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

Challenging Norms: The Impact of Transgender and Gender-Diverse Realities on Work and School Participation

IMPORTANCE

Disruption in school and the workplace are health concerns for transgender people.

OBJECTIVE

To evaluate transgender individuals' thoughts and comfort with how others perceive their gender identity (social affirmation) and its association with outness in the workplace and mistreatment at work or school.

DESIGN

Cross-sectional survey.

PARTICIPANTS

Survey respondents older than age 18 yr from the Study of Transition, Outcomes & Gender cohort (N = 696; n = 350 assigned male at birth, n = 346 assigned female at birth [AFAB]).

OUTCOMES AND MEASURES

Ever "out" to employer and treated unfairly at work or school or fired from job. Predictors were high social affirmation and comfort with how others perceive own gender identity. Descriptive statistics and logistic regression were used for analyses.

RESULTS

Individuals reporting high social affirmation were less likely to experience mistreatment at work or school than those with low social affirmation (odds ratio [OR] = 0.57, 95% confidence interval [CI] [0.38, 0.86]). Individuals AFAB who felt comfortable with how others perceived their gender identity were less likely to be out to their employers than individuals AFAB who did not (OR = 0.45; 95% CI [0.20, 0.97]).

CONCLUSIONS AND RELEVANCE

Individuals with high social affirmation were less likely to experience work or school mistreatment, and feeling comfortable with how others perceive their gender identity did not signify the need to be out. Plain-Language Summary: Occupational therapy practitioners can play a pivotal role when working with transgender individuals by assisting in creating new routines for self-presentation at work or school, navigating social environments, and providing guidance in self-advocacy skills. Individuals assigned male at birth may be in greater need because they report lower levels of social affirmation and acceptance at school and work than individuals assigned female at birth.

Operationalizing inclusion: moving from an elusive goal to strategic action

To mitigate the structural and institutional biases that contribute to inequities in health, we need a diverse cadre of individuals to feel included and advance within our field in order to bring a multicultural set of perspectives to the studies we conduct, the science we generate, the health and academic systems we design, and the medical and scientific knowledge we impart. There has been increasing focus on diversity, inclusion, and equity in recent years; however, often these terms are presented without adequate precision and, therefore, the inability to effectively operationalize inclusion and achieve diversity within organizations. This narrative review details several key studies, with the primary objective of presenting a roadmap to guide defining, measuring, and operationalizing inclusion within work and learning environments.

Diversity in the pediatric research workforce: a scoping review of the literature

The purpose of this scoping review is to determine trends in racial and ethnic representation, identify barriers and facilitators to greater diversity, and assess strategies and interventions to advance diversity among those in the pediatric research workforce in the U.S. We conducted a scoping review of PubMed supplemented with the authors' personal library of papers published from January 1, 2010, to December 31, 2021. To be eligible, papers had to provide original data, be published in English, report information from a U.S. healthcare institution, and report on outcomes of interest relevant to the child health field. The diversity of faculty has modestly increased over the past decade but reflects a worsening representation compared to overall population trends. This slow increase reflects a loss of diverse faculty and has been referred to as a "leaky pipeline." Strategies to plug the "leaky pipeline" include greater investments in pipeline programs, implementation of holistic review and implicit bias training, development of mentoring and faculty programs targeted to diverse faculty and trainees, alleviation of burdensome administrative tasks, and creation of more inclusive institutional environments. Modest improvements in the racial and ethnic diversity of the pediatric research workforce were identified. However, this reflects worsening overall representation given changing U.S. population demographics. IMPACT: Racial and ethnic diversity in the pediatric research workforce has shown modest increases but worsening overall representation. This review identified barriers and facilitators at the intrapersonal, interpersonal, and institutional levels that impact BIPOC trainees and faculty career advancement. Strategies to improve the pathway for BIPOC individuals include greater investments in pipeline and educational programs, implementation of holistic review admissions and bias training, institution of mentoring and sponsorship, alleviation of burdensome administrative responsibilities, and creation of inclusive institutional climates. Future studies should rigorously test the effects of interventions and strategies designed to improve diversity in the pediatric research workforce.

How Do Academic Medicine Pathways Differ for Underrepresented Trainees and Physicians? A Critical Scoping Review

PURPOSE

Academic medicine faces difficulty recruiting and retaining a diverse workforce. The proportion of medical students who are underrepresented in medicine (URiM) is smaller than the proportion of URiM's in the general population, and these numbers worsen with each step up the academic medicine ladder. Previously known as the "leaky pipeline," this phenomenon may be better understood as disparate "pathways with potholes," which acknowledges the different structural barriers that URiM trainees and faculty face in academic medicine. This critical scoping review analyzed current literature to determine what variables contribute to the inequitable "pathways and potholes" URiM physicians experience in academic medicine.

METHOD

The authors combined scoping review methodology with a critical lens. The comprehensive search strategy used terms about academic medicine, underrepresented groups, and leaving academic medical careers. One reviewer conducted screening, full text review, and data extraction while in consultation with members of the research team. Data extraction focused on themes related to pathways and potholes, such as attrition, recruitment, and retention in academic medicine. Themes were iteratively merged, and quality of contribution to the field and literature gaps were noted.

RESULTS

Included papers clustered into attrition, recruitment, and retention. Those pertaining to attrition noted that URiM faculty are less likely to get promoted even when controlling for scholarly output, and a hostile work environment may exacerbate attrition. Recruitment and retention strategies were most effective when multi-pronged approaches changed every step of the recruitment and promotion processes.

CONCLUSIONS

These studies provide examples of various "potholes" that can affect representation in academic medicine of URiM trainees and faculty. However, only a few studies examined the link between isolating and hostile work environments, the so-called "chilly climate," and attrition from academic medicine. Understanding these concepts is key to producing the most effective interventions to improve diversity in medicine.

The Impacts of Engagement in the Latino Medical Student Association

Importance

The Latino Medical Student Association (LMSA) is a student-run national organization founded in 1972 dedicated to recruiting and retaining members enrolled in health professions programs through academic and social support activities. This study investigates the career impact of member participation in LMSA.

Objective

To determine if engagement in LMSA at the individual and school levels contributes to retention, success, and commitment to underserved communities.

Design

A voluntary online retrospective 18-question survey sent to LMSA-member medical students in the United States and Puerto Rico from the graduating classes of 2016-2021.

Setting

Students in medical schools in the United States and Puerto Rico.

Main Outcomes and Measures

There were 18 survey questions. A total of 112 anonymous responses were collected from March 2021 to September 2021. The survey queried levels of engagement with the LMSA and agreement on questions related to support, belonging, and career development.

Results

There is a positive relationship between level of engagement in the LMSA and social belonging, peer support, career networking, community engagement, and career commitment to serve Latinx communities. These positive outcomes were enhanced for respondents reporting strong support for their respective school-based LMSA chapters. We did not find a significant relationship between participation in the LMSA and research experiences during medical school.

Conclusions and Relevance

Participation in the LMSA is associated with positive individual support and career outcomes for members. Supporting the LMSA as a national organization and within school-based chapters can increase support for Latinx trainees and enhance career outcomes.

Workplace inclusion: A scoping review of the qualitative literature

BACKGROUND

An inclusive workplace culture supports and values the individual and collective work processes of workers from diverse backgrounds. The reality or perception of inclusion or exclusion at work can influence the social functioning, health, and well-being of workers. However, we lack knowledge about the concepts relevant to inclusion at the workplace. Furthermore, research is needed to better understand the drivers and obstacles to workplace inclusion to better promote participation in working life.

OBJECTIVE

This scoping review of the qualitative literature identifies the barriers to and facilitators of workplace inclusion.

METHODS

Systematic searches of five databases were conducted from 2000 to January 2020. Pairs of reviewers independently screened and reviewed all citations and full-text articles. We used Arksey and O'Malley's scoping review framework which advances through five stages. Barriers and facilitators of workplace inclusion were categorized relative to a multi-layered conceptualization of workplace inclusion and grouped by theme. Studies were described and thematic results totaled and communicated with evidence tables and conceptual maps.

RESULTS

Thirty-nine qualitative studies met our inclusion criteria. All five domains of the multi-layered framework were represented by the reported shared experiences of study participants. Organizational level factors, especially attitudinal barriers were the most reported barriers to workplace inclusion. Facilitators of workplace inclusion focused on employer level factors and most often cited the role of inclusive leadership and support.

CONCLUSION

Workplace inclusion requires consideration of societal, organizational, employer, and interpersonal level factors in addition to individual worker characteristics.

Sparking a Movement, Not a Moment: Framework and Outcomes From a Pediatrics Department-Wide Coalition to Advance Anti-Racism

OBJECTIVE

The Stanford Pediatrics Advancing Anti-Racism Coalition (SPAARC) was created to promote a culture of anti-racism through immediate action, development of nimble systems, and longitudinal commitment toward equity. Evaluate gaps in the Stanford Department of Pediatrics (DoP) efforts to advance anti-racism and form a coalition of faculty, staff, and trainees to prioritize, design, and implement targeted activities with immediate and long-term measurable outcomes.

METHODS

A needs assessment was conducted across all DoP members in July to August 2020 to identify gaps in anti-racism efforts. Listening sessions were recorded and transcribed to extrapolate key themes and 2 rounds of consensus surveys were done to identify and prioritize actions. Actions teams were created and co-led by faculty-staff dyads with trainee representation. A final activity survey was conducted in January 2021 to determine the specific activities (ie, interventions) each team would design and implement.

RESULTS

Ten small group listening sessions (70 participants) and 3 surveys (1005 responses) led to the creation of 7 action teams with associated activities 1) training, 2) community engagement and research, 3) communication, 4) faculty and staff recruitment and advancement, 5) leadership representation, 6) human resources, and 7) staff engagement. Four hundred forty-three (41%) DoP members were directly involved in SPAARC through participation in the needs assessment, action teams, and/or implementation of activities.

CONCLUSION

SPAARC can serve as an adaptable framework for how a DoP can create a coalition to identify gaps in anti-racism efforts and create and implement targeted activities with associated outcomes.

Prevalence and Impact of Academic Violence in Medical Education

Situations of mistreatment in the academic environment are prevalent worldwide, but research in this area is scarce in middle-low-income countries. This study aimed to estimate the prevalence of mistreatment inflicted against Brazilian medical students. In addition, characterize these situations and analyze their consequences. Cross-sectional study conducted with 831 medical students from public and private institutions. Absolute and relative frequencies of the analyzed variables and possible associations were determined through univariate and multivariate logistic regression. Chi-square test of association with second-order Rao-Scott adjustment was also used. The response rate was 56%. Public institution pointed to a higher prevalence of mistreatment when compared to private (59% versus 43%). Female students were the most affected. Verbal and psychological aggression was more prevalent. The aggressor usually was a faculty member. Mistreatment incidence increased over the years of training, with higher rates in the internship. About 94% of the students felt affected in anyway, with 77% feeling diminished and depressed. More than 50% reported impaired academic performance. Almost 30% sought help from experts. The reporting rate was extremely low. Adequate identification of the situations by the victims, safe reporting mechanisms and, an educational system capable of maintaining an appropriate learning environment are essential to break this destructive cycle.

Stress levels of nursing students: A systematic review and meta-analysis

CONTEXT

Nursing students experience psychosocial stress in their workplace. Available statistics are at variance, and hence, the need to know the overall prevalence of psychosocial stress among nursing students.

AIMS

This study aimed to determine the prevalence of psychosocial stress among nursing students through meta-analysis.

MATERIALS AND METHODS

PubMed, Cochrane, Web of Science, CNKI, and China Biomedical Literature Service System were searched for articles. Search terms include "psychosocial stress," "nursing students." Articles were included if they used validated psychosocial stress assessment instruments. Of the 15 articles with data on stress prevalence, 8 met all inclusion criteria. Each article was independently reviewed by the authors and relevant data were abstracted. Statistical analysis was done using Revman 4.1.

RESULTS

Overall, the average score for stress among nursing students was 3.70 (95% confidence interval [CI]: [3.33, 4.06]) based on the analyzed 15 articles with a sample size of 9202.

CONCLUSION

This study showed that the stress level of intern nursing students was mainly moderate.

Ableism within health care professions: a systematic review of the experiences and impact of discrimination against health care providers with disabilities

PURPOSE

People with disabilities experience concerning rates of ableism and are significantly under-represented within healthcare education and professions. Focusing on healthcare professions is important for enhancing the diversity and inclusion of equity-deserving groups within the workforce. The objective of this review was to explore the experiences and impact of workplace discrimination and ableism among healthcare providers and trainees with disabilities.

METHODS

Systematic searches of seven databases from 2000 to January 2022 were conducted. Five reviewers independently applied the inclusion criteria, extracted the data and rated the study quality.

RESULTS

48 studies met our inclusion criteria, representing 13,815 participants across six countries over a 21-year period. The findings highlighted rates and types of workplace ableism, which occurred at the institutional (i.e., inaccessible environments, physical barriers and unsupportive work environments) and individual level (i.e., negative attitudes, bullying, harassment). The impact of ableism on healthcare providers included difficulty disclosing due to fear of stigma, and effects on well-being and career development.

CONCLUSIONS

Our findings revealed a critical need for more research on the experiences of ableism amongst healthcare providers and the impact it has on their well-being. Further efforts should explore mechanisms for including and welcoming people with disabilities in healthcare professions.Implications for rehabilitationWorkplace ableism is prevalent in health care professions and could be discouraging people with disabilities from entering or completing health care education and training, leading to an under-representation of this equity-deserving group within health care.More efforts are needed to recruit, retain and support people with disabilities in the health care workforce.Health care providers who have a disability often experience workplace discrimination and inaccessible physical environments which can impact their health and well-being.Managers, senior leadership and health care organizations should advocate for improved social inclusion of employees with disabilities.

Doing the Work-or Not: The Promise and Limitations of Diversity, Equity, and Inclusion in US Medical Schools and Academic Medical Centers

While the number of positions, committees, and projects described as "Diversity, Equity, and Inclusion (DEI)" work has grown rapidly in recent years, there has been little attention to the theory, praxis, or lived experience of this work. In this perspective, we briefly summarize the research and concepts put forth by DEI leaders in higher education more broadly, followed by an analysis of the literature's application to academic medicine. We then discuss the ways in which language obscures the nature of DEI and the necessity of scholarship to evaluate the extensive range of practices, policies, statements, and programs the label is given to.

Employee Health and Wellness Outcomes Associated With Perceived Discrimination in Academic Medicine: A Qualitative Analysis

IMPORTANCE

Organizational culture and workplace interactions may enhance or adversely impact the wellness of all members of learning and work environments, yet a nuanced understanding of how such experiences within health care organizations impact the health and wellness of their membership is lacking.

OBJECTIVE

To identify and characterize the reported health and wellness outcomes associated with perceived discrimination among academic medicine faculty, staff, and students.

DESIGN, SETTING, AND PARTICIPANTS

This qualitative study analyzed anonymously submitted written narratives from 2016 that described experiences related to inclusion in the workplace or lack thereof. Narratives that described health outcomes associated with work- or school-based discrimination were purposively sampled. Participants were faculty, staff, and students at health-related schools or hospitals affiliated with the University of Pennsylvania. Data analysis was performed from March 2019 to January 2020.

EXPOSURES

Self-reported experiences, both witnessed and personal, of discrimination in the workplace.

RESULTS

A total of 315 narratives were collected, and 115 narratives from 115 participants were analyzed. Most respondents identified as female (70 respondents [60.9%]), non-Hispanic White (68 respondents [59.1%]), and heterosexual (89 respondents [77.4%]) and had worked at the institution for at least 1 year (99 respondents [86.0%]). The outcomes associated with adverse workplace experiences were broad and ranged in nature from emotional to mental and physical. Most reported outcomes were emotional (101 respondents [87.8%]), and more than 1 in 10 narratives (14 respondents [12.2%]) described a mental or physical health outcome. Many of the participants felt devaluated, overexerted, and hopeless, resulting in clinically relevant manifestations, such as increased stress and anxiety levels and even elevated blood pressure.

CONCLUSIONS AND RELEVANCE

This qualitative study identified a continuum of negative outcomes on employee health and well-being associated with perceived discrimination and chronic exclusion in the workplace. These findings suggest the need for organizations to promote inclusion as a component of workplace wellness interventions.

Faculty Recruitment, Retention, and Representation in Leadership: An Evidence-Based Guide to Best Practices for Diversity, Equity, and Inclusion from the Council of Residency Directors in Emergency Medicine

Improving the recruitment, retention, and leadership advancement of faculty who are under-represented in medicine is a priority at many academic institutions to ensure excellence in patient care, research, and health equity. Here we provide a critical review of the literature and offer evidence-based guidelines for faculty recruitment, retention, and representation in leadership. Recommendations for recruitment include targeted recruitment to expand the candidate pool with diverse candidates, holistic review of applications, and incentivizing stakeholders for success with diversity efforts. Retention efforts should establish a culture of inclusivity, promote faculty development, and evaluate for biases in the promotion and tenure process. We believe this guide will be valuable for all leaders and faculty members seeking to advance diversity, equity, and inclusion in their institutions.

The emergence of a texas collaboration to improve well-being in learning health systems

Prior models of well-being have focused on resolving issues at different levels within a single institution. Changes over time in medicine have resulted in massive turnover and reduced clinical hours that portray a deficit-oriented system. As developments to improve purpose and professional satisfaction emerge, the Texas Medical Association Committee on Physician Health and Wellness (PHW) is committed to providing the vehicle for a statewide collaboration and illuminating the path forward.To describe the existing health and wellness resources in Texas academic medical centers and understand the gaps in resources and strategies for addressing the health and wellness needs in the medical workforce, and in student and trainee populations.Various methods were utilized to gather information regarding health and wellness resources at Texas academic medical centers. A survey was administered to guide a Think Tank discussion during a PHW Exchange, and to assess resources at Texas academic medical centers. Institutional representatives from all Texas learning health systems were eligible to participate in a poster session to share promising practices regarding health and wellness resources, tools, and strategies.Survey responses indicated a need for enhancing wellness program components such as scheduled activities promoting health and wellness, peer support networks, and health and wellness facilities in academic medical centers. Answers collected during the Think Tank discussion identified steps needed to cultivate a culture of wellness and strategies to improve and encourage wellness.The Texas Medical Association Committee on Physician Health and Wellness and PHW Exchange provided a forum to share best practices and identify gaps therein, and has served as a nidus for the formation of a statewide collaboration for which institutional leaders of academic medical centers have affirmed the need to achieve the best result.

Diversity Is Not Enough: Advancing a Framework for Antiracism in Medical Education

Medical students, residents, and faculty have begun to examine and grapple with the legacy and persistence of structural racism in academic medicine in the United States. Until recently, the discourse and solutions have largely focused on augmenting diversity across the medical education continuum through increased numbers of learners from groups underrepresented in medicine (UIM). Despite deliberate measures implemented by medical schools, residency programs, academic institutions, and national organizations, meaningful growth in diversity has not been attained. To the contrary, the UIM representation among medical trainees has declined or remained below the representation in the general population. Inequities continue to be observed in multiple domains of medical education, including grading, admission to honor societies, and extracurricular obligations. These inequities, alongside learners' experiences and calls for action, led the authors to conclude that augmenting diversity is necessary but insufficient to achieve equity in the learning environment. In this article, the authors advance a 4-step framework, built on established principles and practices of antiracism, to dismantle structural racism in medical education. They ground each step of the framework in the concepts and skills familiar to medical educators. By drawing parallels with clinical reasoning, medical error, continuous quality improvement, the growth mindset, and adaptive expertise, the authors show how learners, faculty, and academic leaders can implement the framework's 4 steps-see, name, understand, and act-to shift the paradigm from a goal of diversity to a stance of antiracism in medical education.

Consideration of equality, diversity, and inclusivity as a higher function

Equality, inclusivity, and diversity remain pertinent topics in healthcare not only for the benefit of patients but also for the workforce. Schemes have existed for many years, but in spite of the progress being made, it remains necessary to reiterate the importance of these terms and to make a conscious effort to enforce them. This paper describes prejudices and stereotypes as a function of the Bayesian brain, beyond human control, and suggests that a higher function is needed to recognise and over-ride these innate thought processes.

Building Inclusive Work Environments

A truly inclusive organization cultivates a sense of belonging and value in its members, realizing their contributions are vital to its success. Acknowledging and then dismantling exclusionary systems and policies are essential to creating environments grounded in diversity and equity. This process requires intentionality, accountability, and swift action on the part of leadership. Additionally, the role of organizational accountability, through tracking performance metrics, gauging employee satisfaction and engagement, and routinely assessing identified goals and objectives, is critical to sustaining inclusivity. In this article, we present a review of the literature and offers recommendations to build and sustain an inclusive environment.

Medical Students' Experience of Harassment and Its Impact on Quality of Life: a Scoping Review

OBJECTIVES

Medical students' experiences of harassment and its influence on quality of life were examined.

DESIGN

A set of databases were employed in this review, and using ATLAS.ti, a set of emergent themes were identified.

RESULTS

The initial search identified 4580 potential articles for review. The inclusion and exclusion criteria reduced the list to 48 articles. Two predominant emergent themes were categorised as 'Antecedents' of 'harassment' and 'Consequences' on quality of life.

CONCLUSIONS

Harassment likely has an adverse impact on quality of life, although more empirical research is required to establish more definitive links between the two variables.

Medical Students' Experience of Harassment and Its Impact on Quality of Life: a Scoping Review

OBJECTIVES

Medical students' experiences of harassment and its influence on quality of life were examined.

DESIGN

A set of databases were employed in this review, and using ATLAS.ti, a set of emergent themes were identified.

RESULTS

The initial search identified 4580 potential articles for review. The inclusion and exclusion criteria reduced the list to 48 articles. Two predominant emergent themes were categorised as 'Antecedents' of 'harassment' and 'Consequences' on quality of life.

CONCLUSIONS

Harassment likely has an adverse impact on quality of life, although more empirical research is required to establish more definitive links between the two variables.

Rationale for the Design and Implementation of Interventions Addressing Institutional Racism at a Local Public Health Department

Purpose

The Bureau of Communicable Disease (BCD) at the New York City Department of Health and Mental Hygiene developed and implemented a multi-level intervention to: 1) establish bureau-wide race consciousness; 2) provide opportunities to examine the contemporary manifestations of racism impacting institutions and communities; 3) develop praxis applying a racial equity and social justice lens to communicable disease surveillance; and 4) center the experiences of Black, Indigenous, People of Color (BIPOC) staff.

Methods

A staff committee designed and implemented a multipronged initiative grounded in Public Health Critical Race (PHCR) praxis. The findings from a qualitative report focused on the experiences of POC staff formed the basis of the initiative.

Results

Three major themes were identified in the report (Microaggressions Report) as factors that resulted in institutional inequities within the workplace: race-based biases in promotion of staff; lack of opportunity sharing for professional growth; and dominant power relations silencing the voices of POC staff. Based on findings from the Microaggressions Report, BCD designed and implemented seven interventions including: 1) Racial Identity Caucusing; 2) Multimedia Learning; 3) All-staff Workshops; 4) Social Breakout Committee; 5) Surveillance and Data Equity; 6) Core Values Development; and 7) Committee for Hiring, Retention and Promotion.

Conclusion

We describe the rationale, design, and implementation of a multipronged intervention at a local health department as a strategy to address institutional racism. The creation of a Microaggressions Report and the PHCR methodology framed our ongoing effort to improve workplace culture and promote equitable opportunities for POC staff.

Where Do I Fit In? A Perspective on Challenges Faced by Asian American Medical Students

Asian American medical students (AAMSs) face significant bias in the medical learning environment and are more likely than White students to perceive their school climate negatively. Little is known about the factors that contribute to AAMSs' negative experiences. This perspective aims to describe AAMSs' experiences with diversity and inclusion efforts using survey data from a midwest regional conference, Asians in Medicine: A Conference on Advocacy and Allyship. AAMS respondents reported feeling excluded from diversity and inclusion efforts and conference participants advocated for institutional culture and climate assessments stratified by race and disaggregated into Asian subgroups.

Testing Two Student Nurse Stress Instruments in Chinese Nursing Students: A Comparative Study Using Exploratory Factor Analysis

Background

The development and transformation of nursing within professional tertiary education have exerted a great pressure and challenge upon nursing students. Stress experienced by nursing students is a common precursor of psychological distress and attrition. However, no scale is specifically used to evaluate the sources of stress experienced by nursing students in Mainland China. Aims and Objective. This study is aimed at testing and comparing the reliability and validity including sensitivity and specificity of two nursing students' stress instruments, the Chinese version of Student Nurse Stress Index Scale (SNSI-CHI), and the Stressors in Student Nursing Scale (SINS-CN) in Chinese nursing students, and describing the stress status of nursing students in China.

Methods

A cross-sectional survey was conducted in two nursing schools in Henan Province from August 2017 to January 2018. Data were collected by using a questionnaire comprising the Chinese version of SNSI (SNSI-CHI), the Chinese version of SINS (SINS-CN), and the Chinese Perceived Stress Scale (CPSS). Homogeneity and stability, content, construct and concurrent validity, and sensitivity and specificity were assessed.

Results

The Cronbach's alpha (α) of SNSI-CHI was 0.90, and the item-to-total correlations ranged from 0.35 to 0.66. The Cronbach's α of SINS-CN was 0.93, and the item-to-total correlations ranged from 0.19 to 0.61. The findings of exploratory factor analysis (EFA) confirmed a good construct validity of SNSI-CHI and SINS-CN. The Pearson's rank correlation coefficients, between total scores of SNSI-CHI and CPSS and SINS-CN and CPSS, were assessed to 0.38 (P < 0.01) and 0.39 (P < 0.01), respectively. Regarding the CPSS, as the criterion, the cut-points of SNSI-CHI and SINS-CN for the area under the receiver operator characteristic (ROC) curve were 0.77and 0.66, respectively.

Conclusion

Both scales are valid and reliable for evaluating the source of stress of student nurses in China. Each has its own characteristics, but the SNSI-CHI demonstrated marginal advantage over the SINS-CN. The SNSI-CHI is short, is easily understood, and with clear dimension for the nursing students, and the SNSI-CHI is more acceptable for the users in China.

Who is hurting? A prospective study of surgeon ergonomics

BACKGROUND

There is a paucity of prospective data related to surgeon ergonomics, which affects career longevity. Robotic surgical systems may mitigate pain and workload. We hypothesized that ergonomic outcomes would vary based on surgeon height and gender, and the relative benefit of robotic surgery would vary based on these demographics.

METHODS

Surgeons received questionnaires to fill out immediately before and after surgery to enable calculation of pain scores and task load. Surgeons who were ≤ 66 inches tall were considered "short". Univariable and multivariable regression analyses were performed where appropriate using Stata-MP version 14.2 (StataCorp LLC, College Station, TX).

RESULTS

There were 124 questionnaires given to 20 surgeons; 97 (78%) were returned, and 12 (12%) laparoscopic operations were excluded, leaving 85 (69%) questionnaires for further analysis: 33 (38%) from short surgeons, and 24 (28%) from women, for 30 (35%) robotic and 55 (65%) open operations. There were 44/85 (52%) surgeons who reported worse pain after surgery. Overall pain scores (1.1 ± 2.6 vs 1.5 ± 2.6, p = 0.70) were similar for robotic and open operations. In multivariable analysis, greater surgeon pain scores were significantly associated with short surgeons (p < 0.001), male surgeons (p < 0.001), and long operative times (p = 0.03). Physical demand was lower for robot vs open operations (median 10 vs 13, p = 0.03). When short surgeons (p = 0.04) and male surgeons (p = 0.03) were examined as sub-groups, lower physical demand during robotic operations persisted, but was lost when only examining tall surgeons (p = 0.07) and female surgeons (p = 0.13).

CONCLUSIONS

Short surgeons and male surgeons reported significantly more pain after both open and robotic operations but had less physical demand when using the robotic system. Future work should focus on mitigation of surgeon height-related factors and seek to understand ergonomic gender differences beyond height.

Assessment of Perceptions of Professionalism Among Faculty, Trainees, Staff, and Students in a Large University-Based Health System

Importance

With a renewed focus on medical professionalism, an opportunity exists to better define its standards and application to meet the needs of an increasingly diverse workforce given the important association between interprofessional behavior and patient care.

Objective

To examine the context of how professionalism is operationalized and perceived in diverse health care work and learning environments.

Design, Setting, and Participants

A qualitative mixed-methods analysis of survey data collected from February to April 2015, was conducted followed by analysis of narrative data collected in June 2017. The setting was 2 health systems and 4 health professional and graduate schools. Participants were faculty, trainees, staff, and students (3506 survey respondents and 52 narratives) affiliated with the University of Pennsylvania and the University of Pennsylvania Health System. Data analysis was conducted in 2018 and 2019.

Exposures

Independent variables included the following respondent characteristics: gender identity, sexual orientation, race/ethnicity, position, generational age group, length of employment at institution, disability status, belief system or religion, and primary site of work or study.

Main Outcomes and Measures

Survey questions were used to assess participants' perception and experiences of professionalism in the workplace as measured by a 5-point Likert-type scale.

Results

For the survey, there were 3506 respondents from a pool of 18 550 potential respondents (18.9% response rate). Of 3506 survey respondents, 2082 of 3231 (64.4%) were women, 331 of 3164 (10.5%) identified as gender or sexual minority groups, and 360 of 3178 (11.3%) were non-Hispanic Black individuals. In adjusted analyses, women compared with men (adjusted odds ratio [aOR], 1.8; 95% CI, 1.4-2.3) and Asian individuals (aOR, 2.0; 95% CI, 1.7-2.3) and Hispanic individuals (aOR, 2.0; 95% CI, 1.4-2.7) compared with non-Hispanic White individuals were more likely to value institutional professionalism. In addition, gender identity and sexual minority groups compared with heterosexual respondents (aOR, 1.5; 95% CI, 1.2-1.8) and non-Hispanic Black individuals compared with non-Hispanic White individuals (aOR, 1.3; 95% CI, 1.2-1.4) were statistically significantly more likely to consider changing jobs because of unprofessional behavior at work. The qualitative analysis of narratives revealed that marginalized populations (including but not limited to women, gender and sexual minority groups, racial/ethnic minority groups, those who identify as having a disability, and religious minority groups) reported (1) greater infringements on their professional boundaries, as well as increased scrutiny over their professional actions, and (2) a tension between inclusion vs assimilation.

Conclusions and Relevance

The findings of this study highlight the need for health care organizations to revisit how they define and operationalize professionalism to improve inclusivity.

"Not a Woman-Question, But a Power-Question": A Qualitative Study of Third Parties on Psychological Violence in Academic Medicine

Background

Psychological violence is a persistent issue in academic medicine and affects the health and safety of health care workers. This violence is also debated as part of medical culture. Third parties, persons learning about violations after it happened, may provide an understanding of the interplay between gender and psychological violence. Perspectives on research on psychological violence in academic medicine are currently lacking.

Methods

In this qualitative exploratory study, interviews were conducted with women from a working group on equal treatment at one medical university in Austria. This group monitors discrimination and harassment and consists of medical doctors, natural scientists, administrative staff, and students. To recruit participants, an email invitation was sent to members of the working group. Of 20 eligible persons, 12 women participated. After written consent from participants, individual interviews were conducted face-to-face, audio-recorded, and transcribed verbatim. Data were analyzed with grounded theory.

Findings

Participants described a firm organizational culture with persistent, historically grown gendered structures. Potential threat of psychological violence affected mostly “weaker,” less powerful persons, and often women. Descriptions of violence indicated harm to those affected, but intent to harm was doubted. Interventions strengthened the individual, but some participants demanded collective responsibility.

Conclusion/application to practice

Few descriptions could be classified as psychological violence. Findings indicated a need to change organizational cultures where lower positions pose a potential threat to experiencing harm. Occupational health practice should include training in sensitization to psychological violence, protection of those targeted, deconstructing power accumulation, and promoting diversity in career patterns and working styles.

Consequences of Medical Hierarchy on Medical Students, Residents, and Medical Education in Otolaryngology

Objective

To (1) review concepts of medical hierarchy; (2) examine the role of medical hierarchy in medical education and resident training; (3) discuss potential negative impacts of dysfunctional hierarchy in medical and surgical training programs, focusing on otolaryngology; and (4) investigate solutions to these issues.

Data Sources

Ovid Medline, Embase, GoogleScholar, JSTOR, Google, and article reference lists.

Review Methods

A literature search was performed to identify articles relating to the objectives of the study using the aforementioned data sources, with subsequent exclusion of articles believed to be outside the scope of the current work. The search was limited to the past 5 years.

Conclusions

Two types of hierarchies exist: “functional” and “dysfunctional.” While functional medical hierarchies aim to optimize patient care through clinical instruction, dysfunctional hierarchies have been linked to negative impacts by creating learning environments that discourage the voicing of concerns, legitimize trainee mistreatment, and create moral distress through ethical dilemmas. Such an environment endangers patient safety, undermines physician empathy, hampers learning, lowers training satisfaction, and amplifies stress, fatigue, and burnout. On the other hand, functional hierarchies may improve resident education and well-being, as well as patient safety.

Implications for Practice

Otolaryngology–head and neck surgery programs ought to work toward creating healthy systems of hierarchy that emphasize collaboration and improvement of workplace climate for trainees and faculty. The goal should be to identify aspects of dysfunctional hierarchy in one’s own environment with the ambition of rebuilding a functional hierarchy where learning, personal health, and patient safety are optimized.

Quantifying gender disparity in physician authorship among commentary articles in three high-impact medical journals: an observational study

BACKGROUND

Scholarship plays a direct role in career advancement, promotion and authoritative recognition, and women physicians remain under-represented as authors of original research articles.

OBJECTIVE

We sought to determine if women physician authors are similarly under-represented in commentary articles within high-impact journals.

DESIGN/SETTING/PARTICIPANTS

In this observational study, we abstracted and analysed author information (gender and degree) and authorship position from commentary articles published in three high-impact journals between 1 January 2014 and 16 October 2018.

PRIMARY OUTCOME MEASURE

Authorship rate of commentary articles over a 5-year period by gender, degree, authorship position and journal.

SECONDARY OUTCOME MEASURES

To compare the proportion of men and women physician authorship of commentaries relative to the proportion of men and women physician faculty within academic medicine; and to examine the gender concordance among the last and first authors in articles with more than one author.

RESULTS

Of the 2087 articles during the study period, 48% were men physician first authors compared with 17% women physician first authors (p<0.0001). Of the 1477 articles with more than one author, similar distributions were found with regard to last authors: 55% were men physicians compared with only 12% women physicians (p<0.0001). The proportion of women physician first authors increased over time; however, the proportion of women physician last authors remained stagnant. Women coauthored with women in the first and last authorship positions in 9% of articles. In contrast, women coauthored with men in the first and last author positions, respectively, in 55% of articles.

CONCLUSIONS

Women physician authors remain under-represented in commentary articles compared with men physician authors in the first and last author positions. Women also coauthored commentaries with other women in far fewer numbers.

Implicit Bias: What Every Pediatrician Should Know About the Effect of Bias on Health and Future Directions

Implicit bias has entered modern discourse as a result of our current sociopolitical climate. It is an area that has been largely explored in the social sciences, and was highlighted in the landmark 2003 IOM report, Unequal Treatment, as a contributor to racial/ethnic health disparities. Implicit bias is the process of unconscious societal attitudes affecting our individual understanding, actions and decisions, thus leading to assumptions about groups. Immigrant populations are particularly at risk in our present-day environment, and as a result experience limited healthcare access and higher levels of psychological distress. There are many measures of implicit bias, but the most highly regarded tool is the Implicit Association Test (IAT), as it is valid and reliable. Some level of pro-White/anti-Black bias has been found in most systematic reviews and studies, although there are less studies on bias towards Latinx populations. Limited evidence exists about the association between implicit bias and health outcomes. However, existing publications have demonstrated clear associations between bias and treatment recommendations, nonverbal communication, adverse birth outcomes and provider communication styles. Implicit biases can be unlearned via debiasing strategies, but these have not been examined extensively amongst health care providers. Future research must rely on more than pre- and post-IAT measurements to examine the effect of these strategies on improving patient outcomes. Additionally, healthcare system leadership must prioritize implicit bias trainings for students and medical staff and make greater tangible efforts to improve workforce diversity as a debiasing strategy.

Measuring Organizational Cultural Competence to Promote Diversity in Academic Healthcare Organizations

Purpose: To evaluate what drives respondent perceptions of health system organizational cultural competence. Methods: We estimated associations between survey respondent (n=3506) demographic characteristics, length of employment, position, and place of work and their reported perceptions of institutional culture. Results: In adjusted analyses, respondents self-identifying as non-Hispanic black versus non-Hispanic whites, females versus males, and lesbian/gay/bisexual/transgender/queer versus heterosexuals were significantly less likely to rank the cultural competence of their organization above average. Conclusion: Minorities and women were less likely to rank their organization as culturally competent. Organizational efforts to achieve cultural competency would benefit from measuring this factor to target their efforts.