Diversity in EMS: Conquering Implicit Bias in the Prehospital Environment

Diversity in EMS is a new bimonthly column in which rotating authors will confront difficult questions of bias and discrimination in the emergency medical services and how agencies can lead change in their communities.

This is the second of a two-column series on implicit bias in the prehospital environment. In our August column we distinguished between explicit bias (e.g., racism) and implicit bias, sharing the “bad news” that we all have implicit biases despite our good intentions. These human biases can impact our perceptions and actions, producing discriminatory behavior. We discussed how implicit biases might affect an EMT during his or her work, which could negatively affect care, putting patients in danger.

In this column we share the “good news,” which is that we need not be the passive victims of our human biases. There are things all of us can do to reduce and manage our biases and training programs EMT administrators can provide to their personnel. The ultimate goal of both is to reduce the likelihood that human biases will affect the important work of EMS professionals.

What Can Individuals Do?

The social psychologists who study bias and prejudice have not only enlightened us as to how biases manifest, they have also documented, through their research, the effectiveness of various “debiasing” techniques.¹ Every individual can take steps to reduce and manage his/her biases. Reducing our biases means we are trying to weaken the associations in our heads between groups (e.g., people suffering mental illness) and the stereotypes we have about them (e.g., “they lie about their health problems”). Reducing biases is not quick or easy, but one way we can do that is to have positive contact with groups we stereotype. This reflects the well-documented “contact theory.”^2,3  

It’s a long slog to reduce our biases, so it is a good thing we can manage them—immediately. There are three elements to managing our biases: If we are 1) aware of our implicit biases and 2) motivated, we can 3) choose to implement bias-free behavior. Regarding the first: Even though implicit biases can affect us outside of conscious awareness, once a person is aware of this phenomenon, he or she can start to recognize when implicit associations pop into their head. Indeed, a person can train him/herself through self-reflection and practice to recognize when stereotypes intrude on their assessments of people and/or situations. A person is “motivated” if he or she cares about discrimination and wants to act in a bias-free manner. 

Regarding the third point, if we recognize an implicit association and are motivated, we can override the implicit association and engage in bias-free behavior.

What Can EMS Leaders Do?

Not surprisingly, training is key. The scientific literature indicates that knowledge of implicit biases is the first step toward addressing them. Implicit-bias awareness training programs, such as Fair and Impartial Policing, educate first responders on the science of bias and provide trainees with the skills they need to produce bias-free service.4 Law enforcement agencies have been implementing such training for at least a decade. Increasingly, implicit-bias training is provided to doctors and nurses, teachers and administrators, retail service providers, and the list goes on. 

The key objectives of this training are to:

• Educate attendees on the modern science of bias;
• Discuss the ways bias might manifest in their day-to-day decision-making and work;
• Outline the consequences to their effectiveness and safety of acting on biases;
• Provide skills for reducing and managing biases.

Such training should not be “canned” but instead be customized for the specific work of the audience. Science that is specific to the medical and EMT arena should be presented, and examples and exercises must reflect the day-to-day work of the EMS provider. The training must be engaging and interactive, allowing for discussion and personal reflection, and a good program recognizes—and works to reduce—the defensiveness some people bring to training on biases. 

Due to popular demand, Fair and Impartial Policing, which has been training law enforcement first responders since 2008, has developed a customized curriculum for the fire/EMT audience that meets these specifications.⁴ 

Implicit-Bias Training Works

Experimental evaluation research has shown that well-constructed implicit-bias training can be very effective. There is a significant and growing body of evaluation research showing that implicit-bias training impacts attitudes, intentions, and behaviors in various trainee audiences (e.g., police, educators, medical personnel). 

For instance, research shows that:

• Compared to members of control groups, implicit-bias trainees are more aware of bias and concerned about discrimination,^5–8 have increased motivation to behave in a bias-free manner,^6,9 and intend to use bias-reducing and bias-managing techniques.^5–10 
• Importantly, studies have documented reductions in biased behavior as a result of this training.^5-6,8,10-13

As we outlined in our August column, all people in every profession have biases that can affect perceptions and behavior. The good news is that we are not helpless or hopeless, and EMTs can learn to recognize biases and implement “debiasing” skills. 

References

1. Ludolph R, Schulz PJ. Debiasing health-related judgments and decision making: A systematic review. Medical Decision Making, 2017; 38(1): 3–13. 

2. Allport GW. The Nature of Prejudice. Palo Alto, Calif.: Addison-Wesley Publishing, 1954. 

3. Dovidio JF, Love A, Schellhaas FMH, Hewstone M. Reducing intergroup bias through intergroup contact: Twenty years of progress and future direction. Group Processes & Intergroup Relations, 2017; 20(5): 606–20. 

4. Fair and Impartial Policing, www.fipolicing.com. Information on the fire/EMT curriculum is at https://fipolicing.com/ems-fire

5. Carnes M, Devine PG, Isaac C, et al. Promoting institutional change through bias literacy. J Diversity Higher Ed, 2012; 5(2): 63–77. 

6. Carnes M, Devine PG, Manwell LB, et al. The effect of an intervention to break the gender bias habit for faculty at one institution: A cluster randomized, controlled trial. Acad Med, 2015; 90(2): 221–30. 

7. Devine PG, Forscher PS, Austin AJ, Cox WTL. Long-term reduction in implicit bias: A prejudice habit-breaking intervention. J Exper Social Psych, 2012; 48: 1,267–78. 

8. Forscher PS, Mitamura C, Dix EL, Cox WTL, Devine PG. Breaking the prejudice habit: Mechanisms, timecourse, and longevity. J Exper Social Psych, 2017; 72: 133–46.

9. Sekaquaptewa, D., Takahashi, K., Malley, J., Herzog, K. & Bliss, S. An evidence-based faculty recruitment workshop influences departmental hiring practice perceptions among university faculty, Equality, Diversity, and Inclusion, 2019; 38: 188–208. 

10. Devine PG, Forscher PS, Cox WTL, Kaatz A, et al. A gender bias-breaking intervention led to increased hiring of female faculty in STEM departments. J Exper Social Psych, 2017; 73: 211–5. 

11. Burroughs EA. Reducing bias in faculty searches. Notices of the AMS, 2017; 64(11): 1,304–7.

12. Russell J, Summers A. Reflective decision-making, and foster care placements. Psychology, Public Policy & Law, 2013; 19: 127–36. 

13. Smith JL, Handley IM, Zale AV, et al. Now hiring! Empirically testing a three-step intervention to increase faculty gender diversity in STEM. Bioscience, 2015; 65(11): 1,084–7. 

Lorie A. Fridell, PhD, is a professor of criminology at the University of South Florida and founder of Fair and Impartial Policing, Tampa, Fla. 

Brad Keating, MPH, NRP, is a fire-medic with Mountain View Fire Rescue, Longmont, Colo.