Abstract
This review aims to comprehensively consolidate and synthesize the existing body of empirical research on the perceptions and experiences of healthcare professionals, trainees, and students concerning microaggression interactions within diverse clinical settings. The review protocol was registered with the international prospective register of systematic reviews (PROSPERO CRD42024546443). We employed the Joanna Briggs Institute’s mixed-methods systematic review approach. Comprehensive electronic database searches were conducted across eight databases (Medline, Embase, CINAHL, PsycINFO, Scopus, Web of Science, Social Science Database, and ProQuest Dissertation and Theses) from their respective inception dates up to October 1, 2023. The selection criteria included studies reporting instances of interprofessional or intra-professional microaggressions occurring in clinical environments among healthcare professionals, trainees, and students identifying as heterosexual and without disabilities. In total, 37 studies met the eligibility criteria and were included in our review. Our analysis revealed three primary themes: Racial Microaggressions in the Clinical Environment, Gender Microaggressions in the Clinical Environment, and Religious Microaggressions in the Clinical Environment. Research must delve deeply into these experiences to better understand their long-term consequences, while policy initiatives should be designed to establish equitable, inclusive, and respectful healthcare environments. Collaborative endeavors bridging research and policy are paramount to dismantling barriers and nurturing an inclusive healthcare landscape.
Introduction
Microaggressions, as defined by D. W.Sue et al. (2007), pertain to the brief and recurring verbal, nonverbal (behavioral), and environmental affronts encountered in everyday life. These affronts, whether deliberate or inadvertent, communicate derogatory, hostile, and negative messages based on attributes such as gender, race, religious affiliation, and sexual orientation ( D. W.Sue et al., 2007). D. W.Sue et al. (2007) introduced a taxonomy of gender, racial, and sexual orientation microaggressions, organizing them into three primary categories: microassaults, microinsults, and microinvalidations. While these three forms vary in terms of perpetrator awareness and intentionality, they all communicate explicit or concealed messages to the targeted groups ( D.Sue, 2010; D.Sue et al., 2019). Microassaults resemble “traditional” racism, sexism, or heterosexism at the individual level, marked by deliberate and conscious behaviors that involve subtle or explicit derogation of an individual based on their race, gender, or sexual orientation. They involve the use of verbal expressions, behaviors, and environmental cues with the intent of either attacking the targeted individual’s group identity or causing them harm. This can manifest through name-calling (e.g., using racial epithets), avoidance behavior (e.g., discouraging interracial marriages), or intentional discriminatory actions (e.g., promoting a less-qualified heterosexual employee over a nonheterosexual colleague; D.Sue, 2010; D. W.Sue et al., 2007). Microinsults can be likened to “contradictory communication.” They involve subtle slights that are often concealed, sometimes unconsciously, behind an initial façade of a compliment or a positive statement directed toward the target individual or group. These statements are subsequently undermined by a metacommunication that conveys an insulting or negative connotation. Microinsults typically manifest through verbal expressions, behaviors, and environmental cues to convey rudeness, insensitivity, slighting, or insults that undermine an individual’s racial, gender, sexual orientation, or group identity and heritage (D.Sue, 2010; D. W.Sue et al., 2007). Microinvalidations, like microinsults, often occur without the conscious awareness of the perpetrator. They are widely acknowledged as the most pernicious form of microaggression, primarily because they directly exclude, negate, or nullify the psychological thoughts, emotions, beliefs, and experiences of the targeted group through the use of verbal expressions, behaviors, and environmental cues (Sue, 2010; D. W.Sue et al., 2007).
The consequences of microaggressions transcend mere personal offense. According to Torres et al. (2019), Molina et al. (2020), and MacIntosh et al. (2022), regular and repeated exposure to microaggressions is associated with various adverse outcomes for healthcare professionals, trainees, and students: (a) diminished overall well-being and health disparities: this includes increased levels of anxiety, depression, trauma responses, hypertension, and higher rates of alcohol use. These effects are particularly pronounced among individuals who may struggle to articulate the impact of these exchanges; (b) erosion of self-esteem and diminished confidence. These negative impacts are exacerbated in clinical and educational settings; and (c) elevated rates of burnout. Experiencing microaggressions contributes to burnout, which, in turn, impairs learning, academic performance, and overall achievement.
Moreover, healthcare professionals, trainees, and students already face heightened risks of stress and burnout due to the rigorous demands of their training and work environments. Consequently, the cumulative impact of enduring microaggressions in clinical settings can have long-lasting repercussions, potentially compromising their success and exacerbating challenges in recruiting and retaining women and other underrepresented healthcare professionals in an already vulnerable pipeline (MacIntosh et al., 2022; Molina et al., 2020; Torres et al., 2019). While effective communication remains essential for ensuring high-quality patient care, it can be challenging in clinical settings (Molina et al., 2020). The dynamic and demanding clinical environment, marked by fluctuating shift schedules and a constant influx of off-service rotators, makes it difficult for healthcare professionals to cultivate meaningful long-term relationships and maintain effective communication (Molina et al., 2020). This is particularly evident in settings like the emergency department, where microaggressions are more likely to occur (MacIntosh et al., 2022; Molina et al., 2020; Torres et al., 2019).
To date, most reviews on microaggressions in healthcare have focused on two main areas: (a) microaggressions between faculty and students/trainees in healthcare education, academic, or classroom settings, and (b) interactions between healthcare professionals and patients, particularly marginalized individuals, in clinical settings. The existing evidence on microaggression interactions among healthcare professionals, trainees, and students is predominantly limited to interprofessional microaggressions observed within perioperative or surgical specialties (Ehie et al., 2021; Sprow et al., 2021), medical or nursing disciplines (Pusey-Reid & Blackman-Richards, 2022), and racial microaggressions (Gilliam & Russell, 2021; Pusey-Reid & Blackman-Richards, 2022). Recognizing the existing gaps in the literature and the negative impact of repeated exposure to microaggressions in healthcare, this review aims to comprehensively synthesize all available evidence on the perceptions and experiences of healthcare professionals, trainees, and students regarding microaggression interactions across various clinical environments. Our secondary aim is to enhance understanding of the consequences of microaggression interactions to guide the future of practices, policies, and research.
Methods
This review followed Joanna Brigg’s Institute approach to mixed-methods systematic reviews methodology, specifically the convergent approach framework, and adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement (Page et al., 2021), as detailed in Supplemental Appendix A. The review protocol was registered with the international prospective register of systematic reviews (PROSPERO CRD42024546443).
Search Strategy
We systematically conducted searches in eight electronic databases (Medline, Embase, CINAHL, PsycINFO, Scopus, Web of Science, Social Science Database, and ProQuest Dissertation and Theses) from their inception until October 1, 2023, encompassing both published and unpublished English language studies. The search strategy was structured around three primary concepts: (“Healthcare”) and (“Professionals” or “Trainees” or Student”) and (“Microaggression”) (see Supplemental Appendix B). Keywords, subject headings, and combinations were refined with the assistance of a medical librarian to optimize the search outcomes for each database. The reference lists of the included studies and prior reviews were also scrutinized to ensure that no relevant studies were inadvertently omitted. The EndNote X9 program (The EndNote Team) was employed to import and remove duplicate records and screen the remaining articles. Two independent reviewers (T.L.-B.P. and S.S.) assessed the titles abstracts, and the full texts of studies against the predefined eligibility criteria. Any disagreements that arose were resolved through discussion to achieve consensus, or by consulting a third reviewer (S.A. or H.I.).
Eligibility Criteria
The inclusion criteria encompassed published and unpublished primary qualitative, quantitative, or mixed-methods studies reporting on (a) instances of interprofessional or intra-professional microaggression, including microassaults, microinsults, or microinvalidations, (b) microaggressions occurring among healthcare professionals, trainees, and students who are heterosexual and without disabilities, (c) microaggressions occurring within the clinical environment (e.g., hospital wards, outpatient departments, or workplaces, resident or specialty training programs, clinical placements). The exclusion criteria encompassed studies reporting on (a) instances of sexual orientation or disability microaggressions, (b) microaggressions occurring among nonheterosexual or non-gender conforming healthcare professionals, trainees, or students, as these specific populations have specific and unique needs that may not apply to the general population, (c) microaggressions occurring between the healthcare team and patients, families, or external parties, (d) microaggressions occurring in contexts other than the clinical environment, (e) interventions designed to address microaggressions, including curriculum modifications, standardized patients scenarios, and simulations.
Quality Appraisal
Two independent reviewers (T.L.-B.P. and S.S.) conducted a methodological quality appraisal of the included studies using Hong et al.’s (2018) Mixed Methods Appraisal Tool, as described in Supplemental Appendix C. All studies were included, regardless of their methodological quality, to comprehensively gather and interpret all pertinent data related to healthcare professionals, trainees, and students and to avoid potential bias and inconsistencies that can arise when selecting studies based on their methodological quality (Hong et al., 2018; McDonagh et al., 2013). Any disagreements that arose during the quality appraisal process were resolved through discussion to achieve consensus or by consulting the third reviewer (S.A. or H.I.).
Data Extraction and Synthesis
The two reviewers (T.L.-B.P. and S.S.) independently extracted relevant data from the included studies, including author(s), publication date, country of origin, study design, methodology, population characteristics, and outcomes or themes and subthemes related to the perceptions and experiences of healthcare professionals, trainees, and students regarding microaggression interactions in the clinical environment. We employed a qualitative convergent integrated approach to synthesize findings across various methodological designs and address the research questions (Lizarondo et al., 2020). The conversion of quantitative data into qualitative formats was achieved through the process known as “qualitizing,” a process involving the abstraction and transformation of extracted quantitative data into textual descriptors such as categories, narratives, themes, or typologies (Stern et al., 2020). Subsequently, these “qualitized” data were collated and combined with qualitative data directly obtained from qualitative studies using Sandelowski and Barroso’s (2006) two-step approach. The initial step involved the generation of data into meta-summaries by grouping codes that shared similar meanings. In the second step, a meta-synthesis process was employed, generating novel interpretations and thematic insights related to the perceptions and experiences of healthcare professionals, trainees, and students regarding microaggression interactions in the clinical environment. To ensure the credibility of the synthesized data, Nowell et al.’s (2017) framework for establishing trustworthiness was upheld at every stage of thematic analysis.
Results
Search Outcomes and Study Characteristics
The search strategy yielded 3,373 records. After removing duplicates, 2,218 titles and abstracts were screened and 177 full texts were further assessed for eligibility. In total, 37 studies met eligibility requirements and were included in this review (see Figure 1).
PRISMA flow diagram.
These studies were published between 2010 and 2023 and included 16 qualitative, 17 quantitative, and 4 mixed-methods investigations. Among these, 33 studies underwent peer review and 4 were non-peer-reviewed—3 dissertations/theses (Greenwood, 2022; Mosier, 2022; Thomas, 2019) and 1 pre-print (Walker et al., 2023). Thirty-four single-country studies were conducted across the United States (n = 31), the United Kingdom (n = 3), and Italy (n = 1). Two studies were conducted across multiple countries—the United States, the United Kingdom, Uganda, South Africa, and Kenya (Ali et al., 2023), and Kuwait, Saudi Arabia, Bahrain, Yemen, Iraq, Palestine, Jordan, Lebanon, and Syria (Al Rashed et al., 2022). A total of 8,381 responses from healthcare professionals, trainees, and students were analyzed across the included studies. Detailed characteristics of these studies are presented in Table 1.
Characteristics of the Included Studies.
Note. CWB-C = Counterproductive Work Behavior Checklist; IQR = interquartile range; MIBI = Multidimensional Inventory of Black Identity; PHQ-2 = Patient Health Questionnaire-2; PODS = Perceived Occupational Discrimination Scale; RCS = Racial Climate Scale; REMS = Racial and Ethnic Microaggressions Scale; RMAS = Racial Microaggressions Scale; Sexist MESS = Sexist Microaggression Experiences and Stress Scale; SVS = Stereotype Vulnerability Scale; WBI = Well-Being Index.
On synthesizing the data and incorporating D. W. Sue et al.’s (2007) taxonomy of microaggressions, 3 main themes and 12 subthemes were identified, as illustrated in Table 2 and Supplemental Appendix D.
Summary of Critical Findings.
Theme 1: Racial Microaggressions in the Clinical Environment
Ascription of Intelligence and Criminal Status
Healthcare professionals, trainees, and students from diverse racial backgrounds frequently experience instances of racial microaggressions that detrimentally affect their well-being and hinder their professional progress. These microaggressions often manifest as biased assessments that portray individuals as intellectually inferior, less skilled in communicative and practical aspects or possessing only niche skills, and less successful based on their race and ethnicity (Brooks et al., 2023; Farid et al., 2021; Miller et al., 2023; Mosier, 2022; Pusey-Reid et al., 2022; Thomas, 2019; Walker et al., 2023). Consequently their thoughts and opinions are often marginalized or met with hostility, invalidation, or rejection (Ackerman-Barger et al., 2022; Al Rashed et al., 2022; Alimi et al., 2023; Farid et al., 2021; Miller et al., 2023; Mosier, 2022). They may face unconstructive feedback regarding their English fluency and accents (Alimi et al., 2023; Brown et al., 2021; Greenwood, 2022; Kay et al., 2022; Kim et al., 2022; Morrison et al., 2023; Osseo-Asare et al., 2018; Sudol et al., 2021; Thomas, 2019), or insinuations of “tokenism” and “affirmative action.” (Ackerman-Barger et al., 2022; Brooks et al., 2023; Bullock et al., 2020; Cedeño et al., 2023; Espaillat et al., 2019; Morrison et al., 2023; Pusey-Reid et al., 2022). Racial microaggressions also involve presumptions of individuals as dangerous, violent, criminal, or deviant, solely because of their race, leading to the mistrust and alienation of people of color by their peers (Ackerman-Barger et al., 2022; Alimi et al., 2023; Brooks et al., 2023; Greenwood, 2022; Koech et al., 2023; Nfonoyim et al., 2021; Sudol et al., 2021). Subsequently, this resulted in lower peer evaluation scores, leading to decreased program satisfaction and poorer mental health.
Second-Class Citizens
Healthcare professionals, trainees, and students of color express feeling less respected, alienated, receiving fewer learning/career progression opportunities, and experiencing favoritism in clinical and social settings (Al Rashed et al., 2022; Alimi et al., 2023; Greenwood, 2022; Kim et al., 2022; Koech et al., 2023; Miller et al., 2023; Morrison et al., 2023; Mosier, 2022; Nfonoyim et al., 2021; Pusey-Reid et al., 2022; Sudol et al., 2021; Thomas, 2019; Thomas-Hawkins et al., 2022; Walker et al., 2023). Their successes/achievements were often invisible, downplayed, or attributed to others. When acknowledged they were often perceived as “atypical” or “exceptional” examples of their race (Alimi et al., 2023; Flores & Bañuelos, 2021; Greenwood, 2022; Sudol et al., 2021; Thomas, 2019; Yang et al., 2023). Conversely, their mistakes/shortcomings are often scrutinized and overamplified, and they are held to stricter standards, less leniency, and face more severe punishments (Greenwood, 2022; Koech et al., 2023; Nfonoyim et al., 2021; Osseo-Asare et al., 2018; Thomas, 2019). For some, this treatment, and their inability to adapt to the “hidden curriculum” or “play the game,” led to decreased job satisfaction and learning motivation, heightened stress, social isolation, and “imposter syndrome” (Ackerman-Barger et al., 2022; Greenwood, 2022; Koech et al., 2023; Morrison et al., 2023).
Due to preconceived notions about the appearance of healthcare professionals, individuals of color are frequently misidentified as nonphysicians or nonclinical/ancillary staff. This is due to the belief that they “could not possibly occupy high-status positions” or “fit the mold” (Brooks et al., 2023; Brown et al., 2021; Bullock et al., 2020; Farid et al., 2021; Flores & Bañuelos, 2021; Greenwood, 2022; Ibrahim & Riley, 2023; Morrison et al., 2023; Nfonoyim et al., 2021; Osseo-Asare et al., 2018; Pusey-Reid et al., 2022; Thomas, 2019; Walker et al., 2023). Despite efforts to correct this mislabeling and wearing proper attire, and possessing identification badges, the issue persists, leading to a discouragement among many (Brown et al., 2021; Osseo-Asare et al., 2018; Thomas, 2019). In response, some individuals adopted a “siege mentality,” striving for perfection and overcompensating, to demonstrate their abilities, receive equal recognition, and challenge prevailing biases (Bullock et al., 2020; Greenwood, 2022; Mosier, 2022; Nfonoyim et al., 2021; Osseo-Asare et al., 2018; Thomas, 2019; Yang et al., 2023).
Pathologizing Cultural Values and Communication Styles
The perception that the values and communication styles of healthcare professionals, trainees, and students of color are considered abnormal led these individuals to feel a compelling need to conform and assimilate to the dominant culture and viewpoints. This often involved concealing or transforming aspects of their true identity to gain acceptance and fair treatment in the clinical setting (Brooks et al., 2023; Brown et al., 2021; Bullock et al., 2020; Goulart et al., 2021; Greenwood, 2022; Osseo-Asare et al., 2018; Walker et al., 2023). Despite expressing concerns, they frequently face dismissal of their experiences, and are advised to “leave their cultural identity” behind. This treatment leads some to question whether they are merely being “oversensitive,” “too fatigued,” or “projecting their feelings and insecurities onto others” (Alimi et al., 2023; Bullock et al., 2020).
In rare instances where individuals of color are viewed favorably, it often stems from ulterior motives and an assumption of racial or ethnic homogeneity. They reported being exploited as “linguistic and cultural assets” and being compelled to fulfill “equity work,” a “cultural tax,” or a “minority tax” (Brown et al., 2021; Espaillat et al., 2019; Flores & Bañuelos, 2021; Kim et al., 2022; Koech et al., 2023; Nfonoyim et al., 2021; Osseo-Asare et al., 2018; Yang et al., 2023). Due to their race and bilingualism, they are assigned additional responsibilities without compensation. These include serving as ambassadors or experts on racial or ethnic issues, being called to fix diversity problems, providing interpretation and translation services, and having to shoulder additional care for minority patients (Brown et al., 2021; Cedeño et al., 2023; Farid et al., 2021; Flores & Bañuelos, 2021; Koech et al., 2023; Osseo-Asare et al., 2018; Yang et al., 2023). Moreover, institutions do not always provide sufficient resources to ensure that these tasks are achievable. Furthermore, these situations detract from their professional and academic pursuits, leading to increased burnout, decreased satisfaction, and diminished performance (Cedeño et al., 2023; Flores & Bañuelos, 2021; Nfonoyim et al., 2021; Osseo-Asare et al., 2018; Yang et al., 2023).
Alien in Own Land, Color Blindness, and Denial of Individual Racism
Individuals of color are frequently mistaken for being foreign-born and lauded for speaking fluent English, leading to feelings of not belonging (Alimi et al., 2023; Brown et al., 2021; Greenwood, 2022; Kay et al., 2022; Kim et al., 2022; Morrison et al., 2023; Osseo-Asare et al., 2018; Sudol et al., 2021; Thomas, 2019). Even after clarifying their background, others continued to disregard their explanations and question their heritage (Kay et al., 2022; Morrison et al., 2023; Osseo-Asare et al., 2018; Thomas, 2019; Yang et al., 2023). In addition, these individuals also face challenges such as a lack of effort to remember and correctly pronounce names, renaming, nicknaming, or Anglicizing names, group-labeling, and misidentifying their identity (Alimi et al., 2023; Farid et al., 2021; Kay et al., 2022; Kim et al., 2022; Morrison et al., 2023; Osseo-Asare et al., 2018; Thomas, 2019; Yang et al., 2023). They also encountered cases where the dominant group perpetuated racial and ethnic stereotypes or exoticized them, invading their personal space (Espaillat et al., 2019; Goulart et al., 2021; Greenwood, 2022; Ibrahim & Riley, 2023; Kay et al., 2022; Kim et al., 2022; Morrison et al., 2023; Nfonoyim et al., 2021; Osseo-Asare et al., 2018; Pusey-Reid et al., 2022; Sudol et al., 2021; Walker et al., 2023; Yang et al., 2023). When confronted, the perpetrators deliberately ignored their mistakes, denied racism by citing multiracial friendships, or attempted to “gaslight” the affected individuals by suggesting that they were being overly sensitive (Alimi et al., 2023; Brown et al., 2021; Bullock et al., 2020; Kay et al., 2022; Morrison et al., 2023).
Environmental Racial Microaggressions and Others
In clinical settings, healthcare professionals, trainees, and students of color often find themselves as the sole representatives of their racial and ethnic backgrounds (Alimi et al., 2023; Bullock et al., 2020; Osseo-Asare et al., 2018), intensifying feeling of self-consciousness and isolation. Moreover, the glaring absence of diverse healthcare leaders, supervisors, and mentors leaves individuals of color with inadequate social and professional support when racial microaggressions occur, and a lack of role models in their field to emulate (Bullock et al., 2020; Cedeño et al., 2023; Greenwood, 2022; Morrison et al., 2023; Nfonoyim et al., 2021; Osseo-Asare et al., 2018; Sudol et al., 2021; Walker et al., 2023; Yang et al., 2023). This absence also hinders their likelihood of entering and succeeding in their education and training, and working with supervisors and mentors who share similar identities and experiences. Consequently, these individuals are more likely to experience less fulfilling mentoring relationships, more racial microaggressions, feelings of isolation, and professional development challenges (Cedeño et al., 2023; Greenwood, 2022; Morrison et al., 2023; Osseo-Asare et al., 2018; Thomas, 2019; Walker et al., 2023; Yang et al., 2023).
Individuals of color generally underreported or failed to report instances of microaggressions due to pressures of hectic schedules, clinical responsibilities, and assessments (Bullock et al., 2020; Osseo-Asare et al., 2018; Thomas, 2019; Yang et al., 2023), and a lack of trust in their institutions’ ability to treat them fairly and effectively handle discrimination and diversity (Farid et al., 2021; Greenwood, 2022; Kay et al., 2022). This occurred when institutions: (a) did not respond in a proactive or timely manner, (b) did not have proper reporting systems in place, (c) had bureaucratic hindrances preventing action, or (d) lacked the appropriate professionals or interventions to respond adequately to feedback (Greenwood, 2022; Kay et al., 2022; Morrison et al., 2023; Osseo-Asare et al., 2018; Thomas, 2019; Walker et al., 2023; Yang et al., 2023). Individuals tended to opt for silence to avoid damaging relationships, jeopardizing potential evaluations or grades, being fired, or being perceived as “playing the race/ethnicity card” (Bullock et al., 2020; Nfonoyim et al., 2021; Osseo-Asare et al., 2018). Weak institutional commitments to cultural competency, and diversity promotion, and recruitment of underrepresented groups exacerbated these issues (Flores & Bañuelos, 2021; Osseo-Asare et al., 2018; Thomas, 2019).
Environmental racial microaggression can also manifest as racially explicit or inappropriate information in the clinical environment, including curricula, comments, handbooks, and imagery (e.g., pictures, videos, and other media; Brooks et al., 2023; Greenwood, 2022; Yang et al., 2023). More significantly, in the form of welfare, pay, or promotion discrimination for individuals of color, even when they possess more qualifications and work experience (Greenwood, 2022; Mosier, 2022; Myers et al., 2023; Thomas, 2019; Walker et al., 2023). While less common, some experienced explicit acts of racial microassaults, including the use of racial epithets, stereotype-laden language, and racist humor (masked as attempts to forge “connections”), and bullying, harassment, or targeted threats within clinical environments (Al Rashed et al., 2022; Brooks et al., 2023; Brown et al., 2021; Cedeño et al., 2023; Farid et al., 2021; Kay et al., 2022; Morrison et al., 2023; Walker et al., 2023).
Theme 2: Gender Microaggression in the Clinical Environment
Assumptions of Inferiority
Women healthcare professionals, trainees, and students frequently encounter gender-based microaggressions that undermine their perceived competence in various aspects encompassing intelligence, temperament, and leadership capabilities (Ali et al., 2023; Alimi et al., 2023; Barnes et al., 2019, 2020; Chatterjee et al., 2021; Espaillat et al., 2019; Farid et al., 2021; Ibrahim & Riley, 2023; Samora et al., 2020; Sudol et al., 2021; Thum et al., 2021). These biases manifest in the delineation of gender-specific roles and responsibilities, grounded in the presumption that women are suitable primarily for various supportive/assistant positions. Consequently, women are frequently assigned fewer complex cases and patients and are precluded from assuming active leadership roles, which curtails their autonomy and learning and growth opportunities. Compared to men, women facing more inquiries, interruptions, and challenges to their medical competency and decision-making abilities. Moreover, they face skepticism regarding their status as healthcare professionals gender-based microaggressions permeate various roles and hierarchical levels, perpetuated even by junior healthcare team members, ancillary staff, or interns (Barnes et al., 2019, 2020; Brown et al., 2021; Chatterjee et al., 2021; Farid et al., 2021; Goulart et al., 2021; Miller et al., 2023; Sobel et al., 2023).
Notably, successful women sometimes may have their accomplishments erroneously attributed to men, with others expressing surprise that a woman could perform just as well as, or even better than, her male counterparts. Women also reported receiving remarks that they receive opportunities not because of their talents, but because they are “token women” (Barnes et al., 2019, 2020; Brown et al., 2021; Farid et al., 2021; Miller et al., 2023; Parini et al., 2021). Women healthcare professionals, trainees, and students also contend with stereotypes of being temperamentally inferior, emotionally driven, and lacking the fortitude for tough decisions, discouraging them from pursuing leadership roles (Barnes et al., 2019; Flores & Bañuelos, 2021; Goulart et al., 2021; Sudol et al., 2021). Consequently, women often face questions about their presence at leadership meetings, compelling them to downplay their femininity and emotions and adopt masculine behaviors and communication to gain respect and opportunities (Farid et al., 2021; Goulart et al., 2021; Myers et al., 2023).
Second-Class Citizens
Women healthcare professionals, trainees, and students consistently report observing preferential treatment being given to men, leading to being misidentified as nonphysician or nonclinical staff, such as nurses, therapists, or receptionists. Such problems persists despite efforts to correct these misconceptions, leaving many women feeling disheartened and resorting to ignore the issue rather than address it (Alimi et al., 2023; Barnes et al., 2019, 2020; Brooks et al., 2023; Brown et al., 2021; Chatterjee et al., 2021; Espaillat et al., 2019; Goulart et al., 2021; Miller et al., 2023; Samora et al., 2020; Sudol et al., 2021; Walker et al., 2023). In addition, this pervasive sense of “invisibility” leads to undervaluation and underappreciation of their talents and character (Ali et al., 2023; Alimi et al., 2023; Barnes et al., 2019, 2020; Brown et al., 2021; Chatterjee et al., 2021; Espaillat et al., 2019; Farid et al., 2021; Flores & Bañuelos, 2021; Goulart et al., 2021; Ibrahim & Riley, 2023; Miller et al., 2023; Mosier, 2022; Myers et al., 2023; Parini et al., 2021; Thum et al., 2021), and women may question their worth compared to male colleagues (Ali et al., 2023). Moreover, the existence of a “boys club,” where male colleagues bond or socialize outside of work/training, exacerbates this issue by providing men with a platform for building advantageous working relationships with senior members and robust support networks (Ali et al., 2023; Barnes et al., 2019, 2020; Goulart et al., 2021).
Women often face higher standards and increased scrutiny for their mistakes, resulting in more severe penalties for relatively minor infractions (Ali et al., 2023; Barnes et al., 2019, 2020; Farid et al., 2021; Goulart et al., 2021; Myers et al., 2023; Nfonoyim et al., 2021; Parini et al., 2021; Sobel et al., 2023). The pressure compels women healthcare professionals to “overcompensate” and invest extra time and effort to gain formal recognition (Ali et al., 2023; Barnes et al., 2019, 2020; Chatterjee et al., 2021; Farid et al., 2021; Ibrahim & Riley, 2023; Myers et al., 2023; Nfonoyim et al., 2021). For example, women adapt by feigning interest in male-dominated activities (e.g., sports) and participating in socializing outside of work to foster connections and gain access to exclusive “spaces,” like the “doctor’s lounge,” or “locker rooms.” Such “spaces” can significantly influence their career advancement, learning experiences, access to potential mentors, and favorable work schedules (Barnes et al., 2019, 2020).
Traditional Gender Roles
Women healthcare professionals, trainees, and students encounter traditional gender role stereotypes dictating that they should embrace nurturing roles, marry near childbearing age, and prioritize their “domestic roles” (Bullock et al., 2020; Farid et al., 2021; Morrison et al., 2023; Osseo-Asare et al., 2018). Women encounter discouragement from pursuing specific fields despite their abilities, due to the perception that certain specialties are unsuitable for women and doubts over their commitments following childbirth (Ali et al., 2023; Barnes et al., 2019, 2020; Espaillat et al., 2019; Farid et al., 2021; Goulart et al., 2021; Ibrahim & Riley, 2023; Parini et al., 2021; Samora et al., 2020; Sudol et al., 2021). There is also an expectation for women to choose certain specialties perceived as more compatible with family life. Some women are told that their chosen field should allow them to be available for their families, ostensibly to prevent their husbands from seeking extramarital relationships (Espaillat et al., 2019). Unlike men, women faced more intrusive questions about fertility goals, pregnancy timing, family size, and decisions not to have children. They also face additional pressure to justify their plans for childbearing and receive more unsolicited family-planning advice (Ali et al., 2023; Barnes et al., 2019, 2020; Espaillat et al., 2019; Goulart et al., 2021; Thum et al., 2021; Walker et al., 2023).
During residency, an unwritten rule discourages women from having children, with a constant reminder to reaffirm their commitment to their careers, evident from remarks like “I hope you are not pregnant” (Ali et al., 2023; Barnes et al., 2020; Goulart et al., 2021; Thum et al., 2021; Walker et al., 2023). In addition, women who experience pregnancy hardships/miscarriages often keep this information to themselves, as they fear being perceived as “missing cases due to a miscarriage” or being suspected of malingering (Ali et al., 2023; Barnes et al., 2019, 2020). Following childbirth, women have reported diminished support from their colleagues and institutions, including the lack of physical resources for breastfeeding in the workplace. Some have been told that their “breastfeeding is taking too long,” implying that they are attempting to avoid work (Farid et al., 2021; Goulart et al., 2021).
Sexual Objectification and Language
Women healthcare professionals, trainees, and students may experience a devaluation of their professional competence, being reduced to mere sexual objects judged solely from their physical appearance. Instead of evaluating their capabilities, discussions frequently revolve around their looks, expectations regarding appearance, and suggestions for altering their physical traits (Alimi et al., 2023; Barnes et al., 2019, 2020; Chatterjee et al., 2021; Espaillat et al., 2019; Goulart et al., 2021; Parini et al., 2021; Sudol et al., 2021; Yang et al., 2023). Consequently, women feel compelled to invest resources to manage their appearance, whether through dressing for a positive impression or adopting less revealing and more traditionally feminine styles to deter comments (Barnes et al., 2019, 2020; Ibrahim & Riley, 2023; Sudol et al., 2021). Pet names like “princess,” “sweetheart,” or “girl,” intended as compliments or appearing innocently endearing, are perceived as belittling, patronizing, and a constant reminder of their gender (Barnes et al., 2019, 2020; Espaillat et al., 2019; Ibrahim & Riley, 2023; Parini et al., 2021). Moreover, sexist language labeling assertive women as “bitchy,” “unladylike,” “hostile,” or “difficult,” reflect deep-seated stereotypes suggesting that women should be docile, soft, and conventionally feminine. Consequently, this leads women to preemptively apologize for their assertiveness (Ali et al., 2023; Barnes et al., 2019, 2020; Bullock et al., 2020; Chatterjee et al., 2021; Farid et al., 2021; Flores & Bañuelos, 2021; Goulart et al., 2021; Greenwood, 2022; Miller et al., 2023; Nfonoyim et al., 2021; Parini et al., 2021; Sudol et al., 2021). Women from racial/ethnic minority groups, particularly Asian women, report higher frequencies of experiencing exoticization and unwanted sexual attention (Alimi et al., 2023; Cedeño et al., 2023; Goulart et al., 2021; Sudol et al., 2021; Yang et al., 2023).
When women raise concerns about sexist microaggressions, they are often met with a dismissive responses like “being too oversensitive,” trivializing their experiences as “just harmless fun” (Barnes et al., 2019; Ibrahim & Riley, 2023; Samora et al., 2020). Moreover, the acceptance of sexist humor directed at women as “normalized” and “harmless” establishes a precedent for socially unacceptable hostility toward women. This societal conditioning also reinforces the belief that men and women have distinct, predetermined roles to play (Flores & Bañuelos, 2021; Goulart et al., 2021; Ibrahim & Riley, 2023; Samora et al., 2020; Sobel et al., 2023).
Environmental Gender Microaggressions and Others
Women healthcare professionals, trainees, and students have reported instances where men assert their right to sexualize women by displaying inappropriate images and content in the workplace, even during formal lectures and presentations (Goulart et al., 2021; Samora et al., 2020; Sobel et al., 2023; Sudol et al., 2021; Thum et al., 2021). Women refrain from reporting such incidents due to: (a) insufficient confidence in the institution’s ability to address discrimination and provide equitable treatment, (b) a lack of accessible and secure reporting channels, (c) an absence of female counselors/mentors, and (d) concerns regarding possible retaliatory actions (Barnes et al., 2019, 2020; Goulart et al., 2021; Ibrahim & Riley, 2023; Parini et al., 2021; Walker et al., 2023). Their disenfranchisement with the reporting process was exacerbated when women encountered adverse outcomes or futile attempts while reporting such incidents. For instance, (a) having their concerns ignored or undervalued, (b) the necessity for prolonged and exhausting procedures, (c) the preference for their perpetrator’s testimony over theirs, and (d) instances where the focus shifted back to the victim, compelling them to grapple with the consequences (Barnes et al., 2019; Goulart et al., 2021; Ibrahim & Riley, 2023; Parini et al., 2021; Walker et al., 2023). More significantly, these microaggressions may manifest in welfare, promotion, or pay inequalities, despite women having more qualifications and work experience (Ali et al., 2023; Farid et al., 2021; Mosier, 2022; Myers et al., 2023; Parini et al., 2021). For example, maternity leave policies have proven difficult to navigate, offering insufficient coverage and failing to adjust clinical productivity targets to be more manageable (Ali et al., 2023).
Moreover, women also reported a change in departmental/institutional expectations after pregnancy. These changes entail either a reduced expectation as they anticipate women would work shorter hours to accommodate family responsibilities or an increased expectation for them to exert more effort to compensate for any work absence during their pregnancy (Ali et al., 2023). While less common, some healthcare professionals, trainees, and students of color report explicit acts of gender microassaults, such as being threatened, overt gender discrimination, being “hit on” or experiencing sexual harassment within the clinical environment (Al Rashed et al., 2022; Brown et al., 2021; Chatterjee et al., 2021; Goulart et al., 2021; Greenwood, 2022; Parini et al., 2021; Sobel et al., 2023; Sudol et al., 2021; Thum et al., 2021; Walker et al., 2023). Notably, these gender-based microaggressions are not nonexclusive to men; women can also be perpetrators, sometimes exhibiting greater severity and intensity than their male peers (Barnes et al., 2020; Flores & Bañuelos, 2021; Goulart et al., 2021; Parini et al., 2021; Samora et al., 2020; Sudol et al., 2021; Thum et al., 2021).
Theme 3: Religious Microaggression in the Clinical Environment
Religious Microinsults and Microinvalidations
Healthcare professionals, trainees, and students from diverse religious backgrounds frequently encounter remarks or actions that perpetuated inaccurate perceptions regarding their religious affiliations. Many find that their diverse religious practices or lack thereof are regarded as abnormal, sinful, or deviant (Bullock et al., 2020; Espaillat et al., 2019; Thomas, 2019; Yang et al., 2023). Notably, Muslim healthcare practitioners, trainees, and students face overtly Islamophobic encounters, including being labeled as “terrorists” or associated with terrorism, raising concerns about personal safety (Bullock et al., 2020; Murrar et al., 2023; Yang et al., 2023). Furthermore, they encounter situations where their religious practices are considered “foreign, bizarre, and exotic,” contributing to feelings of being exoticized and undervalued in terms of privacy and status (Alimi et al., 2023; Goulart et al., 2021; Murrar et al., 2023). Moreover, individuals from diverse religious backgrounds are burdened with the unfair assumption that they possess identical beliefs, customs, and values, resulting in an inequitable workload due to their religious identity. They are expected to represent staff and patients sharing of similar religious backgrounds and advocate for religion-inclusive policies and accommodations, akin to a “religious tax” (Alimi et al., 2023; Murrar et al., 2023).
In response, individuals from diverse religious backgrounds sometimes concealed their religious identity to conform to the dominant religious group’s values and practices, even if these conflicted with their own (Murrar et al., 2023). Furthermore, even individuals from the dominant religious groups encountered religious microaggressions when their religiosity is perceived to conflict with their competence as healthcare professionals, trainees, or students (Espaillat et al., 2019; Murrar et al., 2023). For example, participants reported facing comments such as “how can anyone in medicine be very religious or believe in God” and “it is impossible to be a pro-life, Christian, physician while remaining rational . . .” (Espaillat et al., 2019).
Environmental Religious Microaggressions and Others
Healthcare professionals, trainees, and students reported: (a) a lack of representation of individuals from diverse religious backgrounds in senior or leadership positions (Alimi et al., 2023), (b) the dominance of one religious belief in coursework and academic materials (Espaillat et al., 2019), and (c) structural discrimination, such as dismissal or unfair work arrangements based on religious identity (Murrar et al., 2023). Even in the face of explicit environmental microaggressions, individuals often refrain from speaking out to avoid straining social relationships, compromising future evaluations or grades, and further discrimination (Murrar et al., 2023).
Discussion
This review consolidated the perceptions and experiences of healthcare professionals, trainees, and students concerning microaggression interactions within diverse clinical settings findings. The implications of this review are discussed in the sections below and Table 3.
Summary of Implications for Practice, Policy, and Research.
Racial Microaggressions
Our review revealed that healthcare professionals and trainees from diverse racial backgrounds frequently encountered racial microaggressions, profoundly affecting their personal lives and careers. As substantiated by prior reviews (Ehie et al., 2021; Pusey-Reid & Blackman-Richards, 2022), these microaggressions emanated from biased judgments that assessed their intelligence, skills, and achievements solely through the lens of their race/ethnicity. Consequently, their voices were marginalized, and their opinions invalidated, with stereotypes persisting and success incorrectly attributed to factors like “tokenism” and “affirmative action.” (Ehie et al., 2021; Pusey-Reid & Blackman-Richards, 2022). As also indicated in previous reviews (Gilliam & Russell, 2021; Pusey-Reid & Blackman-Richards, 2022), individuals of color adopted a “siege mentality,” striving for perfection and investing additional time and effort to challenge these biases and demonstrate their capabilities. However, even with these efforts, their achievements were still downplayed, and they were characterized as “atypical” or “exceptional” examples of their race (Gilliam & Russell, 2021; Pusey-Reid & Blackman-Richards, 2022). These racial microaggressions extended to the perception of individuals of color as dangerous or criminal, negatively affecting peer evaluations, program satisfaction, and overall mental well-being (Ehie et al., 2021). Therefore, future research should extensively explore the long-term consequences of racial microaggressions on the academic and professional trajectories of healthcare professionals and trainees from diverse racial backgrounds. Insights from such research would better inform institution leaders and policymakers in creating inclusive and diverse workplace environments and aid in formulating and implementing comprehensive anti-racist training and policies.
Echoing the insights of a previous review by Ehie et al. (2021), the presence of racial/ethnic minority healthcare leaders, supervisors, and mentors significantly contributes to reducing disparities among these underrepresented groups, cultivating a sense of belonging, and nurturing the professional growth of healthcare professionals, trainees, and students from diverse racial backgrounds. However, the scarcity of diverse leaders and mentors persists. The is unsurprising, as research consistently indicates a diminishing representation of underrepresented minorities with each hierarchal advancement, resulting in an inadequate number of advocates for the concerns of underrepresented minority professionals, trainees, and students (Lett et al., 2018). Subsequently, their capacity and potential to drive positive organizational changes and provide personalized mentorship opportunities are constrained. Establishing racially inclusive mentorship programs is imperative, as subpar mentorship encounters are associated with heightened burnout among healthcare professionals and trainees, contributing to diminished personal and professional achievements and growth, particularly noticeable among racial/ethnic minority groups (Sargent et al., 2009). In the short term, institution leaders and policymakers could bolster the diversity in the recruitment process to expand the pool of diverse candidates poised to assume roles as healthcare leaders and mentors (Vela et al., 2021). For long-term sustainability, a viable retention strategy is needed, involving the establishment of a national network of racial/ethnic minority preceptors. This network would provide mentorship from the initial stages of healthcare education, through graduation, postgraduate training, and clinical practice (Mason et al., 2016). These joint initiatives would effectively alleviate the burden borne by diverse leaders and mentors when spearheading diversity initiatives and consequently augment the quality and potential pool of future racial/ethnic minority leaders and mentors (Vela et al., 2021).
As affirmed by Ehie et al. (2021) and Pusey-Reid & Blackman-Richards (2022), witnessing preferential treatment toward the dominant racial group undermines the achievements of individuals of color, intensifying feelings of social isolation. This is compounded by recurrent misidentification of their roles. Future research should focus on discerning the specific mechanisms sustaining this preferential treatment, its long-term repercussions, and the intersections with racial microaggressions. In addition, strategies to rectify these misidentifications and promote inclusivity should be formally studied. Achieving racial equity necessitates introspection among all professionals, trainees, and students. Cultivating self-awareness and exploring personal biases, fears, and assumptions form the foundational step in shifting discussions and highlighting the detrimental effects of microaggressions. To establish racial equity and prevent the perpetuation of microaggressions, healthcare professionals and trainees should be willing to: (a) acknowledge the existence of microaggressions, (b) engage in challenging or uncomfortable discussions, (c) actively listen to concerns, and (d) exhibit receptiveness to acknowledge errors instead of resorting to avoidance, dismissal, or defensive response (Feaster et al., 2021; Molina et al., 2020).
Consistent with previous reviews (Ehie et al., 2021; Pusey-Reid & Blackman-Richards, 2022), participants in our review emphasized the importance of hospital institutional policies that prioritize equal treatment and recognition for healthcare professionals and trainees, regardless of their racial background, as well as initiatives to foster diversity. These policies should encompass various aspects of healthcare practice, including role assignments, mentorship, and representation within leadership positions (Ehie et al., 2021; Pusey-Reid & Blackman-Richards, 2022). Previous research has indicated that while healthcare institutions typically uphold policies that prohibit unlawful discrimination, these policies primarily focus on preventing overt expressions of bias, and they may fall short of effectively addressing microaggressions originating from subtle prejudices (Periyakoil et al., 2020). This is compounded by the fact that implicit biases (including microaggression) are more resistant to change compared to overtly biased actions and language (Sprow et al., 2021). Therefore, institution leaders and policymakers need to take deliberate actions to educate individuals about microaggressions, establish norms to reduce this behavior, and foster a culture of zero tolerance for such incidents. This proactive approach ensures that instances of microaggressions are not overlooked and maintains a congenial and collegial professional work environment, particularly for racial minority groups (Periyakoil et al., 2020).
As indicated in previous research (Ehie et al., 2021; Gilliam & Russell, 2021), our review reported that the denial of individual racism and cultural blindness presents significant challenges for individuals of color, affecting their sense of belonging and the quality of their working relationships. Moreover, the practice of “othering” the cultural values and communication styles of individuals of color places imposes pressure to conform to the dominant culture, resulting in the suppression of their identities and voices (Ehie et al., 2021; Gilliam & Russell, 2021). These dynamics carry broad implications for mental health, academic and professional performance, and overall job satisfaction. According to prior research, nonrecipients of microaggression (dominant group) typically hold more influential positions to intervene, and recipients of microaggressions are more inclined to seek support from friends/members of their community rather than authority figures (Torres et al., 2019). Therefore, healthcare institutions and relevant stakeholders should implement peer support/allyship training to foster “allies,” defined as peers from the majority group who collaborate with racial/ethnic minority groups to promote change by advancing diversity, equity, and inclusion efforts while fostering cooperation among these groups (Feaster et al., 2021). This training could incorporate strategies such as redirecting conversation back to the interrupted individual, acknowledging and amplifying the voice of the individual who initially proposed an idea, and demonstrating support for those unfairly targeted (Feaster et al., 2021; Torres et al., 2019). In doing so, bystanders can be transformed into “active upstanders,” well-equipped to interrupt microaggressions and provide timely support to affected individuals. Furthermore, further research should focus on cultivating environments that genuinely value the diversity of cultural and communication styles, thereby empowering individuals of color to embrace their identities. Moreover, hospital and workplace policy initiatives should not solely emphasize tolerance but rather cultivate a culture where diversity is respected and appreciated, and where critical dialogues on microaggressions can occur.
In addition, our review findings emphasized that individuals from diverse racial groups often bear an inequitable workload (that is uncompensated) due to the assumption that they hold identical beliefs, essentially acting as advocates for inclusive racial policies, sometimes labeled a “racial tax.” To evade potential repercussions, some individuals opt to conceal their racial identity and conform to the practices of the dominant group. Instead of embracing their racial diversity, many choose to suppress it, which is regrettable. Institutions and policymakers could consider implementing remunerated positions tailored for these individuals to officialize and incentivize their role as ambassadors. This practice benefits offers mutual advantages: (a) it ensures patients’ unique and specific needs are addressed, (b) it provides tailored and racially-appropriate mentorship to trainees and students, and (c) it efficiently distributes the responsibility for steering diversity initiatives among various healthcare professionals from similar religious backgrounds, ensuring a balanced allocation of tasks and prevents overburdening specific groups of individuals (Lett et al., 2018).
Gender Microaggressions
Our review findings elucidated that gender-based microaggressions on women resulted in diminished competence, reduced autonomy, and consistent challenges to their decision-making abilities. These observations were corroborated by previous reviews (Gilliam & Russell, 2021; Sprow et al., 2021), underscoring the need to investigate how these gender-based microaggressions influence women’s careers and the long-term consequences to better develop and implement strategies to mitigate these microaggressions and promote equitable opportunities for women in healthcare. Institutional policies should advocate for gender equity, addressing challenges in roles and responsibilities faced by women and ensuring resource accessibility. To achieve this, relevant stakeholders must periodically assess if women have sufficient decision-making authority, appropriate representation in leadership roles, and adequate inclusion in organizational-level processes and policy development (Nardi et al., 2020). Diversity initiatives and support systems are also needed to encourage women to challenge gender stereotypes and support their leadership aspirations. Furthermore, policies could aim to create an equitable environment by addressing role mislabeling, and ensuring equal access to opportunities, resources, mentorships, and sponsorships, with a focus on eradicating the “boys club” culture (Sprow et al., 2021).
Women from the included studies in this review revealed that they felt compelled to adopt masculine communication styles and behaviors to avoid negative professional consequences, as similarly reported in recent reviews (Gilliam & Russell, 2021; Sprow et al., 2021). Thus, future research endeavors should prioritize developing strategies to empower women to express themselves authentically while garnering due respect and support in their roles. Moreover, institutional policies should actively endorse the recognition of diverse communication and leadership styles, and underscore the manifold benefits of gender diversity within the healthcare domain (Molina et al., 2020). Similar to other reviews, our review also highlighted that the objectification of women based on their physical appearance and the use of sexist language to undermine women in the healthcare sector is commonplace (Gilliam & Russell, 2021; Sprow et al., 2021). In this context, research investigations must explore the ramifications of objectifying women based on their appearance and using sexist language in the healthcare sector. Interventions should aim to eliminate these behaviors and engender a culture that embodies respect and inclusivity, while institutions must enact zero-tolerance policies against discrimination and harassment (Periyakoil et al., 2020). Our review reiterated that women generally did not report instances of gender microaggressions due to a lack of trust in existing reporting channels, fear of retaliation, and disenchantment with the reporting process (Sprow et al., 2021). To address this, healthcare institution leaders and policymakers should establish robust reporting platforms featuring simple reporting structures, ensure reporter anonymity, and allow both the victims and witnesses of the microaggression incident to file reports (Gilliam & Russell, 2021). These measures can help overcome hierarchical relationships that create power differentials between the perpetrator and the target, simplifying incident reporting, and minimizing unintended consequences. In addition, alongside this comprehensive and accessible reporting system, healthcare institution leaders and policymakers should ensure the establishment of a review committee, with diverse representation. This committee should be empowered to promptly resolve microaggression incidents, ensure policy adherence, and identify and address individuals demonstrating concerning behavioral patterns through reeducation and retraining efforts (Gilliam & Russell, 2021). Future research should also examine its effects on women’s career progression and overall well-being to inform strategies to enhance the representation of women, especially in leadership positions, address the gender pay gap, and explicitly recognize women’s contributions to healthcare (Ehie et al., 2021; Pusey-Reid & Blackman-Richards, 2022).
Religious Microaggressions
Unlike previous reviews by Ehie et al. (2021), Gilliam and Russell (2021), Sprow et al. (2021), and Pusey-Reid and Blackman-Richards (2022), the identification of religious microaggressions stands as a novel aspect of our review. These individuals faced situations where their religious practices or lack thereof were portrayed as deviant or abnormal. Particularly, Muslims were faced overt Islamophobic encounters, being labeled with stigmatizing terms like “terrorist,” leading to concerns about personal safety. In addition, their religious practices were often depicted as exotic and foreign, infringing on their privacy and positioning them as inferior to the dominant religious group. It is imperative to exploring methods to accommodate diverse religious beliefs and practices to foster a more inclusive and supportive healthcare clinical environment (Ehie et al., 2021; Molina et al., 2020; Pusey-Reid & Blackman-Richards, 2022). Future research should assess how education/training can assist health professionals in navigating diverse religions and preventing microaggressions (Ehie et al., 2021; Molina et al., 2020; Pusey-Reid & Blackman-Richards, 2022).
In addition, our review highlights that individuals from diverse religious groups often bear an inequitable workload due to what has been termed a “religious tax.” As previously stated, institutions and policymakers could consider the establishment of formally remunerated positions for these individuals to incentivize their roles as ambassadors. This practice is anticipated to yield positive outcomes for patients, trainees, students, and healthcare professionals hailing from diverse religious backgrounds (Lett et al., 2018). Environmental religious microaggressions included the lack of diverse religious representation in senior roles, the dominance of one religious belief in academic materials, and structural discrimination based on religious identity. Similarly, individuals refrained from speaking out to avoid social tensions or further discrimination; therefore, the establishment of robust, anonymous, and accessible reporting systems is vital to empower victims of microaggressions is crucial (Gilliam & Russell, 2021).
Limitations
The exclusive focus of English language studies may have led to publication bias, as potentially omitting pertinent research conducted in other languages. Given that most of the studies incorporated in this review were carried out in Western countries, this could limit the diversity and applicability of insights to healthcare professionals, trainees, and students in non-Western contexts. Therefore, future research in this area should strive for greater geographical, cultural, and economic diversity. Furthermore, forthcoming research should explore the experiences and needs of healthcare professionals, trainees, and students who identify as nonheterosexual, nongender conforming, and those with disabilities. Furthermore, it is imperative to acknowledge that diverse nonclinical workplace contexts (including research/healthcare education institutions, pharmaceutical companies, health insurance agencies, government entities, healthcare administration, nonprofit organizations, and telehealth/telemedicine companies) may also confront instances of microaggressions, albeit possibly underrepresented in extant literature. Hence, there is a need for additional research in these domains and a comparative analysis between experiences in clinical and nonclinical settings to foster a comprehensive understanding of microaggression phenomena.
Conclusion
This review highlights the pervasive issue of microaggressions faced by healthcare professionals, trainees, and students in the clinical environment and its impact on their psychological well-being and career progression. Racial microaggressions are common, leading to marginalized voices and the need to prove their professional competence. Future research should focus on understanding and mitigating these effects, utilizing measures such as anti-racist training and mentorship programs, which are essential components in fostering diversity and inclusivity within the healthcare domain. Gender-based microaggressions against women challenge their perceived competence and professional autonomy, requiring investigations and strategies that promote gender equity. Policies should proactively address resource and recognition disparities in resources and sexism. Research should also explore the systemic aspects of microaggressions, the long-term effects, and diversification in leadership roles, promote cultural competence, awareness, and constructive discourse.
Supplemental Material
sj-docx-1-tva-10.1177_15248380241265380 – Supplemental material for Microaggression Interactions Among Healthcare Professionals, Trainees and Students in the Clinical Environment: A Mixed-Studies Review
Supplemental material, sj-docx-1-tva-10.1177_15248380241265380 for Microaggression Interactions Among Healthcare Professionals, Trainees and Students in the Clinical Environment: A Mixed-Studies Review by Sophia Archuleta, Halah Ibrahim, Travis Lanz-Brian Pereira and Shefaly Shorey in Trauma, Violence, & Abuse
Footnotes
Acknowledgements
The authors would like to thank the following individuals: Ms. Noorhidayah Bte Noor Azmen for her assistance, as a reviewer, for the quality appraisal process; and the Medical Librarian from the National University of Singapore for her assistance with developing the search strategy.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
Data Availability Statement
The authors confirm that the data supporting the findings of this study are available within the article and its appendices.
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