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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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Student Learning Outcomes

Learners will be able to:

Define implicit and explicit bias.

Explain how implicit bias impacts judgement and decision-making in Healthcare.

Identify best practices in Nursing to avoid and address 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.

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……

List characteristics that might influence others to form explicit or implicit biases about an individual.

How could these biases impact the quality of care provided to patients?

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Implicit Bias and Health Workforce

Marcelin et al. (2019) identified the following unconscious biases affecting various groups of Healthcare Workers in the USA:

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

Type of Bias	Example
Racial	Medical School admissions officers gave preference to white students
Gender	More positive adjectives used when describing male versus female residents

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Implicit Bias and Health Workforce

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

Type of Bias	Example
Sexual & Gender Identity	Physicians not disclosing sexual/gender identity on application for fear of being rejected.
Disability	Disabled physicians report feeling compelled to work twice as hard to keep up with able-bodied peers, reported experiencing stigmatizing behaviours and microaggressions and felt they did not belong.

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Implicit Bias and Health Care

Marcelin et al (2019) found that:

Stereotypes inadvertently play a significant role in medical education

Automatic associations are made of client’s age, gender, racial identity with certain disease conditions - for example, a black child with acute pain may be incorrectly assumed to have Sickle Cell Anemia.

Implicit bias may lead to misdiagnoses or no diagnosis, which can greatly affect Patient’s health outcomes.

Marcelin et al., 2019

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Effects of Implicit Bias in Healthcare

Hall et al (2015) found that Implicit Bias in Healthcare settings in the US impacted:

Client–provider interactions
Treatment decisions
Treatment adherence
Client health outcomes

Client–provider interactions involving Black and Minority Ethnic Groups was characterized by:

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

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Combating Implicit Bias: Why?

Impartial treatment of clients is sadly a cultural norm in Healthcare¹.

To adhere to Professional Nursing Standards, we must work to reduce explicit and implicit bias, and provide equal treatment for all.

The Code of Conduct (NMC UK, 2018) states that Nurses must:
“Avoid making assumptions and recognise diversity and individual choice”
“Challenge discriminatory attitudes and behaviours relating to the care of people”
“Be aware of, and reduce as far as possible, any potential for harm associated with your practice”

Fitzgerald & Hurst, 2017
South African Nursing Council- ‘Code of Ethics’

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

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Conscious Inclusion

“the practice of being mindful of the diverse needs, experiences, and perspectives of individuals within a group or organisation. It requires recognising and addressing the biases and structural inequities that may prevent certain groups from fully participating or feeling welcome. This approach goes beyond passive tolerance and actively seeks to create environments where all voices are heard, respected, and engaged.”

The Oxford Review, 2026

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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

Recognize 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.

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
Evaluate members of the target group based on personal, rather than group-based, attributes

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.

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

Nursing and Midwifery Council. (2018). The code: Professional standards of practice and behaviour for nurses, midwives and nursing associates. https://www.nmc.org.uk/globalassets/sitedocuments/nmc-publications/nmc-code.pdf

Office of Diversity and Outreach (n.d.). Unconscious Bias. University of California, San Francisco. Accessed from: https://diversity.ucsf.edu/resources/unconscious-bias

The Oxford Review. (2026). Conscious Inclusion: Definition and Explanation. https://oxford-review.com/the-oxford-review-dei-diversity-equity-and-inclusion-dictionary/conscious-inclusion-definition-and-explanation/

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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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