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Nursing issues
Professional discrimination toward nurses increases nurse silence threatening patient safety outcomes
  1. Nicole Zhang1,
  2. Breanna Casas2
  1. 1 Nursing, Hartwick College, Oneonta, New York, USA
  2. 2 The Valley Foundation School of Nursing, San Jose State University, San Jose, California, USA
  1. Correspondence to Dr Nicole Zhang, Nursing, Hartwick College, Oneonta, NY 13820, USA; nicole.zhang{at}

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Commentary on: Nursing practice environment and employee silence about patient safety: The mediating role of professional discrimination experienced by nurses

Implications for practice and research

  • More research should be conducted to understand the underlying mechanisms shaping the associations between professional discrimination and nursing silence.

  • Rates of professional discrimination tend to be high and similar to other types of discrimination within the nursing profession.

  • The environment created by nursing leadership and interdisciplinary superiors can inhibit bedside nurses’ interventions in patient safety.

  • Bedside nurses risk patient safety when they feel that they cannot adequately voice their concerns to their superiors.

  • Research can be expanded to include:

    • Exploration of the safety impacts the nursing workplace has on discrimination of minority patient populations.

    • If there is a correlation between the safety of minority nurses (including international and foreign-educated nurses) and the safety of their assigned patients.


Nursing silence and inability to voice concerns in the professional healthcare development has recently been identified as a significant issue that affects patient safety and ultimately well-being and decreases the standard of care.1 This area has been poorly researched and there has been a need to identify the elements of this professional silence and discrimination that is present in the nursing work environment. A commentary examining an article by Kritsotakis et al 2 will be conducted with the goal of sharing the findings and broader implications for nursing.


This study is a multicentre cross-sectional design. Over the period between January and April 2019, a series of nurses and nursing assistance in Greece were evaluated using the Practice Environmental Scale for Nursing Work Index (Revised). In all, 607 healthcare workers (including registered nurses (RNs) and nursing assistants (NAs)) were evaluated using the Experiences of Discrimination Index. Employee silence about safety is measured using a Likert Scale. Statistical analyses were done using process macros and using Statistical Package for the Social Sciences (SPSS) software. Ethical approval for the study was received and protection for confidentiality were taken.


Kritsotakis et al 2 found that the elements of staffing and resource adequacy that were evaluated correlated with less experienced professional discrimination and associated with less silence about patient safety. Although two-thirds of the participants experienced some kind of discrimination in the nursing profession, less professional discrimination was correlated with a better work environment.


In healthcare, nursing silence and not speaking up is a common and multifaceted problem. There are factors affecting nursing silence at multiple levels ranging from the individual level to systems factors. This workplace issue negatively impacts patient health and safety outcomes.

Seminal works mapping out the impact of the work environment on the quality of patient care underpin the need.3 Kritsotakis et al (2021) described the relationship between nurse silence, nurse discrimination and patient safety. When nurses experience profession-related discrimination, there is less support for sharing professional safety concerns, ultimately impacting the safety of patients under their care.

This issue was previously studied in depth in the context of minority and internationally educated nurses.4 In addition to being a professional imperative to address the workplace hostilities that may be present among healthcare workers, it is also a diversity, equity and inclusion issue to begin to understand what discrimination in the nursing workplace looks like for both nurses and patients alike. This study adds to the professional narrative of discrimination, as it developed a metric that specifically accounts for the nursing workforce.

Implicit bias has been shown to shape workplace discrimination and ultimately affect safety due to nursing silence.5 The complex connections that are coming forward regarding workplace discrimination in nursing are groundbreaking. Elucidating tangible ways to address this issue of discrimination in order to improve patient outcomes, nursing silence and workplace environment will be a key issue in healthcare going forward.



  • Competing interests None declared.

  • Provenance and peer review Commissioned; internally peer reviewed.