Journal of Nursing Education

Syllabus Selections: Innovative Learning Activities Free

Combining SOAP Notes With Guided Reflection to Address Implicit Bias in Health Care

Ragan Johnson, DNP, FNP-BC, CNE; Angela Richard-Eaglin, DNP, FNP-BC, CNE, FAANP

Implicit bias has been shown to negatively affect patient–provider interaction, health care disparities, and patient outcomes. Researchers have suggested that the graduate nursing program could be the intervention point to foster awareness of and decrease implicit bias prior to full-time practice (Haider et al., 2011; Schultz & Baker, 2017). Faculty in graduate nursing programs are tasked with developing teaching strategies that allow for realizing, reflecting, understanding, assessing, and correcting biases (Schultz & Baker, 2017).

Paterson and Zderad (1988) postulated that nurse educators should guide students to better define themselves and their patients to improve outcomes. They also encourage professional nurses to reflect on the practice of nursing as an ongoing experience. Their humanistic learning theory served as a framework to support an implicit bias assignment that was integrated into the written Subjective Objective Assessment and Plan (SOAP) note for students enrolled in the initial nurse practitioner clinical course, which requires students to reflect on actual and/or potential bias during each patient visit.

The Implicit Association Test at Project Implicit® ( and online implicit bias training modules were assigned to students as preclass activities. Students were not asked to share their results. A subsequent reflection activity was designed to be included with each SOAP note submission. The goals of the activity were to introduce students to implicit bias and its negative effects on patient outcomes, to allow students an opportunity to realize their own biases, and to encourage reflection on how these may affect patient care on a patient-by-patient basis. Reflection has been associated with moving students toward change (Schultz & Baker, 2017). Students received feedback from faculty and were provided tools and skills to help with reducing implicit bias, such as mindfulness and meditation prior to patient encounters, seeking feedback from outside observers, and increasing empathy for others (Schultz & Baker, 2017).

As part of their SOAP note template, students were asked to include a reflection (≤ 250 words) about the associated patient visit. Students were provided with questions to help stimulate their reflection. Sample questions included:

  • Did I think about any socioeconomical and/or environmental factors that may contribute to the health and access of this patient?
  • How was my communication and interaction with this patient? Did it change from my customary pattern?
  • How could bias influence care for this patient?

Student reflections received from this assignment were thoughtful. One student shared forming a negative opinion about an African American female patient after calculating the patient's age at the time of giving birth and realizing that the patient was an adolescent mother. Another student shared preconceptions about patients in a rural clinic, namely “expect[ing] the patient population to be less invested in their health care, less educated, and make poorer lifestyle choices.” With reflection, the same student noticed a pattern of oversimplifying concepts during patient interaction based on these assumptions. Other themes from the reflections included assuming pain and benzodiazepine medication-seeking behavior in patients.

The Implicit Association Test has documented limitations (Blanton, Jaccard, Strauts, Mitchell, & Tetlock, 2015; Maina, Belton, Ginzberg, Singh, & Johnson, 2018) such as whether the arbitrary metrics of the test highlights simple associations versus bias. Forscher et al. (2019) also found that implicit measures do not necessarily result in behavior change. However, the purpose of this assignment was to enhance awareness through reflection, which is often the most important catalyst for change. It is important to introduce the concept of implicit bias early in the program. Nurse practitioner programs may consider ensuring that implicit and explicit bias is threaded throughout their curriculum. Students were intentional and thoughtful in their written reflections, with several students also posing questions for faculty guidance on how to mitigate their biases. This assignment provides some validation to support the notion that bringing awareness to personal biases may improve provider–patient relationships, which may ultimately improve patient outcomes. Assignments aimed at addressing explicit bias in health care are still needed. Faculty may consider using the modern racism scale as a measure of explicit bias and develop objective structured clinical experiences to address implicit and explicit bias in nurse practitioner programs.

Ragan Johnson, DNP, FNP-BC, CNE

Angela Richard-Eaglin, DNP, FNP-BC,
Duke University College of Nursing


  • Blanton, H., Jaccard, J., Strauts, E., Mitchell, G. & Tetlock, P.E. (2015). Toward a meaningful metric of implicit prejudice. Journal of Applied Psychology, 100, 1468–1481. doi:10.1037/a0038379 [CrossRef]25602125
  • Forscher, P.S., Lai, C.K., Axt, J.R., Ebersole, C.R., Herman, M., Devine, P.G. & Nosek, B.A. (2019). A meta-analysis of procedures to change implicit measures. Journal of Personality and Social Psychology, 117, 522–559. doi:10.1037/pspa0000160 [CrossRef]31192631
  • Haider, A.H., Sexton, J., Sriram, N., Cooper, L.A., Efron, D.T., Swoboda, S. & Cornwell, E.E. III. . (2011). Association of unconscious race and social class bias with vignette-based clinical assessments by medical students. JAMA, 306, 942–951.21900134
  • Maina, I.W., Belton, T.D., Ginzberg, S., Singh, A. & Johnson, T.J. (2018). A decade of studying implicit racial/ethnic bias in health-care providers using the implicit association test. Social Science & Medicine, 199, 219–229. doi:10.1016/j.socscimed.2017.05.009 [CrossRef]
  • Paterson, J.G. & Zderad, L.T. (1988). Humanistic nursing. New York, NY: National League for Nursing.
  • Schultz, P.L. & Baker, J. (2017). Teaching strategies to increase nursing student acceptance and management of unconscious bias. Journal of Nursing Education, 56, 692–696. doi:10.3928/01484834-20171020-11 [CrossRef]29091241

The authors have disclosed no potential conflicts of interest, financial or otherwise.


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