Fast thinking: How unconscious bias and binary language contribute to rationing of care to older persons

Abstract

Background Binary or categorical thinking is a way of thinking in which the brain unconsciously sorts the masses of information it receives into categories. This helps us to quickly process information and keeps us safe through pattern recognition of possible threats. However, it can also be influenced by unconscious and conscious biases that inform our judgements of other people and situations. Objectives To examine nursing practice with older people through the lens of unconscious bias. Methods In this critical analysis, using Kahneman's fast and slow thinking, we argue that nurses working with hospitalised older people often rely on thinking quickly in hectic work environments, which can contribute to unconscious and conscious bias, use of binary language to describe older persons and nursing tasks, and ultimately rationing of care. Results Binary language describes older persons and their care simplistically as nursing tasks. A person is either heavy or light, continent or incontinent, confused or orientated. Although these descriptions are informed in part by nurses' experiences, they also reflect conscious and unconscious biases that nurses hold towards older patients or nursing tasks. We draw on explanations of fast (intuitive) and slow (analytical) to explain how nurses gravitate to thinking fast as a survival mechanism in environments where they are not supported or encouraged to think slow. Conclusions Nurses survival efforts in getting through the shift using fast thinking, which can be influenced by unconscious and conscious biases, can lead to use of shortcuts and the rationing of care. We believe that it is of paramount importance that nurses be encouraged and supported to think slowly and analytically in their clinical practice. Implications for practice Implications Nurses can engage in journaling and reflecting on their practice with older people to examine possible unconscious bias. Managers can support reflective thinking by supporting nurses through staffing models and encouraging conversations about person‐centered care in unit practices.

Nurses' knowledge and beliefs on pain management practices with hospitalised persons living with dementia: A qualitative descriptive study

“…Other scholars have also noted that nurses do not report using specific paint assessment tools (Krupic et al., 2020; Krupić et al., 2018; McCorkell et al., 2017). This practice may be related to the complexity of workflow and the fast pace of the hospital environment, resulting in nursing practices that often rely upon fast thinking because nurses lack the time to look up available assessment tools (Hunter & Dahlke, 2023). Moreover, similar to other scholars findings (Krupic et al., 2020; Krupić et al., 2018; Minaya‐Freire et al., 2020; Seffo et al., 2020), participants discussed the need for enhanced staffing levels to assess and manage the needs of PLWD.…”

“…According to Kahneman (2011) when people use fast thinking, they make decisions based on efficiency rather than slow thinking which | 3227 is based on reflection and is more demanding cognitively. Fast thinking practices rely upon previous experiences that provides the nurse with an ability to assess a situation quickly, but may not always be the best approach to complex care, such as managing pain in a hospitalised PLWD (Hunter & Dahlke, 2023).…”

“…As a part of practice change, nurses also require strategies to help them identify unconscious biases formed by negative stereotypical beliefs and dementia stigma. Some successful approaches that have been shown to have success are programs that include self-reflection exercises that lead to awareness and internalisation of how to improve the care of PLWD (Hunter & Dahlke, 2023).…”

“…Positive ageism includes beliefs that older persons are wise or positive feelings about one's older family members (Hinchliff, 2016). In benevolent ageism, an individual may have a positive perspective of older persons, but unconsciously believe they require assistance leading to paternalistic behaviour through over‐accommodation (Cary et al., 2017; Hinchliff, 2016; Hunter & Dahlke, 2023). Moreover, prevalent among nurses are negative stereotypes that may include stereotypical beliefs that pain is an inevitable part of the normal ageing process and that dementia is an inevitable part of ageing (Ben‐Harush et al., 2017; Bernardes et al., 2015; Okbamicael, 2019; Rababa, 2018; Scerri et al., 2020).…”

“…Mindlines are closely aligned with best practices; however, when nurses have underlying negative stereotypes, prior experience may be relied upon rather than best practice recommendations. Nurses also use shortcuts, which are potentially biased patterns of thinking quickly in practice (Hunter & Dahlke, 2023). These shortcuts can be applied to pain management practices, identifying this as their foundational knowledge, rather than knowledge based on best practice recommendations.…”