See stigma happening? Here are five ways to step in
You hear a colleague make a stigmatising comment. A patient says something to a member of staff. Or someone makes a joke that crosses the line. You know it isn't okay. But what do you actually do?
Speaking up in the moment isn't always easy. Maybe you're worried about making the situation worse, you're unsure whether what you witnessed was really stigma, or you assume someone else will step in. And in some situations, particularly where there are power imbalances, speaking up can feel risky, with real concerns about the impact on your job, your relationships with colleagues or your working environment.
As Dr Ann Bagchi explains in our latest Tackling Stigma Champion interview, having a “toolbox” of possible responses can make it easier to act.
A number of bystander intervention frameworks, often developed to address harassment and discrimination, can also offer practical approaches for responding to stigma.
1. Direct, Distract or Delegate
In the Step Up to Stamp Out Stigma (Step Up SOS) intervention, Ann Bagchi teaches three basic ways a bystander can respond: direct, distract or delegate.
Direct: Address what has happened in the moment. This doesn't necessarily mean confrontation. It might be as simple as saying, “Hey, we don't do that.”
Distract: Interrupt or redirect the situation. You might change the subject, create a reason to pull someone aside or otherwise break the interaction.
Delegate: Bring in someone else who has the authority or ability to respond.
The three approaches aren't mutually exclusive. You might distract in the moment, check in with the person affected and later escalate the incident to someone with greater authority.
The right response will depend on the situation. Ann argues that being direct can be particularly powerful because it makes clear to the person experiencing stigma that the behaviour isn't considered acceptable. But intervention shouldn't unnecessarily escalate the situation or cause further harm.
2. Want more options? Try the 5Ds
The 5Ds of Bystander Intervention were developed by anti-harassment organisation Right To Be, building on the Three Ds (Distract, Delegate and Direct) pioneered by the Green Dot bystander program and used in the Step Up Intervention above. Right To Be added Delay in 2015 and Document in 2017, creating the five approaches used today.
Direct: Address the behaviour clearly and succinctly. For example: “That comment isn't appropriate,” or “We don't speak about patients that way here.” Right To Be recommends first considering whether it is safe to intervene directly and whether doing so could escalate the situation.
Distract: Interrupt the situation without directly confronting the behaviour. You could change the subject, ask the person experiencing stigma a question or find another reason to draw them away from the interaction.
Delegate: Ask someone else to help. In a healthcare setting, this could mean involving a senior colleague, manager or another person who is better placed to intervene.
Delay: If you can't respond in the moment, check in afterwards. You might say, “I heard what happened earlier. That wasn't okay. Are you alright?” You can also ask whether there's anything you can do to support them or help them report what happened.
Document: Make a record of what happened, where appropriate. But documentation shouldn't take priority over supporting the person experiencing harm, and Right To Be stresses that any recording or notes should not be shared without that person's permission.
The important thing is that you don't have to confront someone directly to intervene. Sometimes supporting the person afterwards, getting someone else involved or simply interrupting what's happening may be a better option.
3. Think about your own position: WAKE
WAKE is an active bystander framework that can help healthcare workers respond to microaggressions and hostile behaviour in the workplace. It draws on strategies from the Green Dot bystander intervention program mentioned in the 5 Ds, but puts particular emphasis on recognising the power, position and strengths you bring to a situation.
W – Work with who you are: Start by thinking about what you bring to the situation. What are your strengths? What approach are you most comfortable using? Do you have common ground with the person involved? And what power or privilege do you have that might make it easier for you to speak up?
A – Ask questions or make direct statements: You can question what's been said, with something as simple as “What do you mean by that?”, or respond more directly by naming a stereotype or assumption and making it clear that you're uncomfortable with it.
K – Involve key people: Bring in someone with influence who can help. That could mean asking a colleague you know will speak up to step in, raising the issue with a supervisor or documenting what you've witnessed. It doesn't always need to be explicit: even making eye contact or signalling to someone else can prompt them to act.
E – Employ distraction techniques: If you don't feel able to address the comment directly, interrupt or redirect the interaction instead. Change the subject, bring the conversation back to the task at hand, or use body language to signal that the comment isn't welcome. The aim is to stop the interaction and create an opportunity to move on without necessarily confronting the person directly.
4. Don't know what to say? Try I-RANT
Developed by a team of US medical educators, I-RANT is a newer bystander intervention tool designed specifically for healthcare team members responding to microaggressions from patients towards their colleagues.
While it hasn't yet been tested for peer-to-peer interactions, the principles could be useful there too. Participants in the original training specifically asked for it to be expanded to cover microaggressions between team members and from more senior colleagues.
Unlike more open-ended frameworks, I-RANT provides a short, structured script to follow, so you don't have to work out what to say in the moment.
I – Introduction: Start by acknowledging the comment and its potential impact, for example by explaining that while it may not have been intended that way, it could be hurtful.
R – Role: Clearly state the role of the person who was targeted. For example, “Dr X will be the physician taking care of you today.”
A – Affirm: Reinforce the person's expertise or abilities, such as “She is an excellent board-certified physician.”
N – Negate: Directly challenge the assumption behind the comment. For example, “Her age does not have anything to do with her ability to care for you.”
T – Transition: Bring the conversation back to the person's healthcare and what needs to happen next.
5. What about staff? Discrimination 911
Developed at Texas Children's Hospital, Discrimination 911 was designed specifically to help healthcare workers intervene when they witness a patient or family member discriminating against a colleague. It takes inspiration from the clinical algorithms healthcare workers already use in emergencies, providing step-by-step pathways and suggested language for responding.
The framework includes four algorithms covering discriminatory statements, discriminatory requests, mistaken identity, and acknowledging and supporting the colleague who was targeted. Depending on the situation, the algorithms help you assess what's happening, decide whether and how to respond, use suggested language and return the focus to patient care.
Importantly, the response doesn't end when the interaction does. The authors describe acknowledging what happened and supporting the colleague who experienced the discrimination as the most important part of the framework, noting that a lack of response or acknowledgement from colleagues can sometimes be more hurtful than the original microaggression.
This is something that can definitely be applied for patients too.
Discrimination 911 was initially designed to respond to racism, although feedback from participants suggested its principles could also apply to sexism, transphobia, ableism, ageism and other forms of discrimination.
There isn't one 'right' way to intervene
These frameworks overlap for a reason.
Being a good bystander isn't about memorising the right acronym or delivering the perfect response. It's about having enough options available that when something happens, you're less likely to freeze, assume someone else will deal with it or stay silent because you don't know what to say.
Context matters. So does safety. And any intervention should consider what will best support the person experiencing stigma rather than simply making the bystander feel that they have done something.
It is also important not to put all the responsibility for tackling stigma onto individual healthcare workers.
As Ann points out in our Tackling Stigma Champion interview, stigma is shaped by social norms and the conditions in which behaviour occurs. Speaking up can challenge those norms in the moment, but organisations and leaders also need to create environments where people are supported to intervene and where stigmatising behaviour isn't allowed to become normal.