Revealing Disparities: Health Care Workers’ Observations of Discrimination Against Patients

Abstract

• Issue: Discrimination against patients in health care settings on the basis of race, ethnicity, or language can negatively impact quality of care and health outcomes. Workers on the front line of care delivery can provide insights about the nature of this discrimination, helping to inform opportunities to address bias and unequal treatment.
• Goals: To understand discrimination against patients from the perspective of health care workers.
• Methods: Six focus groups of health care workers followed by a survey of 3,000 health care workers across a variety of care settings.
• Key Findings: Surveyed workers, across all races, ethnicities, ages, genders, and care settings, personally witnessed discrimination against patients and consider it to be a serious problem. Younger health care workers and health care workers of color were more likely than their older or white counterparts to acknowledge witnessing this discrimination. Just under half of all health care workers indicated the discrimination causes them stress.
• Conclusions: Discrimination against patients based on race, ethnicity, or language is a serious problem that impacts care delivery and workforce morale. Health systems can take steps to facilitate reporting and tracking of discrimination, review treatment of non-English-speaking patients, measure equity in outcomes and experiences, and train workers to identify and respond to racism. Industry leaders and policymakers can pursue strategies to change health professionals’ education and better listen to patients and health care workers of color.

Introduction

Discrimination based on race or ethnicity presents a serious barrier to obtaining high-quality, equitable health care. Because health care workers bear witness to the treatment of patients in the course of their jobs, they can provide a fuller understanding of how and where discrimination in health care provision occurs, as well as how it can be reduced.

Previous research has documented the discrimination that health care workers who are members of racial or ethnic minority groups personally experience — whether from their peers, from patients, or from leadership in their workplaces.¹ Our study of their perceptions and observations of racism, or discrimination based on race or ethnicity,² is unique in at least four ways: 1) in the breadth of discrimination experiences we examined; 2) in the significant representation of Black, Latino, and Asian American and Pacific Islander (AAPI) health care workers among those we surveyed; 3) in differentiation of experiences by workplace; and 4) in the light it sheds on the stress workers face as a result of discrimination.

In this brief, we report on health care workers’ witnessing of discrimination against patients, how this discrimination impacts patient care, and how it affects the health care workers who witness it. We also share strategies that health care workers believe would reduce discrimination based on race or ethnicity.³

Overview of Study Design

In partnership with the Commonwealth Fund, the African American Research Collaborative (AARC) conducted both qualitative and quantitative research. In November and December of 2022, AARC held six focus groups with health care workers, including one focus group for each of the following: employees in community health clinics, employees in hospitals, Black health care workers, Latino health care workers, white health care workers, and immigrant health care workers. While there was no AAPI-only focus group, AAPI health care workers participated in the clinic, hospital, and immigrant focus groups.

From March 14 to April 5, 2023, AARC fielded a survey of 3,000 health care workers employed in hospitals, outpatient facilities, long-term care, private practice, addiction and mental health services facilities, and community clinics across every region of the United States. Among the professionals represented were 26 job titles including but not limited to nurses, doctors, licensed practical nurses, dentists, medical assistants, dental hygienists, physician assistants, mental health workers, and administrators. The survey oversampled Black, Latino, and AAPI health care workers and had a robust sample of white health care workers. The survey questions were informed by learnings from the focus groups and recommendations from an advisory panel comprising experts and researchers from academic institutions, health care providers, and health care worker associations. (For further detail, see “How We Conducted This Study” at the end of this brief.)

Key Findings

While there was substantial variation by age and race, more than half of health care workers reported that discrimination based on race or ethnicity against patients is either a crisis or a major problem. Black and Latino health workers were more likely to indicate racism against patients is a crisis than white or AAPI workers. Respondents ages 18 to 39 were much more likely than those age 40 and older to consider racism against patients to be a major problem or crisis. While health care workers age 60 and older were less likely to indicate racism against patients is a major problem or crisis, a substantial one-third indicated it is.

Health care workers’ perception of how big a problem racial and ethnic discrimination against patients is varied by the patients they interact with and where they work. For example, mental health care workers are more likely to say racism is a major problem or crisis compared to the health care workforce as a whole (68% vs. 52%). In community-based health care facilities like health centers or school clinics, 63 percent of health care workers said racism against patients is a crisis or major problem, compared to 51 percent in long-term care facilities, 47 percent in outpatient facilities, and 55 percent in hospitals. Seventy-nine percent of health care workers in facilities with majority-Black patients and 66 percent working in facilities with majority-Latino patients said discrimination based on race or ethnicity is a crisis or major problem. This compares to 52 percent for health care workers in facilities with majority-white patients and 47 percent for facilities with no majority racial or ethnic group.

Forty-seven percent of all health workers indicated they have witnessed discrimination against a patient based on race or ethnicity. Of those who witnessed discrimination, nearly three-quarters said that they observed it in the past three years. Black, Latino, and younger health workers were among the most likely to say they have observed racism against patients.

The likelihood of a worker witnessing discrimination is correlated with the racial makeup of patients at a health care facility. Employees of a facility with mostly Black or Latino patients reported witnessing discrimination at higher rates than those at facilities where most patients are white or where no race is a majority.

We asked health care workers about a number of common patient experiences and whether for each they agree or disagree that there are disparities in care for patients of color or patients who mostly speak a language other than English. About half of health care workers agreed that based on their experiences, medical providers can be more accepting of white patients engaging in self-advocacy than they are of patients of color doing the same.

Similarly, half agreed that patients of color can be treated differently than white patients and are less likely to receive medication when seeking treatment for pain. Fifty-seven percent of health care workers agreed that patients who speak a language other than English may not always receive the same quality of treatment provided to English-speaking patients.

One of the most striking findings is the 20-percentage-point difference between Black health care workers and health care workers overall (68% vs. 48%) who agreed that medical providers can be more accepting of white patients’ self-advocacy compared to Black patients’ self-advocacy. Similarly, Latino health care workers were 15 percentage points more likely than health care workers overall to agree that patients who primarily speak a language other than English may not always receive equal-quality treatment from health care providers when compared to patients who are English-dominant speakers.

For both questions, agreement among all health care workers was quite high, perhaps unsurprising given the impact that self-advocacy can have on health outcomes. But the higher agreement among Black and Latino health care workers indicates that they have unique observations on quality of care when it comes to the racial or ethnic communities to which they belong. These unique observations may be just one reason to value a diverse workforce.

Racism in health care impacts not only patients but also large numbers of health care workers. Just under half of health care workers, and majorities of Black, Latino, and AAPI health care workers, report that dealing with racial or ethnic discrimination in health care creates some or a lot of stress for them. The likelihood of experiencing stress related to racism varies by the race and age of health care workers and the race or ethnicity of patients in the facility where respondents work. Those most likely to report experiencing a lot of stress from dealing with racism are Black and Latino workers, young health care workers, and those employed in facilities with a majority of Latino or Black patients.

Discussion

Our research indicates that about half of health care workers view discrimination against patients as a crisis or major problem. Their concerns appear grounded in real-world experience, as similar percentages report having witnessed discrimination against patients — with many saying their most recent observation occurred in the past three years. Even among those demographic groups less likely to report witnessing discrimination, the percentages saying they have witnessed discrimination remains troublingly high. Our results reflect a problem recognized by significant percentages of health care workers across race, ethnicity, gender, age, region of the country, job type, and type of health care facility.

Discrimination’s impact on health workers. Discrimination against patients also takes a serious toll on health care workers’ well-being. This is particularly concerning as medical facilities seek to hire and retain clinicians and other health workers at a time of widespread staff shortages across the health care field. With the U.S. Bureau of Labor Statistics projecting a nationwide shortfall of some 275,000 nurses by 2030, continuing discrimination within the health system will likely undermine efforts to fill that and other hiring gaps.⁴

Black and Latino health workers in our study experienced stress resulting from discrimination in their workplaces at alarmingly high rates compared to their white counterparts. This should be concerning to medical schools, nursing schools, and hospitals trying to diversify the health care workforce. A recent study found that health care workers who witness racism by other clinical staff often lack options allowing them to discuss and report such experiences.⁵ Our research indicates that health care workers also struggle with the added emotional labor of dealing with discrimination in their workplaces — a heightened concern for those attempting to recruit and retain nurses, physicians, and other staff of color.

Generational differences. We are struck by the significant differences in health care workers’ responses based on age. Younger workers are more likely than their older colleagues to say they have witnessed discrimination against patients, more likely to report that racism against patients is a crisis, and more likely to experience stress as a result. Further research could clarify these generational differences in experiences of racism and potentially inform efforts to prevent younger health workers from leaving the profession.

What We Can Do

Health system leaders and policymakers have the responsibility to create safer and more equitable care settings for patients and the people caring for them. In our survey, we tested multiple strategies to see which of them health care workers thought would be most effective at decreasing discrimination based on race or ethnicity in health care. The following solutions were deemed very or somewhat effective by two-thirds or more of the workers we surveyed. They can be initial steps in addressing discrimination in health systems, with knowledge that they will be generally seen as worthwhile by a solid majority of the workforce.

Provide an easy way for patients and health care staff to anonymously report situations involving racism or discrimination. Health care systems need to create simple mechanisms for health care workers to anonymously report instances of discrimination or racism, and for patients to report concerns on how they are treated. Anonymous reporting presents difficulties in ensuring accountability and facilitating follow-up actions. By implementing confidential reporting methods, we can maintain follow-up procedures while protecting the identity of the person making the report. Moreover, it is crucial to enhance patient awareness of the available reporting options within health systems.

Examine policies to be sure they result in equitable outcomes. Health care organizations should regularly conduct comprehensive reviews of their policies and procedures to ensure they are oriented toward equitable health care outcomes for patients of color as well as equitable treatment of health care workers. Toward this end, several health systems are implementing “racial equity progress reports.”⁶ In addition, the American Medical Association has adopted a strategic plan to advance health equity, and the Association of American Medical Colleges has developed a framework for addressing and eliminating racism in academic medicine.⁷

Require classes on discrimination at professional schools. Medical, nursing, and other health professional schools should include courses on discrimination, race, and racism and make these required for all students. Schools also should review curriculum to remove any inappropriate references to race or ethnicity.

Create opportunities to listen to patients of color and health care professionals of color. Nearly seven of 10 health care workers endorse efforts by health care organizations to create opportunities to listen to patients of color and health care professionals of color. Support jumps to three of four for Black, Latino, and AAPI health care workers and a similar proportion of those who serve primarily Black and Latino patients.

Examine treatment of non-English-speaking patients. Three-quarters of Latino, AAPI, and Black health care workers say that evaluating how non-English speakers are treated to identify whether additional or improved translation and staff training are needed is an effective strategy.

Train health care staff to spot discrimination. Health care workers require training to ensure they can recognize instances of discrimination and bias within health care interactions and understand how discrimination can lead to poor health outcomes.