NURSING EXAM STUDY GUIDE

The Nurse's Role in Addressing Discrimination

Protecting and Promoting Inclusive Strategies in Practice Settings, Policy, and
Advocacy
American Nurses Association (ANA) | Position Statement 2018

Comprehensive Side-by-Side Study Guide with 20-Question Practice Exam

SECTION 1: PURPOSE AND ANA POSITION STATEMENT

TOPIC / CONCEPT DETAILED EXPLANATION

Purpose of the Position Statement To reiterate the significance of a
nondiscriminatory stance and provide guidance in
creating inclusive strategies for nursing care of all
individuals of all ages and from all populations.

ANA's Ethical Foundation The ANA Code of Ethics directs nurses to

respect the inherent dignity, worth, unique
attributes, and human rights of all individuals
(ANA, 2015, p.17).

Definition of Discrimination Merriam-Webster: "the practice of unfairly

treating a person or group of people differently
from other people or groups of people."

ANA's Core Position Discrimination has no place in nursing practice,

education, or research. All patients are equal and
must be treated with impartiality, respect, and
civility regardless of demographics or
socioeconomic status.

Recognition of Progress ANA acknowledges progress in national efforts to

eliminate discrimination related to race, gender,
and socioeconomic status — but concerted
efforts must continue to eliminate all forms.

Where Impartiality Begins Impartiality begins at the level of the individual

nurse and must be reflected within every health
care organization.

Unconscious Bias All nurses must recognize the potential impact of

unconscious bias and practices that contribute to
discrimination, and actively seek opportunities to
promote inclusion.

ANA Policy Stance ANA supports policy initiatives directed toward

abolishing all forms of discrimination. Any
organizational policy that inadvertently supports
discrimination — whether targeting a group or
individual employees — is wrong and must be
stopped.
SECTION 2: HISTORY AND PREVIOUS POSITION STATEMENTS

PREVIOUS STATEMENT / SOURCE KEY CONTENT AND SIGNIFICANCE

ANA (1998) — Discrimination and Racism in Called for equality and justice at both individual
Health Care and population levels. Warned that ignoring
discriminatory behaviors leads to an ever-
increasing gap in health disparities and negates
professional values.

ANA (2016) — The Nurse's Role in Ethics and Provided additional documentation in support of
Human Rights eliminating discrimination based on ethical
obligations outlined in the Code of Ethics for
Nurses with Interpretive Statements.

Recommendations in the 2016 Statement Outlined numerous recommendations with

implications for individual nurses, the nursing
profession, nursing education, nursing research,
and health care organizations.

The 2018 Position Statement Upholds all previous position statements by

denouncing discrimination of any kind. Serves as
a revision that consolidates and reinforces earlier
guidance.
SECTION 3: TYPES OF DISCRIMINATION AND MICROAGGRESSIONS

3A. Bases of Discrimination

CHARACTERISTIC / BASIS NOTES AND EXAMPLES

Race One of the most commonly cited bases;
contributes significantly to health disparities,
especially in cardiovascular and metabolic
disease risk.

Gender Includes both patient-facing and workforce

discrimination. Example: male nurses
experiencing stereotyping and microinvalidations.

Age Patients of any age group may face differential

treatment based on age-related assumptions.

Religion Beliefs and religious practices may lead to

assumptions or biased treatment decisions.

Socioeconomic Status (SES) Even when SES is controlled, disparities persist

— African Americans remain at greater risk for
hypertension and other metabolic diseases
regardless of income.

Pregnancy Explicit example used in the document as an

evolving basis for discrimination.

Political Affiliation Listed as another recognized basis; the list

continues to grow over time.

Military Status Service members and veterans may face

differential treatment.

Family Medical History / Genetic Testing Newer, evolving basis: genetic information can
now be weaponized to justify unequal treatment.

3B. Intentional vs. Unintentional Discrimination — Side-by-Side Comparison

INTENTIONAL (BLATANT) UNINTENTIONAL (IMPLICIT)

DISCRIMINATION DISCRIMINATION
Also called: Explicit or blatant discrimination Also called: Implicit bias or unconscious
discrimination

Occurs when an individual or group acts upon Resides OUTSIDE the perpetrator's awareness
attitudes and beliefs (Black, Johnson & (Bertrand, Chugh & Mullainathan, 2005)
VanHoose, 2015)

Manifested as microaggression type: Manifested as microaggression types:

MICROASSAULT MICROINSULT and MICROINVALIDATION

Involves deliberate, conscious choice to treat Can be equally as detrimental as intentional

 someone differently discrimination despite being unconscious

Must not be tolerated and must be immediately Requires all nurses to engage in self-reflection
addressed (ANA Recommendation) and examine personal biases

Example: Refusing to provide optimal care based Example: Expressing negative stereotypes about
on a patient's race men in nursing (microinvalidation)

3C. Types of Microaggressions — Side-by-Side Comparison

TYPE OF
EXAMPLE IN NURSING
MICROAGGRESSIO DEFINITION
CONTEXT
N
Microassault A conscious, deliberate A nurse explicitly refusing to treat a
discriminatory action — most patient of a particular ethnicity.
closely aligned with intentional
discrimination.

Microinsult An unconscious communication A colleague implying that a male

that conveys rudeness and nurse is less suited for pediatric
insensitivity, demeaning a person's care due to gender.
identity.

Microinvalidation Unconscious behavior that Telling a male nurse that 'nursing

disavows or excludes the is really a women's profession,'
experiences and realities of a negating his identity and
marginalized group. experience.
SECTION 4: PERCEIVED DISCRIMINATION AND ITS HEALTH
EFFECTS

ASPECT OF PERCEIVED
DETAILS AND SUPPORTING EVIDENCE
DISCRIMINATION
Definition When individuals believe they have experienced
discrimination based on personal characteristics,
they may exhibit poorer physical and
psychological health (Sutin, Stephan &
Terracciano, 2015).

Mental Health Connection There is a well-documented link between

perceived discrimination, racism, and mental
health — including chronic health conditions and
personality development — as a key factor in
understanding health disparities among ethnic
groups.

Delay in Seeking Care Those who report perceived discrimination

believe they are not receiving optimal care,
causing them to delay seeking treatment —
leading directly to poor health outcomes (Lee,
Ayers & Kronenfeld, 2009).

Adherence to Treatment Plans Patients experiencing perceived discrimination

have difficulty adhering to prescribed treatment
plans, creating downstream health complications.

Internalized Racism Perceived discrimination can lead to internalized

racism, which creates ongoing stressors that
further negatively affect health status (Williams,
2012).

Race vs. Socioeconomic Status While some researchers attribute disparities

solely to SES, others show disparities persist
even controlling for SES. African Americans
remain at greater risk for hypertension and
metabolic disease regardless of income (Monk,
2015).
SECTION 5: HEALTH DISPARITIES

EXPLANATION AND RESEARCH

CONCEPT / FINDING
SUPPORT
Definition of Health Disparities The grouping of unequal health outcomes across
demographic populations — commonly
associated with race, ethnicity, and
socioeconomic factors (Lee, Ayers & Kronenfeld,
2009).

Long-Standing Association with Discrimination The delivery of health care has long been
associated with discrimination, whether perceived
by the patient, or actual/inadvertent on the part of
the provider or institution (Reynolds, 2004).

Income Does Not Protect (Hastert, 2016) Inequities in health outcomes were NOT related
to income but to demographics, specifically race
and ethnicity — even the highest-income
Americans from minority groups experience
disparities.

Combined Race and SES Impact Brooks et al. (2017) and Link et al. (2017)
demonstrated BOTH a race/ethnic AND
socioeconomic impact on health and health
outcomes — it is not simply one or the other.

Stigma as a Cause Stuber, Meyer & Link (2008) suggested stigma

should be included alongside prejudice as a
perceived cause of discrimination, and therefore
a cause of poor health outcomes.

Meta-Analysis Evidence (Pascoe & Richman, Described the negative impact of a patient's
2009) perceptions of discrimination regarding health
care delivery on their actual health outcomes —
perceptions directly alter outcomes.

Access and Funding Factors (Burgess et al., Health disparities are influenced by an immense
2008) web of factors: actual illness variation among
demographic groups, access to health care, and
health care funding policies.

ANA's Position on Equal Screening Regardless of demographic expectations, all

patients must be equally screened for elevated
blood pressure, blood glucose, HIV,
vision/hearing changes, BMI, cancer screenings,
mental health screenings, and receive all
preventive services such as vaccinations.
SECTION 6: ANA RECOMMENDATIONS — WHO MUST DO WHAT

STAKEHOLDER RECOMMENDATION KEY PRINCIPLE

All Nurses Must not tolerate intentional or Zero tolerance for explicit
blatant discriminatory practices and discrimination
must immediately address them.

All Nurses Must engage in a period of self- Resolve internal conflicts to ensure
reflection regarding personal and patient safety
professional values related to civility,
mutual respect, and inclusiveness.

All Nurses Must seek out and support nursing Create an inclusive culture
practice environments that embrace
inclusive strategies and promote
civility and mutual respect for
patients, coworkers, and the
community.

All Nurses Must advocate for policies that are Policy advocacy
inclusive and promote civility and
human rights for all health care
workers, patients, and others in the
organization and community.

All Nurses Must encourage all health care Systemic accountability

agencies to adopt and aggressively
maintain inclusive policies,
procedures, and practices with
mechanisms for reporting violations
and interventions to prevent
recurrence.

All Nurses Must work within the profession and Cross-sector collaboration
with other professionals (social
workers, clergy, advocacy
organizations) to create diverse,
inclusive communities sustaining
safe, quality care (ANA, 2010).

All Nurses Must embrace justice and caring, Core guiding principles
diversity and inclusiveness, and
civility and mutual respect as guiding
principles in all aspects of health
care delivery.

Nurse Researchers Must support and conduct research Inclusive research design
that is inclusive in nature, including
diverse populations and their health
care needs.

Nurse Managers, Must assess policies to ensure Policy assessment and enforcement
Supervisors, support of inclusiveness, civility, and
Administrators mutual respect; lack of such policies
may result in environments that fail
to sustain high-quality, safe health
 care (ANA, 2010).

Nurse Educators Must promote a diverse workforce by Workforce diversity through

developing education practices that education
attract and retain students from all
backgrounds, to reflect the diversity
of the US population (Graham et al.,
2016).

All Nurses (Patient Must embrace a patient-centered Cultural competence in direct care
Care) approach responsive to the
individual cultural needs and
concerns of their patients and
families (Cuevas, O'Brien & Saha,
2017).
SECTION 7: CIVILITY — A KEY ANA CONCEPT

ELEMENT OF CIVILITY DETAILED EXPLANATION

Definition (Lower, 2012) Civility is an ACTIVE behavior — not passive —
that embodies mutual respect, promotes
communication, and fosters collaboration among
nurses, patients, and the health care team.

Why Civility Matters ANA takes the explicit position that all patients
are equal and should be treated with impartiality,
respect, and civility — regardless of their
demographics or socioeconomic status.

Civility in Practice Nurses must seek environments that promote

civility and mutual respect. Creating a civil
environment is part of addressing both intentional
and unintentional discrimination.

Civility vs. Discrimination Organizational policies that support individual

employees who are discriminatory violate civility
principles. ANA is clear: this is wrong and must
be stopped regardless of whether the policy is
formal or informal.
SECTION 8: SUMMARY — KEY TAKEAWAYS

KEY THEME SUMMARY POINT

Scope of the Problem Discrimination continues to affect the health of
populations — it is not a historical issue but an
ongoing one.

Both Types Must Be Addressed Both intentional and unintentional discriminatory

practices must be addressed by individual nurses
and the profession as a whole.

Self-Examination is Required Given the impact of unconscious discrimination

from attitudes and stereotyping, all nurses must
examine their biases and prejudices for signs of
discriminatory actions.

Health Disparities Persist Health disparities continue to exist and are

influenced by health policies, individual
discriminatory actions, marginalization, and
perceived discrimination by the affected
population.

Nursing's Collective Responsibility The nursing profession is responsible for

promoting an environment of inclusiveness where
all patients receive safe, quality care, and
caregivers are intolerant of any discriminatory
practice.
SECTION 9: PRACTICE EXAM — 20 MULTIPLE CHOICE QUESTIONS
Instructions: Select the best answer for each question. Rationale is provided after each question to reinforce
learning.

Question 1: According to the ANA position statement, where does impartiality BEGIN in addressing
discrimination?
A. At the national policy level
B. At the level of the individual nurse
C. Within health care funding legislation
D. Through nursing school curricula
Correct Answer: B. At the level of the individual nurse
Rationale: The ANA position statement explicitly states that 'impartiality begins at the level of the individual nurse and
should occur within every health care organization.' Each nurse bears personal responsibility before systemic change
can occur.

Question 2: Which of the following BEST defines 'civility' as described in the ANA position
statement?
A. The absence of conflict in the workplace
B. A passive acceptance of differing viewpoints
C. An active behavior that embodies mutual respect, promotes communication, and fosters collaboration
D. A legal obligation to treat patients equally
Correct Answer: C. An active behavior that embodies mutual respect, promotes communication, and
fosters collaboration
Rationale: Lower (2012) defines civility as an ACTIVE behavior — not passive — that embodies mutual respect,
promotes communication, and fosters collaboration. This is a frequently tested definition in the document.

Question 3: A nurse unknowingly tells a male colleague that 'nursing is really a woman's
profession.' This statement BEST represents which type of microaggression?
A. Microassault
B. Microinsult
C. Microinvalidation
D. Intentional discrimination
Correct Answer: C. Microinvalidation
Rationale: Microinvalidations are unconscious behaviors that DISAVOW the experiences or identity of a group. Telling
a male nurse his profession is 'really for women' negates his professional identity and is a classic microinvalidation.
Microinsults demean; microassaults are conscious and intentional.

Question 4: Implicit or unintentional discrimination is BEST characterized as:

A. Less harmful than intentional discrimination because the person does not mean any harm
B. Equally as detrimental as intentional discrimination, though it resides outside the perpetrator's awareness
C. Only harmful when combined with direct verbal abuse
D. Primarily a leadership-level problem, not a bedside nursing issue
Correct Answer: B. Equally as detrimental as intentional discrimination, though it resides outside the
perpetrator's awareness
Rationale: Bertrand, Chugh & Mullainathan (2005) are cited in the position statement: implicit discrimination can be
equally as detrimental as intentional discrimination despite residing outside the perpetrator's awareness. Impact does
not depend on intent.

Question 5: Research cited in the ANA position statement (Hastert, 2016) found that health
disparities were primarily associated with:
 A. Access to employer-sponsored insurance
B. Education level attained by the patient
C. Demographics, specifically race and ethnicity — NOT income
D. Geographic location and urban vs. rural setting
Correct Answer: C. Demographics, specifically race and ethnicity — NOT income
Rationale: Hastert (2016) reported that discrimination and resulting inequities in health outcomes were NOT related to
income but to demographics, specifically race and ethnicity. This is a key finding supporting the persistence of systemic
racial disparities beyond economics.

Question 6: According to the position statement, which of the following is a consequence of

perceived discrimination on patient behavior?
A. Patients seek more frequent preventive screenings
B. Patients are more likely to report symptoms early
C. Patients may delay treatment and have difficulty adhering to treatment plans
D. Patients are more trusting of nurse practitioners than physicians
Correct Answer: C. Patients may delay treatment and have difficulty adhering to treatment plans
Rationale: Those reporting perceived discrimination believe they are not receiving optimal care, may delay treatment,
have difficulty adhering to treatment plans, and may experience internalized racism — all creating ongoing stressors
that further affect health status.

Question 7: Which ANA position statement first called for equality and justice at both individual and
population levels in addressing racism in health care?
A. The Nurse's Role in Ethics and Human Rights (2016)
B. Discrimination and Racism in Health Care (1998)
C. The Code of Ethics for Nurses with Interpretive Statements (2015)
D. Nursing's Social Policy Statement (2010)
Correct Answer: B. Discrimination and Racism in Health Care (1998)
Rationale: The 1998 ANA position statement on Discrimination and Racism in Health Care was the foundational
document calling for equality and justice at individual and population levels. The 2018 statement builds upon and
upholds this earlier work.

Question 8: A nurse manager notices their facility's patient assignment policy tends to place
minority patients with less experienced staff. According to ANA, this is BEST described as:
A. An acceptable practice if driven by staffing shortages
B. Organizational policy that inadvertently supports discrimination, which is wrong and must be stopped
C. A microassault only if the manager is aware of the disparity
D. Permissible if it is not in writing
Correct Answer: B. Organizational policy that inadvertently supports discrimination, which is wrong and
must be stopped
Rationale: ANA takes the position that organizational policy that inadvertently supports discrimination is in error. It does
not matter whether it is a formal policy or one that supports discriminatory individuals — it is wrong and must be
stopped.

Question 9: According to Monk (2015), which population continues to be at greater risk for
hypertension and other metabolic diseases REGARDLESS of socioeconomic status?
A. Hispanic Americans
B. Asian Americans
C. African Americans
D. Native Americans
Correct Answer: C. African Americans
Rationale: Monk (2015) found that regardless of SES, African Americans continue to be at greater risk for hypertension
as well as other metabolic disease. This supports the ANA position that race and ethnicity — not merely income — must
be considered in health care delivery.
Question 10: What is the PRIMARY role of nurse educators, according to the ANA's
recommendations?
A. To conduct research on microaggressions in clinical settings
B. To assess existing organizational policies for discriminatory content
C. To promote a diverse workforce by attracting and retaining students from all backgrounds
D. To develop patient satisfaction surveys that measure perceived discrimination
Correct Answer: C. To promote a diverse workforce by attracting and retaining students from all
backgrounds
Rationale: Graham et al. (2016) supports ANA's recommendation that nurse educators must develop education
practices to attract and retain students from all backgrounds, so that the nursing workforce begins to reflect the diversity
of the overall U.S. population.

Question 11: The term 'health disparities' as used in the ANA position statement BEST refers to:
A. Differences in hospital facility quality between urban and rural areas
B. Variation in nurse-to-patient staffing ratios across hospital departments
C. The grouping of unequal health outcomes commonly associated with race, ethnicity, and socioeconomic
factors
D. The gap in medical research funding between specialties
Correct Answer: C. The grouping of unequal health outcomes commonly associated with race, ethnicity,
and socioeconomic factors
Rationale: Lee, Ayers & Kronenfeld (2009) define health disparities as the grouping of health outcomes unequally
distributed across demographic populations. This is a direct definition from the supporting material section of the
document.

Question 12: Which type of microaggression is a CONSCIOUS and DELIBERATE discriminatory

action — most closely aligned with intentional discrimination?
A. Microinvalidation
B. Microinsult
C. Microassault
D. Implicit bias
Correct Answer: C. Microassault
Rationale: A microassault is conscious and deliberate, making it the form of microaggression most closely aligned with
blatant/intentional discrimination. Microinsults and microinvalidations are unconscious, while implicit bias underlies
unintentional discrimination more broadly.

Question 13: ANA's position on health screenings states that ALL patients should be equally
screened regardless of demographic. Which of the following is listed as a required screening?
A. Genetic predisposition testing for all patients over age 40
B. HIV screening
C. Family mental health history review
D. Military service history assessment
Correct Answer: B. HIV screening
Rationale: The ANA position statement explicitly lists HIV screening among the health risk factors all patients must be
equally screened for, along with elevated blood pressure, blood glucose, changes in visual and hearing capacity, BMI,
cancer screenings, mental health screenings, and vaccinations.

Question 14: A nurse tells a patient, 'People like you usually don't follow through with treatment
anyway.' This statement is an example of:
A. Legitimate clinical concern based on population data
B. A microinsult — an unconscious communication that conveys insensitivity and demeans the patient's
identity
C. A microinvalidation of the patient's cultural background
D. Intentional discrimination only if the patient files a formal complaint
Correct Answer: B. A microinsult — an unconscious communication that conveys insensitivity and
demeans the patient's identity
Rationale: Microinsults are unconscious communications that convey rudeness and insensitivity, demeaning a person's
racial or group identity. Assuming non-compliance based on group membership is a textbook microinsult, even if the
nurse believes they are being clinically realistic.

Question 15: Which meta-analysis directly described the negative impact of patients' perceptions of
discrimination on their ACTUAL health outcomes?
A. Burgess et al. (2008)
B. Williams (2012)
C. Pascoe and Richman (2009)
D. Stuber, Meyer & Link (2008)
Correct Answer: C. Pascoe and Richman (2009)
Rationale: Pascoe and Richman's (2009) meta-analysis is specifically cited in the document for describing how a
patient's perceptions of discrimination regarding health care delivery negatively impact their actual health outcomes — a
direct causal link between perception and outcome.

Question 16: According to the ANA position statement, what should a nurse do when they encounter
an organizational policy that discriminates?
A. Report it privately to the nurse manager and await resolution
B. Accept it if it is an established institutional tradition
C. Advocate for policies that are inclusive and promote civility and human rights, and encourage agencies to
stop the discriminatory practice
D. Document the policy and include it in annual performance reviews
Correct Answer: C. Advocate for policies that are inclusive and promote civility and human rights, and
encourage agencies to stop the discriminatory practice
Rationale: ANA recommends that nurses must advocate for inclusive policies and encourage all health care agencies
to adopt and aggressively maintain inclusive policies, procedures, and practices. Both discriminatory policies AND
policies supporting discriminatory individuals must be stopped.

Question 17: The link between perceived discrimination and health, including mental health and
chronic conditions, has been studied as a key factor for understanding health disparities in which
population group?
A. Veterans and active military personnel
B. Pediatric populations under age 12
C. Ethnic minority groups
D. Rural populations with limited hospital access
Correct Answer: C. Ethnic minority groups
Rationale: The position statement states: 'The link between perceived discrimination, racism, and health, including
mental health, chronic health conditions, and personality development, has been a focus for greater understanding of
health disparities among ethnic groups.'

Question 18: A nurse manager reviews their unit's policies and finds no mechanism for reporting
discrimination violations. According to ANA recommendations, what should the nurse manager do?
A. Assume staff will handle incidents informally
B. Assess and update policies to include methods for reporting violations and require interventions to avoid
recurrence
C. Escalate directly to legal counsel without changing departmental policy
D. Post a general notice about respectful behavior in the break room
Correct Answer: B. Assess and update policies to include methods for reporting violations and require
interventions to avoid recurrence
Rationale: ANA recommends that nurses encourage health care agencies to adopt and aggressively maintain policies
that contain METHODS FOR REPORTING VIOLATIONS and REQUIRE INTERVENTIONS to avoid recurrence. Nurse
managers must actively assess and correct policy gaps.
Question 19: Which two groups of researchers found BOTH race/ethnicity AND socioeconomic
status contribute to health and health outcome disparities?
A. Pascoe and Richman (2009); Williams (2012)
B. Brooks et al. (2017); Link et al. (2017)
C. Burgess et al. (2008); Hastert (2016)
D. Monk (2015); Lee, Ayers & Kronenfeld (2009)
Correct Answer: B. Brooks et al. (2017); Link et al. (2017)
Rationale: The position statement notes: 'Brooks et al. (2017) and Link et al. (2017) did demonstrate both a race/ethnic
AND socioeconomic impact on health and health outcomes.' This contrasts with Hastert's finding that income alone was
insufficient to explain disparities.

Question 20: Which of the following BEST summarizes the ANA's overall position on the nursing
profession's responsibility regarding discrimination?
A. Nurses should avoid clinical discussions about race and ethnicity to prevent bias
B. The nursing profession is responsible for promoting an environment of inclusiveness where all receive
safe, quality care and caregivers are intolerant of any discriminatory practice
C. Discrimination is primarily a societal problem that exceeds the nurse's scope of practice
D. Nurses should defer to physicians when discrimination complaints involve medical decision-making
Correct Answer: B. The nursing profession is responsible for promoting an environment of inclusiveness
where all receive safe, quality care and caregivers are intolerant of any discriminatory practice
Rationale: This is the direct summary statement from the ANA position document. Nursing bears collective and
individual responsibility — not only for avoiding discrimination but for actively promoting an inclusive environment and
being intolerant of any discriminatory practice.

— End of Study Guide —

American Nurses Association | 2018 Position Statement | [Link]