Belonging in the Clinical SettinG

​By Bree Bode, Gladys Pico-Gleason, Kameron Kempker, and Paige Hammond

In the United States, a variety of inequities present people of minoritized groups with roadblocks to healthcare and equitable health outcomes. When people, especially members of the Black community, experience multiple roadblocks they may feel discouraged to practice health seeking behaviors due to stress and medical mistrust (1). In fact, BIPOC communities have a greater number of people who have been historically marginalized and underserved, or are under- insured, than white communities (2,3). Compared to non-Hispanic whites, people of color continue to have poorer health outcomes (3). Black people living with heart disease, and American Indian and Alaskan Natives living with diabetes, experience higher mortality rates than non-Hispanic whites (3). As another example, quality of care is lower and pain management is less adequate among under-resourced minoritized groups (2).

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Healthcare systems must “do no harm” by intentionally incorporating diversity, equity, and inclusion (DEI) into policies and clinical practices, actively working to improve health equity, and going beyond DEI to demonstrate a commitment to fostering a sense of belonging among all kinds of groups and stakeholders in the clinical community setting; this includes patients, caregivers, and employees. Belonging should uphold the wants and needs of people who identify as neurodivergent, LBTQUIA+, and people with varying physical abilities.
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Fostering a sense of belonging is important for equitable care and starts with considering how people’s lived experiences and biases (implicit and explicit) inform interactions that affect health equity (2,3). Exploring and documenting the ways in which clinical communities create a culture of belonging while simultaneously honoring the intersections of people’s lived experiences in the clinical setting is important to advance health equity-driven practices.

Belonging in the Clinical Setting
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So, what does it take to foster a sense of belonging for all in clinical settings?

Fostering a sense of belonging beyond DEI requires a commitment to action that focuses on assessing and demonstrating what “belonging” means to different people. There is a call from health equity communities to practice more action-oriented and sustainable DEI initiatives that cultivate effective demonstrations and narratives of belonging in the clinical setting. This requires a sustained effort by all kinds of clinicians to address health inequities and bias in the healthcare system. This also requires significant changes in the medical education system so that future clinicians are equipped to do the same. Further, academic advisors and their clinical partners can foster belonging in the medical education system by modeling belonging.

As we all know, clinical settings were tested during the pandemic. Still now, exacerbated tensions due to COVID-19 are intact (4, 5). The concept of “do no harm” must evolve to explicitly include avoiding harm across the many dimensions of wellness (6). For this to occur, we need a new concept of “clinical community”, which is inclusive of community residents and centers the importance of collaborations and interactions between clinical settings (e.g., local hospitals, clinical practices, community health centers) and the communities they serve, as well as between different professions within the healthcare system (7). This new concept of “clinical community” will give voice to patients and other community members in designing policies and interventions that consider their needs, values, and priorities (7).

In fact, prior to the pandemic, being part of the “clinical community” started before a person walked through the physical doors of a clinical space. Thus, much of the emphasis put on implicit bias training prioritized the notion that health starts where we live, work, and age. . However, the front door to the “clinical community” changed and became a virtual portal. More training is needed to address implicit bias among frontline workers within the new virtual front door environment. For example, “patient portals” are often in English only, texting is often without language options, and even phone trees skip over options once you choose a language other than English. These situations are all too common and create barriers, stunt feelings of belonging, and contribute to harm in the process of accessing care.

So, where do we start to foster belonging in clinical settings?

Practices that can Advance Belonging

While community needs and priorities should ideally inform all kinds of practices and policies to advance a sense of belonging in clinical settings, here are a few starting points that may provide a platform for reflection and further action.

First, host listening sessions for community residents who can raise action-oriented sustainable equity practices. These community-based practices center community resident voices to foster practical applications and demonstrations of belonging, which can restore medical trust.

Second, consistently demonstrate clinical staff belonging by convening different departments from within the institution (e.g., community health, language services, and DEI professionals, medical students) in all phases of the clinical decision-making processes that inform policies, guidelines, and regulations of the clinical environment and system. If belonging has been enmeshed in the policies, systems, procedures, and interactions between departments and other members of the “clinical community”, the recovery time from tense situations should be shorter when these situations arise.

Third, define the expectations of the clinical and academic community advisor in medical/ clinical education settings. This includes empowering students to participate in developing goals for their journey, setting healthy boundaries, affirming their culture and values, and feeling a sense of belonging before they enter the profession.

Fourth, it is important to have inclusive onboarding practices for clinical staff in which implicit bias training can be translated into cultural context. Namely, center the fact that the physical and virtual doors are only representative of the navigating process a patient had to follow prior to deciding to enter the clinical space and interact with a provider. The training should be informed by and inclusive of multiple perspectives including, but not limited to, diversity of languages, religions being observed by patients, neuro and physical diversity, cultural differences, history and past experiences of specific communities, and the organizational culture of different departments within the clinical practice including medical students. Training should always include ways to utilize technology or other patient access points, so all people in the “clinical community” can consistently feel a sense of belonging.

References
1. Powell, W., Richmond, J., Mohottige, D., Yen, I., Joslyn, A., & Corbie-Smith, G. (2019). Medical Mistrust, Racism, and Delays in Preventive Health Screening Among African American Men. Behavioral medicine (Washington, D.C.), 45(2), 102–117. https://doi.org/10.1080/08964289.2019.1585327
2. Clinical Orthopaedics and Related Research®, 469
3. Kaiser Family Foundation
4. Kim, S. S., Roberts, T. M. E., Khusbo, J. E., Watriboonruang, W., Parks, A., & Lewczyk, J. (2022). Asian American nursing students’ experiences of racial microaggressions amid the COVID-19 pandemic: Focus group discussions. Nurse Education in Practice, 64, 103459103459. https://doi.org/10.1016/j.nepr.2022.103459
5. MacPherson, K. (2022). Covid and racism cause nurses of color to face "dual pandemic". Rutgers University. Retrieved March 26, 2023, from https://www.rutgers.edu/news/covid- and-racism-cause-nurses-color-face-dual-pandemic
6. Hettler, B. (1976). The six dimensions of wellness. Retrieved from http://www.hettler.com/sixdimen.htm
7. Schiavo, R. (2015) Addressing health disparities in clinical settings: Population health, quality of care, and communication, Journal of Communication in Healthcare; Strategies, Media, and Engagement in Global Health. 8:3, 163-166, DOI: https://www.tandfonline.com/doi/full/10.1080/17538068.2015.1107352

Image Credit
​Pexels, cottonbro studio: https://www.pexels.com/photo/health-workers-wearing- face-mask-3957987/

Authors Bio
Bree Bode, PhD, MPH, CHES is an Evaluation Specialist with Michigan Fitness Foundation, a healthy equity advocate, and community-based public health researcher. She is the President of GLC-SOPHE and board member of Kent County Food Policy Council. She also serves on the Board of Directors of Health Equity Initiative. 

Gladys Pico-Gleason is a Community Health Nurse, Supervisor of a Community Health Program - More Life Más Vida, and Co-Chair of the No Surrender Running Club.

Kameron Kempker is a student at Grand Valley State University studying Psychology (B.S. candidate 2023), a mentor and coach to middle school youth, and a former nationally recognized collegiate athlete who has been frequently interfacing with the health and hospital system after sustaining an injury. 
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Paige Hammond is Health Equity Initiative’s Freelance Project Coordinator, and a student at The College of New Jersey pursuing degrees in Public Health and Communication Studies.