Mitigating Implicit Bias and Microaggression in the Emergency Department

Implicit bias causing microaggression inevitably will be witnessed in emergency departments due to stereotypes instilled in staff and patients subconsciously throughout their lives. Staff members need to become self-aware of their own implicit biases to decrease their aggression toward patients and coworkers, thus improving safety and decreasing care inequality.

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Mitigating Implicit Bias and Microaggression in the Emergency Department

Emergency Department staff see every type of unique patient, from differing religious, ethnic, cultural, and racial backgrounds to varying gender preferences, weight, age, insurance coverage, and income status. This constantly changing, stressful environment can easily lead to implicit bias and microaggression from both patients and staff working in emergency departments. Implicit bias is a form of prejudice that occurs both unconsciously and unintentionally and affects judgment, decisions, and behavior. A common behavior associated with bias is microaggression, a brief verbal, behavioral, or environmental indignity, whether intentional or unintentional, that communicates hostile, derogatory, or negative prejudicial insult. Implicit bias can lead to patient and staff discrimination causing safety concerns and care inequality. With leadership awareness and staff training, unconscious bias can be mitigated, as well as witnessed microaggression decreased.

Implicit bias is most commonly seen causing intentional microaggression when patients single out staff, police presence, and other patients through biases instilled in them from their past experiences, such as influence from gang activity, white supremacy groups, religious affiliation, etc. Unfortunately, it is not limited to patients. Healthcare workers are susceptible to implicit bias through assumptions that a patient or even a coworker is going to behave in a certain way, perhaps by how they look (I.e., covered in tattoos, ear gauges, or piercings), without any other interactions. According to a study by Anthony Greenwald and M.R. Benaji in 19951, implicit bias does not escape any person since "much of our social behavior is driven by learned stereotypes that operate automatically – and therefore unconsciously – when we interact with other people.” These learned stereotypes are built into our subconscious throughout our whole life, therefore, not easily swayed. "The ability to distinguish friend from foe helped early humans survive, and the ability to quickly and automatically categorize people is a fundamental quality of the human mind. Categories give order to life, and every day, we group other people into categories based on social and other characteristics. This is the foundation of stereotypes, prejudice, and, ultimately, discrimination"2.

Emergency Department personnel create a "thick skin" in an attempt to keep daily biased insults and behaviors from affecting them. However, these repeated interactions have undue consequences. One specific example, personally witnessed by myself as a charge nurse, involved an African American nurse who had recently graduated nursing school and had just begun her emergency department career. A white supremacist patient came into one of her assigned rooms, and after taking one look at her, instead of seeing a person with feelings, he saw her only by her skin color. He called her inappropriate slurs and cast harsh glances. We were able to find the patient another nurse, but you could visibly see how their interaction, however brief, had deeply impacted her. She was distraught for the remainder of her shift and transformed from that one instance for the rest of her life. She will have implicit bias around certain types of patients from that situation.

Healthcare workers, especially in emergency departments, witness patients and coworkers living up to their implicit biases consistently as patients, family, and staff often act their foulest during some of the worst moments in their lives. Haggins, MD, who researches health care access disparities and improving care to historically marginalized populations for the Department of Emergency Medicine at the University of Michigan Medical School in Ann Arbor, stated in 20223, "ED providers face gaps in knowledge of patient's medical histories, a lack of long-standing patient-provider relationships, and numerous work distractions - all of which can translate into medical decisions based on stereotypes or gut feelings instead of best medical practices." Some common examples of these stereotypes or gut feelings, just to name a few, include seeing a disheveled, foul-smelling, lethargic person and automatically assuming the person is homeless and either drunk or on drugs; seeing someone covered in tattoos, especially on their neck and face and thinking they probably have a dark past and jail time; or seeing someone come in with a gunshot wound saying, "This just happened to me randomly, I don't know why, I was just standing there" and staff immediately saying to each other, "Yeah right, we hear that all the time, you did something to provoke this.”

Healthcare workers cannot change patient bias, but there are ways they can change their own biases to give more empathetic, compassionate care to the underserved, marginalized groups holding their main implicit biases. Haggins, MD3 reported two crucial thought changes to correct staff bias, thus preventing microaggression toward vulnerable populations. First, understanding structural competency through awareness of patient legal, social, and economic policies that affect a patient's access to health care and community resources. Second, becoming culturally humble through a willingness to learn from patients as their own experts from their lived experiences. According to The Joint Commission2, "with organizational support, skills training, and cognitive resources, clinicians who are highly motivated" can control biased thoughts to improve patient safety and care disparities.

In conclusion, healthcare workers must strive to become more self-aware, to recognize and overcome their own implicit biases to understand each individual person with different lived experiences that shaped them into who they are today. They must strive to be more compassionate, even to those they previously thought to be undeserving. They must intentionally change their thinking with each biased thought to catch themselves in those thoughts and give their coworkers and patients a chance to prove them wrong. Lastly, staff must offer evidence-based medical care, under any circumstance, to prevent their biases from diverging from the care that should be provided to all patients alike. The first step to change is acknowledging one's biases and being willing to adapt.

References/Resources

1The Development of Implicit Attitudes: Psychological Science

2 Quick Safety 23: Implicit bias in health care: The Joint Commission

3 Bias in the emergency department: Association of American Medical Colleges

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nancyEDRN

About nancyEDRN, BSN

Nancy Fry, MBA, BSN, RN, CEN with 11 years of emergency care experience in both bedside and supervisory positions.

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Specializes in orthopedic/trauma, Informatics, diabetes.

There is also implicit biases and microagressions between staff in all areas. Going through it right now.  

And from pts to staff. Yesterday had a pt request a new nurse simply because the nurse had an accent. 

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Specializes in Emergency services, transfer center services, MBA..

Unfortunately, I also witnessed leadership-to-staff bias much more often than I expected. I felt, as a charge nurse, I needed to advocate for staff when leaders made snap decisions from staff looks and the few instances they saw those staff versus what I witnessed working alongside staff day in and day out. 

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Honestly, toughen the hell up. This generation has become offended by everything. Everyone has turned into a little dictator that demands everyone bow at their feet cater to their every need. Ban me if you want for saying it, but the culture that pushes this insane nonsense is ruining societies the world over. No wonder people live in terror of offending each other and no one knows how to form a decent  human relationship anymore. They live in a perpetual world of false persecution cooked up by deluded minds.

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nancyEDRN said:

 A white supremacist patient came into one of her assigned rooms, and after taking one look at her, instead of seeing a person with feelings, he saw her only by her skin color. He called her inappropriate slurs and cast harsh glances. We were able to find the patient another nurse, but you could visibly see how their interaction, however brief, had deeply impacted her. She was distraught for the remainder of her shift and transformed from that one instance for the rest of her life. She will have implicit bias around certain types of patients from that situation.

Might that have been an opportunity for the new nurse to consider that this person had been in abusive environments his whole life and could have been suffering from traumatic injury that went back to his childhood? No excuse for his abusive language, but the reasons for it were probably more of an occasion for pity than personalizing the event and deep, lifelong distress. As a white RN in an inner city trauma center, being exposed to this kind of abuse was routine. I considered the source and gave every new patient the benefit of the doubt which served me and my patients very well. Abusive people are far more often than not leading disasterous lives and when I encounter them, when the initial emotion dies down,  I often feel a great sense of gratitude that I've been spared what they live every day, and sorrow for them and the people that have to deal with them. 

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