Go to the webpage (https://cwc.law.northwestern.edu/freed-clients/).  You should see several photos with names.  These are the exonerated clients of the center.  Choose and click on four names, and read their biographical summaries.  For each, write a few sentences explaining specifically how each of the following factors played a role in the wrongful conviction.  If one or more of these factors had no role, simply put "not applicable." Overall the assignment should be about two pages, or 600 words long.   Individual's name, and crime falsely convicted of: Erroneous eyewitness identification False/coerced confession False forensic evidence Ineffective counsel Perjury Police/prosecutor misconduct. https://doi.org/10.1177/1043659619859055 Journal of Transcultural Nursing 2020, Vol. 31(2) 178 –187 © The Author(s) 2019 Article reuse guidelines: sagepub.com/journals-permissions DOI: 10.1177/1043659619859055 journals.sagepub.com/home/tcn Research Introduction Advance care planning (ACP) is an important process of communication and planning for desired outcomes during a serious illness. This process involves identifying and dis- cussing decisions that might need to be made during the course of a serious illness (e.g., how to address progressive respiratory failure), identifying a patient’s preferences for those decisions (e.g., to receive invasive mechanical ventila- tion), determining how to meet these identified patient-spe- cific needs, and communicating about those preferences, needs, and plans with family members, treatment providers, and others involved in the person’s care (National Institute on Aging, 2018). Engaging in ACP is empirically associated with decreased psychological distress (e.g., anxiety, depres- sion) for patients, increased quality of life, reductions in the use of costly end-of-life care, and decreased acuity and dura- tion of grief for family members (Luckett et al., 2014; Meghani & Hinds, 2015; Silvester & Detering, 2011a, 2011b; Sobanski, Jaarsma, & Krajnik, 2014; Walczak, Butow, Bu, & Clayton, 2016; Walczak et al., 2015; Wright et al., 2008). ACP could especially benefit patient populations with higher burden of serious illness and limited access to health care resources. American Indian and Alaska Native people (AI/AN), for example, generally have poorer access to care, consistently worse health outcomes, and higher prevalence of many serious illnesses compared with the general U.S. population (Indian Health Service, 2018). Yet ACP and pal- liative care services are used considerably less by AI/AN patients than the general population (Bush et al., 2014; Connor, Elwert, Spence, & Christakis, 2008; Cort, 2004; Karim, Bailey, & Tunna, 2000; Schim, Doorenbos, & Borse, 2006; Sharma et al., 2015). However, Marr, Neale, Wolfe, and Kitzes (2012) found that AI/ANs were just as likely as non-AI/ANs to utilize palliative care services when they were presented with the opportunity in a clear, u ...

1. Go to the webpage (https://cwc.law.northwestern.edu/freed-
clients/). You should see several photos with names. These are
the exonerated clients of the center. Choose and click on four
names, and read their biographical summaries. For each, write
a few sentences explaining specifically how each of the
following factors played a role in the wrongful conviction. If
one or more of these factors had no role, simply put "not
applicable." Overall the assignment should be about two pages,
or 600 words long.
Individual's name, and crime falsely convicted of:
Erroneous eyewitness identification
False/coerced confession
False forensic evidence
Ineffective counsel
Perjury
Police/prosecutor misconduct.
https://doi.org/10.1177/1043659619859055
Journal of Transcultural Nursing
2020, Vol. 31(2) 178 –187
© The Author(s) 2019
Article reuse guidelines:
sagepub.com/journals-permissions
DOI: 10.1177/1043659619859055
journals.sagepub.com/home/tcn
Research
Introduction

2. Advance care planning (ACP) is an important process of
communication and planning for desired outcomes during a
serious illness. This process involves identifying and dis -
cussing decisions that might need to be made during the
course of a serious illness (e.g., how to address progressive
respiratory failure), identifying a patient’s preferences for
those decisions (e.g., to receive invasive mechanical ventila-
tion), determining how to meet these identified patient-spe-
cific needs, and communicating about those preferences,
needs, and plans with family members, treatment providers,
and others involved in the person’s care (National Institute
on Aging, 2018). Engaging in ACP is empirically associated
with decreased psychological distress (e.g., anxiety, depres -
sion) for patients, increased quality of life, reductions in the
use of costly end-of-life care, and decreased acuity and dura-
tion of grief for family members (Luckett et al., 2014;
Meghani & Hinds, 2015; Silvester & Detering, 2011a, 2011b;
Sobanski, Jaarsma, & Krajnik, 2014; Walczak, Butow, Bu, &
Clayton, 2016; Walczak et al., 2015; Wright et al., 2008).
ACP could especially benefit patient populations with
higher burden of serious illness and limited access to health
care resources. American Indian and Alaska Native people
(AI/AN), for example, generally have poorer access to care,
consistently worse health outcomes, and higher prevalence
of many serious illnesses compared with the general U.S.
population (Indian Health Service, 2018). Yet ACP and pal -
liative care services are used considerably less by AI/AN
patients than the general population (Bush et al., 2014;
Connor, Elwert, Spence, & Christakis, 2008; Cort, 2004;
Karim, Bailey, & Tunna, 2000; Schim, Doorenbos, & Borse,
2006; Sharma et al., 2015). However, Marr, Neale, Wolfe,
and Kitzes (2012) found that AI/ANs were just as likely as
non-AI/ANs to utilize palliative care services when they
were presented with the opportunity in a clear, understand-

3. able, and relevant manner.
859055 TCNXXX10.1177/1043659619859055Journal of
Transcultural NursingLillie et al.
research-article2019
1Southcentral Foundation, Anchorage, AK, USA
2University of Washington, Seattle, WA, USA
3University of Colorado School of Medicine, Aurora, CO, USA
Corresponding Author:
Kate M. Lillie, PhD, Researcher, Southcentral Foundation, 4085
Tudor
Centre Drive, Anchorage, AK 99508, USA.
Email: [email protected]
Culturally Adapting an Advance Care
Planning Communication Intervention
With American Indian and Alaska Native
People in Primary Care
Kate M. Lillie, PhD1 , Lisa G. Dirks, MLIS, MAdm1,
J. Randall Curtis, MD, MPH2, Carey Candrian, PhD3,
Jean S. Kutner, MD, MSPH3, and Jennifer L. Shaw, PhD1
Abstract
Introduction: Advance care planning (ACP) is a process in
which patients, families, and providers discuss and plan for
desired treatment goals. American Indian and Alaska Native
people (AI/AN) have higher prevalence of many serious, life-
limiting illnesses compared with the general population; yet
AI/ANs use ACP considerably less than the overall population.
Method: We conducted a qualitative study to culturally adapt an
existing ACP intervention for AI/ANs in two primary
care settings. Results: We found that it is important to
incorporate patients’ cultural values and priorities i nto ACP,
determine who the patient wants involved in ACP

4. conversations, and consider the culturally and locally relevant
barriers
and facilitators when developing an ACP intervention with
AI/AN communities. Discussion: At the core, ACP interventions
should be clear and understandable across populations and
tailored to facilitate culturally appropriate and meaningful
patient–
provider communication. Our results and methodology of
culturally adapting an intervention may be applicable to other
underrepresented populations.
Keywords
advance care planning, Alaska Native, American Indian,
culturally acceptable, culturally adapt, Native American,
palliative care,
palliative medicine
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Lillie et al. 179
Efforts to improve ACP must go well beyond specialty
care settings, as providers in primary care commonly treat
and diagnose patients with serious illnesses, and represents a
setting in which patients and providers routinely develop
long-term relationships (Detering et al., 2014; Hebert,
Moore, & Rooney, 2011; McCormick, Chai, & Meier, 2012).
Increasingly, nurses are among those providers being trained
to provide ACP to patients (Christensen, Winters, Colclough,
Oley, & Luparell, 2019; Epstein et al., 2019). One promising
intervention for improving ACP in both specialty and pri -

5. mary care settings is a patient-provider communication tool
developed by Curtis and colleagues at the University of
Washington (Au et al., 2012). The tool uses a questionnaire,
Improving Communication about Serious Illness (ICSI), to
assess individual patient preferences, as well as barriers and
facilitators, for communicating about life-sustaining therapy
and experiences at end of life. This information is then col -
lated into a one-page “Jumpstart” form that is provided to the
patient and the provider with a summary of the patient’s per-
sonal preferences for ACP, as well as suggestions tailored to
these preferences about how to initiate a conversation about
ACP at the next clinical appointment.
Earlier efforts to improve ACP focused on training nurses
and other providers to have the knowledge, tools, and skills
to initiate conversations about ACP (Lesperance et al., 2014).
Curtis et al.’s (2018) intervention expanded previous efforts
by providing an individualized, patient-centered tool that
prepares patients and their families (or other caregivers) to
initiate conversations about ACP, thereby enabling patients
to participate more actively and equally in communication
and decisions about their health care. A recent trial of the
intervention with outpatients with diverse underlying ill-
nesses resulted in a borderline significant increase in the fre -
quency of ACP conversations and significant improvement
in patient-reported quality of ACP conversations (Curtis
et al., 2018).
Previous studies demonstrate the importance and effec-
tiveness of adapting interventions for cultural acceptability
(Allen et al., 2006; Barrera, Castro, Strycker, & Toobert,
2013; Boyd-Ball, 2003; Hirchak et al., 2018; Lau, 2006).
Cultural acceptance is defined as the extent to which a
treatment is relevant and engaging among a cultural group
in which the intervention has not been previously imple-
mented (Barrera et al., 2013; Lau, 2006). Adaptations

6. related to cultural acceptability typically involve modify-
ing “nonactive” treatment components of the intervention:
style or language or the intervention, the person delivering
the intervention, or the treatment setting. Few studies have
focused on AI/AN perceptions and cultural acceptability of
ACP. One study found that AI/AN patients perceived
health care providers as making advanced care decisions
for them, while health care providers reported that patients
made autonomous decisions for themselves, highlighting
highly divergent cultural views of communication and
decision making (Colclough & Brown, 2014). ACP ideally
begins when patients are well enough to participate in
ongoing discussions about anticipated prognosis and
potential care trajectories (Houben, Spruit, Groenen,
Wouters, & Janssen, 2014; Jones, Moss, & Harris-Kojetin,
2011; Luckett et al., 2014). Health care providers and sys-
tems, however, may not be prepared to engage AI/AN
patients and families in discussions about ACP that recog-
nize, respect, and consider important factors that affect
patient preferences and priorities, including spiritual
beliefs, social norms, and cultural values about autonomy,
decision making, and hope (Colclough & Brown, 2014;
Hampton, 2005; Kissane et al., 2012; McConnell,
O’Halloran, Donnelly, & Porter, 2015; Walczak et al.,
2014). Thus, development of culturally acceptable and
appropriate tools that promote patient-centered ACP with
AI/AN patients is important to ensure that all seriously ill
patients receive optimal palliative and end-of-life care
(Kissane et al., 2012; McConnell et al., 2015; Walczak
et al., 2014).
In this study, we developed a culturally acceptable,
patient-centered ACP intervention, referred to herein as
ACP-AIAN, for use with AI/AN populations in primary care
settings. This article reports on the cultural adaptation pro-

7. cess resulting in the ACP-AIAN. The findings of our study
are applicable to all health care professionals, including
nurses and providers, who interact with patients with serious
illness.
Method
Design
We used a mixed-method design and community-based par-
ticipatory research (CBPR) approach to culturally adapt and
test the ACP-AIAN in two primary care settings in two states
with AI/AN adults living with serious illness. CBPR is a
community-engaged approach that requires the long-term
commitment and equitable involvement of researchers and
community partners to address a topic of mutual interest to
improve community health. CBPR has been called a “trans-
formative research paradigm that bridges the gap between
science and practice through community engagement and
social action to increase health equity” (Wallerstein & Duran,
2010, p. S40) and is particularly relevant to research involv-
ing health disparities, such as palliative care research and
practice in AI/AN communities. This CBPR study originated
within Southcentral Foundation (SCF), a large tribally owned
health care organization in Alaska, which established an
internal research department to promote self-determined
research by AI/AN people and for AI/AN people. The SCF
Research Department is staffed by a largely AI/AN work-
force. More than 75% of the SCF Research Department staff
are AI/AN. In 2016, an investigator within the SCF Research
Department approached tribal health leaders to propose this
study to improve primary palliative care, which they
180 Journal of Transcultural Nursing 31(2)

8. endorsed. In addition to consenting to participate in the
study, AI/AN people were employed on this study from
design to dissemination as principal investigators, clinical
research coordinators, data analysts, research assistants, and
authors. A Community and Scientific Advisory Board
(CSAB) was also engaged to provide oversight of all study
activities, as described below. The university and study site
institutional review boards approved the study.
Community and Scientific Advisory Board
A CSAB was formed to provide input on the protocol and
study procedures and guide the development of the ACP-
AIAN. Members included AI/AN community members
with personal or professional expertise related to palliative
care and scientific experts in palliative care communication
and tribal health research. Scientific advisors were con-
sulted regularly through email or phone conference for
feedback on scientific implications of proposed adaptations
to the intervention based on focus group data. The commu-
nity advisors, including three members from each site, met
in July 2017 in Anchorage to provide input on interpreta-
tion of focus group data and feedback on proposed changes
to the intervention. The community advisors met again with
the study team in September 2017 to provide feedback on
the next version of the revised intervention, and this feed-
back was used to finalize the ACP-AIAN. Community
advisors represented diverse AI/AN communities from
Alaska and the Southwestern United States.
Sample
Purposive sampling was used to recruit patients with serious
illnesses, caregivers, primary and palliative care providers,
and health care administrators to participate in focus groups.

9. Patients and caregivers were recruited through flyers, word-
of-mouth, and Facebook; we used emails to recruit providers
and administrators.
•• Patient eligibility criteria: (1) AI/AN, (2) age ≥18
years, (3) in the care of a primary care provider at a
participating clinic, (4) seen in primary care at least
twice in the previous 12 months, and (5) having a
diagnosis of at least one serious, life-limiting illness
as defined by International Statistical Classification of
Diseases and Related Health Problems
•• Caregiver eligibility criteria: (1) age ≥18 years and
(2) the primary caregiver of a family member who
was eligible for participation
•• Provider and administrator eligibility: (1) a provider
(MD, DO, NP, PA) or administrator or other member
of an integrated primary care or palliative care team
(e.g., RN, CMA, LPC) and (2) having been employed
at SCF or First Nations Community HealthSource
(FNCH) for at least 1 year prior to the focus groups
Setting
This study was conducted in two AI/AN health care systems:
SCF and FNCH. SCF is a tribally owned and operated non-
profit health care organization serving 65,000 AI/AN people
living in Anchorage, Alaska; the Matanuska-Susitna Valley;
and 55 rural villages. FNCH, the only Title V Urban Indian
Health program in New Mexico, is a federally qualified
health center in Albuquerque serving an urban AI population
of about 12,000 from rural and urban communities across the
Southwestern United States. Combined, these organizations
serve people representing more than 250 federally recog-
nized tribes, nearly half of all such tribes in the United States.

10. In October 2015, the Alaska Native Tribal Health Consortium,
of which SCF is a member and with which it shares a health
campus in Anchorage, established the first palliative care
program specifically designed to serve AI/AN people. The
Alaska Native Tribal Health Consortium subsequently part-
nered with SCF to develop and pilot, in one SCF primary
care clinic, a culturally adapted ACP conversation guide and
advance directive form. These partners also developed online
modules to train SCF primary care providers to engage
patients in conversations about ACP. Our study was devel -
oped to complement these efforts by developing a culturally
adapted tool designed to “jumpstart” these conversations by
providing both patients and providers individualized infor -
mation about patient preferences for ACP communication.
Focus Groups and Cognitive Interviews
There were six focus groups conducted between March and
July 2017. Each focus group lasted 1 to 2 hours. Information
was presented about palliative care and specifically ACP and
an overview of study procedures and instruments, including
the original ICSI and Jumpstart form (see Au et al., 2012, for
details on original ICSI and Jumpstart). Participants were
asked to provide feedback throughout the presentation and
make suggestions for improving the intervention and study
procedures. Specifically, participants were asked for feed-
back on the ICSI and Jumpstart form that would improve the
tools’ capacity to collect patient preferences and priorities for
ACP communication and communicate this information in
writing back to patients and providers in a clear, easily under-
standable, and effective manner.
Following analysis of focus group data and initial cultural
adaptation of the ACP intervention (ICSI questionnaire and
Jumpstart form), 10 patients and caregivers who had previ -
ously participated in a focus group participated in individual

11. cognitive interviews to assess the revised, culturally adapted
ACP-AIAN. Each participant completed one section of the
ACP-AIAN. Participants were then asked to provide feed-
back on how to improve the materials for maximal usability
and acceptability. While participants each completed and
gave feedback on different sections of the intervention, they
were also asked to share general feedback on the instruments
Lillie et al. 181
overall. Focus group and cognitive interview participants
each received a $50 gift card.
Analytic Approach
Audio recordings of focus groups were transcribed verbatim.
Researchers uploaded transcripts into ATLAS.ti 8 (ATLAS.ti
Scientific Software Development GmbH, Berlin, Germany).
Two researchers initially independently reviewed two tran-
scripts and then met to compare observations and identify a
set of codes and code definitions. The data were then coded
by the same two researchers, who regularly discussed and
compared coded data manually to assess inter-rater reliabil-
ity. Discrepancies in code applications were discussed until
consensus was reached. Codes and code definitions were
revised accordingly, and data were recoded. This iterative
process was repeated until consistency between the coders in
code application was achieved.
Coded data were analyzed using thematic analysis (Braun
& Clarke, 2006) to identify key themes about culturally
acceptable and appropriate palliative care, generally, and
ACP, specifically. We decided to align themes with the
domains of the ICSI questionnaire (e.g., Talking about Health

12. care, Barriers/Facilitators, etc.). We used an iterative process
for finalizing the adaptations to the ACP-AIAN. First, we
shared results and suggested adaptations with the CSAB for
direction and feedback. We then used and the focus group
data and CSAB feedback to further refine the ACP-AIAN for
use in the cognitive interviews. We then reviewed interview
data to generate a second, refined version of the ACP-AIAN,
with consultation from the scientific advisors. Last, the ACP-
AIAN was again presented to the CSAB for a final revision.
Results
Thirty-five people enrolled in the study, including 19
patients/caregivers and 16 health professionals. The sampl e
was nearly evenly split between men and women. Two thirds
of the sample were AI/AN, and about one half had a college
or graduate-level degree. About half the sample was between
the ages of 40 and 60 years. Table 1 provides detailed demo-
graphic information on the sample.
General feedback from focus group participants indicated
that the original ICSI questionnaire and Jumpstart form
should be made more understandable and easier to use by
reducing reading level, removing jargon, and simplifying
language (e.g., “barrier to ACP” became “what makes talk-
ing about ACP harder”). Other suggestions included adding
“I don’t know” as an option on the ICSI questionnaire, using
the term provider instead of doctor to be more inclusive of
all types of health professionals providing primary or pallia-
tive care, and replacing the word “pain” with “suffering” to
more broadly include psychological, spiritual, and physical
aspects of illness experience. Few suggestions were made for
adapting the Jumpstart form, and these focused on making
the language clearer, removing unnecessary words, and sim-
plifying the layout to be less visually distracting and “busy”.

13. Table 2 summarizes overarching themes, discussed below.
Culture
The original ICSI questionnaire assessed the influence of
spirituality and religion on the patient and his or her health
care wishes. Focus group participants strongly endorsed add-
ing questions about the importance and role of culture in the
patient’s life and health care choices in addition to the spiri-
tuality and religion questions. Thus, we added content spe-
cifically focused on cultural beliefs and values on the
questionnaire portion of the ACP-AIAN (Figure 1).
Talking About Health Care
The original ICSI questionnaire focused on ACP conversa-
tions solely between the patient and his or her doctor. Focus
group participants suggested asking patients who they want
involved in ACP communication in addition to their primary
care provider, reflecting awareness that health care decisions
are, in some contexts, considered a collective action and
responsibility. Therefore, we added a question on the ques-
tionnaire portion of the ACP-AIAN to determine if the
patient wanted anyone else involved in the ACP conversation
with his or her primary care provider (e.g., spouse, children,
behavioral health clinician).
What Makes Talking About Care Harder/Easier
The original ICSI questionnaire asked patients about “barri -
ers” and “facilitators” to talking with providers about
advance care. Focus group participants suggested removing
the jargon and simply asking patients what makes talking
about their care harder or easier. Focus group participants
provided numerous suggestions regarding what would poten-
tially make talking about care harder or easier for AI/AN

14. patients, including the availability of culturally relevant and
appropriate information about ACP and wanting to reduce or
prevent conflict in the family regarding their care. Thus, we
added several options on the questionnaire portion of the
ACP-AIAN regarding what makes talking about care harder
(Table 3) or easier (Table 4).
Cognitive Interviews
Participants in cognitive interviews provided overall positive
feedback on the ACP-AIAN, indicating that it was clear,
straightforward, understandable, and easy to follow.
Participants did suggest a few improvements to the ACP-
AIAN, such as to streamline response categories, revise the
documents to include fewer overall words, and include open-
ended responses in order to further individualize the ques-
tionnaire and allow patients to add information pertaining
182 Journal of Transcultural Nursing 31(2)
their ACP communication preferences not already asked on
the questionnaire. We revised the ACP-AIAN in accordance
with these suggestions.
Discussion
Our study provides insight into increasing the cultural
acceptability and usability of a patient-centered, individual-
ized ACP intervention for AI/AN people. We believe that the
findings of our study are potentially applicable to other AI/
AN communities as our study sites represented a large,
diverse range of AI/AN geographic and cultural groups. Our
results indicated that asking about the role of cultural beliefs
and values in a person’s life is a critical compone nt of

15. understanding individual preferences and priorities for ACP
communication. In response to this finding overall, and spe-
cific data collected on the relevance of culture to ACP com-
munication, we added a section in the ACP-AIAN on the
importance of AI/AN cultural beliefs and values to the
patient and how the patient perceives these factors to influ-
ence the specific health care choices (Figure 1). Our findings
also suggested the importance of asking who the patient does
and does not want to be involved in their ACP conversations
(e.g., spouse, children, other health care providers). We also
found that a multitude of barriers (Table 3) and facilitators
(Table 4) may exist for AI/AN patients when talking about
health care (e.g., cultural values, spiritual and religious
beliefs, past experiences with a provider) that were not
Table 1. Demographic and Site Information for Focus Group
Participants Conducted From March 2017 to August 2017 at
Southcentral
Foundation (SCF) in Anchorage, Alaska, and First Nations
Community HealthSource (FNCH) in Albuquerque, New
Mexico.
Characteristic SCF (N = 20), n (%) FNCH (N = 15), n (%) Total
(N = 35), n (%)
Role
Provider/administrator 10 (29) 6 (17) 16 (46)
Patient 10 (29) 9 (26) 19 (54)
Gender
Male 11 (31) 5 (14) 16 (46)
Female 9 (26) 10 (29) 19 (54)
Race
AI/AN 14 (40) 9 (26) 23 (66)
Non-AI/AN 4 (11) 6 (17) 10 (29)
Unknown 2 (6) 0 (0) 2 (6)

16. Education
Less than high school 0 (0) 1 (3) 1 (3)
High school graduate 2 (6) 2 (6) 4 (11)
Some college 5 (14) 7 (20) 12 (34)
Bachelor’s 7 (20) 0 (0) 7 (20)
Master’s 2 (6) 2 (6) 4 (11)
PhD 4 (11) 3 (9) 7 (20)
Age (years)
18-39 9 (26) 2 (6) 11 (31)
40-59 8 (23) 10 (29) 18 (51)
60-79 3 (9) 3 (9) 6 (17)
Note. AI/AN = American Indian and Alaska Native.
Table 2. Key Themes and Subthemes From Focus Groups to
Adapt an Advance Care Planning (ACP) Communication
Intervention for
Use with American Indian and Alaska Native People.
Theme/subtheme Example quote
Culture/role in ACP
communication
“Can you add maybe like a suggestion, of adding the word
culture, I know you have the religious
and spirituality but maybe putting cultural beliefs, I think some
people might register that more.”
Talking about health care/
identifying key people
“Sometimes it’s the CMA that’s taking your blood pressure that
has a better rapport with the
patient, than the care provider . . . it doesn’t necessarily have to
be the person that had the

17. “MD” behind their name, or their BSN. It’s really [about] who’s
the person that best can speak
with the patient, because they’re part of the team, too.”
What makes talking about care
harder or easier/provider-
initiated communication
“ . . . when you’re scared about something and you don’t really
want to talk about it, you’re
going to avoid if . . . And if your provider doesn’t bring it up,
then you’re gonna get out of that
appointment and think, ‘Whew, I didn’t have to touch that, this
time.’”
Lillie et al. 183
captured in the original intervention developed for a general
U.S. population. Last, our results indicate that ACP commu-
nication needs to be clear and understandable to the popula-
tion and individual with whom it occurs. For AI/AN
communities in this study and, we would argue most, or all
communities, this means using language that is
straightforward and descriptive, without jargon, and not
unnecessarily “wordy”, as well as acknowledging that ACP
communication is not a quick, one-time conversation, and
inviting patients time to contemplate, ask questions, consult
with family members, and discuss ACP at subsequent visits.
We advise that our results be considered when planning and
Figure 1. The “Culture” section that was added on the
questionnaire portion of the revised, culturally adapted ACP-
AIAN (advance

18. care planning intervention for American Indian and Alaska
Native people), based on findings from focus groups and
cognitive interviews at
Southcentral Foundation (SCF) in Anchorage, Alaska, and First
Nations Community HealthSource (FNCH) in Albuquerque,
New Mexico.
184 Journal of Transcultural Nursing 31(2)
implementing palliative care interventions more generally,
and specifically ACP with AI/AN communities to maximize
the benefits of these interventions for patients and the likeli -
hood that patients will initiate and engage in ACP conversa-
tions. In the next phase of this research, we will evaluate the
effectiveness of the ACP-AIAN for increasing the occur-
rence and quality of ACP communication with AI/AN
patients as well as their satisfaction with the intervention.
The methodology we employed to increase the cultural
acceptability of the intervention is not limited to ACP
interventions and AI/AN communities but may also be
applicable to other health-related interventions and popu-
lations. We gathered feedback and suggestions from stake-
holders on the intervention via qualitative focus groups
and cognitive interviews, and we used these data to cultur-
ally adapt the intervention in an iterative manner, based on
our findings. We included patients, caregivers (all family
members), providers, and administrators as the stakehold-
ers, since all had a common interest in high-quality,
patient-centered palliative care communication. Moreover,
we engaged—through a CSAB—diverse people with expe-
rience and expertise with AI/AN cultures, research with
Tribal communities, health communication, and palliative

19. care to ensure the successful development of a culturally
adapted intervention for ACP. Our study reinforces the
importance of culturally adapting an intervention to a tar-
get population, undertaking a CBPR approach, and involv-
ing stakeholders in every aspect of the research, as the
Table 3. The “What Makes Talking About Care Harder” Section
of the Revised, Culturally Adapted ACP-AIAN.
What makes talking about care harder?
1. I don’t know what kind of care I would want if I got very
sick.
2. I’m not ready to talk about the care I would want if I got very
sick.
3. I don’t like to talk about getting very sick.
4. My provider never has time to talk about what would happen
if I got very sick.
5. I would rather concentrate on staying alive than talk about
this.
6. Talking about things like death or dying can bring them
closer.
7. I have a living will, and that means I don’t need to talk with
my provider about the care I would want if I were too sick to
speak for
myself.
8. My ideas about the kind of medical care I want change at
different times.
9. I have not been sick enough to talk with my provider about
the care I would want if I got very sick.
10. I’m not sure which provider would be taking care of me if I
got very sick.
11. There is not a trustworthy person who could make health
decisions for me.

20. 12. I cannot talk about this due to my spiritual or religious
beliefs.
13. I do not think that my wishes would be followed at home.
14. I have other priorities in my life that I need to focus on
right now.
15. I never have an opportunity to speak with my primary care
provider alone.
16. It is difficult to talk with my provider about this.
17. I would rather talk with someone other than my primary care
provider.
18. My provider does not understand my culture or language.
19. My primary care provider does not talk with my other health
care providers.
Note. ACP-AIAN = advance care planning intervention for
American Indian and Alaska Native people. The added
responses on the ACP-AIAN are in
italics.
Table 4. The “What Makes Talking About Care Easier” Section
of the Revised, Culturally Adapted ACP-AIAN.
What makes talking about care easier?
1. I have had the experience of being very sick so it is easier to
talk about.
2. I have had family or friends who were unable to participate in
decisions about their care, and that makes it easier for me to
talk about.
3. I want to have the best quality of life I can in the future if I
become very sick.
4. I do not want to be a burden on my friends and family if I
become very sick.
5. A health care provider other than my primary care provider
has discussed this with me, and that makes it easier to talk
about.

21. 6. I know what I want if I were to become very sick and I want
my wishes to be followed.
7. I want my friends and family to know what I want if I got too
sick and cannot speak for myself.
8. I do not want my family to be in conflict about my care if I
become very sick and cannot speak for myself.
9. I have received culturally relevant and appropriate
information about the care I could receive if I were to become
very sick.
Note. ACP-AIAN = advance care planning intervention for
American Indian and Alaska Native people. The added
responses on the ACP-AIAN are in
italics.
Lillie et al. 185
adaptation yielded differences that our data suggest will
improve the understandability, relevance, and effective-
ness of intervention with AI/AN people and their providers
(Barrera et al., 2013; Hirchak et al., 2018).
This study has some important limitations. Our data were
collected at primary care facilities in two urban locations:
Anchorage, Alaska, and Albuquerque, New Mexico. Thus,
our findings may primarily be representative of urban AI/
ANs. Although rural AI/ANs travel to these facilities to seek
care and likely were included in our sample, we did not look
at how perceptions of ACP and palliative care interventions
may have differed between rural and urban AI/ANs. Rural
and urban AI/ANs appear to differ in health disparities
(Baldwin et al., 2002; Grossman, Krieger, Sugarman, &
Forquera, 1994) and access to health care (Kulinna et al.,
2017), which likely also influence ACP communication. One

22. study found that urban AIs reported inadequate access to care
and public transportation, while rural AIs reported communi -
cation, culture, structural, physical, and supportive barriers
(Itty, Hodge, & Martinez, 2014). Thus, it is plausible that a
culturally acceptable ACP intervention might differ between
rural and urban AI/ANs, and future research should explore
this further. Another limitation to our study was that our find-
ings were derived from a relatively small sample of patients
and providers (N = 35) at only two institutions serving AI/
AN populations, which suggests that our findings may have
limited generalizability, although we mitigated this limita-
tion by selecting sites with a broad range of tribes repre-
sented by the patient population.
In conclusion, this study demonstrates the feasibility
and acceptability of culturally adapting an ACP interven-
tion for use in and with AI/AN populations. Our findings
suggest that such adaptations are critical for the success of
health service interventions in diverse populations, par-
ticularly those that rely on a shared understanding of
patient, family, and/or community-based values, priori-
ties, and goals. In addition, our results may inform policy-
makers and public health officials who are interested in
ACP with AI/AN populations across the United States.
Nurses often spend the most time with patients compared
with other health care providers, and increasingly, nurses
are being trained to provide ACP to patients and their fam-
ilies (Christensen et al., 2019; Epstein et al., 2019).
Therefore, there is increasing evidence that it is beneficial
for health care systems to educate and empower nurses in
discussing end-of-life care with AI/AN people and other
underrepresented groups, so that they can initiate such
discussions and advocate for these growing patient popu-
lations. The next phase of our research will examine the
effectiveness of this culturally adapted ACP intervention
with AI/AN communities. We encourage researchers to

23. use similar, stakeholder-engaged, community-based and
participatory, qualitative methodology to culturally adapt
interventions with specific patient populations, especially
those that are underrepresented in research, for the
purpose of increasing access to acceptable, inclusive, and
effective palliative care services.
Acknowledgments
We thank the patients, caregivers, providers, administrators, and
tribal leadership at Southcentral Foundation in Anchorage and
First
Nations Community HealthSource in Albuquerq ue for their
contri-
butions to this project. We also wish to thank the Community
and
Scientific Advisory Board members who guided the study and
sub-
stantially shaped its design and implementation. We also thank
Dr.
Emily Haozous, who conducted two focus groups and two
cogni-
tive interviews and assisted with obtaining institutional review
board approval in New Mexico. We thank Dr. Caroline Stephens
for reviewing the manuscript. Finally, we thank the Palliative
Care
Research Cooperative Group for their dedicated and generous
sup-
port and assistance in developing and implementing the study.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with
respect
to the research, authorship, and/or publication of this article.

24. Funding
The author(s) disclosed receipt of the following financial
support for
the research, authorship, and/or publication of this article: This
study
was supported by the National Institute of Nursing Research of
the
National Institutes of Health under Award No. 5R21NR016611-
02.
ORCID iD
Kate M. Lillie https://orcid.org/0000-0002-2258-126X
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A R T I C L E
Diversity improves performance and outcomes
L. E. Gomez, M.D., M.B.A., Patrick Bernet, Ph.D.
JOU
Funding: This research did not receive any specific grant from
funding agencies
in the public, commercial, or not-for-profit sectors.
Abstract: Background: Research on the effects of increasing
workplace diversity
has grown substantially. Unfortunately, little is focused on the
healthcare
industry, leaving organizations to make decisions based on
conflicting findings
regarding the association of diversity with quality and financial
outcomes. To
help improve the evidence-based research, this umbrella review
summarizes
diversity research specific to healthcare. We also look at studies
focused on
professional skills relevant to healthcare. The goal is to assess
the association
between diversity, innovation, patient health outcomes, and
financial
performance.

33. Methods: Medical and business research indices were searched
for diversity
studies published since 1999. Only meta-analyses and large-
scale studies
relating diversity to a financial or quality outcome were
included. The research
also had to include the healthcare industry or involve a related
skill, such as
innovation, communication and risk assessment.
Results: Most of the sixteen reviews matching inclusion criteria
demonstrated
positive associations between diversity, quality and financial
performance.
Healthcare studies showed patients generally fare better when
care was
provided by more diverse teams. Professional skills-focused
studies generally find
improvements to innovation, team communications and
improved risk
assessment. Financial performance also improved with
increased diversity. A
diversity-friendly environment was often identified as a key to
avoiding frictions
that come with change.
Conclusions: Diversity can help organizations improve both
patient care quality
and financial results. Return on investments in diversity can be
maximized when
guided deliberately by existing evidence. Future studies set in
the healthcare
industry, will help leaders better estimate diversity-related
benefits in the context
of improved health outcomes, productivity and revenue streams,

34. as well as the
most efficient paths to achieve these goals.
Keywords: Diversity-Outcomes-Profits-Innovation-Risk
Author affiliations: L.E. Gomez, Howard University College of
Medicine, 520 W Street NW,
Washington, D.C. 20059, USA; Patrick Bernet, Florida Atlantic
University, 3200 College Ave,
Liberal Arts, Room LA.435, Davie, FL 33314, USA
Correspondence: Patrick Bernet, Ph.D., Florida Atlantic
University, 3200 College Ave,
Liberal Arts, Room LA.435, Davie, FL 33314, USA., email:
[email protected]
ª 2019 by the National Medical Association. Published by
Elsevier Inc. All rights reserved.
https://doi.org/10.1016/j.jnma.2019.01.006
INTRODUCTION
iscussions about workforce diversity too often
become distracted, revolving around hot-button,
Dpolitically-charged language, missing opportunities
to focus simply on making a clear case for the value of di -
versity that demonstrates clinical and financial
improvements.1 Both the IOM and NIH have long reported
the potential value of diversity in maximizing health benefits
of medical teams that bridge cultural and linguistic gaps.2,3
Unfortunately, many patients are still managed by

35. homogenous care teams, with outcomes reflecting large
RNAL OF THE NATIONAL MEDICAL ASSOCIATION
disparities in clinical care efficacy. Blacks are 30% less
likely to receive revascularization at coronary angioplasty
and 40% less likely to receive coronary bypass surgery.4
Black women are 40% more likely to die from breast
cancer,5 and their babies have a mortality rate 2.5 times
greater than whites.6 Disparities even occur in the man-
agement of simple chronic conditions, with black and
Hispanic youth much more likely to die from diabetes
complications.7 Beyond the human cost lies a financial
edge, as revenues decrease under pay-for-performance
reimbursements that penalize quality shortcoming associ-
ated with such disparities.
Several studies specific to the healthcare setting support
the growing disparities listed above. Studies find greater
diversity improves the accuracy of clinical decision-
making, leading to higher patient satisfaction and result-
ing in improved health outcomes.8 Yet many studies were
unable to find significant association between diversity and
clinical outcomes, even in simple concordance relations
matching patient and physician characteristics.9,10
The paucity of studies specifically focusing on diversity
and medical outcomes is not necessarily a barrier to action;
just a note of caution. Our strategy with this paper is to
identify diversity research relating to the business si de of
healthcare because the ability to ’keep the doors open’ is
an essential precursor to improving healthcare delivery for
all patients. We also include a look at studies focusing on
other professions that use similar skill-sets to those needed
in healthcare, including risk assessment and communica-
tion. Like much progress in medicine, several large sample
population-specific studies would be generally preferred,

36. but ignoring related research while waiting for that ideal
study can be outright irresponsible.
To organize the business justifications for diversity, our
study provides an objective review of recent research on
diversity, testing the evidence for possible links to financial
and quality outcomes. Our goal is to address the following
four questions: Is there a correlation between diversity and
patient health outcomes? Is there an association between
workforce diversity and financial outcomes? Does that
strength of association differ betweenworker-level diversity
and that of top management? Are there associated corporate
conditions that moderate those relationships?
VOL 111, NO 4, AUGUST 2019 383
mailto:[email protected]
https://doi.org/10.1016/j.jnma.2019.01.006
Table 1. Summary of related research.
Review Methods and setting Diversity dimensio n Findings
Outcomes studies
LaVeist, Pierre,
2014.8
This meta-analysis cites 25 studies of diversity and
cultural competence in the healthcare industry.
Workforce diversity in:
Race, Ethnicity.
Outcomes:

37. Patient compliance,
Consumer satisfaction
� More diverse medical teams gave more accurate
diagnoses, had higher patient satisfaction, and saw
greater compliance.
� This study also hints at lower long-term costs as
another possible benefit.
Jerant
et al.20119
Healthcare
Focus
Measures patient-physician concordance, care
management process measures.
Concordance
between physician
and patient race
and/or gender.
� Three of 24 measures showed positive findings, such
as a higher likelihood of mammography adherence
for female patients with female doctors. All other
measures showed no association with concordance.
Schnittker,
Liang, 2006.10
Healthcare
Focus
1999 survey of 4000 patients about

38. concordance and encounter impressions.
Concordance
between physician
and patient race
and/or gender.
� No significant association between concordance
and impressions, such as, whether the patient felt the
doctor "knew enough or asked enough questions
about your health".
Pitts, 2005.11 Longitudinal study of 2500 Texas public
school districts 1995e1999, measuring:
� outcomes/performance
BStandardized sufficiency exams
BDrop-out rates
BHigh-SAT performance
� company characteristics:
BRacial diversity
BRepresentation (The match between race-
ethnic-gender diversity of the company and
that of the community they serve.)
Workforce and
management: Race,
Representation.
Outcomes:
Sufficiency exams,
Drop-out rates, SAT
performance

39. � Teacher-level diversity:
Bimproved standardized sufficiency exams worsened
Drop-out rates
worsened High-SAT performance
� Administrator-level diversity:
Bno impact on standardized sufficiency exams no
impact on Drop-out rates
worsened High-SAT performance
� Teacher-level representation:
Bno impact on standardized sufficiency exams no
impact on Drop-out rates
worsened High-SAT performance
� Administrator-level representation:
Bimproved standardized sufficiency exams improved
Drop-out rates
improved High-SAT performance
Levine et al.,
2014.12
Representative samples of financial traders from
several markets buy and sell in simulated markets
based on real world data.
Market-level diversity in
Ethnicity
Outcome:
Price prediction
accuracy
� The diversity of the entire pool of traders impacts the

40. accuracy of the market price established by that
pool.
� Given that each trader works in isolation, the effect is
continued.
D
IV
ER
SITY
IM
PR
O
V
ES
PER
FO
R
M
A
N
C
E
A
N
D
O
U
TC

41. O
M
ES
384
V
O
L.
111,
N
O
4,
A
U
G
U
ST
2019
JO
U
R
N
A
L
O
F
TH
E
N
A
TIO

42. N
A
L
M
ED
IC
A
L
A
SSO
C
IA
TIO
N
continued.
Review Methods and setting Diversity dimension Findings
purely due to conflicting assessments of valuation
(implicit in buy-sell decisions of others).
� Viewed another way, ethnic homogeneity induces
confidence in the decisions of other group members,
whether warranted or not.
Risk assessment skills studies
Muller Lewellyn,
2011.13

43. 1997e2005 longitudinal study of 74 US banking
industry companies; half of which specialized in
subprime lending. Measured excessive risk-taking
behavior based on participation in subprime
lending.
Board-level diversity
in: Gender.
Outcome:
Risk assessment
� Boards with higher gender diversity were much less
likely to engage in excessive risk taking (subprime
lending).
Chapple,
Humphrey,
2014.14
Includes
Healthcare
Companies
Industry-level assessment of Australia S&P 300
companies, measuring the impact of portfolio-
average board gender diversity on the financial
performance the entire portfolio of industry
companies.
Board diversity in:
Gender

44. Outcomes:
Portfolio returns.
� Board gender diversity showed no significant impact
on overall industry average returns.
Post, Byron,
2015.15
Includes
Healthcare
Companies
Meta-analysis of 140 separate studies on board
gender diversity and corporate performance.
Outcomes measured:
� Profit (accounting profit)
� Market performance (Tobin’s q, for long-term
market expectations),
� Monitoring (oversight of managerial activities)
� Strategy involvement (board influences
strategic decision making)
Board-level diversity
in:
Gender.
Outcomes:

45. Profit, Market
performance,
Monitoring
oversight, Strategy
involvement
� Profit was higher with greater gender diversity
� Monitoring oversight was higher with greater gender
diversity
� Market performance was unaffected by gender
diversity
� Strategy involvement was unaffected by gender
diversity
Productivity studies
Kunze, Boehm,
Bruch, 2013.16
Study of 147 German companies measuring the
impact of age-diversity on � Operational
performance (employee productivity and
employee retention)
� Organizational performance (current profits
and expected growth)
Workforce diversity
in:
Age.
Outcomes:

46. Operational,
Organizational.
� Age diversity is associated with improved Operation
and Organizational performance.
� Age diversity was also associated with greater group
conflict, but this effect disappeared with diversity-
friendly company climate and policies.
continued.
D
IV
ER
SITY
IM
PR
O
V
ES
PER
FO
R
M
A
N
C
E
A
N

47. D
O
U
TC
O
M
ES
JO
U
R
N
A
L
O
F
TH
E
N
A
TIO
N
A
L
M
ED
IC
A
L
A
SSO

48. C
IA
TIO
N
V
O
L
111,
N
O
4,
A
U
G
U
ST
2019
385
continued.
Review Methods and setting Diversity dimension Findings
McKay, Avery,
Morris, 2008.17
Study of salesperson performance in 743 US retailer
stores in 2005. Measured worker perceptions of the
company’s diversity climate.

49. Workforce diversity
in:
Race, Gender.
Outcomes: Sales
� Pro-diversity work climate was associated with signifi-
cantly higher sales production for black and Hispanic
employees. Specifically, blacks in low-diversity
climates made $8.90 per hour less than whites, but
7.41 more in pro-diversity climates. The improvement
was even greater for Hispanics.
� Gender differences in sales performance were not
impacted by the diversity climate.
� Diversity climate had no significant effect on white
productivity, making the net effect of a pro-diversity
climate on overall company sales was strongly
positive.
Dreachslin,
Portia, Sprainer,
2000.18
Healthcare
Focus
Focus groups of Nursing Care Teams at large US
hospitals evaluated factors impacting
performance.
Team-level diversity
in:

50. Race, role.
Outcome:
communication
effectiveness
� The alternate perspectives within racially diverse
groups are a source of potential conflict.
� This can be mediated through leadership that ac-
knowledges alternate perspectives
Innovation studies
Lorenzo et al.,
2017.19
Includes
Healthcare
Companies
Survey of 171 German, Swiss and Austrian
companies of all sizes, representing many
industries (chemicals, technology, manufacturing,
finance and healthcare). Measured diversity and
financial performance, identifying the share of
revenue drawn from new products and services
in the most recent 3 years.
Management-level
diversity in:
Age,

51. Gender,
Immigrant status,
Experience variety:
-Industry
-Company
-Academic
Outcomes: Revenue
from new products
� Revenue from new products and services is higher in
companies with higher diversity in 4 dimensions:
Immigrant status (1st or 2nd generation), gender,
multi-industry and multi-company experience).
Specifically, companies with above-average levels of
these diversity measures earned 38% more revenue
from new products and services.
� Gender diversity only pays off beyond tokenism (20%)
� Age diversity had a negative impact on revenues
from innovation and diversity in academic back-
grounds had no impact..
� Co-variate: Large and complex companies benefit
more from higher levels of diversity (in all dimensions).
� Co-variate: Openness in work environments and
continued.

52. D
IV
ER
SITY
IM
PR
O
V
ES
PER
FO
R
M
A
N
C
E
A
N
D
O
U
TC
O
M
ES
386
V

53. O
L.
111,
N
O
4,
A
U
G
U
ST
2019
JO
U
R
N
A
L
O
F
TH
E
N
A
TIO
N
A
L
M
ED

54. IC
A
L
A
SSO
C
IA
TIO
N
continued.
Review Methods and setting Diversity dimension Findings
encouragement of different perspectives amplify the
positive impact of diversity.
Crisp, Turner,
2011.20
An extremely broad meta-analysis of over 100
studies of diversity in the workplace.
Team diversity in
Race
Gender.
Outcomes: Various
measures of
Productivity and

55. Creativity.
� Finds the process of adapting to greater diversity
stretches ’cognitive flexibilities’, making everyone on
the team more creative and improving collective
and individual judgement
Miller, Triana,
2009.21
Includes
Healthcare
Companies
Compare Fortune 500 companies using 2003
data. Measured:
� Board racial and gender diversity
� Innovation (proxied by the proportion of sales
invested in Research & Development).
� Reputation (Fortune’s reputation measure
based on opinion of peer executives in the
same industry)
Board-level diversity
in: Race, Gender.
Outcomes:
Reputation,
Innovation
� Board racial diversity associated with higher
reputation

56. � Board racial diversity associated with higher
innovation.
� Board gender diversity associated with higher
innovation
� Hints that diversity improves innovation via more ac-
curate risk assessment. A new opportunity that feels
unfamiliar (thus riskier) to a homogeneous group may
be better recognized (thus less risky) to a more diverse
group (with broader experience)
Financial studies
Erhardt,
Werbel,
Shrader,
2003.22
Compare 1993 and 1998 financial performance
for 127 large US companies representing many
industries (manufacturing, finance and
transportation-utilities).
Board-level diversity
in:
Race, Gender.
Outcomes:
Return on Investment
Return on Assests.

57. � Return on assets increases associated withracial and
gender board diversity increases.
� Return on investments increases associated with
racial and gender board diversity increases
Richard, Murthi,
Ismail, 2008.23
Includes
Healthcare
Companies
6-year longitudinal study of Fortune 1000 firms
(representative sample), estimating the impact
of racial diversity (entire staff) on short-term
outcomes (revenue per employee) and
long-term profitability (Tobin’s q, based on
market valuation).
Workforce diversity
in:
Race.
Outcomes: Short-t
erm productivity
and Long-term
profitability
Short-run productivity:
� Increases with diversity up to a point, then decreases.
� Co-variate: Service industries gain the most from
diversity.
� Co-variate: Unstable environments hurt the most from

58. diversity.
Long-run productivity:
� Increases with diversity.
continued.
D
IV
ER
SITY
IM
PR
O
V
ES
PER
FO
R
M
A
N
C
E
A
N
D
O
U
TC
O

59. M
ES
JO
U
R
N
A
L
O
F
TH
E
N
A
TIO
N
A
L
M
ED
IC
A
L
A
SSO
C
IA
TIO
N
V

60. O
L
111,
N
O
4,
A
U
G
U
ST
2019
387
co
nt
in
ue
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61. a
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s
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).
DIVERSITY IMPROVES PERFORMANCE AND OUTCOMES

89. 388 VOL. 111, NO 4, AUGUST 2019
MATERIALS AND METHODS
Our analysis begins with an umbrella review of studies
focused on the impact of diversity in the workplace. For
the purposes of our research, ’diversity’ is broadly defined
to recognize differences in race, age, ethnicity, educational
background and gender of workers, managers, customers
or teams, including nurses, technicians and physicians.
Inclusion criteria
Studies published in English after 2000 were eligible for
inclusion if they assess clinical or business outcomes
associated with workforce diversity. US-based studies
were preferred, but international studies were included if
carried out in a similar business environment. Studies set
in the healthcare industry were preferred, and studies of
professionals using healthcare-related skills, such as risk
assessment, were also included. Studies must focus on
diversity of a group of people. Meta-analyses or large
sample size studies were preferred, but integrative research
was included if analysis was based on a broad collection of
related research. Studies focused exclusively on a single
clinical condition were excluded, as those would limit the
generalizability of findings. Additionally, studies must link
workforce diversity to either a clinical or business
outcome. That outcome can be the ultimate outcome, such
as business profit or patient health, interim outcomes, such
as employee productivity, or quality measures, such as
clinical protocol adherence.
The MEDLINE and Web of Science indices were
searched for studies using the term ’diversity’ in combi -
nation with any of the following terms: outcomes, dis-
parities, profits, returns, revenues, costs, compliance,

90. mentoring, and leadership.
Evaluation process
The initial catalogue of studies was built by merging the
independent searches of two investigators, both of whom
independently reviewed, summarized and coded each.
Information collected included industry setting, sample
size, research methods, type of diversity, outcome mea-
sures, and findings. We also documented author sugges-
tions on causal linkages or underlying mechanisms
associating outcomes to workforce diversity.
RESULTS
The literature search grossed 675 papers as possibly
eligible for inclusion. Many of these were excluded from
consideration because their focus was a single medical
condition rather than a global effect. Concordance studies,
of which there are many, were also excluded due to a
narrow focus on the characteristics of only physicians
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
DIVERSITY IMPROVES PERFORMANCE AND OUTCOMES
rather than the entire medical team. The 16 reviews that
met inclusion criteria are incorporated into the umbrella
review. The characteristics, populations, methods and
findings are summarized in Table 1.
These papers look at diversity in multiple dimensions.
One subset focuses on diversity of Board leadership, while
others drill down to the shop floor. Some measure changes
in skills or efficiency, while others measure interim out-
comes such as patents or investment decisions, and still
others measure ultimate outcomes such as corporate profits

91. or consumer satisfaction. Papers are discussed below in
groupings based broadly on the locus of key findings:
outcomes, risk assessment skills, task productivity, product
or service innovation, and financial returns.
Outcomes studies
Increased diversity in the healthcare workforce helps
reduce or eliminate racial health disparities, according to a
2014 meta-analysis of 25 studies.8 Composed of research
set entirely in the healthcare industry, this broad analysis
included studies that looked at the race, ethnicity, cultural
competence and language diversity of providers, ranging
from characteristics of the entire organization, down to
healthcare teams, including physician and nursing staffs.
Improvements were noted in patient compliance and
satisfaction scores. Additionally, clinical uncertainty of
both regarding diagnoses and treatment options was
reduced. While this is the only sample study focused
exclusively on clinical outcomes, some include healthcare
in higher level multi-industry analyses, and others focus on
core skills central to multidisciplinary professional teams .
A large-scale study of all Texas schools reveals diver-
sity’s impact in public education systems.11 They find
student performance most-improved when there was
greater management diversity, and a closer racial match
(representation) between management and student.
Notably this was a top management-level effect only; there
was no significant impact of diversity at the teacher level.
Given the importance of communication and education in
healthcare, such findings suggest the significant effect of
diversity, not just of those working directly with patients,
but the hospital leadership who design the content,
distribute the necessary resources and decide which ser -
vices are appropriate for which patients.

92. Diversification improves performance not just by
“providing variety in perspectives and skills, but also
because diversity facilitates friction that enhances delib-
eration and upends conformity” that results in better risk
assessment.12 This study of investment company decision-
making found that diversity among investment analysts
resulted in less exposure to involvement in price bubbles,
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
such as the housing market crash of 2007, allowing those
companies to fare better when the bubble burst and lead to
the financial crisis. A similar effect might reasonably be
expected in clinical decision making based on experiences
with differing patient populations. The ability of invest-
ment analysts to accurately forecast future company per-
formance based on current measures is roughly equivalent
to a physician’s ability to accurately diagnose a condition
based on past clinical experience in cases when tests are
inconclusive. This study looked at the diversity of entire
investor markets, such as soy bean traders or corporate
bond analysts. In healthcare, this might be analogous to an
entire research community spread across universities,
hospital systems, or the pharmaceutical industry, high-
lighting the importance of diversity in all settings.
Risk assessment studies
A longitudinal study of the banking industry that spanned
the sub-prime crisis found that banks with gender-diverse
boards were less likely to get involved with the high-risk
loans that crippled much of the financial industry in the
sub-prime crisis.13 Specifically, banks with more gender-
diverse boards were less likely to be involved in risky
sub-prime activities associated with the 2007 crisis. If di -
versity dilutes the mono-socioeconomic perspective of top
management, it would be expected that these new points of
view could improve risk assessment which are at least

93. partially based on the subjective judgements of those
leaders. Similarly, second opinions in healthcare often
contribute to improved patient health outcomes and
reduced risk.
At a higher level of analysis, a market-wide assessment
of Australia S&P 300 companies measured the impact of
industry-average board gender diversity on the financial
performance of entire portfolios of companies.14 While
this study found no evidence of positive returns from
gender diversification, the high level of abstraction
employed likely interfered with conclusive findings. It
nonetheless supported that gender diversity does not
hinder performance in any parameter measured.
A meta-analysis of 140 separate studies15 finds Boards
with greater gender equity fulfilled monitoring re-
sponsibilities more often, and that this vigilance was also
associated with higher accounting returns. In healthcare,
this kind of due diligence could manifest, for example, in
observations that female doctors monitor patients more
closely, yielding lower rates of hospital readmissions.26
Similar diligence and patience may partially explain the
diversity advantage derived from race concordance
observed in other studies.27
VOL 111, NO 4, AUGUST 2019 389
DIVERSITY IMPROVES PERFORMANCE AND OUTCOMES
Productivity studies
Age-range diversity also improves corporate performance. A
study of 147 companies finds age diversity associated with
higher employee productivity and retention, as well as higher

94. profits and growth projections.16 This study also notes age
diversity is associated with creating greater internal conflict.
However, if balanced by a no “age-discrimination" climate
within the company, supported by management and HR
policies, these conflicts do not arise. Other studies also note
potential for increased internal conflict associated with
various forms of diversity but reinforce the neutralizing po-
wer of supporting policies and a positive work environment.
Just such a pro-diversity work climate was associated
with higher sales production for black and Hispanic em-
ployees in a large-scale study of salesperson performance
at a major national US retailer.17 In lower pro-diversity
climates, blacks trailed white salespeople productivity by
$8.90 per hour, while in diversity supportive climates,
black sales exceeded that of whites by $7.41. Significantly,
white productivity remained relatively unchanged, making
the net effect of a pro-diversity climate strongly positive.
Hispanic employee sales improvements were even more
dramatic, increasing to $25.52 in sales per hour. Viewed
another way, these findings demonstrate that diversity may
be more than a path to equity; it may enable women and
minorities to become top performers, simultaneously
improving overall company profits.
Possibly hinting at background mechanisms through
which diversity-accepting environments achieve higher
performance, a study of nursing care teams found com-
munications effectiveness significantly improved with
greater team diversity.18 Groups in which leaders set a
positive, accepting tone were associated with lower levels
of team conflict and miscommunication.
Innovation studies
“Companies with higher levels of diversity get more reve-

95. nue from new products and services”.19 Focused on man-
agement diversity, this study of 171 companies measured
the impact of gender and racial diversity on innovation
revenues using financial performance, operating statistics,
and employee surveys. They found companies with above-
average diversity were rewarded with 38% more revenue
from innovative products and services. They also empha-
sized that diversity must exceedmere tokenism; particularly
in top management. The study showed that the proportion
women in top management needed to exceed 20%, in order
for the company to experience themost significant increases
in innovation revenues.
A broad meta-analysis of over 100 studies finds the
process of adapting to greater diversity stretches ’cognitive
390 VOL. 111, NO 4, AUGUST 2019
flexibilities’, making everyone on the team more creative
and improving collective and individual judgement.20
A study of Fortune-500 firms employing robust statis-
tical methods finds gender and race board-level diversity
associated with both greater innovation and corporate
reputation.21 Reputation, measured by industry surveys,
improved with racial diversity. Innovation, as measured by
research and development investment, improved with both
racial and gender diversity. Highlighting the importance of
risk assessment, the study concludes “the less information
they have on the attractiveness of the market, the more
innovation is perceived as a risk”. Finally, the authors
attribute improved risk assessment to the greater number
of social ties held by minorities and women, noting “these
weak ties, in turn, are known to be valuable because they
provide non-redundant information”. These gains are
especially relevant in dealing with the diverse consumer
mix of critical access hospitals.

96. Financial studies
A sizable highly-regarded longitudinal study of 127 large
US companies finds clear evidence that the combined racial
and gender diversity of a board is positively associated with
both return on assets and return on investments.22
One study found the impact of diversity varied both
over time and by industry. In another longitudinal study of
Fortune-500 US companies spanning 1997e2002,23
workforce diversity was measured with the sophisticated
Blau’s index of heterogeneity.28 Long-run performance,
based on market expectations inferred by stock valuation,
increased consistently with higher diversity. Measuring
short-run performance based on variations in revenue per
employee, this study finds initially decreasing revenue
with increasing diversity, then an increase after a threshold
is reached. This could indicate that the benefits of diversity
are only achieved after they progress beyond tokenism.
The effect was most pronounced in the service sectors,
which would include healthcare, and also highlighted the
importance of setting a positive climate to minimize fric-
tions and maximize returns.
Not all studies find evidence of positive financial returns
associated with diversity. A narrow study of just 9 com-
panies could detect no improvement to return on assets
associated with the presence of women or minorities on
boards.24 However, this study did cite similar diversity-
associated internal conflicts reported in the other larger
studies, while it did not control for corporate environment,
missing an opportunity to elaborate on preliminary findings.
A broad study of 1002 US firms found ethnic diversity
was associated with higher sales, more customers, higher

97. market share, and larger profits.25 Again, greater gender-
diversity improved sales, customer base and profits. Of
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
DIVERSITY IMPROVES PERFORMANCE AND OUTCOMES
interest this study is based on the composition of the entire
company workforce; not just that of the board or top
management.
DISCUSSION
Limitations of our study stem primarily from the relative
newness of diversity research in general, and healthcare
applications specifically. Women and minorities have
become more numerous in service and business roles in
just the last few decades, and even less time has passed
since they started appearing on boards. Hungry for a large
enough representation in workforces and adequate passage
of time to track longitudinal change, most studies to-date
do the best they can with limited data. While some
studies can support quantified outcomes with reasonable
confidence, the exact outcome varies somewhat from one
study to the next. Our study explores this growing field,
looking first for evidence of performance consequences of
diversity, and then for mechanisms through which those
outcomes might be achieved. Even with a conservative
research approach, our study draws several key lessons
from past studies.
Our first conclusion is diversity improves performance.
It is associated with higher profits and a range of financial
rewards including: innovation, increased productivity,
improved accuracy in risk assessment and has already been
associated with improved patient health outcomes. Even
the relatively few studies that find no diversity-related

98. gains do not suggest negative effects on performance.
Future studies should provide more precise estimates of
how much and what kind of diversity has the most positive
effects on performance and health outcomes.
Specific mechanisms through which performance im-
provements manifest are identified in our umbrella study.
Improvements in personal productivity, team communi-
cation, employee retention all have all been shown to
contribute to enhanced outcomes that are both financial
and clinical. Looking deeper, behind these ’interim’ steps,
are several core skills that benefit from diversity. Creativity
and innovation appear to blossom in more diverse setting.
Risk assessment is more precise and balanced in more
creative environments. These two core skills e risk
assessment and creativity e are vital in a healthcare
setting.
Simple diversity is not a panacea. Even these early
studies identify key enabling characteristics. First, the
organization must set diversity-friendly policies and
foster an open environment that minimizes the negative
consequences of frictions that are inevitable with any
culture change, including those associated directly with
diversity.16,18,19 Second, diversity appears to be
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
effective only when it extends beyond tokenism,.19,23
Lastly, gains from diversity are maximized when re-
flected in top management and board posi-
tions.13e15,21,22,24 Although most findings above were
not drawn exclusively from studies set in the healthcare
industry, basic concepts such as diversity-friendly pol-
icies, tokenism, team communication, risk assessment
seem universal and relevant.

99. Implications
Diversity is associated with better financial performance
and a higher quality of patient care. Many organizations
are already embracing it as a core strategy. In 2016, Intel
initiated a program to invest $300 million to increase the
diversity of its workforce, justifying the move largely
based on its financial returns.29,30 Beyond parochial mo-
tives, greater industry diversity may also help address
disparities in the population.31
Despite these benefits, women and minorities are still
poorly represented in professional and management ranks.
Perhaps part of the problem has been where attention was
focused. Unfortunately, much discussion centers on regu-
lations, quotas, tax incentives and other “carrots and
sticks”. Our goal with this paper is to ’boost the signal
above the noise’ of this politically charged discourse.
Appealing simply to the organization’s self-interests, we
attempt to objectively demonstrate the financial and
quality returns to diversity.
APPENDIX A. SUPPLEMENTARY DATA
Supplementary data to this article can be found online at
https://doi.org/10.1016/j.jnma.2019.01.006.
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Diversity improves performance and
outcomesIntroductionMaterials and methodsInclusion
criteriaEvaluation processResultsOutcomes studiesRisk
assessment studiesProductivity studiesInnovation
studiesFinancial studiesDiscussionImplicationsAppendix A.
Supplementary dataReferences
ORIGINAL ARTICLE
Effective diversity, equity,
and inclusion practices
Gurwinder Kaur Gill1, Mary Jane McNally, MHA1,
and Vin Berman, MBA, CHRL1
Abstract
Demographics in Canada, and the workplace, are changing.
These include population changes due to race, ethnicity,
religion/faith,
immigration status, gender, sexual identity and orientation,
disability, income, educational background, socioeconomic
status, and
literacy. While this rich diversity can present challenges for
patient experiences/outcomes and working environments, it can
also

110. present opportunities for positive transformation. For successful
transformation to take place, strategies should focus on
“Diversity, Equity, and Inclusion” (DEI) versus “diversity”
alone and on creating inclusive team environments for positive
staff
experiences/engagement. There is a growing understanding of
the relationship between the providers’ work environments,
patient outcomes, and organizational performance. This article
leverages the principle of improving the healthcare provider’s
experience based on Health Quality Ontario’s Quadruple Aim
(“people caring for people”). Based on learnings/experiences,
the
top three successful practices from the organization’s DEI
strategy have been outlined in this article.
Introduction
Demographics in Canada, and in the workplace, are changing.
This includes trends in immigration, internationally trained
professionals, languages/communication styles, religious/faith
communities, a diverse Indigenous population, single parents,
low-income populations, mental/physical health and lesbian,
gay and transgender populations.1 In healthcare, these trends
can result in health inequities (health differences between
population groups defined in social, economic, demographic,
or geographic terms—that are unfair and avoidable).
From a race perspective alone, racism/cultural oppression have