As a brand-new pediatric nurse sitting at the nurses’ station at 3 in the morning, my fatigue from the night shift was overshadowed by adrenaline and the sense of pride I felt as I independently cared for my patients under my shiny new nursing license. The nurse next to me was admitting a patient with sickle cell anemia who was diagnosed with an acute pain crisis. My “new nurse” brain was ready to soak up all I could learn from her admission. I leaned over to my colleague and asked her to give me a rundown on the diagnosis, why the patient was coming in, what the labs looked like, and what she thought the plan of care would be. This experienced nurse co-worker turned to me and said, “Well – you know how all of these patients are.”
Individuals from marginalized groups face chronic, continuing and daily microaggressive stressors from typically well-intentioned individuals who are unaware of their demeaning insults, slights and actions. These microaggressions are absolutely destructive to individuals, affect patient outcomes in healthcare settings, and can dissolve healthy work environments. The main discussion in this blog isn’t how to identify microaggressions; I’ll leave that responsibility to you. The focus is more on how we address microaggressions – how we can keep our work environment a safe space for everyone – while also being professional yet intervene with the offending person.
The conversation I shared above occurred almost a decade ago and although I have no idea where this nurse is anymore, I want to thank her. This situation remains relevant in my mind and changed my perspective on how important it is to engage, even if it initially feels uncomfortable. I frequently think I should have said something like: “I’m concerned about the comment you made regarding ‘you know how all of these patients are.’ Can you help me understand what you mean?” This is what I’ve learned that I wish I knew then:
The 5 D’s
These are five strategies to interrupt microaggressionsoutlined by the authors of “Becoming Active Bystanders and Advocates: Teaching Medical Students to Respond to Bias in the Clinical Setting.” We adapted the 5 D’s for our organization, replacing display discomfort with “Document” to highlight accountability for behavior. Since they all start with the letter “D,” it’s easy to remember:
1 Direct – Deal directly with the aggressor by confronting the comment. Try using statements like, “I’m concerned about what just happened and here’s why.” How I should have responded in my example could look something like this: “Can you help me understand why you said/did that?” This curiosity allows for engagement and for you to offer additional information or a different perspective on the situation.
2 Delegate – Ask for assistance, a resource or help from a third party. Sometimes because of context or power structures, being direct is extremely difficult and, in some situations, can be dangerous. Hierarchy was a factor in why I didn’t respond to the microaggression I witnessed, as the nurse had so much more experience than I did. Feel empowered to escalate the situation to your preceptor, charge nurse, manager, educator, director, human resources department, or anyone else who can help provide support and direction. As a new nurse, I could have reached out to my charge nurse for support.
3 Document – Write down details of the incident on a personal document, including the time and date, who was involved, where it happened and what was said. If you were a witness but not directly involved, offer to provide this documentation to the person being affected, should they decide to take action. Imagine if the comments made in the example I provided happened multiple times with that same nurse. When there is consistency in microaggressive behavior, documentation is so important to remember, including times and details that could easily meld together. This documentation is often pivotal when holding others accountable for their actions or words. Familiarize yourself with your organization’s chain of command for escalating incidents so you can share the documentation appropriately.
4 Distract – Derail the incident by interrupting it with a distraction method. Ignore the aggressor, and engage directly with the person who is being harassed. This response can diffuse the intensity of the situation and demonstrate to the person being harassed that they are not alone. Ideas for distraction include asking for assistance, dropping papers or a bag near the situation, or bringing up a different topic to immediately shift the aggression off the individual. Imagine if the comments in my scenario were made directly to the patient and their family. That would be an opportunity to distract; offer them water, close a door or discuss the plan of care for the day.
5 Delay – Many of us can be at a loss for words when a situation is actively unfolding. For me, I was so confused and flabbergasted with what the nurse said that I needed a moment to process it. In other microaggressive scenarios, anger and frustration are very real responses, so engaging the aggressor further in the heat of the moment isn’t always the wisest strategy. It’s OK to delay your response. Immediately check in with the recipient as a person. Ask them if they are OK, offer to sit with them for a while, and offer to share resources or help file a report if they would like to. Process the situation, reflect, and when you decide on your “I wish I would have said ...” statement, go back to the aggressor and engage with them if it is safe to do so.
What can I do?
AACN offers resources to create an equitable, diverse and inclusive work environment: