Researchers Uncover Factors Behind Health Care Workplace Inclusion


A qualitative narrative analysis of 300-plus submitted essays led to answers as to what factors contribute to inclusive environments at work or education institutions.

Jaya Aysola, MD

Jaya Aysola, MD

A new study analyzing health care employee-submitted essays has identified a multitude of contributors to inclusive workforce culture, which researchers believe can improve health care providers’ environments and ultimately improve patient outcomes.

A qualitative narrative analysis of 300-plus submitted essays led to answers as to what factors both contribute to inclusive environments at work or education institutions, and what more can be done to improve such qualities in health care, corresponding author Jaya Aysola, MD, told MD Magazine®.

“We found areas in medicine that we could improve in, such as cultural competence—sort of similar to other institutions right now,” Aysola, of the Perelman School of Medicine, University of Pennsylvania, said.

Throughout June 2016, researchers sent out a weekly email call for written narratives to employees of health care organizations. The weekly call—limited to 6 hospitals, 4 health sciences schools, and outpatient facilities within a university-based health care system in Pennsylvania—contained an anonymous link to 2 open-ended questions requiring employees reflect on instances of inclusion or lack thereof within their work environments.

The calls also asked employee for their demographics. Employees could only answer the calls once.

In the 315 submitted narratives, researchers reported 188 (59.7%) identifying as women, with another 10 (3.2%) identifying as transgender and 9 (2.9%) declining to answer. The majority (n= 238; 75.6%) identifying as heterosexual, and 49 (15.6%) identified as lesbian/gay/homosexual/bisexual.

A majority of employees were also non-Hispanic white (159; 50.5%) and primarily spoke English (275; 87.3%). Religious beliefs were nearly split between non-Christian (152; 48.3%) and Christian (151; 47.9%).

Employees primarily reported having worked at their institution for 10 or more years (107; 34%) and being in a staff position (113; 35.9%). The most commonly reported primary site of work was a school of medicine (126; 40.0%). All but 48 employees (15.2%) had been at their institution for more than a year.

A majority of responses included the presentation of some event relevant to the question, reactions to the event, and a conclusion. Researchers noted that, even under granted anonymity, some responses expressed fear of sharing stories, and others often immediately followed negative stories with positive statements.

Researchers found consistency in 6 factors that affect inclusion: the presence of discrimination; a silent witness; interplay between hierarchy, recognition, and civility; effectiveness of leadership and mentors; support for work-life balance; and perceptions of exclusion by inclusion efforts.

The underlying thread among these 6 factors, researchers wrote, “was the need to belong and feel recognized and valued.”

“There is evidence that discrimination manifesting most commonly as unequal expectations and microaggressions for both women and minorities in medical fields leads to social isolation,

disengagement, and burnout not just for those who experience discrimination but for bystanders as well,” researchers wrote.

In reported challenges with inclusion, employees consistently described negative effects on both their job performance and overall wellbeing. They also reported symptoms of stress, anxiety, and a sense of hopelessness, researchers noted.

That said, there was also a lot of reference to systemic cultures that “influenced their interpersonal dynamics and provided specific strategies to improve organizational culture that focused on leadership training and expanding collegial networks.”

What caught the attention of Aysola was the consistencies found in the narratives—regardless of workplace, employee type, and other demographics. She also noted the effort and length of writing put into each narrative—underlying the “appetite for answering the question.”

“Medicine is not immune to what’s going on in the national discourse, the lack of parity in the workforce,” Aysola said. “We need to be talking about this much more than we are, and we need a systematic approach to catching this much better than we have been.”

Improvements to such an approach would be doubly beneficial in the health care workforce. Researchers emphasized that all health care professionals and providers should possess a “working understanding of how unconscious biases may influence daily interactions with colleagues and patients.”

More explicit integration of methods that allow for inclusion and improved work environments needs to be considered in health care, Aysola said.

“It’s a very pivotal time, where we need to look at other industries and come to the conclusion that every perspective and voice needs to be better heard,” Aysola said.

The study, "Perceptions of Factors Associated With Inclusive Work and Learning Environments in Health Care Organizations," was published online in JAMA Open Friday morning.

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