ORIGINAL ARTICLE

Effective diversity, equity, and inclusion practices

Gurwinder Kaur Gill1, Mary Jane McNally, MHA1, and Vin Berman, MBA, CHRL1

Abstract Demographics in Canada, and the workplace, are changing. These include population changes due to race, ethnicity, religion/faith, immigration status, gender, sexual identity and orientation, disability, income, educational background, socioeconomic status, and literacy. While this rich diversity can present challenges for patient experiences/outcomes and working environments, it can also present opportunities for positive transformation. For successful transformation to take place, strategies should focus on “Diversity, Equity, and Inclusion” (DEI) versus “diversity” alone and on creating inclusive team environments for positive staff experiences/engagement. There is a growing understanding of the relationship between the providers’ work environments, patient outcomes, and organizational performance. This article leverages the principle of improving the healthcare provider’s experience based on Health Quality Ontario’s Quadruple Aim (“people caring for people”). Based on learnings/experiences, the top three successful practices from the organization’s DEI strategy have been outlined in this article.

Introduction

Demographics in Canada, and in the workplace, are changing.

This includes trends in immigration, internationally trained

professionals, languages/communication styles, religious/faith

communities, a diverse Indigenous population, single parents,

low-income populations, mental/physical health and lesbian,

gay and transgender populations.1 In healthcare, these trends

can result in health inequities (health differences between

population groups defined in social, economic, demographic,

or geographic terms—that are unfair and avoidable).

From a race perspective alone, racism/cultural oppression have

been realities for many minority groups. Nurses working across

Canada speak of their experiences of discrimination, racism, and

the challenges of working effectively in such environments.2

However, “cultural diversity” goes beyond values, beliefs,

practices, and customs; in addition to racial classification and

national origin, there are many other faces of diversity.3 These

include age, socioeconomic status, religion/faith, immigration

status, gender, sexual identity and orientation, disability, income,

educational background, socioeconomic status, and literacy.

While this rich and broad diversity among population groups

can present challenges for patients, working environments, and

organizations, it can also present opportunities for positive

transformation. For this transformation to take place, the focus of

a successful and effective strategy would need to shift from

“diversity” alone to “Diversity, Equity, and Inclusion (DEI).”

The recognition and embracing of diversity (the range of dif-

ferences among population groups) is essential and foundational.

From a patient’s perspective, going beyond to include equity and

inclusion can result in positively changing a patient’s life, expe-

rience, and outcomes as well as an organization’s outcomes.

Experiences and initial research show that Osler’s DEI initiatives

have the potential to improve equitable access to quality and

safe care, reduce (unnecessary) readmissions or emergency

department visits and length of stay as well as liabilities and

errors. For example, errors can occur when a patient does not

speak the same language as the provider potentially resulting in

miscommunication of diagnosis or prognosis.

From a staff perspective, staff training and education focused

on DEI versus diversity alone within Osler is beginning to

transform the work and team environment and, in turn, positively

impact the patient experience. There is a growing understanding

of the relationship between nurses’ work environments, patient/

client outcomes, and organizational and system performance.2

This is evident from the principles of Health Quality Ontario’s

Quadruple Aim which states that “at its core, healthcare is about

people caring for people.” Evidence also shows that healthy work

environments yield financial benefits to organizations in terms of

reductions in absenteeism, lost productivity, organizational

healthcare costs,2 and costs arising from adverse patient/client

outcomes2 as well as staff experience and engagement.

One key learning for the organization has been that creating

inclusive societies takes time and requires work beyond merely

“not-excluding.”4 Another has been that it is not about

“universalism and treating all the same, i.e. equality; it’s about

equity—the absence of avoidable or remediable differences

among groups of people” (World Health Organization).5 The

difference between equality and equity? “Equality is giving

everyone a shoe. Equity is giving everyone a shoe that fits.”

Key practices from Osler’s DEI strategy have been outlined

in this article with a focus on the healthcare provider/work

environment:

1 William Osler Health System, Brampton, Ontario, Canada.

Corresponding author:

Gurwinder Kaur Gill, William Osler Health System, Brampton, Ontario,

Canada.

E-mail: [email protected]

Healthcare Management Forum 2018, Vol. 31(5) 196-199 ª 2018 The Canadian College of Health Leaders. All rights reserved. Article reuse guidelines: sagepub.com/journals-permissions DOI: 10.1177/0840470418773785 journals.sagepub.com/home/hmf

1. Leadership commitment

2. The DEI training/development for inclusive teams and

the work environment

3. Staff engagement to leverage champions for positive change

Leadership commitment

Commitment “from the top” has been essential to the success

of Osler’s DEI strategy. Senior leadership understands that

“sensitivity to diversity issues at the senior executive level has

an effect on diversity management practices used by hos-

pitals.”6 Successful leadership practices at Osler include:

� A leadership team that understands the value and

impacts of health equity, inclusion, and social justice.

� Osler’s corporate values—Respect, Excellence, Account-

ability, Diversity, and Innovation—aligned with DEI.

� Senior leadership commitment to a DEI portfolio with

human and financial resources.

� Osler’s DEI plan has been developed in close collabora-

tion with, and monitored by, senior leadership.

� The plan aligns with Osler’s corporate strategic plan/

priorities and has clear goals, objectives, indicators, and

defined metrics.

� Accountabilities are defined and shared across the

organization including mechanisms for raising and addres-

sing DEI issues. For example, at Osler, senior leaders from

patient experience, legal, human resources, health equity

and inclusion, and ethics collaborate and provide consulta-

tion on issues related to Performance, Accommodation,

Harassment and Human Rights (PAHHR).

� The DEI is incorporated into Patient and Family Advi-

sory Councils that are diverse in membership. Patients

provide insights and guidance on creating tipping points

for positive change.

Diversity, equity, and inclusion training/ development for inclusive teams and work environments

Similar to other organizations with “diverse” workforces,

Osler’s management is faced with handling requests for which

there is limited precedence. For example:

� Staff requesting time to pray several times daily.

� Being excused from working in areas where religious

items may interfere with imaging equipment.

� Being excused from mask-fit testing as beards cannot be

trimmed on religious grounds.

� Requesting to finish work early because of young children.

� Requesting more time to prepare reports, or having

workspaces modified, to accommodate disability.

� Refraining from working with colleagues who make

derogatory comments/jokes about their community/

cultural groups.

� Requesting different assignments because colleagues

converse in a language not understood.

� Patients/families requesting different providers (poten-

tially due to discrimination).

Understanding and meeting diverse needs and creating

inclusive environments stems from being culturally competent.

Campinha-Bacote3 states that to meet the needs of culturally

diverse groups, healthcare providers must engage in the process

of becoming culturally competent—a set of congruent beha-

viours, attitudes, and policies that come together in a system,

agency, or among professionals and enables that system,

agency, or those professionals to work effectively in cross-

cultural situations.

How managers respond and address the above kinds of

requests have resulted in either inclusion/alienation. Successful

DEI training/development at Osler includes the following:

Creating safe spaces for employees to have a dialogue and share experiences

This informal, “self-managed” approach invokes understanding

and appreciation. Mandatory diversity training (what does this

look like anyway?) is a requirement at Fortune 500 companies.

But a substantial body of research shows that this training is not

particularly effective at encouraging people to confront their

biases. In fact, it can provoke the opposite effect. “People, not

surprisingly do not like to be told what think.”4,7 Another reason

why self-managed teams may be more successful is when pro-

grams are not actually branded “diversity efforts.”8 Thus, Osler

has a substantial focus on creating safe spaces and opportunities

for employees to voluntarily share experiences.

Stories shared by colleagues have invoked compassion,

empathy, and understanding. For example, struggles of those

who have a disability are new to Canada and/or are low income

or vulnerably housed. Or, after feeling safe to share they were

gay or lesbian, struggles with bias/discrimination.

Creating safe spaces has enabled participants to open up

their hearts and minds to compassion and new learning. Some

admitted that, in their limited understanding of diversity/

diverse groups, they had made incorrect assumptions about

some of their colleagues resulting in negative stereotypes.

Completed pre/post assessments have demonstrated an

upward trend of learning and appreciation/understanding of

differences. Written feedback included heartwarming respon-

ses to “what will I do differently” or “which behaviour will I

Appropriate learning opportunities will yield positive outcomes and a workforce composed of nurses who are open-minded, inclusive, and respectful of all colleagues and recipients of nursing services. Individual members of the workforce identify and are cooperative with one another to address barriers to equity and diversity and build practice environments in which every person’s contribution is valued thus allowing the full potential of all to be maximized. These individuals refuse to participate in discrimination, harass- ment, or bullying and address the issue in a way that will effect change. Registered Nurses Association of Ontario.2

Gill, McNally and Berman 197

change as of today” including being more open and under-

standing of staff and patients’ differing practices/beliefs.

A foundational tenet included in this training is from Dr.

Jean Watson, PhD: “To care for someone, I must know who I

am. To care for someone, I must know who the other is. To care

for someone, I must be able to bridge the gap between myself

and the other.”

Focusing on self-awareness, self-reflection, and reduction of bias, perceptions, and assumptions

Osler’s DEI training/education has a significant focus on self-

awareness, self-reflection, and bias. Significant research

demonstrates that all humans engage in conscious and uncon-

scious processes based on images stored in memory (note 1).

Unconscious bias affects healthcare providers every day; it can

reduce the quality of care and increase errors.9 And that there

are higher levels of racial bias among clinicians directly linked

with biased recommendations (note 2).

The years of subconscious associations affect what we think

we see, how we react, how we feel, and how we behave. “Any effort

to build inclusion . . . has to address our perceptions (and biases).

This takes time . . . but is also more like to endure.”4

A tool used in the training includes one developed by

Dr. Milton Bennett: the Developmental Model of Intercultural

Sensitivity (Figure 1). It has helped staff understand the process

by which they can learn to value and respond respectfully to

people of all cultures. Participants are asked to pause and self-

assess where they are on the scale and then to reflect what they

can do to do better to move from ethnocentrism to being more

ethno relative.

Focusing on cross-cultural communication

Communication styles can negatively affect relationships. It is

imperative to be aware of other’s differing communication

styles as well as one’s own. Intercultural communication is

influenced by factors including how power and authority are

shared in the culture, values of individualism and collectivism,

and the role of context in communication. Edward Hall pro-

posed a continuum of low to high context with respect to

contextualizing the messages sent and received. Low-context

cultures (such as Canadian) emphasize the words with less

emphasis on the context such as who says it and how it is said.

In high-context cultures (such as Asian), the context of the

message is just as important as the words used and influences

how the message is understood.10 For example, Communica-

tion becomes a key issue in developing collegial relations in the

team. The literature demonstrates a strong association between

racial diversity and difficulties with communication and con-

flict resolution in teams. Research highlights a significant

association between diversity, group conflict, and communi-

cation difficulties.11 There is a strong business case for initi-

ating communication about culture as a platform for change.11

Leaders who validate different perspectives and demon-

strate a willingness to talk about differences achieve a positive

outcome.2 This involves listening, reflecting, and nonjudge-

mental approaches and focusing on nonverbal communication.

We’ve often “spoken” volumes without saying a word.

Building capacity of employees to understand legal implications

Legal obligations and implications are essential to incorporate

into DEI training. Whether we “agree” with different practices or

not is a moot point in situations superseded by law, for example, the

Ontario’s Human Rights Code. This code recognizes the dignity

and worth of every person in Ontario and provides for equal rights

and opportunities and freedom from discrimination, such as dis-

ability, creed, family status, sex, and gender identity. Employers

have a legal duty to accommodate the code-related needs of people

who are adversely affected by a requirement or standard.

Achieving organizational expectations through living the organization’s core values

Not leaving anything to chance, that respecting each other’s

differences is the “right thing to do,” also include a component

Denial Defensive Minimize Accept Adapt Integrate

1– 3: Ethnocentric Sees own culture as central to reality

4-5: Develops ethno-relative

views

Experiences culture in the context of others

Figure 1. The Bennett Scale: developmental model of intercultural sensitivity.

All of us, despite the best of all possible intentions, are affected by unconscious processes. -Dr. Michelle van Ryn, PhD, Mayo’s Research Group

198 Healthcare Management Forum

that speaks to the organization’s values and expectations.

Osler’s values—respect, excellence, accountability, diversity,

and innovation—are an integral part of DEI training and per-

formance development.

Through manager engagement, a “Diverse and Inclusive

Teams” module has been developed and is delivered in

person to groups. The curriculum includes organizational

and individual values, self-assessment/reflection, value-

based exercises, Osler’s code of conduct, anti-harassment

and discrimination, cross-cultural communication, and bias

(implicit and explicit). The results/impacts, through pre/post

assessments and evaluations, are remarkable.

Staff engagement to leverage champions for positive change

Change champions are key to creating tipping points

and cultural shifts to embracing DEI initiatives. In the

Journal of Applied Social Psychology, using a sample of

4,597 healthcare sector employees, research indicated that

diversity practices are associated with a trusting climate that,

in turn, is positively related to employee engagement.12

Key staff engagement mechanisms that have invoked

DEI change at Osler:

� The Diversity Advisory Council: Interdisciplinary staff

learn about, and work on, impacts and issues related

to DEI.

� The Accessibility Advisory Committee: Internal staff/

volunteers and external community members ensure

barriers are reduced for patients, staff, physicians,

volunteers, and visitors with physical and/or mental

health issues.

� The Women of William Osler Committee: Members

foster a collaborative environment that is gender-

inclusive, respectful, equitable, and accessible whilst

enabling personal and professional growth through a

lens of gender equity.

� The Lesbian, Gay, Bisexual, Transgender, Queer,

2-Spirited, Intersex, Asexual, and Allies Committee:

Members foster a collaborative, welcoming and safe

environment that is informed, inclusive, respectful,

equitable an accessible for all patients, families, staff,

physicians, and volunteers.

� Performance, Accommodation, Harassment, and

Human Rights Task Force: Senior leaders from patient

experience, human resources, legal counsel, ethics, and

equity and inclusion discuss/provide recommendations

that stem from PAHHR.

Conclusion

Change must begin with senior leadership with account-

abilities being shared among middle management. We cannot,

however, underestimate the power of including and engaging

all staff/individuals for positive transformation. Each of us

must serve as culturally competent role models and share our

skills and knowledge with others and we must engage in dis-

cussions and challenge questionable behaviours or institutional

practices.13

The initiatives and practices shared have demonstrated

positive outcomes impacting individual employees, the team/

work environment, the organization as a whole, and patients/

families. The DEI initiatives are no longer departmental based

initiatives or projects but essential for cultural transformation.

Notes

1. Dr. Michelle van Ryn, PhD, Mayo’s Research Group.

2. David Williams, PhD, MPH, Ronald Wyatt, MD, MHA.

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Gill, McNally and Berman 199

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