Advances in Health Sciences Education

, Volume 23, Issue 3, pp 587–599 | Cite as

Adaptive reinventing: implicit bias and the co-construction of social change

  • Javeed SukheraEmail author
  • Alexandra Milne
  • Pim W. Teunissen
  • Lorelei Lingard
  • Chris Watling


Emerging research on implicit bias recognition and management within health professions describes individually focused educational interventions without considering workplace influences. Workplace learning theories highlight how individual agency and workplace structures dynamically interact to produce change within individuals and learning environments. Promoting awareness of individual biases shaped by clinical learning environments may therefore represent a unique type of workplace learning. We sought to explore how individuals and the workplace learning environment interact once awareness of implicit biases are triggered within learners. In accordance with longitudinal case study methodology and informed by constructivist grounded theory, we conducted multiple longitudinal interviews with physician and nurse participants over 12 months. Our results suggest that implicit bias recognition provokes dissonance among participants leading to frustration, and critical questioning of workplace constraints. Once awareness is triggered, participants began reflecting on their biases and engaging in explicit behavioural changes that influenced the perception of structural changes within the learning environment itself. Collaboration, communication and role modeling within teams appeared to facilitate the process as individual and workplace affordances were gradually transformed. Our findings suggest a potential model for understanding how individual learners adaptively reinvent their role in response to disruptions in their learning environment.


Implicit bias Workplace learning Stereotyping Stigma Dissonance 



This study was supported by grants from the Academic Medical Organization of Southwestern Ontario, Childrens’ Health Foundation London Health Sciences Centre and Associated Medical Services—Phoenix Fellowship


  1. Balmer, D. F., & Richards, B. F. (2017). Longitudinal qualitative research in medical education. Perspectives on Medical Education, 6(5), 306–310. Scholar
  2. Baxter, P., & Jack, S. (2008). Qualitative case study methodology: Study design and implementation for novice researchers. The Qualitative Report, 13(4), 544–559.Google Scholar
  3. Billett, S. (2004). Workplace participatory practices: Conceptualising workplaces as learning environments. Journal of Workplace Learning, 15(5/6), 312–324.CrossRefGoogle Scholar
  4. Billett, S. (2010). Subjectivity, Self and Personal Agency in Learning Through and for WOrk. In M. Malloch, L. Cairns, K. Evans, & B. O’Connor (Eds.), The SAGE handbook of workplace learning (pp. 60–72). Thousand Oaks: Sage Publications.Google Scholar
  5. Chan, T., Mercuri, M., Van Dewark, K., Sherbino, J., Schwartz, A., Norman, G., et al. (2017). Managing multiplicity: Conceptualizing physician cognition in multi-patient environments. Academic Medicine. Scholar
  6. Chapman, E. N., Kaatz, A., & Carnes, M. (2013). Physicians and implicit bias: How doctors may unwittingly perpetuate health care disparities. Journal of General Internal Medicine, 28(11), 1504–1510. Scholar
  7. Charmaz, K. (2006). Constructing grounded theory: A practical guide through qualitative research. London: Sage Publications Ltd.Google Scholar
  8. Doornbos, A. J., Bolhuis, S., & Simons, P. R.-J. (2004). Modeling work-related learning on the basis of intentionality and developmental relatedness: A noneducational perspective. Human Resource Development Review, 3(3), 250–274.CrossRefGoogle Scholar
  9. Dovidio, J. F., & Gaertner, S. L. (2000). Aversive racism and selection decisions: 1989 and 1999. Psychological Science, 11(4), 315–319. Scholar
  10. Eraut, M. (2004). Informal learning in the workplace. Studies in Continuing Education, 26(2), 247–273.CrossRefGoogle Scholar
  11. Greenwald, A. G., & Banaji, M. R. (1995). Implicit social cognition: Attitudes, self-esteem, and stereotypes. Psychological Review, 102(1), 4.CrossRefGoogle Scholar
  12. Greenwald, A. G., McGhee, D. E., & Schwartz, J. L. (1998). Measuring individual differences in implicit cognition: The implicit association test. Journal of Personality and Social Psychology, 74(6), 1464.CrossRefGoogle Scholar
  13. Hernandez, R. (2018). Medical students’ implicit bias and the communication of norms in medical education. Teaching and Learning in Medicine, 30(1), 112–117. Scholar
  14. Hernandez, R. A., Haidet, P., Gill, A. C., & Teal, C. R. (2013). Fostering students’ reflection about bias in healthcare: Cognitive dissonance and the role of personal and normative standards. Medical Teacher, 35(4), e1082–e1089.CrossRefGoogle Scholar
  15. Kennedy, T. J., & Lingard, L. A. (2006). Making sense of grounded theory in medical education. Medical Education, 40(2), 101–108.CrossRefGoogle Scholar
  16. O’reilly, M., & Parker, N. (2013). ‘Unsatisfactory Saturation’: A critical exploration of the notion of saturated sample sizes in qualitative research. Qualitative Research, 13(2), 190–197.CrossRefGoogle Scholar
  17. Popay, J., Rogers, A., & Williams, G. (1998). Rationale and standards for the systematic review of qualitative literature in health services research. Qualitative health research, 8(3), 341–351.Google Scholar
  18. Ross, H. J. (2014). Everyday bias: Identifying and navigating unconscious judgments in our daily lives. Lanham: Rowman & Littlefield.Google Scholar
  19. Schlachter, S., & Rolf, S. (2017). Using the IAT: How do individuals respond to their results? International Journal of Social Research Methodology, 20(1), 77–92.CrossRefGoogle Scholar
  20. Staats, C., Capatosto, K., Wright, R. A., & Contractor, D. (2015). State of the science: Implicit bias review 2015. Kirwan Institute for the Study of Race and Ethnicity (Vol. 3). The Ohio State University.Google Scholar
  21. Stake, R. E. (1995). The art of case study research. Thousand Oaks: Sage.Google Scholar
  22. Stone, J., & Moskowitz, G. B. (2011). Non-conscious bias in medical decision making: What can be done to reduce it? Medical Education, 45(8), 768–776. Scholar
  23. Sukhera, J., Miller, K., Milne, A., Scerbo, C., Lim, R., Cooper, A., et al. (2017a). Labelling of mental illness in a paediatric emergency department and its implications for stigma reduction education. Perspectives on Medical Education, 6, 1–8.CrossRefGoogle Scholar
  24. Sukhera, J., Milne, A., Teunissen, P. W., Lingard, L., & Watling, C. (2017b). The actual versus idealized self: Exploring responses to feedback about implicit bias in health professionals. Academic Medicine. Scholar
  25. Sukhera, J., & Watling, C. (2018). A framework for integrating implicit bias recognition into health professions education. Academic Medicine, 93(1), 35–40. Scholar
  26. Teal, C. R., Gill, A. C., Green, A. R., & Crandall, S. (2012). Helping medical learners recognise and manage unconscious bias toward certain patient groups. Medical Education, 46(1), 80–88.CrossRefGoogle Scholar
  27. Teal, C. R., Shada, R. E., Gill, A. C., Thompson, B. M., Frugé, E., Villarreal, G. B., et al. (2010). When best intentions aren’t enough: Helping medical students develop strategies for managing bias about patients. Journal of General Internal Medicine, 25(2), 115–118.CrossRefGoogle Scholar
  28. Teherani, A., Martimianakis, T., Stenfors-Hayes, T., Wadhwa, A., & Varpio, L. (2015). Choosing a qualitative research approach. Journal of Graduate Medical Education, 7(4), 669–670.CrossRefGoogle Scholar
  29. Teunissen, P. W. (2015). Experience, trajectories, and reifications: An emerging framework of practice-based learning in healthcare workplaces. Advances in Health Sciences Education Theory and Practice, 20(4), 843–856. Scholar
  30. Teunissen, P., Boor, K., Scherpbier, A., Van der Vleuten, C., Diemen-Steenvoorde, V., Van Luijk, S., et al. (2007a). Attending doctors’ perspectives on how residents learn. Medical Education, 41(11), 1050–1058.CrossRefGoogle Scholar
  31. Teunissen, P., Scheele, F., Scherpbier, A., Van Der Vleuten, C., Boor, K., Van Luijk, S., et al. (2007b). How residents learn: Qualitative evidence for the pivotal role of clinical activities. Medical Education, 41(8), 763–770.CrossRefGoogle Scholar
  32. Valsiner, J. (1994). Culture and human development: A co-constructionist perspective Annals of Theoretical Psychology (pp. 247–298), Springer.Google Scholar
  33. van der Zwet, J., Zwietering, P. J., Teunissen, P. W., van der Vleuten, C. P., & Scherpbier, A. J. (2011). Workplace learning from a socio-cultural perspective: Creating developmental space during the general practice clerkship. Advances in Health Sciences Education Theory and Practice, 16(3), 359–373. Scholar
  34. van Nunspeet, F., Ellemers, N., & Derks, B. (2015). Reducing implicit bias: How moral motivation helps people refrain from making “automatic” prejudiced associations. Translational Issues in Psychological Science, 1(4), 382–391. Scholar
  35. Wearne, S., Dornan, T., Teunissen, P. W., & Skinner, T. (2012). General practitioners as supervisors in postgraduate clinical education: An integrative review. Medical Education, 46(12), 1161–1173. Scholar
  36. Yin, R. K. (2009). Case study research: Design and methods. Thousand Oaks: SAGE publications.Google Scholar
  37. Zestcott, C. A., Blair, I. V., & Stone, J. (2016). Examining the presence, consequences, and reduction of implicit bias in health care: A narrative review. Group Processes & Intergroup Relations, 19(4), 528–542. Scholar

Copyright information

© Springer Science+Business Media B.V., part of Springer Nature 2018

Authors and Affiliations

  1. 1.Schulich School of Medicine & DentistryWestern UniversityLondonCanada
  2. 2.London Health Sciences CentreLondonCanada
  3. 3.Maastricht UniversityMaastrichtNetherlands

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