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Course: Fundamentals of Nursing

Topic: Unconscious Bias- Conscious Inclusion

The Nurses International Community

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COPYRIGHT

NI Privacy Policy and Terms of Use.

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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.

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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.
National Center for Cultural Competence, n.d.c

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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 behaviours 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.b
National Center for Cultural Competence, n.d.c
National Center for Cultural Competence, n.d.a

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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.c
Ross H., 2020
National Center for Cultural Competence, n.d.a
Office of Diversity and Outreach, n.d.

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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,, n.d.b

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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.b
Amodio & Ratner, 2011, as cited in National Center for Cultural Competence, n.d.b

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Take a moment and think about……

How do you think implicit bias affects healthcare?

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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 residents

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

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Implicit Bias and Health Workforce

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.

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

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Implicit Bias and Health Care

Stereotypes inadvertently play a significant role in medical education
Automatic associations are made of client’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.

Marcelin et al., 2019

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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:

Client–provider interactions
Treatment decisions
Treatment adherence
Client health outcomes

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

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

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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

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Effects of Implicit Bias in Healthcare

These implicit bias were around:

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

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Effects of Implicit Bias in Healthcare (Continued)

Some kind of bias was evident in

Diagnosis
Treatment recommendations
Number of questions asked of the client
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 counterparts¹low 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

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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

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Effects of Implicit Bias in Healthcare

Implicit bias in healthcare providers leads to :

Disparities in healthcare service provision
Client dissatisfaction with care
Possible negative client health outcome

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Combating Implicit Bias: Why?

Impartial treatment of clients 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’

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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’.

Oxford University Press, 2021
Kaleidoscope Group, n.d.

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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 client feels valued, understood and cared for
Care is individualized and client-centered

Kaleidoscope Group, n.d.

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

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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

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Personal Awareness and Acknowledgement

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

Ferron & Zagaja, 2016

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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

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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

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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

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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 inferences 2
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

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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 client's point of view and try to understand their situation.

Ferron & Zagaja, 2016

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Partnership Building

Teach Back

Reframing the interaction with the client 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 client is asked to teach back the information provided by the healthcare professional.
Help confirm client understanding of health care instructions.
It is associated with improved adherence, quality, and client safety.

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Critical Thinking Question

Reflection:

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

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References:

American Academy of Family Physicians. (2019). Implicit Bias Training: Participant guide [Pdf]. The EveryONE Project® : Advancing health equity in every community. 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. https://www.nursingcenter.com/journalarticle?Article_ID=3832944&Journal_ID=54016&Issue_ID=3832735#P31

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References:

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. https://extensionpublications.unl.edu/assets/pdf/g1375.pdf

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

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References:

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. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4638275/

Institute for Healthcare Improvement (2017, September 28). How to reduce implicit bias. http://www.ihi.org/communities/blogs/how-to-reduce-implicit-bias

Kaleidoscope Group (n.d.). Conscious Inclusion at Work. Retrieved on September 20, 2021 from https://kgdiversity.com/conscious-inclusion-at-work/

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References:

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. https://academic.oup.com/jid/article/220/Supplement_2/S62/5552356

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

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

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References:

National Center for Cultural Competence( n.d.c). 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 on September 20, 2021 from https://www.lexico.com/definition/inclusion

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References:

Ross H.(2020, January 24). Implicit Bias: Recognizing the Unconscious Barriers to Quality Care and Diversity in Medicine. American College of Cardiology- Cardiology Magazine. 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’. https://www.sanc.co.za/wp-content/uploads/2021/04/Code-of-Ethics-for-Nursing-in-South-Africa.pdf

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