How you can tackle casual racism and microaggression in the NHS

The steps every nurse can take to confront unconscious bias and be an authentic ally

The steps every nurse can take to confront unconscious bias – whether their own or others’ – and be an authentic ally

  • A new report on race inequalities in the workplace details the realities of casual racism, microaggressions and unconscious bias in the NHS
  • The cumulative effect of microaggressions is felt by individuals and organisations, and change will involve a range of approaches that start with accepting there really is a problem
  • Advice on how to confront and deal with microaggressions at work, including the 7As of Authentic Allyship, created by nurse leader Yvonne Coghill
Picture: iStock

A toy monkey being left on top of the locker of a black member of staff, a comment from a passing consultant that if a black colleague had been on television it must have been Crimewatch, being passed over for jobs or promotions because of the colour of your skin – or conversely, being told you had got the job to fulfil a diversity quota.

These are just some of the shocking experiences outlined in a report on workforce race inequalities in the NHS.

Casual racism is a grim reality in NHS workplaces

Published in July by think tank the King’s Fund, the report describes these as examples of ‘casual racism’ or ‘microaggressions’, and paints a picture of workplaces where such things still happen.

The report also talks about the impact of unconscious bias – behaviour that may not be intentionally detrimental, but which can have a devastating impact nonetheless.

As nursing colleagues, leaders and managers, how do you react if something like this happens in your team or on your watch? How do you recognise it in colleagues – or yourself – and what do you do about it if you do?

What are microaggressions?

Microaggressions can be defined as comments, actions or incidents of indirect, subtle or unintentional discrimination towards a minority or non-dominant group. They can be so subtle as to be almost unnoticable, except to the recipient.

Though they aren’t always deliberate or ill-intentioned, they can have a devastating impact on individuals, the workplace and patient care.

Although the term was first coined to refer to abuse on the basis of race, it has since been expanded to include other marginalised groups.

A microaggression can be verbal – for example, someone saying something that subtly puts someone down, possibly claiming it was ‘just a joke’ if someone objects – or behavioural – for example, ignoring someone in a marginalised group in favour of someone in a dominant or privileged position.

Wendy Irwin: ‘We need to recognise
the complexity of people’s experiences’

How well does nursing respond to the complexity of people’s identities?

According to RCN head of equality and diversity Wendy Irwin, a new approach is needed to create inclusive organisations, and that involves looking at all the characteristics that makes up a person, rather than just one.

One of the risks, she says, is that organisations have tended to separate out issues, looking, for example, at gender inequality then inequality on the basis of ethnicity, or sexuality. This ignores the complexity of people’s identities and how different characteristics, such as race, age and gender, all affect people’s experiences.

‘We stand in a space of multiple complexities and it is that space of complexity that nursing – and particularly the NHS – has been unwilling to engage in. It’s very easy to look at a single slice and then move on.

‘That means we don’t create what I call a diversity soup, where we have indistinguishable ingredients, but we’re clear how each of these things when placed together or near each other creates specific life experiences for individuals that share that bundle of protected characteristics.’

She says the big challenge for the NHS and particularly for nurses is to ask ‘well how does nursing respond?’.

‘Previously there has been a sort of complicity. The law doesn’t like it when I talk about my complexity, even though that is my existence. We’re probably going to see some massive changes, and maybe even a change in law that says someone can experience discrimination on the grounds that they are older and female.’

How can nursing improve access to leadership roles for people from minority groups?

These are all issues that have been occupying the RCN’s nurses in management and leadership forum, which over the past year has been seeking members’ views on how to ensure and promote inclusivity.

The forum was due to hold a fringe event at this year’s RCN congress to learn from individuals’ experiences and help establish a way forward for nurse managers and leaders.

Craig Davidson: ‘Nursing should be as
diverse as the communities we serve’

Newly qualified nurse Craig Davidson, who was to have co-chaired the event, believes nursing has to take action to promote inclusivity at every level. He says his own experience of growing up gay in a society that constantly told him this was a ‘wrong’ thing to be, has inspired him to be a champion for people from minority groups, particularly those who face social injustice.

‘The nursing workforce should be as diverse as the communities we serve, and I think that for people who are from black, Asian and minority ethnic backgrounds, for our LGBT colleagues, for colleagues who are trans, colleagues with neurodiversity or a disability, you do need to look at equity to access positions, particularly when you look at leadership roles. How can we actively encourage and work with people to get them into these positions?’

Microaggressions have a cumulative effect

Northern Care Alliance NHS Group equality and inclusion programme manager Tara Hewitt, who is co-founder of the Trans Equality Legal Initiative, says there’s often an inter-relationship between a variety of things that lead to the inequalities that exist at work.

Tara Hewitt: ‘Microaggressions build up
and can affect an entire community’

‘Some of them are around how people experience the world differently; some of them are about how the world impacts on people; some are about the impact we have on each other. Microaggressions are behaviours or language that indirectly lead people to feel excluded or feel less valued. That has a weathering effect.

‘When you’re engaging in situations where you experience those feelings because of somebody else’s behaviour over and over, you’re having to use energy that you’re not necessarily able to put into your own performance, or that affects your well-being, because of having to constantly face those situations.

‘An example from the LGBT world is someone saying “you’re one of the good trans people” or “you’re not one of those activists” or “you don’t look trans; you look like a woman”.

‘Sometimes those microaggressions don’t come from an intentionally negative place, but the impact that they have is absolutely negative. They build up over time and that can affect an entire community because everybody’s facing it, and that’s one of the factors why certain people don’t progress in their careers and why people leave professions or organisations.’

Tackling discrimination has a positive impact on the quality of patient care

Ask RCN deputy president Yvonne Coghill if she has ever experienced microaggressions or unconscious bias and she responds with a sound that’s somewhere between a laugh and a heavy sigh.

‘So many things,’ she says, before reeling off some shocking daily experiences.

‘If you walk into some shops in London, for example, and you go to find yourself something for your hair. On the shelves, you will find shampoo for white hair – Head & Shoulders and all the rest of it – is just sitting on the shelves nicely. The stuff for black hair is sitting behind the counter with a security tag on it. So you have to ask for it and they have to take the security tag off. Now why would they do that? They do it because they think the black person will stick the hair product in their handbag, that’s why.’

‘The business reasons for doing this are incredibly robust, as well as encouraging quality patient care and doing it for moral reasons because it’s fair and right, it also saves money; it’s a no brainer’

Yvonne Coghill, RCN deputy president and director of the Workforce Race Equality Standard

Ms Coghill, who is director of NHS England’s Workforce Race Equality Standard (WRES), says that tackling discrimination – including microaggressions and unconscious bias – is vital to improving patient care.

How allyship will bring meaningful change for NHS staff and organisations

‘I don’t think a lot of people understand the link between race equality and high quality patient care. I think some think it’s because all those black folks want to have high-level positions and well-paid jobs, as opposed to seeing that valuing your staff and appreciating them and making them feel they are important, motivates them to give higher quality patient care; it motivates them to want to stay in the organisation and it motivates them to actually talk positively about the health service when they’re outside of it so we can get more people coming in.

‘The business reasons for doing this are incredibly robust, as well as encouraging quality patient care and doing it for moral reasons because it’s fair and right, it also saves money; it’s a no brainer.’

Ms Coghill recently drew up the ‘7 As of Authentic Allyship’, which a colleague turned into a simple infographic. She did it, she says, because the principles and practices seemed obvious to her, but clearly weren’t to other people.

The 7As of Authentic Allyship

  1. Appetite Do you have the appetite to immerse yourself in the complex, emotive world of race equality?
  2. Ask Ask questions about race, be curious, read, learn and educate yourself
  3. Accept Accept there is really a problem. More data isn’t needed
  4. Acknowledge Openly acknowledge that the problem needs to be dealt with
  5. Apologise Express sympathy that racism is affecting people of certain races
  6. Assume Don’t. Instead, develop informed views by seeking to understand individuals
  7. Action Take demonstrable steps to establish equality and be accountable

Created by Yvonne Coghill

No ‘golden bullet’, but a range of actions that can be taken

High-level initiatives such as unconscious bias training won’t cure the problem, says Ms Coghill. ‘You go through the training and that’s great, and it makes you more aware that we are, as human beings, programmed to be biased. But what it doesn’t do is make a difference.

‘Your knowledge is your knowledge and you may say yes, I get that, and next time I go into an interview situation, I will think about this. Invariably your life moves on, and you move on, and you default back to being who you are. It doesn’t change anything much.’

‘Let go of the idea that you have no “isms” – lean into the idea that you do, and it’s when you are able to confront that, that you’re able to do something about it’

Wendy Irwin, RCN head of equality and diversity

There is no ‘golden bullet’, inclusion programme manager Ms Hewitt agrees. ‘Rather, you need a whole range of actions, they need to be outcomes-focused, and they need to be measured. With bias, you can either process it out, or you can water it down – for example, by having wider representation on interview panels.

‘If you have different people with different experiences and different backgrounds, their biases are going to be different, so it stops one bias having an overwhelming impact.’

The RCN’s Ms Irwin says that for managers, simply telling people not to behave in a sexist way, for example, isn’t enough. ‘This is deep structure, and you have to tackle these things structurally rather than simply linguistically. Just because you’ve said it is not enough.

‘You don’t just change culture because someone has asked you to – you change it by creating incentives, pivots, gadgets, metrics, narratives, and accountability that make it so. Not a lot of organisations get that – yet. They think in the short term, and this is longer than long term’

Picture: iStock

Acknowledging our biases is an important step

People shouldn’t blame themselves for their biases, she says, but they should understand and accept that they exist, and that they shouldn’t be allowed to affect decision-making or behaviour. We all make assumptions even if we don’t realise we are doing it, she says – for example, if asked to picture a pilot, chances are we will imagine a white man.

‘It doesn’t mean that people are racist, it just means that we live in a society that structures things in a particular way. You can’t live in it and not be affected by it. It’s not a get-out clause, but it is the case for everybody. Let go of this idea that you don’t see colour, because that’s not helpful.

‘Let go of the idea that you have no “isms” – lean into the idea that you do, and it’s when you are able to confront that, that you’re able to do something about it.’

Authentic allyship: what can you do now?

Yvonne Coghill explains how to put the 7As of Authentic Allyship into practice:

Yvonne Coghill: ‘You have to start
accepting that this is real for people’

‘When I talk to colleagues who are not from black, Asian or minority ethnic backgrounds, and I ask them why they’re not involved with this, they say that they don’t know what to do,’ Ms Coghill says.

‘What needs to happen first and foremost is that you need to ask yourself some questions: Am I really up for this? Have I got the stomach for it and am I going to be able to put myself out there? Am I going to have the energy to keep it going? And if I don’t, if I start this and stop in the middle, it’s going to look really bad.’

Once you have decided you have the appetite, you need to find out more about it, she says.

‘Asking is about making sure you learn. When you don’t know, you go and find out. And when you’ve done all that, you have to start accepting and acknowledging that this is the case, that this is real for people – it’s understanding that this is not in people’s heads or their imagination, or that they’ve got a “chip on their shoulder”; it’s real.

‘The apology is interesting because people say “well, I haven’t done anything; it’s not my fault”. But it’s not about apologising for yourself per se, it’s about actually saying “I’m really sorry that this is happening to you” and “I’m sorry that the world’s the way it is and it’s unfair”.

‘I think that is absolutely key and we have to do that. You shouldn’t assume that you’ve got the answer. And ultimately, you need to take action once you’ve done all those other things. It could take you a while to move around the circle of the 7As – some people are quicker at doing this and more comfortable with self-reflection than others. But it’s important to work through it, then act.’

Jennifer Trueland is a health journalist

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