Table 3.

Recommendations for Impactful Clinician Implicit Bias Training (IBT): Illustrative Quotations from Patient and Clinician Stakeholders

State law and policy
Scope of trainees required to take IBT	“They should make everyone train for that as far as nurses, clinicians, pretty much anyone in the medical field.” (FG04 #1) “Begin this training when they are getting their education… So it goes to everybody who's involved in this entire process from the lab technicians, the end people, the phlebotomists who are taking your blood, the nurse who's checking you in for your appointment… your OB. So everybody is getting the same training and it's across the entire span of your care and not just at this one stage of your care.” (FG05 #01)
Scope/intensity of IBT requirements	“Implement a time limit or a time frame on how much training should be done. You know, if you're doing a certain amount of hours of, you know, in order for them to really, really get it or really understand it. Like, not just a simple computer training for an hour and then that's it, you don't have to do it for another two years.” (FG03 #1)
Accountability/enforcement of IBT	“I think lawmakers could tie it to funding, right. So it's like if there's a lack of compliance, if hospitals aren't, like, you know, getting better results, that could have financial implications. I find that that's a great motivator.” (FG05#2) “Unless it's tied to something like performance standards, I think it's unlikely that any kind of a training really will drive the kind of change we need, right… I think people will go back to, like, business as usual unless it's, like, you know, “Oh, three strikes, I hit my three strikes and that means I'm on probation.” (FG05 #3) “If there was a law set or they pushed the law, everyone's going to listen to law… So I feel like if they implemented it and were strict on it, you would see less and less cases [of biased care]” (FG04 #1).
Funding	“Implement more funding so that aside from trainings, [providers] can be a little bit more educated on just the different mistreatments of African-American people or people of color in the hospitals.” (FG03 #1)

IBT content, format, and other qualities
Content—Richness/nuance	“I would definitely put in, like, the history of Black people and medicine in this country so they can see it's not just something that might or might not be happening some places. I want—I would want them to understand that it's something that's systemic and it's, like, ingrained … and also it's probably in them and they don't realize it..” (FG02 #2) “Teaching people about the mistrust I think will be huge… Teaching the history of the mistrust of the Black community, and… the communities of color in general.” (FG02 #1)
Content—Connection to site	“Look at cases of people we took care of rather than have it be hypothetical… I think it would create—would definitely provide a mirror where we can really see how we in real-time are potentially causing harm. I think that it's just much more personal if it's someone that you took care of and you were, you or somebody you know, were involved in that person's care.” (CA07) “I think that would be really interesting if, like, specific to our hospital giving, like, specifics, so that it was real, that those [inequities] are happening.” (CA04)
Content—Real patient stories	“I really feel like hearing the narrative or the person that is impacted by implicit bias, bias and racism, I think those stories are sometimes more impactful and can create change than any, you know, one hour little training that the people are going to put together. Because sometimes you can—what's the word I'm looking for? Like, not associate that you're causing harm to real people… But say for example, like … five people who had been affected by implicit bias told their stories, but they didn't have to call the doctor out. But they told their story, [the doctor] would know, ‘Oh, that was my client.’ You know what I mean? ‘That was my patient.’ So I think it'd be more impactful that way, to know like, ‘Yes, doctor, you are causing harm to people, even though you might not have thought that you were doing so, but you've impacted someone in a negative way.” (CA01) “Tie it to patient examples or real-life experiences so that it would help put this theoretical thing in context. The example I gave with triage, I don't think anyone that would be involved with that would say, “I actively made this decision or said this thing about a patient because of their race,” but if confronted with that reality or shown that scenario and said, “How do you think that race would play into this?” I think might be a little bit more realistic… Sometimes more everyday, commonplace examples can be helpful.” (CB01)
Content—Connection, relatability and credibility for providers	“I would ask people a lot of times when they have felt like someone wasn't listening to them or you know, to start from a personal experience to personalize this.” (FG04 #3) “Training must get people to understand that they need a training.” (CA05) “There should be some type of way that providers can do some self-reflection and see like, what it is that they're doing in their own practice that could be—that implicit bias can be coming out that could be causing harm in that way.” (CA01) “You know, you can turn on a training and walk away and come back, you know. But if it grabs you, you're going to want to participate.” (CB03)
Format—Not using online self-administered	“if you had, like, during a skills day… where you could really really feel and sit down and actually take time and work within it. I think that is a better way than [online trainings]. We, honestly, we don't really—We're just trying to get through them as fast as we can because we're doing 10,000 other things at the same time.” (CB08) “It's such a terrible platform for learning, actually learning. People don't usually change just because they've interacted with a bullshit workplace education platform on the clock” (CB09)
Format—Interactivity	“I think that [impactful training] would allow for feedback, knowledge exchange, having other clinicians, having clinicians of color share what they've dealt with. I think just the sharing aspect of it because the computer, that's just kind of one-sided, right? …I think it would improve camaraderie, you have the clinic staff, everybody's there talking and I could say what I'd experienced, somebody else can say what they experienced.” (CA02) “You know, I will just say that any training that I've gone through that has really stuck with me is, like, role playing… If someone's put in that kind of situation where they're treated poorly because of what they look like, they're going to remember that.” (FG05 #1) “Having to, like, digest the course material and discuss it with other people can be challenging. But that's where a lot of times growth happens. And so having a module… where you're just, you know, you're reading it and then you're taking a test afterwards, isn't necessarily as helpful as, like, that processing with other people.” (CA04)
Other—Application to practice and skills-building	“Ideally, a training like that with such a sensitive subject would be like in person with protected time, where you get to like act out different scenarios. Like, [midwifery group] came and we did like an antiracist training… where we acted out scenarios, where someone says something and then you have to like think on your feet and adjust it and I find that much more impactful.” (CA09) “We did this one like OB emergency drill… and people moved through the room and so you weren't just, like, sitting… And there were those different speakers at each station doing a different skill thing. And so I think that, like, breaking it down like that could be really good…breaking it down and, like I said, applying it to patient care.” (CB06)
Other—Frequency/regularity/continuity	“At the rate that we're going, it should be like every 6 months, 6 to 12 months, like, because, like, 2 years is like you're going to take it one year and forget it 3 weeks later and just go back to, like, what you were doing previously.” (FG02 #1) “Did you say that this is something that has to be done every two years? (FG04 #3)  Facilitator: Correct. “Come on, now. Every two years? This is—Implicit bias happens every day. This is a weekly training, not an every two year training.” (FG04 #3) “Exactly.” (FG04 #1) “Implicit bias training, I think, also needs to just be something that is just ongoing forever. For a long—that it's something that is required and ongoing, and right now.” (CA07)

Health care facility IBT implementation
Selection of trainers	“Have somebody that's not from the hospital do – be the leader of the roundtable, and then they'll have times to really focus and get all their things dialed and be able to facilitate a conversation that is safe and that is – can get back on track… All the pitfalls of small-group leadership plus very confrontive topic, somebody that really has their kind of spiel and how they're going to do this and is comfortable with it, that could be I think a big boon.” (CB09) “Before the training gets rolled out there really needs to be—you really need to consult the people who are the most affected by it.” Interviewer: And when you're describing that are you picturing like people who would present the material or people who would develop the material? “Both really. If you're really going to be serious about it, it helps to come from the horse's mouth. It's just like a yoga teacher teaching somebody how to box. I mean like it needs to—there needs to be some credibility or some believability or some take it seriousness, something like that.” (CB05)
Managing logistics	Clinicians “have to definitely have a set-aside time where they are able to only do the training. And that would fail if they don't have that.” (CA04) “We are so overworked right now that, like, it's hard to find any extra time for anything. So [leadership] would have to allow us the time or, like, carve a certain amount of time or, like, have somebody cover us…” (CB08) “It's hard to leave the floor to do [trainings], but then people don't want to do it outside of work time, right. And so having an incentive. I mean, I don't want to say, I mean, yeah, in a way, that people are getting compensated for the training. I mean, everybody's time is valuable, you know.” (CB06)
“Safety” of training environment	“Emphasizing a non-judgment environment [would help]. I think that in medicine we've done a good job of shifting, reviewing mistakes for bad outcomes. It used to be that you're going to get – you're going to go down for this one… and we really shifted with a peer review sort of thing. Let's look at this bad outcome, and there's no blame. Let's just learn from it and understand how we can do better next time… I think developing some kind of a way [in IBT] of non-judgmentally fleshing out what people feel, what people – really looking at where what they feel comes from and non-judgmentally helping them with it.” (CB10) “I know there's some hard truths to be told in things like this but it has to be tactful enough to not make someone defensive… People shut down because they feel like something's directed towards them. So there needs to be some expert, some therapist or behavioral specialists or something like that will be able to just say maybe we could say this a different way just because it was more important just to get the point across. To not put people in defense.” (CB05)
Use of data to inform and guide training approach	“I think they should work on gathering data… Basically did this training change anything? … You know, reviews of, like, nurses' recommendations, doctors' recommendations, feedback that they get from their patients… Just, yeah, I worry if they're not gathering that information we'll never really know if it's working and then won't have any information to, like, make improvements if it is or if there's tweaks that need to be made.” (FG05 #6) “I think that they need to watch, maybe. Like, I want to say kind of like babysit the people that it didn't really reach. < laughs> And possibly put them through more training if they need to go through more training. But I think that the leaders need to be one, I think the leaders or whoever you choose in the hospital to be a leader, I think that they need to be a diverse group of people. And if they notice something off or if they notice somebody not really taking to this training, kind of help them, help them along with it. Like, give them scenarios, like real life scenarios.” (FG02 #1)

Health care facility environment of IBT
Leadership decisions, commitment and communications re: IBT	“[Leaders should] keep talking about it. Help educate their other staff. Just make it an ongoing conversation. I mean, people might be like, “Okay, oh, my God, here she goes talking about it again.” But at least it's, like, I mean, I'm talking about it because it's important. I'm talking about it because I'm passionate about it and, you know, this is reality. Reality is is we, Black women go in, give birth and they're not coming out with their babies or vice versa. … So I would just say keep talking about it.” FG02#3 What leadership can do regarding providers who are not taking antibias work seriously: “Somebody can look at a screen, they can take the training and be like, “Blah, blah, I'm just going through a training.” But if you pull them to the side and say, “Hey, this is going on. That's going on.” A lot of times you just have to confront people head on.” (CA02)
Clinic culture and interpersonal dynamics	“Create a safe space for providers to talk, ask, interact… Maybe providing a safe space to have real conversations and to air real concerns. Yeah. I would like to ask questions and not be perceived as ignorant or racist for asking them, but we're all a little bit concerned.” (CB10) “I do think that being in person and being able to kind of form nonwork-related, like, have nonwork-related interactions and friendship could be really beneficial in fostering kind of like honest and vulnerable conversations.” (CA07)
Accountability practices re: IBT and reductions in biased care	“As long as there's like some kind of level after the training to hold people accountable [that] would be really important as well. Like, as far as there's clear steps as well on how to check in and make sure people are following protocol, also have clear steps for, like, people to be able to file a complaint and actually have them actioned… Also transparency as well… You guys could do the training but we also need to know that as patients that the training has been done and it's being implemented.” (FG01 #1) “What could possibly help is a penalty. Like, you know, how are you going to if you're caught doing the wrong thing to this patient, like, what are—What's the consequences going to be? … Penalty kind of makes people, like, “If we don't do this, we're going to get in trouble.” You know? “I might lose my job over mistreating a person of color.” And so therefore, all right, “Training says do this, then all right, I'm going to do this.” (FG03 #1) “For those who are less on the journey with [committed antibias work], we have to hold people accountable and that is hard and scary work, you know, where hierarchy is involved… Holding everyone accountable in a different kind of way than an eLearning module does.” (CA10) “How do you assess what the person got from the training? How likely are they to implement any of the training modules into their current practice and then according to the patients, like what does the before and after look like when a staff gets trained in implicit bias?” (CA08)
Opportunities for ongoing complementary antibias learning	“I just, I would like to see more, and more types of, you know, education—you know, maybe in person, maybe one on one… whatever it would take just to saturate a person's brain with these truths … I just think there just needs to be like more to counteract all of what's already in your head.” (CA06) “I'm not sure that a training just once a year will have a significant impact. I think what would have more of an impact is integrating training throughout the year and in various clinical settings and measuring that, not just a training once a year… Discussion of what it looks like to have dignity in pregnancy in childbirth—and that be a year-long discussion in various meetings or trainings outside of just the modules you do online … Internal trainings and discussions with leaders in the DEI space about how to address, diversity, equity and inclusion issues within the institution throughout the year… just having that set as an expectation. Then, you know, these sessions will happen throughout the year within various departments and not just once a year through a training because it's required by law. So better integrate it into the institution.” (CA08)

Provider trainee commitment and behaviors
Motivation/commitment to training	“Just make sure the staff actually takes it seriously and not just like taking it just to say that they did it. Just taking it seriously and having an open mind taking the training.” (FG03 #3) “Getting people to understand how relevant this is and that it's a responsibility as a provider to have this training. Like, it's really as important as knowing how to whatever, you know, manage a hemorrhage… It really is.” (CB06)
Recognition of own biases and need for change	“I think to make change I think it usually works a little better if you're uncomfortable at the least, if that makes sense. Because if it's really well done, I hope that it would cause people to be a little introspective and pause for a moment and be like, “Hey, you know.” You see the title [of the training] and you're like, “Oh, I don't do that. I'm fine.” But hopefully if it's well done, it would cause people to think a little more… But not in a shameful way, because that doesn't work either. But in a thoughtful way.” (CB03) “People got to be aware of how they are affecting—how they are biased towards others. Because we can do all this training all we want and people …. probably won't take it serious because they think it's not, because they think they're not the problem… They have to be aware of their own actions and their own thinking, their own bias.” (FG01 #4)

“FG” denotes focus group participants: Black women who had been a patient in maternity care services. “CA” and “CB” denote interview participants from two facilities: multidisciplinary hospital-based perinatal clinicians.