Equity-

oriented

approaches:

Possibilities for Supporting Integration

of Internationally Educated Nurses

Goals

– Offer a snapshot of the discrimination faced by nurses in the workplace

– Consider the particular challenges faced by Internationally Educated Nurses

– Offer “equity-oriented” strategies for preventing and responding

Argument

– Discrimination is known to be harmful on health both directly (e.g.

hypertension) and indirectly (e.g. access to resources);

– Interpersonal and structural forms of discrimination are continuous with one

another; we all have relationships to these forms of discrimination;

– Nurses face multiple forms of discrimination, varying with their social

positioning;

– IEN nurses in particular face considerable discrimination;

– Equity-oriented approaches can help prevent discrimination at the

organizational and individual level, and mitigate the impact.

Some terminology…

Structural Violence

…the often mundane systemic exclusion and disadvantage that is built into everyday social patterns and institutions, social forces “that drive up the risk of ill health for some while sparing others, [becoming] embodied as health and disease among individuals” (Farmer, Kim, Kleinman, & Basilico, 2013, p. 9).

…suffering is ‘structured’ by historically given (and often economically driven) processes and forces that conspire- whether through routine, ritual, or, as is more commonly the case, the hard surfaces of life- to constrain agency. For many, including most of my patients and informants, choices both large and small are limited by racism, sexism, political violence, and grinding poverty” (Farmer, 2003).

Trauma

Experiences involving disruption in trusted relationships as the result of violence, abuse, war or other forms of political oppression, or forced uprooting and dislocation from one’s family, community, heritage, and/or culture”

Mason et al, 2012

Race and Ethnicity

“race” and “ethnicity” are both socially constructed

categories, capturing how not only skin color but also

culture, accent, or religion can be defined as a marker of

“otherness” (Nagel, 2003).

Racializing

…the social process by which people are labelled according to particular physical characteristics or arbitrary ethnic or racial categories, and then dealt with in accordance with beliefs related to those labels

(Agnew, 1998).

Discrimination

Discrimination in health care

-widespread, well-documented

-based on race, ethnicity, age, income, stigma related to particular

health issues (e.g. mental health, obesity, certain forms of cancer, HIV

status, substance use)

-continuous with, reflective of, and contributes to wider social

discrimination

-literature is predominantly concerned with recipients of care

Discrimination against nurses

In the context of nursing, a “feminized”, “white” profession with Christian and military roots:

– Nurses experience discrimination based on gender, professional status,

– Racialized nurses experience racism intertwined with these other forms of discrimination

– Significant literature on racial discrimination against nurses (e.g. from Ethel Johns to Das Gupta and beyond)

– Includes continuity between structural (e.g. pay, advancement, assignments) and interpersonal forms

– Violence is intertwined with discrimination

Discrimination faced by IEN

Racial discrimination(systemic, interpersonal)

Anti-immigrant discrimination(systemic, interpersonal)

Practice setting

Discrimination for IEN in Canada

IE “Physicians rarely reported instances of discrimination in communication with patients or nurses. Instead, they were concerned with instances of discrimination within their own professional group. Nurses, on the other hand, reported discrimination at the hands of patients and their families as well as racialization by physicians, management, and other nurses”.

Neiterman & Burgeault, 2015

…racialized nurses, when, too afraid of

backlash, refuse to report experiences of

abuse.

The fear is there . . . Depending on the . .

. level of abuse . . . “Do I report it or do I

silently bear it because I am who I am . . “

Choiniere et al, 2015

Type A: Isolate Type B: Small group

Type C: Direct institutional

Type D: Indirect institutional

• Intentionally harmful action by a dominant group individual against subordinate members

• Not embedded in a largescale organizational setting

• Intentional harmful actions taken by small subgroup of the dominant group against subordinate members

• Discriminatory actions by the small group are not supported by the majority in the organization, or may be supported to a low degree in a less extreme form

• Intentionally harmful actions and/or negative effects toward subordinate group

• Embedded in large-scale organizations

• Actions are organizationally prescribed

• Manifested through formal or informal rules, policies, or procedures carried out routinely by large numbers of employees

• Both the policies and the actions to carry them out are considered forms of discrimination

• Neither prejudice nor intent to harm but impose negative effects on subordinate group

• Embedded in large-scale organization or community, which prescribes practices

• Past-in-present discrimination: e.g., applied age restrictions or use of remote employee history for hiring and job promotions

• Side effect discrimination: e.g., using school credentials for hiring or promotion when some minorities never had the opportunity to earn those credentials

From Tuttas, 2015: Discrimination Typology (Feagin & Eckberg, 1980).

Racial discrimination – what

keeps it alive?

We are all embedded in a world of

inequities, including race-based

thinking, that we are encouraged to

ignore – to protect privilege

Racial discrimination – what

keeps it alive?

Whiteness

– “Whiteness” is an ‘ideology’, not

just a property of individuals

– “White” people generally do not

think of themselves as a group or

acknowledge themselves as racial

actors

– Implicit, subconscious bias

Colour blindness

– “I treat every one the same”; “I don’t see colour”

– Supports overlooking discrimination; blame inequities on those who experience them

– “White respondents avoided acknowledging how they are implicated in racial inequality in health care” (Malat et al 2010).

What can be done?

Equity-oriented approaches

What is an ‘equity-oriented’

approach?

Inequities are

– Unfair

– The result of social

arrangements

– Potentially remediable

Thus requires action at level of

– Individual

– Organization

– Society

At the level of our own thinking:

Choose how to develop our own relationship to race/racism/whiteness:

-Blindness to privilege OR silent awareness OR active alliances

-no need for guilt or defensiveness

Don’t conflate “culture” (which is highly complex) with race or ethnicity

Avoid simplistic “cultural” explanations for behaviours

Think of culture, including the culture of health care, as dynamic and

changeable

Believe complaints of discrimination (don’t downplay, explain away, defend)

In our own interpersonal

interactions:

Learn how to and challenge stereotypes:

“It sounds like you think nurses from the Philippines have inadequate education…”

Correct misperceptions:

“they actually have more required clinical hours and a stronger emphasis on IPR…”

Learn how to and respond to bias:

“hold on a minute…”

10 Strategies to Guide Organizations in Enhancing Capacity for Equity-Oriented Services

• Explicit commitment to equity

• Supportive structures, policies, and processes

• Revision use of time

• Attend to power differentials

• Tailor care, programs and services to context

• Actively counter oppression

• Promote community + patient participatory engagement

• Tailor care, programs and services to histories

• Enhance access to social determinants of health

• Optimize use of place and space

Key Dimensions of Equity-Oriented Services

Inequity-Responsive Care

Contextually-Tailored Care

Trauma- and Violence-Informed Care

Culturally Safe Care

Harm Reduction

At the level of

organizations

– Healthcare institutions need to ensure that they have policies in place

addressing discrimination against nurses.

– All healthcare personnel need training to work with colleagues of different

ethnicity and nationalities and to manage discriminatory interactions.

– Supervisors may need more training to support nurses and manage

discriminatory interactions, including those interactions originating from

patients and their families.

Wheeler 2014

At the level of society:

– Immigration policy

– Licensing exams

– Pay equity

“I was quite impressed . . . they seemed to be walking the talk . . . had not only

policies, but . . . approaches . . . of sensitizing individuals in management . . . to

follow through . . . where people are not afraid to come out and say, ‘these are the

abuses I’m experiencing’”

Choiniere et al, 2015

References

Anstey, K., & Wright, L. (2014). Responding to discriminatory requests for a different healthcare provider. Nursing Ethics, 21(1), 86-96. doi:10.1177/0969733013486799

Baptiste, M. M. (2015). Workplace Discrimination: An Additional Stressor for Internationally Educated Nurses. Online Journal of Issues in Nursing, 20(3), 1-1. doi:10.3912/OJIN.Vol20No03PPT01

Choiniere, J. A., MacDonnell, J., & Shamonda, H. (2010). Walking the Talk: Insights Into Dynamics of Race and Gender for Nurses. Policy, Politics & Nursing Practice, 11(4), 317-325. doi:10.1177/1527154410396222

Farmer, P., Kim, Y. J., Kleinman, A., & Basilico, M. (2013). Introduction: A biosocial approach to global health. In P. Farmer, Y. J. Kim, A. Kleinman & M. Basilico (Eds.), Reimagining global health: An introduction (pp. 1-14). Berkeley and Los Angeles, CA: University of California Press.

Farmer, P. E. (2003). Pathologies of power: Health, human rights, and the new war on the poor. Berkeley, CA: University of California Press.

Koch, J., Everett, B., Phillips, J., & Davidson, P. M. (2014). Diversity characteristics and the experiences of nursing students during clinical placements: A qualitative study of student, faculty and supervisors' views. Contemporary Nurse: A Journal for the Australian Nursing Profession, 49, 15-26. doi:10.5172/conu.2014.49.15

Malat, J., Clark-Hitt, R., Burgess, D. J., Friedemann-Sanchez, G., & Van Ryn, M. (2010). White doctors and nurses on racial inequality in health care in the USA: whiteness and colour-blind racial ideology. Ethnic & Racial Studies, 33(8), 1431-1450. doi:10.1080/01419870903501970

Moore, J., & Continelli, T. (2016). Racial/Ethnic Pay Disparities among Registered Nurses (RNs) in U.S. Hospitals: An Econometric Regression Decomposition. Health Services Research, 51(2), 511-529. doi:10.1111/1475-6773.12337

References continued

Neiterman, E., & Bourgeault, I. L. (2015). The shield of professional status: Comparing internationally educated nurses’ and international medical graduates’ experiences of discrimination. Health: An Interdisciplinary Journal for the Social Study of Health, Illness & Medicine, 19(6), 615-634. doi:10.1177/1363459314567788

Nichols, J., & Campbell, J. (2010). The experiences of internationally recruited nurses in the UK (1995-2007): an integrative review. Journal of Clinical Nursing, 19(19/20), 2814-2823. doi:10.1111/j.1365-2702.2009.03119.x

Nielsen, A.-M., Stuart, L. A., & Gorman, D. (2014). Confronting the cultural challenge of the whiteness of nursing: Aboriginal registered nurses' perspectives. Contemporary Nurse: A Journal for the Australian Nursing Profession, 48(2), 190-196. doi:10.5172/conu.2014.48.2.190

Tuttas, C. A. (2015). Perceived Racial and Ethnic Prejudice and Discrimination Experiences of Minority Migrant Nurses: A Literature Review. Journal of Transcultural Nursing, 26(5), 514-520. doi:10.1177/1043659614526757

Wheeler, R. M., Foster, J. W., & Hepburn, K. W. (2014). The experience of discrimination by US and Internationally educated nurses in hospital practice in the USA: a qualitative study. Journal of Advanced Nursing, 70(2), 350-359. doi:10.1111/jan.12197