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Abstract
What is inclusion and inclusive leadership?In this article, based on the literature and my own experiences, I try to shed light on the concepts of inclusion and inclusive leadership, as well as what leaders need to do in order to be inclusive. Inclusion means the act of including or being included in a group, which creates a sense of belonging as well as empowers individuals to contribute in an authentic and meaningful manner. Inclusive leadership is important in the health professions and health professions education so that health professionals and faculty in health professions education are able to contribute to their work in ways that they find meaningful.
What do leaders need to do to be inclusive?To be inclusive leaders need to to do the following: truly believe in inclusion, define the boundaries of acceptable behaviours, make difficult diversity conversations possible, build authentic diverse relationships, develop shared leadership, drive and role model inclusive practices in the organisation, and find the right balance between individual and institutional EDI initiatives. Driving inclusion in a health professions (education) organisation demands changes in the concept of leadership, as well as the organisational policy and culture.
- behaviour
- management
- Senior medical leader
- values
Data availability statement
All data relevant to the study are included in the article or uploaded as supplemental information.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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Introduction
While the awareness of equity–diversity–inclusion (EDI) and the willingness to address inequalities are increasing throughout the world, I propose that inclusive leadership is key to bringing about disruptive changes. As an ethnic minority female migrant, who has faced and overcome numerous barriers in a white-dominated society, and made it to a leadership position in a Dutch academic medical centre, inclusive leadership is close to my heart.1 I, myself, have benefited from my mentors who were inclusive in their leadership. In my own institution, I currently try to drive inclusion and inclusive leadership through my research and as member of the Steering Committee Diversity and Inclusion of our academic medical centre. This article outlines my ideas of inclusive leadership based on the current literature and my own experiences, and provides a go-to list of inclusive leadership behaviours.
So far, the attempts to achieve EDI, especially for people from ethnic minority backgrounds or under-represented in medicine, are skewed towards empowering individuals in underprivileged positions to achieve their potential, while keeping the structural barriers that are in place intact.2 An example is implementing mentoring programmes for under-represented individuals in an organisation while maintaining the age-old metrics and quality frameworks for promotion in place. This is in stark contrast to the evidence presented in the literature, which suggests that employing institution-based initiatives to change the organisational structures and culture is more effective in garnering shifts in EDI in contrast to individual-based initiatives.3 An example of such organisational change could be embedding inclusive hiring practices in the culture of the organisation.
What is inclusion?
While inclusion has been defined or described in different ways in the literature and different fields of study, for me, inclusion refers to being included in a group which creates a sense of belonging as well as empowers individuals to contribute in an authentic and meaningful manner.1 4 I feel a sense of belonging to my work organisation as I was promoted to professor while retaining my core Indian values and identity. I have the empowerment to contribute meaningfully through the membership of the Steering Committee on Diversity and Inclusion.
The concepts of diversity, equity, positionality and privilege
To me, ‘Diversity refers to representation of individuals of varied backgrounds in society in specific contexts such as professions, work organisations and research populations’.1 I find that equity is essential for building diversity. ‘Equity refers to the practice of embedding systems that ensure equal opportunities to all, regardless of their background or personal characteristics, with the aim of promotion of fairness, impartiality and access’.1 5 Merely having diversity and equity (access to opportunities for people with diverse backgrounds) does not guarantee inclusion.1 6 To understand inclusion, I find it a prerequisite that everyone understands positionality and privilege. A reflection on and understanding of one’s personal values and perspectives which are shaped by social identities and experience is called understanding one’s own positionality.7 Positionality also includes understanding of one’s own position relative to others. My positionality is that I am a brown, heterosexual, highly educated woman, coming from a previously colonised country, India, had little money growing up, but now belong to the higher-income percentile families in the Netherlands and am an ethnic minority in my current context. In my experience, reflecting on one’s positionality can be a confronting and a perspective-changing experience. Thus, inclusion needs deliberate efforts which begin with reflection on and awareness of one’s own privileges, as well as the relative position of the less privileged. Privilege is defined as an unequal opportunity to access power and other resources.8 This power can be related to varied aspects such as wealth, assets, social position, skin colour, sexual orientation, geographical and historical positions, as well as the intersection of these characteristics. A white highly educated heterosexual male from a high-income/wealthy family has far more privileges in comparison with a black homosexual female from an impoverished family. Privileges account for different starting points for different individuals in the society in education or job opportunities or health, and have exponential effects on further opportunities and successes.9 10 To cite examples from the health professions education field related to ethnic minority background, ethnic minority background students are less likely to: be selected or admitted to study medicine,11 score equal to their white counterparts in assessments,12 have experiences of inclusion during their education,13 be selected for specialisation training14 and become a specialist in medicine.14
Inclusive leadership as an antecedent of inclusion
Inclusive leadership is one of the antecedents of inclusion at work alongside the creation of an inclusive climate and engaging in inclusive practices.15 The former can drive the latter two. Thus, inclusive leadership is key to bring about inclusion at work. Inclusive leadership comprises management philosophy and values on diversity and equal employment opportunity, as well as strategies and decisions on creating a meta-narrative on an inclusive culture and actively handling resistance to diversity efforts.15 With the Steering and Programme Committees on Diversity and Inclusion in our organisation, we try to create a meta-narrative on how inclusion is important in an organisation by emphasising this in meetings with the senior leadership and creating visible diversity initiatives and celebrations. Leaders have to especially be aware about exclusionary practices (eg, having informal get-togethers where drinking alcohol is the norm excludes people who do not drink13), and strive to create an inclusive culture in their teams and organisations. Shore and collegaues have proposed an inclusion framework for leaders to consider for their team members and organisations. It includes belongingness (whether an employee feels that she belongs to the broader group at work) on the one hand and uniqueness on the other (whether the employee feels that her unique qualities are considered important at work) (see figure 1). The combination of low belongingness and low uniqueness leads to exclusion, while that of high belongingness and high uniqueness leads to inclusion.15 This means that the leader has to get the balance of belongingness and uniqueness ‘right’ for her team or organisational members to feel included. I perceived the dean of my faculty approving my giving my professor’s inaugural lecture in English instead of the majority language, Dutch, as something that increased my sense of belongingness to the organisation. I perceived the support I received from my university to wear an Indian saree beneath my professor’s toga (robe) at my inaugural lecture as supporting my uniqueness within the majority culture.
Inclusion framework for individuals in a team or organisation (adapted from Shore and colleagues15).
How does inclusive leadership manifest?
There are three levels at which inclusive leadership manifests: the level of the individual leader, the relational level and the organisational level16 (see figure 2). At the individual level, the inclusive leader demonstrates cultural humility, and tolerance for uncertainty and ambiguity. In my role as the head of my research group or as a tutor in our bachelor of medicine curriculum, I try to role model a curiosity for other cultures, while accepting that I may not know everything about them. I may sometimes be uncertain about things that I say and do, while always willing to accept my mistakes and willing to be addressed on them. At the relational level, the inclusive leader develops shared leadership at all levels, deliberately invests in developing relationships across differences, invests in diverse networks and builds authentic relationships. I encourage shared leadership in my research group, recruit team members from diverse backgrounds, purposefully build diversity in my networks and try to be authentic in my relationships. At the organisational level, the inclusive leader sets standards and defines the boundaries for acceptable behaviours, creates a brave space for conversations centred around differences, role models understanding and comfort around diversity, and is authentic in their approach to diversity.16 Our Steering Committee on Diversity and Inclusion has set standards for acceptable behaviours and created a brave space to talk about differences at an institutional level through a keynote and panel discussion on EDI. Our hospital Board of Directors try to role model understanding and comfort around the uncomfortable (for many) topic of EDI. I strongly feel that leaders should be authentic in their approach to diversity. They should engage in it because they authentically believe in it. Ticking the boxes with regard to EDI does not achieve EDI.
Inclusive leadership behaviours.16
What can leaders learn from diversity and inclusion affinity networks to practise inclusion?
I recommend leaders use what is known from affinity networks to promote diversity and inclusion. Affinity networks are groups formed for enhancing professional opportunities for certain groups, such as bicultural network groups and Lesbian, Gay, Bisexual, Transgender, Queer, and Intersex (LGBTQI+) networks.3 EDI affinity networks need to resolve three types of sociological dilemmas before designing their diversity and inclusion policies.3 These are about adoption of: sameness or differences discourse, individual-based or organisational initiatives, and institutional embedding or independence (see figure 3). Since it is ultimately the leaders who drive such policies in the organisation, they need to be competent in resolving these dilemmas.
Three dilemmas for leaders (adapted from Slootman3).
The first dilemma is on choosing between the sameness and the differences discourses. Often leaders believe that if they see and treat all people as equal (not different from each other), they are practising equality. This perspective on diversity is called the ‘sameness’ discourse (‘we are all different, therefore we are all the same’), and it ignores the structural inequalities that underprivileged individuals face. In contrast to this is the ‘differences’ discourse. This discourse acknowledges that people have different starting points and some are more disadvantaged than others.3 Only if leaders acknowledge differences can they celebrate them and demonstrate their added value. This ‘differences’ discourse can be actioned by leaders in two ways. The first way is by using the ‘business case’ perspective to convince people of the value of diversity and inclusion, which states that diversity in teams leads to more productivity and creativity. The second way is by using the ‘social justice perspective’, which states that every human being has the right to access all opportunities. The business case perspective is more likely to lead to individual empowerment or training strategies, while the social justice perspective can help to bring about structural and systemic changes.3
The second dilemma is choosing between individually empowering or advancing activities and organisational change activities. Individually empowering activities, such as bicultural mentoring programmes, tend to help an individual, by teaching the individual to beat the system and be successful, but they are less poised to change the system to reduce structural inequalities. Organisational change, such as introducing quota for women on top management structures, helps in taking away structural inequalities.
The third dilemma is choosing the level of institutionalisation of affinity networks. Should networks be independent of organisations or embedded within them? Independence from organisations helps the networks to remain critically active, but embedding them within organisations provides them with the necessary funding and long-term sustainability. Our Steering Committee on Diversity and Inclusion is embedded within the organisation and we clearly see that the decisions made in this type of construction get support and traction from the top management and the initiatives seem to have continuation and sustainability.
Leaders need to resolve these dilemmas in order to decide which EDI strategies should be used within a team or in an organisation.
Why is inclusive leadership relevant and essential in the health professions and health professions education?
Just as in other fields, inclusive leadership is essential in the health professions and health professions education to drive inclusion through an inclusive climate and inclusive practices. The beneficiaries of diversity and inclusion are manifold: students/future health professionals, current health professionals and patients. Diversity and inclusion in the student population leads to high-quality health professions education and training.17 Diversity and inclusion among physicians providing healthcare provides better access and high-quality healthcare to underserved populations, decreases health inequities among minority patients and leads to better research on health problems of the underserved populations.17 The biggest outcome is high-quality, sustainable healthcare.17 The Lancet Global Health Commission on High Quality Health Systems has deemed equity in healthcare to be an essential component of the quality of healthcare.18 Equity in healthcare cannot be achieved without a healthcare workforce that mirrors the diverse patient population, and to achieve this equity, inclusive leadership in health professions and health professions education is non-negotiable.
Reflection on my own experience
If I look at my own experiences in inclusion, my mentors (who are actually white and belong to the majority culture in my context) welcomed and celebrated my different perspective, gave me a feeling of being genuinely understood, invested in building an authentic relationship with me, treated me like an equal and helped me navigate my way through the unfamiliar cultural context I was working in. I relied heavily on their support throughout my career track to be a professor. This was especially important because I was passionate about holding on to my Indian roots and identity, while it felt like the system was demanding individualistic behaviours from me that were important in the majority culture, but were against my collectivistic cultural values and norms. I will be forever grateful for their authentic and inclusive leadership. They serve as role models for inclusive leadership in their respective organisations.
As a member of the organisational Steering Committee on Diversity and Inclusion, I try to contribute a different perspective from my background, provide my understanding of EDI research and policies in our discussions, ask critical questions on ideas about EDI, try to role model inclusive leadership in a visible way, while being authentic to myself and my relationships. I place authenticity to the core of my being.
Conclusion
Inclusive leadership in health professions and health professions education entails the following for leaders: truly believing in inclusion, defining the boundaries of acceptable behaviours, making difficult diversity conversations possible, building authentic diverse relationships, developing shared leadership, driving and role modelling inclusive practices in the organisation, and finding the right balance between individual and institutional EDI initiatives. This makes the case for bringing about changes in the current concept of leadership and encouraging leaders to be inclusive. The inclusive leadership behaviours illustrated in this article provide ready-to-use tips for all leaders.
Data availability statement
All data relevant to the study are included in the article or uploaded as supplemental information.
Ethics statements
Patient consent for publication
Ethics approval
Not applicable.
Acknowledgments
The author would like to thank Dr Anouk Wouters and Dr. Malou Stoffels, from Amsterdam UMC location Vrije Universiteit Amsterdam, the Netherlands, and Dr Marieke Slootman, Inholland University of Applied Sciences, Amsterdam, the Netherlands, for their feedback on an earlier version of this manuscript.
Footnotes
Twitter @r_kusurkar
Contributors The author conceptualised, wrote and edited this article. The author is solely responsible for the article. This article has not been submitted or published in any other journal.
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.
Author note R.A. Kusurkar is professor and research programme leader, Research in Education, at Amsterdam University Medical Centers (UMC) location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands; She is Associate Editor on EDI for Medical Teacher, a Fellow of AMEE and a Fellow of KIPRIME (Karolinska Institute Prize for Research in Medical Education);