What is unconscious bias in healthcare?
Unconscious or implicit bias refers to attitudes and stereotypes that influence our judgement without our awareness. They come from upbringing, culture, media and experience. The brain uses shortcuts to make fast decisions, and on a busy shift those shortcuts run constantly. Most of the time they help. Sometimes they lead us to judge a person by the group they belong to rather than by the facts in front of us.
Bias matters in healthcare because it can widen health inequalities that are already well documented in the UK. National maternal death enquiries by MBRRACE-UK have repeatedly found that Black and Asian women are more likely to die during or after pregnancy than white women. The government's independent review of equity in medical devices (2024) found that pulse oximeters can overestimate oxygen levels in people with darker skin, which can delay recognition of low oxygen. Some of these gaps come from systems and devices; some come from individual decisions.
Examples of unconscious bias in clinical practice
These are the types of bias people most often ask about, with examples you may recognise from practice.
| Type of bias | What happens | Clinical example |
|---|---|---|
| Stereotyping | Assuming a person has traits because of a group they belong to | Putting an older patient's confusion down to dementia without checking for infection or medicines |
| Affinity bias | Favouring people who are like us | Spending longer explaining options to patients who share your background |
| Confirmation bias | Looking for information that fits a first impression | Labelling a patient with a history of drug use as "drug-seeking" and not examining them properly |
| Diagnostic overshadowing | Blaming new symptoms on an existing diagnosis such as mental illness or learning disability | Treating an autistic man's agitation as a behavioural crisis when he has appendicitis |
| Attribution bias | Explaining behaviour by character rather than circumstances | Calling a patient "non-compliant" for missed appointments without asking about transport, caring duties or literacy |
| Halo and horn effects | One feature colours the whole judgement | Judging a colleague's competence by accent or confidence rather than their clinical work |
Pain, skin tone and symptoms
Research in several countries suggests pain may be under-recognised and under-treated in some ethnic minority groups and in women. Signs that depend on skin colour, such as cyanosis, pallor, jaundice, rashes and early pressure damage, can look different on darker skin, and many teaching materials have mostly shown them on white skin. Make sure you can recognise these signs on all skin tones, and use objective measures while understanding their limits.
A paramedic attends a 45-year-old woman with chest pain. She is tearful and says she has had a stressful week. The easy conclusion is anxiety. A bias-aware paramedic notices that pull, asks "What else could this be?", and carries out the same chest pain assessment they would for anyone, including an ECG and thinking about atypical presentations of acute coronary syndrome in women. The decision then rests on evidence, not assumption.
How does bias affect colleagues? Microaggressions at work
Bias shapes who gets asked to teach, who is listened to in meetings, who is called "not a good fit" at interview, and who is referred for performance concerns. NHS England's Workforce Race Equality Standard data has shown for years that staff from ethnic minority backgrounds are more likely to report bullying, harassment or abuse from colleagues, and less likely to be appointed after shortlisting, than white staff. Internationally educated professionals often describe being doubted or overlooked.
Microaggressions are everyday comments or actions, often unintended, that send a negative message about a group. Examples include:
- Repeatedly mispronouncing a colleague's name without trying to learn it.
- Asking "Where are you really from?"
- Sounding surprised that an internationally educated doctor or nurse is highly skilled.
- Assuming a Black or Asian woman in scrubs is not the doctor.
- Talking over a colleague with an accent, or repeating their point and taking credit.
Each comment may seem small. Repeated over months, they wear people down, affect retention and can make staff less likely to speak up about safety.
What does the Equality Act 2010 say?
Unconscious bias is not itself unlawful, but what it leads to can be. The Equality Act 2010 applies in England, Scotland and Wales (Northern Ireland has separate equality law). It protects people from discrimination at work and when receiving services, including healthcare.
The nine protected characteristics are age, disability, gender reassignment, marriage and civil partnership (in employment), pregnancy and maternity, race, religion or belief, sex, and sexual orientation.
| Prohibited conduct | Healthcare example |
|---|---|
| Direct discrimination | Refusing to register a patient because they are gay |
| Indirect discrimination | Offering appointments only by online booking, with no alternative, which disadvantages many older and some disabled people |
| Failure to make reasonable adjustments | Not offering a longer appointment or easy-read information to a patient with a learning disability who needs it |
| Harassment | Repeated jokes about a colleague's accent or religion |
| Victimisation | Giving a nurse fewer training opportunities after she raised a discrimination complaint |
NHS bodies also have the public sector equality duty under section 149, which is why services carry out equality impact assessments when they change. Separately from the law, discriminatory behaviour can be a fitness to practise concern for your regulator.
What can clinicians do to reduce unconscious bias?
There is limited evidence that a one-off training session changes behaviour for long. Habits and structures built into everyday work are more reliable.
- Notice your first impression: Name it to yourself and ask what you are assuming and what it is based on.
- Slow down at decision points: Bias is strongest when you are tired or rushed. Pause before decisions on discharge, pain relief, referral or escalation.
- Use structured tools for everyone: Apply early warning scores, pain scales and checklists consistently, knowing their limits. Structure reduces the pull of first impressions.
- Ask, do not assume: Ask patients about their preferred name, language, beliefs and needs. Ask colleagues how to say their names.
- Consider the opposite: Ask: would I decide the same if this patient were a different age, sex, ethnicity or background? If not, think again.
- Seek other views and check your data: Discuss uncertain decisions, welcome challenge, and where possible look at audit data by group, such as referral rates by ethnicity or deprivation.
Watch the language in your notes
Frequent flyer. Drug-seeking again, nothing wrong. Non-compliant with meds.
Fourth attendance this month with abdominal pain. Previous bloods and imaging normal. Reports not taking omeprazole as she cannot afford prescriptions; discussed exemption options. Examined today: see findings below.
Labels like these shape how the next clinician sees the patient and can lead to genuine illness being dismissed. Describe facts and behaviour. Patients increasingly read their own records, so write as if they will. Use a professional interpreter when needed, and avoid relying on family members, especially children, except in an emergency.
What should you do if you witness discrimination?
The GMC, NMC, HCPC and GPhC all expect you to challenge discrimination and support people affected. That does not always mean a formal complaint. A calm word at the time often works best. Active bystander approaches are a useful guide:
- Direct: calmly name it. "I don't think that comment is OK."
- Distract: interrupt, for example by asking the targeted person to help you with something.
- Delegate: ask someone with more authority, such as the nurse in charge, to step in.
- Delay: check on the person afterwards and ask if they want support to report it.
- Document: record what happened and support a formal report if appropriate.
If a patient is abusive or asks not to be treated by someone because of a protected characteristic, follow your local policy and involve a senior colleague. Abuse should be reported and staff supported, while making sure the patient still receives safe care. If you are the target, record what happened and seek support from your manager, a Freedom to Speak Up Guardian, a staff network or your trade union.
How do regulators view bias and discrimination concerns?
Good Medical Practice (2024) says doctors must treat patients and colleagues fairly and with respect and sets clearer expectations about a working environment free from bullying, harassment and discrimination. The NMC Code asks nurses and midwives to treat people as individuals, avoid assumptions and challenge discriminatory behaviour. HCPC and GPhC standards say similar things.
Regulators may see discriminatory behaviour as an attitudinal concern, which can be harder to remediate than a knowledge gap. Insight here means accepting the impact of what you said or did, even if you did not intend it, understanding why it was harmful, and showing specific changes that others can see.
Learning more about equality and bias
Our course Equality, Diversity and Unconscious Bias covers the Equality Act, common clinical biases, practical techniques and how to write a reflection and remediation plan if a concern has been raised about your behaviour. If bias affected a prescribing decision or your notes, Medication Errors: Reflection and Remediation and Record Keeping and Documentation: Remediation Course may also be relevant. A course supports your learning; it does not decide the outcome of any process.
Frequently asked questions
What is an example of unconscious bias in nursing?
A common example is assuming an older patient's new confusion is dementia, so infection, dehydration or medicine side effects are not checked. Another is giving less pain relief to a patient labelled as drug-seeking without a proper assessment. Using structured tools consistently and asking what else could explain the picture helps reduce these errors.
What is diagnostic overshadowing?
Diagnostic overshadowing happens when new symptoms are wrongly put down to a person's existing diagnosis, such as a mental illness, autism or a learning disability. For example, agitation in a non-verbal patient is assumed to be behavioural when the cause is pain from a physical illness. It is a recognised cause of missed diagnoses and avoidable harm.
Is unconscious bias training mandatory in the NHS?
There is no single national legal requirement for every NHS worker to complete unconscious bias training. Many employers include equality, diversity and inclusion in statutory and mandatory training. Check your employer's requirements. Evidence suggests one-off sessions have limited lasting effect, so habits and structured decision-making matter more.
What are the 9 protected characteristics?
Under the Equality Act 2010 they are age, disability, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion or belief, sex, and sexual orientation. Marriage and civil partnership is protected in employment only. Northern Ireland has its own separate equality legislation.
Is unconscious bias illegal?
Holding a bias is not unlawful. But if bias leads to discrimination, harassment, victimisation or a failure to make reasonable adjustments, that can breach the Equality Act 2010. It can also raise fitness to practise concerns with your regulator, whether or not anyone takes legal action.
What is a microaggression in healthcare?
A microaggression is an everyday comment or action, often unintended, that sends a negative message about a group. Examples include asking a colleague where they are really from, repeatedly mispronouncing their name, or seeming surprised that an internationally educated clinician is skilled. Individually small, repeated microaggressions cause real harm and affect retention.
How do I reflect on a complaint about discriminatory behaviour?
Describe what you said or did specifically, without minimising it as banter. Separate your intention from the impact and accept the impact. Link it to patient safety and team culture, describe any appropriate apology, and set out concrete changes with independent evidence such as supervision or multi-source feedback over time.
Related courses
Equality, Diversity and Unconscious Bias
This course explains the Equality Act 2010 and what it means for clinical care and teamwork, how unconscious bias can affect clinical decisions and…
Medication Errors: Reflection and Remediation
This course explains why medication errors happen, what you must do when one occurs, and how to show a regulator or employer that you have understood…
Record Keeping and Documentation: Remediation Course
This course explains what good clinical documentation looks like, why record-keeping concerns arise, and why altering or falsifying a record is…
Sources and further reading
- Equality Act 2010. legislation.gov.uk.
- Equity in medical devices: independent review (2024). Department of Health and Social Care.
- Saving Lives, Improving Mothers' Care. MBRRACE-UK.
- NHS Workforce Race Equality Standard data reports. NHS England.
- Good Medical Practice (2024). General Medical Council.
- The Code: Professional standards of practice and behaviour for nurses, midwives and nursing associates. Nursing and Midwifery Council.
Practitioner Insight is an independent education provider. It is not affiliated with or endorsed by the GMC, MPTS, NMC, HCPC, GPhC or any NHS organisation, and this information is not legal advice. If you have been referred to a regulator, speak to your defence organisation, trade union or legal representative.
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