Implicit Bias in Healthcare: We Can All Do Better

By Holly Carlson MS, RN, CCRN

We are entering the time of year where we commemorate historical leaders who have made what we have a reality for each of us. These leaders fought all types of battles with distinguished courage and strength; courage and strength that separated them from the ordinary.

Like those who have given us the gift of freedom and liberty, equal rights, and give a voice to people who are marginalized and disadvantaged. We as healthcare professionals also care for people who are marginalized and disadvantaged. Because of this we must be culturally and linguistically competent.

All healthcare professionals are trained in cultural competence from their earliest point of formal education. Sometimes the purpose is clear as to why, other times it feels like a box is being checked.  To practice good cultural competence in the workplace we need to identify and address implicit bias towards our patients and coworkers.

When culture and linguistic competence occurs as a result of a box checking process people needing care are marginalized, disparities in the quality of care occur, and access to healthcare is impacted.

Why is Cultural Competence Important?

According to the Centers for Disease Control culture is defined by group membership, such as racial ethnic, linguistic or geographical groups or as a collection of beliefs, values, customs ways of thinking, communicating and behaving specific to a group. The key words to focus on are:

How do you and the people in your organization behave towards people who are not a part of your “group”?  Are you letting your implicit bias steer your communications with others?

Cultural Competence in the Workplace

The U.S. Department of Health and Human Services (HHS) have created national standards for Culturally and Linguistically Appropriate Services (CLAS). These standards are very high level and don’t speak to healthcare providers on an individual or relatable level. Here are a few of the HHS standards:

• Advance and sustain organizational governance and leadership that promotes CLAS and health equity through policy, practices, and allocated resources.
• Offer language assistance to individuals who have limited English proficiency and/or other communication needs, at no cost to them, to facilitate timely access to all health care and services.
• Establish culturally and linguistically appropriate goals, policies, and management accountability, and infuse them throughout the organization’s planning and operations.
• Collect and maintain accurate and reliable demographic data to monitor and evaluate the impact of CLAS on health equity and outcomes and to inform service delivery.

There are 15 standards in total, but do they really address how people are cared for? It is difficult to translate to the day-to-day.

An organizations cultural and linguistic competency is more dependent on how individual employees communicate and behave than HHS’ 15 standards. HHS’ breakdown some barriers but they do not directly address ways your organization can genuinely be culturally and linguistically competent.

Implicit Bias Examples

Cultural competence in healthcare and linguistic competency continues to be an issue. Really, we need to be culturally competent in nearly all interactions with people who are not in our group These interactions are all impacted by implicit bias in healthcare. Implicit bias centers on attitudes that translate into behaviors that affect our understanding and decisions without us really knowing it. Walk the halls of your organization and listen to what people are saying. Do you hear things like?

• “She is Filipino and doesn’t know how to use he or she in a sentence.”
• “His preferred pronouns are they, them, their, theirs. None are a proper use of grammar, so I refuse to use them.”
• “I cannot stand talking to Native Americans, they speak so slow and always have long pauses before they answer.”
• “He lives an “alternative lifestyle” (followed by an eyeroll).
• “Their political beliefs are causing our country to fall apart.”
• “They are fat because they are lazy.”
• “Mrs. Jones is a type 1 diabetic.”
• “He suffers from Alzheimer’s.”

All of these examples could be just a part of typical conversation, but is what we are saying influencing our thoughts and behaviors? Do our beliefs interfere with how we interact with the people we care for? Are there assumptions being made? How often are we labeling people? If so, then there are definitely negative consequences for the people we care for.  Implicit bias in healthcare creates barriers to and disparities in care for people who do not align with our individual group.

Implicit biases are unintentional blind spots in our perceptions and thoughts that manifest in our behavior and communication with others. These influences are usually formed by the groups we associated with. It is human nature to recognize differences but being cognizant of differences and our opinions of them is key to promoting cultural and linguistic competence.

What implicit biases do you have?

Project Implicit is a collaboration of researchers who have put together multiple implicit bias tests. Their purpose is to bring awareness to individual bias towards groups who are at risk of experiencing prejudice and injustice. Following this link to Project Implicit will give you the opportunity to see where your blind spots are. Share this link, everyone has implicit biases. Self-awareness and addressing our individual bias are the most important steps we can take to being culturally and linguistically competent.

Continually working on being culturally and linguistically competent eliminates care disparities and increases access to healthcare, something we all need.

Resources

LINK: Implicit Bias Tests. https://implicit.harvard.edu/implicit/selectatest.html.

Center for Disease Control. Tools for Cross-Cultural Communication and Language Access Can Help Organizations Address Health Literacy and Improve Communication Effectiveness. https://www.cdc.gov/healthliteracy/culture.html. Updated August 11, 2020. Accessed January 13, 2021.

Department of Health and Human Services. National CLAS Standards. Accessed January 13, 2021. https://thinkculturalhealth.hhs.gov/clas/what-is-clas.

Holly Carlson MS, RN, CCRN is a freelance writer and owner of HDC Consulting.  Holly is a registered nurse with 25 years of healthcare experience in both acute and post-acute healthcare environments. Her experience includes direct care, organizational leadership, facility management, and organization culture development.