Training to spot microaggressions should be mandatory in pharmacy foundation education

If pharmacy foundation training is to become genuinely inclusive, system-level commitments must translate into everyday behaviour. One practical way this can be achieved is through structured education on microaggressions — subtle but impactful behaviours that shape learning environments long before formal complaints are ever raised.

As pharmacists, progress towards expanded prescribing responsibilities, the ability to speak up, challenge assumptions and work confidently within hierarchies is no longer optional. Training environments that overlook microaggressions risk undermining not only trainee wellbeing but prescribing practice and patient safety.

Easy to overlook, hard to ignore

Microaggressions are often described as brief, everyday verbal or behavioural slights that communicate exclusion or negative assumptions. While rarely intentional, their cumulative impact can affect wellbeing, learning and professional confidence. In pharmacy training environments, where hierarchies and assessment pressures exist, these experiences can undermine the development of confident, independent practitioners.

An equality, diversity and inclusion (EDI) clinical fellowship exploring the lived experiences of pharmacy trainees across the South West, Thames Valley and Wessex region identified microaggressions as a significant but under-recognised feature of training. The project used an online survey with quantitative and free-text responses. Almost half (47%) of respondents reported experiencing discrimination during their foundation year, with 40% of incidents involving subtle or underhand behaviours rather than overt racism^​1​.

These experiences predominantly took the form of cumulative microaggressions, including mispronunciation of names, repeated questioning about background or identity, exclusion from workplace interactions and assumptions about competence or communication ability. Behavioural microaggressions — such as being ignored in discussions or subjected to heightened scrutiny compared with peers — were also commonly reported and contributed to feelings of “othering” and a lack of belonging within teams.

While individual incidents were often perceived as minor, trainees described their cumulative impact as significant, leading to reduced confidence, increased anxiety, and a reluctance to speak up or engage fully in learning opportunities. This aligns with wider evidence demonstrating that recognising and addressing microaggressions can improve psychological safety, enhance cultural competence, and support more inclusive learning environments for both trainees and educators, as well as build confidence to challenge behaviours and promote allyship in practice^​2​.

Pharmacy foundation trainees frequently rotate across workplaces and teams, navigating new expectations while being assessed by those who hold authority over progression. Although overt discrimination is addressed through policy, trainees often report uncertainty about how to respond to behaviours that feel ambiguous, “minor” or difficult to articulate. Supervisors, in turn, may feel unsure how to intervene when no malicious intent is perceived. This gap between policy and practice allows microaggressions to persist — not because they are accepted, but because they are poorly understood. Although professional standards emphasise professionalism, respect and inclusive practice^​3​, translating these principles into everyday interactions can be challenging without structured opportunities for reflection and discussion. 

Why this matters for future prescribers

The implications extend beyond culture alone. Independent prescribing requires pharmacists to ask questions, challenge decisions, acknowledge uncertainty and advocate for patients. These behaviours depend on psychological safety.

Training environments that normalise silence, discomfort or fear of being labelled “difficult” risk shaping future prescribers who are less likely to speak up — with potential consequences for prescribing quality and patient care. If pharmacy education focuses solely on technical competence while neglecting the interpersonal skills needed to navigate complexity and power, it leaves trainees underprepared for autonomous practice.

Addressing microaggressions is therefore not an “EDI add‑on”, but part of preparing pharmacists for safe, collaborative and person‑centred prescribing.

Developing microaggressions training within foundation education

In response to these challenges, a dedicated unconscious bias and microaggressions training session was developed and embedded within the foundation pharmacist programme at Health Education Improvement Wales (HEIW). The aim of the workshop was not to allocate blame, but to explore how everyday language, assumptions and behaviours can influence learning, teamwork and professional interactions. 

The session forms part of a broader programme addressing unconscious bias, inclusive practice and professional behaviours. Its development drew on established guidance, including the Royal College of Pharmacy’s race microaggressions toolkit^​, and educational principles that prioritise reflection, dialogue and psychological safety.^​4​

Crucially, the training focuses on impact rather than intent. By recognising microaggressions as products of systems, habits and cultures — rather than individual failings — participants are encouraged to reflect without defensiveness and consider their role in shaping inclusive environments.

Interactive methods — including facilitated discussions, realistic scenarios and reflective prompts — enable trainees and supervisors to practise listening, responding and challenging constructively. These skills are directly transferable to prescribing consultations, where understanding patient context, navigating uncertainty and reflecting on one’s own assumptions are essential.

Who the training is for — and why that matters

Although delivered primarily to foundation trainees, the training is intentionally relevant to the entire pharmacy team, including supervisors, tutors and educational leads.

For trainees, it supports:

• Greater awareness of how communication affects others;
• Confidence in raising concerns and navigating difficult conversations;
• Development of reflective, inclusive professional behaviours.

These capabilities are particularly important as trainees move towards independent prescribing roles that require leadership, shared decision-making and patient advocacy.

For supervisors, tutors and educational leads, the training reinforces their responsibility to model inclusive behaviours, and actively create environments where questioning and challenge are welcomed. These are not abstract ideals — they underpin safe learning and safe prescribing.

Evidence of impact

Feedback from the training sessions demonstrated strong engagement and relevance, with an average rating of 4.58 out of 5. Trainees consistently valued having a safe space to discuss experiences, hear perspectives different from their own and develop a clearer understanding of microaggressions and their effects.

Supervisors reported that the quality of discussion and participation was the most impactful element, suggesting the training fostered reflection, empathy and professional growth. In informal feedback, trainees from ethnic minority backgrounds described feeling heard and validated — often for the first time within formal education settings.

While qualitative, these insights suggest that the training is helping to normalise conversations that are essential for inclusive practice but too often avoided.

Addressing the counterarguments

Some may argue that mandatory inclusion training already exists, or that microaggressions are too subjective to be addressed through education. However, feedback from foundation trainees suggests that generic inclusion training often fails to translate into everyday practice. When inclusion is presented in abstract terms rather than grounded in real-world scenarios, it is easily dismissed. 

Others may worry that focusing on microaggressions risks making learners overly cautious. In practice, the opposite may be true. Improving awareness, establishing a shared language and building confidence to respond constructively supports clearer, more respectful communication, and enables trainees to recognise and address issues earlier, where it is safe to do so.

Findings from the fellowship survey reinforce this^​1​. While about 80% of participants initially reported not experiencing microaggressions, this figure fell to about 50% after engagement with microaggressions themes and lived-experience examples. This suggests that education equips individuals to recognise, name and respond to behaviours that might otherwise go unchallenged.

Why pharmacy education must act now

As pharmacists take on expanded prescribing roles, expectations around leadership, communication and accountability will only increase. Embedding microaggressions training within foundation education complements wider NHS initiatives — including inclusive pharmacy practice principles^​5​, the Safe Learning Environment Charter^​6​ and the trainee support guide^​7​ — by operationalising inclusion at the point where professional habits are formed.

If pharmacy is serious about retaining a diverse workforce and supporting safe prescribing practice, it must invest in learning environments that enable openness, challenge and growth.

An inclusive profession is built not only through policy but through everyday practice — taught, modelled and reinforced from the very start of training.