The Institute of Medicine’s landmark publication Unequal Treatment1 describes gender bias as unequal access or treatment that is not justified on the basis of an underlying health condition. In a health care setting, bias against women may be manifested when women are diagnosed, counseled, treated, or otherwise managed not just differently, but to a lesser degree of adherence to established standards of care than men with comparable health status. Potential effects of this bias include worse health outcomes for women, marked by higher complication, morbidity, and mortality rates.2 This expression of prejudice is believed to be implicit, operating at an unconscious level on the basis of situational cues.3 When a nearly invisible impediment to equitable quality health care can potentially undermine roughly half of the world’s population, it should warrant our attention. In the United States, our 309 million residents comprise 50.8% or 156.5 million females4 who may receive substandard health care.
My personal interest in the topic was piqued after returning home from my granddaughter’s funeral following an automobile crash and reading study findings that female trauma victims with life-threatening injuries comparable to males were less often triaged by emergency medical service personnel to trauma facilities and less often transferred by nontrauma physicians to trauma centers.5 Because both initial transport6 and secondary transfer to a trauma center7 correlate with more favorable clinical outcomes, whereas initial triage to a nontrauma facility is associated with a 30% higher mortality rate,8 the potentially lethal implications of both of those findings hit home immediately and personally.
I found it hard to reconcile that a practice arena heavily accustomed to following protocols and procedures based on valid research delivered a lower standard of care to women. In pursuit of answers and facts, I examined the literature surrounding this issue, hoping to locate evidence that my concern was unfounded. What I found was that this detriment to women’s health does not exist as a rare, isolated occurrence limited to third world countries, but has flourished as a pervasive, largely unrecognized phenomenon in the United States and throughout the world.9 I shared my findings in a 2012 editorial titled “Is there gender bias in critical care?”10
In the 5 years since that report, research continues to describe and affirm the nature, extent, and effects of gender bias with some awakening of awareness to its existence and potential for harm. The Table provides a sampling of the literature findings related to gender bias, with an emphasis on studies relevant to critical care. Please refer to it to become acquainted with or to refresh your own recognition of this problem and, I hope, to ignite your interest in contributing to its eradication. To support you in this effort, we can consider some of the approaches suggested for reducing or managing gender bias and then highlight a possibly promising breakthrough discovered serendipitously.
Strategies to Mitigate Gender Bias in Health Care
A number of approaches have been employed to help prevent or reduce implicit bias in health care. A frequent starting place is to help health care professionals gain some awareness of their own vulnerability to this form of prejudice. This step is often accomplished using the Implicit Association Test (IAT)—software that measures automatic associations evoked by rapid reactions in response to specific visually presented features representing various races, genders, ages, and sexual orientations. As different features are presented, the computer-based program tracks changes in response latency that reveal implicit bias. The IAT has been used in hundreds of studies across many disciplines and can be previewed at Harvard’s Project Implicit website.137
Merely exposing health care workers to the IAT may not alter attitudes or beliefs, however, so multiple strategies are often used, including combinations of education about implicit bias, prejudice, and stereotyping; peer discussions and focus groups; self-reflection; reading about implicit bias; and practicing skills aimed at countering stereotypical responses. To date, none of these has produced any blockbuster success. According to Zestcott et al,138 more research is needed to determine which of these interventions are effective, to understand how provider bias affects care, and how to motivate providers to control implicit bias.
One window into understanding these dynamics may have opened recently and surreptitiously, while shining a plausible and promising path to success.
An Unanticipated Breakthrough in Helping to Eliminate Gender Bias in Health Care
In 2005, after a random chart audit in a few high risk patient areas revealed that only 33% of vulnerable patients had received appropriate venous thromboembolism (VTE) prophylaxis, patient safety staff at Johns Hopkins Hospital launched a collaborative program to maximize adherence to VTE prophylaxis guidelines by means of a checklist.139 Further examination of these findings revealed that whereas 31% of male trauma patients did not receive VTE prophylaxis, for female trauma patients, that failure rate was 45%, making women nearly 50% more vulnerable to thrombi/emboli.140 Checklists were used as clinical decision support devices based on their effectiveness in improving compliance with other guidelines related to infection control141 and reducing postoperative complications.142 Among the lessons learned with this project was that while many interventions to foster staff buy-in for this effort may have contributed to substantial improvements in VTE prophylaxis compliance observed in successive project reports,143–145 2 other aspects were requisite for success: (1) The checklist order sets must be evidence based, user friendly, efficient, smoothly integrated into normal work-flow, and enable real-time performance monitoring, and (2) physician participation in completing all checklist requirements needs to be mandatory to achieve consistent compliance.139 In addition to the checklists, a “culture of safety” should include instruction in safety science, recognition of possible safety problems, design of evidence-based solutions, monitoring for improvements, and empowerment of all caregivers to halt procedures when safety appears to be compromised.146
Continued work with these computer-based mandatory checklists as clinical decision support tools has not only expanded their application as effective means for maximizing staff compliance with best practices, but has also afforded an apparent breakthrough into achieving desired clinical practice results while erasing disparities ascribed to race and gender bias. Lau et al145 describe attainment of significantly improved VTE prophylaxis compliance for hospitalized medical and trauma patients with concurrent elimination of preexisting racial and gender disparities. For medical patients, compliance with prescribed risk-appropriate VTE prophylaxis improved from 70% for black patients and 62%, for white patients (P = .015) before protocol implementation to 92% for black patients and 88% for white patients with no differences in compliance between the races (P = .082). Similarly, for trauma patients, the proportion of males prescribed VTE prophylaxis before the protocol was significantly higher than for female trauma patients (70% vs 55%, P = .045), whereas after protocol implementation, compliance increased for both male (86%) and female (81%) trauma patients (P = .078).145 Although other reports have highlighted the strong association between strict adherence to established guidelines and improved patient outcomes,147–149 Lau et al rightly underscore their unique findings of mutual and simultaneous benefits in both optimal and equitable patient care: “These findings highlight the potential of health information technology approaches to improve the quality of care for all patients and eradicate health-care disparities.”145(p6)
How Critical Care Nurses Can Contribute to Eliminating Gender Bias
Some of the cumulative lessons that critical care nurses can take away from these studies:
Evidence of gender bias against women in delivery of health care services is pervasive and persistent.
Acknowledging the existence of gender bias against women is a necessary first step in eliminating it.
Gaining insight into one’s own biases via the IAT can be a valuable personal enlightenment.
Critical care staff who would like to eliminate gender bias at their facility can learn from the experiences of multidisciplinary teams at Johns Hopkins Hospital as they refined their checklists141,150 designed the culture of safety,146 and implemented the VTE prevention program.139,143
Monitoring for gender bias includes observing for errors, omissions, or deviations from established protocols, standing orders, and national guidelines in our own setting as well as upon receipt of patients from emergency medical services or other facilities.
Just as with security concerns, the culture of safety demands that when you see something in a health professional’s practice that deviates from expectations, you say something so the practice is not permitted to continue or repeat.
If gender bias against women can be reduced by ensuring that all health care providers follow established protocols for practice in their clinical area, then we may not have a panacea but surely a promising means to eradicate a significant proportion of the gender bias that surrounds us. Critical care nurses can make their contributions via their insights and participation as integral members of the collaborative teams tasked with eliminating gender bias while maximizing compliance with best practices. Critical Care Nurse looks forward to hearing about your progress against gender bias, so please keep us informed.