Research| Volume 49, ISSUE 2, P175-197, March 2023

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The Experiences of United States Emergency Nurses Related to Witnessed and Experienced Bias: A Mixed-Methods Study

Published:December 16, 2022DOI:



      The purpose of this study was to obtain a broad view of the knowledge, attitudes, beliefs, and lived experiences of emergency nurses regarding implicit and explicit bias.


      An exploratory, descriptive, sequential mixed-methods approach using online surveys and focus groups to generate study data. Two validated instruments were incorporated into the survey to evaluate experiences of microaggression in the workplace and ethnocultural empathy. Focus group data were collected using Zoom meetings.


      The final sample comprised 1140 participants in the survey arm and 23 focus group participants. Significant differences were found in reported experiences of institutional, structural, and personal microaggressions for non-white vs white participants. Respondents who identified Christianity as their religious group had lower mean scores on items representing empathetic awareness. Respondents who identified as nonheterosexual had significantly higher mean total Scale of Ethnocultural Empathy scores, empathetic awareness subscale scores, and empathetic feeling and expression subscale scores. Thematic categories that arose from the focus group data included witnessed bias, experienced bias, responses to bias, impact of bias on care, and solutions.


      In both our survey and focus group data, we see evidence that racism and other forms of bias are threats to safe patient care. We challenge all emergency nurses and institutions to reflect on the implicit and explicit biases they hold and to engage in purposeful learning about the effects of individual and structural bias on patients and colleagues. We suggest an approach that favors structural analysis, intervention, and accountability.

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      Lisa Wolf is Director, Emergency Nursing Research, Emergency Nurses Association, Schaumburg, IL. ORCID identifier:


      Altair Delao is Senior Research Manager, ENA, Schaumburg, IL. ORCID identifier:


      Cydne Perhats is Senior Research Associate, ENA, Schaumburg, IL. ORCID identifier:


      Anna Valdez is Professor, Sonoma State University, Windsor, CA. ORCID identifier:


      Tania Strout is Director of Emergency Research, Maine Medical Center, Portland, ME. ORCID identifier:


      Paul Clark is Assistant Professor, UNiversity of Louisville, Louisville, KY. ORCID identifier:


      Michael Moon is Associate Professor, University of the Incarnate Word, San Antonio, TX. ORCID identifier:


      Stephanie Frisch is Nurse Scientist, University of Pittsburgh, Pittsburgh, PA. ORCID identifier:


      Michael Callihan is Assistant Professor, University of Alabama, Tuscaloosa, AL. ORCID identifier: