Portal de Periódicos da CAPES

Addressing Functional Biases in Procedural Environments

2021; Lippincott Williams & Wilkins; Volume: 275; Issue: 3 Linguagem: Inglês

10.1097/sla.0000000000005211

1528-1140

Jacqueline M. Soegaard Ballester, Jason J. Han, Celina M. Yong,

Hospital Admissions and Outcomes

As we strive to achieve a more diverse and inclusive workforce in medicine, an important part of the process is to look beyond our workforce composition to also reexamine our surroundings critically. How we have chosen to construct our physical environment—and the associations embedded in those decisions—can reflect our profession's values to those within and outside the system. The permanence of our walls, halls, and tools then perpetuates biases by projecting certain stereotypes, reinforcing specific identities while alienating others, and broadly influencing how people think and behave every day. For clinicians who work in procedural settings, these considerations include the choice of equipment. Much of the equipment in circulation today, from the basic setup (eg, operating table and lights) and traditional open instruments (eg, needle holders and forceps) to laparoscopic and endovascular tools, were generally built to accommodate the stature, strength, and hand size defaults of men and of the global north.1,2 Although those design choices likely reflect the demographic circumstances of a previous time, they have often not been updated to accommodate the increasing sex, ethnic, and racial diversity in a changing workforce. Catheterization and endovascular equipment, such as insufflators for balloon valvuloplasty or syringes used to inject contrast, are designed such that operators with smaller hands may find it difficult to ergonomically generate sufficient force. In the operating room, smaller hands can limit users from comfortably “palming” instruments such as needle holders. They may also make it challenging, if not unfeasible, to manipulate the controls in the handles of laparoscopic or endoscopic instruments without repositioning hands mid-maneuver or using a second-hand assist.2,3 In finding these devices difficult to hold or operate as designed, the ergonomic workarounds operators must devise may lead to reduced economy of motion or even increased rates of hand, shoulder, or cervical discomfort or injury.4 Absent a mentor who can suggest or demonstrate mitigating techniques and workarounds, female trainees and others of shorter stature and smaller hand size are often left to improvise on their own. Bias can also be tangibly experienced in the wearing of required surgical garb and protective equipment. Hospital-issued medical scrub outfits, which are generally unisex in form and sizing, often do not accommodate for sex and body-type differences in body proportions and may also poorly fit bodies at extremes of height or weight. Recognition of these realities has spurred the advent of several brands that offer fit- and comfort-oriented commercial scrubs.5 However, this option is often not available to surgeons and proceduralists because they are usually required to wear hospital-issued scrubs in procedural settings. In some cases, the biases inherent in procedural garb can even become deterrents to entry into surgical fields. For Muslim women, religious observance in dress, particularly as pertains to head covering and exposed forearms, can be discordant with expected surgical attire. Absent alternatives such as a sterile hijab, and without institutional policies that inform how these situations should be handled, female Muslim students and trainees have reported experiencing conflict and distress during their surgical experiences. In many cases, this led them to abandon the pursuit of operative specialties altogether.6 Standard size options available for items such as sterile and nonsterile disposable gloves and sterile gowns also remain suboptimal for some members of the workforce. Because many healthcare settings carry limited size options (eg, large and extra-large) and may have limited stock for smaller sizes, clinicians who require smaller gloves or gowns may be required to use ill-fitting protective equipment, leading to limited comfort, dexterity, or tactile feedback. As any clinician can intuitively understand, poorly-fitting, loose gloves can make even the simplest bedside procedures significantly more difficult. Some considerations extend to matters of clinician safety. For instance, lead aprons are required among staff exposed to radiation in settings such as the catheterization laboratory, interventional radiology suite, or hybrid operating room. When wearing oversized lead with large arm holes, the operator's left chest area closest to the C-arm fluoroscopy machine may not be adequately protected. Pregnant women or those with different body types face even greater occupational risks unless their unique dimensions are accounted for in design considerations. Many clinicians learn to cope with suboptimal fit and design, or eventually resort to procuring their own equipment. Rather than shifting the responsibility to individuals, institutions should recognize that by offering limited options, they are continuing to convey a subliminal message regarding the “appropriate” size and stature of surgeons and proceduralists. Moreover, these functional disadvantages also reinforce the false notion that certain phenotypes are better suited for carrying out procedures, because evaluations of their technical skill may be bolstered by the advantage of having equipment specifically optimized for their use. Conversely, the experience of clinicians in training who struggle while using ill-adapted instruments and equipment can negatively impact trainee self-confidence and self- and external assessments of technical skill. Poor evaluations may in turn have ramifications for trainees’ progress, opportunities for procedural autonomy, and how their overall clinical and technical strength is perceived in their training program.7 We can look to other industries to understand the importance of user-focused and inclusive design. An important comparison can be made with the design of gear and equipment for different sports. In athletics, as in surgery, performance can be improved, and the chance of injury decreased, by optimizing the fit between user and equipment. Indeed, in nearly every sport that uses equipment, increased understanding of biomechanics and technological advancements have resulted in options for tailoring equipment to the athlete—from sports shoe sizes and arch shapes, to golf club length, to tennis racket size, grip, and stiffness. In some sports this is largely based on size, but in other sports sex-based options exist. These recognize the myriad differences in biomechanics and strength distribution between men and women. Nevertheless, many female athletes continue to feel that there is a relative lack of research in female exercise physiology, and that effort and support in equipment design continue to disproportionately favor men. Their frustration is being channeled into change—as one example, the dearth of suitable boxing gloves for women spurred the establishment of a women-focused boxing gear brand called Society Nine.8 Beyond merely expanding equipment options, the company's mission is focused on promoting awareness and “inclusion, first and foremost.” Addressing these biases in procedural settings will require a multipronged approach (Table 1). With equipment and apparel, instead of providing default options based on preconceptions about workforce composition, health systems can strive to understand the distribution of needs among staff. Although financial considerations may preclude institutions from being able to precisely tailor to demand, proactively seeking input from its members signals a thoughtful shift. Beyond addressing known areas of concern, eliciting open-ended feedback during this process might identify additional, unanticipated areas where design can be improved. Common items such as gloves, gowns, and scrubs may be easy to acquire, but equipment such as lead aprons and open or laparoscopic surgical instruments will require a collaboration between proceduralists and manufacturers to design more equitably. To accommodate different hand sizes and strength, tools and handles could be designed with hand grip adjustment options (or different size options altogether) and could incorporate offloading mechanisms to minimize necessary force.3,9 To incentivize manufacturers to invest in these changes, hospitals can consider including standards for diversity and inclusion in equipment and instrument design as part of their vendor negotiations and contracts. Some changes will require investing in platforms that remove strength and size from the equation, including robotic surgical and interventional equipment, power injectors, and weightless lead. These investments will serve to level the playing field, helping trainees of all body dimensions to succeed and facilitating ongoing recruitment of talented and diverse applicants. Adjustments originally intended to help one group—such as reducing radiation for pregnant operators—could ultimately lead to benefits for everyone. Finally, physical changes in tools and environments will need to be accompanied by changes in accepted neutral techniques, habits, and ultimately institutional culture. TABLE 1 - Recommendations for Potential Solutions to Address Current Functional Biases in Procedural Settings Inclusion in Design & Supply Provision Promoting Neutral Technology & Techniques Changing Habits Changing Culture Stock gloves, scrubs, head coverings, and gowns in proportion to the distribution of sizing and fitting needs of the workforce by seeking feedback from staffProvide surgical sterile hijabs and other alternatives to promote inclusivity regarding cultural and religious observance of dress codesSupply appropriately fitting lead to accommodate left chest and breast area, changes with pregnancy, and consider weightless lead optionsInstrument design: - Conduct a review all current instruments to ensure their design fits the composition of the evolving healthcare workforce - When there is to be a single size options based on an average “neutral” user, ensure the average is based on representative sample of operators of different sex and race/ethnicity - Consider providing a range of size options for instruments where a single “neutral” option does not appropriately accommodate the range of users - Consider adjustable laparoscopic handles that accommodate differences in finger size, hand size, and grip strength - Incorporate instrument mechanisms that do not rely on operator size or strength Normalize the use of equipment by diverse operators by adopting techniques and approaches that minimize reliance on size and force and reduce ergonomic disadvantages: - Two-handed maneuvers - Robotic surgery and percutaneous intervention - Power injectorsSupport ongoing research in user biomechanics to inform inclusive techniques and equipment design Adjust table height to primary operator or have step stools of varying height options available in all procedural roomsProvide ergonomic evaluation and coaching, especially for high-risk staff: - Pregnancy - Extremes of height - Existing disabilities - Recovery from injury Promote inclusivity by eliciting workforce requests, input, and continual feedback regarding garb, instruments, equipment, and procedural spacesNormalize staff making requests for alternatives when standard garb, equipment, and instruments are inappropriate for themEstablish workplace policies that inform how to handle cultural and religious differences in allowable dress The associations we observe and experience through our structures and functional equipment continue to reinforce outdated norms in medicine. They are not, however, an immutable reality, and it is our responsibility to revise our work environments to eliminate ingrained biases. Indeed, the practice of wearing gloves in an operative setting originated when Caroline Hampton—the lead scrub nurse in Dr. William Halsted's operating room—developed contact dermatitis from the antiseptic solutions used at the time.10 To protect herself, she began wearing a pair of gloves specifically designed for her, and over time this practice became the standard. A century later, we find ourselves with an opportunity to update lingering functional biases in our work environment to be more reflective of our diversifying workforce and make sure the gloves will fit whoever may choose to wear them.