Perceptions of Factors Associated With Inclusive Work and Learning Environments in Health Care Organizations: A Qualitative Narrative Analysis

Abstract

Importance: Diversifying the health care workforce remains a critical goal for health care organizations focused on reducing disparities in care. However, it remains unknown what factors create inclusive health system environments and help organizations retain a diverse workforce. Objective: To understand from members of the health care workforce what factors contribute to inclusive work and learning environments and what can be done to improve inclusion within health care organizations. Design, Setting, and Participants: A qualitative narrative analysis of responses to a weekly email call for narratives within health care organizations sent June 1, 8, 15, and 22, 2016. The email contained an anonymous link to 2 open-ended stimulus questions asking for stories reflecting inclusion or lack thereof within participants' work environments as well as demographic questions. The study took place at 6 hospitals, including a free-standing children's hospital and a Veterans Affairs medical center, 4 health sciences schools (Medicine, Nursing, Dental, and Social Policy and Practice), and outpatient facilities within a university-based health care system in Pennsylvania. There were 315 completed narratives submitted from health care system executives (n = 3), staff (n = 113), academic faculty (n = 97), trainees or students (n = 99), and 3 who declined to specify their positions. Main Outcomes and Measures: Workplace experiences with inclusivity, implications of these experiences, and recommendations to improve inclusion within environments. Results: Of 315 narratives submitted from members of the health care system, in 188 (59.7%) the writer self-identified as female; in 10 (3.2%), as transgender/queer; in 38 (12.1%), as non-Hispanic black; in 152 (48.3%), as non-Christian; in 31 (9.8%), as having a language other than English as their primary language; and in 14 (4.4%), as having a disability. Analysis of the narratives revealed 6 broad factors that affected inclusion within health care organizations: (1) the presence of discrimination; (2) the silent witness; (3) the interplay of hierarchy, recognition, and civility; (4) the effectiveness of organizational leadership and mentors; (5) support for work-life balance; and (6) perceptions of exclusion from inclusion efforts. Challenges with inclusion had negative effects on job performance and well-being, with reports of stress, anxiety, and feelings of hopelessness. Most respondents referenced a systemic culture that influenced their interpersonal dynamics and provided specific strategies to improve organizational culture that focused on leadership training and expanding collegial networks. Conclusions and Relevance: This narrative analysis provides a taxonomy of factors that health care organizations can use to assess inclusion within their learning and work environments as well as strategies to improve inclusion and retain a diverse health care workforce.