5
Transforming the Institutional Climate to Enhance Diversity in Health Professions

The intervention strategies to increase diversity in health professions described in previous chapters all focus on improving the yield of qualified underrepresented minority (URM) students matriculating to health professions training programs. Such strategies address potential institutional and policy-level “barriers” (e.g., financial constraints, admissions practices that disadvantage URM students), as well as relatively underutilized opportunities to create institutional standards to enhance diversity (e.g., accreditation standards).

Equally important to these efforts, however, is the need to assess and improve, where necessary, the institutional climate for diversity. This includes strategies that encourage the introduction of diverse viewpoints in classroom pedagogy, attract and support URM students and faculty, and transform institutions and institutional environments to support diversity-related goals. This chapter will explore such strategies. The chapter begins by providing a framework for understanding how the institutional climate influences diversity efforts and how diversity is linked to the educational mission of health professions training institutions. Second, the chapter reviews literature that assesses the impact of racial and ethnic diversity in educational settings on student and institutional outcomes. Specific strategies to transform the institutional climate for diversity are then discussed, followed by the committee’s recommendations for change.

Throughout this discussion, the committee emphasizes several conditions and characteristics of institutional change processes that must be



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In The Nation’s Compelling Interest: Ensuring Diversity in the Health-Care Workforce 5 Transforming the Institutional Climate to Enhance Diversity in Health Professions The intervention strategies to increase diversity in health professions described in previous chapters all focus on improving the yield of qualified underrepresented minority (URM) students matriculating to health professions training programs. Such strategies address potential institutional and policy-level “barriers” (e.g., financial constraints, admissions practices that disadvantage URM students), as well as relatively underutilized opportunities to create institutional standards to enhance diversity (e.g., accreditation standards). Equally important to these efforts, however, is the need to assess and improve, where necessary, the institutional climate for diversity. This includes strategies that encourage the introduction of diverse viewpoints in classroom pedagogy, attract and support URM students and faculty, and transform institutions and institutional environments to support diversity-related goals. This chapter will explore such strategies. The chapter begins by providing a framework for understanding how the institutional climate influences diversity efforts and how diversity is linked to the educational mission of health professions training institutions. Second, the chapter reviews literature that assesses the impact of racial and ethnic diversity in educational settings on student and institutional outcomes. Specific strategies to transform the institutional climate for diversity are then discussed, followed by the committee’s recommendations for change. Throughout this discussion, the committee emphasizes several conditions and characteristics of institutional change processes that must be

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In The Nation’s Compelling Interest: Ensuring Diversity in the Health-Care Workforce present to ensure the success of efforts to enhance the institutional climate for diversity. These include: The need for “holistic” institutional change. Evidence suggests that efforts to enhance diversity require comprehensive, systematic changes in the ways that institutions value and respond to diversity. By themselves, “added-on” diversity programs (e.g., sensitivity training, cultural programs, and workshops) are unlikely to affect meaningful change absent systematic, integrated diversity efforts. The need for strong institutional leadership. Institutional leaders—including university presidents, deans, governance bodies, department chairs, and other administrators—must clearly articulate the importance of diversity for the institutional mission. In addition, institutional leaders must establish clear expectations for all students, faculty, and staff regarding diversity goals and the roles all members of the campus community must adopt to attain these goals. The need for a long-term perspective. Academic institutions are slow to change. In addition, the history of diversity efforts in higher education suggests that improvements are often modest and ebb and flow with changing policy contexts, social attitudes, and resource constraints. A long-term perspective is needed to maintain the institutional commitment to diversity and realize gains over time. The need for adequate resources. In the current fiscal climate, almost all academic institutions are facing tight budgets and limited resources. Institutional diversity efforts, however, cannot be developed and implemented without adequate resources to invest in programming, training, support services, and other tools that are an important aspect of a comprehensive diversity plan. The need for planning and evaluation. Institutions should develop long-range diversity plans and regularly evaluate the effectiveness of diversity efforts, with an eye toward modifying the plan where necessary. Support for the importance of these conditions for diversity efforts is summarized in this chapter. These efforts require strong, sustained institutional commitment and support from many sectors of the university community. As will be discussed below, such changes can be expected to result in tangible benefits for training institutions and their students, including improvements in pedagogy and educational outcomes for all students, as well as better care for the patient populations that these institutions serve. DEFINING “DIVERSITY” AND THE “INSTITUTIONAL CLIMATE” As noted above, earlier discussions of diversity in this report have focused on efforts to improve the structural diversity within health profes-

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In The Nation’s Compelling Interest: Ensuring Diversity in the Health-Care Workforce sions training settings. Structural diversity is defined as the numerical and proportional representation of URM groups among students, faculty, and administrators (Hurtado et al., 1998; Gurin et al., 2002). Many higher education institutions place the largest share of emphasis on this dimension of diversity. Diversity, however, also can be conceptualized as the diversity of interactions that take place on campus (e.g., the quality and quantity of interactions across diverse groups and the exchange of diverse ideas), as well as campus diversity-related initiatives and pedagogy (e.g., the range and quality of curricula and programming pertaining to diversity, such as cultural activities and cultural awareness workshops; Milem, Dey, and White, this volume). Each of these dimensions influences the others; indeed, research evidence indicates that students’ experiences with campus diversity affect the quality of their educational experiences and learning outcomes (to be reviewed later in this chapter). This evidence formed part of the basis of the University of Michigan’s successful defense of its rationale for considering race and ethnicity in admissions processes in the Grutter v. Bollinger et al. U.S. Supreme Court case (Krislov et al., 2003). The institutional climate for diversity is defined as the perceptions, attitudes, and expectations that define the institution, particularly as seen from the perspectives of individuals of different racial or ethnic backgrounds. The institutional climate is influenced by several elements of the institutional context (see Figure 5-1), including the degree of structural diversity, the historical legacy of inclusion or exclusion of students and faculty of color, the psychological climate (i.e., perceptions of the degree of racial tension and discrimination on campus), and the behavioral dimension (i.e., the quality and quantity of interactions across diverse groups and diversity-related pedagogy; Hurtado et al., 1999). Each of these elements influences others; an institution’s historical legacy of inclusion or exclusion, for example, can affect the ability of the institution to successfully recruit URM faculty and students. The institutional history and degree of structural diversity, in turn, can influence the nature and quality of intergroup relations, classroom diversity, and individuals’ perceptions of the racial climate. Perceptions of the racial climate often vary among individuals of different racial and ethnic backgrounds and campus roles (e.g., faculty, students, staff) but are significant because these perceptions are both a product of the institutional environment, as well as a significant predictor of individuals’ future interactions and campus experiences (Hurtado et al., 1999). In this framework, structural diversity is an important first step toward enhancing the climate for diversity but is insufficient in and of itself to create an institutional climate that supports and values diversity as central to the educational mission. The institutional context, in turn, is influenced by forces external to the institution (i.e., the policy context and the sociohistorical context). The

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In The Nation’s Compelling Interest: Ensuring Diversity in the Health-Care Workforce FIGURE 5-1 Elements influencing the climate for racial/ethnic diversity. SOURCE: Hurtado et al., 1999. governmental and policy context can powerfully affect structural dimensions of diversity, as financial aid policies and programs, state and federal policy regarding affirmative action, and court decisions related to desegregation of higher education institutions all may shape the socioeconomic and racial/ethnic diversity of the student body. Similarly, the sociohistoric context influences institutional and individual attitudes toward diversity, as social and political movements have often shaped popular opinion regarding diversity and access to higher education (Hurtado et al., 1999). The institutional climate for diversity is therefore “conceptualized as a product of these various elements and their dynamics” (Hurtado et al., 1999, p. 6). It is distinct from the institutional “culture” (i.e., the stable norms and beliefs that may constitute an organizational system). More importantly, however, the institutional climate is malleable and can be altered through systemic intervention efforts aimed at each of the elements of the institutional context. Each of the dimensions of the institutional climate may influence diversity efforts, in both positive and negative ways.

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In The Nation’s Compelling Interest: Ensuring Diversity in the Health-Care Workforce Institutions that focus exclusively on the numeric or proportional representation of URM students on campus, have, in many cases, found that insufficient attention to other dimensions of the campus climate for diversity may pose challenges to the effective integration and retention of URM students. Greater proportions of URM students can cause conflict and resistance among students and faculty if the institution does not anticipate and take steps toward maximizing cross-racial interactions and facilitating discussions about diversity (Milem, Dey, and White, this volume). Training and educational programs, for example, to better inform students and faculty of the value of diversity in the institution can help to facilitate positive diversity interactions, while cultural exchanges and workshops may assist diverse students as they attempt to integrate into the campus environment. Attention to the structural dimensions of diversity is therefore important, but only as an initial step towards comprehensive diversity efforts (Chang, 2001). THEORY AND RESEARCH ON DIVERSITY AND LEARNING A growing body of research demonstrates that college students, of all racial and ethnic backgrounds, benefit from interaction with a diverse group of college student peers (see also discussion in Chapter 1). This research indicates that it is not merely the case that the presence of diverse students on campus fosters richer learning experiences. Research also indicates that student learning experiences are enhanced in proportion to the frequency and quality of students’ informal interactions across racial and ethnic lines. These informal interactions, along with the discussion of racial/ethnic issues in classroom settings, confer benefits for students’ academic development, as well as for their civic and community orientation. While the majority of this research has been conducted with undergraduate students, many of the principles regarding diversity’s benefits extend to health professions training settings (Tedesco, 2001), as will be discussed below. Gurin et al. (2002), in seminal research that formed the core of the social science evidence base cited by the University of Michigan in its Supreme Court defense, utilized longitudinal data from two student surveys (a survey conducted at the University of Michigan and a national survey of student collegiate experiences) to assess whether students’ diversity experiences as undergraduates were related to their “learning outcomes” (defined as the use of active thinking, intellectual engagement and motivation, and academic skills) and “democracy outcomes” (i.e., citizenship engagement, belief in the compatibility of group differences and democracy, the ability to take the perspective of others, and cultural awareness and engagement). Over 11,000 white, African American, Asian American, and Latino students were among the national sample, while the Michigan sample included

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In The Nation’s Compelling Interest: Ensuring Diversity in the Health-Care Workforce over 1,500 white, African American, and Asian American students, all of whom were surveyed as they entered college and again after 4 years. Among both the Michigan and national samples of students, Gurin and colleagues found that diversity experiences were significantly related to learning outcomes upon follow-up, even after adjusting for students’ academic and socioeconomic background (i.e., gender, SAT scores, high school grade point average [GPA], parents’ educational level, racial composition of high school and neighborhood growing up), institutional characteristics (among the national sample), and prior scores on learning outcome measures. In the national sample, informal interactional diversity was especially significant for all four racial/ethnic groups in predicting intellectual engagement and academic skills, as was the impact of classroom diversity on these measures for white and Latino students. Among the Michigan students, both classroom diversity and campus-facilitated diversity activities (i.e., participation in multicultural events and intergroup dialogues) were significantly and positively associated with active thinking and intellectual engagement for all racial groups (Gurin et al., 2002). Similarly, diversity experiences were found to significantly predict students’ democracy outcomes, even after adjustment for students’ prior academic and socioeconomic background and precollege racial exposure, as well as measures of democracy orientation upon initial assessment. For all racial groups, informal interactions across racial and ethnic lines were associated with higher levels of citizenship engagement and awareness and appreciation of racial and cultural diversity. Classroom diversity was associated with these outcomes for white, Asian American, and Latino students, again after controlling for students’ prior scores on these measures. In the Michigan sample, informal cross-racial and ethnic interactions, classroom diversity, and campus-sponsored events and dialogues about multicultural issues were associated with students’ belief in the compatibility of differences with democratic processes, the ability to understand the perspectives of individuals from other groups, and engagement in racial and cultural issues, while controlling for students’ background characteristics and prior scores on democracy measures, although the strength of these relationships varied by racial/ethnic group (Gurin et al., 2002). Gurin and colleagues concluded that students who were exposed to higher levels of campus diversity, experienced and discussed diversity issues in the classroom, and participated in informal discussions across racial and ethnic groups were better able to understand and consider multiple perspectives, deal with the conflicts that different perspectives sometimes create, and “appreciate the common values and integrated forces that harness differences in pursuit of the common good” (University of Michigan, 2000, p. 5). These students can best develop the capacity to understand the ideas and feelings of others in an environment characterized by a diverse study

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In The Nation’s Compelling Interest: Ensuring Diversity in the Health-Care Workforce body, equality among peers, and discussion of the rules of civil discourse. Diversity experiences in college were also associated with a range of better cognitive and intellectual outcomes. Interactions with peers from diverse racial backgrounds, both in the classroom and informally, were associated with greater levels of engagement in active thinking processes, growth in intellectual engagement, and motivation and growth in intellectual and academic skills (Gurin et al., 2002). Similarly, Chang (2001), using data from a national, longitudinal survey of college students’ attitudes and experiences before, during, and after college, assessed whether the degree of racial/ethnic diversity that students experience on campus was associated with educational outcomes. Data from over 18,000 college students attending 392 4-year colleges and universities were utilized, with controls for variation in institutional size, location, type, religious affiliation, gender (coed or single-sex), and selectivity. Chang assessed whether students’ self-reported experiences of having socialized with someone of a different race and having discussed racial issues while in college were associated with the degree of racial diversity at the students’ institution. In addition, he assessed whether these experiences were associated with four educational outcomes (retention, satisfaction with college, intellectual self-concept, and social self-concept). Chang found that campus diversity was a small, but statistically significant, predictor of students’ likelihood of forming interracial friendships and talking about race and ethnicity, even after students’ background (e.g., socioeconomic status, standardized test scores) and campus environment were taken into account. In addition, Chang found that socializing with students of another racial or ethnic background had a small but significant direct effect on students’ self-reported satisfaction with college and social self-concept, and discussion of racial issues similarly was a small but significant predictor of students’ intellectual self-concept (Chang, 2001). Hurtado (2001) also assessed the relationship between undergraduate students’ diversity experiences and their assessments of civic, job-related, and educational outcomes. Using longitudinal data from nationwide surveys of students and faculty, Hurtado found that students who reported that they studied with someone of a different racial or ethnic background while in college were more likely upon one-year follow-up to report having greater acceptance of people of different racial/ethnic groups, greater cultural awareness, greater tolerance of people with different beliefs, a greater ability to work cooperatively with others, and greater critical thinking skills, among a range of other learning, job-related, and civic outcomes. These relationships remained significant even after controlling for institutional selectivity, students’ prior academic performance, and academic habits (e.g., hours per week spent studying; Hurtado, 2001). The finding that students benefit from diversity in the classroom and in

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In The Nation’s Compelling Interest: Ensuring Diversity in the Health-Care Workforce informal interactions has been extended to health professions educational settings. Whitla and colleagues (2003), in a survey of recent Harvard and University of California, San Francisco, medical school graduates’ attitudes regarding diversity in medical education, found that students reported experiencing greater levels of diversity in medical school than in their prior educational experiences, as the percentage of students reporting contact with other groups increased from 50 percent prior to college to 85 percent in medical school. These trends were true for majority group as well as URM students. Overwhelmingly, these students viewed diversity among their medical student peers as a positive; 86 percent thought that classroom diversity enhanced discussion and was more likely to foster serious discussions of alternate viewpoints. Over three-quarters of the students surveyed found that diversity helped them to rethink their viewpoints when racial conflicts occurred, and the same percentage felt that diversity provided them with a greater understanding of medical conditions and treatments. The pattern of responses did not differ by respondents’ racial or ethnic group (Whitla et al., 2003). While we found no similar published surveys of dental, nursing, and professional psychology students, anecdotal evidence (Davis and David, 1998) suggests that these students may experience similar benefits. Related research in developmental and cognitive psychology offers a theoretical framework to understand these findings. The period of late adolescence and early adulthood is characterized by significant social and emotional growth, as individuals attempt to define their personal and social identity as adults while learning about the complex social structures and communities in which they live and work. Personal and social identity develops best, according to developmental theorists, when young adults are exposed to novel situations, particularly those characterized by diversity and complexity of perspectives and experiences (Gurin et al., 2002). Residential colleges and universities provide students with an opportunity to explore ideas and perspectives that are different from their own prior experiences. In such situations, young people commonly lack a “script” to understand and predict social expectations and roles, and are therefore likely to experience uncertainty and discontinuity as they are exposed to different perspectives, experiences, and viewpoints. Research in cognitive psychology illustrates that this discontinuity is more likely to promote “active,” complex thinking. This form of thinking results in new ways of processing information, promotes intellectual engagement, and reduces dependence on prior learned scripts. Exposure to racial and ethnic diversity in college settings and, more importantly, meaningful interaction across racial and ethnic lines in informal settings and in classroom discussion are experiences that improve active thinking by providing opportunities to identify discrepancies with precollege experiences and to encounter novel and unfa-

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In The Nation’s Compelling Interest: Ensuring Diversity in the Health-Care Workforce miliar perspectives (Gurin et al., 2002). Gurin and colleagues illustrate this phenomenon as they quote a white undergraduate student evaluating a course on intergroup relations: I came from a town in Michigan where everyone was white, middle-class and generally pretty closed-down to the rest of the world, although we didn’t think so. It never touched us, so I never questioned the fact that we were “normal” and everyone else was “different.” Listening to other students in the class, especially the African American students from Detroit and other urban areas just blew me away. We only live a few hours away and yet we live in completely separate worlds. Even more shocking was the fact that they knew about “my world” and I knew nothing about theirs. Nor did I think that this was even a problem at first. I realize now that many people like me can go through life and not have to see another point of view, that somehow we are protected from it. The beginning for me was when I realized that not everyone shares the same views as I, and that our different experiences have a lot to do with that (Gurin et al., 2002, p. 338). Because of stark patterns of racial and ethnic residential housing segregation, most high school students entering college have limited experience with individuals from other racial, ethnic, and socioeconomic groups (Frankenberg and Lee, 2002). Very few of the freshman students matriculating at the University of Michigan, for example, have had significant contact with students from other racial and ethnic groups (see Box 5-1). As the University of Michigan, in its document The Compelling Need for Diversity in Higher Education, notes, “[t]he costs of this persistent and BOX 5-1 Racial and Ethnic Segregation in Detroit-Area Schools Schools in the Detroit metropolitan area are among the most segregated in the nation, although many metropolitan school districts are also characterized by high levels of segregation: In 60 of the 83 school districts in the three-county Detroit metropolitan area, the black student population is 3 percent or less; 82 percent of African American students attend schools in only three districts; More than 90 percent of the area’s white students attend schools in districts with black student populations under 10 percent; Only two school districts in the area come close to reflecting the overall proportions of the Detroit metropolitan region’s African American, Latino, and white students (University of Michigan, 2000).

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In The Nation’s Compelling Interest: Ensuring Diversity in the Health-Care Workforce pervasive racial separation are profound for minorities and non-minorities alike … [m]embers of differential racial and ethnic groups too often are denied the opportunity to benefit from all that our diverse communities have to offer” (University of Michigan, 2000, p. 4). Segregation limits opportunities for individuals to confront and correct racial stereotypes, to learn how to interact with others in an increasingly multicultural America; segregation also fosters mistrust and large gaps in the experiences, values, and viewpoints of different racial and ethnic groups. The University of Michigan determined that such segregation is detrimental to the community’s best interests; moreover, the university asserts that the quality of higher education is vastly improved when the barriers of racial segregation are removed and students from diverse racial and ethnic groups are encouraged to learn from, and with, each other. HOW CAN HEALTH PROFESSIONS TRAINING PROGRAMS ENSURE THE SUCCESS OF DIVERSITY EFFORTS? As noted above, efforts to improve the structural diversity of higher education institutions are a positive first step, but alone they are insufficient to improve the institutional climate for diversity and ensure that diversity benefits both students and the institution. Universities must create conditions in which students from different racial and ethnic backgrounds can have meaningful, productive interactions, and maximize educational experiences. Absent these efforts, institutions that bring together diverse groups run the risk of allowing conflict, misunderstanding, and resentment to poison students’ educational experiences. Fortunately, a body of theory and research has informed efforts to enhance the conditions under which diversity can provide educational benefits. Design Principles for Improving the Campus Climate for Diversity Building on research and theory, Hurtado et al. (1999) outline 12 strategies to achieve an improved climate for and maximize the benefits of diversity. The first four principles are “core” to any institutional efforts for change, while the remaining eight offer guidance for the development of new programmatic initiatives and policies. Hurtado and colleagues stress that these principles represent a comprehensive, “holistic” approach to institutional change and require that institutions possess strong leadership, adequate resources to support change efforts, strong planning and evaluation, and a long-term commitment. Research supporting these design principles is summarized in Hurtado et al. (1999), as well as Milem, Dey, and White (this volume). Core principles include the need to:

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In The Nation’s Compelling Interest: Ensuring Diversity in the Health-Care Workforce Affirm the goal of achieving a campus climate that supports racial and ethnic diversity as an institutional goal. Campus leadership should be able to articulate the need for diversity and communicate institutional goals clearly. In addition, leadership must understand how diversity and educational excellence are “inseparable” (Hurtado et al., 1999, p. 71). Systematically assess the institutional climate for diversity in terms of historical legacy, structural diversity, psychological climate, and behavioral elements to understand the dimensions of the problem. Self-appraisal of the institutional climate for diversity across a range of dimensions is critical to gather “baseline” data on how the institution is experienced by diverse groups, to identify areas of strength and weakness, and to assess the impact of diversity improvement efforts. Such self-assessment should be ongoing and should inform program changes. An example of a “cultural audit” that led to an on-going process of institutional change is provided in Box 5-2.1 Develop a plan, guided by research, experiences at peer institutions, and results from the systematic assessment of the campus climate for diversity, for implementing constructive change that includes specific goals, time-table, and pragmatic activities. Institutions should develop a “template” for change that is based on self-study and identifies measurable goals. This template should serve as a guiding blueprint for departmental and other programmatic activities. Implement a detailed and ongoing evaluation program to monitor the effectiveness of and build support for programmatic activities aimed at improving the campus climate for diversity. Ongoing evaluation will help to assess the effectiveness of programs and serve as the basis for program modification. Evaluation will also serve as a mechanism for holding key elements of the university—including faculty, staff, and administrators—responsible for achieving desired outcomes. The following eight principles are designed to help guide specific programming efforts. These principles may vary in their applicability or relevance across institutions, based on institutional history, type of control, geographic circumstances, etc. They can be tailored to meet the specific circumstances and goals of individual institutions, but they must be accompanied by the four components above—setting priorities, fact finding, es- 1   Examples of institutional diversity efforts provided in this chapter are abstracted from published literature. They do not represent a systematic effort to document “best practices” or to describe the full range of diversity programs implemented in health professions education institutions (HPEIs). For a more comprehensive description of programs to improve the institutional climate for diversity, see Hurtado et al. (1999).

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In The Nation’s Compelling Interest: Ensuring Diversity in the Health-Care Workforce as disease incidence and prevalence, historical factors that might shape health behaviors, and ethnopharmacology (Betancourt, 2003). A third conceptual model, the cross-cultural approach, focuses on developing communication skills and tools for providers to “be aware of certain cross-cutting cultural issues, social issues, and health beliefs while providing methods to deal with information clinically once it is obtained” (Betancourt, 2003, p. 562). These include tools to help providers to better understand patients’ conceptions of health and illness, methods to assess patients’ social contexts, and strategies to facilitate patient–provider negotiation and participatory decision making (Brach and Fraser, 2000; Betancourt, 2003). A limited number of studies have evaluated the impact of cross-cultural education strategies on trainees, in part because of methodological limitations. For example, investigators are often limited in their ability to accurately assess students’ cross-cultural attitudes following training, and “fact-based evaluation” in some cases runs counter to the goal of cross-cultural education (i.e., cross-cultural education strategies often attempt to assist trainees in managing complex information about culture and language, rather than imparting “facts” about racial and ethnic groups, which may inadvertently promote stereotyping of different racial, cultural, or linguistic groups). Several studies, however, have demonstrated gains in trainees’ cross-cultural knowledge and skills following training (Brach and Fraser, 2000; Betancourt, 2003). It is reasonable to assume that racial and ethnic diversity among faculty and students in HPEIs may enhance the quality of cross-cultural education, as such diversity can provide a rich exchange of ideas and opportunities to challenge assumptions. In addition, cross-cultural education programs may assist in efforts to attract URM students to health professions education (e.g., URM students may have greater interest in HPEI programs that include significant cross-cultural education components), and to develop a supportive institutional climate for diversity. The importance of cross-cultural training is increasingly reflected in the ethical and professional principles and guidelines of many health professions disciplines. The American Psychological Association, for example, has published guidelines for multicultural education, training, research, practice, and organizational change for psychologists that “reflect knowledge and skills needed for the profession in the midst of dramatic historic sociopolitical changes in U.S. society, as well as needs of new constituencies, markets, and clients” (APA, 2003, p. 377). The guidelines (summarized in Box 5-5) are designed to provide psychologists with a rationale for addressing multicultural concerns in their professional work, relevant research and information that support the guidelines, and paradigms that broaden the purview of psychology as a profession. Moreover, the guidelines are founded on the following principles:

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In The Nation’s Compelling Interest: Ensuring Diversity in the Health-Care Workforce “Ethical conduct of psychologists is enhanced by knowledge of differences in beliefs and practices that emerge from socialization through racial and ethnic group affiliation” (APA, 2003, p. 382); The quality of education, training, and research in psychology can be enhanced by understanding the interface between racial and ethnic group affiliation and socialization experiences; The understanding and treatment of all people can be enhanced by understanding how race and ethnicity intersect with other dimensions of identity, such as gender, age, sexual orientation, disability, and other factors; BOX 5-5 Guidelines on Multicultural Education, Training, Research, Practice, and Organizational Change for Psychologists Commitment to Cultural Awareness and Knowledge of Self and Others Guideline 1: Psychologists are encouraged to recognize that, as cultural beings, they may hold attitudes and beliefs that can detrimentally influence their perceptions of and interactions with individuals who are ethnically and racially different from themselves. Guideline 2: Psychologists are encouraged to recognize the importance of multicultural sensitivity/responsiveness to, knowledge of, and understanding about ethnically and racially different individuals. Education Guideline 3: As educators, psychologists are encouraged to employ the constructs of multiculturalism and diversity in psychological education. Research Guideline 4: Culturally sensitive psychological researchers are encouraged to recognize the importance of conducting culture-centered and ethical psychological research among persons from ethnic, linguistic, and racial minority backgrounds. Practice Guideline 5: Psychologists are encouraged to apply culturally appropriate skills in clinical and other applied psychological practices. Organizational Change and Policy Development Guideline 6: Psychologists are encouraged to use organizational change processes to support culturally informed organizational (policy) development and practices. SOURCE: APA, 2003.

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In The Nation’s Compelling Interest: Ensuring Diversity in the Health-Care Workforce Understanding of the underrepresentation of some racial and ethnic minority groups in the discipline is explained, in part, by psychology’s history of viewing cultural differences as “deficits” and underappreciation of the role of race and ethnicity in the development of personal and social identity; Psychologists’ ability to promote racial and ethnic equity and social justice is enhanced by an understanding of race, ethnicity, and culture; and “Psychologists’ knowledge about the roles of organizations, including employers and professional psychological associations, is a potential source of behavioral practices that encourage discourse, education and training, institutional change, and research and policy development that reflect, rather than neglect, cultural differences” (APA, 2003, p. 382). A Comprehensive Strategy to Increase URM Applications, Admission, and Success—One Dental School’s Example Throughout this discussion, the committee has emphasized the importance of comprehensive, multipronged strategies to create and support diversity in health professions training programs. Some common elements of successful strategies include efforts to: conduct a self-assessment, identify areas where support for diversity efforts must be improved, and develop a strategic plan for improvement; recruit URM applicants; reduce barriers to the admission of URM students, while maintaining the academic quality of admits; reduce financial barriers to URM student participation; and recruit URM faculty. Columbia University’s School of Dental and Oral Surgery (SDOS) has undertaken such a comprehensive approach, with the result that the school has dramatically increased the racial and ethnic diversity of its students, faculty, and staff and is much better positioned to address the oral health care needs of the region and nation. This change process began with a reassessment of past institutional efforts, which had been less than successful. Until the early 1980s, SDOS enrolled few African American, American Indian, or Hispanic students, and the full-time D.D.S. faculty was almost entirely composed of white males. Recognizing that the school’s reputation as a local and national leader in dental education and ability to serve an increasingly diverse population would suffer without improved diversity efforts, SDOS developed a number of initiatives to transform the school’s climate for diversity (Formicola et al., 2003). SDOS began in the early 1980s by rethinking its admissions processes,

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In The Nation’s Compelling Interest: Ensuring Diversity in the Health-Care Workforce which were heavily dependent upon applicants’ college grade point average, Dental Aptitude Test scores, letters of recommendation, and a personal interview. These policies were typical of other dental schools, but “[led] to considering a narrow range of students for admission and did not permit adequate consideration of a student’s full range of intellectual, social, and personal traits” (Formicola et al., 2003, p. 492). In response, the admissions committee broadened its criteria to include a greater emphasis on applicants’ personal attributes and background, extracurricular activities, difficulties overcome, and other qualitative factors. To facilitate this change of emphasis, admissions committee members were provided with training in interview skills and understanding qualitative attributes that might be beneficial to the school and to the profession. In addition, a new survey instrument was developed to help guide the interviews and ensure that applicants’ qualitative attributes were assessed. Finally, a subcommittee on minority enrollment was appointed to assist the admissions committee in interviewing and assessing applicants with diverse educational and professional backgrounds. As a result, more minority students were admitted; in the 59-year period between 1923 and 1982, SDOS graduated 16 African American and Latino students, while in the period from 1984 to 2001, the school admitted 57 African American and Latino students, graduating 51 of them (Formicola et al., 2003). With the admission of greater numbers of diverse students, SDOS realized that variation in students’ educational background required that the institution provide academic support services. As a result, the school developed tutorial services for first-year students and a summer preenrollment academic enrichment program. These services were offered initially to all students whose records indicated that their preparation could be improved. Gradually, the first-year tutorial program expanded and improved its ability to serve all students, and the summer enrichment program was suspended (Formicola et al., 2003). During this same period, SDOS also sought opportunities to expand its postdoctoral training, while at the same time improving its service to the local community and increasing the numbers of URM faculty. These goals were met with a unique collaboration between SDOS and the Harlem Hospital Medical Center. At the time, Harlem Hospital had expanded its dental service from mainly emergency and oral surgical care to comprehensive care, and expanded its dental clinic facility. This created an opportunity for SDOS and the dental department at Harlem Hospital to collaborate to develop a postdoctoral specialty training program for dentists completing their residency at Harlem Hospital. The residents, who were mainly African American and Hispanic, were required to commit to service in the community as members of the hospital staff, or as faculty in the dental school and/ or in practice in the Harlem community. In return, Harlem Hospital paid

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In The Nation’s Compelling Interest: Ensuring Diversity in the Health-Care Workforce the salary for residents admitted to the postdoctoral program, and tuition was waived by the SDOS. SDOS also realized that the program provided an opportunity to recruit URM graduates into full- and part-time faculty positions at Columbia. These goals have been met: from 1988 to 2000, the program provided postdoctoral training to 21 African American and Latino graduates of the Harlem Hospital Dental Department residency program, 15 of these graduates practice in the Harlem community on the hospital staff, and 12 have faculty appointments at Columbia SDOS. In addition, Harlem Hospital now has a full range of dental specialists available to provide comprehensive care to the community and provide training to general practice residents (Formicola et al., 2003). Following the development of these programs, SDOS also took several other steps to assess and improve the institutional climate for diversity. By the mid-1990s, the school established a faculty Search Committee that included members external to the department and whose recommendations were reviewed by Columbia University’s Health Sciences Affirmative Action Committee. This committee ensured that all faculty search committees conducted a thorough review and considered racial and ethnic minority candidates. In addition, SDOS conducted a climate study, using focus groups composed of randomly selected groups of faculty, staff, and students. The purpose of the climate study was to determine how students from diverse background perceived the dental school environment and to identify areas for improvement. The climate study resulted in several recommendations, ranging from student training and faculty/staff development programs designed to increase awareness of cultural pluralism and diversity, to efforts to ensure that all students were provided equal access to information and opportunities for research activities, internships, and other activities (Formicola et al., 2003). SUMMARY AND RECOMMENDATIONS The institutional climate for diversity—defined as the perceptions, attitudes, and expectations that define the institution, particularly as seen from the perspectives of individuals of different racial or ethnic backgrounds—can exert a profound influence on diversity efforts. Diversity is most often viewed as the proportion and number of individuals from groups underrepresented among students, faculty, administrators, and staff (i.e., structural diversity). Diversity, however, can also be conceptualized as the diversity of interactions that take place on campus (e.g., the quality and quantity of interactions across diverse groups and the exchange of diverse ideas), as well as campus diversity-related initiatives and pedagogy (e.g., the range and quality of curricula and programming pertaining to diversity, such as cultural activities and cultural awareness workshops; Milem, Dey,

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In The Nation’s Compelling Interest: Ensuring Diversity in the Health-Care Workforce and White, this volume). Each of these elements of diversity must be carefully considered as institutions assess their diversity goals. The institutional climate for diversity is influenced by several elements of the institutional context, including the degree of structural diversity, the historical legacy of inclusion or exclusion of students and faculty of color, the psychological climate (i.e., perceptions of the degree of racial tension and discrimination on campus), and the behavioral dimension (i.e., the quality and quantity of interactions across diverse groups and diversity-related pedagogy; Hurtado et al., 1999). Each of the dimensions of the institutional climate may influence diversity efforts, in both positive and negative ways. More importantly, the institutional climate is malleable and can be altered through systemic intervention efforts aimed at each of the elements of the institutional context. Research on Diversity and Learning A growing body of research demonstrates that college students, of all racial and ethnic backgrounds, benefit from interaction with a diverse group of college student peers (see also discussion in Chapter 1). Gurin and colleagues (2002), for example, found that college students’ informal and classroom interactions with students from diverse racial and ethnic groups were associated with students’ subsequent learning outcomes (defined as the use of active thinking, intellectual engagement and motivation, and academic skills) and democracy outcomes (i.e., citizenship engagement, belief in the compatibility of group differences and democracy, the ability to take the perspective of others, and cultural awareness and engagement). While the majority of this research has been conducted with undergraduate students, recent research has extended these findings to medical students (Whitla et al., 2002), and many of the principles regarding diversity’s benefits extend to health professions training settings (Tedesco, 2001). How Can Health Professions Educational Institutions Ensure the Success of Diversity Efforts? Building on this research and theory, Hurtado et al. (1999) outline 12 strategies to achieve an improved climate for diversity. More importantly, these strategies can help institutions to maximize the benefits of diversity. The first four principles (i.e., affirm the value of diversity, systematically assess the climate, develop a plan of action, and institute ongoing evaluation of the plan) are “core” to any institutional efforts for change, while the remaining eight offer guidance for the development of new programmatic initiatives and policies. Hurtado and colleagues stress that these principles represent a comprehensive, “holistic” approach to institutional change and

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In The Nation’s Compelling Interest: Ensuring Diversity in the Health-Care Workforce require that institutions possess strong leadership, adequate resources to support change efforts, strong planning and evaluation, and a long-term commitment. Recruitment, Hiring, and Retention of Underrepresented Minority Faculty Enhancing the racial and ethnic diversity of health professions education faculty can provide support for URM students in the form of role models and mentors, lead to important pedagogical changes, and “bring new kinds of scholarship to an institution, educate students on issues of growing importance to society, and offer links to communities not often connected to our campuses” (Smith, 2000, p. 51). Many health professions training programs have struggled, however, to increase the proportion of URM faculty members. To a degree, these failures are the result of common myths regarding URM faculty recruitment (e.g., that qualified URM faculty candidates are few, too highly sought-after to invest significant efforts into recruiting, and apt to leave following offers from more prestigious institutions; Smith, 2000). Health professions training institutions can take several steps to improve their efforts at recruiting minority faculty. To begin, institutions should carefully examine their mission statement and assess how faculty diversity assists the institution to meet its goals. Identifying and recruiting qualified URM faculty candidates can be improved by utilizing active search processes that go beyond simply posting positions and recruiting though networks that are familiar to the faculty. Search committees should be diverse, to help in assessing and evaluating candidates of different backgrounds, and should have a close working relationship with the university administration to ensure the success of the search process. Once qualified candidates are identified, personal support in the form of a “champion”—someone willing to facilitate communication, advise the candidate, and advocate for the candidate during the search process—can ensure that the search committee has the opportunity to fully assess the candidate. Finally, posthiring support is critical for many URM faculty to address the challenges of earning tenure, balancing teaching and research, and other faculty concerns (Smith, 2000). Minority Student Recruitment and Retention Several health professions training programs have implemented successful URM student recruitment and retention programs. Some elements of successful recruitment efforts include developing academic and educational partnerships with minority-serving institutions, addressing financial

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In The Nation’s Compelling Interest: Ensuring Diversity in the Health-Care Workforce barriers, targeting outreach to URM students, and engaging prehealth advisors. Just as importantly, institutions should develop comprehensive strategies to retain URM students, by providing a range of academic and social supports, including faculty and peer mentoring, tutoring, academic skills assessment, and instruction in study skills. Institutions may increase opportunities for URM students to integrate themselves into the campus community (and take advantage of support programs) through both ethnic- and racial-group interest organizations, as well as general campus programs, such as orientation programs that clearly outline the institutions’ expectations regarding diversity-related policies and goals, and sensitivity training programs that increase awareness and understanding of diversity in the campus context. Recommendation 5-1: HPEIs should develop and regularly evaluate comprehensive strategies to improve the institutional climate for diversity. These strategies should attend not only to the structural dimensions of diversity, but also to the range of other dimensions (e.g., psychological and behavioral) that affect the success of institutional diversity efforts. These strategies include, but are not limited to efforts to: recruit and retain URM students and faculty through a range of academic and social supports, including but not limited to mentoring programs, academic supports, and other strategies integrated into ongoing programs; educate faculty and students regarding the benefits of diversity to the institutional mission; and encourage participation by diverse faculty on core institutional committees, including but not limited to admissions, faculty search, internal review, and promotions and tenure. Education is a critically important initial step toward increasing diversity at many HPEIs. HPEIs must provide all members of the campus community with an explicit rationale for diversity efforts and communicate the principles that underlie such efforts. Educational programs should be ongoing, integrated into regular programming, and regularly evaluated to assess their effectiveness. As with other institutional goals, faculty should be evaluated, as part of ongoing merit and promotion review, on their progress toward achieving the institution’s diversity-related objectives. Recommendation 5-2: HPEIs should proactively and regularly engage and train students, house staff, and faculty, via orientation programs and ongoing training, regarding institutional diversity-related policies and expectations, the principles that underlie these policies, and the importance of diversity to the long-term institutional mission. Faculty

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In The Nation’s Compelling Interest: Ensuring Diversity in the Health-Care Workforce should be able to demonstrate specific progress toward achieving these goals as part of the promotion and merit process. Because of the often difficult nature of racial/ethnic dialogue and potential for conflict, HPEIs should consider developing appropriate conflict mediation and dispute resolution services that may serve to increase understanding and cooperation. An ombuds program may assist efforts to improve the campus climate for diversity by providing an informal, confidential process to assess and resolve disputes. Recommendation 5-3: HPEIs should establish an informal, confidential mediation process for students and faculty who experience barriers to institutional diversity goals (e.g., experiences of discrimination, harassment). Such a process can be established by appointment of an ombudsman who can serve as an arbitrator with the power to investigate complaints and mediate disputes. Innovative institutional diversity models also take into consideration the quality of diversity training experiences that students receive. Well-supported training experiences that expose all students to diverse patient populations increase students’ knowledge and skills in working with underserved groups. Moreover, as the experiences of Formicola et al. (2003) illustrate, training affiliations with community-based health-care facilities can increase access to health care among diverse patient populations and attract more URM students and faculty to training settings. Recommendation 5-4: HPEIs should be encouraged to affiliate with community-based health-care facilities in order to attract and train a more diverse and culturally competent workforce and to increase access to health care. REFERENCES American Psychological Association (APA). 2000. Model Strategies for Ethnic Minority Recruitment, Retention, and Training in Higher Education. Compiled by the Office of Ethnic Minority Affairs, American Psychological Association, May 2000. Washington, DC: American Psychological Association. American Psychological Association (APA). 2003. Guidelines on multicultural education, training, research, practice, and organizational change for psychologists. American Psychologist 58:377–402. Association of American Medical Colleges (AAMC). 2000. LCME Graduation Questionnaire. Washington, DC: Association of American Medical Colleges. Astin AW. 1993. What Matters in College: Four Critical Years Revisited. San Francisco: Jossey-Bass. Betancourt JR. 2003. Cross-cultural medical education: Conceptual approaches and frameworks for evaluation. Academic Medicine 78(6):560–569.

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