Speak-up culture = feedback culture

The In Plain Sight report recognized that Indigenous people experience racism in our health care system. The report recommended “that the BC government continue efforts to strengthen employee ‘speak-up’ culture throughout the entire health care system so employees can identify and disclose information relating to Indigenous-specific racism or any other matter.”[1]

What is “speak-up” culture? How can it help us? How do we develop and nurture it within the health care system? I believe we can simplify the concept by thinking of speaking up in terms of providing feedback. In my experience, knowledge and skills are required to speak up well.

Speaking up through feedback can be a powerful tool to help us improve in our personal and professional lives, but it’s not easy. In busy health care settings, it’s sometimes easier to delay or avoid opportunities to give feedback.

Good feedback needs to be specific, actionable, timely, and delivered with compassion and curiosity. It takes practice! Providing feedback about explicit or implicit racial bias is even more complex due to the difficult emotions elicited. The person giving the feedback might feel anger, fear, or sadness. The person receiving the feedback will often feel shame.

Giving feedback about racism is not as common as it should be. Even if we want to, most of us do not know how to do it in an effective manner. When I give this kind of feedback, I try to provide it in a manner that protects those being harmed by the biased behavior without shaming the other person. Shaming people is not an effective social justice or educational tool,[2] as I can attest to personally. A friend of a friend posted an article on social media about questions you shouldn’t ask same-sex couples who have kids. While out for dinner the week before I had asked one of these questions, and I went online to comment that I found the article useful and to apologize for not knowing better. But when I read a couple comments about how “stupid” people are, I didn’t end up posting the comment or reaching out to apologize, because I felt attacked. I learned from the article but did so in shame and silence, and that relationship was never repaired.

Here are some principles for how to deliver feedback in a good way:

  • Speak to the person privately.
  • Establish a connection with the person.
  • Ask them about the behavior you observed.
  • Provide your feedback about the behavior observed.
  • Keep the dialogue open.

These conversations can be difficult, which is exactly why these skills need to be taught and practised in order for people to feel confident to use them in the real world. As a cultural safety educator, I prefer “calling people in” rather than calling them out. Calling people in means you assume their intention was not to harm and that they do not understand the impact of their behavior, that when they know better they will do better.

Receiving feedback can also be difficult. It requires us to be open, reflective, and honest with ourselves. Understanding the trauma response and how to develop shame resilience can be helpful. Racism is often seen as a moral issue: you are either racist or you are not, and if you are found to be racist you are a bad person. Therefore, when someone is told their behavior is biased, they can feel as if their character is being attacked. This is followed by shame, which triggers a trauma response in the form of either fight (challenge), flight (deny, avoid), or freeze (blank, no words). These responses are all normal. When someone is in a fight, flight, or freeze response, they are able to respond only from their limbic brain; their prefrontal cortex is offline. In other words, they cannot listen to you meaningfully.

Shame thrives in secrecy and silence.[3] To counter the shame around racism, we need to be able to talk about it. We can use the same strategies that are used to address the shame and fear around acknowledging a medical error. This includes normalizing (i.e., we all make mistakes) and creating safe spaces to report and talk about medical errors (i.e., morbidity and mortality rounds). We all have racial bias because we grew up and live in a world with racial bias, including anti-Indigenous bias. We need to normalize that we can all be racist and create mechanisms to report racism and talk about racism. I would like to see education and training opportunities that teach how to give and receive feedback about racism developed and implemented at all levels of medical education so that we all feel empowered to speak up.

I believe having these courageous conversations will have a profound impact on preventing anti-Indigenous racism at the bedside and will save countless lives.
—Terri Aldred, MD


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1.    Turpel-Lafond ME. In plain sight: Addressing Indigenous-specific racism and discrimination in BC health care, full report, November 2020. Accessed 30 November 2022. https://engage.gov.bc.ca/addressingracism.

2.    Brown B. Shame and accountability with Brené Brown. July 2020. Accessed 15 December 2022. https://brenebrown.com/podcast/brene-on-shame-and-accountability.

3.    Brown B. Atlas of the heart. New York: Random House; 2021.

Terri Aldred, MD. Speak-up culture = feedback culture. BCMJ, Vol. 65, No. 1, January, February, 2023, Page(s) 5 - Editorials.

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