Effective Date: 2018
Status: Revised Position Statement
Written by: ANA Center for Ethics and Human Rights
Adopted by: ANA Board of Directors

Purpose

Discrimination in any form is harmful to society as a whole and in opposition to the values and ethical code of the nursing profession, which directs the nurse to “…respect the inherent dignity, worth, unique attributes, and human rights of all individuals” (ANA, 2015, p.17). Discrimination has several definitions in the Merriam-Webster Dictionary, including this one: “the practice of unfairly treating a person or group of people differently from other people or groups of people.” The purpose of this position statement is to reiterate the significance of a nondiscriminatory stance and provide guidance in creating inclusive strategies for nursing care of all individuals of all ages and from all populations.

Statement of ANA Position

The American Nurses Association (ANA) recognizes progress in most national efforts to eliminate discrimination associated with race, gender, and socioeconomic status through improving access to and attainment of health care, and quality of health care. However, concerted efforts must continue for discrimination to be eliminated in all of its forms. ANA recognizes impartiality begins at the level of the individual nurse and should occur within every health care organization. All nurses must recognize the potential impact of unconscious bias and practices contributing to discrimination, and actively seek opportunities to promote inclusion of all people in the provision of quality health care while eradicating disparities. ANA supports policy initiatives directed toward abolishing all forms of discrimination.

History/Previous Position Statements

Previous ANA position statements supported the elimination of discrimination in all of its forms. The position statement on Discrimination and Racism in Health Care (ANA, 1998) called for equality and justice at individual and population levels. The consequences of ignoring discriminatory behaviors and acts include an ever-increasing gap in health disparities and negation of our professional values. ANA position statement on The Nurse’s Role in Ethics and Human Rights (ANA, 2016) provided additional documentation in support of eliminating discrimination based upon the ethical obligations of nurses as outlined in the Code of Ethics for Nurses with Interpretive Statements. Numerous recommendations are outlined in the 2016 position statement with implications for individual nurses, the nursing profession, nursing education, nursing research, and health care organizations. This ANA position statement upholds previous position statements by denouncing discrimination of any kind.

Supportive Material

Discrimination exists when a person is treated unfavorably or unjustly according to a particular characteristic such as race, age, gender, or religion. There are many other characteristics for which discrimination can occur. For example, discrimination can occur on the basis of pregnancy, political affiliation, or military status. The list goes on and may change over time. To illustrate, we now recognize that family medical history and genetic testing can be used as a basis for discrimination. Attitudes and beliefs about personal characteristics in the forms of bias, prejudice, and stereotyping may influence behavior, but the actual act of discrimination, also known as intentional or blatant discrimination, occurs when an individual or group acts upon those attitudes and beliefs (Black, Johnson, & VanHoose, 2015; Gee & Ro, 2009). This form of discrimination may be manifested as microaggressions in the form of a microassault. Implicit or unintentional discrimination can be as detrimental as intentional discrimination, although it resides outside of the perpetrator’s awareness (Bertrand, Chugh & Mullainathan, 2005). Manifestations of unintentional discrimination in the form of microaggressions are unconscious behaviors considered to be rude, demeaning, or damaging to the individual or group. These microaggressions are further classified as microinsults and microinvalidations that disavow the experiences or beliefs of a group (Holley, Tavassoli, & Stromwall, 2016; Sue, 2010). For example, when negative stereotypes are expressed about men in nursing, male nurses may experience microinsults or microinvalidations (Brody et al., 2017).

Perceived Discrimination
When individuals believe that they have experienced discrimination based on personal characteristics, they may exhibit poorer physical and psychological health (Sutin, Stephan, & Terracciano, 2015). The link between perceived discrimination, racism, and health, including mental health, chronic health conditions, and personality development, has been a focus for greater understanding of health disparities among ethnic groups. The effects of perceived discrimination can affect the outcomes of health care, as those reporting this type of discrimination believe they are not receiving optimal care, may delay treatment, have difficulty adhering to treatment plans, and may experience internalized racism, creating ongoing stressors that further affect health status (Blendon et al., 2007; Carlisle, 2015; Williams, 2012). While some researchers have suggested that health disparities are due to socioeconomic status (SES), other researchers have found that disparities continue even when socioeconomic factors are taken into account. That is, regardless of SES, African Americans continue to be at greater risk for hypertension as well as other metabolic disease (Monk, 2015).

Health Disparities
The delivery of health care has long been associated with discrimination, either perceived on the part of the patient or actual or inadvertent on the part of the provider or institution (Reynolds, 2004). Hastert (2016) reported that the discrimination and resulting inequities in health outcomes were not related to income but to demographics, specifically race and ethnicity. However, Brooks et al. (2017) and Link et al. (2017) did demonstrate both a race/ethnic and socioeconomic impact on health and health outcomes. The grouping of these health outcomes is commonly referred to as health disparities (Lee, Ayers, & Kronenfeld, 2009). Stuber, Meyer, and Link (2008) suggested that stigma be included with prejudice as perceived causes of discrimination, and therefore poor health outcomes. Pascoe and Richman’s (2009) meta-analysis described the negative impact of a patient’s perceptions of discrimination regarding health care delivery on that patient’s actual health outcomes. Lee, Ayers, and Kronenfeld (2009) described how perceptions of discrimination led to a delay in seeking health care, resulting in poor health outcomes. Burgess et al. (2008) described an immense web of factors, including actual variations of illness among demographic groups, access to health care, and health care funding policies as reasons for health disparities.

ANA takes the position that it does not matter if an individual’s demographic is expected to have a higher incidence of illness. All patients should equally be screened for all health risk factors, including but not limited to elevated blood pressure, elevated blood glucose, HIV, changes in visual and hearing capacity, and proper body mass index; provide all applicable cancer screenings and mental health screenings; and receive all preventive health services, such as vaccinations.

Finally, ANA takes the position that discrimination has no place in nursing practice, education, or research. It has no place in health care. All patients are equal and should be treated with impartiality, respect, and civility. Civility is an active behavior that embodies mutual respect, promotes communication, and fosters collaboration among nurses and patients and the health care team (Lower, 2012). ANA takes the position that treating the illness or injury is important and the demographic or socioeconomic status should not influence the level of care provided. ANA takes the position that organizational policy that inadvertently supports discrimination is in error. It does not matter if it is an organization’s policy that discriminates or a policy in support of individual employees who discriminate; it is wrong and needs to be stopped.

Recommendations

ANA recommends implementation of the following activities:

• Intentional or blatant discriminatory practices must not be tolerated and must be immediately addressed.
• Nurses must engage in a period of self-reflection regarding their personal and professional values regarding civility, mutual respect, and inclusiveness, and resolve any potential conflicts in ways that ensure patient safety and promote the best interests of the patient (ANA, 2015).
• Nurses must seek out and support nursing practice environments that embrace inclusive strategies and promote civility and mutual respect regarding patients, coworkers, and members of the community.
• Nurses must advocate for policies that are inclusive and promote civility and human rights for all health care workers, patients, and others within the organization and community.
• Nurses must encourage all health care agencies to adopt and aggressively maintain policies, procedures, and practices that embrace inclusiveness, promote civility and mutual respect, contain methods for reporting violations, and require interventions to avoid recurrence.
• Nurses must work both within the profession and with other health care professionals, social workers, clergy, and advocacy organizations to create diverse, inclusive communities that promote, protect, and sustain high-quality, effective, efficient, and safe health care practices (ANA, 2010).
• Nurses in all environments and at all levels must embrace the concepts of justice and caring, diversity and inclusiveness, and civility and mutual respect as guiding principles within the provision of health care.
• Nurse researchers must support and conduct research that is inclusive in nature, including diverse populations and their health care needs.
• Nurse managers, supervisors, and administrators must assess policies to ensure support of inclusiveness, civility, and mutual respect, acknowledging that the lack of such policies may result in environments that fail to sustain high-quality, effective, efficient, and safe health care practices (ANA, 2010).
• Nurse educators must promote a diverse workforce by developing education practices to attract and retain students from all backgrounds. An increased number of diverse nurses in the workforce will begin to reflect the diversity of the overall population in the United States (Graham, Phillips, Newman, & Atz, 2016).
• Nurses must embrace a patient-centered approach responsive to the individual cultural needs and concerns of their patients and families (Cuevas, O’Brien, & Saha, 2017).

Summary

Discrimination continues to affect the health of populations. Discriminatory practices that are either intentional or unintentional must be addressed by individual nurses and the profession as a whole. Given the impact of unintentional discrimination based upon attitudes and stereotyping, all nurses must examine their biases and prejudices for indications of discriminatory actions. Health disparities continue to exist and are influenced by health policies, individual discriminatory actions, marginalization, and perceived discrimination by the affected population. The nursing profession is responsible for promoting an environment of inclusiveness where all receive safe, quality care, and caregivers are intolerant of any discriminatory practice.

Acknowledgment: ANA acknowledges Michele Upvall, PhD, RN, CNE, FAAN and Thomas Ray Coe, PhD, MBA, MHA, MS, RN-BC, NEA-BC, FACHE who contributed to the drafting of this document on behalf of the ANA Ethics Advisory Board.

Column Editor

Liz Stokes, JD, MA, RN
Email: liz.stokes@ana.org

Liz Stokes is the Director of the American Nurses Association Center for Ethics and Human Rights and demonstrates expertise in writing public policy on ethical issues including medical marijuana, assisted death, intellectual disabilities, and women's reproductive health. She is an international speaker on the Code of Ethics for Nurses is published in the Journal of Nursing Regulation and the Journal for Nurse Practitioners. Liz also serves as an Associate Editor for the Journal of Bioethical Inquiry. Liz's sphere of influence as a nurse-attorney combined with her education in bioethics enables a unique contribution to nursing, ethics, law, and policy.