Subtle and Covert Forms of Racism in Health Care Workplaces Today

Subtle and Covert Forms of Racism in Health Care Workplaces Today

Hiam & Hiam

It is established that health care workers from minority groups are the subject of inequity arising from culturally embedded biases, the results of which may include a lack of promotion, as well as, on a more daily basis, “being overlooked and undervalued, having to prove competency, and living with “only-ness” (Moceri, 2014). A recent review and study of bullying finds that “scant attention has been paid to studying the nexus of workplace bullying and race, but there is evidence that subjects of bullying are more likely to be African-American, Hispanic, or to violate ‘traditional gender roles.’”  (Gilbert, Raffo & Sutarso, 2013)

The following short review of research aims to clarify the uncertain terrain of worker-on-worker racial discrimination, especially when it takes the form of harassment, verbal aggression, or subtle but ongoing micro aggression, with particular reference to health care workplaces. It was complied with the aim of finding helpful points of reference for understanding a challenging topic that is not often surfaced in workplaces.

Bullying and incivility  research

A recent review of literature on incivility in the workplace concludes that incivility “has consequences for the wellbeing of employees” as well as reducing their productivity (Leiter, 2013). Incivility is defined (in the organizational behavior literature) as “low-intensity deviant workplace behavior with an ambiguous intent to harm,” (Schilpzand, Pater, and Erez, 2014), and may include behaviors such as talking down to someone, making demeaning remarks, and not listening to somebody (Porath & Pearson, 2010). Incivility may be seen as at the lower-intensity end of a spectrum with bullying, aggression and violence, and as such, has only begun to receive rigorous research attention in the past decade or so. However, a large body of work has now arisen to document the harm done by incivility, which can be highly stressful, demeaning, and marginalizing to the victim(s). Thus the stress-related effects on career, health, and psychological well-being associated earlier in the research stream with bullying, are now being extended to (seemingly) milder forms of poor treatment under the label of incivility. 

Another research team defines incivility as “the exchange of seemingly inconsequential inconsiderate words and deeds that violate conventional norms of workplace conduct,” (Porath & Pearson 2010), which is helpful in that most people can agree more or less as to what the norms of workplace conduct are in a health care clinic or similar setting, and can agree upon cases where someone has a habit of breaking such norms in the way they talk to or relate to another. Porath and Pearson sum up the consequences of workplace incivility by observing that, “While managers are looking everywhere to cut costs and maximize productivity, they are missing a potentially devastating expense: the cost of incivility.” As “norms are shredded,” “productivity plummets.” The documented health effects (as summarized by Porath and Pearson’s review of literature) include “headaches, eating disorders, depression, and suicide, among others.” The point being that ongoing incivility may be just as unhealthy as bullying, the main difference being in the subtlety of the attack, not the impact of it.

Bullying is most commonly documented in workplaces where the perpetrators are coworkers or supervisors. Bullying up the chain of command is far less often reported, for the obvious reason that the bully lacks positional power when facing a supervisor or superior, and is more likely to face correction or censure. Incivility and micro aggression behaviors, the more covert forms of bullying, are less dependent on position and may move laterally and verticality in the organization with relative ease. It is an interesting question as to how much less respectful direct reports are to African American supervisors versus the dominant group. Studies seem to be unavailable on the topic.

Incivility and covert racism

Hall and Fields (2012) report on their study of nurses in their workplaces that “contemporary racism is more subtle than overt.” They find that “subtle racism takes the form of micro aggressions in everyday discourse and practices by whites toward African Americans. This occurs with little to no awareness on the part of whites.” They conclude that “micro aggressions contribute to stress for the target person and may partly account for racial health disparities.”

Other studies documenting racism in contemporary health care take the patient care perspective. Much as earlier studies, widely reported in the media, have shown that bank loan officers decline loans to otherwise identical applicants on the basis of race, studies are documenting differential care for African Americans in what can only be explained as racial bias on part of (usually white) medical practitioners, including doctors and nurses. For instance, Brooker (2015) observes that, “Black Americans experience greater disparities and inequities in pain assessment, management, and outcomes compared with White Americans and many other racial groups.” (They are more likely to be subjected to suspicion regarding legitimate pain med. prescriptions, and to drug testing.) Differential treatment based on race of patients, as well as co-workers, is quite widely documented among contemporary health care workers in the U.S. This makes sense if there are widespread, lingering, covert racist attitudes toward African-Americans in general, and if these covert racist attitudes are pervasive among white health care workers, as numerous studies appear to show is the case. (A widely reported classic, from New England Journal of Medicine, 1999, showed that, all symptoms being equal, white men with chest pains were referred more often than black men for follow-up cardiac care.) 

Institutionalized racism

While it is perhaps unpleasant to contemplate the idea that white nurses or other medical staff might retain, in this enlightened time, any racist attitudes, it is important to recall that, as Wheeler, Foster and Hepburn (2014) put it without mincing their words, “The USA has a long history of institutionalized racism that has affected African American nurses.” Their study sought to ascertain whether racism was still an issue for African-American nurses. The pattern appeared to be strongly persistent: “All nurses [of color, in sample urban hospitals] experienced discrimination from their patients, their nurse colleagues and/or other hospital personnel.” (This does not prove all white nurses or colleagues were racist; only that enough were to insure that all African-American nurses experienced racist treatment in the course of their work.)

There are numerous studies focusing on the experience of African American nurses, but few to none addressing nurse practitioners, nursing supervisors, or doctors, perhaps because African Americans are not found in large numbers in these job categories and thus are harder to study at higher levels. Is it reasonable to assume that racism, in its contemporary, more covert than overt forms (which include commonplace incivility and occasional bullying), might be experienced by the smaller number of African American and other minority healthcare workers who occupy mid-level or supervisory positions in health care? The alternative assumption, that the universal discrimination against African American nurses somehow evaporates when one of them is promoted or achieves a higher academic degree, seems far less plausible.

To be accused of crying wolf

Ezra Griffiths, M.D., a professor of psychiatry and African-American studies at Yale University School of Medicine, commented at a New York Academy of Medicine Section on Psychiatry lecture and discussion that, “Many blacks have come to expect negative, abrasive, or caustic reactions or comments from whites.” The statement, written out on the page, may seem shocking because it expresses an opinion that is rarely voiced out loud in professional or workplace settings (Lehmann, 2004).

While it is commonly accepted amongst minority employees in U.S. workplaces that racism still exists and may be exhibited routinely in the actions and comments of co-workers and supervisors, it is rarely something they mention to others because there is widespread disagreement or denial among non-black employees and managers concerning the question of covert racism in the workplace. The official line is that diversity is good, and hiring and treatment of employees is unbiased. Federal law weighs in on the issue, and most workplaces and their managers are well aware of the need for fair and nondiscriminatory hiring. In this context, where lingering racism is widely acknowledged by minorities but in theory on its way out and legally censured, what are the consequences of claiming racial discrimination?

The most immediate one is likely to be disbelief. The intent of (predominantly white) directors, senior managers, executives, and doctors is clearly to run workplaces free from the contaminating influences of racial or other unfair biases. The first emotional reaction thus may be, “We already voted on a policy for that, isn’t it taken care of?” To change this disbelieving first reaction, one might need to present specific and clear evidence. But contemporary forms of covert bias are much harder to document with 100% certainty. They don’t present a ‘smoking gun,’ only a pattern of apparently selective or biased behavior. It is sometimes hypothesized that micro aggression in contemporary workplaces may be unconsciously racist in the sense that the perpetrators themselves do not espouse racist attitudes and quickly deny any racist bias or motive, as well as any hurtfulness or intent to hurt in their pattern of behavior.

What rises to the level of a fair complaint?

The most common form of discrimination case brought forward in the U.S. is one in which someone feels they were passed over for a job or promotion because of race, in which case, the nature of the proof need not be so specific as to penetrate the ‘black box’ of someone else’s emotions and motives, it must simply be a prima facie (first look) demonstration of disparate treatment. Interestingly, the U.S. Supreme Court has determined that “the burden of establishing a prima facie case of disparate treatment is not onerous” (Texas Dept. of Community Affairs v. Burdine, 450 U.S. 248, 253 (1981). 

A further case often cited in reference to the burden of proof of discrimination is Mitchell v. Office of the Los Angeles County Superintendent of Schools, 805 F.2d 844, 846 (9th Cir. 1986), in which it is stated that the plaintiff may create this prima facie case by “offering evidence adequate to create an inference that an employment decision was based on a discriminatory criteria illegal under [Title VII].”  Similarly, in a famous McDonnell Douglas case (411 U.S. at 802), the plaintiff needed only to raise an inference of disparate treatment, not actual proof of such treatment. 

The legal treatment of employment law cases is only tangentially relevant here: It addresses the general approach taken by the law to the question of proving racial bias. Generally speaking, when a plaintiff seeks remedy for what she sees as a bias in hiring, she is not required to prove through specific self-revelatory quotations that the employer is a self-professed racist. It is more pragmatically only necessary to show that the denial of a job cannot be readily explained based on qualifications and thus by inference seems to be selectively based on the candidate’s race. (A far rarer form of legal proof arises when a hate crime is prosecuted; in such cases, the prosecutor has the burden of proving hate, which leads to costly and unpleasant trials. The level of proof is different in such cases because the charge is based on proving the presence of a hate motive within the ‘black box’ of that person’s emotional makeup.)

Taking claims at face value

This dip into the topic of legal proof is intended to help clarify the practical problem of how to assess a feeling in an employee that they are being singled out for unfair, inappropriate, or hurtful treatment in their workplace due to their race. 

If we apply the general standards of prima face appearance of discrimination as used by courts and the National Labor Relations Board, then what is required is disparate treatment that cannot be explained by objective factors. A white employee who is respectful and polite toward white supervisors, managers and coworkers, but impolite or uncivil to a black supervisor, would under these standards clearly by singling out the minority supervisor for discriminatory treatment. However, a case such as this one would not end up in court, but would most likely be resolved (or not) internally, within the organization, where there may not be any established procedures for bringing these types of complaints forward, nor as clear and specific standards of investigation and proof, as currently exist in employment discrimination cases. If the matter is treated informally, then it is hard to say whether the organization will treat it with respect, or be dismissive of it. Many, if not most, employees may not wish to run the risk of being accused of crying wolf, and may not have the stomach to see through any lengthy sequence of investigation, which might rebound in reduced opportunities with that employer in the future.

Falling short of full equality

Roscigno and Yavorsky (2015) observe that, despite efforts to route out discrimination in workplaces through diversity initiatives, etc., widespread inequalities still exist. They write that,  “It is becoming all too clear that there remains a ‘black box’ surrounding how and why such inequality persists, and the extent to which discrimination is playing a role…” The black box of human beliefs, motives and emotions is hard enough to delve into for each of us individually; some people spend decades pursuing a better understanding of themselves. For researchers, the more covert and hidden the racism becomes, the harder it is to document and study. Similarly, from an executive perspective, it may be far harder to ferret out the remaining effects of racism in workplaces today, than it was to make initial gains by overthrowing obvious, overt forms of discrimination in the past. 

Unless the taboo among the ‘ruling class’ against talking about, or even believing in, covert and subtle forms of workplace racism can be overcome, the progress of minorities in the workplace and their advancement into leadership roles will continue to be stalled at the current, rather incomplete, stage of progression.

References

Staja Q. Booker, MS, RN, Are Nurses Prepared to Care For Black American Patients in Pain? Nursing, January 2015, Vol. 45, Issue 1, pp. 66-69 (quote from p. 66).

Jacqueline A. Gilbert, Deana M. Raffo, & Toto Sutarso, Gender, Conflict, and Workplace Bullying: Is Civility Policy the Silver Bullet? Journal of Managerial Issues, Vol 25, No. 1, 2013, pp. 79-98.

Joanne M. Hall, PhD, and Becky Fields, PhD, RN, Race and Microaggression in Nursing Knowledge Development, Advances in Nursing Science, Jan/Mar 2012, Vol. 35, Issue 1, pp. 25-38.

Christine Lehmann, Bias Toward Some Residents Can Impede Health Care, Psychiatric News, 10 Oct. 2014.

Michael Leiter, Causes and Consequences of Workplace Mistreatment, in SpringerBriefs in Psychology Vol. 8, 2013, pp. 31-44.

Joane T. Moceri, PhD, RN, Univ. of Portland, Hispanic Nurses’ Experiences of Bias in the Workplace, Journal of Transcultural Nursing, January 2014, Vol. 25 No. 1, 15-22.

Christine L. Porath and Christine M. Pearson, The Cost of Bad Behavior, Organizational Dynamics, Vol. 39, No. 1, pp. 64-71, 2010.

Vincent J. Roscigno and Jill E. Yavorsky, Discrimination, Diversity, and Work, Routledge International Handbook of Diversity Studies, Chapter 29, 2015 (quote from p. 274).

Pauline Schilpzand, Irene E. De Pater, and Amir Erez (Oregon State Univ., National Univ. of Singapore, Univ. of Fl., Gainsville), Workplace Incivility: A Review of the Literature and Agenda for Future Research, J. Organizational Behavior, 2014, advance publication on web, no page numbers.

Rebecca M. Wheeler MA PhD RN, Jennifer Foster CNM PhD RN, and Kenneth W. Hepburn PhD, The Experience of Discrimination by US and Internationally Educated Nurses in Hospital Practice in the USA: A Qualitative Study, Journal of Advanced Nursing Vol. 70, Issue 2, 2014, pp. 350-359.

Copyright © 2015 by Alex Hiam & Deirdre Hiam. Reproduction for reasons other than monitory gain is permitted in hope of encouraging discussion, thought and action.