1. Bucknor-Ferron, Patricia MSN, RN, CGRN
  2. Zagaja, Lori MSN, RN, CGRN

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BIAS, the multifaceted negative evaluation of one group and its members relative to another, can be manifested directly or indirectly. Studies have shown that physicians may recommend more advanced and effective medical treatments for White patients than for Black patients.1 This is an example of direct bias. Ethnic disparities have been shown to be more pronounced when treatment guidelines aren't specific; this is an example of indirect bias.1Unconscious bias, which is unintentional, is common and persistent. It can be activated quickly and unknowingly, despite a person's best intentions. After describing the problem and its consequences, this article outlines steps nurses can use to combat it.


Focusing on the problem

Healthcare professionals typically don't view themselves as being biased. Because healthcare professionals are human, they have an unintentional "disconnect" between their desire to provide equal treatment and the way their clinical decision making is influenced by patients' race, ethnicity, socioeconomic status, and other social group membership traits, all of which are tenets of disparity.


Managing unconscious bias is difficult due to intrinsic blind spots. These blind spots may be the result of confirmation bias, which causes people to recognize information that reinforces their prior beliefs and disregard information that doesn't reinforce those beliefs. Trying to control this kind of bias requires constant vigilance and commitment to make a difference. When unconscious bias isn't recognized and managed, it may lead to healthcare disparities.


According to Healthy People 2020, health disparity is a health difference that's closely linked to social, economic, and/or environmental disadvantages.2 Health disparities adversely affect groups of people who've systematically experienced greater obstacles to health based on their racial or ethnic group; religion; socioeconomic status; gender; age; mental health; cognitive, sensory, or physical disability; sexual orientation or gender identity; geographic location; or other characteristics historically linked to discrimination or exclusion.2


Potentially negative consequences of disparities in healthcare include lack of preventive care, mismanagement of symptoms, being underserved, experiencing extended waiting times for appointments and diagnostic tests, and dealing with professional caregivers who don't take the time to understand language and cultural differences. Although cultural competence is a mandatory nursing responsibility, overcoming cultural bias remains a persistent challenge in healthcare.


Patients who experience healthcare disparities perceive that the healthcare system presents insurmountable obstacles that they can't easily penetrate. They may view the system as unwelcoming, uncaring, complex, and difficult to navigate.


Tapping five strategies

Knowing that unconscious bias leads to disparity, nurses must try to eliminate it. The following five strategies may help.


1. Personal awareness. This is the process of looking inward to recognize beliefs and values that can lead to unconscious bias. Recognition can lead to the development of self-regulatory behaviors to mitigate the influence of bias on patient interactions.3 Acquiring personal awareness requires an internal compass that's used to guide daily interactions. This compass can help nurses recognize acceptable and unacceptable attitudes and behaviors and stay on the right path when faced with the continual threat of unconscious bias. It forces nurses to constantly look inward and creates an awareness of how they're perceived by others, laying the foundation for a therapeutic nurse-patient relationship.


2. Acknowledgment. Without acknowledgment that a problem exists, no action can be taken to solve the problem. With acknowledgment comes the acceptance of accountability and responsibility to make a difference. Nurses and other healthcare professionals must move to suppress unconscious bias by initiating responses to foster positive behaviors, such as empathy.


3. Empathy. Healthcare professionals must be able to empathize with patients and their circumstances to understand what they're feeling. Nurses can develop empathy by making a conscious effort to understand the patient's situation, become fully immersed in the patient's point of view, and get a sense of what it's like to be walking in the patient's shoes.4 Most people naturally have a sense of empathy, but some patients and situations can raise a barrier to empathy. For example, caring for patients who participate in risk-taking behaviors that result in adverse health outcomes can make it more difficult for a caregiver to be empathetic. Refusing to acknowledge this emotional necessity can produce negative outcomes during patient interactions and care. To overcome these barriers to empathy, healthcare providers must consciously make an effort to recognize and acknowledge that the barriers exist and deliberately implement a practice that aligns with unbiased patient care.


4. Advocacy. Support for patients as they navigate a complex healthcare system is called advocacy. Nurses can be patient advocates by assisting with communication with other members of the healthcare team, identifying best treatment options, and ensuring that a patient's rights aren't overlooked. In the presence of unconscious bias, nurses' advocacy can support patients to receive the individualized care they need. Nurses must advocate for patients with tact, compassion, and professionalism, and communicate and collaborate with other healthcare team members to support the patients' needs. Patients should be able to sense that their nurses intend to do what's best for them to provide safe outcomes.


5. Education. Enhanced knowledge is central to raising awareness, recognizing the existence of unconscious bias, and reducing its prevalence. Education can be introduced in formal curricula for healthcare providers and nurses. Another approach is to offer education that focuses on sensitivity and the existence of unconscious bias in healthcare facilities. Nurses can educate others during their daily interactions to raise awareness about the consequences of unconscious bias. Routine staff meetings can provide another forum for education, giving nurses an opportunity to share their experiences and beliefs and to explore options to mitigate this challenge. Educating others about unconscious bias helps create an environment that fosters equal treatment for all patients with an open and accepting approach. Besides strengthening the knowledge base, education creates an atmosphere promoting a strong nurse-patient relationship based on empathy and understanding, ultimately resulting in high-quality and equitable patient care.



Positive changes

Although many healthcare providers don't see themselves as being biased, it's a common and persistent problem. Unrecognized and unmanaged, unconscious bias can lead to health disparities, resulting in potentially negative consequences for patients. Using the five strategies offers a positive framework that can be used by nurses and other healthcare professionals to overcome unconscious bias and provide optimal patient care.




1. Dovidio JF, Fiske ST. Under the radar: how unexamined biases in decision-making processes in clinical interactions can contribute to health care disparities. Am J Public Health. 2012;102(5):945-952. [Context Link]


2. Healthy Healthy People 2020. Foundation health measures. 2016. [Context Link]


3. Teal CR, Gill AC, Green AR, Crandall S. Helping medical learners recognise and manage unconscious bias toward certain patient groups. Med Educ. 2012;46(1):80-88. [Context Link]


4. Santry HP, Wren SM. The role of unconscious bias in surgical safety and outcomes. Surg Clin North Am. 2012;92(1):137-151. [Context Link]