Power Dynamics Perpetuate DEI Inaction: A Qualitative Study of Community Health Clinic Teams

INTRODUCTION

Team-based care, established as the gold standard model for providing care more than a decade ago,¹ allows integrated clinical teams with different and complementary skills and perspectives to provide efficient, high-quality health care services to diverse patient populations. Within clinical teams, White individuals typically hold positions with the greatest power in the medical hierarchy (eg, physicians), whereas those of minoritized racial-ethnic identity groups/persons of color (POC) typically occupy positions with the least power (eg, medical assistants), exacerbating societal issues related to discrimination, injustice, and inequity.^2-7 (See Supplemental Appendix 1 for terms used in this article and related terms.) Little is known about experiences of race and role power dynamics within community health clinic teams and how these interactions impact clinic culture. Furthermore, few studies have evaluated the perspectives of staff members in roles with lower power who are disproportionately POC and comprise a majority of the health care team. The aim of our study was to understand the perspectives of clinic staff members across races and roles in order to inform future interventions to improve health care teams with respect to diversity, equity, and inclusion (DEI, also referred to as EDI) and more effectively address race-related issues within health care.

METHODS

RESULTS

DISCUSSION

Using a critical-ideological approach, we set out to understand the race-related experiences of community health clinic team members, focusing on those with the least amount of power in the clinic. Overall, we identified 3 key findings: (1) POC team members experience hidden challenges related to managing an emotional burden that White team members are not aware of; (2) those with the least amount of power in the clinic (ie, support staff who identify as POC) bear the brunt of the burden and paradoxically have the least amount of power to bring about change, resulting in DEI inaction; and (3) relationship building provides a buffer to race-related experiences and is, to some extent, reparative and protective for POC team members.

Our first key finding was that POC team members across clinic roles face hidden challenges regarding the time and effort needed to internally manage discriminatory experiences and to accommodate and thereby continue operating day-to-day in the workplace. These findings align with scholarly work examining the emotional outcomes and psychological damage of race-related events,^12-15 and work examining race and role power dynamics in the workplace^16,17 wherein POCs mask emotions of anger, disbelief, and frustration to ensure a task or process continues to run smoothly in the moment.¹⁸ Further, in response to being dismissed or devalued when reporting discriminatory incidents, racial-ethnic minorities bury triggering incidents as a means of protection from further internal damage.^13,19 Finally, findings illustrate that clinic members with greater race-based and role-based power (ie, White clinicians and clinic leaders) remain largely unaware of the energy expended by POC.

Perhaps the most compelling finding of the current study, our second key finding, is that the intersectionality between race and role perpetuates discrimination and DEI inaction in the clinic space. Given that support staff roles are often occupied by POC, the additive effect of race-based and role-based power dynamics produces a workplace environment primed for biases to exist without acknowledgment, as those with greater power are often unaware of the negative experiences of those with less power.²⁰ This finding is consistent with conclusions from recent literature exploring and determining why race-related issues persist in workplace settings, including health care.^19-23 Those injured also have little power to bring about systemic change because of the deeply embedded hierarchy in health care, meaning that these dynamics continue largely unchecked. Further, when POC staff members take a risk and put themselves in a vulnerable place to raise concerns, White staff members tend to close the conversation, which prevents any opportunity for repair.^19,24 Given that these dynamics perpetuate inaction, deliberate rebalancing of power will have to be done by those who are currently in positions of power.

Our third key finding is that both interpersonal actions and system-level changes are necessary for cultural shift. Previous work exploring elements contributing to healthy workplace cultures aligns with this finding^25-27 and shows that without a sense of belonging and value, diversity and equity efforts are not lasting in the workplace.²¹ Given the efficiency expected in health care and that the medical hierarchy does not lend itself to equal valuation across roles, relationships often default to being transactional with minimal positive feedback for team members, especially support staff. Meaningful demonstrations of antiracism require an investment of time and effort that show genuine commitment amid competing demands by leadership.²⁶ On the basis of our finding that time invested in developing relationships within teams, active recognition of staff members’ contributions, and tangible antiracism action steps demonstrated by leadership foster safety and equity, we recommend that leadership take on the onus of identifying and offering repeated, experiential, and interactive trainings grounded in improving relationships among team members as alternatives to ineffective one-time DEI trainings.

This study has both limitations and strengths. First, although researcher bias is inevitable as acknowledged in our critical-ideological paradigm,^8,9 investigators attempted to mitigate this bias by using a standardized interview tool, involving trained graduate-level research assistants, and offering participants the choice of interviewer based on shared racial-ethnic identity.²⁸ Several staff members commented, without being prompted, that they felt comfortable sharing explicit thoughts with a POC interviewer and that they would have not been as open or would have declined to share these experiences if interviews had been conducted solely by White interviewers. Second, the use of a virtual platform may have limited connectedness and sense of safety during the interviews because of minor sound quality issues and reduced ability to communicate nonverbally.²⁹ POC participants, however, often expressed gratitude at the end of their interview for being intentionally recruited and having dedicated time and space to reflect on and share their race-, ethnicity-, and role-related experiences. Lastly, we ensured strong ecological validity through a robust and diverse sample across clinic location, participant role within the medical hierarchy, and individual identity. The current study focused on race as a foundation rather than on other marginalized identities (eg, gender, socioeconomic status, ability); therefore, addressing intersectionality is outside the scope of this study, and would be a good direction for future research. Another future research direction includes evaluation of impact of system DEI initiatives on diverse staff. Two coauthors (L.M.R. and S.P.M.) conducted this inquiry into existing and subsequently implemented DEI initiatives in the same FQHC system (eg, workshop in trauma and resilience including from racism and bias, appointment of executive sponsors to DEI work groups, and required online education modules); a manuscript describing that undertaking is in preparation.

CONCLUSIONS

Although it is important to address health disparities for POC patients, it is equally important to “look in-house” by examining the racial-ethnic dynamics within health care teams. The fact that staff occupying positions with less power are also disproportionately POC is both an explanation for why race and role dynamics persist within clinics, and also a complicating factor for effectively addressing these dynamics. By attending to this group through opportunities to report issues and work through complex dynamics as a team, there is healing for all—the individuals themselves, as well as those with more power—even as solutions are in progress.