Discrimination is prominent in healthcare settings.⁸ Some healthcare workers experience discrimination from patients, patients’ family members, and co-workers because of their race, ethnicity, skin color, accent, disability, gender, sexual orientation, low-wage job title – to name a few.^9–13 Healthcare workers who are discriminated because of their race are experiencing racism that is defined as a system that gives preferential advantage to the dominant racial group – white people.¹⁴ While some may use discrimination and racism interchangeably, it is important to note that these two concepts are distinct from one another. These instances of discrimination are the outcome of an enduring history of discrimination in the U.S. that has permeated in many institutions including healthcare settings.¹²

This issue is crucial since marginalized groups make up most of the healthcare workers in the U.S.¹⁵ In the American healthcare industry, womxn perform about 25 of the 30 health occupations.¹⁵ While white healthcare workers represent most of U.S. healthcare workers, racial differences exist in specific occupations. Among registered nurses, 73.5% are white while 10.4% are Black, 8.4% are Asian, 5.7% are Latinx, 1.5% are multiple/other race, 0.4% are American Indian/Alaska native, and 0.1% are Native Hawaiian and other Pacific Islander.¹⁵ People of color dominate most of the low-wage healthcare occupations (e.g. nursing aide, home health aide, and personal aide).¹⁵ Immigrants are also a growing sector of the healthcare industry. A 2016 survey showed that 1 in 6 healthcare workers are non-U.S. born.¹⁶ The substantial number of womxn and people of color who comprise most of the low-wage healthcare occupation, suggest that these groups are susceptible to discrimination in the workplace. Discrimination is associated with negative health and well-being.¹⁷ Therefore, healthcare workers at risk as recipients of discriminatory behaviors are also at risk for poor health. Such poor health outcomes include psychosocial stressors, high blood pressure, cognitive impairment, and poor sleep.¹⁷ Within research among healthcare workers, the relationship of discrimination and poor sleep quality is an understudied topic.¹⁸

The U.S. population have been sleeping less in the last decade. According to the National Sleep Foundation (NSF), the recommended number of hours of sleep for adults is seven to eight hours.¹⁹ The percentage of adults in the U.S. that reported short sleep duration, sleeping less than seven hours, increased from 30.9% in 2010 to 35.6% in 2018.²⁰ Glaring disparities among groups exists with short sleep duration highest among Blacks (45.5%), womxn (35.8%), the 45–65 year old age group (37.4%), and those with an education level less than a bachelor’s degree (38.8%).²⁰ Notably, 45% of healthcare support workers and 36.3% of healthcare practitioners reported short sleep duration.²⁰

Several factors may explain poor sleep quality among healthcare workers. Most healthcare settings operate in 24-hour shift schedules with variations in scheduling and control among workers.²¹ A meta-analytic review of studies on permanent and rotating shifts found that workers with permanent schedules reported the highest frequency of sleep duration while those who work in rotating shifts reported the least number of sleep duration.²² Economic pressure and low-wages may also lead some healthcare workers to work a second job which decreases the number of hours they sleep per day.²³ Discrimination is associated with poor sleep quality.¹⁸ Discrimination affects sleep hygiene that may cause daytime sleepiness ²⁴, poor sleep quality ²⁵, insomnia ²⁶, and fatigue.²⁷ These circumstances and experiences of discrimination in the workplace may provide insight of how discrimination is associated with sleep.

Several factors may explain the mechanisms in which experiences of discrimination influences poor sleep. Individuals who experience chronic discrimination may develop hypervigilance because of the constant anticipation of experiencing discrimination. This hypervigilant state may disrupt sleep and can increase high blood pressure,¹⁸ placing individuals at higher risk for cardiovascular disease.²⁸

Some individuals are ostracized because of identifiable characteristics related to their race, ethnicity, or culture. These discriminatory behaviors that engender feelings of exclusion have been associated with psychological distress that may affect sleep quality.²⁹ These experiences may affect the performance of healthcare workers in the workplace. Previous studies show that inadequate and inconsistent sleep among healthcare workers is associated with trouble communicating with co-workers ³⁰, poor diet ³¹, obesity ³², increased work-family conflict ³³, and functional limitation ³⁴ that has been associated with increased risk for injuries and medical errors that can place the worker and patients at-risk ^35,36.

Some forms of discrimination in the workplace are bullying and discourtesy. The phrase “nurses eat their young” has plagued the nursing profession for decades, depicting that older and more experienced nurses tend to bully and instigate incivility or rudeness toward young and newly hired nurses.³⁷ Therefore, a workplace environment that fosters a people-oriented culture can potentially alleviate the effects of incivility and discrimination in the workplace. Job resources like organizational policies and practices can potentially act as a buffer from the effects of discrimination. Buffering has been used in health and social science research as a factor that protects or lessens the negative effects of another factor such as a stressful event. ³⁸

People-oriented culture pertains to the customs and practices in the workplace environment that develops cooperation and trust among the administrative staff and workers, involves workers in the decision-making process, and maintains transparency through open communication.³⁹ People-oriented culture has been examined in healthcare settings and has demonstrated that healthcare workers who perceive lower people-oriented culture in their workplace are associated with obesity ³² and poor sleep quality ⁴⁰ among workers while high perceptions of people-oriented culture are associated with less psychological distress and mental health expenditures.⁴¹ Because previous studies demonstrate that healthcare workers experience discrimination from patients and their co-workers alike ^9–11, the role of people-oriented culture among colleagues can potentially assuage the effects of discrimination. However, it is also possible that people-oriented culture can also exacerbate short sleep as associated with discrimination especially in workplace settings where workers have low inter-cultural training and understanding. This has been found as a barrier to building trust and communication in the workplace.⁴² The healthcare setting in the U.S. is becoming more diversified with respect to race, gender, and immigration status, which can be a deterrent to developing a people-oriented culture working environment if workplace settings are not adopting practices that are inclusive of a diversified workforce.

While discrimination and poor sleep quality among healthcare workers have been examined separately, there is little research that specifically examines how discrimination experienced by the healthcare worker population is associated with poor sleep quality. Moreover, little is known about how the workplace environment can buffer the effects of discrimination to improve sleep quality outcomes within this population. The purpose of this article is to 1) evaluate the associations of discrimination and short sleep duration among healthcare workers and determine if people-oriented culture buffers poor sleep outcomes, 2) identify how discrimination manifests and who are the perpetrators in the healthcare worker environment, and 3) appraise how people-oriented culture is constructed and the extent to which it addresses discrimination and the effect of discrimination on short sleep duration among healthcare workers. Study results can help healthcare administrators understand how discrimination in the workplace environment can affect sleep outcomes. Furthermore, these results can help inform the development of people-oriented culture programs and resources that address discrimination in the workplace.

This study employed a mixed-methods approach using an explanatory sequential design. Quantitative data was first collected and analyzed which informed the objectives of the qualitative data to help further understand the findings of the quantitative results.⁴³

For the quantitative portion of the article, we used the 2018 data from the Boston Hospital Workers Health Study (BHWHS), a prospective cohort study that was established in 2006 to examine the working organization and condition, behaviors, and health outcomes among healthcare workers from two large hospitals in the same health system in Boston, Massachusetts.⁴⁴ The study’s participants are nursing directors, assistant nursing directors, clinical nurse managers, staff nurses, and patient care associates (PCA). The 2018 data surveyed about 2,000 workers and had a 55% response rate. The initial sample was N=1,101. After eliminating observations with missing data on key variables short sleep (n=41), discrimination (n=92), and people-oriented culture (n=123), our final sample size for this study was N=845.

For the qualitative portion of the study, we conducted 16 semi-structured interviews of unit nurse directors.

Demographic data including age, gender, race, immigrant status, job title (1 = nurse; 2 = PCA; 3 = Other [e.g., nursing director, clinical nurse manager, etc.]), and number of hours worked per week were obtained from the self-reported surveys disseminated from BHWHS. The demographic data were used as covariates for the models.

The outcome variable of interest is short sleep duration derived from one of the items of the Pittsburgh Sleep Quality Index (PSQI).⁴⁵ The PSQI measure is a self-rated questionnaire that evaluates sleep quality in the past month. The BHWHS only used three items from the measure and this study only used the short sleep duration item. To measure short sleep duration, responses were dichotomized categorizing 6 hours of sleep or less as “Yes” and more than 6 hours of sleep as “No.” This cutoff is consistent with previous studies.^33,34

Discrimination, the primary independent variable, was measured using five questions from the Job Discrimination scale.⁴⁶ This instrument has a Cronbach’s alpha of 0.79 for internal consistency. Participants were asked about experiences of discrimination and self-reported using a five-point Likert scale with responses from never to once a week or more. We calculated the mean average scores of the five items. Participants who answered “a few times a year” to at least one of the questions in the discrimination measure were then asked, “What do you think is the main reason for these experiences?” Participants were instructed to only choose one category (e.g., ancestry or national origins, gender, age, etc.).

People-oriented culture was used as the buffering measure for the study using four questions from the Organizational Policies and Practices questionnaire.³⁹ This instrument has a Cronbach’s alpha of 0.82 for internal consistency. Participants were asked about cooperation within a workgroup and self-reported using a five-point Likert scale with responses from strongly disagree to strongly agree. We calculated the mean average scores of the four items.

Univariate analysis examined the descriptive distribution of the variables. We then compared the variables by short sleep duration using chi-square tests and t-tests. Four models are presented using logistic regression to examine the odds of reporting short sleep duration in association with perceived reception of discriminatory behaviors and controlling for the variables of interest in the subsequent models. Interactions between perceived discriminatory behavior and people-oriented culture were examined to determine if people-oriented culture moderated the effects of discrimination on short sleep duration. Observations are non-independent since workers are clustered within units, so we accounted for this clustering by including hospital units as random effects using the “vce (cluster)” command which allows units to correlate. Missing cases were handled using listwise deletion. Data was analyzed using Stata 15 SE.

Qualitative data was analyzed using grounded theory ⁴⁷ and thematic analysis.⁴⁸ We employed solo coding by following Saldaña’s ⁴⁸ recommendations that required consulting with another trained researcher during the progress of the data analysis to discuss, process, and validate the findings. In addition, the coder also kept memos during data analysis. First the trained researcher began with open or initial coding of transcripts to generate a list of codes. Codes were analyzed and facilitated creating categories and sub-categories based on patterns from the data. The relationships between categories and sub-categories were assessed and established themes related to perceived experiences of discrimination in the workplace and the operationalization of people-oriented culture. Data was analyzed using Atlas.ti 8.0 which is a software that facilitates the organization and analysis of text, images, audio, and video data.

The point of integration is when components of the quantitative and qualitative findings intersect or merge.⁴³ In this study, the point of integration occurred in its design and in the analysis. We used data from the qualitative findings to address gaps in the quantitative data concerning aspects of perceived discrimination that healthcare workers experienced and the extent to which people-oriented culture addressed discrimination and potentially influence sleep outcomes.

Our quantitative findings show that the perception of discrimination is significantly associated with short sleep duration for all the models but Model 4, indicating that quantitative measurements of the relationship between discrimination and short sleep duration has its limitations. However, people-oriented culture did not buffer the effect of discrimination on short sleep duration, but the independent effect of the association of people-oriented culture and short sleep duration was statistically significant and showed that healthcare workers with perceived high people-oriented culture in the workplace had decreased odds of short sleep duration. In addition, people-oriented culture slightly attenuated the association of discrimination and short sleep duration. We also needed to further understand the mechanisms in which discrimination transpires and who executes these behaviors in the workplace. Moreover, while people-oriented culture is significantly associated with short sleep duration, we do not know why people-oriented culture did not moderate the effects of discrimination on short sleep. Thus, we want to examine how people-oriented culture is constructed and what it addresses in relation to discrimination to the extent that it can influence the quality of sleep among healthcare workers.

The unit nurse directors discussed many forms of violence that nurses and PCAs experience including abuse, harassment, bullying, and discriminatory behaviors from their co-workers, patients, and patients’ family members, however, our study aimed to focus on discrimination which is distinct from the other forms of violence mentioned.

A limitation of the study is that experiences of discrimination is self-reported which may indicate potential bias and inaccurate introspection. However, experiences of discrimination are subjective; therefore, self-report is an appropriate method of measuring discrimination.^64–66 Another limitation is that while our sample is representative of the socio-demographic make-up of nurses in the U.S., it does not reflect the full diversity of nurses and PCAs. Qualitative interviews were conducted among unit nurse directors which limits direct understanding of experiences of discrimination based on recipients’ perceptions that excludes the experiences of nurses and PCAs. The qualitative interviews also did not explicitly ask questions regarding experiences of discrimination and how healthcare workers perceive people-oriented culture. This limited our understanding of how these constructs transpired; however, the use of grounded theory in the qualitative analysis permitted for themes related to discrimination and people-oriented culture to emerge. Finally, while the study is longitudinal, the 2018 wave was the first time that discrimination was measured in the survey instrument. Thus, this study is cross-sectional in nature and cannot explain causality.

The study has several strengths. Previous studies have analyzed the influence of discrimination on sleep quality and outcomes separately within the healthcare worker population: this study is one of the few that specifically examines the impact of discrimination on a particular sleep outcome, short sleep duration, among healthcare workers. It also assesses the mitigating influence of people-oriented culture in the workplace to diminish the influence of discrimination. A notable strength of the study is our use of a mixed-method approach that permits the triangulation of data to gain a more in-depth understanding of the findings. While discrimination has been ever present in society, the increasing reports of explicit forms of discrimination in the U.S. will continue to affect the health and well-being of marginalized groups.