Nursing School Uses Police Simulation to Help Nurses Combat Unconscious Bias

On October 31, Washington State University (WSU) College of Nursing announced it had received a $1.3 million grant to adapt the law enforcement community’s Counter Bias Training Simulation (CBTism) program for use in nursing school simulation labs.

The grant came from the National Institute on Minority Health and Health Disparities at the National Institutes of Health.

Past studies have shown that patients sometimes receive different levels of care based on characteristics such as race, weight, gender, and sexual orientation. A new simulation training tool for nursing students could help raise awareness of these issues and ultimately help alleviate them.

“My main goal is to reduce the impact bias has on people’s lives,” said grant co-recipient Lois James, Ph.D., assistant dean of research at WSU College of Nursing, in comments to NurseJournal. “For the most part, it’s in environments and professional groups where there’s some degree of hierarchy, a slight power differential such as between a provider and a patient. I’m not just studying bias for the sake of understanding it but for the sake of improving it.”

Generally speaking, the definition of bias is the action of supporting or opposing something based on personal opinions, as opposed to more objective factors. Bias can positively or negatively influence action. For example, choosing only healthy foods can be considered a positive bias.

Many biases, however, are based on stereotypes rather than facts and information. A bias is a cognitive shortcut that can lead to discriminatory practices and poor decision-making. There are two types of bias; Conscious bias is expressed overtly through verbal or physical communication. It can also lead to more subtle forms of behavior such as exclusion from a group.

Implicit or unconscious bias is relatively common in healthcare and happens outside of a person’s awareness of their actions. It may even contradict what a person states are their usual beliefs and values.

The danger of unconscious bias? It affects a person’s behavior outside of their awareness and can interfere with decision-making. In the healthcare environment, implicit or unconscious behavior can lead to disparities in receiving care and potentially worsened patient outcomes.

Unconscious or implicit biases may begin to develop at an early age but can be influenced and reduced through training, which can begin in nursing school. This is the foundation of CBTsim in a law enforcement context, and it’s now being developed for nursing audiences with support from the recent grant.

“Should the training prove to be effective there is great potential for it to be adapted for nursing students in the university setting,” James told NurseJournal. “This would also include medical students, or any students that practice patient care in a simulation setting, allowing them to recognize their biases and practice equitable and inclusive care in a safe space where consequences of making a mistake can be learned from.”

Using the grant, James and colleagues plan to develop a new tool — CBTsim Healthcare — based on known disparities within the healthcare system. CBTsim uses video simulations in law enforcement that feature diverse actors, so trainees can practice making decisions based on a simulated scenario.

Law enforcement CBTism users assess their reactions to situations and reflect on why they took a given course of action. Data shows that when people are made aware of unconscious biases and are given correct information, it can help change their actions. Nursing schools prepare students for the full spectrum of patient care and its many eventualities. This includes identifying and educating students about unconscious bias.

Once CBTsim Healthcare is developed, the researchers have chosen to engage 100 nurses from Providence Health and Services, a large healthcare system in Washington, to test the effectiveness of the video nursing school simulation lab program. James said the program will be developed during the first year of the grant, and the team plans to initiate the randomized controlled trial in September 2024.

She anticipates the results of this study will be the same and different from the results that have been demonstrated in law enforcement.

“I anticipate similar results in that the processes by which people come to recognize and understand their implicit (or unconscious) biases will be the same regardless of professional group,” James explained. “However, I anticipate different results in that the types of biases that might be most prevalent and thus most susceptible to change might differ between nurses and police officers.”

In the WSJ press release, James said the CBTsim Healthcare video simulations will likely cover diversity in race, gender, sexual orientation, and socioeconomic status. At the start of the intervention, the participants will undergo baseline testing, including their ability to interact with diverse patients in ways that promote positive relationships.

The group will be split in half, with the control group watching a standard training 1-hour lecture on implicit bias and the other half taking part in CBTsim Healthcare. Later, both groups will be retested in the nursing simulation lab and then followed in their clinical practice for six months.

“The predominant bias we saw in our policing cohort was against community members suffering homelessness and this was where we saw the biggest disparity reduction following the training interventions,” James said. “It is possible that nurses might have different implicit biases, for example against members of the trans community.”

James is passionate about reducing unconscious bias in healthcare to improve patient outcomes and promote positive provider-patient relationships.

“My hope is that by bringing implicit bias into conscious awareness we will reduce the likelihood that any associations we have that might lead to discriminatory action are not as likely to pop up and influence us outside our awareness,” she said. “The danger of implicit bias is that we aren’t aware of our potentially negative impact. However, we are responsible for the impact that we have on others, not just our intentions. ‘First do no harm’ does not mean to not cause intentional harm, it means all harm.”