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Implicit Bias and How to Reduce It

Contact Hours: 2

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Contact Hours: 2

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Course Purpose   

The purpose of this course is to assist the healthcare professional in understanding how implicit bias can affect the quality of care provided to patients within the healthcare system and to provide a brief overview of strategies to reduce implicit bias once it is recognized.

Overview 

Implicit bias refers to attitudes or stereotypes that affect our understanding, actions, and decisions in an unconscious way, making them difficult to control. It may present as biases against groups of people who have a different gender, sexual orientation, racial group, or ethnicity, and can occur anywhere, including the criminal justice system, healthcare system, schools, and workplace settings. This course provides an overview of implicit bias, a test commonly used to identify it, and strategies to help reduce it once it is identified. 

Objectives

Upon completion of the independent study, the learner will be able to:

  • Define implicit bias
  • Differentiate between implicit bias and explicit bias
  • Understand how stereotypes influence implicit bias and how it affects patient care
  • Review tests are commonly used to help identify implicit bias
  • Implement strategies to help reduce implicit bias within an organization

Policy Statement

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Disclosures

Fast CE For Less, Inc. and its authors have no disclosures. There is no commercial support. 

Fast Facts: Implicit Bias and How to Reduce it

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Implicit Bias and How to Reduce it Pretest

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Introduction

Joanne is a Nursing Manager in an intensive care unit. She is interviewing nurses for an open position in her unit. During the interview process, Joanne’s decision to hire a nurse should be based only on the applicant’s qualifications. Joanne can achieve this by creating an environment that is conducive to focusing on the applicants and their responses during the interviews, such as paying attention and removing outside distractions from the environment, including cell phones. After the interviews, Joanne must take enough time to think, and decide to whom she should offer the coveted position. It seems simple enough; interview the nurses and select the best applicant; however, research suggests that Joanne’s decision on who she hires may be influenced by the race and gender, and physical appearance of the applicant. This is an example of implicit bias. Joanne may not be aware of it, but her decision to hire a nurse may be influenced by the nurses’ appearance, skin color, ethnicity, or accent. She did not intend for bias to occur, it happened implicitly. 

Psychologists Mahzarin Banaji and Anthony Greenwald first described implicit bias in 1995. They suggested that social behavior is largely influenced by unconscious associations and judgments. Implicit bias refers to attitudes or stereotypes that affect our understanding, actions, and decisions in an unconscious way, making them difficult to control. ¹ Simply put, bias describes the ability to rapidly find patterns in small bits of information. These patterns form outside the conscious at a young age and are caused by positive or negative attitudes and stereotypes that are developed about certain groups of people. 

Implicit bias is also known as unconscious bias or implicit social cognition. ¹ It may present as biases against groups of people who have a different gender, sexual orientation, racial group, or ethnicity, and can occur anywhere, including the criminal justice system, healthcare system, schools, and workplace settings. 

Definitions
CodeMeans the public health code.
CompetenceHaving the capacity to function effectively as an individual and an organization within the context of the cultural beliefs, behaviors, and needs of a given community.
CultureThe integrated patterns of thoughts, communications, actions, customs, beliefs, values, and institutions associated, wholly or partially, with racial, ethnic, or linguistic groups, as well as religious, spiritual, biological, geographical, or sociological characteristics.
Cultural BlindnessAn organization that provides services with the expressed philosophy of being unbiased, and functions with the belief that color, or culture make no difference and that all people are the same.
Cultural CompetencyAcceptance and respect for difference, continuing self-assessment regarding culture, careful attention to the dynamics of difference, continuous expansion of cultural knowledge and resources, and a variety of adaptations to service models, where healthcare professionals can effectively use their cultural knowledge during interviewing, assessment, and treatment.
Cultural DestructivenessAttitudes, policies, and practices that are destructive to cultures and consequently to the people within the culture.
Cultural IncapacityOccurs when organizations and healthcare professionals do not seek to be culturally destructive but lack the capacity to help people of various cultures.
Cultural Pre-CompetenceOccurs when there is an awareness and an attempt to improve services to a specific population, and where healthcare professionals are aware of perceptions, values, and other elements of their own culture and of cultures different from their own.
Cultural ProficiencyOrganizations hold culture in high esteem and attempt to add to the knowledge base of culturally competent practice by conducting research, developing new therapeutic approaches based on culture, and publishing and disseminating the results of demonstration projects. In this stage, healthcare professionals lead cultural competence in practice by training others in cultural competence, recruiting personnel from diverse cultures, and conducting research that adds to the knowledge base.
DepartmentDepartment means the department of licensing and regulatory affairs.
Implicit BiasAn attitude or internalized stereotype that affects an  individual’s perception, action, or decision making in an unconscious manner and often contributes to unequal treatment of people based on race, ethnicity, nationality, gender, gender identity, sexual orientation, religion, socioeconomic status, age, disability, or other characteristics.
Issue DateThe date that the initial license was granted to the licensee by the  Department. 
Stark LawA Law that improves care provided to patients within the healthcare system. The law has three components:
Prevents healthcare professionals from referring patients to a business which they have financial or familial interest.
Prevents billing of Medicare or other insurance providers when a physician makes an improper referral.
Establishes exceptions of the provisions above.
Implicit Bias and Explicit Bias

An implicit bias may be opposite of a person’s conscious beliefs without them realizing it. ² For example, it is possible to like some parts of a certain social group or approving of a certain action, while simultaneously being biased against that group or action on an unconscious level, such as liking Mexican food but not liking people who speak the Spanish language. 

An explicit bias is a bias that an individual is aware of on a conscious level, for example, feeling threatened by young African American men, and delivering hate speech as a result.

It is important to understand that implicit bias can also become explicit bias. ² This occurs when an individual becomes consciously aware of the prejudices and beliefs that they possess, and then makes a conscious choice whether to act on those beliefs.

Bias Occurrences

Implicit biases are present in all areas of society, even during daily interactions. Often, they may present as microaggressions that make others from a different group feel uncomfortable or aware of the specific prejudices that an individual may have.

Gender Stereotypes

Gender biases are another common form of implicit bias. Gender biases occur when men and women are judged based on traditional masculine and feminine traits. ⁴ For instance, a male who expresses interest in nursing may be steered away from the field and instead be steered towards being a physician, because traditionally, the nursing profession is associated with a career for women. Likewise, a woman who is a physician may be perceived as not experienced enough, or not having enough knowledge to be a ‘good’ physician, or even be misidentified as the nurse, whereas a male physician may not experience such assumptions. A person may express the examples of gender stereotypes without realizing it. 

Health Care

Healthcare is another setting where implicit bias is present. Racial and ethnic minorities and women are less likely to receive an accurate medical diagnosis, appropriate treatment options, are more likely to receive inadequate pain management, and are more likely to experience poor clinical outcomes. ⁵ Additionally, it has been revealed that Black children are not given the same compassion or level of care that is provided for White children.

LGBTQ+ Community 

Just like racial and gender biases, people may also have implicit biases against members of the LGBTQ+ community. ²These biases may not be evident to the person who has them, and they may not be expressed openly. An example of this would be assuming that a woman or man is in a heterosexual relationship because that is the norm for society, when in fact a woman or man may have a same sex partner. Just as other biases on race and gender, biases experienced by the LGBTQ+ community are extensive, and they are not just solely based on the LGBTQ+ person’s relationships. 

Legal System

Implicit biases can be highlighted in the legal system and with law enforcement. For instance, minorities are more likely to be stopped by law enforcement and incarcerated. The unconscious bias of perceiving a minority person as a threat, and then working to reduce the threat whether

it exists or not, can result in a cascade of events that is caused by implicit bias. An example of implicit biases that occurs in law enforcement is the shooter bias; a researched tendency among some the police officers to shoot Black civilians more often than White civilians, even when they are unarmed. Black people are also arrested at disproportionally high rates, given harsher sentences, and Black juveniles are more often tried as adults for the same crimes as their White peers. Black boys are also seen as less childlike, less innocent, more violent, more responsible for their actions than their non-Black peers.

Racial Stereotypes

Unconscious racial stereotypes are one of the most prominent examples of implicit bias, which can occur when someone has an unconscious preference for one race over another without realizing it. This type of bias can manifest in small interpersonal interactions and can have a broader implication in the legal system or any other part of society. ³For example, one evening Judy decides to go for a walk. While walking, in the distance she sees a young Black male walking on the same side of the street as her. Upon seeing him, she immediately crosses the street without even thinking about it. Why did she take this action? Likely because of an implicit stereotype that Black men are violent. This stereotype results in microaggression, which is a subtle, nonverbal way to communicate hostile, derogatory, or negative prejudices even though the individual is unaware of them. In this instance, Judy’s action of crossing the street communicates an implicit bias that she is not aware of; the young man walking on the same side of the street as her is dangerous.

Work

Implicit bias is also present in the workplace. For instance, a study that tracked employment statuses of White and Black applicants found that applicants with stereotypically white names received more interviews than applicants with ethnic sounding names, regardless of the profession. This resulted in the revelation of another form of bias; namely hiring bias, where applicants with stereotypically White sounding names were perceived more favorably prior to an interview than ethnic named applicants.

Causes of Implicit Bias

One of the main reasons people develop biases is because of the natural tendency of our brains to look for patterns and associations to make sense of the environment. ⁷ Even as early as the age of five, children group people based on traits (race, skin color, sex), and can distinguish the differences among groups. Notably, in early childhood a child can recognize what sets them apart from other groups and may believe that what is different from themselves is bad. For instance, a five-year-old boy may only want to play with other boys, saying, “I don’t like girls.” When a child recognizes differences in others and sets negative attributes to what is different from themselves, they may begin to develop implicit bias. 

Bias can also be developed because of the brain’s tendency to simplify our surroundings. To reduce cognitive overload, the brain may make mental shortcuts to make it easier and faster to process information. ⁷ The ideas of cause and effect can be considered a mental shortcut, however when a mental shortcut is processed inaccurately, implicit bias may develop. For instance, a person who witnesses a traumatic event such as a car crash caused by an intoxicated young male with visible tattoos may associate any young male with tattoos as being irresponsible. In this instance, the brain recalls information associated with the traumatic event and creates a mental shortcut, inaccurately associating the young male with irresponsibility, which results in the possibility of implicit bias developing.

In addition, influences from media, culture, and even how people are raised as children can contribute to implicit biases forming. Media is readily accessible, and while it has many benefits, it can also lead to implicit biases. The way people are portrayed on television, or the language used in an article can cause implicit biases to develop. For instance, television programs can portray White females as nurses, and White males as a successful businessman, making the assumption that all nurses are females, and that all successful businessmen are males. 

The way people are raised also can contribute to implicit bias. Parental attitudes can influence a child’s thoughts and implicit prejudices. Likewise, siblings, school setting, and the cultural environment can all play a role in shaping beliefs and developing implicit biases.

Testing for Implicit Bias

Implicit Attitude Test (IAT)

An Implicit Association Test (IAT) is a psychological test whose objective is to reveal unconscious attitudes, automatic preferences, and hidden biases by measuring the time that it takes an individual to classify concepts into two categories. The IAT is taken online and must be performed as quickly as possible. ⁶The faster an individual categorizes certain words or faces of a category, the stronger the bias they are likely have about that category. For instance, if an individual reacts significantly faster when pairing the word Success with Skinny than with Fat, Success and Skinny are implicitly more associated, and more interconnected in the participant’s mind, revealing that the individual may have implicit bias against fat people being successful. Implicit Association Tests are just one of several tests that measure unconscious attitudes and beliefs, however, IATs along with Priming Tests are the most used to test for implicit biases. 

Priming Test

Priming Tests, also known as Associative Priming tests, are also implicit bias tests that are designed to measure the strength of association between two targets and primes. ⁶The targets are two categories that are compared, and the primes are the attributes that are tested to reveal associations to the targets. The priming effect is shown when the exposure to a particular stimulus affects subsequent reactions, with or without intention.

How to Reduce Implicit Bias

Unconscious prejudices and negative attitudes toward certain groups of people can compromise healthcare when those prejudices involve patients. Although implicit, biases can be changed when individuals recognize that they have them. There are eight tactics that cleverly spell out IMPLICIT to help the healthcare professional identify implicitness¹:

Introspection 

Take implicit association test (IAT) to help identify prejudices.

Mindfulness

When under pressure, we are more likely to inappropriately rely on memory shortcuts that can lead to implicit bias. To reduce the risk, an individual should increase mindfulness by doing stress and pressure relieving activities such a meditation, yoga, or focused breathing exercises. Improving mindfulness has been found to improve coping with pressure and stress, and adjusts biological reactions that influence emotions, attention, and habit formation. 

Perspective-Taking

Put yourself in the position of the person being stereotyped. When thinking about (or experiencing) what someone else is going through, or even reading or watching content on the subject, you are more likely to have empathetic feelings towards the person being biased against. 

Learn to slow down

Before interacting with people from different groups, you should first pause and think before taking any actions that can cause bias. For instance, the next time you see behavior that is stereotypical of a group, pause to think about it. Then consider examples of people from that same group who are positive examples and separate the stereotypes from being generalized to an entire group of people.

Individuation

This tactic relies on evaluating people based on their own personal characteristics rather than the characteristics associated with their group. This could include connecting over shared interests. For instance, healthcare professionals must build relationships with patients to establish trust. Relationship building can occur through finding shared identities, such as parenting, common interests, sports teams, and even surviving illness. Individuation can be used to help inform clinical decisions by using what is known about a person’s specific, individual, and unique attributes. 

Check your messaging

Many people may say “I don’t see color,” but this may be a statement that should be replaced. Instead, we should consider using terminology that embraces multiculturalism or other differences. Using specific messages that are designed to create a more inclusive environment can assist in reducing implicit bias. 

Institutionalize fairness

Diversity and inclusion should be supported at the organizational level. Organizations have a responsibility to support a culture of diversity and inclusion because individual action is not enough to deconstruct systemic inequities. To overcome implicit bias throughout an organization, it should consider implementing an equity lens; a checklist that helps one to consider their blind spots and biases to assure that great ideas and interventions are not only effective, but also equitable.

Take two

Resisting implicit bias is lifelong work, and one will have to constantly restart the process and look for new ways to improve. The strategies that have been described require constant revision and reflection while working towards cultural humility. Examining your own assumptions is just a starting point.

Considerations

Education is crucial. Understanding what implicit biases are, how they can arise, and how, to recognize them are important aspects in working towards overcoming such biases. Learning about other cultures and what language and behaviors may come off as offensive are critical as well. When something is familiar it is difficult to change any habit, including being biased. Employees and organizations should take a systematic approach to identifying bias and incorporate a process for improvement, practice, and reflection to improve healthcare equality.

Implicit bias training has already been incorporated in different educational and law enforcement settings and these organizations have seen the benefits of training. However, there is a potential of rebound effect, where the bias that was originally suppressed increases. There is also the concern about the morality of implicit bias, and the perception that it is inherently wrong. Regardless of the position (support or not in support of), it should not stop individuals from recognizing that thoughts, feelings, and actions can be implicitly influenced by social cues.

Conclusion

Raising awareness of implicit bias and reducing it is important, however individuals and organizations must make a concerted effort to increase participation and engagement of people belonging to underrepresented groups to achieve true diversity and inclusion. Studies show that health care professionals have the same level of implicit bias as the general population and that higher levels are associated with lower quality care. In medical practice, the unconscious beliefs, and stereotypes that a healthcare professional may have can influence their decision making, the quality of care a patient receives, and ultimately, the patient’s outcome. Healthcare professionals with higher levels of bias are more likely to demonstrate unequal treatment recommendations, disparities in pain management, and even lack of empathy toward minority patients. In addition, stressful, time-pressured, and overloaded clinical practices can exacerbate unconscious negative attitudes.

Although implicit bias is unintentional, it can have serious consequences. This is exemplified in the classic Institute of Medicine report “Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care,” the authors concluded that bias, stereotyping, and clinical uncertainty on the part of health professionals may contribute to racial and ethnic disparities in health care, often despite the healthcare professional’s best intentions. In addition, studies have also shown that discrimination and bias at both the employee and organizational levels can contribute to health disparities for patients. Racial and ethnic diversity will continue to increase, and it is imperative that healthcare professionals identify and use strategies to reduce biases.

References
  1. Beeghly, E., & Madva, A. (2020). An introduction to implicit bias: Knowledge, justice, and the social mind. Routledge.
  2. (2022, March 8). Bitbrain. https://www.bitbrain.com/
  3. Eberhardt, J. L. (2020). Biased: Uncovering the hidden prejudice that shapes what we see, think, and do. Penguin.
  4. Gender stereotyping. (n.d.). OHCHR. https://www.ohchr.org/en/women/gender-stereotyping
  5. The harmful effects of racial stereotyping. (2021, September 9). Alliance Work Partners. https://www.awpnow.com/main/2020/06/29/the-harmful-effects-of-racial-stereotyping/
  6. (n.d.). Project Implicit. https://www.projectimplicit.net/
  7. Ruhl, C. (2020, July 1). Implicit bias is a type of unconscious bias. Study Guides for Psychology Students – Simply Psychology. https://www.simplypsychology.org/implicit-bias.html
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