California Implicit Bias Training

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Health Equity is a rising area of focus in healthcare. This renewed attention is being given to ongoing data showcasing discrepancies and gaps in the accessibility, expanse, and quality of healthcare delivered across racial, gender, cultural, and other groups.

Yes, there are some differences in healthcare outcomes purely based on the differences between people of different genders or races. More and more evidence points to the vast majority of healthcare gaps stemming from individual and systemic biases.  

Policy change and restructuring is happening at an institutional level across the country, but this will only get us so far. In order for real change to occur and the gaps in healthcare to be closed, there must also be awareness and change on an individual level.

Implicit, or subconscious, bias has the potential to change the way healthcare professionals deliver care in subtle but meaningful ways and must be addressed to modernize healthcare and reach true equity.  

This California Implicit Bias training meets the “Implicit Bias” requirement needed for California nursing license renewal.

What is Implicit Bias?

So what is implicit bias and how is it affecting the way healthcare is delivered? Simply put, implicit bias is a subconscious attitude or opinion about a person or group of people that has the potential to influence the actions and decisions taken when providing care. This differs from explicit bias which is a conscious and controllable attitude (using racial slurs, making sexist comments, etc.).

Implicit bias is something that everyone has and may be largely unaware of how it is influencing their understanding of and actions towards others. The way we are raised, our unique life experiences, and an individual’s efforts to understand their own biases all affect the opinions and attitudes we have towards other people or groups (7). This California Implicit Bias training course will increase your awareness of implicit bias in your nursing practice.

Implicit bias can be applied to both positive or negative influences. For example, if a patient’s loved ones tells you they are a nurse, you may immediately feel more connected to them and go above and beyond the expected care as a “professional courtesy.” This doesn’t mean you dislike your other patients and their loved ones, just that you feel more at ease with a fellow healthcare professional which shapes your thoughts and behaviors in a positive manner.  

More often though, implicit biases have a negative connotation and can lead to care that is not as empathetic, holistic, or high quality as it should be.

Common examples of implicit bias in healthcare include:

• Thinking elderly patients have lower cognitive or physical abilities 
• Thinking women exaggerate their pain or have too many complaints 
• Assuming patients who state they are sexually active are heterosexual  
• Thinking Black patients delay seeking preventative or acute care because they are passive about their health 
• Assuming a chatty college student is asking for ADHD evaluation because she is lazy and wants medication to make things easier

On a larger, more institutional and societal level, the effects of bias create barriers such as:  

• Underrepresentation of minority races as providers: in 2018 56.2% of physicians were white, while only 5% were Black and 5.8% were Hispanic (2) 
• Crowded living conditions and food deserts for minority patients due to outdated zoning laws created during times of segregation (18). 
• Difficulty obtaining health insurance for minority or even LGBTQ clients, decreasing access to healthcare (3). 
• Lack of support and acceptance for LGBTQ people in the home, workplace, or school as well as lack of community resources leads to negative social and mental health outcomes. 
• Due to variations in the way disabilities are assessed, the reported prevalence of disabilities ranges from 12% to 30% of the population (17). 

Implications

Once you have an understanding of what implicit bias is, you may be wondering what it looks like on a larger scale and what it means in terms of healthcare discrepancies. More and more data stacks up each year with examples that span all types of diversity, from race to gender, age, disabilities, religion, sexual identification and orientation, and even Veteran status.

Examples of what subconscious biases in healthcare may look like include:   

• Medical training and textbooks are mostly commonly centered around white patients, even though many rashes and conditions may look very different in patients with darker skin or different hair textures. This can lead to missed or delayed diagnoses and treatment for patients of color (9).  
• A 2018 survey of LGBTQ youth revealed 80% reported that their provider assumed they were straight or did not ask (12). And in 2014, over half of gay men (56%) surveyed who had been to a doctor said they had never been recommended for HIV screening, despite the increased risk for the disease (10).  
• A 2010 study found that women were more verbose in their encounters with physicians and may not be able to fit all of their complaints into the designated appointment time, leading to a less accurate understanding of their symptoms by their doctor (4).  For centuries, any symptoms or behaviors that women displayed (largely related to mental health) that male doctors could not diagnose fell under the umbrella of “hysteria”, a condition that was not removed from the DSM until 1980 (22). 
• When treating elderly patients, providers may dismiss a treatable condition as part of aging, skip preventative screenings due to old age, or overtreat natural parts of aging as though they are a disease. Providers may be less patient, responsive, and empathetic to a patient’s concerns or even talk down to them or not explain things because they believe them to be cognitively impaired (22).  
• Racial minorities, particularly Black or Hispanic patients, are often thought to be less concerned or more neglectful of their health. These patients are also most often those living in poverty, which goes hand in hand with crowded living conditions and food deserts due to outdated zoning laws created during times of segregation. This means less access to nutritious foods, fresh air, or clean water which has overall negative effects on health (19). Minority patients are also still disproportionately uninsured, which leads to delayed or no care when necessary (3).  

Although these are only a few examples, there are obvious and substantial consequences of these biases; which is why it is vital that we address them in this California Implicit Bias training course.  

This has obvious negative connotations or repercussions at the time of care and can lead to client dissatisfaction or suboptimal treatment and missed preventative care. Over time the effects of implicit bias can add up and lead to even larger consequences.

Examples include:  

• A 2020 study found that Black individuals over age 56 experience a decline in memory, executive function, and global cognition at a rate much faster than their white peers, often as much as 4 years ahead in terms of cognitive decline. Data in this study attribute the difference to the cumulative effects of chronically high blood pressure more likely to be experienced and undertreated by Black Americans (16). 
• Lack of health insurance keeps many minority patients from seeking care at all. 25% of Hispanic people are uninsured and 14% of Black people, compared to just 8.5% of white people. This leads to a lack of preventative care and screenings, a lack of management of chronic conditions, delayed or no treatment for acute conditions, and later diagnosis and poorer outcomes of life-threatening conditions (3). 
• A 2010 study showed men and women over age 65 were about equally likely to have visits with a primary care provider, but women were less likely to receive preventative care such as flu vaccines (75.4%) and cholesterol screening (87.3%) compared to men (77.3% and 88.8% respectively) (4).  
• About 12.9% of school-aged boys are diagnosed and treated for ADHD, compared to 5.6% of girls, though the actual rate of girls with the disorder is believed to be much higher (5).  
• Teenagers and young adults who are part of the LGBTQ community are 4.5 times more likely to attempt suicide than straight, cis-gender peers (11).  

Impact of Historic Racism

In addition to discrepancies in insurance status, representation in medical textbooks, and representation among medical professionals, there is a long history of systemic racism that has created generational trauma for minority families, leading to mistrust in the healthcare system and poorer outcomes for those marginalized communities.  

Possibly one of the most infamous examples is the Tuskegee Syphilis Study. In 1932, this experiment tested 600 Black men, two-thirds of which had syphilis. The researchers collected blood and monitored the progression of symptoms in the men in exchange for free medical exams and meals. Informed consent was not collected from these participants were given no information about the study other than that they were being “treated for bad blood,” even though no treatment was actually administered. By 1943, syphilis was routinely and effectively treated with penicillin, however the men involved in the study were not offered treatment. Their progressively worsening symptoms continued to be monitored and studied until 1972 when it was deemed unethical. Once the study was stopped, participants were given reparations in the form of free medical benefits for the participants and their families. The last participant of the study lived until 2004 (6).  

The “father of modern gynecology,” Dr. J. Marion Sims, is another example steeped in a complicated and racially unethical past. Though he did groundbreaking work on curing many gynecological complications of childbirth, most notably vesicovaginal fistulas, he did so by practicing on unconsenting, unanesthetized, Black enslaved women. The majority of his work was done between 1845 and 1849 when slavery was legal and these women were likely unable to refuse treatment, sometimes undergoing 20-30 surgeries while positioned on all fours and not given anything for pain. Historically his work has been criticized because he achieved so much recognition and fame through an uneven power dynamic with women who have largely remained unknown and unrecognized for their contributions to medical advancement (23).  

Another example is the story of Henrietta Lacks, a young Black mother who died of cervical cancer in 1951. During her treatment, Dr. Gey, a prominent cancer researcher at that time, collected a sample of cells from her cervix. Up until this point, cells being utilized in Dr. Gey’s lab died after just a few weeks, and new cells needed to be collected from other patients. Henrietta Lacks’ cells were unique and groundbreaking in that they were thriving and multiplying in the lab, growing new cells (nearly double) every 24 hours. These highly prolific cells were nicknamed HeLa Cells and have been used for decades in the development of many medical breakthroughs, including studies involving viruses, toxins, hormones, and other treatments on cancer cells and even playing a prominent role in vaccine development. Henrietta Lacks never gave permission for these cells to be collected or studied, and her family was unaware of the existence of these cells or their prolific usage in medical research until 20 years after her death. Her family has now sought legal action to require recognition of Henrietta in studies that utilize her cells, as well as financial compensation from companies that profited off of her cells (15).

When considering all of the above scenarios, the common theme is a lack of informed consent for Black patients and the lack of recognition for their invaluable role in society’s advancement to modern medicine. It only makes sense that these stories, and the many others that exist, have left many Black patients mistrustful of modern medicine, medical professionals, or treatments offered to them. This mistrust may be heightened if the provider caring for them doesn’t look like them or seems dismissive or unknowledgeable about their unique concerns. The memory of these types of events has left a lasting impact on generations of Black families and it is important to remember that in order for medical professionals to provide empathetic and racially sensitive care. 

Exploring Areas of Bias

Culture

Cultural competence is a common buzzword used in healthcare training programs and information about various religions, ethnicities, beliefs, or practices is often integrated into medical training. Students and staff members are often reminded that the highest quality of care anticipates the unique cultural needs a client may have and aims to provide care that is holistic and respectful of cultural differences. An awareness of the potential variances in care, such as dietary needs, desire for prayer or clergy members, rituals around birth or death, beliefs surrounding and even refusal for certain types of treatments, are all certainly very important for the culturally sensitive healthcare professional to have (and the distinctions far too many for the scope of this course); however, there is also a fine line between being aware of cultural similarities and stereotyping.  Since this course is a required California Implicit Bias training, it is essential that this topic is covered. 

Clinicians should make sure to understand that people hold different identities, beliefs, and practices across racial, ethnic, and religious groups. Remember that just because someone looks a certain way or identifies with a certain group does not mean all people within that group are the same. Holding assumptions about clients of a particular race or religion, without getting to know the individual needs of your client, is a form of implicit bias and may cause your client to become uncomfortable or offended.  

Simply asking clients if they have any cultural, dietary, or spiritual needs throughout the course of their care is often the best way to learn their needs without making assumptions or stereotyping. Overall, it should be thought of as extending care beyond cultural competence and working on partnership and advocacy for your client’s unique needs. 

Maternal Health

One of the most strikingly obvious places that implicit bias has tainted the healthcare industry is in maternal health. Repeatedly, statistics show that Black women experience twice the infant mortality rate and nearly four times the maternal mortality rate of non-Hispanic white women during childbirth.  

Let those numbers sink in and realize that this is a crisis. Pregnancy and childbirth are natural processes, but do come with inherent risks for mother and baby; but in a modern society, women should feel comfortable and confident in their care, not scared they won’t be treated properly or even survive. Home births among Black women are on the rise as they seek to avoid the biases of the hospital setting and maintain control over their own experiences (21).  

The reasons for this disparity and Black women fearing for their lives when birthing in hospitals are many. This disparity exists regardless of socioeconomic class or education, indicating that a more insidious culprit, implicit bias, is hugely responsible (21).  In order for true change to come, this topic must be addressed in this California Implicit Bias training. A few notes that indicate the prevalence of implicit bias in healthcare throughout history are listed below:  

• False beliefs about biological differences between white and black women date back to slavery, including the belief that Black women have fewer nerve endings, thicker skin, and thicker bones and therefore do not feel pain as intensely.  
• These beliefs are obviously untrue, but subconscious bias towards those beliefs still exists as Black and Hispanic women statistically have their perceived pain rated lower by health care professionals and are offered appropriate pain management interventions less often than white peers.  
• Complaints from minority patients that may indicate red flags for conditions such as preeclampsia or hypertension are often downplayed or ignored by healthcare professionals.  
• Studies show healthcare professionals may believe minority patients are less capable of adhering to or understanding treatment plans and may explain their care in a condescending tone of voice not used with other patients.  
  • One in five Black and Hispanic women report poor treatment during pregnancy and childbirth by healthcare staff. 
  • These patients are less likely to feel respected or like a partner in their care and may be non-compliant with treatment recommendations due to feeling this way, however this just perpetuates the attitudes held by the healthcare providers (21).

Reproductive Rights

Branching off of maternal health is reproductive justice. Biases surrounding the reproductive decisions of women may negatively impact the care they receive when seeking care for contraception or during pregnancy. While some of these inequities may be more profound for women of color, women of all races can be and are affected by biases surrounding reproduction, which is why it is being covered in this California Implicit Bias training course.

Examples of ways implicit bias may affect care include:  

• Some healthcare professionals may believe there is a “right” time or way to become pregnant and feel pregnancy outside of those qualifiers is undesirable; this can stem from personal or religious beliefs. While healthcare staff are certainly entitled to hold these beliefs in their personal lives, if the resulting implicit biases are left unchecked, they can lead to attitudes and actions that are less compassionate when caring for their clients. Clients may feel shamed or judged during their experiences instead of having their needs addressed (8). Variables that may be perceived as unacceptable or less desirable include: 
  • Age during pregnancy. Clinicians may feel differently about pregnant clients who are very young (teenagers) or even those who are in their 40s or 50s (8).  
  • Marital status during pregnancy. Healthcare professionals may have beliefs that clients should be married when having children and may have a bias against unmarried or single clients (8).  
  • Number or spacing of pregnancies. Professionals may hold beliefs about how many pregnancies are acceptable or how far apart they should be and may hold judgment against clients with a large number of children or pregnancies occurring soon after childbirth.
  • Low-income and minority women are more likely to report being counseled to limit the number of children they have, as opposed to their white peers (15).  
• Method of conception. Some healthcare professionals may have personal beliefs about how children should be conceived and may have negative opinions about pregnancies resulting from fertility treatments such as IVF or surrogacy (8).  
• Personal or religious beliefs about contraception may also cause healthcare professionals to provide less than optimal care to clients seeking methods of birth control.  
• Providers may believe young or unmarried clients should not be given access to contraception because they do not believe they should be engaging in sexual activity (8). 
• Providers, or even some institutions such as Catholic hospitals, may withhold contraception from clients as they believe it to be immoral to prevent pregnancy. 
• Providers may push certain types or usage of contraception onto clients that they feel should limit the number of children they have, even if this does not align with the desires of the client. This includes the use of permanent contraception such as tubal ligation (15).  
• Providers may provide biased information about the types of contraception available, minimizing side effects or pushing for easier, more effective types of contraception (such as IUDs), despite a client’s questions, concerns, or contraindications (15).
• One study showed Black and Hispanic women felt pressured to accept a certain type of contraception based on effectiveness alone, with little concern for their individual needs or reproductive goals (15).  
• Personal or religious beliefs about pregnancy termination may impact the care provided and counsel given to pregnant clients who may wish to consider termination. Providers who disagree with abortion on a personal level may find it difficult to provide clear and unbiased information about all options available to pregnant clients or may have a judgmental or uncompassionate attitude when caring for clients who desire or have had an abortion (8).  

Case Study

Alexandria is a 22-year-old Hispanic woman who has always wanted a big family with 3-5 children. She met her current boyfriend in college when she was 19 and became pregnant shortly afterward. It was an uneventful pregnancy, and Alexandria had a vaginal delivery to a healthy baby girl at 39 weeks. When that child turned 2, Alexandria and her partner decided they would like to have another baby.

At 38 weeks gestation, Alexandria was at a prenatal appointment when her provider brought up her plans for contraception after the birth. The provider suggested an IUD and stated it could be placed immediately after birth, could be left in for 5 years, and would be 99% effective at preventing pregnancy. Alexandria stated she had an IUD when she was 17 and did not like some of the side effects, mostly abdominal cramping, and that she also might like to have another baby before the 5-year mark.

Her doctor stated “All birth control has side effects, and this one is the most effective. You are so young, do you really want 3 children by age 25 anyway?” 

Power Dynamics and Organizational Decision-Making

Power dynamics is one of the biggest factors perpetuating implicit bias in healthcare. The two are separate but very intertwined, and who is in a position of power often closely relates to the implicit biases that permeate the work culture and healthcare industry. People in positions of power have the ability to shape and influence the thoughts and attitudes of those below them on the hierarchy. This influence may be in relation to the goals, mission, and values of the facility and might help the team reach a common goal, but the influence can also be influenced by the leader’s own implicit biases and cause these subconscious attitudes to become widespread in work culture.

People in positions of power may have an unconscious preference for people with similar backgrounds, attitudes, or ideas to their own. This in turn can influence how work assignments, recognition, praise for work, compensation, or promotions are distributed and can lead to inequities that go largely unnoticed, or at least quietly tolerated, by the rest of the employees. Even if other workers recognize the inequities, they will often say nothing for fear of retaliation from the person in power.

A well-known example of this is the gender wage gap. When women began entering the workforce in increasingly larger numbers throughout the twentieth century, it was often with resistance and societal attitudes that women did not belong in the workplace and should be at home caring for children, cooking, and cleaning. Jobs that were available for women were often assistant-type work for men and came with less recognition and pay. Even when women did reach success in traditionally male roles, they were typically paid less than their male peers.

This may seem like an old-fashioned attitude that has corrected itself over time, but in 2023, the US Department of Labor reports that women still are only making an average of 83.7% of the salary paid to their male counterparts across all education levels and ages/years of experience (9). This disparity is even greater in Black and Hispanic women.

There are endless similar examples of how those in positions of power and with decision-making capabilities within a work culture have created disparities and inequities over time, particularly in healthcare. It doesn’t have to all be bad though, recognizing and understanding how power and decision-making intertwine with implicit bias also gives those in positions of power the ability to make changes towards equity or, even better, put a diverse group of people in power so implicit biases are challenged and evolve the work culture.

In healthcare, some of the examples of positions of power with the biggest impact include:

• Admissions personnel at healthcare programs such as nursing and medical schools
  • Determines who gets into these programs and what qualities are considered valuable in future doctors/nurses
• Hiring committees for faculty at healthcare programs such as nursing and medical schools
  • Determines who is educating future doctors and nurses and what representation of professionals in healthcare is presented to students
• Faculty at healthcare programs such as nursing and medical schools
  • Directly affects how information is taught to future doctors and nurses and may pass on their own biases in relation to patient care
• Hiring departments at hospitals and clinics
  • Determines who is able to work at a facility and shapes the diversity and work culture
• Department managers at hospitals and clinics
  • Directly impacts jobs assignments, teamwork attitudes, evaluation of job performance, and many other supervisory details
• Doctors, nurses, and other healthcare professionals
  • Have a power dynamic over their patients who are trusting them to make safe, informed, and altruistic choices for their health (10)

How to Measure and Reduce Implicit Biases in Healthcare

Assessing for Bias

In order for change to occur, there is a broad spectrum of transitions in individual thought and policy that must occur. Evaluating the presence, and the extent, of implicit bias is one of the first steps.  This California Implicit Bias training will cover both individual and institutional-level focuses. 

On the individual level, possible actions include:  

• Identifying and exploring one’s own implicit biases. Everyone has them and we all need to reflect upon them. This goes beyond basic cultural competence and includes a deeper understanding of how your own experiences or environment may differ from someone else and may have caused you to feel or believe a certain way.   
• Attending training or workshops provided by your job and completing exercises in self-reflection will help you better understand where your biases are and the extent to which they may be impacting your behavior or actions at work and in your personal life. 
• Reflecting on how one’s biases affect actions. Once you have recognized the internal opinions you hold, you can examine ways that those opinions may have been affecting your actions, behaviors, or attitudes toward others. Reflect on your care of patients at the end of each shift. Consider if you made assumptions about certain clients early on in their care. Think about ways those assumptions may have affected your interactions with the client. Think about if you cared for your clients in a way that you would want your own loved ones cared for.  
• If you have the time, volunteer at events or in places that will expose you to people who are different from you. Use the opportunity to learn more about others, their lived experiences, and identify how often your implicit biases may be affecting your view of others before you even get to know them.  

On an institutional level, the measurement of biases can be more streamlined and may utilize tools like surveys.  

• Monitoring patient data and assessing for any broad gaps in diagnoses, preventative care, and treatment rates, as well as health outcomes across racial, ethnic, gender, and other spectrums. Recognizing gaps or problem areas and assigning task forces to evaluate further and address the underlying issues.  
• Regularly poll clients and employees of healthcare facilities to determine who might be experiencing the effects of bias and when. 
• Require employee participation in implicit bias presentations or courses, allowing employees to self-identify areas where they may be biased.

Acting to Reduce Bias

Once the presence and extent of bias has been identified, individuals can make small, consistent changes to recognize and address those biases in order to become more self-aware and intentional in their actions. Some possible ways to address and reduce implicit bias on an individual level include:  

• Educating oneself and reframing biases. In order to change patterns of thinking and subsequent behaviors that may negatively impact others, you can work on broadening your views on various topics. This can be done through reading about the experiences of others, watching informational videos or documentaries, attending speaking engagements, and just listening to the experiences of others and gaining an understanding of how their lives might be different than yours.  
• Understanding and celebrating differences. Once you can learn to see others for their differences and consider how you can adapt your care to help them achieve the best outcomes for their wellbeing, you are able to provide truly equitable care to your clients. This includes understanding differences in experiences, perceptions, cultures, languages, and realities for people different from yourself, recognizing when disparities are occurring, and advocating for change and equity.  

When enough people have recognized and addressed their own implicit biases, advocacy can extend beyond the individual care of clients and reach the institutional level where change is more easily seen (though no more important than the small individual changes). One of the most effective ways to make institutional-level changes is through the representation of minority groups in positions of power and decision-making. Simply keeping structures as they are and dictating change without any evolution from leadership is not likely to be effective in the long term. Including minority professionals in positions of leadership or in decision-making panels have the most potential to make true and meaningful change for hospitals and healthcare facilities.

Examples of institutional-level changes include:  

• Medical schools will need to take a broader, more inclusive approach when admitting future doctors, incentivize minority students to choose careers in healthcare, and invest in their retention and success (11).  
• Properly training and integrating professionals like midwives and doulas into routine antenatal care and investing in practices like group visits and home births will give power back to minority women while still giving them safe choices during pregnancy (1).  
• Universal health insurance, basic housing regulations, access to grocery stores, and many other socio-political changes can also work towards closing the gaps in accessibility to quality healthcare and may vary by geographic location (3).  
• Community programs should be available to create safe spaces for LGBTQ people. Laws and school policies need to focus on how to prevent and react to bullying and violence against LGBTQ individuals (14). 
• Cultural competence training in medical professions needs to include LGBTQ issues and data collection regarding this population needs to increase and be recognized as a medical necessity (14). 
• Medical professionals must be trained in the history of inequality among women, particularly in regard to mental health to ensure proper, modern diagnostics are used. The differences in communication styles of men and women should be taught as well (23).  
• Medical facilities should emphasize respect for a client’s views on controversial topics such as pregnancy/birth, death, and acceptance or refusal of treatments even if it conflicts with a staff member’s own beliefs (16).  
• Healthcare facilities can adopt practices that are standardized regardless of age and include anti-ageism and geriatric-focused training, including training about elder abuse (21). 

Obviously, each geographic area will have differing demographics depending on the populations they serve. What works at one facility may not work at another. Hearing from the community is beneficial for keeping things individualized and allows facilities to gain perspective from the local groups they serve.  

• Town Hall style meetings, keeping hospital board members and employees local rather than outsourcing from travel companies (when possible), and encouraging community involvement from staff members are all great ways to keep a community-centered facility and keep the lines of communication open for clients who may be having a different experience than their neighbor.
  

There are many things that will need to be done in order for equitable, bias-free healthcare to become a norm nationwide. However, taking the time to learn from this California Implicit Bias training, apply it to current practices, and continue to learn about others and their respective beliefs and cultures is just the beginning.

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