CE 1
HOUR
Continuing Education
Addressing Implicit
Bias in Nursing:
A Review
Unconscious preconceptions can undermine therapeutic relationships and
reinforce health disparities.
ABSTRACT: This article examines the nature of implicit, or unconscious, bias and how such bias develops.
It describes the ways that implicit bias among health care providers can contribute to health care disparities and discusses strategies nurses can use to recognize and mitigate any biases they may have so that all
patients receive respectful and equitable care—regardless of their race, ethnicity, religion, sexual orientation, gender identification, socioeconomic status, disabilities, stigmatized diagnoses, or any characteristic
that distinguishes them from societal norms.
Keywords: culturally competent care, discrimination, health care disparities, health care providers, implicit
bias, minorities, patient-centered care, prejudice, vulnerable populations
I
n the late 1800s, Sigmund Freud popularized
the idea that the unconscious mind—that is, the
attitudes and feelings of which we are unaware—
can have a powerful influence on our behavior.
Today, unconscious attitudes that precipitate un­
intentional discriminatory behavior are called “im­
plicit bias.” Not surprisingly, implicit biases exist
among people of all professions. But when nurses
and other health care providers harbor implicit bi­
ases, they may contribute to the health care dispari­
ties experienced by members of racial, ethnic, or
religious minorities and other groups that face dis­
crimination because of such factors as sexual orien­
tation, gender identification, disability, or stigmatized
diagnoses. Fortunately, there are strategies we can use
to recognize unconscious negative attitudes we may
have toward various groups of patients. And with
awareness comes the possibility of overcoming our
implicit biases, so we can consistently adhere to the
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first principle in the Code of Ethics for Nurses with
Interpretive Statements: “The nurse practices with
compassion and respect for the inherent dignity,
worth, and unique attributes of every person.”1
This article briefly describes the types of health care
disparities that persist in the United States, the numer­
ous patient populations that encounter them, and the
ways implicit bias contributes to these disparities by
adversely affecting patient assessment, treatment deci­
sions, and health care follow-up. It also discusses strat­
egies nurses and other clinicians can use to discover
and overcome their own implicit biases.
DISPARITIES IN HEALTH CARE
In 2003, the Institute of Medicine (IOM) produced a
report based on a comprehensive literature review of
racial and ethnic health care disparities that exist in
the United States.2 The report, Unequal Treatment:
Confronting Racial and Ethnic Disparities in Health
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By Mary Curry Narayan, MSN, RN, HHCNS-BC, CTN-A
Care, noted that “racial and ethnic minorities tend
to receive a lower quality of healthcare than nonminorities, even when access-related factors, such
as patients’ insurance status and income, are con­
trolled.” The IOM cited numerous studies provid­
ing substantial evidence that patients belonging to
racial and ethnic minority groups confront lack of
access as well as inappropriate, inadequate, and un­
caring health services.
The terms “health care disparities” and “health
care inequities” refer to the poorer health outcomes
observed in minority and other vulnerable patient
groups compared with those observed in majority
or dominant patient populations. Disparate patient
outcomes are associated with age, sex, religion, so­
cioeconomic status, sexual orientation, gender iden­
tification, disability, and stigmatized diagnoses (for
example, HIV, obesity, mental illness, and substance
abuse).3 These disparities challenge our nation’s com­
mitment to equality.
Inequitable health care remains prevalent in the
United States.4-7 Each year since 2003, the Agency for
Healthcare Research and Quality has produced the
National Healthcare Quality and Disparities Report.
Using many different indicators of health care access,
process, and outcomes, these reports have repeatedly
shown that in the aggregate white patients receive
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better quality of care than patients who are black,
Hispanic, Asian, Native American, Alaska Native,
Native Hawaiian, or Pacific Islander.8 The U.S. De­
partment of Health and Human Services challenged
health care providers to eliminate these disparities in
its publications Healthy People 2010 and Healthy
People 2020, and with the newly proposed Healthy
People 2030 goals, which are now online (see www.
healthypeople.gov/2020/About-Healthy-People/
Development-Healthy-People-2030/Framework).9, 10
All three include among their overarching goals in­
creased longevity and quality of life, as well as the
elimination of U.S. health care disparities. Healthy
People 2020 adds to these goals the creation of “so­
cial and physical environments that promote good
health for all” and the promotion of “healthy devel­
opment and healthy behaviors across all life stages.”
The Joint Commission and the Institute for Healthcare
Improvement (IHI) echo these goals, urging health
care providers to evaluate and address disparities in
their personal practices.11, 12
IMPLICIT BIAS AND HEALTH CARE DISPARITIES
There are many reasons for health care disparities
in the United States, but the IOM reported that one
of the contributing factors is clinician bias toward
patients of racial, ethnic, or cultural minorities.
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Implicit biases among health care providers are
associated with the following negative effects on pa­
tient care4-7:
• inadequate patient assessments
• inappropriate diagnoses and treatment decisions
• less time involved in patient care
• patient discharges with insufficient follow-up
THE NATURE OF IMPLICIT BIAS
Implicit bias is part of the human condition. To be hu­
man is to prefer familiar people. Even very young ba­
bies learn to differentiate “my family” from “others,”
and to see their families as “safe” and “others” as po­
tentially dangerous. As we grow and develop, we are
exposed to massive amounts of data about people
and phenomena. To manage this information, we un­
consciously categorize and assign judgments (with
good or bad connotations) to the data. For example,
we may determine that one particular group is trust­
worthy or pleasant and another is dangerous or dis­
agreeable. Then, as we encounter new representatives
of these groups, we respond automatically, based on
our prior value judgments.
on limited previous encounters or poor sources of in­
formation, including the people who raised us, our
culture, media reports, or anecdotes, and they are
often unconsciously internalized.
Despite an individual’s commitment to egalitarian
values, implicit biases may be triggered by hidden
perceptions, attitudes, or memories.5, 14 The tendency
to default to our implicit biases is heightened in stress­
ful situations,6 perhaps because in such situations we
have less time and energy to consider whether our
initial impressions are correct or whether our behav­
ior aligns with our personal values and commitment
to treat others equitably and with respect.
IMPLICIT BIAS IN HEALTH CARE PROVIDERS
Few studies have specifically investigated implicit bias
among nurses or included large numbers of nurses
among study participants. Those that have address
only a few vulnerable patient populations and indicate
that nurses may be subject to implicit biases when car­
ing for patients who are elderly15; obese16; lesbian, gay,
bisexual, or transgender (LGBT)17; mentally ill18; or
who use injection drugs.19 Studies of implicit bias in
Nurses with implicit biases may demonstrate less
compassion for certain patients and invest less time and
effort in the therapeutic relationship with them,
adversely affecting assessment and care.
Implicit bias is theorized to be rooted in heuristics—
that is, mental shortcuts that help us sum up and re­
spond to situations quickly.13 Based on approaches
that worked for us in the past, we develop strategies
that help us interact automatically in new situations
with representatives of previously encountered groups
of people. Our default reactions can help us manage
our day-to-day activities by allowing us to assess and
act quickly, without deliberation. For example, if
you’re in the middle of a street and a car is headed
your way, you don’t try to determine how fast the car
is going, who is driving the car, or whether they will
stop to avoid hitting you; rather, you hurry across the
street. Heuristics often make life easier or safer and
our choices more efficient. They play an important
role in helping us navigate our environment. But our
automatic responses can generate subtle discrimina­
tory behaviors, which in a clinical context can result
in poor health care delivery.
Stereotypes are often pejorative characteriza­
tions of groups of people that are frequently based
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nurses based on race, ethnicity, religion, disability, or
stigmatized diagnoses are difficult to find, though
small numbers of nurses were included in some stud­
ies of implicit bias among health care providers that
address these predispositions.
Much of the research focused on implicit bias in
physicians or health care teams indicates that provid­
ers’ biases influence their relationships with patients,
the care they provide, and the patients’ health out­
comes. Two comprehensive systematic reviews and
two narrative reviews of studies on the topic shed
light on the nature of implicit bias among health care
providers, its manifestations and effects on patients,
and the situations that promote or exacerbate it.
In their systematic review, FitzGerald and Hurst an­
alyzed 42 studies about health care provider biases, in­
cluding those related to race, ethnicity, socioeconomic
status, literacy, and other factors that render patients
vulnerable to stigmatization.5 Of the 42 studies they re­
viewed, 15 measured biases using an Implicit Associa­
tion Test (IAT), two used subliminal priming, and 25
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used the “assumption method,” which measures par­
ticipant differences in response to clinical vignettes that
are identical except in one respect, such as the race of
the subject. The authors suggested that implicit bias
among health care providers occurred at about the
same rate as it did in the population at large. In 20 of
the 25 studies that used the assumption method, they
found that provider biases appeared to have influenced
diagnoses, treatment recommendations, thoroughness
of patient histories, or the number of tests that were
ordered. They also noted a negative correlation be­
tween the level of implicit bias and indicators of qual­
ity care, a finding they suggest points to an increased
likelihood of poorer outcomes.
Similarly, a systematic review conducted by Hall
and colleagues found that most health care providers
harbor implicit bias toward people of color. This bias
is reflected both in providers’ interactions with pa­
tients and in providers’ treatment decisions, thereby
affecting patient adherence and outcomes, with pa­
tients’ psychosocial health outcomes (for example,
social integration, depression, and life satisfaction)
more adversely affected by provider bias than phys­
ical health outcomes.6
A narrative review by Chapman and colleagues
found that providers with high levels of implicit bias
were perceived by black patients as having poorer
communication skills, delivering a lower quality of
care, and being “less warm, friendly, and team ori­
ented.” The investigators contend that these per­
ceptions could reduce patient adherence, return for
follow-up appointments, and trust in health care
providers.4
Zestcott and colleagues cite studies in their narra­
tive review indicating that providers with implicit bi­
ases spend less time listening to black patients and
that, in the absence of any supportive evidence, pro­
viders hold implicit assumptions that black and His­
panic patients are less likely to adhere to treatment
and are less cooperative than white patients.7 They
note one study suggesting that providers’ difficulty
communicating with Hispanic patients may explain
some of the implicit bias directed at that group and
suggest additional research exploring whether implicit
biases are less likely to influence care in the presence
of clear clinical guidelines that outline evidence-based
best practices.
As with physicians and other health care provid­
ers, nurses with implicit biases may demonstrate less
compassion for certain patients and invest less time
and effort in the therapeutic relationship with them,
adversely affecting assessment and care.
STRATEGIES FOR MANAGING IMPLICIT BIAS
Social scientists have developed strategies that have
been shown to mitigate implicit biases. These include
counterstereotypic imaging, emotional regulation,
habit replacement, increasing opportunities for contact,
[email protected]
individuation, mindfulness, partnership building, per­
spective taking, and stereotype replacement.11, 12, 20-28
(See Table 1.11, 12, 20-28) Health care providers can view
these strategies as tools, putting those they find most
effective into their own personal bias-fighting toolkit.
Recommendations from the Joint Commission
and IHI. The Joint Commission specifically recom­
mends that health care providers use emotional reg­
ulation (controlling thoughts and emotions during
clinical encounters), partnership building (working
with patients as equals toward the common goal of
helping them achieve good health), and perspective
taking (trying to understand the perspective of the
patient) to decrease biases that may lead to health
care disparities.12 In addition to partnership building
and perspective taking, the IHI recommends reduc­
ing bias with counterstereotypic imaging (imagining
the stereotyped person as the opposite of the stereo­
type), individuation (learning about the personal his­
tory of the individual), increasing opportunities for
contact with people from different groups (develop­
ing relationships with members of a different group
with the goal of dissolving stereotypes), and stereo­
type replacement (consciously replacing negative im­
ages of a group with positive images).11
Despite an individual’s commitment
to egalitarian values, implicit biases
may be triggered by hidden perceptions,
attitudes, or memories.
Strategies based in nursing practice. Habit replacement will seem familiar to many nurses because
it’s very similar to the teaching and coaching tech­
niques we use when encouraging patients to change
harmful lifestyle behaviors like smoking or eating a
high-fat or high-sodium diet. And just as a single pa­
tient teaching session is unlikely to help a patient
change lifestyle behaviors, Lai and colleagues found
that one-time interventions to mitigate health care
provider biases, though initially effective, did not
change behavior over time.27 Instead, nurses can use
habit-breaking strategies in conjunction with biasmitigating strategies by employing their own personal
toolkit of bias-breaking interventions.23 They can de­
sign an action plan to dissolve implicit biases with new
behaviors. The plan could include the following steps:
• Recognize the habit’s damaging effects (for exam­
ple, inequitable health care and disparate patient
outcomes).
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• Make a commitment to break the habit, recalling
the Code of Ethics for Nurses1 and the values that
brought you to nursing.
• Use several of the bias-mitigating strategies listed
in Table 1.
• Persistently practice the more desirable habits us­
ing the bias-mitigating strategies you find most
effective.
The habit of nonbiased thinking needs to be con­
sciously practiced over time. Each strategy in the tool­
kit can help reinforce the others,23 and eventually the
habit of biased thinking can to a greater or lesser de­
gree be replaced by the habit of nonbiased thinking.
Mindfulness is another bias-management strat­
egy familiar to nurses. The specific goal of mindful­
ness is to empty the mind of distracting thoughts so
Table 1. Self-Interventions to Mitigate Implicit Bias11, 12, 20-28
40
Strategies
Description
Recommended by
Counterstereotypic
imaging
Nurse, recognizing bias, purposely identifies members of a
group who counter the stereotypical image of the group,
and replaces the automatic biased image with the positive
image. Related to mindfulness.
Institute for Healthcare Improvement,
2017
Emotional regulation
Nurse reflects on “gut feelings” and negative reactions (dislike, fear, frustration) to patients from vulnerable groups.
Nurse then intentionally strives to be empathetic, patient,
and compassionate. Related to mindfulness and perspective taking.
Joint Commission,
2016
Habit replacement
Nurse frames recognized biases as bad habits to be broken.
Develops and uses a personal toolkit of self-interventions
to replace the bad habit of biased thinking with the good
habit of accepting and caring about each patient as an individual. Related to emotional regulation, individuation,
mindfulness, and strategies nurses use to help patients
change harmful lifestyle behaviors.
Devine and
colleagues, 2012
Increasing opportunities
for contact
Nurse seeks to develop relationships with members of a
group to which the nurse does not belong, with the goal
of dissolving stereotypes.
Institute for Healthcare Improvement,
2017
Individuation
Nurse mindfully seeks to see patients as individuals instead of as members of a stigmatized group. Related to
therapeutic relationship, patient-centered care, and culturally competent care.
Institute for Healthcare Improvement,
2017
Mindfulness
Nurse purposely takes the time to calm thoughts and feelings by being mindful of the present moment, which can
help the nurse act compassionately toward the patient.
Related to emotional regulation and perspective taking.
Burgess and
colleagues, 2017
Partnership building
Nurse intentionally frames the clinical encounter as one in
which the nurse and patient are equals, working collaboratively toward the same goal.
Institute for Healthcare Improvement,
2017, and Joint
Commission, 2016
Perspective taking
Nurse purposely and empathetically thinks about what
the patient is thinking and feeling, stimulating feelings of
caring and compassion. Related to mindfulness and therapeutic relationship.
Institute for Healthcare Improvement,
2017, and Joint
Commission, 2016
Stereotype replacement
Nurse reflects on negative reactions to members of vulnerable populations, acknowledges stereotypical responses,
considers reason for the feeling, and commits to respond
with compassion in the future. Related to self-reflection.
Institute for Healthcare Improvement,
2017
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that we might focus on the present moment, with­
out assumptions or judgments.29 It allows us to be
more deliberative in our actions and enables us to
recognize our biases before we automatically act on
them. Mindfulness interventions have been used to
reduce stress and to improve provider–patient com­
munication.28 The concept of mindfulness is related
to the ethical concepts of empathy and compassion,
which are cornerstones of nursing.
Ponte and Koppel suggest using the S.T.O.P. mind­
fulness technique developed by Elisha Goldstein to be­
come mindful of the assumptions we want to avoid or
the values we want to bring to our patients.28, 30 Before
entering the patient’s room, a nurse might take several
seconds to do the following:
• Stop what you’re doing.
• Take some slow, deep breaths.
• Observe your thoughts, feelings, and assump­
tions.
• Proceed with patient care.
The goal of this practice is to help nurses recognize
what they are feeling about the patient, so they can
ground themselves in the values they wish to bring to
the patient encounter.
anxious, or fearful. Such feelings may indicate im­
plicit bias and prompt self-reflection. Thoughtfully
reflecting on the meaning and origin of such feelings
and whether they influence the quality of relation­
ships with patients can help nurses acknowledge and
control previously unrecognized biases.
IATs. Another way to discover implicit biases is
to take one or more of the IATs available at Proj­
ect Implicit (https://implicit.harvard.edu/implicit/
education.html), an international, nonprofit organi­
zation founded in 1998 by scientists from the Uni­
versity of Washington, Harvard University, and the
University of Virginia.31 This website contains 14 in­
struments for measuring some of the most prevalent
biases—those related to race, ethnicity, skin color,
religion, age, gender, overweight or obesity, sexual
orientation, or disability. The web-based instruments
developed by the Project Implicit research group are
the tools most widely used by researchers investigat­
ing biases.5, 31 According to the program manager of
Project Implicit, in 2018, approximately 25 million
people had completed, or at least started taking, the
tests on this website (e-mail communication, April
2019). The tests are readily accessible, without cost,
One way to discover implicit biases is to pay attention to gut
feelings. Nurses can ask themselves if they anticipate unpleasant
experiences when caring for any particular group of patients, or if
any group makes them feel uncomfortable, anxious, or fearful.
Burgess and colleagues have proposed that health
care providers can use mindfulness techniques to rec­
ognize, reduce, and control implicit biases.22 They cite
literature suggesting that mindfulness can reduce im­
plicit biases among health care providers by prevent­
ing the triggering of automatic stereotypic reactions
and can enable clinicians to recognize and moderate
their biases even after they have been triggered. They
cite studies suggesting that mindfulness promotes
compassion. Since stressed clinicians are more likely
to rely on their automatic (potentially biased) first
impressions, reducing stress lessens the risk of im­
plicit bias in clinical encounters.
RECOGNIZING IMPLICIT BIASES
One way to discover implicit biases is to pay atten­
tion to gut feelings. Nurses can ask themselves if they
anticipate unpleasant experiences when caring for
any particular group of patients, or if any particular
group of patients makes them feel uncomfortable,
[email protected]
to anyone who seeks to understand more about their
hidden biases. Each test takes about 10 minutes to
complete. The tests consist of images and evaluative
statements that the test taker is instructed to sort as
quickly as possible.
After completing a test, test takers immediately
receive their results. Although it can be upsetting to
receive results indicating potential implicit biases,
learning about these can enable people to employ
strategies to reduce them or mitigate their effects on
future interactions. Although the IATs are reliable and
valid research instruments, their developers explicitly
state that, at their current stage of development, they
should not be used to diagnose bias but rather as edu­
cational tools.31
It’s important to remember that implicit bias is
different from prejudice. Implicit bias means we have
the instinctive tendency to evaluate other groups
against the norms of our own groups. Prejudice, on
the other hand, means that one feels consciously and
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overtly that some groups are inferior, an attitude that
can be used to justify discriminatory actions.
ADHERING TO NURSING’S BEST PRACTICES
Nursing’s best practices include the development of
strong therapeutic relationships and the provision
of culturally competent, patient-centered care.32, 33
Nurses who are committed to these practices form
positive relationships with their patients, which dis­
solve bias.
Therapeutic relationships. To be successful in
meeting patients’ health goals, nurses are encouraged
to establish a therapeutic relationship with each of
their patients. The key to a therapeutic relationship is
true caring for the patient.34 Caring therapeutic rela­
tionships start with getting to know patients and their
unique values, priorities, challenges, and strengths.
Understanding each patient’s perspective, the nurse
works with the patient to achieve the patient’s health
care goals.
Patient-centered care emphasizes patients as col­
laborative partners with unique psychosocial needs
that are as important as their clinical needs.35 Patientcentered care requires us to listen carefully and re­
spectfully to patients until we understand them as
individuals with unique needs and preferences, though
they may belong to groups with which we are unfa­
miliar or uncomfortable. With understanding, we can
develop care plans that meet patients’ psychosocial
needs, including those for respect and consideration.
Culturally competent care. Patients whose back­
ground differs from that of their care providers in
any way (race, ethnicity, religion, sexual orientation,
gender identification, socioeconomic status, disabili­
ties, stigmatized diagnoses, or any characteristic that
distinguishes them from societal norms) are entitled
to receive care that is effective and respectful of their
cultural differences. Culturally competent care is an
intrinsic element of the patient-centered care initia­
tive.36 Culturally competent care is patient-centered
care, and patient-centered care is culturally compe­
tent care.
Embedded in each of these concepts are the strat­
egies of individuation, perspective taking, and part­
nership building. Together, these approaches subvert
the negative automatic responses that characterize
implicit bias, enabling us to meet our patients’ need
for individualized respectful care.
Individuation requires us to listen carefully and re­
spectfully to patients, seeking to understand their per­
spectives, experiences, values, preferences, and hopes.
Perspective taking challenges us to understand
what patients are thinking and feeling, to see their
illness through their eyes. This can often be accom­
plished when we show genuine interest in patients
and ask them about their experience with their cur­
rent illness and the way it affects their families and
lives.
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Partnership building recognizes the important
role patients have in their own care. Nurse and pa­
tient collaborate, aligning the care plan with the pa­
tient’s goals in order to promote patient adherence
and well-being.
WHEN BIASES PERSIST
Implicit biases are difficult to eliminate, but when
nurses acknowledge those they have, they can try to
understand their origin and work to ensure that they
do not adversely affect patient care. Health care agen­
cies and facilities can guide clinicians toward unbiased
care by supporting clear practice guidelines, such as
those published by professional organizations for dis­
ease management and organizations promoting eq­
uitable care. Such guidelines provide a clear path to
good care, limiting the influence of implicit biases by
leaving little open to subjective interpretation in terms
of assessment, diagnosis, treatment, and follow-up.37
In addition, health care organizations can
• provide educational sessions on the causes and ef­
fects of implicit bias, as well as mitigation strategies.
• seek to reduce factors, such as inadequate staffing,
that create stress, putting staff at risk for inappro­
priately using heuristics to guide care.
When individual nurses work to recognize biases
and employ strategies to counter them, and health
care organizations seek to reduce stress that can per­
petuate the inappropriate use of heuristic responses,
we grow in our abilities to develop therapeutic rela­
tionships and to provide culturally competent and
patient-centered care. In the process, we advance the
proposed Healthy People 2030 goal of eliminating
health care disparities in the United States. ▼
For 22 additional continuing nursing education
activities on the topic of patient-centered care, go
to www.nursingcenter.com/ce.
Mary Curry Narayan is a home health clinical nurse specialist, a
certified transcultural nurse, a clinical education consultant, and
a doctoral student at George Mason University College of Health
and Human Services, Fairfax, VA. The author thanks Lauren
Kuykendall, PhD, and R. Kevin Mallinson, PhD, RN, both of
George Mason University, for their recommendations in the preparation of this manuscript. Contact author: marycnarayan@gmail.
com. The author and planners have disclosed no potential conflicts
of interest, financial or otherwise.
REFERENCES
1. American Nurses Association. Code of ethics for nurses with
interpretive statements. 2nd ed. Silver Spring, MD; 2015.
2. Smedley BD, et al., editors. Unequal treatment: confronting
racial and ethnic disparities in health care. Washington, DC:
National Academies Press; 2003.
3. Braveman PA, et al. Health disparities and health equity: the
issue is justice. Am J Public Health 2011;101 Suppl 1:S149S155.
4. Chapman EN, et al. Physicians and implicit bias: how doctors
may unwittingly perpetuate health care disparities. J Gen Intern
Med 2013;28(11):1504-10.
ajnonline.com
5. FitzGerald C, Hurst S. Implicit bias in healthcare professionals:
a systematic review. BMC Med Ethics 2017;18(1):19.
6. Hall WJ, et al. Implicit racial/ethnic bias among health care
professionals and its influence on health care outcomes: a
systematic review. Am J Public Health 2015;105(12):e60-e76.
7. Zestcott CA, et al. Examining the presence, consequences, and
reduction of implicit bias in health care: a narrative review.
Group Process Intergroup Relat 2016;19(4):528-42.
8. Agency for Healthcare Research and Quality. 2017 national
healthcare quality and disparities report. Rockville, MD; 2018
Sep. AHRQ Pub. No. 18-0033-EF. https://www.ahrq.gov/sites/
default/files/wysiwyg/research/findings/nhqrdr/2017nhqdr.pdf.
9. U.S. Department of Health and Human Services. Healthy
people 2010: understanding and improving health. Washington,
DC; 2000. https://www.healthypeople.gov/2010/document/pdf/
uih/2010uih.pdf.
10. U.S. Department of Health and Human Services. Healthy
People 2020; 2010 Nov. ODPHP Publication No. B0132.
https://www.healthypeople.gov/sites/default/files/HP2020_
brochure_with_LHI_508_FNL.pdf.
11. Institute for Healthcare Improvement, IHI Multimedia
Team. How to reduce implicit bias. 2017. http://www.ihi.
org/communities/blogs/how-to-reduce-implicit-bias.
12. Joint Commission. Implicit bias in health care. Oakbrook
Terrace, IL; 2016 Apr. Quick safety: an advisory on safety
and quality issues, issue 23; https://www.jointcommission.
org/assets/1/23/Quick_Safety_Issue_23_Apr_2016.pdf.
13. Kahneman D. Thinking fast and slow. New York, NY: Farrar,
Straus and Giroux; 2011.
14. Blair IV, et al. Unconscious (implicit) bias and health dispari­
ties: where do we go from here? Perm J 2011;15(2):71-8.
15. Schroyen S, et al. Ageism and caring attitudes among nurses
in oncology. Int Psychogeriatr 2016;28(5):749-57.
16. Waller T, et al. Assessing bias against overweight individuals
among nursing and psychology students: an implicit associa­
tion test. J Clin Nurs 2012;21(23-24):3504-12.
17. Sabin JA, et al. Health care providers’ implicit and explicit
attitudes toward lesbian women and gay men. Am J Public
Health 2015;105(9):1831-41.
18. de Jacq K, et al. The variability of nursing attitudes toward
mental illness: an integrative review. Arch Psychiatr Nurs
2016;30(6):788-96.
19. von Hippel W, et al. Implicit prejudice toward injecting drug
users predicts intentions to change jobs among drug and al­
cohol nurses. Psychol Sci 2008;19(1):7-11.
20. Allport GW. The nature of prejudice. Reading, MA: AddisonWesley Publishing Company; 1954.
21. Ames DL, et al. Taking another person’s perspective increases
self-referential neural processing. Psychol Sci 2008;19(7):642-4.
22. Burgess DJ, et al. Mindfulness practice: a promising approach
to reducing the effects of clinician implicit bias on patients.
Patient Educ Couns 2017;100(2):372-6.
23. Devine PG, et al. Long-term reduction in implicit race bias:
a prejudice habit-breaking intervention. J Exp Soc Psychol
2012;48(6):1267-78.
24. Foroni F, Mayr U. The power of a story: new, automatic as­
sociations from a single reading of a short scenario. Psychon
Bull Rev 2005;12(1):139-44.
25. Koole SL. The psychology of emotion regulation: an integra­
tive review. Cogn Emot 2009;23(1):4-41.
26. Lai CK, et al. Reducing implicit racial preferences: I. A com­
parative investigation of 17 interventions. J Exp Psychol Gen
2014;143(4):1765-85.
27. Lai CK, et al. Reducing implicit racial preferences: II. Interven­
tion effectiveness across time. J Exp Psychol Gen 2016;145(8):
1001-16.
28. Ponte PR, Koppel P. Cultivating mindfulness to enhance nurs­
ing practice. Am J Nurs 2015;115(6):48-55.
29. Kiken LG, et al. From a state to a trait: trajectories of state
mindfulness in meditation during intervention predict changes
in trait mindfulness. Pers Individ Dif 2015;81:41-6.
30. Goldstein E. Stressing out? S.T.O.P. Mindful 2013 May 29.

31. Project Implicit. Implicit Association Test (IAT) overview.
2011. https://implicit.harvard.edu/implicit/education.html.
32. Campinha-Bacote J. Delivering patient-centered care in the
midst of a cultural conflict: the role of cultural competence.
Online J Issues Nurs 2011;16(2):5.
33. Campinha-Bacote J. The process of cultural competence in
the delivery of healthcare services. Blue Ash, OH: Transcul­
tural C.A.R.E. Associates; 2015. http://transculturalcare.net/
the-process-of-cultural-competence-in-the-delivery-of-health­
care-services.
34. Registered Nurses Association of Ontario. Nursing best practice guideline: establishing therapeutic relationships. Supplement. Toronto, ON; 2006 Mar. https://rnao.ca/sites/rnao-ca/
files/storage/related/943_BPG_TR_Supplement.pdf.
35. NEJM Catalyst. What is patient-centered care? 2017. https://
catalyst.nejm.org/what-is-patient-centered-care.
36. Joint Commission. Advancing effective communication, cultural competence, and patient- and family-centered care: a
roadmap for hospitals. Oakbrook Terrace, IL; 2010. https://
www.jointcommission.org/assets/1/6/ARoadmapforHospitals
finalversion727.pdf.
37. U.S. Department of Health and Human Services, Office of
Minority Health. National standards for culturally and linguistically appropriate services in health and health care: a
blueprint for advancing and sustaining CLAS policy and
practice; 2013 Apr. https://www.thinkculturalhealth.hhs.
gov/pdfs/EnhancedCLASStandardsBlueprint.pdf.
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