Stepping In 4 Respect: Building a Culture of Respect and Inclusion

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By Jann T. Balmer PhD RN FACEHP FAAN

One day after the presidential election of 2016, several of our residents reported significant discriminatory and disrespectful incidents in the hospital. The events of August 2017 in Charlottesville escalated the incidence of a pattern of discriminatory behavior in our health system and our community.  Some of the injuries of white supremacists required hospitalization so the Confederate flag, and other discriminatory wearables and tattoos were evident to our faculty, staff, residents, trainees, and students. Most of these clinicians and team members represented the cultures that were the targets of the conflict in our small city. 

In a proactive move, the Health System leadership created a task force of students, residents, nurses, attending physicians, chaplains, FEAP (faculty and employee assistance program), DIO, Deans, CMO, and CNO to review the situation. The group described the major problem as “failure to respond to acts of disrespect involving health professionals, trainees and students” and that a multi-pronged approach to addressing this challenge was needed. The approach includes education and training, policy, resources for reporting and support and setting expectations through messaging.

This case study focuses on the education and training initiative developed by the University of Virginia Health System (School of Medicine, Nursing, University Physicians Group and Medical Center). The curriculum, based in wisdom theory and associated evidence, serves as the foundation for the approaches that we use in this organizational change initiative.

Drs. Peg Plews-Ogan and Greg Townsend lead the Stepping In 4 Respect Collaborative with support from Dr. Susan Kools in the SON and Dr. Susan Pollart. The Office of Continuing Medical Education, with support from the SON CE office, serves as the educational design, logistic/commercialization and accreditation team. We have a large interprofessional planning committee who pulled together a two-day Train the Trainer Conference in November 2019.  This conference responded to the expressed interest from other academic institutions who wanted to use our framework, resources, and the IRB research study, etc. for their institutions.

The potential for assessing the impact of this approach on organizational change and culture in a number of academic medical centers and health systems, creates an opportunity for multi-institutional analysis of the model. The Office of CME worked with the UVA Licensing and Ventures Group to create licensing agreements and IRB reliance agreements for these institutions. Through collaboration with Micron Research, a UK-based specialist data company, a multi-functional web portal collects all of the pre/post and six-month survey data from all Train the Trainer conferences and two-hour workshops, and houses all of the educational materials that UVA created for this program.

The two-day Train the Trainer program prepares potential Collaborative institutions to build and train their leadership teams in an immersive organizational change strategy that addresses discriminatory and disrespectful interactions while adhering to their core mission of healthcare. Each institution can integrate and expand the Stepping In 4 Respect curriculum to align with their organizational priorities, structure and mission. Currently, six academic health institutions/health systems are implementing the Stepping In 4 Respect Workshop to their faculty, staff, and trainees and participating in the IRB study through reliance agreements. Three additional academic/health systems are joining the Collaborative.

The Stepping In 4 Respect Workshop is a highly interactive, two-hour session that provides faculty, staff, and trainees with information about how and why addressing discriminatory behavior is critical to meeting our mission here at UVA. Through the introduction of the B.E.G.I.N. framework (Breath, start with Empathy, set the Goal, Inquire, Engage), based on wisdom research, we provide the scaffolding for the “duty to act” and address these situations when they occur.  We provide participants with “back pocket” phrases for each of the 5 steps in the framework. The re-enacted video scenarios depict discriminatory behavior from patients, families, peers and supervisors that occurred over the past several years and reflect actual events at UVA. These scenarios serve as the foundation for building awareness and creating urgency for action. All of the Stepping In 4 Respect Collaborative institutions utilize this two-hour workshop as the primary vehicle for engaging clinicians, trainees and staff.

The video scenarios serve as the triggers for a group debrief. The facilitators guide the discussion of the scenario to help participants reflect on the emotions and frustrations that can result from these types of interactions. The discussion is followed by “improvisation” exercises in a “fishbowl” environment so that volunteers can respond with a follow-up conversation to the event and the entire group has an opportunity to respond with questions, comments, etc. In most sessions, the workshop can include three videos during the course of the two-hour session.

The other critical element of this project focuses on measuring of the impact of this initiative on our individuals, teams and organization. Through the design and utilization of the Stepping In web portal, with Micron Research, collection of all pre, post-workshop and 6-month survey data, as well as resources and CE credit information for learners, is accessible through this web portal. The web portal design has four levels:

1) IRB/research access, which is limited to the de-identified data for all of the survey questions by meeting/session.

2) Facilitator access, which provides access to all of the videos, resources, information and a list of the participants/session, but no access to the research data.

3) Administrator access, which uploads the names and email addresses for facilitators and participants per scheduled meeting/session. The administrator manages all of the enrollment and distribution of the invite/pre-workshop survey.  Subsequent surveys are pre-programmed to go out to the participants. The administrator deletes any no-show participants to keep the IRB data is accurate.

4) Participant/learner access, which provides entry to the pre, post and 6 month surveys, resources and information about CE credit.  Each of the Stepping In Collaborative Institutions has a unique version of the web portal for their institution. The institution can review all of their survey data as desired. The University of Virginia as the lead institution in the IRB study can have access to the aggregate data from all of the institutions participating in the Stepping In 4 Respect Initiative.  Additionally, a one-time student survey is scheduled annually as a “canary in the mine” assessment of organizational change at each of the Collaborative institutions.

Since the impact of COVID, we have been holding these sessions virtually. We are currently limiting each session to 20 people. Our AV vendor manages all of the technical and logistic elements of the workshop as the content; discussions, etc. require the full attention of the facilitators. Since July 2020, UVA has trained over one thousand (1,000) clinicians and staff members through over 66 Zoom sessions.

Preliminary Research Results

At UVA, the initial review of results (Feb 2021) from the Stepping In 4 Respect initiative are as follows:

  • 54.4% of participants reported having witnessed examples of discriminatory behavior in the health care setting in the preceding six (6) months
  • 21.7% speak directly to the perpetrator
  • 30.1% speak to the target.

Workshop Impact

The workshop data shows that of all participants:

  • 81.4%  Are likely/very likely to change responses to discriminatory behavior (n=194)
  • 83.1     Have improved their response to incidents of discriminatory behavior (n-77)

The University of Virginia/UVA Health is pleased to share our lessons, insights and work with other leading academic health systems. We believe that the commitment of our healthcare professionals, support staff, trainees and students is focused on the delivery compassionate care while supporting our valued colleagues and team members.

Jann T. Balmer, PhD RN FACEHP FAAN, is the Director, Continuing Medical Education at the University of Virginia School of Medicine,


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