title: Unconscious Race and Class Biases among Registered Nurses: Vignette-Based Study Using Implicit Association Testing.
abstract: BACKGROUND
  Implicit bias is an unconscious preference for a specific social group that can have adverse consequences for patient care. Acute care clinical vignettes were used to examine whether implicit race or class biases among registered nurses (RNs) impacted patient-management decisions.
  
  
  METHODS
  In a prospective study conducted among surgical RNs at the Johns Hopkins Hospital, participants were presented 8 multi-stage clinical vignettes in which patients' race or social class were randomly altered. Registered nurses were administered implicit association tests (IATs) for social class and race. Ordered logistic regression was then used to examine associations among treatment differences, race, or social class, and RN's IAT scores. Spearman's rank coefficients comparing RN's implicit (IAT) and explicit (stated) preferences were also investigated.
  
  
  RESULTS
  Two hundred and forty-five RNs participated. The majority were female (n=217 [88.5%]) and white (n=203 [82.9%]). Most reported that they had no explicit race or class preferences (n=174 [71.0%] and n=108 [44.1%], respectively). However, only 36 nurses (14.7%) demonstrated no implicit race preference as measured by race IAT, and only 16 nurses (6.53%) displayed no implicit class preference on the class IAT. Implicit association tests scores did not statistically correlate with vignette-based clinical decision making. Spearman's rank coefficients comparing implicit (IAT) and explicit preferences also demonstrated no statistically significant correlation (r=-0.06; p=0.340 and r=-0.06; p=0.342, respectively).
  
  
  CONCLUSIONS
  The majority of RNs displayed implicit preferences toward white race and upper social class patients on IAT assessment. However, unlike published data on physicians, implicit biases among RNs did not correlate with clinical decision making.
authors.affiliation: Center for Surgery and Public Health, Harvard Medical School and Harvard School of Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, MA. Electronic address: ahhaider@partners.org.
authors.forename: Adil H
authors.initials: AH
authors.lastname: Haider
authors.affiliation: Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD.
authors.forename: Eric B
authors.initials: EB
authors.lastname: Schneider
authors.affiliation: Implisci, Charlottesville, VA.
authors.forename: N
authors.initials: N
authors.lastname: Sriram
authors.affiliation: Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD.
authors.forename: Valerie K
authors.initials: VK
authors.lastname: Scott
authors.affiliation: Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD.
authors.forename: Sandra M
authors.initials: SM
authors.lastname: Swoboda
authors.affiliation: Center for Surgery and Public Health, Harvard Medical School and Harvard School of Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, MA.
authors.forename: Cheryl K
authors.initials: CK
authors.lastname: Zogg
authors.affiliation: Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD.
authors.forename: Nitasha
authors.initials: N
authors.lastname: Dhiman
authors.affiliation: Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD.
authors.forename: Elliott R
authors.initials: ER
authors.lastname: Haut
authors.affiliation: Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD.
authors.forename: David T
authors.initials: DT
authors.lastname: Efron
authors.affiliation: Armstrong Institute of Patient Safety, The Johns Hopkins University School of Medicine, Baltimore, MD.
authors.forename: Peter J
authors.initials: PJ
authors.lastname: Pronovost
authors.affiliation: Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD.
authors.forename: Julie A
authors.initials: JA
authors.lastname: Freischlag
authors.affiliation: Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD.
authors.forename: Pamela A
authors.initials: PA
authors.lastname: Lipsett
authors.affiliation: Department of Surgery, Howard University College of Medicine, Washington, DC.
authors.forename: Edward E
authors.initials: EE
authors.lastname: Cornwell
authors.affiliation: Department of Health Policy and Management, The Johns Hopkins Bloomberg School of Public Health, Baltimore, MD.
authors.forename: Ellen J
authors.initials: EJ
authors.lastname: MacKenzie
authors.affiliation: Center to Eliminate Cardiovascular Health Disparities, Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD.
authors.forename: Lisa A
authors.initials: LA
authors.lastname: Cooper
mesh_terms: D000328:Adult; D001741:Black or African American; D001244:Association; D001291:Attitude of Health Personnel; D003657:Decision Making; D005260:Female; D054625:Healthcare Disparities / Q000208:ethnology*; D006801:Humans; D016015:Logistic Models; D008297:Male; D008396:Maryland; D008875:Middle Aged; D009726:Nurses / Q000523:psychology*; D011446:Prospective Studies; D011581:Psychological Tests; D063505:Racism / Q000523:psychology*; D012923:Social Class; D014473:Unconscious, Psychology; D044465:White People