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Combating Implicit Bias in Nursing

Ann Feeney, CAE
Updated September 28, 2023
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Implicit bias causes healthcare inequities. Learn how you can fight implicit bias as a nurse.
Nurses and doctors talking togetherCredit: Getty Images

Implicit or unconscious bias is not intentional, but it has a detrimental impact. Implicit bias in nursing affects nurses’ quality of life and patient outcomes.

In a Robert Wood Johnson Foundation study, researchers found that 79% of nurses experienced or observed racism or discrimination from patients and 59% saw or experienced it from colleagues.

Asian and Black nurses are particularly likely to have experienced racial aggression, and 94% of Asian and 93% of Black nurses report that it has affected their mental well-being.

Explore more about implicit bias, including how it impacts nurses and patients. Discover some components of effective implicit bias training for nurses.

Understanding the Impact

Implicit and even explicit bias in healthcare is not new, as a history of racism in nursing can tell us. Even though many schools try to address the issue, bias affects every aspect of healthcare: healthcare delivery, public health, workplaces and learning environments, and workforce diversity.

Bias results in worse health outcomes for people of color, such as higher maternity death rates among Black women or racial and ethnic disparities in treatment and outcomes among Black and Hispanic heart attack patients.

In the Workplace

Implicit bias is visible in work satisfaction, morale, and career development. Bias such as racism in nursing can affect:

  • Who attends and graduates from nursing school
  • Who is selected for interviews, advanced in the hiring process, and hired
  • Team communication (such as who is interrupted or talked over)
  • Who is formally or informally mentored and sponsored
  • Who is encouraged to pursue further education or advancement opportunities
  • Salary and other compensation
  • Bullying, teasing, hazing, or other staff negative behavior
  • Stress, burnout, and well-being
  • Staff retention

In Patient Care & Bedside Manner

Bias also causes healthcare disparities for patients based on their race, ethnicity, sex and gender, sexual identity, weight, socioeconomic status, and age:

  • Bedside manner and patient communication (such as talking down to patients or family members or treating them as though they are not intelligent and competent)
  • Pain management (such as the stereotype that Black people are less sensitive to pain than others or that lower-income patients are more likely to be drug seekers, resulting in those patients not receiving care for their pain.)
  • Whether patients are believed and listened to when they first report symptoms or causes (that patients with historically excluded identities are not believed)
  • How thoroughly a clinician explains information to a patient (that clinicians may leave out nuances of the patient’s condition or the consequences of decisions or omit or push a patient toward or away from certain interventions or options)
  • Assumptions about compliance (often that patients would have no reason for not complying or that they do not or would not comply with treatment plans)
  • Not understanding or addressing barriers to care (that clinicians misunderstand the causes for patients’ decisions in managing their health, possibly resulting in their recommending treatments that cannot effectively address the patient needs and concerns)
  • Diagnoses (such as women or patients from other groups burdened with negative stereotypes being told “it’s all in your head” or having conditions dismissed as depression — and then allowing that depression to remain unaddressed)
  • Stereotypes (such as people who are overweight, among other characteristics and identities, being believed to be lazy and undisciplined)

Even the best-intentioned clinician, educator, or colleague may hold implicit and unconscious biases. Fortunately, awareness and training can help make those biases conscious, allowing them to take action to limit the harm implicit bias can cause, whether by unlearning the biases or putting practices in place that protect their patients and colleagues.

Components of Effective Implicit Bias Training

Effective implicit bias training for nurses can improve nursing school curricula, continuing education, and workplaces. However, ineffective training, such as suggesting that it can’t change because implicit bias is everywhere, can have negative effects. This ineffective training tacitly justifies the harmful effects implicit bias has in nursing and other healthcare environments.

Effective implicit bias training for nurses introduces the concept and teaches people to recognize and manage their biases, change their behavior, and measure their progress in fighting discrimination in nursing. While it creates discomfort, especially among people unaware of their biases, the right kind of discomfort leads to learning and change. These steps can make training effective and ensure that change and learning last.

Create a Safer Space for Dialogue

People may be uncomfortable for many reasons during implicit bias training for nurses. Often, people do not want to think of themselves as biased. They may often feel uncomfortable describing their experiences either as holding or being subjected to bias or overt racism in nursing.

It can be important for training to emphasize honesty, respect, and creating safer spaces for genuine inquiry and learning. It may also be important to determine whether potential participants can agree that the main outcome of training is learning and changing together to reduce discrimination in nursing.

Organizational Support without Hierarchy

Hierarchy can create environments in which any existing biases can have more intense consequences because of power differences in an organization. Employees may be uncomfortable describing experiences if they feel that their managers or leaders will judge them.

Leaders can set examples by describing their biases and vulnerabilities to bias, displaying consistent behavior that builds trust, and avoiding using their privilege in retaliatory ways.

Awareness Building

Especially in healthcare, most of us think of ourselves as good people who treat others fairly and equitably and strive for the best patient outcomes. This mentality creates cognitive dissonance and discomfort whenever we learn how our implicit biases could cause harm.

Accepting our biases can challenge a self-perception that we are “good.” Programs and initiatives can reduce the sense of denial, blame, or self-blame by explaining that implicit biases are mental shortcuts with evolutionary and biological roots and that reducing implicit bias can be hard work that everybody shares.

Skills Development

Implicit bias training for nurses is not a one-and-done session but the start of learning and developing skills to identify and address bias. We need to develop skills in managing bias in the same way that it can be difficult to follow a healthy diet when surrounded by biological promptings to eat too much junk food.

Use of Real-world Scenarios

Role-playing and real-world scenarios let learners develop their skills for the bias and racism in nursing that they will encounter in themselves and others. Learning how to respond can include bystander training. The more familiar people are with analyzing behavior and responding to bias, the more likely they will use these skills in real settings.

Active Participation and Discussion

Implicit bias training for nurses must include active participation and discussion. Elements of reflection, self-reflection and open discussion can help learners understand the concepts and their own experiences and role in combating implicit bias.

Ongoing Learning

Acting on implicit bias training for nurses requires ongoing learning and reinforcement. Even the best intentions can be made irrelevant on busy workdays with urgent tasks when those who have received training forget to apply the changes they’ve learned. Consider making ongoing implicit bias reflections part of regular meetings or communications.

Evaluation and Feedback

Finally, make sure those who implement training follow up on and address responses and requests. The follow-up should integrate feedback into ongoing additional training and communication. Those in leadership can make it clear that they expect progress and action by modeling these changes.

The Challenges of Addressing Implicit Bias

Addressing implicit bias can be challenging. Surfacing your biases can be painful, especially when it involves acknowledging health disparities and implicit biases.

For members of historically excluded groups, reliving experiences of bias and discrimination in nursing can be especially disturbing. The important work of addressing biases to improve workforces and patient outcomes should not come at the cost of those who are already most vulnerable.

The Future of Nursing

Understanding and combating implicit bias in nursing is vital to recruiting and retaining an increasingly diverse workforce, building workplace engagement and belonging, and improving patient outcomes.

Encountering discrimination and racism in nursing causes burnout and disengagement among nurses, whose work and well-being are keys to better patient outcomes. By fighting implicit bias in nursing, you can make a measurable change in your staff, community, and population’s health.

Page last reviewed on September 8, 2023