Original Article

The Influence of
Race and Gender on
Nursing Care Decisions:
A Pain Management
Intervention
James Cavalier Jr, PhD, Sharon B. Hampton, PhD,
---

Rae Langford, EdD, Lene Symes, PhD, and Anne Young, EdD

- ABSTRACT:
Background: Understanding whether a patient’s race or gender and/or
the nurse’s race or gender influence how nurses form care decisions
can contribute to exploration of methods that can positively affect
disparate treatment. Aims: This research examined how the variables
of race and gender of both the nurse and the patient influence nurses’
decision making about pain management. Design: A randomized four-
group post-test–only experimental design was used to examine the
variables and variable interactions. Settings: An investigator-
developed case vignette tool hosted online was used to obtain data
about nursing pain management decisions. The vignette intervention
was developed to simulate four exact patient scenarios that differed
only by patient race and gender. Participants/Subjects: A quota sample
of 400 nurses was recruited using a self-selected face-to-face recruit-
ment technique. Methods: A four-way between-groups analysis of
variance assessed whether the gender of the nurse, race of the nurse,
gender of the patient, or race of the patient made any differences in the
From the Nelda C. Stark College of dose intensity of pain medications selected by the nurse sample. Re-
Nursing, Texas Woman’s University,
Houston, Texas.
sults: No significant interactions were noted between any combina-
tions of the four independent variables. A significant main effect was
Address correspondence to James noted in medication intensity for nurse gender (F [1,384] ¼ 9.75,
Cavalier Jr, PhD, Nelda C. Stark
p ¼ .002). Conclusions: Data trends suggested that gender stereotypes
College of Nursing, Texas Woman’s
University, 6700 Fannin Street, about how patients managed pain played a role in dose intensity de-
Houston, TX 77030. E-mail: cisions because female patients on average were given higher doses of
[email protected] pain medication than male patients were by all the nurses in the study.
Received February 24, 2017; Further research is needed in this complex area of study.
Revised October 12, 2017; Ó 2017 by the American Society for Pain Management Nursing
Accepted October 12, 2017.
Patient care decisions are often complex and can be confounded by several
1524-9042/$36.00 provider-specific factors. For example, clinical uncertainty; stereotypes about pa-
Ó 2017 by the American Society for
Pain Management Nursing
tient gender, race/ethnicity, age, and other preconceived notions; and provider
https://doi.org/10.1016/ characteristics such as gender, race, age, and previous experiences have been re-
j.pmn.2017.10.015 ported as influencing delivery of patient care (Cooper et al., 2003; Ferguson &

Pain Management Nursing, Vol 19, No 3 (June), 2018: pp 238-245

 Race and Gender in Nursing Care Decisions 239

Candib, 2002; Hagerty & Patusky, 2003; Tarlier, 2004; & Dominguez, 2003; Women and Heart Disease Fact
van Ryn & Fu, 2003). Judgments associated with a Sheet, n.d.). There is a growing body of literature
patient’s status are often made through the activation that reports differences in care practices as they relate
and recall of nurses’ education, experience, insight, to pain and pain management. Although it is accepted
and intuition. The greater the decision-making uncer- that biases exist, current literature remains mixed on
tainty, the more likely a provider is to lean on precon- how those biases affect care. Although literature states
ceived notions about the patient, thus creating an that the race and gender of the provider do not influ-
avenue to let bias influence care decisions. ence whether a provider will treat a patient’s pain
This study examined whether specific factors (Weisse et al., 2003; Weisse, Sorum, Sanders, & Syat,
such as race and gender of patients and race and 2001), bias appears to exist in the manner in which
gender of providers influenced patient care decisions pain management options are selected as treatment
made by nurses. Every individual experiences some choices.
type and intensity of pain during their lifetime, and Specifically, differences in care practices related to
pain occurs in every health care settings. Using pain patient gender produce mixed results. Women
as the content focus allowed a broad range of nurses continue to be perceived to be more likely to report
from multiple specialties to serve as study participants. pain, more sensitive to pain, and less likely to endure
It was hypothesized that nurses who were matched pain than men (Defrin, Shramm, & Eli, 2009;
with patients on the characteristics of race and gender Wandner, Scipio, Hirsh, Torres, & Robinson, 2012).
would make different care decisions than nurses who However, in a recent study of 80 physicians and 113
were partially matched or not matched for race and nurse providers using vignettes and virtual patient
gender. images, male patient pain was rated higher than
Research related to factors that influence dispar- female pain and was treated more readily (Wandner
ities such as pain management and nonadherence to et al., 2014).
care recommendations primarily has been in the In addition, differences may exist in gender-
domain of medicine and has focused on many of the concordant and -discordant provider-patient relation-
contributing factors, such as socioeconomic status, ships. Several studies reported that providers were
health systems, utilization, and access, with little focus more likely to administer medications to patients of
on the behavior and care decisions of the provider (van like or concordant gender (Safdar et al., 2009; Weisse
Ryn & Fu, 2003). Empirical evidence suggests that et al., 2001, 2003) than to patients of different or
provider-patient interactions may influence patient discordant genders. However, Criste (2003) found no
outcomes, satisfaction, adherence, and disparities in difference in how male and female certified registered
health; however, theory development and research nurse anesthetists managed patients’ pain, and Safdar
related to the topic are poor (Cooper et al., 2003; et al. (2009) found no difference between patient
Ferguson & Candib, 2002; Hagerty & Patusky, 2003; gender and the pain medications prescribed.
Tarlier, 2004). Health outcomes studies examining When examining race, White patients were
provider-level sources where the race and gender of viewed as being more sensitive to and willing to report
the provider and patient are studied are sparse and pain (Green et al., 2003; Wandner et al., 2012) than
without consensus (Meghani et al., 2009). Much of non-White patients. However, when differences in
the inquiry has been focused on patient-level sources pain management based on race were assessed using
for disparities, disregarding the potential contribution virtual human patient technology, Black patient pain
of the health care provider. Provider characteristics intensity was rated higher and was more likely to be
such as age, gender, race/ethnicity, and provider atti- treated with pain medication (Wandner et al., 2014;
tude may be significant factors in understanding the Weisse et al., 2003). Non-White physicians were also
etiology of care disparities (Deepmala, Franz, Aponte, found to better relieve patient pain compared with
Agrawal, & Wei, 2012; Meghani et al., 2009). White physicians (Heins, Homel, Safdar, & Todd,
It is well documented that differences in care 2010). Congruent with disparity-based health care
based on gender and race exist (Borkhoff, Hawker, & research (Center for Disease Control and Prevention
Wright, 2011; Constantinescu, Goucher, Weinstein, & [CDC], 2013; National Cancer Institute, 2015; Perry,
Fraenkal, 2009; Cooper et al., 2003; Cooper-Patrick Harp, & Oser, 2013; Williams & Sternthal, 2010),
et al., 1999; Epstein et al., 2003; Ferguson & Candib, Black female patients received the least aggressive
2002; Landers, 2009; Malat, van Ryn, & Purcell, 2006; pain management intervention (Weisse et al., 2003),
Mulvaney-Day, Earl, Diaz-Linhart, & Alegria, 2011; further confusing the understanding of this issue.
National Cancer Institute, 2015; Schulman et al., Nurses log more patient contact hours than any
1999; Stevens, Shi, & Cooper, 2003; Weisse, Sorum, other health care providers, yet research related to
240 Cavalier Jr et al.

race, gender, and the nurse-patient experience is identified. These included the gender and race of the
limited. Nurses maintain a key role in determining patient and the gender and race of the nurse. The
how and when nursing and medical interventions are dependent variable was identified as the patient care
implemented. Nurses function as gate keepers deter- decisions made by the nurse for an identified patient.
mining when various ancillary health care disciplines Registered nurses comprised the sample. Black and
may access patients. Nurses are most often the health White, male and female, licensed and practicing regis-
care professionals responsible for educating patients tered nurses who expressed confidence in making
about care processes, procedures, and how to develop pain care decisions were included in the study. The
and maintain healthy lifestyles. It is because of these Institutional Review Board at Texas Woman’s Univer-
facts that this research attempts to identify whether sity approved the study.
the gender and race of the nurse and the race and Patient care decisions were measured using four
gender of the patient influence pain management vignettes that provided simulated patient scenarios
choices and thus influence health disparities. that directed the nurse participant to make decisions
about pain management for the patient in the scenario.
All vignettes provided identical clinical scenarios with
CONCEPTUAL FRAMEWORK the exception of the race and gender of the patient. A
Imogene King’s A Systems Framework for Nurses pro- picture of the patient was supplied with each vignette
vided the conceptual model to guide this research. and depicted one of four faces (a White female, a Black
King presents personal, interpersonal, and social sys- female, a White male, and a Black male; Fig. 1).
tems as domains of nursing in her Theory for Nursing. The patient has a history of hypertension, gastro-
Although care decisions are influenced by the personal esophageal reflux disease, and hepatitis C and is
system, it is the perception, judgment, and action 20 hours postoperative after open ventral hernia repair
phase of the interpersonal system domain that forms with mesh implant. The patient states that pain is a 7
the predominant framework for this study. on a 10-point scale (0 ¼ no pain, 10 ¼ worst pain).
‘‘Perceptions and judgments are involved in every Your assessment reveals that the patient is alert and ori-
type of human interaction; however, perceptions, judg- ented, blood pressure ¼ 122/64, heart rate ¼ 73,
ments, and mental actions are not directly observable’’ respirations ¼ 21, and temperature ¼ 97.9 F. The pa-
(King, 1981, p. 60). In the personal system domain, tient currently has a patient-controlled analgesia
perceptions and self are major concepts. Self relates (PCA) pump with the following settings: PCA
to the nurses’ culture, values, beliefs, and life experi- morphine dose 1 mg/1 mL, lockout 10 minutes;
ences that assist them with maintaining balance in maximum dose 20 mg in 4 hours. The patient has
their lives (King, 1981, p. 26). Self informs nurse and received instruction on the use of the PCA pump
patient perceptions, which influence nursing care. It with return demonstration. The allotted 20 mg has
is the recall of education and nursing experience as already been used and the patient is locked out for
well as a nurse’s concept of self that assists with the the next 45 minutes. The PCA is due to be discontin-
derivation and implementation of patient care deci- ued in 4 hours. No other pain medications have been
sions. Perceptions are what nurses use to form judg- administered.
ments in the assessment, interpretation, and planning The following medications have been ordered for
of patient care in an attempt to assist patients in the breakthrough pain. Which medication would you
achievement of health goals. Judgments manifest in administer now?
the form of clinical reasoning, which determines The researchers created a research tool that
which actions nurses will select to assist the patient included the four case vignettes and a measure with
in achieving health. ‘‘Action is a sequence of behaviors four weighted pain management responses that ranged
of interacting persons that includes: mental actions, from the least intensive care choices to most intensive
physical actions, and mental actions to exert some con- care choices. Four different medications that are often
trol over the events and physical action to move to prescribed for breakthrough pain and appropriate for
achieve goals’’ (King, 1981, p. 60). the treatment of the patient’s pain were offered as
pain management responses. A panel of expert judges
consisting of a senior nursing faculty and three prac-
METHODS ticing registered nurses (one medical-surgical and pedi-
A randomized four-group post-test–only experimental atric nurse and one acute care nurse practitioner)
design was used to determine whether selected char- weighted the questionnaire’s potential responses on
acteristics of the patient and the nurse influenced pa- a scale of best to worst. After several revisions, using
tient care decisions. Four independent factors were a consensus approach, the panel achieved 100%
 Race and Gender in Nursing Care Decisions 241

Vignette 1 Vignette 2 Vignette 3 Vignette 4

Troy, 42 y/o Black Shantel, 42 y/o Black Christopher, 42 y/o Michelle, 42 y/o White

Male Female White Male Female

FIGURE 1. - Vignettes. y/o ¼ Years old.

consensus on the scale. The options were determined, participant quota consisted of 100 White women,
agreed on, and placed in order by a panel of experts. 100 Black women, 100 White men, and 100 Black
The panel rated option 1 as the best practice and op- men (Table 1). The research instrument was hosted
tion 4 the least appropriate given the vignette in the Survey Monkey online survey management plat-
(Fig. 2). Each medication provided produced an in- form. An Internet link was provided to potential partic-
crease in the analgesic effect when taking into consid- ipants that could be accessed via computer or mobile
eration potency, onset, half-life, and clinical device. Once a participant logged on to the survey
experience of the researchers, compared with the and consented to participate, he or she was randomly
next, which informed the pain management intensity. assigned to a case vignette. Recruitment continued un-
Differences allowed the researchers to distinguish be- til all patient scenarios assignments were randomly
tween dose effects in pain management versus nurse filled (Table 1).
preference. All data were analyzed using the Statistical Pack-
The vignettes were constructed using an exten- age for Social Sciences (SPSS) Version 22.0 (IBM
sive literature review and consultation with nurses Corp., Armonk, NY, USA). A four-way between-groups
for standard care practices. The tool was examined analysis of variance (ANOVA) was used to assess the ef-
for content validity using a panel of experts. Reliability fects of the race and gender of the nurse participants
of the instrument was examined using inter-rater and the race and gender of the simulated patients on
consensus agreement among the panel of reviewers. pain management decision making. The four indepen-
Quota sampling was used and a self-selected face- dent variables used in the statistical analysis were
to-face recruitment was employed using a collegial gender of the nurse, race of the nurse, gender of the pa-
marketing approach and involving social media, pro- tient, and race of the patient. The dependent variable
fessional networking, and the use of family and friends was the pain management decisions made by the
to obtain the desired participants. A total of 827 nurses nurses.
were recruited to achieve random assignment of 400
participants to the four treatment groups. Each nurse
RESULTS
1. Dilaudid (hydromorphone hydrochloride) 1 mg IV push A sample of 400 practicing registered nurses were
2. Morphine 2 mg IV push included in the final analysis. The nurse participants
3. Toradol (ketorolac tromethamine) 30 mg IV push ranged in age from 22 to 78 years with a mean age of
4. Vicodin (hydrocodone and acetaminophen) 5/500 mg 2 tablets by mouth 43.7 years (standard deviation [SD] 11.52). Fifty-six
(14%) were educated at the associate degree or
FIGURE 2. - Four weighted pain management responses. diploma school level, 176 (44%) held a bachelor’s de-
IV ¼ intravenous. gree, and 168 (42%) held a graduate degree.
242 Cavalier Jr et al.

TABLE 1.
Sampling Procedure by Strata and Case Vignette

Patient Scenarios

Black Female Black Male White Female White Male Totals

Nurse Participants
Black female 25 25 25 25 100
Black male 25 25 25 25 100
White female 25 25 25 25 100
White male 25 25 25 25 100
Total 400

The weighted pain management scores for the was a difference in dose intensity selected by female
nurse participants ranged from 10 to 40 with a mean versus male nurses (Table 2).
score of 24.18 (SD 11.77), which indicated that the The mean dose intensity administered by female
average pain management score was of moderate in- nurses was 22.35 (SD 11.65), whereas the mean dose
tensity. It was interesting to note that 117 (29.3%) of intensity administered by male nurses was 26.0 (SD
the nurses scored 10, which is the lowest intensity rat- 11.65). Female nurses were more cautious in their
ing, and 111 (27.8%) scored the highest intensity rating pain management approach. The main effects for
of 40. nurse race, patient gender, and patient race were not
A four-way ANOVA was performed and all para- significant. All means and standard deviations for the
metric assumptions were met. Levene’s test was con- interactions and main effects are displayed in
ducted with a significance of level of .261, indicating Tables 3 and 4.
no violation of homogeneity of variances. The results Although pain management was not significantly
of the four-way ANOVA (Table 2) indicated no signifi- influenced by the race of the nurse or the race and/
cant interaction effects between any combinations of or gender of the patient, and there were no significant
the four independent variables. There was a statisti- interactions among the independent variables, there
cally significant main effect for nurse gender F
(1,384) ¼ 9.75, p ¼ .002. However, the effect size
was small (partial h2 ¼ 0.025). This means that there
TABLE 3.
Means and Standard Deviations of Pain
Management Scores for Interactions Among
TABLE 2.
Nurse and Patient Gender and Race
Analysis of Variance Results for Main Effects and
Interaction Effects of Gender and Race of Nurses Nurse Nurse Patient Patient
and Patients Gender Race Gender Race M SD N

Variable df F p Female White Female White 24.40 12.27 25

Black 19.60 10.98 25
Main effect of nurse gender (NG) 1, 384 9.755 .002 Male White 22.40 10.91 25
Main effect of nurse race (NR) 1, 384 0.002 .966 Black 22.00 11.55 25
Main effect of patient gender (PG) 1, 384 1.334 .249 Black Female White 24.00 12.58 25
Main effect of patient race (PR) 1, 384 0.309 .578 Black 21.20 11.30 25
NG  NR 1, 384 0.221 .638 Male White 20.80 10.77 25
NG  PG 1, 384 1.539 .215 Black 24.40 13.25 25
NG  PR 1, 384 2.242 .135 Male White Female White 26.80 12.82 25
NR  PG 1, 384 0.529 .467 Black 30.40 11.36 25
NR  PR 1, 384 0.002 .966 Male White 22.00 12.25 25
PG  PR 1, 384 0.968 .326 Black 26.00 12.58 25
NG  NR  PG 1, 384 0.661 .417 Black Female White 25.20 9.63 25
NG  NR  PR 1, 384 1.539 .215 Black 27.20 11.73 25
NG  PG  PR 1, 384 1.759 .186 Male White 25.20 11.22 25
NR  PG  PR 1, 384 0.002 .966 Black 25.20 11.23 25
NG  NR  PG  PR 1, 384 0.221 .638
M ¼ mean; SD ¼ standard deviation.
 Race and Gender in Nursing Care Decisions 243

Some studies cited statistically significant differ-

TABLE 4. ences when examining the race of the provider
Mean and Standard Deviations for Pain (Heins et al., 2010, Wandner et al., 2012, 2014),
Management Scores for Main Effects whereas other studies supported this study, finding
that race was a not a statistically significant factor in
Variables M SD N
pain management decisions (Weisse et al., 2001, 2003).
Nurse Gender When examining the role of patient race in pain
Female 22.35 11.65 200 management decisions, studies by Weisse et.al. (2001)
Male 26.00 11.65 200 supported the findings of this study that revealed pa-
Nurse Race tient race to be a nonfactor in pain management deci-
Black 24.15 11.49 200
White 24.20 12.09 200
sions. However, Wandner et al. (2012) found that
Patient Gender Black patient pain was viewed to be more intense
Female 24.85 11.86 200 and was treated more aggressively. When examining
Male 23.50 11.68 200 the role of patient gender in the literature, Wandner
Patient Race et al. (2014) and Safdar et al. (2009) found nurses
Black 24.50 12.02 200
White 23.85 11.55 200
tended to select more intense dosages of medication
for female patients than for male patients. These find-
M ¼ mean; SD ¼ standard deviation. ings were not supported by this study. This study
found no interactions among the four independent
were two interesting trends. White male patients variables when looking at pain management. This is
received the lowest dose intensity (mean [M] 22.6, an important finding because the examination of
SD 11.27), whereas White female patients received possible interaction effects between patient and nurse
the highest dose intensity (M 25.1, SD 11.76) of all characteristics and their influence on pain manage-
the patient groups. This is suggestive of stereotyping ment have not been featured prominently in the
behavior. Second, White female nurses gave the high- literature.
est dose intensity to White female patients (M 24.4, The trend in this study that White women
SD 12.27), suggesting a trend of gender concordance received the highest dose intensity and White men
among White female nurses (Tables 3 and 4). the lowest suggests that some stereotyping behaviors
were present. This trend is congruent with the litera-
ture (Wandner et al., 2012, 2014). However, with the
DISCUSSION
exception of White female providers, and contrary to
It is well accepted that effective provider-patient rela- the literature, there was not a propensity for gender-
tionships improve patient health outcomes (Lewin, concordant relationships to select more aggressive
Skea, Entwistle, Zwarenstein, & Dick, 2009). This treatment options for like genders (Safdar et al.,
research study sought to identify whether nurses’ 2009; Wandner et al., 2014; Weisse et al., 2001, 2003).
gender and race and nurse perceptions of patients’
gender and race influenced patient care decisions us-
STRENGTHS AND LIMITATIONS
ing pain management as the clinical case. Significant
differences were noted between male and female This study’s balanced experimental research design
nurses in administration of pain medication. Female employing random assignment to the four treatment
nurses tended to select less intense treatment options conditions and the use of a four-way ANOVA to
than male nurses when medicating patients in pain. examine potential interactions among the four inde-
These findings were consistent with results of some pendent variables are a major strength of this study.
previous studies and inconsistent with others. Weisse The large sample of 400 with a balanced representa-
et al. (2003) reported that female physicians pre- tion among gender and race distinctions of the
scribed lower medication dosages than male physi- sampled nurses is a strength and is unique to similar
cians. However, female physicians in the emergency pain research studies where samples of nurses tend
room were more inclined to prescribe opioid analgesia to be predominately White women and samples of
and analgesia in general compared with male physi- physicians predominantly White men. The major limi-
cians (Safdar et al., 2009). There were no significant in- tation of this study may lie in the sensitivity of the tool
teractions differences found among the four used to measure pain management decisions. An
independent variables and no main effects for race of expansion of case studies with additional care manage-
the nurse or race and gender of the patients. Support ment decisions to form a more complex scale might
for these results is mixed. enhance the instrument and provide greater variability
244 Cavalier Jr et al.

and sensitivity to the pain management choices and in appropriate interventions as necessary. With the
pain management scores. United States becoming increasingly diverse, data-
driven methods to decrease disparities across gender
and race are needed. Nurses are well positioned to
CONCLUSIONS
advocate for patients in a manner that can improve pa-
The nurse-patient relationship is the foundation of tient outcomes. It is the nurse who stands in the gap
nursing care. Provider-patient relationship ‘‘involves for patients to ensure that their health care needs are
interaction between individuals in non-equal positions, met. It is the nurse who monitors the treatment plan
is often non-voluntary, concerns issues of vital impor- and works closely with the medical team to ensure
tance, is therefore emotionally laden, and required that the appropriate treatment is available for each pa-
close cooperation’’P. 903 (Ong, De Haes, Hoos, & tient at each encounter. It is the nurse who should
Lammes, 1995). Patients place an immense amount advocate for all that is ‘‘good and right [with] a vision
of trust in health care professionals to affiliate with for what makes exquisite care’’ (Tanner, 2006,
them to assist them in achieving their health goals p. 209) to ensure that the patient not only receives
while in very vulnerable states. The findings indicate quality care but nurse-driven care.
that overall nurses use moderation in pain manage- Understanding where causation for disparities ex-
ment choices. It further found that female nurses are ists in marginalized patient populations is an important
even more conservative than their male counterparts element in combating differences in care and care out-
in those decisions. Race of the nurse providers was comes. This research study highlights the needs for
not found to be a statistically significant factor in selec- more research on the influence of race and gender
tion of dose intensity. Likewise, gender and racial char- on patient care decisions. Given the enormity of health
acteristics of the patient did not factor significantly in disparities and its impact on patient quality of life, pa-
the nurse provider decision-making process. tient and health system finances, and care outcomes,
Continued research is needed in this area to allow further research is still called for to better appreciate
for a better understanding of the provider contribution the effects of the provider and patient characteristics
to health disparities, allowing for the development of on care decisions.

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