Introduction
Biases, stereotyping, and prejudice persist in society, with the level of bias for healthcare professionals found to be at the same level as the general population (Edgoose et al., 2019). In this special issue, we have explored how biases and prejudices cause many health inequities and contribute to healthcare disparities for our patients in known and unknown ways. Less explored aspects of biases and stereotypes are on the functioning of our interprofessional teams and how biases and stereotypes contribute the psychological safety for individuals within our interprofessional teams and negatively affect optimal team functioning (Edmondson, 2019; IHI, 2017).
The American Nurses Association revised the nursing code of ethics in 2015, with an explicit statement addressing bias toward our patients and our colleagues (Persaud, 2019). This provision reads:
The nurse, in all professional relationships, practices with compassion and respect for the inherent dignity, worth, and uniqueness of every individual, unrestricted by considerations of social or economic status, personal attributes, or the nature of health problems (p. 1).
Biases in the workforce, whether conscious or unconscious in nature, affect our ability to fully function in our nursing roles and responsibilities and they negatively affect our feelings of inclusion, belongingness, and membership within a team (Clark, 2020; Edgoose et al., 2019). Poor team performance affects many negative system and patient outcomes such as high turnover, chronic lack of staffing, and difficultly in curtailing medical errors (Tuttas, 2014). Bias influences the culture of safety of our overall healthcare organizational behaviors (Frazier et al., 2017; Verschelden, 2017) and the psychological safety of team members (Edgoose et al., 2019). Teams work effectively if they have a sense of belonging and membership with each other including a larger connection within the environment of the healthcare systems; when they have a sense of their security from a culture of safety; when they are able to speak and be heard within their interprofessional teams; and when they work within an environment that values the diversity of all groups and members of the team (Edmondson, 2019).
Nurses and nursing leaders are ethically responsible to create inclusive and safe environments for all team members as well as possess skills of mitigating biases and stereotypes present in our workplace (Persaud, 2019). This article explores the definitions of biases and the links to psychological safety and inclusion in healthcare teams; how to uncover our own biases; and how to begin to build trust and mutual respect for all team members by addressing bias and, ultimately, promote high-functioning healthcare teams.
Case Study
Ann, an African American registered nurse, has worked on the orthopaedic floor for 3 years now. She enjoys caring for orthopaedic patients and their families and she has worked hard to complete the certification in orthopaedics this year. She feels she is different from her coworkers in terms of race and ethnicity. Generally, Ann works well with her coworkers; however, she notes that often coworkers' comments to her are only about her hairstyles or they make assumptions about the food that she eats or how she celebrates holidays. The questions are awkward to her, she knows if she changes anything about her hair or her lunch there will be questions asked of her; these comments are consistent and cause her to feel called out as different from others-so much so that she tries not to change anything about herself or mention her personal life very often. Ann notes that the conversations are different with her than with others. For instance, typically topics such as "what did you do over the weekend?" or even "how have you been?" do not come up for her; more often conversations are about her personal characteristics (hair, skin) or habits (food, holidays). She feels she is excluded from forming more personal relationships with her coworkers. Her work as a nurse is accepted by her peers and she feels listened to and respected, yet she consistently finds her peers to do not naturally engage her in conversations during breaks or events outside of the unit. And more importantly to Ann, she has heard co-workers make negative comments about patients whose ethnicity was different from theirs. She feels that she has heard biases, prejudices, and stereotypes implied before and does not know how to address statements that to her appear biased; she fears that she will cause a disruption in the team and that she would be blamed for accusing someone of being biased. Ann would like to be considered for promotion to a nurse manager, but is fearful that similar comments about patients could have been shared about her or her peer's beliefs are unknown to her and these beliefs will affect her chance for promotion. Ann realizes that she really does not know how her colleagues feel about her.
Definitions of Bias
Biases are unfounded judgments, prejudices, or attitudes based on the characteristics of people or groups of people that can be positive or negative (Mateo & Williams, 2020). Biases are malleable in nature, not permanent; thus, individuals can take personal steps to limit how biases affect their decisions and behaviors (Dasgupta, 2013). Stereotypes are the same in that they are beliefs that are conscious or unconscious and created by a sense of "knowing something is true" (Rosenbaum, 2019). Bias and stereotyping are harmful if what we believe is actually not true but based upon conscience or unconscious beliefs, or when it is communicated or shared with others who cannot safely push back against the wrong belief; thus, stereotypes and biases are threats to our psychological safety (Verwijs, 2020). Biases are inherently wrong and often based upon conclusions the believer knows to not be true, yet they hold the belief for known or unknown reasons (Verwijs, 2020).
Implicit Biases
Implicit biases are unconscious beliefs, attitudes, feelings, or judgments and can be contrary to what we think ourselves (Kurdi & Banaji, 2021). Science demonstrates for us that we form unconscious bias from outside factors such as media messages, institutional policies, and family preferences (Edgoose et al., 2019). Implicit biases are less conscious and intentional, and thus less controllable by us. Therefore, examining and understanding our unconscious or implicit bias warrants examination of our thoughts, rationales, and emotions in an informed manner (Edmondson & Lei, 2014).
First steps of uncovering our own biases are a personal examination of ourselves. A favored screening tool to uncover implicit bias is the Implicit Association Test from Project Implicit (Project Implicit, 2011). After examining personal implicit biases, we can implement strategies to replace habits, make commitments to break habits, or dissolve beliefs to mitigate implicit bias in our practice, with our teams, and within our communications and interactions with our clients (Narayan, 2019). Biases exist, as in all social interactions, and when left "unconscious" they contribute to healthcare disparities and poor team functioning often in silent ways (Alingh et al., 2019). In our case study, Ann heard implicit bias from her colleagues and felt these biases could be attached to her, she noted conversations and connections with her were different from her peers both of which impacted her feeling of belongingness to the group, acceptance by those around her.
Two common types of implicit bias are confirmation bias and affinity bias (Persaud, 2019). Both of these biases are noted within our case study. Confirmation bias is a tendency of people to confirm an unfounded belief about someone's race or ethnicity (Kappes et al., 2020). Ann experienced questions from others that were confirming their previous beliefs about her personal habits or her physical characteristics. Affinity bias is when people are drawn to those who are similar to them in their race, ethnicity, upbringing, or background (Persaud, 2019). Ann experienced affinity bias by witnessing how different the conversations were between herself and others in her team.
Explicit Bias
Overt expression of a prejudice or attitudes/beliefs toward certain groups is a definition of explicit bias. Explicit bias by its nature is intentional and controllable and highly destructive to healthcare teams and patient/family interactions. In Ann's case was bias felt explicit, as it was related to only talking to her about her hair and foods; even after working in the team for 3 years her peers still did not ask about her personal life. Experiencing explicit bias has long-lasting effects on our ability to trust and engage with the perpetrator (Al Omar et al., 2019). Witnessing explicit bias has a cascading negative impact on effective teamwork, including distrust, loss of belonging and membership, increased burnout, and disengagement. Ann has doubts about applying for promotion because she overheard what coworkers said, which caused her to doubt herself and her capabilities as a registered nurse. And as importantly, when left unchecked, explicit bias can infect the beliefs and behaviors for groups and teams of people demonstrating the powerful influence of normalizing and accepting biased beliefs or attitudes of others (Burke et al., 2016).
Psychological Safety
Psychological safety is a condition wherein you feel included, sense a safe space to learn and contribute, and feel safe to challenge the status quo-all without a fear of being judged or marginalized or punished by others (Clark, 2020; Edmondson, 2019). In safe environments, all members of the interprofessional team feel heard, feel included, feel respected, and communicate openly with each other; and conversely, in unsafe environments, members sense feelings of not belonging, not being included, not a member of the group, or fear impending reprisal or punishment (Clark, 2020). With psychological safety, team members sense support and recognition of their personal ability to grow and learn, their ability to question the status quo will be accepted by others, and ultimately, their ability to communicate between each other during routine or critical/crucial clinical decisions or assessments contributes to positive healthcare outcomes for our patients (Rosenbaum, 2019).
Inclusion and psychological safety are closely aligned to each other with inclusion defined by how well the contributions, presence, and perspectives of different groups are integrated and valued (Dreachslin et al., 2012). Inclusion can be a workforce/team ethic of valuing membership, opinions and work of others, and promoting a sense of belonging to the group (Verschelden, 2017). Psychological safety can be sensed by an individual and inclusion can be sensed within the climate and environment wherein the healthcare team is developed and promoted.
The Institute for Healthcare Improvement connects "Joy at Work" to psychological safety and ultimately healthcare quality (Perlo et al., 2017). Meaning that individuals need to feel joy at work to be a committed member of the team and value healthcare quality and equity; without joy at work people shut off, burnout, remove themselves as a part of the team, and avoid seeking inclusion and necessary communication to promote healthcare quality (Narino, 2021; Perlo et al., 2017). Narino (2021) states focusing on joy at work and addressing biases, inclusion, psychological safety, and equity are intertwined as "... it's about creating spaces for people to feel psychologically safe to address race and racism and having agency to change systems" (para. 2).
What to Do With Bias?
Edgoose et al. explain, "If we fail to learn our blind spots, we miss the opportunity to avoid harm" (2019, p. 31); thus, the first step of dealing with implicit bias is introspection, examination of self, and acknowledging our biases exist. The Project Implicit continues to be the "gold standard" to help us evaluate our own personal biases. Project Implicit is an online implicit association test wherein the strength of associations between concepts or words and evaluations of good or bad or evaluations of characteristics are measured and interpreted (Project Implicit, 2011). Edgoose et al. (2019) go further to define 7 more steps for identifying and dealing with bias by helping individuals and healthcare teams focus on mindfulness and self-care, encourage gathering the perspectives of others, learn to slow down, looking at individual characteristics and not group characteristics, checking your messaging, institutionalizing fairness, and "take two"-a lifelong practice of humility and addressing power imbalances in our lives (see Table 1).
Bystander Intervention Model
Members of the interprofessional teams see and hear comments and situations that threaten the well-being of others and need to develop skills of addressing biases that occur in day-to-day team activities (Columbia Health, 2021). Table 2 interprets the Step Up! five steps to apply to your daily practice and also as a guide for teams to work together. Step Up! starts with noticing the event and moves to interpreting the situation as a problem, taking personal responsibility to get involved, knowing how to help and the resources you have on hand at your institution to help you, and finally, learning the skill of stepping up and stepping into events, conversations, or situations that threaten others (Columbia Health, 2021). Applying these steps within your own practice or as a model of practice within your teams is one way of learning to address harmful events that left unexplored, can negatively affect team quality and outcomes of care.
Conclusion
Although overtly discriminatory and biased behavior has declined in the United States (Nelson, 2002), organizations are now experiencing a "tidal wave" of claims highlighting the failure of organizations to embrace fully eradicating bias and harassment (Edmondson, 2019; Garran & Rasmussen, 2019). Diversity contributes to the success of any organizations including healthcare systems (Hunt et al., 2015); yet many members of teams often experience bias directed toward their race or gender that threatens their personal sense of belonging to the team (Brathwaite, 2018; Hall et al., 2015; Salles et al., 2019). Biases still happen and continue to affect the psychological safety of the team by way of eroding a sense of belonging, feeling not heard, or fear of reprimand for speaking; thus, teams need effective and evidence-based strategies to address bias and individual team members need the support of their peers and the greater organization to affect positive change and promote high-effective teams. Promoting diversity within teams has been identified as key to decreasing health disparities (Edgoose et al., 2019) and how to support diverse team members can be enhanced by proactive, thoughtful, and engaged steps of addressing bias and ultimately promoting team cohesion and functioning (Edmondson, 2019).
Reflection on the Case Study
The nurse in our case study has experienced many of the implicit biases known to occur in teams and, unfortunately, witnessed explicit bias. Her experience demonstrates how threatened psychological safety is a real experience for many people. Although Ann had not experienced overt disrespect, and fortunately, feels she contributes to the quality orthopaedic care delivered to their clients, she works in a team where she does not have the beginnings of a sense of belonging within her team.
The biases and stereotypes and prejudices team members hear cause them to fear reprisal, should they bring them up, lessen their sense of belonging, and can cause them to question their ability to be a leader within their teams. Ann's team could benefit from the steps of uncovering personal biases within themselves and also within the interactions within the team as presented earlier. Often the persons experiencing bias and threats to safety are not the ones to bring this up to the team. Nursing leadership and guidance is needed to safely open these conversations for everyone to explore. Nursing leadership has an ethical responsibility to create inclusive spaces for all team members; they need to possess the skills to mitigate the impact of bias and build diversity and inclusion within their organization. The responsibility of leadership is to model the behaviors that can be examples for their teams. This case study demonstrates that nursing leadership needs to initiate skills training related to identifying bias and foster an inclusive workspace and have a plan to continue diversity and inclusion training on an ongoing basis.
An environment that has not worked to uncover implicit and unconscious bias leaves many wary of being different, not belonging, or threatened as in Ann's example. Although the team may feel day-to-day work is not affected by bias, many teams are actually compromised due to the poor psychological safety for every member of the team. To be a highly functioning team and team member, all team members need to feel heard, know they are accepted within the team, and will have the same opportunities of promotion. Highly functioning teams promote the well-being of each other, and ultimately, promote high-quality outcomes of care. This case study demonstrates how a threat to psychological safety holds back valuable team members from being fully engaged within the team and their confidence to be leaders on their units and in their organizations. Promoting diversity within teams has been identified a key to decreasing health disparities and the actuality of how to support diverse team members, while less often addressed, needs to be enhanced by proactive, thoughtful and engaged steps of addressing bias and ultimately promoting team cohesion and functioning (Edmondson, 2019).
References