Diversity in health care teams: Space for Difference? (WC 2014-039)


Starting date: 01/06/2014

Project title:

Diversity in health care teams: Space for Difference?


Key words: diversity - health care teams - intersectionality - culturally responsive design - action research


Today, diversity receives increasing attention within Dutch health care and medical education (Lagro-Janssen, 2007). Generally diversity seems to refer to cultural or ethnic diversity of patients. Attention for diversity in health care relates to the ‘multicultural’ society and the more diverse composition of patient groups (Çelik et al, 2008; Suurmond et al, 2007; Verdonk et al, 2009; Helman, 2000; Campinha-Bacote, 2003; Seeleman et al, 2008, 2011). This attention is mainly given in by ethical considerations and social responsibilities for democratisation and humanization of care. Additionally, the acknowledgement of diversity as an important health care issue is related to the call for more person-centered medicine and care (Charon, 2006; Koren, 2010; Miles & Mezzich, 2011; Stewart et al., 2003).
Less attention seems to exist for the diversity of health care professionals. Processes of interculturalisation in health care organizations and government policies that are introduced to adequately deal with the subject of diversity in care, foremost aim to open up medical health care services to ethnic minority patient groups and to reduce health disparities in society (Congress, 1992; Dogra, 2007; Like, 2011). It is in light of trying to stimulate cultural competency of professionals in dealing with culturally and ethnically diverse patients that focus turns towards diverse health care professionals themselves.
An instrumental approach appears to characterize the dealing with diversity in health care. Though there is being referred to the need for equal representation and participation of all societal members and (sub)groups within the work environment on the basis of human rights and values of social justice, the dominant perception is that if diversity is managed well health care organizations can become better equipped to meet the demands of a competitive medical field (Cox, 1994; Jackson & Ruderman, 1995; Thomas & Ely, 1996). This links up with Zanoni et al.’s (2010) conclusion that studies on diversity in organisations until the 1990s were generally characterized by an instrumental view on social differences.
The instrumental idea that ‘diversity is good for business, when handled well’ (Thomas & Ely, 1996) is apparent in many studies on diverse team functioning (Wang et al, 2013; Watson et al, 1998; Jackson & Ruderman, 1995). Diversity here is defined in very different ways, ranging from diversity in functional background, organizational tenure, educational background to culturally and/or ethnically diverse or mixed gender teams (Bell et al, 2011; Wang et al, 2013; Paletz et al. 2004) and findings vary accordingly. Nevertheless, the recurrent conclusion is that diverse teams can support tendencies for creativity, innovation and effectivity and thus constitute an essential feature for the general welfare of organisations. Different from this, other studies stress the complex and fluctuating connection of social cohesiveness and group performances in diverse team settings, and describe a difference between the ‘promises and realities of diversity’ (Grumbach & Bodenheimer, 2004; Carte & Chidambaram, 2004; Mannix & Neale, 2005).
Up till now, the cultural and ethnic diversity of health care professionals is reported to be insufficient as to the representation of the population (Flores & Combs, 2013; Merchant & Omary, 2010; Nunez-Smith et al., 2012; Price et al., 2005). Stegers-Jager et al. (2012; 2013) and Leyerzapf et al. (forthcoming) conclude that participation of culturally diverse medical students and professionals in academic hospitals in the Netherlands is lacking despite the increased diversity of students that start medical education. These studies point towards the influence of social interactions and social hierarchies present on the work floor on inclusion and selection of -perceived- ethnically and culturally diverse professionals. They stress that in order to establish equal career opportunities for all, attention for these aspects of social power dynamics and a more diverse representation of the population in the medical faculty and clinic is necessary (Thomas and Ely, 1996).
Looking for ways to change the demographic aspects of the work force of an organisation, several studies take as a starting point the complex dynamics of professional competence and academic excellence which are influenced by social interactions and connections between professionals and within teams (Mitchell et al, 2011; Weaver et al, 2011; Finn et al, 2010; Van den Brink & Benschop, 2012). Whereas some studies repond to the underrepresentation of ethnic minority students and doctors by calling on them to ‘make themselves more visible’ and actively undertake actions such as seek out role models and ask for mentoring support (Mahoney et al., 2008; Merchant & Omary, 2010), these studies stress the neccesity for improving the overall ‘diversity climate’ of organizations (Price et al. 2005; 2009). They state that issue of diversity should be addressed starting out at the start beginning of the medical education and with professionals and students collectively (Stegers-Jager & Themmen, 2013; Stegers-Jager et al, 2012; Verdonk & Abma, 2013).
Acknowledging that the ‘managing’ of diversity should be conceived as changes in both the representation of professionals, the organisation as a whole, ie. context, and the knowledge and sensitivity of professionals towards it, this research focuses on studying diversity in daily practice and from a bottom-up lens.
Problem definition
This research proposes to study diversity within diverse academic health care teams and how team members individually and collectivelly experience and deal with diversity in their daily practice, from a critical diversity perspective.
There is a potential risk of stigmatising cultural minorities or minority groups when studying them, instead of bringing an effective and fruitful dealing with difference in work situations closer. To be aware of the potential stigmatizing effects of research on diverse health care teams, is especcially relevant when studying the situation of diversity in health care within the Netherlands. Dutch dominant debates on ‘allochthone’ and ‘autochtone’ culture and identity, and inclusion of people with a minority background reflect stereotypes and negative images of ‘others’ and are greatly influenced by political anti-migrant sentiments and the development of populist ‘hyperrealism’ (Prins, 2002). Nevertheless, one could detect a similar pitfall in a definitive belief in the goodness and richness of diversity and a potential tendency to romantisize diversity as the exotic subject (Ramarajan & Thomas, 2010).
To refrain from researching from a starting point of presupposed definitions on diversity in organisations, as either inherently positive or ‘negative’ and from a top-down perspective, we believe it is important to study bottom-up, from an emic view point and through a critical-empirical research using an intersectionality perspective how diversity is socially enacted and performed in daily work practices and what this implies for health care professionals and the interculturalisation of health care organizations (Jhutti-Johal, 2013; Verdonk & Abma, 2013; Tsouroufli et al, 2011).
We believe it is essential to hold a dynamic and contextual perception of diversity and thus we will direct our study to how both -perceived- minority as well as majority professionals of health care teams in academic hospitals understand and act upon the concept of diversity in their daily work environment –with this also moving from the abstract and theoretical concept to the actual socially lived experience.
We will zoom in on health care teams consisting of professionals holding diverse positions and with diverse professional expertise within an academic medical organisation. The multidisciplinairy health care team constitutes the practical and social context in which health care professionals, ie. physicians, nurses, paramedics and management, operate and encounter diversity in different forms. The term diversity here includes several interpretations ranging from the broad concept used within the societal and political discourse on participation and inclusion of people with ‘different’ or minority backgrounds to the interpretation of diversity as a normative idea and ethical ideal. The starting point will be culturally diverse health care teams, ie. those which include professionals with an ethnic minority background. However, focus will be on all possible different forms of perceived diversity on the basis of the intersectionality of different characteristics of individuals and groups, the interpretation of human diversity as a socially enacted relational imaging of being both relatively ‘same’ and ‘different’ and of identity as a dynamic, ever-evolving process (Verdonk & Abma, 2013; Tsouroufli et al, 2011; Knudsen, 2006).
Here, the concept of ‘space’ is central as we view teams as micro-worlds and see diversity-in-teams as closely connected with the different ways in which professionals are in a continuing social negotiation of being relatively ‘same’ and/ or ‘different’. is concerned with knowledge on the ‘quality’ of perceived ‘space’ that team members experience to be ‘different’, to expres their ‘selves’ and ‘manage their own multiple identities’. Space here is interpreted as at the same time physical/ material, social and emotional, following Lofland (2000). We parallel with Ghorashi & Sabelis (2012) in their perspective that to do right to social diversity in organizations and in order to create an inclusive atmosphere and eventually try to achieve equal opportunities for all professionals, focus needs to be foremost on developing sensitivity towards and dialogue on difference instead of sameness, ie. creating ‘space for difference’.
With the bottom up approach and dynamic intersectionality perspective and combining case-study and action-oriented methodology, we follow Zanoni et al. (2010) who argue for critical and empirical research on workforce diversity. Zanoni et al. (2010) make clear how studies on diversity in organisations are flawed by a positivistic ontology of identity, inadequate theoretization of the concept of power and downplayed the role of organizational and societal context (Zanoni, 2010: 4-5). Zanoni et al. call for empirical research on diversity as a social and dynamic practice in an organizational setting, for studying how diverse workforce members themselves make sense of this complex concept, and with them to search actively for ways to stimulate social change throughout this performative research process (Zanoni, 2010: 7-10).
Our research perspective also links up with Cox’s (1994) and Thomas & Ely’s (1996) call for a holistic and processual understanding of diversity and other studies that hold the view that corresponding with the current ‘multicultural society’ bottom-up changes within health care organisations are required to ceate an adequate climate to diversity.
Setting: VU University Medical Centre
The VU Medical Centre is located in the ‘multicultural’ city of Amsterdam. VU/ The Free University and VUmc are amongst the most culturally diverse universities of the Netherlands. Estimates on students with a minority background range from 20 to 30% of the student population, depending on the definition of the parameters used. Numbers of students with a minority background who study medicine are relatively high compared to those in other areas of education. At a national total of 13.9% minority students in all areas of education, 5% was registered for medicine (Wobma & Ooijevaar, 2010).
In the Netherlands the dominant concepts used when discussing minority or majority backgrounds are ‘allochthonous’ as opposed to ‘autochthonous’, with a distinction between ‘western’ or ‘non-western’ allochthones. The current definition is that of the CBS (Dutch research instute for government statistics) that determines that someone is ‘allochthone’ when he or she, or at least one parent, is born outside the Netherlands. Accordingly, in 2010, 20% of the Dutch population was defined allochthonous. The subcategory ‘western’ includes only people from Europe, North-America, Australia and New-Zealand; ‘non-western’ includes those from other regions. Societal and political discussions on immigration and integration centers mostly around ‘non-western allochthones’ (CBS, 2012). These distinctly exclusive terms have an influence on the discours on participation and inclusion of minorities in the Netherlands and as such will receive attention in the research.
VU and VUmc have placed the subject of diversity and interculturalisation high on their agendas. Their ambition is to enhance diversity in the fields of education, research and within the medical centre. To set an example, VUmc was the first in the Netherlands to employ a muslim spiritual counsellor. This focus may be connected with the history of origin of VU University, namely its ‘sociaal-christelijke’ identity and the fact that it was the first academic education institute in the Netherlands to welcome students from all socio-economic backgrounds in the country.
In 2007, VUmc started the project Interculturalisation, aimed at making the education, patient care, personnel and the organisation in general more ‘colourfull’. Here, interculturalisation was defined as a process through which different cultures are perceived as valuable, and form positive mutual connections. The commission Interculturalisation includes staff from the medical education division and the medical centre. Examples of current initiatives on diversity and interculturalisation are the publication of the brochure ‘Kleurrijk VUmc’ (2013) and the internal website for employees with information and advice on how to deal with diversity among patient groups and within care contacts (online since October 2013). On different wards within the medical centre are ‘ambassadors’ active who strive for awareness-raising on interculturalisation. Also, special training is available for staff and executives of both VU and VUmc to enhance cultural competence, and in the medical education curriculum cultural competence and interculturalisation are key focus points.
In 2011, the commission Interculturalisation assigned the department of Medical Humanities (in Dutch Metamedica) to study the moving on of medical students with a minority background to physicians-in-specialty-training positions and specialist positions, proceeding from the observation that the increase in cultural diversity of the student population could only marginally be observed among physicians-in-training and specialists. Although precise figures are not available, because registration of HRM according to ethnic origin is deemed problematic in the light of possible discrimination, it is estimated that there are only 5 to 7% minority physicians-in-specialty-training and 2 to 4% minority specialists in the academic hospital.
The research on diversity in academic health care teams builds on insights from this earlier study on minority medical students and physicians in VUmc. This study concluded that minority physicians-in-specialty-training and not-in-specialty-training, experience barriers in obtaining specialist positions. These include manner of speaking, a lack of knowledge of career opportunities, a lack of social support and role models. Here, ethnic or cultural background but also factors such as social-economic status, gender differences and age seem important as to whether or not someone is selected. Also, due to stereotyped imaging on diversity and cultural identity, minority physicians-in-training feel they need to perform better and are constantly jugded extra critically as opposed to their majority colleagues. The research shows that specific processes of in- and exclusion are enacted on medical wards through social networking in which minority physicians-in-training are easily ‘at a disadvantage’. To refrain from the risk of distributing full responsibility and opportunity for action and change in the hands of individual minority physicians or with minorities collectively, and to prevent talent from passing unnoticed, the study stresses the need for development of awareness and sensitivity towards forms of ‘categorical thinking’ in medical qualification processes. Thet conclude that educators and heads of department can be a positive influence in stimulating an inclusive and respectful atmosphere and interaction in daily work on medical wards, but also that majority and minority physicians should work together is critically re-evaluating and discussing processes of qualification and selection in the academic work environment in order to create more space for diversity within the medical centre.