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Driving organizational transformation: empowering middle managers to prioritize diversity, equity, and inclusion within the healthcare sector

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Driving organizational transformation: empowering middle managers to prioritize diversity, equity, and inclusion within the healthcare sector

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Content Driving Organizational Transformation: Empowering Middle Managers to Prioritize
Diversity, Equity, and Inclusion Within the Healthcare Sector
Virginia Solis
Rossier School of Education
University of Southern California
A dissertation submitted to the faculty
in partial fulfillment of the requirements for the degree of
Doctor of Education
August 2024

© Copyright by Virginia Solis 2024
All Rights Reserved

The Committee for Virginia Solis certifies the approval of this Dissertation
Gloria Aquino Sosa
Eric Canny
Patricia Tobey, Committee Chair
Rossier School of Education
University of Southern California
2024

iv
Abstract
Due to competing priorities from both direct reports and senior leadership, middle managers
have struggled to effectively address organization-wide diversity, equity, and inclusion goals.
This descriptive case study utilizes the Burke-Litwin change model and critical race theory
frameworks. The Burke-Litwin change model identifies both transformational and transactional
factors that integrate to influence change throughout an organization, while critical race theory
recognizes racism as a systemic component of organizational operations within an American
context. The study examined 16 middle managers through interviews and document analysis to
understand how they prioritize DEI and contribute to achieving DEI goals.
Keywords: diversity, equity, inclusion, middle management

v
Dedication
To my treasure, Tali, whose presence was felt throughout this entire journey, even as a peanut in
my belly. Thank you for encouraging mommy to always keep pushing through. I hope the idea of
equity becomes a reality sometime in your lifetime.
To my husband, Antonio. You have been my rock throughout the hardest chapter of my life.
Your endless patience, selflessness, and encouragement have gotten me to the finish line, and I
will never be able to thank you enough.
To my parents. Will you ever know the influence you have had on me? Mom, your unwavering
dedication and loyalty toward the things that matter most. Dad, your hard work ethic and
creativity continuously fueled me when I had nothing left to give through this process.

vi
Acknowledgments
Thank you to my family, my dear friends, faculty members, Cohort 22, and my study
participants who have been my support and lifeline throughout my Rossier doctoral journey.
Thank you to Dr. Patricia Tobey, whose direction, support, and encouragement have been
invaluable. You have no idea how grateful I am to have you as my dissertation chair.
Dr. Eric Canny, ever since taking accountability with you, I knew you would be an
invaluable member of my committee! Thank you for your guidance and insights along the way.
Profesora Gloria Aquino Sosa, your mentorship and guidance have been tremendous
since graduate school at Saint Mary’s. Thank you for your unending encouragement through
these years.
To my mother-in-law, Vicky. You have been here for our family in so many ways. Thank
you for caring for Tali when I needed a nap or an extra hand. I appreciate you so much, loca.
Cohort 22, thank you for the lessons learned from each and every one of you; they have
been some of the greatest in my life. I hope this connection never ends.
To my study participants, your leadership and discerning sense of justice and belonging
make our world a better place. Know that you are changing the world for the better.
Fight on!

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Table of Contents
Abstract.......................................................................................................................................... iv
Dedication........................................................................................................................................v
Acknowledgments.......................................................................................................................... vi
List of Tables ...................................................................................................................................x
List of Figures................................................................................................................................ xi
List of Abbreviations .................................................................................................................... xii
Chapter One: Introduction to the Study...........................................................................................1
Context and Background of the Problem.............................................................................1
Purpose of the Project and Research Questions...................................................................2
Importance of the Study.......................................................................................................3
Overview of Theoretical Framework and Methodology .....................................................4
Definition of Terms..............................................................................................................5
Organization of the Study ....................................................................................................6
Chapter Two: Review of the Literature ...........................................................................................8
What Is Diversity, Equity, and Inclusion? ...........................................................................8
Critical Race Theory..........................................................................................................11
The Relationship Between DEI and CRT..........................................................................13
Organizational Barriers to Diversity, Equity, and Inclusion..............................................14
“Doing DEI Right” ............................................................................................................15
DEI & Middle Management ..............................................................................................18
Burke-Litwin Organizational Change Theoretical Model .................................................24
Conceptual Model..............................................................................................................28
Conclusion .........................................................................................................................35
Chapter Three: Methodology.........................................................................................................36

viii
Research Questions............................................................................................................36
Overview of Design ...........................................................................................................36
Research Setting.................................................................................................................38
The Researcher...................................................................................................................39
Sample and Population ......................................................................................................40
Instrumentation ..................................................................................................................40
Data Collection ..................................................................................................................41
Data Analysis.....................................................................................................................42
Ethical Implications...........................................................................................................44
Summary............................................................................................................................45
Chapter Four: Findings..................................................................................................................46
Participants.........................................................................................................................46
Participant Summary..........................................................................................................53
Qualitative Findings Overview..........................................................................................53
Findings Research Question 1: External Environment......................................................54
Summary of Findings for Research Question 1.................................................................62
Findings Research Question 2: Company Culture and Work Climate ..............................64
Summary of Findings for Research Question 2.................................................................71
Findings Research Question 3: Management Practices.....................................................74
Summary of Findings for Research Question 3.................................................................80
Findings Research Question 4: Understanding Motivation...............................................82
Summary of Findings for Research Question 4.................................................................86
Summary............................................................................................................................87
Chapter Five: Discussion and Recommendations..........................................................................88
Burke-Litwin Change Model .............................................................................................88

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Summary of Findings.........................................................................................................89
Recommendations for Practice ..........................................................................................91
Implementation of Recommendations...............................................................................98
Recommendations for Future Research.............................................................................99
Conclusion .......................................................................................................................100
References....................................................................................................................................102

x
List of Tables
Table 1: Data Sources 38
Table 2: Participant Demographics 47
Table 3: Summary Table of Findings: External Factors 63
Table 4: Summary Table of Findings: Company Culture and Work Climate 72
Table 5: Summary Table of Findings: Management Practices 80
Table 6: Summary Table of Findings: Motivation 86
Table 7: Table of Recommendations 91

xi
List of Figures
Figure 1: Impact of DEI-Related Policies and Resources at the Workplace 10
Figure 2: Critical Race Theory 12
Figure 3: Burke-Litwin Organizational Change Theoretical Model 25
Figure 4: Conceptual Framework 29

xii
List of Abbreviations
CRT Critical race theory
BLCM Burke-Litwin change model
ERG Employee resource group
DEI Diversity, equity, and inclusion
CEO Chief executive officer
EO Equity office
EC Executive committee
BS BioScience (a pseudonym)
TCA Thematic content analysis

1
Chapter One: Introduction to the Study
Diversity, equity, and inclusion (DEI) have become more pervasive in various industries
in recent years (Arsel et al., 2022; Dixon-Fyle et al., 2020; King, 2022). Research has shown that
when organizations prize DEI, they are able to respond better to challenges, secure talent, and
address their customers’ unmet needs, which ultimately leads to financial outperformance
(Dixon-Fyle et al., 2020). While integrating DEI into the core of the mission of institutions and
all of its employees is ideal for attaining related targets (Olzmann, 2020), there is a lack of
appropriate knowledge and experience among middle management when it comes to setting the
proper framework for implementing such goals (Hirte, 2018). For this research, a middle
manager is a person who manages a team or individuals and has a manager who sits above them
in the organization (McKinsey & Company, 2020). Furthermore, a middle manager is not at the
executive level but rather ‘in the middle’ of the organization; they translate senior-leadership
visions to the teams who execute them.
Research suggests that companies can make DEI goals attainable with the help of middle
managers who ultimately shape employees’ environments and daily experiences (Creary, 2021;
Field et al., 2023). If organizations do not engage middle managers to advance DEI efforts,
making substantial gains in this area will prove difficult. The problem of practice of this research
highlights the difficulty of middle management to prioritize DEI at a U.S.-led healthcare forprofit organization.
Context and Background of the Problem
This research focused on a U.S.-based healthcare company, BioScience (BS, a
pseudonym), which has been in operation for more than 45 years and whose mission is to work
smarter and play better. The organization’s focus remains on life-saving medications. This

2
organization employs approximately 13,000 people and is the smaller sister organization to a
larger global conglomerate. In 2020, BS’s CEO funded an equity office (EO), and the equity
officer reports directly to him.
BioScience’s renewed energy and focus on DEI has given way to many new forms of
goal-setting throughout the organization. Some of these goals are company-wide, while others
remain within specific units due to needs across the organization. Nevertheless, the EO remains
hopeful that the C-suite’s highly influential and visible support will significantly aid in meeting
DEI goals. Since the inception of the EO, the CEO’s decision to champion it has proven critical
to the advancement of DEI and the strategic focus areas that include BS’s employees, patients,
and the community. This paper’s strategic goal will focus on the company’s employees,
specifically its middle managers.
What we know to be true about this problem is that middle managers are often uncertain
about their role in DEI or do not see DEI work as part of their core job function (Creary, 2021).
This research still requires the inclusion of different settings and perspectives to provide a more
comprehensive understanding. While numerous studies address how middle managers meet
organization-wide goals and how companies can achieve DEI objectives, middle managers’
efforts in a healthcare setting to reach DEI goals remain unexplored. More research must
examine this problem of practice, as reaching DEI goals in the healthcare industry will ultimately
benefit the patients it serves.
Purpose of the Project and Research Questions
The purpose of this study was to determine the specific ways that middle managers
implement and reach organization-wide DEI goals. Senge (1990) stressed that growth will
increase when organizations focus on creative learning. Furthermore, he shared that once we

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prioritize creativity and experimentation to explore new opportunities and understand gaps, we
can create connections for growth and increased flexibility. To gain clarity on this problem of
practice, this study addressed four research questions:
1. What are the external factors that contribute to an organization’s approach to DEI?
2. How do middle managers influence and shape company culture and work climate
around DEI?
3. What are the middle manager practices that most greatly affect the direction of DEI at
the organization?
4. What are the effects of leadership motivation around DEI goals for the organization?
Importance of the Study
The business case for DEI remains compelling. Cox and Blake (1991) provided an
extensive framework that amplifies the cost-benefit analysis for DEI and highlights the links
between diversity management and its contributions to a competitive advantage for
organizations. These connections include cost savings, talent attraction, a marketing advantage,
increased creativity, decision-making, and a more fluid work environment (Triana, 2017). In
contrast, Dixon-Fyle et al. (2020) stressed the challenges associated with making progress on
DEI initiatives, including fragmented DEI plans, the reliance on individual contributions toward
DEI, and the lack of a clear link between DEI goals and the organization’s business strategy.
When considering these obstacles, middle managers can play a significant role in reaching DEI
goals (Bryant & Stensaker, 2011).
Central to this problem is that middle managers are often uncertain about their role in
DEI or do not see DEI work as part of their core job function (Creary, 2021). The research still
needs to incorporate different settings and perspectives to address this issue comprehensively.

4
By examining various organizational environments and industries, including technology,
government, and education, we can gain a more nuanced understanding of the challenges and
opportunities middle managers face in promoting DEI. Additionally, incorporating diverse
perspectives from middle managers of different backgrounds, regions, and organizational
cultures will provide a richer, more inclusive view of the problem and potential solutions. This
comprehensive approach will help develop targeted strategies to empower middle managers to
see DEI as a central aspect of their roles and to effectively drive meaningful change within their
organizations.
Overview of Theoretical Framework and Methodology
This study leveraged the critical race theory (CRT) framework accompanied by the
Burke-Litwin change model (BLCM) as the conceptual framework. Critical race theory positions
race and racism as central to understanding social reality and the negotiation of American
consciousness (Crenshaw et al., 1995). I selected CRT for this research due to its emphasis on
how historical influences around race shaped human behavior; furthermore, it connects to
concepts such as the permanence and centrality of racism, race as a social construction,
storytelling, and counter-storytelling (Busey et al., 2022).
Concurrently, the BLCM examined the organization’s place in the context of an external
environment, one that is affected by the larger global economy (Coruzzi, 2020). Since BLCM
emphasized that the organizational climate can change by altering organizational conditions, the
links between historical inferences (CRT) and human behavior (SCT) complement one another.
They provide an overall understanding of why difficulties exist with middle management
prioritizing DEI efforts.

5
This research utilized a qualitative method. In qualitative research, the researcher relies
more heavily on text and data imagery, has unique steps in data analysis, and draws on diverse
designs (Creswell & Creswell, 2018). I conducted interviews, focus groups, and observations
with the study subjects.
Definition of Terms
The following definitions offer a clear understanding of their use and relevance to this
study.
Healthcare: efforts to maintain, restore, or promote someone’s physical, mental, or
emotional well-being, especially when performed by trained and licensed professionals
(Merriam-Webster, n.d.-b).
Burke-Litwin change model (BLCM) posits that the organizational climate, a malleable
set of psychological properties in the immediate workplace, can be modified by altering
organizational conditions such as organization structure, managerial behavior, and systems
(Coruzzi, 2020).
Chief executive officer (CEO): the executive with the chief decision-making authority in
an organization or business (Merriam-Webster, n.d.-a).
Equity office (EO): a team responsible for implementing an organization’s diversity and
inclusion strategy (Gartner, n.d.).
C-suite: An organization’s senior executives (Indeed, n.d.).
Critical race theory (CRT): a framework that examines race, racism, and racialized
citizenship (Busey et al., 2022).
Diversity, equity, and inclusion (DEI): three closely linked values held by many public
and private organizations that support different groups of underrepresented individuals, including

6
people of different races, ethnicities, religions, abilities, genders, and sexual orientations, among
others (Dixon-Fyle et al., 2020).
Diversity: Arsel et al. (2022) defined diversity broadly as real or perceived physical or
socio-cultural differences attributed to people and the representation of these differences in
research, market spaces, and organizations.
Equity refers to fairness in the treatment of people in terms of both opportunity and
outcome (Arsel et al., 2022).
Employee resource groups (ERGs) are voluntary, employee-led groups that can have a
few members or a few thousand. They are typically based on a specific demographic, and they
are dedicated to fostering a diverse and inclusive work environment within the context of the
organization’s mission, values, goals, business practices, and objectives (Kaplan et al., 2009).
Frozen middle: a term used to stereotype the middle management of organizations today
(Spreitzer & Quinn, 1996). Typically, this refers to middle managers who are slowing
organizational progression due to a lack of motivation or a reluctance to take risks (Williamson,
2023).
Inclusion refers to creating a culture that fosters belonging and incorporation of diverse
groups and is usually operationalized as opposition to exclusion or marginalization (Arsel et al.,
2022).
Middle manager: Middle managers are management personnel intermediate between
operational supervisors and policymaking administrators (Merriam-Webster, n.d.-c).
Organization of the Study
The following sections outline the content of the five chapters of this paper. Chapter One
introduces the problem of practice: the difficulty of middle management prioritizing DEI within

7
a U.S.-led, for-profit healthcare organization. It also presents the purpose of the study and the
research questions. Chapter Two reviews the literature, summarizing what is known and
unknown about the research topic. Chapter Three details the research methodology, including
how the study was conducted. Chapter Four summarizes the research findings. Finally, Chapter
Five concludes with a summary of the findings, implications, and conclusions.

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Chapter Two: Review of the Literature
In this chapter, the discussion first delves into the context of DEI to understand its
meaning, history, and significance as it relates to organizational change. It discusses several
factors that affect an organization’s middle management buy-in and action around reaching their
organization’s DEI goals. Specifically, discussion takes place on how multiple aspects around
buy-in are foundationally linked to CRT. Overall, however, there is a lack of clear, measurable
data, which has prevented firms from building tailored strategies and measuring their long-term
success around DEI methods and programming (Buttinger, 2023).
A review of the research indicates the relationship between DEI and corporate America—
as opposed to governmental agencies, not-for-profit organizations, and educational institutions—
and DEI and middle management, specifically, examined through the lens of the BLCM. This
model helps recognize the need to emphasize six of the 12 key drivers of organizational change.
Specific emphasis addresses six factors: leadership, organizational culture, and external
environment serve as the transformational aspects of change, while management practices, work
climate and motivation play transactional roles.
What Is Diversity, Equity, and Inclusion?
Diversity, equity, and inclusion are three closely linked values held by many public and
private organizations that support different groups of underrepresented individuals, including
people of different races, ethnicities, religions, abilities, genders, and sexual orientations, among
others (Dixon-Fyle et al., 2020). For this research, diversity refers to real or perceived physical
or socio-cultural differences attributed to people and the representation of these differences in
organizations; equity refers to treating people fairly as it relates to both opportunity and outcome;
inclusion includes creating a culture that fosters belonging and the incorporation of diverse

9
groups (Arsel et al., 2022). Together, DEI is typically associated with an orientation toward
procedural and distributive justice in both organizations and institutions (Arsel et al., 2022).
History of Diversity, Equity, and Inclusion
The history of managing diversity in the United States has progressed from enslavement
through civil rights legislation and affirmative action to DEI (Pennington, 2020). However, over
this period, it is possible that the minimal progress that the United States has made regarding
race has been overlooked. It was only in 1964 that the Civil Rights Act made it illegal for any
business to practice discrimination in hiring (Buttinger, 2023). Even in his time, W. E. B.
DuBois (1903) expressed that race remained a particularly challenging dilemma. Despite the
progress made in some areas of diversity, nearly 20% of Black corporate professionals feel as
though no one who looks like them will gain promotion to the senior-most positions in their
companies (Center for Talent Innovation, 2020). The criticality of DEI is that it is the right thing
to do and the best thing to do for business (Cox & Blake, 1991; Dixon-Fyle et al., 2020).
Why Is Diversity in the Workplace Important?
The work of organizational DEI is wide-reaching to include people of different races,
ethnicities, religions, abilities, genders, and sexual orientations (Bernstein et al., 2020; Köllen et
al., 2018; McKinsey Explainers Working Group, 2022). Companies that are diverse, equitable,
and inclusive secure top talent, respond to challenges more efficiently, and meet diverse
customers’ needs (Cox & Blake, 1991). Furthermore, companies that prioritize DEI financially
outperform their industry peers, boost creativity and innovation, and engage in higher-quality
problem-solving (Cox & Blake, 1991; Dixon-Fyle et al., 2020). Minkin (2023) found that
employees tend to experience a positive impact from DEI policies and resources associated with

10
DEI at their workplace, and most workers shared that the DEI measures indicated in Figure 1 had
a somewhat or very positive impact at their place of employment.
Figure 1
Impact of DEI-Related Policies and Resources at the Workplace
Note. From A Majority of Workers Say Focusing on DEI at Work Is a Good Thing by Pew
Research Center, 2023. (https://www.pewresearch.org/social-trends/2023/05/17/diversity-equityand-inclusion-in-the-workplace/st_2023-05-17_culture-of-work-dei_0-08-png/) Copyright 2023
by Pew Research Center.

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Olzmann (2020) shared that the underrepresentation of historically excluded groups
continues due to persisting systemic inequalities. This remains true despite the identified benefits
of DEI and the decades of programs targeted at increasing diversity in science, technology,
engineering, mathematics, and medicine specifically (Olzmann, 2020). These circumstances
inform how the intermingling of race, racism, and power shapes the distribution of influence and
control (Delgado & Stefancic, 2023).
Critical Race Theory
Critical race theory originated in the 1970s when a group of lawyers, activists, and
scholars from across the country realized that while the Civil Rights Movement had come to a
plateau, new forms of racism began to emerge (Rocco et al., 2014). This group believed new
strategies were needed to combat these subtler forms of racism that they were experiencing
(Rocco et al., 2014). To assist in this approach, CRT shifts the research lens away from a deficit
view of communities of color as places of cultural poverty and disadvantages and, rather, focuses
on the richness of cultural knowledge, skills, abilities, and contacts of socially marginalized
groups that often go unrecognized and unacknowledged (Yosso, 2005).
Since CRT recognizes the historical patterns of racism and how they are ingrained in
modern institutions, it views racism as a system-wide problem rather than a form of individual
bigotry (Delgado & Stefancic, 2023). Advocates for radical change within organizations insist
that corporate policies and programs be scrutinized regarding how they affect underrepresented
employees (Delgado & Stefancic, 2023). Change within organizations means breaking the glass
ceiling, erasing salary differentials, and eliminating harassment and discrimination (Rocco et al.,
2014). This research focuses on the integral relationship between CRT and DEI. Specifically, the
research exhibits how CRT is used to deconstruct a dominant culture’s constructed view of race

12
(Figure 2) and explains how the construct is used to suppress people of color in society (Movius,
n.d.).
Figure 2
Critical Race Theory
Note. Original image created for this dissertation.

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The Relationship Between DEI and CRT
Critical race theory and DEI are similar in their focus on understanding and addressing
issues of systemic inequality and discrimination, particularly concerning race and ethnicity.
However, they approach these issues from slightly different angles (Delgado & Stefancic, 2023).
While CRT is an academic and legal framework that emerged in the late 20th century, DEI is a
broader organizational and social concept that focuses on creating environments where all
individuals, regardless of their background, have equal opportunities to thrive (Delgado &
Stefancic, 2023). According to Delgado and Stefancic (2023), these two concepts are related in
several ways:
● Analyzing root causes: Both CRT and DEI delve into the root causes of inequality.
CRT does this by critically examining how historical and institutional racism persists,
while DEI identifies systemic barriers that prevent equal participation and
representation.
● Addressing structural inequalities: Both approaches seek to address structural
inequalities. Critical race theory aims to reshape legal and institutional frameworks to
dismantle racial hierarchies, while DEI aims to create inclusive environments that
counteract biases and promote fairness.
● Intersectionality: Both concepts acknowledge the intersection of various forms of
identity and oppression. Critical race theory emphasizes the intersection of race with
other forms of identity, while DEI acknowledges that individuals have multiple
dimensions of diversity that can lead to unique experiences of discrimination.
● Organizational and societal change: DEI is often implemented at the organizational
level to improve workplace diversity and promote inclusive practices. Critical race

14
theory’s insights can inform these efforts by highlighting the historical and systemic
factors contributing to disparities.
In summary, while CRT and DEI have distinct origins and approaches, they intersect in
their pursuit of dismantling systemic barriers and inequalities while promoting a fair and just
society for all individuals, regardless of their background. Although there has been much
emphasis on the implementation of DEI in the workplace, many organizations continue to fall
short of implementing long-term and effective strategies.
Organizational Barriers to Diversity, Equity, and Inclusion
Diversity, equity, and inclusion efforts have evolved into a core business function that
large and small businesses invest in aggressively (Dong, 2021). While there has been much
progress with respect to the outward support and buy-in of DEI in corporate America, many
organizations fail to make good on their commitments to DEI (Kraus et al., 2022), leading to
questions regarding the industry’s longevity (Dong, 2021). The inability of organizations to
succeed in implementing their DEI commitments occurs due to (a) organizations operating as
race-neutral by way of leadership, (b) the cultural complexities around discussions about equity,
and (c) a reduced urgency around DEI goals due to a changing external environment. With these
barriers in mind, an effective DEI strategy must involve organizational leaders overcoming this
narrative by acknowledging past DEI failures and implementing immediate and evidence-based
structural changes (Kraus et al., 2022).
For an organization’s leadership to operate in a race-neutral way means that it attempts to
address racial disparities without directly targeting benefits exclusively to racially
underrepresented groups. In doing so, leadership’s race-neutral remedies are presumed to help
minorities without hurting majority group members (Myers & Ha, 2018). Since DEI policies are

15
seen as controversial, employees disagree about whether they are necessary and what their
consequences may be (Iyer, 2022). People who belong to advantaged groups that benefit from
the status quo can be especially opposed, which can ultimately undermine the implementation of
DEI policies, thus resulting in continued inequality, wasted resources, and tension within the
organization (Myers & Ha, 2018).
An organization’s cultural complexities around discussions about equity must be
overcome through skill development and engagement in positive interactions. Such exchanges
might include pursuing an important and shared organizational purpose, mixing diverse group
members frequently over time, enabling these differing groups to acquire equal standing in
contributing to success, and providing collaborative interdependence, interpersonal comfort, and
self-efficacy. These continued interactions help to challenge the guiding assumptions of the
organizational culture (Bernstein et al., 2020).
Reduced urgency around DEI goals due to a changing external environment has increased
(Olzmann, 2020). To combat these developments, organizations must reassess their current
recruitment strategies to reimagine workplace environments. Doing so contributes to an inclusive
and equitable organizational culture free of institutional barriers while also promoting equal
opportunities for everyone to succeed, thrive, and bring their authentic selves to the workplace.
The following section will reflect how implementing impactful company-wide DEI strategies
can affect lasting organizational change.
Doing DEI Right
To obtain the buy-in needed for an organization to drive a successful DEI strategy and
meet its goals, its leaders must frame DEI as an opportunity for their entire organization and
provide an avenue for all members to meaningfully engage in it (Beach & Segars, 2022). In this

16
instance, diversity management is critical. Diversity management is defined as “planning and
implementing organizational systems and practices to manage people so that the potential
advantages of diversity are maximized while its potential disadvantages are minimized” (Triana,
2017, p. 324). Diversity management includes attracting and retaining a diverse workforce and
fostering an inclusive environment so that employees, regardless of their backgrounds, can work
together toward organizational objectives (Triana, 2017).
Dedicated Time
Goals and time are deeply intertwined (Etkin, 2019). Research on time management
within organizations highlights a significant challenge: employees often face the pressure of
juggling multiple tasks simultaneously (Fried & Slowik, 2004). This can dilute their focus and
impede progress towards long-term objectives. In the context of DEI initiatives, this challenge
becomes even more pronounced.
Kara et al. (2022) emphasized that achieving DEI goals demands both time and patience.
They advocated for the allocation of protected time, ensuring that employees can dedicate the
necessary attention and effort to DEI initiatives without being overwhelmed by competing
demands (Kara et al., 2022). This approach is essential for fostering meaningful and sustainable
progress in DEI efforts. Supporting this perspective, Faucett et al. (2022) underscored the role of
leaders in healthcare in redistributing DEI efforts strategically. They argued that leadership can
drive the successful implementation of DEI initiatives by advocating for policies and practices
that create a diverse and inclusive environment (Faucett et al., 2022). Ultimately, this focus on
DEI is beneficial for the company’s bottom line, enhancing its overall performance and
competitive edge.

17
DEI Is Good for Business
Respondents in Schaefer and Darling’s (1996) research expressed that they viewed work
as an opportunity to serve others, integrating it into the rest of their lives. This sentiment reflects
a belief that work should align with personal values and contribute to the greater good, which, in
turn, fuels their dedication to DEI initiatives. Senge (1993) emphasized that personal
commitment is a key requirement for becoming a learning organization. When individuals are
personally committed to DEI, they are more likely to engage in self-reflection, seek out new
perspectives, and champion inclusive practices within their teams and the broader organization.
Pinkett (2024) highlighted that beyond the personal case for DEI, there is also a
compelling business case. By recognizing both the personal and business benefits of DEI,
organizations can create a more inclusive and equitable workplace that drives both individual
fulfillment and organizational success. Senior leaders play a critical role in this process by
holding middle managers accountable for advancing DEI initiatives, ensuring that these efforts
are consistently prioritized and integrated throughout the organization.
Accountability of Reaching DEI Goals
Tucker (2023) highlighted that leading organizations invest more heavily in resources
and leadership support for their DEI programs. These organizations prioritize raising awareness
about DEI, developing policies that reflect their commitment to these programs, and
implementing measures to hold leaders accountable to these commitments. Compared to other
organizations, these top-tier entities are significantly more likely to set measurable DEI goals,
integrate objectives into senior leaders’ performance goals, and include targets in managers’
performance plans (Tucker, 2023).

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The creation of sustainable change rests with the organizations that possess the power
and authority to transform their culture, ensuring equitable access to care and resources for
diverse learners and patients (Mason et al., 2023). Such comprehensive systems are particularly
effective in shaping an organization’s culture, values, and norms (Lerr & Slocum, 2005). By
setting clear, measurable goals and holding leadership accountable, these organizations foster an
inclusive environment and ensure that their initiatives are effective and enduring. The
responsibility of driving this change lies with those in positions of power who can influence and
reshape organizational culture, ultimately ensuring that every individual has fair access to
opportunities and resources.
DEI and Middle Management
In the following section, the reader will learn about middle management’s role in
executing DEI strategy and goals throughout organizations. This section highlights what it
means for middle managers to be in the “frozen middle” and how they affect organization-wide
change, it provides the reader with an understanding of the intersections of middle management
and DEI and lastly, why middle management should be the focal point in driving DEI
initiatives. Understanding these facets of this group will further support the reader in
understanding the criticality of an organization’s middle manager population in reaching their
strategic goals.
What Does It Mean to Be in the Frozen Middle?
The term “frozen middle” is a term used to stereotype the middle management of
organizations today (Spreitzer & Quinn, 1996). Gjerde and Alvesson (2020) shared that these
employees are typically in mid-level management, and they may be viewed as the employees
who hinder an organization’s progress because they are seen as incapable, and perhaps

19
unmotivated or afraid to take risks. While middle managers may be perceived in this manner,
they play a critical role in ensuring the successful execution of strategic initiatives essential for
an organization to achieve its goals (Spreitzer & Quinn, 1996).
McConville (2006) discussed that categorizing middle management is difficult since the
boundaries between levels of hierarchy are often blurred and may be ambiguous resulting in few
authors having attempted to define the role. This has resulted in middle line management often
described in terms of what it is not (McConville, 2006). These feelings and attitudes toward
middle management are especially important as we discuss how this group can affect and
implement organizational wide change.
How Do Middle Managers Affect Organization-Wide Change
When examining the roles and responsibilities of middle managers, it is crucial to
acknowledge the extensive scope of their influence throughout an organization. Spreitzer and
Quinn (1996) discussed that middle managers can create transformational and transactional
change not only targeted at themselves, but inclusive of their work units, and their larger
organizations. Relatedly, Field et. al., (2023) conveyed the pivotal impact of middle management
in the creation of vision, coaching, and skill development of their direct reports, and the role that
middle managers play in promoting connectivity and creativity across organizations. These
aspects inform the reader that change implementation is possible in the middle layers of an
organization.
Gutenberg (2017) and Bernstein et al., (2020) point out that change initiatives have
enjoyed limited success due to inconsistent behavioral changes which are neither fully adopted
nor ultimately sustained; this has been linked to inadequate implementation efforts. There is an
opportunity here for middle managers to capitalize on their unique position between upper and

20
lower levels in the organization and engage in fluid learning that is critical to implementing and
sustaining such change. The following section will delve into the BLCM and how linking it to
middle management’s challenges around organizational change is the key to making significant
and long-lasting change with DEI efforts.
Influence of Middle Management
There is growing evidence that middle managers’ position in the organization centralizes
their contributions, particularly their ability to promote communication throughout the
organization (Birken et al., 2012). Gutberg (2017) posited that middle managers can capitalize on
their position between upper and lower levels in the organization. Doing so involves them
engaging in ambidextrous learning to implement and sustain radical change. Through
ambidextrous learning, an organization incorporates elements of both exploration and
exploitation among employees (Gutberg, 2017). In terms of organizational change, exploration
has been associated with radical innovation, while exploitation has been linked only to
incremental change (Benner & Tushman, 2003).
Additional literature finds that middle managers leverage their access to knowledge and
networks to serve as conduits, transferring information regarding the strategy down through the
lower levels of the organization (Birken et al., 2012) while simultaneously translating the
strategy or vision into actionable processes and steps to adopt by front-line employees (Belasen
& Belasen, 2016; Dopson & Stewart, 1990; Floyd & Wooldridge, 1992; Uyterhoeven, 1989).
Middle managers also direct the flow of information both upward and downward (Floyd &
Wooldridge, 1992), communicating from the individual contributors and back to senior
leadership.

21
When attention is given to middle managers regarding implementation and change
management, research suggests that they play a central role in affecting significant reforms in
organizations, notably in organizational culture change efforts (Gutberg & Berta, 2017). Theories
of both implementation and change management further support leaders’ role at all levels in
facilitating organizational change. Specifically, leaders at the middle management level are those
with supervisory or managerial roles and who are neither individual contributors nor senior
leaders (Floyd & Wooldridge, 1997; Wooldridge et al., 2008). Bernstein et al. (2020) and
Freeman (2014) suggested that engagement of leadership at multiple levels of an organization
aids in ensuring the success of strategic initiatives aimed at large-scale change and in sustaining
these changes long-term (Willis et al., 2016). In the following section, discussion takes place on
the key factors that will support middle managers in their efforts for organizational change.
Storytelling
Senior leaders must demonstrate effective communication when engaging in DEI efforts,
as employees expect them to lead by example (Baker, 2014). According to McClellan (2006),
when senior leaders share personal stories, they show patterns to help make connections, making
DEI concepts more relatable and impactful. Employee narratives not only keep DEI initiatives
alive but also ensure that the strategic vision remains current and tangible (Baker, 2014).
McClellan (2006) also noted that stories often arise from challenging situations, and by sharing
these experiences, senior leaders provide practical illustrations of problem-solving.
Supporting this perspective, Harrison-Train et al. (2021) suggested that storytelling can
enhance empathetic skills and deepen appreciation for DEI. Moreover, storytelling can bridge the
gap between abstract DEI principles and everyday business practices. When leaders share their
own experiences and the experiences of employees, they humanize DEI efforts, making them

22
more accessible and meaningful to the entire organization. This approach is particularly crucial
in addressing patient health disparities, as fostering an inclusive environment can lead to
improved patient care and health outcomes for diverse populations.
Relating DEI to Patient Health Disparities
Gill et al. (2018) underscored the significant connection between providers’ work
environments, patient outcomes, and overall organizational performance. Building on this,
research by El-Galaly et al. (2023) and Washington et al. (2023) found that DEI initiatives
enhance collaboration, empathy, and psychological safety within healthcare settings.
To effectively demonstrate the direct impact of DEI on patient care, organizations must
take deliberate actions (El-Galaly et al., 2023). This includes setting intentional DEI-based goals,
forming diverse research and leadership teams, improving community engagement, and
designing targeted outreach interventions (Washington et al., 2023). These strategies directly
contribute to better patient outcomes by ensuring that diverse patient needs are understood and
addressed.
A critical factor in the success of these strategies is the role of middle managers in
embedding DEI into their management style. By integrating DEI principles into their daily
actions and decision-making processes, middle managers ensure that the organization’s DEI
goals are implemented across the organization.
Embedding DEI
Embedding DEI into team management goes beyond rhetoric. Klagge (1996) described
middle managers as integrators who create organizational unity, facilitators who channel human
diversity into group processes, and implementers who establish systems to recognize and reward
actions that promote unity and leverage diversity. It is essential to proactively create inclusive

23
spaces (Dachner & Beatty, 2023). Thus, middle managers must integrate DEI into their daily
actions to demonstrate its practical application within the organization. Creary et al. (2021)
found that managers’ active involvement in DEI efforts shows care and interest in their
employees and supports their growth. When employees perceive that their managers are invested
in their advancement and success, they feel valued by the organization, which enhances their
sense of psychological safety and encourages them to contribute more effectively.
Creating Psychological Safety
Edmondson and Lei (2014) emphasized that when employees perceive their work
environments as psychologically safe, they are more likely to take risks without fearing negative
repercussions. This encourages the sharing of creative ideas, innovative behaviors, and proactive
suggestions, which benefit the organization. While Edmondson and Lei (2014) identified
psychological safety as crucial for understanding phenomena such as voice, teamwork, team
learning, and organizational learning, Singh et al. (2013) found that psychological safety
mediates the relationship between a positive diversity climate and employee performance.
To unlock the true potential of all employees, middle managers must promote and
actively build a psychologically safe environment for their teams. Despite employees’ potential
hesitation to speak up about issues due to concerns about negative consequences, middle
managers should explicitly invite input and feedback, modeling openness and admitting their
own fallibility (Edmondson & Roloff, 2009). These efforts are critical for driving organizational
change, as they foster a culture of continuous improvement and innovation, enabling the
organization to adapt and thrive in a rapidly evolving environment.

24
Burke-Litwin Organizational Change Theoretical Model
W. Warmer Burke and George H. Litwin were two prominent organizational change
consultants who developed the BLCM in the 1960s (Burke & Litwin, 1992). This model (Figure
3) identifies where change happens in an organization and how it flows between different parts
of said organization (Burke & Litwin, 1992). This model exhibits the effects of change between
12 drivers of organizational design. Using this model, one can identify which organizational
variables need to be adjusted and why. Once these variables are detected, the organization will
be able to analyze, diagnose, and possibly predict the effects of change throughout an
organization (Burke & Litwin, 1992).

25
Figure 3
Burke-Litwin Organizational Change Theoretical Model
Note. Adapted from A causal model of organizational performance and change by W. W. Burke
and G. H. Litwin, 1992, Journal of Management, 18(3), p. 528.
(https://doi.org/10.1177/014920639201800306). Copyright 1992 by the Southern Management
Association.
The significance of this model rests in the interrelatedness of the 12 drivers that can
contribute to the success or failure of organizational change (Burke & Litwin, 1992). If one
variable is overlooked or bypassed, it can lead to the entire system failing, requiring managers
and employees to undertake the challenging task of restoring conditions to their previous state.

26
Gaining a deeper understanding of this change model requires differentiating between the
external environment, transformational factors, and transactional factors of change within an
organization.
The following sections will begin with the author identifying the roles of the external
environment as the lone foundational factor, followed by both the transformational and
transactional factors of organizational change.
External Environment
The visual model displays the external environment at the top, shown as a dark blue
rectangle; this placement of the external environment exhibits what creates the need for change.
Examples of external factors that affect an organization include a weakening economy, industry
competition, the arrival of new technology, or shifts in social trends and conditions (Kolay &
Sahu, 1992). This model frames how social trends and conditions directly relate to the CRT
position that all individuals have equitable opportunities to succeed regardless of their
background, given the focus on external environmental circumstances (Delgado & Stefancic,
2023). The following section reveals how changes in the external environment have a direct
impact on transformational factors.
Transformational Factors
Transformational change happens in response to the external environment (Delgado &
Stefancic, 2023). Transformational factors elements are core to an organization’s performance,
and they make up the fundamental structure of an organization and directly affect the mission
and strategy, organizational culture, and leadership of the organization:
● mission and strategy: the core purpose for the organization’s existence
● leadership: the actions, philosophies, and values of senior managers

27
● organizational culture: the behavior and values that are accepted within the
organization.
The arrows showing the interaction between these transformational factors and the
transactional factors are shaded downward to indicate that, although the upper and lower
elements both impact each other, the impact is stronger in the downward direction. In essence, to
effect change, these three elements must be aligned and addressed.
Transactional Factors
In tandem, transactional factors are more easily changed and may not necessarily have
the same kind of impact on organization-wide performance as transformational ones (You,
2021). Although important to the success of organizational change, if the three transformational
factors support the change, modifications in these areas are likely to be unsuccessful. The
transactional factors are
● structure: The way the organization is set up in terms of roles and functions,
communication, lines of authority, and decision-making.
● systems: The processes and procedures that are in place to support operations.
● management practices: How managers and people with authority and responsibility
execute the strategy daily.
● work climate: The prevailing attitude and morale of the people working for the
organization.
● task and individual skills: The degree of “fit” between the skills required for the job
and the skills of the people doing the job.
● individual needs and values: The degree to which the organization’s processes and
systems fulfill employees’ needs and allow them to feel satisfied.

28
● motivation: The intrinsic and extrinsic factors that motivate people to perform well
consistently.
While all 12 drivers influence each other, the arrows illustrate the diverse relationships
between elements that the authors identified as the most significant (Burke & Litwin, 1992). It
becomes evident how a change in one element can have a broad impact across the organization.
However, while improvements in any transactional factor can affect performance, lasting effects
rely on alignment with transformational elements (Burke & Litwin, 1992). Together, these
transformational and transactional factors influence employee motivation and, consequently,
organizational performance.
Although many factors affect organizational change, the BLCM identifies the
relationship between the level of changes and factors of changes. The model aids in identifying
the connections between the 12 strategic, operational, and individual factors important for an
organization’s success. The following section of this paper will amplify the six factors used as a
conceptual model for this research.
Conceptual Model
The following segment highlights six of the 12 factors included in the BLCM that
directly involve and impact the middle management population at an organization. Those six
factors are (a) external environment, (b) leadership, (c) culture, (d) management practices, (e)
work climate, and (f) motivation (Figure 4). This conceptual model further illustrates a shift in
the placement of the external environment and both transformational and transactional factors.
The interrelatedness of these factors remains key in the quest to recognize how middle
management’s role remains central to organizational change around DEI.

29
Figure 4
Conceptual Framework
This conceptual framework reflects how transformational elements are core to an
organization’s performance (You, 2021). In this structure, leadership, organizational culture, and
external environment are situated at the top, indicating that three equally influential components
are directly and foundationally linked to a specific transactional factor, which are the day-to-day
operations within the organization (Antonakis & House, 2014; Burke & Litwin, 1992). The
transactional factors listed in this conceptual framework are management practices, work unit
climate, and motivation; each of these factors is directly related to and affected by a
transformational element. The interconnectedness among these transactional factors is
noteworthy.
This framework reflects leadership aligned with management practices, organizational
culture aligned with work unit climate, and external environment aligned with motivation. The

30
following sections will delve into why the transformational and transactional drivers interrelate
and how they are applied to the problem statement and this research.
Leadership
Leadership is a transformational factor in this conceptual framework because it directly
affects how middle managers implement their leadership practices. For this paper, leadership
refers to executives providing overall direction and serving as behavioral role models for all
employees (Burke & Litwin, 1992). Effective leadership is necessary for achieving
organizational goals, creating a positive work environment, and managing through change.
Leadership plays a key role in setting the organization’s direction, communicating its vision and
values, and creating a culture that supports the achievement of its mission and strategy (Hu et al.,
2013).
Successful leadership provides direction and empowers employees to take ownership of
their work, develop their skills, and contribute to the organization’s success (Hu et al., 2013;
“Joint Effort,” 2011). Thus, understanding and developing effective leadership assists in change
management and achieving long-term success (Burke & Litwin, 1992). Although leadership in
this context is also not the same thing as management, this transformational factor relates to
management practices as it has a direct effect on the accomplishment of goals (Antonakis &
House, 2014).
Management Practices
Management practices are considered a transactional factor and include the management
processes and procedures that an organization uses to achieve its goals (Burke & Litwin, 1992;
Spreitzer & Quinn, 1996). These practices can include human resource management, financial
management, strategic planning, and performance management, along with other management

31
functions. Effective management practices are essential for achieving an organization’s mission
and goals, managing change, and ensuring the long-term success of the organization. They can
also affect employee satisfaction, productivity, and performance while impacting an
organization’s ability to respond to internal and external changes (Kolay & Sahu, 1992).
Culture
The second transformational factor included in the conceptual framework includes the
foundation of an organization’s culture. Organizational culture refers to the shared values,
beliefs, norms, and behaviors that define the identity and character of an organization (Burke &
Litwin, 1992). Research indicates that standalone initiatives have little value if they are not
grounded in a positive, inclusive culture in an organization open to driving cultural change
(Buttinger, 2023). Organizational culture shapes how employees perceive and experience their
work environment, their sense of belonging, and their level of commitment to the organization’s
mission and goals (Abbas, 2022). Organizational culture is an essential factor in managing
change in an organization.
When initiating organizational change, it is important to assess the culture and ensure that
the change aligns with the organization’s values and beliefs (“Joint Effort,” 2011; Nguyen &
Mohamed, 2011). Also, establishing effective communication is crucial when sharing about
change and ensuring that the new culture is promoted and reinforced (Abbas, 2022). By
understanding and managing organizational culture, an organization can improve employee
satisfaction, engagement, and performance, which can then lead to long-term success (Nguyen &
Mohamed, 2011). Organizational culture directly impacts the second transactional factor of work
climate.

32
Work Climate
Work climate refers to the attitudes, perceptions, and feelings of employees toward their
work environment, including their job satisfaction, motivation, and engagement (Abbas, 2022;
Sexton et al., 2017), and in these instances, middle managers play a central role. A positive work
climate is one where employees feel supported, valued, and engaged in their work. On the
contrary, a negative work climate can lead to low morale, high turnover, and decreased
productivity (Abbas, 2022). On both occasions, middle managers can influence their direct
reports and the larger organization (Buttinger, 2023).
When managing change, an important aspect to consider is that of the proposed changes
toward the organization’s work climate (Sexton et al., 2017). When employees perceive change
positively, job satisfaction, motivation, and engagement can increase (Buttinger, 2023). As such,
when changes are perceived negatively, a decrease in job satisfaction and an increased resistance
to change may occur (Buttinger, 2023). Together, these factors can contribute significantly to an
organization’s fluid culture.
External Environment
As mentioned earlier in this chapter, external environmental factors have a direct impact
on transformational change (Burke & Litwin, 1992), and, furthermore, these external factors can
affect an organization’s mission and strategy, its leadership, and its culture. The broader external
environment is listed as the final transformational factor in this conceptual framework. Burke
and Litwin (1992) explained that external environments are outside conditions or situations that
influence the performance of the organization; some examples of these conditions might include
a weakening economy, industry competition, the arrival of new technology, or shifts in social
trends and conditions. The impact of the external environment remains pertinent here as social

33
factors can influence where focus shifts in an organization (Buttinger, 2023; Lingras et al.,
2021).
Research confirms that the well-defined cause-and-effect relationships between the
organization’s internal and external environments are linked to organizational effectiveness
(Burke & Litwin, 1992; Roodt et al., 2003; Salancik & Pfeffer, 1978). However, insightful
leaders who recognize their organization’s external environment are selective with the forces
they engage with and act accordingly. The leadership role in this process is neither passive nor
isolated (Burke & Litwin, 1992); on the contrary, it remains assertive and resolute.
Motivation
Bandura was the first to demonstrate that self-efficacy, the belief in one’s ability to
succeed in specific tasks, directly influences the tasks individuals choose, the effort they invest,
and their emotional experience during task performance (Bandura & Cervone, 1986; Pearlmutter,
1998). Bandura also discovered that learning occurs both through these beliefs around selfefficacy and through social modeling. According to Bandura, motivation refers to the level of
ambition and commitment an employee has toward achieving the goals of the organization
(Bandura & Cervone, 1986; Chughtai et al., 2023). Bandura stressed that perceived self-efficacy
is another cognitive factor that plays an influential role in the exercise of personal agency in
ways that affect motivation.
Motivation is employees’ internal drive that will determine the level of effort and
persistence that they put into their work (Bandura & Cervone, 1986). To manage employees’
motivation during a change initiative, it is important to communicate the reasons for the change
along with the benefits to the organization and its employees (Abbas, 2022; Chughtai et al.,
2023). Providing opportunities for employees to provide feedback and participate in the change

34
process can also help to create a positive work climate and increase engagement and motivation
(Bandura & Cervone, 1986; Nwanzu & Babalola, 2019). In instances of organizational change, it
is integral for middle managers to support themselves, navigate these transitions and aid their
teams and direct reports.
Influence of Middle Management
There is growing evidence that shows that middle management’s position in the
organization centralizes their contributions, particularly their ability to promote communication
throughout the organization (Birken et al., 2012). Gutberg and Berta (2017) posited that middle
managers can capitalize on their position between upper and lower levels in the organization and
engage in ambidextrous learning to implement and sustain radical change (Gutberg & Berta,
2017). In terms of organizational change, exploration has been associated with ‘radical’
innovation, while exploitation has been linked only to incremental change (Benner & Tushman,
2003).
Birken et al. (2012) noted that middle managers leverage their access to knowledge and
networks to transfer information regarding the strategy to the organization’s lower levels while
translating the strategy or vision into actionable processes and steps to be adopted by front-line
employees (Schraeder, 2023). Middle managers can also direct the flow of information both
upward and downward (Floyd & Wooldridge, 1992), communicating from the individual
contributors and back to senior leadership.
When attention is given to middle managers in implementation and change management,
research suggests that it plays a key role in affecting significant reforms in organizations, notably
in organizational culture change efforts (Gutberg & Berta, 2017; Sudirman et al., 2019). Theories
of both implementation and change management further support the importance of leadership at

35
all levels. As these leaders have supervisory and/or managerial roles but are neither individual
contributors nor senior leaders, it is important to facilitate such change at the middle
management level (Floyd & Wooldridge, 1997; Woolridge et al., 2008). Leaders’ engagement at
multiple organizational levels is key to the success of large-scale change initiatives and in
sustaining these changes long-term (Willis et al., 2016).
Conclusion
This chapter exhibited how the intersections of DEI and CRT influence an organization’s
ability to change. It then demonstrated the views of middle managers at for-profit organizations
and how their value within them can affect change. The author then moved into sharing about the
BLCM, followed by an introduction of a conceptual framework used for this research. Chapter
Three presents the steps needed to implement the methodology needed to conduct this research.

36
Chapter Three: Methodology
This chapter outlines the qualitative research design for this study, including the
methodology, sampling criteria, and interview protocols, and will align with aspects of the
BLCM conceptual framework. Also included are the descriptions of my positionality and the
ethics practiced while completing this study. The purpose of this research was to gain a deep
understanding of what motivates middle managers to engage in and act upon DEI work.
Specifically, the research focused on the middle management community within a particular
healthcare company located in the United States. The following section will outline the research
questions pertaining to middle management’s motivation in engaging in DEI at the company.
Research Questions
1. What are the external factors that contribute to an organization’s approach to DEI?
2. How do middle managers influence and shape company culture and work climate
around DEI?
3. What are the middle manager practices that most greatly affect the direction of DEI at
the organization?
4. What are the effects of leadership motivation around DEI goals for the organization?
Overview of Design
The methodological design for this study was qualitative, utilizing semi-structured virtual
interviews to obtain the answers to the research questions. I chose qualitative methods for this
study because semi-structured interviews support an individual’s holistic perspective and, in
turn, can provide an enhanced meaning of the experiences acquired from the individual.
Conducting semi-structured interviews can unlock a deeper understanding of the participants’
responses along with the desired outcomes for this study (Creswell, 2014; Merriam & Tisdell,

37
2016). Leveraging a theoretical lens supports orienting and guiding the researcher’s perspective
while conducting a study (Creswell, 2014).
This research utilized CRT as its theoretical lens, positioning race and racism as central
to understanding social reality and the American consciousness (Crenshaw et al., 1995).
Additionally, the BLCM was employed as a theoretical framework to understand the linkages
between foundational change levers, including organizational leadership, culture, and the
external environment, and their impact on middle management and motivation. Aligned with
CRT and BLCM, the interview questions were designed to provide insight into the motivations
middle managers experience regarding DEI (Table 1).

38
Table 1
Data Sources
Research questions Overall approach Participants and
settings
Data collection
methods
What are the external
factors that
contribute to an
organization’s
approach to DEI?
Qualitative; interview
protocol to
understand how
external factors
affect DEI within
the organization
Middle managers
working at BS; are
the focus of this
study.
Semi-structured
interviews and
document analysis
How do middle
managers influence
and shape company
culture and work
climate around
DEI?
Qualitative; interview
protocol to
understand how
middle managers
shape the overall
culture at BS
Middle managers
working at BS; are
the focus of this
study.
Semi-structured
interviews and
document analysis
What are the middle
manager practices
that most greatly
affect the direction
of DEI at the
organization?
Qualitative; interview
protocol to
understand the
managerial
practices that are
employed with
their direct reports
Middle managers
working at BS; are
the focus of this
study.
Semi-structured
interviews and
document analysis
What are the effects
of leadership
motivation around
DEI goals for the
organization?
Qualitative; interview
protocol to
understand how
leadership
motivation shifts
the impact of DEI
goals
Middle managers
working at BS; are
the focus of this
study.
Semi-structured
interviews and
document analysis
Research Setting
The study was conducted at a U.S.-based healthcare company, BS, considered a pioneer
in the healthcare industry. Operating for over 45 years, BS is driven by the mission to work
smarter and play better and focuses on life-saving medications. The company employs

39
approximately 13,000 people and is a smaller sister organization to a larger global conglomerate.
In 2020, BS’s CEO established an EO, with the equity officer reporting directly to him.
BS’s renewed emphasis on DEI has introduced numerous goal-setting initiatives
throughout the organization. While some goals are company-wide, others are tailored to specific
units to address their needs. The EO remains optimistic that the visible and influential support
from the C-suite will significantly aid in achieving DEI goals. Since its inception, the CEO’s
decision to champion the EO has advanced DEI and focused on strategic areas that include BS’s
employees, patients, and the community. This paper will focus on the strategic goals related to
the company’s employees, specifically the middle manager population.
The Researcher
Considering the participants in this study, I must disclose that I am a current employee of
the company, serving as a senior manager in the EO, and have been with the organization since
2010. My positionality may affect participant interviews due to existing working relationships
between the participants and me as the researcher. This familiarity could introduce bias or
assumptions from either party. Additionally, these relationships may have led to varying aspects
in interviews, such as going off-topic, naming specific individuals in responses, and potential
feelings of superiority among participants due to being “selected to participate.”
Having worked in the DEI space for a long time, my prior relationships with known
participants may introduce biases about them based on their department or perceived
characteristics. To mitigate these potential drawbacks, I adhered closely to the interview guide
while maintaining a balance of friendliness and professionalism. Additionally, I reminded
participants that the interview would be recorded to discourage discussions on unrelated topics or
the naming of specific individuals.

40
Sample and Population
I recruited the target population for this research, middle managers, through purposive
sampling. Middle managers are management personnel intermediate between operational
supervisors and policymaking administrators (Merriam-Webster, n.d.-c). These employees have
individual contributors who report to them as well as managers to whom they report; they are
positioned in the middle of the organization, and they are not at the vice president level
(McKinsey & Company, 2020). This group’s selection supports the research questions and helps
to understand what motivates these managers to do DEI well.
I interviewed 16 middle managers at BS. I recruited them via BS’s human resources
newsletter. This newsletter highlights updates, upcoming requirements, and opportunities
specific to the middle management community at BS.
For an employee to be considered for this research, they had to meet the following
inclusion criteria: be a full-time employee at BS, have at least one direct report; direct reports
must be full-time employees, have worked at BS for a minimum of 1 year, be over age 18.
Additionally, the following exclusion criteria applied: participants could not be a vice president
or officer at BS.
I identified participants who met all of the study criteria using a Qualtrics pre-survey to
determine if survey respondents were eligible. Once all 16 middle managers submitted their presurveys, they received an email message from my USC email account requesting their
participation in the study and including an interview date.
Instrumentation
I interviewed participants using an interview guide. I conducted the interviews using a
semi-structured approach so that I asked questions in a predetermined thematic approach. While

41
I had a set list of questions to explore, I used questions flexibly (Merriam & Tisdell, 2016). This
interview method was appropriate due to instances where a participant offered additional
information based on an answer to a question, as this additional information proved useful in
helping to understand context (Merriam & Tisdell, 2016).
I asked all interviewees 12 questions: three neutral questions, three linking questions, five
key questions, and one closing question. The questions focused on external factors that affect
DEI, the influence of middle managers, the practices that they leverage to affect change, and the
effects of motivation around DEI. These questions supported the understanding of the specific
tactics that middle managers across the organization can leverage around DEI goals.
Data Collection
Each interview lasted approximately 50 minutes; however, several went beyond the
allotted time. I conducted the interviews via Google Hangouts and recorded them on my
password-protected computer (Merriam & Tisdell, 2016) via Otter.ai. Once the interviews were
complete, I informed participants that I might contact them during data analysis for follow-up
interviews for clarification purposes. I completed data analysis at a later date via ATLAS.ti.
To ensure consistency among participants, I followed the same interview guide for each
interview (i.e., ask the same questions and follow the same format). I also requested that all
participants verbally agree to a waiver of confidentiality during the interview. I answered all
questions prior to, during, and after the interview, and I provided my contact information for any
questions that arose post-interview. I contacted three study participants for clarification postinterview.

42
Data Analysis
The following section describes how I analyzed the interview data. Once all interviews
were complete, I transcribed and coded each interview to identify themes. I compiled and
corroborated all data for accuracy and completeness in ATLAS.ti.
I used descriptive statistics to identify patterns in participants’ responses. Lochmiller and
Lester (2017) shared that descriptive analysis identifies patterns, trends, and/or frequencies in the
data. Descriptive analysis also identified additional support strategies for middle managers to
remain motivated in meeting DEI goals at the organization. Lochmiller and Lester (2017) stated
that descriptive analysis summarizes the data and presents the overall findings. Data from the
interviews was compiled and transported to Microsoft Excel (Microsoft Corporation, 2018).
Thematic Content Analysis
To examine the interview responses, I used a thematic content analysis (TCA; Braun &
Clarke, 2006) generated through the ATLAS.ti platform. Thematic content analysis provides a
descriptive presentation of qualitative data that is leveraged from the interview transcripts.
Lochmiller and Lester (2017) explained that TCA allows the researcher to identify codes that aid
in understanding the research. While there are different approaches to conducting TCA (Braun &
Clarke, 2006), I adopted the following process: (a) familiarization, (b) coding, (c) theme
generation, (d) theme review, (e) defining and naming themes, and (f) write up.
Familiarization
I reviewed each participant’s interview to identify themes including motivators,
opportunities, and obstacles for middle managers to reach organizational DEI goals. I also
reviewed the audio of each interview and read the transcribed interview to ensure transcription
accuracy.

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Coding
A code is a label that provides meaning to the data in a short word or label that is applied
and symbolically links or summarizes a portion of the language-based data (Lochmiller & Lester,
2017). Codes connect individual pieces of information across each participant’s interview
responses, which, in turn, creates a more comprehensive data set. They also provide individual
meaning to specific portions of data that the participants shared.
I leveraged the ATLAS.ti software to manually code the interview data to identify words
and thematic sentiments. I found some of the commonalities in certain words, phrases, or general
themes that participants shared. I identified codes based on the semi-structured interview
questions, and since all questions posed specific inquiries, themes were more easily identifiable.
Theme Generation
I reviewed the participant interviews for specific patterns within the identified codes. It
was important to link the findings to the conceptual framework, which reflected how the external
environment, organizational culture, management practices, and motivation shape middle
managers’ experiences and their motivation to achieve organizational DEI goals. While
generating these themes, I remained mindful of potential biases to avoid influencing the
participants’ shared experiences. Themes are largely based on personal interpretation of the data
(Lochmiller & Lester, 2017), connecting various categories in the data.
Theme Review
The generating of themes required a thorough review of all the categories to ensure
appropriateness and alignment with the research findings. As I collected data, I identified and
eliminated unnecessary information to reduce data saturation (Merriam & Tisdell, 2016). By
scrutinizing the data in this way, I aimed to identify the evidence needed to establish the final set

44
of themes. Ensuring alignment with the research questions necessitated reviewing this final
collection of themes several times.
Defining and Naming Themes
I identified the established themes by leveraging concepts reflected during participant
interviews. Merriam and Tisdell (2016) recommended creating themes based on what is
collected and noted in the data, such as common words or phrases. I ensured the categories
aligned with the research intention, which helped in recognizing similarities among participant
responses.
Write Up
I needed to determine the target audience for this research. Although the data were
intended for the BS organization, this study’s results were specifically aimed at the EO. This
office has an interest in keeping middle managers motivated to achieve organizational DEI goals.
This analysis was designed to suggest actions for all middle managers to take as they work to
create a more diverse and inclusive workplace while striving to meet DEI objectives.
Ethical Implications
To conduct the research in a trustworthy and ethical manner, I employed two specific
strategies. Firstly, I employed triangulation, utilizing multiple data sources or methods for the
study that I compared and cross-checked.
Secondly, to gain additional clarity on individual responses, I conducted follow-up
interviews with the same participants, especially considering that they provided varied
perspectives (Merriam & Tisdell, 2016). This second strategy was member checking and entailed
soliciting feedback on preliminary/emerging findings from the data analysis. Doing so supported

45
the research by ruling out misinterpretations, biases, and misunderstandings of what I observed
(Merriam & Tisdell, 2016).
Summary
This section displayed the method for data collection in this research. Through semistructured interviews, I sought to gain a deeper understanding of middle managers’ experiences
and motivations toward DEI in a healthcare company. Specifically, the research intended to
support BS’s EO in motivating middle managers to reach their strategic goals around DEI.
Chapter Four will detail this study’s results based on the interview data. The findings will be
linked back to the research questions.

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Chapter Four: Findings
The problem of practice of this research highlights the difficulty of middle management
to prioritize DEI at a U.S.-led healthcare for-profit organization. This study leveraged the CRT
framework and the BLCM conceptual framework. The implementation of BLCM highlights the
influence of six of the model’s 12 factors; those factors are external environment, leadership,
culture, management practices, work climate, and motivation. To gain clarity on this problem of
practice, the study addressed four research questions:
1. What are the external factors that contribute to an organization’s approach to DEI?
2. How do middle managers influence and shape company culture and work climate
around DEI?
3. What are the middle manager practices that most greatly affect the direction of DEI at
the organization?
4. What are the effects of leadership motivation around DEI goals for the organization?
Participants
Based on organizational roles, this qualitative study sampled middle managers from
across the organization in their natural work settings. The study examined the experiences of 16
men and women regarding their beliefs and perceptions of how middle managers implement and
reach organization-wide DEI goals. I collected data through semi-structured interviews
scheduled to meet their availability. A priori and posteriori coding informed the findings and
subsequent analysis. Conducting the interviews on Google Hangout allowed for greater
flexibility and reach across a broader geographical area. I conducted these interviews via Google
Hangout as the participants were over a varied geographical area and for convenience. To protect
the participants’ identifiable attributes, pseudonyms replaced actual names. Table 2 highlights

47
the general demographic characteristics of the respondents. All participants indicated that they
were middle managers with at least one direct report who was a full-time employee.
Table 2
Participant Demographics
Participant Gender Race/ethnicity Tenure at
organization
Tenure in
current role
Area within
organization
Alex Male White 16 3 Technical
Ben Male White 10 5 Production
Christian Male Black 18 5 Technical
Dahlia Female Latinx 6 2 Equity
Erin Female No disclosure 5 3.5 Human resources
Frederick Male White 24 1 Technical
Grace Female Black 22 4 Sales
Helena Female Latinx 12 2.5 Sales
Isabel Female Latinx 21 8.5 Sales
Journey Female Black 14 2 Production
Kaleb Male Black 7 3.5 Equity
Lucia Female Latinx 17 4 Equity
Myla Female Black 8 6 Sales
Nelson Male Asian 8 2.5 Production
Oliver Male White 5 2 Research
Pia Female Asian 36 4 Technical
Note. The column titled tenure reflects participants’ roles as middle managers in their current
roles.

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Alex is a White male and a full-time employee who has been employed with the
company full-time for 16 years. He has been in his current role for 3 years. His position as a
senior director is in the technical function of the organization at a satellite office. He holds an
informal DEI role with the organization in addition to his full-time role. He is a retired military
and retired police officer who leverages his experience as a volunteer with the company’s
preparedness and response team. During his interview, Alex stressed mental health and
psychological safety. Alex is not much of a social media user and attributes that to his age. He
has a son who is on the autism spectrum.
Ben is a White male and a full-time employee who has been employed with the company
full-time for 10 years. He has been in his current role for 5 years. His position as a team lead in
the production function of the organization at the main office. He does not hold a formal DEI
role with the organization. During his interview, Ben emphasized hiring diverse talent,
specifically related to those who are earlier in a career (i.e., interns, post-docs). He stressed
location when it comes to potential talent, and he believes that certain communities might be
“disproportionately impacted” by limiting the talent pool to specific areas.
Christian is a Black male and a full-time employee who has been with the company for
18 years. He has been in his current role for 5 years. His position as a director is in the technical
function of the organization at a satellite office. He holds several informal DEI roles with the
organization, including leadership in several ERGs. Christian described himself as a son,
husband, and father to a young child; he shared how these identities helped him to consider other
dimensions of diversity when it comes to his involvement in DEI initiatives at the organization.
He shared, “I have to make sure that the workplace is so much better by the time [my daughter]
gets here. So that’s another motivation for me is to ensure those things get to where they are.”

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Dahlia is a Latinx female and a full-time employee who has been employed with the
company for 6 years. She has been in her current role for 2 years. Her position as a director is in
the equity function of the organization at the main office. She holds a formal DEI role with the
organization. Although Dahlia identified as Latinx in the pre-survey for this research, she
mentioned her mixed-race identity as an integral part of her outlook on DEI efforts:
I feel like, you know, being mixed race and having a background in, like, team sports. …
I think it’s so cool when you can bring people together to accomplish a single goal and
get the best out of people and work together as a team.
Erin is a female and a full-time employee who has been employed with the company for
5 years. She has been in her current role for 3.5 years. She preferred not to disclose her
race/ethnicity information. Her position as a senior director is in the human resources function of
the organization at the main office. She does not hold a formal DEI role with the organization.
Erin shared that her personal experiences around family play a significant role in the way she
views DEI. She described marrying into a Japanese family and that her children are “hapa,” also
known as “half and half.” Furthermore, she expounded on her “30-plus year journey of
navigating respect and [her] values as a woman.”
Frederick is a White male who has been employed with the company full-time for 24
years. He has been in his current role for 1 year. His position as a team lead is in the technical
function of the organization at the main office. He does not hold a formal DEI role with the
organization. During Frederick’s interview for this study, he reflected on how his family’s past
experiences have helped shape his thoughts about DEI. Specifically, watching his father, who
was a defense attorney, impacted his thoughts about equity, especially as it relates to “everyone
deserving” a chance.

50
Grace is a Black female and a full-time employee who has been employed with the
company for 22 years; she has been in her current role for 4 years. Her position as a director is in
the organization’s sales function; she is a remote employee. She holds several informal DEI roles
with the organization. During her interview, Grace emphasized allyship, particularly from White
men, in advancing DEI efforts. She highlighted that building rapport is a key step in breaking
down biases. Grace shared an instance where she and a colleague bonded over Marvel and Star
Wars, which created a new connection that might not have existed otherwise.
Helena is a Latinx female and a full-time employee who has been employed with the
company for 12 years; he has been in her current role for 2.5 years. Her position as a director is
in the sales function of the organization at the main office. She holds several informal DEI roles
with the organization including leadership in an employee resource group and sponsorship of a
separate affinity group. Helena is a former scientist who expressed how she views DEI as the
overlapping of two disparate entities that create innovation. Further, her experiences as a Latina
have shaped the way she shows up in the workplace. This plays an important role in how she
leads. Helena stressed “bringing others along” and “making spaces for people that might look
like [her] or have [her] background.”
Isabel is a Latinx female and a full-time employee who has been employed with the
company for 21 years; she has been in her current role for 8.5 years. Her position as an executive
director is in the sales function of the organization at the main office. She holds several current
and former informal DEI roles with the organization including prior leadership in an employee
resource group. During her interview, Isabel emphasized belonging and shared about viewing the
world through the lens of her immigrant mother and the language barrier that she faced. This

51
lived experience has helped her to “appreciate when [she] sees others who may be slightly
different.”
Journey is a Black female and a full-time employee who has been employed with the
company for 14 years; he has been in her current role for 2 years. Her position as a senior
director is in the production function of the organization at the main office. She holds several
informal DEI roles with the organization. Journey moved to the United States 2 years before this
study from London and has Nigerian roots. She shared that this piece of her identity plays a large
part in how she views DEI. Since she is not from the United States, she has noticed the
differences in how DEI is viewed here versus in the United Kingdom. She described DEI as
more “embedded … from top to bottom” as a “stark” attribute that she has noticed specifically in
the United States.
Kaleb is a Black male who has been employed with the company full-time for 7 years.
He has been in his current role for 3.5 years. His position as a senior director is in the equity
function of the organization at the main office. He holds a formal DEI role with the organization.
Kaleb emphasized his family and civil rights activists’ impact on his personal journey and sense
of obligation with DEI, specifically his involvement outside of his professional life and in the
community with his philanthropic work. He described himself as a “recipient and a product of so
much that has come before [him].”
Lucia is a Latinx female who has been employed with the company full-time for 17
years. She has been in her current role for 4 years. Her position as a senior director is in the
equity function of the organization at the main office. She holds a formal DEI role with the
organization. Lucia shared that “lived experience” and being “the only” motivated her

52
involvement in DEI efforts. Her story of when she graduated from college and being the only
Hispanic in her graduating class of 80 students was a shock to her grandparents in the audience.
Myla is a Black female and a full-time employee who has been employed with the
company for 8 years; she has been in her current role for 6 years. Her position as a senior
director is in the sales function of the organization at the main office. She holds several informal
DEI roles with the organization, including leading several affinity groups at the organization.
Myla shared that it is important to liken DEI to humanity because
when you start talking [diversity and inclusion], you put people up against the wall. They
automatically have their perceptions of what it is. When you say humanity, it brings
people forward a little bit, and they’re willing to hear what you have to say.
Nelson is an Asian male who has been employed with the company full-time for 8 years.
He has been in his current role for 2.5 years. His position as a director is in the production
function of the organization at the main office. He does not hold a formal DEI role with the
organization.
Nelson shared that his responsibility as a middle manager is rooted in helping others. He
shared a personal reflection on how he views his principal role as a middle manager: “For me,
it’s primarily to provide opportunities for individuals who, without sort of this additional help,
would not have had these opportunities. I kind of just see it as sort of trying to level the playing
field.”
Oliver is a White transgender male who has been employed with the company full-time
for 5 years. He has been in his current role for 2 years. His position is in the organization’s
research function at the main office. He holds a formal DEI role with the organization, which
includes leading an employee resource group at the organization.

53
Oliver attributes much of his understanding of DEI to witnessing the mistreatment of his
former colleagues and the actions of those mistreating them. These incidents highlighted how
everyone involved was “embedded in these systems” that were “a part of things.”
Pia is an Asian female who has been a full-time employee with the company for 36 years.
She has been in her current role for 4 years. Her position as an executive director is in the
technical function of the organization at a satellite office. She has held informal DEI roles with
the organization. Pia believes in helping early-in-career talent attain their goals; she has done so
by sponsoring college students to “increase participation for underrepresented groups in STEM.”
Participant Summary
The biographical portraits of these middle managers allow us to understand how their
lived experiences, coupled with their personal accounts within the workplace, shape their
approach to DEI. Each participant exuded management traits, including awareness,
communication, and reflection. The following section will discuss how these middle managers
leverage their positions within the organization to further DEI in attempts to reach affiliated
organization-wide goals., coupled with their accounts within the workplace, shape their approach
to DEI.
Qualitative Findings Overview
Data collection occurred through 16 hours of interviews with middle managers across
various organization functions. The foundation of previous research on DEI alluded to
opportunities with middle management related to accountability, awareness, and communication.
The anticipated and discovered themes originated from research questions around
individual and organizational factors brought about by middle management practices. These
findings contradict the assumption that the frozen middle is incapable of supporting

54
organization-wide DEI goals. As such, the research presents the factors relevant to each research
question and offers a lens to better understand how leveraging and focusing on middle managers
assists in reaching organization-wide DEI goals.
Findings Research Question 1: External Environment
Two major themes and several sub-themes emerged to address Research Question 1,
which aimed to identify external factors that might affect the organization’s approach when
considering its support of DEI goals. The two major themes in the interview data were personal
experiences and geographic location, while social unrest/current events and patient health
disparities were sub-themes. These themes interconnect with CRT, which acknowledges
historical patterns of racism embedded in modern institutions (Delgado & Stefancic, 2023); they
also provide a glimpse into how and what employees become aware of as related to DEI. This
study’s findings expose how such external happenings influence the extent to which middle
managers are aware of DEI and how they address it.
All participants’ narratives involved racial or ethnic mistreatment, reflections on the
global Black Lives Matter protests, and considerations regarding patients during the COVID-19
pandemic in 2020. These occurrences shaped the direction of the interviews and seemed to
profoundly influence how participants recalled their own experiences with DEI at the
organization.
The primary external factors influencing how the participants viewed DEI efforts were
their experiences and the organization’s geographic location. These components played the most
significant role in shaping participants’ attitudes toward DEI. For many participants, encounters
with discrimination or exposure to diverse environments profoundly influenced their
commitment to DEI initiatives. These experiences fostered a deeper understanding and empathy

55
toward the challenges underrepresented groups face, motivating the interviewees to actively
support and promote DEI efforts at the organization. In addition, the organization’s geographic
location played a key role. Being situated in an area with a diverse population shaped how the
participants perceived and prioritized DEI. Due to the organization’s location, study participants
were often more attuned to inclusivity and equity, driven by the need to reflect and serve their
community appropriately.
In addition to these primary factors, other relevant external elements included current
events related to social unrest and patient needs. The social unrest that has been prominent in
recent years, particularly global movements such as Black Lives Matter, heightened awareness
and urgency around DEI efforts. Participants noted that these events served as catalysts for
introspection and action, compelling them to address systemic inequalities in their organization.
Lastly, patient needs influence DEI at the organization, where disparities in patient care
based on race, ethnicity, and socioeconomic status are well-documented. The interviewees
recognized that promoting DEI is not just a moral imperative but key to providing equitable care
and improving patient outcomes. These external pressures reinforced the importance of DEI,
shaping how the interviewees approached their roles and responsibilities within the organization.
Personal Experiences
The study results showed that reflecting on personal accounts was important for all
participants, specifically regarding childhood experiences and how memories can shape
sentiments around DEI. Ben and Lucia emphasized that their “lived experiences” significantly
influence how they approach DEI within the organization. Additionally, Dahlia, Helena, Journey,
and Lucia noted that an individual’s personal “background” significantly shapes how DEI is
internalized and subsequently practiced by them. Furthermore, these reflections provided insights

56
into how they can further embed DEI among their teams. For example, Grace shared that
exposure to different cultures as a child instilled a sense of curiosity:
I was raised in a household where we didn’t have a lot of money, but I was raised in a
household where, you know, for your birthday, my dad would take you to a new cuisine
you had never tried. … He took me to a Vietnamese restaurant when I was 16. He was
like, “You’re gonna love this.… I’m taking you somewhere special to dress up.” And
then we go, and we have Vietnamese food. From the time I was little, my mother would
do this once a year when you had your date with mom, you know, so I was the youngest,
and I was the last to get Thai food. … And then she would talk to you about it. … We ate
around the world, and we listened to all music. You know, Frank Sinatra on Saturday,
Janis Joplin and Aretha Franklin on Mondays and Tuesdays. Like it was that kind of
home. And their answer to everything is good music is good music, good food is good
food. And you should always be curious.
These positive memories helped to shape sentiments around differences with others and
reinforced curiosity and keeping an open mind. Similarly, these experiences subconsciously
played a role in the compassion that the interviewees exhibited. Isabel shared a complementary
reflection, specifically on how she viewed her mother’s journey:
My mother was an immigrant, so she was born and raised in Lima, Peru. So, I grew up
learning that, you know, she’d been treated different. We were being treated differently
because of that, maybe because of her strong accent and language. And so, I think
addressing those challenges and growing up with those challenges helped me appreciate
more when I see others that are impacted, that may be slightly different, or they, too, have
either language barriers or other barriers because of their background.

57
Isabel’s beliefs and attitude toward diversity stem from her desire to help others in the
same way she helped her mother. These personal experiences significantly influenced both how
study participants felt and their leadership styles. Helping others has become embedded in the
way that they manage their teams. The organization’s geographic location amplified this effect,
as those in more diverse areas often encountered a broader range of perspectives and challenges,
deepening their empathy and understanding.
Geographic Location
According to study participants, another major factor influencing an organization’s
approach to DEI relies heavily on its geographic location. Kaleb and Erin attributed their
personal growth and worldview to the support of their local “communities,” while Ben, Journey,
and Nelson credited exposure to “different cultures” as a key factor in expanding their
understanding of the world. Nine participants mentioned this aspect as one critical to the
organization’s sentiments around DEI. Some shared that the organization’s physical office
location played a key role in recognizing the importance of DEI. Frederick’s sentiments are an
example:
[This area] attracts people from all over the world. So, you are going to get a lot of
diversity because of that. … You get people from all over the world and a foodie place,
so you get all the foods from around the world. So, I think that’s one of the external
factors.
Erin complemented this position by sharing,
I think part of it is the environment that you’re in. If we think about our leadership in [the
global office], it’s much more, you know, European descent, more homogeneous
population. [It] does not have the diversity that we have here.

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Beyond the physical location of the main office, some participants noted that geographic
location, in general, coupled with social unrest, influenced their perception of DEI. Although
Journey moved to the United States from the United Kingdom, she was very much aware of the
social unrest in the United States while living in her homeland, specifically the global turmoil
surrounding the killing of Black people by police officers. She shared her reflections upon
moving to the United States:
But because we were a Black family, moving to the [United States], they were … a little
bit taken aback that we were making that move, and that’s because of what we see on
TV. That’s because of the impressions that we get of how society is [in the United
States]. … If you’re driving, you know, you could get pulled over by a police officer, and
you could get shot, all of those kinds of things, which is not something that is as rampant
in, I guess, the [United Kingdom].
Erin shared a similar sentiment around geographic location and social unrest, “I think it’s
a challenging time to be an American. There’s a lot of social unrest, I think. Years and decades
and centuries of discrimination, I think, have really come up to the forefront.”
The results show that geographic location and social unrest connect to how the
organization views DEI. An organization’s geographic location often dictates its exposure to
various social, political, and economic dynamics, which in turn shape the experiences and
perceptions of its employees. Such perceptions can permeate the organization, influencing
policies, practices, and the overall organizational culture. Consequently, the interplay between
geographic location and social unrest informs and shapes the organization’s approach to DEI.

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Social Unrest/Current Events
When asked about the external factors that have contributed to the organization’s
sentiments toward DEI, exactly half of the study participants mentioned the killing of George
Floyd or the global Black Lives Matter protests. They mentioned this theme apart from politics
or religion. Dahlia, Frederick, and Journey cited “a lot of history” when discussing what has
influenced external surroundings, emphasizing the deep historical complexities of the United
States. Further, Journey and Oliver highlighted “societal structures” as having a significant
influence on how the environment is shaped. Helena shared, “I think we’ve been in a political
environment where George Floyd and other situations have shown that we don’t live in a just
society, and there’s things that corporations can do.” Similarly, Oliver also reflected on this
particular current event. He shared, “And because, like, I know a lot of people were impacted by
George Floyd’s death here, and there were a lot of people who weren’t realizing the extent of
societal and structural racism impacting all facets of life.”
Lucia explained how the killing of George Floyd helped to shape the path of DEI at the
organization. Specifically, she shared how this instance prompted the company to think about
why DEI should be important for all employees:
Social factors came into play and first started with the murder of George Floyd but
clearly also occurring in multiple other places all around the company really gave light to
the importance of [DEI] in the company. And it was almost as if the business case for
why this work matters was written for us. Now, of course, we had to shape it our way.
We had to respond our own way. We had to use our own words. But at the end of the
day, it was almost like a launching pad.

60
The intersection between the geographic location of the organization coupled with the
social unrest surrounding the killings of Black people influenced many study participants. For
them, witnessing these events firsthand, either through local news or direct personal experiences,
brought the realities of systemic racism and inequality into sharper focus. This increased
awareness often resulted in a heightened and deeper commitment to DEI efforts among them. As
a result, it nurtured a more supportive and collaborative environment for advancing DEI
initiatives.
Patient Health Disparities
A focus on patients was also a major contributor toward recognizing DEI at the
organization. Half of the study participants also mentioned this contributing theme. Grace,
Helena, and Isabel highlighted “health equity” as a central focus when reflecting on the work of
their respective teams. Additionally, Helena and Oliver’s reference to an “inequitable system”
further underscored the importance of prioritizing underrepresented patient populations. Given
that the organization’s focus and mission is to create life-saving medications for patients, it made
sense that sentiments around patient health disparities were a leading theme for interviewees, as
Grace highlighted,
When you don’t feel seen or recognized, or you’re seen, but you’re not allowed to speak,
you never really feel like you fully belong or are included in what turns out to be the dayto-day decision-making that informs the way we show up for patients and customers. And
if you won’t see me, a member of the organization that hired you, how are you going to
see the patient who looks like me but doesn’t have anything else in common with you?
Similarly, Kaleb shared,

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So, if we’re not doing this work, if we’re not doing the diversity work that we’re doing to
ensure the effectiveness of our medicines in all patient populations, then we’re not [doing
what our patients need]. So, we live up to our motto when we adopt these DEI practices
into our work.
While these sentiments are rooted in the recognition of the need to link patient health to
DEI, a deep understanding of oppressive systems also emerged regarding the COVID-19
pandemic of 2020. The pandemic exposed and exacerbated health disparities, disproportionately
affecting marginalized communities and highlighting the systemic inequalities embedded in
healthcare and broader societal structures.
Helena observed the dire impact of the organization not recognizing patient medical
needs and how a failure to do so perpetuates a “racist system:”
If we think about how to reach new patients, we recognize that we work in a system that
has inequities. And so, if our goal is to have the right patient on the right and medicine,
we need to consider that some patients are not getting the right medicine, or at the right
time or right care because we have a racist system or we have a non-inclusive system. So,
one is just the business that we’re in, which was greatly elucidated during COVID
because we saw those health inequities come to bear.
Dahlia furthered this message around the effects of the COVID-19 pandemic by sharing,
In addition to COVID, which further amplified health disparities for different
communities have been, I guess, more fuel to push the sense of urgency for all
organizations. And I think that’s something that, you know, helped the [EO] to gain even
more momentum that we needed.

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Summary of Findings for Research Question 1
In summary, the convergence of the COVID-19 pandemic and heightened awareness of
systemic oppression profoundly influenced the study participants’ attitudes toward DEI (Table
3). It reinforced linking patient health to DEI initiatives, recognizing that equitable healthcare
outcomes intertwine with broader social justice issues. This period of crisis and reflection
deepened their understanding of the systemic barriers that need to be addressed to achieve true
equity in healthcare and beyond. The interviewees, therefore, emerged as advocates for DEI and
key drivers in implementing practices that support both employees and patients, ensuring that the
organization’s DEI efforts are both comprehensive and impactful.

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Table 3
Summary Table of Findings: External Factors
Theme Participant name Quote
Personal experiences Christian I have to recognize the women in my
life that had a huge impact on me.
First, my mom, secondly, my wife,
so addressing things that could be of
interest to them in their world, also
important. And then third, the
future, I have a daughter.
Geographic location Ben I think part of it is being in [this area],
you know. … That’s generally part
of the values of where we live. I
mean, not across the board, but
that’s part of what helps us [here],
you know, in this area.
Social unrest/current events Erin I think it’s a challenging time to be an
American. There’s a lot of social
unrest, I think. Years and decades
and centuries of discrimination, I
think, have really come up to the
forefront.
Patient health disparities Pia I think what [the company] did was
just look at the makeup of clinical
trial patients, just as an example. I
don’t remember all the numbers
right, but it looked at … probably
like 10 different medicines … and
the representation was
predominantly White, and that
doesn’t represent the makeup of the
patients we serve. So, I think we go
in a data-driven way to understand
what the issue is. So, I think
knowing that right, like assessing
that, then we can go and then make
changes.

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Findings Research Question 2: Company Culture and Work Climate
Two major themes addressing Research Question 2 reflect how the interviewees viewed
their effect on the overall culture as related to DEI. A culture of awareness and intentionality
were the major themes, with three sub-themes: continuous learning, allyship, and empathy.
These themes underscore the role of middle managers in shaping the organization’s DEI
landscape. Their engagement in continuous learning signifies a commitment to personal and
professional growth, fostering an environment where ongoing education around DEI is valued
and prioritized.
The study identified two main themes and three sub-themes illustrating how middle
management affects company culture and work climate. The main themes are the interviewees’
awareness and ability to reflect on DEI, and their intentionality behind DEI efforts. The subthemes were engaging in continuous learning on DEI topics, practicing active allyship, and
demonstrating empathy. While the primary themes had the most significant influence on the
participants’ attitudes, the additional elements, though less prominent, also contributed to the
overall findings.
Awareness/Reflection
All study participants had an awareness of DEI or were able to reflect on it as part of their
roles. Several participants, including Ben, Erin, Helena, Journey, Kaleb, and Nelson, discussed
how exposure to “different cultures and backgrounds” has shaped their understanding of the
broader organization’s culture around DEI. Similarly, Alex, Christian, Erin, Frederick, Grace,
and Journey highlighted how empathy and “understanding” the experiences of others influence
their personal approach to working with diverse teams. The following excerpts reflect how they
described their awareness of DEI or how they reflected on it. Helena shared,

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I think to make people feel heard in a given space. So, I think just how are we running
meetings so that everyone has a voice is a simple thing. Two, just check on the kind of
feedback that you’re giving your people. Are you giving women feedback that you would
give a man? Are you giving feedback to a Black gentleman that you would give to a
White gentleman or a White woman? That sort of, like, checking your bias, do the, like,
extra step to see if you really are being fair and equal, … and so maybe recognizing
maybe where your person is coming from, and checking the kinds of feedback that you’re
giving to people and is it appropriate would be kind of the concrete thing that I would
recommend people do?
Similarly, Journey reflected on the interactions that she has had with her team:
Having to understand cultural differences, having to understand, just try and understand
how, for example, as someone in my team is … English is … actually two people on my
team English is not their first language. So just understanding how that presents itself in
the work that they do and the way that they express themselves, and then also their
culture within the country that they live in and all of that kind of stuff as well. There is no
way that I could do my job effectively without taking into account that my team is so
diverse, and I have to use it. I have to leverage that and use that diversity.
Other study participants provided examples of how they showed awareness of DEI.
Ben shared his reflections on the way his team conducts meetings:
I’ve been more mindful about it in terms of how we conduct meetings, how we, how I
can encourage, and ensure that everyone has a voice, everybody is, you know, has the
ability to speak up and make their perspective known and also to learn from each other.

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Lucia discussed her “awareness of the experiences of others,” emphasizing her
understanding of the diverse backgrounds and challenges her team members face. By
acknowledging these varied experiences, Lucia created inclusive spaces within her team,
ensuring that every member felt valued and heard. This approach fostered a supportive
environment where team members could thrive and contribute their perspectives, ultimately
enhancing the overall team dynamic and effectiveness. Lucia’s actions illustrate how heightened
awareness can lead to tangible improvements in inclusivity and team cohesion.
Also, while there was a general recognition among the interviewees around DEI, Grace
was self-aware of opportunities for her growth. She added, “I got issues, too. We all have them.
We all have them. The goal is to work on them together and to not be afraid of them.”
While awareness of DEI efforts at the organization was significant among the study
participants, this recognition must permeate all tiers—from the organization’s C-suite leadership
to entry-level employees—to create a truly inclusive and equitable environment. Bridging this
awareness with intentionality is key. The following section highlights how the interviewees
demonstrated intentionality around DEI efforts, providing insights into their strategies,
challenges, and successes.
Intentionality Around DEI
Fourteen interviewees shared compelling stories that highlighted their intentionality
toward DEI efforts. Alex, Christian, and Journey specifically highlighted how they “lead by
example,” while Erin, Grace, and Lucia emphasized that “continuous learning” is essential for
advancing DEI goals. These stories varied widely but consistently underscored a deep
commitment to fostering an inclusive workplace. Participants discussed proactive measures and
that they regularly sought feedback from their teams to ensure that DEI initiatives were effective

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and inclusive. They reflected this intentionality in everyday actions and decisions, demonstrating
a genuine dedication to embedding DEI into the fabric of the organization.
Frederick shared an example of designing a meeting with DEI in mind:
So, we also have a weekly huddle, a chapter huddle, and DEI is the second topic we
cover, after we cover, you know, out-of-office stuff, … who’s going to be out of office
and things like that.
Similarly, Myla shared,
We’ve done a lot of things where we get individual conversations. We’ve done a lot of
things around music, where we’ll have music playing in the background as we’re
working, and it’s different genres of music and everybody collaborates around the music.
We’ve done things where we bring in food, food and music have been a beautiful thing.
Also harmful because the food part because you’re eating all these yummy things, and
people are trying different things, and it just broadens the perspective and the
conversations because everyone loves and is proud of their heritage and ethnicity and all
the things and the food that they bring the music, the culture that they bring to life and so
allowing that shows humanity.
Kaleb discussed how he leverages all of the voices on his team in the spirit of DEI:
The fact that they have a voice on a team is helping to contribute to [diversity and
inclusion]. And what I do to foster that is to make sure that everyone’s voices and
perspectives and ideas are valued or elevated or implemented. … They get a chance to
present at board meetings. They get a chance to present in town halls with various senior
leaders.

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Isabel also expressed that she is intentional around DEI at the organization, specifically
how she created ongoing training sessions with another colleague:
I partnered with one of my colleagues that went through [a] program with me, and we
decided to have a monthly mini-training session. And so, we would only spend about the
first 15 minutes on sharing the content and things that we learned, but then opening it up
to the attendees. At first, we just started with our department, but then we started hearing
that others wanted to participate; they heard about it. And so then more and more and so
then it got very big, where we [an audience of 300 to 400 people].
By showing intentionality around DEI, the interviewees help to create a workplace that
celebrates diversity, pursues equity, and practices inclusion at every level. The following
sections provide insights into the subthemes in the data concerning shaping the company culture
and work climate.
Continuous Learning
Continuous learning emerged as a theme for 12 participants. Of those who mentioned this
point, there was an emphasis on genuine curiosity and probing around personal stories. Isabel
and Dahlia associated continuous learning with engaging in “intentional conversations” with
their direct reports, while Lucia and Oliver discussed how the company has embraced “hard”
discussions when tackling challenging topics. Overall, these participants expressed positive
sentiments toward continuous learning. Erin reflected on the questions she asks herself when
working with her team: “How do I listen differently, probe differently, listen deeply?” Oliver
expressed a similar sentiment around his approach to continuous learning by sharing that he
“always has so much to learn” and emphasized the significance of books as “game changers of
people’s understanding.”

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Alex shared that he incorporates learning outside of work toward how he manages his
team:
I’ve been seeing a life coach. And there’s some things in my life that aren’t aligning to
my values and that’s causing me not to feel fulfilled. And I never knew any of that until I
met a life coach. And then I take that with my team.
By remaining open to continuous learning, study participants experienced feelings of
“authenticity,” “growth,” and “challenge.” This openness enhanced their personal and
professional development and evidenced how they connected with their direct reports. Through
continuous learning, they displayed a sense of humility and “humanity,” which fostered stronger,
more authentic relationships within their teams. This approach allowed them to navigate DEI
topics more effectively, creating an environment that emphasizes continuous improvement and
mutual respect. This aspect, in some instances, translated into the formation of allies between the
interviewees and their direct reports.
Allyship
When it came to the allyship, 13 participants expressed this aspect as important to
company culture. “Understanding differences” is deeply ingrained in the company’s culture,
according to Journey, Grace, and Erin, who continue to act as allies to others within the
organization. Meanwhile, individuals like Christian, Frederick, Lucia, and Pia take on mentoring
roles, aiming to help others navigate and learn the organization.
While some participants did not explicitly call out the words “ally” or “allyship,” the
following examples exhibit those of support and advocacy that appeared positive for the
organization’s overall culture. Journey shared her feelings about understanding the perspective of
others:

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You don’t necessarily have to experience everything to be able to understand. You just
need to put yourself in the shoes of the person who has experienced it. And I think that is
something that is very evident within the company.
Correspondingly, Frederick also shared a sentiment around allyship at the organization,
So, I’m not necessarily an active member, because I’ve been so busy, but I’m part of [two
ERGs] that I’ve kind of connected with. I’ve done some sessions in the past.… I mean,
obviously, as an ally. I’m not a, you know, an African American or Native American or a
woman, you know, but I do that as an ally and as a supporter.
Oliver shared an example of how his learning is a work in progress and how he incorporates
these learnings into conversations with his direct reports:
Something that didn’t come from DEI here but that I’ve been trying to do is pay more
attention. … For employees that work for me, what are relevant and important things for
them? So, like, paying attention to Ramadan this year, and also paying attention to
comments a different colleague made about 911 [because] I have a Muslim employee
from Lebanon.
The company’s culture embeds the act of allyship. Participants highlighted that active
allyship involves supporting colleagues from diverse backgrounds, advocating for inclusive
practices, and challenging biases in the organization. The findings underscore that allyship is a
sustained and integral part of the company’s approach to DEI, driven by leadership and mirrored
by the interviewees. The practice of allyship can be closely linked to empathy, as it requires
understanding and sharing colleagues’ feelings, further reinforcing the importance of creating a
supportive and inclusive workplace.

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Empathy
Twelve participants exhibited empathy during their interviews, demonstrating an
understanding and concern for the experiences and emotions of their direct reports. Grace and
Kaleb conveyed a sense of “obligation” to advocate for those who may not speak up for
themselves, while both Grace and Myla emphasized the importance of keeping a “focus on
humanity” when engaging with others, both inside and outside the workplace. These participants
shared personal anecdotes and reflections that highlighted their ability to put themselves in
others’ shoes. This empathetic approach helped to build trust and rapport among their teams and
fostered a more inclusive and supportive work environment. Their empathetic leadership styles
contributed to creating a culture where employees feel heard, valued, and respected, ultimately
enhancing overall organizational morale and performance. Alex shared his thoughts as a leader
in the organization, given his positionality:
I mean, it’s hard to understand DEI as a White male who’s 53, right, unless I have
training and understanding, and then I have an environment of people that have struggled,
and they share their stories and their impact, and I can learn from that. And then, I, it
allows me to be empathetic and understand the situations.
Oliver shared an experience where one of his employees’ mother died of COVID and
how he tried “to figure out a way that [his employee] didn’t have to use up vacation time so that
he could support and be with his family during a very difficult time.”
Summary of Findings for Research Question 2
The study identified two main themes and three sub-themes illustrating how middle
management affects company culture and work climate. The main themes are the interviewees’
awareness and ability to reflect on DEI, and their intentionality behind DEI efforts. The sub-

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themes include engaging in continuous learning on DEI topics, practicing active allyship, and
demonstrating empathy. While the primary themes had the most significant influence on the
attitudes of the study participants, the additional elements, though less prominent, also
contributed to the overall findings.
The themes and sub-themes mentioned in this section underscore the role middle
managers play in shaping the organization’s DEI landscape (Table 4). The aspects of the overall
work culture and company climate around DEI highlight the significant influence these
employees can have on the broader organization. The findings from the interviews reveal the
perceived impact middle managers have on change management concerning DEI.
Table 4
Summary Table of Findings: Company Culture and Work Climate
Theme Participant name Quote
Awareness/reflection Nelson I feel like because we have a very diverse
team that we can represent society in
that way. Meaning like someone who
has had a very poor upbringing or
someone who’s brought up here in the
United States versus someone who
grew up elsewhere, internationally. So,
I think bringing those different
perspectives to the table allows us to
create a product that is applicable to
many different types of people.
Intentionality around DEI Pia So, I have challenged the bro club. I’m
like, ‘Hey, I see you guys go do this,
this and this.’ So, it’s like, ‘Oh, why
didn’t you invite me?’ deathly silent.
Because I can say that I can use my
voice right because the other women
are just telling me what happened.
They’re not going to voice it. So, feel

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Theme Participant name Quote
that empowerment; you embody it
every day.
Continuous learning Dahlia I went out … on the internet and tried to
figure out, well, how I do I have a
freaking career conversation? What
questions do I ask? … and I, like,
researched. I found some good
questions. I figured it out. And every
time I did it, it got easier. And I don’t
know, I don’t know if I would have
done that. I wouldn’t have done that. I
wouldn’t have those conversations. I
don’t think I would have if I didn’t
have this foreseen function of having [a
manager goal]. So, I believe in the
power of goal-setting and intention, and
I think that is one of the really cool
things I’m excited to be a part.
Allyship Frederick So, a lot of my work is providing
guidance, direction, coaching, making
connections, teaching, teaching them in
some ways, and explaining things. I’ve
been here long enough to have a lot of
history. So, I can give them some
perspective sometimes on things.
Knowing what they like to do and what
they’re good at and finding them
opportunities where they can do that.
Empathy Journey So, in any case, having to understand
cultural differences, having to
understand, just try and understand
how, for example, as someone in my
team is English … actually two people
on my team English is not their first
language. So, just understanding how
that presents itself in the work that they
do and the way that they express
themselves, and then also their cultural
within the country that they live in and
all of that kind of stuff as well.

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Findings Research Question 3: Management Practices
A prominent theme that emerged during this research was that study participants
managed their teams daily with an emphasis on DEI. Specifically, they consistently highlighted
two themes of embedding DEI and communication while making time for DEI and hiring
practices, and having a genuine interest in DEI also emerged from the data analysis. These
consistent practices became second nature for the managers as they navigated the organization
while managing and supporting DEI. This section will highlight these frequently mentioned
practices.
One key theme was the integration of DEI into daily practices. This approach stood out
significantly, demonstrating a commitment to fostering DEI within their teams and the broader
organization. Effective communication also ensured that DEI efforts were understood and
supported across all organizational levels. These practices underscored the participants’
proactive stance in championing DEI initiatives and fostering inclusive work environments.
Additionally, the three remaining sub-themes of making time for DEI, intentionality in hiring
practices, and having a genuine interest in advancing DEI efforts within the organization
emerged with equal frequency.
Embedding DEI
Fifteen interviewees shared how they practice leadership through action regarding DEI.
While Erin, Kaleb, and Lucia each described being “highly intentional” in embedding DEI into
their management practices, Ben and Nelson continuously reflect on “how to develop” their
direct reports, ensuring that DEI principles are integrated into their growth and development
strategies. Frederick shared, “So, I’ll start, I mean, basically demonstrating [DEI], doing it, living

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it, breathing it, you know, not making it just words, which I think [the company] is pretty good,
even at the officer level has been really good.”
Both Kaleb and Myla expressed a sentiment around “making sure” to leverage their
positions to embed diversity within their teams, whether that is related to “[ensuring] that
everyone’s voices and perspectives and ideas are valued, elevated or implemented” or
guaranteeing “having a diverse team” to spark innovative ideas.
Journey shared that embedding a DEI perspective is ingrained into how she leads and that
there are benefits of doing so:
There is no way that I could do my job effectively without taking into account that my
team is so diverse, and I have to use it, I have to leverage that and use that diversity to our
advantage because that’s what makes our team unique.
The interviewees play a key role in advancing DEI within the organization, underscoring
their leadership in this context. Embodying their principles through action enhances their
credibility and authenticity, fostering positive communication.
Communication/Storytelling
Similar to the last section, 15 interviewees expressed that communication was a specific
tactic that they leveraged around DEI. Erin, Helena, and Nelson emphasized that “different
perspectives” greatly enrich the organization. Another perspective from Christian emphasized
the impact of “connecting diversity to stories,” while Lucia noted that “sharing stories” is
another powerful way to advance DEI within the organization. Erin shared that she is deliberate
when she connects with her direct reports: “I have to really challenge myself when I go into
conversations of how I probe differently about people’s interests and ambitions and motivations
because some are much more assertive by nature, and others aren’t.” Equivalently, Christian also

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shared about the intentionality he makes around holding meetings and designating time with a
DEI lens,
So, once a month, I give them a sounding board. Sometimes, you’re sharing things and
learning about what someone else is doing. Other times, you’re responding to questions
you have, like, “Hey, did you hear this? What’s that about? Or did you see this new
position that was posted? Does anybody know what that is?” They’re able to ask those
questions, direct feedback to our senior leaders. I compile that to send it over to those
senior leaders.
Lucia explained that she recently developed community communication practice within
the organization and that doing so benefited the company’s culture. These new conversations
emerged during the social unrest of 2020 following the killing of George Floyd. Lucia said,
We have brought topics that have never before really been discussed in the workplace.
And we have provided some guardrails for how to have some of those conversations to
avoid some of that divisiveness. And in that regard, I think [the company’s] culture has
evolved in recent years to be able to have some of those hard conversations that people
weren’t ever even willing to have before.
The participants consistently highlighted communication as a key tactic with their direct
reports, requiring deliberate action from managers who seamlessly integrated it into their
leadership style. Likewise, making time for DEI efforts was an important practice in interactions
with their teams.
Making Time
Twelve interviewees mentioned that making time was a factor in how they embedded
DEI efforts at the organization. Whether by “volunteering for events” like Pia or “participating in

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[the company’s ERG] groups” like Isabel, the participants demonstrated a deliberate
commitment to making time for DEI. Intentionally or not, incorporating dedicated time proved
helpful. Such was the case with Alex, who described an upcoming teambuilder he was planning
for his team:
We’re going to do a vision board exercise with a consultant next week, and we’re just
going to spend two hours with old school magazines cutting stuff out and glue sticks.
And we’ll do one side about your personal vision board. And maybe the other side about
work can be shared and not be shared. … It’s just about the opportunity to see where you
want to be.
Dahlia shared that she makes an intentional effort to have important conversations with
her employees and how doing so has proved to be beneficial for both them and her:
Last year and the year before, I set the goal of having intentional career conversations
with my people every quarter. And … it was just this forcing function that I did it. I had
to do it because I said I was going to do it. And I had them, and they were, like, some of
the greatest conversations I’ve had with my people.
Another way the interviewees reported leveraging time occurred through information
sharing with a broader audience, creating a multiplier effect. Isabel distributed her knowledge to
others by setting aside the time to do so
As the interviewees reflected on the instances of making time to address DEI, they
highlighted the varied and boundless opportunities to affect change within the organization.
While some study participants built DEI into their responsibilities, others felt a deep sense of
responsibility to share DEI-related knowledge with colleagues. This multifaceted approach also

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extended to hiring practices, where participants emphasized recruiting and retaining diverse
talent to strengthen the organization’s commitment to DEI across all levels.
Hiring Practices
Similar to the last section, hiring practices were a theme that arose from 12 interviews.
While Kaleb, Lucia, and Nelson highlighted the organization’s “focus on attracting top talent,”
Ben, Christian, and Nelson stressed that having a “diverse pool of candidates” is essential for
ensuring fair hiring practices. The topic of hiring also arose in relation to the extent to which
participants believed that they had “a say” in hiring decisions. Christian focused on how to
approach what a potential candidate pool can look like:
Something that impacts me is I do a lot of hiring at times. And I was talking to another
hiring manager about the [candidate] pools and going, “I don’t quota. I don’t go out and
say I’ve got a new role. Let me find a woman, or let me find the person of color.” No,
when I have this new role, how do I ensure it gets to a large, diverse group of people so
that I can get the best candidates? I think, because if I only go to one university, how do I
know I truly got the best?
Helena reflected on her practice during the actual interview of putting an added focus on
inclusion:
I follow the inclusive hiring guidelines. I also, when I do interviews, I put in the text of
my questions in the chat so that people who maybe are a little different or hard of hearing
have an opportunity to read things. And then how I try to run my group as a place where
people can express themselves. In addition to me checking my feedback, how am I
providing comments both positive and constructive to my female staff versus my male
staff. … So that’s kind of my little zone.

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While both examples pertain to hiring methods, the study participants viewed hiring
through an equitable lens. From sourcing talent to hiring talent, the 12 interviewees demonstrated
an interest in making progress on the organization’s DEI efforts.
Genuine Interest in Advancing DEI
The final theme around management practices that advance DEI efforts focuses on
managers having a genuine interest in DEI. Eleven interviewees exhibited how taking a sincere
interest in DEI at the organization has played a role in how they lead their teams. Some
participants including Dahlia, Helena, and Isabel, discussed how they “encourage others” to
engage in DEI efforts, while others emphasized the importance of “building” in various ways.
Whether it was through “building connections” like Helena, “building trust” like Erin, or
“building community” like Isabel, these middle managers expressed a genuine commitment to
DEI and advancing its goals. Ben shared that he “[sees] experience as a great benefit in having a
diverse workforce, like diversity of educational backgrounds, of ethnicity, of gender, and every,
like, diversity factor.”
Christian shared how his allyship of loved ones causes him to consider DEI when it
comes to decision-making:
I’ll get asked why are you an officer in [the women’s employee resource group]? Because
that’s the one that makes people pause like, “What? Why are you doing that?” And [I]
say, “Well, a better workplace for women is a better workplace for me.”
Another perspective from middle management compared DEI to “humanity,”
highlighting how a focus on humanity can break down barriers and foster deeper conversations.
Both Alex and Myla made this comparison.

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Summary of Findings for Research Question 3
Overall, the interviewees’ practices underscored their role in driving DEI efforts through
their leadership, communication, time management, hiring decisions, and personal dedication to
fostering inclusive workplace cultures (Table 5). These managers exemplified proactive
approaches to integrating DEI into their daily operations and demonstrated a commitment to
continuously leaning into DEI in support of their teams. Given these insights into specific
management practices used to advance DEI, questions arise about how motivation around DEI
influences how senior leaders can support middle management in driving change. The following
section will examine the effects of such motivation around DEI, exploring strategies and
initiatives that can enhance collaboration and alignment between senior leaders and middle
managers to achieve shared DEI goals.
Table 5
Summary Table of Findings: Management Practices
Theme Participant name Quote
Embedding DEI Kaleb [Diversity and inclusion] is a priority. It
is something that has been
communicated and shown through
both verbal, written and action,
communications, that this is a
commitment. So, for me, [diversity
and inclusion] has become not only the
business of our leaders, but it’s
become the business of our entire
company.
Communication/storytelling You know, we went through a number of
tragedies on my team last year, and
that is bonding in the most horrible
way, where people just deeply
genuinely care about one another …

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Theme Participant name Quote
and so it’s having those questions and
those conversations can also help them
where they’ve hit a block because
they’re holding themselves to some
expectation that they that they have
and there’s times when I tell them, I
don’t have that expectation of you. …
You have to have that connection as a
person for them to feel vulnerable,
comfortable being vulnerable to share
where they’re struggling.
Making time Lucia I have been on the core team of that
group now for almost 6 years. And it’s
not something that I have to continue
doing. It’s not something that is
mandated to me. It is something that I
choose to do … and then besides that,
you know, it’s also the engagement
with all of the other groups,
participating in [ERG group] talks,
agreeing to be their keynote speaker if
they reach out to me, you know, and if
I can’t do it, then finding somebody
else who can. And I realized that that
may not be in my exact job
description, but it’s things that I do
want to do to help embed [diversity
and inclusion] in my own day-to-day
practices.
Hiring practices Nelson But when it comes to hiring or like, let’s
say I need to build a sub-team of
people, I don’t think I need an Asian
person a Black person or you know a
Latin American person on the team. I
don’t think that way, it’s more around
like this person had a, you know, very
poor upbringing but overcame these
challenges, went to the non-traditional
educational route but still resilient, but
is having a hard time breaking down or
getting an opportunity. So those are the
types of candidates I look for. And to

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Theme Participant name Quote
me that’s increasing diversity and
being inclusive.
Genuine interest in DEI I know in the beginning, when I first
joined [the company], I learned about
the [Latino ERG] … So, I joined. …
And so that was one way for me to
connect with other Latinos at [the
company] and learn about their jobs.
So, I don’t in my day-to-day job, I
might not work with people in the
research group or in different parts of
the organization. So, it was really
interesting to be able to meet folks that
do all kinds of roles at [the company].
But we all came together as a
community because of that connection.
And we all wanted to help others feel
like they belong.
Findings Research Question 4: Understanding Motivation
The study participants articulated various motivations surrounding DEI, emphasizing two
primary drivers: ethical considerations and business benefits. First and foremost, several
participants highlighted the moral imperative of “doing the right thing” for patients. They
expressed a deep-seated belief that promoting DEI within healthcare organizations is both
morally correct and essential for providing equitable and respectful care to all patients. This
perspective resonated strongly among those who viewed healthcare as a fundamental human
right, advocating that healthcare services should be accessible and inclusive regardless of race,
ethnicity, or background.
Moreover, these motivations were not mutually exclusive but complementary, as
participants saw ethical imperatives and business advantages as mutually reinforcing aspects of

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their commitment to advancing DEI. They believed that aligning ethical values with strategic
business goals could create a sustainable framework for promoting diversity and inclusion within
their healthcare organization, ultimately benefiting both employees and the communities they
serve.
Motivation around DEI was a prominent theme in the interview data. Participants
highlighted two primary ways motivation impacted organization-wide DEI goals. First, they
emphasized “doing the right thing,” and second, they recognized that DEI is good for business.
The following examples provide a glimpse into the study participants’ feelings about motivators
of DEI at the organization.
Doing the Right Thing
Half of the study participants expressed views around “doing the right thing” as related to
DEI. Several participants highlighted practices that middle managers “should” adopt. Helena
emphasized that middle managers “should encourage their teams” to engage with DEI initiatives,
Erin stressed that they “should be held accountable” for DEI efforts, and Frederick suggested
that there “should be consequences” for middle managers who do not effectively fulfill their
responsibilities. Whether the sentiment of “doing the right thing” was toward their colleagues or
when thinking about patients, there was an expressed feeling of “paying it forward.” Such as the
case of Christian, who said, “I’ve learned over the course of my life that sometimes I am
different, or I have an impact on people differently.” Oliver also shared that DEI is the “right
thing to do” and how “[paying] it forward to the people who have really told me about their
lives” helps him reflect on how his past relationships and experiences continue to promote a deep
sense of equity for him.

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Helena said, “If you can see it, you can be it,” amplifying the importance of “bringing her
other colleagues along” into spaces to which they may not have access. Nelson and Pia expressed
“leveling the playing field” and helping others to find their voice while navigating a corporate
atmosphere. While these examples highlight the impact of prioritizing DEI at the organization,
Frederick and Grace emphasized the impact that DEI can have on patients, too. Frederick shared,
Close to all the people that work here are not primarily motivated by money. Otherwise,
they’d be working on Wall Street, you know, or, you know, making cigarettes or
something. I think they are here because of the mission, and I think that naturally attracts
people with certain perspectives, certain beliefs, certain ethical systems and ways of
thinking to the company. You know, and so that, I think, reinforces itself.
Grace stressed that the absence of a DEI lens at the organization trickles down to the
patient. This sentiment has the power to lead to inequities for both employees and the patients
they serve:
When [a person] doesn’t feel seen or recognized, or [they’re] seen, but [they’re] not
allowed to speak, [they] never really feel like [they] fully belong or are included in what
turns out to be the day-to-day decision-making. That informs the way we show up for
patients and customers. And if you won’t see me, a member of the organization, … how
are you going to see the patient who looks like me but doesn’t have anything else in
common with you?
While half of the study participants held a deep sense of doing the right thing for both
their colleagues and patients, others highlighted that DEI is good for business, meaning that they
believed that prioritizing DEI can benefit the company’s financial performance.

85
DEI Is Good for Business
When asked about how DEI serves as a motivator at the company, half of the respondents
mentioned the correlation between DEI and profitability. This viewpoint underscores that while
DEI is ethically important, generating profit and income for owners, employees, and leaders
remains a key priority for a money-generating company. Grace and Isabel discussed how their
work “impacts health equity” for underserved communities, while Alex highlighted that focusing
on colleagues’ DEI-related stories has helped him “learn from” those experiences. These
examples illustrate how corporate DEI goals benefit not only patients but also the organization’s
employees. Below are several examples of how the company’s earnings continue to be a
significant motivator for the interviewees. Frederick shared how “companies that have higher
diversity, treat their people better … do better.”
As Helena likened “patient impact to business impact, which equals dollars.” Leveraging
data to communicate DEI impact was mentioned as a motivating factor as well. Lucia shared,
In order to connect [DEI] to the business, the data is of critical, utmost importance, … but
in one way or another, the data is really what is going to help people know that these
disparities exist, that these opportunities are present. You don’t have to believe me. You
don’t know me. But look at these numbers; they tell the truth.
Other respondents linked motivation and storytelling when thinking about the company’s
profit. Christian shared how “being able to show [how] without diversity, this is how we failed,
… connecting the diversity to those stories that will really change the needle for people.” Oliver
hopes that leadership will

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look back and say we really did help people’s health and we helped people’s access to
drugs, and we helped people have longer lives. And it wasn’t just certain kinds of people
like that. I’m hoping that is a motivating factor for people in leadership.
Summary of Findings for Research Question 4
Motivation around DEI emerged as a significant theme among participants, influencing
organization-wide goals in two primary ways: ethical considerations and business outcomes
(Table 6). Many participants emphasized the ethical imperative of “doing the right thing,” both
toward colleagues within the organization and in their interactions with patients. Conversely,
participants also recognized the business case for DEI, noting its correlation with profitability
and organizational success.
Table 6
Summary Table of Findings: Motivation
Theme Participant name Quote
Doing the right
thing
Kaleb To know that we are reaching patients and we can
stand behind the statement that we know or
have a high degree of certainty that our
medicines are effective in all patient
populations. That’s what motivates our
leadership, to be able to say that we have
proactively ensured that our medicines are
effective across all patient populations, is a big
sort of stake in the ground. And in order for us
to continue to positively impact the lives of the
patients that rely on us, it does involve being
inclusive in our approach.
DEI is good for
business
Helena Business imperatives. Are you getting the
business results that you need? Are you getting
the staff and the hiring that you would like to? I
think, at the end of the day, it’s more than just a
moral initiative. It is a business initiative.

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Summary
Participants drew from both their personal and work experiences when sharing their
beliefs about advancing DEI at the organization. They felt a strong responsibility to enhance DEI
sentiment within their teams and across the entire employee population. Participants
demonstrated their commitment through their ownership of embedding DEI practices into their
management approach, including leading by example, communicating about DEI, and making
time for it.
At the heart of this research is the finding that the interviewees’ position allows them to
influence both strategic decisions and everyday interactions. Thus, leveraging them in advancing
DEI is compelling. The in-depth analysis of these narratives and document analysis provided
insights into these individuals’ experiences and how they could use their leadership capital and
strategies to succeed in driving positive change around DEI efforts. With these practices in mind,
several recommendations can support the prioritization of DEI and empower middle managers.
Chapter Five will delve into comprehensive recommendations derived from the insights
and robust data obtained throughout the study. Building on the participant perspectives and
thematic analyses, Chapter Five aims to offer actionable guidance that aligns with the
overarching goal of fostering DEI within the organization.

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Chapter Five: Discussion and Recommendations
The intention of this study was to examine how middle managers advance DEI
throughout the organization. Major findings of this study found that they play a significant role
in the dissemination of expectations around DEI, especially with regard to relating DEI to patient
health disparities, embedding DEI into everyday actions, and creating a psychologically safe
environment for their direct reports. In concert with the actions of middle managers, senior
leaders played a significant role in advancing DEI efforts as well. Study findings revealed that
senior leaders must recognize the importance of storytelling, allowing dedicated time to enact
DEI opportunities, sharing how DEI is “good for business,” and holding middle managers
accountable for working toward the DEI goals of the organization.
The following research questions provide an outline to examine when considering the
influence that middle managers have on reaching DEI organization-wide goals:
1. What are the external factors that contribute to an organization’s approach to DEI?
2. How do middle managers influence and shape company culture and work climate
around DEI?
3. What are the middle manager practices that most greatly affect the direction of DEI at
the organization?
4. What are the effects of leadership motivation around DEI goals for the organization?
Burke-Litwin Change Model
This study adopted the BLCM and highlighted the need for diagnosing and managing
organizational change from a holistic, open-systems perspective (Coruzzi, 2020). While Litwin’s
early work concluded that organizational climate affects employee performance (Boone, 2012),
the BLCM posits that organizational climate, a flexible set of psychological characteristics in the

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workplace, can be modified by altering conditions such as structure, managerial behavior, and
systems. Furthermore, it highlights the “cascading influence of leadership on management
practices, teams, individual motivation, and performance” (Coruzzi, 2020, p. 422).
The a priori coding of the interview transcripts revealed that three transformational levers
and three transactional levers would aid in enlisting the support and action of middle managers
around the organization’s DEI efforts. The BLCM exhibits how transformational factors driven
by the external environment impact transactional factors, collectively influencing motivation and
organizational performance (Burke & Litwin, 1992).
The noteworthy transformational variables discovered in the interviews were leadership,
culture, and external environment, and they were heavily influenced by the transactional
variables of management practices, work climate, and motivation to execute transformational
changes (Coruzzi, 2020). The model provides comprehensive and interconnected elements
within an organization, illustrating how they influence recommendations for change initiatives.
Summary of Findings
For a variety of reasons, middle managers may not always see DEI work as part of or
central to their roles. The participants shared that feelings of inadequacy around DEI and the
resources available to them perpetuate an opportunity for them to support DEI. This study’s
findings suggest that senior management also plays a significant role in supporting middle
managers to feel empowered to support DEI efforts. The participant narratives challenge the idea
of the frozen middle title and that employees in these roles choose not to support DEI.
Based on interviews and literature, the study revealed significant insights related to
Research Question 1, which focused on external factors contributing to the organization’s DEI
aspirations. The two primary factors identified were the storytelling of personal experiences and

90
the geographic location of the organization. These were followed closely by the impact of social
unrest/current events and patient health disparities.
For Research Question 2, which examined middle management’s influence on the overall
culture of the organization, two major themes emerged: awareness and intentionality around
DEI. Three sub-themes supported these themes: continuous learning, allyship, and empathy.
Research Question 3 explored how the participants managed their teams daily with an
emphasis on DEI. The prominent themes were embedding DEI into daily practices and
communication. Additionally, the interviewees consistently highlighted making time for DEI,
refining hiring practices, and demonstrating a genuine interest in DEI. These practices became
ingrained in the managers’ routines as they navigated and supported DEI within the organization.
Lastly, for Research Question 4, the study participants articulated various motivations
surrounding DEI. They emphasized two primary drivers: ethical considerations and business
benefits. Many participants underscored the moral imperative of “doing the right thing” for
patients, believing that promoting DEI within healthcare organizations is morally correct and
essential for providing equitable and respectful care to all patients. This perspective resonated
particularly with those who view healthcare as a fundamental human right, advocating for
accessible and inclusive healthcare services regardless of race, ethnicity, or background.
The next section will present recommendations for practice based on these findings.
Drawing from the insights gathered through interviews and literature, the section presents
actionable steps for middle managers and senior leaders to enhance DEI efforts at the
organization. These recommendations focus on effectively integrating DEI principles into daily
management practices. By implementing these recommendations, the organization can better

91
align its DEI goals, ultimately contributing to a more equitable and productive workplace culture
in service of its patients.
Recommendations for Practice
The purpose of this study was to identify how middle management supports the
organization in reaching its organization-wide DEI goals. Table 7 presents recommendations for
both short-term and long-term implementation. While some will take longer to show progress, it
is essential to also include those that can be enacted more quickly. Given the data-driven and
scientific nature of our organization and industry, it will be necessary to incorporate measurable
impacts. While DEI is fundamentally a people-centered business endeavor, many of the listed
recommended actions must be measurable, allowing the EO to effectively report on their impact
year over year.
Table 7
Table of Recommendations
Research question Recommendation
1 Senior leaders must incorporate personal stories when engaging with
direct reports.
Middle managers must relate DEI to patient health disparities.
2 Middle managers must embed DEI into everyday actions.
Middle managers must create a psychologically safe working
environment.
3 The organization must provide dedicated time for employees to “do
DEI.”
4 The organization must share how DEI is good for business.
Senior leadership must hold middle management accountable to DEI
goals.

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RQ 1: External Factors That Contribute to an Organization’s Approach to DEI
The two external factors that affect DEI at the organization, as study participants shared,
were personal stories and patient disparities in the healthcare system. The following
recommendations exhibit how senior leaders can leverage the transformational lever of external
environment factors when engaging and utilizing the transactional lever of motivating their
middle management as per the BLCM (Burke & Litwin, 1992). The BCLM emphasizes that
environmental factors are the most significant and impactful drivers of change, with most
changes being traced back to these external influences (Burke & Litwin, 1992). Therefore, it is
crucial for middle managers to consistently monitor for issues that could impact their teams.
Recommendation 1: Incorporate Personal Stories When Engaging Direct Reports
Senior leaders must exhibit strong communication when exhibiting how to engage in DEI
efforts, as employees look to them to practice what they preach (Baker, 2014). McClellan (2006)
noted that when senior leaders share personal stories, they show patterns to help make
connections. Employee stories breathe continual life into the concepts and keep strategic vision
current and tangible (Baker, 2014). This study’s findings revealed the role of senior leaders’
storytelling in communicating about DEI in various settings.
This study’s findings suggest that when sharing about DEI aspirations, it will be
beneficial for senior leaders to use storytelling when presenting to their broader functional teams
(such as town halls), during leadership team meetings, and in conversations with their direct
reports (middle management). McLellan (2006) explained that stories often originate from
problematic situations, and by sharing these stories, senior leaders can illustrate solutions. Study
participants highlighted the power of storytelling to demonstrate how DEI has improved business

93
outcomes. To support these findings, Harrison-Train et al. (2021) suggested that storytelling can
enhance empathetic skills and deepen appreciation for DEI.
Recommendation 2: Relate DEI to Patient Health Disparities
Study participants shared how external factors like patient disparities helped them to link
DEI to the mission of the organization. While Gill et al. (2018) emphasized that there is a
relationship between providers’ work environments, patient outcomes, and organizational
performance, further research conveyed that DEI fosters collaboration, empathy, and
psychological safety (El-Galaly et al., 2023; Washington et al., 2023).
The EO must illustrate the connection between DEI and its direct impact on patient care
(El-Galaly et al., 2023) via both internal communications and resources for employees to
leverage. The organization will need to adopt and support more intentionality and DEI-based
goal-setting, more diverse research and leadership teams, better community engagement, and
better-tailored outreach interventions, among others (Washington et al., 2023). Doing so will
continue driving focus around the betterment of all patients.
RQ 2: Middle Managers’ Influence on Company Culture and Work Climate Around DEI
This study identified two leading opportunities where middle managers can influence
their direct reports around DEI aspirations to include (a) embedding DEI into everyday actions
and promoting and (b) building a psychologically safe working environment for their teams. It
should be no surprise, then, that middle managers oftentimes function as change agents,
succession planners, and project initiators and, therefore, make significant contributions to
organizational success (Do & Nuth, 2020). When middle managers focus on the transformational
lever of culture, the organizational, a shift in the day-to-day team climate will follow (Burke &
Litwin, 1992).

94
The BLCM defines company culture as the prevailing beliefs, behaviors, values, and
norms that develop within an organization (Burke & Litwin, 1992). Middle managers should
remain mindful of their organization’s desired state, including the expected employee behaviors
and the values the organization prioritizes. The work climate, which reflects employees’
perceptions of their colleagues and the working environment, also plays a significant role in
shaping views of the organization and influencing job satisfaction (Burke & Litwin, 1992).
Recommendation 3: Embed DEI Into Everyday Actions
Embedding DEI into managing a team requires more than lip service. Klagge (1996)
noted middle managers as integrators creating organizational unity, facilitators releasing human
diversity into group processes, and implementers of necessary supporting systems for
recognizing and rewarding actions that foster unity and unlock diversity. Many participants
shared the need to embed DEI into their everyday management style and to witness other leaders
doing so. While the most well-intentioned employees may be worried or lack the confidence to
handle DEI-related challenges and conversations, the need remains to create inclusive spaces
(Dachner & Beatty, 2023).
Middle managers must embed DEI into their everyday actions to exhibit how to enact it
within the organization. Creary et al. (2021) shared that managers’ involvement in DEI exhibits
care and interest in their employees while supporting their growth. Furthermore, when
employees feel like their manager wants to help them advance and thrive in the workplace, they
feel important to the organization.
Recommendation 4: Create a Psychologically Safe Working Environment
The study participants identified the feeling of safety as an important aspect of their
working environment. Edmondson and Lei (2014) stressed that when employees perceive their

95
work environments as psychologically safe, they are more likely to take risks due to the reduced
fear of negative repercussions. Furthermore, organizations can benefit from employees’ creative
ideas, innovative behaviors, and proactive suggestions. While Edmondson and Lei posited
psychological safety as a critical factor in understanding phenomena like voice, teamwork, team
learning, and organizational learning, Singh et al. (2013) found that psychological safety
mediates the relationship between diversity climate and employee performance.
To unlock employees’ potential, middle management must promote a psychologically
safe environment and build one for their teams. Even though employees may hesitate to speak up
about potential issues due to concerns about negative consequences, middle managers must
explicitly invite input and feedback while modeling openness and fallibility themselves
(Edmondson & Roloff, 2009). This approach is key to preventing diversity from negatively
impacting performance and learning.
RQ3: Practices That Greatly Affect the Direction of DEI
The interplay between middle management and their effects on change within the
organization requires steadfast commitment. This study found that middle managers must
implement dedicated time for employees to take action on DEI with the agreement and support
of senior management. The relationship between senior leadership and middle management
emerged continuously among study participants, aligning with the BCLM, which emphasizes the
link between leadership and management to enact organizational aspirations (Burke & Litwin,
1992). The BLCM shares that management practices define management style and how
managers engage with their employees. These practices encompass the behaviors and activities
of managers, typically aligned with executing the organization’s overall strategy (Burke &

96
Litwin, 1992). The role of middle management is especially critical in ensuring time and
resources are allocated for DEI efforts.
Recommendation 5: Allocate Dedicated Time for DEI
The recommendation is to allocate dedicated time for DEI. Study participants mentioned
that the lack of time was a factor in their ability to put effort toward DEI. Goals and time are
inextricably linked (Etkin, 2019). Several scholars studying time in organizations have
highlighted that a significant challenge for employees is the demand to simultaneously pursue
multiple tasks (Fried & Slowik, 2004). Kara et al. (2022) found that achieving DEI goals requires
time and patience, and they further advocate for allocating protected time to ensure a successful
outcome.
The role of time in this study suggests that employees need protected time to act upon
DEI efforts, underscoring the need for senior leaders to provide protected time to middle
management. Faucett et al. (2022) championed this notion by mentioning how leaders across
healthcare can champion strategies for redistributing DEI efforts, fostering a diverse and
inclusive environment that benefits all members of the organizations while mitigating health
inequities.
RQ4: Effects of Motivation Around DEI
There is growing recognition that DEI efforts may fall short because they do not
effectively motivate attitudinal and behavioral change (Legate & Weinstein, 2024). Mention of
intrinsic motivation was shared among participant interviews when discussions of DEI and
motivation arose. While Chalofsky and Krishna (2009) explored a deeper level of intrinsic
motivation, meaningfulness, and its connections to employee commitment and engagement, the
BCLM asserts that motivation is crucial for successful change. The real challenge will be to

97
sustain motivation for DEI during change management by harnessing both intrinsic and extrinsic
motivators (Burke & Litwin, 1992).
Recommendation 6: Demonstrate How DEI Is Good for Business
A common theme that arose among study participants was around the collective mission
of the organization. The mission to work smarter and play better grounded the interviewees and
caused them to reflect on the reasons they came to work every day: to help patients while having
fun doing so. Respondents in the Schaefer and Darling (1996) study expressed that they viewed
work as an opportunity to serve others, integrating it seamlessly with the rest of their lives.
With this in mind, it aided in understanding the motivations behind study participant
commitments to advance DEI at the organization. Senge (1993) emphasized that personal
commitment is a key requirement for becoming a learning organization.
This recommendation advises senior leaders to connect employee intrinsic motivation to
the organization’s profitability when discussing DEI with their direct reports. Pinkett (2024)
highlighted that beyond the personal case for DEI, which includes benefits like expanding
diversity of thought, improving health and wellness, mitigating biases, and enlarging networks,
there is also a strong business case for DEI. This encompasses winning the competition for
talent, strengthening customer orientation, increasing employee trust and performance,
improving decision-making, fostering innovation, and enhancing the organization’s image, all of
which contribute to the organization’s profitability.
Recommendation 7: Enforce Accountability of Reaching DEI Goals
Tucker (2023) described that best-in-class organizations provide more resources and
leadership support for their DEI programs, do more to drive awareness about DEI, shape policies
that are consistent with a commitment to DEI, and use measures to hold leadership accountable

98
to stated DEI commitments. Relative to other organizations, these best-in-class organizations are
significantly more likely to report having measurable goals for DEI, have DEI as part of senior
leader performance goals, and have DEI goals as part of manager performance plans (Tucker,
2023). The responsibility for creating sustainable change lies with the entities that have the
power and authority to shift the culture to ensure equitable access to care and resources for
diverse learners and patients (Mason et al., 2023).
In this instance, the EO, in agreement and collaboration with senior leadership, must
support this shift in culture by linking DEI accountability measures by means of reward systems
that are performance based. Such systems represent a particularly powerful means for
influencing an organization’s culture, values, and norms (Kerr & Slocum, 2005). Examples of
rewards systems in this context might include reaching DEI efforts as related to bonus pay or
other payout recognition.
Implementation of Recommendations
Several recommendations can be implemented through the BLCM. This model identifies
where change happens in an organization and how it flows between different parts of said
organization (Burke & Litwin, 1992). The significance of this model rests in the interrelatedness
of the 12 drivers that can contribute to the success or failure of organizational change (Burke &
Litwin, 1992). Using this model, one can identify which organizational variables need to be
adjusted and why. Once these variables are detected, the organization will be able to analyze,
diagnose, and possibly predict the effects of change throughout an organization (Burke & Litwin,
1992).
While this study utilized the BLCM, the research identified six key components of this
framework that had the most significant impact on the organization, forming a conceptual

99
framework. The transformational components at the top are leadership, organizational culture,
and external environment, each serving as a foundational link to specific transactional factors
that pertain to the day-to-day operations within the organization (Burke & Litwin, 1992). The
transactional factors in this conceptual framework include management practices, work unit
climate, and motivation. Each of these factors is directly related to and influenced by a
corresponding transformational component.
Recommendations for Future Research
This section highlights three opportunities for future research in the realm of middle
managers and DEI. Middle managers play a central role in the success of DEI initiatives within
healthcare organizations (Do & Nuth, 2020). By exploring the following recommendations for
future research, we can gain a deeper understanding of how middle managers can be more
effectively supported and empowered to drive meaningful and lasting DEI outcomes.
First, further research should explore the role of senior leadership in advancing DEI in
collaboration with middle management. Understanding the dynamics between these two levels of
leadership aids in developing strategies that ensure the effective implementation of DEI
principles throughout the organization. Study participants perceived that senior leaders support
DEI; however, this support does not always extend to middle management. Further research
should explore the role of senior leadership in advancing DEI in collaboration with middle
management. It is essential to investigate how senior leaders can be effectively leveraged in
partnership with their direct reports/middle managers to enhance DEI efforts.
The second recommendation emphasizes the need for effective communication strategies
around DEI in healthcare organizations. In the fast-paced, data-driven healthcare industry,
organizations often face multiple competing priorities. Despite these challenges, DEI messaging

100
must remain a top priority. Effective communication strategies can help embed DEI principles
into the organization’s core, ensuring that other initiatives do not overshadow them.
The final recommendation aligns with psychological safety and its contribution to DEI in
healthcare organizations. Psychological safety is a shared belief that the team environment is safe
for interpersonal risk-taking. In a psychologically safe workplace, employees feel comfortable
expressing their thoughts, questions, concerns, and mistakes without fear of embarrassment,
rejection, or punishment (Los Angeles Pacific University, 2021). This is especially important in
healthcare settings, where open communication can directly impact patient care and outcomes.
While the healthcare industry has unique challenges and opportunities when it comes to
DEI, the insights gained from research in this field can have far-reaching implications. By
understanding how middle managers can more effectively implement DEI strategies, healthcare
organizations can improve patient outcomes, enhance employee satisfaction, and build more
resilient and adaptable teams. This research will contribute to the healthcare industry by
providing practical insights that can help all organizations create more inclusive and equitable
workplaces.
Conclusion
After several years of working in the DEI space at the study site, it became clear to me
that a focus on leveraging middle managers to advance DEI goals might be the key to advancing
them. The company had long concentrated its efforts on engaging senior leaders for DEI buy-in
and relying on individual contributors to carry much of the DEI workload. However, in
numerous conversations over the years, middle managers have expressed uncertainty about what
they need to do around DEI and how they need to do it. Middle managers are the vital
connection between senior leaders and individual contributors, capable of empowering and

101
understanding the needs of both. This makes them crucial for driving meaningful and sustained
DEI progress across the organization.
This research underscores the critical role that middle managers play in prioritizing and
advancing DEI within organizations. Middle managers are central to effectively driving DEI
initiatives, and they are positioned uniquely to influence both strategic decisions and daily
interactions. Their ability to affect organizational culture and employee behavior highlights the
importance of leveraging their position to advance DEI efforts. The commitment of middle
managers to DEI is evident through their proactive engagement, which includes leading by
example, communicating DEI priorities, and dedicating time and resources to these initiatives.
In examining the participants’ experiences, the research revealed their profound sense of
responsibility to promote DEI across their teams and the broader organization. Drawing from
both personal and professional experiences, these managers demonstrated strong ownership of
embedding DEI practices into their management approaches. The analysis of their narratives
provided insights into how middle managers utilize their leadership capital and strategies to drive
positive change. Based on these findings, more emphasis on leveraging the middle management
population will move the needle positively for DEI efforts at the organization.

102
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Abstract (if available)

Abstract Due to competing priorities from both direct reports and senior leadership, middle managers have struggled to effectively address organization-wide diversity, equity, and inclusion goals. This descriptive case study utilizes the Burke-Litwin change model and critical race theory frameworks. The Burke-Litwin change model identifies both transformational and transactional factors that integrate to influence change throughout an organization, while critical race theory recognizes racism as a systemic component of organizational operations within an American context. The study examined 16 middle managers through interviews and document analysis to understand how they prioritize DEI and contribute to achieving DEI goals.

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Creator Solis, Virginia (author)

Core Title Driving organizational transformation: empowering middle managers to prioritize diversity, equity, and inclusion within the healthcare sector

School Rossier School of Education

Degree Doctor of Education

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Degree Conferral Date 2024-08

Publication Date 09/11/2024

Defense Date 09/11/2024

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Tag diversity,equity,inclusion,middle management,OAI-PMH Harvest

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