Expert Preceptors and Understanding Implicit Bias

Learn how a nursing professional development specialist reflected on her learning regarding diversity, equity, and inclusion (DEI) concepts and integrated them into her hospital's preceptor development program.

Five years ago, as a white heterosexual cisgender woman in Southern California, I never thought much about my implicit biases or health disparities. I thought if I treated everyone with respect, that was enough. But I was wrong. After exposure and education about DEI concepts, I am now more aware of some of my biases and how they affect my thoughts and actions. I think about the disparities people of color experience in our healthcare systems and beyond. I want to learn more and, in my role as a nursing professional development specialist, I look for ways to incorporate what I've learned into our hospital's educational curriculum.

Preceptors

In 2021, a team of nurse leaders began to build an innovative, evidence-based preceptor training program at Children's Hospital Los Angeles. We discussed curriculum needs and preceptor competencies, and it was clear to us we needed to include content on DEI. More than ever, preceptors are cultural influencers. They impact not only their preceptees' clinical practice, but also how their preceptees interact with their colleagues, patients and families. This cultural influence is why being intentional about what we included in the curriculum was so important.

Preceptor Development Program

The Preceptor Development Program (PDP) is a three-day interactive series of workshops that uses Kolb's experiential learning theory as a framework. The series begins with fundamental concepts, gradually building on these basic concepts and adding more complex concepts in the second and third workshops. For this blog, I will focus only on the DEI content infused throughout the program. 

Identifying Biases to Build Psychological Safety

The first workshop begins with "Building a Strong Foundation." The first part of the presentation introduces the concept of psychological safety and how the preceptor can influence this concept in the preceptee. We connect DEI and psychological safety through the concept of implicit biases. M.D. Thomas (2020) stresses that understanding one's own biases is critical to creating a psychologically safe environment, and creating such an environment can influence inclusion and belonging. We define implicit biases and share examples of these biases during the first workshop. 

We then discuss the potential impact of biases on building an inclusive and psychologically safe environment. The preceptors participate in a reflective exercise where they write about biases they may have that could affect the relationships they are building with their preceptees. These biases could include not only different cultures or ethnicities, but also age, gender, nursing school or previous careers. I give the example of a particular nursing school I hesitated to hire from due to their previous poor reputation. I challenge the group to consider their biases and what they've thought about their preceptees before they even meet them and how it may impact how they treat them as their preceptors. Everyone can have biases. Our experiences and work environments influence our beliefs and reveal stereotypes, but taking the time to consider our biases will help us be better preceptors and nurses. 

'The Fullest Name' Activity

Next, we lead an activity called "The Fullest Name" adapted from Paul Gorski's awareness activity Preceptors split into groups of two or three and share answers to the following questions:

1. Who gave you your name? Why?
2. What is the ethnic origin of your name, if any?
3. What are your nicknames, if any?
4. What name do you prefer to be called?

They participate in a meaningful discussion and then groups take turns introducing each other to the entire class, sharing some of the information they learned. In one class, a preceptor shared the name she preferred to be called, and those of us who knew her were shocked. For years, we had called her by another name; we felt awful. If we had only asked, maybe she would have shared, and then she would have been known by her preferred name at work. We recommend the preceptors do this same activity with their preceptees. Some benefits of this activity include learning the names their preceptees want to be called from day one, making sure they pronounce them correctly, learning about the preceptees' backgrounds or ethnic origins, and getting to know them on a deeper level.

Platinum Rule

At the end of the presentation, we compare the Golden Rule with the Platinum Rule. Although we are taught the Golden Rule as a child and it does have good intentions, it focuses on myself and what I prefer. The Platinum Rule acknowledges our differences and encourages us to get to know each other so that we may treat others the way they want to be treated. We discuss simple personal examples and work-related scenarios where it might be helpful to use the Platinum Rule when working with a preceptee.

DEI and the Preceptor Role

During the second workshop in the PDP, we dedicate an hour to presenting and leading activities related to DEI and the preceptor role. Key concepts discussed include the following:

• A reflective exercise on equality, equity and justice so they can not only incorporate these concepts into their practice, but also teach their preceptees.
  • Equality: evenly distributed tools and assistance
  • Inequality: unequal access to opportunities
  • Equity: custom tools that identify and address inequality
  • Justice: fixing the system to offer equal access to both tools and opportunities
• The concept of identity salience means preceptors have a chance to identify and describe different aspects of their identities, how they relate to their identities and how that changes depending on their environment. Some cultural identity groups might include gender, religion, ethnicity, class, language, sexual orientation and education.
  • For example, a preceptor who identifies as a man may feel like a minority among nurses, but a majority in other aspects of his life. He is still a man, but how he sees himself and how others see him depends on the circumstances. The salience we put on our different identities is also discussed; some might identify more with their religion than they do with their race or ethnicity, or vice versa. The importance of reflecting on our own identity and getting to know our co-workers and preceptees as individuals and how they identify is emphasized.
• An assessment of implicit biases is included. Each preceptor in the class is given the opportunity to complete an Implicit Association Test (IAT). These tests measure attitudes and beliefs that people may or may not know they have or are willing to share. There are many different tests; following is the one I took.
  • I believe that men and women are equal when it comes to science. I believe that both can excel in the subject, and both can have careers related to science. However, when I took this IAT, I associated men with science more than I did women. I was surprised and even discouraged by the results, but I am now aware that it is one of my biases. During class, preceptors have the same aha moments, and some have the same reactions to their test results. Either way, they learn more about themselves and bring this new awareness to their roles as preceptors and nurses.

Types of Implicit Biases

In the last PDP workshop, we focus on six types of implicit biases and discuss everyday situations where they may exist. These conversations are real and may be difficult to face at times.

These examples show us how we are affected by many of these biases and how they can impact how we interact with not only our preceptees, but our patients too. As preceptors learn more about their biases, they can be more aware how they treat their preceptees, co-workers and patients. The PDP participants are also encouraged to share this knowledge and help their preceptees recognize their biases too.

Call to Action

Department leaders, nursing professional development specialists and preceptors, you are encouraged to look inward and make a difference. What can you do to improve your new nurses’ experiences during their orientation and the culture in your departments? Take action with these few simple steps:

1. Reflect on your own biases and the culture in your department.
2. Review preceptor training and transition to practice programs.
3. Acknowledge where you can add DEI principles and concepts.
4. Create a safe space, and challenge preceptors to identify and face their biases.
5. Add activities from this blog, and make it fun and inspiring!
6. Evaluate the impact of your work on preceptors and preceptees.

Making these changes can create an environment where staff feel seen, heard, accepted and valued. Taking these simple steps can have a positive impact on your organization too.