Hanne Harbison

In the current political and sociocultural climate, there is an urgent need to be able to talk about difficult topics with others, some of whom you may not agree with. This communication skill is crucial for nurses who need to be able to talk about challenging issues with diverse people. We know that people from marginalized and minoritized backgrounds and racial groups receive inferior healthcare, which results in increased morbidity and mortality. While there is a need to address these disparities from a systemic and structural perspective, there is also a need to address them on an interpersonal level. 

To help students develop the ability to identify and interrupt bias in the provision of healthcare, the faculty in the women’s health gender-related nurse practitioner and midwifery programs have developed assignments to help students practice discussions about racism and bias in a way that promotes listening, understanding, and empathy. The goal of these assignments is to promote diversity, equity, and inclusion in our classrooms and in the healthcare environment as our students graduate and become professionals. The masters program is between four and five semesters depending on specialty, and students from both the women’s health and midwifery specialties are together in their clinical courses for three semesters. These assignments take place during the three semesters when the students are in the same courses.

The team that developed these assignments used four guiding principles adapted from “A Toolkit for Addressing Racism in Nursing and Healthcare,” published by the Organization of Nurse Leaders. These are: 1) Start with Heart—being aware of one’s own biases, using empathy and focusing on the desired outcome for the conversation, 2) Create a Safer Space—having and enforcing boundaries and monitoring the tone of the conversation, 3) Practice Self Awareness—being aware of how you react under stress and doing your own work to educate yourself about the effects of racism and bias, and 4) Facilitate Open Dialogue—understanding that these conversations may make us uncomfortable, and giving students tools to make them easier. Using these principles helps to make the conversations during these assignments purposeful and productive. 

The first assignment we developed is a discussion of either an article or a podcast that addresses racism in healthcare. This discussion occurs at the beginning of each of the three semesters where the students are together. We assign the piece along with a few questions to think about as homework prior to the in-class. The discussion takes place in small groups—usually five-six students with one faculty member. We created a facilitator guide and a learner’s guide to set expectations and provide resources and tools for these discussions. The guides include strategies for how to deal with difficult or strong feelings that can come up in these discussions. Additionally, the guides include a resource list for learning more about racism and bias in healthcare and more generally. They also include a set of proposed ground rules, intended to guide the process of the discussion so that everyone involved knows how to participate. The ground rules are taken from a variety of sources including Ibram X. Kendi’s book, How to Be an Antiracist, Ijeoma Oluo’s book So You Want to Talk About Race, and circle practice as practiced by the Restorative Practices @ Penn. It is important to have buy-in from the entire group regarding the ground rules. To that end, the first part of each discussion involves everyone reviewing the proposed ground rules, suggesting additional ones as needed, and agreeing to abide by them.

In each group, the faculty member guides the conversation with the pre-chosen questions. Each student is given the opportunity to respond or pass. Once all the students have had a turn, we move on to the next question. The questions include things like—what surprised you about the content, how did the content make you feel, and where have you seen examples of what the content discusses in your own lives?

After the discussion we have the students complete an anonymous survey using a Likert Scale with choices of Strongly Disagree, Disagree, Neutral, Agree and Strongly Agree. Some of the questions include asking about the student’s comfort level in the discussion, whether they think having these discussions is important, if practicing these discussions is helpful and if they would like additional resources. The students have responded overwhelmingly positively to these discussions.

The second assignment is a scripting assignment, where the students develop a script for how they would have a difficult conversation with a colleague or patient. We do three of these scripting assignments over the three semesters we have all the students together. The faculty develop the scenarios for the first two, and we have the students bring a scenario from their own experiences for the third scenario. The assignment asks the students to develop two different written scripts—one is an “academic” version which is written for an audience of peer clinicians with appropriate sources and citations. The second is the “clinical” script. This is written using language that is accessible to the public and is phrased in a way that the student would speak to a colleague or patient. We give the students examples of both types of scripts in the assignment instructions, so they have a model to work from.

The order of the scenarios is important. We move from a topic that is less charged to the final example where we address the topic of racism, which is typically more charged. Our thought is that having these conversations in this order allows the students to scaffold the communication skills we want them to learn.

The first script is a discussion of weight management. This topic is introduced in a lecture prior to the scripting assignment. Weight bias in healthcare has been well documented and has been shown to have negative effects on health and health seeking behaviors. The second script involves a case where a provider dismisses the concerns of a patient who does not speak English as their first language and has different cultural beliefs around health and healing than the provider. For the third script, the students bring their own scenario. We ask the students to choose a situation where they have witnessed racial micro-aggressions or overt discrimination of a patient or colleague from a marginalized racial identity. At the beginning of the third semester, we ask the students to pay attention to interactions between providers, staff, and patients in their clinical placement with the intention of noticing microaggressions or overt discrimination. The faculty check in with the students at several points in the semester to assess their progress on identifying a scenario.

In each scripting assignment, the students read aloud their scripts to their group members and are given verbal feedback. The feedback is given following the ground rules for the assignments. Feedback is intended to be constructive and help the students ensure their scripts are clear and useful, i.e. is this something you would say. We also want the scripts to consider power dynamics, body language, and location and timing of the encounter.

Both assignments help the students understand how racism and bias affect health and healthcare. By giving students tools and space to practice, these assignments empower our students to hold conversations that often feel challenging. Students appreciate these opportunities to improve their ability to work with a range of patients and the chance to talk in a safe space about issues that are increasingly hard to discuss.

Hanne Harbison is a senior lecturer and the director of the women’s health and gender-related nurse practitioner program at Penn’s School of Nursing.

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This essay continues the series that began in the fall of 1994 as the joint creation of the College of Arts and Sciences, the Center for Teaching and Learning and the Lindback Society for Distinguished Teaching. 

See https://almanac.upenn.edu/talk-about-teaching-and-learning-archive for previous essays.