Counter Bias Training Simulation Healthcare

"Of all the forms of inequality, injustice in health is the most shocking and the most inhuman because it often results in physical death." - Martin Luther King Jr. One cause of this injustice is bias in healthcare delivery resulting in minority health disparities. Biases that are explicit (such as blatant prejudice or bigotry) are rare among healthcare professionals, but implicit biases (unconscious ways in which beliefs, attitudes, and values influence perceptions of the world and the people in it) are systemic and widespread. Implicit bias is the unconscious or semiconscious attribution of particular qualities to members of a particular social group. For example, associating African Americans with criminality, LGBTQ+ members with perversion, or people suffering homelessness with drug seeking. Biases such as these can lead to damaged patient-clinician relationships (PCR), discriminate administration of treatment such as pain medication, and consequent health disparities that are extreme and inexcusable. Innovative methods for reducing the impact of implicit bias on PCR and consequent minority health disparities are critical.

The research team has developed Counter Bias Training Simulation (CBTsim), an innovative and unique training program that uses simulation to make trainees aware of implicit biases and learn to overcome or "counter" them. A version has been developed, tested, and demonstrated a reduction in bias for police officers. CBTsim has great relevance to healthcare, for which existing implicit bias trainings are typically lecture based, and may be ineffective at reducing the impact of bias on PCR. A health care version of CBTsim would differ from existing programs by integrating bias awareness and reduction into actual patient care and communication skills via simulation, and could have a revolutionary impact on reducing bias in PCR nationwide. As such, this study developed "CBTsim Healthcare" and evaluated its effectiveness at reducing bias in PCR and subsequent minority healthcare disparities.

This study was jointly conducted in the Washington State University College of Nursing Simulation Lab (aims 1 and 2) and Providence Medical Center (aim 3) in Spokane WA. First, a culturally diverse team developed CBTsim Healthcare scenarios based on an extensive review of the literature on healthcare disparities. Then, a randomized control trial was conducted with 91 nurses to test the effectiveness of CBTsim Healthcare. Nurses received 2 hours of baseline testing, then 50 nurses (treatment group) received a 4-hour CBTsim Healthcare training and the other 41 nurses (control group) watched a 90 minute implicit bias documentary, more typical of current standard practice. Then, all 91 nurses received 2 hours of post-intervention testing. Testing included a demographic questionnaire, a scale to measure biased attitudes, patient care scenarios, and feedback on perceived training effectiveness. Nurses were then assessed for patient satisfaction using Press Ganey scores. Using this innovative design, Specific Aims were:

Aim 1: Measure the impact of CBTsim Healthcare on nurse implicit bias and prejudice.

Aim 2: Analyze the impact of CBTsim Healthcare on nurse interactions with patients in hypothetical scenarios.

Aim 3: Evaluate the impact of CBTsim Healthcare on disparities in patient satisfaction with healthcare in the hospital setting.

All major health agencies have identified minority health disparities as a matter of extreme urgency. The economic impact is an estimated $230 billion a year,32 and the social justice impact is immeasurable. Implicit bias and its impact on PCR is a cornerstone of systemic inequity, and it is one that can be feasibly addressed.

• CBTsim (Behavioral): Experimental: CBTsim is a simulation based implicit bias training platform
• bias documentary (Behavioral): A documentary about unconscious bias

Primary outcomes

• Patient care scenarios [Baseline and immediately post intervention]: Participants were asked to respond to three patient care scenarios and scored on their responses - scores ranged from 30-90 with higher scores indicating better (more equitable) performance
• Stereotypical Attitudes [Baseline and immediately post intervention]: The stereotypical attitudes scale has four sections (race, gender, LGBTQ, socio-economic status) where participants are asked to rate their agreement with certain stereotypically held beliefs. Scores range from 20-100 and higher scores on the scale indicate more stereotypical attitudes.
• Nurse engagement [Immediate post intervention]: Nurses were asked to respond "yes" or "no" to various questions about whether they believed the training was engaging, beneficial for reducing bias, and whether they believed it will help them in the hospital setting
• Press Ganey Scores [Three months pre intervention and three months post intervention]: Standardized patient satisfaction metrics, rating care on a scale from 1 (very poor) to 5 (very good)
• Qualitative feedback [3 month post intervention]: Nurses were asked to comment on how they believed the training had impacted their patient care

Sex: All, ages: 18 Years to any, accepts healthy volunteers

Inclusion Criteria:

* Registered nurse working full time at the test hospital

Exclusion Criteria:

* Not a registered nurse working full time at the test hospital