Here, we will critically reflect on the development process and the content of the Diversity Compass. Additionally, we will provide some recommendations for future research and practice.
The development process
First, we would like to reflect on the PD process that we used to develop the Diversity Compass. PD is based on the assumption that inclusion of stakeholders, and particularly engaging in co-creation together with end-users, is beneficial for the quality and feasibility of a new intervention [41, 43]. It has been argued before that participatory approaches are valuable for developing and evaluating (dialogical) CES instruments [36, 48]. Participation may also help with bridging the gap between research and practice [49], as well as with creating momentum, ownership of the intervention and a network of relations, which all increase the likelihood of attaining practical implementation and social impact [39, 40]. By engaging in dialogue with different stakeholders for a period of thirteen months in this study, we tried to facilitate more awareness of social injustices, different perspectives and experiences of diversity and inclusion and the importance of addressing diversity-related moral challenges regularly and at different levels throughout the healthcare organization.
Nonetheless, creating and executing a developmental process for a CES instrument that is congruent with the subject matter itself, i.e. diversity and social justice, is in itself a moral challenge. Especially when considering the extent to which this study fully achieved to be participatory, dialogical and inclusive. Although we tried to be as inclusive as possible in the different phases of the PD process, also by actively including and listening to the voices of several peer-experts and (former) patients, some perspectives were missing, such as that of informal caregivers. This is an important criticism related to social justice, specifically as dealing with the moral challenges that were discussed in this study and in the Diversity Compass itself, is strongly dependent on who has a seat at the table. Additionally, the exclusion of those with marginalized voices perpetuates epistemic injustices despite best intentions [39]. Therefore, we acknowledge that including additional and different stakeholders in the study could have offered insights that might have influenced the developmental process and outcome. Also, in future research, the perspectives of care-receivers have to be included actively when evaluating the deliberation process and outcomes of using the Diversity Compass.
Moreover, it is important to critically reflect on our own role and position as people and ethicists in facilitating the PD process that led to the Diversity Compass. We actively participated in the production of the instrument. Rather than being neutral observers, our own social location and normative background as people, ethicists and researchers influenced our interaction with the participants and the set-up and outcome of this study.
The team that facilitated the development of the Diversity Compass consisted of white, cisgendered women with different western European backgrounds and at different stages of their academic careers. The limited cultural and gender diversity in the composition of the research team may have contributed to researcher bias and can therefore be considered a limitation. While we hope to have mitigated potential blind spots and biases as much as possible by engaging in a co-creative process with individuals with various intersectional social identities and we actively sought feedback and support from professionals with different minoritized identity characteristics, we are aware that our personal background influenced the conception, process and outcome of this study.
Additionally, from a methodological and normative standpoint, our approach to doing ethics in healthcare is routed in philosophical pragmatism, hermeneutic ethics and discourse ethics and is based on the idea that moral learning takes place by deliberating on concrete experiences, contextual knowledge and by placing yourself in the shoes of others [25, 28, 31,32,33, 36]. This also means that content ought to be determined together and knowledge is dependent on the stakeholders, process and specific context in which reflection takes place [2]. This approach is different to other CES contexts and strongly defines the developmental process we engaged in here, i.e. by facilitating dialogue to develop a dialogical CES instrument. Other normative approaches to CES, likely would have led to a different process and tool.
Moreover, the study was financed by the healthcare organization itself. We were invited as ethicists and researchers by the diversity officer of the healthcare organization to develop a tool to promote diversity-responsiveness. Additionally, some of the participants were recruited from the personal network of this diversity officer, who was also a director of the organization, which likely lead to elements of bias in some of the group compositions. Both considerations raise questions regarding our own impartiality, independence and biases in the developmental and recruitment process that led to the Diversity Compass. The setting also creates the possibility of a conflict of interest: carrying out our study in a way that is fully in accordance with our academic and ethical bonafide way is possibly at odds with completing our assignment in a way that is satisfactory to the organization who issued it. What if the organization was not happy with the outcomes or tools? What if we needed more time and resources for our study? What mitigated the risk of biases and a conflict of interest, was that we discussed these issues upfront and stressed the importance of our own independence and freedom in shaping and conducting the study. The organization could agree on this. Before the start of the project, we wrote an elaborate research proposal including our planning, approach, (recruitment) methods and envisioned outcomes. This created a situation in which this risk was not fully eradicated, but at least expectations on both sides were managed from the start and we tried to address inherent biases as much as possible.
Furthermore, in we believe that a risk of a conflict of interest is immanent to practically all situations where clinical ethicists engage in studies together with healthcare organizations and professionals that seek to change practices [25]. Especially in participatory research, those with lived experience (participants) and external researchers engage and learn with each other in order to challenge traditionally asymmetric relationships and move towards an inclusive approach where they can create new ways of acting and knowing, together [39]. This presupposes interdependency and immersion of the researcher in practice, rather than a detached, independent and supposedly ‘unbiased’ researcher.
The Diversity Compass
A vast body of evidence has shown that health care needs are unequally met across social communities, linking social inequalities to structural health disparities among different, minoritized patient populations [3, 8,9,10,11,12]. Additionally, there is unequal gender and minority representation in the healthcare workforce, especially among physicians [13]. This demonstrates disparities in recruitment and is another challenge in achieving equity in organizations [12, 14] and promoting cultural competence in health and care [15]. Dealing with these inequities requires a systemic approach. However, supporting healthcare professionals to recognize and attend to patients’, colleagues’ and their own social identities that can underlie their moral perspectives, may contribute to more inclusive and just work environments, and help professionals with providing good care for all.
The objective of the Diversity Compass is to support healthcare professionals to reflect on and address moral challenges related to intersectional aspects of diversity and social justice issues that they experience in daily practice in a structured, dialogical way. The goal is to stimulate moral awareness, learning and dialogical competences among healthcare professionals and help them with delivering diversity-responsive care by actively considering their own and others’ social identities. In a way, the process that led to the development of the Compass may thus be seen as part of the objective and outcome of this study. This is because we facilitated dialogue with different stakeholders about their perspectives on and experiences with diversity and social justice, thereby trying to create awareness and facilitating reflection on those very subjects throughout this study.
Furthermore, on purpose, the Diversity Compass provides no answers or concrete moral judgments regarding the right thing to do in a specific situation in which someone experiences a diversity-related moral challenge. Rather it consists of seven recommendations and a dialogical reflection method. This is different to the way diversity is often approached in bioethics, i.e. by mainly addressing theoretical concerns when balancing diversity with other ethical principles, or reflecting on moral pluralism and cultural diversity in general [50, 51]. However, this approach is similar to other dialogical methods in CES and ethics education [27, 30, 31, 36, 52].
Some benefits of the Diversity Compass are that it was designed to respond to the needs of end-users, can be used flexibly and independently by different care professionals and, most importantly, that it is specifically tailored to addressing diversity-related moral challenges in healthcare practice. Given increasing social pluralism, diversity in social identities and existing disparities in care access and practices [3, 8,9,10,11,12], it is necessary to provide support with facilitating more inclusive and diversity-responsive care and work environments [16, 24] and to do so by taking an intersectional approach [19, 20, 53]. The Diversity Compass was designed to respond to this need. It is a practical, low-threshold instrument that can be used in different healthcare contexts and is responsive to the inherent complexity of engaging in dialogue on various moral perspectives between different, minoritized and majoritized stakeholders.
However, despite these benefits, reflecting on diversity-related moral challenges requires modesty and vigilance. It is important to watch out for problematic stereotyping and to address biases, blind spots and potential pitfalls, also regarding the content of the Diversity Compass. The Diversity Compass is a dialogical instrument. However, dialogical practice does not guarantee that the process of the dialogue or its outcome is inherently just or morally good, and actually does what it tries to accomplish. Therefore, a key issue regarding the Diversity Compass refers to the question how and whether this instrument can ensure an inclusive and diversity-responsive reflection process and deliberative outcome.
This is particularly concerning as others have argued that healthcare professionals may specifically refer to cultural differences between themselves, patients, families, or populations, as a way to mask their own ethical uncertainties, biases, racism or moral distress [16, 21]. Also, it has been argued that normalization of or indifference towards social hierarchies, privileges and disadvantages remains a challenge in Dutch healthcare organizations that particularly impact minoritized healthcare professionals [54]. When considering the dialogical nature of the Diversity compass this may, for instance, mean that professionals who discuss a case could end up over-problematizing certain aspects of diversity or someone’s social identity as the reason for why they experience a situation as morally troublesome, rather than detecting systemic social justice issues or gaining insight into personal prejudices instead of blaming the Other. Personal and systemic blind spots and biases may lead to a lack of awareness of social inequities [22, 23]. These considerations signify a key challenge for using a dialogical intervention like the Diversity Compass, where the particularities (and perceptions of the quality and inclusiveness) of the process and outcome is dependent on those participating in the deliberation.
A cornerstone of the Diversity Compass are the seven recommendations which we consider necessary to uphold when engaging in the actual deliberation method in order to facilitate a safe environment for dialogue to occur. This means that being attentive to feelings, recognizing and reflecting on personal prejudices, showing earnest curiosity, respect, the will to engage in dialogue, to support each other and facilitate safety and trust as much as possible, are central to creating the necessary conditions in which the reflection method should be used. Organizations and professionals have a shared responsibility to facilitate an inclusive space in which non-hierarchical dialogue can occur, power relationships can be addressed and a moral judgment can be formulated that actually promotes diversity-responsive care and equity within organizations, rather than, for instance, encouraging stereotypes, racism or unsafe environments for minoritized others. However, there is no definitive certainty that the Diversity Compass will always be used to this end.
A final issue relates to the implementation of the Diversity Compass and to the question to what extent it actually contributes to more inclusion and diversity-responsiveness in care and work environments. Sara Ahmed has rightly warned for the ‘non-performativity’ of doing diversity in organizations: diversity documents are often mere paper trails with no, or little actual effect on transforming institutions or facilitating more equality [55]. Although Ahmed focusses on the (non)effect of policies rather than on ethics support instruments, this concern also applies here. Others have also argued that employing CES instruments structurally, is key to ensure that attention for the ethical dimension of care is meaningful and ongoing [34]. Moreover, a single instrument like the Diversity Compass alone is not sufficient to address diversity-related moral challenges and facilitate social justice and organizational change. Rather, different organizational strategies, policies, ethics and diversity training and interventions ought to be implemented and dialogue should occur regularly at all levels of healthcare organizations in order to create an environment that is safe and inclusive of all [56] and where diversity-responsiveness becomes the norm. Working toward social justice requires a structural and systemic approach in organizations [16, 26].
Recommendations
The Diversity Compass is designed with and for a particular healthcare organization based on the wishes and needs of the healthcare professionals that participated in its development. It is currently embedded within a diversity toolbox that is used by professionals in the diversity ambassador network that were key contributors to the development of the instrument, in their daily work environments. However, further research is required on the feasibility, effectiveness and implementation of the Diversity Compass. This includes studying if, where and how (frequently) the dialogical CES instrument is being used and whether it actually contributes to moral learning on diversity and social justice issues and to more inclusive care and work environments in practice.
Additionally, future research is necessary to critically reflect on and examine how diversity issues can be addressed in a recurring and systematic way and at different levels of healthcare organizations through dialogical CES, including in policy, care strategies and recruitment, in order to facilitate sustainable change towards increasing social justice in healthcare organizations. It is likely that, to achieve desirable and long-term change, healthcare organizations should structurally implement and integrate the Diversity Compass into existing team meetings at different levels of the organization. This also requires training healthcare professionals and managers to use the tool in the way it is intended, i.e. by adhering to dialogical principles.
In order to make healthcare more diversity-responsive and just with the help of CES, an instrument like the Diversity Compass is not enough. It cannot stand on its own. Rather, we believe that facilitating diversity-responsiveness and equity requires a comprehensive approach that combines different interventions, including suitable organizational policies and strategies, training, ethics and diversity education and continuous reflection and dialogue at all levels of an organization. This also means that clinical ethicists themselves should be trained to engage in more diversity-responsive practices in the CES they provide and the reflection tools they develop. Furthermore, an inclusive organizational culture and ethical climate – in which dialogue about social justice is valued, and in which moral questions related to diversity are attended to and approached with care and accountability – are necessary prerequisites to safely reflect on diversity-related moral challenges in systems where hierarchies and power relationships exist. Thus, the Diversity Compass should be part of a structural endeavor to promote diversity-responsiveness and social justice in healthcare organizations.
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