Abstract
Racial microaggressions are subtle and everyday actions that communicate derogatory messages or assumptions based on an individual's race. These seemingly minor acts, often unintended, can accumulate to undermine patient well-being and contribute to healthcare disparities. They are the unnoticed comments, gestures, or attitudes that carry significant impact. Through a systematic analysis of the literature, we highlight the insidious nature of racial microaggressions and their impact on healthcare outcomes. The objectives of this paper are to:
• Present real-life instances from research to showcase the tangible effects of racial microaggressions.
• Identify the everyday scenarios within healthcare interactions where racial microaggressions often occur.
• Emphasise the need for recognition and understanding of these biases for fostering better patient–provider relationships.
Also, by analysing the fundamental elements underpinning racial microaggressions such as systems, interactions, vulnerabilities and consequences, we explore the implications it has on healthcare policy and management. Most importantly, we address the importance of identifying and tackling racial microaggressions in order to create a more inclusive healthcare environment.
Keywords: Microaggression, healthcare, behavioural, subtle bias, workplace
Introduction
In the United Kingdom’s (UK’s) Healthcare System, an often overlooked but critical concern silently hinders the pursuit of equitable care – racial microaggressions.
The term racial microaggression is used to describe subtle, often subconscious actions, comments or behaviours that convey negative or discriminatory messages towards people of a particular racial or ethnic group. 1 These actions can be hurtful and offensive, despite not being as overt as more explicit forms of racism.
Racial microaggressions can take many forms, including:
Stereotyping: Making assumptions about someone based on their race, like assuming all Asian people are good at maths or all Black people are athletic.
Environmental microaggressions: Creating an unwelcoming or hostile environment for people of certain racial backgrounds, like using racially insensitive imagery.
These microaggressions can be harmful because they contribute to a hostile or unwelcoming atmosphere for individuals from marginalised racial groups, which can erode self-esteem and well-being over time. It is important to recognise and address racial microaggressions to foster a more inclusive and respectful society.
This paper highlights the significance of racial microaggressions within the UK healthcare context. By exploring- real-world cases and citing notable research, we aim to expose the subtle biases that permeate healthcare interactions and foster a more inclusive healthcare environment.
Importantly, the UK continues to attract large numbers of international medical graduates (IMGs) of which many are from marginalised racial groups. In 2022 more than half (52%) of the doctors who joined the workforce were IMGs (GMC workforce report 2022). Therefore addressing this issue is crucial to improving integration and employee retention.
Literature review
Research on racial microaggressions within the UK Healthcare System has revealed distinct types of microaggressions, their profound effects on healthcare staff's mental well-being, and the consequences for teamwork and burnout.
Types of microaggressions
Microaggressions encompass various subtle expressions of bias that can be categorised into distinct types including:
Microinsults: Subtle comments or actions that demean or belittle an individual's racial identity. These can manifest in statements that undermine the accomplishments or qualifications of healthcare staff from minority backgrounds, subtly implying that their achievements are due to affirmative action rather than merit. 2
Microinvalidations: Instances where a healthcare staff member's experiences, perspectives, or concerns related to their racial background are dismissed or trivialised. This might involve downplaying the significance of cultural or ethnic issues raised by staff, indirectly suggesting that these factors are irrelevant in the healthcare context. 2
Microassaults: Overt expressions of racism that directly target an individual's racial identity. These can include racial slurs, derogatory comments, or discriminatory actions that create a hostile environment for healthcare staff from minority backgrounds. 3
Mental effects on healthcare staff
The psychological toll of racial microaggressions on healthcare staff is well-documented. Estacio and Saidy-Khan report on migrant nurses in the UK encountering racial microaggressions that led to feelings of isolation and distress. 4 Such experiences can undermine self-esteem, contributing to decreased job satisfaction and compromised mental well-being (Derald Wing sue, 2010).
The cumulative effect of racial microaggressions can create additional stressors for healthcare professionals, affecting their performance, that is, racial battle fatigue. This refers to the emotional and mental strain experienced by individuals from racially marginalised groups due to ongoing encounters with racism and discrimination. 5
Microaggressions can affect healthcare professionals’ performance and evaluations during the annual review of competency progression in the NHS. When these disparities align with data collected by the NHS Workforce Race Equality Standard (WRES), it highlights potential systemic issues related to bias and microaggressions, emphasizing the need for organisations to address these concerns for fair and equitable career progression within the NHS. 5
Long-term impact on teamwork and burnout
The implications of racial microaggressions extend beyond individual well-being. Research by Smith et al. 5 indicates that racial microaggressions can foster a toxic work environment, eroding trust and communication among colleagues. 5 These tensions may jeopardise effective teamwork and collaboration, negatively affecting patient care. 6 Furthermore, the accumulation of microaggressions can contribute to healthcare staff burnout, impacting staff retention rates and healthcare system sustainability by causing decreased job satisfaction, increased stress and reduced commitment among affected employees, leading them to seek employment elsewhere 7
Estacio and Saidy-Khan offered first-hand accounts from migrant nurses in the UK, detailing their experiences of subtle biases within healthcare interactions. The migrant nurses frequently faced discrimination in the form of denied opportunities for further career development based on racial and/or ethnic factors. 4 The study by Smith et al. examines the deterioration of interprofessional relationships due to racial microaggressions, emphasizing its negative impacts on teamwork caused by eroding trust, lowering morale, and hindering effective communication leading to increased stress, burnout, and disruptions in patient care quality. 5 Carter et al. 7 explored the repercussions of microaggressions on healthcare staff burnout, offering insights into the long-term consequences. 7
These studies demonstrate the interplay between racial microaggressions, mental well-being, teamwork dynamics and burnout. This creates a compelling case for addressing and mitigating these biases to foster a more inclusive and supportive environment.
System components: root causes of racial microaggressions
The exploration of racial microaggressions within the UK Healthcare System requires a nuanced understanding of the systemic components that perpetuate these biases. Through these components, we can uncover the root causes through which biases can impact healthcare.
Instances in literature
Hall et al. 8 explore how the underrepresentation of minority staff in leadership roles influences institutional norms. Green et al. 9 examines the influence of implicit biases and stereotypes on healthcare interactions. Kaprielian and Arnold 10 emphasise the role of cultural competency training in preventing misunderstandings. Nelson and Gadson 11 examine the power dynamics that can suppress addressing microaggressions. Ortega et al. 12 report on the role of organisational policies in shaping the response to microaggressions.
Understanding these root causes is fundamental for designing targeted interventions and policies that help foster an inclusive and equitable healthcare environment.
Institutional norms and culture
When leadership positions lack diversity, the perspectives of marginalised individuals are often excluded from decision-making processes. For example, if executive boards or managerial roles predominantly comprise individuals from certain ethnic backgrounds, policies and practices may be skewed toward those perspectives. 8 This dynamic can perpetuate a culture that marginalises healthcare staff from diverse backgrounds, indirectly contributing to microaggressions. 8
In the UK, WRES and MWRES data illustrate how microaggressions affect healthcare professionals. Disparities in career progression, wage gaps and retention rates highlight these effects, emphasizing the need for diversity and inclusion initiatives. 5
Implicit bias and stereotypes
The healthcare system in the UK is a reflection of UK society as a whole. Implicit biases, formed by societal stereotypes, can therefore permeate in healthcare interactions. These subconscious biases can influence how healthcare staff interact with colleagues and patients; For example, if a healthcare provider unconsciously associates certain racial or ethnic groups with particular traits, it can result in microaggressions that reflect these biases. 13 Actions or comments stemming from these biases can create an environment where staff from marginalised backgrounds feel undervalued or misunderstood. 9
Lack of cultural competency training
The absence of cultural competency training can hinder effective communication and collaboration. 14 Without proper training, healthcare staff may unintentionally rely on their own cultural frames of reference in their interactions. This can lead to microaggressions when individuals from diverse backgrounds do not fit these frames. 15 Providing education on cultural competence equips staff with the skills to navigate these differences and mitigates against inadvertent bias. 10
Hierarchical power dynamics
Power dynamics within healthcare settings can amplify microaggressions. Junior staff may feel powerless to address or challenge microaggressions from seniors. This can create an environment where discriminatory behaviours go unaddressed due to fear of retaliation or retribution. 15 For instance, a nurse might hesitate to confront a racially insensitive comment from a physician due to concerns about their professional standing. This dynamic perpetuates an environment where microaggressions thrive. 11
Organisational policies and practices
A lack of clear reporting mechanisms or accountability structures can discourage healthcare staff from reporting instances of bias which may include indirect dismissal of whistle-blowers from jobs. 16 This silence fosters a culture where microaggressions go unchecked and unaddressed, creating a cycle of biased behaviours. If there is no established process for raising concerns about microaggressions, healthcare staff may opt to remain silent, creating a tolerance for such behaviours. 12
Interactions and feedback loops: amplifying racial microaggressions
Instances in literature
LaVeist et al. 17 discuss the impact of patient-provider interactions on healthcare staff. Hagiwara et al. 13 highlight the significance of systemic feedback loops in sustaining biased behaviours. Williams and Wyatt 18 examine the implications of biased care on patient outcomes.
Patient–provider interactions
When healthcare staff are exposed to racial microaggressions from patients, they may inadvertently internalise these biases. 2 For example, a healthcare provider being stereotyped by a patient based on their racial background may lead to increased vigilance in interactions with other patients, perpetuating biases through behaviours such as code-switching, emotional guarding, avoidance, mistrust, self-censorship, seeking allies, and mental preparation. 17
Colleague–colleague interactions
A healthcare staff member who witnesses a microaggression against a colleague but does not intervene may contribute to a culture of tolerance. 14 This lack of intervention can indirectly validate the biased behaviour, creating a feedback loop where microaggressions are normalised.
Systemic feedback loops
A lack of consequences for perpetrators of microaggressions can embolden their behaviour. If healthcare staff repeatedly engage in microaggressions without repercussions, it suggest that these actions are permissible. This can lead to a persistent cycle of biased behaviours. 13
Patient outcomes and biased care
When healthcare staff are influenced by microaggressions, it can lead to biased care delivery. A healthcare provider who has internalised stereotypes may unintentionally offer suboptimal care to patients from minority backgrounds. 13 This biased care perpetuates health disparities contributing to examples like poorer black maternal outcomes including a greater rate of maternal and foetal deaths as well as reduced access to mental health services. 18
Vulnerabilities and adaptations: navigating racial microaggressions
Vulnerabilities
The lack of diversity in healthcare staff can create an environment where perspectives from minority backgrounds are marginalised. 19 Staff from diverse backgrounds may face tokenisation, where they are seen as representatives of their entire race, diminishing their individual contributions; this can lead to feelings of isolation and being unable to speak up against racial microaggressions. 20
Adaptation strategies
Educational interventions, such as cultural competency training, can help healthcare staff recognise and mitigate unconscious biases. 20 This equips staff with the skills to navigate diverse perspectives effectively. Additionally, creating safe reporting mechanisms for racial microaggressions encourages staff to come forward without fear of retaliation, promoting accountability. 19
Instances in literature
Crenshaw’s 20 work on intersectionality highlights the vulnerabilities faced by minority staff. Luo et al. 19 discuss the effectiveness of cultural competency training in mitigating racial microaggressions.
Emergent properties and thresholds: uncovering complex dynamics
Emergent properties
Emergent properties, in the context of racial microaggressions, refer to the unexpected and often amplified effects that arise from the accumulation of biased behaviours. 21 Microaggressions might seem isolated, but their aggregation can lead to a toxic work environment where trust erodes, communication breaks down, and inclusivity falters. 22
Thresholds of impact
Thresholds are the points at which small changes in inputs lead to significant shifts in system behaviour. 22 In the case of racial microaggressions, thresholds are reached when the cumulative impact of biased behaviours reaches a tipping point. At this juncture, the environment shifts from one where microaggressions are isolated incidents to one where they contribute to a broader culture of exclusion and inequity. 21
Instances in literature
Instances from the literature illuminate the concept of emergent properties and thresholds. Lickel et al. 22 discuss the emergent properties that arise from microaggressions’ accumulation. Blazey et al. 21 delves into the thresholds at which microaggressions contribute to a culture of exclusion.
Implications for intervention
Rather than solely addressing individual microaggressions, interventions should also focus on systemic shifts to prevent the accumulation of biased behaviours Blazey et al. 21 By recognizing when a threshold of impact is approaching, healthcare organisations can proactively implement strategies to interrupt the cycle and promote a culture of inclusivity.
Case studies and models: illustrating real-world contexts
Case studies
Imagine being a colleague of a nurse who, like myself, is from a minority group and is subjected to a barrage of disparaging comments about their cultural practices. This incident was an example of racial microaggressions in the real world and served as a sobering reminder of how microaggressions can significantly alter the dynamics of our workplace.
Theoretical models
Theoretical models provide frameworks to understand the complexity of racial microaggressions. One such model is the ‘Microaggressions Framework’ proposed by Sue et al. 2 This model categorises microaggressions into three types – microassaults, microinsults and microinvalidations – enabling a comprehensive analysis of these behaviours. Understanding this framework helps identify where interventions can be most effective.
Instances in literature
Research by Estacio and Saidy-Khan 4 presents case studies of migrant nurses encountering racial microaggressions. 2 model offers a theoretical lens for dissecting microaggressions.
Implications for intervention
Case studies and models guide interventions. Analysing real cases allows healthcare organisations to tailor interventions to specific contexts. Additionally, models like Sue et al.’s 2 provide a roadmap for intervention strategies, helping healthcare systems address microaggressions systematically. It is important to note however, that there will be no solution that can solve all racial microaggression.
Policy and management implications: guiding systemic change
Policy interventions
Healthcare organisations must implement clear and robust anti-discrimination policies that explicitly address microaggressions. These policies should outline reporting mechanisms, consequences for biased behaviours, and support systems for those affected. Policies that ensure accountability can be a deterrent to microaggressions. 23
Management practices
Healthcare leaders should prioritise diversity and inclusion in leadership roles to ensure varied perspectives are represented. Promoting open communication channels encourages staff to report microaggressions without fear of retaliation. 14 Additionally, investing in cultural competency training and education for all staff fosters a more inclusive work environment. 24
Instances in literature
Curtin et al. 23 discuss the importance of strong anti-discrimination policies in preventing microaggressions. Cleaver et al. (2019) emphasises the role of leadership and training in fostering inclusivity.
Future research recommendation based on literature
Intersectionality and layered identities
Exploring how multiple aspects of identity, such as race, gender and socioeconomic status, interact can provide a more nuanced understanding of the challenges faced by healthcare staff, this is intersectionality. 20 Intersectionality requires recognition of how multiple aspects of an individual's identity intersect and, highlights the need for tailored approaches to addressing discrimination. Future research should explore how intersectionality contributes to experiences of racial microaggressions.
Longitudinal studies
Tracking the experiences of microaggressions of healthcare over time needs to be included in staff surveys. Researchers can uncover how these biases accumulate and influence career trajectories, mental well-being and job satisfaction. Longitudinal data can inform targeted interventions to support staff throughout their careers. 6
Organisational culture change
Research can explore successful strategies for implementing policies, training programs, and leadership practices that foster inclusivity. Understanding how healthcare organisations effectively transition from a culture that tolerates microaggressions to one that actively opposes them can guide future initiatives. 23
Impact on patient outcomes
Investigating whether biased behaviours among healthcare staff influence patient outcomes can provide insights into the broader consequences of these biases. Understanding this connection can strengthen the case for comprehensive interventions. 18
By outlining potential future research directions, we identify areas for deeper insights and more effective strategies to address racial microaggressions. Embracing these directions fosters a continuous cycle of understanding, action, and improvement within the UK Healthcare System.
Discussion
This paper explores racial microaggressions within the UK Healthcare System, offering a comprehensive understanding of their origins, impact and potential interventions. Throughout our exploration, several insights have emerged that underscore the urgency and significance of addressing racial microaggressions.
The complexity of bias in racial microaggressions refers to the intricate and multifaceted nature of prejudices and stereotypes that can underlie microaggressions among healthcare professionals. These biases encompass both conscious and unconscious prejudices, influenced by cultural, societal and historical factors, making it challenging to comprehensively address them within the healthcare workforce and are subtle yet insidious expressions of bias that can significantly impact healthcare staff's well-being, teamwork and patient outcomes. 18
The systemic roots of microaggressions in the healthcare system highlights that these subtle forms of discrimination are often symptomatic of broader systemic issues, including institutionalised racism or disparities in healthcare access. These issues require comprehensive, system-wide changes and policies to effectively combat microaggressions and promote equity in patient care and workforce diversity. 18
In the context of the UK Healthcare System, emergent properties within microaggressions refer to the unforeseen or unintended consequences of these behaviours. When multiple instances of microaggressions accumulate over time, they can collectively contribute to a hostile or unwelcoming work environment, impacting staff morale, patient care quality, and overall healthcare outcomes. 4
The thresholds of impact emphasises the need to address not only individual incidents but also their collective impact on staff well-being, patient trust, and healthcare disparities. A tipping point is reached when microaggressions surpass a threshold, resulting in substantial systemic consequences. 14
Addressing microaggressions requires a multi-pronged approach, including policies, training, leadership changes and accountability mechanisms. 12
Addressing racial microaggressions is not only a moral imperative but also a strategic necessity for advancing healthcare equity in the UK. Creating an inclusive environment is not just about embracing diversity – it is about recognising the unique perspectives that diverse staff bring, and leveraging those perspectives to improve patient care. By eliminating racial microaggressions, healthcare organisations can foster a culture of respect and inclusivity that benefits staff, patients, and the broader healthcare system. 19
A healthcare system free from racial microaggressions promotes better communication, stronger teamwork and enhances the quality of patient care. 10 When healthcare staff from diverse backgrounds feel valued, respected, and empowered, they are more likely to contribute fully to their roles and collaborate effectively. 2 Furthermore, by breaking down the barriers that microaggressions create, healthcare organisations can bridge health disparities, providing equitable care to all patients.
Conclusion
Our exploration into racial microaggressions within the UK Healthcare System demonstrates a path toward creating a more equitable and inclusive environment. By understanding the origins, dynamics, and consequences of these biases, we can develop targeted interventions that reshape the very fabric of healthcare interactions. Addressing racial microaggressions is not only a matter of cultural change – it is an essential step toward fostering a healthcare landscape where all voices are heard, all perspectives are valued, and all patients receive the care they deserve.
Footnotes
Competing Interests: The authors declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.
Funding: The authors received no financial support for the research, authorship and/or publication of this article.
Ethical approval: As this study is a review of the literature on microaggressions, ethical approval was not required nor sought
Guarantor: The author KB accepts full responsibility for the conduct of the study, had access to the data, and controlled the decision to publish.
Contributorship: KB was responsible for the concept, manuscript writing and critical editing. PF was responsible for manuscript writing, literature review and manuscript editing.
Provenance: Not commissioned; peer-reviewed by Jacky Hayden and Ava Robertson.
ORCID iDs: Promise Firi https://orcid.org/0009-0007-0523-3160
Kwaku Baryeh https://orcid.org/0000-0002-2807-1965
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