Structural Inequality and Diversity in Nursing

by | Mar 30, 2013 | Asian-American and Pacific-Island Nurses, Black and African-American Nurses, Hispanic and Latino Nurses, LGBT Nurses, Magazine, Men in Nursing, Nurses with Disabilities

Various inequalities exist in structured social systems. Women, people of color, the uneducated, the poor, and those who face disabilities have often gone voiceless and powerless throughout history, and their struggles persist today. These groups of people are marginalized and face discrimination, prejudices, and sometimes oppression. Nursing, a profession predominantly populated by women, isn’t any different.

For the purpose of this article, discrimination will be defi ned “as a showing of partiality or prejudice in treatment, action, or policies directed against the welfare of minority groups.”¹ Discrimination can happen anywhere a power imbalance exists between groups of people, such as in education, in social and political contexts, and even health care. In particular, “discrimination in the health sector is disturbing as it violates the basic principles articulated by care providers.”¹ Generally, nurses experience discrimination based on their gender, race, lifestyle, and physical disability. In nursing, discrimination and oppression have lead to lower salaries, hostility from colleagues in the workplace, and unequal access to professional development training programs and career advancement opportunities.

Oppression, like discrimination, involves structural limitations—imbalances and inequities across groups causing constraints not only in the physical environment, but also in social relations, economic status, and political situation.² When discrimination against a group of people is encouraged and consistently exercised by those in power, it causes unequal access to opportunities, thus leading to oppression. As power structures in society become more established, oppression becomes the norm. Thus, oppression occurs today not because society actively seeks to disempower some groups of people, “but rather because of the effects of societal norms, laws, and unchallenged assumptions.”³

In health care, a cultural imperialism exists such that the medical model—the physicians’ practices, views, values, and beliefs—is the dominant culture and the established norm. Nursing, as “the other group,” can be “viewed as both different and invisible and is devalued and objectifi ed by the dominant group.”⁴ Though times have changed, nurses continue to be an oppressed group as they have experienced repeated, widespread, and systematic injustice under a patriarchal system by physicians, administrators, and marginalized nurse managers.^4,5 The forms of discrimination and oppression, as experienced by nurses within the profession and the health care sector, have been documented and analyzed below, specifi cally, gender discrimination, racial discrimination, lifestyle discrimination, and discrimination based on disability. In addition, this article will take a closer look at horizontal violence, an expression of oppressed group behavior evolving from years of oppression, fi nding implications for nurse leaders to empower nurses and nursing students.

Nursing in a male-dominated world

From a global perspective, nursing has been regarded as an oppressed profession, largely due to the fact that it is female dominated.⁶ Various patriarchal cultures around the world condone the unequal power relationships between men and women, favoring men.⁷ This gendered hierarchy of women in subordinate roles emphasizes male domination and marginalization of women in society.⁸ Historically, before the late 19th century, women who provided nursing care were either nuns or domestic servants. “Nursing was then an unskilled occupation, poorly paid, and disreputable,” a position held only by women of low social status.⁹

The unequal power balance between physicians and nurses has resulted in nurses keeping their voices silent while in the workplace. Nurses may not challenge physicians in the workplace, fearing confl ict, stress, or reprisal.⁸ This could become problematic, especially if nurses have concerns about harm to the patients. Churchman and Doherty conducted a qualitative research study in the United Kingdom on nurses’ views of challenging doctors’ practice in an acute hospital and found nurses still lack the confi dence to question doctors’ decisions. When dissent was warranted, nurses played the “doctor-nurse game” to appease the physicians; this “game” refers to the hidden manner in which nurses have infl uenced physicians’ decision making by providing information and making suggestions about patient care, without appearing to undermine a physician’s status.⁸

Gender discrimination

Gender discrimination refers to distinction, exclusion, or restriction made based on socially constructed gender roles and norms, those that prevent individuals from experiencing full human rights.¹⁰ In reviewing the literature, two types of gender discrimination in nursing were found. The fi rst type refers to the preferential treatment of men in nursing— specifi cally with regards to career advancements—and the second type refers to society’s view of male nurses, potentially leading to unequal educational opportunities for males.^1,10

In a profession dominated by women, it seems puzzling that female nurses still face gender discrimination. In 2005, Statistics Canada reported there were 314,900 regulated nurses (which consists of registered nurses and registered practical nurses) in the country, and of these, 94.5% were women.¹¹ This data is comparable to 2005 U.S. data, where roughly 5.9% of the nursing workforce is comprised of men. The proportion of male nurses in Australia and the United Kingdom is slightly higher at 7.2% and 10.1%, respectively.¹² Indeed there is a signifi cantly lower number of men in nursing, yet they are disproportionately represented in management such that in the United Kingdom, approximately 45% of those in senior management positions and higher education courses are male nurses.1 Additionally, male nurses are reportedly higher paid and move directly into middle and upper remuneration brackets faster than their female counterparts.^1,13

A survey conducted by Hader that collected information from over 1,500 nurse leaders from New Zealand, Canada, China, and Saudi Arabia revealed male nurses move into management positions at a younger age and faster than their female counterparts. The other type of gender discrimination in nursing involves the negative effeminate stereotypes society associates with male nurses. This may be because society as a whole views nursing as women’s work because it is a caring profession.¹⁴ The media’s portrayal of male nurses and physicians seems to be an accurate refl ection of society’s views of men in health care as well. In movies like Meet the Parents, in which the lead actor plays a male nurse, the character is perceived as less masculine. Conversely, male physicians are generally portrayed as confi dent and masculine in the media. There also tends to be a patriarchal stereotype in health care, where the physicians are viewed as leaders and nurses are handmaidens carrying out their orders.¹⁵ Male nurses may experience gender bias at work from their patients and colleagues or through social stereotypes that question the masculinity of men entering the nursing profession.¹⁶ Such stereotyping has lead to poor recruitment of males into nursing, as well as unequal access of male nurses in their training and education.

Gender discrimination towards male nurses can also lead to unequal access during nurse education and training. Kouta and Kaite reported male nurses were prohibited from training in obstetrics and gynecology due to gender bias, causing male and female nursing students to have different learning experiences.¹⁰ Similarly, Patterson and Morin found male nursing students were unable to participate in providing postpartum care to maternal patients.17 Other factors, such as the very low proportion of male faculty in nursing and limited opportunities to work with male nurses in clinical settings, were also reported to have contributed to the male nursing students’ perception of gender bias during their nurse training.¹⁰ Interestingly, a study conducted by Olawaiye, Shelton, and Withiam explored gender bias toward male resident training in vaginal deliveries at a community hospital, and the researchers found no difference between male and female residents’ experience.¹⁸

Racial discrimination

Society has used race to create distinctions between people based on visible or other shared characteristics such as skin color or religious affi liations.¹⁹ Racial discrimination involves hostility towards members of particular racial groups enacted within organizations and institutions. In health care and nursing, racial discrimination still exist. In 2002, The American Nurses Association published a study conducted by Bessent, who surveyed more than 5,000 nurses, including African Americans, Hispanics, Asians, American Indians, and Caucasians. The survey found minority nurses experience barriers to their progress in nursing, and “59% of African American respondents, 53% of Asian respondents, and 46% of Hispanic respondents” reported feeling they were denied a promotion because of their ethnicity.20 Results from the survey also identifi ed barriers to career advancements, which include educational, institutional, personal, and professional obstacles. This data is consistent with data from the United Kingdom. For example, in Kingma’s 1999 study, black nurses in the United Kingdom with matching qualifi cations and experience lagged at least fi ve years behind in career progression compared with their white counterparts.¹ In addition, blacks and minority ethnic groups in the United Kingdom are underrepresented in nurse manager and senior leadership positions.²¹ Similarly in the United States, Hispanics and African Americans are underrepresented in nursing leadership positions when compared to the general population.¹³

Race also plays a role in nurses’ salaries in the United States. For example, among nurses earning more than $120,000 per year, more than 90% of these nurses are Caucasians; 4% are black, and only 2% are Hispanics or Asians.¹³

The Royal College of Nursing in the United Kingdom has acknowledged that institutional racism occurs in nursing.^22,23 Nurses in the United Kingdom described their experiences with racism as being negatively stereotyped by colleagues and the public, having patients reject their care, and being excluded from various opportunities.²³ In addition, research from Aston Business School and Lancaster University Management School in the United Kingdom both found National Health Service (NHS) organizations where bullied and discriminated against ethnic minority nursing staff reported poor staff engagement and patient experience. Nurses belonging to ethnic minority groups in the United Kingdom also reported unfair treatment in the workplace, such as being prevented from attending further training programs that their Caucasian colleagues would have otherwise been encouraged to partake in.²⁴

Literature on racial discrimination in the United Kingdom and United States demonstrate that nurses belonging to ethnic minority groups do not have equal access to job opportunities, career advancements, and training programs when compared to their white counterparts.

Lifestyle discrimination

Society’s prevailing heterocentric view has led to oppression and discrimination towards the lesbian, gay, bisexual, transgender, and queer/questioning (LGBTQ) community. Consequently, LGBTQ nurses may be perceived as “invisible” members of the nursing workforce, ignored and underrepresented in professional organizations and pathologized in the nursing curriculum.²⁵ This is supported by the fact that there is limited empirical literature on the experiences of LGBTQ nurses in the workplace.^25,26

Heterosexual nurses’ negative attitudes towards LGBTQ nurses are referred to as homophobia, biphobia, and transphobia.²⁵ LGTBQ nurses also experience discrimination from societal discourse and predominating heterocentric institutional values, beliefs, and practices. A study conducted in the United States by Randall as cited in Eliason et al., surveyed over 100 nurse educators and found 10% of the respondents thought lesbians should not be allowed to teach in schools of nursing. These negative attitudes towards LGBTQ nurses have led nurses to have concerns about disclosing their sexuality to coworkers.

A study conducted by Eliason et al. explored the experiences of 261 LGBTQ nurses in the workplace and found 22% of participants work in LGBTQ-unfriendly environments. Nurses in the study described experiences ranging from harassment and derogatory statements from colleagues about their sexual orientation to job losses or not having their contract renewed despite years of excellent performance reviews.²⁵

Another study conducted by Giddings and Smith explored the experiences of lesbian women in the profession of nursing. Many of the participants experienced homophobic reactions not only from heterosexual colleagues but also from “closeted” lesbian colleagues. One participant argued that lesbian nursing students chose to not disclose their sexual orientation to their faculty and classmates for fear of discrimination or being labeled as deviant. None of the participants discussed experiencing discrimination for career advancement because of their sexual orientation.

Disability discrimination

Having a disability presents many challenges for nurses and nursing students. There have been reported situations in which HIV-positive nursing students or nurses were expelled from their programs or terminated from their employment.1 The U.S. Equal Employment Opportunity Commission and the Americans with Disability Act defi ne disability as a “physical or mental impairment that substantially limits one or more of the major life activities,” including having a record and being regarded as having such an impairment. As recorded, the two major types of disabilities that put nurses in a disadvantaged position are learning disabilities and physical disabilities.

Research has revealed that nurses with physical disabilities sometimes feel compelled to leave the profession for fear of not “pulling their weight” or putting patients at risk. In a study conducted by Neal- Boylan that explored the exper ience of nurses and phys i c i ans with a physical and sensory disability, it was found that the nurses’ employment agencies did very little to accommodate the nurses’ disabilities or to retain them. In addition, the nurses reported the need to hide their disability from their patients and colleagues. Interestingly, both the nurses and physicians reported their colleagues seemed to have less compassion for them with regards to their disabilities, despite having a professional understanding of how the disability could be limiting them.27 Disability also narrows and alters career choices and trajectories for nurses with disabilities.

Nursing students with a learning disability may not have equal access to training programs that accommodate their learning needs. Although it is illegal for nursing schools to deny admission to an applicant because of a learning disability, nurse educators and mentors do not always have adequate knowledge on how to fully support the learning needs of students with a learning disability.²⁸ Once admitted to the program, it is the student’s responsibility to inform the school of any disability and request accommodations.²⁹ Yet, many students with a learning disability do not disclose it to their faculty for fear of being rejected or discriminated against.³⁰ Generally, efforts to meet the needs of students with disabilities include extra time to complete examinations, courses, or the program as a whole.²⁹ Modifying courses to best meet the learning style of the student is not always done. Studies have suggested that nursing students with a disability experience stigmatized and prejudiced attitudes from staff as well.³⁰

Oppressed group behaviors in nursing

According to Freire, there are five salient dimensions of oppressed group behaviors: “assimilation, marginalization, self-hatred and low-self esteem, submissive-aggressive syndrome, and horizontal violence.”³¹ Oppressed groups assimilate the values and norms of the dominant group, believing they will gain acceptance, recognition, and power if they become more like the oppressor.³¹ For example, nurse leaders tend to adopt the values and norms of the dominant group in an attempt to achieve those goals. Successful assimilators, such as nurse managers and administrators, become marginalized from both groups, as they still exhibit behaviors of the oppressed group and therefore are not able to become full members of the oppressor group. The oppressed group develops low self-esteem and self-hatred as they continue to internalize the values of the oppressor group. Submissive-aggression syndrome occurs when the oppressed group feels anger towards the oppressor group but is unable to express those thoughts and feelings freely for fear of reprimand. This occurs when nurses constantly complain about hospital policies or the physicians they work with, but rarely confront the oppressors. The nurses, feeling powerless but still attempting to exert some form of control, engage in destructive behaviors toward one another, such as bullying and sabotage. This phenomenon is called horizontal violence, an issue that plagues nursing today.

The submissive behaviors of nurses towards hospital administrators and physicians have evolved throughout history, leading to horizontal violence. These acts do not only involve overt behaviors such as physical violence, but include subtle behaviors such as gossiping, eye rolling, belittling or criticizing colleagues in front of others, and isolating colleagues during group activities.5 Horizontal violence is prevalent in nursing, and it negatively affects not only nursing recruitment and retention, but also patient outcomes.³²

Implications for nursing

There are many factors that contribute to oppression in nursing. Widespread change is needed in nursing, in the health care system, and in society at large to curb the problem. Empowering each nurse is a crucial starting point. For nurses, change must start with working toward developing the critical consciousness of nurses and other health care professionals. This would involve allowing issues to be brought to the forefront, refl ecting on the basis of generalizations and biases that inform thoughts and actions, and openly examining them.¹⁹ In this manner, individuals develop critically refl ective skills and consciousness begins by becoming aware of the extent to which they hold power, knowledge, and privilege in relation to other groups.¹⁹ Nurse educators can help their students develop a critical awareness by embedding refl ective exercises in the nursing curriculum, allowing the learner to engage in praxis.

To help decrease nursing bias, “nursing faculty members need to become sensitive to subtle incidents of gender bias that may have a signifi cant impact on student learning and success.” Nursing faculty must also become aware of male nurses’ contributions to the profession while evaluating texts, courses, and the curriculum for feminine nursing stereotypes.³³

To foster an understanding of the unique expertise and scopes of practice of different health professions—of how individual professions fi t within the trajectory of patient care—inter-professional education and collaboration must occur.³⁴ This is important to foster trust, respect, openness, and a positive attitude to other health care professions. Faculty in health care and hospital administrators must work together to create an environment that is supportive of inter-professional collaboration and education.

Within the health care setting, health professionals, including physicians, nurses, allied health, managers, and hospital administrators, must come together and develop policies to address discrimination, and eliminate abuse and disrespectful behavior in the workplace.⁵ Workplace diversity councils must be established to help support minority groups. There is also a need to develop programs to help minority nurses learn how to overcome discrimination “in the workplace, develop leadership skills that can open doors to career mobility, and negotiate with their employers to achieve more equitable treatment.”20 Health care leaders, including nursing leadership, must become more aware of the various resources available in the workplace and community to support nurses who are experiencing marginalization.³⁰ Training programs need to be established to allow staff to become more aware of wider systemic issues (such as gender bias, racism, LGBTQ issues, and disabilities) that contribute to discriminatory practices towards various nursing groups.

From a research perspective, there is a need to conduct research that describes the marginalization of certain nursing groups and its impact on nursing recruitment, staff retention, and patient outcomes. To highlight the unique contribution of nursing, it is important to conduct research on nursing-sensitive patient outcomes. Studies also need to be developed to further examine how nurses view and understand oppression and their beliefs on the most effective ways to address this issue.⁴

Lastly, nurses need to resist the oppressive status quo that is pervasive in workplace cultures.⁴ If individual nurses question and resist the status quo, then, as a group, their voices become stronger

References

1. M. Kingma, “Discrimination in nursing,” International Nursing Review, 46 (1999), 87–90.
2. P. Stevens and J. Hall, “Applying critical theories to nursing in communities,” Public Health Nursing, 9 (1992), 2–9.
3. R. Northway, “Disability and oppression: some implications for nurses and nursing,” Journal of Advanced Nursing, 26 (1997), 736–743.
4. D. Dong and B. Temple, “Oppression: a concept analysis and implications for nurses and nursing,” Nursing Forum, 46 (2001), 169–176.
5. J. Longo and R.O. Sherman, “Leveling horizontal violence,” Nursing Management, 38 (2007), 34–37; 50–51.
6. M.J. Birks, Y. Chapman, and K. Francis, “Women and nursing in Malaysia,” Journal of Transcultural Nursing, 20 (2009), 116–123.
7. World Health Organization, “Health Topics: Women’s Health,” (2010), www.who.int/topics/womens_health/en/.
8. J. Churchman and C. Doherty, “Nurses’ views on challenging doctors’ practice in an acute hospital,” Nursing Standard, 24 (2010), 42–47.
9. L. McDonald, Florence Nightingale at First Hand, York Road, London: 2010 Continuum UK.
10. C. Kouta and C.P. Kaite, “Gender discrimination and nursing: A literature review,” Journal of Professional Nursing, 27 (2010), 59–63.
11. Statistics Canada, “National survey of the work and health of nurses,”
12. J. Daly, S. Speedy, and D. Jackson, Contexts of Nursing (3rd ed.), 2010 Chatswood, AU: Elsevier.
13. R. Hader, “Nurse leaders: A closer look,” Nursing Management, 41 (2010), 25–29.
14. D.M. Wilson, “Meet the Men Who Dare to Care,” Johns Hopkins Nursing, 7 (2009)
    
15. K. Lunau, “The enduring stereotype of the male nurse,” Maclean’s, (2011).
16. BC Nurses’ Union, “Men in nursing,” (2011)
17. B.J. Patterson, K.H. Morin, and N. Colby, “The experience of being cared for by nursing students after giving birth.” Paper presented at NLN Education Summit, San Antonio, Texas: National League for Nursing, 2003.
18. A. Olawaiye, J.A. Shelton, and M. Withiam-Leitch, “Is there gender bias toward male residents in an obstetrics and gynecology training program?” Journal of Reproductive Medicine, 51 (2006), 479–483.
19. J.L. Johnson, J.L. Bottorff, B.A. Hilton, A.J. Browne, and S. Grewell, “Recognizing discrimination in nursing practice: fi ndings from a study of South Asian women and their health care providers in British Columbia,” The Canadian Nurse, 98 (2002), 1–6
20. H. Bessent, (2002). Minority nurses in the new century. Washington, D.C.: American Nurses Association.
21. A. Waters, “Statistics reveal that BME nurse managers are under-represented,” Nursing Standard, 26 (2011), 9; 20.
22. N. Lipley, “Facing inequality,” Nursing Standard, 13 (1999), 12–13.
23. P. Kendall-Raynor, “Action plan to support black staff as research shows racism persists,” Nursing Standard, 22 (2008), 6.
24. J. Myers, “Career progression is not without prejudice,” Nursing Standard, 26 (2011), 1.
25. M.J. Eliason, J. DeJoseph, S. Dibble, S. Deevey, and P. Chinn, “Lesbian, gay, bisexual, transgender and queer/questioning nurses’ experiences in the workplace,” Journal of Professional Nursing, 27 (2011), 237–244.
26. L.S. Giddings and M.C. Smith, “Stories of lesbian in/visibility in nursing,” Nursing Outlook, 49 (2001), 14–19.
27. L. Neal-Boylan, “An exploration and comparison of the work life experiences of registered nurses and physicians with permanent physical and/or sensory disabilities,” Rehabilitation Nursing, 37 (2012), 3–10.
28. S. Tee and M. Cowen, “Supporting students with disabilities— promoting understanding amongst mentors in practice,” Nurse Education in Practice, 12 (2012), 6–10.
29. L. Helms, J. Jorgensenn, and M.A. Anderson, “Disability law and nursing education: An update,” Journal of Professional Nursing, 22 (2006), 190–196.
30. D.J. Wright and V. Eathorne, “Supporting students with disabilities,” Nursing Standard, 18 (2003), 37–42.
31. L.K. Matheson and K. Bobay, “Validation of oppressed group behaviors in nursing,” Journal of Professional Nursing, 23 (2007), 226–234.
32. G. Corbin and C. Dumont, “Defeating horizontal violence in the emergency department,” American Nurse Today, 6 (2011), www.americannursetoday.com/article.aspx?id=8314&fid=8276.
33. A.S. Anthony, “Gender bias and discrimination in nursing education. Can we change it?” Nurse Educator, 29 (2004), 121–125.
34. Interprofessional collaboration, http://healthprofessions.dal.ca/