant (> 8000 of each group).

Theoretical framework

Models were conceptualized in line with the adapted Behavioral Model for Vulnerable Populations described by Gelberg and colleagues [ 28 ], in which the use of healthcare services represents a health behavior that is influenced by upstream population characteristics. The main population characteristics of interest in this study include demographic characteristics (“predisposing” factors) of gender, ethnicity, immigrant generation, and religion. Other factors that we attempt to account for given the available data include the “predisposing” factors of age, marital status, education, and employment; the “enabling” factor of family income; and the “need” factor of perceived and evaluated health status.

Healthcare experiences

Discrimination in healthcare was measured with a single yes/no question: “Has a doctor or other medical care worker ever treated you less well or received you less well than other patients?” Likewise, foregone healthcare was also assessed with a yes/no question: “During the past 12 months, have you foregone health care for yourself?”. Each measure was coded dichotomously.

Demographic characteristics

As this study was explicitly interested in group disparities in healthcare experiences, we conducted analyses across a series of demographic measures, all of which were self-reported in the survey. Characteristics of interest include gender, immigrant generation (“French-born”, which refers to French-born individuals to French-born parents; first generation immigrant; or second generation immigrant), country of origin (for either the individual or parent, depending on the relevant immigrant generation, grouped into geographic categories), and religion.

Additional survey items were included as control variables in this study, including age (weighted M = 39.1, SD = 12.4), marital status (married = 46.7%, weighted) socioeconomic status, and health status. Socioeconomic status was measured with three variables for self-reported monthly income (weighted M = 1681€, SD = 954€), educational attainment (weighted: less than middle school equivalent = 11.3%, middle school equivalent = 13.3%, vocational training = 26.9%, high school equivalent or higher = 48.6%), and employment status (weighted: employed = 73.1%, unemployed = 8.8%, student = 5.4%, inactive = 12.7%). Health status was also measured with three variables, consisting of self-rated health (weighted M = 1.83, SD = .79), history of chronic illnesses (yes = 27.1%, weighted), and number of healthcare visits in the last year (weighted: none = 8.2%, once = 24.4%, several = 67.5%).

Analyses proceeded in three main steps. First, we described rates of discrimination in healthcare settings experienced by various groups as the predicted probabilities of experiencing discrimination based on demographic characteristics. We calculated these predicted probabilities from logistic regression models of healthcare discrimination, and we contrasted coefficient estimates against a reference group for statistical comparison. For each demographic factor of interest (gender, migrant generation, origin, and religion), we constructed three nested models. The first model included the demographic predictor, with age and gender (if gender was not the factor investigated) as covariates; the second model added covariates for socioeconomic status; the third model added covariates for health status.

Second, we reported the predicted probabilities of foregoing healthcare across the demographic groups of interest, and then calculated the average marginal effects (AMEs) of the demographic characteristics of interest on those predicted probabilities. We did this by modeling reports of foregone healthcare across three nested logistic regression models: the first included only the demographic factor of interest; the second added discrimination; and the third added all other demographic characteristics, socioeconomic status, and health status. We present our findings as AMEs for two main reasons. First, AMEs are less affected by bias arising from unobserved heterogeneity across nested logistic models than odds ratios or raw logistic regression coefficients [ 29 , 30 , 31 ]. Second, we believe that AMEs provide a more intuitive description of effect size than odds ratios or logistic regression coefficients, as AMEs can be read as percentage-point increases in predicted probability.

Finally, we determined how much of the disparities in foregoing healthcare across various groups is potentially explained by experiences of discrimination in healthcare. We did this by calculating the percentage of the Model 1 AME (that is, the AME of a group demographic characteristic) explained by the addition of discrimination as a covariate in Model 2, so that: % explained = 1 – ( AME Model 2 / AME Model 1 ). Statistical significance of the “percent explained” was tested by contrasting a demographic characteristic’s AME in Model 2 against the same AME in Model 1. Put another way, we tested the null hypothesis that the addition of discrimination in the model resulted in no change in the estimated AME for a demographic characteristic.

Descriptive statistics of the sample are shown in Table 1 . Overall, the survey-weighted prevalence of reporting discrimination in healthcare settings was 3.9%, with a range of 2.6 to 9.3% across the various demographic groups examined. In bivariate comparisons, significantly higher rates of discrimination were observed for: women compared to men; 1st generation immigrants compared to French-born; those with origins in Overseas France, Africa, and Turkey compared to those from Mainland France; and Muslims and those with no religion compared to Christians.

Also seen in Table 1 , the survey-weighted rate of foregone healthcare was 10.9% overall, ranging from 6.2 to 22.0% across demographic groups. Bivariate comparison tests are displayed in the table, and represented graphically in Fig. 1 , as predicted probabilities of foregoing healthcare across demographic groups. Blue bars correspond to the reference groups, black bars indicate significant difference from reference group levels, and grey bars indicate no significant difference. The probability of foregoing care was higher for: women compared to men; second-generation immigrants compared to French-born; people with origins in Overseas France, North Africa, or mixed origin (partially from France) compared to those from Mainland France; and Muslims and those who reported “Other Religion” compared to Christians. In contrast, the probability of foregoing care was lower for people of Southeast Asian origin.

Predicted probabilities of foregoing healthcare. Predicted probabilities were derived from logistic regression of foregoing healthcare on demographic characteristics, with no covariates ( N = 21,729). Bar colors represent statistical significance in logistic regression of foregoing healthcare on demographic characteristics: blue = reference group; black = ( p < .05); grey = ( p > .05)

Predicted probabilities of foregoing healthcare were then calculated across a series of nested models; the results are displayed in Table 2 and illustrate three main findings. First, discrimination in healthcare settings was strongly associated with having foregone healthcare across all models in which it was included (Models 2 and 3). In the fully adjusted Model 3, the AME of discrimination was 0.14 – the largest effect size of all covariates, corresponding to a 14-percentage point increase in the predicted probability of foregoing care. Second, the AMEs associated with women, Muslim, Buddhist, or other religion, as well as origin in North Africa or Southeast Asia, which were statistically significant in Models 1 and 2, were no longer significant with the addition of other sociodemographic factors as covariates in Model 3. Third, the AME of certain demographic characteristics was not fully explained by any of the added covariates (i.e., it remained statistically significant even in the most strictly controlled model). Namely, in Model 3 there were significant AMEs of foregoing healthcare for second-generation immigrants, those with an origin in Overseas France, or those with mixed origin (regardless of whether or not it was partially from France).

Finally, we examined the proportion of the disparities in foregone healthcare potentially explained by reporting discrimination in healthcare settings; the results are shown in Table 3 . Discrimination explained a statistically significant proportion of the disparity for women relative to men (17%), second-generation immigrants relative to French-born individuals (8%), people with origins in Overseas France (13%), North Africa (22%), and Sub-Saharan Africa (32%) relative to those with origins in Mainland France, and Muslims (26%) relative to Christians.

This study used data from a national population-representative survey to look at the experiences of people who are socially disadvantaged due to gender, immigration, race/ethnicity, and religion, within the healthcare setting in France. We examined rates of reported discrimination and how they may explain disparities in rates of foregoing healthcare among those groups. Overall, our findings suggest that discrimination in healthcare is associated with foregoing medical care, and that this is especially important for women and people in minority racial or religious groups.

More specifically, our results suggest three main points. First, we showed that disadvantaged social groups – particularly women, immigrants, those of African origin, and Muslim religion – are more likely to have experienced discrimination in healthcare settings. The population prevalence of discrimination of 3.9%, which was in line with prior research across more than 30 European countries documenting national rates of discrimination in primary care between 1.4 and 12.8% [ 32 ], obscures the heterogeneity across groups, with rates nearly doubling for disadvantaged groups. For many of these groups, this finding is consistent with a broad base of existing literature, as they have been shown to face higher risks of discrimination in French society. Immigrants and their children from Sub-Saharan Africa, North Africa, and the French overseas territories report higher rates of perceived discrimination, measured through both general and setting-specific discrimination questions (at school, on the labor or housing markets, etc.) [ 33 ]. These minority groups also face racism more frequently [ 34 ]. Among religious groups, our observation of a high rate of discrimination against Muslims in the healthcare system echoes previous findings of discrimination in other settings [ 33 ], especially the labor market [ 35 ], and high levels of anti-Muslim prejudice in French society overall [ 36 ]. In contrast, there seems to be a specificity of the healthcare setting for women. Our findings are consistent with qualitative evidence showing that women tend to report discrimination in healthcare settings more often than men [ 37 ], but differ from findings in other settings (school, the labor and housing markets) where women are less likely to perceive discrimination [ 33 ]. One possible factor contributing toward this setting-specificity could be the higher rate of healthcare utilization by women, which would in turn increase their exposure to the possibility of experiencing discrimination within that setting.

Second, our analysis documented disparities in the rates of foregoing medical care across populations of social disadvantage due to gender, immigration, race/ethnicity, and religion. Many of the groups with higher rates of foregoing healthcare were the same as those who reported higher rates of discrimination in healthcare – women, immigrants (though second-generation, rather than first), people with origins in Africa or Overseas France, and Muslims. Other groups with comparatively high rates of foregoing healthcare were those with mixed origins, and those who reported as “Other Religion”. For some groups, these findings are in line previous research on foregoing care: for example, there is evidence of higher rates of foregoing healthcare among adult women in Sweden and adolescent girls in the USA [ 18 , 38 ]. Similarly, prior research has consistently documented higher rates of foregoing care among disadvantaged racial and ethnic minority groups in the US [ 39 , 40 ]. However, there is less existing research on migrant generation and foregoing care, and our finding of higher rates of foregoing care among second-generation immigrants in France differs from a study of immigrant children in the USA, which documented higher rates of foregone care for first-generation immigrants, but not second-generation [ 41 ]. We are not aware of other reports of foregone healthcare by religion.

Finally, we examined the potential explanatory role of experiences of discrimination in the healthcare setting on foregoing healthcare. We found reports of discrimination to be robustly linked with foregoing care: in our fully adjusted model of foregoing care, discrimination in the healthcare setting was associated with an average 14 percentage-point increase in the predicted probability of foregoing care. Of note, this contrasts with a prior study that found the link between discrimination and decreased healthcare utilization to be explained by socioeconomic status [ 16 ]. These findings can also be considered alongside a USA-based study that found discrimination to be associated with more frequent healthcare visits [ 13 ] together, these studies are consistent with the model described in this paper, in which healthcare need (observed as frequency of visits) is an enabling factor for discrimination in healthcare, which results in a higher likelihood of foregoing future care [ 28 ]. Overall, findings in this study are consistent with existing research on discrimination as a barrier to healthcare: in addition to the previously mentioned Swedish study linking discrimination with foregone healthcare, qualitative research from Spain has described experiences of discrimination as a factor limiting access to healthcare [ 42 ], and experiences of discrimination have been linked to avoiding dental care in Australia [ 43 ].

We also contextualized this relationship by determining the potential proportion of disparities in foregoing care that could be explained by experiences of discrimination in healthcare. Groups for whom discrimination explained an especially large proportion of disparities in foregone care were people with origins in Sub-Saharan Africa (32%) and Muslims (26%). Also of note were women (17%); although the proportion explained was lower for women than for some other groups, the fact that they constitute half of the population points toward a large potential effect of discrimination when considered at the level of French society. Interestingly, the proportion of the disparity in foregoing care for second-generation immigrants explained by discrimination was small (8%). Taken together with the findings by region of origin, this suggests that discrimination may be of particular importance for healthcare utilization among immigrants who are more readily racialized based on their appearance and face higher levels of racism already.

This study has a number of limitations that should be noted. First, this was cross-sectional and thus no causal inference regarding discrimination and foregoing healthcare can be made – it is for this reason that results are framed in terms of the potential explanatory nature of discrimination. Future studies should consider possible natural experiments or other quasi-experimental designs in order to more rigorously test any causal relation between discrimination and foregoing healthcare. Second, we used a single-item measure of discrimination in healthcare settings, framed as being treated poorly compared to other patients. It is possible that a different assessment of discrimination, such as an adapted version of the Everyday Discrimination Scale [ 44 ], would reveal a different pattern of rates of discrimination. Third, we did not examine the specific type of healthcare that individuals reported having foregone, and thus do not know to what extent the foregone care was necessary. Finally, although this study was nationally representative of France, findings may be dependent on the societal dynamics and healthcare setting specific to France at that time (2008–2009), and consequently not generalizable to other settings. However, the rates of both discrimination in healthcare settings and of foregoing care are generally similar to those described in Sweden [ 18 ] – which has a different healthcare system and a more homogenous population – suggesting that similar trends may exist at least in other parts of Europe. Further, given the contemporary increase in far-right voting and associated anti-immigration politics in France, we would hypothesize that our estimates here represent lower bounds for experiences of discrimination in the present.

With these potential limitations in mind, the implications of this study can be discussed. We observe disparities between social groups in terms of discrimination in healthcare settings – a negative phenomenon itself – as well rates of foregone healthcare, an important hurdle in the functioning of any health system [ 45 ]. The affected groups represent large sections of French society (e.g., women, major immigrant groups, etc.), suggesting a substantial burden when considered at the national level. These disparities stand in opposition to the global goals of health equity [ 46 , 47 , 48 ], and should be considered in the discussion and design of interventions and health policies. Suggested interventions to reduce discrimination in healthcare settings include provider-level interventions, grounded in psychology research, that aim to improve provider understanding of bias and increase perspective-taking and empathetic behaviors [ 49 ], such as an intervention involving feedback on biased behaviors and interactions with a virtual patient that may reduce racial bias in pain medicine prescribing [ 50 ]. More systemic actions include policies that increase organizational accountability for discrimination, or social marketing campaigns that aim to shift population norms with anti-discrimination messaging [ 51 ]. The robust linkage between experiences of discrimination and foregoing healthcare observed in this study, especially among women, immigrants of African origin, and Muslims, adds additional context to the web of barriers that people in socially disadvantaged groups face and points to potential high-priority groups around which interventions may be structured.

The health status of disadvantaged and minority populations is a topic of increasing policy and scientific relevance for many countries around the world [ 52 , 53 , 54 ]. This study provides evidence that discrimination within healthcare settings may partially explain disparities in rates of foregone healthcare, contributing to the health inequalities observed across various disadvantaged groups. Researchers and policymakers who aim to improve the health of disadvantaged groups should be mindful that some barriers to healthcare for disadvantaged populations may lie in the experiences of healthcare itself, and those experiences are a potential place of action from which future policy and research can proceed.

Availability of data and materials

The data that support the findings of this study are available from the French Institut national d’études démographiques (INED), but restrictions apply to the availability of these data, which were used under license for the current study, and so are not publicly available. Data are however available from the authors upon reasonable request and with permission of INED.

Abbreviations

Average marginal effects

European Union

Human immunodeficiency virus

Trajectories and Origins

United States of America

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This work was supported by funding from the INED International Relations and Partnerships Department. The funding body played no role in the design of the study, the collection, analysis, and interpretation of data, or in writing the manuscript.

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Rivenbark, J.G., Ichou, M. Discrimination in healthcare as a barrier to care: experiences of socially disadvantaged populations in France from a nationally representative survey. BMC Public Health 20 , 31 (2020). https://doi.org/10.1186/s12889-019-8124-z

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Understanding nurses’ responsibilities in promoting equality and diversity, david peter stonehouse senior lecturer in nursing associates, school of health and community studies, leeds beckett university, leeds, england.

• To understand the terms equality, diversity and inclusion

• To recognise your responsibilities in promoting equality and diversity

• To count towards revalidation as part of your 35 hours of CPD, or you may wish to write a reflective account (UK readers)

• To contribute towards your professional development and local registration renewal requirements (non-UK readers)

Nurses have a duty to promote the values of equality and diversity during their interactions with patients and their families and carers, as well as peers and colleagues. This article defines the terms equality, diversity and inclusion, and explains the importance of the Equality Act 2010 and the Human Rights Act 1998 in protecting people from various types of discrimination. It also outlines nurses’ responsibilities in promoting equality and diversity by treating all patients and colleagues with respect and dignity, providing compassionate leadership, and practising in accordance with the ethical principle of justice. The article encourages and empowers nurses to recognise and challenge discrimination wherever they see it, thereby delivering high-quality care to all patients.

Nursing Standard . doi: 10.7748/ns.2021.e11531

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Stonehouse DP (2021) Understanding nurses’ responsibilities in promoting equality and diversity. Nursing Standard.

Published online: 06 April 2021

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Combatting Racism in Nursing Education

Aacn & nln committed to upholding diversity, equity, inclusion, belonging & justice.

Washington, DC — Blatant displays of racism by a nursing student or any others are deeply disturbing, unacceptable, and emphasize the critical need for continuing efforts to support diversity, equity, inclusion, belonging, and justice. To create a society where all are respected and valued, we must work together to combat racism, including within the ranks of the nursing profession. We will not uproot the deepest health disparities embedded within our health care system if we do not confront the corrosive impact of racism and discrimination.

The American Association of Colleges of Nursing and the National League for Nursing are resolute in our commitment to addressing racism in nursing education while upholding the concepts of diversity, equity, inclusion, belonging, and justice. We stand together against attacks to censor and dismantle programs that educate students and nursing providers about all forms of racism and that promote inclusion.

In the words of Dr. Ibram Kendi, “[We must] believe in the possibility that we can strive to be antiracist from this day forward. Believe in the possibility that we can transform our societies to be antiracist from this day forward. Racist power is not godly. Racist policies are not indestructible. Racial inequities are not inevitable. Racist ideas are not natural to the human mind.”

About the National League for Nursing

Dedicated to excellence in nursing, the National League for Nursing is the premier organization for nurse faculty and leaders in nursing education. The NLN offers professional development, networking opportunities, testing services, nursing research grants, and public policy initiatives to its nearly 45,000 individual and 1,000 institutional members, comprising nursing education programs across the spectrum of higher education and health care organizations. Learn more at NLN.org.

April 15, 2024

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Nursing Provision 8: the ANA Code of Ethics

This essay about the role of nurses under Provision 8 of the American Nurses Association (ANA) Code of Ethics uses the metaphor of an orchestra to depict the multifaceted responsibilities of nurses in healthcare. It describes nurses as both versatile musicians and composers who not only provide direct patient care but also advocate for social justice and equity. The essay highlights how nurses, guided by Provision 8, advocate for the rights and dignity of all patients, especially the vulnerable and marginalized. It also addresses the complex ethical dilemmas nurses face and their role in crafting healthcare policies and practices that promote public health and ensure equitable access to care. Overall, the essay portrays nurses as essential contributors to a harmonious healthcare system, emphasizing their role in leading efforts towards a just and fair healthcare environment.

How it works

In the grand orchestra of healthcare, where numerous professionals play their parts to create a melody of healing, nurses hold a distinctive role, akin to versatile musicians adept at both solos and harmonizing with others. This analogy becomes particularly apt when considering the American Nurses Association (ANA) Code of Ethics, especially Provision 8. This provision orchestrates nurses’ commitment to health, safety, and patients’ rights, framing their role not just as caregivers but as advocates for social justice and equity in healthcare.

Imagine nurses as the violinists in the healthcare symphony.

Just as violinists draw emotion and depth from their strings, nurses bring compassion and advocacy to their practice. Provision 8 charges them with a melody that resonates beyond hospital walls into the broader societal realm, where health disparities and inequities play out. They are to use their voice and actions to champion the rights of all patients, ensuring that the vulnerable and marginalized are not left without a melody in their healthcare journey.

The provision also casts nurses in the role of composers, tasked with crafting healthcare experiences that are safe, respectful, and dignified. But composing such experiences requires more than just medical knowledge; it calls for an understanding of the social and economic factors that influence health. Nurses, with their on-the-ground perspective, are uniquely positioned to lead initiatives that address these determinants, be it through community outreach programs, public health advocacy, or policy reform efforts.

Facing ethical dilemmas is akin to navigating dissonant chords in music. Nurses, guided by the principles of Provision 8, must sometimes make difficult decisions that weigh individual patient needs against broader public health considerations. These moments require a delicate balancing act, striving to preserve the integrity and dignity of care amidst complex and challenging circumstances.

In this light, Provision 8 is not merely a guideline but a calling for nurses to engage deeply with their practice. It encourages them to see themselves as integral players in a larger movement towards a healthcare system that is just, equitable, and attuned to the needs of all its members. Through their advocacy, dedication, and compassion, nurses play a critical role in ensuring that the healthcare symphony is one that uplifts every individual, leaving no one behind.

This piece is an imaginative essay that weaves together the principles of Nursing Provision 8 with the concept of an orchestra, illustrating nurses’ roles in healthcare through the metaphor of music. It highlights their commitment to advocacy, justice, and ethical practice through a unique and creative lens.

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"Nursing Provision 8: The ANA Code Of Ethics." PapersOwl.com, Apr 22, 2024. Accessed April 23, 2024. https://papersowl.com/examples/nursing-provision-8-the-ana-code-of-ethics/

"Nursing Provision 8: The ANA Code Of Ethics," PapersOwl.com , 22-Apr-2024. [Online]. Available: https://papersowl.com/examples/nursing-provision-8-the-ana-code-of-ethics/. [Accessed: 23-Apr-2024]

PapersOwl.com. (2024). Nursing Provision 8: The ANA Code Of Ethics . [Online]. Available at: https://papersowl.com/examples/nursing-provision-8-the-ana-code-of-ethics/ [Accessed: 23-Apr-2024]

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Black workers’ views and experiences in the U.S. labor force stand out in key ways

A U.S. Postal Service employee scans a package. (Brandon Bell/Getty Images)

There are more than 21 million Black Americans in the U.S. labor force today. Their workforce experiences are varied but stand out from people of other races and ethnicities on several important measures: They are more likely to be employed in certain postal work, transit, health care and security fields; report experiencing more racial discrimination on the job; and place a higher value on diversity, equity and inclusion efforts in the workplace.

For Labor Day, here are facts about Black workers’ labor force experiences and attitudes, drawn from federal data sources and recent Pew Research Center surveys.

Pew Research Center conducted this analysis to understand the views and experiences of Black workers in the United States and how they differ from those of people from other racial or ethnic backgrounds. Findings are based on data from the U.S. Bureau of Labor Statistics, the U.S. Census Bureau and Center surveys. Additional information about each survey and its methodology can be found in the links in the text of this post.

In the Center surveys, references to workers or employed adults include those who are employed part time or full time; are not self-employed; have only one job or have multiple jobs but consider one their primary job; and whose company or organization has 10 or more people.

References to White, Black and Asian adults include those who are not Hispanic and identify as only one race. Hispanics are of any race. Asian American respondents include only English speakers.

Black Americans make up large shares of workers in certain transit, health and security occupations, according to Bureau of Labor Statistics (BLS) data from 2022, the most recent year available. Black workers account for about 13% of all U.S. workers, including those who work full time, part time and are self-employed. They make up especially large shares of employees in certain occupations, including postal service clerks (40.4%), transit and intercity bus drivers (36.6%), nursing assistants (36.0%), security guards and gambling surveillance officers (34.5%), and home health aides (32.5%).

A bar chart showing occupations where Black workers make up 25% or more of the workforce.

Black workers make up much smaller shares of farmers, ranchers and other agricultural managers (1.5%). They also tend to be underrepresented in some science, engineering and technology occupations such as veterinarians (2.2%), mechanical engineers (3.6%) and electrical and electronics engineers (6.0%).

A 2021 Center survey found that Black adults see barriers for Black workers in STEM fields, including an unwelcoming professional environment and the need for more mentorship and representation for young people in science, technology, engineering and math.

Black workers generally earn less than U.S. workers overall, according to BLS data from 2022. Among full-time wage and salary workers, the median weekly earnings for Black workers ages 16 and older are $878, compared with $1,059 for all U.S. workers in the same age group. Among workers of other races and ethnicities in the same age group, the median weekly earnings are $823 for Hispanic workers, $1,085 for White workers and $1,401 for Asian workers. And the differences hold when accounting for education level – Black workers earn less than those in other groups even among workers with bachelor’s or advanced degrees.

Household income for Black Americans has lagged behind that for Americans of other races for several decades, according to U.S. Census Bureau data .

The unemployment rate for Black Americans is the highest of any racial or ethnic group and roughly double the rate for the U.S. overall, BLS data shows. In 2022, the unemployment rate for Americans ages 16 and older was 3.7% for men and 3.6% for women, according to BLS annual averages . Among Black Americans, the unemployment rate was 6.3% for men and 6.0% for women. This compared with around 3% each for White and Asian men and women and about 4% each for Hispanic men and women.

Monthly unemployment figures showed a record-low unemployment rate for Black Americans in April of this year, but it has begun to tick back up .

As with gaps in household income, Black Americans have experienced higher unemployment rates than their White counterparts for decades. Researchers have identified a variety of factors causing this trend , including racial discrimination and gaps in education, skills and work experience.

Black workers are the most likely to say they’ve experienced discrimination at work because of their race or ethnicity, according to a February 2023 Center survey of U.S. workers . About four-in-ten Black workers (41%) say they have experienced discrimination or been treated unfairly by an employer in hiring, pay or promotions because of their race or ethnicity. Much smaller shares of Asian (25%), Hispanic (20%) and White (8%) workers say the same.

Among Black workers, 48% of men and 36% of women say they’ve experienced discrimination or unfair treatment by an employer due to their race. There are no gender differences among White and Hispanic workers, and the sample size for Asian workers is too small to analyze men and women separately.

A bar chart that shows Black workers are most likely to say they've faced workplace discrimination due to race or ethnicity.

A quarter of U.S. workers say being Black makes it harder to succeed where they work, the February survey shows. Just 8% of U.S. workers say being Black makes it a little or a lot easier to be successful where they work, 50% say it makes it neither easier nor harder, and 17% aren’t sure.

Among Black workers, 51% say that being Black makes it harder to succeed where they work. By comparison, 41% of Asian, 23% of Hispanic and 18% of White workers view being Black as a disadvantage in their workplace. And about four-in-ten or fewer among Asian (39%), Hispanic (29%) and White (7%) workers say that being their own race or ethnicity makes it harder to be successful where they work.

A bar chart showing that about half of Black workers say that being Black makes it harder to succeed where they work.

Majorities of Black Americans see racial and ethnic bias as a major problem in hiring and performance evaluations generally, according to a separate Center survey of all U.S. adults conducted in December 2022 . Some 64% of Black adults say that, in hiring generally, bias and unfair treatment based on job applicants’ race or ethnicity is a major problem. This compares with 49% of Asian, 41% of Hispanic and 30% of White adults who view racial and ethnic bias in hiring as a major problem.

When it comes to performance evaluations, 56% of Black adults say that, in general, racial and ethnic bias is a major problem. About four-in-ten Asian or Hispanic adults and 23% of White adults say the same.

A bar chart that shows Black Americans more likely than other racial and ethnic groups to describe racial bias in hiring and performance evaluations as a major problem.

Black workers especially value diversity in their workplace, the February survey of workers found. Regardless of how diverse their workplace is, 53% of Black workers say it is extremely or very important to them to work somewhere with a mix of employees of different races and ethnicities. That percentage is larger than the shares of Hispanic, White and Asian workers who say this. And 42% of Black workers say they highly value a workplace with employees of different ages, compared with smaller shares of workers who are Hispanic (33%), Asian (30%) or White (24%).

There is a similar trend in views of workplace accessibility: 62% of Black workers say it is extremely or very important to them to work at a place that is accessible for people with physical disabilities, compared with 51% of Hispanic, 48% of White and 43% of Asian workers.

The vast majority of Black workers say that increasing diversity, equity and inclusion (DEI) at work is a good thing, but a sizable share give their employer low marks in this area, according to the February workers survey .

A bar chart that shows about three-in-ten Black workers say their employer pays too little attention to DEI.

Around eight-in-ten Black workers (78%) say that focusing on increasing DEI at work is a good thing. Just 1% of Black workers say this is a bad thing, and 20% view it as neither good nor bad. While majorities of Asian (72%) and Hispanic (65%) workers also say that focusing on increasing DEI is a good thing, roughly half (47%) of White workers hold this view. In fact, 21% of White workers say it’s a bad thing.

But when it comes to their own employer’s DEI efforts, 28% of Black workers say their company or organization pays too little attention to increasing DEI – the largest share of any racial or ethnic group. Black workers are also the least likely to say that their company or organization pays too much attention to DEI. Just 3% hold this view, compared with one-in-ten or more among Hispanic (11%), White (16%) and Asian (18%) workers.

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A look at Black-owned businesses in the U.S.

8 facts about black americans and the news, black americans’ views on success in the u.s., among black adults, those with higher incomes are most likely to say they are happy, fewer than half of black americans say the news often covers the issues that are important to them, most popular.

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Guest Essay

It’s Time to End the Quiet Cruelty of Property Taxes

A black-and-white photograph of a beaten-up dollhouse sitting on rocky ground beneath an underpass.

By Andrew W. Kahrl

Dr. Kahrl is a professor of history and African American studies at the University of Virginia and the author of “The Black Tax: 150 Years of Theft, Exploitation, and Dispossession in America.”

Property taxes, the lifeblood of local governments and school districts, are among the most powerful and stealthy engines of racism and wealth inequality our nation has ever produced. And while the Biden administration has offered many solutions for making the tax code fairer, it has yet to effectively tackle a problem that has resulted not only in the extraordinary overtaxation of Black and Latino homeowners but also in the worsening of disparities between wealthy and poorer communities. Fixing these problems requires nothing short of a fundamental re-examination of how taxes are distributed.

In theory, the property tax would seem to be an eminently fair one: The higher the value of your property, the more you pay. The problem with this system is that the tax is administered by local officials who enjoy a remarkable degree of autonomy and that tax rates are typically based on the collective wealth of a given community. This results in wealthy communities enjoying lower effective tax rates while generating more tax revenues; at the same time, poorer ones are forced to tax property at higher effective rates while generating less in return. As such, property assessments have been manipulated throughout our nation’s history to ensure that valuable property is taxed the least relative to its worth and that the wealthiest places will always have more resources than poorer ones.

Black people have paid the heaviest cost. Since they began acquiring property after emancipation, African Americans have been overtaxed by local governments. By the early 1900s, an acre of Black-owned land was valued, for tax purposes, higher than an acre of white-owned land in most of Virginia’s counties, according to my calculations, despite being worth about half as much. And for all the taxes Black people paid, they got little to nothing in return. Where Black neighborhoods began, paved streets, sidewalks and water and sewer lines often ended. Black taxpayers helped to pay for the better-resourced schools white children attended. Even as white supremacists treated “colored” schools as another of the white man’s burdens, the truth was that throughout the Jim Crow era, Black taxpayers subsidized white education.

Freedom from these kleptocratic regimes drove millions of African Americans to move to Northern and Midwestern states in the Great Migration from 1915 to 1970, but they were unable to escape racist assessments, which encompassed both the undervaluation of their property for sales purposes and the overvaluation of their property for taxation purposes. During those years, the nation’s real estate industry made white-owned property in white neighborhoods worth more because it was white. Since local tax revenue was tied to local real estate markets, newly formed suburbs had a fiscal incentive to exclude Black people, and cities had even more reason to keep Black people confined to urban ghettos.

As the postwar metropolis became a patchwork of local governments, each with its own tax base, the fiscal rationale for segregation intensified. Cities were fiscally incentivized to cater to the interests of white homeowners and provide better services for white neighborhoods, especially as middle-class white people began streaming into the suburbs, taking their tax dollars with them.

One way to cater to wealthy and white homeowners’ interests is to intentionally conduct property assessments less often. The city of Boston did not conduct a citywide property reassessment between 1946 and 1977. Over that time, the values of properties in Black neighborhoods increased slowly when compared with the values in white neighborhoods or even fell, which led to property owners’ paying relatively more in taxes than their homes were worth. At the same time, owners of properties in white neighborhoods got an increasingly good tax deal as their neighborhoods increased in value.

As was the case in other American cities, Boston’s decision most likely derived from the fear that any updates would hasten the exodus of white homeowners and businesses to the suburbs. By the 1960s, assessments on residential properties in Boston’s poor neighborhoods were up to one and a half times as great as their actual values, while assessments in the city’s more affluent neighborhoods were, on average, 40 percent of market value.

Jersey City, N.J., did not conduct a citywide real estate reassessment between 1988 and 2018 as part of a larger strategy for promoting high-end real estate development. During that time, real estate prices along the city’s waterfront soared but their owners’ tax bills remained relatively steady. By 2015, a home in one of the city’s Black and Latino neighborhoods worth $175,000 received the same tax bill as a home in the city’s downtown worth $530,000.

These are hardly exceptions. Numerous studies conducted during those years found that assessments in predominantly Black neighborhoods of U.S. cities were grossly higher relative to value than those in white areas.

These problems persist. A recent report by the University of Chicago’s Harris School of Public Policy found that property assessments were regressive (meaning lower-valued properties were assessed higher relative to value than higher-valued ones) in 97.7 percent of U.S. counties. Black-owned homes and properties in Black neighborhoods continue to be devalued on the open market, making this regressive tax, in effect, a racist tax.

The overtaxation of Black homes and neighborhoods is also a symptom of a much larger problem in America’s federated fiscal structure. By design, this system produces winners and losers: localities with ample resources to provide the goods and services that we as a nation have entrusted to local governments and others that struggle to keep the lights on, the streets paved, the schools open and drinking water safe . Worse yet, it compels any fiscally disadvantaged locality seeking to improve its fortunes to do so by showering businesses and corporations with tax breaks and subsidies while cutting services and shifting tax burdens onto the poor and disadvantaged. A local tax on local real estate places Black people and cities with large Black populations at a permanent disadvantage. More than that, it gives middle-class white people strong incentives to preserve their relative advantages, fueling the zero-sum politics that keep Americans divided, accelerates the upward redistribution of wealth and impoverishes us all.

There are technical solutions. One, which requires local governments to adopt more accurate assessment models and regularly update assessment rolls, can help make property taxes fairer. But none of the proposed reforms being discussed can be applied nationally because local tax policies are the prerogative of the states and, often, local governments themselves. Given the variety and complexity of state and local property tax laws and procedures and how much local governments continue to rely on tax reductions and tax shifting to attract and retain certain people and businesses, we cannot expect them to fix these problems on their own.

The best way to make local property taxes fairer and more equitable is to make them less important. The federal government can do this by reinvesting in our cities, counties and school districts through a federal fiscal equity program, like those found in other advanced federated nations. Canada, Germany and Australia, among others, direct federal funds to lower units of government with lower capacities to raise revenue.

And what better way to pay for the program than to tap our wealthiest, who have benefited from our unjust taxation scheme for so long? President Biden is calling for a 25 percent tax on the incomes and annual increases in the values of the holdings of people claiming more than $100 million in assets, but we could accomplish far more by enacting a wealth tax on the 1 percent. Even a modest 4 percent wealth tax on people whose total assets exceed $50 million could generate upward of $400 billion in additional annual revenue, which should be more than enough to ensure that the needs of every city, county and public school system in America are met. By ensuring that localities have the resources they need, we can counteract the unequal outcomes and rank injustices that our current system generates.

Andrew W. Kahrl is a professor of history and African American studies at the University of Virginia and the author of “ The Black Tax : 150 Years of Theft, Exploitation, and Dispossession in America.”

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ISU officials hosted a listening session in response to racist video. Students stayed silent.

A listening session hosted by Indiana State University officials in response to recent racist incidents didn't go as planned, with many participating in a silent protest.

According to the Indiana Statesman , Indiana State University's campus newspaper, the listening session, led by the president's office and others, took place in a hall auditorium from 4-5 p.m. on Tuesday, April 18. The session followed an initial protest on April 8 after a student, identified by some on social media as a member of the nursing program, posted a video containing racist comments against the Black community on Yik Yak sometime in March.

Before it started, protestors stood outside, passing out red duct tape and flyers, with intentions to “symbolize the lack of acknowledgment and action from university leadership regarding issues of racism and discrimination," the Indiana Statesman reported. Representatives from Indiana State University were unavailable for comment.

Indiana State University: An ISU nursing student was shown in a racist video. Here's what happened next.

Here's what we know:

Indiana State University student posts racist video

According to the Indiana Statesman, response from students follow a student video posted to Yik Yak, a social networking app, containing discriminatory remarks against the Black community.

One woman, about to get her doctorate, commented on the issue on TikTok. "Black women have been screaming about how they get treated in the health care field for generations. The fact that she's so openly and blatantly racist while also learning to practice medicine is so scary."

Indiana State University students protest in response to racist incidents on campus

An initial protest was held from 1-5 p.m. on April 8 at the former Lincoln Quad with four main demands. These included repercussions for the student’s behavior; a statement denouncing the video; a zero-tolerance policy regarding hate speech on campus; and amendments to the university’s code of conduct to oppose hate speech and implement repercussions for future incidents.

Nadia Lomax, one of the students involved in the protest, said the goal was to make sure silence isn't an option when faced with hate speech. “We’re here to make sure something like this doesn’t get swept under the rug again. The damage that occurs because of that (the lack of university response) is that students are told silence is OK and that they don’t matter,” Lomax said to the Statesman.

The university issued a response on April 10 and held a listening session for students on Tuesday. The Statesman reported that students sat silently through a presentation and were encouraged to join breakout rooms afterward. The protest continued, and provost Chris Olsen, and other faculty, expressed concern for recent events and encouraged students to speak up.

At exactly 5 p.m., when the session ended, the protest did as well. According to the Statesman, Andrea Arrington from the Department of History, addressed the students, saying, “We learned from you today in your silent protest… If there are things you want to teach us, please teach us."

How did Indiana State University respond to video, student protests?

Indiana State University President Deborah Curtis issued a statement on April 10 after the April 8 student protest. "The student's comments in the video in no way represent the ideals and goals of Indiana State University. We are appalled by the sentiments expressed in the video and condemn those comments in the strongest terms."

"This video impacts the entire campus community, but it deeply affects students from marginalized groups. Make no mistake — we hear you. We see you. We support you. We have been and will continue to work for you."

The office of the president and other faculty offices, also hosted a listening session earlier this week to allow students to voice their opinions and concerns. Instead, students silently protested at the event.

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Looking through racism in the nurse–patient relationship from the lens of culturally congruent care: A scoping review

Mojtaba vaismoradi.

1 Faculty of Nursing and Health Sciences, Nord University, Bodø Norway

Cathrine Fredriksen Moe

Gøril ursin, kari ingstad, associated data.

Authors do not want to share the data.

This review aimed to identify the nature of racism in the nurse–patient relationship and summarize international research findings about it.

A scoping review of the international literature.

Data sources

The search process encompassed three main online databases of PubMed (including MEDLINE), Scopus and Embase, from 2009 until 2021.

Review methods

The scoping review was informed by the Levac et al.’s framework to map the research phenomenon and summarize current empirical research findings. Also, the review findings were reflected in the three‐dimensional puzzle model of culturally congruent care in the discussion section.

The search process led to retrieving 149 articles, of which 10 studies were entered into data analysis and reporting results. They had variations in the research methodology and the context of the nurse–patient relationship. The thematical analysis of the studies' findings led to the development of three categories as follows: bilateral ignition of racism, hidden and manifest consequences of racism and encountering strategies.

Racism threatens patients' and nurses' dignity in the healthcare system. There is a need to develop a framework of action based on the principles of culturally congruent care to eradicate racism from the nurse–patient relationship in the globalized context of healthcare.

Racism in the nurse–patient relationship has remained a relatively unexplored area of the nursing literature. It hinders efforts to meet patients' and families' needs and increases their dissatisfaction with nursing care. Also, racism from patients towards nurses causes emotional trauma and enhances job‐related stress among nurses. Further research should be conducted on this culturally variant phenomenon. Also, the participation of patients and nurses should be sought to prohibit racism in healthcare settings.

1. INTRODUCTION

According to the American Nurses Association, racism is defined as ‘assaults on the human spirit in the form of biases, prejudices and an ideology of superiority that persistently cause moral suffering and perpetuate injustices and inequities’ (American Nurses Association, 2021 ) (P.1). Neoliberalism across the globe has made that racism remains invisible in terms of restructuring social classes, producing race categories and racialization (Ahlberg et al., 2019 ). Racism as prejudice and discrimination based on individuals' race and skin colour is a common healthcare problem across the globe. Ever increasing demographics, globalization and cultural changes in the healthcare context have attracted the attention of policy makers and international authorities to this phenomenon (George et al., 2015 ).

1.1. Background

Racism is the main cause of the patient's harm. Those patients who experience racist discriminations often have poor healthcare outcomes and access to health care, and suffer from mental health issues (Stanley et al., 2019 ). Racism in its common form as implicit racial bias specially negative attitudes towards the patient of colour can be pervasively observed in the relationship between patients and healthcare providers leading to healthcare disparities (Hall et al., 2015 ; Sim et al., 2021 ). It can also hinder appropriate and adequate use of health care, following up screening programmes and preventive behaviours, adherence to the therapeutic regimen and trust in healthcare providers (Powell et al., 2019 ; Pugh et al., 2021 ; Rhee et al., 2019 ). Disparity due to racism leads to the development of new disabilities in patients or even can worsen the present one (Rogers et al., 2015 ).

Nurses are located at the forefront of patient advocacy and they are expected to address inequities in the provision of care to their clients. However, structural racism can be observed in nursing practice (Iheduru‐Anderson et al., 2021 ; Villarruel & Broome, 2020 ). The counter racism role of nurses across healthcare settings emphasizes the identification of discriminatory care, and the development of tolerance, respect and empathy models for other healthcare professionals (Willey et al., 2021 ).

Ethics is one part of the anti‐racism paradigm with solutions that prohibit racist attitudes and behaviours in health care (Ho, 2016 ). Racism violates ethical practice among healthcare professions specially among nurses who are committed to the provision of equitable care to patients as the main part of social solidarity (Hamed et al., 2020 ; Weitzel et al., 2020 ).

The international research mainly has addressed racism towards patients. The occurrence of racist behaviours from patients towards healthcare professionals should be also investigated to create an equitable environment that hinders racism from both sides. It has been stated that black, Asian and minority ethnic nurses receive a different treatment from patients as being racially stereotyped and are considered less powerful in comparison with white nurses (Brathwaite, 2018 ; Truitt & Snyder, 2019 ). Patients' prejudicial and discriminative behaviours in terms of rejecting suggested care, verbal abuse and even physical violence have been described by these nurses as very painful and disrespectful behaviours leading to moral distress and reduction in the quality of patient care (Chandrashekar & Jain, 2020 ; Keshet & Popper‐Giveon, 2018 ).

Racism in the healthcare system has a long history. The identification of the nature of racism and its manifestations helps develop appropriate strategies for its elimination from the healthcare system (Mateo & Williams, 2021 ). The development of actions to tackle racism and racial discriminations has been chosen as a high‐level event at the 76th session of the United Nations General Assembly (UNGA) in 2021 (World Health Organization, 2021 ). Nevertheless, our knowledge of the extent of racism in healthcare systems and how it can be detected and prevented has remained limited. A probable reason is that racism directly influences the identity and rationality of healthcare professionals, which hinders holding discussions on this phenomenon in public discourses (Hamed et al., 2020 ). Open discussions on the issue of racism within the nursing profession help identify the underlying causes of racism and eradicate it from the healthcare context (Iheduru‐Anderson et al., 2021 ).

Further research is needed to better define racial, ethnic and cultural factors contributing to racism in healthcare systems and develop strategies that minimize their impacts on patient care (Godlee, 2020 ; Paradies et al., 2014 ).

2. THE REVIEW

Previous reviews of the international literature have taken a general perspective towards racism in the multidisciplinary context of health care (Chen et al., 2021 ; Sim et al., 2021 ). None of them have investigated racism in the context of the nurse–patient relationship to articulate its characteristics. Therefore, this review of international literature was undertaken to identify the nature of racism in the context of the nurse–patient relationship and summarize international research findings about it.

2.2. Design

A scoping review was performed. It is a research method by which the breadth of evidence in a field is mapped and the nature of the research phenomenon is identified (Daudt et al., 2013 ). The findings of scoping reviews can inform planning for future research and policy making (Westphaln et al., 2021 ).

This scoping review was carried out based on the review framework suggested by Levac et al. ( 2010 ) consisting of the following steps: identification of the research question; literature search and retrieving relevant studies; selection of studies; charting; collating, summarizing data and reporting results; consultation (Levac et al., 2010 ). These review steps were described under subheadings suggested by the journal's author guidelines.

2.3. Search methods

The review question was identified as follows: ‘what is the nature of racism in the nurse–patient relationship?’ The review question was kept broad enough to identify all aspects of this phenomenon in various caring situations, but it focused on related incidents only within the relationship between nurses and patients. It was also formulated by PICO:

P (Population): patients and nurses; I (Interest): racism, and racist attitudes and behaviours in the nurse–patient relationship; Co (Context): all contexts in healthcare including short‐term, long‐term, acute healthcare settings, child, adult, physical and mental healthcare.

The authors designed the review protocol and agreed on its details (Supporting Information 1 ). They performed a pilot search on Google Scholar and some specialized databases to identify relevant search keywords and phrases. The search process initially was established using the development of keywords, Medical Subject Headings (MeSH), and thesauruses' entry term that were translated into databases. The Boolean method and truncations with the operators of AND/OR were used to create the search sentence, which was pilot‐tested to ensure of its adequacy for retrieving relevant studies and selection of the most relevant databases for conducting the search.

The search sentence included all variants of terms related to nurse, patient, racism (e.g. racial bias, racial prejudice, racial discrimination, covert racism, racial disparity) and relationship (e.g. communication and interaction) in the context of healthcare. After conducting a pilot search, three main online databases that covered the majority of the peer‐reviewed and scientific international literature on racism in the field of nursing consisting of PubMed (including MEDLINE), Scopus and Embase were chosen for conducting the search. A librarian was also consulted to ensure of the accuracy of the search process.

2.4. Search outcome

Retrieved studies should have met the following inclusion criteria to be included in the review: original and empirical studies (qualitative/quantitative/mixed methods); focused on the phenomenon of racism; the nurse–patient relationship; racism from patients towards nurses and from nurses towards patients; various healthcare contexts such as short‐term, long‐term, acute healthcare settings, child, adult, physical and mental healthcare; being published in English language in scientific peer‐reviewed journals.

The publication date was restricted as from 1 January 2009 until 31 October 2021 to comprehensively access relevant studies. Any article that did not provide empirical data (e.g. reviews, commentaries, letters, conference proceedings, books) and did not overlap the main domains of the review (i.e. nurse, patient, racism) was excluded. The search coverage was enhanced through conducting a manual search inside some reputed journals with the history of publishing relevant studies and cross‐referencing from selected studies' bibliographies and previous reviews. The EndNote software was used for data management.

2.5. Quality appraisal

Risk of Bias assessment and quality appraisal generally are not applicable to scoping reviews. Therefore, all relevant studies were included in the reporting of the review results.

2.6. Data abstraction

To prevent bias, the authors (MV, CFM, GU, KI) independently screened the titles and abstracts of retrieved studies. Also, they independently read the full texts of the studies to make decisions on their inclusion or exclusion based on the pre‐determined eligibility criteria. Discussions were held by the authors to reach agreements on the selection of articles and their inclusion in data analysis and reporting results.

An extraction table was used to chart data, facilitate data importing from the selected studies, and categorize their general characteristics based on the author's name, country, publication year, sample and setting and research design.

2.7. Synthesis

The analytic framework was developed by drawing tables to collate, summarize and compare the studies' findings in relation to the review phenomenon and present an overview of relevant literature's breadth (Levac et al., 2010 ). Also, the studies' findings were thematically analysed by comparing their similarities and differences to gain a more abstract and at a higher lever insight into racism in the nurse–patient relationship.

The consultation step is optional and aims at the provision of stakeholders' involvement by suggesting complementary references and giving insights beyond those found in the reviewed literature. The sensitivity of the research topic and the requirement to obtain ethical permissions for collecting data from nurses and patients hindered the authors to follow this step. Therefore, it was removed from the review process.

The review findings were reflected to the three‐dimensional puzzle model of culturally congruent care by Leininger and McFarland ( 2002 ) via the main aspects of the cultural competence puzzle at the healthcare provider's and patient's levels consisting of ‘cultural diversity’, ‘cultural awareness’, ‘cultural sensitivity’ and ‘cultural competence’ (Leininger & McFarland, 2002 ; Schim et al., 2007 ).

The reason for the selection of culture as the analytical framework in this review lies in its application as the point of reference to the concepts of race and ethnicity. Culture is a dynamic concept, broadly encompasses commonalities and diversities in people and communities, and pervasively influences all aspects of life and healthcare (Schim et al., 2007 ). This synergy can help heal racism in the healthcare system (Hassen et al., 2021 ).

The Preferred Reporting Items for Systematic reviews and Meta‐Analyses extension for Scoping Reviews (PRISMA‐ScR) was used to guide this review (Tricco et al., 2018 ).

3.1. Search results and selection of studies

In the search process, 149 studies were retrieved (Table 1 ). Duplicates and irrelevant studies were excluded during title screening and abstract reading via holding discussions between the authors. Therefore, 24 articles underwent full‐text reading and assessment, of which 10 studies were entered into data analysis and reporting results given the inclusion criteria (Figure 1 ).

Results of the different phases of the review

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The process of search and inclusion of studies in the scoping review

3.2. Characteristics of selected studies

The general characteristics of the selected studies have been presented in Table 2 . They were published between 2009 and 2021 indicating the review coverage for more than one decade. Five studies were conducted in the United States (Benkert et al., 2009 ; Cottingham et al., 2018 ; Martin et al., 2016 ; Purtzer & Thomas, 2019 ; Wheeler et al., 2014 ), two in Norway (Debesay et al., 2014 , 2021 ), one each in the United Kingdom (Deacon, 2011 ), Australia (Lyles et al., 2011 ) and Canada (McFadden & Erikson, 2020 ).

List of final articles included in the research synthesis and reporting results

The studies mainly used the qualitative design (Cottingham et al., 2018 ; Deacon, 2011 ; Debesay et al., 2014 , 2021 ; Martin et al., 2016 ; McFadden & Erikson, 2020 ; Purtzer & Thomas, 2019 ; Wheeler et al., 2014 ), but two studies used the quantitative design (Benkert et al., 2009 ; Lyles et al., 2011 ). They were conducted in hospitals and community healthcare settings and were categorised based on their focuses as follows: patients' trust in nurses in relation to their racial identities (Benkert et al., 2009 ), nurses' confrontation with the racist expression by patients (Deacon, 2011 ), patient‐reported racial discrimination and communication with nurses (Lyles et al., 2011 ), perspectives of internationally educated nurses and American educated nurses about interactions with patients (Wheeler et al., 2014 ); nurses' experiences of home care provision to ethnic minority patients (Debesay et al., 2014 ); satisfaction of various racial groups of parents with neonatal nursing care (Martin et al., 2016 ); experiences of nurses of colour about negotiating with patients (Cottingham et al., 2018 ); health disparities during the nurse–patient relationship (Purtzer & Thomas, 2019 ); racializing mothers and breastfeeding (McFadden & Erikson, 2020 ); nurses' critical encounters with ethnic minority patients (Debesay et al., 2021 ).

3.3. Racism in the nurse–patient relationship

The thematic analysis of the studies' findings led to the development of three categories: bilateral ignition of racism, hidden and manifest consequences of racism and encountering strategies.

3.3.1. Bilateral ignition of racism

Pervasive racist perspectives and stereotypies among patients and nurses shaped their racist behaviours and negatively impacted the nurse–patient relationship.

Implicit bias among nurses towards racial and ethnic minorities was available in the form of having a general assumption about minorities, and was reflected through indirect negative racist expressions during the nurse–patient communication rather than direct impolite racist remarks (Debesay et al., 2021 ). From the macro‐perspective, power bias innated in the patient–nurse relationship. Considering patients in a weaker social position was the main cause of racist incidents (Debesay et al., 2021 ; Purtzer & Thomas, 2019 ).

Racism in institutional practice and policies also contributed to negative stereotypes. Ethnic minority patients who did not follow institutional guidelines were considered outsiders. They were labelled as clients who could not get integrated into social values, and were subject to racist remarks. Education in terms of hidden curricula and by learning from others when nurses worked in healthcare settings established racist stereotypes and attitudes towards patients (McFadden & Erikson, 2020 ; Purtzer & Thomas, 2019 ).

From a micro‐perspective, bias and stereotypical attitudes leading to racist behaviours rooted in nurses' personal perspectives towards ethnic minorities who had limited language proficiencies and substance dependencies, and suffered from mental illness (Debesay et al., 2021 ; Lyles et al., 2011 ; McFadden & Erikson, 2020 ; Purtzer & Thomas, 2019 ). Instead of assessing patients' cultural and ethnic backgrounds and investigating their cultural identities, nurses guessed on patients' cultural characteristics and needs based on their habits and last names to plan healthcare interventions (McFadden & Erikson, 2020 ). Failure to follow‐up nurses' health‐related advice, patients' socio‐economic factors and stereotypical attitudes developed by patients themselves towards their own physical and mental in‐capabilities enhanced racial distortions among nurses (McFadden & Erikson, 2020 ; Purtzer & Thomas, 2019 ).

On the other hand, patients' racism towards nurses was revealed in the experiences of nurses. Patients committed racial aggression when nurses were unable to meet their needs, which in some cases were unreasonable and beyond the defined nurse–patient relationship. Also, nurses' communication with accent triggered racist behaviours in patients (Cottingham et al., 2018 ; Debesay et al., 2021 ; Wheeler et al., 2014 ).

Nurses did not consider their position higher than patients in the nurse–patient interaction rounds. Nevertheless, some patients placed nurses at the lowest hierarchy of humanistic relationships and labelled them as subordinates. Patients' perspectives of nurses' ethnicity and cultural backgrounds determined the levels of nurses' competencies to provide care and receive respect. Nursing care was rejected by some patients, because of their personal orientations towards nurses' culture and ethnicity (Cottingham et al., 2018 ; Wheeler et al., 2014 ).

3.3.2. Hidden and manifest consequences of racism

Negative consequences of racism in the nurse–patient relationship were reported by both patients and nurses. Working in an environment in which stereotypical and racist attitudes influenced the nurse–patient relationship triggered the feeling of insecurity and uncertainty. Fear of making mistakes and crossing ethnic and cultural boundaries of minorities and the possibility of conflicts between patients' and families' beliefs, and nursing interventions enhanced work‐related stress among nurses (Debesay et al., 2014 , 2021 ). Nurses faced uncertainties with regard to how withhold their own personal prejudices and at the same time provide nursing care according to professional commitments (Debesay et al., 2021 ; Purtzer & Thomas, 2019 ).

Apparently, health disparities occurred given tensions between nurses and patients rooted in racist perspectives. They hindered nurses' efforts to provide appropriate care to patients and improve the nurse–patient relationship. When patients were not given opportunities to assert their cultural identities, they were discouraged to follow nurses' interventions and health‐related advice leading to more healthcare issues (Debesay et al., 2021 ; McFadden & Erikson, 2020 ; Purtzer & Thomas, 2019 ).

Patients mainly were dissatisfied with receiving support by nurses and complained about nurses' superior, cold and without sympathy communication style, inattention to their caring needs, not receiving suitable education, not spending enough time with patients and frequent nurses' turnover (Lyles et al., 2011 ; Martin et al., 2016 ; McFadden & Erikson, 2020 ).

A negative consequence of nurses' racist behaviours was the development of a negative perspective among patients towards the healthcare system. Racism was generalized to the whole healthcare system rather than taking it as a personal matter in the nurse–patient relationship (Benkert et al., 2009 ). Consequently, patients displayed disappointment or anger to all nurses and retaliated it, which damaged the sense of justice and pride even among those nurses who did their best to provide equitable care to patients (Debesay et al., 2021 ).

Those nurses who were subject to racist behaviours from patients experienced job‐related and emotional stress, which depleted their psychological resources and energy to deliver care. Assumption of incompetence due to racism led to emotional shift and encouraged nurses to retaliate. Therefore, instead of concentration on patient care, nurses focused on managing frustration and emotional trauma (Cottingham et al., 2018 ). Social isolation and disconnection, and leaving the nursing profession were some risky consequences of racist incidents (Cottingham et al., 2018 ; Wheeler et al., 2014 ).

3.3.3. Encountering strategies

Nurses and patients used strategies to avoid racism or at least minimize its impact on the nurse–patient relationship. Respect, trust and active participation in nursing care worked quite fine against stereotypical and racist behaviours. Compassionate care and respectful style of communication by nurses, friendliness, patience and taking care of patients' concerns and spending enough time for education were highlighted. These strategies could be all summarized into being patient‐centred (Lyles et al., 2011 ; Martin et al., 2016 ; Purtzer & Thomas, 2019 ).

Cultural mistrust as the outcome of racism could be avoided through the development of racial concordance in the nurse–patient relationship. The suggested strategy to achieve concordance was the provision of care by those nurses who had similar cultural and racial backgrounds to those of patients (Benkert et al., 2009 ; Lyles et al., 2011 ). Also, cultural understanding through the acknowledgment of patients' culture and learning about their values, ceremonies and traditions, integration of patients' values into nursing care and setting healthcare goals to preserve patients' cultural identity was required. Avoiding the creation of an unpleasant atmosphere in the nurse–patient relationship through not directly questioning patients' cultural characteristics, and balancing between care delivery and cultural rituals such as touching patients and undressing them helped prevent crossing cultural borders and creating the feeling of racism. Moreover, leading ethnic minority patients in healthcare journey and covering the gap between them and the requirements of the healthcare system were the main strategies for patient advocacy (Debesay et al., 2014 , 2021 ; McFadden & Erikson, 2020 ; Purtzer & Thomas, 2019 ).

When nurses faced racism from patients, they tried to avoid personalizing racist incidents and made jokes of them to control their anger and defend their own emotional well‐being. They considered such sorts of abuses one part of their daily work life that should be coped with (Cottingham et al., 2018 ; Deacon, 2011 ). Given the lack of policies in healthcare settings to manage racism, nurses coped with the situation and rationalized racist behaviours to reduce related emotional burdens. They tried to ignore racism and attributed it to patients' background diseases, age, previous negative life experiences and inability to take the responsibility of their own behaviours. As a confrontation strategy, some nurses reported the racist incident to authorities, used medications to calm patients, applied distraction techniques to patients, asked patients to refrain from being assaultive, and informed patients of their behaviours. In the worst case, some nurses decided to change their workplace (Cottingham et al., 2018 ; Deacon, 2011 ; Wheeler et al., 2014 ).

4. DISCUSSION

This scoping review of the international literature aimed to identify the nature of racism in the nurse–patient relationship and summarize international research findings about it. An overview of the breadth of the international literature on this phenomenon was presented consisting of three categories developed by the authors. Culture is intertwined with the phenomenon of racism and can critically influence the nurse–patient relationship (Crampton et al., 2003 ). Racism as an individual and systemic prejudice is imprinted in cultural artefacts and discourses (Salter et al., 2017 ). Racist perspectives, stereotypies and behaviours from patients and nurses can be attributed to cultural bias as the interpretation of situations and others' actions according to own set of personal perspectives, experiences and cultural standards.

Delivering unbiased and individualized care to culturally diverse patients is influenced by nurses' cultural competencies. Also, patients' personal attitudes and perspectives, and balancing the power between nurses and patients in healthcare situations are crucial to the development of an appropriate climate for patient care (Oxelmark et al., 2018 ; Vaismoradi et al., 2015 ). Accordingly, the findings of this review were discussed using the main aspects of the cultural competence puzzle consisting of cultural diversity, cultural awareness, cultural sensitivity and cultural competence as the elements of the three‐dimensional puzzle model of culturally congruent care at nurses' and patients' levels (Leininger & McFarland, 2002 ; Schim et al., 2007 ). The dimensions of this model have also the capacity to be the part of the patient's participation in the provision of culturally congruent care (Schim et al., 2007 ). Therefore, our discussion using this model covers racist behaviours from both patients and nurses. A summary of the review findings in connection to the culturally congruent care model has been presented in Figure 2 .

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The review findings in connection to the culturally congruent care model

4.1. Cultural diversity

According to the review findings, racist behaviours in the nurse–patient relationship rooted in implicit and power biases demonstrating that the patient and the nurse had a low social position. Stereotypical attitudes were developed towards patients with limited language proficiencies, low socio‐economic conditions and different last names and cultural backgrounds.

Globalization is the cause of cultural diversities in health care. Similarities and differences between cultures in terms of race, ethnicity, nationality and ideology shape humanistic relationships in health care (Schim et al., 2007 ). The patient's and healthcare provider's cultural contexts are crucial in the development of the therapeutic relationship. The establishment of a constructive relationship between nurses and patients without the acknowledgment of their cultural diversities is impossible (Gopalkrishnan, 2018 ). Marginalization of ethnicities and minorities in the healthcare system should be avoided and instead their cultural diversities should be acknowledged and respected. All measures should be taken to avoid tensions when contacts between cultures occur. The assessment of cultural diversities is the cornerstone of planning for the provision of culturally congruent care through appropriate exposure to cultural differences and prevention of racism (Schim et al., 2007 ). Diversities in nurses' cultural backgrounds have been shown to be advantageous for the healthcare system in terms of improving the quality of patient care and healthcare economy (Gomez & Bernet, 2019 ).

4.2. Cultural awareness

In this review, education had an influence on the development of racism towards patients through hidden curricula and by learning at the workplace. Nurses felt uncertain about how to provide care that was congruent to patients' cultural backgrounds without having stress about crossing patients' cultural boundaries. Those nurses who faced racism from patients often were unable to manage the situation, were emotionally overloaded, and lost their concetration on the provision of care. Similarly, patients' racist behaviours towards nurses were attributed to a lack of understanding of nurses' cultural backgrounds.

Gaining knowledge about and recognition of other cultures help to identify the uniqueness of each culture and commonalities between the cultures. Cultural awareness aims at identifying similarities and differences between cultures in terms of religious rituals, routines, preferences and behaviours. It recognizes interpersonal comfort zones and customizes care to them, and suggest a method by which people can interact with others' cultures in the caring relationship leading to the delivery of culturally sensitive care (Schim et al., 2007 ).

Cultural awareness often happens in the process of informal nursing education because direct education may not be able to provide sufficient opportunities for nurses to become culturally aware (Hultsjö et al., 2019 ; Kaihlanen et al., 2019 ). Raising awareness about caring situations in which misinterpretations may occur help with the detection of underlying causes and finding a counteraction framework by which an equitable communication is made with patients and their satisfaction is preserved (Crawford et al., 2017 ; Tan & Li, 2016 ). Comparisons of cultures and discovery of common ethical values in the nursing profession help develop skills for the creation of dialogue between individuals' and facilitate integration to the global nursing context (Leung et al., 2020 ).

4.3. Cultural sensitivity

In this review, institutional practice and policies contributed to the development of negative stereotypes by which ethnic minority patients who did not follow institutional guidelines were subject to racist behaviours. Cultural sensitivity consists of individuals' attitudes towards others and themselves and understanding others' cultural characteristics. It motivates individuals to be cross‐cultural and acknowledges others' cultural heritages. Judging others' cultures based on own culture is against the principle of cultural sensitivity (Schim et al., 2007 ). Measures taken in healthcare systems to reduce bias and racism should encompass all types of inequalities among ethnic minorities (Sim et al., 2021 ). Improving cultural sensitivity enhances cultural intelligence and facilitates understanding the impact of culture on health and diseases. Therefore, the provision of intercultural healthcare based on understanding differences and similarities between cultures leads to the reduction of health inequalities and improvement of healthcare quality (Göl & Erkin, 2019 ; Yilmaz et al., 2017 ). Public and social media have important roles to tackle the problem of patients' racist behaviours towards nurses in care situations. They can debate healthcare policies, promote public health behaviours, educate patients and inform them of cultural norms in healthcare settings and engage them in the development of an environment that respects cultural diversities. Improving cultural sensitivity involves an increased focus on human rights. Individuals' equal worth and rights regardless of race, ethnicity, language and religion lay the foundation of human rights (United Nations, 2021 ).

4.4. Cultural competence

The findings of this review showed that patients could not assert their cultural identities and were dissatisfied with nurses' inappropriate communication style and lack of attention to their needs. Although there was no indication of training to nurses about culturally congruent care in our findings, the main focus of strategies to avoid racism by nurses was to acknowledge the patient culture, behave respectfully and provide compassionate care. This coping strategy supported nurses' personal well‐being and at the same time prevented the creation of negative stereotypes towards patients' cultural backgrounds. It is the demonstration of a series of behaviours and taking related actions indicating that healthcare professionals know how to acknowledge cultural diversities and are aware of and sensitive towards the patient's culture (Schim et al., 2007 ).

In the context of health care, it is to adapt care and comply skills to patients' needs. Being culturally competent facilitates culturally congruence care in the nurse–patient relationship. Cultural competence for ethnic minorities requires organizational support (Taylor, 2005 ) and it should include work at the system level (Sharifi et al., 2019 ). Cultural education and training have been emphasized as mitigating strategies that can reduce racism and bias, and enhance cope with cultural diversities. Cultural competence is an important strategy by which health inequities can be addressed (Horvat et al., 2014 ). It requires practising self‐reflexivity on routines that cause racism and bringing implicit bias to own conscious (Bradby et al., 2021 ; Medlock et al., 2017 ; Olukotun et al., 2018 ). Training about diversities and being exposed to cultural differences in practical placements can promote cultural competence and consequently interaction with culturally diverse patients (Levey, 2020 ; McLennon et al., 2019 ). Promoting cultural competence among healthcare providers prevents healthcare encounters and reduces shame and embarrassment among care receivers (Flynn et al., 2020 ).

4.5. Limitations and suggestions for future studies

This scoping review provided an overview of international knowledge about racism in the nurse–patient relationship in spite of retrieving a few empirical studies on this important phenomenon. More studies might have been published in languages other than English that could not be included in this review, and should be considered by future researchers. Racism in the nurse–patient relationship has remained a less explored area of nursing research specially regarding racism from patients towards nurses. Therefore, more studies about racism in the context of the nurse–patient relationship and in various healthcare contexts should be conducted to improve our knowledge of this culturally variant phenomenon and devise a general unified strategy for the eradication of racism from the nurse–patient relationship.

5. CONCLUSION

Racism threatens patients' and nurses' dignity in the healthcare system. It hinders efforts to meet patients' and families' needs and increases their dissatisfaction with nursing care leading to the loss of trust in nurses and reduction of quality of care. Also, racism from patients towards nurses causes emotional trauma and enhances job‐related stress among nurses leading to their turnover. Nurses often apply coping strategies to relieve the emotional pressure of racist incidents and protect their own emotional well‐being.

Racism in the globalized context of healthcare should be prevented and nurses' and patients' well‐being and dignity should be preserved. It needs the establishment of acts and legislations that prohibit racist behaviours and enforce their report to healthcare authorities to seek support and prosecute racist people. Also, there is a need to develop a framework of action based on the principles of culturally congruent care to eradicate racism from the nurse–patient relationship in the globalized context of healthcare.

The practical implications of the review findings based on the culturally congruent care model are as follows:

Development of a practical guideline to help nurses and patients acknowledge cultural diversities and promote their awareness and sensitivity towards other cultures;
Improvement of nurses' cultural competence through education and training about how to avoid racism during the provision of care to patients with different cultural backgrounds;
Development of policies and practical strategies to ensure that patients are held responsible for racist behaviours that create a toxic environment for healthcare professionals;
Comparing cultures and removing misperceptions about other cultures through communication and dialogue between nurses and patients;
Rectification of institutional policies contributing to the creation of stereotypies about cultural minorities;
Use of public and social media to inform patients of cultural norms in healthcare settings;
Collaboration between associations supporting the human rights of nurses and patients for the development and implementation of zero‐tolerance and anti‐racism policies;
Emphasis on the equal worth of people and human rights in healthcare settings;
Cultural socialization of nurses through education and training about customizing care to patients' cultural backgrounds, demonstrating respect and providing compassionate care;
Active screening and detection of stereotypes, implicit bias and racist attitudes among nurses through self‐reflexivity.

CONFLICT OF INTEREST

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

AUTHOR CONTRIBUTIONS

MV was involved in review design. MV, CFM, GU and KI were involved in data acquisition, analysis and interpretation for important intellectual content, drafting the manuscript and revising it for intellectual content and giving final approval of the version to be published in the journal.

PEER REVIEW

The peer review history for this article is available at https://publons.com/publon/10.1111/jan.15267 .

Supporting information

Vaismoradi, M. , Fredriksen Moe, C. , Ursin, G. & Ingstad, K. (2022). Looking through racism in the nurse–patient relationship from the lens of culturally congruent care: A scoping review . Journal of Advanced Nursing , 78 , 2665–2677. 10.1111/jan.15267 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]

The authors have received no financial support the research, authorship, and/or publication of this article.

DATA AVAILABILITY STATEMENT

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Former civil servant says ‘racism in Cabinet Office’ forced her to resign

Rowaa Ahmar’s claims were made in the court papers of a discrimination case against the Cabinet Office

A former senior civil servant has said in court papers that “a hostile racist working environment” in the Cabinet Office meant she was “forced to resign”.

Rowaa Ahmar, who has now withdrawn a discrimination case against the Cabinet Office, said that “the racism within the Cabinet Office appeared to be unrelenting and systemic” and claimed that she was frozen out of ministerial meetings after complaining about it.

Ahmar, who is of Egyptian and French dual heritage, was head of policy at the illegal migration taskforce, which was convened to tackle the arrival of small boats across the Channel. She said that she was unwelcome at discussions about sending people to Rwanda because she was not onboard with the “racist ultra-hostility” of their policy proposals.

An employment tribunal hearing against the Cabinet Office and senior civil servants began on Monday but the case was withdrawn on Wednesday. Ahmar had lodged two claims arguing she was subject to “direct discrimination and harassment on the grounds of her sex and race” as well as “victimisation”.

The Cabinet Office said her claims were “completely unfounded” and noted that Ahmar had withdrawn the case with no payment made.

Ahmar said that at the taskforce she tried to focus small boats policy on criminal gangs and “to add constructively to the debate and to move it away from prejudice and blame”, but managers “were onboard for the racist ultra-hostility which a boomerang (‘no returns’) policy would involve, and they saw me as [an] unwelcome visitor to their taskforce”.

She disagreed with civil service directors who she said viewed the “ultra-hostile environment” as “practical, necessary and gratifying”.

Ahmar said in her claim that she first took a secondment from the Treasury to become a chief of staff ahead of Cop26, before being ordered to leave the climate summit early after complaining of bullying and harassment.

In an internal investigation it was found that a “bullying, harassment and discrimination” complaint she brought against a manager was “partially upheld”, with behaviour that “amounted to bullying”, but that there was “no malice” and it was an issue of communication.

After being sent back early from Cop26 in November 2021, Ahmar took up a role at the illegal migration taskforce in January 2022.

It was while at the taskforce that she said she was increasingly blocked from meetings and then told that her secondment from the Treasury was ending abruptly for “poor behaviour”. She said they told her it was for bullying someone who wished to remain anonymous.

Ahmar said in the papers: “I believe that speaking up against racism was a career death sentence at the [taskforce].”

She believes her HR file was “red-flagged” in the new role as she had brought a race and bullying, harassment and discrimination complaint. The Cabinet Office argued in documents that her behaviour in the first six weeks at the taskforce was “negative and problematic, leading colleagues to feel overburdened, disrespected or undermined” and “received concerns” that the behaviour “amounted to bullying”.

The tribunal judge, Richard Nicolle, ruled on Thursday that details of the documents could be published after a successful application by news organisations led by the Guardian.

In court papers she accused the head of the civil service, Simon Case, of showing a “lack of support” and “cold-shouldering” her allegations of racism and harassment after she resigned.

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She said in the claim she was “harassed, discriminated against, victimised” and that other white staff were not subject to the same treatment.

The cabinet secretary and two of the other named officials – Alex Chisholm, the permanent secretary in the Cabinet Office, and Sarah Harrison, the chief operating officer – were all accused of being “untrustworthy” over how they dealt with her complaints. Tribunal documents show Case and the two other officials argued they played only “minor roles”, and the judge accepted this.

She said she had enjoyed her time at the Treasury and excelled there but, quoting from her resignation letter in the papers, Ahmar said she had a “terrible experience at the Cabinet Office”, where she claimed she was “racially bullied and victimised, and worked in a very hostile working environment”.

A Cabinet Office spokesperson said: “These allegations are completely unfounded and the Cabinet Office has always firmly denied all of the claims in this case. We were prepared to robustly defend them in court.

“The claimant has withdrawn all of these claims and we have agreed to that. No payment has been made, including in relation to the legal costs incurred.”

Ahmar’s solicitor, Lawrence Davies, of Equal Justice solicitors, said in a statement afterwards: “The claims raised important issues of public interest about alleged sexism and racism at the Cabinet Office. The department who polices the standards of the entire service and plays a central role in advising ministers.

“The claimant believes that senior management must begin to become fully accountable for their conduct. The claimant bravely brought these matters to tribunal and hoped to inspire senior management and HR change at the Cabinet Office by her action. She did not wish to litigate but was left with no other option. She stands by her allegations of race and sex discrimination as set out in her claim.”

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Recognizing history of Black nurses a first step to addressing racism and discrimination in nursing

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Beginning with oppression

Black nurses in Canada

Racism reinforced through nursing education

Towards an anti-racist profession

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How Nurse Leaders Can Address Discrimination in Nursing

What Are Examples of Discrimination in Nursing?

Discrimination Among Nurses

Discrimination Involving Nurses and Patients

The Impact of Implicit Bias on Patient Care

Patient Discrimination Against Nurses

Racism in Nursing

Systemic Racism in Nursing

The Impact of Systemic Racism in Nursing and Healthcare

The Impact of Systemic Racism on Nurses of Color

Racist Attitudes from Nurses and Patients

Ageism in Nursing

The Impact of Ageism on Nurses

The Impact of Ageism on Nursing Care

Ageism Against Older Nurses Compromises Patient Care

Ageist Attitudes Impede Quality Care

Gender Discrimination in Nursing

The Impact of Gender Discrimination in Nursing

How to Combat Gender Discrimination in Nursing

Strategies to Tackle Gender Discrimination in Nursing

The Importance of Diversity in Nursing Leadership

Diversity in Nursing Leadership Promotes Cultural Competence

Diversity in Nursing Leadership Breaks Down Stereotypes

Unified Care for the Future

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Nursing students’ experiences of educational discrimination: a qualitative study

Conclusions

Theme 1: inappropriate role of nursing professors (or instructors)

Lack of sufficient self-confidence in nursing professors and its transfer to the student

The educator role in motivating or eliminating motivation

Theme 2: Strict rules

Differences in compliance with laws and regulations

Nurses are being strictly monitored

Theme 3: lack of nursing professional independence

Lack of supportive organizations for nurses

Lack of proper social status of nursing in society

The high authority and power of physicians over other disciplines

Implications for research/practice

Limitations of study

Availability of data and materials

Acknowledgements

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How to attain gender equality in nursing—an essay

Huge shortage

Why are men under-represented?

Brief history of men in nursing

What can be done?

Better public understanding

Better recruitment

More financial investment

Confrontation of stereotypes

Continuing men’s long history in nursing

Discrimination in healthcare as a barrier to care: experiences of socially disadvantaged populations in France from a nationally representative survey

Conclusions

Theoretical framework

Healthcare experiences

Demographic characteristics

Availability of data and materials