Positive patient outcomes are dependent on the provision of culturally competent care. Providers must consider the diverse beliefs, attitudes, values, and behaviors governing personal health care choices. This article offers an inquiry into challenges to consider with our modern population, conscientious practice adjustments needed to accommodate inclusivity, and the benefits of equitable delivery of care.

“Of all the forms of inequality, injustice in health care is the most shocking and inhumane.”

Dr. Martin Luther King Jr., at the 2nd National Convention of the Medical Committee for Human Rights, March 25, 1966

The subtleties of language are timeless; however, as the narrative on health care delivery continues to morph, organizations and individual providers find themselves wanting to be more accountable. Systemically, conversations include ongoing assessment and commitment to change when addressing social disparities and the health care needs of marginalized communities. This dialog has provided an opportunity for delivering effective, quality care to patients with varied beliefs, attitudes, and values – termed cultural competence (asamonitor.pub/3iZCx4k).

To further our understanding of and obligation to the principles of diversity, equity, and inclusion (DEI), we must formalize each term’s significance. Chosen definitions are vital in guiding communication as our profession evolves and creates safe, respectful, and welcoming environments for our patients.

Key terms, as defined by the American Psychological Association (asamonitor.pub/3FoKO9f):

  • Diverse: involving the representation or composition of various social identity groups in a workgroup, organization, or community. The focus is on social identities that correspond to societal differences in power and privilege, and thus to the marginalization of some groups based on specific attributes – for example, race, ethnicity, culture, gender, gender identity and expression, sexual orientation, socioeconomic status, religion, spirituality, disability, age, national origin, immigration status, and language. There is a recognition that people have multiple identities and that social identities are intersectional and have different salience and impact in different contexts.
  • Equity: providing resources according to the need to help diverse populations achieve their highest state of health and other functioning. Equity is an ongoing process of assessing needs, correcting historical inequities, and creating conditions for optimal outcomes by members of all social identity groups.
  • Inclusion: an environment that offers affirmation, celebration, and appreciation of different approaches, styles, perspectives, and experiences, thus allowing all individuals to bring in their whole selves (and all their identities) and to demonstrate their strengths and capacity.

Integration of these terms as a unit shows each is necessary for the other’s success. Enhanced awareness of the intricacies surrounding each concept also exposes the value of providing culturally competent care within the framework of DEI. The most critical being improved patient-centered outcomes and resultant total population health (J Surg Educ 2021;78:1058-65). Prioritizing DEI supports provider-patient engagement, increasing communication, decision making, and adherence to treatment plans (Int J Clin Pract 2013;67:394-6). However, despite a moral imperative to improve the quality of care provided, there will always be challenges to implementing DEI strategies.

Promoting and implementing cultural competence can present barriers, challenges, and impediments at multiple levels. Recognizing these limitations leads to the possibility of narrowing disparities and improving access for patients with diverse racial and ethnic identities. There is evidence to suggest people of color experience greater incidence and more severe disease burden compared to Whites in the United States (Int Neurourol J 2020;24:180-1). Gaps in health equity should demonstrate to stakeholders that DEI initiatives are more than a luxury, legal necessity, or accreditation/regulatory requirement (Human Resource Management Research 2018;8:45-8; Anesth Analg 2022;134:1166-74). The health care discrepancies among social groups point to inequalities spanning generations, but change can begin with the individual.

“We don’t see things as they are, we see them as we are.”

Anais Nin

Providers may unconsciously play a role in perpetuating health disparities. Evolution has gifted us the ability to increase efficiency by identifying patterns to promote generalizations; regardless, these psychological processes must be examined to avoid prejudice (Group Process Intergroup Relat 2016;19:528-42). The Joint Commission defines implicit bias as “the attitudes or stereotypes affecting our understanding, actions, and decisions in an unconscious manner” (asamonitor.pub/3j2nM0l). Quantifying how much it affects daily interactions is difficult, but the importance of identifying one’s own implicit bias cannot be overstated. Mindfulness in the consideration of unconscious bias requires an intentional multidimensional approach and often aligns with initiatives designed to increase DEI (J Infect Dis 2019;220:S62-73). Although the responsibility of mitigating bias begins with an individual’s curiosity and self-reflection, their journey often needs an environment of support and guidance from the organization.

A major obstacle to effectively maximizing DEI within an organization is being unaware that diversity and inclusion are lacking. Agents of change should expect to encounter both overt and innocuous resistance, but it is difficult to argue against data. In a 2020 report examining how racism affects medicine, researchers found Black Americans make up 13% of the U.S population but represent less than 7% of medical students and less than 3% of practicing physicians (asamonitor.pub/3FqYmRI). Additionally, Lyons et al. established that more women than men in medicine continue to experience negative comments about their gender (36% to 4%), gender discrimination (65% to 10%), and sexual harassment (30% vs. 6%) (Am J Med Sci 2021;361:151-68). It is beyond the scope of this article to present the disparities within each attribute of diversity; however, the authors feel highlighting a sample of figures makes a powerful statement: there is still work to be done. Health care organizations committed to DEI and fostering culturally competent care must be willing to act. Leadership must cultivate mentorship, humility, and change through targeted training. Also important is exploration of inclusive strategies leading to better hiring practices and increased retention of diverse employees (Advances in Clinical Medical Research and Healthcare Delivery 2021;1).

The importance of progressing DEI has also been identified at the institutional level. The World Health Organization stated, “health equity is achieved when everyone can attain their full potential for health and well-being” (asamonitor.pub/3HqXQG). With support from the American Medical Association (AMA), the Liaison Committee on Medical Education (LCME) Standards on Diversity mandate engagement in efforts to attract/retain diverse students and develop programs to broaden diversity among applicants (asamonitor.pub/3Hs84pG). Mirroring these efforts, nursing has also evaluated its role in promoting DEI in health care. Published in 2018, the American Nurses Association (ANA) position statement regarding discrimination includes the recommendation that “nurses in all environments and at all levels must embrace the concepts of justice and caring, diversity and inclusiveness, and civility and mutual respect as guiding principles within the provision of health care” (Online J Issues Nurs 2019;24). The significance of these statements demonstrates that both a global and national response is necessary to set objectives and measure progress when combatting health inequalities.

Numerous strategies have been proposed for promoting DEI initiatives in health care. To optimize efforts, objectives must be tangible and sustainable for achieving buy-in. Progress begins with the first step; Stanford promotes the following four (J Natl Med Assoc 2020;112:247-9):

  1. Ensure DEI is ingrained within the culture by making it integral to the mission and outputs within the organization
  2. Integrate stakeholders from all levels of the organization and ensure all groups are included in discussions to enact and maintain DEI efforts
  3. Share successes and failures with similar organizations, as it is this discourse that will allow the organization to reflect on strengths and weaknesses in previous DEI strategies
  4. Start young – engage with local communities and schools to ensure persons from underrepresented groups get early exposure to fields in medicine.

This is not an all-encompassing list; however, implementation of the above DEI framework would move the needle closer to cultural competence within your organization. Each step charges your providers with the mission of DEI and allows for delivery of culturally competent care.

Incorporating DEI into both culture and strategy has measurable benefits for our patients, providers, and health care organizations. As previously discussed, prioritizing DEI leads to increased patient trust/communication, adherence to care plans, and reduction of health care discrepancies. For providers, increasing diversity often leads to enhanced familiarity, more comfortable rapport, and boosted creativity when caring for a diverse patient population (asamonitor.pub/3UQkXwD). Finally, organizationally, successful DEI integration breeds improved business outcomes by cultivating employee engagement, assists with retention, and ultimately leads to revenue growth (asamonitor.pub/3Hwuy98).