" Discrimination " , the Main Concern of Iranian Nurses over Inter- Professional Collaboration: an Explorative Qualitative Study

Introduction: People in various professions may face discrimination. In the nursing field, discrimination among nurses in the workplace, regardless of race, gender or religion have not been studied; a problem that leads to a reduction in the quality of nursing care and nurse turnover. Discovery of the concerns of nurses about inter-professional collaboration is the purpose of this study. Methods: The present study is conducted by using a qualitative content analysis. The data collection process included 22 unstructured and in-depth interviews with nurses between April 2012 and February 2013 in the medical teaching centers of Iran. A purposive sampling method was used. All interviews were recorded, typed, and analyzed simultaneously. Results: The category obtained from explaining nurses' experiences of inter-professional collaboration was " discrimination " that included two subcategories, namely (1) lack of perspective towards equality in authorities, and (2) professional respect and value deficit. Conclusion: Nurses' experiences are indicating their perception of discrimination that influences the collaboration between nurses, which should be taken into account by managers. The findings of the present study help to managers about decision making on how to deal with staff and can be helpful in preventing nurse turnover and providing better services by nurses.


Introduction
In sociological terms, discrimination refers to a condition under which people with the same role do not receive equal social benefits.In addition, it stands for a situation, where attributed features and criteria are regarded as the bases for the distribution of power or wealth. 1 According to Heritage Dictionary, discrimination literally means "making a difference in the way lower class are treated, not based on individual merits," "prejudging the performance," and "denying equal opportunities (such as education, employment, loan, housing, health care)". 2 In addition, discrimination means deprivation and detriment to an individual or a group, belonging to a specific social group.That is, suffering from unfair and unjust treatments and loss only because of membership in a specific group. 3,4Several studies in social sciences indicate discrimination in different areas of service provision.These studies not only suggest discrimination, but also reveal how far members of a social group suffer from these losses and from stigmas attributed to them, limiting their social and business life. 5nder discriminative conditions, equal opportunity for a social activity does not exist, and people are in unequal conditions Copyright © 2015 by Tabriz University of Medical Sciences in terms of education or career choice. 2 Discriminative procedures are mostly categorized into eight general groups: Gender, race, lifestyle, religion, social position, geographical nationality/region, disability, and political beliefs. 6iscrimination exists in interpersonal and institutional levels, directly or indirectly.Interpersonal discrimination refers to discriminative interaction among people, which usually can be perceived directly.
Institutional discrimination indicates discriminative policies or practices within organizational structure, which are barely visible. 7,8The most subtle form of indirect discrimination is unjustifiably and considerably lower share of a specific group, compared to others. 7ll organizations and groups, including medical care and nursing organizations, are conventionally suffering from discrimination.In nursing profession, evidence from the previous studies suggest increased rate of discrimination, leading to a sort of taboos.Results show that these cases may happen in different areas, like: workforce training (basic and frequent training courses, and higher education), employment (which usually affects an individual development), and retirement period. 7For example, in some of qualitative studies conducted in Iran, discrimination as a theme is reported by researchers that lead to reduction of nurse's commitment, reduction in the quality of nursing care and nurse turnover. 9,10While, having equal opportunities in workplace and being treated fairly, without discrimination, by deploying appropriate procedures and policies are recognized and issued regulations of Nursing Federation. 11any reports have shown that discrimination causes several inappropriate results such as psychological stress, helplessness, and frustration.These negative feelings prohibit people from achieving their desirable goals. 12Nurses, also, experience psychological or ethical distresses when they do not feel competent or their nursing activities are judged undesirable by their peers. 13Groups that are traditionally discriminated, seek to fight against it and obtain social justice. 7The stressful nature of injustice stimulates people emotionally to exhibit retaliatory behaviors, inattentiveness, poor performance, aggression, degradation, decreased commitment, tension and conflict, and leaving. 14n the other hand, discrimination is regarded to be a factious behavior (any inappropriate behavior, confrontation or conflict ranging from verbal to physical abuses).These behaviors are known to act like barriers against inter-professional communication and collaboration.In that, the effect of factious behaviors between nurses, physicians, and other medical care personnel prohibits communication, collaboration, and information exchange, leading to an adverse impact on patient's dynamics and consequences, including occurrence of adverse incidents, medical mistakes, safety risk, and lower quality of medical care; 15,16 while, collaboration and team work are essential factors in nursing. 17ncrease of collaboration among nurses for maintaining an effective and safe therapeutic environment is critical. 18In a way that collaboration is taken as a nursing standard and ethical code in nursing. 19ased on this, nurses are required to comply with such ethical codes as harmlessness, kindness, independence, justice, and ethics of care.These items are essential not only in nurse-patient relations but also in relationship between nurses and other medical personnel. 20ince, inter-professional collaboration among nurses is a complex and multifaceted process that does not occur spontaneously, it is affected by several negative and positive factors. 21To have a collaborative environment, it is essential for a team to overcome existing barriers. 22herefore, taking discrimination into account to be an effective factor and seeking to identify its features are essential.Investigation into these factors through a qualitative study, which encompasses multiple data collection methods, and studying the events, norms, and values from participants' point of view, allows a clear and comprehensive scrutinizing, understanding, and identification of this phenomenon. 23Thus, to study and discover the concerns of nurses about interprofessional collaboration, their experiences as the core in medical care services have been used.

Materials and methods
Considering the nature and collaboration and acquiring a comprehensive perception of intended concept, participants were selected from among nurses employed at teaching hospitals.Twenty-two participants were working in emergency, internal medicine, surgery, hemodialysis, post CCU, CCU, and ICU (lung, general medicine and surgery) wards of health and training centers of Tabriz, Tehran, and Ilam Universities of Medical Sciences.Participants included 5 males and 17 females aged 31-years old, on average, (ranging from 20 to 50).Out of them, 16 participants were married and 6 ones were single.In terms of educational level, a number of 6, 15, and 1 subject had diploma, bachelor, and master degrees, respectively.All of them had at least one year of work experience.
In this study, purposive sampling methods were used.Once informed consents were obtained, data were collected through in-depth and unstructured interviews with participants.Interviews were digitally recorded and typed verbatim on the same day, and used as main data.Interviews with every participant were conducted in 1-2 sessions in a private room, in their workplace.Each interview lasted between 30 and 90 minutes.The data were collected during April 2012 and February 2013.
Simultaneous with data collection, final analysis of data was performed using conventional content analysis method.In this method, pre-determined categories are not applied, but collected data lead to formation of categories and their names.First, analysis of data begins with reading the text several times in order to engage in data and develops an overall sense, then the text is read verbatim and codes are extracted.Codes are then categorized, and the relationship between them is found. 24uring the study, specific methods are used to ensure rigor of data.On the one hand, prolonged engagement of the researcher, her contacts with research sites, relevant authorities and participants helped gaining participants' trust, and on the other hand, helped the researcher to better understand the study setting.Member check was used to ascertain rigor of data and codes extracted.Member check was conducted by examination of some interviews' texts, and extracted codes and categories by the researcher as well as two nursing researchers, and consensus was reached.Results were also confirmed by some non-participant nurses.Interviews were conducted according to time arrangement by participants.During the study, confidentiality of data and participants' option to take part and withdraw at any stage were observed.The present study was approved (grant number: 91-11-2-91191) by the Ethics Committee of Tabriz University of Medical Sciences.

Results
After the analysis of data, the category obtained from explaining nurses' experiences of inter-professional collaboration was "discrimination".It included a number of subcategories, namely (1) lack of perspective towards equality in authorities (2) professional respect and value deficit .

1) Lack of perspective towards equality in authorities
Pursuing justice in all areas is a must in every workplace.In the present study, differences in supportive behaviors of managers and in treatments, as well as unfair payments, were features indicating lack of equality in the authorities' perspective.
Difference in supportive behaviors of managers.Supporting nurses is a prerequisite for their fine performance.It encourages them towards collaboration for better service delivery.It could be understood from participants that managers' supportive behavior would affect their collaboration; while, they felt differences in this regard, which were obvious in various aspects of managers' support for nurses and other personnel, including physicians.In that, some of them mentioned such behaviors as unfairness in the way some personnel were treated while the specific staff was supported.A participant describes the difference in supports came from managers: "Why those who work harder are given more reprimand, and ignored further, comparing to those who does not work".Another nurse says:" A mistake by an intern is immediately reported to the office, which not only it is not applied to non-interns, but also they are supported as if nothing has happened."Another nurse mentions differences in regulations and says: "rules are not the same for all.They are just imposed on some personnel."Participants referred to these differences not only within nurses, but also between nurses and other professions, including physicians.Such differentiations are known to be adifference in valuing nurses versus physicians.In this case, a participant states:" If a doctor did not do his/her job correctly and made a mistake, nobody would see it and it would be ignored.But, if a nurse wrote a nursing report in two lines, he/she would immediately be reprimanded by the head nurse.Here, what doctors say is highly valued.Nurses are crushed".
Difference in the way managers treat personnel.Another example of the lack of equality in authorities' perspective is differences in the way mangers treat nurses in different areas.It suggests the lack of uniformity in their behaviors towards their employees -for example, differences in the way people are warned.A participant describes these differences as:" Although, some make much more and bigger mistakes than me, their mistakes are ignored.But as I commit a tiny mistake, I will be treated as harsh as possible.Why should it be like that?There is really a difference in the way authorities treat us.They prefer some people".
Differences in the way people are valued and regulations are imposed, as well as differentiation between personnel with and without work experience are other examples mentioned by participants.As a participant says: "while only some personnel are valued, regulations are for others.Rules are not the same for all.If we complained to the head nurse, the answer would be that they have long track record.They are not given any warning, or it is veiled and negligible.I am not treated the same as the one with 23-year track record.We are not treated equally ".This differentiation between less experienced and more experienced personnel appears in their experiences differently, i.e. a feeling of difference, which should exist among people but does not.Another participant puts in:" a new employee does not differ from one with long track record in terms of work load, work shift, and working hours.There is really no difference".Unfair payments.Ensuring fairness and moderation in every area is an essential need of human social life, leading to employees' satisfaction and integrity in an organization.Financial needs are especially important, according to participants.In that, in addition to on-time payment, ensuring justice in payment based on the performance, should be taken in to account by managers.Participants' experiences imply that this principle is violated.A participant says: "Not valuing for additional work a nurse is the problem.We are the same, in terms of contractual and official employments.I am paid as equal as him/her, so why I should put in additional work and not him or her".Disregarding people's performance and unfairness of the payments are important and effective factors, impacting their performance and collaboration.Other nurse states: "There is no difference between the one who actually works and the one who does not really work.They are the same.There are no benefits for the personnel.When it does no matter why I should bother myself ".

2) Professional respect and value deficit
Lack of respect and value for employees from manages was an issue frequently mentioned in this study by participants.It includes such features as inter-professional stigmas, disrespecting the personality of people, lack of valuing between superior and subordinate, and disregarding meritocracy .
Inter-professional stigmas.Many participants have regarded nursing to be a human and conscientious job, which requires specific attention from managers, including the sense of be professionally valuable, to achieve its objectives.Considering that nurses must work in specific wards, their interest and capabilities for working in such departments may be neglected.Therefore, working in a particular department may be taken as a lack of value for themselves -a kind of professional stigma.Another participant says:" We are categorized into our department.For example, ICU staff, CCU staff.Why internal medicine ward is always called burnt staff?Black list?Place of exile?Why they define bound between staff".
Disrespecting personality.Respecting others, regardless of their status, is an undisputed social rule, especially in the workplace.Violating this ethical principle causes a sense of being different or a feeling of being discriminated by the superior.A participant describes how he/she is undermined: "When I make a small mistake, the ward head warns me badly, immediately and loudly in public, questioning my personality."This will greatly affect professional performance of people and their feedback to the superior.The same participant adds: "Due to this problem, I even talked to the matron that I no longer wanted to work here.My personality was damaged.Everybody expects respectful social status when to go to work, to find social dignity.I don't work to lose my personality.When something hurts my personality, I confront it".

Lack of valuing between superior and subordinate.
Respect is a mutual issue among people.It is an important feature in collaboration, which should be noted in different levels of corporate management.Valuing employees by a manager may be perceived differently by them.What has been mentioned frequently by the participants as one of their concerns is that they are not valued by managers for what they do.In this regard, a participant mentions managers' negligence in fulfilling professional needs over a working shift and says: "When your superior does not value you.I was working the graveyard shift.I had 70 patients and lots to do ...Not only they did not send someone for help, but also they never thanked me.Subordinates do not matter to the superiors".Another nurse says:" nurses do not respect each other, especially when it comes to nurse/authority (head nurse, matron)." Disregarding meritocracy.Meritocracy is an important instance of professional respect and value in nursing.Disregarding Copyright © 2015 by Tabriz University of Medical Sciences it, is conceived by the employees as disrespect, affecting their performance.Ignoring meritocracy in the workplace may be perceived differently by nurses.A nurse defines meritocracy as regarding her capability by her superior and says: "Scientifically, I empowered myself clinically.I tried and hoped my efforts being seen, but they were not.When you progressed but ignored, it is a disaster".Another nurse refers to meritocracy as taking appropriate professional position and adds: "People do not fit their position.A lady has recently come to the hospital, and after less than a month clinical work, she become responsible for accrediting.A position that is not even given to someone with 24-year track record".

Discussion
Findings of the present study indicate that perceiving and experiencing discrimination are the main concern of nurses in collaborative working, and affect the way they collaborate.This is while in today's civilized world, treating fairly or ensuring organizational justice is a critical principle for working in a social system. 25rganizational justice is a key process for positive relationships between change management and favorable outcomes. 26his concept shows the connection between employees' behavior with professional motivation and satisfaction. 27Previous studies on the factors affecting motivation, performance, not leaving, and employee's retention within medical care systems show that these staff, due to poor career development, poor development perspective, and lack of positive supervision, feedback, and understanding, feel unsupported and unvalued, and become demotivated. 28,29The concern is that they are not appropriately supported or motivated, which affect medical care quality. 30,31Participants based on findings of this study confirm the results of the mentioned research, in that they consider experiencing and perceiving organizational discrimination as a factor affecting how they collaborate with others.They maintain that discrimination demotivate them for collaboration and clinical work, and even encourages them to quit; while, ensuring justice is an important factor influencing organization's survivability and health in long term. 32It is a fundamental requirement of organizational behavior, causing increased feeling of attachment, loyalty, and trust in employees towards the organization.It also enhances human and social resources of the organization. 33xperimental evidence confirms a direct correlation between perceived justice with important organizational attitudes and organizational behaviors such as leaving career. 34Perceiving more and better organizational justice is related to higher satisfaction and commitment to the workplace, and taking extra-role. 35n fact, perceiving organizational justice is an imaginative subject, and we are likely to compare our status with others around us. 36 Indeed, these are organization's staff that assess how fair organizational interactions and procedures are, determine the work load, payments, work benefits, and facilities, and make comparison between them .37 In terms of the characteristics and features of discrimination, findings of this study reveal how differences in managerial behaviors are perceived by participants.However, these differences exist in different areas, what is common in all of them is disregarding individuals' performance and behavior; while, people in organizations expect various benefits (financially, emotionally, or socially) for what they offer to the organization.How these benefits are distributed, has extra importance.Studies on justice suggest that people assess benefits distribution methods, the nature of benefits, and how they are treated, and perceive how fair they are.This, per se, sets the context for predicting fairness or unfairness of the way they will be treated by the organization in the future. 38Therefore, organizations have to be adequately sensitive to financial and facility factors, as well as their impact on their employees' commitment and performance.In addition, payments should be fair and proportionate to the performance of individuals, so that they would have a sense of justice and equality.

Conclusion
Findings of the present study have been led to the discovery of properties and characteristics of discrimination as the main concern of nurses in inter-professional collaboration, based on their experiences.This is a subject less addressed; while, it has considerable impact on being motivated to stay or leave a profession.This influences the collaboration between nurses, which should be taken into account by managers, who are required to put in adequate efforts to alleviate discrimination and achieve organizational justice for creating motivation and career development, and for enhancing employees' performance.Regarding that the present study is the outcome of an investigation by a group of researchers into a real subject; results can be used to overcome the barriers against effective collaboration, leading to the enrichment of nursing profession and better performance.
In addition, considering that the present study resulted from research in a real context, category and subcategories obtained can provide health workers, service providers, policy makers, and teachers with a broad vision to overcome obstacles to collaboration, leading to a more fruitful nursing profession, and an opportunity for providing better practice.
Also studies conducted about discrimination in other countries emphasis on gender, race, lifestyle, religion, social position, geographical nationality/region, disability, and political beliefs in nursing not inter-professionals such as this study.This issue must be considered in future research studies and using qualitative and quantitative methodologies are required.
Perhaps the most important limitation of this study is the data collection method.

Using the observation technique can be advantageous
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