DOI: https://doi.org/10.21203/rs.3.rs-684145/v1
Background: Although the need for justice and the elimination of injustice (or discrimination) is now a universally accepted principle, discrimination is still an unpleasant experience for many nursing students. This study aimed to explain the experiences of nursing students of educational discrimination and find out the main factors that cause this feeling.
Methods: This is a qualitative study conducted in the nursing faculty of Shahr-e-Kord and the Iran university of medical science (IUMS) in Iran. Twelve nursing students were selected by purposeful sampling method and were interviewed. All interviews were analyzed according to the content analysis method.
Results: Three main themes and ten subcategories appeared. Extracted themes include: "inappropriate behavior of nursing professors (or instructors) " with 3 subcategories (1- discriminatory behavior by nursing professors (or instructors), 2- lack of sufficient self-confidence in nursing professors and transferring it to the student, and 3- the educator role in motivating or eliminating motivation); "Strict rules" with 3 subcategories (1- inequality in implementation of rights and rules among students of different disciplines, 2- differences in compliance with laws and regulations, and 3- nurses are being strictly monitored), and " Lack of nursing professional independence " with 4 subcategories (1- lack of authority, 2- lack of supportive organizations for nurses, 3- lack of proper social status of nursing in society, and 4- the high authority and power of physicians over other disciplines).
Conclusions: In our study, it was shown that nursing students feel the most discrimination in front of medical students. Feelings of discrimination reduce self-confidence in nursing students. Therefore, nursing educators and professors must think of a solution, or at least they themselves should not cause this feeling in them by inappropriate behavior and discriminatory speech and words.
Achieving professional values of nursing is a prerequisite for resolving conflicts, improving the quality of nursing care services, and increasing nurses' job satisfaction [1]. The core values accepted and endorsed by the American College of Nursing Associations (AACN) (1998) include human dignity, honesty, autonomy, altruism, and social justice, with social justice gaining so much attention in recent years. AACN defines social justice as fair treatment regardless of economic status, race, ethnicity, age, nationality, disability, or sexual orientation [2]. On the contrary, social injustice is the difference between what is and what should be [3].
The issue of social injustice or discrimination in the nursing profession has always been accompanied by serious doubts and concerns [4]. Nurses' response to social injustice is also not always admirable [5]. Although in recent decades several quantitative and qualitative studies have been conducted to establish the concept of social justice among nursing graduates [6–9] but it seems that academic nursing education has not been successful in this issue and lots of nursing students feel discrimination in both theoretical and practical courses [10].
Proper education plays a major role in educating justice-seeking nurses. Social justice and its importance in health care are among the nurses' curricula. Further attention to this issue in the practical and objective fields of education by educators can affect the thoughts, attitudes, and behaviors of students to pursue justice in health systems. However, unfortunately, the Iranian education system has failed to promote justice due to insufficient educational content, limited qualifications of nursing educators, and inappropriate educational approaches [10]. Given the importance of this issue, a qualitative approach was done to adopt a deep understanding of nursing students' experiences of educational discrimination based on realistic results from the real experiences of participants. Therefore, the purpose of this study was to explain the perception and experiences of nursing students of educational discrimination and finding out the main factors that cause this feeling in nursing students in Iran.
Since the purpose of this study was to explain the perception and experiences of nursing students from educational discrimination and this is a subjective definition with unknown dimensions and depends on the context of its formation, its clarification will require deep understanding. Therefore, qualitative methodology and content analysis method were used to better answer the question. Qualitative content analysis is a suitable method for analyzing written, verbal or visual messages that, among other qualitative methods, is not dependent on a specific philosophical point of view and therefore helps the researcher with sufficient flexibility in advancing their study [11].
In this type of research, the text of the interviews is reviewed several times to be broken down into the smallest constituent and meaningful units (theme). After making a list of themes, and reviewing these words to clarify the similarities in their concept in order to place them in a subcategory based on the axis found between the themes, the same subtraction and inductive flow of the subclasses continued. These reviews, the sliding of the layers on top of each other, and the merging between the initial writings and the final classifications are repeated several times that the researchers eventually reach an acceptable stability between the data and a sense of satisfaction about the classes and subclasses [11].
Twelve nursing students from Shahr-e-Kord university of medical science and the Iran university of medical science (IUMS) were selected (to ensure the necessary experience, sampling was done from second to fourth-year nursing students). Participants were chosen among male and female students by target sampling method (appropriate to qualitative research). In order to collect data, semi-structured interviews were conducted. The interview began with open and general questions and then gradually addressed private and deeper issues. This type of interview is suitable for qualitative research due to its flexibility and depth. Questions from all participants such as “Did you, as a nursing student, feel discriminated against in your training? What do you call educational discrimination?”. The interviews continued until the desired information saturation was reached. Information saturation means that no new theme is added to the data as a result of the interviews [12].
The research environment is appropriate for a qualitative research and all interviews were conducted by the researchers according to the characteristics of communication with students and by applying interview techniques in places where students were available and according to their requests.
All interviews were recorded, then handwritten, word by line, coded, and analyzed according to the content analysis method. The technique of returning to the participants was used to ensure the strength of the data. This is a common method of validating data in qualitative studies.
During the research process, from data collection to the end of analysis and reporting of findings, issues such as informed consent, anonymity, confidentiality of information, the right to withdraw arbitrarily were considered as ethical considerations. The recorded interviews were analyzed by the researchers according to the qualitative content analysis method and using the MAXQDA-version 10.
Participants in this study shared their experiences of educational discrimination. During data analysis, three themes and 10 subcategories appeared. The extracted themes and classes focus on the reasons that are caused nursing students to feel discrimination, which is described below (Table 1).
| Inappropriate role of nursing professors (or instructors) | Discriminatory behavior by nursing professors (or educators) |
| Lack of sufficient self-confidence in nursing professors and its transfer to the student | |
| The educator role in motivating or eliminating motivation | |
| Strict rules | Inequality in supervising and implementation of rules among students of different disciplines |
| Differences in compliance with laws and regulations | |
| Nurses are being strictly monitored | |
| Lack of nursing professional independence | Lack of nursing authority |
| Lack of supportive organizations for nurses | |
| Lack of proper social status of nursing in society | |
| The high authority and power of physicians over other disciplines |
In this regard, many students considered the reason for the feeling of discrimination is the behavior of their professors with students who are all on the same level in terms of seniority (both in the field of teaching theory and in the field of clinical education in the hospital). Regarding this theme expressed one of the participants:
“At the beginning of the classes, after entering to the nursing faculty, the professor said: You had a very bad last year and you were not successful at all, and it made you come to a field (nursing) that is not a good job for your future at all …". Because one of his own children is studying medicine. (Participant number two).
Some students believed that the behavior of professors in the theoretical and clinical classes was different and sometimes even contradictory. For example, a student said, "it is written in nursing textbooks that a nurse should first, have a strong relationship with the patient so that he or she is comfortable. So, the lessons and rules give us that authority. but I personally went up to one of the patients and greeted him warmly. Then the professor came and said why did you become intimate with the patient? ... Go very formally, ask questions and come back ...." (Participant number two)
Many students believed that their instructors do not have enough self-confidence and authority in the internship environments and show weakness in the face of medical students and their professors, which cause others to dare to discriminate between nursing students and other disciplines. In this regard, a student said:
" If a fellowship comes in the patient’s room with their students, our instructors tell us -in front of the medical students- to go out and we will come back later. They tell us not to argue, the room is for them (medical students).
Another student said:” It is upsetting that if while we’re using a classroom and medical students also want to use the room, they have the authority to make us leave the class, and our instructor is not so confident to not let this happen! “(Participant number seven).
Students stated that instructors have an important role in motivating students and make them to work and study more enthusiastically, but unfortunately in many cases they are being compared with medical students and this causes them to lose motivation and self-confidence to continue their education and feel ashamed of being a nurse.
In this regard, a student said: "We were in the second semester … Our professor told us, what field would you like to learn more about? Ask me some questions about it. Some students said that we would like to know more about pharmacology, so that if a doctor ordered a medication, and we thought that the medication interfered with another or it was not appropriate, we could mention it to them or we would like to be so good to know what is good for the patient now and to do it ... The instructor said: you never can do that... (Participant seven).
In addition, another student said, "One of the professors said: each of you who does not like nursing has to go and study medicine. I think medicine is much better!' (Participant five)
Violation of the rules by medical students and failure to deal with them, lack of supervision of medical students, excessive supervision of nursing students, failure to comply with the rules in the field of medicine, etc. were cited by many students as a source of discrimination. For example, a student described his experience of discrimination in this regard: "There is no rule for medical students. There may be rules, but there is no supervision on them. They go to the hospital anyway they want. Sometimes they do not even wear a uniform"(participant five).
The participating students believed that the level of compliance with university rules and regulations and the clinical environment of hospitals were not the same simply because the disciplines were different. A student considered the extent of compliance with hospital rules and regulations not only in their dressing code, but also in the hospital's clinical regulations and communication with the patient, saying: "For example, a medical student can talk to patients in any way they want and they have the right to treat the patient as they wish, but if nursing student greet warmly with patients, they will face punishments from their staff and trainers" (participant two).
The students stated that so many rules and regulations for nurses and nursing students have been defined in detail and that non-observance of them has bad consequences that it seems that this group is under a microscope! One student described his experience as "from the very beginning there are certain rules for nursing that do not exist for any other field. For example, the length of the uniform should be that inches below the knee or be so loose; pants should not be jeans at all; the fabric of the pants should be either black or blue, etc.… Everybody can understand from the student's appearance what field they are, nursing or medical?! "(Participant two).
Another student said, "Doctors are not strict at all, and that in itself is discrimination" (participant six).
Doctors' interference in nurses' affairs and nurses' non-objection, being dependent on the doctor, reducing the quality of nursing care due to the nurse's unquestioning obedience to the doctors, etc., were all points that students mentioned and will eventually lead to feelings of discrimination.
One student said: "if nurses object to the doctors, in many cases, it has very bad consequences for them, so look, we do whatever they say... and whatever the doctor orders, we do... and what does this mean? It means that the genius of the nurse goes blind "(participant seven).
The students said that another factor that causes nursing to lack a proper professional independence and as a result suffer a lot of discrimination from others, are their lack of support for each other.
In this regard, it can be attributed to factors such as the feeling of futility of nursing liability insurance, lack of defense support for the nurse, consider a low worth of the nurse's work even in the nursing system, different behavior of even nursing staff with nursing students in front of medical students, not appreciating the work of nursing students, etc.
A student complained about the behavior of nursing staff towards nursing students, saying, "Even nursing staff do not respect us, they don’t consider us as their future coworkers" (participant four).
Students consider that one of the things that causes discrimination is the lack of a proper social position for nursing in society and the view of all people. Regarding the role of the media in creating a negative attitude towards the nursing profession, one student said: "In TV movies, nurses are always changing sheets, or saying yes to doctors’ orders...! Or even in the novels I read the doctor is always in a superior position, but the nurse always is insulted! these things change the people’s attitudes towards nursing”.
The same student commented about the negative attitude of people in the community, including patients, towards nurses: "It means that when you tell patients that I am a nursing student, they will not answer you anymore ... but if a doctor comes, everyone will respect them" (Participation Nine).
Another factor that has reduced the authority and professional independence of nurses is the high authority of medical practitioners in the Iranian society, which has led to a sense of superiority over other disciplines. A student said: “I heard it myself that a nursing supervisor objected to an intern medical student. But what happened eventually?... The nursing supervisor went to the head of the hospital and apologized" (Participant seven).
Or another student said: "A nurse in the hospital cannot show genius and creativity in any way; even if it is true, the head nurse or the supervisor says: how dare you to interfere in the treatment of the patient?" (Participant 15). " But in other countries, multidisciplinary teams are gathered including a nurse and decide for the treatment of a patient”,", he added "Such things will not happen in our society (Iran) for another thousand years! Because there is only a medical commission and they do not consider the nurse, even if she has a lot of knowledge" (participant seven)
In this study, it was found that one of the factors that instigates a sense of discrimination in nursing students was the inappropriate behavior of educators and clinical instructors in the university educational environment and then in the hospital. The students stated that from the very first semesters, their professors cause nursing students to lose their motivation by comparing the field of nursing with medicine and makes them become disenchanted with their profession. In addition, many students feel insignificant in compared with medical students after entering the clinical environment. because nursing instructors discriminated against them or they were supported in front of the hospital staff. In fact, the attitudes and behavior of the instructor can play a great role in motivating a student to work in clinic setting or turn them away from their field, which in itself is closely related to the instructor's vision of nursing. Certainly, a nursing educator who believes in his profession and is passionate about nursing will also indoctrinate this interest to his students. In fact, student support by the instructor increases students' confidence and motivation, learning, professional development, and positive outcomes [13]. Therefore, according to the findings of this study, it is suggested that nursing school authorities be more careful in selecting nursing instructors and professors, and hire people who not only are impeccable academics, but are also passionate with the field. Consistent with our results, other studies showed that effective educators are important as a key strategy as well as a facilitator of education in empowering and supporting nursing students" [14, 15]. In a study by Witzel et al. (2008), it was found that the support of the faculty and instructors were the most important source of support for nursing students during their studies [16]. Therefore, officials should not ignore the importance of selecting efficient, effective, and experienced nursing and instructors.
In this study, another factor that created a sense of discrimination among students was the existence of very detailed and strict rules for nursing students that made them feel that their behavior and even their physical presence were under constant control. This feeling was intensified when they saw the lack of attention and supervision on other students (especially medicine). We believe that the reason for this is the atmosphere in Iran hospitals where there is a superiority of medical practitioners. In fact, medical practitioner has a dominance in Iran healthcare system in terms of income and authority compared to other professions [17]. This monopoly, may cause many staff, especially nurses, to feel incompetent and it might affect the quality of their performance. In this regard, the study of Aiken et al. showed how the idea of being under the control of physicians has affected job satisfaction and professional identity of nurses and reduced the quality of patient care [18]. Roxburgh and his Colleagues also reported that nursing students need to feel empowered in order to efficiently study, and function in a clinical environment. This feeling is formed in an environment which the student feels belonged and supported by other nurse’s health care staff and not that only nurses have to enforce the rules and there are no rules for the rest [19]. Unfortunately, few studies have been done to compare compliance with laws and regulations between different disciplines, so this study may be a good start to address this issue.
Another issue mentioned was the lack of professional independence in the field of nursing which may instigate much of the discrimination feeling. The results of our study suggest an unconscious lack of self-confidence in nursing professors towards medical professors and students. The existence of facilities and educational classrooms available in the hospitals exclusive to medical students, involvement of physicians in matters related to nursing and even ordering and forbidding them in some issues, the lack of a proper professional position in society and among patients and other issues, all of which indicate the lack of independence and professional identity of nursing. Quoting du Toit, stated that having independence in the clinical activities of leadership and management power in the health care system, skills, critical thinking and commitment to the profession is important for the formation of a professional identity in nursing [20].
Impaired professional independence can affect the learning process of nursing students. But having a positive professional identity and independence can increase nurses' confidence in quality nursing care. However, this picture contrasts with what nurses see in practice. Nursing students often encounter professional identity problems in their own learning process. Students who do not experience a positive professional identity will experience lower self-esteem, weakened clinical reasoning skills, experienced many problems in interpersonal communication, and a sense of belonging to the nursing profession [21]. This will lead to less flexibility and efficiency when facing healthcare challenges, and being aware of these challenges and problems will be important for students' ability to learn and perform care tasks [21, 22]. Hovere et al., Stated that the nature of nursing has not always been clear and that nurses continue to suffer from stereotyped statements about nursing. These public stereotypes can create a stressful environment in health care systems [23]. Therefore, nurses and nursing students should do a high-quality care work to improve the negative image of the profession, increase public awareness about their various roles and advanced nursing positions, and to be better seen, they can use their power through the media [24].
One of limitations of this study- like all qualitative studies- was the consideration of the two nursing faculties (Shahr-e-Kord nursing faculty and Iran Nursing faculty in Tehran) and two teaching hospitals in Iran. As such, it may not be a representative of the experiences of all the nursing profession members in Iran. Limitations of our study proposed the need for conducting further studies with larger and mixed groups and in different cultures.
In our study, it was shown that nursing students feel discrimination in many cases, and because most of the groups that cooperates and interacts with nurses are doctors and medical students, the feeling of discrimination particularly stems from medical practitioners and students. Feelings of discrimination in many cases cause a lack of interest and motivation to choose nursing or reduce self-confidence in students. This can negatively affect training of efficient and professional nurses for the future and cause problems for the health and treatment system. Therefore, it is necessary for nursing educators and professors to avoid causing the feeling of discrimination by inappropriate attitudes towards nursing students. More studies are required to elucidate the reasons of injustice in clinical education environment and finding a solution to this issue.
Ethics approval and consent to participate
The participants were selected after the approval of Ethics Committee of Shahr-e-Kord University of Medical Sciences and necessary permissions (Code: 92-5-22) were granted. Prior to the interviews, the participants were informed about their anonymity, confidentiality of their information, the research method and objectives, and their right to leave the study at will. The participants also signed informed consent forms.
Consent for publication
Not applicable.
Competing interests
The authors declare that they have no competing interests.
Funding
This study was funded by the Department of Research, Shahr-e-Kord University of Medical Sciences, Shahr-e-Kord, Iran.
Author Contributions
Zahra Hadian Jazi: Conduct interviews with participants, Conceptualization, Methodology, Writing- Reviewing and Editing, Formal analysis.
Mohammad Kazzem Gheybi: Reviewing and Editing in terms of clinical aspects.
Zahra Zare: Conceptualization, Reviewing and Editing, Formal analysis.
Hooman Shahsavari: Conceptualization, Reviewing and Editing, Formal analysis, Supervision.
Acknowledgements
The authors of this article consider it necessary to express their gratitude and thanks to the students participating in this study who shared their experiences with us.