By Dorothy Brooks
Healthcare systems have collectively turned their attention to promoting equity and rooting out bias. The results of a recently published study of how emergency nurses experience and react to bias suggests much work remains. Further, the authors maintained significant change is likely to require a firm commitment from the upper ranks of institutions to ensure equity is not just a slogan.1
“The first thing we found in our study is from the people who are racialized as non-white or non-straight. Their position was that this is a top-down problem,” explains Lisa Wolf, PhD, RN, CEN, FAEN, FAAN, director of emergency nursing research for the Emergency Nurses Association and the lead author of the study. “In other words, institutions need to make it very clear [what their] policies are around equity and inclusion, and that people know the consequences for violating those principles.”
Wolf and colleagues asked participants about their experiences with institutional, structural, and personal microaggressions (statements that indicate a kind of disparagement or dismissal that are not overt). For instance, the authors reported emergency nurses from marginalized groups said they experience harm daily from both patients and leadership.
This could come in the form of blatant expressions of bias, but it also could involve assumptions about their backgrounds, incomes, or intelligence. Other microaggressions might involve inappropriate questions or mannerisms directed at the nurses.
Conversely, some white emergency nurses said they felt bias directed toward them for their treatment of patients from marginalized groups. For example, white nurses reported that in their experience, patients from marginalized groups might intimate only someone from their nationality can understand them. Further, some nurses indicated patients from marginalized groups often are confrontational or unkind.
In sum, Wolf and colleagues noted the nursing profession faces some occupational-related challenges when it comes to addressing bias. “Nursing is a very nonconfrontational sort of structure,” Wolf notes. “We try to educate people on an individual level. We don’t want to make waves or cause trouble.”
For instance, when emergency nurses were asked how they respond when they witness a colleague’s bias, most indicated they would privately try to educate that person on better behavior. “They would never report a nurse who was exhibiting biased behaviors toward a patient,” explains Wolf, noting they would prefer to have a one-on-one conversation.
However, the nurse exhibiting biased behavior likely is acting that way toward other patients. Without higher-level consequences or intervention, the behavior could continue. “In the same way that you would report someone consistently making medication errors, someone who is consistently treating people differently due to some characteristic of theirs should be similarly identified, and appropriate mediation should take place,” Wolf says. “You have to make it really clear that this behavior will be addressed, and then you have to follow through. Then, people will start to report more.”
Aswita Tan-McGrory, MBA, MSPH, director of the Disparities Solutions Center in Boston, says one of the best ways to overcome resistance to the notion that bias is a problem is to show the data. “You’ve got to collect demographic data, you’ve got to make sure it’s reliable, and then you have to use it,” says Tan-McGrory, administrative director of the Mongan Institute at Massachusetts General Hospital (MGH). “[When] your patient satisfaction scores are really bad for people of color, but generally great for white patients, it’s very hard to argue [there is no problem].”
Tan-McGrory notes it is important for leaders to ensure the department is collecting information about race, ethnicity, and language at a minimum so that staff can understand the patients they are serving. “The data doesn’t have to be perfect, but it has to be good enough so that you can stratify it and feel confident overall in what the results are,” she says.
Similarly, it is important for leaders to understand their staff. “It doesn’t always have to be [broken down] by race. It really has to be around lived experience,” Tan-McGrory says. “Do you have a staff that really understands what it is like to be hungry, what it is like to be poor, and what it is like to not be able to speak English?”
Such knowledge comes with empathy and the ability to connect with patients who are experiencing such hardships. Also, it is important for staff to understand what it is like to struggle with substance use or know someone who does. “That ultimately leads to better care, better decision-making, and better patient satisfaction scores,” Tan-McGrory says.
MGH relies on data when it comes to identifying incidents involving bias or racism. “We have a system where staff can file a patient safety report, and we recently launched a pilot where we have a tag where staff members can [indicate] that they feel like the incident involved some bias or discrimination,” Tan-McGrory explains. “Every one of those patient safety reports gets sent to our leadership here, including myself ... and we review them.”
Such reports help leaders identify areas or units that might need more support, training, or resources. Further, when it comes to training, the focus at MGH is not on the removal of bias, a task Tan-McGrory calls impossible.
“Our goal is to realize that we do have bias, and some of it is conscious, and some of it is unconscious,” she says. Instead, leaders focus more on “general awareness and sensitivity to how [bias] can play out when we are making decisions for patients, administer medication, or even [affect] how we make decisions as a team.”
REFERENCE
1. Wolf L, Delao A, Perhats C, et al. The experiences of United States emergency nurses related to witnessed and experienced bias: A mixed-methods study. J Emerg Nurs 2023;49:175-197.
Healthcare systems have collectively turned their attention to promoting equity and rooting out bias. The results of a recently published study of how emergency nurses experience and react to bias suggests much work remains. Further, the authors maintained significant change is likely to require a firm commitment from the upper ranks of institutions to ensure equity is not just a slogan.
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