Dr Flo Chan Mow and Anton Blank at Kidz First Hospital, Auckland. (Photo: Fliss Thompson)

Kidz First, the children’s hospital in South Auckland, is confronting unconscious racism in its own staff through its in-house implicit bias programme. Here, Dr Flo Chan Mow and Anton Blank talk to Teuila Fuatai about what that looks like.

In Aotearoa, we know there’s deep-seated, implicit bias among our healthcare workers that works against Māori and Pasifika.

For example, research shows that healthcare workers, particularly doctors, tend to believe that Māori patients are sickly and non-compliant.

The non-compliance aspect is really dangerous because when healthcare workers believe that, they’re less likely to give patients the complete range of options around their illness. It means if you’re Māori, you’re less likely than a Pākehā patient to hear about all the treatments, testing procedures, specialist opinions and clinic follow-ups available for your illness.

There’s a similar pattern around birth control for Māori and Pasifika women.

Basically, the data shows that Māori and Pasifika women are less likely to be offered the pill, and more likely to be offered an IUD or other more invasive birth control option. The bias here is the belief that Māori and Pasifika women don’t take birth control pills regularly.

The other odd thing we see is to do with pain and people of colour. Research overseas tells us that when we see a white person in pain, we have a more urgent response. But when we see people of colour in pain, it’s not the same — we don’t feel the same urgency. And certainly, the pain medication data in New Zealand backs that up. Māori women are less likely to be offered an epidural, for example, and less likely to be offered antidepressants.

And, when you look at all of those things at a system level, the research shows that the bias in individual, everyday decisions being made by healthcare workers while they’re caring for patients actually contributes to patterns of ongoing inequities for Māori and Pasifika in health.

It’s how we know implicit bias isn’t totally random. It’s the attitudes sitting in our brain that we’re not really aware of. These are informed by our societal context, and by the attitudes around us — which means, even if you’re Māori and Pasifika, you’re not immune because you’re part of that societal context. Everyone has the potential to hold these biases.

It’s one thing to point that out ­­­­­— but it’s another to ask people to change their attitudes and behaviours.

At Kidz First Children’s Hospital, most families who come through our doors are Māori and Pasifika. We know, anecdotally and in theory, that these families are treated differently because of who they are. It’s backed up by lots of reports and research into different types of racism in the health system. And it’s also what we hear in our own circles and what we experience in our jobs.

For us in South Auckland, we knew it was time to own up to that, and to do better by the families who come to us when they have a sick child.

It’s why we set up our implicit bias programme for staff in our acute in-patient service. That’s now in its second year, and about 200 people are involved, including our doctors, nurses, clerks, healthcare assistants, and cleaners — as well as staff like social workers, physiotherapists and occupational therapists.

This programme emerged out of the Māori Child Health Research Collaborative (which is a thinktank of experts) and a partnership with mana whenua exploring ways to address health equity for Māori in Counties Manukau.

We’ve focused on acute in-patient services because this is where staff are working under pressure. And research tells us that when workers are under pressure and stressed, their behaviour will be triggered by their biases.

When we started the programme in 2021, we told staff about the data around implicit bias and they recognised it immediately. No one was really surprised, and staff gave examples of how Māori and Pacific families were treated differently in our hospital because of it.

Staff said Pākehā patients often got a more responsive service — with Māori and Pasifika not prioritised in the same way. They were pushed down waiting lists, as one person put it. This means whānau Māori are having to wait longer to be seen by a doctor compared to other groups — which shouldn’t happen because we know that longer waiting times for treatment leads to poorer health outcomes.

Another staff member talked about how Māori were often labelled as challenging and “stroppy”, sometimes just because a family member was heard speaking loudly and swearing. As a result, these families were more likely to be surveilled, and assumptions were made around them needing a social worker. And we know that when our families don’t have a good experience, they’re less likely to come back to a service.

When it came to Pasifika patients and families, one staff member identified how they were viewed as more compliant. That was linked to Pasifika being treated as a lower priority compared to other ethnic groups in hospital. Staff knew Pasifika were more likely not to make a fuss, or to question doctors and nurses about information and decisions. And that comes back to values around respect and authority in Pasifika cultures.

The real challenge has been to untangle the individual attitudes and behaviour that resulted in these situations.

We’ve known about implicit bias for decades but most of the strategies addressed the issue at a systemic level. However, the research and discourse about implicit bias in Aotearoa has developed significantly over the last five years, so we wanted to develop a programme focused very specifically on the point of contact between workers and whānau.

One of the first training exercises we did was about stereotypes. We had different ethnic groups: Māori, Pasifika, Indian, Asian. And everyone wrote down all the stereotypes associated with that group. They also described how they felt towards that particular group.

Staff were very uncomfortable with that exercise because it revealed the latent attitudes they had towards various ethnic groups. Internationally, white populations tend to have more positive characteristics and stereotypes associated with them. People of colour are more likely to be stereotyped as non-compliant, difficult and aggressive.

We see these same patterns in Aotearoa, and this is what our training exercise revealed.

The main thing we want during the training is for people to see the bias in themselves while they’re on the job. A lot of staff were able to identify attitudes and situations where another staff member’s bias had affected how a Māori or Pacific family was treated. But it’s a different thing to check yourself when it’s your behaviour and your bias that’s going to determine what’s happening with a patient.

For instance, Flo’s been through the training many times, and she learned that she makes assumptions that women will be more emotional in the workplace — and that Pasifika women will probably have children. Because of the training, she’s been able to challenge these assumptions because neither is true.

In a workplace like this, addressing implicit bias often means slowing down.

Everyone knows what the stereotypes are, and even though we think they don’t influence our behaviour, the brain has stored that information. When we’re under pressure, or on automatic-pilot mode, it’s going to trigger our behaviour without us realising. That’s why it’s important to slow things down.

Early in the programme, a staff member identified inconsistencies in how staff behaved depending on how they felt at a particular moment. For example, they talked about how, when staff were feeling judgmental, their attitude often put a lot of blame on patients. So, they’d ask questions like: “Why didn’t you get the prescription and follow instructions?”

We know that doesn’t help a family whose child is unwell. And, for Māori and Pasifika, we also know there are lots of barriers around getting medication. It’s why we need to be aware that comments like that are often harmful and stigmatising —and why getting staff to practise tools, like slowing down their breathing and on-the-ward meditation, makes a difference. We want them to think before they blurt out something.

Staff say that they’re much more aware of their implicit biases following the training.

One of the doctors in the programme has made a spreadsheet of her clinic patients, which showed that Māori attend clinic like any other group but Pasifika don’t.

When we looked at what was happening, we identified an implicit bias among staff that likely contributes to that lower attendance among Pasifika. Because it’s not unusual for Pasifika families to miss clinic, she found there wasn’t any urgency to follow up with them. And that only perpetuated the current pattern.

Now that we’ve highlighted this, we can make sure that we’re not just letting those families wander off. Staff can actually give them a call and see why they aren’t coming. Then we can look at what we can do at our end. For example, appointments are often scheduled by the hospital without any input from families about whether they’re available or can get time off work. We can fix that by simply contacting families and shifting our own approach to making appointments.

One of the interesting things we’ve looked at is how receptive our staff are to facing up to implicit bias in themselves. Almost everyone wants to address it. We don’t get a lot of resistance, but when it does come, it tends to be from the same cohort: older Pākehā staff.

We also know that, for some of our staff, the programme has been triggering because of their own experiences of implicit bias. There are many staff of colour here: Māori, Pasifika, Asian, Indian, other new migrant groups. And, for all of them, we’re touching on their personal life experience as well.

Being able to talk about their experiences in workshops seemed to be a kind of relief. It’s like, “I can actually talk about it. This is what I’ve been experiencing all this time. There’s a name for it and there’s evidence.”

We’ve also found that the students who come through have a different mindset. They understand what implicit bias is. They talk about racism. They know what a microaggression is. They’ve been educated in a really different way.

We’ve also worked with a small group of Māori and Pacific families who’ve come into hospital with their children. What came through strongly with them was how health literate they were. All the families told us what was wrong with their child in quite detailed ways, what medications needed to be administered, and when they needed to be administered. We also talked about the need for them to be hyper-vigilant once they got into hospital — because of the implicit bias that operated in our staff.

Addressing our own implicit bias is about looking at the small picture. We’re focusing on the point of engagement between staff and patients. It’s where we, as staff, can make a difference.

We also know that we need to address systemic inequities, and we’re looking across the system and identifying where there are barriers for medication, treatment and information for Māori and Pasifika.

It’s about making simple changes that make a difference, and we’re developing a measure so that we can track changes over time.

It’s not one or the other but both. We need to address the bias in the workforce and the system to achieve long-term, sustained change for Māori and Pasifika.

The ultimate vision is to address the structural and organisational barriers, but this must start with shifting the mindset of the workforce. This is the necessary starting point to ensure staff can serve whānau Māori and Pasifika, so they experience high-quality healthcare and equity.

• You can read about what it’s like to be on the receiving end of biased health care in this piece by Aroha Gilling.

As told to Teuila Fuatai. Made possible by the Public Interest Journalism Fund.

Dr Flo Chan Mow is a senior doctor at Kidz First Hospital, the children’s hospital in South Auckland. She was born and raised in Sāmoa, and is among the founding members of SouthSeas Healthcare, in Ōtara, the largest Pacific primary healthcare provider in New Zealand. Alongside her clinical work, research and leadership of the implicit bias staff programme at Kidz First, Flo mentors and teaches medical students and junior doctors coming through the system. 

 Anton Blank (Ngāti Porou, Ngāti Kahungunu) has a background in social work, communications, Māori development, public health and literature. He was the principal investigator of the 2016 report “Unconscious bias and education — a comparative study of Māori and African American students”. Anton now works across justice, health and education, developing strategies to mitigate unconscious bias and its impact on Māori. This includes his ongoing work at Kidz First. Anton is also the editor and founder of the Māori literary journal Ora Nui.

© E-Tangata, 2023