key: cord-0049541-qmc3dooy
authors: Jacobs, Barbara S.; Hatzigeorgiou, Marianthi N.; McCamant, Karen L.
title: Cultivating a Culture:: Implementing Methods to Embrace Diversity and Inclusion
date: 2020-09-04
journal: Nurse Lead
DOI: 10.1016/j.mnl.2020.08.003
sha: c80087ed1e8d21214d11c0a3ff6f3567e5f02918
doc_id: 49541
cord_uid: qmc3dooy

Anne Arundel Medical Center, Annapolis, Maryland, was the recipient of this year's American Organization for Nursing Leadership’s Prism Award, an award which recognizes an organization with advanced diversity efforts. The medical center, part of Luminis Health, added diversity as a core organizational value in 2009, making efforts to provide care to diverse populations and support an inclusive work environment for staff. Through strategic initiatives and community partnerships that target recruiting efforts, the organization has created a culture in which difficult conversations about differences are supported and encouraged. Additionally, targeted hiring initiatives have increased diversity among hospital leadership. Diversity and inclusion initiatives focus on creating a culture that welcomes and supports everyone, regardless race, ethnicity, or sexual orientation/identity.

A nne Arundel Medical Center (AAMC), is a 390bed community hospital located in historic Annapolis, Maryland. Conscious, focused efforts toward increasing diversity and inclusion throughout the system and community have been underway for several years. Prior to receiving this American Organization for Nursing Leadership award, AAMC received the American Hospital Association's Carolyn Boone Lewis Equity of Care Award in 2019. This honor recognizes health systems and hospitals for their efforts to reduce inequities and advance diversity and inclusion. AAMC had previously been named a Top Performer by the Human Rights Campaign (HRC) for advancing diversity in the workplace related to sexual orientation and identity, and later this year, AAMC will receive the lesbian, gay, bisexual, transgender, queer Healthcare Equality Leader designation in the forthcoming Healthcare Equality Index 2020 published by the HRC. The Human Rights Campaign Foundation is the educational arm of America's largest civil rights organization working to achieve equality for lesbian, gay, bisexual, transgender, and queer people. HRC envisions a world where lesbian, gay, bisexual, transgender, queer people are embraced as full members of society at home, at work, and in every community.

The national recognition comes as a direct result of multifaceted efforts outlined by leadership and put in place throughout the organization. Providing culturally sensitive care and supporting a culture of inclusivity embracing and celebrating diversity requires concerted initiatives. At its inception, the targeted work on diversity and inclusion initiated within the nursing department; this quickly was brought to the attention of leadership and made a system-wide effort. To date, nursing continues to play a leadership role.

Though propelled by the nursing department's efforts, diversity was not a new idea with leadership at AAMC. In 2009, both executive and board leadership at AAMC added diversity to its list of organizational values. The organization later launched the Cultural Diversity and Workplace Advocacy Collaborative in 2012, beginning as a nursing-only initiative. After signing the American Hospital Association #123forEquity pledge in 2016, the board of directors created the Health Equity Taskforce as an opportunity to better understand patient and hospital data in identifying possible inequities and prioritize initiatives to create system-wide efforts. To ensure input from frontline clinical staff, registered nurses were included on this multidisciplinary team. Since then, all levels of leadership have demonstrated commitment to diversity and inclusion by supporting many broadly focused and targeted initiatives. In 2018, the hospital created a role solely focused on these efforts and hired its first director of diversity and inclusion.

The incorporation of diversity into the True North metrics (hospital-wide performance metrics on strategic goals) helped strengthen the commitment to increase diversity and inclusion within the workforce and leadership. The True North metric calls AAMC to increase diverse candidates interviewed for all open positions. To ensure implementation of this strategy, posted positions remain open to accept applications until the slate includes at least 1 racially or ethnically diverse candidate.

Additionally, to provide better, more culturally competent care, AAMC collects race, ethnicity, and language data on nearly 100% of patients. Recently, AAMC expanded to include sexual orientation and gender identity data, with such demographics documented on more than 3,000 patients. To ensure ongoing data collection across the system and maintain data integrity, the hospital developed and implemented continuing education and training for all employees.

Leaders at AAMC recognize that diversity extends beyond race to encompass cultural, socioeconomic, and nationality differences, as well as variation in sexual identity and orientation. With that understanding, AAMC employed several initiatives to cultivate a culture to embrace diversity and inclusion. The impact of several of these initiatives is tracked by the Diversity, Equity, and Inclusion Leadership (DEIL) Scorecard, a metric tool developed to drive and monitor improvements.

In order to disseminate the information collected as well as identified inequities, the hospital developed a Health Equity Report to connect patient demographic data to outcomes and report to leaders and staff. Data extraction for the report led to the reprioritization of several efforts already underway to address health outcome inequities and create effective, long-lasting strategies to reduce them. Clinical champions for each identified health disparity were responsible for the development of action plans to ensure targeted improvements. Elements of these plans include education, peer-to-peer data sharing, collaborative protocol design, and evaluation of outcome data.

To further encourage transparency and conversation, AAMC became the first hospital in the United States to support a chapter of the national organization Coming to the Table (CTTT) . Founded in 2006 as a program of Eastern Mennonite University in Harrison, Virginia, CTTT focused on providing leadership, resources, and a supportive environment for all who wish to acknowledge and heal the wounds from racism rooted in the United States' history of slavery. The CTTT chapter at AAMC, started in 2017, has expanded that vision to include creating a culture that values all types of diversity and implicit bias, not only related to the African-American experience. Monthly meetings are held during work hours to provide the opportunity for dialogue among staff in all roles and levels. Sessions usually begin with a brief presentation, though the primary focus is on the sharing of stories among the participants. Typically, 20 to 30 staff members attend the sessions; however, following the racial unrest that occurred in the spring of 2020, several hundred staff have consistently participated in CTTT virtual meetings.

In order to fully enculturate diversity and inclusion as an organizational value, AAMC embraced a nontraditional approach toward workforce education. Over the past 2 years, the DEIL Council has sponsored an interactive theater approach to engage leaders and staff in open dialogue about varying cultures to help them learn to recognize and mitigate the impact of unconscious bias. The program utilizes scenes drawn from real hospital employee and patient experiences to illustrate broad cultural perspectives on incidents and issues. During each sketch, reflective moments and facilitated self-assessment opportunities enable participants to achieve the following learning objectives, which are to:

Bring awareness to unconscious bias, provide tools and techniques for mitigating unconscious bias and reducing negative outcomes from bias Improve cultural competence and sensitivity Strengthen the ability to engage in cultural conversations as a service provider Attain knowledge, skills, and abilities to interrupt the presence of bias in the workplace In 2018, about 2200 of the roughly 4800 leaders and staff attended these interactive diversity theater educational sessions and the feedback was overwhelmingly positive.

Other efforts by the DEIL Council led to the formation of several business resource groups (BRGs) that help leaders across the organization have a more inclusive decision-making model for policy and procedure development by including diverse perspectives. Although specific tactics may vary, the broad objectives of all of these inclusion groups are to:

Ensure equity in opportunity Increase workforce diversity Enhance workplace culture to foster inclusion Eliminate disparity and barriers to culturally customized care Increase supplier diversity and minority-owned business enterprise participation Achieve an inclusive employer of choice and diverse leader in health care

To improve cultural competency, the lesbian, gay, bisexual, transgender, queer, intersex, asexual/allied BRG has implemented a gender identity training module through the online learning management system. BRGs also help increase leadership diversity; the African-American BRG developed a professional mentoring program to encourage success and growth for persons of color within the organization.

In addition to its incorporation into the True North metrics, several initiatives aid in increasing workplace diversity. Recruiting practices were analyzed and redesigned to explore prioritizing and incentivizing student placement from programs supporting diverse student populations, such as historically black colleges and universities. Over the past year, nurse recruiters have cultivated relationships with Morgan, Coppin, and Bowie State Colleges in Maryland, as well as Howard University in Washington, DC. In addition to participating in job fairs at those institutions, AAMC nurse recruiters regularly meet with academic leadership to offer resources for success, including resume writing workshops and interview preparation sessions.

AAMC's work on inclusivity in the workplace and clinical practice environment also includes outreach to the National Association of Hispanic Nurses. In 2019, AAMC nurse recruiters attended the annual National Association of Hispanic Nurses conference in Reno, Nevada, to network and discuss employment opportunities. AAMC nurse recruiters also participate in the annual Hispanic Health Festival in Severn, Maryland, and lead an outreach session at The Center of Help in Annapolis during Hispanic Heritage Month. The recruiters provide dinner and host presentations by Spanish-speaking employees who describe their experiences working at the hospital. Additional resources are provided in Spanish, including information about completing employment applications and 1-on-1 coaching sessions.

Anne Arundel Medical Center has increased the collection, stratification, and use of race, ethnicity, and language data to improve quality and safety by implementing procedures that ensure thorough and accurate data collection. Through extensive education, the hospital has equipped staff with the confidence and cultural fluency to ask patients the questions necessary for complete data collection.

Ongoing system-wide action plans are continuously evaluated by the medical center board for effectiveness in improving cultural competency and diversity efforts. The AAMC Pulse Survey of Employee Engagement now includes a diversity, equity, and inclusion question. In its initial poll, the hospital ranked 4.23 of 5 in how effectively employees think leaders promote and support diversity, equity and inclusion. Data from this survey led to additional training opportunities for staff and providers on how to engage with patients and families when discussing issues of diversity, equity and inclusion. Empowering staff with the skills to form a more authentic connection with a diverse patient population has improved the patient experience.

In October of 2017, AAMC implemented the DEIL Scorecard as a metric tool to demonstrate workforce diversity efforts. Goals were set by the DEIL Council and address applicants, candidates, and existing workforce. Since implementation, leadership diversity has increased from 14% to 21%, full-time new hires are currently 57% diverse, and there is an overall 37% system-wide diversity. Diverse applicants make up 61% of the applicant pool, and selected candidates are about 56% diverse. The DEIL Scorecard has revealed an 8% increase in workforce diversity and 10% increase in new hire diversity since its implementation, which was coupled with additional initiatives. The True North dashboard's definition of leadership (in the diversity category) was expanded to include the positions supervisor and above, and is currently exceeding the goal that 75% of open leadership positions have at least 1 diverse finalist candidate. The DEIL Council tracks these metrics to see that AAMC is making continuous improvement in targets and goals.

As the great American poet and civil rights activist Maya Angelou said, "Do the best you can until you know better. Then when you know better, do better." Creating a culture in which diversity is valued and people feel included regardless of race, ethnicity, sexual orientation, or identity remains challenging for hospitals. Board and executive leadership commitment to providing educational resources and support for targeted initiatives throughout all levels is imperative to drive workforce changes that improve patient experience and reduce health disparities.

AAMC remains committed to advancing diversity and inclusion in all aspects services and operations. In the wake of the racially divisive events that occurred during the spring of 2020 and against the backdrop of the coronavirus disease-19 pandemic, AAMC offered a variety of activities to promote healing and create safe space. These included a virtual faith-based service that was attended by more than 300 people; a "White Coats for Black Lives" demonstration across all 3 health system campuses; additional sessions of CTTT to increase opportunities for discussions; and other muchneeded leadership discussions about how to improve racial justice and equity throughout our health system and communities. The Health Equity Task Force has been relaunched as the Health Equity and Anti-Racism Task Force, bringing together a diverse group of stakeholders from across the health system, its public health partners, and community groups. This team will put into motion a new and lasting plan to guide the changes necessary to become a more equitable and just health system.

Professional Nursing Practice and Magnet. She can be reached at kmccamant@aahs.org. All authors are employed at AAMC, Annapolis, Maryland. 1541-4612/2020/$ See front matter Copyright 2020 by