대학의학에서 다양성(Diversity)과 포용(Inclusion) 측정: The Diversity Engagement Survey (Acad Med, 2015)

대학의학에서 다양성(Diversity)과 포용(Inclusion) 측정: The Diversity Engagement Survey (Acad Med, 2015)

Measuring Diversity and Inclusion in Academic Medicine: The Diversity Engagement Survey

Sharina D. Person, PhD, C. Greer Jordan, PhD, MBA, Jeroan J. Allison, MD, MS,

Lisa M. Fink Ogawa, PhD, RN, CNE, Laura Castillo-Page, PhD, Sarah Conrad, MS,

Marc A. Nivet, EdD, MBA, MS, and Deborah L. Plummer, PhD, MEd

지속적인 건강 불평등, 인구구조의 변화, ACA이후 보험 환자의 증가 등으로 인해 이제 졸업할 의사들이 보다 다양해지고 첨단의 진료에 준비되게끔 하고, 문화적인 역량을 갖추게끔 하는 것이 미국 academic medical center의 과제가 되고 있다. 따라서 여러 기관이 다양성과 포용에 대한 자신의 역량을 평가하고 이를 통해 얻은 insight에 적절히 반응하는 것이 필요하다.

Persistent health disparities,1 changing population demographics,2 and growing numbers of insured patients following the enactment of the Affordable Care Act3 make graduating a diverse physician and scientific workforce prepared to advance high-quality, culturally competent health care and research increasingly challenging for U.S. academic medical centers. Therefore, it is imperative for institutions to assess their organizational capacity for diversity and inclusion and respond effectively to insights gained.4

DES(Diversity Engagement Survey)를 만들어서 AMC가 지역사회의 다양성에 어떻게 대응하고 있는지 측정하였다.

We created the Diversity Engagement Survey (DES) to measure how well academic medical centers are responding to the diversity of their community members (i.e., their faculty, staff, and students).

방법

Method

배경

Background

DES를 뒷받침하는 요인들은 수년간의 다양성/포용/관여에 관한 문헌 고찰과 이를 다양성관리에 적용해본 경험에서 나온 것이다. 앞서 12개 조직에서 이 도구를 반복적으로 사용해 본 결과, 그 기관의 구성원이 다양성에 대해서 가진 관점을 평가하는데 유용했다. 그러나 진단을 하거나 미래에 어떤 식으로 intervention을 해야하는지에 있어서는 효과적이지 않았다. 도구의 효과성을 개선하기 위해서, 어떻게 각 기관의 문화적 조건이 관여와 포용에 의해서 영향을 받는지 알아보았다.

The factors that undergird the DES emerged from years of study of the diversity, inclusion, and engagement literature and applied diversity management experience. Previous iterations of the instrument were used with 12 organizations (6 corporations, 4 hospital systems, 1 government agency, and 1 social service organization). These previous iterations were useful in evaluating perspectives about diversity among individuals at the participating institutions. However, they were not as effective in providing diagnostic data and strategic direction for future interventions. To improve the effectiveness of the instrument, we recognized the need to focus on how the cultural conditions of an institution are influenced by the interplay of engagement and inclusion.

DES의 개념 근간

Conceptual underpinnings of the DES

문화, 분위기, General purpose engagement survey와 달리, DES는 관여와 포용에 관하여 기관의 문화와 사회적 역동적 측면을 보여주기 위한 것이고, 문화와 사회적 역동(institutional culture and social dynamics)은 생산성과 고용 안정에 강하게 관련되어 있디고 알려진 관여와 포용(engagement and inclusion)에 관계가 있다고 알려진 바 있다.

Unlike culture, climate, or general purpose engagement surveys the DES is designed to reveal the aspects of institutional culture and social dynamics related to engagement and inclusion that have been shown to be the most strongly related to productivity and employee retention.5,6 

DES 프레임워크에서 다양성은 인간의 다름에 관함 모든 측면을 포괄하며, 포용, 상호존중, 다양한 관점에 대한 인식 등을 포함하는 핵심 가치이다. 포용(Inclusion)은 개개인이 정보에 접근하고, 소속감, 직업안정성, 사회적 지지를 느끼는 것에 영향을 주는 사회적 프로세스의 집합이다. 다양한 관점/경험/지식을 포용하는 조직 문화가 없이는 다양성의 잠재력은 온전하게 실현될 수 없다.

Within the DES framework (described below), diversity is conceptualized as encompassing all aspects of human differences and is viewed as a core value that embodies inclusiveness, mutual respect, and awareness of multiple perspectives.7 Inclusion is conceptualized as a set of social processes that influence an individual’s access to information and sense of belonging, job security, and social support received from others.8,9 Without an institutional culture that supports the inclusion of the differences in perspectives, life experiences, and knowledge that individuals bring to the institution, the full potential of diversity cannot be realized.4

조직의 모든 구성원이 참여하게끔 하는 것은 진정으로 포용성있는 AMC를 만드는 토대이다. 성공적인 참여는 기본적 지능적/정서적 요구를 충족시켜줌으로부터 시작될 수 있다.

Engagement of every member of the institution is the foundation on which a truly inclusive academic medical center is built. Successful employee engagement is derived from meeting the basic intellectual and emotional needs of workers.10–14

참여는 비전과 조직의 목적을 공유하는 것, 동지애(camaraderie), 구성원의 기여에 대한 인정 등으로부터 싹튼다.

Engagement results from cultural conditions that foster a shared sense of the vision and purpose of the organization as well as camaraderie and appreciation of employees’ contributions to the institution.

• 비전과 목적의 공유: 조직의 미션에 기여해야 하는 정당한 근거를 제시 A sense of vision and purpose provides employees with a compelling reason to contribute to the organization’s mission.
• 동지애: 소속감을 제공함과 더불어 주변에 손을 내밀 수 있게 만들어줌 Camaraderie gives employees a sense of belonging and provides them with opportunities to reach out and personally connect with those around them.
• 인정: 조직에 대한 개개인의 기여와 가치를 인정해줌 Appreciation recognizes individuals’ contributions and values what each person brings to the organization.

DES 프레임워크

The DES framework

• 1. 공동의 목표 
  1. Common purpose: Individuals experience a connection to the mission, vision, and values of the organization.
• 2. 신뢰
  2. Trust: Individuals have confidence that the policies, practices, and procedures of the organization will allow them to bring their best and full self to work. 
• 3. 개인의 기여에 대한 인정
  3. Appreciation of individual attributes: Individuals perceive that they are valued and can successfully navigate the organizational structure in their expressed group identity. 
• 4. 소속감 
  4. Sense of belonging: Individuals experience their social group identity as being connected with and accepted in the organization. 
• 5. 열려있는 기회 
  5. Access to opportunity: Individuals perceive that they are able to find and utilize support for their professional development and advancement.
• 6. 동등한 보상과 인정
   6. Equitable reward and recognition: Individuals perceive the organization as having equitable compensation practices and nonfinancial incentives. 
• 7. 문화적 역량
  7. Cultural competence: Individuals believe the institution has the capacity to make creative use of its diverse workforce in a way that meets business goals and enhances performance. 
• 8. 존중
  8. Respect: Individuals experience a culture of civility and positive regard for diverse perspectives and ways of knowing.

DES 도구

The DES instrument

문헌조사와 현장경험으로부터 문항을 개발함. 22개 문항, 8개의 참여와 포용 요인들. 각 문항은 기관과 구성원의 관계의 핵심을 잡아내기 위하여 만들었으며, 개개인이 기관의 현실을 어떻게 느끼는지에 대해서 알아보려는 것이 아니었음. 모든 문항은 1인칭, 긍정형으로 서술되어 있음. 마지막으로 주관식 문항 포함.

We proposed survey items derived from a review of literature and our own experience in the field relative to the framework’s factors. The final DES consisted of 22 items chosen to reflect the eight engagement and inclusion factors (see Table 1). Each item was created to capture the essence of the relationship between the institution and its members, not individuals’ perceptions about how they, and those who share a group identity with them, perceive or experience institutional practices. All items were written in the first person and phrased positively. We also included a final open-ended question (“If you wish, please provide additional comments on the diversity and inclusion efforts”) to provide the respondents the opportunity to express any concerns, insights, or experiences related to their institutional context.

5점척도

All responses on the 22-item instrument were scored on a 5-point Likert scale

파일럿 테스트

Pilot testing and survey implementation

안면 타당도와 내용 타당도는 저자 중 1명이 소속한 기관의 대표 응답자들로 구성된 리뷰 패널이 평가하였음. 동일한 설문을 한 개의 AMC에서 2011년 3월 파일럿 설문 시행함. 이후 전 AAMC와 the Group on Diversity and Inclusion 를 통해서 전 AAMC 소속 기관에 설문 응답을 요청. 이후 추가적으로 13개의 AMC에서 시행

Face and content validity of the survey were assessed and improved through a review panel consisting of representative respondents at the home medical institution of one of the authors. The same survey was piloted at an academic medical center in March 2011. After the pilot, an invitation to participate in the survey benchmarking process was sent through the Association of American Medical Colleges (AAMC) and the Group on Diversity and Inclusion to all AAMC member institutions. The survey was subsequently administered to 13 additional U.S. academic medical centers from March 2011 through April 2012.

통계 분석

Statistical analysis

내적 일관성

Internal consistency.

We measured the internal consistency of the eight engagement and inclusion factors by calculating Cronbach alphas.

구인 타당도 

Construct validity.

CFA를 시행. 

Based on the expected mapping of survey items to engagement and inclusion factors, we performed confirmatory factor analysis (CFA) via structural equation modeling to investigate construct validity and to examine the dimensionality of the DES. We examined item correlations and selected two representative fit indices—comparative fit index (CFI)18 and the standardized root mean square residual (SRMR)19—to assess model fit. 

• CFI is an index that ranges from 0 to 1; values greater than 0.90 are considered an indicator of a good fitting model.18 
• The SRMR is an absolute measure of fit and is defined as the standardized difference between the observed and predicted correlation; models with an SRMR value less than or equal to 0.08 are considered good.19

인구통계학적으로 서로 다른 집단 사이간 비교함.

We also sought to demonstrate the instrument’s usefulness in understanding specific disparities within a given institution by distinguishing between the experiences of different demographic groups.

준거 타당도

Criterion validity.

기존 문헌에서 제시된 핵심 응답자 특성을 바탕으로 DES factor mean score 차이를 확인함.

As a final step in assessing the utility of the DES, we examined criterion validity, which is a measure of how well a construct predicts an outcome based on information from other variables.17 Here, we examined differences in DES factor mean scores based on key respondent characteristics suggested by the literature, such as race/ethnicity, gender, and sexual orientation. Respondents had the opportunity to self-identify as lesbian, gay, bisexual, transgender, queer, questioning, asexual, or other. For purposes of analysis and reporting we collapsed these responses into one category labeled LGBTQ.

결과

Results

전미에 걸쳐 13694명 응답. 14개 참여기관의 평균 응답률은 26.7%

Broad representation across each region of the United States was obtained through the 13,694 respondents to the DES. The average response rate across the 14 participating institutions was 26.7% (SD = 9.5), and institutional response rates ranged from 11% to 46%.

내적 일관성 Internal consistency

The Cronbach alphas for the eight engagement and inclusion factors of the DES ranged from 0.68 to 0.85 (Table 1), with an overall Cronbach alpha of 0.96.

구인 타당도 Construct validity

명확하게 세 그룹으로 나눠짐

The graphical displays of institutions’ mean engagement and inclusion factor scores clearly delineated institutions with higher, middle, and lower degrees of engagement and inclusion by their respondents (Figure 2).

흑인-백인간 차이가 기관의 DES level과 유의한 상관관계

We also found that greater disparity between black and white respondents at the institutional level was strongly correlated with lower black respondent scores. Spearman correlations for institutional rankings based on disparities and institutional rankings based on black respondent mean item scores ranged from 0.70 to 0.95 and were statistically significant for all items except 4 and 14 (see Supplemental Digital Table 1 at http://links.lww.com/ACADMED/A303).

준거 타당도 Criterion validity

흑인, 히스패닉/라틴 응답자가 배깅ㄴ보다 점수가 낮음. 여성 응답자가 남성보다 낮음

Analysis of the responses by demographic group revealed that black respondents and Hispanic/Latino respondents had lower mean factor scores than white respondents. Female respondents had lower mean factor scores than male respondents (Table 2).

Discussion

예컨대, 만약 한 기관의 DES 총점과 특정 요인에 대한 세부 그룹의 점수가 모두 낮았다면, 조직 전반에 대한 정책 변화가 필요함. 반대로, 전체적 DES는 높은데, 특정 그룹만 낮다면 그 그룹에 대한 intervention이 필요함.

For example, if both an institution’s overall and subgroup scores for a given factor or item are equally low, changes in organization-wide policy may be needed. On the other hand, if the overall score is high but a subgroup score is low, a policy targeting the subgroup may be appropriate.

전반적으로 Cronbach alpha는 reliable. Common purpose 요인에 대한 낮은 Cronbach alpha의 원인은 'violation of the essential tau equivalence assumption'일 수 있음. 이는 여기에 속한 두 문항의 observed variance가 크게 달랐기 때문이다. 그러나 이 가정을 위배할 경우 보통 alpha coefficient가 저평가 되기 때문에, 여기서 보고한 값은 실제 값의 하한 정도가 될 것이다. DES가 기존의 문헌을 바탕으로 face validity를 갖추고 있고 리뷰 패널의 검토를 거쳤기에 common purpose를 유지하기로 결정.

Overall, the Cronbach alpha results indicate that the DES is a reliable instrument. One possible explanation for the marginally low Cronbach alpha of the common purpose factor may be violation of the essential tau equivalence assumption,21 which is suggested because the observed variances of the two items comprising this factor were significantly different (data not shown). However, violation of this assumption usually leads to underestimation of the alpha coefficient, so it is reasonable to assume that the reported coefficient represents a lower bound for the true value. Because the entire DES has face validity based on existing literature and vetting with the review panel, we have chosen to retain the common purpose factor in the survey.

다양성에 대한 조직의 역량을 기르기 위해서는 조직 내 다양한 그룹이 어떻게 느끼고 있는가를 먼저 알아야 할 것이다.

To build institutional capacity for diversity, institutions must start with an understanding of the extent to which their various groups feel included and engaged.25

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Acad Med. 2015 Dec;90(12):1675-83. doi: 10.1097/ACM.0000000000000921.

Measuring Diversity and Inclusion in Academic Medicine: The Diversity Engagement Survey.

Person SD1, Jordan CG, Allison JJ, Fink Ogawa LM, Castillo-Page L, Conrad S, Nivet MA, Plummer DL.

Author information

• 1S.D. Person is associate professor, Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts. C.G. Jordan is associate vice chancellor, Diversity and Inclusion, and assistant professor, Departments of Nursing, Psychiatry, and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts. J.J. Allison is associate vice provost, Health Disparities Research, and vice chair and professor, Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts. L.M. Fink Ogawa is clinical assistant professor and director, Quality and Safety Scholarship, University of Kansas Medical Center School of Nursing, Kansas City, Kansas. L. Castillo-Page is senior director, Diversity Policy and Programs and Organizational Capacity Building Portfolio, Association of American Medical Colleges, Washington, DC. S. Conrad is senior research analyst, Association of American Medical Colleges, Washington, DC. M.A. Nivet is chief diversity officer, Association of American Medical Colleges, Washington, DC. D.L. Plummer is vice chancellor, Diversity and Inclusion, and professor, Departments of Psychiatry, Quantitative Health Sciences, and Nursing, University of Massachusetts Medical School, Worcester, Massachusetts.

Abstract

PURPOSE:

To produce a physician and scientific workforce that advances high-quality research and culturally competent care, academic medical centers (AMCs) must assess their capacity for diversity and inclusion and leverage opportunities for improvement. The Diversity EngagementSurvey (DES) is presented as a diagnostic and benchmarking tool.

METHOD:

The 22-item DES consists of eight factors that connect engagement theory to inclusion and diversity constructs. It was piloted at 1 AMC and then administered at 13 additional U.S. AMCs in 2011-2012. Face and content validity were assessed through a review panel. Cronbach alpha was used to assess internal consistency. Confirmatory factor analysis (CFA) was used to establish construct validity. Cluster analysis was conducted to establish ability of the DES to distinguish between institutions' degrees of engagement and inclusion. Criterion validity was established using observed differences in scores for demographic groups as suggested by the literature.

RESULTS:

The sample included 13,694 respondents across 14 AMCs. Cronbach alphas for the engagement and inclusion factors (range: 0.68-0.85), CFA fit indices, and item correlations with latent constructs indicated an acceptable model fit and that items measured the intended concepts. Cluster analysis of DES scores distinguished institutions with higher, middle, and lower degrees of engagement and inclusion by their respondents. Consistent with the literature, black, Hispanic/Latino, female, and LGBTQ (lesbian, gay, bisexual, transgender, queer) respondents reported lower degrees of engagement than their counterparts.

CONCLUSIONS:

The DES is a reliable and valid instrument for assessment, evaluation, and external benchmarking of institutional engagement andinclusion.

PMID:

 

26466376

 

[PubMed - in process]