Considerations for leadership

There are a multitude of considerations for leaders whose workforce includes neurodivergent individuals, which will increase with the rising number of neurodivergent staff and necessary inclusive practices. These challenges may include the recognised lack of general awareness of neurodivergence both by employers and fellow employees, which can be addressed by the provision of education and training.3 15 There will be a requirement for leaders to be sensitive to, and facilitative of, accommodations necessary for their neurodivergent workforce. Furthermore, leaders will be required to advocate and set benchmarks for neuroinclusion by developing and sustaining policies and practices to ensure neurodivergent staff are supported and protected.3 This will also include the need for leaders to ensure a commitment to the inclusion of neurodivergence within organisational EDI agendas. Such challenges will pose demands for leaders striving for compassionate and inclusive practice, who will need to enable positive cultural and environmental changes within healthcare organisations, to ensure neuroinclusion is supported and maintained within the workplace. This article will explore potential solutions for these leadership challenges.

Equality, diversity and inclusion

Despite an increasing focus on EDI within the workforce, it is recognised that the neurodivergent cohort can often be overlooked in the diversity conversation.3 4 8 The 2022 Messenger review of leadership for a collaborative and inclusive future within UK healthcare,16 advocates a step-change in the way the principles of EDI are embedded within healthcare leadership and indeed, this requires action to be taken to create inclusive workplaces. As such, organisations will be required to have an inclusive agenda to attract, retain and support people with neurodivergent conditions, to recognise their talents and ensure they reach their full potential within the workplace. Furthermore, neurodivergence should be formally recognised and included within organisational EDI policy and guidance.3 15

However, the research base highlights not only a potential lack of understanding about neurodivergence in general within the workforce, but a dearth of guidance on how to support or accommodate those who are neurodivergent. Indeed, it was reported in May 2022 that employment tribunals relating to neurodivergence were up by a third in just 1 year.17 Furthermore, a report by the Chartered Institute of Personnel and Development details that only 1 in 10 organisations consider neurodivergence in their people management practices.6 As such, given the relatively high prevalence of neurodivergence within the population, it appears some organisations may be failing to address the needs of their neurodivergent workforce.

Neurodivergence: disability or competitive advantage?

Neurodivergence can be considered a disability under the Equality Act 2010, which means that organisations have a legal obligation to make reasonable adjustments within the workplace and an individual’s role, to remove or minimise any potential disadvantage. This was demonstrated in the case of Sherbourne v N Power18 where an occupational health team stated that although the claimant had not yet received a diagnosis of autism, it was likely that he would receive one, and thus be considered disabled under the Equality Act. The respondent was found to have indirectly discriminated against the claimant on the grounds of his disability, in addition to failing to make reasonable adjustments.18 This highlights organisations’ responsibilities to their employees, in addition to how discrimination can occur prior to diagnosis. However, JC v Gordonstoun Schools Ltd reminds us that the effects of neurodivergence must be considered on a case-by-case basis.19 This appeal considered a student with attention deficit hyperactivty disorder (ADHD) who had been expelled from school, where the appellant argued that her daughter was disabled, and therefore, her expulsion amounted to unlawful discrimination. However, the tribunal found that her ADHD did not ‘substantially and adversely affect her ability to carry out normal day-to-day activities’, thus was not considered a disability.19

Although neurodivergence can be considered as a disability on a case-by-case basis, the neurodiversity movement encourages acceptance and inclusion of neurological differences, which should be recognised, embraced and accommodated.3 4 Furthermore, it acknowledges the strengths as well as the challenges of neurodivergence, in contrast to traditional medical models whereby ‘disorders’ are diagnosed based on perceived deficits and/or pathology. While the medical model of disability focuses on one or more health impairments of the individual, the social model of disability recognises that disabilities can be caused by the way society is organised rather than the impairment of any individual.5 For example, consider a wheelchair user trying to access a building with a step; if the building had been designed or adapted with a ramp, there would be no issue of access. As such, neurodivergence should be considered within this social model, whereby we acknowledge the barriers that may be placed on those who are divergent in a neurotypically designed world. This model can help us to identify these barriers impeding others and consider how they could be addressed to benefit those that think or function differently relative to the neurotypical ‘norm’.5

While neurodivergence could be perceived as a disability within some neurotypical workplace environments, like all disabilities there are still capabilities and strengths to be acknowledged. The relative strengths of some neurodivergent conditions compared with their perceived limitations are presented in figure 1. Appreciating neurodivergent individuals’ abilities, challenges and broader ranges in functioning, will help not only to encourage self-determination but also enable supportive accommodations.20

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Figure 1

Displaying the perceived limitations that are often associated with neurodivergent conditions compared with the relative strengths of these same groups.5 6 ADHD, attention deficit hyperactivity disorder.

When considering such neurodivergent strengths, it is not surprising that these are now often viewed as a competitive advantage within the workplace. This approach is apparent in proactive talent management strategies in industries such as business, finance and technology and is increasingly recognised by large corporations such as Microsoft, Ford and Ernst & Young.21 Targeted inclusion programmes and encouraging accommodations for differently abled employees, enables their unique talents and abilities to be used further in the workplace. This has the benefit of boosting productivity, innovation and quality improvement on a macro level, while improving the management abilities of the individual leaders of these organisations.21

It is acknowledged that while research has furthered the discussions regarding neurodivergence within business organisations, there is very little written in the sphere of leadership theory and neurodivergence.22 While this discussion is outside the scope of this article, it is recognised that there are currently no specific models of leadership which are purposefully inclusive of neurodivergence, and it is questioned whether traditional leadership theory works in a neurodivergent context.22 23 There are, however, conceptual models which propose how cognitive characteristics associated with neurodivergence may serve as strengths and positive influence for leadership behaviours/outcomes and recognition for neurodivergent individuals as leaders.22

Intersectionality and neurodivergence

Intersectionality can be defined as the dynamic overlap and ‘intersection’ of multiple social characteristics such as gender, race, sexual orientation, class and disability, which collectively form an individual’s overall identity, an identity which may be subject to unique forms of discrimination or privilege.24 As such, intersectionality may play a crucial role in drawing attention to the distinct experiences of marginalised groups, with social factors influencing the identification, classification and assistance given to individuals who may be neurodivergent.

It has been demonstrated that intersectionality impacts on multiple facets of managing neurodivergence, such as standardised assessment methods potentially possessing intersectional bias, and the misattribution of particular traits to gender or social/cultural customs among certain ethnicities, rather than a developmental neurominority.3 25 For example, the recognised practice of averting eye contact when communicating with individuals of authority within Afro-Caribbean cultures, can also be a behaviour exhibited in autism. Furthermore, data identify that the prevalence of LGBTQ+ people (lesbian, gay, bisexual, transgender, queer/questioning, plus) is known to be higher in the neurodivergent community, where coexistence of minority characteristics can interplay to further compound negative impacts.3 25 26

Indeed, intersectionality can potentiate disadvantage for certain neurodivergent communities, with individuals of non-white ethnic groups, for example, who may also be female, being at greater risk of being underdiagnosed and undersupported, when compared with their white, middle-class, male, cisgender counterparts, from whom socially constructed ‘norms’ have been derived. Thus, the importance of intersectionality is clear, with neurodivergent people of colour, women, non-binary and LGBTQ+ experiencing compound adverse effects regarding a range of outcomes.3 As such, leaders should advocate for these cohorts to be represented when designing workplace accommodations, policy and programmes, to reduce the impact of additional structural inequalities related to the intersection of race, sexuality and gender, when providing support for those with neurodivergent needs.3 25

Neurodivergence and social justice

There are a variety of thoughts on the meaning of neurodivergence. It is variably postulated as a biological fact, a difference in neurochemistry, an emergent paradigm or a social justice movement. Indeed, there are those who propose that neurodivergence is the ‘next frontier’ in social justice, following in the footsteps of other societal diversities, such as gender, race, religion and sexual orientation.3 4 Thus, it is proposed that it should be recognised as a subcategory of EDI; and subject to the same social dynamics, valued acceptance and accommodations as all other forms of diversity.20 However, it is recognised that wider general knowledge of neurodivergence may be lacking, and it is acknowledged that simply providing education and awareness may help in providing some social justice for this population.15

Embedded in the concept of social justice is the philosophy that all individuals should have access to opportunities irrespective of difference or group membership, however, it also reminds us that some groups within our society continue to face injustices and barriers because of their differences.27 Indeed, a central principal of social justice is the removal of such barriers (be they systemic, physical or attitudinal) so that all may experience their lives unencumbered by their differences or abilities. Within the workplace, these barriers are numerous for those who are neurodivergent and may limit employability, realisation of potential or full/active participation.3 8 15

This concern for social justice within the workforce compels us to be vigilant and should raise critical questions for healthcare leaders. Organisations should provide supportive accommodations that meet the need of those who are neurodivergent, to overcome those unfair social norms and environments which may benefit the neurotypical and hinder the neuroatypical. Moreover, in purposefully enabling a neurodivergent workforce, comes with it the responsibility to understand and support these individuals within the workplace.6 7 11

Previous research has highlighted that the academic literature is lacking in contextualised, evidence-based practical advice for employers and employees,7 11 however, guidance from the business sector is more abundant.6 As such, approaches to promote inclusion of neurodivergent individuals in our healthcare workforce regarding recruitment, retention and reasonable adjustments are discussed below.

Recruitment and retention

Inclusive recruitment processes must exist to provide opportunities for staff from a range of backgrounds. Many recruitment processes are orientated towards neurotypical minds, and therefore, may unintentionally exclude neurodivergent talent. This can include issues such as job descriptions/advertisements, unempathic interviewers or even the employer’s onboarding process.6

Employing organisations should include a positive declaration that they are open both to accepting candidates with different styles of thinking and to discuss reasonable workplace adjustments for those who are neurodivergent.6 Candidate filtering tools that focus on removing unconscious bias should be considered and applicants should be offered opportunities throughout the hiring process to disclose they are neurodivergent, as this can facilitate positive discussion on potential adjustments, but there is no obligation for candidates to make such disclosures.6 It is important to be cognisant that some employees may fear potential consequences of disclosure, such as disparate treatment in hiring, workplace interactions and career advancement, as well as concerns about being treated or viewed differently from others.15 An appropriate response is critical should an applicant choose to make any such disclosure and this should, therefore, be incorporated into interviewer briefing and employer training.6

Interviews can often be a test of social competence which may be challenging for those who are neurodivergent. An ill-informed or unempathic interviewer may make negative judgements on an applicant’s suitability for a role, which further highlights the importance of training in neurodivergence awareness and inclusion. Alternative assessment methods to interviews could be used, but where conventional interviews still occur, interviewers should ask direct and specific questions and avoid placing unnecessary time pressures on applicants. Moreover, it is important to be considerate of unconventional body language and/or differing styles of social interaction, which may be the result of an individual’s neurodivergence.6

Although inclusive recruitment is essential to promote a diverse workforce, given the current pressures and workforce crises within healthcare, we must also consider the importance of staff retention. A strong induction programme, regular appraisals and one-to-one meetings between managers and staff should be a key part of any retention strategy.28 Onboarding workspace questionnaires and occupational health assessments can be used to identify reasonable adjustments.6 Furthermore, it is also important that neurodivergent employees are assisted to identify clear long-term career pathways, with equal development opportunities available to all, to facilitate continued development and ongoing career satisfaction.3 5 15

Reasonable adjustments and accommodations

Although the Equality Act 2010 stipulates that employers have a duty to make ‘reasonable adjustments’ to support people with disabilities in the workplace, it is deemed good practice to consider this for any employee. Many accommodations are inexpensive and can produce benefits including increased employee productivity, morale and retention.29 McDowall et al 3 provide a clear framework for the explanation of both formal adjustments (an additional feature of employment) and informal accommodations (available to all), with categorisation into ‘environmental’, ‘assistive technology’ and ‘coaching’, as described below. However, it is interesting to note that their survey review of 990 UK employees identified that only 29.9% of those with neurodivergence reported having formal adjustments in place.3 It is also important to acknowledge, however, that some employees may not feel comfortable to disclose their neurodivergence, while others may not be aware they have a specific neurotype.15

Environmental: Some workplace environments can present as a barrier to prevent neurodivergent staff from performing at their best, where surroundings and/or equipment may act as a trigger for sensory overload or distraction. In many cases, accommodations for environmental issues are often simple and cost-effective,5 with particular attention given to employees’ sensory preferences, environments, social interactions and work patterns.6 Such adjustments may include frequent work breaks, hybrid working, a flexible schedule, adapted policy/procedures, adjusted noise levels/intensity of lighting and private office or space enclosure.3 However, as with all employees, it is important to recognise that not everyone with neurodivergence will have the same preferences regarding workspaces.

Given the growing trend towards working from home, especially within the post-pandemic landscape, the specific support needs of those with neurodivergence working remotely are currently poorly evidenced and understood.30 Indeed, the impact of the COVID-19 pandemic must be acknowledged, with research detailing a multitude of psychological and environmental challenges for the neurodivergent community.31 Many neurodivergent individuals may have benefited from working remotely, however evidence has identified significant challenges for some including video conferencing issues, problems working in the home environment and disruption to routine.30 32 Furthermore, it must be acknowledged that those adjustments which may be successful onsite may not be successful for remote working, highlighting how accommodating neurodivergence within the workplace is a dynamic rather than static process.32 Moreover, in time of crises such as the COVID-19 pandemic, it has been suggested that the many policy responses may offer opportunities to advance social justice, by addressing persisting inequities and making workplaces more inclusive of neurodivergence. This includes offering communication alternatives, removing on-site workplace stressors, promoting online communications and a cultural shift towards more flexible individual working arrangements.30 32 Indeed, post-pandemic working has highlighted how tailor-made support or accommodations should be implemented considering individual circumstances and characteristics, including the heterogeneity of neurominority conditions.

Assistive technology: This may include adjustments and tools such as: mind-mapping software, specialist spell-checkers, dual screen or reading stand, software to support organisation/time management, coloured overlays/material printed on coloured paper, font size change of reading materials and specialist training to use technological adjustments.3 Other practical strategies can include software tools for staff who wish to undertake screening to identify workplace strengths and challenges. These allow individually tailored plans and adjustments to be formulated, providing support based on weaknesses, irrespective of diagnosis. Similarly, employers can implement software packages, such as speech-to-text or text-to-speech software, as inclusion tools to help those who may have difficulty with text and reading. This assistive digital technology can instantly support neurodivergent employees and can also be useful for those with low literacy skills or English as a second language. A recent workforce survey highlighted that 43% of employees with disabilities do not feel comfortable asking for workplace adjustments,33 however, strategies such as these (which can be made available to all staff), will not only support the entire workforce, but also remove the need for anyone to identify as neurodivergent if they do not feel able or willing to do so.

Coaching: Neurodivergent employees may find it useful to have additional support from Human Resources, specialist coaches and other vocational support assistance, as well as family and external mentors. Adjustments may include specialist work strategy coaching for: memory issues, organisational issues, time management issues, literacy, numeracy, communication and well-being.3 Employee resource groups and support networks can advocate the reality and benefits of neurodivergence within the workplace. It is good practice to have information on such groups clearly signposted, including information at the onboarding process, on the staff intranet and on the job vacancies section of the organisation’s webpage.6

Other supportive mechanisms: While evidence is scarce in the academic literature related to inclusive approaches to neurodivergence within the healthcare workplace, there are examples of individual hospital trusts or organisations employing innovative supportive approaches. These include schemes such as a ‘Neurodivergence Staff Network Group’ and ‘Differently-Abled Buddy System’. Staff network groups bring together those who have experience of, or an interest in neurodivergence, to discuss experiences, plan future activities/events and develop policy and strategy to better meet the needs of the neurodivergent workforce. The ‘differently-abled scheme’ allows new neurodivergent staff to buddy-up with an established member of staff who is also differently-abled. These are strategies which can be enabled within any workplace and are used to build and maintain confidence for neurodivergent staff and facilitate supportive allies and systems for inclusion. Furthermore, they encourage openness about neurodivergence, enabling individuals to feel more supported in discussing individual needs and seeking appropriate adjustments.

It must be noted, however, that reasonable adjustments are not the only solution for enabling positive recruitment and retention. The management of neurodivergent staff within the workplace not only requires accommodations, but also necessitates enabling a psychologically safe environment, line management resourcing and ensuring long-term career satisfaction.3