How to Identify Bias in the NICU

by Shawn Smith, MD

As a pediatrician that works exclusively in the neonatal ICU as a hospitalist, I have noticed a few things over many years.

Most physicians and nurses think they treat all patients the same, but knowing everyone has implicit bias, this likely isn’t true. 

This world teaches us bias in everything we observe… when learning world history in school, when watching what race the criminals are in movies as well as what race the professionals are — including doctors and nurses. 

Everyone, including physicians and nurses, “brings their bias to work.”

It becomes obvious when the medical team may discuss patients and parents differently:

• Is there a single parent at the bedside instead of two?
  
• Are the parents always at the bedside for rounds or are some parents unable to attend? If parents are absent, has the medical team discussed support options for the family?
  
• Do parents have other children at home that they are unable to bring to the NICU due to visitor restrictions or because they are busy managing virtual school and working from home and cannot visit during bedside rounds?
  
• Do parents have the option of extended work leave or are they forced to return to work or risk losing employment while their baby is in the NICU?
  
• Are the parents of the same sex? How comfortable are we asking the proper way these families would like to be addressed or do we avoid it altogether because we are uncomfortable?
  
• Do we speak in hushed tones if a Mom is on medications for depression and anxiety, which some potential side effects may cause an infant to be admitted to the NICU for close observation? What about the parents struggling with opioid addiction versus one that admits to marijuana use? Are we more compassionate for one over the other?
  
• Do we jokingly laugh or poke “harmless” fun at baby names? If so, is it possible that we can then speak to, think of, and treat these parents without judgement if we already feel their first decision (naming their child) was not a good one?
  
• Do we treat families that are on the hospital or advisory board or those that are able to donate funds differently than other patients? Is this the expectation?
  
• Do we update parents that require an interpreter as often as we do our English-speaking families?

Some of these everyday occurrences are not noticeable to some, but once made aware of our biases, we can “check them” and then choose to respond differently. When physicians and nurses respond differently, we can narrow the gap on health disparities demonstrated so starkly between Black and white babies. 

Doctors and nurses absolutely want to provide the best care for our patients, but being unaware of implicit bias makes that impossible. 

The undeniable difference of how race plays a role was put on display last year after the killing of George Floyd and the disparities of COVID-19 in Black and Brown communities.

Often non-white patients feel they are spoken to with less compassion and report having felt being treated differently than other patients.

For the past 3 years, I have facilitated small-group talking sessions for pediatric trainees and nurses. They have been largely very welcoming to this conversation and have become aware of their own bias which comes from joining the conversation. 

I have facilitated these small group discussions with over 375 pediatric trainees and nurses. I have witnessed the residents go on to create a Resident Diversity Task force, with specific and tangible requests — create an advocacy portion to their weekly Morning Reports to discuss disparities in health care including current conditions such as COVID-19, bias in pain management and environmental racism.

Change will not come overnight as the problem has been in existence for hundreds of years. However, knowing that physician bias can contribute to patient harm and disparate outcomes means we cannot ignore this problem. The good news is that by bringing awareness to our own biases, physicians and nurses can make immediate changes in their patient care for babies and families at the bedside. These conversations also give tools for physicians and nurses to call out bias in their colleagues in a way that centers the patient and our collective inherent desire to do good.

I encourage everyone to speak up within their own circles, at work or home when loved ones express implicit bias and gently correct them or ask why they made the comment and consider why it may cause harm. It is not the intent of your statement, but the IMPACT of your words or actions. 

Shawn Smith, MD is an attending Physician with 14 years of practice, Neonatal ICU Hospitalist at Women’s Hospital and Assistant Professor at Northwestern Feinberg School of Medicine.