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By LISA EISENHAUER
Oct. 14, 2020

After a doctor left the room at a Bon Secours Mercy Health hospital, the patient he had been tending turned to a chaplain and said: "I don't want an Arab on my care team."

The patient's comment left the chaplain at a loss as to how to respond, says Nathan Ziegler, the Cincinnati-based system's vice president of culture and inclusion. While the system wants patients to be comfortable, to accommodate a prejudice-based request would go against one of Bon Secours Mercy's core values — to respect the human dignity of all people, including its own employees — and potentially support a claim of workplace discrimination.

Zieglar

"We have not only a moral obligation to stand up for our associates, but we also have a legal obligation," Ziegler says. "How we frame that for our patients is what becomes tricky."

To help chaplains who find themselves in such uncomfortable situations, Ziegler and his staff developed training that they began sharing this year. They are adding it to diversity and inclusion lessons already being taught across the ministry, which has about 60,000 associates at sites in seven states and Ireland.

Recognize, reflect, reduce
The goal of the new training module is to show employees how to recognize, reflect on and reduce prejudice – what Ziegler calls the "three R's" — in a framework that is based on Bon Secours Mercy's values. "We give them some prompts and some tools to stand on the mission and say, 'I'm sorry, but this is our mission and we are not able to make those types of accommodations for you. I'm willing to help you calm down or to be here to support you spiritually, but we can't do that,'" he says.

Chaplain Raymond Barnes greets a patient on the other side of a closed glass door at Bon Secours DePaul Medical Center in Norfolk, Virginia. Chaplains were the first group of employees in the Bon Secours Mercy Health system to get training on how to respond to negative bias among patients directed at care providers.

Photo courtesy of Bon Secours Mercy Health

Based on what he hears from care providers, Ziegler says patients are expressing biases more often these days than in the past. He suspects it is the result of pushback from people who don't support the steps the nation has taken toward racial equity in the last few decades. He also believes that the emergence of social media has helped amplify and spread the views of people who harbor prejudices based on such characteristics as race, gender, culture and nationality.

A study 2019 in the JAMA Internal Medicine journal based on the experiences of 50 medical students and physicians found "a wide range of experiences with biased patient behavior ranging from belittling comments to outright rejection of care."

"Participants described a large negative effect on their emotional well-being and the clinical care environment, and many described uncertainty regarding appropriate and effective ways to respond to these encounters," according to the study's findings.

Facing moral distress
Philip Anderson, chief mission officer for the mid-American group at Bon Secours Mercy, was among those who raised the issue of patient bias to Ziegler and suggested that the system develop related training. He's been involved in mission work for 15 years and has seen an uptick in open displays of bias by patients in the last three or four years as discussions and policies related to race and ethnicity have been at the forefront of the national conversation.

"There is all kinds (of bias). … I think that the comments we (chaplains) have heard the most are about providers coming from different cultures," Anderson says.

Often, the comments will start with a patient using the opportunity to chat with a chaplain to complain that they couldn't understand a care provider, he says. Those comments then sometimes shift to outright racist statements such as "I do not want an African physician being my doctor."

Anderson says it was when he saw the moral distress such comments were causing chaplains that he stepped forward to urge that the system come up with some training and tools. The chaplains "didn't want to get into an argument with the patient, they just wanted to know how to respond with some personal integrity, to find some language about how to gently push back on some of these stereotypes," he says.

Examining bias in sickness and health
That language is among the tools provided in the training. For patients who complain about not being able to understand a doctor, for example, the lessons encourage chaplains and providers to be assertive and ask whether the patients asked the doctors to repeat or clarify instructions. If patients make racist comments, the training encourages associates to speak positively about the presence of care providers of diverse backgrounds and the fact that those associates are on the team because they are skilled and to convey that racial comments about any associate are unacceptable.

In addition to giving chaplains and others within the system tools for responding to bias, Anderson says Bon Secours Mercy's diversity training has provided a platform to talk about how the dynamics of race and culture play out across the system. "I think it was really, really helpful for us in terms of just looking at these issues and what are some opportunities that we have to improve as well," he says.

Before Bon Secours Mercy developed the patient bias module, Ziegler says, the system's diversity and inclusion training was mostly about teaching associates how to identify their own skewed perceptions of others and how to address those biases before they act. He said adding in the new section that focused on bias from patients took him back to the research stage to figure out where the prejudice was coming from and how best to address it.

He found biases evolved among humans as subconscious shortcuts that told them how to respond to others in times of danger. When people are healthy, they can ignore those superficial and irrational biases. "But when we are sick, tired, scared, angry, dying, those biases are more likely to come out because that's the state in which the biases were helping human beings in the beginning," Ziegler says.

Just the start
The proper response isn't to ignore biases, he says, it's to follow the three R's and recognize, reflect and reduce them.

The training also covers the need for associates to accept that the process of addressing biases within themselves and others is ongoing and that there is no simple solution.

"What I tell people is I don't want you to think that this is the end of it. This is the start of it," he says. "Even as a trainer, I am constantly going through this process of learning about my biases and checking them and changing the impact of them on my interactions with people."