A recent article published by researchers of Stanford University detailed significant racial and ethnic disparities in the quality of care among California neonatal intensive care units (NICUs).1 This article captured much attention over the last several months because it was one of the first to provide evidence for the association between the quality of care and racial/ethnic disparities. Their data demonstrated persistent and continued racial and ethnic disparities between and within NICUs.1 In other words, nonwhite and Hispanic infants had worse outcomes within the same NICU. Then, in January 2018, another article was published by New York City researchers documenting very similar results: that nonwhite infants (ie, black and Hispanic infants) were more likely to be cared for at poorer-performing hospitals with higher rates of morbidity and mortality.2 This study confirmed that the quality performance of a birth hospital contributes to infant morbidity and mortality differentially for white, black, and Hispanic infants. In both of these studies, findings demonstrated that black and Hispanic infants were disproportionately likely to receive care at lower-performing hospitals2 and outcomes were also worse for nonwhite infants even within the same hospital.1

These studies should make us uncomfortable because they make it very hard to ignore the fact that nonwhite infants (may) are not receiving the highest quality of neonatal care. The results from these studies were compiled from large, population-based birth records with strong statistical analysis and rigor of findings. The results suggest that the quality of care from neonatal providers (eg, nurses, doctors, practitioners) may be different based upon race and ethnicity bringing into question whether neonatal care providers actually provide impartial, unbiased care. A nationally representative birth cohort study from 2007 compared racial and ethnic differences between the United States and England.3 Even in England, where universal healthcare is standard, racial and ethnic disparities persisted for nonwhite infants. To best sort out some of these complex issues, researchers in this study developed a measure of social economic status that included both employment and poverty along with education. Social economic status, employment status, and other social risk factors did not explain the outcome differences among racial and ethnic groups.3 We believe that neonatal caregivers think that they are providing consistent high-quality care on a day-to-day basis; however, we must acknowledge the potential presence of unconscious biases and systemic issues influencing racial and ethnic disparities in NICUs across the nation.

If, while reading this, you are saying to yourself, "No way! I know that I give the same quality of care to all the infants I care for, regardless of race or family characteristics": this may be your personal reality. You may not consciously provide different care to the white or black infant in your assignment, but we all have implicit biases and personal judgments that influence how we interact with that infant's family. For example, do you treat all families the same way at all times? This also includes treating families as unique individuals. Do you ever choose to not encourage a family to participate in care because they seem uncaring, unclean, or just not right for this baby? Psychologists define implicit bias as the negative evaluation of another person based on membership as a part of a group or personal characteristic, and this can be either overt or covert.4

Within nursing curriculum, students routinely receive education about personal attitudes and beliefs and about how to put these aside to be professional and "nonjudgmental" providing care for all patients with equality. Yet, if we only encourage future nurses to not be something without giving them the tools to adequately address or understand what their implicit biases may be, how will they actually be able to practice impartial care once they leave nursing school? How can we provide impartial high-quality care if we are not aware or even understand how our own personal biases and values influence the care we provide? Just as a medical-surgical nurse may hold biases toward overweight patients, NICU nurses may have similar biases toward substance-abusing mothers whose infant is admitted for neonatal abstinence syndrome.

As providers in a difficult environment like the NICU, where outrageous but real stories are often used as trading cards among the staff, informal conversations and thoughts about implicit biases are commonplace. Take for instance these examples: a homeless mother who delivers a 500-g infant, who is now living at the Ronald McDonald House and not visiting as much as the unspoken NICU staff expectations; or, a surgical infant born to non-English-speaking family who is unstable and requiring constant changes to the plan of care and care providers fail to provide them the same level of interaction because it is too hard to use the interpreter system as compared with the time spent with a mother who visits daily and meaningfully engages with staff. Admittedly, there are differences in the care that could be provided in each of these cases potentially based on group or family characteristics. To reduce racial and ethnic disparities, care providers must assess how their care may differ between patients based on implicit or unintentional biases. This will require honest and likely uncomfortable reflections and discussions with patients and co-workers. Until we confront these issues head on, racial and health disparities will continue to result in poorer neonatal outcomes for disadvantaged populations.

Some may argue that the results from these studies are biased themselves due to hospital characteristics or the known rates of premature birth among particular racial groups; however, the Stanford researchers1 make a compelling point that racial and ethnic disparities persist when controlling for hospitals that cared for more black or Hispanic infants than white infants. Meaning, even though rates of preterm birth were higher among blacks and Hispanics at particular hospital locations, these infants continued to be cared for in hospitals with lower quality of care, which are also the hospitals in the higher morbidity and mortality quartile. Both studies concluded that black and Hispanic (ie, nonwhite) infants had higher rates of severe mor-bidities and more likely to be born in poorer-performing hospitals.1,2 Interestingly, researchers remain unsure as to why moms in disadvantage populations continue to deliver at these hospitals when distance or access to health care has not been shown to explain choice for birth hospital.

Neither of the studies we have discussed directly measured implicit bias. However, research has demonstrated that implicit and/or unintentional bias is linked to quality of care and informs hospital performance and patient outcomes.5 This suggests that by addressing implicit biases, a modifiable characteristic, it is likely to have a significant impact on reducing the racial and ethnic disparity gap and improve morality. Several studies have shown that if outcomes are improved in low-performing hospitals, there is a significant narrowing of disparities.6,7 Thus, improvements to processes rather than outcomes, such as providing culturally competent care, could be effective in closing the quality of care gap, regardless of social risk.

Neonatal providers need to be intentional about how identified racial disparities are visible in their own unit and address biases by confronting them. If we continue to pretend as though care is impartial, it will perpetuate the racial and health disparities impacting outcomes for our tiniest and sickest patients. It is important to begin having open conversations with our coworkers about implicit biases-even if it is uncomfortable. Our own personal discomfort with these issues is the least of what many vulnerable populations have experienced their entire lives. It is time for providers to recognize the truth that racial and health disparities do exist in neonatal care and our implicit biases are impacting neonatal outcomes.

Ashlee J. Vance, MA, RN, RNC-NIC

PhD Candidate; Duke University School of Nursing

[email protected]

Jacqueline M. McGrath, PhD, RN, FNAP, FAAN

Co-Editor; Advances in Neonatal Care

[email protected]

Debra Brandon, PhD, RN, CCNS, FAAN

Co-Editor; Advances in Neonatal Care

[email protected]

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