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Requests for reprints should be addressed to Aziz A. Ansari, DO, SFHM, FAAHPM, FACP, Division of Hospital Medicine, Loyola University Medical Center, 2160 S. First Ave, Maywood, IL 60153.
Unconscious biases can have significantly negative consequences at all levels within health care organizations. Biased communication is a barrier to patient care, and unchecked biased physician–patient communications negatively affect health outcomes.
Moreover, unexamined biased communication from leaders normalizes biased behavior adopted by those they lead. This accepted behavior becomes embedded in cultural norms and has contributed to historical barriers in care, especially for marginalized populations.
Leaders must be intentional about communication that promotes social relationship stability and includes a lens of leadership humility.
This article highlights the necessity of health care leaders in addressing implicit bias mitigation throughout organizations by using the 5 Rs of Cultural Humility (5 Rs: Reflection, Respect, Regard, Relevance, Resiliency), a coaching framework for the clinician–patient environment (Table).
Using contributing theories of leadership, socialization, organizational climate, and culture, the following provides a conceptual model for leaders to address implicit biases and incorporate cultural humility in health care organizations.
TableThe 5 Rs of Cultural Humility
Reflection
Aim: One will approach every encounter with humility and understanding that there is always something to learn from everyone. Ask: What did I learn from each person in that encounter?
Respect
Aim: One will treat every person with the utmost respect and strive to preserve dignity and respect. Ask: Did I treat everyone involved in that encounter respectfully?
Regard
Aim: One will hold every person in their highest regard while being aware of and not allowing unconscious biases to interfere in any interactions. Ask: Did unconscious biases drive this interaction?
Relevance
Aim: One will expect cultural humility to be relevant and apply this practice to every encounter. Ask: How was cultural humility relevant in this interaction?
Resiliency
Aim: One will embody the practice of cultural humility to enhance personal resilience and global compassion. Ask: How was my personal resiliency affected by this interaction?
Leaders are situated to display and support the norms of behavior in health care systems. The 5 Rs is a clinical coaching tool originally designed to assist hospitalists in acknowledging implicit biases with a mindful and compassionate response. Promotion of the 5 Rs is based in cultural humility principles that acknowledge that no one will ever be an expert on individuals in any social or cultural group.
The inherent opportunity for reflection within the 5 Rs allows this tool to be used on a larger scale beyond the provider–patient interaction. An organization and its values are reflective of the sum of its individuals’ minds and principles, and norms and assumptions are at the core of organizational culture.
The negative impacts of implicit biases between individuals, especially at the senior executive leadership level (eg, C-suite, director-level positions), have a ripple effect through the organization. Senior leaders, by virtue of their role and influence, are in a unique position to exemplify examples that reject implicit bias through cultural humility practices. Leaders have a responsibility to promote inclusion, well-being, and equanimity in addition to setting a healthy cultural tone in the workplace.
Each component of the 5 Rs has an ask and aim. Individuals must ask themselves if they agree with the aim. If in agreement, the user can proceed with reflecting on the associated question. Disagreement with the aim indicates tension and provides opportunity for internal exploration, as well as personal and professional growth, if the user chooses to investigate why disagreement with the aim exists. The 5 Rs can be used in the moment of an interaction or in reflection afterwards, by oneself, with a mentor, colleague, or coach.
The Figure represents a heuristic for individual leaders to use when incorporating the 5 Rs into everyday use. Cultural humility is a transformative act that is adopted during the process of socialization through thinking, feeling, and doing.
Thinking, feeling, and doing represent the organizational culture elements that can be grounded in the 5 Rs of practice. Organizational culture shifts toward cultural humility when leaders cognitively couple the 5 Rs with thinking and feeling and are seen applying this coupling in action through daily interactions (eg, “doing”). Three applications for leader practice of the 5 Rs of Cultural Humility include: 1) Addressing individual leader implicit biases; 2) Using it as a socialization or on-boarding tool; and 3) Extending it to changing or supporting the existing organizational culture.
Leaders’ implicit biases have an impact on supporting acceptable or unacceptable behaviors toward others. Specifically, leaders support organizations through actions of hiring, promoting, and guiding people. A leader's unexamined implicit biases can result in conflicting actions and statements that create an ambiguous environment for how to treat others with regard and respect. The perspective-taking inherent in the 5 Rs brings awareness to one's potential biases. It helps bridge emotional and subjective views to an objective lens of humility
that allows for greater equity and inclusion throughout the organization.
Socialization and On-Boarding
Leader behaviors exhibited during the process of on-boarding and socializing are crucial in the development of culture. Organizational culture is defined as a pattern of basic assumptions in how the group solves problems through mutually understood norms of behavior.
Leaders exemplifying the 5 Rs during socialization and on-boarding is pivotal in organizational management, as the absorption of newcomers into work groups creates an organizational cultural feedback loop. Newcomers develop normative behavior by observing and adopting words and actions of their leaders. This transformative time for newcomers provides an opportunity for leaders to share the continual act of thinking, feeling, and doing to the extent that leadership and cultural humility practice become inherent actions.
Extending the 5 Rs to Organizational Culture
Organizational culture and climate have distinctive, but overlapping, concepts that support cultural humility. Visual artifacts and shared assumptions and values are generally accepted factors of organizational culture.
Organizational climate includes rewarding behavior from leaders, which then supports acceptable norms of organizational culture. Leadership behaviors that are grounded in the 5 Rs become the organizational climate and culture essential in transforming the outcomes of everyday interactions. Leaders can extend and represent a 5 Rs culture when they reflect on their behavior. Reflective practice for a leader includes active, intentional, and accountable behaviors and interactions. Thus, extension of expected, cultural behaviors that clinicians and nonclinicians provide must be emphasized in the current business models where patient-centered care depends on interdependent teams.
These extended intentional leader behaviors also tie into an organization's wellness. They promote cultural values alignment by reducing cultural ambiguity, provider burnout, and increasing resiliency. A positive relationship exists when organizational and physician values align,
which contributes to reducing or mitigating burnout rates. In addition, a positive workplace contributes to increased provider morale and retention rates.
Implicit biases are present throughout institutions and have an effect on individual leader behaviors and organizational culture. This article identifies 3 moments where application of the 5 Rs contributes to a cultural humility transformation for leaders. The first moment occurs at the individual level with acknowledging that everyone has implicit biases. The second occurs during socialization of newcomers to the organization or during team formation. A third moment occurs when leaders affirm and sustain a culture of reflection, such as with the 5 Rs practice.
Inertia occurs when “the biased and the target of the biased are forced to dwell in the roles they play.”
The 5 Rs of Cultural Humility is a tool for physicians and leaders to explore how their own biases effect cultural transformation. It incorporates mindfulness, compassion, and perspective-taking into its framework to coach individuals and groups to higher aims.
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