Perceptions of racism in a children’s psychiatric inpatient unit: a qualitative study of entrenching and uprooting factors

doi:10.21203/rs.3.rs-1871611/v1

Introduction

It is well documented that race plays a role in health care access and outcomes. However, discussions about race in the workplace are often avoided.

Aim/Question

We sought to identify factors that may contribute to or deter from racism to inform interventions to sustain a psychologically supportive environment for patients and staff.

Methods

We conducted individual interviews about perceptions of race and racism using a purposive sample of twenty-two individuals in an acute child psychiatric inpatient service. We analyzed interviews systematically with thematic analysis guided by a constructivist grounded theory conceptual framework.

Results

We identified two countervailing processes: 1) Entrenching – factors that sustain or increase racism: Predisposing, Precipitating, and Perpetuating; and 2) Uprooting – factors that rectify or reduce racism: Preventing, Punctuating, and Prohibiting. We organized each of the elements in a “6P” model organized along a temporal sequence around sentinel racist events. For each of the six components we go on to include: Contributing Factors, Emotional Reactions, and Behavioral Responses as reported by participants.

Implications for Practice

Identifying factors that entrench or uproot racism can inform specific steps to improve the care of all children and families on an inpatient child psychiatry unit. These interventions could be applied to milieu-based inpatient settings serving patients of all ages.

Racism

inpatient care

children and adolescents

health disparities

What is known on the subject?

The impacts of racism on health are well documented, and are greater for mental than for general health.
Mental health professionals are well positioned to help dismantle racism and structural barriers compromising optimal patient care.

What the paper adds to existing knowledge

We describe a systematic and orderly way to identify factors that contribute to entrenching racism as the status quo or that help to uproot it.
By incorporating a racial equity lens, we can better understand daily racism and inform the optimal antiracist actions most relevant to an inpatient psychiatric setting

What are the implications for practice?

Our two-domain / six-theme model may serve as a rubric for individuals to engage in systematic and orderly self-reflection, or for organizations in auditing or programmatic evaluation
The unique strengths of a mental health environment can be harnessed toward the elimination of racism and racist practices in clinical care and in the workplace

Conversations about racism are challenging to have, and perhaps even more so in a healthcare setting, where disparities in care go against the grain of a shared mission to serve every patient in an equitable way (Khazanchi, Evans, & Marcelin, 2020). The correlation of poor health outcomes with lower education attainment and higher poverty levels is real, but it is confounded by the independent role of racism (Calhoun & Martin, 2021). Race is a social construct rather than a biological given, but the impact of racism on health a reality (Paradies et al., 2015), and greater for mental than for general health (Bailey et al., 2017; Krieger, 2014). The mechanistic underpinnings of the impact on racism on health are increasingly understood. For example, the “high-effort coping” required to live in a social environment rife with daily microaggressions is linked to a “weathering” effect manifest across a range of metrics (Geronimus, Hicken, Keene, & Bound, 2006), including premature aging and shortened telomere length (Chae et al., 2014), in turn a reflection of living under chronic stress (Berger & Sarnyai, 2015). Although direct causation cannot be established from association, downstream consequences may include the recently documented secular increase in Black adolescent suicide rates (Sheftall et al., 2021).

Disparities in areas of patient- and family -centered care, effective treatment, care coordination, patient safety, and receipt of preventive services, all continue to exist for Black and racially underrepresented individuals as compared to white (AHQR, 2018). In this article we will specifically focus on issues pertaining to Black patients, their families, and inpatient unit staff.

Black patients are less likely to feel that they are treated with respect by their providers, and less likely to feel they are included in their treatment and clinical decision-making process. Psychiatric treatment disparities exist as well: Black adolescents with depression are less likely to receive treatment (Alegria, Vallas, & Pumariega, 2010), and when compared to white, Black children are more likely to be given a diagnosis of conduct disorder, and less likely one of ADHD (Fadus et al., 2020). Troubling disparities based on race exist among providers as well: Black clinicians are less likely to be respected by patients and colleagues, and more likely to be seen as less qualified than their white peers (Serafini et al., 2020). In addition, there are racial differentials in workplace satisfaction (Nunez-Smith et al., 2009; Osseo-Asare et al., 2018), and occupational injuries and illness (Rospenda, Richman, & Shannon, 2009; Shannon, Rospenda, Richman, & Minich, 2009). Despite these sobering facts, the healthcare workplace is typically reticent to address issues related to race (Nunez-Smith et al., 2007). Persistent racial disparities suggest a gap between knowledge and the conscious practice of assessing, identifying, and eliminating racism in nursing and medical practice. Any improvement hoped for in alleviating racial disparities must begin with an awareness of perspectives and challenges related to race in the work environment (Acosta & Ackerman-Barger, 2017).

Institutional racism is entwined into all aspects of mental healthcare, including psychiatric inpatient units (Wade, 1993). The intensity of acute patient care can in fact intensify race-based differences in care. Among other metrics, the use of seclusion, and of mechanical or chemical restraints is telling: their use is significantly higher among Black than white patients, both in adults (Nash et al., 2021; Smith et al., 2021) and in children and adolescents (Donovan, Plant, Peller, Siegel, & Martin, 2003; Martin, Krieg, Esposito, Stubbe, & Cardona, 2008). Our study showed that Black children were four times as likely to be restrained or secluded and Hispanics were 50% more likely to be restrained or secluded. These differential rates are well documented, have remained largely unchanged, yet have rarely been viewed through a lens of racial equity, one that could lead to meaningful change. Psychiatry and the mental health professions are well positioned—and indeed have a role and responsibility—to dismantle racism and structural barriers compromising optimal patient care (Ben-Cheikh, 2020). Regrettably, and as so well-articulated by others, “the disappointing irony is that of all sectors of healthcare, mental health is best equipped to stand against racism”, yet has failed to do so (Mensah, Ogbu-Nwobodo, & Shim, 2021). This need not be the case. Mental health professionals are particularly attuned to psychosocial contributing factors and routinely engage in reflective practice and attention to interpersonal nuance.

In this qualitative study we took on the topic of racism in an intentional and explicit way by assessing the perceptions of providers working in a children’s psychiatric inpatient unit.

Participants and individual interviews

The lead author, a Black woman who is an African native with a foreign accent—demographic information that is pertinent to this study—conducted individual, semi-structured interviews organized around a list of sensitizing questions (Appendix 1). Each of the interviews was 1-hour long. Semi-structured interviewing is a flexible, commonly used method in qualitative research in healthcare that uses a prepared list of questions to guide researchers and participants to “co-create meaning” through an exploration of thoughts, feelings, and opinions, especially those around potentially sensitive or personal topics (Barriball & While, 1994; DiCicco-Bloom & Crabtree, 2006). Interviewees were not necessarily asked each of the ten sensitizing questions.

Participants and ethics approval

Using purposive sample (Emmel, 2013), we selected 22 active staff members working in a 16-bed inpatient psychiatric service (serving children under the age of 14). The unit is part of a large tertiary health care setting and is closely affiliated with academic medical and nursing institutions. In recruiting participants, we were attentive to include representation across gender, self-reported race and ethnicity, discipline, and career stage, (Appendix 2). We obtained ethics approval from the Yale University Institutional Review Board (Protocol # 2000028849), which considered the study exempt under 45CFR46.104 (2)(ii). Participants provided verbal in lieu of written consent.

Data collection, qualitative analysis, and theoretical framework

Each interview was digitally recorded and transcribed for analysis using rev.org. We uploaded the collection or sample of transcripts into software for qualitative analysis (NVivo version 12; QSR International, Melbourne, Australia). We coded the transcripts according to the principles of thematic analysis, a qualitative approach involving the active construction of overarching patterns and meaning across a dataset (Braun & Clarke, 2006; Kiger & Varpio, 2020). Thematic analysis allows the flexible exploration of rich text data to construct themes that “reframe, reinterpret, and/or connect elements of the data” without developing a final theory. We approached analysis, interpretation, and conceptualization using a constructivist grounded theory (CGT) frame, which focuses attention on an overall network and the internal experience of its social actor. Grounded Theory (Glaser & Strauss, 1967) studies underlying social processes that shape individual experiences, and in which investigators and participants co-construct research by sharing their respective and at times conflicting perspectives (Charmaz, 2006). This process of co-construction can aid in the acquisition of new knowledge, and invites their active and creative interpretation (Singh & Estefan, 2018). We followed Braun and Clarke’s six-step analytic method, adopting an inductive approach, with our research questions evolving beyond the initial sensitizing questions. This flexible process was critical, as both the cultural context and the content of the interviews changed over time.

Three authors (UA, CI, LC) coded independently throughout the study span in an iterative manner, with coding and interviewing interdigitated to allow for the inductive approach to inform subsequent interviews. Two authors (UA, AM) then combined and triangulated codes, and established the final codebook to eliminate redundancies, clarify domains, themes, and subthemes. In this way we ensured theoretical sufficiency (Saunders et al., 2018). Each final code was supported by quotes from more than one participant.

Of note, we refer to “sentinel events” at different points in our results below. These refer to instances of race-based injury, such as, for example: experiencing or witnessing overt or insidious racism, being the target of racially weaponized language, or being excluded or overlooked based on race. These events can occur, for example, between patients, staff, and/or families. Whenever relevant, we indicate examples of the specific event, or of the individuals involved. All results are anonymized, unidentified, and not traceable back to their individual source. Unless noted otherwise, all verbatim quotes come from Black staff and are indicated between double apostrophes (“x”).

Through iterative thematic analysis we developed a model consisting of two overarching domains: I) Entrenching: factors that sustain or increase racism, and II) Uprooting: factors that rectify or reduce it. We divided the domains into three subdomains each, all of them starting with the same letter for ease of explanation, thus resulting in an alliterative “6P” thematic model. We go on to describe these different components in the six tables that follow. We organized the tables following a similar rubric: 1) Definition of the subdomain; 2) Organization into three recurrent themes: a) Contributing factors; b) Emotional reactions; and c) Behavioral responses; and 3) Description of subthemes, each in turn supported by representative quotations.

I. Entrenching: factors that sustain or increase racism in an inpatient psychiatric

1. Predisposing: factors contributing to a racist workplace

Inpatient psychiatric units are embedded in the communities they serve. As such, they incorporate and reflect the realities of their larger social context. Racialized views and racist practices have been ingrained into the American experience over centuries and continue to cast a shadow on institutions and practices in overt and subtle ways. Such longstanding structural components have kept racial minorities from being fully represented among staff, thereby maintaining a predominantly white authority hierarchy. Black individuals may perceive themselves as less competitive or welcome in the workplace and hiring decisions and onboarding experiences can reaffirm those preconceptions. Once employed by a milieu experienced as cold at best and hostile at worst, retreating or shying away may become an adaptive response – one compounded by being made to feel invisible, "as if I was not right there in front of you, feeling your awkward discomfort".

Table 1

Predisposing factors: allowing racist events to occur in the first place
Theme	Subtheme	Sample quotes
Contributing factor	Structural racism / institutional factors	The broader health care system has used it, race, to facilitate a caste system, this underlying caste system in the US. (White staff)
	Distrust of authority perceived as hostile	...we’re not necessarily trained on how to respond when a kid comes to you and says, "Hey, why are cops killing Black people?", or "I don’t respect security because I don’t respect cops."
	Shortage of diverse staff	...with a lack of diversity, of staff not having experienced it themselves, it's hard to understand exactly how these kids' home life is.
	Invisibility / avoidance	I’m still here and you’re not even acknowledging me. You skip over me, literally walking right past.
Emotional reaction	Ambivalence about addressing	...it feels like such an anxiety-inducing thing to bring up. If I do, will there be a change? (Black staff). ...I felt like anything I had to say didn’t matter. I was trying to get the words out in between sobs, but felt I was being down. (White staff)
	Denial: believing that racism is not a problem	Comments like "that wasn’t a race thing" can be very invalidating when being on the receiving end.
	Reluctance to speak up / fear of retribution	I just feel like I want to speak up, but then I’m nervous. You just don’t know if you’re going to be supported by others, maybe make things worse. That because some leaders are white that there would be retribution.
Behavioral response	Inhibition	I don’t think our Black staff would feel comfortable calling that out. Because they think that they’re going to get in trouble in some way.
	Walling off: raising a psychological shield as a protective measure	...when I come in knowing you’re probably not going to acknowledge me, it’s not going to affect me anymore. (Black staff) Some will shut down or just put up their guard, like "I’m not talking to you, because you don’t look like me, you don’t know where I come from, you’re judging me, and I don’t feel comfortable around you." That might not be the case, but that’s the perception of a bunch of the kids.
	Tentative or ineffective practice	All of us are trained in how to prevent behavioral escalation. I am proud of what we do and how professional we all are. But I would be naive to say the color of a kid's skin has absolutely nothing to do in why we may address the same situation in different ways with a lighter-skinned child.

Addressing racism head on was just as complicated across races. The need to talk about "the elephant in the room" was counterbalanced among Black staff by a reluctance to speak up, to "make waves", to possibly encounter or even invite retribution or other consequences. In turn, white staff ranged in their views from denial of a problem that did not affect them directly, to a defeatist notion that nothing said from their privileged position would be welcome or taken as anything but a defensive or invalidating token gesture. The confluence of these factors can result in a healthcare setting designed to help but can feel paralyzed and ineffectual, and which Black patients, families, and staff may come to tolerate, rather than engage with.

2. Precipitating: factors that ignite racist events

Two factors–overcrowding and the COVID-19 pandemic–were repeatedly identified as contributing to frayed nerves and tensions running high, resulting in a charged clinical environment in which racist words or actions were more likely to ensue. Overcrowding had gone from an infrequent occurrence to the new status quo. A state-wide scarcity of inpatient beds, compounded by heightened clinical needs, discharge delays, and a small physical footprint to start with, all contributed to an overcrowded unit running routinely over census. The pandemic interfered with disposition plans by "all but gutting" [white staff] outpatient and step-down resources. It thinned the ranks of on-the-ground staff and clinicians and required more and longer shifts to cover the unit's needs, particularly as staff became ill or required quarantining. The strained interactions between and across patients and staff at times spilled over as racist remarks or overt insults. By weaponizing language, children sought in a maladaptive way the attention and care they craved for, made even more pressing in the context of limited-to-no in-person family contact.

Table 2

Precipitating factors: occurring proximal to a racist sentinel event
Theme	Subtheme	Sample quotes
Contributing factor	Crowding in a constrained physical space	The unit has been over census for a very long time. That means carrying a lot of patients, a lot of turnover.
Contributing factor	Pandemic	The resources we had tapped into in the community are more scarce, which translates into a lot of bounce backs with our discharge planning having become a shell of what it was in non-pandemic times.
Emotional reaction	Anger	...how can I handle it in a way that I'm still not judged and labeled as angry or bitter? We still have to uphold certain standards while being attacked.
Emotional reaction	Fear	If this is all I see on paper, it may give me some hesitation, whether I want to engage, or feel on the defense, expecting you to be aggressive.
Behavioral response	Racialized assumptions	...not giving enough credit to the childness of Black children with "bad behaviors," treating them as if they were a much older teenager, when truly they are young children.
	Racialized language	But it’s like this boy is going to be a thug, he's going to be dead, he’s going to be in jail. That might be true, but you are at work, you still have to provide a certain level of treatment and care and empathy, sympathize with their situation. ...more than once, when we had white kids who were younger described as angelic or cherubs or things like that.
	Inconsistent practices	When one of our children, an African American child that was held down on the ground and restrained we all debriefed afterwards. It was some 15 of us in the room. And I asked, "Do you think race had anything to do with this?"

Being on the receiving end of racist slurs from dysregulated patients resulted in a range of emotional reactions for several interviewees–from sadness or hurt, to the harder-to-acknowledge anger back at a child. Clinical handoffs or written descriptions of children heading into the unit could be suffused by racist animus or become a "kind of chart virus, hard to get rid of" [white staff], which could set the stage for a tinderbox ripe for a sentinel event. Racialized assumptions, whether preexisting or stoked by ill-timed communication, could lead to the use of racialized language, or to a differential response to children's general needs or patterns of aggression. Inconsistent practices across patients’ race could become downstream manifestations or provide an igniting spark.

3. Perpetuating: factors that sustain racist events

Presumptions about others that preclude curiosity or openness can contribute to a cementing of problematic relationships across racial lines. Distorted preconceptions are detrimental to patients who can be stereotyped from the outset: boys considered "rarely angelic but often ‘guilty until proven otherwise’", girls viewed as manipulative or over-sexualized. Just as misguided and ostracizing can be the presumptions made about Black male staff, who can be taken to be threatening or dangerous, "when we only want to work, to help, to be a role model". A sense of hopelessness was common among some Black staff, who doubted how long the emphasis on DEI-related activities would last, before "the pendulum swung back, as it always has". At a more proximal level, staff of all races struggled with the physical constraints and limitations of an old building that have been retrofitted into an inpatient psychiatric unit: "when a child uses racial slurs in front of others, we simply can't go aside and have the privacy (or the simple removal) that are needed in that moment". Further frustrations came from a paucity of guidelines regarding what language or behaviors would warrant report or escalation, or of an anonymous way in which to raise concerns. In fact, the mere tenet of anonymity was questioned by some, who again raised concerns over possible reprisal or punitive consequences.

Table 3

Perpetuating: ongoing racist occurrences after sentinel event
Theme	Subtheme	Sample quotes
Contributing factor	Presumptions that preclude curiosity or openness	They see a phenotype come in the door and they start automatically to try to understand that person. But it’s based on stereotypes largely. And that is why we be so mindful in the workplace. We can’t help it, it’s automatic: all human beings try to categorize people. I’m Black, I’m tattooed up. You look on the media, this is the angry Black man, the ghetto guy's description to a T. According to what the media wants to portray and they see, they’re just like, "We’ll see how long he lasts."
	Hopelessness	I feel like people will do it for a couple of months because there’s all this attention on DEI right now. But in a couple of months, people will forget about it, and then just go back...
	Unit constraints that preclude timely interventions	It would help, being able to remove the child from the regular community until some form of discussion or debriefing took place, but even the logistics of doing that are difficult. ...not such a large unit where you could isolate and have full privacy with them.
	Lack of resources to address or report racist events	When stuff like that happens on unit, I feel like we should have a safety net...If you’re telling me I can’t tell a kid not to call me the N word, then what do I do? I don’t get it. If you’re not going to support me emotionally, then what do I do?
Emotional reaction	Fear of retaliation	Even if I could report an incident, would I? Is "anonymous" ever really?
	Defensiveness	it’s a really flimsy excuse in my mind, because whether it’s intentional or not, the point is that it’s very clearly hurting the patient.
	Fear of being labeled racist	I feel the if they openly said they were uncomfortable, they could be described as racist and unwilling to learn.
	Shame	...a culture of white shame that can be used by white people to prevent other white people from talking about race.
Behavioral response	Ignoring / wishing away	Nobody says anything in the larger group. I’m not sure if people have taken them [staff or patients] aside and said anything. I know I haven’t, but I’m not aware of what other people have done. But in the larger group, nothing has been said.
	Not attending / disregard organized events	My tacit interpretation was "I don’t understand what the big deal is. We shouldn’t be taking away time from our work to do this [DEI- and racism-related training]".
	Physiological responses	Waking up out of my sleep, working it through. The situation just kept ringing in my ears.
	Modifying behaviors or self-censoring	For us, we have different consequences than they would have, so we have to watch your behavior, to censor yourself a little bit more than they do.

Emotional reactions among white staff–or those attributed to them–included a reluctance to admit discomfort, which could be taken for an inability or unwillingness to learn; defensiveness in swiveling attention away from impact onto underlying intent or explanations; or by outright "white shame" subverting the capacity to engage in conversations that are as necessary as they can be discomfiting. The downstream behavioral manifestations can manifest from the dismissive (ignoring, wishing away, not participating in DEI-related educational sessions) to the depleted and resigned:

There is a disconnect. They don't realize that consequences are very different, for children as much as for us staff. If there's a white child who acts out or gets in trouble, consequences are usually much lighter (so to speak) than those for a Black child. [Black milieu counselor]

II. Uprooting: factors that rectify or reduce racism in an inpatient psychiatric setting

4. Preventing: decreasing the likelihood of racist practices and events occurring in the first place

Among the reasons cited for hope and optimism, perhaps none was more highly mentioned than the hiring of diverse staff: “the more we look like the population we serve, the better able we are to care for children and families". A clear sense of stable staff demographics was challenging during a time of high staff turnover exacerbated by the pandemic, including with nurse travelers filling in gaps in coverage. Notwithstanding this consideration, there was a positive feeling of renewal on seeing more milieu counselors, nurses, and physicians of color—of regaining a foothold that can be difficult to sustain:

One of the things I loved, at least in our time, was that in the team of attendings, one was a woman who was Black, the other a man from Latin America. Our nurse manager was a Black woman two. And so, I felt like those conversations, A, happened, and B, were easier, maybe than in most other settings, where there isn’t any diversity. [Black nurse]

Apart from recruiting and retaining more staff of color, one suggestion was having exit interviews conducted by a third party. The information collected in this way could prove useful in disambiguating whether staff had left moving toward better opportunities rather than retreating from environments experienced as unwelcoming or hostile.

Table 4

Preventing: decreasing the likelihood of racist events occurring in the first place
Theme	Subtheme	Sample quotes
Contributing factor	Enhancing diversity of staff	...there's been a shift in the diversity of the staff, for the better: it used to be a predominantly white staff, both nurses and counselors, and now that is not the case. Now you have predominantly Black and brown folks.
	Culturally informed care	I really, really, really like when we have African American young girls, how the staff makes a concerted effort to make sure that they have the right hair care products. That's the epitome to me of being culturally sensitive. It seems like something little, but it really is a big thing, because a kid will behave better if they feel better, if they feel like they look good.
	Ongoing DEI activities specific to the unit	Learning about DEI issues and about racism as they impact our work is really important. Not an option, really. More like the trainings need to be required, with the time built in so that it does not become an add-on, an "unfunded mandate" that could even backfire or foster resentment.
Emotional reaction	Gratitude	...there are groups of people feeling so relieved that they have this institutional permission to share their personal experience.
Emotional reaction	Discomfort	It is inevitable for some to feel very uncomfortable because they have believed themselves not capable of racism. If you grow up in America, you're going to be inculcated in racialized views. It just feels so uncomfortable for people to own and acknowledge.
Behavioral response	Naming race and racism explicitly	I think just saying the words "race" and "racism" helped staff start to open up. Maybe it's OK talking about it; we don't need to be always walking on eggshells.
Behavioral response	Individual actions to improve knowledge	I know it changed a few people; some who were saying they had not been aware of the impact of race and racism in their daily work and interactions.

Enhancing the diverse makeup of staff was the first and most natural conduit for the provision of culturally informed and sensitive care. But not all depended on longer term and gradual efforts such as hiring practices. Small things and attention to seemingly minor details could make a major difference for the better: hair care products, toys, books, music, and movies encompassing different backgrounds made children feel welcome and nurtured.

Grassroots educational activities that had first started as a staff member's initiative, took off, became a regular and incrementally attended offering later complemented by systemwide training opportunities. Sessions were sparsely attended at times, often by the same participants, who had "bought in even before coming to the first one". Making the in-services and educational opportunities “less mandated and more possible” was key: release time from clinical duties allowing attendance is a necessity so as not to have critical content devolve into “an add-on elective”.

Institutional “permission and encouragement to speak up”, to take on a subject matter traditionally deemed "off-limits", was met with gratitude, with relief at not being left alone to deal with challenging situations and unresolved, festering emotions. In contrast, some staff–even those who had expressed gratitude–conceded the discomfort inherent in broaching the subject, yet “without discomforting friction, there can be no forward movement.”

One concrete and often alluded example of discomfort was in the outright mention of race and racism, of using the term unapologetically and not hiding behind euphemistic alternatives. Naming racism and racist practices for what they are was framed as a prerequisite, when not an imperative. Not eliding difficult words was cited as a precondition for the work necessary to prevent further racist instances from happening, and to move the unit toward its aspirational best.

5. Punctuating: interrupting / stopping racist events in real time

Participants expressed agency in being able to intervene in the moment, as sentinel racist events took place, such as the weaponizing of language or making racial slurs. There were fewer concerns about how to intervene or what to say, given on experiencing or being a bystander to such events, "it is clear what to do, so long as we know we are supported". Experiencing that support, and seeing it provided to others meeting similar clinical challenges, provides the necessary encouragement and positive feedback necessary to stand firm and not let events go unnoticed. With that backing in place, four concrete steps were clear and consistent across a number of participants: 1) intervene in the moment, not expecting there will be a better or even an alternative opportunity to do so; 2) address the event with members of the community, whether directly targeted or witnessing it; 3) implement a corrective response, starting with an apology, that focuses on the impact of those on the receiving end of racism, rather than on the intent of those expressing it; and 4) support the aggrieved through attentive listening, though not at the expense of shaming the offender by singling them out. An expedient way of maintaining this delicate balance is by focusing on discrete actions, rather than on specific individuals

Table 5

Puncturing: interrupting / stopping racist events in real time
Theme	Subtheme	Sample quotes
Contributing factor	Leadership open to learning and supporting patients and/or staff who go through racist experiences	I don't want to second-guess my actions: leadership having my back can make that possible. (Black staff) ...leadership being able to set the stage for these conversations to take place, without people feeling judged or being liked or being seen as bigoted or racist or whatever. (White staff)
Emotional reaction	Feeling supported by other colleagues and leaders	The really the big thing is communicating with each other and sharing, being honest. Being open to where people have been, have come from, are going through.
Emotional reaction	Courage to speak up and address on the spot	Sometimes you feel drained and just kind of let it go. But I can find the courage, I guess, to speak up when it's affecting my clinical care, my decision-making.
Behavioral response
	Intervene in the moment	Make it clear that doing nothing in this context should not be an option: inaction is racist in itself.
	Addressing explicitly with milieu if event was witnessed	If others witnessed the event, the response should not be just a one-on-one discussion. It needs to be addressed with the entire group. It is not about pointing fingers or intended to embarrass anyone; it is an opportunity for everyone to learn and grow.
	Corrective response that focuses on impact over intent	"It doesn’t matter if you own it, hurtful is hurtful. It doesn’t matter if you own it or if you have the right "to say it" you should not be using that word."
	Supporting the aggrieved through attentive listening	Validating the anger that she's feeling, “Beating him up is not going to be the solution, but yes, that's racist, and your anger is valid”. Then to the other kid, "That was racist language. We don't use racist language here." "But she made me mad." "Okay, but that is racist language."

6. Prohibiting: decreasing the likelihood of future events

By considering the entirety of the racial experience in the unit—the painful and challenging as well as the ability for corrective action—staff articulated ways for the unit to move forward. Rather than lamenting past and even recent occurrences, they expressed a shared interest, a commitment even, to turn around racist events into opportunities for growth, learning, and identification of actionable items for prevention, resulting in a virtuous cycle of clinical improvement. Remaining open in a non-defensive, curious, and with a growth-directed mindset, would be central to the task. Acceptance of one's own contributions and blind spots, humility in having them pointed out, and a commitment to personal growth were specifically mentioned, as was cultural humility in embracing opportunities to learn about others' realities, whether of patients or staff.

Table 6

Prohibiting: decreasing the likelihood of future racist events
Theme	Subtheme	Sample quotes
Contributing factor	Turning sentinel events into learning and prevention opportunities	...every time I addressed a kid who had made a racial slur...I wasn’t educating the kids only. I would also have the staff members be there and they would hear me talking to the kids and I would hope that they would understand. Or I would speak loud enough so that they heard me, too.
Contributing factor	Non-defensive awareness and recognition of specific incidents of covert or overt racism	When you allow yourself to look closely, racial tensions—addressable, improvable, remediable racial tensions—can be found at so many levels: patient-on-patient, staff-on-patient, patient-on-staff, staff-on-staff. Our clinical milieu and our workplace will be better in the measure that we don't hide from these realities.
Emotional reaction	Acceptance	Don't be defensive, accept it, learn from it, move on: move on doing better.
	Humility after being shown how actions are inherently racist	You like to think you're not at all racist, but somehow your actions are, at some level you are, and it must all have seeped in somehow.
	Cultural humility	Don't pretend to know what you don't. Remain curious and open.
Behavioral response	Enhanced exposure to diverse ideas and people	Exposure, exposure, exposure is one of the greatest goods that you can do in terms of just having different groups of people interacting and working together.
	Ongoing learning and education both at an individual level and at a unit group level	I am embarrassed to say I had to look up Tuskegee. I had no clue. I need to own not knowing what I don't know and educate myself. What is it that we as a unit we don't see? What are the blind spots we need to address in order to do better?
	Milieu-based interventions to address shortcomings	Training opportunities are important, but we can't simply "train ourselves out of it": we need to do some of the hard work in the daily interactions, not just in the classroom.
	Individual actions that correct prior errors	I've been trying to be conscious of my behaviors and presuppositions—trying to unlearn and correct myself.
	Normalizing speaking up	We should move from "supporting" to "normalizing" the ability—the necessity—to address racism and racial tensions, to not let them fester over time.

Enhancing exposure to diversity—starting with hiring practices toward a more representative staff—would provide a natural opening for individual and group-wide learning and tolerance. Bringing the lessons learned during in-service trainings and education into daily practices "on the floor", turning missteps or missed opportunities into conduits toward improved practice and preventive efforts, and a unit-wide normalization of the need to speak without fear of reprisal or consequence, were cited by some Black as well as white staff as conducive to co-constructing the kind of clinical setting and workplace environment everyone could feel proud of being a part of.

In this study we undertook an individual (self-reflective) as well as a collective (unit-wide) self-inventory of racism in the daily workings of a children’s psychiatric inpatient unit. We did so in an intentional, honest, and systematic way in which we: a) interviewed a sample broadly inclusive along professional and self-identified racial and ethnic lines; b) focused on staff's views of racism as affecting both patient care and their own personal experience; and c) did not conflate race with racism (Hardeman, Murphy, Karbeah, & Kozhimannil, 2018), focusing deliberately on the latter. By increasing awareness that racism is a real, pervasive, and often unacknowledged reality of everyday life and clinical care, the interviews we conducted may have been directly productive to participants. But more broadly, our goal was to incorporate a racial equity lens to better understand daily racism, to inform the necessary antiracist actions most relevant to a specific clinical ecology, and to make the lessons learned scalable to other inpatient mental health settings.

The “6P” model we organized our thematic findings around is adapted from a “4P” model of clinical formulation we had posited before (Henderson & Martin, 2018) as an alternative to the recognized limitations of the classic biopsychosocial approach. (Ghaemi, 2009). The first of the three Ps are similar in the two models and can be complemented by an accompanying question: Predisposing (why me / why them / why here?); Precipitating (why now?); and Perpetuating (what allows the status quo to remain entrenched?) The final P, Protective, addresses the underlying strengths upon which to build uprooting actions. In this study, we divided the final P into Preventing (before), Puncturing (during, in real time, as a racist event unfolds); and Prohibiting similar instances from occurring in the future. This two-domain / six-theme model may serve as a rubric for individuals or organizations to engage in systematic and orderly self-reflection or auditing exercises.

Recommendations

The specific recommendations we go on to make are informed by our study findings, and loosely organized along a series of action steps advanced by European Psychiatric Association’s Task Force on Racism (Schouler-Ocak et al., 2021).

1. Recognize and name racism

Naming a loaded term and engaging in conversations about it is a precondition or first step to make antiracist work possible. The Task Force has put forth the term of "speak up guardians", individuals who should be supported in their efforts to foster these types of exchanges. We would add, quoting one of our study participants, that such champions will do well if being able to "open doors and inviting frank discussion, rather than closing doors and alienating could-be supporters". Those latent allies—in our view including anyone and everyone—might at first respond in one or more maladaptive ways (McKenzie & Bhui, 2007): a) angry dismissal; b) misunderstanding or personalizing institutional as individual racism, even if the two are not mutually exclusive; c) focusing on intent, rather than on the impact of their actions; or d) Ignoring, or asking for more investigation, corroboration, or research, rather than considering steps toward system-wide remediation or personal growth along an antiracist continuum (Calhoun, Martin, & Calhoun, n.d.) The identification of racism at play during clinical or interprofessional situations should not be construed as de facto accusation or a gotcha moment, so much as a legitimate and real-time learning opportunity.

2. Make racial equity perspectives and antiracist practices a routine part of training and education

The impact of racism on general health, and particularly on mental health, should be incorporated as a matter of course into all training offerings. From the moment of credentialing, to onboarding, through in-services, and on to formal curricula or hospital- or system-wide training, social determinants of health in general, and racial equity need to be routine educational components. Education leading to actionable practice should not be an ‘add-on’ or ‘unfunded mandate’ leading to increased burden or de facto minority tax on those most directly impacted by racism (Williamson, Goodwin, & Ubel, 2021). It should also involve more than a self-selecting group of those already on an antiracist developmental progression. Given that racist actions impact not only the individuals on their receiving end, but indeed the entire social environment, educational opportunities or requirements should not be circumscribed to nursing, medical, and social work professionals and trainees. Milieu counselors, recreational therapists, educators, and administrative, environmental, and food services support staff—indeed anyone who is a part of the unit's fabric—should be equal beneficiaries.

There is a wide range of available programs, curricula, and learning models that can be incorporated into practice, including some that can be yoked to accreditation (Nora, 2022). Including everyone involved in the life of a unit is in fact the first of six core components deemed most appropriate to nursing practice, as proposed in a pithy summary (Coleman, 2020). The others include adopting an explicitly antiracist position, considering intersectionality as a core competency, and fostering the kind of community-academic partnerships and transdisciplinary resources we are fortunate to count with, but that are admittedly not always available. Finally, addressing power and privilege, implicit bias, and microaggressions are important competencies for everyone.

3. Harness the unique strengths of a mental health environment

Inpatient psychiatric settings can be an especially propitious environment in which to apply racial equity principles and advance antiracist practices: Milieu-based, congregate care inpatient units require cross-disciplinary collaboration; mental health professionals are particularly attuned to the role of social determinants of health on patient outcomes; psychological principles rely on reflective skills; and inpatient units routinely address charged affect and physical, verbal, or racialized aggression. The rich interplay between patients and staff during periods of high stress, together with collaborative treatment planning and daily clinical exchanges, all coalesce into a forum in which to foster, model, normalize, and make constructive use of conversations difficult to take on. As a microcosm, an inpatient setting demands concurrent attention to structural racism embedded into a larger societal context, as to institutional, interpersonal, and internalized forms of racism. Charged with making things ‘talk aboutable’, psychiatric and mental health professionals can take the lead, rather than follow other areas of nursing or medicine in actualizing antiracist practice. Moreover, psychiatric and mental health work environments can exemplify how to incorporate guidelines for staff wellbeing that are attuned to cultural and racial specificities.

Child psychiatric inpatient units offer unique opportunities and challenges. At exquisitely malleable stages of their development, children's course can be molded or derailed in response to environmental and peer influences. The modeling of prosocial and antiracist behaviors in a milieu setting can go a long way during their formative years. On the other hand, the countertransference inherent to working with young children who are commonly disinhibited, and the protective emotions elicited in those charged with their care, can quickly exacerbate latent tensions underlying an already charged clinical setting.

4. Commit to the elimination of racism and racist practices as core mission values and share successes and challenges with other communities of practice

The elimination of racism is an aspirational goal, an ultimate destination. But the hard labor that will take us there can only occur with intentional daily antiracist practice. A concerted commitment is necessary to weather the inevitable challenges and frictions that will emerge along the way. Only the unit-wide and institutional embracing of antiracism as a core mission value will make the work possible. Intentional and strategic efforts of outreach, recruitment, hiring, retention, and promotion of individuals from underrepresented and racialized groups needs to be a central and actionable step within that mission. Informing antiracist practice through the living experience of those impacted by racism—ideally including and complemented by the voices of patient, family, peer, or community advocates—will ensure that efforts are well placed, ring true, and are not self-serving. For example, rewarding or recognizing excellence in advancing antiracism might incentivize efforts, as well it should, but should be a byproduct, never an outright goal.

The lessons learned in any single setting, no matter how small or idiosyncratic, can be informative and lead to scalable impact. Findings specific to one child psychiatric setting can be relevant and generalizable to other milieus, regardless of the age range or diagnostic population they serve. Finally, it behooves the leaders of inpatient psychiatric spaces engaged in antiracist practice to share their findings, their successes as much as their challenges, with comparable settings in their region or throughout relevant communities of practice—collaborative groups that create and share knowledge in a specific practice toward the development of expertise (de Carvalho-Filho, Tio, & Steinert, 2018). The annual meetings of nursing, psychiatric, or social work national organizations are a natural conduit through which to magnify these urgently needed activities.

Limitations

We recognize several shortcomings. First, conducted at a single site within a large hospital network and affiliated with adjacent academic institutions, the setting of our study may not resonate with stand-alone psychiatric faculties. Second, social desirability likely tempered some responses, particularly between a Black interviewer and white participants, or across perceived power or education differentials. Third, we did not complement our qualitative methodology with objective metrics or quantitative outcomes. Length of employment stratified by race and gender would have been particularly informative. Fourth, the effects of the pandemic and certain aspects of inpatient clinical work migrating online, most notably during the prolonged period during which family visits were entirely forbidden, introduced a unique set of stressors that contributed to exhaustion and burnout, and may have exacerbated or confounded responses.

To our knowledge, this is the first qualitative study to examine staff’s perceptions of racism in an inpatient psychiatric unit. Despite its limitations, findings from this work can inform the practice in comparable settings by providing a rubric through which to assess the individual or unit-wide impact of racism, that in turn can inform antiracist actions. The proof of this work will be in implementing its recommendations in the setting from which they emerged. Using this line of research as a springboard for remediation and reform will help us move to the kind of equitable clinical and work environment we strive for. Our mental health, and that of those under are care, deserve no less.

Acknowledgments

Supported by the Riva Ariella Ritvo Endowment at the Yale School of Medicine, by NIMH R25 MH077823, “Research Education for Future Physician-Scientists in Child Psychiatry.

Disclosures

The authors have declared that they have no competing or potential conflicts of interest.

Ethical considerations

This study was approved by the Yale Human Investigations Committee (Protocol # 2000028849).

Correspondence

Andrés Martin, Child Study Center, Yale School of Medicine, 230 South Frontage Road, New Haven, CT, 06520-7900, USA; Email: [email protected]

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Sensitizing questions

Describe your experience of working on the unit
1. What do/did you like and what don’t/didn’t you like?
How did your work interface with other staff members and leadership on the unit?
1. Nurses, milieu counselors, environmental or administrative support staff, trainees in psychiatry or psychology
2. Nursing and medical leadership
Describe your experience caring for children and families on this unit
1. What aspects did you enjoy? Why?
2. What aspects were less enjoyable? Why?
People understand, perceive, and experience race in different ways (both positive and negative)
1. How do you view race?
2. Does race matter? In what ways?
3. In your experience, how have you perceived race to factor into interactions with staff?
4. In your experience, have you experienced race in interactions with staff members or unit leadership?
5. In your experience, have you observed differences in the care of children or families of different races?
6. Have you had experiences in the unit that are related to your race?
7. In your opinion, what is the general feeling about discussing race in the workplace?
Describe your experience of how race may have played a role in your experience in the unit (whether with staff, leadership, patients, or their families)
1. Positive
2. Negative
3. Can you recount any challenging experiences with children and families where race may have played a role?
4. What about other people? Have you observed how race may affect others?
Can you recount an experience(s) where race may have played a role in the care of a child or their family? Specifically, from the perspective of
1. Staff
2. Children
3. Families
Does race ever come up as a point of discussion in your care of patients?
Are there times when you have felt comfortable or uncomfortable to understand or manage unique challenges with families of a race different from yours?
1. Are there times when you have felt/noticed that other colleagues have struggled in this way?
Are there times when you have felt comfortable or uncomfortable to understand or manage unique challenges with families of a race like yours?
Is there anything else you would like to add or to ask me?

Characteristics of study participants (n = 22)

Characteristic	n	%
Gender
Female	14	70
Male	8	30
Race (self-reported)
Black	12	60
White	8	40
Other / multiracial	2	10
Ethnicity (self-reported)
Latinx / Hispanic	5	25
Discipline
Medicine	8	37
Nursing	7	32
Milieu counselor	3	13
Psychology	2	9
Administrative / environmental support	2	9
Career stage
Five or more years working in unit	13	65
Currently in training	7	36
Leadership position	5	25

Perceptions of racism in a children’s psychiatric inpatient unit: a qualitative study of entrenching and uprooting factors

Status:

Journal Publication

Version 1

Abstract

Introduction

Aim/Question

Methods

Results

Implications for Practice

ACCESSIBLE SUMMARY

Introduction

Methods

Participants and individual interviews

Participants and ethics approval

Data collection, qualitative analysis, and theoretical framework

Results

Discussion

Recommendations

1. Recognize and name racism

2. Make racial equity perspectives and antiracist practices a routine part of training and education

3. Harness the unique strengths of a mental health environment

Limitations

Conclusions and next steps

Declarations

References

Appendix 1

Appendix 2

Status:

Journal Publication

Version 1