Perspectives in Hospital Medicine

The No Judgment Zone: Building Trust Through Trustworthiness

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© 2021 Society of Hospital Medicine

The collective struggle felt by healthcare workers simultaneously learning about and caring for patients impacted by SARS-CoV2 infections throughout 2020 was physically and emotionally exhausting. The majority of us had never experienced a global pandemic. Beyond our work in the professional arena of ambulatory practices and hospitals, we also felt the soul-crushing impact of the pandemic in every other aspect of our lives. Preexisting health disparities were amplified by COVID-19. Some of the most affected communities also bore the weight of an additional tsunami of ongoing racial injustice.1 And as healthcare workers, we did our best to process and navigate it all while trying to avoid burnout—as well as being infected with COVID-19 ourselves. When the news of the highly effective vaccines against SARS-CoV2 receiving emergency use authorization broke late in 2020, it felt like a light at the end of a very dark tunnel.

In the weeks preceding wide availability of the vaccines, it became apparent that significant numbers of people lacked confidence in the vaccines. Given the disproportionate impact of COVID-19 on racial minorities, much of the discussion centered around “vaccine hesitancy” in these communities. Reasons such as historical mistrust, belief in conspiracy theories, and misinformation emerged as the leading explanations.2 Campaigns and educational programs targeting Black Americans were quickly developed to counter this widely distributed narrative.

Vaccine uptake also became politicized, which created additional challenges. As schools and businesses reopened, the voices of those opposing pandemic mitigation mandates such as masking and vaccination were highlighted by media outlets. And though a large movement of individuals who had opted against vaccines existed well before the pandemic, with few exceptions, that number had never been great enough to impact public health to this extent.3 This primarily nonminority group of unvaccinated individuals also morphed into another monolithic identity: the “anti-vaxxer.”

The lion’s share of discussions around vaccine uptake centered on these two groups: the “vaccine hesitant” minority and the “anti-vaxxer.” The perspectives and frustration around these two stereotypical unvaccinated groups were underscored in journals and the lay press. But those working in communities and in direct care came into contact with countless COVID-19-positive patients who were unvaccinated and fell into neither of these categories. There was a large swath of vulnerable people who still had unanswered questions and mistrust in the medical system standing in their way. Awareness of health disparities among racial minorities is something that was discussed among providers, but it was something experienced and felt by patients daily in regard to so much more than just COVID-19.

With broader access to vaccines through retail, community-based, and clinical facilities, more patients who desired vaccination had the opportunity. After an initial rise in vaccine uptake, the numbers plateaued. But what remained was the repetitive messaging and sustained focus directed toward Black people and their “vaccine hesitancy.”

Grady Memorial Hospital, a public safety net hospital in Atlanta, serves a predominantly Black and uninsured patient population. We found that a “FAQ” approach with a narrow range of hypothetical ideas about unvaccinated minorities clashed with the reality of what we encountered in clinical environments and the community. While misinformation did appear to be prevalent, we appreciated that the context and level of conviction were heterogenous. We appreciated that each individual conversation could reveal something new to us about that unique patient and their personal concerns about vaccination. As time moved forward, it became clear that there was no playbook for any group, especially for historically disadvantaged communities. Importantly, it was recognized that attempts to anticipate what may be a person’s barrier to vaccination often worked to further erode trust. However, when we focused on creating a space for dialogue, we found we were able to move beyond information-sharing and instead were able to co-construct interpretations of information and co-create solutions that matched patients’ values and lived experiences.4 Through dialogue, we were better able to be transparent about our own experiences, which ultimately facilitated authentic conversations with patients.

In September 2021, we approached our hospital leadership with a patient-centered strategy aimed at providing our patients, staff, and visitors a psychologically safe place to discuss vaccine-related concerns without judgment. With their support, we set up a table in the busiest part of our hospital atrium between the information desk and vaccine-administration site. Beside it was a folding board sign with an image and these words:

“Still unsure about being vaccinated? Let’s talk about it.”

We aptly called the area the “No Judgment Zone.”

The No Judgment Zone is collaboratively staffed in 1- to 2-hour voluntary increments by physician faculty and resident physicians at Emory University School of Medicine and Morehouse School of Medicine. Our goal is to increase patient trust by honoring individual vaccine-related concerns without shame or ridicule. We also work to increase patient trust by being transparent around our own experiences with COVID-19; by sharing our own journeys, concerns, and challenges, we are better able to engage in meaningful dialogue. Also, recognizing the power of logistical barriers, in addition to answering questions, we offer physical assistance with check-in, forms, and escorts to our administration areas. The numbers of unique visits have varied from day to day, but the impact of each individual encounter cannot be overstated.

Here, we describe our approach to interactions at the No Judgment Zone. These are the instructions offered to our volunteers. Though we offer some explicit examples, each talking point is designed to open the door to a patient-centered individual dialogue. We believe that these strategies can be applied to clinical settings as well as any conversation surrounding vaccination with those who have not yet decided to be vaccinated.

THE GRADY “NO JUDGMENT ZONE” INTERACTION APPROACH

No Labels

Try to think of all who are not yet vaccinated as “on a spectrum of deliberation” about their decision—not “hesitant” or “anti-vaxxer.”

Step 1: Gratitude

  • “Thank you for stopping to talk to us today.”
  • “I appreciate you taking the time.”
  • “Before we start—I’m glad you’re here. Thanks.”

Step 2: Determine Where They Are

  • Has the person you’re speaking with been vaccinated yet?
  • If no, ask: “On a scale of 0 to 10—zero being “I will never get vaccinated under any circumstances” and 10 being ‘I will definitely get vaccinated’—what number would you give yourself?”
  • If the person is a firm zero: “Is there anything I might be able to share with you or tell you about that might move you away from that perspective?”
  • If the answer is NO: “It sounds like you’ve thought a lot about this and are no longer deliberating about whether you will be vaccinated. If you find yourself considering it, come back to talk with us, okay?” We are not here to debate or argue. We also need to avail ourselves to those who are open to changing their mind.
  • If they say anything other than zero, move to an open-ended question about #WhatsYourWhy.

Step 3: #WhatsYourWhy

  • “What would you say has been your main reason for not getting vaccinated yet?”
  • “Tell me what has stood in the way of you getting vaccinated.”
  • Remember: Assume nothing. It may have nothing to do with misinformation, fear, or perceived threat. It could be logistics or many other things. You will not know unless you ask.
  • Providers should feel encouraged to also share their why as well and the reasons they encouraged their parents/kids/loved ones to get vaccinated. Making it personal can help establish connection and be more compelling.

Step 4: Listen Completely

  • Give full eye contact. Slow all body movements. Use facilitative gestures to let the person know you are listening.
  • Do not plan what you wish to say next.
  • Limit reactions to misinformation. Shame and judgment can be subtle. Be mindful.
  • Repeat the concern back if you are not sure or want to confirm that you’ve heard correctly.
  • Ask questions for clarity if you aren’t sure.

Step 5: Affirm All Concerns and Find Common Ground

  • “I can only imagine how scary it must be to take a shot that you believe could cause you to not be able to have babies.”
  • “You aren’t alone. That’s a concern that many of my patients have had, too. May I share some information about that with you?”
  • “When I first heard about the vaccine, I worried it was too new, too. Can I share what I learned?”

Step 6: Provide Factual Information

  • Without excessive medical jargon, offer factual information aimed at each concern or question. Probe to be certain your patient understands through a teach-back or question.
  • If you are unsure about the answer to their question, admit that you don’t know. You can also ask a colleague or the attending with you. Another option is to call someone or say “Let’s pull this up together.” Then share your answer.
  • It is okay to acknowledge that the healthcare system has not and does not always do right by minority populations, especially Black people. Use that as a pivot to why these truths make vaccination that much more important
  • Have FAQ information sheets available. Confirm that the patient is comfortable with the information sheet by asking.

Step 7: Offer to Help Them Get Vaccinated Today

  • “Would you like me to help you get vaccinated today?”
  • “What can I do to assist you with getting vaccinated? Is today a good day?”
  • Escort those who agree to the registration area.
  • Affirm those plans to get vaccinated or those who feel closer to getting vaccinated after speaking with you.

Step 8: Gratitude

  • Close with gratitude and an affirmation.
  • “I’m so glad you took the time to talk with us today. You didn’t have to stop.”
  • “Feel free to come back to talk to us if you think of any more questions. I’m grateful that you stopped.”
  • We are planting seeds. Do not feel pressure to get a person to say yes. Our secret sauce is kindness, respect, and empathy.
  • We do not think of our unvaccinated community members as “hesitant.” We approach all as if they are on a spectrum of deliberation.

Step 9: Reflect

  • Understand the importance of your service and the potential impact each encounter has.
  • Recognize the unique lived experiences of individual patients and how this may impact their deliberation process. While there is urgency and we may feel frustrated, the ultimate goal is to engender trust through respectful interactions.
  • Pause for moments of quiet gratitude and self-check-ins.

Conclusion

Just as SARS-CoV2 spreads from one person to many, we recognize that information—factual and otherwise—has the potential to move quickly as well. It is important to realize that providing an opportunity for people to ask questions or receive clarification and confirmation in a safe space is critical. The No Judgement Zone, as the name indicates, offers this opportunity. The conversations that we have in this space are valuable to those who are still considering the vaccine as an option for themselves. The trust required for such conversations is less about the transmission of information and more about the social act of engaging in bidirectional dialogue. The foundation upon which trust is built is consistent trustworthy actions. One such action is respectful communication without shame or ridicule. Another is our willingness to be transparent about our own concerns, experiences, and journeys. Assumptions based upon single-story narratives of the unvaccinated—particularly those from historically marginalized groups—fracture an already fragile confidence in medical authorities.

While we understand that mitigating the ongoing spread of the virus and getting more people vaccinated will call for more than just individual conversations, we believe that respecting the unique perspectives of community members is an equally critical piece to moving forward. Throughout a healthcare worker’s typical day, we work to create personal moments of connection with patients among the immense bustle of other work that has to be done. Initiatives like this one have a focused intentionality behind creating space for patients to feel heard that is not only helpful for vaccine uptake and addressing mistrust, but can also be restorative for providers as well.

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