1 of 37

Course: Oncology Nursing

Topic: Unconscious Bias- Conscious Inclusion

The Nurses International Community

Contact info: info@nursesinternational.org

2 of 37

COPYRIGHT

NI Privacy Policy and Terms of Use.

Contact info: info@nursesinternational.org

3 of 37

Module Goals

Learners will be able to:

Define Implicit and explicit bias.
Describe the concept of implicit bias on the judgment and behavior of health practices.
Recognize nursing's best practices to avoid and address the implicit biases.

Contact info: info@nursesinternational.org

4 of 37

Bias

Bias is a prejudice in favor of or against one thing, person, or group compared with another, usually in a ways that is considered to be unfair¹.
Biases may be held by an individual, group, or institution and can have negative or positive consequences¹.
Bias may be expressed in affect, body language, and differential treatment².
Two types of biases^1,2:

Conscious bias (Explicit bias)
Unconscious bias (Implicit bias)

University of California, San Francisco, n.d., Unconscious Bias
National Center for Cultural Competence, n.d., Its How We are Wired

Contact info: info@nursesinternational.org

5 of 37

Conscious Bias (Explicit Bias)

It is the result of early learning and constant exposure to negative societal portrayals of specific groups¹.
Person is very clear about her/his feelings and attitudes².
Related behaviors are conducted with intent².
Governed by brain’s reflective system devoted to controlled processing³.
In its extreme is characterized by overt negative behaviour expressed through².

Physical and/or verbal harassment
OR, subtle means such as exclusion

Burgess et al., 2004, as cited in National Center for Cultural Competence, n.d., Its How We are Wired
National Center for Cultural Competence, n.d., Two Types of Bias
National Center for Cultural Competence, n.d.,

How is it possible

Contact info: info@nursesinternational.org

6 of 37

Unconscious Bias (Implicit Bias)

Bias that individuals form outside their own conscious awareness¹.
Attitudes or decisions that lead to unintended disparities and inequalities and reinforce cultural biases, resulting in "unintended consequences”².
Stems from one’s tendency to organize social worlds by categorizing¹.
Governed by brains reflexive system³, an automatic processing.
Far more prevalent than conscious prejudice¹.
Often incompatible with one’s conscious values^1,4.

National Center for Cultural Competence, n.d., Two Types of Bias.
Ross H., 2020.
National Center for Cultural Competence, n.d., How is it possible.
University of California, San Francisco, n.d.,
Unconscious Bias.

Contact info: info@nursesinternational.org

7 of 37

Implicit Bias: Why

Ability to rapidly categorize every person or thing encountered is thought to be evolutionary development to ensure survival¹.

Early ancestors needed to decide quickly whether a person, animal or situation they encountered was likely to be friendly or dangerous.
These innate tendencies is shortcut that our brain still uses.

Humans’ cognitive system uses categories and stereotypes rather than individual details of the situation in an effort to reduce cognitive load².

Banaji & Greenwald, 2013, as cited in Marcelin et al., 2019
Macrae et al., 1994, as cited in National Center for Cultural Competence-

‘ Its How We are Wired’, n.d.

Contact info: info@nursesinternational.org

8 of 37

Implicit Bias: Why

Self-protective function of the reflexive system requires that it operates quickly¹.
Reflexive system uses embedded memory from early socialization, life experiences, and social context categorized into stereotypes¹.
In stressful situation, reflexive system override reflective process and allows a person to make decisions based on stereotypes².

National Center for Cultural Competence, n.d., Its How We are Wired.
Amodio & Ratner, 2011, as cited in National Center for Cultural Competence-

‘ Its How We are Wired’, n.d.

Contact info: info@nursesinternational.org

9 of 37

Take a moment and think about…

How do you think implicit bias affects healthcare?

Contact info: info@nursesinternational.org

10 of 37

Implicit Bias and Health Workforce

Marcelin and his friends (2019) identified following unconscious bias affecting various groups in healthcare workforce in US:

Racial Bias�e.g members of a medical school admissions committee displayed significant unconscious white preference¹
Gender Bias�e.g a more positive tone and use of agentic descriptors in evaluations of male residents as compared to female residents²

Capers et al., 2017, as cited in Marcelin et al., 2019
Gerull et al., 2019, as cited in

Marcelin et al, 2019

Contact info: info@nursesinternational.org

11 of 37

Implicit Bias and Health Workforce

Continued….

Sexual and Gender Minority Bias

e.g. Experiences with or perceptions of bias lead to junior physicians not disclosing their sexual identity for fear of application rejection or poor evaluations¹.

Disability Bias

e.g. Physicians with disabilities have felt compelled to work twice as hard as their able-bodied peers for acceptance, struggled with stigma and microaggressions, and encountered institutional climates where they generally felt like they did not belong.²

Lee et al., 2014, as cited in Marcelin et al., 2019
Meeks et al., 2018, as cited in

Marcelin et al., 2019

Contact info: info@nursesinternational.org

12 of 37

Implicit Bias and Health Care

Marcelin et al. (2019)

Stereotypes inadvertently play a significant role in medical education
Automatic associations are made of patient’s age, gender, racial identity with certain disease conditions,

e.g. Black child with bone pain may have sickle-cell disease white child with recurrent respiratory infections may have cystic fibrosis

These learning associations may lead to premature closure and missed diagnoses

E.g Imprecise association of HIV to gay men hampered the recognition of the disease in other gender, children and blood donor recipients.

Contact info: info@nursesinternational.org

13 of 37

Effects of Implicit Bias in Healthcare

A systematic review of literature conducted by Hall and his friends (2015) found that:

Implicit bias,in US, was significantly related to:

Patient–provider interactions
Treatment decisions
Treatment adherence
Patient health outcomes

Patient–provider interactions involving people of color was characterized by:

Dominant communication styles
Fewer demonstrated positive emotions
Infrequent requests for input about treatment decisions
Less patient-centered

Contact info: info@nursesinternational.org

14 of 37

Effects of Implicit Bias in Healthcare

A systematic review of literature conducted by Fitzgerald & Hurst (2017) found that:

Implicit biases existed among physicians and nurses
To similar degrees as the general population
These implicit bias were around:

Race/ethnicity
Gender
Socio-economic status
Age
Mental illness
Weight
Having AIDS
Brain injured patients perceived to have contributed to their injury
Intravenous drug users
Disability
Social circumstances

Contact info: info@nursesinternational.org

15 of 37

Effects of Implicit Bias in Healthcare

Some kind of bias was evident in

Diagnosis
Treatment recommendations
Number of questions asked of the patient
The number of tests ordered�

E.g. Physicians were less certain of the diagnosis of coronary heart disease for middle-aged women, who were thus twice as likely to receive a mental health diagnosis than their male counterparts.¹

Low socio-economic status (SES) latinos and blacks were more likely to have intrauterine contraception recommended than low SES whites²

Maserejian et al.,2009, as cited in Fitzgerald & Hurst, 2017
Dehlendorf et al., 2010, as cited in

Fitzgerald & Hurst, 2017

Contact info: info@nursesinternational.org

16 of 37

Effects of Implicit Bias in Healthcare

In same systematic review,

A study found implicit prejudice of nurses towards injecting drug users significantly mediated the relationship between job stress and their intention to change jobs.

von Hippel et al, 2008, as cited in Fitzgerald & Hurst, 2017

Contact info: info@nursesinternational.org

17 of 37

Effects of Implicit Bias in Healthcare

Implicit bias in healthcare providers leads to :

Disparities in healthcare service provision
Patient dissatisfaction with care
Possible negative patient health outcome

Contact info: info@nursesinternational.org

18 of 37

Combating Implicit Bias: Why?

Impartial treatment of patients by healthcare professionals is an uncontroversial norm of healthcare¹
South African Nursing Council states the following ethical principles of nursing²:

Social justice: expected to act fairly and equitably at all times; pursue justice and advocate on behalf of vulnerable and disadvantaged healthcare users.
Non-maleficence: consciously refrain from doing harm of any nature whatsoever.
Beneficence: do good and choose the “best option” of care under given circumstances.

Fitzgerald & Hurst, 2017.
South African Nursing Council-

‘Code of Ethics’

Contact info: info@nursesinternational.org

19 of 37

Conscious Inclusion

Inclusion defined as-

‘the practice or policy of providing equal access to opportunities and resources for people who might otherwise be excluded or marginalized, such as those who have physical or mental disabilities and members of other minority groups’ ¹

Conscious inclusion is defined as-

‘strategically execute a practical approach to driving the thoughts, beliefs, and behaviors that allow us to value and leverage differences to achieve superior results’ ²

Oxford University Press, Definition of Inclusion
Kaleidoscope Group,

Conscious Inclusion at Work

Contact info: info@nursesinternational.org

20 of 37

Conscious Inclusion

Healthcare professionals do not view themselves as biased
Like any other individual, no nurse is resistant to implicit bias
Nurses must take deliberate actions to eliminate implicit bias and ensure inclusive nursing practice
Nurses practice conscious inclusion when,

Care provided is free of stereotyping
Each patient feels valued, understood and cared for
Care is individualized and patient-centered

Kaleidoscope Group, Conscious Inclusion at Work

Contact info: info@nursesinternational.org

21 of 37

What strategies do you think will help you combat implicit bias in your nursing practice?

Contact info: info@nursesinternational.org

22 of 37

Strategies to Combat Implicit Bias

Personal awareness and acknowledgment
Cultural humility
Stereotype replacement
Counter-stereotypical interactions
Counter-stereotypic imaging
Individuation
Empathy/Perspective taking
Partnership building
Teach-back

Contact info: info@nursesinternational.org

23 of 37

Personal Awareness and Acknowledgement

Ferron & Zagaja (2016)

Personal Awareness:

First step towards conscious inclusion
Process of looking inward to recognize beliefs and values that can lead to implicit bias
Being aware of one’s own biases

Acknowledgment:

Without acknowledgment that a problem exists, no action can be taken to solve the problem
Acceptance of the existence of personal implicit bias
With it comes the acceptance of accountability and responsibility to make a difference

Contact info: info@nursesinternational.org

24 of 37

Practice Cultural Humility

“Cultural competency” might impart a false sense of confidence of championing inclusivity

Might fail to recognize that cultural barriers continue to exist

Cultural humility helps individuals to acknowledge that,

Their view is not nearly as extensive, open, or dynamic as they might perceive.
One need not be and ultimately cannot be experts in all the intersecting cultures they encounter.
One can focus on readiness to learn, be dedicated to lifelong learning.

Juarez et al., 2006, as cited in Marcelin et al., 2019

Contact info: info@nursesinternational.org

25 of 37

Stereotype Replacement

Replacing stereotypical responses for non-stereotypical responses
Involves recognizing that-

A response is based on stereotypes
Labeling the response as stereotypical
Reflecting on why the response occurred

Then considers

How the biased response could be avoided in the future
Replaces it with an unbiased response

Monteith, 1993, as cited in Devine et al., 2012

Contact info: info@nursesinternational.org

26 of 37

Counter-Stereotypical Interactions

Intentionally diversifying own circles, connecting with people from different backgrounds and experiences¹.
Engaging meaningfully with people from stereotyped groups who exemplify attitudes and behaviors that defy the stereotype².
Making small behavioral changes that, with time, can help to retrain one’s brain to classify people as “same” instead of “other”¹

E.g.: Occasionally awkward and uncomfortable introductions with new people from different backgrounds making an effort to read books by diverse authors

Marcelin et al. (2019)
American Academy of Family Physicians. (2019)

Contact info: info@nursesinternational.org

27 of 37

Counter-Stereotypical Imaging

Individuation

Imagining the individual as the opposite of the stereotype¹

Like smart person, or famous person , or a personal friend
This strategy makes positive exemplars salient and accessible when challenging a stereotype validity

2. Brewer, 1988, Fiske & Neuberg, 1990, as cited in Devine et al., 2012.

Seeing the person as an individual rather than a stereotype
Preventing stereotypic inferences²
Evaluate members of the target group based on personal, rather than group-based, attributes²

1. Blair et al., 2002, as cited in Devine et al., 2012.

Contact info: info@nursesinternational.org

28 of 37

Empathy/Perspective Taking

Empathy is the ability to share and understand the feelings and experience of others

Understand perspectives, intentions, and needs of the other before judging them

It let’s one ‘walk in the shoes of others’
Empathy is not automatic

Takes time to be adept at this skill
Requires conscious effort to fully immerse in the patient's point of view and try to understand their situation

Ferron & Zagaja (2016)

Contact info: info@nursesinternational.org

29 of 37

Teach Back

Partnership Building

Reframing the interaction with the patient as one between collaborating equals

Rather than between a high-status person and a low-status person

Institution for Healthcare Improvement (2017)

A method where patient is asked to teach back the information provided by the healthcare professional
Help confirm patient understanding of health care instructions

It is associated with improved adherence, quality, and patient safety

Contact info: info@nursesinternational.org

30 of 37

Case Study/Critical Thinking Question/What would the nurse do?

Reflection:

Describe what you can do to reframe the interaction with a patient as a partnership.

Contact info: info@nursesinternational.org

31 of 37

Reference:

American Academy of Family Physicians. (2019). Implicit Bias Training: Participant guide. The EveryONE Project® : Advancing health equity in every community. Accessed from: https://www.aafp.org/dam/AAFP/documents/patient_care/health_equity/implicit-bias-training-participant-guide.pdf

Bucknor-Ferron, P. & Zagaja, L. (2016). Five strategies to combat unconscious bias. Nursing2021, 46(11): 61 - 62. Accessed from: https://www.nursingcenter.com/journalarticle?Article_ID=3832944&Journal_ID=54016&Issue_ID=3832735#P31

Contact info: info@nursesinternational.org

32 of 37

Reference:

de Guzman, M.R.T, Durden, T.R., Taylor, S.A., Guzman, J.M., & Potthoff, K.L. (2016). Cultural Competence: An Important Skill Set for the 21st Century. NebGuide. Accessed from: https://extensionpubs.unl.edu/publication/9000017519635/cultural-competence-an-important-skill-set-for-the-21st-century-g1375/�
Devine, P. G., Forscher, P. S., Austin, A. J., & Cox, W. T. (2012). Long-term reduction in implicit race bias: A prejudice habit-breaking intervention. Journal of experimental social psychology, 48(6), 1267–1278. Accessed from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3603687/�
Fitzgerald C. & Hurst S. (2017). Implicit bias in healthcare professionals: a systematic review. BMC Medical Ethics, 18 (19). Accessed from: https://bmcmedethics.biomedcentral.com/articles/10.1186/s12910-017-0179-8#citeas

Contact info: info@nursesinternational.org

33 of 37

Reference:

Hall, W. J., Chapman, M. V., Lee, K. M., Merino, Y. M., Thomas, T. W., Payne, B. K., Eng, E., Day, S. H., & Coyne-Beasley, T. (2015). Implicit Racial/Ethnic Bias Among Health Care Professionals and Its Influence on Health Care Outcomes: A Systematic Review. American journal of public health, 105(12), e60–e76. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4638275/�
Institute for Healthcare Improvement (2017). How to reduce implicit bias. Accessed from: http://www.ihi.org/communities/blogs/how-to-reduce-implicit-bias�
Kaleidoscope Group (n.d.). Conscious Inclusion at Work. Retrieved from https://kgdiversity.com/conscious-inclusion-at-work /

Contact info: info@nursesinternational.org

34 of 37

Reference:

Marcelin J.R., Siraj D.S., Victor R., & Kotadia S. (2019). The impact of unconscious bias in healthcare: how to recognize and mitigate it. The Journal of Infectious Diseases, 220 (2): S62-S73. Retrieved from https://academic.oup.com/jid/article/220/Supplement_2/S62/5552356

National Center for Cultural Competence (n.d.). How is it Possible. Georgetown University. Accessed from: https://nccc.georgetown.edu/bias/module-3/2.php

National Center for Cultural Competence (n.d.). Its How We are Wired. Georgetown University. Retrieved from: https://nccc.georgetown.edu/bias/module-3/3.php

Contact info: info@nursesinternational.org

35 of 37

Reference:

National Center for Cultural Competence( n.d.). Two Types of Bias. Georgetown University. Retrieved from: https://nccc.georgetown.edu/bias/module-3/1.php

Office of Diversity and Outreach (n.d.). Unconscious Bias. University of California, San Francisco. Accessed from: https://diversity.ucsf.edu/resources/unconscious-bias�
Oxford University Press (2021). Definition of Inclusion (online). Lexico.com. Retrieved from: https://www.lexico.com/definition/inclusion

Contact info: info@nursesinternational.org

36 of 37

Reference:

Ross H., Jan (2020). Implicit Bias: Recognizing the Unconscious Barriers to Quality Care and Diversity in Medicine. American College of Cardiology- Cardiology Magazine. Retrieved from: https://www.acc.org/latest-in-cardiology/articles/2020/01/01/24/42/cover-story-implicit-bias-recognizing-the-unconscious-barriers-to-quality-care-and-diversity-in-medicine�
South African Nursing Council- ‘Code of Ethics’. Retrievedfrom: https://www.sanc.co.za/wp-content/uploads/2021/04/Code-of-Ethics-for-Nursing-in-South-Africa.pdf

Contact info: info@nursesinternational.org

37 of 37

Please go to

My Learning Experience

to provide feedback on your experience.

Thank you, and come back soon!

Contact info: info@nursesinternational.org