Implicit Bias and Cultural Competency Nursing CE Course

applies their knowledge of a client's culture to their care delivery (Potter et al., 2022).

Transcultural nursing means providing health care to patients based on their culture, values, health-illness context, and beliefs. This concept has emerged in response to the increasing diversity of patients in the health care system. It is a framework for providing culturally sensitive care to patients from diverse backgrounds (Openstax, n.d.).

Crosscultural care refers to care for every patient that focuses on the ability to communicate effectively and provide quality health care to all patients (Betancourt et al., 2024).

Cultural humility is the practice of self-reflection on how one's background and the background of others impact various interactions such as learning, health care, engagement, leadership, and teaching. In addition, the practice of cultural humility means committing to work individually and with others to end inequity and power imbalances (CDC, 2024b; University of Oregon, n.d.).

Culture comprises a group of people who share beliefs, faith systems, values, ways of thinking, and actions. Culture provides a framework in which illness is defined, as people tend to react differently to disease based on their cultural perspective. Patients vary widely in their cultural and spiritual backgrounds and belief systems. Culture includes multiple attributes such as communication style, language, customs, norms, traditions, religion, art, music, dress, and health beliefs and practices. Because culture influences health beliefs and practices, HCPs must examine and address their preconceptions before providing optimal cultural and spiritual care to their patients. When a patient enters the health care system, the HCP's culture, the patient's culture, and the culture of medicine are all juxtaposed. All three cultures influence the outcome of the encounter, and crosscultural care and communication are critical. The core values of crosscultural communication include empathy, curiosity, and respect (Betancourt et al., 2024; NIH, 2024; Potter et al., 2022).

Background

Mahzarin Banaji and Anthony Greenwald first coined the term implicit bias in 1995, arguing that unconscious associations and judgments primarily influence social behavior. These researchers theorized that for every conscious decision made, there are many more decisions made unconsciously based on previously learned information. The human brain begins learning from the moment of birth. People use feedback from loved ones, friends, caretakers, teachers, and the media to alter behavior and shape beliefs early in life. With large amounts of data to process, we categorize and assign judgments (good or bad) to the data. Therefore, inherent biases are formed through exposure to, responses to, and feedback from various sources. For example, people exhibit biases when they exhibit a preference for or aversion to a group of people. These biases are the foundation for stereotypes, prejudice, and discrimination. Once learned, it is difficult to change these stereotypes and prejudices, even when evidence disproves them. Research has shown that implicit bias, specifically bias favoring White individuals and cultures associated with them, occurs in children as young as 3 to 5 years old (Chapman et al., 2013; Glas & Faloye, 2020; Narayan, 2019; Perception Institute, n.d.).

Some biases may be exhibited with awareness and intention, known as intentional or explicit biases. However, implicit biases reside deep in the subconscious and are not accessible through introspection (e.g., examining one's mental and emotional processes). Because most actions occur without conscious thought, implicit biases will often predict how people respond more accurately than conscious values. For example, HCPs can value and intend to provide equitable care to all patients. However, research shows that implicit bias creates health disparities and inequities. Thus, HCPs will use these unconscious attitudes, perceptions, or judgments when making clinical decisions. In addition, stressful situations can compound implicit bias, as acting from these unconscious, initial perceptions requires less time and energy. Therefore, HCPs may exhibit attitudes or behaviors that do not align with their commitment to equitable care (Glas & Faloye, 2020; Narayan, 2019; Perception Institute, n.d.).

Health Disparity and Inequity

Despite increased awareness among patients and providers, disparities in health and health care remain pervasive. Health inequities appear in health outcomes and health care, arising from educational, environmental, and socioeconomic factors. Health results from a complex interplay of factors, including individual (e.g., genetics, lifestyle), population group (e.g., sex, gender, sexual orientation, race and ethnicity, immigration status), and SDOH. There is a strong link between social determinants and health care disparity. Social attributes such as income/wealth, education, access to health care, family and household structure, social support, occupation, neighborhood conditions, and social institutions are examples of SDOH. For example, children living in poverty are more likely to experience obesity. Studies have also shown that Black people are more likely to die of cardiovascular disease than their White counterparts. In addition, transgender men are less likely to have adequate Papanicolaou screening than cisgender  women. Anyone can experience a health disparity based on race, ethnicity, age, sex, gender, sexual identity, religion, immigration status, socioeconomic status, or other characteristics. While social, environmental, and economic disadvantages can impact the degree of health and disease risk factors, they do not account for all gaps in health outcomes among various populations (CDC, 2020; Norris & Harris, 2024; Office of Disease Prevention and Health Promotion, n.d.; Potter et al., 2022).

Although progress has been made in narrowing the gap in health outcomes, health disparities have not been eliminated. For example, the rate of preterm birth declined by 1% from 2021 to 2022. However, Black women have the highest percentage of preterm births (14.6%) compared to White (9.4%) and Hispanic (10.1%) women. In addition, the rates of low-birth-weight infants have increased for Black and Hispanic infants. Infant mortality rates are also higher for non-Hispanic Black (10.9 per 1,000 births), non-Hispanic Indigenous Peoples and Alaska Native (9.1 per 1,000 births), and non-Hispanic Native Hawaiian and Pacific Islander infants (8.5 per 1,000 births; Baciu et al., 2017; CDC, 2024d, 2024e).

Obesity is another condition that affects underrepresented racial and ethnic groups at a disproportional rate. Hispanic children and adolescents (ages 2 to 19) have the highest prevalence of obesity in the US (21.9%). Heart disease is a leading cause of death and disability, disproportionately affecting people of certain races, ethnicities, and genders. For example, Black Americans are 30% more likely to die prematurely from heart disease than their White counterparts. In addition, Black men in the US are twice as likely to die prematurely from a stroke than their White peers. Although the health disparity gap for most outcomes has decreased over time, the gap has increased for some. For example, the Black-White disparity gap for AIDS has grown substantially in diagnoses and mortality (Baciu et al., 2017; Office of Minority Health [OMH], 2023a, 2023b).

Furthermore, approximately 61 million US adults are affected by a disability, which translates to 26% of the US population. Individuals with disabilities face many health disparities, such as higher rates of obesity, smoking, and inactivity; fewer preventive screenings; and higher rates of death from breast and lung cancers. Research also suggests that some LGBTQIA people have more chronic conditions, with a higher prevalence and an earlier onset of disabilities than individuals who do not identify as LGBTQIA (CDC, 2020; Lampe et al., 2024). In the US, the identified LGBTQIA population has increased to 7.6%, highlighting the need for additional cultural competence to reduce health care disparities for this community in particular (Gallup, 2024).

Health care disparities result in poor health outcomes for specific populations and a significant financial burden. The excess disease burden from health care disparities leads to increased costs for health organizations, patients and caregivers, insurers, and employers (through lower work productivity and higher absenteeism). In 2009, the total cost of racial/ethnic disparities was approximately $82 billion, with $60 billion in excess health care costs and $22 billion in lost productivity. In 2018, the total cost rose to $451 billion, which is equivalent to $1,377 per person. A disproportionate share of health care costs in the US is related to patients with complex health needs. Because individuals with lower socioeconomic status and underrepresented racial/ethnic groups often have more chronic health conditions, their cost of care is significantly higher. In addition, underrepresented racial/ethnic groups are more likely to experience adverse events, longer hospitalizations, and more readmissions, and undergo inappropriate and costly tests. These health disparities and inequities primarily occur due to ineffective communication processes, a limited ability to understand different cultures, and implicit biases (LaVeist et al., 2023; Wyatt et al., 2016).

Racism

Interpersonal and structural racism are fundamental causes of health disparities and health inequities. According to the OMH, statistics show that the US population has become increasingly diverse, with approximately 25% of the population being people of color. However, racism can negatively affect a person's physical and mental health, preventing them from attaining optimal health. Across the country, people of color experience poorer health than their White counterparts. These individuals are more likely to be diagnosed with diabetes mellitus, hypertension, obesity, asthma, and heart disease. In addition, Black Americans have a 4-year lower life expectancy than White Americans. Recent data have also shown that Black American, Hispanic/Latino, Indigenous Peoples, and Alaska Native populations experience higher rates of hospitalization and death from COVID-19. These health disparities exist even when accounting for other socioeconomic factors. Both current and historical experiences of racism and discrimination have often led to mistrust of the health care system by people of color. Forced sterilization of women and the Untreated Syphilis Study at Tuskegee are examples of medical abuse that contribute to distrust of the health care system for affected racial communities. This mistrust has carried forward to the COVID-19 pandemic, fueling suspicion of vaccines, vaccine providers, and institutions making recommendations regarding the use of vaccines (CDC, 2020; Norris & Harris, 2024; OMH, 2024a, 2024b).

Interpersonal racism refers to biased responses when individuals interact with others of a different race. For example, interpersonal racism was evident throughout the COVID-19 pandemic, with various attacks on Asian and Asian American communities. Microaggressions (i.e., verbal, behavioral, or environmental discriminatory actions that are typically subtle or indirect, whether intentional or unintentional, against members of a particular group) are forms of interpersonal racism (OMH, 2024a, 2024b; Togioka et al., 2024). According to the National Institute on Minority Health and Health Disparities (NIMHD; 2024), structural racism and discrimination refer to the macro-level conditions, such as institutional policies or residential segregation, that impact individuals and populations. Structural racism and discrimination can limit opportunities and resources that negatively impact access to health care and the well-being of affected individuals or populations based on race, ethnicity, sex, gender, religion, immigration status, physical characteristics or health conditions, sexual identity, social class, or other status. For example, neighborhood segregation has been shown to impact racial disparities directly in health outcomes (NIMHD, 2024).

In the 19th and 20th centuries, racism fueled the segregation of Black and White people in the United States, with segregated hospitals delivering separate and unequal health care. The Civil Rights Act of 1964 was the first step toward desegregating hospitals. However, many of these institutions refused to desegregate until the Medicaid and Medicare program in 1966 threatened to withhold federal funding. Many local, state, and national organizations have attempted to address health and health care inequities in the past few decades. In 1985, the OMH released the Heckler Report, which addressed racial and minority health. It recommended a nationwide approach to improving minority health. In 2003, the IOM released the Unequal Treatment report discussed previously, which included recommendations for addressing disparities in practice and research. Finally, in 2010, the NIMHD became part of the NIH in response to the Affordable Care Act (ACA) becoming law. The NIMHD was tasked with eliminating inequities in health and health care. However, despite efforts at the local, state, organizational, and national levels, health and health care inequities remain due to structural racism (IOM, 2003; Ortega & Roby, 2021).

The ACA was designed to address health inequities by expanding access to health care for more populations (i.e., those experiencing economic inequality who are uninsured). However, even with the expansion of Medicaid and the insurance marketplace, health insurance inequities persist. Another component of the ACA was the shift from fee-for-service to value-based programs to reduce spending and increase the value of care. In addition, incentives were given to institutions that engaged in care coordination and penalized poor-performing hospitals. However, safety-net hospitals (e.g., those serving low-income populations) are less likely to have the resources to engage in value-based models and, therefore, are more likely to be penalized. In addition, lower payment rates from Medicaid and Medicare result in fewer providers accepting patients with these types of insurance. Finally, although numerous studies have demonstrated the continued inequities in health and health care, many researchers fail to connect systemic and structural racism as the likely driver of these inequities. These studies highlight that the problem of health inequity persists, but research has failed to explain how racism and discrimination can impact the poor quality of care. Without citing racism as a primary driver of health or health care inequities, researchers and organizations can propose or imply harmful conclusions to explain the data, such as blaming health inequities on the populations affected by them. These examples demonstrate that structural racism persists and contributes to ongoing health inequities experienced by populations of color (Ortega & Roby, 2021; Togioka et al., 2024).

Implicit Bias in Health Care

Implicit bias affects everyone. Every individual makes unconscious judgments or stereotypes about other people or experiences the biases of others based on a differentiating status. Implicit bias involves activity throughout the brain, including the frontal cortex (i.e., reasoning, first impressions, and empathy), amygdala (i.e., automatic responses to stimuli and fear-flight-freeze response), and temporal lobes (i.e., storage of basic information about individuals and social stereotypes). In some situations, implicit bias can be helpful. For example, a person can quickly assess and instinctually respond based on learned behavior when faced with a dangerous situation. However, implicit bias is usually manifested when automatic responses combined with social conditioning result in bias against another individual based on a differentiating status such as race, ability, immigration status, or sexual identity (American Academy of Family Physicians [AAFP], 2019; Sabin, 2022).

The Implicit Association Test (IAT) is a computerized measurement of implicit preferences that bypasses conscious processing. The University of Virginia, the University of Washington, and Harvard University collaborated to form Project Implicit, using the IAT to examine the thoughts and feelings outside conscious awareness or control. As a result, more than 4.5 million IAT tests were completed between 1998 and 2006, demonstrating that (a) implicit bias is pervasive, (b) individuals are often unaware of their implicit bias, (c) implicit biases can predict behavior, and (d) individuals have different levels of implicit bias. Many health care organizations have begun administering the IAT to HCPs, highlighting that implicit bias exists among HCPs at the same rates as the general population. For example, when the IAT was administered at a conference about obesity-related issues, the results showed that participants associated obese individuals with stereotypes such as being lazy and worthless (Institute for Healthcare Improvement [IHI], 2017; Project Implicit, n.d.). Gopal and colleagues (2021) conducted a systematic review and found that the IAT was commonly used throughout the literature. However, other researchers have questioned whether the IAT can accurately predict discrimination. Due to the conflicting information in the literature, Gopal and colleagues (2021) recommend that the IAT only be used as a tool for self-reflection and learning and not for punitive reasons.

Research has shown that an HCP's implicit bias can negatively impact the patient-provider relationship. In addition, implicit bias can influence treatment decisions, treatment adherence, clinical decision-making, and patient health outcomes. These biases, though unintentional, can have severe consequences for health and health care. Not only can implicit bias perpetuate health care disparities, but it can also negatively impact patient-centered care, communication, trust, and interpersonal treatment. HCPs may not be aware of their implicit bias, but their patients likely are. When a patient experiences implicit bias, they are more likely to rate their experience poorly and less likely to engage meaningfully in their care. Therefore, implicit bias can impact whether patients seek services at a particular organization. Whether explicitly or implicitly, HCPs can make assumptions about patients that can negatively impact the care given. For example, some HCPs may limit shared decision-making or explanations of medical concepts because they assume a patient has limited health literacy. Similarly, HCPs may limit treatment options because they assume that patients cannot afford them (Heath, 2024; IHI, 2017). Other examples of how implicit bias has impacted health care include the following (Baciu et al., 2017; Chopik & Giasson, 2017; IHI, 2017; Vela et al., 2022):

• Black women are more likely to die after a breast cancer diagnosis.
• People of color are more likely to be labeled as too passive about their health care.
• Black men are less likely to receive chemotherapy or radiation therapy for prostate cancer but more likely to have testicle(s) removed for testicular cancer.
• Women are three times less likely to receive a knee arthroplasty than men when clinically appropriate. An underlying bias in this situation is that men are more stoic and more inclined to participate in strenuous activity.
• Black and Latino patients experience longer wait times for medical care. In addition, White HCPs often spend less time with patients of color.
• Non-White patients are less likely to have pain medication (i.e., narcotic or non-narcotic) prescribed. One reason for this variation in treatment is the false belief that Black individuals have tougher skin than White individuals.
• Non-White patients receive fewer renal transplants than White patients.
• Non-White patients receive fewer cardiovascular interventions than White patients.
• Black patients are more likely to die in the ICU while receiving life-sustaining interventions rather than transitioning to hospice care.
• Pediatric non-White patients are less likely to be accurately diagnosed with cystic fibrosis because it is falsely considered a "White disease."
• Negative attitudes or stereotyping about older age are associated with memory impairments, slower recovery from disability, and poor health behavior and physical functioning for aging patients.

Power Dynamics

The patient-provider relationship can foster patient engagement in their care and establish trust. However, a power dynamic can potentially influence this relationship (i.e., how power affects a relationship between two or more people). HCPs are well-educated individuals tasked with providing high-quality, equitable care to patients across various races, ethnicities, gender identities, and other statuses. Unfortunately, HCPs can display implicit bias during patient-provider interactions, resulting in a negative experience and mistrust. When patients experience implicit bias from providers, they may interpret care recommendations as a form of control or dominance in the relationship. Therefore, HCPs must be acutely aware of their communication patterns, particularly their verbiage. According to social psychology theories, people in powerful positions can use first-person plural pronouns (i.e., "we," "ours," or "us") to maintain control over others with perceived lesser power. For example, HCPs with higher implicit bias scores are more likely to use language like, "We will lose weight, right?" This type of language can perpetuate the power dynamic within a patient-provider relationship (DeAngelis, 2019; Sanchez et al., 2020).

Health Disparities in Obstetric and Gynecologic Health

Approximately 700 women in the US die each year during pregnancy or the year after. Another 50,000 women experience severe pregnancy-related complications. Implicit bias in reproductive health care can lead to disparities in health outcomes and access to care for underserved racial and ethnic populations. Multiple factors contribute to health disparities, including underlying chronic conditions, variations in the quality of care, structural racism, and SDOH. Racial disparities are well documented in obstetrics and gynecological care. For example, non-Hispanic Black women have higher preterm birth rates than their White counterparts (CDC, 2024g; Moroz, 2024; Norris & Harris, 2024). Some additional examples of racial disparities in obstetric and gynecological care include:

• Maternal death in the US is more prevalent in non-Hispanic Black women than in other groups. According to data from the CDC Pregnancy Mortality Surveillance System, Black and Indigenous Peoples/Alaska Native women are two to four times more likely to die from pregnancy-related causes than White women (CDC, 2024g; Hailu et al., 2022; Petersen et al., 2019).
• Severe maternal morbidity (SMM) refers to a life-threatening event during pregnancy or delivery or postpartum. Numerous studies have found that women of color were more likely to experience SMM than White women. For example, Black women had a two to three times higher risk of SMM than White women. Similar findings were reported for all other racial and ethnic groups compared to non-Hispanic White women. In a cross-sectional analysis of a large nationwide database, Aziz and colleagues (2019) evaluated over 11.3 million births between 2012 and 2014. The researchers found that non-Hispanic Black women were approximately 80% more likely to be readmitted postpartum and 16% more likely to experience an SMM during readmission than non-Hispanic White women (Aziz et al., 2019; Hailu et al., 2022; Norris & Harris, 2024).
• Impact on postpartum hemorrhage: Gyamfi-Bannerman and colleagues (2019) conducted a retrospective cohort study of 360,000 women who experienced postpartum hemorrhage. After adjusting for comorbidity, non-Hispanic Black women who experienced postpartum hemorrhage had a higher risk of severe morbidity and death than non-Hispanic White women. Okunlola and colleagues (2022) conducted a systematic review of the impact of race/ethnicity on postpartum hemorrhage rates. Eight of the included studies revealed that Hispanic, Black, Asian, Native Hawaiian, and Pacific Islander women had higher rates of postpartum hemorrhage than White women.
• Cancer mortality: Black and Hispanic women have higher cervical cancer rates and associated mortality than non-Hispanic White women. Similarly, non-Hispanic Black women have higher mortality rates for ovarian cancer than White women. In addition, Black women have a 55% higher mortality risk for endometrial cancer than White women. One reason for these disparities is that Black women are more likely to be diagnosed later due to care that varies from recommended guidelines. Finally, Black women have a higher mortality rate for breast cancer, even though they have a lower incidence of the disease than White women (Huang et al., 2020; National Cancer Institute, 2022; Norris & Harris, 2024).
• Infant mortality is defined as the death of an infant before their first birthday, while the infant mortality rate is the number of deaths for every 1,000 live births. In 2022, the infant mortality rate in the US was 5.6 deaths per 1,000 live births. The five leading causes of infant mortality include preterm birth and low birth weight, injuries, sudden infant death syndrome, congenital disabilities, and maternal pregnancy complications. In addition, racial and ethnic disparities exist for maternal pregnancy complications and preterm birth, contributing to disparities in infant mortality rates. In 2018, the infant mortality rates were: non-Hispanic Black 10.9, non-Hispanic Indigenous Peoples or Alaska Native 9.1, non-Hispanic Native Hawaiian or other Pacific Islander 8.5, Hispanic 4.9, non-Hispanic White 4.5, and non-Hispanic Asian 3.5 per 1,000 live births (CDC, 2024d).
• Other outcomes: Racial and ethnic disparities exist across other health outcomes. For example, Latina women have had the highest increase in gestational diabetes compared to other racial/ethnic groups. Asian women have double the risk of severe obstetric perineal lacerations compared with other racial/ethnic groups. Black women are more likely than White women to undergo open surgery and experience surgical complications when undergoing a hysterectomy for benign indications (Norris & Harris, 2024; Quist-Nelson et al., 2017; Shah et al., 2021).

These examples highlight the health disparities and inequities among racial and ethnically diverse populations related to obstetrical and gynecological health outcomes. These differences may be partially attributed to patient-level variables such as biological factors or genetics. However, many of these differences persisted even after researchers controlled for many of those characteristics. Research has also highlighted numerous differences in the health care that women of diverse racial/ethnic populations receive (i.e., health screening, type of care, and level of care). Neither biological nor genetic factors can explain these differences, highlighting systemic and structural barriers to care equity (Norris & Harris, 2024). 

Some examples of these health care disparities include (Dehlendorf et al., 2014; Hsu et al., 2017; Norris & Harris, 2024; Sabatino et al., 2022):

• Health screening: The United States National Health Interview Survey data shows that non-Hispanic Black women have higher mammography screening rates than other groups. However, Indigenous Peoples/Alaska Native and Asian women are least likely to be up to date with recommended cervical and breast cancer screenings.
• Hysterectomy: Black women, Hispanic women, and women with public insurance are less likely to receive minimally invasive techniques (i.e., laparoscopic, robotic, or vaginal) for hysterectomy than White women.
• Ectopic pregnancy: Like hysterectomy procedures, Black and Hispanic women were less likely to receive tube-conserving surgery (i.e., salpingostomy) for an ectopic pregnancy than White women.
• Contraception: Black and Hispanic women are less likely to use highly or moderately effective contraception than White women.

Determining the factors that impact the disparities in health care provided to women of different races and ethnicities can be challenging. These factors can include the patient, clinician, health care system, and sociocultural levels. First, patient-related factors may play some role in the disparities in health outcomes or care received. For example, women may advocate for varying degrees of quality care based on their education level or health literacy. Next, implicit bias among clinicians affects the level of care provided to women of different racial/ethnic groups. In addition to implicit bias, clinician-patient communication may be suboptimal and culturally insensitive. Next, the health care system creates a broader structure for health and care disparities. For example, women of color in the US are more likely to experience financial and insurance constraints, limiting treatment options. Finally, SDOH play an important role in women's health outcomes. For example, women may be labeled as nonadherent to recommended treatments or medications when, in fact, barriers such as stable housing, transportation, or lack of food significantly impact their health choices (CDC, 2024g; Norris & Harris, 2024; Ricks et al., 2021).

According to the SisterSong Women of Color Reproductive Justice Collective, reproductive justice is a person's "right to maintain bodily autonomy, have children, not have children, and parent the children they have in safer and sustainable communities” (SisterSong, n.d.). This organization was founded in 1997 by 16 women of color representing Indigenous Peoples, Latin American, African American, and Asian American communities. The reproductive justice movement differs from the reproductive rights movement of the 1970s, which many people felt only focused on the abortion debate. Instead, the reproductive justice movement focuses more broadly on how factors such as race, ethnicity, social class, ability, and sexual identity can limit patient freedom. In addition, the reproductive justice movement focuses on limiting oppressive circumstances related to informed choices about pregnancy and access to affordable, equitable care and education (i.e., contraception, prevention, and care for STIs, alternative birth options, domestic violence assistance, safe homes, adequate wages, and comprehensive prenatal and pregnancy care; SisterSong, n.d.).

Strategies to Reduce Health Care Disparities

For HCPs committed to providing high-quality, safe, and equitable care, the realization that we all have some implicit bias can be challenging to understand. For health care organizations to deliver equitable care for all patients, strategies must focus on intentional (i.e., explicit) and implicit bias. When HCPs understand that stereotyping and implicit bias are typical aspects of human cognition, they can be more receptive to learning strategies to mitigate their biases. Various techniques have been suggested in literature to mitigate implicit bias in health care and health care organizations (IHI, 2017; Norris & Harris, 2024; Shah & Bohlen, 2023).

Clinician Preparation

Because HCPs are often unaware of their implicit bias, mitigation strategies can be challenging. Many interventions to reduce implicit bias have been implemented in education and criminal justice. However, there have been limited published strategies for health care. Researchers have proposed three conditions necessary to minimize implicit bias: intention to change existing biases, attention to one's stereotypes, and time to practice strategies to break learned associations. HCPs are encouraged to complete a self-assessment of their biases to establish an intention to change them. Once HCPs have identified their implicit biases, strategies can be employed to lessen their effects (IHI, 2017; Norris & Harris, 2024; Shah & Bohlen, 2023).

Some suggested strategies found in the literature are as follows (AAFP, 2019; IHI, 2017; Norris & Harris, 2024; Shah & Bohlen, 2023):

• Stereotype replacement occurs when an individual recognizes responses to an individual or scenario that elicits stereotypes. Then, the individual intentionally replaces the biased response with an unbiased response.
• Counter-stereotypic imaging occurs when individuals recognize their stereotypical responses to another person from a particular background. Then, they visualize interactions with other people from the same background who disprove the stereotype.
• Individuating occurs when an individual's specific details (e.g., background, family, likes, dislikes, work) are evaluated to make better judgments based on the individual instead of group-based assumptions.
• Perspective-taking occurs when an individual actively considers the perspective of the person experiencing a stereotype. Reflecting on what a person may experience because of a stereotype helps identify the impact of implicit bias.
• Increasing opportunities for positive contact occurs when an individual actively seeks opportunities to interact with and experience positive examples of stereotyped groups. These opportunities can include expanding one's network of friends or colleagues where people of other races, ethnicities, gender identities, or other underrepresented groups are present.
• Partnership building occurs when a patient-provider relationship shifts away from the power dynamic of a high-status person and a low-status person. Instead, the relationship reflects collaborating equals.
• Building empathy for others can help to minimize implicit bias. Empathy can bring the HCP and patient together within the context of shared experiences. This strategy can help protect patients from stereotypes and shift the power dynamic.
• Practicing mindfulness can help incorporate self-awareness and assessment while regulating emotions and behaviors. As discussed previously, stress and cognitive overload can increase the likelihood of automatization during interactions, leading to implicit bias. Patient care can be stressful, with the potential for emergent and tense situations. For HCPs, incorporating mindfulness techniques into their daily practice can help increase attention to present experiences and reduce implicit bias in clinical decision-making.

Educational Preparation

Mitigation strategies for HCPs are essential to reduce implicit bias. Universities and other educational institutions play a pivotal role in mitigating implicit biases among medical and nursing students. The need for these early intervention strategies is highlighted because underrepresented groups account for up to 30% of the US population, but only 10.8% of medical doctors are from such groups. Researchers have recommended that learners engage in self-awareness to confront their biases and establish mechanisms to regulate them. Like other clinical skill education, students should have opportunities to practice strategies to reduce bias. Some effective strategies can include writing reflections and group discussion exercises, which can evoke and counter stereotypes in a controlled, simulated setting. In addition, case presentations, actual patient exposures, and intentional immersion experiences can allow learners to engage in critical dialogue regarding biases (Jetty et al., 2022; Mavis et al., 2022; Norris & Harris, 2024; Shah & Bohlen, 2023).

Organizational or Systemic Changes

Health care organizations can employ various system-wide strategies to reduce health disparities and implicit bias. For example, care bundles within various subspecialties in an organization can promote safe and equitable care. However, creating these bundles alone is not enough; hospital organizations need to leverage data to review quality and safety metrics, ensuring safe and equitable care is delivered. For example, the Council on Patient Safety in Women's Health Care developed the "Reduction of Peripartum Racial/Ethnic Disparities" bundle to promote safe care for women. In addition to standardized care practices, this bundle also recommended that every health system provide staff-wide education on implicit bias. Staff-wide education is a recommended strategy for all health care organizations. All health care staff and employees should participate in implicit bias training. Standard educational approaches should also be coupled with simulation training or case-based training. These active learning strategies are most effective in reducing implicit bias. Health care organizations should also complete a comprehensive evaluation of their hiring and disciplinary practices to ensure fairness and equity. Increasing the diversity of the health care workforce has been shown to improve disparities in health outcomes (Britt, 2020; Council on Patient Safety in Women's Health Care, 2016; Mavis et al., 2022; Norris & Harris, 2024).

The IHI white paper, Achieving Health Equity: A Guide for Health Care Organizations, highlights that access to care is insufficient to reduce health disparities. Organizations committed to improving health equity must be prepared to fundamentally change the current system and make health equity a system-level priority. The IHI provides a framework with five core components to guide organizations in making system-level changes toward health equity (Wyatt et al., 2016; refer to Table 1).

Table 1

IHI Framework for Health Care Organizations to Achieve Health Equity

Component	Strategies
Make health equity a strategic priority.	Demonstrate leadership commitment to improving equity at all levels of the organization. Secure sustainable funding.
Develop structure and processes to support health equity work.	Establish a governance committee to oversee equity work. Dedicate resources in the budget to support equity work.
Deploy strategies to address the multiple determinants of health.	Health care services Physical environment Healthy behaviors Socioeconomic status
Decrease institutional racism in the organization.	Physical space: buildings and design Health insurance plans accepted by the organization Policies, structures, and patient care
Develop partnerships with community organizations.	Leverage community assets to work together on improving health and equity.

(Wyatt et al., 2016)

Cultural Competence

Cultural shifts are essential to reducing implicit bias and racism and improving patient care. Creating a cultural shift is a dynamic process that requires an organizational commitment to mitigating implicit bias and reducing health disparities. Health care organizations must take direct action and sustain self-reflection to foster cultural competence among their HCPs. Cultural competence requires a commitment from HCPs to engage in self-reflection and self-critique throughout patient encounters. The NIH defines the delivery of culturally competent care as respectful and receptive to the health ideas, practices, and cultural and linguistic needs of diverse patients. Because culture influences health beliefs and practices, HCPs must examine and address their preconceptions before providing an optimal culture to care for their clients (Georgetown University Health Policy Institute, n.d.; Nair & Adetayo, 2019; Potter et al., 2022; Ricks et al., 2021).

According to the Georgetown University National Center for Cultural Competence (NCCC) framework, culturally competent organizations should value diversity, conduct ongoing cultural self-assessments, manage the dynamics of difference, institutionalize cultural knowledge, and adapt to variety (Georgetown University NCCC, n.d.). To address unique and individualized patient needs, HCPs and organizations should first self-assess their organizational culture. Each health care team member must become aware of their values and beliefs to avoid imposing them on others. Periyakoil (2019) has observed that self-assessment can help clinicians identify personal barriers to enhance their understanding of various cultures. Specific barriers to culturally competent care include the following:

• stereotypes based on ethnicity
• cultural differences
• racial bias
• personal bias
• language barriers
• lack of culturally competent care training
• lack of inclusivity training (Periyakoil, 2019)

A frequent health system-related barrier is a lack of culturally tailored services, including access to medical interpreters. Health care organizations and providers need to work cooperatively to understand and develop the appropriate knowledge, attitude, and skills to deliver the best care to all patients. The importance and value of HCP training regarding cultural competence cannot be overstated. HCPs must listen, understand, and then communicate with their patients using respectful intercultural communication; this skill can be modeled, practiced, and improved. The training should be immersive and skill-oriented (Periyakoil, 2019). Many health care organizations offer guidance on providing culturally competent care. One of the pioneers of this effort in the US is the OMH. The OMH developed culturally and linguistically appropriate standards (CLAS) in 2000 and updated them in 2013. The enhanced CLAS standards intend to assist health care organizations by establishing a blueprint for providing equitable and high-quality health care and eliminating disparities. Thus far, CLAS standards have been successful in helping create a culturally competent environment for health care organizations, providers, and patients (OMH, n.d.). Table 2 depicts the CLAS standards in practice.

Table 2

CLAS Standards to Achieve Cultural Competence 

CLAS standards	CLAS types of care
Principal standard	Organizations and HCPs should provide practical, equitable, understandable, and respectful care responsive to diverse cultural health beliefs, practices, preferred languages, health literacy, and other communication needs.
Governance, leadership, and workforce	Organizations should allocate resources, recruit and support culturally diverse governance, form policies incorporating CLAS, and train their workforce and leadership on an ongoing basis in CLAS.
Communication and language assistance	Organizations and HCPs should provide language assistance to those with limited English proficiency and/or communication needs to facilitate timely access to health care services. Support should be provided at no cost to the health care consumer. This should include, at a minimum, interactive educational materials in multiple languages and the availability of interpreter services.
Engagement, continuous improvement, and accountability	Organizations should perform continuous assessments of their CLAS-related measures and quality improvement activities. Organizations and HCPs should collaborate with community partners to design, implement, and evaluate policies. Organizations should communicate their progress in CLAS standards to all stakeholders and the public.

(OMH, n.d.)

Inclusive Communication

To reduce health disparities and implicit bias within health care, organizations must emphasize the importance of inclusive communication (i.e., addressing all people inclusively and respectfully). Therefore, the CDC has created resources for health care organizations to help ensure their communication products and strategies adapt to each population's specific cultural, environmental, linguistic, and historical contexts. These resources are continually adapted as cultural and language norms continue to change. The CDC also highlights that these resources are not prescriptive or exhaustive but rather a guide to provide suggestions for an inclusive approach to various topics (CDC, 2024c). The CDC highlights five communication principles for health care organizations to build inclusive communication (refer to Table 3).

Table 3

Health Equity Guiding Principles for Inclusive Communication

Principle	Recommendations
Use a health-equity lens.	Consider how long-standing racism and discrimination have led to health inequity. Emphasize the value of ensuring health and health care equity contributes to the common good. Recognize that information alone is not enough; information needs to be usable and delivered in a culturally and linguistically appropriate manner. Recognize that some underserved groups cannot follow public health recommendations due to inequitable resource allocation. Do not blame a person/community/population for an increased risk of a poor health outcome. Improve accessibility to information using alternative communication formats and various languages. Because literacy levels vary among individuals, use plain language to promote understanding.
Understand key principles.	Avoid the use of adjectives such as “vulnerable,” “marginalized,” and “high-risk.” For example, the term “marginalized group” implies that the group's condition is inherent rather than related to causal factors. Instead, try using specific terms (e.g., “underfunded clinics in urban areas”). Avoid dehumanizing language. Use person-first language instead. For example, describe people as having a condition (e.g., “people with diabetes”), not being the condition (e.g., “diabetics”). In addition, defer to the patient's preferred terms (e.g., neurodiverse individuals who prefer to self-identify as “autistic” instead of as “people with autism”). Carefully evaluate the appropriateness of using the term “minority,” as it is often considered a pejorative. Whenever possible, use “people of color” and “underrepresented groups.” Avoid using terms that can have a violent connotation when referring to people or groups. For example, avoid using “target,” “tackle,” and “combat” when discussing interventions. Instead, opt for “engage” or “focus.” Avoid unintentional blaming (i.e., labeling people who refuse or do not seek health care). Instead, say, “people who have yet to receive” a specific treatment.
Use preferred terms.	Use non-stigmatizing language, such as: “people with a disability” instead of “the disabled” “people who use drugs” instead of “drug users” “people experiencing homelessness” instead of “homeless people”
Develop inclusive communications.	Build a diverse workforce, especially in leadership positions. Avoid using images in communication that portray status inequity or unhealthy body images. Instead, highlight images that reflect equity among various groups. Always use images that portray traditional or cultural dress. Insufficient consideration of culture when developing materials may unintentionally result in misinformation and loss of credibility. Check words, phrases, and images to ensure they are not harmful or based on stereotype. Ensure equal access to health services and provide information in accessible formats.
Review resources and references.	The CDC provides resources and references for accessibility, community engagement, culture/language, disability, disparities, race/ethnicity, drug/substance abuse, gender, health equity, health literacy, obesity, pregnancy, and SDOH.

(CDC, 2024c)

 

Community Engagement

Community engagement is a crucial component of promoting equitable health and access to health care services. Employers, health care systems, public health agencies, policymakers, and community- and faith-based organizations can help reduce implicit bias and health disparities. These groups can join efforts to ensure communities access the resources needed to maintain and manage physical and mental health. Shared cultural, family, and faith-based values are familiar sources of support for community members. These entities can powerfully influence communities by highlighting health disparities and inequities among various groups and finding solutions to mitigate implicit biases. For example, community- and faith-based organizations can model healthy lifestyle choices and help connect community members to needed services such as housing, food, and health care. They can help establish trust between HCPs and community members. In addition, when individuals engage with community- and faith-based organizations, there are increased opportunities for positive contact with others from stereotyped groups. Public health agencies can promote equitable access to care by ensuring that information and services are culturally and linguistically appropriate for the community members. These agencies can build partnerships with community leaders to provide resources and education and reduce health disparities (Griffith et al., 2023).

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