The participants included 15 health service providers (2 physicians, 3 nursing supervisors, 2 head nurses, 4 clinical nurses, and 2 nursing assistants), and 3 hospitalized patients. The participants were aged between 32 years and 53 years. Table 1 presents the demographic details of the participants. The results showed four main categories: 1) habitual discrimination, 2) interpersonal relationships, 3) shortage of health care resources, and 4) favoritism (Table 3).
Table 3. “Discrimination in healthcare” with categories, subcategories, and open codes.
Category
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Subcategory
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Open code
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Involvement with discrimination
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Habitual discrimination
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Discrimination being routine in medical centers
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Ignoring patient rights
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Lack of trust in medical personnel
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Interpersonal relationships
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Expectations of acquaintances
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Respect for colleagues and friends
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Likelihood of similar situations
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Reciprocating people’s favors
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Shortage of health care resources
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Shortage of medical equipment and facilities
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Heavy workload
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Infrastructures of medical centers
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Lack of access to physician
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Favoritism
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Discrimination in care due to ethnicity
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Favoritism as a common method
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Ultimate solution to treatment problems
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Category one: Habitual discrimination
This category means that the phenomenon of discrimination in medical settings like hospitals is constantly experienced as a common and routine phenomenon, and health service providers and recipients consider it to be normal. This category consists of the following subcategories: 1) everyday discrimination in medical centers, 2) ignoring patient rights, and 3) low level of trust in medical staff.
1.1 Everyday discrimination in medical centers
This subcategory includes the discriminatory provision of medical services by physicians, nurses, and other health care providers to patients with different conditions. In fact, health service providers declared this as a normal, and even inseparable, part of providing health care in medical centers. For example, participant 3 described: “Discrimination happens in hospitals one hundred percent, and as a doctor, I differentiate between patients. My job is partly based on discrimination, and I consider various issues in my work”. (P3)
Moreover, participant 4 said: “Is no discrimination possible at all? People and the structure of medical centers are such that discrimination is observed in many areas, and its absence is almost abnormal”. (P4)
1.2 Ignoring patient rights
This subcategory is concerned with patients experiencing a lack of attention from medical staff during doctor’s visits and in matters such as patient’s condition and appointment time when patients attend medical centers and clinics to receive outpatient medical services. After such an experience, patients attempt to establish contact by searching for an acquaintance in these medical settings. One patient explained: “Given my condition, I consider it right to resort to favoritism. Perhaps, if the clinic’s appointment system worked properly, I wouldn’t be so inclined to do that. I made an appointment at a clinic and was told to come at a certain time, but, after arriving there, I had to wait for two hours and 45 minutes; why? Why shouldn’t they value my time? If that is the case, then I am forced to use favoritism, so that I can be seen quicker”. (P17)
1.3 Lack of trust in medical staff
In this subcategory, the participants stated that until there is total trust between medical staff (including physicians and nurses) and patients, discrimination between patients will persist in medical settings. In fact, patients not trusting physicians’ and nurses’ performance look for a mediator to be assured of the performance of health care providers. Participant 10 stated:
“For example, they tell us to be more alert; and not to leave the operating room for one moment, or keep checking the patient’s condition in ICU afterward; more accurate treatment and more checking; at the time of anesthesia, make sure that anesthetics are administered at the right dose, and the like”. (P10)
A patient in the cardiac critical care unit (CCU) stated:
“I can say that the only reason I come to this hospital is that my good friend, who is a nurse, works here, and I know that she knows her job at the CCU well. My mind is at rest because my friend is here, and I am sure that the things she does are definitely right. She will tell me if something is wrong, and somehow, I am fully informed about the treatment process”. (P15)
Category two: Interpersonal relationships
This category refers to instances where medical personnel favor their colleagues or family members of their colleagues and associates in providing health care because of their working relationships. This category consists of the following subcategories: 1) expectations of associates, 2) respect for colleagues and friends, 3) the possibility of the occurrence of similar situations, and 4) reciprocating people’s favors.
2.1. Expectations of associates
In this subcategory, medical staff described their discriminating conduct toward patients because of previous acquaintances with some of them, as well as the expectations of these acquaintances to receive exclusive and more health services. Participant 12 explained:
“Right now, I have a patient who is a young doctor from a province; she had gastrectomy, was taken to the operating room twice. She expects more as she knows more. She is a colleague after all. For instance, she asks for opioids, and at first, I tell her that she cannot have more, but she insists and I give her an injection in the end, but I worry about the risk of apnea. Or, colleagues come here and say that since they have been working in this hospital for so many years, they have certain expectations, and want them to be fulfilled”. (P12)
2.2. Respect for colleagues and friends
In this subcategory, medical staff (physicians and nurses) cited their friendly relationships with colleagues and their desire to maintain mutual respect and relationship with colleagues as the grounds for discriminating between patients in particular situations. When colleagues or their family members were hospitalized, the staff treated them differently compared to other patients and argued that the reason for providing different health care to this group was that they wanted to show respect toward colleagues. Participant 3 stated:
“For me, there is no difference between patients, whether I know them or not. But, when a colleague’s father is admitted, I may check over him more frequently, since it is a friend’s father after all, and we are in constant contact, and I am expected to attend to this patient more”. (P3)
2.3. Possibility of the occurrence of similar situations
This subcategory concerns the possibility that medical staff or their family members may find themselves in a situation where their colleagues in other medical centers could provide them with preferential and different care compared to other patients. Bearing this possibility in mind, medical staff provide their colleagues with preferential care. In fact, based on the idea that the same could happen to them, physicians, nurses. and other medical personnel provide different and fuller medical and nursing care compared to what they do for ordinary patients. Participant 4 stated:
“I attend more to a patient that is a relative of a colleague or a friend and attend to them with greater care and sensitivity. I do this because she is a nurse too, and one day one of my relatives can be hospitalized”. (P4)
2.4. Reciprocating people’s favors
According to this subcategory, the medical staff show discriminatory behaviors in providing preferential care and services to reciprocate for favors they have received from their colleagues in the past. Participant 9 said:
“I do this for my colleagues and friends, because of the friendship I have with them. I jump the queue to make an appointment for my friend’s mother because she has done the same for me in the past or will do so in the future. It is like give and take. I make up for her trouble”. (P9)
Category three: Shortage of health care resources
This category deals with essential items needed for providing health care to patients and visitors, but the shortage of resources, which is seen and experienced by both recipients and providers of medical services, leads to discrimination between patients. This category includes the following subcategories: 1) Shortage of medications and medical facilities and equipment, 2) heavy workload, and 3) lack of access to physicians; and 4) medical centers’ infrastructures.
3.1. Shortage of medications and medical facilities and equipment
In this subcategory, shortage of medical equipment such as ventilators and ICU beds and also vital medications, on which patients’ health depends, creates a situation in which these services are provided preferentially to people who are in a particular condition or are associated with or recommended by a particular person or organization. The shortage of medical equipment also causes physicians and nurses to unintentionally differentiate between patients. For example, participant 6 explained:
“Better care is provided in intensive care units than in regular wards because in the wards, I, as a nurse, have eight to ten patients to care for; one of them is intubated, and I don’t have the time or even a monitor to constantly check the patient. There, I am forced to differentiate between patients, and can only attend for two hours of the entire 12-hour shift to this patient because I don’t have the time or the necessary equipment”. (P6)
3.2. Heavy workload
The shortage of physicians, nurses, and other health service providers leads to non-provision of the necessary care and even reduced quality of services and subjects the medical staff to heavy workloads. This forces them to discriminate in providing health care. Participant 9 stated:
“As a head nurse, human resources are especially important to me. The quality of work drops when there is a shortage of manpower, and if there are some favored patients in the ward as well, a significant part of the human resources are spent on them, which affects the quality of care for other patients, and they are less attended to since there are only a few of us”. (P9)
Participant 6 stated: “I have ten patients as the internal ward nurse, and one of them is intubated, how am I supposed to attend to all of them? I am forced to discriminate between them and attend more to those in better conditions. I have no choice because there are only a few of us” (P6).
3.3. Lack of access to physicians
In this subcategory, based on their experiences, nurses cited a lack of access to physicians as one of the reasons for discrimination between patients. Since the probability of a patient’s family members meeting the physician is usually very low, they try to find other ways to be more in touch with the physician. Participant 8 said:
“My brother had an accident and was hospitalized in this hospital. Because of my job and contacts, I was fully in touch with the ward and could meet my brother’s doctor, and so they were more attentive and sensitive to his condition”. (P8)
Also, participant 17 stated:
“The anesthesiologist came to my bedside and asked me if I knew so and so person, and I said yes. So, he told me not to worry, and everything would be done perfectly. At the time of operation, when I was highly stressed, this was very reassuring. People’s presence in the operating room helped me control my stress, and their treatment was different since they knew that I was an acquaintance of this person”. (P17)
3.4. Medical centers’ infrastructure
In this subcategory, serious deficiencies, mainly physical, in the infrastructure of medical centers were identified as a facilitator of discrimination in health care. Congestion of visitors seeking outpatient clinical and paraclinical services, caused by inefficient queuing systems, unsuitable physical conditions, and similar factors, drove visitors to seek medical services through other means. Participant 17 stated:
“For example, why do they ask patients to be at the hospital at 6 o’clock? Why not ask one to come at 6.15 and so forth? When I see that my time is wasted and no one has any respect for my time, then I resort to nepotism and don’t feel guilty about it” (P17).
Participant 16 stated:
“I have a fear of MRI, so I asked to be anesthetized, but the staff at the imaging department told me that there was not such an option, while there was, but they did not want to go through the trouble. Thanks to recommendations from someone I knew, my MRI was done comfortably with anesthesia. I didn’t want to resort to that at first, but I was forced to, and if I had no connections, perhaps I could not do the MRI at all”. (P16)
Category four: Favoritism
This category comprises favoritism as a common and almost unavoidable issue in providing health care so that knowing someone in a medical center is one of the main reasons for choosing that center. This category mentions that finding an acquaintance in a medical center is the main concern of the patients and visitors. This category includes the following subcategories: 1) discrimination in care because ethnicity, 2) Favoritism as a common practice, and 3) favoritism as the ultimate solution to treatment problems.
4.1. Discrimination in care because of ethnicity
This subcategory mentions that medical staff regard ethnicity as a factor in providing medical care and provide better services to people of their ethnicity. Participant 13 stated:
“Where my patients come from is important to me, whether they are from the same region as me. If they are, then I feel that they have been deprived of their rights; they have spent so much money to travel from their hometown to here, and all in vain. I feel obliged to help them in any way that I can”. (P13)
4.2. Favoritism as a common practice
This subcategory mentions favoritism by the staff, as well as by patients and visitors to health care centers, as a common and normal way of receiving medical services, so that the first thing visitors do in order to be hospitalized and receive services is to find an acquaintance, who will ultimately accelerate the provision of health services. Participant 15 stated:
“Since I am a friend of the head nurse, my work is done more rapidly, A few years ago, I had to be hospitalized in another hospital, where I knew no one, and therefore, I had to remain there for ten days. But I think if I knew someone like my friend there, things would have gone faster, and I would have been discharged earlier. Here, tests are done quickly, and the results come in, but it was not like that in the other hospital”. (P15)
Participant 16 said:
“Fortunately, I had no problems as I knew someone in the hospital who put in a word for me, and I was easily admitted, and things were done straight away. Surely it would not have been so easy otherwise. If you don’t have a connection, things are delayed, or you are not hospitalized at all. It is usually like that, otherwise, I or a patient would be less attended to”. (P16)
Participant 13 stated:
“There is discrimination and favoritism in admitting patients. A patient is admitted earlier, or someone rings at night to emphasize to pay more attention to a particular patient, or even comes to the hospital for the sake of that patient. But this is not done for a lot of patients. At the very most, they may ring or discharge the patient by phone. They would not visit the patient face-to-face. Another thing is ICU admission, which is highly nepotistic, and not just any patient is admitted to ICU. Some patients are admitted, and some are not”. (P12)
4.3. Favoritism as the ultimate solution to treatment problems
This subcategory points out that recipients and providers of medical services consider finding an acquaintance a strategy and a solution to their problems. The patient and medical staff both believe that having an acquaintance could help them in medical settings.
Participant 18 stated:
“As the emergency head nurse, I am frequently contacted when an intensive care bed is needed. I assess the patient and if they are likely to die, then I am not much inclined to admit them, so I tell them that there is no bed. An hour later, someone I know rings me on behalf of the patient, so I release the bed” (P18)
Also, participant 16 stated:
“Overall, I think having an acquaintance is very necessary, particularly in the matters of treatment, and with the help of a contact, things progress much better and easier, both qualitatively and quantitatively. I was given more information because I knew someone. For instance, they asked the emergency doctor to write the MRI request on insurance forms, which reduced the costs a lot compared to the noninsured service. But this is not done for all patients”. (P16)
Participant 17 stated:
“I went to the clinic and I was already listed, so I was the first to be visited, which was excellent. For example, test results come in faster, or when I ring to book a time for the ultrasound, I am given a late appointment, but then I ring an acquaintance and I am the first in the queue. Ultrasound is terribly busy, but even there I am the first or second to be served. All this is because of having a friend at the hospital, otherwise, it will be exceedingly difficult”. (P17)