Illinois Implicit Bias Training

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The following course content

Introduction   

Health equity is a rising area of focus in the healthcare field, as renewed attention is being given to ongoing data covering 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 biological differences between people of different genders or races, but more evidence points to the vast majority of healthcare gaps stemming from individual and systemic biases.  

Policy change and restructuring are happening at institutional levels across the country, but this will only get us so far. In order for real change to occur and the gaps in healthcare to close, 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 implicit bias training meets the “Implicit Bias Training for Healthcare Workers” requirement needed for Illinois 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 to some capacity, whether we are fully aware of it or not and it can influence our understanding of and actions towards others. The way we are raised, our unique life experiences, and individual efforts to understand our own biases all affect the opinions and attitudes we have towards other people or groups (6). 

Of course, this can be both a positive or a negative thing. For example, if a patient’s loved one tells you that 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 does not mean that you dislike your other patients or their loved ones, it just means that you feel more at ease in the presence of another healthcare professional and this shapes your thoughts and behaviors in a positive manner.  

However, this is a rare case. Oftentimes, 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% Hispanic (2). 
• Crowded living conditions and food deserts for minority patients due to outdated zoning laws created during times of segregation (15). 
• Difficulty obtaining health insurance for minority or LGBTQ clients, decreasing access to healthcare (3). 
• Lack of support and acceptance for LGBTQ populations in the home, workplace, or school as well as a lack of community resources can lead 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 general population (13). 

Implications

Once you have an understanding of what implicit bias in healthcare is, you may be wondering what it looks like on a larger scale and what it means in terms of healthcare discrepancies. In order to address ways that those in healthcare can identify, address, and overcome implicit biases later in this implicit bias training, we must first cover its implications and outcomes. Listed below are just a few examples of outcomes stemming from subconscious biases in healthcare:

• 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 (8).  
• A 2018 survey of LGBTQ youth revealed that 80% reported that their provider assumed they were straight or did not ask otherwise (11).  
• In 2014, a post-physician appointment survey showcased that over half of gay men (56%) respondents reported that they had never been recommended for HIV screening, despite their increased risk for contraction (9).  
• A 2010 study found that women were more verbose in their encounters with physicians and felt unable 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-III until 1980 (18).  
• When treating elderly patients, providers may dismiss a treatable condition as part of aging, skip preventative screenings due to old age, or over-treat natural parts of aging as though they are a disease. Providers may be less patient, responsive, and empathetic to a patient’s concerns because they believe them to be cognitively impaired (16).  

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 implicit bias training course.  

Below, are just a few more examples of what the long-term effects of what implicit biases in healthcare can lead to if both institutional and personal behaviors are not addressed:  

• A 2020 study found that Black individuals over the age of 56 experience decline in memory, executive function, and global cognition at a rate much faster than white individuals. Data in this study attributes this difference to the cumulative effects of chronic high blood pressure more likely to be experienced and under-treated for Black Americans (14). 
• Lack of health insurance keeps many minority patients from seeking care at all. 25% of Hispanic people, 14% of Black people 8.5% of white people are uninsured in the U.S. 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 a later diagnosis with poorer outcomes of life threatening conditions (3). 
• A 2010 study reported men and women over age 65 were 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 (10).  

Exploring Areas of Bias

Culture

Cultural competence is an essential topic to cover as healthcare professional. There are many training and informational programs that cover how various religions, ethnicities, or beliefs can be integrated into medical practices. Students and staff members are often reminded that the highest quality of care must also meet the cultural needs a client may have no matter if these beliefs or needs differ from the provider’s.  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 an implicit bias training, it is essential that this topic is covered. 

Clinicians should ensure that they 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 a client, is a form of implicit bias and may cause a 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 a client’s unique needs.  

Maternal Health

One of the more 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. Due to this severe prevalence, it is vital that we cover maternal health in this implicit bias training course.

Pregnancy and childbirth are natural processes, but they do come with inherent risks for both the 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 not 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 (17).  

A few examples that showcase the hesitance a Black woman might have with birthing in a hospital setting might include a lack of health insurance leading to poorer general health before pregnancy, a lack of prenatal care, or a lack of care in the weeks following pregnancy. However, the discrepancies still exist at an alarmingly high rate even when looking at minority women with advanced education and high income, indicating that a more insidious culprit, such as implicit bias, is hugely responsible (17). In order for true change to come, this topic must be addressed in this implicit bias training. A few notes that indicate the prevalence of implicit bias in healthcare throughout history are listed below:  

1. 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. This is an entirely false belief. Unfortunately, Black and Hispanic women statistically have their perceived pain rated lower by healthcare professionals and are offered appropriate pain management interventions less often than white peers.  
2. Complaints from minority patients that may indicate red flags for conditions such as preeclampsia or hypertension are often downplayed or ignored by healthcare professionals.  
3. 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. For example, 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 in treatment recommendations due to feeling this way, however, this just perpetuates the attitudes held by the healthcare providers (17).
   

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 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 (7). 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 (7).  
• Marital status during pregnancy. Healthcare professionals may have beliefs that clients should be married when having children and may have bias against unmarried or single clients (7).  
• 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 (12).  
• 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 (7).  

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 (7). 
• 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 (12).  
• Providers may provide biased information about 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 (12). One study showed Black and Hispanic women felt pressured to accept a certain type of contraception based on effectiveness alone, with little concern to their individual needs or reproductive goals (12).  

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 women or may have a judgmental or uncompassionate attitude when caring for clients who desire or have had an abortion (7).

Case Study

Alexandria is a 22 year old Hispanic woman who has always wanted a big family of 3-5 children. She met her current boyfriend in college when she was 19 and became pregnant shortly afterwards. 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?” 

Where Change is Needed

In order for change to occur, there is a broad spectrum of transitions in individual thought and policy that must occur. This implicit bias training will cover both individual and institutional level focuses. 

On the individual level, efforts must focus on:  

• 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 one’s own experiences or environment may differ from someone else, and how these experiences might have developed specific feelings.  
• Reflecting on how one’s biases affect actions. Once one has recognized their internal opinions, they can examine ways that those opinions might have been affecting their actions, behaviors, or attitudes toward others.  
• Educating oneself and re-framing biases. In order to change patterns of thinking and subsequent behaviors that may negatively impact others, one can work on broadening their views on various topics. This can be done through reading about the experiences of others, watching informational videos or documentaries, or listening to the experiences of others and gaining an understanding of how their lives might be different than another. 
  
• Not only understanding, but celebrating differences. Once one learns to see others for their differences, it becomes easier to consider how they can achieve the best care plan and outcomes for well-being. It creates a better, and more promising approach to providing equitable care. This includes understanding differences in experiences, perceptions, cultures, languages, and realities for people different from the provider, 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 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 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 on decision making panels has the most potential to make true and meaningful change for hospitals and healthcare facilities. Examples of institutional-level changes include:  

Medical school admission committees could adopt a more inclusive approach during the admission process. For example, paying more attention to the background and perspectives of their applicants and the circumstances/scenarios in which they came from as opposed to their involvement in extracurricular activities (or lack of) and former education. Incentivizing minority students to choose careers in healthcare as well as investing in their retention and success should become a priority in the admissions process (8). 

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 sociopolitical changes could 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 connection and acceptance. Laws and school policies can focus on how to prevent and react to bullying and violence against LGBTQ individuals (11). 

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 (11). 

Medical professionals must be trained in the history of inequality among women, particularly in regards to mental health, and proper, modern diagnostics must be used. The differences in communication styles of men and women should be taught as well (18).  

Medical facilities should emphasize respect of a client’s views on controversial topics such as pregnancy/birth, death, and acceptance or declining of treatments even if it conflicts with a staff members’ own beliefs (12).  

Healthcare facilities can adopt practices that are standardized regardless of age and include anti-ageism and geriatric focused training, including training about elder abuse (16). 

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 transparent and welcoming 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 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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