Implementation of a Privilege and Resilience Walk in Health Professions Education: Experiences,Insights,and Reflections

Abstract

The privilege walk (PW) has gained traction as a method to raise awareness of privilege and vulnerability across various settings. This experiential activity involves participants responding to statements about their identities and backgrounds by stepping forward or backward, illustrating disparities in social advantage. The PW can contribute to self-awareness, the recognition of diversity, and the cultivation of compassion among health profession students. However, concerns about potential emotional and moral harms have prompted strong criticism. To address these concerns, the authors have integrated a resilience walk (RW) alongside the PW as a curricular addition for healthcare learners. The RW focuses on strengths and protective skills individuals have developed to overcome challenges, providing a balanced perspective. By conducting the PW and RW sequentially and facilitating a brave discussion afterward, facilitators can offer learners a more comprehensive opportunity to reflect on their identities, privileges, and strengths within a supportive environment. The authors provide insights into curricular integration of the PW and RW, effective facilitator training, and navigating the possible range of student reactions during the debrief. Further qualitative research should assess student perceptions and outcomes, enabling educators to optimize their use within healthcare education.

Introduction

In recent years, organizations have utilized the methodology of privilege walks (PWs) to promote awareness of privilege and vulnerability. Along with undergraduate universities, the use of the PW has increasingly gained popularity in nonprofit and corporate settings, as well as the U.S. military. Indeed, the exercise has become a prominent fixture within diversity, equity, and inclusion training in various disciplines.^1–7

The PW is an experiential activity typically conducted in three parts: introduction, activity, and facilitated debrief. During the introduction, facilitators set the stage and explain the meaning of different types of privilege, such as economic privilege, access to enriching experiences in childhood, or identifying with a culturally dominant group. The facilitators also advise participants about potential emotional responses and provide context about why the exercise could be relevant to the participants’ work. ⁷

The structured activity involves lining participants’ elbow-to-elbow with blindfolds on and asking them to take a step forward or backward in response to a series of statements about their identities, family, upbringing, or background. If the participant has been a beneficiary of a social advantage, they take a step forward. If the statement does not apply to them, the participant stands in place or takes a step backward. At the conclusion of the PW, participants are invited to remove their blindfolds and, for the first time, observe their positioning relative to their peers. This can be a powerful moment, as some may find themselves situated at the extremes of the room, while others may be scattered in between. A skilled facilitator leads a subsequent debriefing process, allowing participants to reflect on their feelings, thoughts, insights, and implications for the future.

PWs can be adapted to explore a variety of themes, including ableism, racism, ageism, sexism, homophobia, poverty, and more. ⁸ By engaging in these walks, participants can gain insight into their own privileges and vulnerabilities, become more cognizant of the struggles faced by others, and cultivate empathy and compassion among the participants—toward their peers as well as themselves. Ultimately, the PW can be utilized to create an environment conducive to inspiring participants to engage in social change. ⁹

Potential Benefits and Harms of PWs in Health Professions Education

The ability to recognize, appreciate, and understand the diverse life experiences and identities of patients is essential for health professions education, as it enables students to build meaningful relationships based on authentic connection, empathy, and compassion. Understanding one's own identity, experience, and privilege is a crucial first step in helping health professions learners develop the skills to provide effective person-centered care. The PW powerfully exposes how social inequity is not something that happens to others; rather, inequity can also be observed within the participants’ peer community.

Health professions learners often begin their healthcare training having not experienced much prior formal education in philosophy, social justice, and ethics. In fact, only 3.7% of medical school matriculants in 2023 to 2024 majored in the humanities. ¹⁰ A 2022 study examining undergraduate prerequisites for physician assistant (PA) programs revealed that fewer than 25% of accredited PA programs required English in 2020, and those numbers drop even more precipitously for general humanities or ethics courses: only 8.7% of programs required general humanities and a mere 1.1% required any ethics. ¹¹ Armed with an intuitive grasp of inequity, a strong desire to help their fellow human, and significant training in the sciences, learners participate in the PW without having had many formal opportunities to question their own assumptions, biases, and social privileges. Early health professions learners may also have had only limited opportunities to think about and interrogate the ways in which complicated forces, such structural racism, generational wealth/poverty, and the history of the American insurance system, influence social determinants of health.

In the PW and the subsequent debrief, students can interrogate their own histories and consider how these histories shape the ways in which they move through the world. Through the activity, the participant is challenged to think about unearned advantages and how those advantages shape their experience of being in the world. This kind of active learning can be a powerful moment that students can imaginatively return to as they progress through their education and gain more clinical experience with different patient populations.

The learning value of the PW, however, can be seriously undermined by its potential for harms.^12,13 Educators are increasingly aware of the potential harms of uncovering past traumas or using individuals with marginalized identities as teaching tools for those with more privilege. Ehreke et al have suggested that, without an element of empowerment, PWs may actually worsen attitudes toward groups that are different. ¹

PWs invoke strong emotions within participants by design. ¹⁴ Blindfolded, participants are “alone” in the dark throughout the PW. They experience heightened awareness, seemingly alone with their thoughts while simultaneously acutely aware of those around them. In stepping backward and forward, participants have a kind of physical and embodied experience of encountering their personal sources of privilege or lack thereof. Removing the blindfold and seeing where they are positioned in relation to their peers can intensify their feelings. Participants may experience a range of emotions, from gratitude or relief to anger, discomfort, guilt, or shame. ⁷ Responding to these emotions, participants may react in the debrief sessions with deflection, resistance, numbness, or laments of powerlessness and hopelessness. The potential for conflict among participants who are experiencing different emotions, identities, and privileges is present and demands navigation by a highly skilled facilitator. The intentions of facilitators of the PW—to inspire a kind of social consciousness that rejects oppressive forces and fosters solidarity—may inadvertently backfire and be perceived by participants as shaming or needlessly divisive.^7,13–15

Furthermore, the health professions literature has not extensively explored the effects of PWs or their outcomes. The lack of standardization of questions or facilitator experience and training create a highly variable experience making generalizations difficult to conclude.^16,17

Curricular Opportunity: Enhancing the PW With a Resilience Walk

The PW statements used in our lessons were adapted from ones published by the American Psychological Association. ¹⁸ To expand upon the positive potential of PWs, minimize the potential harms, and better equip students with the skills to view their experiences in a constructive light, we created a novel resilience walk (RW), consisting of 30 statements, to be conducted immediately after the PW and before the debrief session. We also refined some of the original PW statements to address particularities that may be unique to the health professions learner, such as being the first person in the family to pursue a career in healthcare.

The RW follows the same process of the PW, with blindfolded participants stepping forward and backward as facilitators read statements. The RW, however, utilizes a much different set of statements. While the PW highlights sources of unearned privilege that students may or may not have, the RW emphasizes protective skills and strengths that the less privileged may have cultivated or tapped into to achieve past success. For example, in the PW, the facilitator might say, “If there were more than 50 books in your house when you grew up, take one step forward” or “If you ever had to skip a meal or were hungry because there was not enough money to buy food when you were growing up, take one step back.” In the RW, the facilitator makes statements like “If you have a strong understanding of your family's history and culture, take a step forward” or “If you are someone others can rely on in tough situations, take a step forward” (authors’ unpublished RW statements).

Despite immense variability in life stories and experiences, students who enter healthcare training have all succeeded to the extent that they have earned coveted positions within competitive programs. Generally overachievers, they can also be their own harshest critics. By pairing the PW and the RW, learners are provided an experience that gives them the opportunity to both experience the discomfort of confronting unearned advantage, then put that experience of privilege or lack of privilege in dialog with their individual and communal strengths. In the RW, every statement is an invitation to step forward and an opportunity for learners to reflect upon their positive characteristics and their own tools of success.

By adding the RW, facilitators have a stronger pedagogical skeleton upon which they can build a debriefing dialogue that allows learners to appreciate and acknowledge the reality of unearned privilege while also empowering learners to recognize how they can work toward the service of others and build a shared community. By running the two activities in sequence, we have been able to create a comprehensive approach to providing students with the necessary tools to reflect on their identities, experiences, vulnerabilities, and privileges and to thread this into the theme of honoring the common humanity that is at the heart of patient-centered care.

Reflections on Implementing Privilege and RWs With Healthcare Professions Students

The authors have implemented the PW and RW over three years in cohorts of both medical and PA students. The following reflections can be used to guide educators interested in implementing PWs and RWs with their health professions learners.

1. Consider the timing of the activity within the curriculum.

We have deployed the PW and RW at different times in the curriculum: at the beginning of the first year for medical students, and toward the end of the didactic phase for first-year PA students. Both options present different considerations. For cohorts that have not yet bonded, the experience may not have the same sense of gravity as for those who have already built a sense of peer community. Students who have had shared experiences in and out of the classroom, however, may empathize with their peers to such an extent that they have difficulty pivoting to the consideration of the implications for their future work of delivering services and care for their patients.

• 2. Give students a common vocabulary prior to the activity.

Misunderstandings can arise when students use words in different ways. Particularly when discussing topics that are emotionally charged and potentially polarizing, students need to start the conversation with as much of a level educational field as possible. Didactic lessons teaching concepts like “internal, individual, institutional and structural racism,” “intersectionality,” “implicit bias,” and “material and nonmaterial culture” prior to the walks can help students then engage in the debriefing session with trust that their peers, despite their differences, are using language in similar ways.

• 3. Prepare facilitators.

The role of the facilitator in the PW and RW is integral to the success of the activity. Facilitators must have training in active facilitation of difficult topics and possess the insight, emotional intelligence, and a keen awareness of group dynamics. Although they do not need to be experts in social ethics, facilitators should understand the social processes that result in inequity and be able to help learners contextualize their experiences within a larger cultural narrative.

• 4. Expect resistance.

Given the intense emotional responses that can arise during a PW, it is not uncommon for students to resist the activity or “numb out” during the debrief and not engage. Many may be reflecting on their privilege or vulnerabilities for the first time or may find it difficult to grapple with experiences from the past. Moreover, students may struggle to reconcile the concepts of privilege and oppression with the dominant cultural narratives of self-sufficiency, meritocracy, and overcoming hardships. ¹⁹

• 5. Monitor reactions.

Knowing that the PW can stir up intense and often surprising emotions, facilitators should monitor students for their reactions in real time and be prepared to offer support. Additionally, trained counselors should be available to provide assistance to those who are showing signs of distress. To promote a supportive learning environment, it is also recommended that an optional discussion session be offered after the debrief, allowing students the opportunity to reach out for extra support if needed.

• 6. Mind your words.

Care should be taken in selecting language when discussing topics related to race and privilege. The use of terms such as “white privilege,” though in some contexts may be received with an understanding of the complex dynamics of power and history, may in other situations lead to an instantaneous defensive response from individuals.

Quarles and Bozarth recently conducted research into how the term of “white privilege” impacted participation, polarization, and content in lay people's online communication, finding that the mere mention of the word seemed to generate internet discussions that were less constructive and more polarized. ²⁰ Our students are part of the larger ecology of their communities, so there may be some natural spillover effects on them, too. Consequently, the choice of words can have a potent influence on the receptivity to the message, degree of dialog and connection that is established.

7. Unveil the intersection of advantage and disadvantage for the learners.

The health professions educator Stephanie Nixon introduced the concept of critical allyship through the coin model of privilege, which takes an intersectional approach to understanding how systems of inequality, such as sexism, racism, and ableism, interact to create complex patterns of privilege and oppression. This model emphasizes the system, rather than the individual, as the source of oppression. It also allows educators to contextualize how one can be privileged in one system and oppressed in another, as there are multiple coins representing different systems of inequality. ¹⁵ This model provides a useful tool for facilitators to convey the complexities of privilege and oppression during this activity. Facilitators should also be explicit that students do not have control over the circumstances in which they were raised; none of the systems of social privilege or disadvantage suggests a personal judgment toward the learner.

• 8. Create a brave space.

Developing the conditions for students to have brave conversations regarding privilege, power, oppression, and resilience is essential to their educational development. To achieve this, educators must create brave spaces in the classroom environment. Brave spaces, as developed by Rian Arao and Kristi Clemens, consist of five main elements: controversy with civility, owning intentions and impacts, challenge by choice, respect, and no attacks. ²¹ All these elements are necessary to foster an environment in which students can have meaningful dialog and learn from one another in a productive manner. Brave spaces can provide students with a platform to meaningfully disrupt their comfort zones, fostering the potential to broaden their perspectives and engage in challenging conversations.

• 9. Focus on empowerment and solidarity alongside privilege.

Given the future role of health professions students in the lives of their patients and communities coupled with the complex range of emotions evoked by this activity, it is essential to foster a sense of empowerment to aid in their making sense of what has been uncovered in this activity. The RW component provides an opportunity for students to reflect upon their privilege and/or the adversities they have overcome, and how these experiences can better equip them to connect with their patients, build fellowship with their peers and serve their community.

• 10. Be ready to reframe.

Actively helping students reframe their experiences and moving toward productive discussion in the debrief can be a challenging task. Learners may hyper-focus on their guilt at having benefited from unearned advantages, shame from having privilege, discomfort at seeing their position in the PW as compared to their peers, or grief from the realization of the depth of injustice within society. To help pace the discussion and move the discussion toward empowerment, the facilitators need to be ready to reframe the dialogue to a discussion of solidarity, resilience, altruism, overcoming challenges, and empowerment to care for their communities.

• 11. Build community.

The PW and RW may be a “one and done” active learning lesson, but the discussions will likely continue outside of the classroom. Be explicit with the learners about how the exercise can help a cohort learn about each other, appreciate one another, find strengths and opportunities to lean on each other, and grow closer in an authentic way. Consider pairing the PW and RW activity with other community building activities so that the learners can put the concepts of solidarity into action.

Conclusion

The PW is an experiential learning activity that aims to increase awareness of privilege and advantage. Though increasingly popular among educators and diversity trainers, the activity is not well-studied in healthcare education and is not without risk of emotionally and morally harming healthcare learners. For educators considering the implementation of this activity, the RW can help mitigate potential harms and be a useful supplement for educators. Future qualitative research should describe and evaluate student perceptions of the activity. Determining methods for measuring outcomes of the privilege and RWs would also help educators better understand the risks and benefits, as well as gauge the ultimate value of this type of activity within healthcare education.