Inequity, injustice and staff health and wellbeing

Over the next couple of steps we are going to examine staff health and wellbeing from the perspective of what we have called the ‘structural’ in our pyramid of needs and interventions.

The structure we are referring to here is one of basic inequity, and the presence of injustices in NHS workplaces that mirror and reproduce those present in wider society. Some of these recycle financial and material inequities through low pay and insecure employment, while others (often overlapping) are the result of bias, prejudice and discrimination of different kinds.

While The Equality Act 2010 ensures that it is unlawful to discriminate against someone with a protected characteristic, the data shows that staff from an ethnic minority background, the LGBT+ community, or staff with a disability, are disproportionately likely to experience bullying or harassment.

Four layers of inequity

For managers and leaders, it is vital to recognise how, where and when inequity shows up in the workplace. We can develop our understanding of this by re-purposing a model we used in an earlier step. The diagram below shows dynamic relationship between the individual and the systemic we used earlier, this time setting out four connected and mutually reinforcing ‘layers’ – intra-personal, inter-personal, institutional and structural – through which inequities pass and are expressed. Take some time to digest the image and read the summary of each layer below.

Adapted from the National Equity Project

Please note the content of the diagram used in this step will be available to download in a more accessible format at the bottom of this page.

Intra-personal

These are the internalised beliefs we hold about ourselves and others, and about different groups. The judgements that exist in relation to these beliefs – of superiority and inferiority – are what give rise to ignorance, bias and prejudice. These beliefs, which are socialised into us from a very young age, are the mental models of inequity and injustice.

Inter-personal

Our beliefs are enacted through relationships. As is the organisational culture we work in. These relationships and interactions are where experiences of exclusion, bullying, harassment and discrimination are made real. This includes overt and obviously malicious behaviour, but also more covert and subtle behaviour including microaggressions, which are every-day, subtle, intentional — and sometimes unintentional — interactions and behaviours that communicate bias towards a marginalised group.

Institutional

Institutional discrimination refers to those prejudicial practices and policies within organisations that result in the systematic denial of resources and opportunities to members of minoritised groups. This form of discrimination is maintained by the (formal and informal) rules, organisational guidelines, and traditions of an institution and its culture, and the willingness of people working within it to apply them uncritically.

Structural

This is about the cumulative (over time) and combined (in sum total) inequity that occurs societally and economically when institutions (in health care, education, housing, justice, etc) institutionally discriminate. The result is that inequity is ‘baked in’ to the very structure of society and the life chances of different groups.

The impact of inequity on the health and wellbeing of NHS staff is profound, and in the next step we will explore this in more detail.

But to deepen and bring our understanding of these four inter-connected levels of inequity and injustice to life, have a listen to Angela’s story and reflect on the question below.

How do these four levels – the personal, interpersonal, institutional and structural – show up in Angela’s experience?