STATEGIES TO OVERCOME IMPLICIT BIAS IN HEALTHCARE

A well-designed implicit bias training process is a valuable component of bias reduction. However, training must be part of an organizational system that identifies and addresses the causes of implicit bias within the healthcare system. Those in leadership must recognize their biases as well of those of the organization. An organization devoted to inclusivity and a no-tolerance policy toward bias will identify factors that contribute to workplace inequities and change processes and attitudes that enable biased behaviors.

“PRESS” Model for Organizations

Livingston (2020) has developed a five-stage model called PRESS through which organizations can move as they work to reduce bias in the healthcare setting. While this model has yet to be evaluated via scientific research, it provides a potential strategy for bias reduction.

Problem awareness: Some people deny that there is bias in their organizations. Therefore, the first step is to acknowledge that bias exists and that it is a problem. Education and screening tests for implicit bias may help staff members and administrators to identify their own implicit biases.
Root-cause analysis: Root-cause analysis refers to the process of understanding the root causes of bias. An analysis of the structural dynamics that are part of the organization means not only identifying causes of bias but taking steps to address those causes.
Empathy: Empathy, as opposed to sympathy or pity, is more likely to lead to actions that reduce bias. Empathy is defined as understanding others’ emotions together with the ability to imagine what someone else is experiencing. Empathy can be increased by exposure and education, such as listening to colleagues who are members of minority groups talk about their personal experiences of bias and how it affects their lives.
Strategy: Most strategies for change address three interconnected factors: personal attitudes, informal cultural norms, and formal institutional policies. Personal attitudes can be explored via screening tools and interactions. Informal cultural norms can be made clearer via formal education and informal discussions. Formal institutional policies can include zero tolerance for bias, ongoing education for all staff members, and exposure to real-life examples of the effects of bias.
Sacrifice: All members of the organization must appreciate that implementing antibias strategies requires an investment of time, energy, resources, and commitment in order to achieve ongoing, organization-wide promotion of greater diversity, equity, and inclusion.

Self-Awareness Development

Sabin (2022) conducted an extensive literature review on addressing implicit bias in healthcare. After completing the review, she concluded that self-awareness is a cornerstone of efforts to reduce bias.

HARVARD IMPLICIT ASSOCIATION TEST

One way to develop self-awareness is through the use of an educational tool. The Harvard Implicit Association Test (IAT) was created in 1998 for the purpose of measuring and detecting a person’s implicit bias. The test can be used to measure biases in relation to race, sexual orientation, gender, age, and various other categories. This test has been found to offer some insight into how groups of people with different traits, behaviors, and cultures are viewed by others.

The IAT takes about 10–15 minutes to complete and can be accessed on the Project Implicit website (see “Resources” at the end of this course). Participants are asked to sort and categorize a variety of images and words and respond to a questionnaire related to the topic. The strength of association between the various types of content is measured based on how quickly the user reacts to the associations (MAEPD System, n.d.). Results are classified as no bias, slight bias, moderate bias, or strong bias toward people of different races, sexual orientation, and other bias-related categories.

The IAT is not a perfect measurement of implicit bias. There are some criticisms, including the fact that people may take the test multiple times and provide different answers or that various issues could influence someone’s reaction time while taking the test. However, the test results are a good way to start introspection and the process of self-awareness (Practical Psychology, 2022).

“ASK” MODEL

Another strategy to develop self-awareness is the “ASK” model, a practical tool that can be used to address the impact of implicit bias and how culture influences someone’s daily encounters with others (Rose, 2022).

Awareness: Healthcare professionals must increase their awareness of implicit bias to communicate more effectively with patients and colleagues. Improved communication is linked to enhanced trustworthiness.
Sensitivity: Healthcare professionals must be sensitive in their approach to both similarities and differences from other people.
Knowledge: Healthcare professionals should improve their health literacy, which is the comprehension of healthcare and specific health conditions.

“IMPLICIT”

The American Academy of Family Physicians (Edgoose et al., 2019) has identified the following eight strategies, recognized by the mnemonic IMPLICIT, that can be used to heighten awareness of implicit biases:

Introspection: Set aside time to take an objective inventory of implicit biases that may be present in oneself.
Mindfulness: Develop a state of active, open attention to the present by observing one’s thoughts and feelings without judging them as good or bad. Cultivating mindfulness is a tool to identify and manage difficult emotions, such as those that accompany implicit bias, while avoiding self-criticism and self-judgment (Psychology Today, n.d.).
Perspective-taking: Look at situations and circumstances from a viewpoint that is typically different from one’s usual viewpoint. Role playing exercises in an educational setting, such as “putting yourself in someone else’s shoes,” have been shown to be helpful (APA, 2023).
Learning to slow down: Avoid jumping to conclusions about a person or groups of people. Taking the time to slow down allows for the acknowledgment of positive examples of people from the groups for which one may have implicit biases (Maryville University, n.d.).
Individualization: See each person’s individual characteristics that are different from shared characteristics within a group. By individualizing people, healthcare professionals can identify positive characteristics as well as mistaken negative assumptions (Maryville University, n.d.).
Checking messaging: Use statements that embrace inclusivity rather than focusing on what makes someone “different.” One example is Apple corporation’s inclusion statement: “At Apple, we’re not all the same, and that’s our greatest strength” (Maryville University n.d.).
Institutionalizing fairness: Develop organizational programs that include implicit bias recognition and management for all employees. Components of such programs should include building skills in diversity, equity, and inclusion (Sabin, 2022).
Take two: Acknowledge that overcoming unconscious biases is not the result of one training session or one self-awareness test. It is a life-long learning process that requires continual effort.

CASE

Two patients arrive at an outpatient clinic for evaluation prior to surgery for a hip replacement. David is a nurse who is doing the initial pre-operative patient education. He reviews patient information prior to meeting with them. The first patient is Monica, a 55-year-old Asian American woman. The address she provided is known locally as the “poor side of town.” She also noted that her parents are natives of Vietnam and came to the United States just before her birth. Monica listed her occupation as mental health specialist and English as her second language.

The second patient is Adam. He is a 22-year-old White American of European descent. He is on leave from his graduate school studies until he recovers from surgery. He lives in an upper middle-class neighborhood. Adam is engaged to be married, and his wedding is scheduled for early next year.

David prides himself on his unbiased treatment of patients of different races, cultures, genders, and sexual orientation. He begins to make some initial plans for patient education. For Monica, he obtains printed patient education materials in Vietnamese and contacts the interpreter department to find out if anyone is fluent in that language. He assumes that Monica will have trouble paying for any healthcare costs based on her residence address. David also assumes that Monica may work as a counselor in one of the community clinics in her part of town, which is not a safe neighborhood. He also wonders if she will take analgesics as recommended after her surgery, thinking, “Aren’t Asians supposed to be stoic about pain?”

David believes that planning for Adam’s patient education will be easier than Monica’s. He assumes that cost will not be an issue because of his address and the fact that he is studying in a graduate university program. David wonders if Adam’s fiancé will accompany him to his appointment, and guesses that, unless she has a healthcare background, she will be upset at the thought of surgery.

Monica enters David’s office. She is well-dressed, confident, and speaks with a very slight accent in her fluent English. Monica is wearing a diamond-studded wedding band and is accompanied by her husband, whom David recognizes as a local politician who works hard to better the lives of people living in disadvantaged circumstances. David learns that Monica recently completed her Ph.D. in psychology and works at a community clinic in her neighborhood. She has done considerable reading about hip replacement, and David finds that her knowledge is accurate and thorough.

David thinks to himself, “With her abilities, why is she not working and living in a more affluent part of town?” As if reading his mind, Monica tells David that she has chosen to live in the neighborhood in which she grew up and to help the disadvantaged groups in that area. “I’ve been fortunate in my life. I want to help my neighbors be fortunate, too. My husband agrees with me and also works to improve things for the neighborhood and its inhabitants.”

David realizes that he has been wrong on almost every one of his assumptions about Monica. He had anticipated her to be poor, lacking skills in English, and unable to comprehend the necessary patient education. After Monica and her husband leave, David begins to wonder how he could have been so wrong.

David expects that his next meeting with Adam will not contradict any of his assumptions. He is looking forward to an easy teaching session.

Adam enters with a young man whom he introduces as his fiancé. The fiancé, whose name is William, explains that he is here to help interpret for Adam, a native of France, whose English is limited. The two men met when they were attending university in France and recently moved to the United States to continue their studies. William, an American by birth, is fluent in several languages, including French, and says with a smile, “We are both working hard to help him learn English as quickly as possible. He is a good student!” The well-to-do address is that of William’s parents. The two young men are staying there as they continue their studies and prepare for their much-anticipated wedding. Adam may have some initial difficulty with costs related to the surgery, but William assures David that he and his parents are prepared to help with the financial aspects of the surgery. William also explains that he is a bit squeamish around “blood and other medical stuff,” but Adam is very stoic and may actually end up comforting him!

David once again has his expectations turned upside down. Adam is not fluent in English, his finances are limited, and, as a gay man, his fiancé is also male. David realizes that he must provide patient education materials in English and in French and make arrangements for an interpreter to help in William’s absence after surgery.

David uncomfortably realizes that he has made a lot of assumptions based on stereotypes, which are part of implicit bias. He realizes that he must objectively review his behaviors and beliefs in an effort to recognize and reduce faulty assumptions made under the influence of implicit bias.

Discussion

Although David prides himself on being unbiased, his actions contradict this belief. He makes assumptions about people based on where they live, their native language, culture, sexual orientation, and socioeconomic status. To David’s chagrin, he realizes that he may have many unconscious stereotypes and that these may indicate biases he never realized he had.

David has acknowledged his unconscious biases. It is important that he now reviews present and past assumptions and behaviors to identify when and how implicit bias influencing his decisions. He can then take the next step to learn how to change his behavior patterns and thoughts to avoid acting from his own biases.

Strategies for Working with Patients

Rose (2022) has also identified actions that may help in bias reduction in healthcare. These include:

Ask patients to share their social histories with the healthcare team so that the team can support and comprehend the particular challenges those patients face.
Seek out information on implicit bias in order to understand the potential for implicit bias in oneself and to be better able recognize it.
Review one’s decision-making process, be aware of the rationale for decision-making, and avoid making assumptions based on physical appearance, social history, or socioeconomic status.
Use shared decision-making strategies in treatment planning.
Acknowledge cultural differences and diversity and be sensitive to potential bias.
Identify sources of stress and factors that add emotional pressure and try to mitigate stressful situations that may lead to biased decisions.

BIAS REPORTING SYSTEMS

Some healthcare organizations have instituted bias reporting systems. For example, UW Medicine provides an online tool that allows the target or observer of a biased incident to report their concerns. These incidents are evaluated by a skilled incident-response team that gathers additional information and either directs the concern to an existing system or refers the incident for further investigation and follow-up. A quarterly report provides data on the number of bias incidents, the groups affected by the incident, groups reported to have perpetrated the incidents, locations of reported incidents, and the themes of reported incidents (UW Medicine, 2023).

Training Programs

Education and training must be ongoing and part of a broad organizational strategy designed for all employees. Gonzalez and colleagues (2021) have proposed 12 characteristics for effective implicit bias recognition and management training programs.

Create a safe learning environment. It is not easy to recognize and analyze personal implicit biases. Discussions about bias often cause people to become defensive and emotional. People may be afraid of being labeled as racist, homophobic, sexist, etc. A safe learning environment is essential if healthcare professionals are to learn about implicit bias and how to reduce it. A safe environment is one that allows learners to frankly analyze their thoughts and behaviors and maintains confidentiality of the learners.

Adults learn most effectively when they feel that they are being respected and that their input is important. Adults must also know why they are learning. It cannot be assumed that learners will automatically “know” that they must learn about implicit bias. Facilitators must give examples of how implicit bias impacts healthcare services within their organizations. Examples should not include personal identifiers so that confidentiality is maintained and learners do not fear that their own confidentiality is in jeopardy. Adults must know the relevance of education. In other words, they need to know how a training is expected to impact their professional practice and patient outcomes.
Reduce the hierarchy in the safe learning environment. The learning environment consists of learners and facilitators. Facilitators are often viewed as having power over learners. It is important to provide learners with opportunities to ask questions and relay feelings without fear of judgment, ridicule, or censorship. Facilitators should be persons who have experience in helping to reduce implicit bias, are comfortable teaching adults, and include the adult learners in the teaching/learning environment by encouraging questions and objectively addressing issues that are challenging.
Reduce self-blame. Normalizing bias while simultaneously reducing self-blame helps to diffuse anxiety and even resentment related to self-examination of personal implicit biases. Bias is, to some extent, human nature, and not necessarily someone’s “fault.” Healthcare professionals must develop skills to not only recognize their personal biases, but implement strategies so that biases can be reduced and not influence clinical practice. The facilitator should address the issues related to self-blame frankly and be prepared to deal with the possible resentment of learners who are struggling to acknowledge their own implicit biases.
Integrate the science behind implicit bias. Describing the psychology and neuroscience of implicit bias helps to defuse learner tension and adds legitimacy to implicit bias training. Additionally, adults must be able to understand how any new knowledge can be used in a practical fashion. Theorizing should be kept to a minimum.
Create activities that embrace discomfort. Discomfort is an important part of implicit bias training. Discomfort that arises during education and training triggers learners to question their assumptions and highlights the need for change. However, discomfort should not overwhelm the learners. A safe environment means that the discomfort should be accompanied with information about dealing with uncomfortable truths and offering support while remaining objective when discussions lead to issues that are thought-provoking and unsettling.
Implement critical reflection exercises. Critical reflection helps learners to recognize their position in the organization and the world at large to improve understanding of their assumptions as they relate to power and bias. Examples of critical reflection may include presenting learnings with various case studies or role-playing implicit bias situations and then asking learners to share their thoughts and feelings about what they have witnessed and how bias might be reduced in similar circumstances.
Explore the relationship between experience, implicit, explicit, and structural biases. Implicit biases are formed from someone’s life experiences and socialization processes and reflect biased norms within such contexts. Education to reduce implicit bias must stress that this cannot be accomplished by a lone individual but must be part of an organization-wide process. Adults have many life experiences that can help them contribute to a discussion about their experiences, implicit and explicit bias, and structural bias (institutional practices that give advantage to some and disadvantage to others based on identity). It is essential that adult learners be encouraged to share their life experiences.
Implement perspective taking exercises. These exercises serve to help healthcare professionals’ awareness of how standard procedures may be interpreted differently from patient to patient. Understanding the context of a patient’s reaction will help learners to acknowledge their biases and improve patient communication. The perspectives and life experiences of both patients and healthcare professionals can be used in discussion and, in a learning environment, as role play to experience the damage that bias can cause and to learn behaviors to reduce such circumstances.
Implement skill building exercises. Role play and clinical vignettes help to identify ways to address bias. Learners can practice verbalizing how to address bias and reflectively review vignettes for the way patient–healthcare professional interactions are conducted. Adult learners may use role play to “act out” situations they have encountered, reflect on how they responded to these situations, and consider options for some responses that may have been more effective.
Make implicit bias education part of life-long learning. As previously noted, a single training session is not effective. Education and training must be part of an ongoing process that continues for each and every employee. Implicit bias education is truly a life-long learning process. Leadership should not only support bias training and education, but include it as part of mandatory organizational education and training efforts.
Include formative and summative assessments. The effectiveness of the education and training must be evaluated. An organization must establish a system of monitoring incidents of bias before and after training and compare the results. The desired effect of monitoring is to be able to objectively measure outcomes and, hopefully, show that the training has helped to reduce bias. These types of assessments should be used to add to the body of knowledge that is essential to implementing education and training that has an ongoing effect on reducing bias.
Obtain explicit support from leadership. Without leadership support, implicit bias training is doomed to fail. Leadership must support structural change as identified during education, training, and bias monitoring. Their support can be gauged by their backing of the development of policies related to bias reduction and ongoing training and education for the purpose of bias reduction.
(Fairbanks, 2021; Gonzalez et al., 2021)

STUDYING THE EFFECTIVENESS OF IMPLICIT BIAS TRAINING

Despite a growing recognition of the impact of implicit bias and the need to reduce/eliminate it, there are few studies thus far that provide definitive evidence as to the effectiveness of reduction interventions (FitzGerald et al., 2019). Some researchers have found evidence of attitude change and limited behavior change attributed to diversity training, but they concluded that a single diversity training program is not enough to reduce implicit bias in the workplace (Chang et al., 2019).

Vela and colleagues (2022) conducted an extensive literature review of practices to eliminate explicit and implicit biases in healthcare. Quite a few of the articles reviewed showed successful promotion of awareness of implicit bias and an interest in reducing such bias. However, none of the interventions reviewed achieved sustained reduction of implicit bias in healthcare professionals. None of the studies demonstrated that an intervention improved clinical outcomes, the learning environment, interprofessional team dynamics, patient care, health disparities, or patient and healthcare professionals’ satisfaction. Considerably more research is needed to provide definitive evidence regarding approaches to reduce implicit bias and its effects that are effective in the long-term.