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Central resource for all things related to clinical placements!

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COD Report: Providing recommendations for education/placement providers and students.

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Welcome to the Guide to Allyship.

Think of this guide as one of many starting points in your journey to become a better ally. This guide isn't meant to be comprehensive nor is it perfect. There are people far more versed than I, who have dedicated their life's work to this sort of education.

In light of recent events and tragedies, I've been hearing the word "ally" a lot. Many people want to be an "ally", and even more people are unable to fulfill the duties allyship requires.

I use the word "ally" loosely because I find it overused and often abused by those who label themselves "allies." Despite its current misuse, using a different word would only cause confusion. As you read through this guide, be aware that your definition of "ally" may not be the same as the definition I'll introduce you to.

What's so special about this guide?

There are many great guides out there, and I acknowledge their existence. What's different about this guide is that it's open source (any one can contribute to it) and it doesn't get into specifics: racism, transphobia, gender discrimination, etc. and that's by design.

This guide can't and shouldn't be everything to you. At some point, you need to take responsibility and further your education. When you're done with the guide, please find ways to learn more.

Finally, this is a resource to help anyone considering allyship better understand the pros and cons of what being an ally entails. Allies understand their role in collaboration with people whose lives are affected daily by systemic oppression.

Don't take the responsibility of being an ally lightly.

In the summer of 2016, someone I considered an ally stood by and watched as I, a Black person, was berated by a racist. To make matters worse, I had a conversation with this person earlier in the day about the power allies can wield in situations of discrimination. But when the time came for them to take action, they were more interested in protecting their comfort.

Upset, I couldn't understand what happened. Did the conversation we had not get through? What didn't they step up? Then it dawned on me:
Saying you're an ally is much easier than actually being an ally. Saying you're an ally looks good on paper, especially if you're never questioned about your inaction.
Many self-defined "allies" wear the phrase and ideology like an article of clothing, easily discarded when it's no longer fashionable to wear.

If only those from marginalized and underinvested communities could cast away the identities marking them as targets with such ease.

I noted before that I used the word "ally" loosely. In fact, I personally no longer use the word. However, I do think it's a good starting place for those learning to be better allies. I also believe there's an opportunity to explore a better definition of the word. The best definition of "ally" (that I've found) comes from author Roxane Gay in her article for Marie Claire, "On Making Black Lives Matter." In it, she notes:

Black people do not need allies. We need people to stand up and take on the problems borne of oppression as their own, without remove or distance.

We need people to do this even if they cannot fully understand what it's like to be oppressed for their race or ethnicity, gender, sexuality, ability, class, religion, or other marker of identity.

We need people to use common sense to figure out how to participate in social justice.

To recap: Being an ally doesn't necessarily mean you fully understand what it feels like to be oppressed. It means you're taking on the struggle as your own.

An individual from an underinvested community cannot easily cast away the weight of their identity (or identities) shaped through oppression on a whim. They carry that weight every single day, for better or for worse. An ally understands that this is a weight that they, too, must be willing to carry and never put down.

Why allies are necessary

Anyone has the potential to be an ally. Allies recognize that though they're not a member of the underinvested and oppressed communities they support, they make a concerted effort to better understand the struggle, every single day.

Because an ally might have more privilege and recognizes said privilege, they are powerful voices alongside oppressed ones.

Being an ally is hard work.

Many would-be allies fear making mistakes that could have them labeled as "-ist" or "-ic" (racist, sexist, transphobic, homophobic, etc). But as an ally, you're also affected by a system of oppression. This means that as an ally, there is much to unlearn and learn-mistakes are expected. You need to own this as fact and should be willing to embrace the daily work of doing better.
As an ally, you need to own your mistakes and be proactive in your education, every day.
If you refuse to acknowledge that your words and actions are inherently shaped and influenced by systemic oppression, you're setting up yourself to fail.

Lack of self-awareness is not a trait of an ally. You'll be complicit in the oppression of those you intend to help. If you choose not to understand this, but label yourself an "ally", you're essentially a wolf in sheep's clothing. You'll find ways to infiltrate vulnerable communities and wield far more power than someone who is outwardly "-ist" or "-ic" because you're "trusted."

Just as society will not change overnight, neither will you. Here are some important do's and don'ts to consider as you learn, grow, and step into the role of an ally.

The Dos

Do be open to listening

Do be aware of your implicit biases

Do your research to learn more about the history of the struggle in which you are participating

Do the inner work to figure out a way to acknowledge how you participate in oppressive systems

Do the outer work and figure out how to change the oppressive systems

Do use your privilege to amplify (digitally and in-person) historically suppressed voices

Do learn how to listen and accept criticism with grace, even if it's uncomfortable

Do the work every day to learn how to be a better ally

The Don'ts

Do not expect to be taught or shown. Take it upon yourself to use the tools around you to learn and answer your questions

Do not participate for the gold medal in the "Oppression Olympics" (you don't need to compare how your struggle is "just as bad as" a marginalized person's)

Do not behave as though you know best

Do not take credit for the labor of those who are marginalized and did the work before you stepped into the picture

Do not assume that every member of an underinvested community feels oppressed

Contributed by Presley Pizzo. Please credit Presley when referencing this section.

While mistakes are to be expected, what's the best way to go about resolving them?

Note: Parts of this section were originally based on Kayla Reed's (@iKaylaReed) tweet sharing her definition of what it means to be an ally. It's another great definition that'll help you follow along with this section!

Imagine your privilege is a heavy boot that keeps you from feeling when you're stepping on someone's feet or they're stepping on yours, while oppressed people have only sandals. If someone says, "ouch! You're stepping on my toes," how do you react?

Because we can think more clearly about stepping on someone's literal toes than we usually do when it comes to oppression, the problems with many common responses are obvious:

Centering yourself: "I can't believe you think I'm a toe-stepper! I'm a good person!"

Denial that others' experiences are different from your own: "I don't mind when people step on my toes."

Derailing: "Some people don't even have toes, why aren't we talking about them instead?"

Refusal to center the impacted: "All toes matter!"

Tone policing: "I'd move my foot if you'd ask me more nicely."

Denial that the problem is fixable: "Toes getting stepped on is a fact of life. You'll be better off when you accept that."

Victim blaming: "You shouldn't have been walking around people with boots!"

Withdrawing: "I thought you wanted my help, but I guess not. I'll just go home."

In reality, most of us naturally know the right way to react when we step on someone's toes, and we can use that to help us learn how to react when we commit microaggressions.

Center the impacted: "Are you okay?"

Listen to their response and learn.

Apologize for the impact, even though you didn't intend it: "I'm sorry!"

Stop the instance: move your foot

Stop the pattern: be careful where you step in the future. When it comes to oppression, we want to actually change the "footwear" to get rid of privilege and oppression (sneakers for all!), but metaphors can only stretch so far!

Reacting in a fair and equitable way isn't about learning arbitrary rules or being a doormat. Rather, it's about restoring and maintaining dignity and respect for everyone involved - both the person who is hurt, and you. Still, it's hard to remember in the moment, because these issues are so charged in our society. As such, it may be helpful to reframe the situation so that you don't feel defensive.

You may have noticed it's easier to handle being corrected about something you didn't know if you're grateful for and even open to the opportunity to learn rather than embarrassed to have been wrong. Being able to let go of your ego is an incredibly important skill to develop.

Try starting with "Thanks for letting me know" to put yourself in a better frame of mind. If after you say that, you need to take some time to think about the situation, that's fine, too. Just remember that this isn't about changing the other person's frame of mind. They're allowed to be upset about being oppressed.

You've made a mistake and you want to apologize. Where do you begin?

What is an apology?

Before you can apologize, you need to know what an apology is.

Apologies are social contracts that hold you accountable. They tell others that you are taking responsibility, are open to the consequences of your actions, and plan to do better in the future.

Bad apologies are performances meant to protect pride and ego. They exist to make the apologizer feel and look good, while defending their intent.

Good apologies are heartfelt acts that let go of pride and ego. They center the pain of the impacted, regardless of the apologizer's intent.

Think of pain as a gradient-it doesn't have to be extreme to have a significant impact. Accidentally misgendering someone can cause them pain. Stepping on someone' toes can cause them pain.

Attributes of a good apology

Apologies aren't a magic fix and won't solve mistakes of the past, but there are a few attributes that make for a good apology.

Timely
Delivered at the right moment in the right place and time.

Consider the context in which you want to apologize and how that might affect not only you but also the person receiving your apology.

Context can include your current mental state (are you feeling defensive? Upset? Nervous? Calm?), the physical space you're in (private or public area), or the apology's medium (phone, online, text message, in person).

Respects boundaries
Given when the person receiving the apology consents to it.

Your desire to give an apology right now doesn't mean that the receiver is ready for it. Some people need space to process, and you should respect that. When they're willing to reconnect, if at all, they may let you know (or they may not).

Self-aware
Know that the act of apology may not lead to the closure you expect.

The apology receiver may choose to never interact with you again. Either after you give an apology or before you give it. You have to find a way to make peace with that. Do not pressure or shame someone into accepting your apology.

One of the greatest gifts we can give ourselves is learning how to create closure within rather than expecting other people to give it to us.

Reflective
Signals that the apologizer is taking full responsibility for their actions.

Apologizing means letting go of your ego to show that you care about someone and want to make things right. Good apologies center the person being apologized to. They also take direct ownership of the actions that caused pain by naming them clearly.

This Guide is open-source, meaning that anyone can contribute. I'm a queer Black femme and my voice should not be the only one shaping this guide.

If you identify as a member of an underinvested community and want to contribute, please submit a pull-request on this GitHub repository.

If you aren't a GitHub user and would still like to contribute, send me an email at guidetoallyship [to] byamelie [dot] co.

This Guide is a labor of love and provided as a shareable resource for you to use. Please make sure to credit back to the site if you decide to use any content here.

And if you've found this Guide helpful, feel free to show your support and buy me a cup of tea.

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An open-source guide for anyone interested in becoming an ally.

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Preparing for Professional Practice in Health and Social Care

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PREPARING FOR PROFESSIONAL PRACTICE IN HEALTH AND SOCIAL CARE The new edition of Preparing for Professional Practice in Health and Social Care is a welcome resource for students and newly registered Allied Health professionals, emphasising client-centered practice while clarifying expectations from regulatory bodies such as the Health and Care Professions Council (HCPC). The book presents a range of topics—such as law, ethics, interprofessional working, leadership, equality and diversity, team building, communication skills, and reflective practice—ensuring readers are fully prepared for the demands of their profession. Readers will also find: Practical guidance on getting, and keeping, the job – from writing a CV, applying for jobs, interview techniques, as well as career-planning and continuing professional development Each chapter begins with an overview of the content and concludes with key take-home messages and further reading suggestions A set of self-assessment exercises Case studies and examples from clinical practice Preparing for Professional Practice in Health and Social Care is a useful reference for all Allied Health professionals.

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'Your CV looks amazing, but I'm sorry you didn't get the job'

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'Your CV looks amazing, but I'm sorry you didn't get the job'

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🫵🏾Be part of history, buy this book #OccupationalTherapy
The very necessary read for policy makers, leaders, educators, clinicians and students in health & social care
Start change now to embed just occupational therapy to benefit all going forwards
Buy at https://t.co/80FGhDaDNA

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🫵🏾Be part of history, buy this book #OccupationalTherapy
The very necessary read for policy makers, leaders, educators, clinicians and students in health & social care
Start change now to embed just occupational therapy to benefit all going forwards
Buy at https://t.co/80FGhDaDNA https://t.co/DlfFmEHOtr

# data[].attributes.attachment_link.embed_code
🫵🏾Be part of history, buy this book #OccupationalTherapy
The very necessary read for policy makers, leaders, educators, clinicians and students in health & social care
Start change now to embed just occupational therapy to benefit all going forwards
Buy at https://t.co/80FGhDaDNA pic.twitter.com/DlfFmEHOtr
— DrLecturerMish PhD 🇬🇧🏳️‍🌈🇵🇸💙🌺 She/Her/Hers (@LecturerMish) January 27, 2024

# data[].attributes.attachment_link.metadata.attachment_props_source.data.text
🫵🏾Be part of history, buy this book #OccupationalTherapy
The very necessary read for policy makers, leaders, educators, clinicians and students in health & social care
Start change now to embed just occupational therapy to benefit all going forwards
Buy at https://t.co/80FGhDaDNA https://t.co/DlfFmEHOtr

# data[].attributes.attachment_link.metadata.attachment_props.original_text
🫵🏾Be part of history, buy this book #OccupationalTherapy
The very necessary read for policy makers, leaders, educators, clinicians and students in health & social care
Start change now to embed just occupational therapy to benefit all going forwards
Buy at https://t.co/80FGhDaDNA https://t.co/DlfFmEHOtr

# data[].attributes.attachment_link.metadata.attachment_props.text
🫵🏾Be part of history, buy this book #OccupationalTherapy
The very necessary read for policy makers, leaders, educators, clinicians and students in health & social care
Start change now to embed just occupational therapy to benefit all going forwards
Buy at https://t.co/80FGhDaDNA

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Cultural competence & Cultural Safety - E-LfH

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Cultural competence & Cultural Safety - E-LfH

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This programme is in partnership with...

About the Cultural Competence programme

The Cultural Competence e-learning tool is made up of three 20-30 minute learning sessions. The purpose of the tool is to support clinicians in the NHS to gain knowledge and understanding of the issues around culture and health; and how this might influence health care outcomes.

Being Culturally Competent is not only about respecting and appreciating the cultural contexts of patients' lives. Neither is it a one-size-fits-all approach - it's about understanding the way we deliver health care and responding to the needs of our diverse population.

Cultural competence is a key aspect of providing both quality and safe care. This is why health professionals need to be aware and gain understanding of the key issues relating to culture and how this may influence the uptake of health care and treatment options. Developing this knowledge and understanding will influence the way we give care and could have an impact on reducing disparities in health care outcomes.

This e-learning tool provides a resource of information and opportunities for professionals to reflect and review their own understanding and practice. Completing this e-learning tool will enable you to gain insight and confidence in navigating and responding to the varied needs of your patients. This tool can support continued professional development and can be included in your portfolios for revalidation.

The Cultural Competence e-learning tool has been developed by Health Education England e-Learning for Healthcare and is provided free to all healthcare professionals. The tool has been developed in collaboration with the Royal College of Midwives and other key stakeholders.

More information

With the UK population becoming increasingly diverse, it is important that health care professionals do not minimise the cultural context of an individual's health.

We need to work in a way which is inclusive and values diversity. Developing a greater awareness of diverse cultural beliefs can help healthcare professionals in meeting the diverse needs of all patients and families.

In the video below the Chief Nurse of England, Professor Jane Cummings, explains why developing cultural competency is important.

How to access

There are three sessions in total. The first two sessions are aimed at all professional groups. The third session is an additional resource specifically aimed at midwives.

The first session aims to describe what is meant by 'culture' and why it is important for health professionals to be aware of how this can impact health.

The second session describes cultural competence and its importance for health professionals working across cross-cultural situations.

This session looks at the importance of cultural competence in the context of maternity care and aims to help health care professionals support and meet the needs of a changing population.

In order to access the Cultural Competence programme, you will need an e-LfH account. If you do not have one, then you can register by selecting the Register button below.
Register >
To view the Cultural Competence programme, select the View button below. If you already have an account with e-LfH, you will also be able to login and enrol on the programme from the View button.
View >
NHS healthcare staff in England

The Cultural Competence programme is also available to NHS healthcare staff via the Electronic Staff Record (ESR). Accessing this e-Learning via ESR means that your completions will transfer with you throughout your NHS career.

Further details are available here.

Not an NHS organisation?

If you are not an NHS health or care organisation and therefore do not qualify for free access e-LfH Hub, you may be able to access the service by creating an OpenAthens account.

To check whether or not you qualify for free access via OpenAthens, you can view the eligibility criteria and register on the ' OpenAthens ' portal.

Registering large numbers of users

If you are a HR, IT or Practice Manager and would like to register and enrol large numbers of staff within your organisation for access onto the Cultural Competenceprogramme, please contact e-LfH directly.

Organisations wishing to use their own LMS

For HR departments wanting to know more about gaining access to courses using an existing Learning Management System please contact e-LfH directly to express interest.

More information

Please select the following link for more information on how to use the e-LfH Hub.

e-LfH is a Health Education England Programme in partnership with the NHS and Professional Bodies

© e-Learning for Healthcare 2021

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Cultural Competence - e-Learning for Healthcare

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This programme is in partnership with... The Cultural Competence e-learning tool is made up of three 20-30 minute learning sessions. The purpose of the tool is to support clinicians in the NHS to gain knowledge and understanding of the issues around culture and health; and how this might influence health care outcomes.

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"How Studying Privilege Systems Can Strengthen Compassion": Peggy McIntosh at TEDxTimberlaneSchools

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White Privilege - Unpacking the Invisible Knapsack

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White Privilege - Unpacking the Invisible Knapsack

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Joy Warmington MBE on anti-racism, leadership and the courage to speak out

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Listen to this episode from The King's Fund podcast on Spotify. What is anti-racism, and why is it important in the context of health and care? Jo Vigor sat down with Joy Warmington MBE, Chief Executive of the equalities and human rights charity brap, to find out.

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Allegories on Race & Racism - 20 min watch

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Allegories on Race & Racism - 20 min watch

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Allegories on race and racism | Camara Jones | TEDxEmory

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Global Majority Student Experiences of undergraduate Physiotherapy Programmes

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Global Majority Student Experiences of undergraduate Physiotherapy Programmes

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Research article

Open Access

Published:

BMC Medical Education 19, Article number: 372 (2019) Cite this article

9049 Accesses

5 Citations

105 Altmetric

Metrics

Abstract

Background

Previous research has demonstrated that attainment inequalities exist for students from Black Asian and Minority Ethnic (BAME) groups in pre-registration physiotherapy education. While previous research has explored students from BAME backgrounds experience of university, the context of physiotherapy is unique and is under researched. Therefore the purpose of this study was to explore BAME student experiences during their physiotherapy training.

Methods

Using a phenomenological approach pre-registration BSc and MSc students from BAME backgrounds from two universities who had completed both academic and clinical modules were invited to participate. Focus groups followed a topic guide developed from the literature and were facilitated by physiotherapy educators from outside the host institution. They were digitally recorded, transcribed verbatim and analysed thematically. Analytical triangulation was adopted throughout the research process as a mechanism to enhance rigour.

Results

Seventeen students participated from a range of self-identified BAME backgrounds that were also representative of age, gender and course. Themes derived from the data included: feeling an outsider in reflections of belonging, behaviours by others that marginalise BAME and personal strategies to integrate in physiotherapy despite the lack of power and influence. Collectively these themes demonstrate a range of challenges which students from BAME backgrounds face within both an academic and practice learning environment.

Conclusions

While this may not be surprising based on other disciplines, this study demonstrates that studying physiotherapy as a student from BAME background requires persistence to overcome a series of many implicit challenges. Understanding the experiences of students from BAME backgrounds presents unique opportunities to educate the profession and co-create opportunities for a more diverse profession with practitioners and educators as role models. There is a need for greater training for educators to listen to these students' voices and their stories, and understand where institutional structures and practices could be modified to enable BAME student inclusion in physiotherapy education and practice.

Peer Review reports

Background

In recent decades, there has been a significant focus on widening participation to higher education in the UK and worldwide, leading to greater numbers of people studying a higher degree. Yet there has been growing evidence in higher education to suggest that there are differential levels of attainment for those students from different ethnic backgrounds even when other demographic variables are adjusted for [ 1, 2]. This has also been demonstrated in healthcare education [ 3, 4, 5, 6, 7] and specifically physiotherapy in the USA [ 8] and more recently in the UK [ 9].

While these studies demonstrate an attainment gap they do not explain why this occurs. Some studies have tried to explore this through various methods such as surveys, interviews and video analysis of specific interactions. Broadly these studies identify that Black, Asian and Minority Ethnic (BAME) individuals are more likely to feel more isolated or not academic enough [ 2, 10]. Findings also demonstrate BAME students are less likely to participate in extracurricular activities due to cultural or family reasons [ 11]. Steele [ 12] suggests BAME underperformance can been explained by the theory of 'stereotype threat' where an individual from a negatively stereotyped group may feel threatened or anxious in the context of ethnic majority and thus may affect performance. Other research confirms BAME attainment differences in clinical examinations and claim that no overt discrimination was evident from either video analysis of the exam [ 13] or comparison to anonymously marked work [ 14].

However these findings emphasise a deficit model that locates the issue with the individual [ 15, 16]. A deficit focus may lead only to remedial strategies targeting the individual (such as supplementary courses [ 17]) and ignore the broad social factors involved inadvertently excusing discriminatory practices and structures [ 18, 19]. More recently there has been greater acknowledgement that institutional structures and implicit bias may contribute to attainment inequalities [ 20]. As a result many institutions have developed a multi-factorial change programme to address attainment gaps [ 2, 21]. However this broader perspective also has its critiques, suggesting that a change programme may still perpetuate inequality and misrecognition of BAME experience [ 22].

Physiotherapy presents a unique perspective due to its particular history in the UK and worldwide context. The physiotherapy profession has traditionally been perceived as white and middle class [ 23] however figures from 2017 to 18 demonstrate 19% of all UK physiotherapy programme student enrolment identify from a BAME background [ 24]. While this is a greater proportion of the population than most recent census data (14%) from 2011 [ 25], it is still lower than the proportion of BAME students applying 21.53% [ 24]. Recent evidence suggests that applicants from some BAME backgrounds have little knowledge of physiotherapy [ 26] and indicate it has lower status in their communities [ 26, 27]. The nature of the physiotherapy course and the culture of the profession presents some unique issues for some cultural and faith groups, such as expectations of touch and physical handling of clients and varying levels of undress for both learning and practice. These issues have been identified pre-entry [ 26] and there is some evidence of the challenges at the intersection of gender and culture during the programme [ 28]. One study by Haskins [ 29] demonstrated covert bias when physiotherapists assessed a video recording of physiotherapy students of different ethnic backgrounds reciting identical scripts - rating Black, Hispanic and Asian students lower than white students. Inequality may also extend in seeking meaningful employment, where physiotherapy graduates emphasise the burden of assimilation into the predominantly white culture of the healthcare service [ 30]. Apart from these studies, there is limited exploration of how students from BAME backgrounds experience or negotiate these factors throughout their physiotherapy education, making it difficult to know what and how to address it. A focus on the idiosyncrasies of a professional course such as physiotherapy has the potential to illuminate the complex intersection of factors that influence experience and avoid an assumed 'one size fits all' approach. This research aims to explore this phenomenon from the experience and perspective of current physiotherapy students from BAME backgrounds in the South East United Kingdom (UK).

Methods

This study was conducted in parallel with research exploring experiences of students with disabilities [ 31]. Informed by phenomenological approaches [ 32] this qualitative study focused on the BAME students' experiences throughout all aspects of the course.

Ethnic group categories used by the Higher Education Statistics Agency (HESA) [ 33] were adopted to ensure consistency with national demographics. In this paper the term Black, Asian and Minority Ethnic (BAME) is used to describe those groups who describe themselves other than white. Categorisation like this is not ideal, as many heterogeneous groups are included together and we acknowledge this may be a limitation from the outset.

Sample

The study was conducted at two Higher Education Institute (HEI)'s in the South East of England for practical reasons. The total combined pre-registration physiotherapy student population was approximately 500. We were interested in the experiences of physiotherapy students who self-identified as being from a BAME background and based on the proportion of 19% previously identified, a pool of 95 potential participants was estimated. Students from both BSc and MSc pre-registration courses at the two HEI's were invited to participate in the study via a cohort wide email. Those students who volunteered and had completed both academic modules and clinical placements represent a convenience sample [ 34].

Data collection methods

To facilitate collective and shared responses prompted through interaction, focus groups were selected [ 35]. A focus group at the penultimate (MSc year 1 and BSc year 2) and final (MSc year 2 and BSc year 3) level were conducted at each HEI. They followed a topic guide which included; discussion about what participants consider their own ethnic identity, their experiences in university and placement and how ethnic identit (ies) may have impacted, and using our previous research findings as a framework [ 9] we asked the participants to offer explanations of the attainment differences and how it might be addressed. All focus groups were facilitated by experienced qualitative researchers who were also physiotherapy academic staff (MN with AW as co-facilitator, JH with SW as co-facilitator). We acknowledge that none of the researchers identified from a BAME background, however are representative of the academic staff demographics in each HEI and more broadly the profession. To ensure that the participants felt able to share details about all aspects of the university including staff, the interviews were conducted by researchers from outside the participants' institution. The focus groups were digitally-recorded and to aid collective member checking key points were noted on a flipchart during the focus groups. This process helped to avoid researcher assumptions by clarifying meanings and enabling participants to prioritise areas.

Analytical strategy

Digital recordings were transcribed verbatim and anonymised. Using a thematic analysis framework [ 36] all researchers read and familiarised themselves with the transcripts and two researchers (JH, AW) independently assigned initial codes, categories and super-ordinate themes. Following critical discussions with all co-researchers, the lead researcher (JH) reviewed and refined the themes in an iterative process to enhance the depth and transparency of analysis [ 37].

Results

The sample included 17 students (10 F, 7 M, 13 BSc, 4 MSc) with a range of ethnic backgrounds including Black, Asian and Mixed backgrounds. The focus groups lasted approximately 90 min. See Table 1 for participant details.

Table 1 Focus group participant details

Three major themes developed from the analysis of the data of participants experiences. The first theme 'you do feel like an outsider' focuses on the participants' sense of belonging in physiotherapy education. 'Everyone wants to shy away and tip-toe around it' is the second theme and explores the overt and subtle practices of others (particularly tutors, peers and practice educators) that marginalise BAME students. Finally the theme 'we don't have much power and influence' illustrates the personal strategies that are adopted by individuals from BAME backgrounds to establish a sense of belonging in physiotherapy education. In tandem, these themes drawn from the participant experiences also highlight where institutional structures and practices could be modified to enable BAME student inclusion and these are presented in the discussion.

Theme 1 - 'You do feel like and outsider': feeling 'other' in reflections of belonging in physiotherapy

This theme explores the perceptions of participants from BAME backgrounds in relation to (what they identify as) the default physiotherapy student identity, being 'white, middle class, mature and female'. They suggest that this is something they perceived is embedded in a history of physiotherapy and only becomes apparent at the commencement of the course. The participants indicate the acute realisation that there is less BAME representation in physiotherapy in comparison to other aspects of their lives and prior educational experiences. As a consequence their feelings of being an outsider in physiotherapy education are amplified, as this participant identifies:

"at the beginning, when I started ... .there was a lot of, like, Asian people on other courses -like, medicine and biomed, and then when I was, interacting with them, I felt I was on the wrong side (laughter), cos I was in physio, which is the main, like, white people, I was maybe I'm on the wrong course, I should be on the other side" K2, p27

The BAME participants in this study often report that they perceive their professional behaviour is being judged in relation to this default physiotherapy identity. This has significant personal and social implications for them and they articulate this through a process of belonging in physiotherapy education.

"cos you do already feel sort of like an outsider ... ... ... You're always conscious of that ... .. like how are they perceiving me? How am I being?, you know?" J2, p6

"I mean, when I talk to all the ... . lecturers and staff here, and they talk about their background, where they're from, you pick up little things here and there that they're from these nice villages or nice towns and cities where they had a very nice house, erm, front and back garden and, you know, they never had issues with heating or water or, you know, anything like that that you seem to think do you know what?, they're, they're, they might not understand where I'm coming from" K2,p20

This last statement demonstrates how other aspects of identity such as class and socio-economic status intersect with ethnic background, in addition to the obvious power differential between staff and students. Participants interpret the academic institution, and their peers, place a higher value on (what they perceive to be middle class and white) modes of communication that further amplifies their feelings of difference. In addition, the participants feel disadvantaged in that this is not their mode of communication, which leads them to feel isolated, disadvantaged, and stigmatised as these participants highlight

"I think I was speaking quite normal like I don't even know what normal is, but I think I was speaking like alright and they [class peers] were just laughing at everything I was saying ... ... .everything I was saying they was like (laughs), everyone started laughing. I was thinking, "I didn't say a joke here like," but you know what I just took it" J3 p15

"so now, like, we subconsciously just think, like, if we ever like speak in front of the class and we pronounce something wrong that they'll really laugh about it afterwards" K2, p54.

The identification of the default physiotherapy identity by participants goes beyond obvious demographic variables, and includes other characteristics and values. The participants describe an ideal 'extrovert' physiotherapy type that they attribute with characteristics such as: being outgoing, flamboyant, socialising and going to the pub, being sporty or proactive and motivated. The respondents feel vulnerable when attempting to adopt the 'extrovert' physiotherapy identity as they may be positioned negatively based on cultural stereotypes

" ... ..there's certain, like, things you can't say and certain, like, ways that you have to sort of, like, hold yourself because as a black person it's easier to be misconstrued as being either loud or aggressive or rude" J2, p7

By contrast, another participant feels their quiet approach, which they align with their ethnic background, will be judged negatively (isolating myself) in comparison to the default 'forthcoming' approach.

"other students who were not of colour but they were more, maybe more forthcoming with their information, very active, umm, in the team in terms of oh, you know, asking what they're gonna do after work and stuff like that, like I'm very, I'm a, sort of a remote worker, like if I've got work to do I'll just crack on and get on with it, and I think they didn't really like that and they interpreted that as me sort of isolating myself" K3, p7-8

Overall the participants tend to cluster a series of characteristics that they perceive to be highly valued and create an imagined identity that will be privileged in physiotherapy education. This results in them feeling a deficit, and positioned as an outsider, which is intensified in physiotherapy compared to other aspects of their lives. Consequently this impacts on the development of their professional identity as an authentic physiotherapist. .

Theme 2 'Everyone shies away and tiptoes around it' - other peoples' responses and behaviours that marginalise BAME

This theme focuses on the participants' perceptions of the responses of the university staff, practice educators and peers in a variety of contexts relevant to their study as a physiotherapy student. The participants report practices that make them feel included in the physiotherapy community, however these are often isolated and rare. More commonly the participants reflect on practices of ethnic majority staff, peers, practice colleagues that demonstrate ignorance (lack of understanding), denial / avoidance or 'microaggressions' that suggest both advertent and inadvertent racism.

Firstly participants describe a number of responses of staff/peers that they interpret as indicative of a lack of understanding of ethnic/cultural difference. Examples are expressed of where course content highlights ethnic differences and ethnic majority teaching staff discuss it awkwardly or in a way that amplifies the difference.

"when they [lecturers] try to make it, try not to be racist and you can just see it, you can see it, like they're trying not to do it so hard that it just turns into it, they try so hard, like they try and make it so normal, like, umm, there was one time we were sitting in tutorial class and [lecturer] was like, "Yeah, I'm saying the word 'black' you guys shouldn't be worried I'm saying the word 'black' ... . black is normal ... " There was no need for that explanation and [the lecturer] was looking at me, as she was saying she was looking at me as sort of like she was trying to support me, like she's trying to ... ... ... I'm thinking, "It's fine like just say it like." And I was like, stuff like that when you're trying not to do it, it just turns a lot worse it just becomes a lot more awkward, and everyone, everyone all notices it, everyone's like, "Woah, that was a bit different." J3, p12

Rather than respect and value BAME diversity, the students talk of how these examples only tend to 'put a massive magnifying glass over us' J3,p11. And as previously expressed the participants identify that this emphasises how staff and peers do not understand their context from the often privileged perspective.

When issues related to BAME difference occur, the participants mostly describe responses by staff that are interpreted as dismissive or avoiding. For instance the following example recalls where a student raises concerns about racism.

"There was a module that we had to do. It was, uh, what was it called? Clinical Preparations, and I had to do, like ... .,what are my threats?, ... and I mentioned it ... .. being someone who is black I'm scared that there might be racism and I had a white female person in a white coat with me and she was like, "well, that doesn't happen". I was like, well, how would you know? How could you possibly know that that doesn't happen?" J2, p6

And similarly in practice, this black male student recalls an educator response that appears well meaning but avoids confronting the issue.

"so there's certain umm, patients that won't even like look at me. And my educator was open she was like, "Oh, you might not want to go into this with me, cos she's a bit funny." And I think, "What do you mean?" She's like, "She's a bit funny with men." I was like, "Hmm, okay cool." And then I realised and there was 3 physios I saw before and they were all men and I was like, "Okay are you sure it's ... " "Okay, yeah, she's a bit funny with like black men," J3, p18

There are some behaviours observed in others that some students refer to as 'microaggressions'. One participant describes these microaggressions as actions of ethnic majority people based on assumptions of race/ethnicity "instead of yourself as a person" J3, p13. Examples include direct physical behaviours such as hair touching

"They'll say something, they'll touch my hair. They'll do that and then I'll just be like why do you have to do that? Just like, and just, basically just put in a situation where you're isolated by drawing attention to the fact that you're different and it just happens all the time and it's not done because they think that they are ... They would never believe that they have these preconceptions ... ."J2,p19

The findings also highlight examples of where staff and peers prioritise interactions, including verbal and non-verbal communication, with other people more like themselves (e.g. white).

"so, the woman [tutor] was like, Caucasian, and we were, it was just us three [students who were from BAME background] and we were like, everyone else was Caucasian, she was making eye contact with everyone else except us and we felt really left out (laughter) but I don't know why she wasn't making eye contact with us?, but, like, is it the race or ... .."K2, p12

These highlight where participants feel isolated in physiotherapy education. There are other situations where microaggressions are perceived at having a significant impact on their academic success. For instance students talk about perceptions of lower expectations of Black, Asian and Minority Ethnic students.

"I do feel like sometimes when I've got feedback for like an exam, umm, and it's not been like a terrible grade but I just wanted to do better and one of the lecturers was like surprised that I like, received this grade and I wasn't happy about it. And then for someone else [another student] like she told me that she didn't get, like, she basically just passed and it was like, "Oh." The lecturer was like, "Oh, this isn't like you, like I'm really surprised that you haven't, you know, done better. Like what's the problem?" And I just thought like, "What other reason would there be?" This was right at the beginning as well, like why would he just assume that I didn't want to do better? J3,p14

This can lead to perceptions of difference in marking practices and this student talks about differences between her experience as a black woman on placement compared to a white peer:

"We literally had exactly the same responsibilities because it was very similar work. It was just in two different wards ... ..and we took on the same role, blah, blah, blah, and she came out with a grade that was 10% higher than mine ... ... ... Yeah, and part of that was the fact that she got on so well with her clinical educator. Like literally, like, ( laughter) they could be sisters at this point and they just walk along together and me and my clinical educator we look very different and so it's just, it's just interesting. I don't know why, but maybe due to the fact we didn't have that immediate connection where we have something to, you can't, like, look in the mirror and then, like, reflect each other's thing. Maybe that was a thing ... ... .but I think definitely part of that would be the fact that I already had a barrier or being black and it's not something that I particularly like" J3,p20.

It is important to recognise that this example is based on the participant's perception. It is impossible to determine what the clinical educator's motives were, but for the student, that shared sense of belonging through ethnicity was not present. This example and the others illustrated in this theme indicate that from the participant's perspective, BAME difference is either dismissed, avoided or illuminated through microagressions in many physiotherapy contexts.

Theme 3 'We don't have much power and influence' - personal strategies by students from BAME backgrounds to integrate

This theme arose from the participant discussions and from a recognition that they feel disempowered in physiotherapy education. The participants in the study claim "we don't have much power and influence" J2,p25 and they highlight an impression that they "don't know how much can change" K2,p59 and from their position as students it is difficult to challenge because they are always under the pressure to meet the requirements of assessment. Nevertheless the findings indicate personal strategies to establish a sense of belonging in physiotherapy education and these are expressed in contrasting ways. Some strategies confront the perceived default physiotherapy identity by asserting their own ethnic identity. On the other hand, the findings identify strategies of self-regulation that either avoid challenge or conform uncomfortably to the perceived default physiotherapy identity.

To establish a sense of belonging students seek out others within their peer group that they feel they will have an affinity based on other aspects of identity.

"when it comes to studying now, you kind of look for the people who look like you to study - it's really weird, I can't explain it, I can't put an exact reason why I do it but I just, it's just maybe me, I just see it as: if I'm revising with this guy they might know the same amount that I do, we might be on the same equal footings, so let's revise together because you won't make me feel stupid" K3, p16

This example illustrates how creating an equal footing is not just establishing academic equivalence, but that it is also social and cultural. These attempts of belonging extend beyond the programme as one participant talked about seeking mentors or role models in practice and being surprised of the lack of black representation to choose from

"so I didn't really see it [physiotherapy] as a race issue and even discussing it with family, friends, people that I'd come across, I think the only time that I sort of picked up that there weren't a lot of female black women that were doing it when I was researching was when I was looking for mentors and people to actually talk to" K3,p5

The following represents one student's attempts at asserting his own identity in the physiotherapy classroom to challenge the perceived assumptions made related to his ethnicity:

"I like being in a full tracksuit, coming in and then being able to answer every question, just maybe to plant the seed that just because I'm this way doesn't mean that I'm stupid or anything. I don't like stereotypes, I like to challenges stereotypes, so I always am conscious of that; I think umm, in the groups, you know, some people might come off as patronising sometimes, umm, the way I say things like, "Water" and I guess like all the time I can't "War-ter" or "but-ter", I say, "Water, butter," it's just how I speak. Whereas as soon as you say those type of buzzwords, someone else over there might be like, "Okay, this guy can't even speak properly, I might need to take the reins here." K3p19

This student also recognises that he needs to regulate his own behaviour and the findings suggest that students use a variety of strategies to modify and regulate their behaviour as this student indicates.

"It's just you have to ... ... ... ..Regulating your behaviour ... ... ... Yeah, you're constantly criticising what you're doing. You're constantly being like, okay, I can't do that, I can't say that or, okay, I have to be like this or I have to speak like this" J2p7

Others talk of strategies to avoid conflict including; staying silent, ignoring comments, staying calm, not getting upset and just taking it. This black female student talks about how she manages a racist comment in practice:

"I just take it as it's just the way it is; so it's kind of like you acknowledge it but you just move on, you don't really give it too much energy, so, but I dunno if that's, I dunno if that's err, the right thing to do or the wrong thing to do, but at the end of the day that's, yeah ... ..Yeah, at the time just what else can you do? I mean especially on placement you're just trying to get through placement to be honest, you're not really trying to change the world there" K3,p4

Apart from being aware of how they might modify their verbal expression, the students also talk about the impact on how they feel they have to demonstrate skills in a particular ways. In one situation a student reflects on differences between himself, as a black man, within a white placement team and follows this by talking about how he modified his behaviour to manage:

"My reflections, my true reflections, I always write two, I write the one I'm gonna show, and I write one for myself, cos the one where I can be really honest and even write honest things, speak in a certain way, and umm, you know, it's normally reflecting on just my experiences with the team, what I need to do next; if everyone focuses on what they need to do to pass the book, whereas I can focus on how I, how I can manage the team type thing" K2, p8

And another talks about how he modifies his behaviour with white patients

"And I think in terms of the way you act ... ... .I've had like similar things, elderly patients they don't really want to umm, be, interact with a black person. And then sometimes you will try and change your approach so you'll be extra ... like we're nice people cos we're physios, we'll be extra-extra nice to like an elderly white person trying not to seem aggressive or, but I mean you see other white physios will go in and tell their patients off, shouting at their patients, and it's like if we ever did that sort of thing ... ... . we'd be seen as aggressive" J3,p19

These personal strategies of managing ethnic difference in physiotherapy education carry the significant emotional labour as another student articulates:

"but I don't know about you but I think it's emotional labour to have to constantly chat with people's microaggressions just because they don't know. So, like, there are certain things like sometimes somebody will come up and say something ignorant and I'll challenge it. Don't say that because of this, this and this. It's offensive because of this, but once you've done that for 20 times a day for the past week, then it comes to, let's say, the eighth day and you're like, do you know what I'm gonna let this one slide and then it gets to a thing so, like ... I was gonna say it's about picking your battles." J2p26

This theme draws on the personal burden that participants from BAME backgrounds experience in physiotherapy education and wider contexts, and how they adopt varying strategies which either assert their identity or assimilate by modifying behaviours.

Discussion

The findings represent one of the first known studies to explore the experience of physiotherapy students from BAME backgrounds during their studies. We acknowledge that this is a small sample but as participants are from two institutions, this may help to avoid conclusions that the findings are specific to one context. We have taken the qualitative data as a whole, we recognise the sample is heterogeneous and interactions between other factors such as social class, gender or previous educational backgrounds may also influence our findings. Nevertheless the challenges perceived by the participants in this study highlight the occurrence of inequality in physiotherapy education. Although this research did not apply Critical Race Methodology [ 38], the principles of critical race theory [ 39] have been used as a lens to discuss the findings in the context of the structural and cultural aspects of physiotherapy education.

The narratives of the students from BAME backgrounds in this study might be what Solorzano and Yosso [ 38] refer to as 'counter-stories' of those people whose experiences are not often told. Therefore these voices of students from BAME backgrounds offer a way of exposing, challenging the stories of the majority and privilege in physiotherapy as the participants had desired. The participants, in this study, discuss an acute awareness of a position as an 'outsider' to what they perceive as white dominance within physiotherapy in comparison to other healthcare profession courses. They articulate attempts to belong in physiotherapy, a profession which they perceive places value on specific characteristics such as being extrovert and proactive, something that can be in conflict with their racial/cultural backgrounds. The participants then feel at a disadvantage and they have to work harder to demonstrate these characteristics. This has previously been highlighted by other researchers [ 14, 38] where demonstration of ideal characteristics is synonymised with right/good, and simultaneously implies what is not ideal/right (in this case introvert, quiet). This leads to a constant sense of needing to work to fit in and the sense of 'not fully belonging' is particularly significant for BAME students in physiotherapy. These feelings reflect other literature in higher education where students from BAME backgrounds have reported marginalisation and isolation [ 10, 16, 40] or not feeling academic enough [ 2]. One of the key findings of our research is that the data indicates that the context of training to be a physiotherapist, and the profession itself, intensifies the feelings of marginalisation and isolation for BAME students. This intensity of feeling had not been anticipated prior to engagement with the profession and was significantly higher in this context than the other areas of life experienced by the participants.

A second theme arising from the study was in relation to the responses of others through the participant's physiotherapy education journey. The participants described experiences where issues of race/ethnicity were either ignored or denied and these reflect the experiences of social marginalisation that Beagan [ 40] describes in her study of medical student minorities in Canada. Madriaga [ 22] also argues that 'meritocracy', 'value-neutral' and 'colour blind' discourses pervade liberal majority higher education institutions, and that these uphold white privilege by being perceived as 'natural'. Whether intentional or not, such discourses disregard those who are racialised as BAME (ibid), and in the case of the present study it appears that the majority (white) staff, peers and patients are indifferent to the realities of the marginalised students from BAME cultural backgrounds. There were examples of blatant racial/ethnic discrimination by patients in the practice context, which illustrate some of the challenges experienced by students and educational professionals, as they develop therapeutic interactions. However more often there were common, minor, every day acts based on stereotyped assumptions of ethnicity or race that convey disrespect, disregard or contempt that the participants and others refer to as 'microaggressions' [ 41, 42]. Examples of microaggressions have been identified in medicine [ 40] and the wider student community [ 41]. The examples of hair touching, avoiding eye contact, asking 'where are you 'really' from?' and assuming BAME students may have lower academic ability in the present study are not dissimilar to this literature. Therefore this draws attention to the issue of cultural marginalisation of BAME students in the classroom and practice context of physiotherapy education. The source of microaggressions are also widespread, including fellow peers [ 11], patients [ 43] and also those in positions of power such as teachers and clinicians [ 14, 40, 44]. The cumulative burden of microaggressions entrenches power relations and results in institutional racism that continues to marginalise BAME students in physiotherapy.

Despite the challenges identified in the study, the participants reveal their resourcefulness in attempts to integrate in physiotherapy. To avoid the consequences of being judged based on stereotyped assumptions; the students describe how they make efforts to be proactive, assertive or 'extra nice' which are similar to strategies identified in other work in physiotherapy and nursing [ 30] and in medicine and biomedical sciences [ 11]. But largely these strategies indicate attempts to modify behaviour to be 'more like white' and include other actions such as dressing like other students, modifying accents and avoiding confrontations. Beagan [ 40] argues that for self-preservation it is easier to not make a fuss and allow incidents to pass, as students can be perceived as over reactive or too sensitive by the privileged majority who are ignorant to the issues faced. Solorzano & Yosso [ 38] highlight that students of colour have no option but to assimilate to white middle class culture to succeed in university and life. Whilst this study recognises the need for all trainees to assimilate into the context of physiotherapy education, it also reveals some of the unique tensions experienced by BAME students. Consequently, the findings suggest these tensions make the assimilation more difficult for BAME students, highlighting the inequality of experience within the system.

The students in the study were keen to put forward recommendations for addressing the issues they faced and these have relevance in the context of the institutions that participated in the study, but others may draw on these examples. The participants stressed the need to educate staff and fellow peers of the contexts where privilege and disadvantage coexist. Stevenson [ 18] also argues that academic development is necessary so that staff learn to recognise white privilege and feel empowered to deal with issues of race and racism. The students were happy for their narratives to be used as part of these developments and we are identifying physiotherapy specific staff development. We are also currently exploring ways to co-create teaching, learning and assessment approaches [ 18, 19] with students from BAME backgrounds. Smith [ 2] has recently argued the importance of greater representation and role models and we are also developing approaches to establish BAME mentors.

These practices may go some way to give students from BAME backgrounds a greater sense of belonging. However others argue that gains will be minimal if the white dominate narrative remains unchallenged [ 39] and strategies are remedial and shaped on an assumption of deficit [ 19, 43], such as assuming the mentorship programmes alone will solve the issue. There is also need to recognise the system of higher education recreates privilege and entrenches power in systematic ways [ 22] and thus physiotherapy education is embedded within this system. To enable change, physiotherapy educators may need to challenge their own and institutional practices even if this means a willingness to let go of power. Beagan [ 40] claims from her work with medical education that by not questioning and challenging practices, educators are complicit in enabling marginalisation and inequalities for BAME and other identities. Despite these calls to action, it is not possible to identify whole scale inclusive approaches for 'all', because although well meaning, Madriaga [ 22] suggests such approaches promote a liberal ethic that 'everybody is the same' which simultaneously ignores experiences of students of colour.

Conclusions

The findings in this study help to identify for the first time the unmoderated student perspective where structures, curriculum, teaching and learning strategies operate to simultaneously advantage ethnic majority students and disadvantage BAME students in physiotherapy education. Some of these are not dissimilar to other research, but this study highlights some microaggressions that are prevalent in physiotherapy education and how qualities such as extroversion and proactiveness may be privileged in physiotherapy limiting some cultural and ethnic approaches. It also highlights how students from BAME backgrounds demonstrate resourcefulness in attempts to belong in physiotherapy. Yet there is still much work to do to empower BAME students to speak up and advocate that their voices are heard. Students studying towards a physiotherapy degree are required to demonstrate adept academic and clinical skills, alongside all qualified physiotherapists, who are also bound in both behaviour and knowledge by regulatory frameworks (such as the Health and Care Professions Council Standards of Proficiency [ 45] in the UK). The complexity of the student experiences in this study are also impacted by the power imbalances in both the clinical and academic workspace, and in their ability to successfully negotiate and manage complex issues relating to BAME in a 'professional' way.

We hope the themes prompt colleagues to recognise similarities in their own environments and draw their own conclusions and actions. From these findings it is essential that academic practitioners and senior managers continue to interrogate education differentials related to ethnicity. Overt incidents of racism should also be dealt with via appropriate workplace policies and educators should publicly demonstrate intolerance of racism. Critically, BAME students should be empowered to tackle these overt forms of racism as well as the more subtle and oppressive microaggressions. A starting step could be to commit to, and invest in, activities that seek to co-create teaching, learning and assessment approaches with BAME students. By doing this, BAME students would be empowered to disrupt and change any overt or covert racist pedagogic practices. In addition, the lack of visible role models from BAME backgrounds in the profession also poses challenges. We suggest that focus and investment should be directed towards the identification and support of BAME role models and mentors within physiotherapy education, and across the profession. A greater diversity in role models and mentors may assist in making the profession attractive and accessible to potential BAME students. However, encouraging students with greater ethnic diversity into the profession will not remove the tensions experienced by the current BAME students unless it also supported by further education and understanding to address the existing tensions.

Finally, recognising that students from BAME backgrounds are not a homogenous group, we recommend that future research explores the specific experiences of particular ethnic or faith groups in physiotherapy education. Similarly, research exploring the experiences of qualified physiotherapists from these groups is also warranted.

Availability of data and materials

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Abbreviations

BAME:

Black Asian and Minority Ethnic

BSc:

Bachelor of Science

HEI:

Higher Education Institution

HESA:

Higher Education Statistics Agency

MSc:

Master of Science

UK:

United Kingdom

References

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Acknowledgements

Thanks to the students who volunteered to participate in this study and offered to share their experiences.

Funding

Health Education England North West London.

Author information

Affiliations

1. Faculty of Health, Social Care and Education, Kingston University and St George's University of London, Cranmer Terrace, London, SW17 0RE, UK

John A. Hammond & Saskia Walker

2. Department of Clinical Sciences, Brunel University London, London, UB8 3PH, UK

Annabel Williams & Meriel Norris

Contributions

MN, JH, AW, SW conducted the focus groups. JH analysed the data. MN, AW, SW all reviewed the data and analysis and participated in critical discussions. JH wrote a first draft of the article. MN, AW and SW made significant contributions to the final draft, which all authors have approved.

Corresponding author

Correspondence to John A. Hammond.

Ethics declarations

Ethics approval and consent to participate

Approval granted by CHLS REC Brunel University London 8709-MHR-Jan/2018 and reciprocal approval at Faculty of Health Social Care and Education at Kingston University and St Georges University of London. All participants gave written informed consent to participate.

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Participants were made aware that anonymised quotes may be used in publications prior to giving consent.

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The authors declare that they have no competing interests.

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Hammond, J.A., Williams, A., Walker, S. et al. Working hard to belong: a qualitative study exploring students from black, Asian and minority ethnic backgrounds experiences of pre-registration physiotherapy education. BMC Med Educ 19, 372 (2019). https://doi.org/10.1186/s12909-019-1821-6
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DOI: https://doi.org/10.1186/s12909-019-1821-6

Keywords

Physiotherapy

Student

Black Asian and minority ethnic

Qualitative

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# data[].attributes.attachment_link.title
Working hard to belong: a qualitative study exploring students from black, Asian and minority ethnic backgrounds experiences of pre-registration physiotherapy education - BMC Medical Education

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Background Previous research has demonstrated that attainment inequalities exist for students from Black Asian and Minority Ethnic (BAME) groups in pre-registration physiotherapy education. While previous research has explored students from BAME backgrounds experience of university, the context of physiotherapy is unique and is under researched.

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NHS: introduction to British cuisine and diet culture

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NHS: introduction to British cuisine and diet culture

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The coin model of privilege & critical allyship: implications for health

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The coin model of privilege & critical allyship: implications for health

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BMC Public Health 19, Article number: 1637 (2019) Cite this article

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Abstract

Health inequities are widespread and persistent, and the root causes are social, political and economic as opposed to exclusively behavioural or genetic. A barrier to transformative change is the tendency to frame these inequities as unfair consequences of social structures that result in disadvantage, without also considering how these same structures give unearned advantage, or privilege, to others. Eclipsing privilege in discussions of health equity is a crucial shortcoming, because how one frames the problem sets the range of possible solutions that will follow. If inequity is framed exclusively as a problem facing people who are disadvantaged, then responses will only ever target the needs of these groups without redressing the social structures causing disadvantages. Furthermore, responses will ignore the complicity of the corollary groups who receive unearned and unfair advantage from these same structures. In other words, we are missing the bigger picture. In this conceptualization of health inequity, we have limited the potential for disruptive action to end these enduring patterns.

The goal of this article is to advance understanding and action on health inequities and the social determinants of health by introducing a framework for transformative change: the Coin Model of Privilege and Critical Allyship. First, I introduce the model, which explains how social structures produce both unearned advantage and disadvantage. The model embraces an intersectional approach to understand how systems of inequality, such as sexism, racism and ableism, interact with each other to produce complex patterns of privilege and oppression. Second, I describe principles for practicing critical allyship to guide the actions of people in positions of privilege for resisting the unjust structures that produce health inequities. The article is a call to action for all working in health to (1) recognize their positions of privilege, and (2) use this understanding to reorient their approach from saving unfortunate people to working in solidarity and collective action on systems of inequality.

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Background

The narrator at the start of a YouTube video instructs, "Count how many times the team wearing white passes the ball" [ 1]. Six people enter the screen: three wearing white shirts, and three wearing black. They stand in a circle and pass basketballs to each other for 90 seconds. At the end of the video, the narrator says, "The correct answer is 16 passes. Did you spot the gorilla?" A portion of the audience typically misses the gorilla and is baffled by the question [ 2]. The video then repeats to show again that in the midst of the basketball passing, an adult dressed as a gorilla walks into scene, looks at the camera thumping his chest, then leaves. This short exercise demonstrates how it is possible to miss something as obvious as a gorilla, but also invites the audience to imagine how it could be otherwise. That is, the audience had their capacity built to count the number of passes by the team wearing white whereas the narrator could have built the capacity of the audience to spot the gorilla. So it is with privilege: that it is possible to miss something as obvious as an adult in a gorilla suit walking into the screen. It follows that if one missed the gorilla (or privilege), then there is no possibility of engaging in conversation about the gorilla. One might even question the legitimacy of other people's claims about the existence of a gorilla (or privilege). However, the narrator could have built the capacity of the audience to see the gorilla, and so too can people build their capacity to see privilege [ 3]. Building this capacity requires both learning and unlearning, and is the aim of this article.

This article provides a framework, the Coin Model of Privilege and Critical Allyship, for conceptualizing privilege in order to address the even more important question of what to do about it, which is termed practicing critical allyship. In particular, I explore how privilege and allyship are related to health inequity - that is, disparities that are systemic, avoidable, and unfair [ 4]. Efforts to address inequities tend to frame concerns as unfair consequences of social structures that result in poor health, without consideration of the ways in which these same social structures give unearned advantage to others. Unearned advantage, or privilege, is the gorilla. Practicing critical allyship is the orientation to guide action for people who find themselves in positions of privilege in relation to a particular system of inequality.

Disappearing privilege from discussions of health equity is an important shortcoming, because the framing of a problem sets the universe of possible solutions that will follow. If inequity is framed exclusively as a problem facing people who are marginalized, then responses will only attempt to address the needs of these groups, without redressing the social structures causing this disadvantage, or the complicity of the corollary groups who receive unearned (and unfair) advantage from these same structures [ 5 , 6]. This approach, often called anti-oppression [ 7], is well developed in other fields [ 8, 9, 10, 11] but less so within health research [ 12]. To be clear, the ideas presented in this article about privilege and oppression are not new; they have been articulated, advanced and argued for decades, largely by "marginalized" groups to people in positions of privilege who have not been ready or willing to listen. In this article, I seek to translate these ideas in a new way for a general health audience, and it is noteworthy that successful uptake of the ideas in this version must be understood as inextricably linked to my position as someone "on the top of many coins".

The first part of this article introduces the metaphor of the coin, a framework for understanding how social structures offer both unearned advantage ('privilege') and disadvantage ('oppression'). I adapted the coin metaphor from the schematic of privilege, domination and oppression presented by Kathryn Pauly Morgan in "Describing the Emperor's New Clothes: Three Myths of Educational (In)Equality" [ 13]. The Coin Model of Privilege and Critical Allyship aims to inform action to resist and dismantle the unjust structures that produce inequities. The model embraces an intersectional approach to consider how systems of inequality, such as racism, heterosexism and ableism, interact to produce complex patterns of unearned disadvantage and advantage. The second part of this article introduces principles for practicing critical allyship and their implications for mitigating health inequities.

The coin model

The coin

There are norms, patterns and structures in society that work for or against certain groups of people, which are unrelated to their individual merit or behaviour. Put another way, there are (often invisible) systemic forces at play that privilege some social groups over others, such as sexism, heterosexism, racism, ableism, settler colonialism, and classism [ 14]. These unfair social structures have profound effects on health, producing inequities in morbidity and mortality.

Racism is well demonstrated to adversely affect the health of non-white people through interconnected structural, institutional, cultural and psychosocial pathways [ 15, 16]. For instance, there is a breadth of evidence in the American context demonstrating that people who are racialized receive lower quality health services and are less likely to receive routine medical procedures than white Americans [ 17]. Racism and its interconnection with colonialism have created profound health inequities for Indigenous Peoples, including lower life expectancy (by more than 5 years) than the non-Indigenous population in the United States [ 18, 19, 20]. Women and girls have worsened health outcomes, diminished capacity to realize health-related human rights, and reduced access to healthcare, which are related to sexism, and its intersections with class, race and ability [ 21, 22, 23]. People who are gay, lesbian or bisexual face health inequities related to heteronormativity and homophobia [ 24, 25]. Furthermore, there is worsened health among transgender people due to cisnormativity and transphobia, which is exacerbated by other systems of oppression [ 23, 26- 27]. A study in the Canadian province of Ontario found that one in ten trans people who had accessed an emergency room had been refused care or had care terminated prematurely because they were trans, and 40% had experienced discriminatory behaviour from a family doctor [ 27]. A final example is health disparities among people with disabilities related to ableism and its intersections with other systems of inequality [ 28, 29]. Census data from 2015 demonstrated that nearly 14% of Australians with a disability reported disability-based discrimination in the previous year; that disability-based discrimination was more common among people who were unemployed or poor; and, that disability-based discrimination was associated with higher levels of psychological distress and poorer self-reported health [ 29]. These systems of inequality are bad for health.

In the Coin Model, each system of inequality is conceptualized as a coin. Coins do not reflect the individual behaviour of good or bad people. Rather, they are society-level norms or structures that give advantage or disadvantage regardless of whether individuals want it or are even aware of it. Each coin represents a different system of inequality.

These social structures, or coins, give unearned advantage or disadvantage according to one's relationship to that particular system of inequality. For instance, one may consider the coin (or system of inequality) of heterosexism. Heterosexuality is romantic or sexual attraction to people of the opposite sex. Heterosexism, a dominant norm in many societies, views being heterosexual as the only normal and right way to be. People who happen to fit this norm because they are straight (i.e., heterosexual) enjoy advantages from this social structure. For instance, they can openly express affection without fear of discrimination or violence. They see their way of life validated and valued through its regular, positive, and default position as the normal way of being reflected in legal frameworks and popular culture. However, straight people did not choose to be straight; they just are. They did not earn this advantage; rather, they lucked into it by their natural preference for whom they love being in alignment with this broader social norm. They likely did not ask for these benefits, but they receive them all the same. They may not even be aware that they are receiving unearned advantage, but they receive it nonetheless [ 30].

Conversely, people who are not straight do not enjoy this freedom from discrimination and violence, or the sense of inclusion and belonging that results from this social structure. People who are not straight, such as people who identify as gay, lesbian, bisexual, asexual, or two-spirit, did not choose to be that way; they just are. However, their natural preference for whom they love is not in alignment with the dominant norm of heterosexism and, as such, they receive unearned disadvantage. They did nothing to earn it, but they receive it nonetheless. Furthermore, while unearned advantage can be difficult to see, unearned disadvantage is often highly visible to those who experience it.

The bottom and top of the coin: oppression and privilege

It is the same social structure, or coin, that gives unearned disadvantage to some and unearned advantage to others. Groups of people who are disadvantaged by this social structure are viewed as being on the bottom of the coin (see Fig. 1). In this model, I call this side of the coin oppression. Because of the dire health effects resulting from this unfair disadvantage, these are the groups commonly targeted in health promotion research and interventions. The names for these groups are many and familiar, including marginalized populations, disadvantaged groups, vulnerable communities, high-risk groups, priority neighbourhoods, or hard-to-reach populations.

Other groups of people receive advantage from these same social structures, and are viewed as being on the top of the coin. These groups receive benefits from the structures that others do not, which they did not earn. Rather, they receive the benefit because they luck into being in alignment with the norms of that particular social structure. In this model, I call the position on the top of the coin privilege.

Terms used to describe groups of people who enjoy unearned health benefits as a result of systems of inequality are uncommon and hard to imagine (e.g., unfairly advantaged groups, free-lift populations). To view those on the top of the coin as "normal" or "average patients" is erroneous since, by definition, the top of the coin represents people who are the recipients of unearned and unfair benefits because their way of being is valued over others. The goal is not to move people from the bottom of the coin to the top, because both positions are unfair. Rather, the goal is to dismantle the systems (i.e., coins) causing these inequities.

Drawing attention to the top of the coin is important because inequity is relational: the bottom of the coin is disadvantaged compared to the top. Yet, issues of health equity are often framed exclusively as problems facing people on the bottom of the coin. Disappearing the top of the coin, and often the coin itself, functions to maintain the status quo because what one frames as the problem sets the universe of conceivable actions to address it. When the problem is framed as challenges faced by the members of a "vulnerable group" (i.e., bottom of the coin), then potential solutions will focus exclusively on interventions to address their issues. Should actions address the needs of these groups? Of course; these responses are deeply important for redressing existing inequities. However, the bottom of the coin is commonly framed as the entire story of health equity as opposed to just one part. If the problem was viewed not only as the bottom of the coin, but also the coin itself (i.e., the unjust social structure that gives unearned disadvantage to people on the bottom), then a different set of solutions could follow, such as changes to policy and law to create safeguards against discrimination produced by the system of inequality. Indigenous physician and public health leader, Marcia J. Anderson, succinctly captures this point as follows:

"From now on instead of 'vulnerable people' I'm going to use the phrase 'people we oppress through policy choices and discourses of racial inferiority.' It's a bit longer but I think will help us focus on where the problems actually lie." [ 31]

For instance, the coin of ableism reflects the social structure that discriminates against disabled people in favour of people who fit a socially-constructed norm of able-bodiedness [ 32]. In an ableist worldview, there is a particular version of ability that is assumed to be normal or natural (top of the coin), and people who cannot meet this expectation (bottom of the coin) are viewed as a problem who should strive to become, or assimilate to, the norm. Ableism views disability as a mistake or failing rather than a simple consequence of human diversity, like sexual orientation or gender.

Consider the different solutions that become imaginable depending on whether one views the problem as the bottom of the coin (i.e., disabled people) or the coin itself (i.e., ableism). Solutions addressing the bottom of the coin strive to support disabled people to achieve the norm of able-bodied people, including medical care and rehabilitation to fix disability within the body. Conversely, if one views the problem as the unfair social structure of ableism, then the cause of disability shifts: instead of being located within an individual's body, disability is understood as resulting from the social, attitudinal and political environment. Responses become focused on social change to achieve equity for people with disabilities in the same light as equity for other disadvantaged groups where prejudice, segregation, and inaccessibility are viewed as the problem. Responses might focus on rights-based approaches aligned with the United Nations Convention on the Rights of Persons with Disabilities. Actions would shift from focusing on disability as a mistake to instead celebrating difference by creating flexible systems (e.g., through policies, the built environment) that enable and liberate as opposed to disable and exclude.

Problematizing the coin of ableism also shines a spotlight on the profoundly disabling effects of stigmatizing attitudes commonly held by able-bodied people. In many cases, such effects are unintended and unknown to those reproducing them, but profoundly impactful all the same, which brings us to the top of the coin.

Seeing the gorilla: recognizing the effects of invisiblizing privilege

The coin of settler colonialism in the context of Canada provides another useful illustration. If the coin is settler colonialism, then the group receiving unearned disadvantage on the bottom of that coin is Indigenous Peoples. Since the Idle No More movement and 2015 report of the Truth and Reconciliation Commission of Canada, the history and legacy of colonization are starting to be recognized within Canadian society [ 33, 34]. For instance, there is greater attention to the ongoing, devastating effects of Indian Residential Schools on Indigenous Peoples, the harmful effects of the Government of Canada's Indian Act, and the rights-violations embedded in the inequitable provision of public funding to ensure basic determinants of health (e.g., clean drinking water, quality primary education) within Indigenous communities. These examples draw attention to the coin (i.e., settler colonialism) as the source of profound health inequities between Indigenous and non-Indigenous people in Canada. The problem has been relocated from Indigenous People (the bottom of this coin) to the structures (the coin) that create the conditions that produce unearned and unfair disadvantages. The growing ability to see, and thereby devise solutions to address, the coin is an important marker of progress toward dismantling this inequity.

But Indigenous People and settler colonialism are not the complete picture. Similarly, disabled people (bottom of the coin) and ableism (the coin), are not the complete picture. What about the people on the tops of these coins? Who are they? What is their role in dismantling, or as is often the case, unintentionally strengthening the coin?

A key task for people who find themselves on the top of a coin is to see the gorilla; that is, to understand that there is a coin, that it has two sides, and that they occupy the position of unearned advantage (i.e., privilege) on the top. For instance, if Indigenous People are on the bottom of the coin, it is non-Indigenous people (often referred to as settlers) who receive unearned and unfair advantage from these same structures. Seeing the gorilla in this instance means developing the capacity to ask and answer questions such as, "In which ways did I benefit from settler privilege today?" and "In what ways did my actions today reflect and thereby reinforce the coin of settler colonialism?"

In many cases, people on the top of a coin did not ask for the unearned advantage that they receive. However, people are rarely on the top of the coin because of merit or worth (commonly referred to as the myth of meritocracy [ 35]). Rather, they are there, by definition, because they happen to be able-bodied, settlers, white, straight, cisgender, or other aspects of their social identity that they did not choose, but which nonetheless align with historic planes of domination and subordination [ 13].

Just as the disadvantage received by people on the bottom of the coin is unearned and unfair, so too, the advantage received by people on the top of the coin is unearned and unfair. However, these opposite effects of the coin are not evenly understood.

The contradiction of who holds expertise vs who holds power regarding systems of inequality

The unfair disadvantage associated with the bottom of the coin is frequently in plain view - to clinicians and researchers working to address these challenges, and especially to people on the bottom of the coin themselves who may confront these disadvantages daily. Regardless of whether people on the bottom of the coin are fluent in the language of anti-oppression, they typically are expert in the many ways that the coin operates to create disadvantage, dehumanization, lack of safety and social exclusion. Moreover, it is these groups who have historically led movements to dismantle the coins, such as Indigenous Peoples leading movements to redress the harmful effects of colonization on First Peoples and the environment, or Black people leading anti-racism civil rights movements.

However, the unearned advantage associated with being on the top of the coin is often invisible - in health promotion interventions, in health equity research, and especially to the people themselves who occupy positions on the top of coins. Some have argued that the obliviousness of people about their positions of privilege is a key strategy required to sustain the hegemony of systems of inequality [ 36]. Learning to see the gorilla is a strategy for becoming less oblivious and less harmful.

Lack of awareness about the top of the coin has serious implications for meaningfully addressing health equity. This is because lack of recognition of the societal influences that have helped elevate people on the top of coins to reach their professional, economic or social positions commonly leads those same people to presume that they are there exclusively because of their individual merit. Put another way, where privilege is unchecked, it can lead to an irrational sense of entitlement, expertise and access. It then seems logical and, indeed, a moral imperative for those on the top of the coin to be guided by an altruistic urge to save or fix people on the bottom of the coin. However, this logic no longer holds when one considers who possesses expertise regarding the coin and its effects; that is, people on the bottom of coins.

Furthermore, invisibilizing the top of the coin allows people in positions of privilege to view themselves as unconnected to, or outside of, the systems of inequality they are trying to address, as opposed to understanding their direct relationship to people on the bottom of the coin. Instead of understanding their complicity within systems of inequality, disappearing the top of the coin allows people on the top to frame their role in health equity work as neutral, selfless and altruistic. This positioning logically leads to action that (exclusively) assists people on the bottom of the coin as opposed to targeting oppressive systems that are bad for all.

Within the health sphere, the people who typically hold the power to allocate resources, design programs, and draft policy to address the needs of people on the bottom of the coin often find themselves on the top of multiple coins. But who are the real experts in understanding how the coin operates in society? When people in privilege do not realize the powerful implications of that position, they may unwittingly - and with the best of intentions - devote themselves to trying to help people on the bottom without ever understanding: (1) the impact of the coin on their own individual position, (2) how this lack of understanding vastly compromises their insight about the oppressive social structure, and (3) how this lack of insight can lead to actions that serve not to dismantle the coin, but to strengthen the status quo. For instance, the assumed expertise of people on the top of the coin to solve the problems of inequity becomes reinforced, while the assumed neediness and lack of expertise of people on the bottom of coins is further entrenched. Materials resources (e.g., salaries, grant funding) to address health equity commonly flow to people on the top of the coin to design and administer programs for people on the bottom of the coin, thus reinforcing inequities.

In summary, lack of awareness about one's position on the top of coins is dangerous for health equity. Indeed, the invisibility of privilege is central to the functioning and sustainability of the system of inequality. Invisiblilizing the top of the coin, and frequently the coin itself, ensures that the coin remains strong. This is the gorilla, and why movement toward dismantling systems of inequality requires everyone, and especially people on the top of coins, to learn how to see the gorilla.

Recognizing the intersecting nature of multiple coins

A single coin does not represent all privilege or all oppression. Rather, each coin represents a specific system of inequality (e.g., sexism, racism, ableism). Each person typically occupies the position on the top of some coins and the bottom of other coins at the same time. A common pattern is for people to have a well-developed understanding of the system of inequality for which they find themselves on the bottom and, perhaps, frustration, anger or sadness that this unjust system is not better understood by people on the top of that same coin. This insight can be helpful for then considering one's (often limited) knowledge about the systems of inequality where they find themselves on the top.

Furthermore, it is important to recognize that while each coin represents a different system of inequality, the coins do not operate in isolation. Rather, the coins intersect to create complex inter-relating systems of inequality (see Fig. 2). The result is not additive; finding oneself on the same side of two coins does not mean that one is twice as privileged or twice as oppressed. Rather, intersecting systems of inequality produce new and complex patterns of advantage and disadvantage. The relevance and impact of these positions varies according to context, and so one's positions on these multiple coins need to be analyzed together. The term, intersectionality, was introduced by legal scholar and critical race theorist, Kimberlé Crenshaw, and further understood as the matrix of domination by Black feminist scholar, Patricia Hill Collins, in order to characterize the unique forms of oppression faced by women who are Black [ 37, 38]. Intersectionality has been taken up widely, including within the health sphere [ 39, 40].

The intersecting nature of the coins, which produces complex patterns of advantage and disadvantage

Analysis requires the precision of clarifying one's position on the top or bottom of each particular coin, with special attention to those coins for which one is on top, and how these individual positions may amplify each other in different contexts. Importantly, not all coins are the same size; that is, different systems of inequality will matter more or less in different contexts, and depending on their intersection with other patterns of inequality.

Another key insight offered by an intersectional analysis is how experiences of oppression in one system of inequality do not negate positions of privilege in others. For instance, a white person who is poor may clearly understand the oppressive effects of classism, but may not also appreciate the ways they simultaneously benefit from being on the top of the coin of racism. A racialized person who is considered able-bodied may understand the devastating effects of racism while being unaware of how their ableist privilege serves to regularly give them unearned advantage. An intersectional analysis reminds us that the effects of these different positions cannot be understood through a mathematical approach whereby the position on the bottom of one coin cancels out the position on the top of another. This is how even the most articulate activists on certain systems of inequality can unintentionally strengthen other coins where they find themselves on top because of their unrecognized positions of privilege, i.e., their lack of capacity to see that particular gorilla.

This is not about innocence or guilt

Discussions of privilege can lead to faulty assumptions of innocence, and counterproductive attention to guilt. The coin model is premised on an analysis that rejects both of these unhelpful patterns.

Framing people on the top of the coin as oblivious about their unearned privilege does not equate to innocence among those individuals. For the most part, people within the health sphere who are in positions of privilege do not intend to cause harm; however, these coins were created very intentionally by people on the top of the coin. These systems were designed to oppress, and they are sustained, intentionally by some and unintentionally by others, who are on top of the coin. It is not the intent of one's actions that matters but the impact, and the impact of oblivion among people on the top of the coin can be deeply harmful, dehumanizing and violent to people on the bottom of the coin. Indeed, these systems of inequality are harmful to whole societies because they diminish the contributions and talents of people on the bottom of coins through the barriers they face.

Another common narrative is the feeling of guilt among people when considering the unearned benefits they receive because of being on the top of a coin. Feelings of guilt can lead to discomfort, distancing from the issue, denial, or intellectual paralysis. In the context of racism, white academic Robin DiAngelo calls this phenomenon "white fragility" [ 41]. Guilt can become the primary focus of discussion and analysis among people who share positions on the top of a coin. However, the coin model invites analysis of how focusing on guilt serves to strengthen vs dismantle systems of inequality. Guilt leads to feelings of distress among people through reflecting on the unearned advantages and free lifts that make their lives easier. This distress must be understood in contrast to the (often daily) distress, dehumanization, and violence experienced by people on the bottom of the coin. Furthermore, focusing on the guilt born of discovering unearned benefits serves to centre the needs and feelings of people on the top of the coin, which reinforces the coin by crowding out the needs and feelings of people on bottom. In the words of the Black, lesbian poet and philosopher, Audre Lorde:

"Guilt is not a response to anger; it is a response to one's own actions or lack of action. If it leads to change then it can be useful, since it is then no longer guilt but the beginning of knowledge. Yet all too often, guilt is just another name for impotence, for defensiveness destructive of communication; it becomes a device to protect ignorance and the continuation of things the way they are, the ultimate protection for changelessness."[ 42]

If guilt is an unproductive strategy for people on the top of the coin who wish to dismantle inequities, then what might be alternatives? A more productive strategy is to recognize feelings of guilt, and swiftly reframe guilt as responsibility deriving from complicity [ 43]. Embracing responsibility gives rise to action to resist the dominant norms that sustain systems of inequality, which I refer to as practicing critical allyship.

Principles for practicing critical allyship

To work toward dismantling a system of inequality, different orientations are appropriate depending on one's position in relation to that social structure; that is, the side one is on of a particular coin. This article is written for people who find themselves on the top of a coin that they wish to dismantle (i.e., in a position of privilege), and I call this orientation practicing critical allyship.

Within this approach, allyship is not an identity, but an ongoing practice. The focus on critical allyship as a practice aligns with the focus by others on becoming an ally [ 44, 45, 46], or what queer Black author Mia McKenzie describes as "currently acting in solidarity with" to focus on actions in the present [ 47]. This approach learns from the Anti-Oppression Network, which defines allyship as an "active, consistent, and arduous practice of unlearning and re-evaluating in which a person of privilege seeks to operate in solidarity with a marginalized group of people" [ 48].

Practicing critical allyship requires a reorientation from the dominant way of thinking about how people in positions of privilege should address inequities, which assumes that the most ethical and effective way to address health disparities is for people on the top of the coin to use their expertise to help marginalized groups with their problems. "Their problems" are typically framed as caused by the behaviours of individuals or groups, as opposed to the being linked to unearned disadvantage resulting from systems of inequality (i.e., the coin). It follows that appropriate responses involve people on the top of the coin going into communities (locally and overseas) to bring their expertise and solutions to needy individuals. Although often well-intentioned, people on the top of the coin have been socialized to have little understanding of their relationship to social structures, or the contradiction between who holds power versus who holds expertise. This flawed approach strengthens the system of inequality by reinforcing the assumption that people on the top are experts, unconnected to the system of inequality, and that people on the bottom need rescuing. If the goal is to dismantle the systems of inequality that result in health disparities, a reorientation is required whereby people on the top of the coin reorient their motivation from:

This reframing reverses who is presumed to be more expert on dismantling the inequity (i.e., from people on the top of the coin to people on the bottom), and whose thinking and behaviour need to change in order for the inequity to be dismantled (i.e., from people on the bottom of the coin to people on the top). Reframing the problem as the ineffective and unhelpful orientation of people in positions of unearned advantage allows new possibilities for action to come to light. Below I introduce several principles as an entry point for guiding such action, i.e., for practicing critical allyship.

Stop trying to save or fix people on the bottom of the coin

An initial step is to recognize and resist the everyday ways that people on the top of a coin unintentionally strengthen, as opposed to dismantle, the coin; that is, the things we say or do that unwittingly reflect and therefore reproduce the system of inequality. A key step in this practice is to reject the dangerous and misguided urge to save people on the oppression side of the coin, driven by the irrational sense of expertise, entitlement and access [ 49]. Rather, the aim of critical allyship is to operate in solidarity with people on the bottom of the coin. This principle applies to students, researchers or clinicians developing health promotion programs for or conducting research with marginalized communities locally or globally [ 50], without understanding their personal relationship to the systems of inequality that marginalize these communities in the first place [ 51].

This invitation to recognize the harmful effects of a fixing or saving mentality is particularly complex for those involved in clinical care, which is often defined as fixing or saving patients. The challenge is to consider how to meet individual clinical needs without reproducing systems of inequality. How might one deliver health care in a way that resists these systems and rewrites dominant narratives about power? Rehabilitation science researchers Roush and Sharby call on clinicians to consider this paradox for people with disabilities; that is, how to fix impairments while simultaneously celebrating disability as diversity [ 52]. Another approach is cultural safety, developed by Maori nurse, Irihapeti Ramsden, in response to the inability of the mainstream health system to meet the needs of Maori People in Aotearoa/New Zealand [ 53]. Cultural safety requires clinicians to understand their roles within the power differentials inherent in healthcare, including institutional discrimination, and aims to address inequities through both education and systemic change [ 54].

Take active steps to learn about the systems of inequality for which one is in a position of privilege

Practicing critical allyship focuses not on the intent but impact of one's actions, which requires deepened capacity to understand the multifaceted effects (positive and negative) of action or inaction. Thus far, I have emphasized the similarities across systems of inequality; however, the strategies by which each of these systems operate are unique. As such, a crucial step in practicing critical allyship is to actively acknowledge one's positions of privilege and develop understanding of the logics of oppression that sustain and reproduce these inequalities; that is, the ideologies and assumptions that pervade law, policy, norms, attitudes and our everyday actions [ 55, 56].

A starting point for resistance is naming and discussing privilege with others on the top of that coin to diminish oblivion (i.e., to see the gorilla) and collectively build capacity for change. Examples include straight people discussing how they benefit from and reproduce heteronormativity [ 57], able-bodied people considering the unearned advantages they receive from ableism [ 58], white people learning about their role in perpetuating racism [ 41, 59], or settlers exploring settler identity in the context of colonialism [ 60, 61], with careful attention to how these structures simultaneously intersect. Each of these systems requires deep learning and, moreover, unlearning of entrenched assumptions to guide individual and collective action for transformative social change [ 62].

Step back

Systems of inequality centre the presence, voices, needs, feelings, and worldviews of people in positions of privilege. A key step in redressing these power imbalances is for people on the top of the coin to de-centre themselves or to step back. This includes stepping back physically, such as decentring one's privilege by literally making space for people on the oppression side of the coin at a meeting.

There is also transformative potential in stepping back metaphorically. This is the invitation to listen more and speak less. Those in positions of influence can step back to reallocate power to people who have historically been pushed to the margins. This includes making room for - and recognizing as legitimate - the feelings, approaches, and worldviews of people on the bottom of the coin. This requires those on the top of coins to demonstrate humility regarding the assumed rightness of certain ways of doing, communicating, and thinking, and stepping back to make room for alternatives.

This form of stepping back is exemplified by responses to the egregious history of Western-oriented research on Indigenous Peoples. The emergence of Indigenous research methodologies, which are consistent with an Indigenous worldview, recognize the profound violence perpetrated on Indigenous Peoples through the institutions of healthcare and research, and re-imagine research as a transformative process of cultural reclamation that is driven and controlled by Indigenous People [ 63, 64, 65]. This shift calls on non-Indigenous people to step back in terms of the taken-for-granted 'truths' embedded in a Western worldview about research and health. Following centuries of presumed entitlement and access to Indigenous bodies by non-Indigenous people, practicing critical allyship means asking oneself: What is my research to do and, importantly, what is not? [ 66] This reframing invites a shift from studying Indigenous people to studying whiteness, settler identity, and the roles of racism and colonialism in creating health inequities. It also calls for non-Indigenous people to only engage in research with Indigenous Peoples in the spirit of solidarity, which requires a transformative shift among non-Indigenous People who, by definition, find themselves on the top of the coin of settler colonialism [ 46, 67].

The goal of critical allyship is not only to change the behaviour of individuals, but to fundamentally shift the institutional arrangements that keep people up or down. To this end, stepping back involves giving up both symbolic and material power. In many cases, people on the top of the coin have the power to make material changes immediately, such as redirecting a paid speaking invitation to, or choosing to hire, a person on the bottom of the coin. Practicing allyship means looking at the material resources within one's control (personally and professionally) and intentionally finding ways to shift those resources into the pockets of people on the bottom of the coin. This focus on redistribution of material power invites those on the top of coins to reflect critically on how far back one is prepared to step back in order to share the space and comforts accrued through unearned advantages.

Recognize the need for action at the systemic, institutional, interpersonal and internal levels

Interpersonal interactions, in which one uses their power to intervene in moments of discrimination, are important, and often the focus of calls to "be an ally" [ 68]. However, practicing critical allyship requires analysis and change at multiple levels. The "critical" in critical allyship draws explicit attention to systems of power to emphasize that change at the interpersonal level is important but should not eclipse the goal of structural change.

Social structures play out through institutions like science, health care, and education, which are therefore key sites for practicing critical allyship [ 69, 70]. Practicing critical allyship encourages individuals to transform their own institutions [ 71]. For example, this approach invites reflection on how one's academic department, professional body, or hospital may have day-to-day practices that unintentionally reflect and thereby reinforce systems of inequality. This practice requires rejecting the assumption that, for example, sexism or racism are not replicated in one's lab, classroom or clinic, and instead proactively seeking to understand the ways that they are, so that the harmful effects can be mitigated [ 72].

Structures are deeply entrenched throughout society and embodied in its individuals. As such, a further target for analysis and change within critical allyship is the emotional, psychological and spiritual work required to deepen understanding of the intimate connections individuals hold to these systems of inequality. In other words, practicing critical allyship is more than intellectual. For people in positions of privilege, this internal work can be deeply uncomfortable but it rarely leads to lack of safety, which can be a daily threat to members of historically oppressed groups. Furthermore, this internal work is rarely role-modelled within the spheres of science and health; embracing this aspect of practicing critical allyship is therefore particularly important among influential figures within these fields.

Do not use allyship to enhance personal power

Being in a position of privilege offers an iterative cycle of benefit: if one does nothing to dismantle the system offering unearned advantage, one continues to reap these benefits. Ironically, when one recognizes unfairness and strives to address this injustice, it is common for one's personal or professional position to be advanced. Benefits can include approval from people on the bottom of the coin, acclaim for one's expertise, awards for advocacy, praise for courage and selflessness (i.e., the courage to talk about issues that others have to live with daily), being hired for health equity positions, or academic promotion based on achievements in advancing health among marginalized groups.

In some cases, reward for practicing critical allyship is justified, such as publishing peer-reviewed articles or attracting grant funding based on innovative ideas or health-related interventions developed in solidarity with people on the bottom of the coin. Working in solidarity does not preclude the achievement of academic benchmarks, although there is work to be done within promotions processes to recognize the invisible, long-term and often gendered work of trust-earning that underpins equitable partnerships.

A key principle is to recognize and resist the urge to use allyship to advance one's own power. One should not practice allyship to be seen performing the practice of allyship. On the contrary, one should actively resist special recognition for confronting issues that others live with every day.

This principle rejects allyship motivated by altruism, which depends on the work of oppressed groups to praise or affirm the "aspiring ally", and which pursues justice for people on the bottom of the coin [ 26]. Rather, practicing critical allyship seeks justice for all by addressing the systems of inequality that harm everyone [ 73, 74]. A sign of allyship fueled by altruism (vs solidarity) is a defensive response when confronted about one's actions or missteps [ 22]. Practicing critical allyship involves seeing critique as a gift, humbly admitting mistakes, and honouring the critique as a teaching to further uncover one's own entrenched assumptions. Practicing critical allyship "sees illumination of privilege as liberating and consciously uses unearned privilege against itself" [ 45].

Conclusions

The goal of this article is to help people fine-tune their capacity to see the gorilla (i.e., unearned advantage received from unfair systems of inequality) and to offer initial principles for resisting these systems. While these ideas may not yet be mainstream within the health sphere [ 12, 75], insights regarding systems of inequality and anti-oppression are well developed in activist communities [ 76, 77, 78] and in other academic fields [ 8, 9, 10, 11, 79, 80]. For instance, those looking to better understand sexism, heterosexism and cisgenderism can turn to gender studies [ 81, 82]. Those seeking to better understand ableism and ableist privilege can turn to disability studies [ 32, 83]. Those seeking to learn more about racism (including anti-Black racism) and white privilege can turn to the fields of critical race studies, critical ethnic studies, Black studies, and white studies [ 84, 85]. Scholarship on the intersection of racism and sexism is well-developed [ 86], including the seminal work of Crenshaw and Collins on intersectionality [ 37, 38]. Those working in global health can learn from the fields of postcolonialism/anti-colonialism, and feminist postcolonialism in particular, which calls into question the exclusion of non-white, non-Western perspectives within feminism [ 87, 88]. Furthermore, much is to be learned about the Eurocentric orientation of science and health care from the fields of Indigenous studies and Indigenous feminism [ 89, 90]. While these fields may not always centre health and illness as a focus of inquiry, they are crucial because these systems of inequality are such powerful determinants of health.

Limits of and potential for the coin model

While a strength of the coin model is the simplicity of its framework for introducing complex concepts, this simplicity is also a weakness. First is the shortcoming of framing power, a complex phenomenon, in terms of simple binaries. Second, the model risks misrepresenting the intersectional and co-constituting nature of systems of inequality [ 44] by erroneously being construed as a simple stacking of coins. Third is the risk of assuming that all coins are the same size and have the same impact, which is not the intent of this model. For instance, racism and colonization are profoundly powerful in shaping other coins. Others have argued that classism is a system of inequality unlike all others [ 91]; the metaphor of the coin is helpful in reinforcing the primacy of material disparities within all systems of inequality.

A key concern is that the coin model is at risk of delinking history from these systems of inequality; that is, it does not explicitly link people in positions of privilege to their ancestors who intentionally created these systems of inequality. For instance, the coin model does not explicitly require white North Americans of Western European descent to reflect on statements such as, "I live on the traditional lands of Indigenous people that was stolen by my ancestors," or "My wealth of today is also the result of the enslavement of Black people by my ancestors." [ 92] The principles of practicing critical allyship require learning (and unlearning) about systems of inequality, including historic origins, and this important point is not foregrounded as clearly as others by this model.

A further limitation is use of the term 'allyship'. While this term may be new to some in the health sphere, others have critiqued and moved beyond this language [ 93, 94, 95]. Given the audience for this model, the phrase 'practicing critical allyship' was deemed the least worst option, rejecting use of the noun 'ally', and inserting 'critical' to explicitly draw connection to systems of power. More important than the term are the concepts that underpin it, and the action they inform. Some will critique the principles of practicing critical allyship introduced in this article for not going far enough, and those critiques are welcome.

Finally, the coin model seeks to make visible positions of privilege, and offers principles for action for those on top of the coin. Following the tenet of stepping back, the critique rightly follows that this model centres the needs and concerns of people in positions of privilege, which stands to marginalize the oppressed. However, more than centring the needs of people in positions of privilege, this article aims to problematize the unearned advantages received by people in positions of privilege and the dire health impacts of ignoring these injustices. Further, this article is a call to action to recognize one's positions of privilege and the imperative for reorienting one's approach from helping unfortunate people, to working in solidarity on systems of inequality. The principles for practicing critical allyship introduced in this article offer an entry point to this reorientation; however, the practice is neither neat nor easy. Practicing allyship is fraught, messy, ongoing, and laden with missteps [ 46, 67, 96, 97], - but the alternative of reinforcing the status quo is far worse.

In closing

Identifying and transcending widespread, willful oblivion regarding the harms of privilege within the health sphere is a crucial step in the path toward transformative change. As advocated by Freire over four decades ago, systems of oppression ultimately harm those on both sides of the coin (albeit in different ways) [ 73]. We all lose by precluding and compromising the societal contributions of talented and creative people on the bottom of the coin. Working in solidarity across the coin seeks to advance the liberation of those on both the bottom and the top. This requires a shift in orientation in line with this oft-cited quote from Indigenous elder, Lilla Watson: [ 98]

"If you have come here to help me, you are wasting your time. But if you have come because your liberation is bound up with mine, then let us work together."

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Acknowledgments

This article was written in Toronto, which is on the territory of the Huron-Wendat, Petun, Seneca, and most recently, the Mississaugas of the Credit. This territory is covered by the Dish with One Spoon Wampum Belt Covenant, an agreement between the Haudenosaunee Confederacy and the Anishnaabe and allied nations to peaceably share and care for the lands and the resources around the Great Lakes. The ideas presented in this article about privilege and oppression are not new; they have been articulated, advanced and argued for decades, largely by people on the bottom of the coin to people on the top of the coin who have not been ready or willing to listen. In this article, I seek to translate these ideas in a new way for a general health audience, and successful uptake of the ideas in this version must be understood as inextricably linked to my position as someone on the top of most coins. My understanding of the ideas in this article has been informed by the experience and expertise of thinkers who inhabit positions on the bottom of coins, and especially by teachings I have received from people who are racialized, disabled, queer and trans. In particular, I acknowledge the powerful ways that my insights have been developed by the following Black and/or Indigenous women: Atik Bird, Tracy Blake, Lisa Boivin, Dionne Falconer, Katie Gasparelli, LLana James, Stephanie Lurch, Dawn Maracle, Renee Masching, MeLisa Moore, Onyenyechukwu Nnorom, Angie Phenix, Sherri Pooyak, Jackie Schleifer Taylor, Meredith Smith and Ciann Wilson. I thank Muriel Mac-Seing, Pulchérie Mukangwije and Mathieu Simard for leading dissemination of the Coin Model in French. I recognize the important contributions of two blinded and two non-blinded reviewers. I thank Sarah Flicker, LLana James and Barbara Radecki for helpful input on drafts of this article. Any shortcomings with this material are my own.

Funding

Stephanie A. Nixon was funded by a Canadian Institutes of Health Research New Investigator Award during an early stage of developing this manuscript. The funder had no role in the design of the study, in collection, analysis, and interpretation of data, or in writing the manuscript.

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Authors and Affiliations

1. Department of Physical Therapy, University of Toronto, 160-500 University Avenue, Toronto, ON, M5G 1V7, Canada

Stephanie A. Nixon

2. Dalla Lana School of Public Health, University of Toronto, 155 College St Room 500, Toronto, ON, M5T 3M7, Canada

Stephanie A. Nixon

Contributions

This manuscript was conceived and written by SAN. The author read and approved the manuscript.

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Stephanie A. Nixon is a white, straight, cisgender, able-bodied, middle class woman raised in Toronto, Canada, in a family of settler descent.

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Correspondence to Stephanie A. Nixon.

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Nixon, S.A. The coin model of privilege and critical allyship: implications for health. BMC Public Health 19, 1637 (2019). https://doi.org/10.1186/s12889-019-7884-9
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The coin model of privilege and critical allyship: implications for health - BMC Public Health

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Health inequities are widespread and persistent, and the root causes are social, political and economic as opposed to exclusively behavioural or genetic. A barrier to transformative change is the tendency to frame these inequities as unfair consequences of social structures that result in disadvantage, without also considering how these same structures give unearned advantage, or privilege, to others.

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Why I am no longer talking to white people about race 

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Why I am no longer talking to white people about race 

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This article is a pre-cursor to a book of the same title by Reni Eddo-Lodge. Both the article and the book are a brilliant place to start, to learn about race and racism

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Why I’m no longer talking to white people about race

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The long read: For years, racism has been defined by the violence of far-right extremists, but a more insidious kind of prejudice can be found where many least expect it – at the heart of respectable society

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John: We've been engaged in a global conversation about race and racism. You've probably had discussions at home, at school or at work, and in those conversations you've probably heard the term white privilege. You maybe even had this term used in a way that felt like an insult or an accusation. Others will have told you that it's all just made up to make white people feel bad... and none of this is right.

Privilege is a hard concept for people to understand, because normally when we talk of privilege we imagine immediate unearned riches and tangible benefits for anyone who has it. But white privilege and indeed all privilege is actually more about the absence of inconvenience, the absence of an impediment or challenge, and as such when you have it, you really don't notice it, but when it's absent, it affects everything you do.

There are lots of types of privilege out there, the privilege of being born into a wealthy family versus a poor family is kind of obvious, but then there's the privilege of being able-bodied versus having or acquiring a disability that most of us take for granted. I have two very close friends who are wheelchair users and I'll be honest, when I first met them I was completely ignorant about the everyday ways their lives are made harder through no fault of their own. Some of these ways are simply thoughtless, but some of them are just the way we live, just the way we build infrastructure, just the way everything works that just makes their life harder than mine. That's just one of the ways that I am privileged and understanding that, embracing that, doesn't make me a bad person, but ignoring it raises the chance that my friends will be excluded in ways that are not obvious to me and as their friend I can't allow that.

There's a good chance, as a white person watching this, your life is already hard. Every day you have to overcome some difficulty or challenge just to get by, but you can still have white privilege. White privilege doesn't mean you haven't worked hard or you don't deserve the success you've had. It doesn't mean that your life isn't hard or that you've never suffered. It simply means that your skin colour has not been the cause of your hardship or suffering.

There is nothing but a benefit to understanding our own privileges, white and otherwise. It brings us closer to those who are different. It helps us be vigilant about the ways we treat others different than us. It helps us make a society that is fairer and more equal. Having white privilege doesn't make your life easy, but understanding it can help you realise why some people's lives are harder than they should be.

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Psychologist John Amaechi talks about white privilege.

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Roger Kline's most recent Paper with BRAP

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Roger Kline's most recent Paper with BRAP

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Too Hot To Handle - Roger Kline Latest Report Feb 2024

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John Amaechi is a psychologist, a New York Times best-selling author and a former NBA basketball player. In the wake of the George Floyd killing and the Black Lives Matter protests, and at a time when many people want to learn how they can be better allies for black people, we asked John what it means to be anti-racist.

There's a big difference between being not-racist and being anti-racist. I know it doesn't seem like it. I know that both of these things seem equally good, but they're not.

Video Transcript Video Transcript

John: There's a big difference between being not-racist and being anti-racist. I know it doesn't seem like it. I know that both of these things seem equally good, but they're not. Think of an interaction. I'm afraid you've probably had one right? With somebody, maybe even somebody you respect, maybe even someone you love, who says something that's racist, does something that's racist, behaves in a way that's racist. Someone who's not-racist: they won't say or do anything in that moment. They want to not rock the boat. They don't want to be upstanding. Instead, not-racists: they tend to be bystanders. But afterwards, after the event, they'll find other people who are also not-racist and they'll talk to each other about, well, that was terrible, that thing that happened the other day. I would never say anything like that. Anti-racists are different and they come in all shapes and sizes. They come in all ages. Anti-racists are constantly looking around to say, what tools do I have available to make it clear that this is not acceptable? And this, this is what anti-racists do. It's not that they stand up at the dinner table when their uncle's a little bit racist and kick the turkey off. That's not it. But what they do is they say, I'm sorry uncle John. That's not acceptable. That's racist. Quietly and respectfully. What they do is they make sure that they never miss an opportunity to let the world know where they stand, even if they can t change everything. You're probably in a position where other people have a lot more power around you. I know how that feels. Sometimes, we sit and we look around us and we think, how can I possibly change all this? And sometimes you can't. But what you can do is make sure wherever you go, people know where you stand. They know that you're an anti-racist. You become a beacon of light that way. You become someone who makes other people want to be anti-racist too. You've got tools at your disposal. Learn. Read. And make everybody clear where you stand.

Sometimes, we sit and we look around us and we think, 'how can I possibly change all this?' And sometimes you can't. But what you can do is make sure wherever you go, people know where you stand. They know that you're an anti-racist. You become a beacon of light that way. You become someone who makes other people want to be anti-racist too. You've got tools at your disposal. Learn. Read. And make everybody clear where you stand.

If you need support

You should always tell someone about the things you're worried about. You can tell a friend, parent, guardian, teacher, or another trusted adult. If you're struggling with your mental health, going to your GP can be a good place to start to find help. Your GP can let you know what support is available to you, suggest different types of treatment and offer regular check-ups to see how you're doing.

If you're in need of in-the-moment support you can contact Childline, where you can speak to a counsellor. Their lines are open 24 hours a day, 7 days a week.

There are more links to helpful organisations on BBC Action Line.

It's important that you keep yourself safe when confronting racism. For support and advice, see the articles below.

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Not-racist v anti-racist: what's the difference?

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John Amaechi describes the difference between being not-racist and anti-racist.

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White Allyship: in conversation with Prof David Richardson

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Implementing the Workforce Race Equality Standard (WRES) is a requirement for NHS commissioners and NHS healthcare providers including independent organisations, through the NHS standard contract.

The NHS Equality and Diversity Council announced on 31 July 2014 that it had agreed action to ensure employees from black and minority ethnic (BME) backgrounds have equal access to career opportunities and receive fair treatment in the workplace.

This is important because studies shows that a motivated, included and valued workforce helps deliver high quality patient care, increased patient satisfaction and better patient safety.

In April 2015, after engaging and consulting with key stakeholders including other NHS organisations across England, the WRES was mandated through the NHS standard contract, starting in 2015/16. From 2017, independent healthcare providers are required to publish their WRES data.

The first WRES report, was published in June 2016, followed by the 2016 WRES report on 19 April 2017. In the first two years, there have been improvements in some trusts, although a number of organisations still have a long way to go. The 2017 and 2018 WRES data reports showed a trend of continued improvement in a number of areas, but there is still much work to do in some trusts, sectors and parts of the NHS.

The 2022 WRES data report compares data from previous years to assess trends.

NHS providers are expected to show progress against a number of indicators of workforce equality, including a specific indicator to address the low numbers of BME board members across the organisation.

The first phase of the WRES focused on supporting the system to understand the nature of the challenge of workforce race equality and for leaders to recognise that it was their responsibility to help make the necessary changes.

WRES phase two

The next phase of the WRES will focus on enabling people to work comfortably with race equality. Through communications and engagement, we will work to change the deep rooted cultures of race inequality in the system, learn more about the importance of equity, to build capacity and capability to work with race.

Continuous embedding of accountability to ensure key policies have race equality built into their core, so that eventually workforce race becomes everyday business.

The WRES will continue to work to evidence the outcomes of the work that is done, publishing data intelligence and supporting the system by sharing replicable good practice.

With over one million employees, the NHS is mandated to show progress against a number of indicators of workforce equality, including a specific indicator to address the low numbers of BME board members across the organisation.

Alongside WRES, NHS organisations use the Equality and Diversity Systems (EDS2) to help in discussion with local partners including local populations, review and improve their performance for people with characteristics protected by the Equality Act 2010. By using the EDS2 and the WRES, NHS organisations can also be helped to deliver on the Public Sector Equality Duty.

More information to help you understand the WRES, downloadable information, videos and EDS2 can be found in our resources section.

WRES reporting

From 2018, WRES data is collected through the NHS Digital Strategic Data Collection Service (SDCS), which replaced UNIFY 2 the previous platform.

Get in touch

If you have questions about the WRES Programme, please contact the National WRES Implementation Team england.wres@nhs.net.

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NHS England » NHS Workforce Race Equality Standard

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Implementing the Workforce Race Equality Standard (WRES) is a requirement for NHS commissioners and NHS healthcare providers including independent organisations, through the NHS standard contract.

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' The Good Ally is a powerful trojan horse. While the title calls out to every white person who has wanted to know 'How can I become a good anti-racist ally?', it's content delivers hard-hitting facts, stories, and reflections that remind us that it's not about being good, it's about doing better.'
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'On the journey to becoming a better and more effective ally, Nova's book is a must read. It will prompt deep reflection, it will make you smile, and it might even make you cry. Through this process, it powerfully provides the insight and guidance each of us need to be better.' Gary Coombe, CEO P&G - Global Grooming Business

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'A powerful book for change that comes at a time when we need it most. Nova seamlessly weaves together historical and personal storytelling with practical advice, creating a work that is informative, confronting and moving.' Matthew Williams, author of The Science of Hate and Professor of Criminology Cardiff University

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Buy The Good Ally By Nova Reid. Available in used condition with free delivery in the UK. ISBN: 9780008439521. ISBN-10: 0008439524

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