Why Nurses Give Unequal Care: Inside the Hidden Drivers of Discrimination at the Bedside

Discrimination in healthcare is usually imagined as the work of a few bad actors—prejudiced clinicians who deliberately shortchange patients they dislike. A new qualitative study from Iran suggests a far more uncomfortable truth: unequal nursing care often emerges not from malice but from an intricate web of patient characteristics, hospital politics, resource starvation, and the quiet emotional habits of nurses themselves. Published in Nursing Open, the research draws on in-depth interviews with 13 clinical nurses in Tehran and maps, with unusual candor, the forces that push even well-intentioned professionals toward care that is anything but equal.

The scale of the underlying problem is global. A 2023 national survey in the United States found that 60 percent of Black adults and 42 percent of Asian adults reported preparing themselves for potentially unfair treatment before medical visits—psychological armor that patients should never need. Nurses, as the largest group of health professionals in continuous contact with patients, sit at the exact point where such inequities are either challenged or reproduced. Yet most research on the topic has relied on surveys measuring prevalence, leaving the how and why of discriminatory behavior largely unexplored, particularly outside Western healthcare systems with their distinct power dynamics and resource constraints.

The Iranian context sharpens the stakes. The country’s hospitals operate under severe economic sanctions, a depreciating currency, and chronic shortages of supplies, with nurse-to-patient ratios in public general wards often reaching 1:10 to 1:15—far beyond international standards. Extreme workloads, burnout, and the emigration of experienced staff create conditions in which rapid prioritization decisions are made constantly, and in which, the study suggests, discriminatory practices can take root whether or not anyone intends them. Against this backdrop, the research team conducted a secondary qualitative analysis of interviews originally collected between June 2023 and May 2024 in public and private hospitals across Tehran, using conventional inductive content analysis to let categories emerge from the data rather than imposing a pre-existing framework.

The participants—seven women and six men with a mean age of 34.7 years and roughly a decade of clinical experience each—worked in settings ranging from emergency departments and intensive care to surgery, psychiatry, and neonatal units. Saturation was confirmed after eleven interviews, with two additional interviews verifying that no new codes emerged. Rigor was reinforced through member checking with four participants, independent peer review of the coding, an external audit by a qualitative expert, and maximum variation sampling across departments, hospital types, and experience levels. The analysis yielded three overarching categories—patient-related, organizational, and nurse-related factors—comprising ten subcategories in total.

The patient-related findings are the most socially charged. Nurses consistently described how socioeconomic status shaped care: wealthy patients, celebrities, and government officials received faster medications, quicker physician visits, and the best rooms in the ward. One participant put it bluntly, saying such patients are prioritized in almost everything. At the opposite pole, prisoners, people with substance use disorders, homeless patients, and those lacking social support were described as receiving care delivered merely to fulfill a duty—fewer visits, less communication, a lower overall level of attention. Age and gender added further layers: young patients, especially young women, were monitored more carefully and given more explanation, while older adults, despite closer basic monitoring, sometimes saw aggressive treatment quietly scaled back on the assumption that they were old and had underlying diseases anyway.

Clinical condition itself became a vector of inequity. Nurses admitted that end-stage patients—those near death with little hope of recovery—could trigger emotional distancing, with care sliding into a minimal, task-focused routine. One nurse described care for such patients as provided just to keep them alive, not to make them comfortable. Stigmatized infectious diseases acted independently: when HIV or hepatitis appeared in a chart, some colleagues unconsciously kept their distance, delaying even routine tasks in ways that went well beyond standard universal precautions. Patient behavior mattered too—aggressive or demanding patients received less time and attention, while proactive family members who constantly followed up extracted more care for their relatives, a dynamic nurses themselves acknowledged was unfair.

Perhaps the study’s most striking contribution is its demonstration that much discrimination is organizational rather than personal. Nurses in private hospitals reported direct calls from managers flagging socially influential or ‘VIP’ patients as important to the hospital’s reputation and brand, instructing staff to provide everything without delay even when the patient’s clinical condition was no different from anyone else’s. Informal referrals from senior physicians and administrators—conveyed through a single phone call saying a patient is an acquaintance—were enough to reorder care priorities across an entire ward, and nurses who ignored such recommendations risked warnings, lost support, or damaged performance evaluations. In these situations, the researchers argue, nurses function less as agents of discrimination than as enforcers of institutional directives, a dynamic closely aligned with the concept of moral distress: knowing the ethically right action but being constrained from taking it.

Structural scarcity compounded everything. Facing staff shortages, insufficient equipment, and limited beds, nurses described triaging not by who deserved care more but by which patient they could manage faster. Complex, high-risk, or time-consuming patients drifted to the bottom of the list—not out of intent, participants stressed, but because systemic pressure made them the path of least resistance. Compounding this, the study found a striking educational void: nurses reported receiving in-service training on CPR, infection control, and new equipment, but never on how to treat all patients equally. Ethics instruction stayed abstract, with no real clinical examples, so discriminatory habits were absorbed unconsciously from ward culture and senior colleagues, normalized as an unavoidable byproduct of an overburdened system.

The nurse-related factors add a final, human dimension. Tips, gifts, and implicit promises from patients or families fostered a sense of reciprocal obligation, producing faster care and closer follow-up even when nurses knew it was professionally improper. Personal connections and fear of reputational damage when a patient was introduced by someone important created further sensitivity. Emotional responses cut both ways: one nurse described doing everything possible for a child whose condition resembled her own child’s, while another admitted following up less on terminal cancer patients because whatever she did would not make a difference. A third realized, after the fact, that a patient who reminded her of her deceased father had received extra time and attention at the implicit expense of others.

The authors’ conclusion is a call to shift the frame from individual blame to systemic design. Because discriminatory care is embedded in power relations, managerial logics, structural constraints, and educational gaps—not merely personal belief—sustainable change requires transparent triage protocols based on clinical urgency, anonymous reporting systems, ethics rounds where moral distress can be discussed without reprisal, and curricula that teach implicit bias and social determinants of health through case-based learning rather than abstract principle. Simple practices such as self-auditing time spent per patient could help nurses detect unconscious prioritization patterns. As one of the first in-depth qualitative investigations of this phenomenon in the Middle East, the study offers a multi-level framework that is directly actionable for resource-constrained health systems everywhere—and a sobering reminder that fairness at the bedside depends on fixing the system around it, not just the hearts within it.

Subject of Research: Factors contributing to discriminatory nursing care in Iranian hospitals

Article Title: Factors Contributing to Discriminatory Nursing Care: A Qualitative Study From Nurses' Experiences

Article References: Karimian, A., Sadooghiasl, A., Khoobi, M., Mohammadi, E., & Kazemnejad, A. (2026). Factors Contributing to Discriminatory Nursing Care: A Qualitative Study From Nurses' Experiences. Nursing Open, 13(10), Article e70890. https://doi.org/10.1002/nop2.70890

Image Credits: AI Generated

DOI: 10.1002/nop2.70890

Keywords: nursing, healthcare discrimination, qualitative research, Iran, health equity, moral distress, implicit bias, hospital management, ageism, stigma, nursing ethics, workload