NR 307A Week 2 Implicit Bias Self-Audit Reflection Example

Who Got the Extra Sentence: A Two-Week Self-Audit of Explanations Given at the Bedside

Student Name

College of Nursing, Chamberlain University

NR 307A: Advancing Equity, Inclusion, and Diversity in Healthcare

Instructor Name

Month Day, Year

Who Got the Extra Sentence: A Two-Week Self-Audit of Explanations Given at the Bedside

What I Watched For

For six shifts over two weeks on the medical-telemetry unit where I work nights, I kept a pocket notebook and wrote down three things after each patient interaction that involved teaching or explaining: who the patient was, in general terms; what I said; and anything I noticed myself doing or feeling that I had not planned. I did not use an instrument. I wanted to find out whether I explain things differently to different patients, and if so, to whom. The entries below are taken from that notebook, lightly edited for clarity, and each keeps what I felt separate from what I did.

Two course sources shaped what I watched for. FitzGerald and Hurst (2017) reviewed studies of implicit bias among health care professionals and found that clinicians show the same kinds of implicit bias as the wider population. Hall et al. (2015) found in their review that these biases were associated with differences in how clinicians communicate with patients. Neither review told me what my own biases were, which is why I kept the notebook.

Entries

Night 1, 2300. A retired schoolteacher, admitted for a new irregular heartbeat, asked why her blood thinner was being changed. I explained the new medicine, the reason, the bleeding signs to watch for, and then, without planning to, added a sentence about how the new drug does not need blood tests. She thanked me and said it was the clearest explanation she had had. Later: I realized I had enjoyed that conversation and stayed longer than I needed to.

Night 1, 0200. A man in his fifties who works as a roofer, admitted for chest pain, asked me what "troponin" meant after a doctor said it on rounds. I said it was a heart test and it was fine. Later: he asked the same kind of question as the teacher, and I gave him one sentence. I did not add anything about what the test measures or why it is repeated. I noticed I had assumed he did not want the detail.

Night 2, 2200. A woman from Nigeria, admitted for heart failure. Her name has four syllables. At the start of the shift, I read it on the whiteboard, hesitated, and introduced myself without saying it. For the rest of the night I called her "ma'am." Later: I was embarrassed that I had avoided her name, because I had practiced the name of a Polish patient the week before without thinking about it.

Night 3, 0100. An older Black man, admitted after a fainting episode, and his son, who asked for a printed list of every medication his father was getting and the reason for each. I felt irritated. My first thought, before I had done anything, was that the son was going to be difficult. I printed the list and answered his questions. Later: the son's request was exactly what I teach families to do. I did not have that reaction the week before, when a white daughter asked me the same thing for her mother; I had thought she was thorough. I wrote this entry and then did not want to keep it.

Night 4, 2330. A young man who speaks Spanish at home and fluent English at work, admitted for pneumonia. I explained the incentive spirometer carefully, including why it matters, and used teach-back. Later: this one felt right, and I noticed that I slowed down because I had been paying attention to the pattern.

Night 5, 0300. A woman in her seventies with a strong regional accent that I found hard to follow, admitted for a urinary infection and confusion that was clearing. I explained her new antibiotic, then realized I had spoken to her daughter, not to her, even though she was awake and oriented. Later: I did the same thing to a Vietnamese patient months ago, with an interpreter on the phone, and I remember speaking to the interpreter instead of to him.

Night 6, 2200. I asked the Nigerian patient from Night 2, who was still with us, how to say her name. She said it slowly, laughed, and said most people give up. I wrote it on the whiteboard in syllables. Later: it took ten seconds.

The Pattern

Reading the notebook back, the pattern is narrow and specific. I give the extra sentence, the part of an explanation that says why, or what comes next, to patients who remind me of people I talk to outside work: people with jobs like mine or my parents', who use medical words back to me, and who speak the way I do. I give shorter explanations to patients who work with their hands, who have accents I find hard to follow, or whose names I cannot say easily. I did not intend any of this and I would have denied it before these two weeks. Hall et al. (2015) describe differences in how much information clinicians give and how long they spend with patients as one of the ways bias shows up in care, and my notebook shows the same thing on a very small scale.

The Night 3 entry is the hardest. My irritation with the son was not about his request. It was a reaction I had before he finished the sentence, and I had the opposite reaction to the same request from a white daughter a week earlier. I cannot explain that difference in any way that I like. I am recording it because leaving it out would make this audit a description of the person I want to be.

What I did in each case was mostly adequate: I answered questions and printed the list. The pattern shows in what I added when I did not have to, and in whose name I bothered to learn. Those are small things, but they are the things patients remember and the things that decide how much they understand when they go home.

One Replacement Behavior

I am replacing one habit, chosen because it can be observed by a colleague and checked in my notebook. Before any discharge or new-medication teaching, I will ask every patient the same question: "What would you like to know about why we are doing this?" and then give the why to everyone who says yes, rather than deciding for them. A second, smaller change: on the first night I care for any patient, I will ask how to say their name and write it on the whiteboard in syllables. A colleague could check both. For the next two weeks I will keep the notebook and record whether I asked the question and whether I wrote the name.

I do not think these two changes address the reaction I had on Night 3, which happened before I did anything. What they can do is make my actions the same for every patient, even while I am still working on the reaction. FitzGerald and Hurst (2017) note that the evidence on how to reduce implicit bias itself is limited, and I would rather commit to a behavior I can check than to a change in feeling I cannot.

Closing

I expected this audit to show me that I treat patients fairly, with maybe one exception. It showed me a pattern of small differences that I would not have noticed without writing them down. The notebook was the useful part, and I intend to keep it.

References

FitzGerald, C., & Hurst, S. (2017). Implicit bias in healthcare professionals: A systematic review. BMC Medical Ethics, 18, Article 19. https://doi.org/10.1186/s12910-017-0179-8

Hall, W. J., Chapman, M. V., Lee, K. M., Merino, Y. M., Thomas, T. W., Payne, B. K., Eng, E., Day, S. H., & Coyne-Beasley, T. (2015). Implicit racial/ethnic bias among health care professionals and its influence on health care outcomes: A systematic review. American Journal of Public Health, 105(12), e60-e76. https://doi.org/10.2105/AJPH.2015.302903