Proactive Strategies

Using AIR   - Anticipate, Implement, Reflect (Márquez-Magaña, 2017)


            Anticipate : check-in before shift, relationship building/esteem boosting, identify resources, reference growth mindset, grounding, even power pose!

            Connect ahead of time by email/text to anticipate welcome

            How was your morning/weekend/afternoon/friend’s wedding/camping trip?

            Normalize: it’s normal to be nervous/I remember the anxiety of starting shifts

            Where are we going to grow today? (reference own learning goals too)

            Remind of competence in specific areas (can be unrelated)

            Grounding exercise: positive messaging about belonging while doing short breathing exercise (You belong here. You are valuable to our team)

            Develop code phrase that invokes this quickly: we’ve got this, away we go

            Name that bias is in the setting: “I wish that biased and discriminatory language and actions never occurred at this hospital. Knowing the reality, I’ll be checking in regularly with you and all members of the team about experiences of microaggressions and bias.”

            Implement - remind and cue throughout shift, offer time-out/self-care, remind of competent identity, actively combat stereotypes/call out racism/bias

            Let’s check-in about how are doing, can I meet you in 5 minutes?

            How are we doing so far?

            What do you need right now? (time/food/fresh air/resources)

            I noticed that you wrote your notes efficiently/counseled thoroughly about breastfeeding/spoke with confidence/etc

            I noticed bias in the way that patient was discussed at rounds/in the patient education handout/in the policy on visiting hours

            Reflect: check-in after shift, model self-reflection and loving kindness, set measurable goals for next encounter

            Would you mind if I started by reflecting on my patient care/preception goals?

            What did I do that worked for you? What could I do to be more effective

            What did you notice about your day?

            What are your goals? What are we going to shoot for next time?  (write them down so you both have them)

            I appreciated [insert moment] about our shift

            Follow up with an email or text thanking them for their work

Responsive Strategies

Identify that an incident took place

Address the incident with the student, use reflective listening, empathy and inquiry

         Address in the moment when possible

         Name it  - call it what it is, if you’re not sure, do your best.

         Name your experience or lack of experience and your intentions.

         Start with yourself  -  how it impacted you.

         Check in with your student - refer back to creating a welcoming environment.

Special considerations when feedback is for you

         Humility and Openness


         How do my identities and experience inform my reactions?

         Notice if defensiveness is emerging - choose not to go there

         Empathy for and responsibility to the student

         Reach for connectedness

         Practice self-compassion

         Utilize your resources for support and/or to process

Special considerations when feedback is for a team member

         Readiness, time, and place

         Open the conversation and listen reflectively

            What are your thoughts about the interaction with STUDENT at sign-out?

            You wondered if the patient might be more likely to trust her…

            Name behaviors and impact

            When you said “X”, I was concerned that STUDENT might feel as though they are expected to represent their race.

            Invite response

            Invite collaboration in verbalizing expectations and equitable standards


Following up with the Student

         Validate their experience (focusing on impact NOT intent)

         Verbalize Commitment

Your experience matters to me, and you/our patients deserve to be treated respectfully at all times.  I am committed to addressing your concerns and providing equitable care.

         Clarify expectations and invite input about next steps

What are your needs now and moving forward?

What would it look like for me/us to earn your trust?

         Check understanding and clarify next steps

I want to be sure I’ve understood your preferences about next steps…

Allyship Means Action Tip Sheets

UCSF Department of Obstetrics, Gynecology and Reproductive Sciences

Creating a Welcoming Learning Environment:

Combatting Stereotype Threat

What is stereotype threat?

“A situational phenomenon that occurs when individuals who are targets of negative stereotypes underperform due to a conscious or unconscious fear of being evaluated through the lens of these stereotypes.” Steele, 1997

How does it appear in the clinical setting?

Stereotype threat can apply to anyone but it has a disproportionate impact on classes of people already impacted by oppression and bias.

·  Students/learners:  An Asian medical student may not want to stand out from his peers at rounds for fear of confirming the stereotype of the Asian American as the “model minority.”

·  Colleagues: A midwife may feel she cannot ask a question at rounds about a complex condition for fear of confirming the stereotype that midwives are not as well-trained as physicians.

·  Patients: An African American laboring patient may not express her concerns or frustrations readily for fear of confirming of the stereotype of the “angry black woman.”


These fears lead to increased cognitive load and a physiologic stress response (increased heart rate, release of cortisol, etc) distracting people from their work/studies and evidence shows that this often can negatively impact actual performance. One way to think about it is by using a running analogy. If you take two equally prepared runners, but one has to run uphill (a metaphor for dealing with the cognitive load of stereotype threat) while the other runs downhill, who will finish faster? The amount of preparation is not what needs to increase, you need to level the ground people are running on (eg, decrease the impact of stereotype threat).


What can we do to mitigate the effect of stereotype threat?

Eliminating stereotype threat is difficult given the deep, long-standing messaging that creates the stereotypes. However, some techniques have been shown in the evidence to mitigate the impact of

stereotype threat, thereby decreasing the cognitive load and improving performance.

·  Critical self-reflection: maintain self-awareness re how our own behaviors, beliefs and biases may be influenced by stereotype threat and related attention to applying consistent standards

·  Create identity safe environments: hire people of color, post signage that makes clear the environment is intended to be inclusive (all are welcome here, rainbow symbols, Black Lives Matter buttons, etc) and verbalize the values of inclusivity and commitment to equity in interactions; create a mission, vision and goals document that is inclusive and visible

·  Social belonging: make explicit the sometimes unwritten norms of the environment (this is where people eat lunch, feel free to drink the coffee as long as you bring a pound in once in a while, folks usually walk around and greet each other at their desks every morning, etc) and reiterate frequently that they are an integral part of the work being done or the community they are in 

·  Values affirmation:  Invite and validate the learner/patient/colleague’s   own work ethic and commitment to their goals

·  Support positive personal identity: provide copious reinforcing feedback and appreciation of them as unique individuals

·  Reframe tasks: describe difficult tasks as challenges that will take effort, share personal experiences and lessons learned from your own failures, promote a growth mindset—where high performance is a product of action and effort as opposed to innate ability

·  Actively negate stereotypes: openly discuss stereotypes, and cite examples from the persons own performance or habits that refute the stereotype

·  Name stereotype threat as a source of anxiety, directly confronting it: name the problem and invite the person to share whether they think stereotype threat is affecting their performance or health habits and assume responsibility for your contribution to the problem

·  Reattribution: help people attribute setbacks or difficulties to temporary external factors rather than internal factors such as ability.



Aronson, et al. Unhealthy interactions: The role of stereotype threat in health disparities. American Journal of Public Health . January 2013, 103: 50-56.

Steele, C. M.  A threat in the air: How stereotypes shape intellectual identity and performance. American Psychologist, 52 (6), 613-629.

Márquez-Magaña, Leticia. Resiliency to stereotype threat: how can we recognize and cope with the “Threat in the Air”? July 17, 2017.


Ana Delgado, CNM and Kara Myers, CNM