Implicit Bias in Health Care ___________________________________________________________________
CREATING A SAFE ENVIRONMENT Creating a safe environment is the essential first step to exploring issues related to implicit bias. Discussions of race, stereotypes, privilege, and implicit bias, all of which are very complex, can be volatile or produce heightened emotions. When individuals do not feel their voices are heard and/or valued, negative emotions or a “fight-or-flight” response can be triggered [76]. This may manifest as yelling, demonstrations of anger, or crying or leaving the room or withdrawing and remaining silent [76]. Some experts have recommended an exercise involving index cards on which “honest inquiry” is written on one side and “honest response” is written on the other [113]. Learners can then hold up the side of the index card to facilitate questions and seek responses from everyone. Creating and fostering a sense of psychological safety in the learning environment is crucial. Psychological safety results when individuals feel that their opinions, views, thoughts, and contributions are valued despite tension, conflict, and discomfort. This allows the individual to feel that their iden- tity is intact [76]. When psychological safety is threatened, individuals’ energies are primarily expended on coping rather than learning [76]. As such, interventions should not seek to confront individuals or make them feel guilty and/or responsible [77]. When implicit bias interventions or assessments are planned, facilitators should be open, approachable, non-threatening, and knowledgeable; this will help create a safe and inclusive learning environment [77]. The principles of respect, integrity, and confidentiality should be communicated [77]. Facilitators who demonstrate attunement, authenticity, and power-sharing foster positive and productive dialogues about subjects such as race and identity [76]. Attunement is the capacity of an indi- vidual to tacitly comprehend the lived experiences of others, using their perspectives to provide an alternative viewpoint for others. Attunement does not involve requiring others to talk about their experiences if they are not emotionally ready [76]. Authenticity involves being honest and transparent with one’s own position in a racialized social structure and sharing one’s own experiences, feelings, and views. Being authentic also means being vulnerable [76]. Finally, power-sharing entails redistributing power in the learning environment. The educa- tion environment is typically hierarchical, with an expert hold- ing more power than students or participants. Furthermore, other students may hold more power by virtue of being more comfortable speaking/interacting [76]. Ultimately, promoting a safe space lays a foundation for safely and effectively imple- menting implicit bias awareness and reduction interventions.
STRATEGIES TO PROMOTE AWARENESS OF IMPLICIT BIAS
As discussed, the IAT can be used as a metric to assess pro- fessionals’ level of implicit bias on a variety of subjects, and this presupposes that implicit bias is a discrete phenomenon that can be measured quantitatively [79]. When providers are aware that implicit biases exist, discussion and education can be implemented to help reduce them and/or their impact. Another way of facilitating awareness of providers’ implicit bias is to ask self-reflective questions about each interaction with patients. Some have suggested using SOAP (subjective, objective, assessment, and plan) notes to assist practitioners in identifying implicit biases in day-to-day interactions with patients [80]. Integrating the following questions into charts and notes can stimulate reflection about implicit bias globally and for each specific patient interaction: • Did I think about any socioeconomic and/or environ- mental 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 my implicit biases influence care for this patient? When reviewing the SOAP notes, providers can look for recurring themes of stereotypical perceptions, biased com- munication patterns, and/or types of treatment/interventions proposed and assess whether these themes could be influenced by biases related to race, ethnicity, age, gender, sexuality, or other social characteristics. Experts have also formulated questions for each of the three stages of reflection to help increase awareness when guiding nursing students through learning about implicit biases [114; 115]: • Awareness: Recall a patient who you considered chal- lenging, difficult, or uncomfortable to be around. • Critical analysis: Do I or did I have an automatic feeling or judgment about this person? Am I being reminded of someone? What is this person triggering in my background? • New perspective: How might I consciously intervene to mitigate the impact of this bias? What can I do differ- ently when similar thoughts, feelings, or emotions arise?
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