Implicit bias in nursing: Identifying and confronting the issue

Tiffany Montgomery |

As the United States—and hopefully, the nursing profession—becomes increasingly diverse, we must pay more attention to issues of diversity, equity, and inclusion (DEI) in both the classroom and the workplace. DEI terms are often used synonymously but have distinct definitions:

  • Diversity is the identification of differences in demographics such as age, gender, race, education level, class, and so on. It is also linked to differences in thoughts, beliefs, and attitudes. 
  • Equity is treatment which is fair and impartial. This is unlike equality, in which treatment is standardized, regardless of individual needs. 
  • Finally, inclusion is the thoughtful, intentional welcoming of all participants into the work or classroom environment. Inclusive environments are those in which key actors purposefully make everyone feel a part of the team.

DEI may serve as a starting point for acknowledging others’ differences; however, acknowledgment of differences does not always lead to the celebration or embracing of said differences. We must acknowledge our thoughts, attitudes, and beliefs related to our “other” colleagues that lead to personal biases that can serve as barriers to the goal of a more diverse profession—and ultimately, a more diverse healthcare system.

Defining and confronting implicit bias
A bias is a generalized preconceived notion about an individual or group. Racism and discrimination are the outcomes of overt biases. An implicit bias, on the other hand, is an unconscious or unintended bias. Micro- and macroaggressions are subtle, covert—implicit—biases. Here are several examples of implicit biases I’ve actually witnessed and the potential unintentional outcomes of these biases.

Types of
Implicit Bias

Example Scenarios*

Unintentional Outcomes

Financial Bias

Requiring a US $100 deposit before being seen by a primary care provider during a routine healthcare appointment, which will then be credited back to the patient if there is no insurance co-pay required.

Self-selection of middle-class or wealthy patients; causes low healthcare utilization in patients who are not at a certain income level.

This type of practice assumes all patients have disposable income for appointments and may discourage low-income patients from seeking routine healthcare. Furthermore, most insurance co-payments for routine visits are either covered by the Affordable Care Act or are much lower than US $100.

Screening Bias

Offering sexually transmitted disease (STD) screening to single women but not to married women.

Under-reporting of actual STD prevalence, in place of reporting STD diagnoses; over-reporting of STD diagnoses among single (most likely minority) women.

This practice assumes that single women are more likely to engage in high-risk sexual behavior than married women. It may also contribute to the negative perception of single/minority women’s sexual health.

Treatment Bias

Refusing to medicate patients in pain because of the belief that they are drug-seeking.

Devaluing patients’ right to healthcare treatment and their subjective data, in favor of objective data and potentially anecdotal evidence (or more likely, a meritless opinion).

This practice disenfranchises minority patients and others who are regularly undertreated by healthcare providers.

Identifying bias through the IAT
We can subjectively identify our personal biases through introspection and reflection. While this has value, it may be more effective to objectively identify our biases. One way to do this is by utilizing tools like the Harvard Implicit Association Tests (IATs). The IATs cover a range of topics including race, gender, and age bias. By taking the IAT, nurses can become aware of their own perceptions and can work to increase their cultural awareness and cultural sensitivity when working with diverse populations.

During my fall 2018 introduction to nursing class, I decided to tackle the issue of diversity in nursing. I challenged my freshmen students to:

  1. Acknowledge the need for increased diversity in nursing
  2. Identify their personal biases related to age, gender, and race by taking several IATs
  3. Develop solutions to help increase diversity in nursing education and the nursing profession

Some of the reflections they submitted were very introspective. I was encouraged by their commitment to the assignments and class discussions. One reflection, though, really tugged at my heartstrings. As I was grading Grace’s paper, I held back tears and yelled out, “She gets it!” Here’s a portion of her reflection. I hope it gives everyone something to think about.

“I am a White woman growing up in a middle-class suburban family, attending a private university. I have never experienced discrimination because of my family’s economic status, the color of my skin, and although I can sympathize with my fellow women who fell victim to sexism, I am fortunate enough to be able to say I can’t specifically relate. My innocence and sense of normalcy have continued through life, existing uninterrupted. And although I would never describe myself as racist, sexist, or ageist, I am subconsciously and unavoidably a product of my sheltered environment.

I fully consider myself to be a feminist. Looking back on women’s history, I swell with pride at the leaps and bounds we have made towards equality. Although at times I fear for the progression of feminist America, I am excited to be a part of the long-fought battle not only for gender issues, but also those of race and equality. Yet, my IAT results suggested I have a moderate association between males in high career positions and women in family and home positions, as well as a moderate preference for White people over Black people and young people rather than older people. I was baffled by this outcome. How am I a victim to the very thing I preach against?

After some thinking, I realized it was almost impossible for me to receive results any different. The school district in which I grew up was predominantly White, I hung around people who shared my age and background, and my family reinforced stereotypical gender norms. David Rock, founder and CEO of NeuroLeadership Group, wrote in a Psychology Today article that, “Your brain craves certainty and avoids uncertainty like its pain...Like an addiction to anything, when the craving for certainty is met, there is a sensation of reward”. Although I did not like my IAT results, I cannot argue with the science supporting them.

I am lucky for the ability to recognize the privilege that I have. It is time for people to stop with the pleas of ignorance in the nationwide discussion of inequality. Starting nursing school has given me an entirely new perspective. I hope through the exposure of higher education and people from diverse backgrounds I can learn the stories of those who had a life much different than my own. I plan on taking the information that the IAT has given me and moving forward with it. Continuing with knowledge, growth, and curiosity of those around me, I am optimistic that my natural inclinations will one day mirror the well-rounded, tolerant person I aspire to be.

We can—and must—do more
The nursing profession has been a staple in the support of women’s education and work rights. While we acknowledge and celebrate the strides we have made for women, we also need to acknowledge the lack of strides made for young people, men, and people of color. We need to look at our individual beliefs about our minority colleagues—be they age, gender, or race-related. We must be sure we are not contributing to any barriers that prevent increased diversity in our profession. And, we must hold firm to our commitment, through the reciting of the Nightingale Pledge, to “do all in [our] power to maintain and elevate the standard of [our] profession, and... dedicate [ourselves] to devoted service to human welfare.”


Tiffany Montgomery, PhD, RNC-OB, C-EFM, is a Postdoctoral Research Fellow at Drexel University in Philadelphia, Pennsylvania, USA and a member of Sigma’s Nu Eta Chapter at Drexel University. 

Grace Murphy is a junior nursing student at Widener University in Chester, Pennsylvania, USA.

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  • inclusion
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