Group Leadership to Advance a Sense of Belonging while weathering the effects of Diversity Disenfranchisement Distress in Medicine: An interprofessional paradigm
Ronn Johnson, Ph.D., ABPP
Creighton University School of Medicine
&
Francis Kaklauskas, Psy.D
Naropa & Saybrook University
Abstract
The American Association of Medical Colleges (AAMC) represents groups of professionals who share an aspired objective of advancing desirable patient clinical outcomes. The objective is especially relevant to responding to cross-generational disparities documented in under resourced ethnoracial populations. From a psychological or human safety perspective, adherence levels in under-resourced patients are also influenced by health-related anxiety, entrenched cross-cultural mistrust of the system, and negative provider encounters that occur during their transition in care journey. At a minimum, group leaders must recognize an unmistakable nexus between the success of healthcare service delivery, diverse patient outcomes, and the accurate assessment of the above distressing human factors. This paper examines Diversity Disenfranchisement Distress. The article concludes by offering recommendations for group leaders working to facilitate a sense of belonging in various academic medicine and healthcare organizations.
Positive healthcare cultures demonstrate clear correlations to job satisfaction, retention, role performance, and patient outcomes (Dominik & Lang, 2021; Johnson & Johannson, 2020; Wei et al., 2020; Weller et al., 2014). However, clinical teams are often composed of individuals with dispositions, identities, experiences, and cultural values that differ significantly from those they serve. While there has been an increased call for responsive interprofessional healthcare teams to have a spectrum of cultural, ethnoracial, and identity differences within these clinical service groups, this envisioned diversity outcome remains unachieved (Togioka et al., 2024). One concern is that the inadequate cross-cultural responsiveness of the interprofessional teams is expected to aggravate preexisting medical mistrust issues often found in diverse patient populations. Similarly, these same interprofessional cross-cultural barriers can undermine a sense of belonging. As a result, clinically relevant circumstances emerge that erode team functioning or facilitate preventable problems with patient adherence.
This article examines some history and recent research related to these unwanted situations. Ultimately, the authors offer pragmatic suggestions for interprofessional healthcare leadership roles. The terms “group leader” and “leader” in this piece refer to various roles, from upper healthcare management to first-line staff with direct contact with patients, families, and diverse communities. The interprofessional ideas presented may be particularly relevant for organizational leaders, clinic administrators, providers, and group psychotherapists. Scholarship and science have increasingly specialized and siloed (Nilsen et al., 2022). We hope to bring an integrative, expansive, and pragmatic perspective in reviewing interdisciplinary literature, research, undocumented stories, and personal clinical experiences.
Organizations such as the American Psychological Association (APA) and the American Association of Medical Colleges (AAMC) strive to represent professionals who aspire to advance desirable patient clinical outcomes, especially with under-resourced, ethnoracial, and rural populations. To achieve this objective, clinicians, administrators, and organizations must move beyond focusing on techniques and technologies and consider the climate of the clinical work cultures central to reaching team-based organizational outcomes with diverse patients (Stanford, 2020). The contours of diverse, non-dominant, under-resourced, ethnoracial cultures are complex, relationship-oriented, multifaceted, and defy easy categorization or interpretation (Borkowski & Meese, 2020). Achieving preferred clinical outcome metrics across healthcare services, including group psychotherapy, depends on skillful and responsive navigation of these cultures. Some of the desired clinical outcome goals stem from increasing collaboration, mutual respect, motivation, trustworthy providers, and the use of evidence-based culturally responsive modalities of treatment (Gonzales et al., 2023; Bruno et al., 2023; Edmonds et al., 2023; Kaklauskas & Nettles, 2019).
A bi-directional interaction appears between the patient’s culture and the healthcare system. While providers and patients prefer positive outcomes, under-resourced patients may need more engagement with healthcare systems. These diverse patients can balk at adherence to care protocols because of medical mistrust, lack of personal support, poor cultural attunement, and negative provider encounters with their communities (Sarofim, 2024; Kumar, 2024; Kutalek & Wiener, 2014). At a minimum, leaders must move beyond just protocols and techniques to recognize an unmistakable nexus between the success of healthcare service delivery and the accurate assessment of patient-related human, relational, and cultural factors. The targeted clinical outcomes for under-resourced and diverse patients are achieved through collaborative groups of culturally competent interprofessional teams operating within healthcare settings and organizations (Boland et al., 2016; Hepp et al., 2015; Gowda et al., 2019).
A culturally responsive group leader
A culturally responsive leader is a key player in addressing health disparities. Such a leader remains open and empathically attuned to the lived experiences of under-resourced patient groups. Their professional judgments and behaviors exude cultural respect, transparency, and building diverse patient trust through appropriate cross-cultural dialogues. These leaders are dedicated to becoming informed and bold, seeking progress that works to break the cycle of cross-generational health disparity numbers.
Over 60 million Americans reside primarily in rural, Tribal, and geographically isolated communities, leading to significant health disparities compared to those living in urban areas. Rural Americans have higher rates of heart disease, stroke, cancer, mental health issues, suicide risks, chronic lung disease, and other physical and mental health challenges compared to their urban counterparts (McGrath et al., 2023; Nuako et al., 2022; Hagiwara et al., 2023; Pitter & Khoury, 2023; Lister & Joudrey, 2023; Morales et al., 2020; Richman et al., 2016; Weeks, 2023). The jarring disparities coincide with traumatizing experiences sustained by natural groups throughout life, including their experiences within organizations and healthcare systems (Mahajan et al., 2021). Health disparity numbers represent the lives of real people. Predictably, the lived group experiences of diverse patients are not markedly different from the shared oral histories passed down by their ancestors. Group survivors share these histories and stories as part of their cultural fabric. Their accumulated cross-generational memories are recalled as aversive and toxic (Isola, 2024). They reflexively bristle at any organized efforts to change, deny, or reframe the factual details of their traumatic histories.
Natural oppositional responses are also seen whenever they are denied unfettered access to resources designed to assuage the looming disadvantages stemming from racially motivated historical trauma, including healthcare. The situation is tragic from an academic medicine and healthcare organizational work culture perspective. Collectively, the large swath of their histories forms a psychologically taxing form of Diversity Disenfranchisement Distress (Johnson, 2024; Allwood et al., 2021; Williams, 2018; Pearson, 2015). Diversity Disenfranchisement Distress results from induced deficiencies, denied access, destructive actions, loss of educational opportunities, poorer quality medical care, anti-DEI legislation, and limited opportunities for the pursuit of happiness. These circumstances and other disadvantaging acts result in cross-generational disparities attributed to willful misconduct targeting federally defined ethnoracial groups and rural communities (Johnson, 2024).
Clinically, Diversity Disenfranchisement Distress proceeds seamlessly through the recurring traumatic consequences of violence-inducing viewpoints and other acts of intimidation disproportionately aimed at historically marginalized groups (Johnson, 2024). Exposure to these circumstances across centuries has a chronic weathering effect on biopsychosocial functioning. In this case, the accumulative recurrence of stress, discrimination, mistreatment, and adverse social determinants of health fuel a “weathering” effect on historically marginalized patient populations (Geronimus, 1992; Geronimus et al., 2006; McKenna & Brennan, 2024). As a result, millions of people over generations have been excluded from accessing the benefits of achieving their aspired life pursuits and experienced the systematic removal of requisite support resources (Jones & Williams, 2018).
Historically, the history of the Freedmen’s Bureau, approved by Congress in 1865, is a glaring illustration demonstrating the denial of support functions as a symptom of diversity disenfranchisement. For example, predictably, following the Civil War, the weathering effects of being enslaved for centuries meant they were without education, businesses, healthcare, or comparative legal protections needed for their newly acquired freed status (Chyn et al., 2024; Valentin Jr., 2021; Geronimus, 1992; Geronimus et al., 2006). Medically, there was a smallpox outbreak following the war among enslaved people, and countless others went with unmet health needs.
The Freedmen’s Bureau aimed to protect fundamental rights and offered basic needs support to formerly enslaved individuals. Following the war, some support was extended to help establish Black educational institutions from elementary to college. In addition, over 40 “Freedmen’s hospitals” provided care for conditions as a direct consequence of slavery, as well as a high of fourteen Black medical schools. Unfortunately, the Freedmen’s Bureau was defunded in 1872, reducing healthcare and educational opportunities. Many programs, including medical schools, could sustain these efforts for decades. However, that number was significantly reduced after the release of the Flexner Report of 1910 (Laws, 2021; Dent et al., 2021). It was a racially tinged document extremely critical of Black medical colleges. The author of the report felt the only role of Black physicians was to keep Black patients from contaminating the white community. The defunding of the Bureau and the Flexner Report parallel current sentiments in anti-DEI legislation in a few states. A quote from Shakespeare’s “The Tempest” is fitting for comparison: “What is past is prologue” concerning healthcare for historically under-resourced populations.
Everyone has a fundamental right to a reasonable opportunity for good health. From a health perspective, diversity disenfranchisement means groups are systematically denied access to care and exposed to actions designed to prevent good health based on an individual group status (Johnson, 2024; Nuako et al., 2022; Vargas et al., 2020; Nong et al., 2020; McCrae, 2019). Some examples of disenfranchisement are observed in cross-generational healthcare disparities, weak evidence of institutions reversing these disparities/underrepresentation, and growing pockets of federal and state-sponsored anti-DEIB legislation. Collectively, these factors reflect a confirmed intrinsic insensitivity to the plight of marginalized groups and function as the weaponized tools of diversity disenfranchisement.
The history of this country is littered with incontrovertible proof of terrorizing incidents of diversity disenfranchisement involving land grabs, criminal injustice, and similar wrongs in the field of medicine. It reflects the lived experience that is so pervasive it becomes like “Yada, Yada, Yada,” a phrase Merriam-Webster defines as “often used interjectionally, especially in recounting words regarded as too dull or predictable to be worth repeating.” For some, the telling and retelling of ethnoracial health disparities sensitivities are disappointingly dulled due to their consequential pervasiveness. For others, the “Yada Yada” sounds like blaming, discounting, and shaming speak that fuels a form of diversity correction-related fatigue or indifference.
Organizational administrators and group leaders often serve as the invisible glue in promoting a preferred work culture. Given this reality, culturally responsive, influential leaders must rigorously assess psychological safety within historically marginalized groups (Bemak & Chung, 2020; Platt, 2017). This is achieved by probing the underlying assumptions, such as positive intent (Tulshyan, 2024; Ely & Thomas, 2020). Initially, unmistakable work climate indicators are further weakened by feeble and clumsy efforts ostensibly aimed at countering the logical consequences of a negative sense of belonging (Draper-Rodi et al., 2024; Chan et al., 2021; Dover et al., 2020; Wilton et al., 2020).
Data from the AAMC and APA reveal a persistent underrepresentation of ethnoracial physicians and psychologists across centuries (Arredondo et al., 2023; Hanlon, 2022). These documented workforce shortages manifest in diverse patients and are echoed in healthcare providers reporting dissatisfaction due to a lack of belonging (Moore et al., 2023; Lu et al., 2021; Moore et al., 2021; Zerehi, 2006).
Enhancing a sense of belonging in organizational and healthcare settings is critical for organizational leaders. This group intervention process involves reducing diversity disenfranchisement, curtailing diversity-related fatigue, increasing diversity encounter resistance, and half measures (Iyer et al., 2022; Brenman, 2021; Mattes & Lang, 2021). Just as belonging holds intrinsic value in many cultures and subcultures of all types, it is similarly crucial in academic medicine, psychotherapy, and healthcare settings. A sense of belonging fosters enthusiasm, productivity, creative problem-solving, meaningful cross-cultural relational bonds, retention, and, in numerous investigations, improved patient care (Silver et al., 2024; McCluney et al., 2021; Dominik & Lang, 2021; Wei et al., 2020; Weller et al., 2014). Best practices for leaders outlined above involve adaptability in global efforts to mitigate diversity disenfranchisement. Failure to do so can lead to ambivalence, decreased effort, poor attention to detail, more significant disenfranchisement, diversity correction-related fatigue, and reduced desired outcomes across all stakeholders.
In practice, tackling diversity disenfranchisement distress requires increased self-scrutiny, reflection, openness to criticism, a willingness to embrace change, even if it initially causes discomfort and confusion. It is a myth to assume positive intentions are enough to assuage the medical mistrust that took decades to harden with recurring micro and macroaggressions. Still, there are proactive steps essential for steering healthcare systems towards inclusivity and effectiveness for all. Drawing from the research and theories outlined above, our own lived experiences as authors, and the narratives shared with us by friends, family, medical students, residents and patients, there are at least a dozen culturally responsive leadership strategies worth considering as interventions. These strategies aim to reshape everyday cultural norms in units, provider practices, and institutional policies that may undermine a sense of belonging.
1. Group leaders can critically examine their own experiences of belonging, norms, values, and behaviors in the groups based on their life experiences, which can point to barriers to overcoming bias, judgments, and fear of differences. Seeking 360-degree feedback from diverse colleagues and others would be instructive.
2. Group leaders can define, explain, and explore with others what a sense of belonging is and why it is essential.
3. The group leader assesses and then conveys a cogent understanding of potential dysfunctional systematic behaviors and welcomes discussion of new ways of working collaboratively on organizational tasks.
4. Group leaders seek support, consultation, and guidance and attempt to remain hopeful even during times of stagnation, slow progress, rising resistance, or hostility.
5. Assess the work cultural benefits from the effects of a sense of belonging, which are measurable on both the system and individual levels.
6. Group leaders give form and meaning to clinical environments, providing answers, and discussing what is moral, valuable, accurate, and practical. Culture coordinates people’s identities and interactions across institutions, organizations, practice settings, group policies, clinical practices, and norms understood as existential necessities.
7. Promote the sustainability and benefits of the aspired culture and the potential unsustainability of many aspects of modern life that breed burnout, competition, destructive practices, or unwanted group dynamics.
8. Make explicit any implicit norms, defaults, and assumptions. Place these concerns in the spotlight as evidence of rapid and dramatic change that may be required.
9. Anticipate subgroups of skepticism and resistance and present the understanding that belonging is not an immediate shift but a process that requires strategic patience.
10. Convey that no academic medicine or healthcare culture is without biases that affect a sense of belonging.
11. Everyone (including diverse patients) can shape the culture for good or bad. The embedded healthcare culture is a nexus of diverse people, recurring dysfunctional beliefs/dispositions, and unwanted behaviors.
12. Changing the culture requires self-reflection and motivation to engage others historically excluded or marginalized. It is better to try imperfectly than wait for a better moment or perfection.
The persistent challenges associated with achieving a sense of belonging are prevalent and debilitating, and they are reported as chronic weathering conditions experienced by historically under-resourced groups (Tulshyan, 2024; Yemane et al., 2023). Addressing these intractable challenges involves advancing a sense of belonging, which necessitates change at the individual and organizational levels. This article does not critique previous well-intentioned initiatives to reduce recurring Diversity Disenfranchisement Distress. Instead, akin to the past Jim Crow Era, the approach here acknowledges predictable ethnoracially-motivated efforts that undermine a sense of belonging. The goal remains the same as in previous generations: further reducing cross-generational disparities in medicine and organizations.
The author’s perspective articulates a vision for assessing and implementing group-based interventions for Diversity Disenfranchisement Distress. This effort includes using evidence-based interprofessional strategies through which group leaders can effect change at the organizational level. By default, this translates into nurturing a work climate consistent with the institution’s mission and values that charge those in the organizational family to enact cross-culturally diverse initiatives. Here, group leaders mobilize to advance a sense of belonging by aligning healthcare and organizational efforts with their stated institutional values (Dominik & Lang, 2021; Dover et al., 2020; Pearson, 2015).
Leadership and a functioning diverse work culture of belonging are inextricably intertwined. Leaders can be a stable and consistent common factor underlying culturally responsive interventions that address Diversity Disenfranchisement Distress. From a culturally responsive practice standpoint, positive changes begin when organizations or healthcare settings authentically embrace their mission and values statements. Diversity, inclusion, and belonging must be more than mere rhetoric or superficial gestures but enduring, courageous actions that propel the moral arc higher toward a meaningful perception of fairness as assessed by historically marginalized groups.
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