Racism and discrimination in the workplace and especially in nursing have been documented by several researchers (Kushnick 1988, Taylor 2005, Alexis & Vydelingum 2004, Allan et al. 2004, Alexis & Vydelingum 2005). These studies have focused on ways that racism is expressed by the perpetrators, i.e. blatant, overt or the subtle forms. Racism has been studied at the individual and the institutional level. However, most studies in nursing have failed to deal with how individuals internalise the effects of racism on a personal level. Larsen (2007) redresses the balance by theorising how racism is experienced at the individual level and how it affects the individuals’ career paths in particular.

Racism can be classed as anthropologically strange because it has become so familiar that people no longer recognise its impact at different levels. For example, if it is being dealt with at one level, i.e. the institutional level, then it is assumed that the measures taken to redress this will filter down to other levels, i.e. the cultural and individual levels and Larsen's work demonstrates that this is, in fact, not the case.

The experience of racism is multidimensional and can be classified using a tripartite typology (Jones 1997). The first type is individual racism, where the individual is targeted by perpetrators. The second type is institutional racism which results from exclusion from full participation in the benefits offered to other members of the society. The third type is cultural racism which occurs when the cultural practices of ‘dominant’ group are generally regarded by society and its institutions as superior to the culture of the ‘subordinate’ group. Victims of racism are marginalised, subordinated, disadvantaged, restricted, silenced, not told about opportunities nor given cooperation for control (Hagey et al. 2001). Although Larsen (2007) does not distinguish the different types of racism in this paper, it is apparent from the two nurses’ stories that all of them are in operation.

According to Hagey et al. (2001), the stress of racism not only affects social opportunities, but also results in numerous physical and psychological symptoms. Physical and psychological effects include cardiovascular diseases and emotional problems such as depression which can then lead to marriage breakdown, professional difficulties, seeking out new job opportunities and financial insecurity all of which can have an impact on the care that nurses give to their patients.

Nurses use a variety of resources to cope with different types of racism. Using a modified version of the Lazarus and Folkman model of coping, Outlaw (1993) identified three components of coping with racism in her study of African-Americans. These three components include: (a) personal and environmental interaction, (b) primary appraisal (Harm/loss, threat and challenge) (c) and secondary appraisal. According to Outlaw (1993), when one experiences racism, an assessment is made of the situation as harm/loss, threat or challenge. Outlaw eliminated the benign positive appraisals as a possible outcome for racism victims and posits that all encounters with racism are viewed as threat, harm/loss, or challenge but never as irrelevant or benign positive. In Outlaw's revised model, a harm/loss appraisal may result in a passive action such as withdrawal or depression. On the other hand, challenge appraisals encourage emotional growth on the part of the victim. Secondary appraisal is the process by which the victim determines whether or not he or she has the resources to cope with the encounter. The two nurses’ experiences analysed by Larsen mirror the passive action and the challenge modes of responses. However, the gender difference between the two nurses in the study has not been given sufficient attention.

Utsey et al. (2000) reported that gender differences existed regarding the types of coping strategies used by African-Americans in their encounters with discrimination. In individual racism encounters, more women used avoidance coping strategies, while more men used problem-solving techniques. Feagin (1991) explained the preference for avoidance copping as a way of saving energy that could be used to cope with other situations. Feagin states: ‘… the confrontation response is so costly in terms of time and energy that acquiescence or withdrawal are viable options’ (p. 106).

The experiences of Victoria and Alex in Larsen's (2007) study correspond closely to gender differences and strategies adopted as demonstrated by Victoria's use avoidance and Alex's use of a problem-solving approach. It is interesting that Larsen uses these two examples and acknowledges that gender might have an influence to how the respondents embody the experience of racism; however, Larsen does not fully justify or explain this difference. It could be said that as a black woman Victoria faces a double jeopardy situation and suffers disadvantages of both sexism and racism. This could explain her loss of confidence and the effect it has had on her career. In the case of sexism and racism, the experiences of marginalisation includes feelings of anger, hurt, helplessness, powerlessness, self-doubt and confusion; and either a resolution or paralysis. Findings by Utsey et al. (2000) indicate that avoidance coping is a significant negative predictor of self-esteem and life satisfaction and Victoria demonstrated both of theses traits in her deliberations.

The literature indicates that low expectations as a result of racism result is self-fulfilling prophecy (St Denis & Hampton 2002, Axelson 1998). Victoria's deliberations conform to this response to racism. Conversely low expectations from those in a position of power can help justify lack of training and attention to black nurses. The effects of individual racism include lowered self-esteem and inadequate self-concept. Axelson (1998) contends that the Pygmalion effect is a self-fulfilling prophecy where people conform to others’ expectations regardless of their true abilities. Racism may become a state of mind and a set of emotions and values and a set of behaviours. In the case black females, gender plays an important role. Ng (1993) explains that race, class and gender are not just categories, or ideas, or simple concepts; they indicate relationships that affect how humans relate to concrete everyday social relations. Race and gender analysis brings attention to how those biological differences serve to justify differential social, economic and political participation in society (St Denis & Hampton 2002). As a result of this experience, black women lose their self-confidence and withdraw from the situation.

Larsen suggests that individuals may find ways to challenge and change the social conditions or structure in which they live and says that this probably account for the reason why the two nurses interviewed responded to the situation differently. However, this could be seen as blaming the victim as happens in cases of domestic violence (Hart 1992). In this situation, victims are expected to change their behaviour to stop the abuse even though positive results are rare.

Alex dealt differently with a similar situation to Victoria by attributing his treatment to the ignorance and professional incompetence of his abusers although he understood that he was being discriminated against. The role of gender is also evident here as Alex used a macho image and a problem-solving approach to deal with the racism. Moreover, because of his need to support his family, he had no choice but to face the situation in some way. This behaviour is discussed by Hall (1997), who says that Black men respond to infantilisation by adopting a ‘macho’, aggressive-masculine style to challenge the stereotype. Conversely, Herbert et al. (2006) reported that female respondents had a more determined mindset in wanting to succeed in their careers.

Miller and Kaiser (2001) explain that even in situations where important outcomes are at stake, a stigma-related event such as racism may not be perceived as stressful if the victim has the adaptive resources to cope with the potential stressor. The adaptive resources can include psychological, social, behavioural or educational resources. There is therefore wide variability in how and with what effect victims of racism cope.

Miller and Kaiser (2001) discuss two main forms of disengagement coping which stigmatised people's use of disengaging from the stress resulting from the stigma. The first is avoidance coping which involves physical and/or social withdrawal or disengagement from stigma-related stressors. This avoidance often goes hand in hand with selective affiliation with other stigmatised people who are relatively free for prejudice. For example, overseas nurses may choose to associate with other overseas nurses or nurses from their own countries.

Another type of coping response is denial and minimisation of prejudice and discrimination. Here stigmatised people do not make claims of discrimination even when the objective evidence points to the possibility that the poor outcomes they have experienced were due to prejudice. This is disengagement coping because it avoids stress by denying the existence of the problem. Miller and Kaiser (2001) continue to explain that, with this type of coping, there may be an element of wishful thinking in minimising the effects of prejudice, with the belief that acknowledging that others have behaved in a discriminatory way robs them the sense that they can control the situation and social acceptability.

Although Alex seems to have excelled in his career, it is evident that he had to put in a lot of work and effort. It is not usual for example to need a Master's degree to be promoted to an F grade post. Larsen (2007, p. 5) highlights how Alex's ‘… professional skills were being constantly questioned’. This is consistent with previous research (Beishon et al. 1995, Alexis & Vydelingum 2005) which found that black nurses are more qualified than their white colleagues and need to work hard to get promoted to the same post. Goldstein (2002) found that black workers had high stress levels because of additional expectations from managers, colleagues and themselves. One respondent in the study reported that there was a constant pressure to perform at 150%. In addition, Goldstein (2002) reported that black workers were given extra responsibilities without being acknowledged in career progression.

It is well known that nursing is a female-dominated profession, even on an international scale. Male nurses seem to be pressured into some of the best paying and most prestigious nursing specialties or management roles because of stereotypical notions of masculinity. This may be the reason male nurses progress more easily. Of course black male nurses enjoy some of the advantages that their male counterparts enjoy culturally, such as not holding the same responsibility for looking after the home and family.

Winkleman-Gleed (2006) found that immigrant nurses are prepared to change employers where development in their careers is not feasible in their current organisation. Winkleman-Gleed observes that professional identity can be an integral part of personal identity. Career development is therefore important to migrant nurses for their self-worth. If career development is not encouraged by employers, it can hinder individual personal growth and identification of that individual with the work place.

Morgan et al. (2000) reported that racism at work is a significant predictor of black women's psychological well-being and that both racism and the work context explain this link. They also reported that racism at work is moderated by financial stress, as women who perceived greater financial need experienced greater decreases in life satisfaction than women who experienced less need. Larsen acknowledges the embodiment of discrimination in both the case studies, but is gender blind in his approach as he views the cases in their totality than being gender-specific.

Racism at work has also been found to threaten one's personal identity. Luchetta (1995) found that women who define themselves according to their occupational role are more likely to report physical symptoms when exposed to work stress. Detrimental effects can result from experiencing limitations in career progression because of racism in people who identify themselves strongly with their careers.

The challenge is for policy makers to understand that mitigating the detrimental effects of discrimination in society involves more than just focusing on structural inequalities that stem from prejudice and discrimination. There is still need to recognise race, class and gender in their deliberations to help prevent the continuance of all forms of discrimination in the work place. Policy makers need to recognise discrimination as a stressor and implement policies and interventions that enhance the likelihood that victims of discrimination and racism are able to cope adaptively with the stressors they encounter. It is, therefore, necessary to recognise, as Larsen points out, that empowerment of the individual is a way to tackle discrimination and improve job satisfaction among overseas nurses.


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