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Broad realisation of the disparities experienced by both patients and healthcare workers, undoubtedly exacerbated by the COVID-19 pandemic, has led to greater efforts to improve the awareness of the importance of equity, diversity and inclusion (EDI) within leadership. In England, the Messenger Review, a report commissioned by the Health Secretary in 2021 into leadership and management in the health and care sector emphasised the need for ‘embed(ding) inclusive leadership practice as the responsibility of all leaders’.1
The Faculty of Medical Leadership and Management (FMLM) International Conference 2022 invited clinical and academic leaders from across the globe to share their expertise and reflections on how to create equitable and inclusive cultures throughout a range of sessions. There was a clear appreciation of the need for diverse voices, for a space for meaningful introspection and for an opportunity for critical dialogue, in order to develop the skills required to lead inclusively and to share actionable steps to move towards equitable and just healthcare systems. The sessions were incredibly powerful with the perfect blend of data and stories. As frequently quoted by Brene Brown:
If you don’t have the data and you don’t have the story, you don’t have what it takes to move people.2
This commentary aims to draw on the inspiring content that was shared during the conference on the topic of EDI, and will be underpinned by existing literature and personal reflection. It will begin by first defining the relevant terms and will then proceed to exploring the why of the work, followed by the steps that were felt to have the potential to lead to meaningful progress in this space.
Diversity refers to any dimension that can be used to differentiate groups, or people, from one another due to various differing characteristics including gender, age, ethnicity, physical ability and more. Equity refers to taking into consideration a person’s unique circumstances or characteristics and adjusting their treatment, so the end result is equal. This differs somewhat from equality which assumes all people should be treated the same regardless of their circumstances. Inclusion refers to how people experience their environment or workplace in a way that both embraces their uniqueness (or diversity) while simultaneously fostering a sense of belonging for all.3 Justice, in its broadest sense, refers to the moral notion that individuals are to be treated in a manner that is equitable and fair and receive that which they deserve.4 These terms will continue to be explored in more depth throughout this commentary.
The why of the work: acknowledging the stark reality of inequity in healthcare
Dr Habib Naqvi (Director of the NHS Race and Health Observatory) shared sobering statistics on the inequity that exists in the National Health Service (NHS), leading to patients from minoritised communities experiencing notably worse healthcare outcomes.5 These data were brought to life when Dr Rageshri Dhairyawan (NHS Consultant and mixed methods’ researcher) shared the ‘testimonial injustice’ she experienced during her own patient journey,6 a term coined by philosopher Miranda Fricker to explain the prejudice that causes a person to either dismiss or offer a deflated level of credibility to the speaker’s word.7 Such bias experienced by minoritised patients in particular, as illustrated in Dhairyawan’s published story, risks worsening health inequalities not only because the patient testimony is discredited, but also because the subsequent breakdown in trust may result in patients withdrawing from seeking care for fear of not wanting to be disbelieved. Dr Benjamin Jones (physician and PhD student) expanded on the crucial role of trust on health behaviours, sharing how it is not only informed by one’s personal experiences but by the experiences of other institutions (such as educational institutions or the criminal justice service, for which inequity is also a mounting problem), as well as the experiences of trusted friends and family. This complex and delicate layering of trust highlights the volume of work needed to undo decades of inequity, while also accentuating the efforts required to win over the hearts and minds of those whose trust in healthcare services have been understandably broken.
This breakdown in trust and subsequent self-censoring created by the absence of equitable and inclusive cultures is translatable to the workforce setting. Alison Maitland (leadership coach and author) spoke of the risks that result from exclusionary behaviours including staff withdrawal and disengagement, which is particularly alarming if it leads to the reluctance to raise patient safety concerns. The role of inclusion in enabling psychological safe environments where candour is valued is well evidenced,8 yet Maitland referenced the recent report into maternity services in the UK which illustrates all too clearly that the fear of raising concerns among staff remains a pressing issue within today’s healthcare services.9
Moreover, it is known that the way an organisation treats its workforce, particularly its minoritised members, is a good barometer for the culture of care within that organisation.10 Many of the speakers reflected on this and other research, as well as their own lived experience, to make the case that inclusive environments in the workplace for healthcare staff are crucial as they have such a clear impact on patient outcomes. In turn, the business case for equity and inclusion for healthcare staff becomes irrefutable.
While the business case for change is an important part of the movement, the social justice case for equity and inclusion must also be acknowledged. Dr Ming-Ka Chan (paediatrician and associate professor) reminded listeners that the values of justice, fairness and learning must be held close to our hearts and at the forefront of our minds in order to authentically make progress in this space. This reflection highlights the role of values-based leadership in the discussion of EDI, while also emphasising the importance of attributing meaningful significance to these concepts, beyond merely the business case.11
In summary, to build strong foundations for action in this space, an appreciation of the stark inequities that currently exist is required, while paying attention to both the data and the lived experience of individuals affected. While the COVID-19 pandemic caused a notable exacerbation of the entrenched inequity for both patients and healthcare staff, it also shone a spotlight onto this area which, in turn, provides great opportunity for meaningful change; the steps for which will now be explored.
Setting out the steps for change
The speakers and panellists explored and debated a range of positive steps that would enable progress in the space of equity and inclusion. These have been summarised into five core aspects; aligning our intentions from the start, the importance of collectivism and collaboration, the need to create spaces to be both brave and vulnerable, the role of empowering future generations and the powerful reminder that rest is revolutionary on the path to meaningful equity and inclusion. Each of these will be discussed in turn.
Aligning our intentions from the start
Maitland began her session on ‘Rethinking Inclusion to improve outcomes’ by defining the terms diversity and inclusion, reflecting that many leaders do not understand what these terms (and values) mean. Her concise summary of ‘without inclusion, diversity remains unfulfilled potential’, illustrated the importance of ensuring clarity on the meaning behind the terms we use in this topic. Too often the acronym ‘EDI’ or ‘DEI’ is spoken of rapidly, with little appreciation of the true meaning behind each word; the importance of which is vital for enabling meaningful measurement of progress, for holding one another to account and for simply ensuring our teams and organisations are collectively aligned on our intentions from the start. These terms were defined at the start of this paper for this very purpose.
Similarly, the need for an appreciation of the ‘intersectionality’ of identities, a phrase coined by Crenshaw,12 which acknowledges the unique experiences faced by those with overlapping disadvantages, was discussed through many of the sessions. The conversations that followed stressed that intersectionality must be acknowledged early on in our attempts to address inequity in order to avoid inadvertently perpetuating existing systems of injustice, while also harnessing the role that intersectionality offers in terms of enabling co-conspirators for change (which will be explored later).
The tangled web of inequity that is nestled into the fabric of many of our institutions and social structures can feel insurmountable at times. Dr Audrea Burns spoke powerfully of the need to reframe, dismantle and rebuild structures in order to detangle ourselves from centuries of inequity. The concept of designing inclusion into processes and practices from the start was discussed by many of the speakers, along with acknowledgement of the Eurocentric norms that many of these processes are currently built on. The frequently cited Tuckman model13 for group development and team dynamics which follows the process of ‘forming, storming, norming…’ ought to really prompt the question—whose norms are these? Maitland suggested co-creating team agreements as a consistent guide to respecting different perspectives and ways of working. This suggestion is echoed in West’s work on enabling compassionate and inclusive teams by creating and regularly refreshing a team pledge by collectively agreeing ‘five things we must always do and five things we must never do’.14
In summary, we must ensure we ground the work of EDI on firm foundations of justice in order to avoid perpetuating inherent systems of inequity. This can be achieved by being clear on the terms we are using to enable clarity of purpose, being mindful of intersectional identities in order to avoid undermining that purpose, and regularly and deliberately asking ourselves whose voices we are inadvertently leaving out as we work to rebuild inclusion into all that we do.
Collectivism is key
In order to reap the associated benefits of inclusion (such as consistent innovation and enhanced team collaboration, among others), Maitland maintained that the mainstream population in organisations must engage with and lead for inclusion, rather than simply assuming it is for the marginalised groups to navigate. She proceeded to offer guidance on what high-level and mid-level leaders as well as individuals could do to support the journey to inclusion.15
This point was echoed throughout other sessions, particularly in reference to the notion of the ‘minority tax’, where minoritised members of staff have not only the burden of bias and exclusion to contend with but are also tasked with the challenge of pushing for change as EDI champions or similar, alongside often undervalued roles such as mentoring minoritised colleagues.16
Panellists explored the important role of collectivism while debating that meaningful equity may require a shift from acts of allyship (sometimes seen as a favour from those with privilege to the minoritised) to acts of solidarity, where the absence of inclusion is seen as everyone’s problem. The notion that allyship can at times be counterproductive is described powerfully in Emma Dabiri’s book What White People Can Do Next: from Allyship to Coalition where she argues that allyship reinforces unhelpful power dynamics and offers charity at the expense of solidarity; ‘allyship feels like a favour and favours can easily be withheld’.17
Speakers all generally welcomed the increasing momentum towards creating equitable and inclusive cultures but remained guarded against the performative or tokenistic approaches often observed. The importance of sponsorship and leveraging power in order to set people up for success rather than merely nudging them towards it was examined at length; with an agreement that ‘sponsoring with your presence’ was crucial for progress.
This need for collectivism and collaboration was explored further by Mr Ajit Abraham (NHS surgeon and Trust Group Executive Board Director for Equity and Inclusion and Principal, The Staff College: Leadership in Healthcare) acknowledging that the solutions to this wicked problem, which is interdependent by its nature, do not lie with any one individual or group of individuals, but rather, require cooperative work to create synergism across existing silos. This reflects Keith Grint’s well-known work on wicked problems which, he argues, require the leadership to ‘ask the right questions rather than provide the right answers’ in a process of collaborative enquiry.18
To summarise, the challenges of creating equity and inclusive cultures is one that requires acts of solidarity, authentic action and collective community in order to implement long-lasting change.
The need to lean in and to be both brave and vulnerable
In order to meaningfully engage with the work, there was a shared agreement among all speakers and panellists for the need for more frank and candid conversations and brave dialogue, along with time and space for reflexivity. The importance of self-awareness, vulnerability and humility were acknowledged as critical to achieving a deep authentic shift in this work. ‘This is the work of the heart as much as the work of the head’, offered Mr Ajit Abraham, drawing parallels with Brown’s work on wholehearted daring leadership.19 Dr Audrea Burns echoed this sentiment, advocating for the need to lean in bravely by making a conscious and deliberate choice to be vulnerable and to get comfortable with the discomfort; both of which are required to foster a critical consciousness of the imperative of this work and build on the existing momentum for change. This emphasises the paradoxical nature of vulnerability, by which one can be at their greatest emotional strength when choosing to consciously expose themselves to the risk of experiencing discomfort or pain in order to pursue a meaningful purpose.20
Co-created space to share stories, build relationships and draw out the challenges and positives of this work were both praised and urged for, along with the need to actively invite difference to the table and actively invite those who have been silenced to speak. Such space and time to connect with one another on a human level, to unlearn our biases and to relearn new ways of working was thought to be critical for change.
Empowering the next generation to be agents of change
A common theme throughout the conference was the role the next generation of leaders have in pressing for change in important topics such as equity and justice. As we move increasingly towards an age of employee activism,21 where workers are waking up to the notion of demanding more from their leaders,22 the role the follower has in demanding inclusive spaces is incredibly powerful. Active, engaged and empowered followership has an important role in steering the direction of travel on such issues, with many of the panellists sharing feelings of optimism for the future given the passion, determination and creativity demonstrated by many of those following in their footsteps.
The value of distributed leadership models was lauded throughout many of the discussions; the aim being to draw on the passion of junior colleagues while offering them space, time and opportunity to play a meaningful role in leading the change. This was felt to be mutually beneficial since enabling junior members of the team in such a way would not only be an important leadership development opportunity but would also relieve some of the burden from those overstretched with the volume of this work.
The question of how the next generation can be best supported in the area of EDI, prompted a powerful response from Dr Benjamin Jones—‘Support works best when it looks like respect’ he offered, reminding listeners that hearing the voices of the junior members of the team as loudly as all other voices would not only enhance their agency and esteem but may also uncover previously unthought of solutions.
The need to ensure there is a strong focus on equity and inclusion early on in careers (from university and throughout clinical training), was also thought to play a prominent part of the solution for empowering future generations, with the acknowledgement that many educators and trainers would themselves require support and training in order to handle these discussions authentically. A poignant contemplation from Dr Ming-Ka Chan was that if we spent equal amounts of time learning about inclusion and advocating for social justice as we do on the technical aspects of clinical education then perhaps we would have an entirely different health and education system and, conceivably, an entirely different society. Such a profound reflection gives greater meaning to the well-known words of Nelson Mandela—‘Education is the most powerful weapon which you can use to change the world’.
In summary, there is great potential within the next generation of leaders for progressing further in this work. This potential can be harnessed with respectful engagement, distributed leadership models and early, effective and consistent education and training on the importance of equity and inclusion in healthcare.
The role of rest on our long walk to fairness
This commentary has already made the case for the volume of work and continuous effort required to create long-lasting change in the space of equity and inclusion. The complexities associated with enacting this change along with the emotional labour involved in the work was reflected by many of the panellists. ‘It’s a long walk to fairness’ admitted Mr Ajit Abraham, acknowledging that while the progress and momentum is palpable and the small wins should continue to be celebrated, there is still a long way to go. The need for self-care as we navigate this turbulent path came strongly recommended by many of the speakers; ‘Rest is revolutionary’ urged Dr Javeed Shukhera (physician, educator and researcher) reminding listeners that, particularly when we are working and living in such pressure-focussed cultures, that rest can indeed be radical. Moreover, the role-modelling of rest and self-compassion is another critical tool for enabling our future generations as it offers them the permission to do the same. This point is echoed by West who describes self-compassion as being ‘at the heart of our leadership’, central to our ability to model and embody compassionate and inclusive leadership for our teams, organisations and wider systems.23
A paradigm shift is undoubtedly occurring with a greater appreciation and acknowledgement of the importance of equity for patients and inclusion for healthcare staff. The prominence of the topic at the FMLM International Conference 2022 highlights the movement and momentum that is underway. However, the existing inequities and exclusionary environments across the healthcare industry at a global level highlight that there is still much more to do. For her final remarks at the conference Alison Maitland offered a sense of hope and optimism; ‘we can close the gap between the promise and the practice of inclusion’, with this commentary summarising some of the steps that can enable that to occur. The walk to fairness is undeniably long but if we are clear on our intentions and values, make efforts to harness our collective powers, enable our future generations as both leaders and formidable followers while creating space for wholehearted reflection and prioritising time for rest and self-care, the destination may be closer than we think.
Patient consent for publication
I would like to thank Charlie Brown, CEO of The Staff College: Leadership in Healthcare for her valuable comments made on the draft of this article.
Contributors RY is the sole author.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.