The consequences of nurses’ endeavors to overcome inter-professional discrimination

Introduction

Discrimination is a situation in which individuals enjoy unequal rewards in return for the equal roles they play. ¹ Discrimination is observed in different aspects of service provision where members of a social group suffer from stigmas attached to them and limit their business and social life. ² Under discriminatory conditions, there is no opportunity for equal social mobility for different individuals, and they have unequal situation in education or employment. ¹

All organizations and groups including agencies that offer healthcare and nursing services traditionally face discrimination. In the nursing profession, discrimination has led to the formation of some taboos that impact the professional development of individuals. ³ Enjoying equal opportunities in the working environment and fair non-discriminatory behavior by applying suitable procedures and policies is part of the rules recognized and approved by the nursing federation. ⁴

Justice in the organization represents employees’ perceptions of fair treatments in workplace. ⁵ Justice is one of the requirements for any kind of social participation. Continued presence of people in groups depends on their perception of the way fairness is observed. ⁶

Justice is the first virtue of social institutions and social justice is a concept of fair and just relations between the individual and society. ⁷ Social injustice can be described as a situation in which the dominant population is made known of the inequity of others due to their relative position in the structure of power and discrimination. ⁸

Discrimination is an issue that might cause undesirable consequences such as psychological stress, feeling of exhaustion, and suppression in individuals, which are reported repeatedly. These negative feelings prevent individuals from achieving their desired goals. ^9,10

Nurses experience psychological or moral distress when they do not feel competent or when their colleagues assume their nursing activities are at a lower level than the desired state. ¹¹ Groups of individuals, who have traditionally faced discrimination, try to fight against it and create justice in social systems. ³ The stressful nature of injustice makes individuals become inclined to revengeful behavior in terms of emotion and excitement and leads them to turn to behaviors such as negligence, working less, aggression, reducing the quality or the quantity of work, reducing the level of commitment, creating tension or conflict, and leaving an organization. ¹²

Experiencing organizational injustice puts employees under serious stress and pressure from different aspects. ⁷ Individuals react to unfair behavior differently. A significant part of these reactions is harmful to an organization and leads to negative consequences. ^10,13

Understanding how people judge justice in their organizations and how they react to perceived justice or injustice is a critical topic to understand organizational behavior. Collaboration and team work are among vital elements of nursing. ⁹ Increasing collaboration among nurses is essential to maintain a secure and safe therapeutic environment. ¹⁴ However, discrimination prevents relationships, cooperation, and exchange of data and has negative consequences for patients such as the occurrence of adverse conditions, medical errors, endangering patents’ safety, and low-quality care. ^11,15

Few studies have been conducted in the area of organizational justice in the nursing population. ¹⁶ Consideration of the issue of discrimination as an influential factor and the responses of individuals to confront them in the intra-professional collaboration is of particular importance. Research results note discrimination as one of the main concerns of nurses in their intra-professional collaboration process, ¹⁷ and nurses have used strategies to overcome it. ¹⁸ Strategies lead to outcomes. This study assessed nurses’ experiences to explore the consequences of Iranian nurses’ strategies to overcome intra-professional discrimination.

Methods

Participants

In this study, considering the nature of collaboration and to reach a comprehensive perception of applied strategies, participants were selected from among nurses currently employed at hospitals. In all, 25 (19 females and 6 males) participants participated in the study, including 20 nurses, 4 head nurses, and 1 nursing service manager, with a mean work experience of 11.8 ± 6.9 years and an age range of 22–46 years, with a mean age of 34.8 ± 7.1 years (see Table 1).

OPEN IN VIEWER

Table 1.

Demographic characteristics of the study participants.

Participant no.	Age (years)	Gender	Occupation	Work experience (years)
P1	27	Female	Nurse	4
P2	31	Female	Nurse	8
P3	22	Female	Nurse	2
P4	46	Female	Nurse	18
P5	27	Male	Nurse	5
P6	34	Female	Nurse	13
P7	36	Female	Nurse	15
P8	29	Female	Nurse	8
P9	34	Male	Head nurse	10
P10	35	Female	Nurse	16
P11	36	Female	Head nurse	10
P12	38	Female	Head nurse	16
P13	23	Female	Nurse	2
P14	25	Female	Nurse	2
P15	26	Female	Nurse	2
P16	38	Male	Nurse	19
P17	45	Male	Nursing service manager	25
P18	36	Female	Nurse	13
P19	31	Female	Nurse	8
P20	45	Female	Head nurse	23
P21	35	Female	Nurse	10
P22	30	Male	Nurse	8
P23	45	Female	Nurse	20
P24	36	Female	Nurse	17
P25	39	Male	Nurse	21

Results

The classification of results based on data analysis showed that the strategies employed by nurses to overcome inter-professional discrimination lead to the consequences ranging from “seeking justice,” with the features of “vindication of the rights” and “feeling valued,” to “passivity,” with the characteristics of “feeling worthless” and “escape from work” (Table 2).

OPEN IN VIEWER

Table 2.

The process of obtaining theme from categories and subcategories.

Theme	Categories	Subcategories
Seeking Justice	Vindication of the rights	Enjoying benefits
		Feeling of equality
	Feeling valued	Self-esteem
		Satisfaction
Passivity	Feeling worthless	Extinction
		Frustration
	Escape from work	Feeling incapable
		Losing job commitment
		Lack of interest in work
		Leave the profession

The consequences result from practical, interactive, or emotional responses to events and answer the question, “What happens in case of practical, interactive, or emotional responses?”

Discussion

Actually the participants use different active and inactive strategies to overcome the perceived psychosocial issue which have led to some consequences. The consequences are ranging from seeking justice to passivity.

In this study, justice is based on the vindication of the rights and feeling valued. In vindication of the rights, if the efforts lead to the intended benefits such as the promotion of a job, receiving rewards, or having the feeling of equality, in other words, noticing differences in them, it can be said that they have achieved what they deserve. Parallel to vindication of the rights, a person feels valued, which is followed by self-esteem for scientific and practical empowerment and increase in confidence to provide superior healthcare that results in self-satisfaction. Thus, it can be said that a person feels valued through receiving his own rights. Obviously, achieving justice will be an incentive for more individual effort in achieving organizational goals, including communicating with team members and providing more careful attention.

The feeling of individual success and mastery in doing tasks create a positive attitude in nurses; these individuals will also feel stronger and more dominant in performing their tasks and will have better insights into their jobs while gaining a sense of self-esteem. As stated by Zahednezhad et al., ⁵ understanding the organizational justice among the health workers is associated with well-being, attitude, and performance of the staff. If employees’ services are not fairly compensated, it is likely that their confidence and feelings of capability would weaken.

In this study, passivity is the opposite point of seeking justice and is the other consequence of the strategies used by the participants in the study, which indicates a failure to achieve the desired outcome. Its characteristics imply a reduction in self-esteem in the form of extinction, meaning loss of motivation, and the avoidance of effort and frustration caused by the lack of noticing and non-settlement of problems that lead to escape from work; it is felt as a feeling of incapability of performing work that results from mental disability, loss of job commitment, lack of interest in work, and ultimately abandonment of service. In other words, observing organizational justice, the way nurses behave and treating them regarding the distribution of rewards and fair procedures lead to an increase in the level of psychological empowerment of nurses, ⁵ and the perception of injustice in workplace affects various behaviors of employees, including destructive, anti-production, and retaliatory behaviors. ¹³

Psychological stresses and feelings of helplessness and frustration in individuals have been repeatedly reported as undesirable consequences of discrimination, and these negative emotions impede the achievement of desirable goals in individuals. ⁴

In fact, discrimination is among hypocritical behaviors (any inappropriate behavior, exposure, or conflict in a range from verbal abuse to physical abuse); hypocritical behaviors are among the barriers of professional communication and collaboration such that the effect of the hypocritical behavior between nurses, doctors, and other members of the care team has prevented communication, collaboration, and information exchange and has had reverse effects on the patient’s dynamics and outcomes, including the occurrence of adverse events, medical errors, compromising patient safety, and low-quality cares. ^11,23 In other words, justice leads to the integrity of people and injustice causes division between people. ⁶

Nurses also experience psychological or moral distress when they do not feel competent or when their colleagues presume their nursing activities below the desired level. ¹¹ All these issues cause the loss of one’s motivation to strive for presenting the right and fair service; it can become intolerable at a specific time and might lead to leaving the service. This is when collaboration has been considered as the most important factor in preserving and maintaining nurses.

Disappointment, lack of motivation, lack of strength and unwillingness to try, and feeling frustrated from lack of participation in organizational affairs are reported as consequences of discrimination in other studies, ⁹ which reduces the commitment of individuals to organizational values and goals. In fact, loss of motivation to stay good and continue to try and work can be seen in the participants of this study.

The findings of this study regarding the failure to meet the expectations of nurses and the lack of access to justice that leads to their service abandonment resemble the results of a study by Atashzadeh Shouride et al. regarding nurses leaving the profession. In their grounded theory qualitative study, they have referred to issues such as professional/managerial challenges that include dissatisfaction with the nursing profession, management weakness and inappropriate social status of the profession, failure to meet financial needs, lack of access to welfare facilities, non-commitment to profession, nursing heavy workload, inappropriate managerial feedback, uncertainty, inaccurate evaluation of nurses’ performance, lack of clarity in the rules and regulations of the nursing profession, discriminatory implementation of the rules for nurses, disproportionate rewards with nurses ‘performance, authoritarian management practices in nursing, and lack of nurses’ job promotion conditions. They also referred to occupational stress and burnout. ²⁴

In fact, workplace justice is a protective factor of nurses leaving their current profession, and poor workplace justice could negatively affect workers’ psychosocial perception and is the primary motivating factor of nurses’ intention to leave. ¹⁰

In total, it can be said that the fair treatment of individuals, in other words, establishment of organizational justice, is a vital principle for working in social systems in today’s civilized world. ⁶ The concept of justice in organization implies equality and ethical behavior, and organizational justice implies the perception of employees regarding the correctness or incorrectness of the company’s governance and employees’ behavior. ²⁵ This concept is known as a code of ethics in nursing, and nurses are required to observe ethical codes such as not doing harm, kindness, independence, justice, and care ethics in patient care. These issues are essential not only in relationships of nurses with patients but also in their relationships with other nurses and other members of the care team. ^3,11

Studies on factors affecting motivation, performance, survival, and maintenance of the staff within healthcare systems show that these staff have lost their motivation due to poor job development, development prospects, lack of positive monitoring and guidance, feedback, and recognition, which have led to a feeling of lack of support and a lack of value in them. ¹⁰ The concern is that if they are not adequately protected or motivated, it will affect the quality of care. ^12,15 Justice is a basic human need and only nurses who have themselves experienced equity can provide their patients the experience of equity. ¹¹

The findings of this study, based on the participants’ statements, confirm the results of the mentioned studies, so they perceive the experience and perception of discrimination in the organization as an effective factor in how they collaborate with others; thus, they have stated that discrimination leads to loss of motivation for cooperation, work in the clinic, and even the intention to leave service. While observance of justice is one of the most important factors affecting the survival of the organization and maintaining its health in the long run, it is one of the basic requirements of organizational behavior that increases the sense of belonging, loyalty, and trust of individuals to the organization, on human and social capital of the organization. ^5,6 Empirical evidence also confirms that fairness perception is directly related to important organizational attitudes and behaviors, such as the intention to leave a job, ¹⁰ and it is also related to a better understanding of organizational justice, with higher satisfaction, more commitment to the work location, and behaviors beyond duty. ^6,9 This is what managers and practitioners should take into consideration at all levels of management.