I think unconscious bias is one of the hardest things to get at.
-Supreme Court Justice Ruth Bader Ginsburg
Could unconscious bias training prevent an incident like the one at a Philadelphia Starbucks recently in which two black men were arrested after asking to use the restroom? “While this is not limited to Starbucks, we’re committed to being a part of the solution,” Starbucks CEO Kevin Johnson said. Closing our stores for racial bias training is just one step in a journey that requires dedication from every level of our company and partnerships in our local communities.” Starbucks said that it would close its more than 8,000 stores in the United States for one day to conduct training.
What is Unconscious Bias?
Most of us know that bias is a prejudice in favor of or against one thing, person, or group compared with another usually in a way that’s considered to be unfair. Biases may be held by an individual, group, or institution and can have negative or positive consequences. Less familiar is the fact that there are two types of biases:
- Conscious bias (also known as explicit bias) and
- Unconscious bias (also known as implicit bias)
It is important to note that biases, conscious or unconscious, are not limited to ethnicity and race. Though racial bias and discrimination is well documented, biases may exist toward from any social group. One’s age, gender, gender identity physical abilities, religion, sexual orientation, weight, and many other characteristics are subject to bias. Unconscious biases are social stereotypes about certain groups of people that individuals form outside their own conscious awareness. Everyone holds unconscious beliefs about various social and identity groups, and these biases stem from one’s tendency to organize social worlds by categorizing.
Unconscious Bias in Healthcare
In 2017, BMC Medical Ethics published a systematic review assessing a decade’s worth of publications for implicit bias in healthcare professionals. The conclusions stated a need for additional reviews and more homogeneous methodologies, but determined that implicit bias exists in healthcare settings and impacts quality and equity of care. Authors Mahzarin Banaji and Anthony Greenwald address the issue in the book; Blindspot: Hidden Biases of Good People.
Clinician bias is one documented contributor to health care inequalities according to Michelle van Ryn, Ph.D. in her APHA webinar; “Unequal Treatment: Disparities in Access, Quality and Care.”
Dr. van Ryn points out that there is a large and ever-growing body of evidence that patient group identity (race, gender, sexual orientation, size…) can affect clinicians’:
- Questions asked in clinical interviews with patients (and thus information gained)
- Diagnostic decision-making
- Symptom management
- Treatment recommendations
- Referral to specialty care
- Interpersonal behavior predictive of patient trust, satisfaction and adherence
Patients Want a Better Healthcare Experience
Patients are demanding more from their healthcare experience, according to an informative infographic by MM&M. Healthcare providers will likely have to make changes to the way they practice medicine to improve patient satisfaction. The infographic data show a high percentage of patients will switch providers if they are dissatisfied. Implicit bias by physicians and nurses can adversely affect the quality of care, resulting in unhappy patients.
How to Eliminate Unconscious Bias
The first step is to confront unconscious bias straight on.
Conduct a Cultural Audit
An audit of the culture will provide physician leaders and administrators with a sense of where the organization stands relative to where it wants to be. It will surface aspects of the culture and work environment that are viewed as strengths and those that are viewed as deterrents to clinician effectiveness and patient engagement. An audit will also reveal if the culture is viewed and experienced consistently by various demographic and stakeholder groups, as well as identify whether subcultures exist in specific pockets of the hospital. This information is particularly useful when change efforts are being undertaken. Audit results enable leaders to conduct a gap analysis and to develop relevant strategies that bridge the gap.
Consider the Implicit Association Test (IAT)
An assessment tool often used in healthcare is the Implicit Association Test (IAT). The IAT measures attitudes and beliefs that people may be unwilling or unable to report. The IAT may be especially interesting if it shows that you have an implicit attitude that you did not know about. For example, you may believe that women and men should be equally associated with science, but your automatic associations could show that you (like many others) associate men with science more than you associate women with science.
As the most widely used strategy for assessing implicit bias, the IAT has generated a great deal of criticism and a large body of validation studies in response. A careful review of this literature reveals that the IAT has good predictive validity for behaviors that are not under full conscious control. It is a reasonable research tool to measure average levels and distribution of implicit bias for a group. The test-retest reliability of the IAT, however, makes it less suitable as a diagnostic tool for individuals, and the developers do not endorse its use for that purpose.
Following a cultural audit, gap analysis and learning needs assessment, you face a critical decision; hire an external training vendor, or, design the training initiative yourself. There are advantages to both approaches.
Unconscious Bias Training Vendors
Many healthcare organizations purchase Unconscious Bias Training from the Association of American Medical Colleges (AAMC). The AAMC has partnered with Cook Ross, Inc., a leading consulting firm in the country, to create the training in the science behind unconscious bias.
Cook Ross, Inc. and PRISM both offer reputable “off the shelf” unconscious bias training programs and have worked with many healthcare organizations. The advantage of these external vendors are many if you don’t possess instructional design talent and expertise internally. The program delivery is turn-key and can be scheduled quickly, without development time. The disadvantage is that they are rarely customized for an individual hospital or organization. I can vouch for these vendors, but recommend you consider designing your own training and development solution.
Developing Unconscious Bias Training Internally – The “DIY Approach”
Managing the design of your own customized Unconscious Bias training offers many advantages:
DIY Approach Advantages
- Instructional design aligned precisely with your cultural audit and learning needs assessment findings
- Training solution fits with organizational culture and model of patient care
- Able to ensure scientific evidence based thought leadership in the learning content
- Structure the content around workplace situations. To make training feel more relevant and memorable, I’ve found it’s better to organize content around specific workplace situations. Research shows that when information is presented in a way that is linked to our current schemas, we are better able to remember it
- Build Unconscious Bias Learning & Development Competencies amongst Internal HR and Training Staff – ‘Train the Trainer”
- The Post-Training is What Matters Most — The single biggest factor in a lack of success surrounding unconscious bias training, or any training, is the absence of tracking and follow-up against predetermined outcomes. If there is no way for the organization to measure and act on desired outcomes, then the training has failed before it has even started. The DIY approach enables building in measurement and accountability upfront.
Rather than hiring a vendor to facilitate “off the shelf” generic training, consider hiring a consultant with diversity & inclusion expertise, healthcare experience, and instructional design competence to design a custom program for your organization. The aforementioned Dr. Michelle van Ryn of Institute for Equity & Inclusion Sciences (IEIS) does offer training and development lectures and workshops, but provides consulting to tailor or customize solutions for specific healthcare clients. Dr. van Ryn suggests Four Key Questions to Ask Before Hiring A Diversity & Inclusion Training Vendor/Consultant.
I find Dr. van Ryn’s recommendations to be insightful and reflect the best practices for developing organizational cultural competence.
Cultural competence in healthcare describes the ability to provide care to patients with diverse values, beliefs and behaviors, including tailoring health care delivery to meet patients’ social, cultural and linguistic needs. A key component to new care delivery models, such as patient-centered medical homes and accountable care organizations, is the ability to engage and educate patients about their health status. While doing this is challenging with all patients, for diverse patient populations it can be even more difficult due to language barriers, health literacy gap, and cultural differences in communication styles. For Cultural Competency resources, please check out these from U.S. Health & Human Services.
As a Certified Diversity Professional (CDP) and Certified Professional in Learning and Performance (CPLP), Unconscious Bias training is in my wheelhouse…make it part of your healthcare organizational development toolbox.
Looking to learn more about unconscious bias in healthcare? Please view my June 8 ATD webcast “Targeting Unconscious Bias to Improve Patient Care.”