Unconscious bias (also called implicit bias) refers to stereotypes and cultural concepts that all people have, which influence decisions and behaviors apart from conscious realization or intentional control (Staats & Patton, 2013). Recent research suggests that unconscious biases held by medical providers may contribute to health disparities through negative interactions and communication with stigmatized patients (Blair, Steiner, & Havranek, 2011; Zestcott, Blair, & Stone, 2016). Subtle nuances in interpersonal interactions, caused by unconscious bias, can be perceived as a lack of provider concern (Hagiwara, Kashy, & Penner, 2014). This, in turn, affects patient trust and confidence, resulting in decreased engagement and adherence to treatment recommendations (Cooper et al., 2012).
Methods used to teach cultural competence in health care educational settings have generally failed to reduce learners' unconscious biases and motivate changed thinking toward, or interactions with, stigmatized patient populations (Phelan et al., 2014; Zestcott et al., 2016). Recent studies show that unconscious bias tends to increase as students progress through their academic training (Chapman, Kaatz, & Carnes, 2013). Educational strategies often center on awareness of unconscious bias and self-reflection, which can result in significant cognitive dissonance (van Ryn & Saha, 2011). As students attempt to reconcile newly discovered bias with their inner motivation to provide equitable patient care, anxiety, defensiveness, denial of bias, and skepticism regarding the influence of bias on patient care can result (van Ryn et al., 2015). To ensure best patient outcomes, unconscious bias must not only be realized and reflected on, but also understood, assessed, and corrected (The Joint Commission, 2016). This requires educational strategies that use guided debriefing and feedback and provide skills for reducing unconscious bias in patient care (Zestcott et al., 2016).
Participants and Procedure
This article reports unconscious bias teaching strategies implemented as part of an educational module developed by one of the authors (P.L.S.) to fulfill a Master's of Science in Nursing Education practice immersion experience. The module was presented to a convenience sample of 75 students enrolled in a graduate-level social justice and diversity course, under the preceptorship of the course instructor, at a school of nursing in the midwestern United States. The strategies and evaluation methods were approved by the institution's human subjects committee. A summary of educational interventions implemented is found in Table 1.
Educational Interventions to Promote Acceptance and Management of Unconscious Bias
Implicit Association Test
Since 1998, Implicit Association Tests (IATs) have been used to educate the public about hidden biases by measuring how strongly individuals associate certain concepts (e.g., lazy, athletic, good, bad) with various categories (e.g., weight, race, gender, sexuality). Numerous studies have shown the IAT to be a valid predictor of behaviors that are not consciously controlled (van Ryn & Saha, 2011). As a preclass assignment, learners were introduced to the IAT and provided a Web link from which to choose one of four test options to complete (race, age, weight, or sexuality). Learners were instructed to document the test results and write a brief summary of how this could affect their nursing practice and care given to patients. The summary was used for learners' personal reference during the debriefing segment of the in-class lecture.
Health care students can perceive information and feedback about unconscious bias as assigning blame for health disparities or proof of personal prejudice and less than egalitarian motives for patient care (Zestcott et al., 2016). Research suggests that the acceptance of personal bias and motivation to change it requires guided debriefing that (a) provides a safe environment for honest learner feedback, (b) develops knowledge about and understanding of unconscious bias, and (c) affirms learners' egalitarian goals for patient care (Howell & Shepperd, 2012; Teal, Gill, Green, & Crandall, 2012). During the didactic portion of the module, a short message service, real-time, audience response system was used to elicit learner feedback through interactive anonymous polling. Learners used cell phones or laptop computers to respond to the multiple choice poll questions, embedded into PowerPoint® slides, regarding (a) which of the four IATs they took, (b) the test results, (c) their feelings about the test results, (d) retaking of the test, (e) concerns about racism or prejudice, and (f) perceived validity of the test result. A final open-ended poll allowed learners to type in feedback, displayed as ticker messages on the screen, regarding what the IAT result could mean to their nursing practice and patient care.
Learners were then presented facts about IATs, including that the test does not indicate racism, prejudice, or inequitable personal motives. The instructor emphasized these points by expressing confidence in each learner's desire to provide the best care to every patient. This was followed by research evidence regarding unconscious bias in health care providers and how it can contribute to health disparities.
Unconscious biases can be gradually unlearned and replaced with new associations of ideas (Dasgupta, 2013). Moving learners from respect for and acceptance of unconscious bias toward a commitment to change requires strategies for managing newly revealed bias (Teal et al., 2012). Strategies to help change and control bias were categorized based on an adapted version of Bennett's Intercultural Competency Model developed by Teal et al. (2012). Stages of unconscious bias awareness were presented along with corresponding behaviors and management strategies (Table 2). For example, education, internal feedback, and reflection were presented as acceptance stage strategies that help providers recognize the potential impact of newly revealed bias. Strategies to reduce (adaptation stage) and control (integration stage) the potential impact of bias were also presented.
Stages of Unconscious Bias Awareness with Corresponding Behaviors and Management Strategies
Perspective-taking exercises that enable insight, empathy, and relational awareness of patient situations have been shown to reduce resistance toward accepting unconscious bias and improve provider interactions with stigmatized populations (Zestcott et al., 2016). Five patient scenarios were presented during the class module. As a final exercise, learners were instructed to choose one of the five scenarios and write a poem or short prose that reflected the needs, vulnerabilities, and feelings of the patient. Learners were given opportunity to voluntarily share their compositions aloud or submit them for posting to the class learning management system for others to view and read.
To reinforce the concepts taught, learners were instructed to complete another IAT, of their choosing, as a postclass assignment. A summary describing the IAT test result, influence on nursing practice and patient care, and at least one strategy for managing newly discovered bias was submitted for a grade. Learners were provided BATHE (Background, Affect, Trouble, Handling, Empathy) model questions (United States Department of Health and Human Services, 2014), which were used to implement selected bias management strategies through interactions with patients in the clinical setting. Learners were scored based on a grading rubric, with detailed written feedback from the instructor.
Outcomes and Evaluation
In-class interactive polling showed that 95% of learners' IAT results were positive for some level of unconscious bias (Figure 1). Fifty-one percent felt unconcerned about the test result or expected it, whereas 49% felt either surprised, disappointed, skeptical, or disbelieving. Seventy-four percent doubted the validity of the test to some degree.
Types of Implicit Association Tests (IAT) taken and the preand postclass results. Stronger values suggest a higher likelihood of unconscious bias.
Minute papers completed at the end of the class module showed that learning about, understanding, recognizing, and evaluating unconscious bias, and putting oneself in the patient's shoes, were significant lessons learned during the session. Approximately half of learners (46%) submitted their perspective-taking poems or prose for posting to the learning management system. Fifteen percent expressed skepticism or doubt regarding the validity of results from the second IATs taken for the postclass assignment. Of those expressing skepticism or doubt regarding IAT validity, 95% were learners pursuing an adult-gerontology practitioner track, whose test results showed some level of unconscious bias toward the elderly.
In postclass assignments, 70% of learners selected management strategies focused on recognizing bias (acceptance-level), and 20% chose strategies aimed at reducing bias (adaptation-level). Six percent chose the integration-level strategy of humanism (i.e., insight, empathy, and relational awareness), which focuses on controlling bias. Strategies involving debriefing (adaptation-level) and acting on the patient's view and perspective (integration-level) were not selected by any learners. Despite in-class instruction that unconscious bias cannot be removed and should not be suppressed or ignored, 4% of learners planned to suppress or ignore newly discovered biased thoughts and feelings as a management strategy (Figure 2).
Strategies selected by learners to manage newly revealed unconscious bias (postclass).
Learners who completed a postclass survey, conducted 5 weeks after the learning module took place, indicated they were extremely likely or likely to (a) take additional IATs and reflect on the results and (b) learn more about unconscious bias and how it affects nursing practice and patient care. The same learners indicated strong agreement or agreement that they understood (a) what unconscious bias is, (b) how provider unconscious bias can lead to health disparities, and (c) basic strategies for managing unconscious bias.
In-class interactive polling confirmed evidence of cognitive dissonance in the majority of learners due to IAT results. Providing a disclaimer, in both pre- and postclass assignments, that IAT results do not indicate personal prejudice, racism, or less than egalitarian motivation for patient care, could enhance learner acceptance of results. Instruction regarding the potential effects of in-group preference and cultural conditioning on IAT results (Project Implicit®, 2011b) would benefit learners pursuing an adult-gerontology practitioner track.
In postclass assignments, several learners indicated a desire to learn more about the science and research behind IATs. Providing links to Project Implicit (2011a, 2011b) Frequently Asked Questions and for Researchers Web pages would enable access to detailed information, including supported research, publications, and study materials. A resource chart listing management strategies, bias awareness levels, and reiterating negative outcomes associated with suppressing or ignoring feelings and thoughts would contribute to the quality of postclass assignments.
Implications for Nursing Education
With patient populations in the United States becoming increasingly diverse, the importance of implementing teaching strategies that increase nursing learners' acceptance and management of unconscious biases cannot be overstated. Research suggests that providers are more likely to apply unconscious stereotypical characterizations to patients when their cognitive abilities are challenged by time limitations or stress (Teal et al., 2012). Nurses at all levels, from front-line staff to practitioners, experience limitations and daily stress due to a multitude of factors, such as staffing shortages, patient acuity, demands of electronic medical record documentation, and institutional pressure to produce more relative value units. Real changes in attitudes and actions, which positively affect patients, cannot occur through one-time or segmental unconscious bias teaching incorporated into cultural competence modules. Consistent exposure to unconscious bias curriculum, at all levels of nursing academic education, must take place in both classroom and clinical environments to fully integrate information and knowledge into skills for patient care.
In prelicensure settings, introduction to unconscious bias and its effects on patient care could be included in first-year nursing courses. Implicit association tests with guided debriefing could be assigned as part of clinical rotations. Stages of unconscious bias awareness, management strategies, perspective-taking exercises, and patient-centered interviewing skills could be taught in second-year core courses. Implementation of learner-selected management strategies in live clinical settings or through high-fidelity simulation with standardized patients, would complement theory taught.
Current research regarding teaching strategies to address unconscious bias and its effects on patient care focuses almost exclusively on physician–patient interactions and medical student data. Research regarding the effect of unconscious bias on the nurse–patient relationship, as well as effective implementation of acceptance and management teaching strategies in nursing academic settings, is needed to provide evidence-based, practice-driven change in nursing curriculum.
Unconscious biases held by health care providers can contribute to health disparities. Methods used to teach health care learners about unconscious bias often focus on knowledge acquisition and personal reflection. This can lead to cognitive dissonance, which may result in learner defensiveness and skepticism toward personal bias. Teaching strategies incorporating focused debriefing using interactive audience polling, categorized management strategies, and perspective taking resulted in positive graduate-level nursing learner feedback regarding acceptance of newly discovered bias and motivation to manage it. Exposure to unconscious bias curriculum at all levels of nursing education is needed to develop effective interaction and communication skills with stigmatized patients.
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Educational Interventions to Promote Acceptance and Management of Unconscious Bias
| Implicit Association Test (IAT)||Provide Project Implicit®Frequently Asked Questions website. Include disclaimer that IATs do not indicate prejudice, racism, or nonegalitarian motives for patient care. Learners record their results and personal reflections for in-class use.||Validate tool; may cause cognitive dissonance.|
| Anonymous Audience Response Polling||Multiple Choice Polls: Type of IAT taken; test results; learner feelings about test results; doubts about test validity; concerns about racism, prejudice, nonegalitarian motives.
Open-Ended Poll: Influence of implicit bias on nursing practice or patient care.||Provide a safe environment for honest feedback about the test and results.|
| Guided Debriefing||Implicit Association Test Basics: does not indicate racism, prejudice, or nonegalitarian motives; tool validity and accuracy; effect of in-group preference—cultural conditioning on results.
Definition of Unconscious Bias: Helps individuals function within societies; cannot be removed; can be controlled; awareness is key. Unconscious bias and health care providers: influence on patient outcomes and patient–provider interactions.
Stages of Unconscious Bias Awareness.||Develop knowledge and understanding about unconscious bias. Affirm learners' egalitarian goals for patient care.|
| Management Strategies||Education; internal feedback; reflection; cross-cultural encounters; useful experiences; external feedback; debriefing; humanism.||Move learners toward change.|
| Perspective-Taking Exercise||Patient Vignettes: Learners compose a short poem or prose to expressempathy; learner feedback elicited; voluntary sharing (i.e., in class or onthe learning management system).||Reduce resistance throughinsight and empathy.|
| IAT||Graded Written Summary: Test taken; results and feelings about results; influence on nursing practice and patient care. At least one management strategy to implement.||Reinforce concepts taught.|
|Provide Project Implicit® for Researchers website.|
|Management Strategy Implementation||Graded Written Summary: Clinical patient interview; BATHE (Background, Affect, Trouble, Handling, Empathy) questions; quality of patient–provider interaction; identify communication barriers; determine how management strategy coutild be adapted.||Implement concepts taught.|
Stages of Unconscious Bias Awareness with Corresponding Behaviors and Management Strategies
|Awareness Stage||Manifesting Behavior||Management Strategy|
|Minimization||Potential influence or importance of bias is trivialized. Individual believes they can treat all people objectively.||N/A|
|Acceptance||Recognizes that unconscious bias exists, unconscious bias in oneself, and potential influence of bias on patient interactions.||Education: Learning more about unconscious bias.
Internal Feedback: Self-monitoring of thoughts and actions or outcomes of one's actions.
Reflection: Considering or thinking back on behaviors, thoughts, actions, and consequences.|
|Adaptation||Reflects on previously unrealized bias in oneself. Acts on known biases to reduce potential influence.||Preparing for Cross-Cultural Encounters: Mindfulness in advance of an encounter.
Useful Experiences: Seeking experiences that will be helpful to reduce unconscious bias.
External Feedback: Feedback from outside observers.
Debriefing: Talking with trusted people after patient encounters about your experience, perceptions, attitudes, feelings.|
|Integration||Acts on known biases in a way that controls them.||Humanism: Insight, empathy, and relational awareness of patient situations.
Patient-Centric: Considering and acting upon the patient's view and perspective.|