As I contemplated what message to write, I couldn't help but be drawn to the issue that seems most prominent, not only in the recent past but for many years in our nation. When contributing to the Society of Trauma Nurses (STN) Statement of Change (STN, 2020), the visceral feeling elicited by the statement “optimal trauma care and racism cannot coexist” was profound. The statement also recognized that we, as a society, have a long way to go in our commitment to encourage diversity, advocate for inclusion, equity, and social justice for all. Since this statement, the STN board has worked tirelessly toward achieving the goals of change.
Today is a time of self-examination for the STN as an organization and perhaps for all members to ask themselves what they can do as individuals. I asked myself: how can I, as a White female trauma nurse, make a difference? First, I started talking more openly, asking questions, and listening to friends and colleagues about their experiences as a Black woman, a gay man, a disabled teen, as only a few examples of people who are members of vulnerable populations. Second, I acknowledge and understand that everyone has biases and that biases are as natural to humans as breathing, and are formed throughout our lives.
Bias is a state of mind; it's not an action. It becomes dangerous when you act upon your bias in a way that may be detrimental to others, your organization, or yourself. Unconscious biases begin developing at an early age and can be influenced by an individual's environment, values, and experiences (Persaud, 2019). Unconscious biases can be favorable or more commonly unfavorable stereotypes of particular groups of people, that individuals form outside their conscious awareness. It is essential to know that unconscious biases may influence information processed by an individual and can lead to unintended actions or attitudes that have real-life consequences (Marcelin, Siraj, Victor, Kotadia, & Maldonado, 2019).
Often, an individual's unconscious biases may differ from their explicit actions. There's a belief that all patients are treated equally. However, by definition, an individual may lack awareness of their own unconscious biases, and their actions may unknowingly suggest that these biases are active (Marcelin et al., 2019). The most ethical and well-intentioned nurses or leaders may not realize how often bias influences their everyday decision-making (Persaud, 2019). “Unconscious bias is far more prevalent than conscious prejudice and often at odds with one's conscious values. Certain scenarios can activate unconscious attitudes and beliefs. For example, biases may be more prevalent when multi-tasking or working under time pressure” (University of California, San Francisco, 2020). Clinicians aim to deliver impartial care. Health care professionals should be mindful of negative patient assessments that link to membership of a group or particular characteristic (FitzGerald & Hurst, 2017). Trauma nurses who often perform under pressure during high-acuity, trauma response situations, or any other health care professional caring for a vulnerable population, need to develop strategies to mitigate unconscious bias.
In 2015, the American Nurses Association (ANA) revised Provision 1 of the Nursing Code of Ethics (ANA, 2015). It is an explicit statement against bias toward patients, colleagues, and others. Nurse leaders are ethically and professionally responsible not only to embrace diversity but also to work toward inclusivity. For this to occur, nurse leaders must examine their own beliefs, evaluate the processes used for decision-making, and be open to change (Persaud, 2019). Some strategies for addressing unconscious bias include: recognize and accept you have biases; get another's point of view; expose ourselves to groups we tend to have biases against; acknowledge when we feel a little uncomfortable and instead of backing away from it, explore what's causing the discomfort and create opportunities to give and receive feedback, and therefore being approachable about a bias you may not be aware of (National Institute for Children's Health Quality, 2020). Confronting unconscious bias involves the willingness to alter one's behaviors regardless of intent, when the impact of one's biases is revealed and addressed (Marcelin et al., 2019). Also, the practice of affirming the achievement of others, as a part of daily interactions, is perhaps the most impactful way to address unconscious bias (Persaud, 2019; Rowe, 2008).
Biased decisions often occur under situations of stress, and when there is a lack of time or resources to be intentional and thoughtful. If we learn to identify the bias in ourselves, there is less opportunity for unconscious biases to influence our decisions. Examples of these biases can be about our colleagues or a patient. For example, when a clinician responds to a trauma activation along with a team member whom they've felt has previously devalued or intimidated them, then decision-making may be altered or influenced by unconscious bias. There should be thoughtfulness and care when entering these situations by taking time to acknowledge biases, addressing one's reactions during team performance, or in treating the patient as an individual. By doing this, biases, we are not aware of, won't negatively influence the team dynamics or a patient's outcome.
Nurse leaders must also consider other strategies, such as mindfulness, to reduce stress that can lead to biased decision-making. “Mindfulness practices focus attention on the present, as individuals engage and reflect on events and emotions in real-time, instead of defaulting to automatic reactions. A nurse leader with mindfulness practice is more likely to be aware of when negative emotions, such as frustration, are influencing decision-making. Awareness provides the opportunity to pause, reevaluate, and reverse a potentially negative outcome. A simple 2-minute pause between important tasks can increase focus and decrease stress, leading to more thoughtful, unbiased actions” (Marcelin et al., 2019).
Understanding ourselves is by far the most important thing we can do. When aware of bias, people are more than willing to change and less likely to let their bias drive decisions. When you challenge your unconscious biases and think things through instead, you have a much better chance of making good decisions. No matter where your role on the trauma path lies working together to care for diverse patient populations, to demonstrate an openness to change and a willingness to accept differences, will never diminish your light (McMahon, 2020).
FitzGerald C., Hurst S. (2017, March). Implicit bias in healthcare professionals: a systematic review. BMC Medical Ethics, 18(1), 19. doi:10.1186/s12910-017-0179-8
Marcelin J. R., Siraj D. S., Victor R., Kotadia S., Maldonado Y. A. (2019, August). The impact of unconscious bias in healthcare: How to recognize and mitigate It. Journal of Infectious Diseases, 220(Suppl. 2), S62–S73. doi:10.1093/infdis/jiz214
McMahon M. (2020). Let your light shine. Journal of Trauma Nursing, 27(4), 191–192.
National Institute for Children's Health Quality. (2020). Implicit bias resource guide. Retrieved from https://www.nichq.org/resource/implicit-bias-resource-guide
Persaud S. (2019). Addressing unconscious bias: A nurse leader's role. Nursing Administration Quarterly, 43(2), 130–137. doi:10.1097/naq.0000000000000348
Rowe M. (2008). Micro-affirmations & micro-inequities. Journal of the International Ombudsman Association, 1(1), 45–48. Retrieved from https://www.ombudsassociation.org/assets/docs/Volume1Journal.pdf
Society of Trauma Nurses. (2020, June). Special Statement from the STN Board of Directors. Retrieved from https://mailchi.mp/traumanurses/stn-monthly-newsletter-june-2020
University of California, San Francisco. (2020, August). Unconscious bias. Retrieved from https://diversity.ucsf.edu/resources/unconscious-bias