I was far too old when I learned that there were religions other than Christianity. Growing up, I thought anyone from a big city was arrogant. I didn’t know Native American tribes still existed in the United States until I was 25. That’s right, you heard me—25. These assumptions were shaped by my interaction (or lack thereof) with the world around me, but if left unchecked would negatively affect how I care for others.

I should start this article off by telling you I’m not an expert in implicit bias, but I am a voracious pursuer of personal and professional improvement and believe we need to have more conversations that are laden with vulnerability if we are truly going to reduce health disparities (Hall et al., 2015), improve the teaching and learning environment (Fjørtoft et al., 2022), and create a culture of equity in health care (Cooper et al., 2022)

In 2022, my organization determined implicit bias training was needed, and so I, as someone who has been actively pursuing knowledge in this and similar areas for quite some time, volunteered to create a module. In doing so, I was left with so many questions on how nursing professional development (NPD) practitioners can influence the work environment, patient care, and ultimately patient outcomes when we address our own implicit biases and bring this knowledge into our practice. Here are a few key points I have learned on my journey:

Implicit bias is often hard to discuss.

We feel a certain way when we are told we have biases. When discussing bias, prejudice, or stereotyping, it’s not uncommon for my knee-jerk reaction to be defensive and consider all the ways I’m a good person. This is natural. It’s self-protection. But if I bring defensiveness with me to a conversation on how my bias may be impacting others, I won’t be introspective, and change is unlikely.

It's also not uncommon, especially in our current culture, to avoid the topic altogether for fear of offending others, being ridiculed, or experiencing our own shame.

However, it shouldn’t be hard to talk about.

Implicit biases are unconsciously developed through social exposure and are present in all of us. Until we are old enough to start deciding who we socialize with, we have no real control over how bias is developed and even then, our brain is doing its own thing without us even being aware (Harini & Bohlen, 2024).

If this is a process that is inherent in us all, we should be able to talk about it. When discussing implicit bias remember to focus on the impact the bias has, not on intention.

The problem isn’t the bias itself, it’s the behavior that results.

This is especially true in healthcare. When we have biases that we don’t acknowledge that influence our behavior, this can negatively impact patient care and outcomes. Implicit bias can lead us to prefer one group of people over another and assign merit to individuals with certain characteristics. Perhaps most harmful in healthcare is the impact our implicit biases have on our curiosity—we focus on the most obvious information because that’s what validates our beliefs. Delayed diagnosis (Ghattu et al., 2022), inadequate pain management (Eze et al., 2022), and poor patient-provider interactions (Hall et al., 2015) have been linked to implicit bias in healthcare providers.

The consequence of unchecked implicit bias is very real.

If you haven’t already, I encourage you to look at your community health data. Nursing is the most trusted profession in the U.S. for 22 years in a row (Gallup, 2024) and with that responsibility we have a real opportunity to change our communities. I know this responsibility isn’t something we take lightly, but I do think we get overwhelmed with the weight of it. Improving the health of our communities feels like an insurmountable task sometimes, doesn’t it? But think about how many nurses and other healthcare professionals you mentor, teach, lead, and support. If you were to start discussing the impact of our implicit biases on patients and how to address the problem, what kind of an impact might it have? If we were more vulnerable with each other, I feel confident we could change our communities for the better.

A teacher’s implicit bias impacts the learner.

I never take my neurodivergent learners’ needs into consideration when I’m planning education. Why? I have raging attention deficit hyperactivity disorder (ADHD), and yet several eye-opening situations have led me to discover I have significant biases towards my kind. I know from having some difficult conversations that the result of this bias is missed learning opportunities, frustration, and unmet learning outcomes. See Robertshaw (2023) for some insight into how a teachers’ implicit bias can impact neurodivergent students.

Consider how you are assessing students in your classes or when completing competency assessments. Imagine you are conducting a dressing change checkoff and are seated at a table where nurses come to you for evaluation. Before the nurse has started the task, you have unconsciously assigned them to categories that you have mentally labeled as “good” or “bad” simply by seeing their appearance, body language, and nonverbal behavior. Does this impact your assessment of their performance? Most of us would respond to that question with an emphatic “no!” but I encourage you to really give this some thought.

As you review documentation guidelines with staff, do you discuss how word choice and subjective information can influence patient care? When other members of the team read my documentation does that trigger their bias? If so, the result is inadequate patient care and often, poor health outcomes.

We need more action.

How many of us have completed implicit bias training and left wondering how in the world we can apply what we learned in our practice? Training is a great first step in reducing health disparities and improving patient outcomes, but intention is lost without action. A few things we can do to create positive, actionable change:

1. Conduct an assessment of self, system, and community. Ask yourself: What implicit biases do I hold?  How are these biases impacting my nursing and NPD practitioner practice? How does my organization address bias? How is bias impacting our patients, staff, and visitors? What outcomes in my community are associated with implicit bias?
   
   ​To assess your own bias, you can take the free Implicit Association Test (IAT) through Harvard.
2. Identify the gaps. For example, depending on your area of work, you may identify a need for change in nurse-patient interaction, hiring practices, or accountability. You may find a need for continued training to enhance your knowledge. You may identify ways in which your assessments can be more objective. You will likely find areas where you can integrate community health data pertinent to your patient population. Consider what you can influence.
3. Look for evidence-based strategies. Although we are still in the early stages of developing, implementing, and evaluating methods to mitigate implicit bias, there are things that previous research demonstrates you can start doing. Edgoose et al. (2019) provide eight tactics centered around educating, exposing, and approaching implicit biases. These strategies include introspection, mindfulness, perspective-taking, learning to slow down, individuation, checking your messaging, institutionalizing fairness, and encouraging practitioners to take two. It is vital that efforts to mitigate implicit bias don’t simply fall on individuals but are implemented throughout the healthcare system. As you review these strategies consider areas for personal improvement while also assessing the current state of your organization.
4. Go forth and conquer. Address the gaps and don’t forget to make sure you evaluate your effectiveness. When calling out behavior in someone else, find non-threatening ways in which to do so, if possible. You may need to “call out” behavior to prevent further harm, or you may need to “call in” to work toward mutual understanding (Tufts University, 2024). Calling individuals out can be uncomfortable for everyone involved but is critical when behavior is inappropriate and damaging to others. Calling in encourages critical reflection, and is better suited for instances where thoughts, feelings, and perceptions can be explored. You will make mistakes, but don’t avoid the tough conversations. Our patients, our communities, and our fellow nurses deserve it.

References:

Cooper, L.A., Saha, S., van Ryn, M. (2022). Mandated implicit bias training for health professionals – A step toward equity in health care. JAMA Health Forum, 3(8). doi: 10.1001/jamahealthforum.2022.3250

Edgoose, J., Quiogue, M., & Sidhar, K. (2019). How to identify, understand, and unlearn implicit bias in patient care. Family Practice Management, 26(4), p. 29-33.

Eze, B., Kumar, S., Yang, Y., Kilcoyne, J., Starkweather, A., Perry, M.A. (2022). Bias in musculoskeletal pain management and bias-targeted interventions to improve. Orthopedic Nursing, 41(2), p. 137-145. Doi: 10.1097/NOR.0000000000000833

Fjørtoft, K., Konge, L., Christensen, J. & Thinggard, E. (2022). Overcoming gender bias in assessment of surgical skills. Journal of Surgical Education, 79(3). https://doi.org/10.1016/j.jsurg.2022.01.006.

Gallup. (22 January, 2024). Ethics ratings of nearly all professions down in U.S. https://news.gallup.com/poll/608903/ethics-ratings-nearly-professions-down.aspx

Ghattu, M., Buschette, J., & Zarmbinski, B. (2022). Implicit bias contributing to delayed diagnosis in a rare case of endoscopic biopsy proven gastrointestinal amyloidosis. The American Journal of Gastroenterology, 117(10S), p. e2162-e2163. doi: 10.14309/01.ajg.00000870348.66024.d3

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. doi: 10.2105/AJPH.2015.302903

Harini, S.S. & Bohlen, J. (2024). Implicit bias. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK589697/

Robertshaw, S. (2023). How educators’ implicit bias stifles neurodivergent learners. Attitude. https://www.additudemag.com/implicit-bias-educators-learning-differences/#:~:text=The%20Consequences%20of%20Negative%20Teacher%20Bias&text=This%20included%20teachers%20not%20believing,studying%20at%20their%20current%20level.

Tufts University. (2024). Interrupting bias: Calling out vs. calling in. Retrieved from: https://diversity.tufts.edu/resources/interrupting-bias-calling-out-vs-calling-in/