Nursing Programs Use Implicit Bias Training to Address Racial Disparities in Healthcare

California recently launched a new strategy to help erase the stain of racial disparity in healthcare October 1st by signing and enacting CNA-sponsored bill AB 1407.  In light of this, we thought we'd dig into what implicit bias training entails, what are the racial disparities in healthcare it's trying to combat, and what this means for nurses. 

What is Implicit Bias in Nursing?

Implicit bias refers to having attitudes or beliefs one is not aware of that lead to unintentional discriminatory treatment of people based on their race, religion, gender, sexual identity, culture, etc. 

A study reported in JAMA examined data collected from 596,355 adults in the National Health Interview Survey from 1999-2018. The purpose of the study was to identify how racial and ethnic differences have changed over this almost 20-year time period regarding self-reported access to health care, health care affordability, and health status. 

While researchers found improvement in some subgroups, they also found ethnic and racial disparity in healthcare still “largely persisted.” 

And while the study attempted to identify factors that might be contributing to this ongoing disparity such as “different patterns in care-seeking” (which did exist), ethnic and racial disparity in healthcare persisted “even when Americans….shared the same insurance, like Medicare, the government health plan for seniors.”

How States are Combatting Racial Disparities in Healthcare Through Implicit Bias Training

According to the California Nurses Association (CNA) press release, signing this bill “enacted landmark legislation to require implicit bias education and training for nursing students and new graduates in California, an important step in addressing persistent racial disparities, particularly in health care.”

Michigan took similar action earlier this year on June 1, 2021 when Governor Gretchen Whitmer and the Department of Licensing and Regulatory Affairs (LARA) instated new rules effective June 1, 2022.

In the new guidelines set forward in Michigan, new healthcare professionals seeking licensure and/or registration will be required to complete a minimum of 2 hours of implicit bias training while those applying for renewal will need to complete a minimum of 1 hour of training every year.

As of January 1, 2023, nurses who are within the first 2 years of holding a nursing license after obtaining their initial licensure will be required to complete a 1-hour implicit bias course from a board-approved continuing education provider to meet this requirement. 

Nursing students enrolled in a nursing program as of January 1, 2023 or later will receive this training as part of their nursing education.

What Topics Does Implicit Bias Training Cover?

This mandated training will require new graduates and nursing students to directly participate in 1 hour of implicit bias in nursing education that involves the following:

• Identifying current and previous misinformation and unconscious biases.
• Discussing organizational decision-making and the dynamics of power.
• Exploring the effects of oppression and exclusion of minority communities historically and currently and the effects this continues to have on individuals affected.
• Exploring cultural, racial, identity, and provider-community relation issues from the perspective of experts and local, diverse groups. 
• Examining the cultural identity of various ethnic and racial groups.
• Exploring various barriers to inclusion including cultural, institutional, structural, interpersonal, and personal barriers.
• Identifying corrective measures such as policies and practices to reduce implicit bias interpersonally and institutionally.
• Exploring ways to communicate more effectively with people of varying identities related to gender, ethnicity, racial background, and religion.
• Exploring the concept of reproductive justice.
• Examining how implicit bias affects infant and maternal health outcomes leading to health inequities in perinatal care.

What Patients are at the Highest Risk of Facing Racial Disparities in Healthcare?

In a 2018 Critical Care Nurse editorial titled Implicit Bias in Patient Care: An Endemic Blight on Quality Care, JoAnn Grif Alspach, EdD, MSN, RN highlights the characteristics of patients most at risk of implicit bias and substandard healthcare. 

Alspach (2018) noted patients with the following characteristics “have cause for concern regarding whether they will receive the current standard of care for their health problems”

• Older age
• Female
• Non-White
• Non-English speaking
• Disabled
• Poor socioeconomic status
• Non-heterosexual 
• Mentally ill
• Have AIDS
• Drug addicted
• Obese

As Alspach points out, female gender patients represent roughly half the global population, which offers just a glimpse into the magnitude and the scope of this problem.

What Aspects of Patient Care are Most Affected by Implicit Bias?

A systematic review published in 2015 in the American Journal of Public Health (AJPH) examined the degree to which implicit bias regarding race and ethnicity exists in healthcare professionals and how this bias affects health care outcomes.

While the authors discovered some “nonsignificant” associations between healthcare outcomes and implicit bias, the results also revealed a significant relationship between implicit bias and 4 key areas of patient care:

• Patient–provider interactions
• Treatment decisions
• Treatment adherence
• Patient health outcomes

The authors also identified that “implicit attitudes were more often significantly related to patient–provider interactions and health outcomes than treatment processes.”

When is Implicit Bias in Nursing More Likely to Occur?

Experts explain awareness is the first step to help reduce implicit bias including the ongoing racial disparity in healthcare. Part of this awareness requires an understanding around when unconscious discrimination is more likely to occur. 

For example, implicit bias is more likely to rear its ugly head when healthcare staff encounter stressful situations. It’s also more likely to occur when nurses are busy, tired, feeling pressured, or mentally preoccupied with several different things. It can also occur when healthcare staff have to make decisions without all the information they need.

What Are Some Effective Strategies for Reducing Implicit Bias in Nursing?

Eradication of implicit bias directly through prevention alone is not effective. Instead, experts suggest a two-tiered approach consisting of bias awareness strategies and bias control strategies.

Bias Awareness Strategies

Bias awareness strategies often include self-reflection activities while emphasizing the normality of stereotyping in a safe setting that allows for the private self-discovery of personal biases to emerge. Activities that may help reveal unconscious biases include self-reflection exercises such as completion of the Implicit Association Test (IAT), class discussion of bias and the role implicit bias plays in perpetuating health disparities, and reviewing related research.

Bias Control Strategies

Bias control strategies aim to stop automatic discriminatory responses before they occur. The most common bias control strategy is learning to put oneself in another person‘s shoes—also known as perspective-taking. 

This strategy helps nurses see things from the patient’s perspective which helps increase empathy and results in better nurse responses. Other bias control strategies include:

• Building partnerships where nursing care is patient-centered and collaborative versus hierarchical with nurses telling patients what to do.
• Finding common-group identities so nurses gain experience with groups different than their own.
• Replacing stereotypes through conscious choice.
• Individuation, which involves forming perceptions and responses to patients based on their unique characteristics rather than stereotypes.
• Counter-stereotyping which is seeing patients as the opposite of a stereotype.
• Affirming egalitarian goals in which nursing team members agree together to seek the best possible outcomes for patients while working to reduce disparities.

For more implicit bias resources including the only U.S. annual review of implicit bias research addressing ethnic and racial disparity in healthcare and other public sectors worldwide, visit the Kirwan Institute for the Study of Race and Ethnicity at The Ohio State University (OSU).