Unconscious bias and (nursing) care

Abstract

In January 2023 according to Rafferty and Leary (2023), 10 years after what was supposed to be a ‘never again event’ Sir Robert Francis and the CEO of the Patients Association wrote to the Secretary of State for Health in England saying that they were witnessing a ‘scandal playing out at a national level (p. 3)’. What was to have heralded in new standards and new ways of working following the Mid Staffordshire scandal was moving towards yet another disaster. Francis was on record as describing the voice of nursing as being too weak (to prevent this) and not accorded the respect it deserved.

In 2011, the Institute of Medicine published its key document entitled The Future of Nursing: Leading Change, Advancing Health (Institute of Medicine and Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing, at the Institute of Medicine 2011). It heralded in a new dawn of enabling nurses to work to their full scope of practice and take on significant leadership positions. Evaluations showed this did not happen to scale (National Academies of Sciences, Engineering, and Medicine, Institute of Medicine, and Committee for Assessing Progress on Implementing the Recommendations of the Institute of Medicine Report 2016). And again, a decade later nurses were identified as part of a country wide drive to charting a path to achieve health equity (National Academies of Sciences, Engineering, and Medicine, National Academy of Medicine, and Committee on the Future of Nursing 2020–2030 2021). Nurses were lauded as bridge builders and collaborators, essential to moving America's health and care systems forward in a desire to tackle racism and other types of prejudice.

A UK editorial in the Lancet (2019) stated ‘if you enhance nursing, you enhance healthcare. Governments and health systems worldwide should recognise the true potential of nurses (p. 1879)’. Following the pandemic, the Lancet also published an editorial stating that without an immediate and concerted renewal to a commitment to nursing, ‘there can be no effective recovery or strengthening of health systems for the future’ (Lancet 2023, p. 1545).

Despite the ‘call to arms’ from key influential organisations in the United States, the United Kingdom and internationally, we have to ask why nurses continue to feel so disempowered. What is really going on in nursing and our health and care systems? Why can't we seem to move beyond the platitudes and rhetoric and actually move (nursing) care to where it should be in terms of respect, recognition and power?

My reflections on this state of affairs have led me to one main conclusion: our health and care systems operate an unconscious bias towards the people who deliver (nursing) care—specifically the people who are responsible for delivering intimate, bodily care or what we call person-centred fundamental care.

This hypothesis is reinforced by the compound effect of other types of individual, group and organisational bias including gender, ethnicity and age. The people who work in health systems as nurses and carers—support workers, ancillary staff, volunteers—experience individual, group and organisational bias because of the job they do. The closer your job is to human care and managing bodily functions the less your contribution is valued and the more you will experience being ignored, considered unreasonable, having to work without respect or recognition, being perceived as easily substituted in your work and perceived as not really very skilled or proficient in the job you do.

The impact of this unconscious bias is to hinder any real reform or improvement in the care challenges faced around the world and leads to an inability to think creatively or innovatively about solutions. The closest breakthrough has been to think that technology will solve the care problem but without understanding that with unconscious biases limiting creative problem solving in our systems, even this intervention will fall short of the mark.

Bias is a specific inclination, idea, feeling about someone or something that is preconceived or unreasonable (Merrian Webster Dictionary). It is a prejudice in favour of or against one thing, person or group compared with another that's considered unfair and can be held by individuals, groups or institutions with positive or negative consequences. It is social stereotyping about certain groups of people that individuals form outside their own conscious awareness. We all have these potential or real biases. These automatic associations can lead to views that are not accurate and can detract from our ability to make good decisions. Our biases are influenced by our childhood, family networks, religion, nationality, education and life experience. The reason we are susceptible to biases is that we need ‘short cuts’ to handle the information overload we are increasingly exposed to. Unconscious biases create quick and automatic responses to our decision making which are judgemental and they have significant influence over attitudes, behaviours and decision-making.

Lack of recognition of the skill, proficiency and mastery of person-centred fundamental care in our systems leads to ‘lowest common denominator’ substitution—despite the evidence that shows the impact on mortality rates of nursing number and skill mix there is little national or international appetite to understand the workforce needs of nurses in relation to safe staffing levels (Rafferty and Leary 2023). Equally, research on missed nursing care illustrates international patterns of fundamental care neglect which will sooner or later lead to patient harm (Griffiths et al. 2018). Dumbing down care happens with the more tasks, checklists and demands made upon nurses and other carers in the system. What is ignored is the evidence that care needs to be relationship based, build on trust in order for it to guarantee safety and quality. Instead of this, nursing care is forced to embrace a ‘task and time’ mindset, as if every patient was the same with the same needs. Isn't it ironic that as we embrace and celebrate the arrival of personalised medicine where we know we have to tailor therapeutic interventions to suit the genomic makeup of our patients, we haven't even considered the need to tailor each person's care in a personalised way.

The lack of a common language, framework and metrics for personalised care means that systems are bereft of good data that can provide timely feedback on the quality of care being delivered. Proxy measures for person-centred fundamental care tend to be risk assessments for safety and quality purposes: a falls risk rather than assessment of someone's ability to walk unaided, or with help.

Perhaps this is part of what Sir Robert Francis was getting at when he warned the Secretary of State for Health that another crisis was looming. It is not sufficient to introduce empathy training for individual leaders or Schwartz rounds to help teams debrief after difficult situations if the whole of the system is unaware of the feelings and frustrations of a significant nursing and care workforce. Unintentional strategies to disempower people are to undermine roles and leadership capability; fail to respect or acknowledge the personal care work people do; and to create reporting and accountability systems that prioritise risk assessment and compliance over relationship based person-centred fundamental care. And this then reinforces the unconscious bias in the system that care work is as easy as following a set of tasks without having to think.

First, we must acknowledge that this unconscious bias exists, compounded by many other biases that we might hold. Consider the people who provide care—mostly women, people from ethnic minority groups, migrants or international workers, people who come with a range of educational experience, mature aged, and consequently such people will be likely to be perceived as lacking in power, prestige and influence within systems. This means that the work they do and the people they care for are equally at risk of harm because the system has not recognised the way that biases are being stacked up.

After we have considered the reality that our health and care systems operate an unconscious bias towards (nursing) care and particularly person-centred fundamental care and to the people who deliver it, we need to think about what sort of affirmative action we could take. Affirmative action to address these blind spots includes adding person-centred fundamental care into vision, mission statements, our strategic plans and our metrics, key performance indicators and the collection of patient and carer stories. We would see much more investment in nursing career pathways, research, innovation and new models of care. We would also see whole caring workforces come alive with confidence and passion because they would know and see that the vital work they have been doing and will continue to do is now recognised, respected and valued (Merkley et al. 2022).

Several position statements generated by the International Learning Collaborative (ILC) have identified what leaders and organisations can do to acknowledge the importance of care and the importance of nursing leaders (Kitson et al. 2019, 2023, 2024) in the care revolution. The messages are consistent, not only across organisations but across the globe. So, let us collectively reflect on whether my hypothesis may have some truth in it, namely that the biggest challenge we face is to acknowledge and address the unconscious bias our health and care systems hold towards care and in particular person-centred fundamental care. If we can crack this, I reckon we're on a course which will help us not repeat our past mistakes, but will harness the passion, desire and commitment of the nursing profession to lead health and care to where it needs to go.

The author declares no conflicts of interest.