Implicit Bias: Does it Impact Nursing Education?

By Susan Sportsman, PhD, RN, ANEF, FAAN

Our responses to others are influenced by many factors, some of which are attributable to our own thoughts, experiences and emotions, and some that reflect our responses to the behavior of others.  As educators, we bring those thoughts, experiences, and emotions to our interactions with students.  We are called to react positively to all our students, assessing them objectively and providing appropriate challenges for their strengths and support for their weaknesses.  This is a lofty goal and one that is often hard to do. One reason for this difficulty—although certainly not the only one—is the impact of our own biases, particularly those that are implicit.  In fact, concern over the role that implicit biases play in all aspects of our lives is a “hot topic” in both the scientific literature and popular culture.

What is Implicit Bias?
When we have a preference for (or aversion to) a person or group of people, we have a bias. This bias is implicit when attitudes toward certain people are outside of our conscious knowledge. Put another way, implicit bias (or unconscious bias) happens when we allow our own attitudes, feelings, stereotypes or beliefs to impact our judgement or understanding of other people.  It is called unconscious because the biases that drive certain behavior come from an involuntary process based on our deep-seated thoughts (Hendricks, 2019).  We cannot “undo” our unconscious biases; they are unconscious.  However, because of the neuroplasticity of the brain, it is possible for us to create new connections and processes for changing our behavior, even when biases are present (Ackerman-Barger, 2017).

Although we often think that implicit bias results from beliefs regarding race, age, social group, or appearance, Hendricks (2019) suggest that there may be as many as 150 types of bias, including height, weight, marital status, disability, political affiliations, or level of education. We may be exposed to these biases in early childhood, but they are often strengthened by friends, colleagues, entertainment, or media, including social media. Check out the chart below to see some types of implicit bias and examples of them in action.

Implicit Bias

Types Examples
Affinity Bias Positive bias toward people who are like us in some way
Confirmation Bias Finding information that meets our beliefs and ignoring that which supports an opposing belief
Halo Effect When we like a characteristic of someone, we assume that every attribute of this person is positive
Perception Bias The perception that Nurses “eat their young”
Bandwagon Bias My friends don’t like someone (or a group) so I won’t either.

(Adapted from Hendricks, 2019)

A Story from the Field
Apparently, most of us have these biases –and many of us have been hurt by the implicit biases of others. Most of you who know me know that I have a pronounced “East Texas” accent.  Ever since I moved away from my small east Texas home to go to college, I have been teased –usually lovingly; occasionally admiringly—about the way I speak. Sometimes however, a negative bias about my accent has been at the root of uncomplimentary comments. For example, I had a boss once who was NOT from Texas, and several months after I began to work for him, he said, “You know, Susy, because of the way you talk, it took me a while to realize that you were smart.” Not a particularly nice comment –but one that had no particular negative consequence.

Impact of Implicit Bias
However, many times implicit bias CAN be harmful in business, culture, education, and health care—yes, even in nursing education. A number of scholarly articles seek to confirm the negative impact of implicit bias in health care. For example, in a systematic review of 42 studies, FitzGerald and Hurst (2017) evaluated the impact of bias in health care. Twenty-seven articles focused on racial/ethnic bias, but ten other biases were also identified, including gender, age, and weight. Thirty-five of the studies (83%) demonstrated evidence of implicit bias in health care professionals. The authors concluded that healthcare professionals exhibit the same levels of implicit bias as the wider population.  Further correlational evidence in some of these studies found that biases are likely to influence diagnosis and treatment decisions and level of care. Hall, et. al. (2015) in a similar systematic review, found that implicit bias was found to be particularly related to patient-provider interactions and health outcomes.

Most of us are uncomfortable with the notion that we have implicit (unconscious) biases that influence our behaviors. Cherry and Gans (2019) explain why we form such ideas. They suggest that it is the natural tendency of the brain to sift, sort, and categorize information about the world. To do this, we tend to seek out patterns and associations.  In fact, this is a mechanism we use to learn about the world. Given that our brain is constantly inundated with more information than we can possible process, we use short cuts to sort through all this data:  thus the need to find patterns.  (Remember how we encourage students to look for patterns as part of the development of clinical judgment?  It is the same mechanism.) In short, finding—and using—patterns is a normal mental mechanism, resulting in both positive and negative results.

So, what should be done?
Some authorities question the validity of implicit bias, particularly because of the instrument, the Implicit Association Test (IAT), which is most commonly used to identify these biases (French, 2018).   However, most of us intuitively know we have biases that lurk at the edge of our unconsciousness, influencing our behavior in ways we are unaware. What can we do to be sure that we are acting in our students’ (or patients’) best interest?  How can we help our students to be aware of their own biases?

Strategies for all of us
Awareness of our potential for bias is important to avoid acting unknowingly upon our implicit biases.  Strategies that can help all of us act in a thoughtful way, rather than becoming a “prisoner” of our implicit biases, include:

    1. Notice the assumptions and stereotypes we hold. This involves learning to “self-observe.”
    2. Notice what triggers our assumptions.
    3. When we are in situations that trigger our stereotypes, spend time considering the people with whom we are interacting on a personal, individual level. In fact, purposely interacting with individuals with whom we feel uncomfortable may help us examine our stereotypes.
    4. Reflect on these assumptions and stereotypes.
    5. Be mindful of the cues others offer about themselves and the context of the situation.
    6. Try to see things from others’ point of view. Consider how you would respond if you were in the same situation.
    7. Practice constructive uncertainty, which involves learning to slow down decision-making in order to help reduce the impact of bias. This period of slowing down allows us time to gather information through listening (Ross, 2014).
    8. Withhold making a judgment until you have more information and you have reflected on your assumptions and stereotypes.
    9. Ask for feedback on your behavior.

(Adapted from Minority Nurse, 2018 and Ackerman-Barger, 2017)

 Strategies for Our Students
Since research suggests that the biases of health care providers can, in fact, have negative consequences on patient care, as nurse educators we have an obligation to help students recognize the impact implicit biases might have on their nursing practice. Sukbera and Watling (2017) have developed an educational framework to assist educators in preparing students to deal with implicit bias. They recognize that there have not been many efforts to integrate implicit bias-informed curricula into health professional education, probably because of a lack of faculty champions, perceived lack of relevance, and pressure to concentrate on discipline-specific content. The framework these authors developed suggests we use the following principles as we consider ways to integrate this content into our own curricula.

    1. Create a safe and nonthreatening learning context. Judgment about students’ stereotypes and beliefs should never be present!
    2. Present information about the science of implicit bias. There are a variety of opportunities throughout a nursing curriculum that this information can be included, for example, in mental health, leadership, and professional nursing courses and in a variety of clinical and simulation experiences.
    3. Ask students to:
      • Review the literature regarding the impact of implicit bias on behaviors and patients.  Identifying and analyzing such literature can be an effective learning activity for students to understand the current evidence, both pro and con, on implicit bias.
      • Identify their own explicit biases and stereotypes and plan conscious efforts to overcome bias. Structuring opportunities for students to reflect on this topic, perhaps by journaling, can encourage such self-analysis.
      • Consider ways their own biases are influenced by formal and informal environmental and cultural influences. Again, journaling and discussion in small groups can be a mechanism for learning.

(Adapted from Sukbera and Watling, 2017)

When we act on implicit biases and our behavior impacts patients or students, we have an obligation to become more self-aware. Such behavior is common, even normal. However, the more self-awareness we develop, the more effective our practice. Let’s all commit to extending our awareness.

Ackerman-Barger, K. (2017) Understanding Unconscious bias can promote healthy equity. Campaign for Action.  August.  Retrieved, May, 2019.

Cherry, K., Gans, S. (2019) How does implicit bias influence behavior: Explanation and impact of unconscious bias. Verywell Mind.  Retrieved, 2019.

FitzGerald,  X., Hurst, S.  (2017) Implicit bias in health care professionals:  A systematic review.  BMC Medical Ethics. 18(19)

French, D. (2017) Implicit bias gets an explicit debunking.  National Review.  January.  Retrieved, 2019

Hall, W., Chapman, M., Lee, K., Merino, Y., Thomas, T., Payne, B., Eng, E., Day, S., 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.  October.  105(12) e60-76.

Hendricks, B. (2019) Implicit bias in the workplace:  Definition, examples, and impact.  Creating a culture of inclusion,  Retrieved, May, 2019.

Ross, H. (2014) Everyday Bias:  Identifying and navigating unconscious judgment in our daily lives.  London:  Rowman and Littlefield Publisher.

Sukhera, J., Watling, C. (2018) A framework for integrating implicit bias recommendations into health profession education. Academic Medicine.  January.  93(1) 35-40.

__________(2018)  Recognizing implicit bias in health care settings. Minority Nurse. Blog, Minority and Community Health, Nursing Students.   Retrieved, May, 2019.

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