Implicit Bias in Nursing Education and Practice: Promoting Diversity, Equity, and Inclusion

Diversity, Equity, Inclusion, Belonging, and Social Justice: Understanding Implicit Bias in Relation to Nursing Education and Practice Sasha A. Sasha A. Rarang PMHNP (c) PMHNP (c) PNAA Board Member PNAA Board Member PNASC Board Member PNASC Board Member Professor and Dean of Nursing Professor and Dean of Nursing Angeles College, Los Angeles Angeles College, Los Angeles Rarang, PhD, MSN, CCM, RN , , PhD, MSN, CCM, RN ,

Learning Objectives Learning Objectives At the end of the presentation, the participants will be able to: 1. Identify ways to prepare future nurses have the ability to advocate for their patients in meeting the increasingly diverse needs encompassing social characteristics that include but not limited to age, sex, race, ethnicity, sexual orientation, gender identity, family structures, geographic locations, national origin, immigrants and refugees, language, physical, functional, and learning abilities, religious beliefs, and socioeconomic status. 2. Describe approaches in promoting inclusive environment in nursing academia. 3. Distinguish implicit biases that can prevent promoting diversity, health equity, inclusion, belonging, and social justice during performance of patient care. 4. Critique one s level of knowledge, skills, and attitude pertaining to diversity, equity, inclusion, belonging, and social justice in relation to teaching future nurses as well as in performing patient care.

Situation Situation To promote the essence of diversity, equity, inclusion belonging, and social justice, To promote the essence of diversity, equity, inclusion belonging, and social justice, nursing education and practice must cognizant of the impact of implicit bias. nursing education and practice must cognizant of the impact of implicit bias. The need for Nurse Educators to prepare future nurses to become cognizant of The need for Nurse Educators to prepare future nurses to become cognizant of their implicit biases and learn ways to reduce these biases when they start caring their implicit biases and learn ways to reduce these biases when they start caring for patient coming from diverse background (Nursing Education/Academic for patient coming from diverse background (Nursing Education/Academic Nursing) Nursing) The need for current nurses to acknowledge that they have their own implicit The need for current nurses to acknowledge that they have their own implicit biases when caring for patients of diverse background. (Nursing Practice). biases when caring for patients of diverse background. (Nursing Practice). Both future and current nurses must understand the implications of implicit Both future and current nurses must understand the implications of implicit biases in providing nursing care and patient care outcomes. (Nursing Education biases in providing nursing care and patient care outcomes. (Nursing Education and Practice) and Practice) 1. 1. 2. 2. 3. 3.

Background Background The social characteristics The social characteristics - - age, sex, race, ethnicity, sexual age, sex, race, ethnicity, sexual orientation, gender identity, family structures, geographic orientation, gender identity, family structures, geographic locations, national origin, immigration status, language, locations, national origin, immigration status, language, physical, functional, and learning disabilities, religious physical, functional, and learning disabilities, religious beliefs, and socioeconomic status become source of health beliefs, and socioeconomic status become source of health care disparities if care disparities if accompanied with biased thinking and behavior as influenced by preexisting beliefs (myside bias) and social stigmas (social biases) as such forming ones implicit bias.

Background: Background: Social Characteristics/Categories Nursing Faculty, Nursing Students, and Social Characteristics/Categories Nursing Faculty, Nursing Students, and Practicing Nurses must know as they relate to Implicit biases that can impact Practicing Nurses must know as they relate to Implicit biases that can impact quality nursing care. quality nursing care. Implicit bias, also known as implicit prejudice or implicit attitude, is a negative attitude, of which one is not consciously aware, against a specific social group. Implicit bias - shaped by experience and based on learned associations between particular qualities and social categories, including race and/or gender. Individuals perceptions and behaviors can be influenced by the implicit biases they hold, even if they are unaware they hold such biases. Implicit bias is an aspect of implicit social cognition: the phenomenon that perceptions, attitudes, and stereotypes can operate prior to conscious intention or endorsement. (American Psychological Association, 2022).

Background Background Implicit biases impact nursing education through interactions between student nurses and patients that hinder effective communication. Patients who have experienced implicit bias in health care may come to expect negative interactions in the future. Nurse educators hold the responsibility of preparing nursing students to deliver care to diverse populations by guiding them to recognize their responses to cultural and individual differences.

Background Background Nursing Practice Nursing Practice On the other side of the nurses-as-superheros coin lies a hard truth some nurses may not like caring for certain patients. There are some dark side behaviors that some patients may trigger in nurses, which ultimately threaten quality of care. It s a fallacy to think that nurses can separate ourselves from their attitudes, beliefs, and values when they step across the threshold of healthcare into their nursing role. The truth is, nurses may not like caring for some patients because they re different from them. Nurses may struggle to understand them on a basic human level. Nurses may not understand the choices patients make or didn t make that brought them into the hospital.

Assessment Assessment Everyone have implicit biases that have been learned throughout individuals lives. Unlearning them begins with acknowledgement. Understanding Different Types of biases: Affinity bias: A preference for people who look like us. Ageism: Discrimination based on age. Attribution bias: Judgments and assumptions made about a person s behavior that may not reflect reality. For example, attributing blame for a sexual assault on the victim for the clothing they were wearing or alcohol they consumed. Beauty bias: Judgments based on outward appearance. Confirmation bias: Tendency to lean toward evidence that supports our opinions, giving it greater weight. Conformity bias: To achieve acceptance by the social group, individual opinion is swayed and tends to agree or align with group views. Gender bias: Preference for one gender over another. Name bias: Discrimination based on an individual s name. For example, favoring English- sounding names over names from other nationalities. (Todt, 2023)

Assessment Assessment Ethical Principles and Implicit Bias Ethical principles of autonomy, justice, beneficence, nonmaleficence, and veracity must guide the nursing profession and help both nursing students and practicing nurses make informed decisions about their professional practice (Hermel Hermel, et al., 2022) , et al., 2022). Similar to medication, nurses words have the ability to heal or harm (Todt, 2023) Listening is the essence of good communication; it s a skill that requires practice (Todt, 2023).

Intervention for Implicit Bias in Nursing Intervention for Implicit Bias in Nursing Education Education Awareness of students implicit biases is the first step in incorporating efforts to overcome them. Note: A gap exists in nursing education which illustrates the lack of inclusion of implicit bias in the curriculum. Teach to students the application of autonomy as respect for persons The ethical principle of autonomy describes respect for persons (Williams & Anderson, 2018) where students must learn to allow patients to make their own decisions free of bias or influence. Nurse educators must encourage students to make decisions. Students should be provided with unbiased cultural and ethical content that does not influence them to be partial and encourages students to use ethical

Intervention for Implicit Bias in Nursing Intervention for Implicit Bias in Nursing Education Education Students must be taught on how to communicate therapeutically with diverse and vulnerable populations to provide education and teach skills necessary to help reduce negative behaviors associated with these biases to improve patient outcomes (Andrasik et al., 2020). Provide students with an opportunity to practice unbiased actions in either didactic or simulated clinical experiences. This affords them the opportunity to replace negative nonverbal or paraverbal communication behaviors.

Intervention for Implicit Bias in Nursing Intervention for Implicit Bias in Nursing Education Education The ethical principle of justice refers to fair, equitable, and appropriate treatment in what that each person is owed and deserved (Beauchamp & Childress, 2019). Justice involves nurses being impartial, providing resources equitably, and treating all patients fairly despite their ethnicity, socioeconomic status, sexual orientation, or physical and mental condition. An injustice occurs when by an act or omission, a person is denied rights or benefits to which they have a right. Knowing that people from low socioeconomic backgrounds have an unfair disadvantage in education, literacy, and receiving public health messages (Bhaskar et al., 2020), faculty must teach students how to best reach these patients directly to improve equality.

Intervention for Implicit Bias in Nursing Intervention for Implicit Bias in Nursing Education Education The principle of beneficence is a statement of moral obligation that requires one to act for the benefit of others (Beauchamp & Childress, 2019). It can be further defined as acting to prevent harm, protecting and defending the rights of others, and doing good. For example, faculty have a responsibility to teach students to be proactive when caring for patients who identify as transgender or are gender-diverse. This means educating students on culturally sensitive terminology and transgender topics. Example: By teaching students to ask patients their pronoun.

Intervention for Implicit Bias in Nursing Intervention for Implicit Bias in Nursing Education Education The nonmaleficence principle imposes the obligation of a healthcare provider to cause no harm to another person or patient (Beauchamp & Childress, 2019). Nonmaleficence is often associated with the Hippocratic oath and the commitment not to injure or wrong another being. It is essential to understand that this moral imperative has one of the highest stringent of all to attain and potentially overrides all others. Nursing students must first be aware of their own implicit biases to consciously overcome them and thereby practice nonmaleficence. One way this can be done is to spend dedicated class time discussing the Anti- Defamation League's Pyramid of Hate (2022). The Pyramid shows biased behaviors, growing in complexity from the bottom to the top-beginning with elements like stereotyping and microaggressions and growing in complexity and violence all the way up to genocide.

The Pyramid of Hate The Pyramid of Hate The Pyramid shows biased behaviors, growing in The Pyramid shows biased behaviors, growing in complexity from the bottom to the top. Although the complexity from the bottom to the top. Although the behaviors at each level negatively impact individuals and behaviors at each level negatively impact individuals and groups, as one moves up the pyramid, the behaviors have groups, as one moves up the pyramid, the behaviors have more life more life- -threatening consequences. Like a pyramid, the threatening consequences. Like a pyramid, the upper levels are supported by the lower levels. If people upper levels are supported by the lower levels. If people or institutions treat behaviors on the lower levels as being or institutions treat behaviors on the lower levels as being acceptable or normal, it results in the behaviors at the acceptable or normal, it results in the behaviors at the next level becoming more accepted. In response to the next level becoming more accepted. In response to the questions of the world community about where the hate of questions of the world community about where the hate of genocide comes from, the Pyramid of Hate demonstrates genocide comes from, the Pyramid of Hate demonstrates that the hate of genocide is built upon the acceptance of that the hate of genocide is built upon the acceptance of behaviors described in the lower levels of the pyramid. behaviors described in the lower levels of the pyramid.

Anti-bias nursing education Anti-bias nursing education is a a critical tool for supporting students in understanding the nature of hate, for helping build trust, and assisting them to understand how to best respond to these incidents when they happen.

Intervention for Implicit Bias in Nursing Intervention for Implicit Bias in Nursing Education Education The obligation of veracity between patients and providers refers to the timely, accurate, objective, and comprehensive transmission of information (Beauchamp & Childress, 2019). Fundamental to veracity is that all persons are owed the element of respect, the truth will be spoken between the 2 parties, and there must be a sense of trust between patient and provider (Beauchamp & Childress, 2019). Implicit biases in healthcare directly break down the obligation of trust.

Intervention for Implicit Bias in Nursing Intervention for Implicit Bias in Nursing Education Education To help nursing students foster trust with their patients, nurse educators must not rely on theory alone to help students realize their possible implicit biases. Though classroom theory may help students with explicit biases, implicit biases are different and may stem from an emotional derivative (Danvers, 2018). One possible technique to help students defeat implicit bias is the practice of self-cultivation and reflection (Danvers, 2018).

Strategies to Deconstruct Implicit Bias Strategies to Deconstruct Implicit Bias Nursing Practice Implementing the following strategies can help us understand our implicit biases and ultimately improve patient outcomes. Replace the stereotype: Stop, think, and consciously choose to adjust your response to the patient. Counter the stereotype: Pause and reimagine the possibilities for your patient. Individualization See your patient as an individual human, not the disease or condition they have. Take perspective Metaphorically place yourself on the other side of the bed rail and dare to imagine what your patient might be experiencing. Increase opportunities for connection Pull up a stool and spend time with your patient to get to know them. Listen to their stories. Build partnership Work with your patient and embrace them as a care collaborator. Nursing Practice

Recommendations: Recommendations: W Ways to prepare future nurses to have thew ability to advocate for their ays to prepare future nurses to have thew ability to advocate for their patients with increasingly diverse social characteristics. patients with increasingly diverse social characteristics. I Individualized care is specific to each patient and with that comes their ndividualized care is specific to each patient and with that comes their whole identity, whole identity, including where including where they are coming from in terms of they are coming from in terms of ethnicity, race, faith, sexual orientation, community, education, ethnicity, race, faith, sexual orientation, community, education, socioeconomic background and status, and so much more. socioeconomic background and status, and so much more. Students must be taught with must be taught with concrete clinical applications of social concrete clinical applications of social categories provided in case scenarios. categories provided in case scenarios. llowing students to see practical applications of sometimes broad and nebulous concepts of implicit bias. nebulous concepts of implicit bias. Students A Allowing students to see practical applications of sometimes broad and

Implication to Practice Implication to Practice Nurse educators should embrace the idea that implicit biases are inevitable, and efforts should be made to further explore those biases in themselves and the students they teach. Educators are encouraged to provide nursing students with the opportunity to complete the Implicit Association Test (IAT) through Harvard University's Project Implicit to identify and recognize these biases (Gatewood et al., 2019). Link to Harvard s Implicit Association Test (IAT)

Recommendations and Implication to Recommendations and Implication to promoting DEIBSJ promoting DEIBSJ Nursing strives to be at the forefront of quality healthcare. Recognition of implicit bias is an essential measure to improve the patient care of nurses provide at the bedside. Recognition of implicit bias among nursing students through training is equally important. Equal care among patient is a was of promoting inclusivity and belonging. Nurses aim to provide equal care among patients; however, having these biases can be detrimental to provider-patient interactions and interfere with clinical decision-making. Thus, preventing provision of health equity. Nurse educators must evaluate their teaching methodology and curricula to ensure that implicit biases are being discussed across all courses in the nursing curriculum.

Recommendations and Implication to Recommendations and Implication to promoting DEIBSJ promoting DEIBSJ With regards to the structure of our nursing education and healthcare systems where nursing practice is located, the understanding of personal bias can help identify judgements made during recruitment of students, student education and training, as well as when nursing graduates transitioned to practice. Being aware of own biases as a nurse, this is likely to help deliver better patient outcomes. Additional measures include providing a system of reporting discrimination and measuring outcomes either in education or in practice related to reduction of implicit bias. Such measures are fundamental to help mitigate inequality and associated adversity. Sasha Rarang, PhD, MSN, RN

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