The respiratory care workplace should be an equal opportunity setting. But is it? Or do ingrained preferences — known as “implicit bias” — give some people a bigger edge on success than others? We asked three leading RTs, Constance C. Mussa, PhD, RRT, RRT-NPS, Danielle Schryver, MSc, RRT, and Gabrielle Davis, MPH, RRT, CHES, to explain what “implicit bias” means and how we can identify it and weed it out of our profession.
First, can you define “implicit bias” for our readers who may not be familiar with the term?
Constance Mussa: Implicit bias refers to spontaneously activated (i.e., without awareness) favorable or unfavorable attitudes toward a person based on irrelevant characteristics such as race or gender. For example, a hiring manager whose stereotyping of women as caring but more emotional and less competent than men was learned early and reinforced often, so he may have an unfavorable attitude toward a female employee’s application for a leadership role.
It is important to note that many social scientists have provided evidence that “implicit biases do not necessarily operate without awareness of the bias or its effects.”1,2,3 Therefore, they do not recommend using the implicit bias construct to explain persistent disparities in organizational outcomes such as hiring, promotion, and retention of underrepresented groups.
Danielle Schryver: In its simplest terms, I believe implicit bias to be a bias that we hold, that is deeply rooted, and that we are unaware of. It is a part of human nature to categorize and organize the world around us. Even those who hold the principles of inclusion and diversity to the highest importance will still have implicit bias. One of the most important things we can do is to acknowledge and be aware of those biases. Reflecting on your own stereotypes is a great place to start to uncover your implicit biases.
Gabrielle Davis: My favorite definition comes from The Perception Institute: Thoughts and feelings are “implicit” if we are unaware of them or mistaken about their nature. We have a bias when, rather than being neutral, we have a preference for (or aversion to) a person or group of people. Thus, we use the term “implicit bias” to describe when we have attitudes toward people or associate stereotypes with them without our conscious knowledge. A fairly commonplace example of this is seen in studies that show that white people will frequently associate criminality with Black people without even realizing they’re doing it.
How do you believe implicit bias plays out in the typical respiratory care department, and what do you believe are the root causes?
Constance Mussa: From my perspective, implicit bias may play out in the typical respiratory care department in respiratory therapists’ interactions with patients, in hiring practices of respiratory care managers, mentoring, interpersonal interactions, and opportunities for promotion and professional development. Since individuals who make up the leadership team at the organizational and departmental level are ambassadors of the organization’s mission and values, they communicate the values of the organization and the respiratory care department to employees via verbal and nonverbal cues. Consequently, I believe that the root cause of implicit bias in a respiratory care department is primarily attributable to behaviors that are modeled by the organization’s senior leadership team and the respiratory care leadership team.
Danielle Schryver: It is unrealistic to believe that we do not have any implicit biases. It is a part of how we interact with both our colleagues and our patients. When unacknowledged, they can become a source of discomfort and friction within departments.
Gabrielle Davis: Implicit biases are present during the interview process and span throughout the career. Respiratory therapists who are a part of a minoritized group or multiple minoritized groups are most directly and negatively impacted by implicit biases. These biases are caused by passivity and blissful ignorance. Failing to recognize the inequities within our systems and the ways in which people are minoritized further perpetuates this cycle.
What can staff therapists do to minimize incidences of implicit bias in their departments — and in the care their patients receive?
Constance Mussa: Like most people, respiratory therapists are inclined to build social networks of individuals who look like themselves, thereby creating an in-group and an out-group. To minimize implicit bias fueled by automatic in-group vs. out-group distinctions (e.g., in-group seen as having more positive characteristics than out-group), respiratory therapists should be intentional about including their colleagues who are from different backgrounds (e.g., racial, ethnic, religious, cultural, etc.) in their social networks.
Danielle Schryver: We must acknowledge that they exist and evaluate what our own implicit biases consist of. When we acknowledge them, we are more able to recognize if they are creeping into our thought processes and everyday interactions. We can use this recognition to start to build positive connections rather than negative connections.
Gabrielle Davis: Staff therapists and RT leaders can minimize instances of implicit bias in their departments and during patient interactions by first accepting the fact that they have them. It is likely that there are folks reading this that believe they don’t have an implicit bias for any group or person. The fact is, anyone with any life experiences has implicit bias. Exploring one’s own implicit bias and acceptance of that bias is the first step to working to dismantle it and/or shelve it when working in the health care realm.
What steps do you believe department management should take to keep implicit bias out of their departments, and most especially, out of the care patients receive from their therapists?
Constance Mussa: To mitigate the risk of implicit bias within respiratory care departments, managers should avoid behaviors that could create in-group favoritism, such as the leader-member exchange practice embraced by many leaders, which involves selecting a small group of employees with whom a leader establishes a special relationship. Respiratory care managers should therefore examine any informal network(s) they have established in their departments to determine if biases exist in how such network(s) were created, and they should be intentional with regard to being inclusive. If respiratory care managers engage in behaviors that prevent an in-group vs. out-group dynamic from developing within their departments, the risk of implicit bias being transmitted to the patient care environment can be mitigated, as well as the risk of negative work attitudes and low morale among respiratory therapists.
Danielle Schryver: Talk about it. Bring it to the forefront. Invite a guest speaker with expertise in implicit bias to a staff meeting. Include education about it in annual education requirements. Encourage discussion about it.
Gabrielle Davis: Management in RT departments should encourage exploration of implicit biases as it historically hasn’t been focused on during RT programs. Being in management doesn’t absolve management from having similar biases as their staff. RT management can lead by example by taking ownership of their own biases and making an effort to dismantle them. RT management can also make this exploration a requirement rather than a suggestion. While completing a module won’t ensure an RT’s bias won’t impact a patient negatively, it could plant a seed for further growth.
What role do you think RT educational programs should play in ensuring students know what implicit bias is and how to keep it from happening on the job?
Constance Mussa: I think that it is imperative for respiratory care faculty and staff in RT educational programs to model behaviors that are consistent with diversity, equity, and inclusivity (DEI) to help respiratory care students understand the importance of this issue. Additionally, DEI training must be included in the curriculum and should include teaching students how to override their initial instincts related to stereotypes and how to self-edit to prevent bias from affecting the learning experiences of their classmates. Specifically, “although stereotype activation is automatic, stereotype application can be controlled”3 in the learning environment. That can be done by asking students, for example, to justify their decision-making process when choosing classmates to be their team members on assigned group projects.
Danielle Schryver: It is vital that we teach about implicit bias early on and frequently. I include a unit on implicit bias and cultural awareness in my Introduction to Respiratory Care course for my first-year students. I bring it to the forefront early and encourage discussion on the topic. By taking it out of the dark, we can shine a light on it, talk about it, and discuss implications. When students know that this is a normal human trait, they are more likely to open up and explore their own implicit biases. This begins their own journey toward cultural sensitivity and cultural awareness.
Gabrielle Davis: RT educational programs should, at the bare minimum, provide education around caring for patients that are a part of minoritized groups. It is impossible to keep implicit bias from happening on the job. We must do our best to dismantle racism, genderism, sexism, homophobia, transphobia, ableism, and xenophobia. This means that faculty must incorporate inclusive ideas and ways of care into ALL of their courses, even if the topics don’t appear on the NBRC test.
Health professions education is based on whiteness, with a specific focus on cisgender, heterosexual people. We need to teach students that caring for patients with respiratory disease involves them caring for them beyond their lungs. This means respecting and acknowledging a patient’s lived, authentic experience and not defaulting to what society has deemed “normal.” After all, the patient is a person before the person is a patient.
- Hahn A, Judd CM, Hirsh HK, Blair IV. Awareness of implicit attitudes. J Exp Psychol Gen. 2014;143(3):1369-92.
- Onyeador IN, Hudson STJ, Lewis NA. Moving beyond implicit bias training: policy insights for increasing organizational diversity. Policy Insights from the Behavioral and Brain Sciences. 2021;8(1):19-26.
- Williams JC, Korn RM, Mihaylo S. Beyond implicit bias: Litigating race and gender employment discrimination using data from the workplace experiences survey. Hastings Law Journal. 2020;72(1):337.