Culture of discrimination in healthcare: A grounded theory

Abstract

Background

Discrimination in health care is an international challenge and a serious obstacle to justice and equality in health.

Research objective

The purpose of this study was to design a grounded theory of discrimination in health care based on the experiences and perceptions of Iranian healthcare providers and patients.

Research design

This qualitative study was conducted using by the grounded theory method.

Participants and research context

Data were collected through semi-structured interviews with 18 healthcare providers including 11 nurses, two physicians, two nurse’s assistants, and three patients in two general hospitals in Tehran, Iran. Participants were selected through purposeful sampling and analyzed simultaneously using the Corbin and Strauss (2015) approach.

Ethical considerations

The study was approved by the Research Ethics Committee of the University of Social Welfare and Rehabilitation Sciences (Ethics code: IR.USWR.REC.1398.023). Also, after explaining the objectives of the study, all the participants completed and signed the written consent form.

Findings

The “culture of discrimination” was the study’s core category, reflecting the nature of discrimination in health care. The theory of “culture of discrimination in health care” is the result of five main categories: “individual social stimuli,” “culture of discrimination,” “unintentional discrimination,” “conflict with discrimination,” and “dissatisfaction with discriminatory behavior.” These categories cover the underlying factors, strategies, and outcomes of the discrimination process in health care.

Discussion

The results of the study showed that nurses and other health care providers experience unintentional discrimination. Unintentional discrimination refers to discriminatory behaviors and practices of health care providers.

Conclusion

The theory of culture of discrimination in health care can be used as a practical guide to describe and understand the role of health care providers, especially nurses. Further studies with a quantitative approach to applying this theory in medical settings are recommended.

Keywords

Justice discrimination grounded theory delivery of health care

Introduction

Research in the field of justice and equality in health care as one of the principles of bioethics has always been of interest to researchers all over the world. Accordingly, the phenomenon of discrimination in health care is known as the opposite of justice and equality. On the other hand, discrimination is formed gradually and based on the process and based on socio-cultural interactions, it is important to explore this process, its effective factors, and its outcomes. This study explores and describes the process of discrimination in health care based on the experiences of health care providers, especially nurses, and based on Iranian society and culture.

Background

Discrimination in health care means lack of providing or providing incomplete health care based on intrinsic characteristics such as age, gender, race, religion or social characteristics such as income level and socio-economic status. However, receiving medical services fairly and without any discrimination is an important principle of human rights and also in line with the principle of justice and medical ethics.¹⁻³ Discrimination in health care is observed in various forms such as ageism, racism, sexism, discrimination based on religion and language and even based on the nature of the disease which in all of its forms, people’s access to health services is reduced.⁴⁻⁶ On the other hand, discrimination in health care is recognized as a major obstacle to health justice and is experienced as a serious challenge in most developed and developing countries.^6,7 For example, one-third of the U.S. population has experienced discriminatory behavior at least once while receiving medical care. In the European Union, among the elderly over the age of 60, 26% occasionally and 11% have always experienced discriminatory age-related behaviors. Immigrants to different countries are another group of people who experience discrimination in health care and the reason for such discriminatory behaviors by health care providers in medical settings is racial and ethnic differences.^6,8,9

The experience of discrimination in receiving medical services leads to various negative outcomes, both physically and mentally, which are mainly due to the stress after experiencing discrimination in receiving medical services. But perhaps it can be said that the main outcome of the experience of discrimination in health care is to reduce the trust of community and patients to health care providers such as physicians and nurses. In fact, after experiencing discrimination, people do not have complete confidence in the next visits. They understand that the process of follow-up and treatment is incomplete, and eventually, they are no longer willing to continue treatment or follow-up.¹⁰⁻¹²

Preventing discrimination in health care is defined as one of the goals of the World Health Organization. In this regard, various programs and strategies are planned and implemented. Perhaps the most important of these interventions is the emphasis on teaching the principles of medical and nursing ethics to healthcare providers, the emphasis on identifying discriminatory behaviors in medical settings, and also reporting such discriminatory behaviors.^3,13

Despite the various policies that have been implemented to control and eliminate discriminatory behaviors in medical settings, the provision of medical services is still associated with discrimination.¹⁰ It seems that one of the reasons for the ineffectiveness of measures taken to prevent discrimination in health care is less attention to different contexts and socio-cultural contexts that lead to discriminatory behaviors by health care providers.¹⁴ In fact, it can be said that any of the discriminatory behaviors in medical settings can be affected by the socio-cultural conditions and differences of members of the same community.¹⁵ Accordingly, a complete and comprehensive knowledge of the phenomenon of discrimination can help to identify the factors affecting the formation of discriminatory behaviors. The literature review also shows that the most studies in the field of discrimination in health care have been conducted with quantitative approaches, while the phenomenon of discrimination in health care is affected by social interactions and qualitative studies that examine individuals’ experiences of various phenomena can identify the underlying and hidden layers of the social phenomenon of discrimination. Recognizing these hidden layers will be effective in formulating strategies and policies to prevent discrimination in health care. Therefore, this study was conducted to design an underlying theory of discrimination in health care based on the experiences and actions of Iranian health care providers and patients.

Materials and methods

The most appropriate research approach for this study was one that could provide access to the nature, structure, process, and determinants of discrimination in health care in its context, therefore, a qualitative research method with a grounded theory approach was used to conduct this study.^16,17

The research setting consisted of two hospitals in Tehran, Iran, one of which was a public teaching hospital and the other was a private non-academic one. Both hospitals provide specialty and subspecialty medical services. The reason for this choice was the difference in the quality of medical services provided in public and private hospitals.

Participants

Up to date saturation participants were 18 healthcare providers who were employed in two general hospitals in Tehran, selected using purposive sampling with the highest diversity in terms of demographic characteristics (age, sex, work experience, etc.). Table 1 shows the demographic characteristics of the participants. Also, three patients who were selected as participants in this study were hospitalized in medical and surgery wards. All of them had stable physical and mental conditions.

Table 1.

Demographic characteristics of study participants.

Number	Age (Year)	Gender	Marital status	Education level	Work experience (Year)	Ward
P1	38	Male	Married	Master’s degree	16	Nursing office
P2	32	Female	Single	Bachelor	8	Gynecological surgery
P3	40	Male	Single	Doctor of medicine	16	Emergency
P4	53	Female	Married	Bachelor	28	Nursing office
P5	52	Female	Married	Bachelor	25	Nursing office
P6	33	Male	Married	Bachelor	8	Intensive care unit
P7	32	Male	Single	Bachelor	10	Intensive care unit
P8	35	Female	Married	High school diploma	12	Urology
P9	38	Female	Married	Bachelor	15	Orthopedics
P10	48	Male	Married	Doctor of medicine	22	Intensive care unit
P11	36	Male	Married	High school diploma	10	Orthopedics
P12	48	Female	Married	Master’s degree	25	Urology
P13	42	Female	Single	Bachelor	16	Clinic
P14	39	Female	Married	Bachelor	15	Medical
P15	54	Female	Married	Bachelor	25	Medical
P16	41	Female	Single	Master’s degree	16	Clinic
P17	38	Female	Married	Master’s degree	10	Gynecological surgery
P18	40	Female	Married	Bachelor	16	Emergency

Data collection

The main method of data collection was semi-structured and in-depth interviews. All interviews were conducted in a calm environment and after full explanations about the objectives of the study and obtaining consent. The interviews were recorded using an Mp3 Player and then was written word for word on paper. The interviews began with a brief explanation of the participants' personal characteristics and work experience by themselves and with this open-ended question; “Have you ever been in a situation where you could differentiate between patients? The next question was asked based on the answers provided by the participants. During the interviews, exploratory questions were also used to explore the participants’ experiences more deeply, so that the participants could tell all their experiences about discrimination in health care. The interviews continued until the participants believed that there was nothing left to say. Finally, with the question “Does anything else come to your mind that you want to express?” and “If you have something in mind, you can call my number.” The interviews ended.

All interviews were conducted face to face by the first author. In the last two interviews, no new data were obtained consequently data collection was ended after 18 interviews. Duration of interviews was between 20 and 65 min. Box 1 presents the main and exploratory questions during interviews.

Box 1. The questions during interviews.

The main questions are as follows:

1. Have you ever been in a situation where you could differentiate between patients?

2. When was the last time?

3. Could you please tell me how it was?

4. How do you make this difference in patient care?

The exploratory questions:

1. What causes this difference between patients?

2. What do you mean?

3. Please explain more? How?

4. What was your reaction to this difference between patients?

Data analysis

In grounded theory, data collection and analysis are performed simultaneously. In other words, data analysis is performed after the first interview. Therefore, subsequent interviews were performed based on the analysis of previous interviews. Each interview was listened to carefully and after implementation on paper and typing them, the text of the interviews was entered into MAXQDA software. The 2015 Corbin and Strauss coding process was used to analyze the data.¹⁸ The five stages of coding during this process are 1) open coding, 2) development of concepts in terms of features and dimensions, 3) analysis of data based on context, 4) input of the process in analysis, and 5) category integration.

At first, the text of each interview was read several times and key concepts were extracted and coded using the words and phrases that the participants themselves said (The first stage). After that, the emerging codes were examined and analyzed with the aim of developing concepts, and finally, the initial classification of concepts, characteristics and dimensions of each of them were determined (The second stage). Then, the concepts that were categorized in the previous stage were analyzed with the aim of discovering the underlying concepts of discrimination in health care (The third stage). Next, the obtained concepts were analyzed to discover the reactions and strategies that the participants adopt in the face of discrimination in healthcare and the relevant concepts were identified (The fourth step). Finally, all the memos and the emerging concepts were reviewed, as a result of this stage, the core category that covering the other categories was identified and presented as an integrated theory (The fifth stage).

Data rigor

In this study four supporting processes of trustworthiness were applied, namely 1) conformability, 2) dependability, 3) credibility, and 4) transferability. Credibility was confirmed by selecting the appropriate data collection method for the interviews. The researchers interviewed participants for their experiences in their practice environment. Furthermore, member check was used to prolong the involvement of the researcher to increase the credibility of the data and, after encoding, the interview transcripts were returned to the participants to ensure the accuracy of the codes and the relevant interpretations. Dependability was established by detailed and descriptive data analysis and direct references to the professional experiences of the individual. The conformability and consistency of the analysis were maintained through research team meetings to discuss and dissect the preliminary findings. Thematic analysis and the coding process occurred through consensus, and to increase the transferability of the findings, a description of the context, selection, and demographic data of the participants, data collection and the analysis process was presented so that the reader would be able to determine whether the results are transferable to other environments.

Ethical considerations

This study was approved by the Research Ethics Committee of the University of Social Welfare and Rehabilitation Sciences. (Ethics code: IR.USWR.REC.1398.023). Also, participants studied and signed the informed consent form for participating in this study. They were assured of the confidentiality of the information, and that the participants could withdraw from the study anytime.

Findings

The result of data analysis in the present study was the emergence of 873 primary codes. The number of codes was reduced by identifying similar and repetitive items. The codes were classified based on common features, consequently 59 subcategories were emerged. Similarly, after merging the classes and contemplating the meaning of the data and the related primary classes, 16 main subcategories were formed. Finally, continuous comparative analysis of data led to the emergence of five main categories including; “individual-social stimuli,” “culture of discrimination,” “unintentional discrimination,” “conflict with discrimination” and “dissatisfaction with discriminatory behavior.” These categories cover the underlying factors, strategies, and outcomes of the discrimination process in health care.

Individual-social stimuli

Four subcategories were extracted from this category including “physical conditions of patient,” “social level of patient,” “patient awareness of their rights,” and “financial concerns.” According to the experiences of participants, these concepts fueled discriminatory behaviors among health care providers such as nurses and nurse’s aides

Physical conditions of patient

This concept means how the physical condition, type, and nature of the disease in patients cause discrimination in health care. In the data analysis, the participants applied different behaviors and discrimination in health care based on what kind of disease the patient is suffering from and whether its nature is acute or chronic and also how much care is currently required. In addition, age and the poor prognosis of the patient and its condition is another case where health service providers discriminate.

Social level of patient

This concept pays attention to the position and social status of the patient, its job, or even the companions of the patient. For example, doctors, nurses, and assistant nurses were more willing to care for patients with good financial status, who have a special personal reputation due to their socio-political status, and they provided care in a different way for these patients.

Patient awareness of their rights

Based on the experiences of participants, healthcare providers when faced with a patient who does not know much about its illness or is not fully familiar with rights as a patient, they treated them differently.

Financial concerns

The experiences of the participants showed that health care workers who have financial problems provide better and higher quality care in exchange for receiving money or tip from patients, while they do not treat other patients in this way. The analysis of the data showed that nurses’ assistants are more involved in financial problems compared to other health care workers.

Culture of discrimination

The experiences of the participants show that the beliefs in Iranian society and some beliefs among the people of Iran indicate the formation and institutionalization of discrimination in health care, and the occurrence of different behaviors and receiving these services in a different way and with better quality. Three subcategories were extracted from this category including “preferable patient,” “favoritism,” and “changing cultural norms.”

Preferable patient

Based on the experiences of the participants, one of the characteristics and indicators of the institutionalization of discrimination in Iran’s health system is the existence of patients and clients who are considered as preferable and special patients.

The analysis of the experiences of health care providers showed that preferable patients are emphasized and given special attention by different people such as managers, which ultimately leads to a change in the care of patients by nurses and other healthcare providers.

Favoritism

This concept is another indicator of the culture of discrimination in Iranian society and includes “favoritism” as a current and well-known term, norm, normal and almost inevitable in the provision of health care. Based on the experiences of the participants, doctors, nurses and assistant nurses provide nursing care and medical services of a much higher quality in the form of a favoritism to their friends and family members. This favoritism can be seen in forms such as ethnicism in Iranian socio-cultural interactions.

Changing cultural norms

Based on the participants’ experiences, differentiating between patients and actually discriminating between them is becoming a norm in Iranian society. In fact, it is a natural phenomenon that some patients receive higher quality care compared to other patients due to a series of intrinsic and non-intrinsic factors.

Unintentional discrimination

The experiences of the participants showed that health care providers such as nurses are working in situations where they unintentionally discriminate in health care and these discriminatory behaviors are not acceptable and based on their desire. Two subcategories were extracted from this category including “mandatory acceptance of conditions” and “directed discrimination.”

Mandatory acceptance of conditions

According to the experiences of the participants, nurses and assistant nurses discriminate in the care of patients due to reasons such as fear of managers, maintaining their status and job position. However, these cases mainly happen when preferable patients receive a lot of attention and emphasis from managers.

Directed discrimination

This concept means that health care providers are directed towards discriminatory behavior based on the context that exists. Factors such as: “low monitoring of ethical practice,” “low ability to enforce professional nursing ethics codes,” “limited knowledge of medical and nursing ethics principles,” and “lack of prior justice in health.”

Conflict with discrimination

Two subcategories were extracted from this category including “lack of healthcare resources” and “interpersonal relationships.”

Lack of healthcare resources

The daily experience of discrimination in the care of patients occurs due to the lack of some resources needed to provide it, a condition that is normally necessary to provide fair and non-discriminatory care, while the lack of these resources itself provides a platform for discrimination. Based on the experiences of participants, in the conditions of lack of health care resources, differences are made between patients, and some patients are deprived of receiving health services simply because of some inherent characteristics (age, sex, nationality, decease and etc.) or lack of social or political characteristics, and are placed in the next priority.

Interpersonal relationships

The analysis of the participants’ experiences showed that according to the type of working relationships and cooperation with each other, if each other is admitted to the hospital or needs medical services, they receive these services more appropriately and with better quality compared to other patients.

Dissatisfaction with discriminatory behavior

Participants react and respond in different ways when faced with discrimination in health care. Their main reaction was dissatisfaction with discrimination in patient care and discrimination becoming a normal issue. Three subcategories were extracted from this category including “forced acceptance of the situation,” “tolerance of stress,” and “coping with the situation.”

The main concern

The participants’ main concern was the “favoritism” and then the change in health care delivery. In fact, the starting point of the discrimination process in health care is the favoritism. Health care providers establish respectful communication and change the type and quality of care for preferable patient. In this regard, the nurse of the gynecology department stated: “When they call from the nursing or management office that a patient is customized, well, you have to respect more and watch over the patient.” (Participant no. 3)

The ICU nurse also about discrimination and customizing the patient said: “For example, colleagues or a physician has customized a patient, this happens a lot and makes the patient follow up faster, physicians and nurses are more sensitive to the patient. It is more accurate.” (Participant no.7)

The nurse assistant of surgery ward also said “A patient who has been customized from somewhere, such as a nursing or management office, I know that I have to do more care for him/her. For example, a simple case is that when the patient comes down from the bed, it is not necessary to change the sheets, but for this customized patient it must change.” (Participant no. 8)

The context

The process of culture of discrimination takes place in the context of underlying concepts. In other words, study participants, including nurses and physicians, work in a context that encourages discriminatory behaviors when providing medical care. After analysis, the underlying concepts of unintentional discrimination in health care were identified at three; individual, social and national levels. These concepts include “preferable patient” and “limited knowledge of the principles of medical and nursing ethics” (at the individual level), “interpersonal relationships” (at the social level), and “lack of health care resources” (at the national level).

Preferable patient

The preferable patient is an individual who is introduced in medical settings according to his/her individual-social status or familiarity with health care providers and causes a change in the type, amount and quality of health care. Nurses, after encountering a preferable patient as it is expected, pay more attention and consider more sensitivity and accuracy in patient care. Also, during hospitalization the health care is provided with higher quality and quickly. In this regard, the clinical supervisor said “We have different types of preferable patients, a custom model of which I am your colleague, or they customized by higher levels of the organization. They are among politicians and they are the officials of the country, they have high positions and are customized in this way.” (Participant no. 5)

Limited knowledge of the principles of medical and nursing ethics

Lack of knowledge of medical ethics and lack of learning these principles during education and professional activity cause health care providers to pay less attention to these principles and suffer from discrimination in providing health care.

“Whether or not I as a nurse differentiate between patients depends on how much I know about medical ethics. How familiar I am with moral codes. In some hospitals, physicians and nurses do not know much about ethics and how to follow it. They do not know what some of them are, so when we do not know exactly what they are, it is not practical to implement them either.” (Participant no.1)

Interpersonal relationships

The type of relationships that health care providers had in their workplaces emerged as grounds for discrimination in health care. They behaved differently when their friends, acquaintances and family members needed medical care. Also, the expectations of people who were familiar with health care providers led to different behaviors in providing services. In fact, being a colleague and having previous acquaintances leads to discriminatory behaviors in health care.

“Of course I do this myself for my friends and colleagues because of the friendships I have. I got an appointment for my friend’s mother in our own hospital out of turn, because he/she has either done this for me before or I need him/her in the future. It’s like a trade. I will make up for it.” (Participant no. 3)

Lack of health care resources

Participants state that when faced with various challenges such as lack of manpower, lack of medicine and medical equipment, the ground for differences between patients and discrimination in health care is created. In fact, when resources are limited, medical care is not provided fairly. The anesthesiologist said in this regard:

“There are very few ICU beds, there are some patients who need a bed and there are some who do not, but well they are customized from somewhere and it makes me consider many things while transferring the patient to the ICU.” (Participant no. 10)

“It may be a medicine that cannot be found, and we try our best to find it for customized patient. But for a patient who is a stranger or not custom, it is very easy to say that we do not have it at the moment and whenever it comes, your work will be done. Or anything else we can easily put off.” (Participant no. 4)

The action/reaction (strategies to overcome the discrimination in healthcare)

The participants used a wide range of strategies to combat and manage discrimination in health care. Their main strategy was a “culture of discrimination,” in fact the “culture of discrimination” was the core category of this study. A culture of discrimination reflects a set of strategies that health care providers use them consistently in the face of discrimination in health care. These strategies include “forced acceptance of the situation,” “tolerance of stress,” and “coping with the situation.”

Forced acceptance of the situation

Health care providers use this strategy when faced with discrimination. This strategy means that, due to their various circumstances, such as maintaining their current position, threatening their job, fear and coercion from their superiors, they accept to perform discrimination in health care.

A clinical supervisor said, “in order to maintain their job position nurses have to respect more and this is the request of the organization. They do it out of compulsion.” (Participant no. 4)

The ICU nurse said, “We are asked, if we have a solution, we will reject many cases, I can say it is not voluntary, many times I do not like this, many times I disagree in language for example, they say this is customized, I say well, it is. But in practice, I had to differentiate between this patient and the others, because I am working in this system.” (Participant no. 7)

Tolerance of stress

Participants express their grief and dissatisfaction in the form of feelings of guilt, fear, anxiety, and lack of interest in patient care when they practice or observe discrimination in health care. The head nurse of the internal medicine ward said, “Sometimes I do this difference and then I regret it and I do not feel well, sometimes when you resist and do not do it, you are finally forced to do it again.” (Participant no. 12)

One of the nurse assistants said: “I do not like working with a preferable patient, I do not feel good, I am generally afraid that I do something wrong and the head nurse will treat me badly.” (Participant no. 8)

Coping with the situation

This is another strategy of health care providers in the face of discrimination, opposition from participants, as well as protest from the patient or companions when observing and practicing discrimination. Some participants object when faced with discrimination and do not discriminate in health care. The anesthesiologist said, “Whoever the patient wants to be, I do not care much if it is a customized or not, I disagree to differentiate between patients. As far as possible, I do not practice this difference between patients and I deal with the customized patient normally.” (Participant no. 10)

The clinical supervisor said, “Other patients and companions realized that there was someone here who was special. This is not good image and it is not right, but, well it exists. After a while, they realize this and think that we do not take care of their patient and constantly protest; what is the difference between our patient and that patient and such issues.” (Participant no. 5)

One of the nurses said, “For example, it happened a lot during the appointment hour; the patient’s companion says I am a physician and should have more time, the one who is a normal person comes and protests and shouts: because He/she’s a doctor, you allow her to stay more and do not respect me. This causes division between patients and fighting in the ward.” (Participant no. 2)

Factors affecting the process of culture of discrimination in health care

The main factors in the emergence of a culture of discrimination were lack of healthcare resources as well as the financial concerns of health care providers, while professionalism was recognized as a deterrent to discrimination in health care.

Lack of healthcare resources

As previously mentioned, health care providers, including nurses, have problems in providing fair and equal care without discrimination in situations where they are faced with a lack of resources such as human resources, medicine, and medical equipment. Lack of healthcare resources and, on the other hand, the existence of preferable patients aggravates discriminatory behaviors in the provision of medical care.

Financial concerns

The poor economic situation of health care providers, especially nursing assistants, is one of the features of this concept. Nurses’ assistants in this study stated that due to unfavorable financial conditions, they are forced to provide more services to some patients and receive tip in return. In the general view, in Iranian society, in private hospitals compared to public hospitals, patients pay tips to some employees, especially nurse’s aides, in order to receive medical services faster and with better quality.

“I work in three hospitals, but still have a problem. When I see that there are patients who like to pay money, I put more energy to get something.” (Participant no. 8)

Professionalism

Professionalism is related to the learning of the principles of medical ethics by health care providers including physicians, nurses, assistant nurses and others. Professionalism as a deterrent includes the practical implementation of the principles of medical ethics, respect for patient rights, prioritizing human dignity, and promoting justice in the provision of medical services.

“As slogans and words, it is beautiful that two patients who sleep together in two beds should not be different for us, one is a municipal sweeper and the other is the president. This is a slogan; the reality is not like this.” (Participant no. 5)

Outcomes

Minimal care

The participants responded to the culture of discrimination in health care through a variety of strategies. The end result of these reactions was determined as minimal care. This indicates various aspects of providing inappropriate and low quality care to the patient. In fact, minimal care means that patients only receive some basic care while their conditions require higher levels of care and not just common care.

The surgical ward nurse said, “When I have a preferable patient, I have to devote most of my time and energy to it. I have to take care of him/her more carefully, to visit him/her quickly and not rest properly. All this makes me impatient with other patients and I would like my shift to end sooner.” (Participant no. 9)

Based on the participants’ experiences, the culture of discrimination in health care causes minimal care. In minimal care, discrimination has been institutionalized and has become a norm, and it leads to extensive consequences for patients, and perhaps the most important of these consequences are the reduction in the quality of nursing care, the reduction of patient trust in health care providers, and ineffective patient education.

Brief story line

The main concern of the study participants was the favoritism. Their most important strategy in dealing with this concern was the culture of discrimination, which was in fact the central variable of the study. Favoritism and financial concerns were the most important factors facilitating the culture of discrimination. The final outcome of culture of discrimination was minimal care.

Discussion

The aim of this study was to explore the process of discrimination in health care in Iranian health providers and patients. The results of the study showed that nurses and other health care providers experience unintentional discrimination. Unintentional discrimination refers to discriminatory behaviors and practices of health care providers. These discriminatory behaviors are based on conditions and factors that force nurses and health care providers to do them, or these factors lead them to such discriminatory behaviors. In this study, most participants stated that in different situations and according to circumstances, they have to discriminate in providing health care. In fact, participants stated that they were forced to make unethical decisions when providing health care, for reasons such as fear and coercion by superiors. Kligyte et al. pointed out that fear, anxiety, and anger can lead to inhibition of moral decision-making.¹⁹

Lack of health care resources was one of the underlying causes of discrimination in health care. Participants in this study stated that when faced with challenges in their work situation such as high workload, lack of medical equipment such as vital medicines, they unintentionally differentiate between patients and display discriminatory behaviors in the provision of health care.²⁰⁻²² In fact, health care providers, based on their professional duty, tend to observe ethics in the provision health care, but the question arises, how? How can they provide high quality and ethical care with the shortage of health care resources? In fact, they have no choice but to abandon some of these ethical principles when providing health care, because according to the existing conditions, physical care is a priority and attention to ethical principles such as justice is given less attention. The challenge of lack of care resources such as manpower, equipment, medicine, or physical infrastructure of medical centers has been a global challenge and main concern of health organizations in recent decades, which leading to issues such as physical and mental damages, job dissatisfaction, Job burnout and the more importantly moral challenges.^21,23,24

Based on the experiences of the participants in this study, physicians and nurses, due to the friendships they have with their colleagues, provide medical services to them in a different form and quality than other patients. The reason of participants of this study for this kind of discrimination was the expectations of their colleagues, compensation for their efforts, or even the possibility of such situations occurring for themselves or their family members. It seems that this type of interpersonal relationship causes lack of attention and discriminatory and unfair behavior in some aspects of patient care, however, in medical settings; proper professional communication is an effective factor in providing complete and reliable health care to patients.²⁵

“Preferable patient” refers to a person who, due to his/her (social-political) position or through communication with a person among the administrative-therapeutic staff of clinical setting, has influence and can receive health care with a different quality than other people in the community.

Rooddehghan et al. define a preferable patient as a very important patient (VIP). According to this definition, preferable or VIP patients are given priority in receiving medical services and health care. Preferable patient is one of the underlying causes of discrimination in health care in medical settings and it is completely contrary to the principles of medical ethics and the Charter of Patients' Rights. It is against the principles of professional medical ethics that a person has more access to health care resources due to his/her special status such as political position, managerial and executive position. This is one of the main obstacles to the establishment of justice and equality in health.^26,27

The core category of the study was the “culture of discrimination,” this concept refers to the institutionalization of discrimination in health care provision and in fact, discrimination has become part of the culture of health care. The culture of discrimination as the main strategy is composed of concepts such as “forced acceptance of conditions” and “organizational pressure,” which shows the serious weakness of moral and human performance in this field, which is unacceptable in comparison with national and international standards. Providing health care in which institutional discrimination has become a culture leads to widespread harm to providers and recipients of health services and its end product can be considered as reducing the quality of health care.²⁸

Nurses and other participants used adaptation strategies in response to discrimination in health care delivery. “Forced acceptance of conditions,” which is related to the work environment of physicians, nurses and other health care providers, creates a situation in which these people cannot consider the four principles of bioethics, especially the principle of justice in the provision of health services. The participants of the present study stated that it is due to the pressure of managers and officials that they differentiate between patients while providing health care. In fact, it can be said that health care providers can have a positive or negative approach and result in order to implement the principles of bioethics. Dehghani quotes from Penino as saying that the factors influencing the observance of professional ethics are divided into three aspects as follows: 1) personal aspect (personal characteristics, religious values, and family conditions) 2) organizational aspect (leadership, management, communication with colleagues, system of encouragement and punishment, organizational culture, etc.), and 3) environmental aspect (economic, social, and cultural factors). Penino believed that the organizational aspect is more important because it has the ability to control and make more changes.¹⁴

“Stress tolerance” and “coping with the situation” are other strategies used by participants in the face of discrimination. The pressure on medical staff by managers to do things that are contrary to the principles of medical and nursing ethics reflects the ethical principles that govern an organization such as a hospital. In fact, the ethical behavior of managers in the health service system is a predictor of professional ethics observance. Nori Kaabomeir quotes Douglas as saying; if managers and senior executives follow ethical principles in the workplace, there will be an ethical climate that can affect other people in the organization. According to a survey by the Business Ethics Institute, managers’ adherence to ethical principles can reduce employee misconduct by up to 50%. Also, the ethical decision of medical staff is influenced by factors such as fear and anger.²⁹

According to the reactions and coping mechanisms that the nurses in this study chose in response to the culture of discrimination in health care, it can be stated that in some way they experience moral distress in providing nursing care. When nurses are placed in situations where they cannot provide care based on ethical principles, they experience various ethical challenges, especially moral distress. One of the situations where nurses cannot perform nursing care according to nursing ethics standards is favoritism and discrimination in nursing care. In fact, nurses experience moral distress in seeking to cope with discrimination, which itself has many negative consequences for nurses.^30,31

Data analysis shows that the main outcome of the culture of discrimination in health care is “Ignoring the patient” and reducing the quality of health care. When nurses and physicians discriminate in the provision of health care for any reason, the result of this discrimination is damage to the quality of health care from the perspective of other patients. Quality of health care means achieving the most desirable health outcomes so that the care provided is effective, efficient and appropriate. As a result, any factor that is effective in implementing health care processes can also affect the quality of health care provided. As mentioned in the literature, discriminatory behaviors and discrimination in providing health is serious obstacle in providing quality health care.^25,32

Declining patient trust in health care providers as one of the dimensions of “Ignoring the patient,” points to the phenomenon of discrimination in health care in medical settings and following the experience of both providers and recipients of health care, it causes patients to be afraid of not receiving quality health care and ultimately do not have the necessary and sufficient confidence in health care providers.³³

Studies show that patients who are more confident in their therapist are more likely to ignore treatment errors and are more satisfied with health care. Various factors affect the trust between the patient and the physician-nurse. In a qualitative study by Faizi et al. the two categories of “professional characteristics” and “ethical principles” in building trust and confidence between patients and health care providers were explained. Ethical principles such as confidentiality, honesty and equality in health care have played an important role in creating the confidence.³⁴ Trust between patient and physician is a great social capital and an effective factor in patient recovery and satisfaction. One of the main components of trust between the patient and the physician is the physician’s moral commitment to implement the principles such as confidentiality, accountability and equality in treatment.³⁵

“Declining ability to care for the patients” is another outcome of the culture of discrimination in health care. Data analysis of this study showed that when nurses provide discriminatory care, they do not have the ability to provide care for other patients. The presence of preferable patient in medical settings seems to be one of the reasons and takes a lot of time and energy of the nurse and the nurse assistant. On the other hand, most of the preferable patients, due to being special, have more expectations from the health care provider, which causes more workload to be imposed on the health care provider.

This study has faced some limitations, this study was conducted in Iran based on the culture and values of this society, and the experiences of the participants in this study cannot be generalized to other health care providers with different cultures. In addition, the human experience is dynamic, and nurses’ occupational and work environments change with educational, political, economic, and social conditions and expectations of health care. Therefore, it is suggested to conduct other studies with a qualitative approach in other cultures to explore the experiences of health care providers, especially nurses, regarding discrimination in health care.

Conclusion

The “culture of discrimination in health care” theory offers a new perspective on the “what” and “how” of discrimination in the provision of health care in medical settings. This theory holds that there are three strategies for dealing with discrimination in health care including “forced acceptance of the situation,” “tolerance of stress” and “coping with the situation.” Given the fact that combating discrimination in health care is one of the main goals of the World Health Organization in the coming years the “culture of discrimination in health care” theory can be used as a descriptive guide to expand the role of nurses in preventing and controlling discriminatory behaviors in health care.

This study was performed in a hospital environment and in Iran, the experiences of nurses and other health care providers in this environment was evaluated, therefore, the findings may not be compatible with non-hospital settings.

Footnotes

Acknowledgements

This study was extracted from a Ph.D thesis in nursing approved on 29 May 2019 in University of Social Welfare and Rehabilitation Sciences. The researchers would like to sincerely thank all participants in this study including physicians, nurses and nurse aids.

Declaration of conflicting interests

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

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iDs

Mohammadjavad Hosseinabadi-farahani

Eesa Mohammadi

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