Active bystander training for responding to overt patient racism in healthcare

: a systematic review

Abstract

Section A
Overt racism from patients towards healthcare workers is prevalent and continues to rise. Active bystander training offers an emerging approach to upskilling staff to act in support of their colleagues targeted by overt patient racism. This review synthesised the key features of active bystander training and evaluated outcomes using Kirkpatrick’s Four-Level Learning Evaluation Model. A systematic search of four electronic databases (MEDLINE, PsycINFO, CINAHL, ASSIA) identified twelve studies. Due to heterogeneity in study design and outcome measures, a narrative synthesis was conducted in line with Synthesis Without Meta-analysis (SWiM) guidelines. Study quality was assessed using the Medical Education Research Study Quality Instrument (MERSQI). Trainings were typically single-session workshops delivered within medical education settings and frequently incorporated experiential learning methods such as role-play, simulation, and virtual reality. Outcomes were primarily reported at Kirkpatrick’s Level 2, indicating improvements in knowledge, skills, and confidence in using upstander communication strategies. Limited evidence of Level 3 behaviour change or Level 4 organisational outcomes was reported. Methodological quality was restricted by low response rates, limited use of validated measures, and a lack of behavioural and longitudinal outcomes, restricting the strength of conclusions drawn. Active bystander training presents a promising, yet under-researched, approach to supporting healthcare staff in responding to patient racism. Recommendations for the design and delivery of training are presented.

Section B
Mental health inpatient wards report the highest rates of violence from patients of any NHS care setting. Within this, racialised aggression from patients is common and is associated with significant health burdens for staff. Despite this, a paucity of research has been devoted to understanding racialised patient aggression, leaving the phenomenon poorly defined and limiting the development of effective interventions. The present study explored support workers’ experiences of racialised patient aggression in mental health settings, including responses from colleagues, senior staff, and the wider organisation.
Twelve qualitative semi-structured interviews were carried out with support workers with experience of racialised patient aggression in NHS mental health inpatient settings. Analysing data using Reflexive Thematic Analysis generated five themes: ‘A shocking initiation into the role’, ‘The emotional impact of racialised aggression must be protected against’, ‘Racialised aggression has to be navigated within the staff–patient relationship’, ‘How the team responds shapes the experience of racialised aggression’, and ‘Organisational culture underpins responses to racialised aggression’. Whilst racialised aggression in some form appears to be inevitable on mental health inpatient wards, the present findings indicate many areas in which the associated impact on staff may be prevented. Creating organisational cultures of nurture through acknowledgement and care for employees, accompanied by clear support structures, is integral to managing racialised aggression on the wards. Recommendations for organisations and care teams are provided.

Date of Award	2026
Original language	English
Awarding Institution	Canterbury Christ Church University