Implicit bias is defined as an unconscious, negative attitude or perception of certain individuals or groups, according to the American Psychological Association. And in healthcare, these perceptions can be harmful to patients, families, and nurses.
Is bias in nursing interfering with patient care at your workplace? If so, there are both immediate and long-term consequences.
“Bias that is unaddressed within an organization can lead to lower job satisfaction, low morale, and often turnover,” said Amy Barton, PhD, RN, Senior Associate Dean for Faculty and Students at University of Colorado College of Nursing.
Implicit bias in nursing is correlated with burnout and negative impact on the mental health of nurses.
“When the mental health of nurses is strained and nurses are leaving the bedside in droves, it is inevitable that it will put a financial strain on hospital systems,” warned Shermel Edwards-Maddox, PhD, MSN, RN, CNE, RN-BC, a Clinical Assistant Professor at the University of Houston’s Andy & Barbara Gessner College of Nursing. “That negatively impacts patient safety, quality of care, and patient satisfaction.”
The good news is that you have plenty of resources to identify and address bias and create a work culture where everyone feels supported.
Pathways to creating a comfortable work culture
Effectively addressing and overcoming implicit bias, requires a continuous process of self-reflection, education, and proactive strategies. Here are seven ways nurses and leadership can address bias in nursing:
1. Create a diverse nursing workforce that mirrors the patient population served
Research supports that a diverse nursing workforce fosters cultural competence in patient care. But current data shows there is still work to be done to ensure nurses are as diverse as their patients.
In our Nurse.com 2024 Nurse Salary and Work-Life Report, nurses were asked to report their age; gender; and race and ethnicity. In our sample of 3,662 nurses, 89% identified as female, 10% as male, and 0.1% as nonbinary (1% preferred not to answer). Males in nursing are still underrepresented, and their percentage has stalled in recent years.
Some racial and ethnic groups were also underrepresented in our Nurse.com report sample, compared with their proportion in the U.S. population reported by the U.S. Census Bureau.
For instance, 11% of nurses in our salary survey identified as Black or African American, but individuals who identify as Black or African American constitute 13.6% of the U.S. population. Similarly, 7% of nurses in our survey identified as Hispanic, Latinx, or Spanish, but individuals who identify as Hispanic, Latinx, or Spanish constitute 19.1% of the U.S. population.
2. Become aware of your own biases and ask nurse colleagues to do the same
Self-awareness is always the first step to understanding bias, offered Barton.
Understanding that everyone has biases helps many nurses to confront their own. “This helps to lower our defenses so that we can be open and honest with ourselves,” said Edwards-Maddox.
For example, a nurse might assume that a patient with sickle cell anemia has an opioid use issue. Self-reflection prompts the nurse to ask, “Why did I make that assumption?”
“We have to become more aware of how our thoughts drive our actions,” underscored Edwards-Maddox.
Barton recommended these resources to nurses who want to address their own biases:
- National Center for Cultural Competence at Georgetown University’s course on conscious and unconscious biases in healthcare.
- The Joint Commission’s Quick Safety Issue 23 on implicit bias in healthcare.
3. Foster an environment where diversity is embraced
“Clearly articulated, mutually agreed-upon expectations, norms, and values for the work culture are needed,” said Michelle Webb, DNP, RN, CHPCA, a Clinical Assistant Professor and Certified Cultural Intelligence Facilitator and Unconscious Bias Coach at Duke University School of Nursing.
4. Encourage open communication about biases
Nurses can benefit from hearing about their colleagues’ own experiences with bias. “A nurse with training in bias mitigation could effectively lead such a discussion,” said Barton.
Ideally, nurses should address bias with “a spirit of inquiry,” said Edwards-Maddox. She added that nurses should be able to ask questions free of judgment and learn more about what they don’t know or understand. Nurses may find they have something more to learn about vulnerable populations who are often subject to bias.
Nurses wouldn’t hesitate to ask questions if they were caring for a patient with an unfamiliar medical condition. The same can apply when working with patients who are transgender, said Edwards-Maddox. “If the nurse is not familiar with a certain population, start by asking, ‘How can I best support you today?’”
5. Empower your colleagues to address bias right when it’s occurring
“Clear expectations are needed for holding colleagues accountable for observed bias-influenced behavior,” said Webb.
Nurses should be empowered to address bias right when it’s occurring. “Having an idea of how to address it before it happens can help one respond in the moment, when it is most critical,” said Edwards-Maddox. Edwards-Maddox suggested that nurses use these statements:
- “Can you explain what you mean by that comment?” It’s possible that a nurse’s remark reflects unconscious bias. By asking what the nurse meant, a colleague can open the door to a conversation about bias.
- “That comment made me feel uncomfortable.” Nurses should avoid placing blame or labeling a colleague as rude or racist. “Focus on the comment made, not the person,” advised Edwards-Maddox.
6. Provide education on bias early, before nurses enter clinical practice
At CU Nursing College of Nursing at Anschutz Medical Campus, bias is addressed at all levels — for students in the prelicensure program, for RNs returning to graduate school for an advanced practice nursing degree, and for doctoral students.
“Students are given feedback on potential ‘blind spots.’ This awareness enhances the care they provide,” said Professor Gail Armstrong, DNP, PhD, ACNS-BC, CNE, FAAN.
Students participate in clinical simulations, to learn how to ask about patients’ values, preferences, and needs. Everyone, stressed Armstrong, should have the experience of “being seen, heard, and understood.”
7. Explain how bias can negatively impact patient care.
Nurses may make incorrect assumptions because of bias. “This dynamic can make nurses feel defensive. It can contribute to patients and families feeling understandably frustrated,” observed Armstrong.
The bottom line is that providing unbiased care is a key professional priority for nurses in all clinical settings. “Optimal care is provided when a healthcare team orients the plan of care around the patient’s values, preferences, and needs,” emphasized Armstrong.
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