“I’m not biased — so why are we talking about diversity again?” Why does cultural diversity in healthcare matter? From a patient standpoint, the events of the past 18 months have exposed the disparities in the delivery of care. While COVID-19 has affected everyone, the disease has been especially devastating within communities of color and other vulnerable populations. The pandemic has brought significant health disparities to light regarding access to quality care, including preventive care, diagnosis and surgery; access to vaccines; and access to culturally relevant healthcare information.
But this is not about the pandemic; it is about deep-rooted foundations of cultural and social inequities. These same barriers that providers and staff face in the delivery of care also create challenges in working toward an inclusive workplace.
Healthcare professionals, clinic- or hospital-based, should be working together as a cohesive unit. However, issues surrounding gender, socioeconomic status, weight, racial and ethnic identity, or any number of other ways we identify ourselves often get in the way of productive work and positive outcomes. We get lost in the physical aspects of care delivery and dismiss or ignore the nuances in the quality and sensitivities related to the delivery of care to diverse populations. How then do we recognize that it is not always about being right but doing what is right to meet the needs of those we serve? Most importantly, what should we do to begin to transform the culture in our organizations to that of acceptance and inclusion?
Identity, bias and socialization
How do we determine what contributes to who we are? First consider the intricacies of how our identities are formed, and how socialization influences our opinions and outlook. Our identities are shaped by many aspects of our lives as we mature and assume different roles and personae.
An identity wheel (Figure 1) is one type of visual tool that depicts different aspects of how people identify themselves, including gender, race, socioeconomic status, education and other factors.
How we identify ourselves is a complex process. Using the wheel empowers us to identify and express important parts of ourselves that may not be known. It also provides a framework for deeper discussion around one’s identities and how they are more intensely felt or become more visible at different times.
These identities or categories of belonging are fundamental to who we are. Communication is the key to understanding; however, there needs to be a safe way to acknowledge our differences and concepts of self. These categories of belonging are also a significant part of who we are in many situations, such as personal, social and work. As described in Taifel’s theory of social identity, it is also important to work past any “we” versus “them” conflicts in a workplace environment, since these differences can cause underlying or unconscious issues limiting our interpersonal interactions.2
Within this concept of self and identity, biases are formed. By definition, bias equals preference. Everyone has preferences: Bias in and of itself is not a bad thing — it is simply a reflection of your preferences. Ask yourself: How do the people in your close friend group identify? Most likely, you will find that your friend groups are more culturally similar to you as opposed to diverse. You are biased toward people who are similar to you or, stated differently, you have a preference for them. Now think about this: Are you more likely to harbor a negative bias against people with a certain characteristic? Before you emphatically respond, “No, I don’t,” know that research tells us that many of these types of cultural biases often operate at an unconscious or implicit level. Most of the time these thoughts or feelings occur without us intentionally thinking about them.
Socialization or social shaping can happen through explicit means or more subtle implicit means. Think about a sign that says, “men working.” It may imply that men are expected to work construction. Or even more relevant in this context is the expectation that women are nurses and men are physicians.
Socialization is a concept that covers the learned norms around gender, attractiveness, career expectations and stereotypes, among other characteristics. It is an entire process of learning along the course of life and influences behavior, beliefs and actions. It tells you what is reinforced and what gets punished. Biases are the result of socialization. In the process of dismantling any bias you recognize, try to connect the origin of the bias to a specific message you received while growing up.
Social systems are “the patterned series of interrelationships” that make up a coherent whole that exists between individuals, groups and institutions.3 Individuals can belong to multiple socials systems, and those systems can hold a great deal of power. They can dictate or control cliques and pecking order through formal and informal leadership structures. Think about how benefits are seen, real or perceived, about who might be offered flexibility at work? Consider how insurability affects the way we might see our patients, if they have managed care or Medicaid and how that might affect the way we treat them.
Perception and perspective
Biases and prejudices are based on how we perceive people, and they may be real or perceived. For example, just because someone does not have insurance does not mean they cannot pay for their healthcare services. Oftentimes, though, that is the perception. Perception is unreliable, at best, because it is shaped by one’s socialization and life experiences. Often, we perceive that we are right and the other person is wrong simply because we are standing on different sides of a picture. Depending on the perspective, both can be right. But when this perspective mismatch happens, work is halted, processes become inefficient or worse and toxic environments are created when the seeds of misperception are allowed to take root and grow unchallenged.
To prevent misperceptions:
- Address the overall environment and interpersonal dynamics from an internal and external perspective.
- Look internally. Assess how your socialization, identity and experiences have affected the way you see the world and others.
- Look externally. Consider how your patients and staff see and experience the world.
- Look for commonalities between your view and theirs and determine if you can make a shift.
Bias influences patient care and medical decision making in numerous ways. One example is sizeism: An obese patient may not be approved to have knee surgery due to a provider’s assumption that the surgery will not help or is not worth it for someone so large. Transgender clients are challenged by biases from providers who misgender them, project their personal values when it comes to decisions about care or refuse to provide any treatment — the last of which may pose significant compliance concerns.4
Let’s stop looking at people and start truly seeing them.
Integrating diversity into your culture
With this new awareness and information, the key challenge for a practice leader is to integrate these changes into the practice’s culture. A nonprofit organization we’ve worked with provides services to cancer patients, addressing those non-medical needs that may fall through the cracks. They sought training classes around diversity, thinking that changing pronouns and providing more inclusive marketing would be sufficient to become a more diverse and equitable organization. They did not realize that not only was this a cultural change, but it would also take a long time to shape the people, processes, policies and practices within the organization. After gaining an understanding around these basic concepts, the hard work of culture transformation can begin.
Take these actions to begin integrating diversity within your organization’s culture:
- Sharpen your lens of awareness. This may seem like an easy thing to do, but it can be difficult because we do not know what we do not know. We typically do not seek information if we are unaware that an information gap exists. Increasing your awareness will require you to consistently assess your interactions with others, especially those who are different than you. Question the assumptions you make about people you interact with on a daily basis as well as casual encounters. Ask yourself, are your decisions based on facts and objective information or are they influenced by stereotypes and biases? As you develop this new awareness, you may want others to be as aware as you are. That may be a tough order. Make it simple and change your awareness and actions. Think about the adage, “actions speak louder than words.” In this case, it may well be true.
- Build cultural empathy. Cultural empathy is about communication and respect. The goal is to acknowledge the feelings of others and be able to consider those feelings regardless of our experiences. Think about how to step into another person’s shoes. Listen to understand. Be aware of finishing sentences and offering advice when your understanding of the person and their culture may be limited. Avoid generalizing a person’s experience based on their culture. Cultural empathy helps to build positive relationships, no matter the differences. In return, the practice environment can become more positive and supportive, improving well-being in the organization.
- Look for allies and become an ally. Allyship provides an opportunity to educate ourselves and others through a long process based on trust and accountability. Everyone has an opportunity or ability to be an ally because everyone has privilege, and that privilege crosses many lines. It is about using privilege to benefit others who are different than you. Being an ally is about taking small actions that make big impacts. Know that you will make mistakes but hold yourself accountable. Accept the impact of your mistake, apologize and rethink what needs to change next time.
- Be open to crucial and courageous conversations. Understand that offenses may occur on both sides of an issue. There are two sides to every story and while addressing your biases can be scary, living as the object of oppression is hard and scary too. Be willing to have open and honest discussions. Ask questions. Listen and speak without judgment. Be open and receptive to feedback.
- Take care of yourself. This is incredibly important because pushing back against ingrained systems of inequity is hard work. It is frustrating and tiring, so make sure that you set aside time for personal care and recovery. This can take many forms but just make sure it happens.
No matter what, you should get comfortable with being uncomfortable. Listen to all voices. Be inclusive with inclusive language. Be aware and educate yourself. We have a responsibility to ourselves, our organizations and the populations we serve. This is about the journey and all the experiences along the way, one step at a time.
- Brene Brown — “Empathy vs Sympathy”: youtu.be/1Evwgu369Jw
- Dialogues on Diversity: www.dialoguesondiversity.com/programs
- Fenway Health — National LGBTQIA+ Health Education Center: bit.ly/3ox6dnT
- Project Implicit/Harvard University: implicit.harvard.edu/implicit/takeatest.html
- Teaching children about racism/Pretty Good Design: bit.ly/33Wtar5
- Words with racist origins/HuffPost: bit.ly/3hF87l5
- IDARE | Office of Inclusion, Diversity, Anti-Racism, and Equity. “Resources.” Johns Hopkins Bloomberg School of Public Health. Available from: bit.ly/2SRVfh1.
- Tajfel H, Turner JC, Austin WG, Worchel S. “An integrative theory of intergroup conflict.” Organizational identity: A reader, 1979, 56-65.
- Merriam-Webster. “Social System.” Accessed May 19, 2021. Available from: bit.ly/3eYd5Yf.
- Keith K. “HHS Will Enforce Section 1557 To Protect LGBTQ People From Discrimination.” Health Affairs Blog. May 11, 2021. Available from: bit.ly/3fsjF8B.