Recognizing Implicit Bias and Its Effects on Nursing Care

Course Content

Author: Mallory Antico

Contact hours: 1 hour.

Learning Objectives

  • Identify different types of biases.
  • Describe populations who are most at risk for experiencing bias.
  • Discuss the relationship between bias and health outcomes.
  • Describe how to assess one’s own biases.
  • Explain how to mitigate the effects of biases in healthcare.


Bias is when a perception of something or someone is unjustified, either more positively or negatively than it actually is (Gopal et al., 2021). Various biases exist in healthcare that contribute to health disparities in certain patient populations at the individual, organizational, and systems levels, and in order to ensure better health outcomes, healthcare workers must recognize bias and intervene to address it (Sabin, 2022). While there are no debiasing strategies that have shown long-term effectiveness it is accepted that bias recognition, bias management strategies, and diversity, equity, inclusion, and accessibility (DEIA) initiatives are important to decrease bias and advance health equity (Sabin, 2022; Gopal et al., 2021). In Table 1, there is a list of important terminology for the reader to understand prior to moving forward related to DEIA. Since nurses spend a significant amount of time with patients and interact with many members of the healthcare team, they are poised to recognize biases that impact patient care and use strategies to address them.

Table 1. Important DEIA Terminology and Definitions (SAMHSA, 2023)

A set of characteristics that define an individual or group of individuals as belonging to a specific social group. How race is assigned or identified varies by the context of location, time, and cultural factors.
Ethnicity A social group that shares a common culture and language.
Intersectionality The multifaceted interconnecting of different social identities results in distinctive experiences. The term is often used to describe individuals who identify with multiple marginalized groups and thus may encounter compounded discrimination.
Implicit Bias Automatic, unconscious beliefs and attitudes that a person holds, often unknowingly, that may or may not be consistent with their values and beliefs and influence actions and decision-making.
Explicit Bias Conscious beliefs and attitudes that a person knowingly holds that are unjustified.
Stereotyping A commonly held oversimplified belief about a group of people. Many stereotypes are rooted in prejudice.
Microaggressions Intentional or unintentional insults or slights are directed at individuals who are part of a marginalized group that occurs in everyday life.
Prejudice An unfounded disparaging belief about another individual or group.
Racism A complicated system of beliefs that oppress people of color and benefit the dominant group.
Equality All individuals have exactly the same access to resources.
Equity Each individual has access to the resources that they need, recognizing that needs differ and some need more resources than others.

How Does Bias Work?

Decision-making is theorized to have two general types: type one being fast and unconscious processes that allow for rapid decision-making and type two which are slow and deliberate, requiring cognitive resources. Type one has a higher risk of errors and is the more frequent type of decision-making. Miscalculations that can occur with type one decision-making can add up when multiple occur consecutively one after the other to make big changes in outcomes. It is thought that bias develops in the type one decision-making process based on lived experiences early in life (Gopal et al., 2021).

Individuals can have consciously held beliefs while also holding attitudes and stereotypes that are different or even contradictory (Sabin, 2022; Narayan, 2019).). Implicit bias is more likely to appear in certain conditions, like when an individual is tired, has a lot on their mind, or is under stress: all common scenarios encountered in health care (Alspach, 2018; Vela et al., 2022; Narayan, 2019). Individual biases uphold systems and processes that are discriminatory and unfair (Sabin, 2022).

Types of Biases

Implicit vs. Explicit Biases

Explicit bias is when there are conscious preconceived ideas about a group of people. Implicit bias is subconscious, usually automatic ideas about a group of people in which the person is unaware the thoughts are occurring. These thoughts may even contradict a person’s stated values. Both types of biases can impact decision-making and actions (Arnold & Dhingra, 2023).

Individual, Organizational, and Systemic Biases

Individual and organizational biases occur within a larger cultural and socioeconomic construct (Sabin, 2022). The relationship between systemic and individual biases is complex and reciprocal. Systemic and structural bias is upheld by the bias of individuals and organizations. At the same time, systemic and structural bias reinforces the bias of individuals and organizations. There are many ways that bias shows up in healthcare structures at the systems level. In addition to health care, structural inequities in other sectors impact health (see Table 2) (Vela et al., 2022).

Table 2. Structural Inequities that Impact Health (Vela et al., 2022)

Poor access to high-quality education
Violence related to race, gender, ethnicity, or sexuality
Crowded housing and housing insecurity
Access to nutrient-dense food
Environmental toxins
Working conditions and employment
Limited access to green spaces and playgrounds
Intergenerational trauma
Justice system involvement

Bias in the health legislative process

The bias of policy-makers influences legislation and implementation of laws, which contributes to systemic discriminatory practices. Marginalized groups often have less access to care in their communities such as testing locations, vaccine distribution, and healthcare facilities and more environmental stressors and health policy play an enormous role in mitigating these factors (Vela et al., 2022).

Bias in the profession

There is gender bias within the healthcare profession. People often assume male-presenting staff members are doctors and female-presenting staff members are nurses even when their identities are clear. Men are more likely to be introduced by their titles compared to women. Bias related to skin color is also pervasive. Racialized minority healthcare workers report experiencing racism from other staff members. They also experience difficulty reporting experiences of racism and a lack of support from management. Patients may express overtly racist or prejudiced ideologies and microaggressions. Staff members with darker skin are more often mistaken for support staff roles instead of professional roles compared to their light-skinned counterparts (Gopal et al., 2021). Bias often shows up in hiring, compensation, and promotion practices within healthcare organizations (Sabin, 2022).

Bias in research

A fundamental principle of conducting scientific research is to minimize possible biases in literature selection and measurement of data, yet research is undeniably shaped by the contextual biases of the settings in which it is carried out. Grant funding and publication opportunities may not be equal among underrepresented groups (Gopal et al., 2021).

Bias in education

Higher education experiences biases in their systems to include health professions programs (Vela et al., 2022). Systemic bias can lead to limitations in diversity in the healthcare workforce (Sabin, 2022) yet representation is critically important to addressing health disparities (Vela et al., 2022). Trainees in health professions report experiencing microaggressions, racism, and significant stress. Teaching and learning health concepts are often presented through the lens of the White experience, for example when learning about different skin conditions, there are limited pictures of what the condition looks like in a darker skin tone. Race is considered a risk factor for many diseases but it is seldom thought of through the broader context of racism as a social determinant of health. Race-based algorithms are still used in diagnosis, such as the calculation of the glomerular filtration rate and varying antihypertensive therapy based on race (Vela et al., 2022).

Impact of Bias on Health Disparities

Health disparities are poorer health outcomes in minority populations. Health disparities are heavily influenced by social determinants of health, but the bias that affects these groups can also have serious effects on care quality (Narayan, 2019). Healthcare professionals appear to have a similar level of bias as the general population (Alspach, 2018). Patient-nurse interactions can be shaped by bias, showing up in verbal and non-verbal communication and impacting the effectiveness of the interaction. Implicit bias can lead to adverse outcomes, including inadequate assessments, erroneous diagnosis and treatment decisions, decreased involvement in the patient’s care, and inappropriate follow-up (Narayan, 2019). Implicit bias may be associated with increased morbidity and mortality and higher rates of complications (Alspach, 2018). Patients may be less likely to adhere to treatment plans and are more likely to delay care if they feel that their providers are biased (Vela et al., 2022).

Case Study

Maria, an experienced nurse working in a busy urban hospital, was assigned to care for Sarah, a 40-year-old Black American woman (assigned at birth) who had been admitted with severe abdominal pain. Sarah is 34 weeks pregnant with her second child and she worries that she is going into labor early.

Race and Ethnicity

Many studies of implicit bias in healthcare professionals demonstrate a preference for White patients over every other racial and ethnic group even when other characteristics (like socioeconomic status for example) have been controlled. Racial and ethnic groups are affected by and respond to bias in unique ways (Vela et al., 2022).

Black Americans

In the United States, Black patients consistently report experiences of covert and overt racism in a number of studies (Hamed, et al., 2022). They rate interactions with clinicians worse than any other racial or ethnic group which can foster mistrust in the healthcare system and result in delaying or seeking medical care (Sabin, 2022). Black patients report a better experience when they are cared for by healthcare workers of the same race (Hamed, et al., 2022).

Not only do they self-report substandard care, but Black patients are objectively undertreated for pain, have the worst maternal and infant outcomes, and are viewed as less medically adherent than White patients by healthcare workers (Sabin, 2022). Despite having the highest rate of stroke they are the least likely to receive anticoagulation and they are less likely to receive HIV prophylaxis (Hamed, et al., 2022). Some healthcare providers still believe untrue beliefs about biological differences between Black and White bodies, including that Black patients have fewer nerve endings and experience pain differently. These beliefs result in an inaccurate pain assessment and ultimately undertreatment of pain (Saluja & Bryant, 2021).

Case Study Continued.

Maria found herself annoyed with Sarah’s persistent complaints of pain. “She’s overreacting,” Maria thought to herself. “Her physical exam looks fine, she’s probably just having Braxton-Hicks contractions,” she tells the provider. Maria initially attributed Sarah's pain to normal Braxton-Hicks contractions, assuming that she might be exaggerating her symptoms. This implicit bias resulted in a delayed diagnosis, as Maria did not prioritize the necessary diagnostic tests promptly.

Asian Americans

There is a long history of discrimination against Asian Americans and these biases can appear in the healthcare setting. Asian Americans’ experience of bias in healthcare is under-researched and seldom appears in the literature. Given that the term broadly covers so many different ethnic groups from a large geographical range, certain disparities may be hard to identify. There is intersectionality between Asian Americans and other groups like older adults, and immigrants, and English as an additional language that must be considered. Further research is critical to a more in-depth understanding of how Asian Americans experience healthcare (Muramatsu & Chin, 2022).

Indigenous Americans

For centuries, Indigenous Americans have experienced worse outcomes than White Americans. They have experienced the trauma of forced migration, genocide, and discrimination. Their experience of bias in healthcare has largely been understudied despite the existence of known disparities, particularly suicide risk, mortality, drug and alcohol abuse, and depression. Available data suggests Indigenous Americans report experiencing discrimination when seeking healthcare and may avoid seeking care (Findling et al., 2019).

Hispanic Americans

Bias against Hispanic Americans occurs in healthcare systems, contributing to disparities. They have worse healthcare access compared to White Americans and are more likely to rate their health as fair or poor compared to White and Black Americans. Like Asian Americans, Hispanic American discrimination is intersectional with immigration and language proficiency (Chapman et al., 2018). Hispanic women (assigned at birth) report less trust in their healthcare providers than their non-Hispanic White counterparts (Siden, et al., 2022).

Women (assigned at birth)

Women experience bias in medicine in many ways including delayed diagnoses, inadequate symptom management, avoidance of medical care, and mortality. Women often experience disbelief when reporting symptoms or concerns. They are more likely to have their pain attributed to a mental health condition compared to men and women in pain are often described as emotional versus men who are described as brave or stoic. In the past, clinical research on health conditions focused on men due to the belief that menstrual cycles and pregnancy created a challenge in study implementation. As a result, important biological differences were neglected (Villines, 2021).

Maternal and infant mortality rates are highest in Black, Hispanic, and Indigenous Americans. They also have the highest rates of preterm birth, low birth weight, and receiving late or no prenatal care. These disparities point to many years of research showing that structural racism, which is the collective effectsof societies that uphold discriminatory practices, is a large contributor to the problem and individual bias upholds these unfair systems (Saluja & Bryant, 2021).

Black and Hispanic pregnant people who deliver their babies in hospitals report a higher rate of mistreatment compared to White pregnant people. A common theme is the patient feeling like their legitimate concerns are dismissed. As a result, Black and Hispanic pregnant people are increasingly reluctant to seek care, with some opting to give birth in the home or birthing center settings and others avoiding prenatal visits (Saluja & Bryant, 2021).

The disparities in maternal and infant morbidity and mortality in Black patients are particularly high. Black women (Assigned at birth) experienced 40.8 deaths per 100,000 births compared to just 12.7 for White women and mortality in Black infants is double that of White infants. A lack of reproductive health services, especially for those already in at-risk groups, may continue to worsen maternal outcomes (Saluja & Bryant, 2021). Black patients in particular have less access to other reproductive health services such as contraceptives and HIV treatment (Sutton, et al., 2020).

Case Study Continued

Meanwhile, Sarah can tell Maria is not taking her pain seriously. This is her second baby, she knows these aren’t Braxton-Hicks contractions. She is scared that she and her baby aren’t receiving the care they need, but is also afraid that if she speaks up, she will be perceived as “the difficult patient.”

Sexual and Gender Minority (SGM) Individuals

The term sexual and gender minority individuals includes gender minorities such as transgender, gender non-conforming, gender fluid, genderqueer, and nonbinary individuals and sexual minority individuals who are gay, lesbian, bisexual, asexual, or queer. Much of the literature discusses these identities together, but while the groups share similarities in regard to their experience of bias, they are not a monolith (Arnold & Dhingra, 2023). For the purpose of this article, SGM individuals will be discussed as a group but readers should apply this knowledge through the lens of each individual patient’s needs.

Healthcare in America has a long history of stigmatizing SGM individuals including attributing these identities in the Diagnosis and Statistical Manual (DSM) as a mental disorder. Healthcare embraced the idea that anything aside from heterosexuality and cisgender was a condition in need of correcting, an idea that still persists to this day. Another significant blow from the healthcare industry was during the AIDS epidemic when it was only after activism that significant efforts to fight the disease ramped up (Arnold & Dhingra, 2023).

Despite sociopolitical gains for the community, prejudiced views about SGM individuals still permeate society and health care. Those who are SGM individuals and identify with one or more other marginalized groups face compounded discrimination that is often overlooked in the literature. It is not surprising that SGM individuals often mistrust the healthcare profession which may lead to delays in seeking care. They experience increased morbidity and mortality and poorer outcomes than cisgender and heterosexual individuals (Arnold & Dhingra, 2023)

People with Disabilities (PWD)

PWDs are affected by healthcare worker bias, access to care, and adverse social structures that influence health. Often in healthcare, disability is viewed as an individualized problem that there is a need to overcome and the environmental, social, and political barriers that impact the lives of PWD go unaddressed. PWDs are often incorrectly viewed as having a lower quality of life or worse overall health because of their disability. People with physical disabilities are sometimes treated as if they also have cognitive disabilities and those with chronic conditions that can’t be seen are often treated if they don’t have a disability at all (VanPuymbrouck, Friedman, & Feldner, 2020).

Case Study Continued

Sarah rings the call button again. “My pain isn’t getting better and I’ve been waiting awhile. Is there something we can do?” she says to Maria. “No.” Maria responds. The doctor is busy with patients who are more sick than you are. They will be back just as soon as they can.” “When I stand up I think I might be losing a little fluid,” Sarah reports as she shows a tiny wet spot on her hospital gown. Maria replies, “Well, you are carrying around a lot of weight. It’s normal to have a little bladder leakage at this stage.” Sarah thinks to herself, “is she relating this to my obesity right now? Clearly, there’s more than that going on here.” Maria’s bias contributes to even more delay in diagnosis.


There is little literature about religious affiliation and implicit bias in healthcare. Very few national surveys collect data on religion so it is difficult to link them with health outcomes. Given that religion and spirituality impact patient care, it is an area of research that should be explored more (Porter, Lovely, & Phelan, 2021).

National Origin

National origin includes a variety of individual identities in addition to one’s country where they were born. There are immigrants who come to America from elsewhere for opportunities or to be with family, refugees who leave their homes because they face danger, and there are individuals who do not speak English as their first language or at all. Further, people who come to the United States may or may not be documented. Immigrants often face intersectional identities that also face bias such as religion or skin color. Immigrants often face difficulty accessing care. Those who are undocumented may fear being reported and therefore avoid medical care. Others grapple with the complexity of the healthcare system here. Those who are not fluent in English may experience miscommunications with healthcare workers. This results in feelings of frustration, powerlessness, and shame (Esses, 2021).

Recognizing Implicit Bias


Self-reflection is an expanded awareness of an individual’s bias. There are several ways to learn self-reflection as it relates to implicit bias, including question prompts, reading literature on the subject of bias and health disparities, role-modeling, or taking a class (Alspach, 2018; Sabin, 2022). Related to self-reflection, mindfulness interventions can be used to foster empathy and compassion by observing thoughts, feelings, and assumptions and centering one’s values. Mindfulness can avert the triggering of automatic negative thoughts, which in the case of biases, tend to be harmful stereotypes that can impact care (Narayan, 2019).

Nurses can also learn more about their biases by examining their gut feelings in practice. When caring for a patient, they can ask themselves, “Am I anticipating any discomfort, anxiety, or challenges with this interaction?” These gut feelings may be a warning sign of implicit bias. The nurse can reflect on how these feelings might impact their actions, the quality of the relationship, or care delivery which gives them an element of control over the effects of bias (Narayan, 2019).

Implicit Association Test (IAT)

The most frequently cited measure of implicit bias in the literature is the IAT (Gopal et al., 2021) which was created as a part of Project Implicit. Now a 501(c)(3) non-profit organization and international collaborative of researchers, Project Implicit was started by three scientists from different universities to educate the public about bias. The IAT is a series of online tests that have different population foci which can be found in table 3. The test measures associations between these concepts, a sense of them being “good” or “bad” and their association with stereotypes. Test-takers are instructed to select choices quickly, which tests their type one decision-making processes and ultimately focuses on an individual’s unconscious and implicit bias. The data are collected and used for research. (Project Implicit, 2023).

It should be noted that the IAT has limitations. First, it only focuses on the implicit biases of an individual, not on systems and processes, which significantly contribute to disparities. It cannot be used as a tool to diagnose racism or prejudice. The IAT should be used as a tool for individuals to learn and reflect on possible biases and the impact they may have on decision-making (Gopal et al., 2021). Some of the IATs did not have good test-retest reliability and it does not measure behaviors (Vela et al., 2022).

Table 3. Types of Project Implicit IATs (Project Implicit, 2023).

Weapons Association between weapons or harmless objects and race
Transgender Positive or negative association between transgender or cisgender people
Disability Positive or negative association between abled and disabled people
Gender-Career Association between different career and family roles and gender
Skin Tone Positive or negative association between dark and light skin tones
Arab-Muslim Stereotypes of Arab or Muslim individuals
Asian American Stereotypes of Asian Americans
Race Positive or negative association with race
Native Stereotypes of Indigenous Americans
Gender Science Association between science roles and gender
Religion Positive or negative association between different religions
Presidents Preference for presidents
Sexuality Positive or negative association between heterosexual, homosexual, and bisexual individuals
Age Positive or negative association between young and old people
Weight Positive or negative association between different-sized bodies
Hispanic American Stereotypes of Hispanic Americans

Normalizing bias

Greater awareness of bias often prompts motivation for change, however, that can be thwarted in those who are defensive or in a state of denial about their biases. In order to combat bias, there must be a non-threatening, safe environment for learning. It should be emphasized that bias and stereotyping are a normal part of the human experience, likely a protective mechanism to keep ourselves safe. If a course about bias uses discussion, participants should be allowed to keep their reflections private unless they willingly wish to share (Alspach, 2018).

Case Study Continued

The charge nurse, Raya, overhears the interaction. She gently approaches Maria and says, “hey it sounds like your patient is worried in there. Do you need any help?” “No,” Maria says with a smile, “she’s just an anxious new mom. If she keeps being so pushy I’ll be worried she’s just here for the pain medicine.”

Strategies To Minimize Implicit Bias


Controlling Bias

There are several strategies that can be used by an individual on an ongoing basis to manage responses to biased thinking. Clinicians should use emotional regulation strategies during patient encounters to control their thoughts and actions. Emotional regulation strategies may include acceptance of emotions, reframing situations, identifying and reducing triggers, positive self-talk, and sometimes therapy (Narayan, 2019).

Habit replacement strategies that are used to combat other negative behaviors can also be used for bias. The first step is to recognize that implicit bias has detrimental effects. Then a commitment must be made to change the thoughts and behaviors. Next, the tools outlined in this article can be used to mitigate bias and these new skills that work for the individual should be practiced repeatedly until the new habit is having less bias (Narayan, 2019).

Perspective-taking is an empathetic strategy that allows a person to walk in another’s shoes so that they can practice seeing situations from another perspective. Stereotype replacement is when a person learns to recognize stereotyping and instead notices the unique characteristics of an individual. One may also counter-stereotype by consciously noticing when people have the opposite traits of a common stereotype (Alspach, 2018; Narayan, 2019). In order for these strategies to work, one must have regular exposure to social groups that differ from their own, so seeking opportunities to diversify social circles is necessary (Alspach, 2018).

Skill-Building Exercises

Another strategy is to teach nurses how implicit and explicit bias appears in practice and what to do if they witness bias impacting patient care (Alspach, 2018). Before responding to bias, one must consider the potential risks. Consequences of responding directly to bias have different consequences for underrepresented individuals versus those who belong to the majority group. One should consider how choosing to respond or not might impact safety and relationships. Table 4 outlines various statements that can be practiced so that individuals know exactly how to respond to microaggressions and bias (Sue et al., 2019)

Table 4. How to respond to biases (Sue et al., 2019).

Strategy Examples
Restate what was said “I think I heard you saying _______, is that correct?”
Ask for clarification “Could you tell me more about what you mean by that?”
“How did you come to that conclusion?”
Acknowledge underlying feelings “It sounds like you are feeling ________”
“I can understand you feel ______ when you feel disrespected.”
Separate intent from impact “It may not have been your intention, but when you say/do _______ it can be hurtful because ________. Consider trying _______ instead.”
Share your own process “I noticed that you ___________. I used to do that too but then I learned _____________.”
Express your feelings “When you __________ I felt __________. In the future, it would help if __________.”
Challenging stereotypes “Actually, in my experience _________.”
“That’s a common stereotype, but I have learned ___________.”
“Another way to look at it is ____________.”
Appeal to values and principles “I know you really care about _____. Doing/saying _______ really undermines those intentions.”
Promote empathy “How would you feel if someone said that about __________?”
“How do you think they feel when you ____________?”
Tell them they’re too good to say things like that “Come on. You’re too smart to say something so offensive.”
Pretend you don’t understand “I don’t get it.”
“Why is that funny?”
Identify what they have in common “You actually have a lot in common. Did you know they also _________?”
Remind them of policies. “That behavior violates the code of conduct and can get you in trouble.”


Raya responds, “oh, how did you come to that conclusion?” Maria says, “Well, you know, she just keeps calling me saying she’s in pain and asking if there is something we can do. She just has an attitude when she talks to me.” “Another way to look at it,” Raya replies, “is that she is just a worried mom who doesn’t fully trust that the healthcare system will take good care of her. How would you feel if statistically, you have the worst health outcomes in pregnancy care? I bet you’d persist too if you didn’t feel heard.” “Maybe you’re right,” Maria says as she sees the call button go on for Sarah’s room again. “Well, I better go see what she needs.” When Maria went into the room, she found Sarah slumped over in the bed.

Committing to the Reduction in Health Disparities

Healthcare workers are typically motivated by improving patient care quality and reducing disparities. It is helpful to introduce the concept of implicit bias by starting with a shared commitment to improving the care of all. Partnership-building is another strategy that can control bias by involving patients as partners in achieving health goals Approaching interactions between healthcare workers and patients as partnerships instead of a hierarchy where the healthcare workers are the “experts” helps to mitigate some of the impacts of bias (Alspach, 2018; Narayan, 2019). Individuation is when nurses purposefully seek to view people as individuals instead of seeing them as members of a stigmatized group. This strategy can improve the nurse-patient relationship and facilitate culturally competent care (Narayan, 2019).

Ways to identify bias and mitigate its harms should be incorporated into educating nurses and other healthcare staff and evidence-based standardization of practices. It is also important for medical ethics to be included in the curricula of health professions training (Vela et al., 2022). Training should include identifying stigmatizing and negative language directed at patients or in their medical records and how to avoid them (Sabin, 2022).


Maria gasped as she assessed Sarah and looked at fetal monitoring reading. Later, Maria learned that Sarah had experienced a placental abruption. She became hypotensive and passed out due to the bleeding, and eventually had an emergency cesarean section. Sarah survived, but her baby had complications and required a lengthy hospital stay.


Organizational biases require a comprehensive and ongoing DEIA strategy to mitigate the negative effects. Healthcare organizations in the United States have varying degrees in which DEIA has been incorporated into practice. DEIA must be deeply embedded into the organization’s core values and be considered in every facet of operations. Data should be continuously collected and evaluated to monitor performance and progress. Some organizations have created a system of reporting bias that is similar to an incident reporting system and they investigate and address the incident and then transparently report results (Sabin, 2022). Existing quality management procedures can be utilized in a similar manner to evaluate for bias (Alspach, 2018).

Efforts to ensure the composition of the workforce in health professions and education is an important factor in advancing health equity. This takes an intentional effort when it comes to recruitment, hiring practices, compensation, promotions, and program funding in the professional setting and recruitment, scholarship awarding, and admissions procedures for students. When the healthcare workforce is reflective of the wider community, that shared lived experience significantly impacts the nurse-to-patient relationship (Vela et al., 2022).

Ongoing education is crucial in teaching implicit bias. There are several ways that organizations can work to counteract implicit bias in addition to the annual training that is typically used. Similar to grand rounds or morbidity and mortality reports, patient cases can be presented when implicit bias impacts a patient’s outcome (Alspach, 2018). Using journal articles about implicit bias in Journal Club sessions is a similar way to share information about bias.

Education and hiring practices aren’t the only aspects of organizational response to implicit bias. Policies and procedures are often full of bias. Organizations must reduce bias in policies and procedures that may disadvantage some groups and add policies that make the environment less biased, such as consequences for discriminatory behavior (Payne & Hannay, 2021).


The facility where Sarah sought care had only a superficial commitment to health equity. While they had brief staff education about implicit and systemic biases, they did not have ongoing and effective education nor did they fully implement the information into every level of practice

Addressing individual and organizational bias is important, however, addressing the systemic biases in the healthcare system and society as a whole is crucial in advancing health equity. Nurses are skilled in advocacy for patients and can use these skills in advocacy for systemic change. Political advocacy that protects the rights of underserved and underrepresented groups is an important way nurses can get involved in facilitating change in their own social circles and communities (Payne & Hannay, 2021).

Systematic Bias

Addressing individual and organizational bias is important, however, addressing the systemic biases in the healthcare system and society as a whole is crucial in advancing health equity. Nurses are skilled in advocacy for patients and can use these skills in advocacy for systemic change. Political advocacy that protects the rights of underserved and underrepresented groups is an important way nurses can get involved in facilitating change in their own social circles and communities (Payne & Hannay, 2021).


When Sarah recovered, she became an advocate for health equity and founded a non-profit in her baby’s name to support programs that could prevent the scenario from happening to someone else. Not only does she and her organization work with individual facilities, but they also support legislation that protects patients from systemic bias

Bias has a significant impact on the health outcomes of many different groups of individuals, further complicated by the intersectionality of multiple underserved identities. It is critically important for healthcare workers, especially nurses, to understand bias, particularly implicit bias which often goes unnoticed by those who have it. Using the strategies discussed in this article, nurses can provide more safe and effective care to their diverse patients.


Alspach J. G. (2018). Implicit Bias in Patient Care: An Endemic Blight on Quality Care. Critical care nurse, 38(4), 12–16.

Arnold, E., & Dhingra, N. (2020). Health Care Inequities of Sexual and Gender Minority Patients. Dermatologic clinics, 38(2), 185–190.

Chapman, M. V., Hall, W. J., Lee, K., Colby, R., Coyne-Beasley, T., Day, S., Eng, E., Lightfoot, A. F., Merino, Y., Simán, F. M., Thomas, T., Thatcher, K., & Payne, K. (2018). Making a difference in medical trainees' attitudes toward Latino patients: A pilot study of an intervention to modify implicit and explicit attitudes. Social science & medicine (1982), 199, 202–208.

Gonzalez, C. M., Lypson, M. L., & Sukhera, J. (2021). Twelve tips for teaching implicit bias recognition and management. Medical teacher, 43(12), 1368–1373.

Esses V. M. (2021). Prejudice and Discrimination Toward Immigrants. Annual review of psychology, 72, 503–531.

Findling, M. G., Casey, L. S., Fryberg, S. A., Hafner, S., Blendon, R. J., Benson, J. M., Sayde, J. M., Miller, C. (2019). Discrimination in the United States: Experiences of Native Americans. Health services research, 54 Suppl 2(Suppl 2), 1431–1441.

Gopal, D. P., Chetty, U., O'Donnell, P., Gajria, C., & Blackadder-Weinstein, J. (2021). Implicit bias in healthcare: clinical practice, research and decision making. Future healthcare journal, 8(1), 40–48.

Hamed, S., Bradby, H., Ahlberg, B. M., & Thapar-Björkert, S. (2022). Racism in healthcare: a scoping review. BMC public health, 22(1), 988.

Muramatsu, N., & Chin, M. H. (2022). Battling Structural Racism Against Asians in the United States: Call for Public Health to Make the "Invisible" Visible. Journal of public health management and practice : JPHMP, 28(Suppl 1), S3–S8.

Morris, M., Cooper, R. L., Ramesh, A., Tabatabai, M., Arcury, T. A., Shinn, M., Im, W., Juarez, P., & Matthews-Juarez, P. (2019). Training to reduce LGBTQ-related bias among medical, nursing, and dental students and providers: a systematic review. BMC medical education, 19(1), 325.

Narayan M. C. (2019). CE: Addressing Implicit Bias in Nursing: A Review. The American journal of nursing, 119(7), 36–43.

Payne, B. K., & Hannay, J. W. (2021). Implicit bias reflects systemic racism. Trends in cognitive sciences, 25(11), 927–936.

Porter, S. B., Lovely, J., & Phelan, S. (2021). Consideration of religion as a source of unconscious bias affecting surgical outcomes. International journal of surgery (London, England), 90, 105953.