≥ 92% of participants will have a better understanding of the unique challenges of growing up with diabetes and how they can help these patients achieve optimum glycemic control while also maximizing quality of life.
CEUFast, Inc. is accredited as a provider of nursing continuing professional development by the American Nurses Credentialing Center's Commission on Accreditation. ANCC Provider number #P0274.
≥ 92% of participants will have a better understanding of the unique challenges of growing up with diabetes and how they can help these patients achieve optimum glycemic control while also maximizing quality of life.
After completing this continuing education course, the participant will be able to:
The prevalence of type I diabetes in children ages 0 to 19 has been rising rapidly over the last few years with a 21.1% increase since 2001.
For all of these reasons, as well as the variations in pediatric physiology, care of the child with diabetes cannot simply mirror care of adults with diabetes. Nurses need comprehensive training to understand and plan care accordingly. This course aims to explore the growing public health concern of pediatric diabetes and prepare nurses to provide comprehensive, effective, and up to date care to affected children and their families.
In 2018, nearly 27 million people in the United States had a diagnosis of diabetes and, of those, 210,000 were children and teens under age 20 (Centers for Disease Control and Prevention [CDC], 2020).
Over the last two decades, there has been a steady uptick in the percentage of children diagnosed with type I and II diabetes each year with an increase of about 1.9% since 2002 (CDC, 2020).
Currently, the prevalence among racial groups does also varies by type of diabetes.
Incidence of Type I Diabetes per 100,000 Persons Among Children and Adolescents Younger Than Age 20 Years, by Racial or Ethnic Group, United States, 2014–2015
Figure 2, also directly from the CDC’s 2019 Diabetes Report Card, illustrates the incidence of type II diabetes with racial distribution notably different. Incidence for type II diabetes is highest for Black children, with 37.8 of every 100,000 children having a diagnosis of type II diabetes. American Indians follow closely behind with an incidence of 32.8 per every 100,000. White children were affected the least at a rate of 4.5 children per every 100,000 (CDC, 2020).
Incidence of Type II Diabetes per 100,000 Persons Among Children and Adolescents Aged 10–19 Years, by Racial or Ethnic Group, United States, 2014–2015
Risk factors for developing diabetes varies depending on type of diabetes. Potential risk factors for type I diabetes are largely out of an individual’s control. These include (Mayo Clinic, 2021):
Risk factors for type II diabetes includes (Mayo Clinic, 2021):
Exploration of these risk factors as well as genetics and the role of socioeconomic status (and associated accessibility to food) may all help scientists better understand the differences in incidence across racial and ethnic groups for both types of diabetes (CDC, 2020).
In addition to the primary health concern of regulating blood glucose levels and managing hypoglycemia and hyperglycemia and its symptoms, diabetes comes with a long list of long-term complications and possible disabilities. The most common long-term issues, that account for around $327 billion in United States healthcare costs annually, include (CDC, 2021):
It is estimated that people with diabetes have annual healthcare costs 2.3 times higher than people without diabetes (American Diabetes Association [ADA], 2021). Dealing with chronic illness also affects work and school attendance, with over 34% of parents of diabetic children reporting an increase in the amount of school missed due to the disease when compared to peers without diabetes (Schwartz et al., 2010).
The COVID-19 pandemic has also had an effect on the risks of complications from and new development of diabetes. People with diabetes are at an increased risk of experiencing serious complications and even death from COVID-19 illness, with poorer glycemic control related to poorer outcomes. There are also ongoing studies suggesting a correlation between COVID-19 infection and new onset diabetes in children under 18, implying the virus may cause subsequent autoimmune issues (ADA, n.d.).
For the majority of the discussion in this course, type I diabetes will be the focus; however, type II diabetes is also of rising prevalence in the pediatric population, so a solid understanding of the differences between the two is imperative for the expert nurse.
Both types of diabetes involve dysfunction in the way that the body produces or uses insulin. Insulin is a hormone that transports glucose into the cells of the body to be used as energy. It is produced by beta cells in the islets of Langerhans in the pancreas. When a person eats, the body breaks carbohydrates down into glucose and a normally functioning pancreas responds in real time by producing an adequate amount of insulin to transport the glucose into cells and keep blood glucose levels within the normal range.
When insulin is unable to help glucose enter the body’s cells to be used as energy, blood levels of glucose rise, called hyperglycemia. In the short term, hyperglycemia causes symptoms including:
If hyperglycemia is left untreated, the body looks for other sources of energy and starts to break down stored fat into ketones. As ketone levels in the blood rise, they can upset the normal acid-base balance and lead to ketoacidosis, a life-threatening condition causing metabolic acidosis that can quickly lead to renal or other organ dysfunction and death (Kudva, 2020).
In addition to the emergent problems of untreated or severe hyperglycemia, chronic mild to moderate hyperglycemia (as is present with poorly managed diabetes) can cause a whole other host of issues. Excess glucose in the circulation causes chronic irritation to blood vessels, particularly the microvasculature of organs like the kidney and eyes and can cause chronic conditions like retinopathy, renal disease, poor wound healing, cardiovascular disease, and neuropathy (Khardori, 2022b).
Type I Diabetes
Normally in the presence of hyperglycemia, the liver will store additional glucose while waiting on insulin to return levels to normal, however, with improperly functioning liver cells, additional glucose is erroneously released into the bloodstream, further contributing to hyperglycemia. In response to rising blood glucose levels, the beta cells of the pancreas produce more insulin in an attempt to correct this. The body, however, is still unable to use insulin effectively and this only serves to exhaust the beta cells, eventually causing damage or destruction and a reduced number of functional beta cells, leading to insufficient insulin production and further hyperglycemia (Khardori, 2022a).
Type II Diabetes
The cascade of symptoms that follows is similar to those with type I diabetes, though slower to progress because the pancreas does still produce some insulin and the body is able to utilize it in a reduced capacity, unlike the complete lack of insulin in type I diabetes. The exact reason insulin resistance develops is not well understood but seems to be in part related to excess body fat and a sedentary lifestyle (Khardori, 2022a).
Because some function of pancreatic beta cells still remains, especially early on in the disease, type II diabetes can be managed with a combination of lifestyle modification and medications that help the body better utilize insulin and slow the release of glucose from the liver. Later stage disease may need to be managed with insulin administration (Khardori, 2022a).
Monitoring glucose levels is an essential part of managing type I diabetes in children and helps determine immediate insulin needs, safety of the child (risk for hypoglycemia or hyperglycemia), and long-term patterns or trends in a child’s glucose control. Studies have shown a direct relationship between frequency of glucose monitoring and long-term glycemic control (Chiang et al., 2018).
A note on hypoglycemia: Hyperglycemia is the central concern for risk of chronic complications of diabetes, however patients also need to be aware of hypoglycemia as it can be more acutely problematic and life-threatening. Hypoglycemia can occur when insulin administration exceeds glucose availability either due to increased activity/exercise or inadequate carbohydrate intake. Symptoms of hypoglycemia include (Mayo Clinic, 2022):
Self-Monitoring of Blood Glucose levels (SMBG) via finger stick is recommended up to 6-10 times daily and should be done before meals or snacks, before exercise, before bedtime, in the presence of symptoms of hypoglycemia, or more frequently during illness. The target range for blood glucose level is individualized to each client so as to promote a balance between quality of life and reduced incidence of hypoglycemia and hyperglycemia (Chiang et al., 2018)
Urine Ketone Monitoring should be utilized in children who are experiencing illness or prolonged periods of hyperglycemia. The presence or absence of ketones helps guide clinical decision making about insulin therapy and whether or not additional care measures (to prevent or reverse metabolic decompensation) is needed for children with fever, nausea, vomiting, abdominal pain, or other acute symptoms (Chiang et al., 2018).
For children with type I diabetes, subcutaneous injection or infusion of insulin is integral to survival. For those who utilize injections, a combination of 1-2 administrations of long-acting insulin per day and administration of rapid acting insulin with each meal or snack is the current standard.
|Insulin Type||Onset of Action (h)||Peak of Action (h)||Duration of Action (h)|
|Glargine (Lantus, Basaglar, Toujeo)||2–4||None||Up to 24|
Of rising popularity among pediatric patients is continuous subcutaneous insulin infusion systems, or insulin pumps. These systems reduce the need for repeated injection throughout the day by inserting a cannula into subcutaneous tissue which then delivers insulin from a programmable pump.
The pump delivers short-acting or rapid-acting insulin at a slow, continuous basal rate throughout the day and can also be set to give an appropriately dosed bolus with meals and snacks.
The difference in glycemic control between pump users and those preferring injections is small but does point to pump use as resulting in lower hemoglobin A1Cs (HgA1C), lower rates of hypoglycemia, improved quality of life, and higher treatment satisfaction over time. Children who utilize insulin pumps in conjunction with continuous glucose monitoring had the biggest improvement in glycemic control and reduction of hypoglycemia (Chiang et al., 2018).
For patients with type II diabetes, insulin may be necessary in later stage disease if enough overwork and damage has occurred to the beta cells of the pancreas, and they are no longer able to meet the body’s needs for insulin. However, for most type II diabetic children, lifestyle management and non-insulin drug therapies are central to the treatment plan.
Other potential classes of medication can be considered by a child’s endocrinologist as needed, though these are more commonly used in adult patients due to the risk of cardiovascular disease, hypoglycemia, and other significant side effects. These classes include (Steinberg and Carlson, 2019):
It is important for diabetic children and their parents to understand why maintaining close control over glucose levels is so important, particularly when children may not feel symptomatic until levels are very high. Diabetes research repeatedly shows that the duration and severity of hyperglycemia has a direct relationship to the risk of developing microvascular complications. This risk is particularly high for children who are diagnosed young and have many decades of life ahead of them during which they can develop progressive microvascular and organ damage.
Hemoglobin A1C levels should be monitored at 3-month intervals for all children with diabetes.
In a laboratory setting with no extraneous factors, the relationship of carbohydrate intake and insulin administration could perhaps be fine-tuned to mimic the action of a normally functioning pancreas nearly perfectly. However, perfectly predictable eating and activity habits and insulin administration is not realistic for adult patients to achieve, let alone children who are known for being spontaneous, highly active, and having varied eating patterns. Pair this with the fact that children and adolescents may be unable to comprehend, or unwilling to participate in, the all-encompassing lifestyle overhaul that proper diabetes management demands and good glycemic control becomes vastly more complicated. Growing up certainly comes with enough challenges without the additional need to check blood sugar, count carbohydrates, administer insulin, attend frequent medical appointments, and always be alert for signs of acute and chronic complications of an incurable disease.
It is important for nurses to be sensitive to a young patient’s desire to participate in school, sports, family life, and social interactions with peers as normally and as safely as possible without experiencing too much interruption from diabetes care.
Approximately 22% of children with diabetes experience depression or anxiety, compared to about 9% of children in the general population, indicating that an emphasis on comprehensive care and quality of life beyond glycemic control is particularly important for this population. Ongoing assessment of a child and family’s quality of life and assistance from a multidisciplinary team can make a drastic difference in the experience of growing up with diabetes (Akbarizadeh et al., 2022).
Dietary management is perhaps one of the most complex parts of pediatric diabetes management as many factors must be accounted for. Factors that must be considered include (Chiang et al., 2018):
A family approach is most effective, with all family members participating in a healthy eating plan. Caloric intake should be consistent with current growth and development needs, with a focus on fruits, vegetables, legumes, whole grains, and dairy as the primary source of carbohydrates over foods containing added sugars.
Studies indicate that over or underestimating carbohydrate content by up to 10 grams or 15% is unlikely to have a major effect on glycemic control. A dietitian specializing in pediatric diabetes and frequent visits to check-in and reevaluate as children grow is an integral part of diabetes management (Chiang et al., 2018).
Normal childhood experiences like eating out at restaurants, or attending birthday parties and having dessert can absolutely be accomplished with proper planning such as checking menus ahead of time or planning that cupcake into the carbohydrate count for the day. Building confidence and teaching children to participate in their care early on can help with the feasibility and comfort level of going to a friend’s house or somewhere new as well (Chiang et al., 2018).
Physical activity and participation in active play and sports is not only beneficial for overall health and weight management but is also a necessary part of childhood and contributes to positive development, self-esteem, social interactions, and the creation of healthy habits going into adulthood. It is recommended that all children with diabetes participate in at least 60 minutes of moderate to vigorous physical activity each day. The benefits of physical activity, however, must be carefully planned and balanced against the risk of both hypoglycemia and hyperglycemia that can occur with exercise (Chiang et al., 2018).
In non-diabetic individuals, hormonal and metabolic changes that occur during and after exercise are naturally mediated by the body’s ability to control both the peripheral uptake and hepatic release of glucose. For diabetic patients, this intuitive function of the body does not exist. Synthetic insulin inhibits glucose production in the liver and increases glucose uptake peripherally, as does increased activity levels, leading to hypoglycemia if available carbohydrates are not adequate. The risk of hypoglycemia can occur during or immediately after exercise, but also up to 6-12 hours later due to what is called a “lag effect” in hormone fluctuations following exercise. One of the main ways to manage this risk is by anticipating periods of increased activity or exercise and decreasing the amount of insulin given with the meal prior to exercise, or even decreasing the basal rate following activity. This is useful for scheduling sports practice or games when the timing and intensity of activity is known ahead of time. For children who are playing freely, more frequent monitoring of glucose levels before, during, and after activity is necessary as well as familiarity with the symptoms of hypoglycemia and prompt treatment if hypoglycemia occurs (Chiang et al., 2018).
Exercise or sports participation should not be avoided simply because patients are worried about resulting hypoglycemia or hyperglycemia and doing so could cause isolation or feelings of frustration or depression in children and teens. Education about how activity and exercise might affect blood glucose levels and how to anticipate these changes, or address them once they occur, can help instill confidence in patients and their families so that they may participate in desired activities and sporting events with their peers.
Though nutrition and activity levels are some of the most commonly discussed facets of diabetes management, one of the biggest factors related to quality of life for diabetic children and teens is mental health.
Social adjustment may be a primary concern for children or teens and navigating this issue varies by age and developmental stage (ADA, 2021).
Later elementary-aged children should begin developing some comfort and autonomy with their own care, while still being closely supervised by an adult (ADA, 2021). They may begin branching out into various activities or sports and will need to balance the desire to participate with proper management of their diabetes needs.
Starting around age 7, all diabetic children should be screened for depression and anxiety regularly as they grow as the risk of mental health issues is greater for children with chronic illness compared to healthy peers. Tools such as the Pediatric Symptom Checklist (PSC) and the Patient Health Questionnaire (PHQ) can be used to help screen for mental health-related concerns as well as consistently including discussions of mental health in routine care. Beginning around age 10-12, screening for eating disorders should also be included. Clinicians should assist families with open and effective communication so that emerging conflict or problems can be detected and addressed early on and reduce the risk of more serious mental health problems and reduced quality of life (ADA, 2021).
Caregivers and family members have their own unique challenges to navigate, even though they are not the actual patient. Understanding the ways this disease affects the entire family unit is imperative to comprehensive nursing care. Parental depression rates are high among people with diabetic children, particularly in the first few years following diagnosis.
Similar to the needs of the client at each age, the needs of the caregivers vary by the child’s age and developmental level as well (ADA, 2021):
School performance also needs to be assessed as an indicator of how well a child and family are handling the challenges of life with diabetes (ADA, 2021). Frequent health related absences, symptoms of hypoglycemia, or struggling socially all have the potential to cause academic difficulty for the diabetic child. Adequate education and support from teachers, administrators, and school nurses can help a child feel safe and confident at school while also minimizing time spent outside of the classroom and promoting optimum learning (ADA, 2021).
In addition to consistent care from an endocrinologist, children with diabetes should also attend regular primary care appointments and follow regular anticipatory guidance for their developmental level.
When hypoglycemia does occur, 15 grams of oral glucose (in the form of tablet or gel) or 15-gram carbohydrate snack is the preferred treatment as long as patients are alert and able to eat. Blood glucose level should be checked again 15 minutes after the glucose administration or snack. If still hypoglycemic, the 15-gram treatment should be repeated until blood glucose normalizes again. Patients should also consider adjusting the next meal and insulin administration to prevent a recurrence of hypoglycemia (Chiang et al., 2018).
For patients who have altered levels of consciousness or are unable to eat, glucagon injection should be given intramuscularly. Caregivers should be given education on how to prepare and administer glucagon and to carry a glucagon kit with the patient always (Chiang et al., 2018).
A note on alcohol when caring for teens: Alcohol consumption is considered a high risk for teens with diabetes.
Nursing care for patients with hypoglycemia includes swift and accurate detection of symptoms of hypoglycemia, appropriate and quick administration of oral glucose or IM glucagon, frequent monitoring of blood glucose levels, and education for home management of hypoglycemia (Chiang et al., 2018).
Diabetic ketoacidosis (DKA) is a common presentation of patients with a new diagnosis of type I or type II diabetes. DKA occurs when inadequate production or usage of insulin makes the body unable to utilize available glucose and instead turns to stored fat for energy. Blood glucose levels rise as do circulating ketone levels (a byproduct of fat metabolism), triggering metabolic acidosis.
Diagnostic criteria for DKA includes (Raghupathy, 2015):
For patients monitoring at home, urine ketones of > 2+ are also indicative of DKA. Symptoms of DKA may include (Raghupathy, 2015):
Alternative conditions such as pneumonia, acute abdominal processes (appendicitis, peritonitis, etc), and meningitis should be ruled out (Raghupathy, 2015).
As acidosis progresses, organ function (particularly renal) may deteriorate and complications such as cerebral edema, severe hypotension, respiratory failure, and death may result if untreated.
Frequent neurological checks and Glasgow Coma Scale (GCS) assessments are necessary for patients with DKA (Raghupathy, 2015).
Risk factors for DKA include (Raghupathy, 2015):
Nursing care of patients experiencing DKA includes managing continuous insulin infusion, hourly blood glucose checks, every 2–4-hour lab work, frequent monitoring of vitals and neurologic assessments, and quick recognition and action for deteriorating condition or decreasing level of consciousness. In the outpatient setting, nurses should be educating patients about the risks for and signs of developing DKA as well as frequent home blood glucose monitoring and urine ketone monitoring as needed (Raghupathy, 2015).
While hypoglycemia and DKA are serious potential acute complications that may worry parents or children with diabetes, there are many potential long-term complications caused by chronic hyperglycemia and its effect on the microvasculature.
Diabetic kidney disease (DKD) should be screened with an annual assessment for albumin in the urine starting at age 10 or puberty (whichever is first). Kidney damage related to chronic exposure to hyperglycemia and/or concomitant hypertension leads to large protein molecules (such as albumin) being able to leak through the damaged renal cells when they would not normally be able to pass through. Blood pressure management with an ACE inhibitor or angiotensin receptor blocker (ARB) may reverse or delay increased albumin excretion. Risk factors for DKD include (Chiang et al., 2018):
A thorough foot exam should be done annually for diabetic children starting at age 10 or at puberty (whichever is first) and should assess reflexes, proprioception, vibration sensation, and assessment of pain or wounds. Risk factors for diabetic neuropathy include (Chiang et al., 2018):
Hyperglycemia in combination with hypertension and hyperlipidemia increases the incidence of atherosclerosis of the larger blood vessels, which in turn leads to cardiovascular disease, cerebrovascular disease, and peripheral vascular disease, comprising the leading causes of morbidity and mortality in diabetic adults.
Hyperlipidemia is common in diabetic patients and, in part, responsible for the vascular damage and changes experienced by these patients.
For abnormal lipids, initial management should center on better glycemic control and dietary modifications. Statins may be considered for patients older than 10 years who have failed to improve their cholesterol through the above measures after 6 months. For diabetic children with significant family history of dyslipidemia, fasting lipids may be collected as young as 2 years of age (Chiang et al., 2018).
Cigarettes and e-cigarettes increase many of the risk factors diabetic patients already face in regards to vascular health. Routine screening for use of tobacco products is recommended for all diabetic patients starting at age 11. Counseling on the risks of smoking, the need to avoid starting smoking, and cessation support for those patients who do smoke is an important part of diabetes risk management (Chiang et al., 2018).
Jacob is a 14-year-old patient with type I diabetes diagnosed at age 5. He presents for a routine endocrinology check and is noted to be 182 pounds (82nd percentile), height of 70” (50th percentile), BP of 110/72, HgA1C of 8%, and reports of frequent swings between hyperglycemia and hypoglycemia. He uses an insulin pump and checks capillary blood glucose levels before meals, snacks, and as needed. He completed a PHQ-9 which has a score of 12 (with scores between 10-14 indicating moderate depression). He tells the nurse that he had tried out and made the basketball team but had to sit out repeatedly at early morning practices due to hypoglycemic episodes. He had become discouraged with this issue and quit the team after only 2 weeks. As a result, he felt he was missing out on an enjoyable activity with his friends. He reports a variable meal schedule since starting high school and states that he has been taking over more responsibility for his own carbohydrate counting and insulin administration since he is now away from home more often. He typically skips breakfast, eats a protein snack mid-morning, eats a school lunch where he “guesses” on carbohydrates, and then has a balanced meal for dinner where parents help him with the carbohydrate count.
The nurse understands that there are multiple intertwined areas where glycemic control and quality of life goals are not being met and could be resolved with further education. First, and most importantly, this patient is attempting to transition to more autonomy over his diabetes care which is an important milestone for teenagers. However, he does seem to need more guidance and supervision before he can fully assume responsibility, as evidenced by his irregular meal schedule and inconsistent carbohydrate counting. The nurse coordinates a visit with the dietitian to help him better understand carb counting while at school and the importance of meals at regular intervals.
The nurse also notes that this patient is nearing the overweight percentiles and could benefit from getting back into basketball for weight management, improved activity levels, and to promote quality of life through peer interaction and team participation. A plan is made with the patient to eat breakfast before practice and adjust his insulin administration accordingly for the increased period of activity so that he does not become hypoglycemic. A plan to monitor his blood glucose level before, halfway through, and after practice is made but this feels like too much for Jacob. The nurse then arranges for him to trial a continuous glucose monitor so that he can be more aware of his glucose levels in real time during exercise.
The nurse also coordinates with a therapist who specializes in teens with chronic illnesses and Jacob agrees to trial 8 weeks of therapy.
At his next follow-up appointment 3 months later, Jacob is doing well. He is eating breakfast each morning and a snack after basketball practice. The CGM is working well for him and has provided him much more awareness of his glucose levels during activity. He has not had any more episodes of hypoglycemia at basketball and is enjoying his time with friends on the team. The dietician helped him create a list of common foods he likes to eat at the school cafeteria as well as a checklist for carbohydrate counts for him to reference and easily calculate his insulin needs while at school. This has been working well for him and he feels more confident and is experiencing fewer episodes of hyperglycemia. He has been seeing the therapist and reports learning some useful tools but not always remembering to implement them. He has lost a few pounds from basketball and eating more carefully and his HgA1C is 7.5%. His PHQ-9 score is 5.
The nurse’s quick recognition of several common barriers to good glycemic control and quality of life for teenagers helped coordinate a multidisciplinary team to improve this patient’s outcomes. His irregular meal schedule and weak ability to count carbs for himself were directly linked to hypoglycemic episodes during basketball practice which in turn was impacting his ability to socialize and participate in sports like his peers. A continuous glucose monitor provided even more flexibility and freedom for Jacob to feel like he could be an active participant and not just focus on his diabetes. Increased activity and weight management improves his overall health and reduces the risk of complications as well. It is also important to take mental health concerns seriously, and while improving his participation in basketball may have been enough to help with the emerging symptoms of depression, referral to a therapist was a good, proactive choice.
Weaknesses in this plan include a lack of inclusion of parents in the education about how to proceed with placing more responsibility on Jacob for his diabetes management. They may have been unsure how to approach the transition of care or unaware that Jacob was struggling, so further education for them would be beneficial. A support group for parents of diabetic children may benefit them as well. A potential referral to adolescent mental health could be considered but is not strictly necessary as his PHQ-9 score did improve in just a few months.
Given the rising prevalence of diabetes in the pediatric population, as well as the potentially serious or life-threatening acute complications and quality of life reducing chronic complications, familiarity with the many aspects of this disease is imperative for nurses caring for the pediatric population. Continued and evolving education on how to manage the care and education requirements of diabetic patients while also being aware of and balancing their unique developmental needs through childhood is a necessity for quality nursing care. These children and their families are living with this condition day in and day out, and the quality of the care they receive along the way has the potential to drastically affect their quality of life and overall health as they transition into adulthood.
CEUFast, Inc. is committed to furthering diversity, equity, and inclusion (DEI). While reflecting on this course content, CEUFast, Inc. would like you to consider your individual perspective and question your own biases. Remember, implicit bias is a form of bias that impacts our practice as healthcare professionals. Implicit bias occurs when we have automatic prejudices, judgments, and/or a general attitude towards a person or a group of people based on associated stereotypes we have formed over time. These automatic thoughts occur without our conscious knowledge and without our intentional desire to discriminate. The concern with implicit bias is that this can impact our actions and decisions with our workplace leadership, colleagues, and even our patients. While it is our universal goal to treat everyone equally, our implicit biases can influence our interactions, assessments, communication, prioritization, and decision-making concerning patients, which can ultimately adversely impact health outcomes. It is important to keep this in mind in order to intentionally work to self-identify our own risk areas where our implicit biases might influence our behaviors. Together, we can cease perpetuating stereotypes and remind each other to remain mindful to help avoid reacting according to biases that are contrary to our conscious beliefs and values.