I care, even after the first impression: Facial appearance-based evaluations in healthcare context

Racial biases, facial trustworthiness, and resting heart rate variability: unravelling complexities in pain recognition

The study explores whether racial identity and appearance-based trustworthiness judgments can affect recognition of pain in medical students differing in levels of resting heart rate variability (HRV), a measure of parasympathetic control of the heart. After undergoing HRV assessment, 68 medical students (37 females) participated in a dynamic pain recognition task, viewing video clips of White and Black faces, which differed in perceived trustworthiness based on facial appearance, transitioning from neutral to intense pain expressions. Response time, pain intensity attribution and treatment recommendations were analyzed. Pain was recognized slower and estimated as less intense in Black compared to White faces, leading to a lower likelihood of recommending therapy. Pain recognition was faster for untrustworthy-looking White faces compared to trustworthy ones, while perceived trustworthiness had a minimal impact on the speed of pain recognition in Black faces. However, untrustworthy-looking faces were estimated to express more pain, particularly for Black faces. Notably, these biases were more pronounced in individuals with low, rather than high, resting HRV. Considering that therapeutic decisions mirrored pain intensity attribution, it would be important to increase awareness of these biases during medical training in order to promote equity in future pain assessment and treatment.

Facial trustworthiness dampens own-gender bias in emotion recognition

Previous research suggests that emotion recognition is influenced by social categories derived by invariant facial features such as gender and inferences of trustworthiness from facial appearance. The current study sought to replicate and extend these findings by examining the intersection of these social categories on recognition of emotional facial expressions. We used a dynamic emotion recognition task to assess accuracy and response times in the happiness and anger categorization displayed by female and male faces that differed in the degree of facial trustworthiness (i.e., trustworthy- vs. untrustworthy-looking faces). We found that facial trustworthiness was able to modulate the own-gender bias on emotion recognition, as responses to untrustworthy-looking faces revealed a bias towards ingroup members. Conversely, when faces look trustworthy, no differences on emotion recognition between female and male faces were found. In addition, positive inferences of trustworthiness lead to faster recognition of happiness in females and anger in males, showing that facial appearance was able to influence also the intersection between social categories and specific emotional expressions. Together, these results suggest that facial appearance, probably due to the activation of approach or avoidance motivational systems, is able to modulate the own-gender bias on emotion recognition.

First impressions: Integrating faces and bodies in personality trait perception

Faces and bodies spontaneously elicit personality trait judgments (e.g., trustworthy, dominant, lazy). We examined how trait information from the face and body combine to form first impressions of the whole person and whether trait judgments from the face and body are affected by seeing the whole person. Consistent with the trait-dependence hypothesis, Experiment 1 showed that the relative contribution of the face and body to whole-person perception varied with the trait judged. Agreeableness traits (e.g., warm, aggressive, sympathetic, trustworthy) were inferred primarily from the face, conscientiousness traits (e.g., dependable, careless) from the body, and extraversion traits (e.g., dominant, quiet, confident) from the whole person. A control experiment showed that both clothing and body shape contributed to whole-person judgments. In Experiment 2, we found that a face (body) rated in the whole person elicited a different rating than when it was rated in isolation. Specifically, when trait ratings differed for an isolated face and body of the same identity, the whole-person context biased in-context ratings of the faces and bodies towards the ratings of the context. These results showed that face and body trait perception interact more than previously assumed. We combine current and established findings to propose a novel framework to account for face-body integration in trait perception. This framework incorporates basic elements such as perceptual determinants, nonperceptual determinants, trait formation, and integration, as well as predictive factors such as the rater, the person rated, and the situation.

Cognitive and implicit biases in nurses' judgment and decision-making: A scoping review

BACKGROUND

Cognitive and implicit biases of healthcare providers can lead to adverse events in healthcare and have been identified as a patient safety concern. Most research on the impact of these systematic errors in judgment has been focused on diagnostic decision-making, primarily by physicians. As the largest component of the workforce, nurses make numerous decisions that affect patient outcomes; however, literature on nurses' clinical judgment often overlooks the potential impact of bias on these decisions. The aim of this study was to map the evidence and key concepts related to bias in nurses' judgment and decision-making, including interventions to correct or overcome these biases.

METHODS

We conducted a scoping review using Joanna Briggs methodology. In November 2020 we searched CINAHL, PsychInfo, and PubMed databases to identify relevant literature. Inclusion criteria were primary research about nurses' bias; evidence of a nursing decision or action; and English language. No date or geographic limitations were set.

RESULTS

We found 77 items that met the inclusion criteria. Over half of these items were published in the last 12 years. Most research focused on implicit biases related to racial/ethnic identity, obesity, and gender; other articles examined confirmation, attribution, anchoring, and hindsight biases. Some articles examined heuristics and were included if they described the process of, and the problems with, nurse decision-making. Only 5 studies tested interventions to overcome or correct biases. 61 of the studies relied on vignettes, surveys, or recall methods, rather than examining real-world nursing practice. This could be a serious oversight because contextual factors such as cognitive load, which have a significant impact on judgment and decision-making, are not necessarily captured with vignette or survey studies. Furthermore, survey and vignette studies make it difficult to quantify the impact of these biases in the healthcare system.

CONCLUSIONS

Given the serious effects that bias has on nurses' clinical judgment, and thereby patient outcomes, a concerted, systematic effort to identify and test debiasing strategies in real-world nursing settings is needed.

TWEETABLE ABSTRACT

Bias affects nurses' clinical judgment - we need to know how to fix it.

Nursing staff's experience of appearance issues in various nursing situations

Background

Health care professionals frequently interact with unknown patients in a process involving appearance-based judgements and priority-setting, all of which has an effect on health care equality. The healthcare provider–patient interaction is also highly relevant for the awareness and support of patients’ appearance concerns, with an associated possibility for improving patients’ satisfaction with their appearance and health. The aim was therefore to explore nursing staff’s experience of patients’ appearance issues in various nursing situations, with the purpose to facilitate awareness raising and knowledge development.

Method

A qualitative research approach with focus group interviews was chosen due to the exploratory aim of the study. Five semi-structured focus group interviews were conducted with 24 nursing staff in total (19 women and five men). The participants’ ages varied (20 to 45 years) as did their professional nursing experience. The interviews lasted approximately one hour, were digitally recorded, transcribed verbatim and analysed through thematic analysis.

Results

The thematic analysis resulted in the two themes Patient perspective and Professional nursing role, with associated subthemes. The findings showed the importance and impact of appearance issues in nursing situations and how these are linked to the health of the patients. Some groups of patients were identified as more vulnerable than others, which was associated with health care inequalities and health disparities. Value-based strategies along with knowledge, and skills for holistic person-centred care were identified as important resources for the development of appearance-related awareness and support in various nursing situations.

Conclusion

Strategies for improvement can be realised through the educational system for nursing staff, but mainly by using collective reflective learning forums in different workplaces. An empowerment approach is considered a useful framework for the implementation of holistic person-centred care, functioning as a resource for appearance-related awareness and support in various nursing situations. However, more research is needed on the complex and challenging phenomenon of appearance issues in nursing situations. Knowledge development related to successful person-centred strategies for appearance-related awareness and support is important, especially strategies with a salutogenic perspective.

First impressions of child faces: Facial trustworthiness influences adults' interpretations of children's behavior in ambiguous situations

Despite the profound behavioral consequences that first impressions of trustworthiness have on adult populations, few studies have examined how adults' first impressions of trustworthiness influence behavioral outcomes for children. Using a novel task design, we examined adults' perceptions of children's behavior in ambiguous situations. After a brief presentation of a child's face (high trust or low trust), participants viewed the child's face embedded within an ambiguous scene involving two children (Scene Task) or read a vignette about a misbehavior done by that child (Misbehavior Task). In the Scene Task, participants described what they believed to be happening in each scene; in the Misbehavior Task, participants indicated whether the behavior was done on purpose or by accident. In both tasks, participants also rated the behavior of the target child and indicated whether that child would be a good friend. In Experiment 1, young adults (n = 61) and older adults (n = 57) viewed unaltered face images. In Experiment 2, young adults (N = 59) completed the same tasks while viewing images of child faces morphed toward high-trust and low-trust averages. In both experiments, ambiguous scenes and misbehaviors were interpreted more positively when the target child had a high-trust face versus a low-trust face, with comparable patterns of results for the two age groups. Collectively, our results demonstrate that a child's facial trustworthiness biases how adults interpret children's behavior-a heuristic that may have lasting behavioral consequences for children through a self-fulfilling prophecy.

Broadening the stimulus set: Introducing the American Multiracial Faces Database

Face-based perceptions form the basis for how people behave towards each other and, hence, are central to understanding human interaction. Studying face perception requires a large and diverse set of stimuli in order to make ecologically valid, generalizable conclusions. To date, there are no publicly available databases with a substantial number of Multiracial or racially ambiguous faces. Our systematic review of the literature on Multiracial person perception documented that published studies have relied on computer-generated faces (84% of stimuli), Black-White faces (74%), and male faces (63%). We sought to address these issues, and to broaden the diversity of available face stimuli, by creating the American Multiracial Faces Database (AMFD). The AMFD is a novel collection of 110 faces with mixed-race heritage and accompanying ratings of those faces by naive observers that are freely available to academic researchers. The faces (smiling and neutral expression poses) were rated on attractiveness, emotional expression, racial ambiguity, masculinity, racial group membership(s), gender group membership(s), warmth, competence, dominance, and trustworthiness. The large majority of the AMFD faces are racially ambiguous and can pass into at least two different racial categories. These faces will be useful to researchers seeking to study Multiracial person perception as well as those looking for racially ambiguous faces in order to study categorization processes in general. Consequently, the AMFD will be useful to a broad group of researchers who are studying face perception.

Judging health care priority in emergency situations: Patient facial appearance matters

RATIONALE

Extensive research has shown that implicit trait inferences from facial appearance can bias everyday life in a pervasive way, influencing our decisions in different social contexts such as mate choice, political vote and criminal sentence. In situations characterized by time pressure and scant information, decisions based on inferences from facial appearance may have particularly critical and serious consequences, such as in emergency healthcare. No studies today have investigated this aspect in an actual emergency.

OBJECTIVE

The aim of the present study was to go beyond this gap and to determine whether implicit inferences from patients' facial appearance could be predictive of disparities in clinical evaluations and priority of treatment.

METHODS

In total, 183 cases of patients were evaluated by independent judges at zero acquaintance on the basis of different implicit facial appearance-based inferences, including trustworthiness and distress. Color-based priority code (White, Green, or Yellow) attributed by the triage nurse at the end of the registration process were recorded.

RESULTS

Our results showed that more trustworthy- and distressed- looking patients' faces have been associated with a higher priority code.

CONCLUSIONS

The present study shows that specific facial appearance-based inferences influence the attribution of priority code in healthcare that require quick decisions based on scarce clinical information such as in emergency. These results suggest the importance to bring to the attention of the healthcare professionals' the possibility of being victims of implicit inferences, and prompt to design educational interventions capable to increase their awareness of this bias in clinical evaluation.

Professional framing and emotional stability modulate facial appearance biases in nursing students

AIM

Providing the same standard of care to all patients alike, regardless of race, gender, age or any other irrelevant characteristic is imperative in the healthcare profession. In this study we examined whether and to what extent unintentional evaluations based on facial appearance of others affect nursing students' readiness to approach them and provide nursing care.

METHOD

A cross-sectional study was conducted from November 2018 to July 2019. Nursing students (N = 160) enrolled in the Nursing Degree Course of School of Medicine of Bologna University, completed a self-report questionnaire assessing personality traits and evaluated photographs of trustworthy, untrustworthy and neutral-looking male and female faces, while indicating their own approach behavior in a series of social interaction and caretaking scenarios.

RESULTS

Trustworthy faces elicited a higher approach readiness than untrustworthy and neutral ones across scenarios. Nonetheless, the nursing care scenario facilitated the approach toward others perceived as untrustworthy. Emotional stability trait further enhanced the approach of untrustworthy-looking others and provision of impartial care.

CONCLUSION

Present findings suggest that facial appearance bias among nursing students may be downregulated by activating cognitive representations of their professional role as future caretakers and their caretaking motivation. This speaks of the need to integrate as early as possible into existing nursing education programs simulation scenarios aimed to increase emotional awareness and model nursing students' future relational and caring skills.

Pain and satisfaction: healthcare providers' facial appearance matters

Trait inferences based solely on facial appearance affect many social decisions. Here we tested whether the effects of such inferences extend to the perception of physical sensations. In an actual clinical setting, we show that healthcare providers' facial appearance is a strong predictor of pain experienced by patients during a medical procedure. The effect was specific to familiarity: facial features of healthcare providers that convey feelings of familiarity were associated with a decrease in patients' perception of pain. In addition, caring appearance of the healthcare providers was significantly related to patients' satisfaction with the care they received. Besides indicating that rapid, unreflective trait inferences from facial appearance may affect important healthcare outcomes, these findings contribute to the understanding of the mechanisms underlying social modulation of pain perception.

Prospective Associations Between Boys' Substance Use and Problem Behavior Histories and Their Facial Trustworthiness in Adulthood

Introduction: People whose faces look untrustworthy tend to receive harsher social evaluations, including more severe criminal sentences. Yet little is known about how much facial trustworthiness reflects individuals' behavioral histories. We examined whether adolescent histories of delinquency and substance use predict strangers' perceptions of young men's facial trustworthiness.

Methods: Boys (n = 206) recruited from schools with higher juvenile crime rates were assessed repeatedly from ages 10–24 years, including arrest records and self-reported delinquency and substance use. Coders blind to the study's purpose rated participants' facial trustworthiness from photographs taken at ages 14 and 24; parent-reported childhood family income and coder ratings of attractiveness and positive affect at age 24 were considered as controls.

Results: Facial trustworthiness at age 24 (but not age 14) negatively correlated with all measures of problem behavior. Yet, self-reported tobacco use occasions from ages 12–23 had the strongest association with facial trustworthiness at age 24, a relation that persisted when controlling for arrests and delinquency from ages 12–23, other substance use, family income, ratings of age-24 positive facial affect, attractiveness, and age-14 facial trustworthiness (β = −.29, 95% CI [−.42, −.15], p < .001).

Discussion: Although boys' early facial trustworthiness did not relate to their later problem behavior, men with histories of more delinquency and tobacco use appeared less facially trustworthy as adults. Appearance-related biases may have forensic and healthcare implications for young men. Additionally, prevention efforts could leverage information about the early impacts of tobacco use on appearance.

First Impression Misleads Emotion Recognition

Recognition of others’ emotions is a key life ability that guides one’s own choices and behavior, and it hinges on the recognition of others’ facial cues. Independent studies indicate that facial appearance-based evaluations affect social behavior, but little is known about how facial appearance-based trustworthiness evaluations influence the recognition of specific emotions. We tested the hypothesis that first impressions based on facial appearance affect the recognition of basic emotions. A total of 150 participants completed a dynamic emotion recognition task. In a within-subjects design, the participants viewed videos of individuals with trustworthy-looking, neutral, or untrustworthy-looking faces gradually and continuously displaying basic emotions (happiness, anger, fear, and sadness). The participants’ accuracy and speed in recognizing the emotions were measured. Untrustworthy-looking faces decreased participants’ emotion recognition accuracy and speed, across emotion types. In addition, faces that elicited a positive inference of trustworthiness enhanced emotion recognition speed of fear and sadness, emotional expressions that signal another’s distress and modulate prosocial behavior. These findings suggest that facial appearance-based inferences may interfere with the ability to accurately and rapidly recognize others’ basic emotions.

Visual cues that predict intuitive risk perception in the case of HIV

Field studies indicate that people may form impressions about potential partners’ HIV risk, yet lack insight into what underlies such intuitions. The present study examined which cues may give rise to the perception of riskiness. Towards this end, portrait pictures of persons that are representative of the kinds of images found on social media were evaluated by independent raters on two sets of data: First, sixty visible cues deemed relevant to person perception, and second, perceived HIV risk and trustworthiness, health, and attractiveness. Here, we report correlations between cues and perceived HIV risk, exposing cue-criterion associations that may be used to infer intuitively HIV risk. Second, we trained a multiple cue-based model to forecast perceived HIV risk through cross-validated predictive modelling. Trained models accurately predicted how ‘risky’ a person was perceived (r = 0.75) in a novel sample of portraits. Findings are discussed with respect to HIV risk stereotypes and implications regarding how to foster effective protective behaviors.

Emotion recognition in medical students: effects of facial appearance and care schema activation

CONTEXT

Identifying the factors that may interfere with or sharpen the ability to recognise emotions when observing patients is a critical goal in medical education. This study addressed these issues by investigating the effects of facial appearance bias on medical students' emotion recognition (Experiment 1) and whether such bias is modulated by the activation of relational caregiving schema (Experiment 2).

METHODS

In Experiment 1, medical students were asked to recognise the emotions expressed by individuals differing in facial appearance (trustworthy, neutral and untrustworthy). In Experiment 2, they completed the same type of emotion recognition task after activating and anchoring themselves to the representation of the relational/human competences typical of a competent professional caregiver or after a control non-representation condition.

RESULTS

In both experiments, emotion recognition was affected by facial appearance bias: medical students were less accurate and slower in their recognition of emotions displayed by untrustworthy-looking individuals than in their recognition of emotions exhibited by individuals evoking more positive inferences. In Experiment 2, the activation of care schema enhanced medical students' emotion recognition ability regardless of facial appearance-based inferences.

CONCLUSIONS

Medical students' emotion recognition is affected by appearance-based bias, but such bias may be weakened by techniques that harness medical students' personal affective/relational and representational resources. Thus, the results provide a basis for designing curricula aimed at challenging implicit negative bias and promoting medical students' emotion recognition ability starting in the early stages of their education.