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Ivy ZK, Hwee S, Kimball BC, Evans MD, Marka N, Bendel C, Boucher AA. Disparities in Documentation: Evidence of Race-Based Biases in the Electronic Medical Record. J Racial Ethn Health Disparities 2024:10.1007/s40615-024-02132-8. [PMID: 39160431 DOI: 10.1007/s40615-024-02132-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2024] [Revised: 08/05/2024] [Accepted: 08/06/2024] [Indexed: 08/21/2024]
Abstract
Personal implicit biases may contribute to inequitable health outcomes, but the mechanisms of these effects are unclear at a system level. This study aimed to determine whether stigmatizing subjective terms in electronic medical records (EMR) reflect larger societal racial biases. A cross-sectional study was conducted using natural language processing software of all documentation where one or more predefined stigmatizing words were used between January 1, 2019 and June 30, 2021. EMR from emergency care and inpatient encounters in a metropolitan healthcare system were analyzed, focused on the presence or absence of race-based differences in word usage, either by specific terms or by groupings of negative or positive terms based on the common perceptions of the words. The persistence ("stickiness") of negative and/or positive characterizations in subsequent encounters for an individual was also evaluated. Final analyses included 12,238 encounters for 9135 patients, ranging from newborn to 104 years old. White (68%) vs Black/African American (17%) were the analyzed groups. Several negative terms (e.g., noncompliant, disrespectful, and curse words) were significantly more frequent in encounters with Black/African American patients. In contrast, positive terms (e.g., compliant, polite) were statistically more likely to be in White patients' documentation. Independent of race, negative characterizations were twice as likely to persist compared with positive ones in subsequent encounters. The use of stigmatizing language in documentation mirrors the same race-based inequities seen in medical outcomes and larger sociodemographic trends. This may contribute to observed healthcare outcome differences by disseminating one's implicit biases to unknown future healthcare providers.
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Affiliation(s)
- Zalaya K Ivy
- Division of Hematology, Oncology, and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Sharon Hwee
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, University of Minnesota, Minneapolis, MN, USA
| | | | - Michael D Evans
- Biostatistical Design and Analysis Center, Clinical and Translational Science Institute, University of Minnesota, Minneapolis, MN, USA
| | - Nicholas Marka
- Biostatistical Design and Analysis Center, Clinical and Translational Science Institute, University of Minnesota, Minneapolis, MN, USA
| | - Catherine Bendel
- Division of Neonatology, Department of Pediatrics, University of Minnesota, Minneapolis, MN, USA
| | - Alexander A Boucher
- Division of Hematology, Oncology, and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, MN, USA.
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, University of Minnesota, Minneapolis, MN, USA.
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Mosher M, Sailsman S. Implicit Bias in Patient Care Assignments. Am J Nurs 2024; 124:16-17. [PMID: 39051804 DOI: 10.1097/01.naj.0001027672.07497.cc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/27/2024]
Abstract
Identifying and acknowledging biases and working to eliminate them.
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Affiliation(s)
- Macy Mosher
- Macy Mosher is a clinical assistant professor and Sonique Sailsman is an assistant professor, both at Mercer University's Georgia Baptist College of Nursing in Atlanta. Contact author: Macy Mosher, . The authors have disclosed no potential conflicts of interest, financial or otherwise
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Groves PS, Farag A, Perkhounkova Y, Sabin JA, Witry MJ, Wright B. Nurse judgements of hospitalized patients' safety concerns are affected by patient, nurse and event characteristics: A factorial survey experiment. J Clin Nurs 2024. [PMID: 39008405 DOI: 10.1111/jocn.17372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Revised: 05/29/2024] [Accepted: 07/04/2024] [Indexed: 07/17/2024]
Abstract
AIM To test the influences of patient, safety event and nurse characteristics on nurse judgements of credibility, importance and intent to report patients' safety concerns. DESIGN Factorial survey experiment. METHODS A total of 240 nurses were recruited and completed an online survey including demographic information and responses to eight factorial vignettes consisting of unique combinations of eight patient and event factors. Hierarchical multivariate analysis was used to test influences of vignette factors and nurse characteristics on nurse judgements. RESULTS The intraclass coefficients for nurse judgements suggest that the variation among nurses exceeded the influence of contextual vignette factors. Several significant sources of nurse variation were identified, including race/ethnicity, suggesting a complex relationship between nurses' characteristics and their potential biases, and the influence of personal and patient factors on nurses' judgements, including the decision to report safety concerns. CONCLUSION Nurses are key players in the system to manage patient safety concerns. Variation among nurses and how they respond to scenarios of patient safety concerns highlight the need for nurse-level intervention. IMPLICATIONS FOR THE PROFESSION AND PATIENT CARE Complex factors influence nurses' judgement, interpretation and reporting of patients' safety concerns. IMPACT Understanding nurse judgement regarding patient-expressed safety concerns is critical for designing processes and systems that promote reporting. Multiple event and patient characteristics (type of event and apparent harm, and patient gender, race/ethnicity, socioeconomic status, and communication approach) as well as participant characteristics (race/ethnicity, gender, years of experience and primary hospital area) impacted participants' judgements of credibility, degree of concern and intent to report. These findings will help guide patient safety nurse education and training. REPORTING METHOD STROBE guidelines. PATIENT OR PUBLIC CONTRIBUTION Members of the public, including patient advocates, were involved in content validation of the vignette scenarios, norming photographs used in the factorial survey and testing the survey functionality.
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Affiliation(s)
| | - Amany Farag
- College of Nursing, University of Iowa, Iowa City, Iowa, USA
| | | | - Janice A Sabin
- School of Medicine, Biomedical Informatics and Medical Education, University of Washington, Seattle, Washington, USA
| | - Matthew J Witry
- College of Pharmacy, University of Iowa, Iowa City, Iowa, USA
| | - Brad Wright
- Arnold School of Public Health, University of South Carolina, Columbia, South Carolina, USA
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Chinloy S. A Lesbian's Miscarriage: Disengaging Bias and Caring Through Presence and Prayer. J Christ Nurs 2024; 41:103-105. [PMID: 38436340 DOI: 10.1097/cnj.0000000000001150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2024] Open
Abstract
ABSTRACT In my experience of caring for a lesbian couple suffering a miscarriage, I disengaged my bias about their sexual orientation and compassionately cared for their needs. After praying with the couple, I felt a deep connection with them and a palpable peace. Joy shone on their faces and they verbally expressed gratitude. God used me as a caring presence. Christian nurses are vessels for God's love to bring peace and healing.
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Affiliation(s)
- Soraya Chinloy
- Soraya Chinloy, BSN, RN, has worked in telemetry and home healthcare. She is currently studying for her DNP at Palm Beach Atlantic University
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Derbyshire DW, Keay T. "But what do you really think?" Nurses' contrasting explicit and implicit attitudes towards people with disabilities using the implicit association test. J Clin Nurs 2024. [PMID: 38454558 DOI: 10.1111/jocn.17097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Revised: 02/12/2024] [Accepted: 02/28/2024] [Indexed: 03/09/2024]
Abstract
AIMS To investigate how nurses' implicit and explicit attitudes towards people with disabilities (PWD) compare to (1) other healthcare providers and (2) non-healthcare providers. METHOD We present an analysis of secondary data from the publicly available disability Implicit Association Test (IAT). We compare the explicit and implicit attitudes towards PWD for (1) nurses (n = 24,545), (2) other healthcare providers (n = 57,818) and (3) non-healthcare providers (n = 547,966) for a total of 630,238 respondents, between 2006 and 2021. DATA SOURCES We use publicly available data for the Disability IAT from Open Science Framework repository of Project Implicit available at https://osf.io/tx5fi/. REPORTING STROBE checklist. RESULTS There is a distinct contrast between nurses' explicit and implicit attitudes. While nurses have more positive explicit attitudes towards PWD compared to other groups, they also have more negative implicit attitudes towards PWD. As such there is a contrast between nurses' stated (explicit) attitudes and their unconscious (implicit) attitudes towards PWD. Further, we find that implicit bias towards PWD-among all groups-has not improved over the 15 year period of our sample. CONCLUSIONS We present a contrast between nurses' explicit and implicit attitude towards PWD compared to non-healthcare providers. We posit that implicit bias is driven by a combination of workload and stress which drives nurses to unconscious modes of thinking more frequently. IMPLICATIONS We discuss three potential tools for improved educational praxis regarding treatment of PWD; (1) more PWD service user involvement, (2) the use of mindfulness techniques to reduce stress and (3) the use of patient contact simulation to promote education and understanding. PATIENT OR PUBLIC CONTRIBUTION There is no patient or public contribution.
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Affiliation(s)
- Daniel W Derbyshire
- Department of Public Health and Sports Science, University of Exeter, Exeter, UK
| | - Tamsin Keay
- Faculty of Health and Life Sciences, Coventry University, Coventry, UK
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Sparg T, Petersen L, Mayers P, Rogers C. South African adolescents' lived experiences of acquired hearing loss following multidrug-resistant tuberculosis treatment. FRONTIERS IN REHABILITATION SCIENCES 2024; 5:1336346. [PMID: 38469378 PMCID: PMC10925655 DOI: 10.3389/fresc.2024.1336346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Accepted: 01/10/2024] [Indexed: 03/13/2024]
Abstract
Objective The impact of acquiring hearing loss might be exacerbated during adolescence, as this normal transition from childhood to adulthood is characterised by identity construction and social intensity. This study aimed to describe the lived experiences of South African adolescents with acquired hearing loss following aminoglycoside treatment for multidrug resistant tuberculosis. Design The study adopted a descriptive phenomenological design and in-depth, semi-structured interviews were conducted in English, isiZulu and Afrikaans. The data was managed and analysed according to a modified version of Hycner's framework. Study sample Six participants aged 16-24 years with bilateral, mild to profound hearing loss acquired from aminoglycoside treatment were recruited from two South African provinces. Results Three themes emerged which created a triple burden for participants. They endured socio-economic hardship encompassing limited economic and emotional support. Participants battled the consequences of life-threatening MDR-TB including illness, hospitalisation, stigma, and other challenges. Finally, participants were left with life-changing hearing loss. Conclusion The findings indicate the necessity of holistic management of adolescents with aminoglycoside-related acquired hearing loss and serves as motivation to improve ototoxic monitoring practices and patient uptake of monitoring services and calls for the cessation, or at least cautious use, of aminoglycosides.
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Affiliation(s)
- Tarryn Sparg
- Division of Communication Sciences and Disorders, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Lucretia Petersen
- Division of Communication Sciences and Disorders, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Pat Mayers
- Division of Nursing and Midwifery, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Christine Rogers
- Division of Communication Sciences and Disorders, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
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Byrne M, Borzalski C. Analysis of Inclusive Gender, Sexuality and Sexual Orientation Data Elements in Academic Electronic Health Records. Comput Inform Nurs 2023; 41:975-982. [PMID: 37607730 DOI: 10.1097/cin.0000000000001064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/24/2023]
Abstract
Findings from an analysis of three vended academic electronic health records used in health science education are presented in this article. The quality assurance project examined the lexical and semantic fit and content coverage of gender, sexuality, and sexual orientation data elements within the academic electronic health records. A semantic comparative content analysis using a cognitive walkthrough was conducted as a means of comparing the ideal set of gender, sexuality, and sexual orientation data elements with those found in the three vended academic electronic health records. The results indicated a need for alignment to the research literature, expert consensus, and technical standards similar to what is expected for electronic health records used in clinical practice because of a lack of ideal state data elements. The findings align with ongoing issues with bias and disparities seen in the care of the lesbian, gay, bisexual, and transgender population and a lack of diverse, inclusive media and teaching technologies in health science education. The quality project and findings can inform academic electronic health record vendors on how they can create more inclusive systems and bring awareness to healthcare educators about the potential for implicit and explicit bias in their teaching technologies.
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Affiliation(s)
- Matthew Byrne
- Author Affiliations : Saint Catherine University, School of Nursing, St Paul, MN
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Gaber SN, Klarare A, Mattsson E, Rosenblad AK. A comparison of perceptions of caring behaviours among women in homelessness, Registered Nurses and nursing students. Scand J Caring Sci 2023; 37:959-969. [PMID: 35187681 DOI: 10.1111/scs.13071] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 01/14/2022] [Accepted: 02/06/2022] [Indexed: 12/01/2022]
Abstract
BACKGROUND The population of women in homelessness in Europe is increasing and women in homelessness experience multiple healthcare needs. However, there is insufficient understanding about how perceptions of caring behaviours compare between women in homelessness as patients and nurses in their clinical practice. AIM This study aimed to investigate perceptions of caring behaviours among women in homelessness, Registered Nurses and nursing students. METHODS A cross-sectional design was used with convenience sampling to recruit groups of women in homelessness (n = 37), Registered Nurses (n = 92) and nursing students (n = 142) in Stockholm, Sweden. Between August 2019 and December 2020, data were collected through face-to-face interviews or online, using the Caring Behaviours Inventory-24 instrument. Data were analysed using descriptive statistics and group-comparing hypothesis tests. RESULTS Overall, women in homelessness' perceptions of caring behaviours were significantly lower than nursing students (p < 0.001), who in turn scored significantly lower than Registered Nurses (p < 0.001). The Knowledge and Skill domain had the highest score, and the Connectedness domain had the lowest score in all three groups. The ranking of the individual items according to score varied between the groups. However, all three groups had the highest score for the Knowing how to give shots, IVs, etc., item and the lowest score for the Helping the patient to grow item. CONCLUSION Healthcare providers and nurse educators should consider incongruences and congruences in caring behaviours to better prepare Registered Nurses and nursing students to contribute to increased health equity, and more targeted clinical practice for women in homelessness.
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Affiliation(s)
- Sophie Nadia Gaber
- Department of Health Care Sciences, Ersta Sköndal Bräcke University College, Stockholm, Sweden
- Department of Women's and Children's Health, Healthcare Sciences and e-Health, Uppsala University, Uppsala, Sweden
| | - Anna Klarare
- Department of Health Care Sciences, Ersta Sköndal Bräcke University College, Stockholm, Sweden
- Department of Women's and Children's Health, Healthcare Sciences and e-Health, Uppsala University, Uppsala, Sweden
| | - Elisabet Mattsson
- Department of Health Care Sciences, Ersta Sköndal Bräcke University College, Stockholm, Sweden
- Department of Women's and Children's Health, Healthcare Sciences and e-Health, Uppsala University, Uppsala, Sweden
| | - Andreas Karlsson Rosenblad
- Department of Medical Sciences, Division of Clinical Diabetology and Metabolism, Uppsala University, Uppsala, Sweden
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Song J, Min SH, Chae S, Bowles KH, McDonald MV, Hobensack M, Barrón Y, Sridharan S, Davoudi A, Oh S, Evans L, Topaz M. Uncovering hidden trends: identifying time trajectories in risk factors documented in clinical notes and predicting hospitalizations and emergency department visits during home health care. J Am Med Inform Assoc 2023; 30:1801-1810. [PMID: 37339524 PMCID: PMC10586044 DOI: 10.1093/jamia/ocad101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 05/04/2023] [Accepted: 06/02/2023] [Indexed: 06/22/2023] Open
Abstract
OBJECTIVE This study aimed to identify temporal risk factor patterns documented in home health care (HHC) clinical notes and examine their association with hospitalizations or emergency department (ED) visits. MATERIALS AND METHODS Data for 73 350 episodes of care from one large HHC organization were analyzed using dynamic time warping and hierarchical clustering analysis to identify the temporal patterns of risk factors documented in clinical notes. The Omaha System nursing terminology represented risk factors. First, clinical characteristics were compared between clusters. Next, multivariate logistic regression was used to examine the association between clusters and risk for hospitalizations or ED visits. Omaha System domains corresponding to risk factors were analyzed and described in each cluster. RESULTS Six temporal clusters emerged, showing different patterns in how risk factors were documented over time. Patients with a steep increase in documented risk factors over time had a 3 times higher likelihood of hospitalization or ED visit than patients with no documented risk factors. Most risk factors belonged to the physiological domain, and only a few were in the environmental domain. DISCUSSION An analysis of risk factor trajectories reflects a patient's evolving health status during a HHC episode. Using standardized nursing terminology, this study provided new insights into the complex temporal dynamics of HHC, which may lead to improved patient outcomes through better treatment and management plans. CONCLUSION Incorporating temporal patterns in documented risk factors and their clusters into early warning systems may activate interventions to prevent hospitalizations or ED visits in HHC.
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Affiliation(s)
- Jiyoun Song
- Columbia University School of Nursing, New York City, New York, USA
| | - Se Hee Min
- Columbia University School of Nursing, New York City, New York, USA
| | - Sena Chae
- College of Nursing, University of Iowa, Iowa City, Iowa, USA
| | - Kathryn H Bowles
- Department of Biobehavioral Health Sciences, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA
- Center for Home Care Policy & Research, VNS Health, New York, New York, USA
| | | | - Mollie Hobensack
- Columbia University School of Nursing, New York City, New York, USA
| | - Yolanda Barrón
- Center for Home Care Policy & Research, VNS Health, New York, New York, USA
| | - Sridevi Sridharan
- Center for Home Care Policy & Research, VNS Health, New York, New York, USA
| | - Anahita Davoudi
- Center for Home Care Policy & Research, VNS Health, New York, New York, USA
| | - Sungho Oh
- Department of Biobehavioral Health Sciences, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA
| | - Lauren Evans
- Center for Home Care Policy & Research, VNS Health, New York, New York, USA
| | - Maxim Topaz
- Columbia University School of Nursing, New York City, New York, USA
- Center for Home Care Policy & Research, VNS Health, New York, New York, USA
- Data Science Institute, Columbia University, New York City, New York, USA
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Jala S, Fry M, Elliott R. Cognitive bias during clinical decision-making and its influence on patient outcomes in the emergency department: A scoping review. J Clin Nurs 2023; 32:7076-7085. [PMID: 37605250 DOI: 10.1111/jocn.16845] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Revised: 06/16/2023] [Accepted: 07/31/2023] [Indexed: 08/23/2023]
Abstract
BACKGROUND An integral part of clinical practice is decision-making. Yet there is widespread acceptance that there is evidence of cognitive bias within clinical practice among nurses and physicians. However, how cognitive bias among emergency nurses and physicians' decision-making influences patient outcomes remains unclear. AIM The aim of this review was to systematically synthesise research exploring the emergency nurses' and physicians' cognitive bias in decision-making and its influence on patient outcomes. METHODS This scoping review was guided by the PRISMA Extension for Scoping Reviews. The databases searched included CINAHL, MEDLINE, Web of Science and PubMed. No date limits were applied. The Patterns, Advances, Gaps, Evidence for practice and Research recommendation (PAGER) framework was used to guide the discussion. RESULTS The review included 18 articles, consisting of 10 primary studies (nine quantitative and one qualitative) and eight literature reviews. Of the 18 articles, nine investigated physicians, five articles examined nurses, and four both physicians and nurses with sample sizes ranging from 13 to 3547. Six primary studies were cross-sectional and five used hypothetical scenarios, and one real-world assessment. Three were experimental studies. Twenty-nine cognitive biases were identified with Implicit bias (n = 12) most frequently explored, followed by outcome bias (n = 4). Results were inconclusive regarding the influence of biases on treatment decisions and patient outcomes. Four key themes were identified; (i) cognitive biases among emergency clinicians; (ii) measurement of cognitive bias; (iii) influence of cognitive bias on clinical decision-making; and (iv) association between emergency clinicians' cognitive bias and patient outcomes. CONCLUSIONS This review identified that cognitive biases were present among emergency nurses and physicians during clinical decision-making, but it remains unclear how cognitive bias influences patient outcomes. Further research examining emergency clinicians' cognitive bias is required. RELEVANCE TO CLINICAL PRACTICE Awareness of emergency clinicians' own cognitive biases may result to the provision of equity in care. NO PATIENT OR PUBLIC CONTRIBUTION IN THIS REVIEW We intend to disseminate the results through publication in a peer-reviewed journals and conference presentations.
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Affiliation(s)
- Sheila Jala
- Faculty of Health, School of Nursing and Midwifery, University of Technology Sydney, Sydney, New South Wales, Australia
- Neurology Department, Royal North Shore Hospital, St Leonards, New South Wales, Australia
| | - Margaret Fry
- Faculty of Health, School of Nursing and Midwifery, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Rosalind Elliott
- Faculty of Health, School of Nursing and Midwifery, University of Technology Sydney, Sydney, New South Wales, Australia
- Nursing and Midwifery Research Centre, Nursing and Midwifery Directorate, Northern Sydney Local Health District, Royal North Shore Hospital, St Leonards, New South Wales, Australia
- Department of Intensive Care Medicine, Royal North Shore Hospital, St Leonards, New South Wales, Australia
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Rattan J, Bartlett TR. Potential influence of nurses' implicit racial bias on maternal mortality. Public Health Nurs 2023; 40:773-781. [PMID: 37141152 PMCID: PMC10775957 DOI: 10.1111/phn.13201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Revised: 04/08/2023] [Accepted: 04/11/2023] [Indexed: 05/05/2023]
Abstract
Stark disparities persist in maternal mortality and perinatal outcomes for Black and other birthing people of color, such as Native Americans, and their newborns compared to White people in the United States. An increasing body of research describes the phenomenon of implicit racial bias among providers and how it may affect communication, treatment decisions, the patient care experience, and health outcomes. This synthesis of literature reviews and distills current research on the presence and influence of implicit racial bias among nurses as it may relate to maternal and pregnancy-related care and outcomes. In this paper, we also summarize what is known about implicit racial bias among other types of healthcare providers and interventions that can mitigate its effects, identify a gap in research, and recommend next steps for nurses and nurse researchers.
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Affiliation(s)
- Jesse Rattan
- Joint Nursing Science PhD Program, The University of Alabama and University of Alabama in Huntsville, Tuscaloosa
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Meidert U, Dönnges G, Bucher T, Wieber F, Gerber-Grote A. Unconscious Bias among Health Professionals: A Scoping Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:6569. [PMID: 37623155 PMCID: PMC10454622 DOI: 10.3390/ijerph20166569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Revised: 07/31/2023] [Accepted: 08/02/2023] [Indexed: 08/26/2023]
Abstract
BACKGROUND Unconscious biases are one of the causes of health disparities. Health professionals have prejudices against patients due to their race, gender, or other factors without their conscious knowledge. This review aimed to provide an overview of research on unconscious bias among health professionals and to investigate the biases that exist in different regions of the world, the health professions that are considered, and the research gaps that still exist. METHODS We conducted a scoping review by systematically searching PubMed/MEDLINE, CINAHL, PsycINFO, PsycARTICLES, and AMED. All records were double-screened and included if they were published between 2011 and 2021. RESULTS A total of 5186 records were found. After removing duplicates (n = 300), screening titles and abstracts (n = 4210), and full-text screening (n = 695), 87 articles from 81 studies remained. Studies originated from North America (n = 60), Europe (n = 13), and the rest of the world (n = 6), and two studies were of global scope. Racial bias was investigated most frequently (n = 46), followed by gender bias (n = 11), weight bias (n = 10), socio-economic status bias (n = 9), and mental illness bias (n = 7). Most of the studies were conducted by physicians (n = 51) and nurses (n = 20). Other health care professionals were rarely included in these studies. CONCLUSIONS Most studies show that health professionals have an implicit bias. Racial biases among physicians and nurses in the USA are well confirmed. Research is missing on other biases from other regions and other health professions.
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Affiliation(s)
- Ursula Meidert
- School of Health Sciences, Zurich University of Applied Sciences, Katharina-Sulzer-Platz 9, 8400 Winterthur, Switzerland; (G.D.); (T.B.); (F.W.); (A.G.-G.)
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Ridling D, Finch C, Moore JM, Ofamen J, Price W. Nursing's Critical Role in Driving Toward Health Equity: One Organization's Experience. J Nurs Adm 2023; 53:399-407. [PMID: 37463263 DOI: 10.1097/nna.0000000000001306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/20/2023]
Abstract
In the last decade, there has been active discourse within nursing communities regarding healthcare disparities associated with racism. To address this critical problem, a multidisciplinary team at a pediatric healthcare setting identified 33 projects across 4 key drivers of health equity. The drivers of health equity include: 1) developing a diverse nursing workforce; 2) creating a nursing culture with a strong sense of belonging; 3) providing learning and growth opportunities; and 4) providing equitable nursing care. This article describes 1 organization's approach to addressing healthcare disparities associated with racism through a nursing program to address equity, diversity, inclusion, and antiracism.
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Affiliation(s)
- Debra Ridling
- Author Affiliations: Associate Chief Nurse (Dr Ridling), Practice and Research, Nursing; Manager (Finch), Medical Unit; Nursing Professional Development Practitioner (Moore), Nursing; Charge Nurse (Ofamen), Postanesthesia Care Unit; and Director (Price), Workforce Development and Planning, Seattle Children's, Washington
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Wolf L, Delao A, Perhats C, Valdez A, Strout T, Clark P, Moon M, Frisch S, Callihan M. The Experiences of United States Emergency Nurses Related to Witnessed and Experienced Bias: A Mixed-Methods Study. J Emerg Nurs 2023; 49:175-197. [PMID: 36528419 DOI: 10.1016/j.jen.2022.11.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 11/17/2022] [Accepted: 11/20/2022] [Indexed: 12/23/2022]
Abstract
INTRODUCTION The purpose of this study was to obtain a broad view of the knowledge, attitudes, beliefs, and lived experiences of emergency nurses regarding implicit and explicit bias. METHODS An exploratory, descriptive, sequential mixed-methods approach using online surveys and focus groups to generate study data. Two validated instruments were incorporated into the survey to evaluate experiences of microaggression in the workplace and ethnocultural empathy. Focus group data were collected using Zoom meetings. RESULTS The final sample comprised 1140 participants in the survey arm and 23 focus group participants. Significant differences were found in reported experiences of institutional, structural, and personal microaggressions for non-white vs white participants. Respondents who identified Christianity as their religious group had lower mean scores on items representing empathetic awareness. Respondents who identified as nonheterosexual had significantly higher mean total Scale of Ethnocultural Empathy scores, empathetic awareness subscale scores, and empathetic feeling and expression subscale scores. Thematic categories that arose from the focus group data included witnessed bias, experienced bias, responses to bias, impact of bias on care, and solutions. DISCUSSION In both our survey and focus group data, we see evidence that racism and other forms of bias are threats to safe patient care. We challenge all emergency nurses and institutions to reflect on the implicit and explicit biases they hold and to engage in purposeful learning about the effects of individual and structural bias on patients and colleagues. We suggest an approach that favors structural analysis, intervention, and accountability.
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Topaz M, Song J, Davoudi A, McDonald M, Taylor J, Sittig S, Bowles K. Home Healthcare Clinicians Use Judgment Language More Frequently for Black and Hispanic Patients: A Natural Language Processing Study (Preprint). JMIR Nurs 2022; 6:e42552. [PMID: 37067893 PMCID: PMC10152333 DOI: 10.2196/42552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 12/05/2022] [Accepted: 03/16/2023] [Indexed: 03/18/2023] Open
Abstract
BACKGROUND A clinician's biased behavior toward patients can affect the quality of care. Recent literature reviews report on widespread implicit biases among clinicians. Although emerging studies in hospital settings show racial biases in the language used in clinical documentation within electronic health records, no studies have yet investigated the extent of judgment language in home health care. OBJECTIVE We aimed to examine racial differences in judgment language use and the relationship between judgment language use and the amount of time clinicians spent on home visits as a reflection of care quality in home health care. METHODS This study is a retrospective observational cohort study. Study data were extracted from a large urban home health care organization in the Northeastern United States. Study data set included patients (N=45,384) who received home health care services between January 1 and December 31, 2019. The study applied a natural language processing algorithm to automatically detect the language of judgment in clinical notes. RESULTS The use of judgment language was observed in 38% (n=17,141) of the patients. The highest use of judgment language was found in Hispanic (7,167/66,282, 10.8% of all clinical notes), followed by Black (7,010/65,628, 10.7%), White (10,206/107,626, 9.5%), and Asian (1,756/22,548, 7.8%) patients. Black and Hispanic patients were 14% more likely to have notes with judgment language than White patients. The length of a home health care visit was reduced by 21 minutes when judgment language was used. CONCLUSIONS Racial differences were identified in judgment language use. When judgment language is used, clinicians spend less time at patients' homes. Because the language clinicians use in documentation is associated with the time spent providing care, further research is needed to study the impact of using judgment language on quality of home health care. Policy, education, and clinical practice improvements are needed to address the biases behind judgment language.
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Affiliation(s)
- Maxim Topaz
- Columbia University School of Nursing, New York, NY, United States
- Data Science Institute, Columbia University, New York, NY, United States
- Center for Home Care Policy & Research, VNS Health, New York, NY, United States
| | - Jiyoun Song
- Columbia University School of Nursing, New York, NY, United States
| | - Anahita Davoudi
- Center for Home Care Policy & Research, VNS Health, New York, NY, United States
| | - Margaret McDonald
- Center for Home Care Policy & Research, VNS Health, New York, NY, United States
| | - Jacquelyn Taylor
- Columbia University School of Nursing, New York, NY, United States
| | - Scott Sittig
- Department of Health Sciences, University of Louisiana at Lafayette, Lafayette, LA, United States
| | - Kathryn Bowles
- Center for Home Care Policy & Research, VNS Health, New York, NY, United States
- Department of Biobehavioral Health Sciences, University of Pennsylvania School of Nursing, Philadelphia, PA, United States
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Gaber SN, Rosenblad AK, Mattsson E, Klarare A. The relationship between attitudes to homelessness and perceptions of caring behaviours: a cross-sectional study among women experiencing homelessness, nurses and nursing students. BMC Womens Health 2022; 22:159. [PMID: 35546674 PMCID: PMC9092332 DOI: 10.1186/s12905-022-01744-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 04/29/2022] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Women experiencing homelessness have complex and multifaceted healthcare needs and yet they are an underserved population across healthcare services. Nurses are trained to perform an integral role in the provision of equitable healthcare and their attitudes towards homelessness may therefore influence the care that women experiencing homelessness receive. This study aimed to examine correlations between attitudes towards homelessness and caring behaviours, and to test if these correlations differed between the groups of women experiencing homelessness, registered nurses, and nursing students. METHODS A cross-sectional design using convenience sampling was used to recruit women experiencing homelessness (n = 37), registered nurses (n = 90), and nursing students (n = 138) in Stockholm, Sweden between August 2019 and December 2020. The participants answered two questionnaires: the Attitudes Toward Homelessness Inventory and the Caring Behaviours Inventory-24. Correlations between ordinal variables were calculated using Spearman's rank correlation ρ. Tests of equality between two independent correlations were performed using a Z-test applied to Fisher's z-transformed correlations. An advisory board of women with lived experience of homelessness supported the interpretation of the results. RESULTS Weak, negative correlations were identified between the Attitudes Toward Homelessness Inventory and Caring Behaviours Inventory-24. The Attitudes Toward Homelessness Inventory mean total scores (SD) were 4.1 (0.6), 4.2 (0.6), 4.1 (0.5) points for the women experiencing homelessness, registered nurse, and nursing student groups, respectively, with the corresponding scores for the Caring Behaviours Inventory-24 being 4.1 (1.1), 5.2 (0.5), 4.8 (0.7) points, respectively. CONCLUSIONS To promote equitable health for women experiencing homelessness, healthcare providers and nurse educators should consider the role of stigmatising attitudes in relation to caring behaviours.
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Affiliation(s)
- Sophie Nadia Gaber
- Department of Health Care Sciences, Marie Cederschiöld University, Stockholm, Sweden.
- Department of Women's and Children's Health, Healthcare Sciences and E-Health, Uppsala University, Uppsala, Sweden.
| | - Andreas Karlsson Rosenblad
- Department of Medical Sciences, Division of Clinical Diabetology and Metabolism, Uppsala University, Uppsala, Sweden
- Department of Neurobiology, Care Sciences and Society, Division of Family Medicine and Primary Care, Karolinska Institutet, Solna, Sweden
| | - Elisabet Mattsson
- Department of Health Care Sciences, Marie Cederschiöld University, Stockholm, Sweden
- Department of Women's and Children's Health, Healthcare Sciences and E-Health, Uppsala University, Uppsala, Sweden
| | - Anna Klarare
- Department of Health Care Sciences, Marie Cederschiöld University, Stockholm, Sweden
- Department of Women's and Children's Health, Healthcare Sciences and E-Health, Uppsala University, Uppsala, Sweden
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Nguyen P, Kohlbeck SA, Levas M, Hernandez-Meier J. Implementation and initial analysis of Cardiff Model data collection procedures in a level I trauma adult emergency department. BMJ Open 2022; 12:e052344. [PMID: 34992109 PMCID: PMC8739060 DOI: 10.1136/bmjopen-2021-052344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES Our understanding of community violence is limited by incomplete information, which can potentially be resolved by collecting violence-related injury information through healthcare systems in tandem with prior data streams. This study assessed the feasibility of implementing Cardiff Model data collection procedures in the emergency department (ED) setting to improve multisystem data sharing capabilities and create more representative datasets. DESIGN Information collection fields were incorporated into the ED electronic health record (EHR), which gathered additional information from patients reporting assaultive injuries. ED nurses were surveyed to evaluate implementation and feasibility of information collection. Logistic regression was performed to determine associations between missing location information and patient demographic data. SETTING 60-bed academic level I trauma adult ED in a large Midwestern city. PARTICIPANTS 2648 patients screened positive for assault injuries between 2017 and 2020. 198 patients were omitted due to age outside the range served by this ED. Unselected inclusion of 150 ED nurses was surveyed. MAIN OUTCOME MEASURES Main outcomes include nursing staff survey responses and ORs for providing complete injury information across various patient demographics. RESULTS Most ED nurses believed that information collection aligned with the hospital's mission (92%), wanted information collection to continue (88%), did not believe that information collection impacted their workflow (88%), and reported taking under 1 min to screen and document violence information (77%). 825 patients (31.2%) provided sufficient information for geospatial mapping. Likelihood of providing complete location information was significantly associated with patient gender, race, arrival means, accompaniment, trauma type and year. CONCLUSIONS It is feasible to implement information collection procedures about location-based, assault-related injuries through the EHR in the adult ED setting. Nurses reported being receptive to collecting information. Analyses suggest patient-level and time variables impact information collection completeness. The geospatial information collected can greatly improve preexisting law enforcement and emergency medical systems datasets.
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Affiliation(s)
- Peter Nguyen
- School of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Sara A Kohlbeck
- Comprehensive Injury Center, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Michael Levas
- Comprehensive Injury Center, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Jennifer Hernandez-Meier
- Comprehensive Injury Center, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
- Emergency Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
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