DEI in the OR

By Don Sadler

Diversity, equity and inclusion (DEI) has become a flashpoint issue across society over the past few years. DEI is defined as policies and programs that seek to promote the fair treatment and full participation of all people, especially groups that have historically been underrepresented or subject to discrimination on the basis of their race, gender, age, religion or ethnicity.

As we celebrate Black History Month, now is a good time to look at DEI in the perioperative environment. Where do things stand now with respect to diversity in hospital operating rooms and ambulatory surgery centers (ASCs)? What is working, and what isn’t when it comes to achieving diversity in the OR?

Current State is Nuanced

The current state of DEI in the OR “is nuanced and varies by geographic location,” says Lizette Girado, MSN, RN, CNOR, senior clinical program manager with Pfiedler Education, a division of the Association of periOperative Registered Nurses (AORN).

“With their inherent cultural diversity, urban areas often have OR teams that reflect a wide range of ethnicities, genders and cultural backgrounds,” says Girado, who notes that approximately 30 percent of AORN members are people of color. However, this statistic does not necessarily represent a uniform distribution of diversity across the entire country.

“The disparity between urban and rural areas remains a significant challenge,” says Girado.

Justin Fontenot, DNP, RN, NEA-BC, FAADN, associate professor in the School of Medicine at Tulane University, agrees.

“The current state of DEI in the OR varies widely depending on the region and specific institution,” he says. “While there have been improvements in recent years, many OR teams still lack significant diversity, especially in leadership roles.”

According to the Competency and Credentialing Institute (CCI), 58% of CNOR test takers in 2019 were white, 19% were Asian, 6% were Hispanic/Latino and 6% were African American/Black. Meanwhile, the largest cohort of RNs are between the ages of 46 and 55, with an average age of 52, according to 2020 National Nursing Workforce Survey. Just 9.4% of RNs are men. 

“Many institutions have recognized the need for change and the advantages of creating a diverse OR workforce, and some have developed programming to improve diversity,” says Patrick Giam, M.D., FASA, first vice president with the American Society of Anesthesiologists. “However, there is more that can and should be done. Anesthesiologists can help influence hospitals to look at their workforce and set priorities for enhancing diversity.”

There are a number of benefits to achieving a more diverse OR. “Multiple studies have shown that diverse perioperative teams make better decisions,” says Giam. “In the complex, time-critical perioperative setting, making good decisions can be the difference between a positive outcome and an undesirable event.”

Diverse teams demonstrate a welcoming, inclusive environment to the patient population, which aids in delivering optimal health care. “Having a diverse and inclusive workforce increases the likelihood that groups and communities will feel comfortable about accessing community medical services,” says Giam.

“Patients need to trust their perioperative team, which will become easier when they and their families can see themselves reflected in the team caring for them or their loved ones,” says Katie Boston-Leary, Ph.D., MBA, MHA, RN, NEA-BC, the director of nursing programs for the American Nurses Association. “Prioritizing DEI in perioperative nursing not only fosters more teamwork and efficiency, but it also improves the patient experience and outcomes.”

A successful perioperative environment must be dynamic and collaborative. “This is only made stronger when the perioperative team is representative of the diverse patient populations and cultures it serves,” says Boston-Leary. “By committing resources to the recruitment and retention of a diverse OR team, health care organizations will become equity-minded for quality patient care and positive team dynamics.”

According to Girado, a diverse team encompassing varied ethnicities, genders and cultural backgrounds brings a wealth of perspectives and experiences to the OR. “This diversity enhances team dynamics and decision-making processes and ensures a more empathetic and culturally competent approach to patient care,” she says. 

In the high-stakes perioperative environment where patients’ backgrounds and needs can be diverse, a team that reflects diversity is better equipped to understand and respond effectively. “This understanding improves patient trust and satisfaction, which are fundamental for positive patient outcomes,” says Girado,

Respecting Cultural Differences

Beverly Kirchner, MSN, RN, CNOR, CNAMB, believes that diverse teams help ensure safe and appropriate care to various cultures served in the perioperative environment. 

“When there is respect for cultural and socio-economic differences, patients are safer and teams work together for a common goal,” she says. “Diversity is important because we learn from each other.”

Kirchner says she does not view race as a factor when building a perioperative team. 

“I look for the right person who brings their culture, expertise and empathy to the workplace so we can provide care safely and respectfully to every culture we serve,” she says. “Each center has a different culture because the populations we serve differ in all of our centers.”

Ambulatory Surgery Center Association (ASCA) President Amanda Hawkins notes that while the U.S. health care system is experiencing a shortage of nurses, the nation’s health care workforce does not fairly represent the country’s demographic diversity.

“ASCA believes that a more diverse and representative health care workforce is needed to meet the demands of a growing population that is becoming increasingly diverse,” says Hawkins. “To achieve this, we support increased financial support from both government and private sector sources to expand medical education opportunities for all.”

Hospitals and ASCs may experience negative effects by failing to achieve perioperative diversity. 

“Homogeneous teams might miss out on unique insights or be less adept at handling culturally diverse patient needs,” says Fontenot. “Patients may feel less understood or valued if the team does not reflect their background.”

Giam stresses that a lack of diversity may lead to decreased patient engagement and trust, less effective cultural competency and a negative impact on the health care workforce. 

“Ideally, the entire hospital system will be committed to having a diverse workforce,” says Giam. “Hospitals can demonstrate their commitment to diversity and inclusivity by making the perioperative team a high priority in their workforce.”

Girado points out the unconscious biases that can inadvertently arise when there’s a lack of perioperative diversity. “A homogenous team is more likely to have a narrow perspective, which can inadvertently foster unconscious biases in patient care and decision-making,” she says. “These biases can affect the quality of care delivered, leading to disparities in treatment and outcomes. 

A non-diverse team can perpetuate a cycle of inequality within the health care organization. “This can lead to issues in health care equity where certain patient groups may not receive care that is culturally competent or sensitive to their specific needs,” says Girado.

Kirchner believes that focusing on race instead of culture and respect runs the risk of developing an organization that discriminates against certain races or cultural beliefs. “To truly build a diverse organization, I believe leaders must embrace cultural differences and encourage respectful behavior,” she says.

Obstacles to Achieving Perioperative Diversity

Even hospitals and ASCs that recognize the importance of diversity can face obstacles in trying to build a more diverse perioperative staff. 

“Unconscious biases in hiring and promotion processes can hinder diversity,” says Fontenot.

Giam points out that with widespread shortages in many perioperative roles, there may simply not be an adequate supply of qualified diverse candidates to choose from. “In this environment, many hospitals are more focused on finding sufficient qualified clinicians than on building a diverse workforce,” he says.

Girado believes that systemic racism and bias within the field of nursing remain an obstacle to building a more diverse perioperative team. 

“These deep-rooted challenges can manifest in various forms, from biased hiring practices and promotion opportunities to microaggressions and discrimination in the workplace,” says Girado. “This environment can deter qualified candidates from diverse backgrounds from pursuing or remaining in perioperative roles.”

Health care organizations may also encounter challenges in changing long-standing institutional cultures that have not traditionally prioritized diversity and inclusivity. “There may be a lack of awareness among existing staff about the importance of diversity and how biases and racism impact patient care and team dynamics,” says Girado.

Overcoming these obstacles requires a multifaceted approach, Girado adds, including comprehensive anti-racism training, equitable hiring practices, mentorship programs and a commitment from leadership to foster an inclusive and diverse workplace culture.

Take Deliberate Actions

Giam recommends that hospitals and ASCs review their existing policies to make sure they reflect the goal of achieving diversity, equity and inclusion. 

“Then you can take deliberate actions to make educational and employment opportunities available to all groups of clinicians,” he says, “while establishing policies to promote belonging and monitor the success of your diversity initiatives.”

Fontenot agrees. 

“Hospitals and ASCs should implement formal policies that promote inclusivity and provide diversity training to all staff,” he says. “They should also facilitate formal mentorship programs to encourage diverse individuals to pursue and advance in their perioperative careers.”

Girado offers a 10-step process for achieving diversity, equity and inclusion in the perioperative environment:

1. Engage in targeted recruitment and outreach to attract diverse candidates. This may include outreach to minority-focused professional associations, colleges and nursing schools. “Also utilize job boards that cater to diverse populations,” says Girado.

2. Offer scholarships and internships to underrepresented groups in health care. This may help cultivate interest and provide pathways into perioperative careers for these groups.

3. Implement inclusive hiring practices. This is crucial and may involve training hiring managers on unconscious bias, using diverse interview panels and making sure that job descriptions are inclusive and welcoming to all candidates.

4. Establish mentorship and professional development programs to support diverse staff members. “These programs can aid in retention and career advancement, helping to create a more diverse leadership pipeline,” says Girado.

5. Provide cultural competency training. Regular training for all perioperative staff can help create a more inclusive workplace culture that values and respects diversity.

6. Adopt flexible workplace policies and inclusive benefits that cater to a diverse workforce. One example is recognizing different cultural and religious holidays. “Officially recognizing these holidays can make the workplace more welcoming and accommodating for diverse employees,” says Girado.

7. Perform employee inclusivity surveys. Regularly conducting surveys to assess the workplace environment in terms of diversity and inclusivity will help identify areas where improvement is needed. Then be sure to act on the employee feedback you receive.

8. Form partnerships with community organizations. This will assist in recruiting a more diverse and inclusive workforce and help your organization better understand and serve the diverse communities in your area.

9. Focus on staff retention. Devise retention strategies that address the specific needs and challenges of diverse staff members, such as offering support networks, affinity groups and career development opportunities.

10. Evaluate your diversity initiatives. Continuously evaluating the effectiveness of your diversity initiatives and make adjustments based on outcomes and feedback you receive. “This will help ensure that your efforts remain relevant and practical,” says Girado.

An Ongoing Process

Fontenot stresses that building a diverse perioperative team is not a one-time event, but an ongoing process that requires constant evaluation and adaptation. 

“Focus not only on hiring diverse candidates, but also on retaining them and ensuring an inclusive work environment,” he says. “Strong commitment from leadership is crucial for meaningful change.”

“We believe a more diverse health care workforce will better serve the country’s increasingly diverse patient population,” says Hawkins. “This is true not only in operating rooms, but in all health care settings. On behalf of our members, we are committed to advancing that goal.”