Authors: Andrea Lopes Sauers, Rita Ator, Patrice Ayala, Jaime González, Suzanne O'Neal
Categories: Research Report, Microaggression, Physical therapy education, Cultural diversity
Source: Journal, Physical Therapy Education
Authors: Andrea Lopes Sauers, Rita Ator, Patrice Ayala, Jaime González, Suzanne O'Neal
Supplemental Digital Content is Available in the Text.
Microaggressions, although often subtle and unintentional, have a significant impact. These interactions emerge from stereotypes and reinforce marginalization. Perpetrators and bystanders, lacking shared experiences with the targeted identities, may not recognize the harm caused.^1-4^ However, these actions can profoundly affect the recipient's sense of belonging, safety, and self-worth.^5^ In health professions education, including physical therapy, microaggressions are particularly detrimental. They disrupt the learning environment, hinder students' academic and professional development, and contribute to a culture of inequality and exclusion.^6,7^ Despite increasing efforts to promote diversity in Doctor of Physical Therapy (DPT) programs, the presence of microaggressions highlights a continued need to foster inclusivity within physical therapy educational and clinical settings.
Understanding the prevalence of these behaviors and its profound impact on student learning and well-being is crucial for fostering inclusive and supportive educational experiences for all students. This study aimed to quantify the prevalence of perceived microaggressions among DPT students and to explore their lived experiences of these often subtle yet harmful behaviors during their academic journey.
Microaggressions in educational and health care settings have been extensively documented across medicine, nursing, pharmacy, and other health professions but not in physical therapy. Experiencing these behaviors can accumulate and significantly affect mental health, academic performance, professional development, and overall well-being of students, particularly those from underrepresented minority (URM) groups.^6-9^ In medical education, for example, a recent study found that URM students experienced significantly higher rates of racial microaggressions, which contributed to increased levels of burnout and compromised learning.^9^ Another study demonstrated that 61% of medical students experienced microaggressions, and this was associated with depression and school dissatisfaction.^10^ Nursing students from minority backgrounds have reported similar experiences, noting that microaggressions from peers, instructors, and clinical staff often left them feeling isolated and undermined, further exacerbating feelings of imposter syndrome.^11^
The negative experiences of microaggressions during students' education can carry over into their professional careers, affecting job satisfaction, workplace culture, and patient care outcomes. Health care professionals who experience microaggressions during their education are more likely to encounter similar issues in their professional contexts, potentially perpetuating a cycle of discrimination and bias.^12,13^ Addressing microaggressions through institutional support, cultural change, and targeted interventions is vital for improving both the educational and professional environments for URM health professions students and professionals.^12^
Interventions that have demonstrated efficacy in mitigating microaggressions in medical, nursing, and allied health professions training include interactive workshops,^14-16^ bystander and ally training,^17^ curriculum integration of antiracist pedagogy,^18^ and case-based learning approaches.^18^ These strategies enhance students' ability to recognize, respond to, and address microaggressions, fostering a more inclusive and supportive educational environment.
Within health professions, broadly, and physical therapy, specifically, the lack of racial, ethnic, and gender diversity remains a pressing issue. The demographic makeup of the physical therapy profession is overwhelmingly White (75.6%) and female (68.0%), with limited representation from URM groups.^19-21^ The American Physical Therapy Association (APTA) defines URMs as “the racial and ethnic populations that are underrepresented in physical therapy education relative to their numbers in the general population, as well as individuals from geographically underrepresented areas, from lower economic strata, and from educationally disadvantaged backgrounds, and with disabilities.”^22^
Underrepresented minorities and members of other historically marginalized culture groups may be at higher risk for experiencing microaggressions when in settings and environments where essential features of their identity are not represented.^23^ Moreover, microaggressions in educational settings can negatively affect students' mental health, learning capacity, and overall success. Microaggressions have a dose–response relationship with depression and anxiety; they can create an additional “cognitive load” during learning that results in exhaustion and self-doubt and can degrade academic performance.^5,8^ Students who experience microaggressions may tend to isolate and avoid, manifesting as decreased responsiveness to emails, absenteeism, or withdraw from school.^5^ These effects are particularly concerning in graduate- and doctoral-level health profession programs like DPT programs, where sustained concentration and confidence are essential for success.^8^
Efforts to diversify DPT programs, such as the work of the American Council of Academic Physical Therapy's Diversity Task Force, have led to some improvement.^24,25^ The Task Force findings encouraged DPT programs to refine admission processes to be more holistic, ultimately expanding URM student representation.^24-26^ However, increasing diversity without addressing the climate in which these students are educated can lead to negative experiences, such as the microaggressions frequently reported by URM students in clinical settings. A recent study of URM DPT students revealed that many experienced race-based microaggressions during their internships, primarily perpetrated by patients.^26^
The intersection of microaggressions and physical therapy education remains underexplored despite evidence from other health professions highlighting the detrimental effects on students' mental health, learning, and professional development. This study aimed to address this gap by exploring the prevalence and impact of microaggressions on DPT students, providing a foundation for future efforts to create more inclusive educational environments in physical therapy and beyond.
Second- and third-year student physical therapists (n = 101) at Midwestern University, Glendale, AZ location, were asked to participate in this study. Participants were selected using convenience sampling, where all individuals were invited, and those who accepted and were available comprised our research sample.
This explanatory sequential mixed-methods study consisted of 2 a quantitative survey and a qualitative approach using virtual semistructured focus group interviews. This study was approved by the Midwestern University Institutional Review Board.
In the spring of 2022, second- and third-year student physical therapists received email invitations to complete an anonymous online survey. Participation was voluntary, with consent obtained before the survey, which remained open for 10 days. The study investigators developed the survey using the literature for guidance,^27,28^ reviewed, and refined it based on additional discussion before distribution. The survey included demographic data and questions on microaggressions experienced, witnessed, or perpetrated in various settings. The survey distribution, data collection, and analysis were generated using Qualtrics software (Provo, UT). Identifying information, such as name or date of birth, was not collected to ensure anonymity. At the end of the survey, institutional resources, and information on how to formally report a microaggression incident were provided. In addition, students were asked if they were interested in participating in small group interviews to gain more information regarding their experiences. A calendar link was provided for students to sign up. The calendar was only accessible to the primary investigator and the interviewer. The students were asked to use a sham name when signing up for anonymity.
For the qualitative approach, the data collected were analyzed thematically. The study investigators developed, reviewed, and refined interview questions following previously published practical guidance for semistructured interviewing as a data collection strategy^29^ and other studies assessing microaggressions in health care education.^26,30,31^ The interview guide consisted of a set of 6 open-ended questions, with other questions emerging from the interviewer and participants' dialogue (Supplemental Table 1, Supplemental Digital Content 1, http://links.lww.com/JOPTE/A364). A blinded interviewer conducted forty-minute interviews through video conference in June and July of 2022. The blinded interviewer was a Midwestern University learning specialist with a master's degree in education, from the institution's Academic, Communication, and Language Support Department. The interviewer was not associated with the research team and not part of the DPT program. In the interest of anonymity, students were asked to use their established sham name, and cameras were turned off during the interviews. At the end of each interview, the blinded interviewer shared the institutional resources and information on formally reporting a microaggression incident. A pilot test was not performed with participants, but the blinded interviewer met with 2 study investigators before data collection to review the procedures for the semistructured interviews. After the meeting, questions were added to each applied section of the interview guide, so participants could expand their thoughts or provide examples. In addition, the duration of the focus group interviews was set to be 40 minutes based on the interviewer's availability.
Data were audio recorded, transcribed, and analyzed to interpret and summarize students' perceptions and experiences with microaggressions during their DPT educational journey. The data transcription was performed by a research assistant not associated with the DPT program. No personal identifiers were collected in the survey or virtual interview sessions. If any information was revealed as sensitive, personal, or identifiable, the identities were removed during the transcription process to maintain anonymity.
Three study investigators manually executed a systematic thematic analysis to identify and refine codes and construct themes from the data. Data saturation was not assessed. Investigators only accessed the deidentified transcript after the scheduled interviews were completed. Because participants used sham names for anonymity, returning the transcripts to participants for feedback on the findings was impossible. Trustworthiness of the study results was established through the criteria of credibility and dependability.^32^ Credibility refers to the study process, that is, to establish how the data are collected and the analysis procedure are performed and to ensure that no relevant data have been excluded.^32^ Credibility was first attained by interviewing all study participants using the same interview guide.^30^ “Negative case analysis” was used, which means the interviewer asked questions during the interviews to account for unanticipated answers.^32^ This can be difficult to establish, but the interviewer was a learning specialist with previous experience with qualitative research in higher education. Credibility was also achieved by having different investigators who independently analyzed the data.^30,32^ Agreement from these investigators was obtained to define the themes. Dependability refers to stability, the extent to which data change over time and the alterations made in the researchers' decisions during the analysis.^32^ Dependability was established by 1 investigator who kept track of coding decisions during the analyzing procedure, recoding, and relabeling when necessary, during the process.^32^
Fifty of the 101 students agreed to participate in the survey (49.5%), with 2 students consenting to participate but not completing it. Table 1 shows the demographic makeup of the student sample (N = 48). Table 2 reports the quantitative survey data, showing the frequencies and percentages of responses. Of the students surveyed, 25 (52.1%) reported that they have experienced, witnessed, or perpetrated any incidents of microaggressions on campus, in the DPT program, or in the clinic. Fourteen students (58.3%) reported having experienced a microaggression, 16 (66.7%) reported witnessing a microaggression, and 6 (25%) reported being the perpetrator of a microaggression. Twenty students (55.6%) reported that the microaggression perpetrators were classmates followed by 4 students (11.1%) who reported the offenders being another student outside of class, and 4 (11.1%) who reported them being a patient/client.
Twenty-six (54.1%) of the 48 students who completed the survey agreed to participate in the focus group interviews. Data were collected from 7 interview sessions, each consisting of 1–5 students. The mean (SD) duration of the focus group interviews was 38.2(6.3) minutes. Two students scheduled an interview but did not join, and 1 student joined a session but did not participate. Therefore, a total of 23 students participated fully in the focus group interviews. Five themes emerged from the qualitative analysis. Illustrative quotations from students are provided below for each of the 5 themes and labeled with a student participant number (P#). Additional quotations related to each theme can be found in Supplemental Digital Content 1 (Supplemental Table 2, http://links.lww.com/JOPTE/A365).
More than half of the respondents reported experiencing, witnessing, or perpetrating microaggressions within their DPT educational journey. Microaggression topics reported by students included race/ethnicity, age, body composition, and gender. Factors that increased the risk for someone to perpetrate a microaggression included attention-seeking behaviors, not choosing to be educated on the potential impacts of microaggressive comments or behaviors, being part of a clique and lack of knowledge of microaggressions.
Microaggressions based on race/ethnicity were witnessed in the academic environment as noted by the following participant. “I witnessed someone in the program … made a comment about someone else’s race and … was just like trying to be like that person’s race and used a different voice.” (P2) Students reported witnessing microaggressions made based on age not only in the academic environment but also in the clinic environment. “I’ve also seen some evidence of microaggressions throughout my DPT journey … it’s more about age and students and professors categorizing people based on their age versus them as a person and I think … it can be insensitive to someone who’s older than the rest of the class.” (P4) Students discussed microaggressions focused on body composition while in the academic environment as illustrated by the following quotation. “… I felt uncomfortable by faculty members making body composition comments that I just felt were inappropriate.” (P17) Students also expressed experiencing or witnessing microaggressions based on gender in the academic setting as identified by the following participant. “I have witnessed a couple of microaggressions between genders in which some males may talk over or not really take opinions or … won’t really consider a female’s perspective until its confirmed by a male too.” (P5)
Students commented on the presence of cliques and how it can hurt their sense of belonging in the academic setting. One student noted the connection of not belonging to a clique and poor academic performance. “I’ve kind of been in that position myself where I’ve been a little bit stuck a little bit on the outside and it was harder to practice or learn or get like the full experience because I didn’t have those people to interact with.” (P6)
Student data revealed a hesitancy to call out incidents of microaggressions. Students spoke about the fear of retaliation if they reported a microaggression and outlined the fear of losing friendships or a negative response if they confronted a microaggression. “I think people are scared to confront people about the things that they say in fear of the person not liking them anymore.” (P2) Another student added, “When something [microaggression] happens to me … I don’t want to say anything because I’m like ‘what if this person reacts in a negative way and I’ve got this problem on my hands now.” (P7)
Students spoke about how the perceived hierarchy within the academic setting makes calling out a microaggression more challenging, if it was coming from a faculty member. “I actually think it would be harder to have to speak about it to a faculty member than having experience with it like at a job. Because you can always leave your job.” (P6)
Student data revealed several negative impacts of microaggressions within the DPT program. Students discussed how microaggressions can burden their academic success, reporting that microaggressions can cause them to feel frustrated and invalidated. Students further discussed how microaggressions can be distracting and isolating in the academic environment, affecting focus and a sense of belonging. “I know when I’ve experienced it [microaggression], it kind of gets stuck on your mind and it really takes a lot of your focus and distracts you … it kind of just makes you feel like you don’t belong.” (P8). One student noted, “I’ve been in that position myself where I’ve been … stuck on the outside and it was harder to practice or learn or get the full experience.” (P6)
Students reported a lack of knowledge of microaggressions in general and spoke of personal experiences where they were the perpetrator and later realized they had verbalized an unintended microaggression. “For me, when I found out that I was the one doing the microaggression, and I wasn’t aware of it, I was really shocked … I was just really unaware of it.” (P19)
Students spoke about how perpetrators called the microaggressions “jokes” and some blamed the victim for being overly sensitive in the academic setting, as illustrated by the following quotation. “A male made a comment that wasn’t the nicest and another female in the group actually said something in response … and he actually responded and said something along the lines of “oh it seems like you’re just sensitive this week.” (P3)
Students discussed the importance of increasing education on microaggressions and suggested that this education should be embedded early in the DPT curriculum to help diffuse the issues and allow students to recognize microaggressions before they become harmful. “… I didn’t even learn what they [microaggressions] were until my second year here, and I think if I would have learned what they were sooner … I would have been able to identify them faster … I think it would have been more beneficial to everyone if we’re able to identify them and … work at being better at them.” (P19)
This mixed-methods study described the prevalence of perceived microaggressions among student physical therapists and explored these experiences during their educational journey. Most students who participated in the survey reported at least 1 microaggression experience in the past month. Although perpetrated mainly by a classmate, microaggressions were also perpetrated by faculty, staff, and within their first integrated clinical experience. This finding highlights that microaggressions can occur at many levels and environments throughout a DPT curriculum. These results are consistent with previous studies that described microaggressions perceived by different health profession students in their learning environments and during their clinical experiences.^6,7,26,30,33,34^
Students hesitated to address microaggressions due to fear of retaliation or being seen as overly sensitive. Engendering a supportive environment and encouraging open dialog may help mitigate this.^1,7^ A safe environment helps students to learn and share their experiences and enhance their confidence.^6,7^
Students stated that microaggressions are distracting, create anxiety, and negatively affect their confidence and sense of belonging. These results are consistent with previous studies related to microaggressions experiences in different health professions students.^7,26,30,33,34^ The cumulative effect of repeatedly being disregarded and invalidated create an additional burden that students must navigate within their learning experience.^30,35^ The negative impact on their psychological well-being and the continuous internalization of the microaggressions they experienced may influence their academic progress.^6,33^ This study also found that student physical therapists believed that microaggressions negatively affected their learning and academic performance.
Students often lack awareness of microaggressions, failing to recognize when they themselves are offenders. These findings emerged in a study of pharmacy students.^30^ This study showed that students frequently do not acknowledge when they are the source of a microaggression. Microaggressions often stem from unconscious bias, leaving the offenders unaware of their impact.^5^ During the interviews, students described various factors that increased the likelihood of someone being a perpetrator of microaggressions. These included attention-seeking behaviors and trying to “be funny,” lack of knowledge, being part of a clique, choosing not to educate oneself, or ignoring education about microaggressions. Although most individuals can recall a moment when they were the target of a microaggression, the reality is that they may have all been the source of microaggressions at some point in their lives.^5^ Understanding what a microaggression is and identifying situations when you were the offender is key and a powerful way to address and reduce unconscious bias and the prevalence of microaggressions. Recognizing that everyone, regardless of intent, has implicit bias and commit microaggressions is a crucial first step toward creating a positive learning environment.^30^
Students reported that early education and awareness may help mitigate microaggressions and create a culture of inclusivity, belonging, and professionalism where microaggressions are not tolerated. Initiatives to promote inclusion have been introduced to improve the diversity within the physical therapy profession and within DPT educational programs,^24^ including defining URMs in physical therapy and highlighting the need for promoting a diverse physical therapy student population and professional workforce.^24,25^ However, DPT programs must go beyond merely increasing the diversity of the student body. URM students are more likely to experience microaggressions in health professions settings and programs.^8^ Thus, it is crucial to address microaggressions to retain URM students and by extension URM physical therapists. A recent study described how microaggressions may affect optimal learning for URM medical and nursing students during their education and showed consistent examples of microaggressions with peers, faculty, preceptors, and structural elements of the curricula.^7^ Although we did not explore microaggressions categorized by students' self-identity, this study found similar results with microaggressions occurring in different settings and throughout students' DPT educational journey. Students also mentioned the negative impact of cliques, which can create an exclusive environment based on various factors, including race or gender. This establishes harmful boundaries, reinforces stereotypes, and makes it challenging for individuals who do not conform to the clique's identity to feel accepted or successful.^36^
Another strategy to promote inclusion into the learning environment and curriculum may be designing a syllabus to create a classroom culture of belonging. Language is critical in syllabus design and influences students' perception of the professor.^37^ For example, the instructor might add a statement to the syllabus to reassure students—particularly those from underrepresented backgrounds—that their voices, perspectives, and existence are valued.^37^ However, faculty and students are likely to hold implicit bias, which may still lead to microaggression in the classroom.^38^ We found that microaggressions may span the spectrum from racial and tribal comments to gender identity, sexual orientation, ageism, and body composition. Previous studies have shown that URM health care professions students perceived that their experiences throughout their education were affected by racial microaggressions.^7^ For instance, data on race or ethnicity are commonly provided in cases used in the classroom without any sociodemographic background. This is problematic because more relevant indicators of health profile are the social and structural determinants of health.^38^ Furthermore, a stronger emphasis should be placed on socioeconomic determinants of health and the promotion of equity in the DPT classroom, as opposed to using race and ethnicity as the foundation for health issues.^7,38^ Sabus and VanHoose^38^ proposed a guide to racial and cultural representation in academic and clinical teaching and assessment in physical therapy education. This guide supports diversity and inclusion in teaching. It helps physical therapy educators, for example, to create patient cases that achieve diversity and accurate representation of culture, race, and ethnicity, as well as challenge the implicit bias of the learner.^38^
Cultural awareness and implicit bias training may be strategies to foster a critically conscious ethos focusing on creating equitable spaces in which all students can thrive. Offering these training opportunities and resources to students, faculty, and staff may help create safe and inclusive learning environments to mitigate microaggressions during students' DPT education.^5,7^ A recent systematic review (SR) appraised available evidence on the experiences and perceptions of health care professionals and students, about interventions addressing implicit bias and microaggressions in the clinical setting.^6^ Of the 23 studies included in the SR, only 1 included physical therapists as participants. This SR found that these interventions brought participants into a safe space that improved their understanding of implicit bias and microaggressions in the clinical setting. Participants stated that they felt more competent in recognizing microaggressions and knowing when to respond to them after learning the new information. The delivery of the interventions was praised and appreciated by the participants because it allowed for an accepting and open environment to express ideas and opinions during group discussions. Positive outcomes from the interventions generated a strong sense of advocacy and the need for additional training sessions in their educational or health care institutions. Participants also emphasized the importance of using real-world examples and sharing personal experiences with implicit bias and microaggressions in group discussions. Some believed that such workshops should be incorporated early into the school curriculum, which supports the findings of this study.
Effective interventions include interactive workshops,^14-16^ bystander and ally training,^17^ curriculum integration of antiracist pedagogy,^18^ and case-based learning approaches.^18^ In DPT programs, these strategies can play a vital role in fostering cultural humility and creating a more inclusive learning environment. Interactive workshops on diversity, equity, and inclusion can provide students with the knowledge to navigate challenging conversations, understand implicit bias, and support their peers from URM groups. Bystander and ally training may prepare DPT students and faculty with the tools to recognize and address microaggressions in real time, engendering a culture where discrimination and bias are not tolerated. Integrating antiracist pedagogy throughout the DPT curriculum—such as including content on health disparities, systemic racism in health care, and the role of physical therapists in promoting social justice—ensures that students learn to advocate for equitable care for all patients effectively. In addition, case-based learning allows students to engage in real-world scenarios where microaggressions often occur, whether from patients, peers, or in clinical environments.
Implementing these strategies early on and throughout DPT curricula is crucial for students to develop skills in both patient care and professional interactions that prioritize respect, inclusion, and sensitivity to diverse identities. These interventions can mitigate the incidence and impact of microaggressions, and prepare future clinicians to contribute to a health care system that values diversity and actively works to reduce health disparities. By addressing microaggressions early and often within the academic setting, DPT programs can improve student experiences, satisfaction, retention, and, ultimately, their ability to serve diverse patient populations effectively.
This study was conducted within a single DPT program, which can limit the generalizability of the findings. Although all second- and third-year students were encouraged to participate, self-selection bias was possible. First-year students were not recruited for this study because they were new to the campus and the program by the time the study was conducted, but they may have also experienced microaggression earlier in their DPT journey. Pilot testing of the quantitative survey and the interview guide for the focus group interviews was not performed, but the investigators followed previously published guidance and other studies assessing microaggressions in health care education^26-31^ to enhance clarity, use, and flow of the survey and interview guide questions. Investigators also sought for feedback from the learning specialist about the interview guide questions before data collection. In addition, the measurement properties of the surveys used, such as validity and reliability, were not investigated, which might influence the results of this study.
The investigators did not categorize the microaggressions by location. Nonetheless, inferences can be reasonably made based on the identified perpetrators themselves. For example, patient/client, clinical instructor, or another health care professional would most likely be occurring in the clinic environment. Future research will look further into the specifics of microaggressions such as this. Finally, as researchers investigating microaggressions, we recognize that our positionalities could influence our perspectives, methodologies, and interpretations. Our diverse backgrounds—encompassing race, gender, sexual orientation, education level, and personal experiences—shape our understanding of microaggressions and the experiences of those affected by them. Throughout our research process, we actively reflected how our identities, experiences, and potential biases shaped our engagement with the data and thematic analysis.
This study described the prevalence of perceived microaggressions among student physical therapists and explored these experiences during their educational journey. Microaggressions can exist in a DPT program, but students are unsure about the concept. In addition, they are hesitant to call out microaggressions but recognize that it can negatively affect their experience. Finally, they acknowledge that education may help mitigate microaggressions. These findings are consistent with previous studies related to microaggressions in health care education. Further investigation should evaluate microaggressions during the educational journey using a reliable and valid microaggression measurement tool in different DPT programs. Additional research on whether curricula that integrate microaggressions and implicit bias training reduce the prevalence of perceived microaggressions in the learning environment would provide valuable information. Finally, more qualitative research designs are needed to examine the perceptions of URM student physical therapists regarding implicit bias and microaggression interventions within their educational journeys.