Increasing diversity is a complex issue dealing with deep seated beliefs and both implicit and explicit biases. Enhanced diversity will not be accomplished easily and requires time, planning, and a willingness to be uncomfortable. In this chapter, we will explore what qualities and theories of leadership will help an individual steer an organization through the cultural shifts needed to promote and foster diversity within the health care workplace and out into the community. To do this, we will focus on four leadership approaches/theories: Situational Leadership, Leader-Member Exchange Theory, Transformational Leadership, and Authentic Leadership. The discussion will then shift to what actions leadership can take to promote diversity within their work force followed by a discussion on the actions that can be taken to promote diversity and cultural sensitivity in interactions with members of the communities being served.
The demographics of the United States have changed over the past 40-50 years, and this is projected to continue. The number of non-Hispanic, white Americans has been decreasing since the 1980s and is projected to encompass 64.3% of the U.S. population by 2020, a 15.7% decrease (Judy, 1995). With this comes an increase in the percentages of other ethnic or racial populations. By 2020, it is projected that 12.9% of the U.S. population will be African American, 6.5% will be Asian, and 16% will be Hispanic (Judy, 1995). These changes in the overall population will also be reflected in the labor force. By 2020, only 68% of the U.S. labor force is expected to be non-Hispanic white individuals, down from 76% in 1995 (Judy, 1995). It is predicated that by 2020, 14% of the labor force will be Hispanic individuals, 6% Asian, and 11% African Americans (Judy, 1995).
As these demographics have shifted, companies, including health care organizations, have been working to increase the diversity of their work force to match the populations that they serve. Companies are actively recruiting and hiring individuals that have historically been in the minority in terms of identity characteristics such as race, gender, ethnicity, sexuality, religion, and socioeconomic status. The desire to increase diversity stems from the benefits that come along with approaching problems from different perspectives instead of through a single homogeneous lens. For health care organizations, the benefits of diversity extend into the communities in which they serve.
Increasing work place diversity requires an overall shift in an organization’s culture, which is often easier said than done. Historically, the work force has been dominated by Caucasian, middle-to-upper class men. During this time dominated by a single demographic, the multiple levels of culture (artifact, espoused values, and basic assumptions) were established and became part of employees’ work identity. When workers are faced with the challenge of adapting this culture, they may themselves feel threatened and become defensive by what they see as a question of their own personal identity (Osland, 2011). A strong leader willing to work with employees through their complex, personal beliefs is necessary to successfully facilitate a cultural shift.
Organizational leaders play a critical role in establishing and promoting work place culture. Employees look to leaders to set the context in which they will function within an organization. Establishing an environment that reflects the desired values of an organization requires more than just words from leadership; it requires action and the embodiment of these values. If employers espouse certain values but act in ways that directly contradict them, employees will see through the empty words and will look outside of the organization for a company that demonstrates the culture that they desire to participate in. A disingenuous atmosphere can make it difficult for companies to attract and retain talented individuals and becomes especially important when considering work place diversity. We will explore what behaviors leaders can demonstrate and what actions they can take to successfully promote diversity in their organization.
Diversity and Cultural Competence
Financial incentives have been a major driver of increasing diversity in the work place. From a business perspective, companies have recognized that hiring employees with different perspectives and ideas drives innovation and problem-solving within their organizations (Nemeth, 1986). From a health care perspective, diversity in the work force has been shown to result in better healthcare outcomes in minority populations. A literature review done by The U.S. Department of Health and Human Services in 2006 found that minorities and non-English speaking patients received better healthcare when treated by workers of a similar background (HHS, 2006). The evidence reviewed attributed this to patients having a better understanding of health information discussed, increased likelihood of follow-up visits, and better interpersonal relationships with the health care provider (HHS, 2006). This study showed that increased diversity in the healthcare work force resulted in increased access to quality health care and an overall improvement in public health (HHS,2006).
Webster’s Dictionary (2018) defines diversity as “the inclusion of different types of people (such as people of different races or cultures) in a group or organization.” This definition is a good starting point to consider when a company wants to change the culture of its workforce, but what it fails to encompass is that establishing diversity in an environment requires more than just inclusion. It requires cultural respect and competence toward ‘different types of people’.
Cultural competency requires an individual to consider how culture can affect how another person perceives and understands the world around them. In the work place, this involves embracing difference perspectives and ideas and ensuring that deserving individuals are rewarded (either through promotion or some other form of recognition) within the organization to demonstrate that they are not just employed to fill an arbitrary quota.
In a health care setting, cultural competency is best defined as “the knowledge, skills, attitudes, and behaviors required of a practitioner to provide optimal healthcare services to persons from a wide range of cultural and ethnic backgrounds” (Cohen et al., 2002). Cultural competence requires that health care providers can use a completely different approach than they would for someone with a similar cultural background as they themselves have. Demonstrating cultural competence is critical in a healthcare setting, as it can play a role in decreasing health inequity (Betancourt, 2005; Cohen et al., 2002).
Some argue that achieving true diversity requires more than just cultural competence. Competence is often viewed as a set of skills that once learned can be mastered and applied to every situation (Lokko,2016) which is not necessarily the case. Diversity and cultures are dynamic which requires constant education and adaptation of skills, which is why Lokko et al. (2016) recommend the promotion of cultural respect as opposed to cultural competence. Cultural respect requires an individual to accept that there will always be skills to learn and mistakes made. It involves a sense of humility because it is an acknowledgement that one cannot possibly know everything that there is to know about a person’s cultural identity in every given situation.
Promoting diversity, cultural competence, and cultural respect within an organization requires a strong commitment from leadership. In the next section of this chapter, we will discuss how leaders ought to commit to change within themselves to embrace diversity as well as encourage change within their followers/employees.
Leading the Way Toward a More Diverse Work Force
When leaders are driving a cultural change within an organization, it does not solely revolve around changing follower/employee attitudes; it involves self-reflection and personal change. Leaders ought to first identify and understand their own feelings and biases toward diverse populations to understand what they will face when working with their employees (Rowitz, 2013). This introspection will also allow them to assess their leadership style and skills to identify both strengths and weaknesses that will work for and against them during this cultural shift. In this section, we will first discuss what leaders can do as individuals to aid in promoting a diversity culture shift; we will then discuss how different leadership styles can both help and hinder this process.
According to Rowitz (2013), cultural competency, which is necessary for true diversity to thrive, occurs in the following stages: awareness, understanding, and action. One does not just decide that they are going to advocate for diversity and start doing so. They must first come to terms with their own stereotypes and biases, understand cultural values and norms of the groups they intend to interact with, and then act to promote diversity within their target area. This is especially important for individuals in leadership roles. Before they can develop an atmosphere designed to promote diversity within their organization, they need to first understand the obstacles that will be faced when working toward this cultural shift. Leaders ought to honestly address what stereotypes they have toward different groups and consider what implicit biases they may have. According to the Kirwan Institute for the Study of Race and Ethnicity at The Ohio State University website (2015), implicit bias is defined as “the attitudes or stereotypes that affect our understanding, actions, and decisions in an unconscious manner.” This type of bias is not always consistent with how an individual believes that they view those that are different from them.
Biases are shaped by our experiences and influences as we grow and develop in our environments. Because these biases occur on a subconscious level, they require an individual to seek out tools to help identify what groups they may be directed toward. Leaders need to critically evaluate how they think about, speak to, and act toward members of different cultures. Once they gain awareness about their own thoughts, feelings, and interactions, they can begin to educate themselves to overcome their prejudices.
Leaders should not isolate themselves in this quest for understanding, they should reach out to members of minority groups that they wish to engage with in their community or in their work force to gain perspective about the discrimination and challenges that these individuals face daily (Rowitz, 2013). They should learn about culturally appropriate language to promote inclusivity and respect in their environment. Leaders should recognize that this is a lifelong learning process and should seek out and encourage feedback (Rowitz, 2013). Diversity and inclusion are sensitive topics, and missteps will be made. Leaders need to be prepared for conflict and discomfort as they work to understand the perspectives of others; these instances should be approached with empathy, humility, and a willingness to learn.
During this time of self-reflection, leaders should assess their leadership style, along with their strengths and weaknesses, and evaluate how these will influence their goal of promoting diversity both in the workforce and in their community (Myers, 2007; Rowitz, 2013). There are many different leadership theories/styles that have been studied and researched, some involving natural-born leadership traits and some involving skills that can be developed. In this section, we will focus on four of these leadership styles and how they might work for or against an organizational shift toward diversity.
Context for Diversity and Leadership
Promoting Diversity and the Situational Approach to Leadership
The first leadership style that we will evaluate is the Situational Approach to Leadership. This approach is interesting because it does not just consider leader characteristics, it looks at followers, too. Situational leadership involves a leader analyzing the level of follower competence and commitment to the goal, in this case diversifying the work force population, and adjusting their leadership style to match it (Northouse, 2016). Leaders should strive to find a balance between directive behaviors (such as establishing goals and timelines, defining roles, and giving directions) and supportive behaviors (such as asking for input, sharing information about oneself, and listening) based on follower/employee competence and commitment levels (Northouse, 2016).
Situational leadership may be beneficial in an organization that is working to increase diversity and cultural competence either in their work force or in their interactions with the community that they serve due to the overall flexibility of the approach. As followers learn and grow, their competence will improve and this approach will allow leadership to adjust their style to meet the changing needs of their followers.
For example, in a company where employees have a low level of commitment to improving diversity and a low level of competence, particularly cultural competence, a coaching leadership style with high directive behaviors and high supportive behaviors would be required (Northouse, 2016). Leaders would need to set clear goals and expectations regarding the development of cultural competence and inclusion in the work place while also demonstrating the achievement of these goals in their own behaviors. Leaders would also need to be available to listen to employee concerns regarding the changes in company culture and how they may feel threatened by this change. Leaders should also help manage conflicts as they arose and provide praise when goals are met. Within this approach, leaders can adjust their style as employees’ attitudes and competence improved.
This approach does not come without some drawbacks, though. One hurdle associated with taking this approach when working to increase diversity is that it fails to take follower demographics into account when assigning them to a category. It also fails to distinguish between one-on-one leader-follower relationships and leader-organization or leader-group relationships (Northouse, 2016). Leaders may be forced to assign a category to the organization, especially in large health care systems, instead of to individuals resulting in mismatch between leadership styles and follower categories for several individuals. If this occurs, it may affect the strength of support or dissent that a leader faces when working toward this cultural shift.
Promoting Diversity and Leader-Member Exchange Theory
One leadership style that could prove to be detrimental to expanding diversity in the work place is the practice of Leader-Member Exchange (LMX) theory. This theory focuses on the relationships established between a leader and a follower. High quality relationships involve a high level of trust and partnership between individuals and can result in things like low employee turnover, job promotion, and more rapid career advancement (Northouse, 2016). Low quality relationships result in fair treatment of employees but strictly within the confines of their contract.
Employing Leader-Member Exchange theory in the work force can be detrimental to the development of diversity because these high vs low quality, or in-group vs out-group, relationships can be influenced by conscious and/or unconscious biases. In-group relationships may occur more frequently between individuals with similar cultural or ethnic backgrounds, as individuals may find it easier to establish trust with someone to whom they can more easily relate (Tsui,1992). This may prevent minority individuals from achieving the same career levels as equally or even less qualified majority individuals despite their best efforts and qualifications. If this practice is occurring within an organization that is claiming to support diversity, employees will see through the talk, and retention rates of minority individuals will decline. This leadership practice will work against expanding diversity because it appears to be discriminatory (Northouse, 2016). If a leader identifies this practice within their organization, they should address this with transparency and encourage others to expand their in-groups, offering all employees the opportunities to advance through hard work and innovation.
Promoting Diversity and Transformational Leadership
Leaders that utilize a transformational approach may see increased success in promoting diversity and shifting the culture of their organization. With this leadership approach, leaders are working toward increasing the ethics and standards within themselves and their followers (Northouse, 2016). Goals are clearly outlined and leaders demonstrate the morals/values that they want to see promoted within the company. These leaders are often charismatic and able to inspire their followers to change and find their place within the new culture (Northouse, 2016). Transformational leaders not only inspire their followers, they provide support and guidance, which is important during culture shifts.
Transformational leadership lends itself to increasing diversity and inclusion within an organization as this often requires individuals to re-evaluate how they view people who are different, which often means identifying their own prejudices and faults. Having a leader who embodies the change and values while also providing a supportive, judgement-free environment to change and grow allows followers to emulate someone they respect and make mistakes along the path to change. Transformational leaders recognize the need to be lifelong learners which is necessary when dealing with diversity and cultural competency as these concepts are dynamic and not a set of skills that can be singularly mastered.
As mentioned earlier, research concerning transformational leadership has found that individuals exhibiting this form of leadership tend to be charismatic individuals who can easily garner follower support through their confident, clear, and inspiring communication skills (Northouse, 2016). This implies that transformational leaders are born with the traits needed to successfully use this approach and that these are not skills that individuals can learn. If this is indeed the case, a downside to this leadership approach regarding diversity promotion is that it will only be applicable in organizations that have a transformational leader directing the cultural shift in the company. It implies that any attempt at this leadership style by someone not possessing the necessary traits will result in a lack of buy-in by followers. If the research is incorrect and these are traits that can be strengthened and/or learned, this leadership approach would be ideal for promoting diversity, as its ultimate intent is to direct an organization toward values that “reflect a more humane standard of fairness and justice” for all (Northouse, 2016).
Promoting Diversity and Authentic Leadership
The Authentic Leadership approach may have the most potential for widespread promotion of diversity. This approach has not been studied for as long as some of the other leadership styles and different researchers have different perspectives regarding authenticity. In this chapter, we will focus on the developmental perspective of authentic leadership because, at its core, this is something that an individual can learn and develop throughout their life. The fact that it is not defined by the possession of certain inherent traits increases its potential for widespread adoption; people are not excluded from embodying this style based on personality characteristics that they may or may not possess.
Developmental authentic leadership focuses on four distinct components which are enhanced by certain characteristics. The first component is self-awareness or the ability to recognize one’s own strengths and weaknesses (Northouse, 2016). This is a critical component for promoting diversity. As discussed earlier in this section, awareness is the first step toward cultural competency. A leader’s ability to understand where they fall short or excel in terms of cultural perspectives and assumptions will allow them to educate themselves and grow while also allowing them to empathize with the changes that they are asking their followers to make.
The next component is internalized moral perspective which involves allowing one’s own values and beliefs to guide decisions made and actions taken as opposed to being influenced by outside forces (Northouse,2016). This is a very important thing to consider when trying to adopt a new culture that embraces and promotes diversity. A leader will be faced with many challenges during a cultural shift and their vision will be called into question at different points throughout the transition. An authentic leader will listen to others’ perspectives but will ultimately follow their own moral compass toward what they know is right. A strong moral compass is enhanced by a leader’s ability to truly understand their purpose and follow their values that guide them toward the right thing to do (Northouse, 2016). Being self-aware allows an authentic leader to acknowledge that they are not always right and may not always know how best to approach a conflict or challenge to their overall goal.
Leaders must also be able to employ balanced processing, which involves a leader seeking out and actively listening to dissenting views or opinions with an open mind to determine if there is a better way to approach a problem or view a situation (Northouse, 2016). Balanced processing is especially valuable for promoting diversity as leaders ought to be willing to consider perspectives of individuals from different cultural and ethnic backgrounds without bias or prejudice. Doing this will result in leaders garnering trust and respect from their followers which will enhance their commitment to the overall goal of promoting diversity.
Finally, an authentic leader must practice relational transparency; they must be willing to share their honest, authentic selves with their followers (Northouse, 2016). This requires that leaders share their own successes and struggles as they move along the path toward reaching their goal. This helps followers to relate to the leader as they experience similar situations which builds trust. It allows followers to see the leader in action working toward the common goal and not just telling them how they should be doing things or what values they should uphold. Though there is not a lot of data demonstrating organizational outcomes of authentic leadership, the components discussed above clearly demonstrate an approach that lends itself to promoting diversity within organizations and in community partnerships with healthcare organizations.
Leading to Promote Organizational Diversity
Increasing diversity within an organization will not happen without a cultural shift in the work place. Even with structural mechanisms in place to increase diversity, a lack of diversity-embracing culture will undermine these mechanisms and cause employees to seek work elsewhere (Myers, 2007). This shift does not happen overnight and it does not occur without setbacks and opposition. Leadership within the organization needs to be prepared for these challenges, and this can best be done through proper planning and by employing leadership styles/approaches that we discussed earlier in the chapter.
Leaders will need to first be willing to perform a self-assessment to determine their own level of cultural competency and areas of weakness that they should address while guiding their company toward a more diverse culture (Rowitz, 2013). They need to look at whether their own biases result in more frequent promotion of individuals that are like them, whether they are distributing workload equitably among different groups, and whether they are more likely to praise or criticize an employee based on their cultural or ethnic backgrounds (Myers, 2007). Leaders need to be ready to do more than talk about diversity; they need to demonstrate cultural competency in how they treat employees with diverse identities (Rowitz, 2013).
Leaders should also assess the organization to determine where it is falling short in promoting diversity; this allows for proper strategic planning and allocation of resources to improve the work environment and overall employee attitude toward diversity and cultural change (Chin, 2012). Without acknowledging the problems that exist, it becomes very difficult to adequately address them. This can lead to problems with retention of minority workers; if the promotion of diversity is present in speech but not in action (through promotions, mentoring, non-hostile environments), skilled, marginalized employees will seek out other opportunities for employment, even if it results in decreased compensation (Myers, 2007). It is also very valuable for leaders to speak with members of marginalized groups to gain their perspective on the company culture and experiences in the work place. Obtaining and applying feedback will result in the development interventions that are more likely to meet the needs of the diverse population that the company is trying to attract (Rowitz, 2013).
Once leadership has performed a thorough evaluation of the current company culture regarding diversity, they can develop a strategic plan that clearly outlines how they will move forward to increase diversity within the organization. Weech-Maldonado et al. (2018) promotes doing this via a systems approach to improve the likelihood of success. Cultural shifts to promote diversity cannot be accomplished at an organizational or individual level alone; they need to occur at every level of the system. At the management level, cultural competency and diversity promotion need to be incorporated into the management system; adequate resources must be planned for and allocated to sustain any training programs utilized; diversity goals need to be set, communicated, and assessed; and policies, such as anti-bullying and anti-harassment policies, need to be put into place (Chin, 2012; Cordova, 2010; Etowa, 2017; Weech-Maldonado, 2018).
At the human resources level, active and deliberate recruitment and retention of minority/marginalized employees is necessary to increase and sustain diversity within an organization. Cultural competency training should be provided for current and future employees (including at the management and leadership levels), diversity policies should be incorporated into on-boarding materials and advancement training, and managers should receive training on incorporating cultural competency and inclusion into work load allocation, performance goal setting, and promotions (Cordova, 2010; Weech-Maldonado, 2018). Finally, at the individual level, employees should be encouraged to evaluate their own potential biases and how their cultural background affects and shapes these (Weech-Maldonado, 2018).
Leaders should also look for diversity champions at different levels throughout the company; these are the individuals that strongly support the promotion of diversity in the company and are willing to aid leaders in moving the company forward toward its inclusion goals (Chin, 2012; Etowa, 2017). Champions can provide support to coworkers struggling with the culture shift and how they fit into the new system as well as to marginalized coworkers looking for acceptance in the work place.
Leaders should be prepared to face conflict among individuals and should encourage the sharing of different perspectives. By doing this, they can give a voice to marginalized individuals and allow them to identify problems that still need to be addressed within the organization (Etowa, 2017). Encouraging and mediating conflict also maintains open communication where people can feel safe voicing their concerns and frustrations. Making employees feel heard will most likely result in more buy-in to the culture shift.
Strong leadership support is required to successfully steer a culture shift to increase organizational diversity and, to be most effective, this ought to be done at all levels of the company. To increase the likelihood of success, leaders need to carefully assess the current work climate, be deliberate in their diversity promotion planning/goal-setting, solicit input from marginalized groups to ensure their needs are being addressed, and prepare to evaluate and adjust systems as the plan moves forward. In the next section, we will discuss how many of these same principles can be applied in health care organizations to improve care delivered to culturally and ethnically diverse patient populations.
Leading to Address Diversity in Communities Served
In a health care organization, it is important for leaders to address the diverse needs of individuals in the communities being served. Fortunately for leadership, this is often done through improving diversity within the organization. Having a work force that mirrors the community being served can reduce health disparities among minority populations, as it can increase access to care (Lokko, 2016). Providing cross-cultural and cultural sensitivity training to medical providers and staff can also improve community relationships and encourage members to seek out care as needed (Betancourt, 2005; Lokko, 2016). As discussed in the previous section, leaders need to be aware of how they and their organization fall short in addressing the needs of the individuals they serve. Leaders should go out into the community to hear firsthand what services and policies are lacking within their organization that may be perceived by residents as barriers to receiving care (Rowitz, 2013; Lokko 2016).
One area that often needs to be addressed within healthcare is language barriers. Patients that do not speak English as their first language, or at all, require the services of an interpreter and ideally medical literature translated into their native language. This can reduce the likelihood of misinterpretation of medical information and medical errors that may result from this misinterpretation while also demonstrating a respect for cultures other than one’s own (Anderson, 2003).
Leaders should also incorporate diversity and inclusion parameters in organizational quality assessment tools (Betancourt, 2005). Getting feedback from patients and community members regarding how their cultural needs are or are not being met will provide valuable insight regarding where diversity policies may be falling short or excelling. This evaluation will help to avoid continued use of policies that fail to meet community needs so that they can be redesigned or ended, allowing resources to be directed toward programs that are working or toward the development of new programs designed to more effectively address community needs.
We are living in a global community, and the United States is especially unique given its culturally and ethnically diverse population. Organizations, particularly those in the health care sector, need to address and promote diversity to remain relevant in this constantly evolving society. In this chapter, we learned about several different leadership approaches/styles an individual attempting to improve cultural diversity within their organization may employ. This chapter serves to highlight styles that may be particularly beneficial or harmful in situations of organizational cultural shifts. We also discussed key steps for leaders to consider when attempting to improve diversity within their organization and when working with diverse communities; these included steps at both the individual and organizational levels. Promoting diversity is a large undertaking challenged by biases, sensitivities, and an overall fear of change. Strong leadership is necessary to direct an organization through resistance and roadblocks to achieve diversity goals and improve inclusion.