Implicit Bias in the Care of Obese African American Women: A Reflective Practice for Intensive Care Unit APRNs

Although many African Americans in the United States have experienced a substantial improvement in health equality, a number of gaps still exist socially, economically, and in health care delivery.1 For example, racial disparities in the intensive care unit (ICU), particularly in the care of African American women who are obese, have not been well documented and studied. However, a few studies showed that African American women often face higher rates of ICU admissions and worse outcomes compared with their White counterparts.2,3 These disparities can be attributed to several factors, including access to health care, socioeconomic status, underlying health conditions, and discrimination in medical treatment.4 Additionally, African American women may experience delays in receiving critical care and are less likely to receive specific life-saving interventions, which can contribute further to delays in treatment.1Advanced practice registered nurses (APRNs) in acute and critical care settings can implement strategies that directly address health care disparities, particularly among African American women. Evidence-based strategies include improving access to quality care, enhancing cultural competence among health care practitioners, and addressing systemic inequities within the health care system, starting at the individual level in the patient care unit. Thus, we aim here to examine and raise awareness of the racial biases and discrimination in the US health care system. The column also encourages self-reflection among health care practitioners, specifically APRNs, who are directly involved in the diagnosis and management of acutely or critically ill African American women experiencing obesity.BD was the beloved matriarch of 2 daughters, 7 grandchildren, and 3 great-grandchildren. Like many African American women, BD faced numerous challenges throughout her life, including struggles with her weight and limited access to accurate health education and information about chronic illnesses associated with obesity such as hypothyroidism, liver failure, diabetes, and hypertension. For BD, this limited access was influenced by several factors, including barriers to culturally responsive health care, limited availability of preventive health education in her community, financial constraints that hindered consistent medical follow-up, and difficulties navigating complex health care systems. These barriers made it harder for her to obtain preventive care and the resources necessary for managing chronic health conditions effectively. Despite her efforts to seek medical care, BD’s encounters with the health care system were often marked by dismissal, miscommunication, and systemic bias. For example, her concerns about symptoms related to her chronic conditions were sometimes minimized or attributed solely to weight rather than being fully investigated. At times, medical details were not clearly communicated, leaving her with a reduced understanding of her diagnoses and treatment options. She also faced delays in specialist referrals and had limited discussions about preventive care strategies.Ten years before her death, she shared with the first author her painful and long experience of feeling overlooked and unheard in medical and health care settings. As an African American woman, she often felt that her symptoms were not only minimized or solely linked to lifestyle choices but also that she was not being examined comprehensively. For instance, issues like fatigue, weight fluctuations, and shortness of breath were frequently chalked up to diet, lack of exercise, or body weight without a thorough investigation of potential underlying medical problems. Sometimes, the focus was on lifestyle changes, with less emphasis on exploring other contributing factors such as hormonal imbalances, heart issues, or metabolic problems. This approach sometimes made her feel that her concerns were not fully acknowledged or that the complexity of her health issues was oversimplified. She remembered waiting almost 7 years before finally being diagnosed with hypothyroidism—years during which she reported to practitioners persistent fatigue, unexplained weight gain, cold intolerance, joint and muscle pain, and fertility issues. During that period, she sought care from multiple practitioners in outpatient primary care clinics and urgent care facilities. Several times, she described feeling exhausted despite getting enough sleep and gaining more weight despite trying to change her diet and increase physical activity. Most of the advice she received focused on lifestyle changes. Practitioners often told her to lose weight, exercise more, or watch her diet, sometimes blaming stress, aging, or lack of activity for her symptoms, rather than exploring possible endocrine or metabolic causes. Once, she mentioned that even small tasks left her feeling overwhelmingly tired and that she experienced significant hair thinning and cold sensitivity. The provider reassured her that fatigue is common among working adults and again emphasized weight-management advice rather than ordering laboratory tests or referring her to an endocrinologist. The diagnosis was finally made years later during a visit with an African American primary care provider, who took a more thorough look at her symptoms and ordered thyroid function tests. The laboratory results confirmed hypothyroidism, explaining many of the symptoms she had been experiencing for years.After her diagnosis of hypothyroidism, BD was prescribed thyroid hormone replacement and initially felt relieved that her symptoms finally had a clear medical explanation. However, she reported receiving limited guidance on the importance of close monitoring, dosage adjustments, and regular laboratory follow-up after starting treatment. As a result, several months passed without consistent monitoring of her thyroid levels or medication adjustments. Over time, BD developed new symptoms including palpitations, restlessness, increased sweating, and difficulty sleeping. Her condition eventually worsened, leading to severe tachycardia, shortness of breath, and profound weakness. Ultimately, she was hospitalized in critical condition and required care in the ICU, where tests indicated she had developed hyperthyroidism from excessive thyroid hormone replacement. During this hospitalization, BD described feeling frightened and overwhelmed, especially since the treatment meant to improve her health had caused a life-threatening complication.The delay in diagnosis was not simply a medical oversight but a reflection of more profound inequities—implicit bias, lack of cultural awareness, and the silent barriers that prevent many women of color from receiving timely, respectful, and individualized care. Over time, the accumulation of these experiences eroded BD’s trust in health care practitioners. Her encounters left her feeling invisible and powerless, reducing her motivation to adhere to treatments or attend follow-up visits. The lack of competent communication—combined with judgmental attitudes and fragmented care— contributed to her poor disease management by health care practitioners. A contributor to BD’s diminished confidence in managing her obesity and comorbidities may have been posttraumatic stress rooted in years of medical neglect and discrimination, a phenomenon observed in the African American population. BD’s story illustrates how systemic injustices and silent barriers—such as provider bias, inadequate representation in research, and limited access to supportive education—can have life-altering consequences. BD’s downward spiral in physical and mental health was not merely the result of individual behavior or disease progression but the cumulative effect of structural racism and inequitable care. In the end, repeated hospitalizations, ICU stays, and complications from her chronic conditions led to her untimely death.The case presented illustrated an African American woman’s years of chronic illness progression due to misdiagnosis that stemmed from systemic bias. Despite repeatedly seeking medical assistance for symptoms of chronic disease, the patient was dismissed and told to lose weight, resulting in a delayed diagnosis and worsening health. BD’s lived experiences reflect how implicit bias, poor communication, and structural racism can lead to preventable suffering and loss. Given the limited number of studies on African American women’s experiences in the ICU, we present 2 salient themes that emerged from the literature as a basis for introspective or reflective practice among APRNs and other practitioners in the ICU.A synthesis of the literature regarding implicit bias affecting African American women in critical care reveals that weight stigma is deeply embedded within the US health care system and significantly influences the quality of care for patients living with obesity.4–8 Studies consistently demonstrate that stigma and biases toward weight—both implicit and explicit— are pervasive among health care practitioners, shaping biased clinical decision-making, attitudes, and behaviors.4,7,8 These biases often manifest in inequities related to pain management, patient-practitioner communication, and treatment planning, ultimately leading to poorer outcomes.4,7–9 Beyond adverse effects on clinical outcomes, the psychosocial implications of stigma are profound, contributing to internalized shame, anxiety, depression, and the avoidance of health care services,7,9,10 further aggravating poor health outcomes, as experienced by BD. Notably, in the acute and ICU settings, weight stigma often emerges as discomfort or frustration among staff when caring for obese patients, resulting in strained interactions, diminished empathy, and inconsistent adherence to evidence-based care protocols.4,6,11Collectively, published articles illustrate such dynamics on how stigma functions as both a silent barrier to quality care and a catalyst for deteriorating health trajectories. These dynamics are consistent with BD’s experience, which was characterized by disease progression, leading to emotional distress, mistrust, and hindered adherence to medical regimens. Over time, these factors contributed to multiple hospitalizations, worsening comorbidities, and a preventable decline in health. BD’s story underscores how implicit bias, when unacknowledged, perpetuates a cycle of misdiagnosis, psychological trauma, and health disparities among the African American population and, more specifically, among obese women. Unfortunately, to the best of our knowledge, no data-based article has been published on dismantling implicit or silent biases in acute and ICU settings. However, APRNs can leverage their clinical and leadership roles to address implicit biases and promote equitable, high-quality care outcomes.Studies examining disparities in critical care highlight the compounding effects of race, sex, and weight bias in shaping discriminatory outcomes.12–17 Among African American women, obesity interacts with systemic racism to amplify risks for adverse events such as maternal mortality, cardiovascular disease, and critical illness complications.1,2,4,12,13,17 Research shows that African American women experience disproportionately higher rates of cesarean deliveries, stroke mortality, diabetes, and hypertension— results that persist even after controlling for socioeconomic status.1,14,15 These patterns reflect the enduring influence of structural racism, discrimination, and institutional neglect in health care,2,12,16 which can look like BD’s 7 years of waiting for a diagnosis. In the ICUs, APRNs play a pivotal role in addressing these inequities by role-modeling for staff nurses and other members of the health care team. Guided by the American Nurses Association (ANA) Code of Ethics for Nurses With Interpretive Statements,18 particularly provision 8, APRNs have an ethical responsibility to advocate for social justice and equitable care delivery while paying attention to biased experiences in marginalized populations, such as those illustrated by the case of BD. By recognizing and addressing implicit bias, APRNs can foster culturally responsive communication, improve patient engagement, and promote trust between patients and health care practitioners.2,4,6Interventions for patients such as resilience-based training to manage stress related to racial discrimination and weight-related chronic disease management and those for health care practitioners such as implicit bias education have shown promise in mitigating disparities.8,19 In states such as Illinois, mandated implicit bias training for licensed professionals reinforces these goals by requiring practitioners to acknowledge and counteract unconscious stereotypes that influence health and health care delivery outcomes. APRNs can lead by integrating such education or competencies into their clinical practice, staff development, and organizational policy.6,18 Ultimately, advancing equity in critical care demands intentional, research-informed strategies that address both racial and weight-based discrimination. Starting with self-reflection on their own biases, APRNs can role-model empathy, advocate for systemic and structural reform, and implement evidence-based interventions. By doing so, APRNs can help dismantle the silent barriers that defined BD’s experience— ensuring that no patient’s care or dignity is compromised by unfairness.Building upon the themes above, APRNs can champion the implementation of standardized, evidence-based protocols for ICU admissions, pain management, and critical life-saving interventions. Such protocols will minimize the potential for subjective biases to influence decision-making processes.3,14 Additionally, APRNs can assume leadership roles in interdisciplinary advocacy and organize quality improvement initiatives that meticulously monitor disparities in outcomes across various demographics, including race. Moreover, they can advocate for health policy reforms that integrate cultural competence and weight sensitivity into the foundational fabric of health care systems.16 In addition to clinical interventions, APRNs are qualified to offer psychological support by proactive screening for anxiety, depression, and stress. Facilitating referrals to resilience-building programs or community-based resources addresses the combined adversities of weight stigma and racism. By employing these multifaceted strategies, APRNs will proactively and actively interrupt the cycle of mistrust and inequity. Adding “weight sensitivity” to cultural sensitivity care advances a model of health care delivery that is compassionate and responsive to the distinct needs of obese African American women within acute and critical care settings. As members of the most trusted and ethical professionals among the public,20 APRNs are well suited to alleviating the complex challenges of stigma and racial bias within critical care settings through a synthesis of introspective, evidence-based practice and assertive patient advocacy.To enact practical cultural, racial, or “weight-sensitive” care, APRNs must engage in periodic self-assessment to identify and address implicit biases that may affect their clinical judgments, nurse-client therapeutic communication, and empathetic responses toward their obese African American female patients.21,22 APRNs can also use structured educational programs, reflective journaling, and peer debriefing to identify and reduce unconscious biases that may negatively impact patient outcomes. By employing these approaches, APRNs can develop therapeutic interventions founded on trust and mutual respect. Incorporating nonstigmatizing language and shared decision-making helps them acknowledge patients’ experiences, strengthen relationships, and enhance trust. In turn, this fosters better adherence to treatment plans, thereby improving the overall quality of care.8,22BD’s story is not an isolated tragedy but a reflection of recurring inequities in the US health care system—especially among African American women navigating complex chronic conditions. BD’s racially biased experience resulted in a progressive, downward-spiraling illness trajectory, an example that should urge us to move beyond awareness toward action through research, education, and system-level quality improvement initiatives. Further research is needed to explore how implicit bias and cultural disconnects affect ICU care resulting from chronic diseases among obese African American women. Qualitative studies could illuminate patients’ lived experiences of bias and mistrust, while quantitative research could evaluate the impact of bias-reduction interventions on diagnostic accuracy, treatment adherence, and patient satisfaction. Expanding community-based participatory research models would also ensure that patients’ voices directly shape interventions intended to serve them. A quality improvement initiative could be implemented that focuses on embedding cultural humility (including weight sensitivity) and implicit bias education into clinical practice.At the policy level, several states currently mandate implicit bias training for health care professionals, including Illinois, as a licensure renewal requirement. For example, beginning in 2026, the Illinois State Board of Nursing requires all nurses to complete training designed to help practitioners recognize and mitigate the unconscious stereotypes that influence clinical decision-making. Similar requirements are being adopted in states such as Michigan, Maryland, and California. Health care systems can build on these requirements by implementing awareness programs, simulation training, and reflective practice sessions within nursing education and ongoing staff development. By integrating this training into annual competency assessments and clinical orientation, facilities can foster a culture of care that values awareness, accountability, and empathy. This implicit bias training emphasizes that nurses must address health disparities, promote equity, and challenge institutional barriers that perpetuate discrimination and biased outcomes.Finally, in BD’s case, ethical nursing practice would have required active listening, thorough investigation of symptoms, and culturally responsive communication. Upholding ANA’s moral standards is essential not only for individual patient advocacy but also for systemic change. The next step is to translate understanding into measurable action: developing research-informed, ethically grounded, and policy-aligned interventions that dismantle silent barriers. By merging evidence-based practice with moral and regulatory mandates, institutions can, in the future, ensure that no patient’s suffering—like BD’s—is prolonged or overlooked due to inequity or silence.