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In medicine’s push for workforce diversity, culture of belonging is key

Better hiring practices, open discourse, and accountability will support a culture of belonging and allow for workforce diversity.

In the past decade, and especially in the last five years, healthcare has been working to crack the code of embedding antiracism into the fabric of the industry through workforce diversity.

But far from the quotas sometimes conjured when imagining healthcare’s DEI workforce initiatives, the road to a more just and antiracist healthcare workforce must be paved with empathy, understanding, and a culture of belonging, according to G. Rumay Alexander, EdD, RN, FAAN, the senior equity advisory for the National Commission in Addressing Racism in Nursing for the American Nurses Association (ANA).

“The biggest message is tied into our definition of racism at the commission, and that is the assaults on the human spirit and the moral suffering that it causes,” Alexander, also a professor at UNC Chapel Hill’s schools of nursing and dentistry and the UNC Chapel Hill assistant dean of Relational Excellence, said in an interview.

“When you insult the spirit of someone, when you really gut the spirit, they're just a shell. It's one of the worst things you can do to a person,” Alexander noted. “They get the sense that you don't care about them, that they are just another peg in the machine. Then things get compromised, including patient care, including relationships with each other when there is preference.”

That’s far from what anyone in the healthcare industry wants for the workforce. Beyond the moral imperative that everyone feels safe in their workplace, data shows that nurses who are more fulfilled in their jobs tend to see better quality outcomes, especially in terms of patient satisfaction and experience scores.

And amid a mounting clinician shortage problem, promoting antiracism in the healthcare setting will be paramount.

The research shows that providers of color are fleeing the healthcare industry because of experiences of racism. In 2022, a Nursing Outlook study showed that non-White nurses intended to leave their jobs at rates nearly double those of White nurses. That may be because non-White nurses were more likely to report emotional distress, including instances of discrimination and racism.

These situations keep coming up because healthcare has a belonging problem, according to Alexander.

“In a hospital, systemic issues arise, and systems problems require systems solutions,” she explained. “A lot of this stems around belonging and understanding that belonging is about the experiences of people, be it patient or employee or provider.”

It’s become a well-known DEI best practice to create a seat at the table for traditionally underrepresented groups. Healthcare organizations have embraced the notion that they need to hire a diverse provider workforce—and many institutions and medical schools are working on building pathways to cultivate more diverse medical school and residency applicants—but it’s what happens once people walk through the door that matters.

“Supposedly these institutions are hiring for diversity, but once they get diverse candidates and they hire them as employees, they insist on conformity,” Alexander said. “You hired me because I'm different, but once I come, you want me to be just like you.”

“The work is in that sense of, ‘what does it look like when I belong?’” she continued.

Arriving at a culture of belonging is going to require more than just a set of check-the-box items, Alexander asserted. Instead, healthcare organizations—and the people who work every day inside of them—will need to commit to learning deep empathy for their coworkers, which Alexander said can help the “inclusion” in DEI.

This starts with the hiring process, which many healthcare organizations have already started to home in on.

Armed with the understanding that racial concordance is good for patient outcomes and patient-provider relationships, many hospitals and clinics are working to hire a more diverse staff of clinicians.

The desired level of diversity is still hard to come by, according to some analyses, potentially due to a lack of diversity in aspiring healthcare professionals. Some health systems and medical schools are making concerted efforts to reach kids before they enter undergraduate education to inspire them to a career in medicine, while others are working to eliminate cost as an entry barrier to medical school.

When it comes to the actual hiring process, Alexander recommended organizations require hiring teams to review implicit bias trainings that go beyond check-box modules. Regular review before any hiring decision may reduce the risk of bias seeping in. Cutting the number of handoffs (first, second, third, and even fourth rounds of interviewing) may also reduce the risk of bias, as Alexander noted that each handoff is an opportunity for bias to arise.

Beyond the hiring process, organizations need to focus on the inclusion part of DEI. Diversity will always be there, Alexander said, but it’s whether an organization delivers on inclusion that will make the difference.

That means encouraging staff members to reflect on their own biases and stereotypes.

“That's the internal piece,” Alexander acknowledged. “That's where we each have to work on ourselves. Why do I believe what I believe about you? What do I really know? Why am I acting the way? The most culturally appropriate provider understands themselves, and they have to be educated because it is in their hands.”

That provider education can be the hard part, with many nurses already overworked and hard-pressed for time with their patients. But education is important, Alexander said, and by pulling in community context, it can create a sense of empathy that allows nurses to acknowledge their own biases, move past them, and work more productively with their peers and patients.

“That's what inclusion is all about. That's what belonging is all about,” Alexander stated. “You want people to be treated as insiders, not outsiders, in their healthcare environments, and it is so helpful when you reflect on the community.”

At the end of the day, this community-focused perspective is also good for the patient, Alexander added as an aside. Racism in medicine hurts patients, too, with multiple reports showing patients who’ve experienced discrimination being reticent to access care again.

An antiracist workforce culture will benefit direct patient care, Alexander said.

When moving through an antiracism journey, Alexander asserted that healthcare organizations need to decide what they will and will not tolerate. There will be staff members who maintain their biases and deny the reality of their colleagues, and it’s up to organizations to decide the extent to which that is tolerated.

“How do you hold people accountable? Because culture is about accountability,” Alexander said. “Who gets away with what? Who is held to the same set of rules?”

“The work of diversity does not belong under the human resources office. It's a separate entity because it's really about advocacy and justice as a goal,” she concluded.

“Diversity is a fact. Inclusion is a goal. You're going to have differences. You're going to have diversity. It's what you do with it. It's how you treat these differences. We still have to be able to sit in a room and hold a courageous dialogue and call each other in.”

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